recently two of my pts in a hospital outpt setting were discharged by their consultants with the plan to 'continue with physio management'. The problem for my supervisor and i was that we were not achieving gains with physio (the pts had platued for a number of reasons) and we were considering sending them back to the consultant for review of their condition as it was becoming apparent that interventions other than physio might be needed. The consultants, however, seemed to 'get in first' and handball / discharge them to physio for continued management, stating that there was nothing further they were able to do for the pt.
What happens in this situation when both parties decide they are unable to appropriately manage the pt and feel other involvement is needed?? with one pt i wrote a letter to the consultant (with the guidance of my supervisor) stating the reasons we thought he needed a follow up and why discharging him to physio was inappropriate. My supervisor dealt with the other pt as it was an ongoing issue. Has anyone else come across this situation in a hospital setting where different departments refer pts back and forth? Is there a 'higher power' in this type of situation that decide whats best for the pt? or do the departments need to compromise and come to an agreement on a course of treatment?
Tuesday 25 September 2007
distracting visitors
Has anyone needed to ask family or visitors to leave a treatment session? i was treating a 22yo pt who presented with knee instability and occasional sharp pain. She was fitting her physio sessions in amongst uni lectures and one time arrived with 2 friends. They walked into the treatment rooms with her and in doing so said 'oh its ok that my friends come in isnt it??' to which i said that was fine so long as they allowed us to focus on the physio session. During assessment they were all talking and i politely asked if they could leave the chat till later as we had limited treatment time. During HLB Ax they were laughing and distracting the pt and thus affecting the outcome, and again i asked that they please sit quietly while the session continued. This happened a couple more times throughout the session and whilst i found it easy to ask them to be quiet and not distract the pt i felt unable to ask them to leave, seeing as id already said they could come in. Has anyone else asked people to leave? What is the best way to go about it?
Tuesday 18 September 2007
Conversion disorders
While on my neurology placement I came across approx 4 patients with a ‘conversion disorder’ otherwise known as Hysterical neurosis. Apparently that it is post grad stuff but I found it very interesting. For those of you who are unsure here are some facts:
- essentially a conversion disorder is when psychological symptoms manifest as physical symptoms (although there is no evidence of organic cause of the symptoms)
- It is a psychiatric condition
- Common signs and symptoms may include paralysis in an arm or leg, difficulties swallowing, sudden blindness/deafness, or nonepileptic seizures
- Symptoms usually appear suddenly and may follow a stressful experience
- Conversion disorder is rare
- affects women more than men
- most commonly people between age 10 and 35 years of age
Case study: One of my patients who was only young had been assaulted and had presented to the hospital with L sided weakness. The doctors did all the CT/MRI scans and found no organic cause of his weakness and so gave him the dx of a conversion disorder secondary to the stress of the assault. Initially I found it really hard to get my head around this diagnosis as his symptoms were very real i.e. he was unable to stand on his L leg with out it collapsing and shaking like mad. But then when my CCT saw him, the first thing she said was that he had a conversion disorder- just by looking at him. I guess looking back, that his presentation didn’t really fit. He would
- hop on his right leg to get around- which is very strange as it takes a lot of strength in both legs to hop
- he had 2-3 falls (which apparently is a sign of conversion)
- he had pain the whole way down his (L) side which was not dermatomal and had no apparent cause
- when testing sensation and proprioception his results were inconsistent and it appeared as though he was trying to get them wrong
I guess essentially we need to be mindful of this condition and that it exists. Even though it is rare (I saw 4 patients on 4 weeks with it…)
- essentially a conversion disorder is when psychological symptoms manifest as physical symptoms (although there is no evidence of organic cause of the symptoms)
- It is a psychiatric condition
- Common signs and symptoms may include paralysis in an arm or leg, difficulties swallowing, sudden blindness/deafness, or nonepileptic seizures
- Symptoms usually appear suddenly and may follow a stressful experience
- Conversion disorder is rare
- affects women more than men
- most commonly people between age 10 and 35 years of age
Case study: One of my patients who was only young had been assaulted and had presented to the hospital with L sided weakness. The doctors did all the CT/MRI scans and found no organic cause of his weakness and so gave him the dx of a conversion disorder secondary to the stress of the assault. Initially I found it really hard to get my head around this diagnosis as his symptoms were very real i.e. he was unable to stand on his L leg with out it collapsing and shaking like mad. But then when my CCT saw him, the first thing she said was that he had a conversion disorder- just by looking at him. I guess looking back, that his presentation didn’t really fit. He would
- hop on his right leg to get around- which is very strange as it takes a lot of strength in both legs to hop
- he had 2-3 falls (which apparently is a sign of conversion)
- he had pain the whole way down his (L) side which was not dermatomal and had no apparent cause
- when testing sensation and proprioception his results were inconsistent and it appeared as though he was trying to get them wrong
I guess essentially we need to be mindful of this condition and that it exists. Even though it is rare (I saw 4 patients on 4 weeks with it…)
Monday 17 September 2007
Hi all,
My second post of this week:
Subarachnoid Haemorrhage (SAH)
1) Diagnosis:
- Full Neurological examination
- Ongoing neurological observation (E.g. GCS)
- CT Scan
i. Confirm the diagnosis in 95% of causes
ii. Blood may be widely distributed or more localized
iii. Can also identify other conditions such as hydrocephalus and ICH
- Cerebral Angiogram
i. Undertake by all patients
ii. Four vessel angiography
- Lumbar Puncture
i. Presence of blood in CSF is a positive result
ii. Patient has LP done needs to RIB at least 6 hours
- TCD’s
i. Measure the velocity of blood flow in intracranial vessels
ii. A reading of 120cm/s is significant
2) Things need to consider when seeing patients who has SDH on ward
i. Make sure you know what type of surgery the patient had done, E.g.) If
patient had a craniectomy, they are not allowed to sit up without a helmet
ii. No driving or RTW for at least 6 weeks (For discharge planning)
iii. Fatigue can be a problem for some months post bleed (Impact on your clinical
decision)
iv. Always ask your patient whether they have any dizziness; you need to know
whether the dizziness is position related or movement related. From my 4
weeks experience, it is not uncommon for patient to have some forms of
vestibular impairments.
My second post of this week:
Subarachnoid Haemorrhage (SAH)
1) Diagnosis:
- Full Neurological examination
- Ongoing neurological observation (E.g. GCS)
- CT Scan
i. Confirm the diagnosis in 95% of causes
ii. Blood may be widely distributed or more localized
iii. Can also identify other conditions such as hydrocephalus and ICH
- Cerebral Angiogram
i. Undertake by all patients
ii. Four vessel angiography
- Lumbar Puncture
i. Presence of blood in CSF is a positive result
ii. Patient has LP done needs to RIB at least 6 hours
- TCD’s
i. Measure the velocity of blood flow in intracranial vessels
ii. A reading of 120cm/s is significant
2) Things need to consider when seeing patients who has SDH on ward
i. Make sure you know what type of surgery the patient had done, E.g.) If
patient had a craniectomy, they are not allowed to sit up without a helmet
ii. No driving or RTW for at least 6 weeks (For discharge planning)
iii. Fatigue can be a problem for some months post bleed (Impact on your clinical
decision)
iv. Always ask your patient whether they have any dizziness; you need to know
whether the dizziness is position related or movement related. From my 4
weeks experience, it is not uncommon for patient to have some forms of
vestibular impairments.
Base of Skull Fracture
Hi All,
I am going to share with you some knowledge which I have learnt for the last four weeks in neurosurgery ward. They are as follows:
Base of Skull (BOS) Fracture
1) Most common clinical features are blood or CSF from ear or nose
2) Those patient with CSF leakage may complain of a salty tasting fluid running down the back of throat
3) Patient has BOS fracture with CSF leak is far more severe and potentially life threatening when compare to patient who only has BOS fracture
4) Two main complications for BOS fracture with CSF leak are:
- Cerebral Infection ( Particular bacterial meningitis)
- Pneumocephalus( Accumulation of air in cranium)
5) Medical Management:
- BOS fracture with not CSF leak is managed conservatively
- If a feeding tube is required, an orogastirc tube is used instead of nasogastric tube.Nasogastric tube is not used due to the risk of increased trauma to the region
- For surgical repair, it involves a frontal lobe craniotomy with repair of the dural defect using a fascia lata graft
6) Physiotherapy Management:
- Consult neurosurgical registrar before mobilizing
- Many of these patients will have vestibular problem due to the proximity of the BOS fracture to the VIII cranial nerve.
- If patient has vertigo on ambulation, he/she may need stemetil (medication) regularly
7) Respiratory Care
- All suction should be performed via the guedels airway or via an endotracheal tube or trachyeostomy. This will avoid further trauma to the region and minimise the risk of infection
I am going to share with you some knowledge which I have learnt for the last four weeks in neurosurgery ward. They are as follows:
Base of Skull (BOS) Fracture
1) Most common clinical features are blood or CSF from ear or nose
2) Those patient with CSF leakage may complain of a salty tasting fluid running down the back of throat
3) Patient has BOS fracture with CSF leak is far more severe and potentially life threatening when compare to patient who only has BOS fracture
4) Two main complications for BOS fracture with CSF leak are:
- Cerebral Infection ( Particular bacterial meningitis)
- Pneumocephalus( Accumulation of air in cranium)
5) Medical Management:
- BOS fracture with not CSF leak is managed conservatively
- If a feeding tube is required, an orogastirc tube is used instead of nasogastric tube.Nasogastric tube is not used due to the risk of increased trauma to the region
- For surgical repair, it involves a frontal lobe craniotomy with repair of the dural defect using a fascia lata graft
6) Physiotherapy Management:
- Consult neurosurgical registrar before mobilizing
- Many of these patients will have vestibular problem due to the proximity of the BOS fracture to the VIII cranial nerve.
- If patient has vertigo on ambulation, he/she may need stemetil (medication) regularly
7) Respiratory Care
- All suction should be performed via the guedels airway or via an endotracheal tube or trachyeostomy. This will avoid further trauma to the region and minimise the risk of infection
Sunday 16 September 2007
relaxation : not just for the hippies
Hi All,
I had been working with patients who suffers from dypsnea the last 4 weeks. I have used relaxation techniques on many occassions. Some patients are a little bit uncomfortable with this 'new age' thing, some are willing to try anything that works.
One of my patients was an anxious lady who was diagnosed with Type 2 Resp. Failure (recovering) with a past medical history of Breast Cancer (in remission), she also suffered hip and groin pain when actively flexing her hip. I taught her breathing control combined with relaxation technique because of her dyspnoea. No one could figure out or dwell into too much why she's anxious. I guess after we all have been working in the medical respiratory ward for a while, we just assume the dypsnoea's to do with respiratory diseases. The day before her discharge, she revealed to me that she's been worrying about the cancer cells might have spread to her hip as that's what happened to her sister who died to similar cause. She then told me that she used the relaxation breathing technique to help coping with her anxiety related dyspnoea when she was in the scanning machine and that it will be her daily practice from now on. (She's been cleared from cancer, by the way. It was a false alarm.)
I have learned two things from this:
1. it takes time to piece together the cause of dyspnoea sometimes, it's not always so straight forward, anxiety may be the cause, but what is the cause of the anxiety, that's the part we need to have some patience to figure it out.
2. relaxation technique works on ppl who are receptive to it.
I had been working with patients who suffers from dypsnea the last 4 weeks. I have used relaxation techniques on many occassions. Some patients are a little bit uncomfortable with this 'new age' thing, some are willing to try anything that works.
One of my patients was an anxious lady who was diagnosed with Type 2 Resp. Failure (recovering) with a past medical history of Breast Cancer (in remission), she also suffered hip and groin pain when actively flexing her hip. I taught her breathing control combined with relaxation technique because of her dyspnoea. No one could figure out or dwell into too much why she's anxious. I guess after we all have been working in the medical respiratory ward for a while, we just assume the dypsnoea's to do with respiratory diseases. The day before her discharge, she revealed to me that she's been worrying about the cancer cells might have spread to her hip as that's what happened to her sister who died to similar cause. She then told me that she used the relaxation breathing technique to help coping with her anxiety related dyspnoea when she was in the scanning machine and that it will be her daily practice from now on. (She's been cleared from cancer, by the way. It was a false alarm.)
I have learned two things from this:
1. it takes time to piece together the cause of dyspnoea sometimes, it's not always so straight forward, anxiety may be the cause, but what is the cause of the anxiety, that's the part we need to have some patience to figure it out.
2. relaxation technique works on ppl who are receptive to it.
Saturday 15 September 2007
Global overview
I had a pt this week who presented with no pain but the last three years after an annual sports carnival she gets quad pain. So she came to me to see what she could do to prevent it from happening again and the carnival was the next day. How do you treat no pain? In this situation PMH is important she had a hx of sprained ankles and knee ligament damage on the same side. This suggested that she had instability problem on that side which also is the side of her quad injuries. So i tested her SIJ which showed massive instability and subsequently had lead to her ankle, knee and quad problems. So when stumped take a step back and view the whole picture.
Thursday 13 September 2007
Neuro exposure
Hello all,
Coming to the end of my neuro prac, just thought I'd share some things that I learnt. I struggled throughout this prac, stemming partially from my poor/undeveloped observation skills. Subtle things like muscle activation I found difficulty to see, and hence decipher the problems, and what to do to fix this. I thought that my skills would improve over time, and they did a little but not enough to be effective or entirey accurate.
I feel in this situation I would have benefitted from specific guidance and examples from senior staff, rather than being asked continuously what i could seeand to "think about it". I take responsibility for not requesting help in this way, and I feel that it could have been offered more by the supervisors when they saw me having troubles.
As well as this I think there needs to be a lot more exposure to real patients and neurological problems at university, rather than getting thrown in the deep end, having only 4 weeks to start learning and developing these skills. I'm not sure any of our opinions make a difference to course changes but was curious if anyone else had experienced similar issues, or has any suggestions on how I could handle this situation in the future.
Coming to the end of my neuro prac, just thought I'd share some things that I learnt. I struggled throughout this prac, stemming partially from my poor/undeveloped observation skills. Subtle things like muscle activation I found difficulty to see, and hence decipher the problems, and what to do to fix this. I thought that my skills would improve over time, and they did a little but not enough to be effective or entirey accurate.
I feel in this situation I would have benefitted from specific guidance and examples from senior staff, rather than being asked continuously what i could seeand to "think about it". I take responsibility for not requesting help in this way, and I feel that it could have been offered more by the supervisors when they saw me having troubles.
As well as this I think there needs to be a lot more exposure to real patients and neurological problems at university, rather than getting thrown in the deep end, having only 4 weeks to start learning and developing these skills. I'm not sure any of our opinions make a difference to course changes but was curious if anyone else had experienced similar issues, or has any suggestions on how I could handle this situation in the future.
Aboriginal communities
Hi all,
sorry for the lateness of this blog...its a delayed one from whilst i was on rural prac. I was in Port Hedland which has quite a large indigenous population. Near to town and on the outskirts are numerous aboriginal communities. I was lucky enough to visit one, which i thought was definately one of my highlights there. It was about 2 hours outside Port Hedland, in the bush. Now a lot of these communities have major issues with drugs, alcohol and domestic violence, however this particular one was supposed to be a 'dry' community. Still when i turned up there I would still have to say I was in a little bit of shock. The community was very small with run down houses with smashed windows, wrecked cars everywhere and no one to be seen. It looked like a deserted ghost town. There was a small nursing post along with a few portable classrooms as a school and a small shack as the local shop and that was it. The physiotherapist and myself treated people as outpatients in the small nursing post which was definately different from the usual location of treatment. It was amazing to see how small the community was and the limited resources available. I'm glad i got to witness this whilst on my prac because a lot of the residents living here were often patients on the ward in the local hospital where i was based, and it definately helped me with discharge planning by knowing what they patients were returning to and what resources were available to them. Anyone else had any similar experiences?
sorry for the lateness of this blog...its a delayed one from whilst i was on rural prac. I was in Port Hedland which has quite a large indigenous population. Near to town and on the outskirts are numerous aboriginal communities. I was lucky enough to visit one, which i thought was definately one of my highlights there. It was about 2 hours outside Port Hedland, in the bush. Now a lot of these communities have major issues with drugs, alcohol and domestic violence, however this particular one was supposed to be a 'dry' community. Still when i turned up there I would still have to say I was in a little bit of shock. The community was very small with run down houses with smashed windows, wrecked cars everywhere and no one to be seen. It looked like a deserted ghost town. There was a small nursing post along with a few portable classrooms as a school and a small shack as the local shop and that was it. The physiotherapist and myself treated people as outpatients in the small nursing post which was definately different from the usual location of treatment. It was amazing to see how small the community was and the limited resources available. I'm glad i got to witness this whilst on my prac because a lot of the residents living here were often patients on the ward in the local hospital where i was based, and it definately helped me with discharge planning by knowing what they patients were returning to and what resources were available to them. Anyone else had any similar experiences?
Tuesday 11 September 2007
Quality of Life
We have been reading and talking about quality of life and how it is one of the most important issues to consider when it comes to treating a patient. However, the reality does not always match with the ideal.
I was doing a discharge planning/review for my COPD patient today and she is requiring 24 hrs home O2. The hospital which I am having my placement at does not issue patients with Home O2 with 4 wheeled walker. It's not much of a big problem if the patient can afford it. For those who are on pension, they will be forced to be housebound and not being able to enjoy outdoors with their partner/family.
I believe this is only one small example on how patient's quality of life is affected due to funding issues. I feel quite frustrated by such situations but at the same time feeling helpless. Does anyone here know of similar situations or ideas on how to problem solve?
Chin.
p.s. sorry for the late posting, was not able to think of an issue to post up until today!
I was doing a discharge planning/review for my COPD patient today and she is requiring 24 hrs home O2. The hospital which I am having my placement at does not issue patients with Home O2 with 4 wheeled walker. It's not much of a big problem if the patient can afford it. For those who are on pension, they will be forced to be housebound and not being able to enjoy outdoors with their partner/family.
I believe this is only one small example on how patient's quality of life is affected due to funding issues. I feel quite frustrated by such situations but at the same time feeling helpless. Does anyone here know of similar situations or ideas on how to problem solve?
Chin.
p.s. sorry for the late posting, was not able to think of an issue to post up until today!
Monday 10 September 2007
CCT's- not just those nasty ppl who do your final Ax
Hey Guys,
just a word of advice i've sort of realised somewhat late into my pracs! I'm currently on my last prac and my CCT has started asking me about where i want to apply, who i'm going to use as referees, what I'm going to include in my resume, etc. She has given me some really sound advice with regards to all of this stuff which has been so helpful. I guess what I'm trying to say is that CCT's really are a good resource as we don't have much contact with our lecturers this year to ask all those burning q's. I'm lucky that my CCT has offered to help me in this area but if you find you have a bit of extra time with them, don't hesitate to ask them for help in this area, i've found it really useful!
just a word of advice i've sort of realised somewhat late into my pracs! I'm currently on my last prac and my CCT has started asking me about where i want to apply, who i'm going to use as referees, what I'm going to include in my resume, etc. She has given me some really sound advice with regards to all of this stuff which has been so helpful. I guess what I'm trying to say is that CCT's really are a good resource as we don't have much contact with our lecturers this year to ask all those burning q's. I'm lucky that my CCT has offered to help me in this area but if you find you have a bit of extra time with them, don't hesitate to ask them for help in this area, i've found it really useful!
Multidisciplinary Rehab
Hey everyone, just a quick thought this time about how important it is to appreciate other allied health professionals. We all throw the terms "multidisciplinary" and "health care team" around a bit, and I'm sure everyone will mention something to this effect in their PCR's. But it's quite different when you actually get to see speech therapists (ST's) and OT's doing their thing for yourself. I have always quite enjoyed the hospital environment for the opportunities to work with other health professionals, but I have occasionally lost sight of the importance of other professions. On my current placement pts will spend 3 hours per day in physio sessions, whilst only half an hour with the ST or OT, so it's easy to rank PT as having more relevance and importance.
I was allowed to sit in on a ST session with a young stroke pt who had trouble forming the words for what she wanted to say. I was quite fascinated by the different techniques the therapist used and the relationship she had with the pt. I learned what a wide field health care in rehabilitation can be, and have a much better appreciation for what ST's do. Anyone who has an opportunity like this, I highly recommend it.
I was allowed to sit in on a ST session with a young stroke pt who had trouble forming the words for what she wanted to say. I was quite fascinated by the different techniques the therapist used and the relationship she had with the pt. I learned what a wide field health care in rehabilitation can be, and have a much better appreciation for what ST's do. Anyone who has an opportunity like this, I highly recommend it.
Children
Hi guys,
On my current placement, i am finding that a lot of the clients bring their children along to appointments with them. This is mainly the ladies who have little children and whose husbands work full time, and also those that have appointments after school (as they work too) and have to bring the kids along as they have nobody else to mind them.
When the children are occupied and are behaving (or are tiny and sleeping in the pram!) this is no problem. However, when the children are misbehaving or need attention so they dont cry, the mothers are always having to lift their heads (majority are in for back pain) and are not relaxed at all during the session. This really stops the treatment from being totally effective and often means that the sessions run over time as the kids are often interrupting.
I suppose this situation probably cant be helped a lot of the time, and physios in private practice may find the same thing.
But i just thought i would put it out there - some children have frustrated me this week and i usually love kids! :)
On my current placement, i am finding that a lot of the clients bring their children along to appointments with them. This is mainly the ladies who have little children and whose husbands work full time, and also those that have appointments after school (as they work too) and have to bring the kids along as they have nobody else to mind them.
When the children are occupied and are behaving (or are tiny and sleeping in the pram!) this is no problem. However, when the children are misbehaving or need attention so they dont cry, the mothers are always having to lift their heads (majority are in for back pain) and are not relaxed at all during the session. This really stops the treatment from being totally effective and often means that the sessions run over time as the kids are often interrupting.
I suppose this situation probably cant be helped a lot of the time, and physios in private practice may find the same thing.
But i just thought i would put it out there - some children have frustrated me this week and i usually love kids! :)
Sunday 9 September 2007
psychological problems
hey guys- two for me today too!
I have an interesting patient at the moment that has what appears to be an ascending paralysis. On admission to hospital 3 months ago they were walking and now they are unable to even maintain static sitting as the paralysis has ascended up to their trunk. The doctors have tried every known test to try and determine the cause and they have absolutely no clue what is going on. The patient is obviously and understandably becoming more and more distressed, upset and frustrated and is now convinced that she has gone mad. And the patient is constantly asking me wether they will walk again or be able to look after their two young children again! I am finding it hard to answer- I mean I have just been saying that I don’t know because I don’t know the diagnosis! I just find it hard to treat a patient with such a prominent psychological element- because you just have to be so careful about what you say!
I have an interesting patient at the moment that has what appears to be an ascending paralysis. On admission to hospital 3 months ago they were walking and now they are unable to even maintain static sitting as the paralysis has ascended up to their trunk. The doctors have tried every known test to try and determine the cause and they have absolutely no clue what is going on. The patient is obviously and understandably becoming more and more distressed, upset and frustrated and is now convinced that she has gone mad. And the patient is constantly asking me wether they will walk again or be able to look after their two young children again! I am finding it hard to answer- I mean I have just been saying that I don’t know because I don’t know the diagnosis! I just find it hard to treat a patient with such a prominent psychological element- because you just have to be so careful about what you say!
NEURO AND BACK PAIN
Hi everyone
I just wanted to talk a little bit about Neuro placements and back pain. I don’t know about any one else but I am finding that no matter how hard I try to protect my back and get my supervisors to help me I still get a sore back at the end of the day. I try my hardest to always bend my knees and use my body weight and contract my TA’s. Especially when we are transferring people that are 3 times my body weight. I would really just love to use the hoist for all my patients! I just don’t know wether it is something that I have to accept! Any thoughts????
I just wanted to talk a little bit about Neuro placements and back pain. I don’t know about any one else but I am finding that no matter how hard I try to protect my back and get my supervisors to help me I still get a sore back at the end of the day. I try my hardest to always bend my knees and use my body weight and contract my TA’s. Especially when we are transferring people that are 3 times my body weight. I would really just love to use the hoist for all my patients! I just don’t know wether it is something that I have to accept! Any thoughts????
Friday 7 September 2007
Time
One major thing i find hard about private practice is sticking to time. My appointment times were 1hr initial and 30min follow-up, but are now 40min and 20min for the last two weeks of prac. The first couple of days i was running behind time by about 10mins but through the week i have managed to get close to finishing on time. I have found that the section which takes the longest for me is the S and O. Rx can be completed fairly efficiently because by then you have your head wrapped around what you are doing. Some pointers i have been given to get through S quickly are, if your pt starts to ramble, say you need to get something and leave the cubicle, as soon as you get back ask your next question. Remember though you need to be polite because if you are rude they wont come back no matter how good a physio you are. If people are rambling use leading questions to get them back on track, but begin with open questions so as not to limit the info they give. Get your head around the current history (ie: mechanism of injury, time frame etc) because this gives you the best idea of what may be going on. Then you can really focus in on asking appropriate questions for the remainder of the form. After S you should go into O with options of what is going on and one of those should be you "gut" feeling. This i find really speeds up your Ax because you have in your head exactly what structures are possibly affect and you can test and knock them of the list untill you get a +ve which you can run with. Anyone else got handy hints? From what i have been taught S is by far the most important section of your initial Ax and get that right and you can see pt in 40mins and 20mins.
Tuesday 4 September 2007
personal details
We are taught throughout our course that building rapport and trust with our patients is essential, and i certainly agree. As we see some of out pts on a very regular basis this trust can build naturally, however last week i found that some people were so comfortable that they confided in me more as a friend rather than their health professional.
2 pts i saw last week highlighted this; during a subjective with a 65yo man, simple questioning of hand numbness (as he previously had thoracic outlet syndrome) led him to tell me about his impotence problem and his current treatment to rectify this. He seemed to feel it was necessary to tell me even after i tried to move the conversation along. Another lady confided in me how she was a victim of domestic voiolence with her ex husband and started telling me all the horrible things that he had done to her in great detail. In both these cases i managed to change the conversation eventually, but in doing so felt like i might appear rude and uncaring.
I know i can change the subjective to more yes/no questions but thats not always appropriate. I guess i need to either learn to not be affected by patients' emotional problems, or not allow those conversations to happen in the first place. Has anyone else found it difficult in that fine line of being genuinely compassionate and caring and becoming someone patients' feel they can confide in?
2 pts i saw last week highlighted this; during a subjective with a 65yo man, simple questioning of hand numbness (as he previously had thoracic outlet syndrome) led him to tell me about his impotence problem and his current treatment to rectify this. He seemed to feel it was necessary to tell me even after i tried to move the conversation along. Another lady confided in me how she was a victim of domestic voiolence with her ex husband and started telling me all the horrible things that he had done to her in great detail. In both these cases i managed to change the conversation eventually, but in doing so felt like i might appear rude and uncaring.
I know i can change the subjective to more yes/no questions but thats not always appropriate. I guess i need to either learn to not be affected by patients' emotional problems, or not allow those conversations to happen in the first place. Has anyone else found it difficult in that fine line of being genuinely compassionate and caring and becoming someone patients' feel they can confide in?
Monday 3 September 2007
Safety and dischardge
Hi guys,
2 posts from me this week because I'm running a bit behind schedule!!I'm currently treating a lady who has been admitted for a blood clot in her right lower leg, but has a previous left hemiplegia. Medically she is ready for d/c but when the physio r/v'd her this morning they didn't think she was safe walking independently and needed close standby assistance. When I reviewed her later in the day she still needed standby assistance but on 1 occasion when she almost lost her balance, she stopped herself, had a short rest and then started walking again. Myself and one of the other physios were discussing that perhaps she may have been this unsteady on her feet before she came into hospital but it was difficult to tell and to make things more complicated she only speaks limited english!! We'll keep reviewing her until we think she is "safe" but how long can you do that for before you decide that she may have been like that before she came in? I think it would be a good idea to talk to the family but haven't seen any of them present as yet. Any thoughts?
2 posts from me this week because I'm running a bit behind schedule!!I'm currently treating a lady who has been admitted for a blood clot in her right lower leg, but has a previous left hemiplegia. Medically she is ready for d/c but when the physio r/v'd her this morning they didn't think she was safe walking independently and needed close standby assistance. When I reviewed her later in the day she still needed standby assistance but on 1 occasion when she almost lost her balance, she stopped herself, had a short rest and then started walking again. Myself and one of the other physios were discussing that perhaps she may have been this unsteady on her feet before she came into hospital but it was difficult to tell and to make things more complicated she only speaks limited english!! We'll keep reviewing her until we think she is "safe" but how long can you do that for before you decide that she may have been like that before she came in? I think it would be a good idea to talk to the family but haven't seen any of them present as yet. Any thoughts?
Not enough patients
Hey guys!
I'm finding on the prac I'm currently at, my supervisors are struggling to find enough patients for me. As it's my cardio prac treatment sessions don't take that long. I feel like the days that I don't have many patients, I generally feel i do "worse" because I'm not being pushed to be efficient. On the days I have lots of pts I work efficiently and my supervisor is really happy with what I do. I've asked my supervisor for a bigger caseload and she is doing the best that she can to give me lots of patients. How can I show my supervisor my strengths if I don't feel like i'm getting the chance to?
I'm finding on the prac I'm currently at, my supervisors are struggling to find enough patients for me. As it's my cardio prac treatment sessions don't take that long. I feel like the days that I don't have many patients, I generally feel i do "worse" because I'm not being pushed to be efficient. On the days I have lots of pts I work efficiently and my supervisor is really happy with what I do. I've asked my supervisor for a bigger caseload and she is doing the best that she can to give me lots of patients. How can I show my supervisor my strengths if I don't feel like i'm getting the chance to?
Handovers...
I just wanted to talk about patient handovers from physio's in perth hospitals to country physio's when a patient is discharged. being on my country placement, i just had a 20yr old guy come in 1 week post tibia fracture and stabilisation. he had been in hospital in perth (not mentioning any names!) for his op and we recieved a faxed referral from the physio that was treating him in hospital. all the referral said was his name, age, the actual injury and what surgery he underwent. i think that either the physio was very slack, or she just assumed that the patient would be able to pass on all the necessary info to me himself. when he came into see me with his mother, neither of them could tell me if he was supposed to be non or partial weight bearing, and also they had no other instructions as far as exercises went. he had been partial weight bearing as he had not been told otherwise (turned out he was non weightbearing for 6 wks!). The physio i am working with had to call this physio and ask her all the details, and basically told her how useless her handover was and that she expected better.
So i think the lesson learnt is for us all to make an effort with handover and referral summaries, as we cant expect the patients to remember (or be honest) about their instructions. I think it is also just curtesy to include as much info as we can so that we dont leave other physios with no understanding of our patient, or make more work for them.
So i think the lesson learnt is for us all to make an effort with handover and referral summaries, as we cant expect the patients to remember (or be honest) about their instructions. I think it is also just curtesy to include as much info as we can so that we dont leave other physios with no understanding of our patient, or make more work for them.
Knowledge Gap
It seems like on some placements we are expected to know or to find out more in-depth knowledge than what we have learnt from the course. And often we have been told by lecturer/tutors/future employers that critical thinking is an essential skill.
Critical thinking is quite difficult to be assessed in the traditional written exam. As anyone who is good at memorising literature is, in someway, able to spit out what's memorised.
I feel that by giving more score weightings on assignment type (i.e. to eloborate about a disease in-depth) to encourage to explore knowledge based on our curiosity (rather than what's dictated strictly by the marking criteria) would be more beneficial for the student. By giving more score weighting on this type assessment will also give the students the message that the university values our learning based on curiosity and critical thinking, but not route-learning or just about passing the exams.
What do you all think about this? or about current written assessment method and whether it help us to do well in 4th year placements?
Critical thinking is quite difficult to be assessed in the traditional written exam. As anyone who is good at memorising literature is, in someway, able to spit out what's memorised.
I feel that by giving more score weightings on assignment type (i.e. to eloborate about a disease in-depth) to encourage to explore knowledge based on our curiosity (rather than what's dictated strictly by the marking criteria) would be more beneficial for the student. By giving more score weighting on this type assessment will also give the students the message that the university values our learning based on curiosity and critical thinking, but not route-learning or just about passing the exams.
What do you all think about this? or about current written assessment method and whether it help us to do well in 4th year placements?
Sunday 2 September 2007
Supervisor impressions
Hello friends.
I would just like to share some difficulties that I am having with my neuro prac (surprise!). I have two patients, one a rather complex MCA stroke, and one with more cerebellar based problems. Every time my supervisor comes, I am treating the complex patient, and tend to get grilled about my observations, treatments, rationales etc. (The facility supervisor also mainly observes me with this pt.) My other patient, however, I am managing quite well with. I understand his problems, and all of my treatment sessions are going well. I think both my supervisors have an impression of me that is based solely on this patient which I struggle with, without seeing my more competent side.
Because a lot of this prac is quite new, and not covered in any depth at uni, I feel quite lost, especially with only four weeks to get my head around it and demonstrate competence. I've been doing a lot of study (but it's very different from practical observation and treatment skills) and have redone a SOAPIER that I am hoping will get a better reception on Monday than my last one.
Does anyone have any other suggestions to help me drag myself out the other end of this prac?
I would just like to share some difficulties that I am having with my neuro prac (surprise!). I have two patients, one a rather complex MCA stroke, and one with more cerebellar based problems. Every time my supervisor comes, I am treating the complex patient, and tend to get grilled about my observations, treatments, rationales etc. (The facility supervisor also mainly observes me with this pt.) My other patient, however, I am managing quite well with. I understand his problems, and all of my treatment sessions are going well. I think both my supervisors have an impression of me that is based solely on this patient which I struggle with, without seeing my more competent side.
Because a lot of this prac is quite new, and not covered in any depth at uni, I feel quite lost, especially with only four weeks to get my head around it and demonstrate competence. I've been doing a lot of study (but it's very different from practical observation and treatment skills) and have redone a SOAPIER that I am hoping will get a better reception on Monday than my last one.
Does anyone have any other suggestions to help me drag myself out the other end of this prac?
Experience
I am currently treating a pt who has a sore and stiff back which is constantly flairing up. He usually gets it cracked either by a physio or one of his mates on the mines. He is very worried that he will lose his job if they find out about his back so he asked that the treatment session be confidential. He is also very worried about missing work due to post treatment soreness which has happened with another physio. Due to this he asked if my supervisor could do the "cracking" rather than me. This is the first time this year that someone has asked if the supervisor could do it, which this time she could. If next time she is too busy to help how can i convince this pt that i am capable of doing it? I will try explaining to him what and how much time we spent covering this topic at uni and tell him that i have performed it on other pts and students countless times. What i would like from you guys is a back up plan if this doesn't work.
Saturday 1 September 2007
Dumb student and impatient supervisor
Hi All,
I am experiencing some difficulties in my placement and I am really frustrated at the moment:
My Curtin Supervisor came for mid-placement yesterday and it was the worst two hours I have so far. My supervisor has high expectation on student, for example: She expects student to know the effect and mechanism of every single drug on patient’s medicine chart.
I could only answer some of her questions and she was very impatient after a while. I was threatened and not motivated after the first hour. I confess my knowledge in neurology is limited but I do look up things which I don’t know. I tried hard to revise my neuro every night after clinic, but some skills (e.g. Observation) really come with experience.
I am planning to get some extra supervision next week and do you guys have some strategies to deal with this? I would love to hear your advice,thanks!
I am experiencing some difficulties in my placement and I am really frustrated at the moment:
My Curtin Supervisor came for mid-placement yesterday and it was the worst two hours I have so far. My supervisor has high expectation on student, for example: She expects student to know the effect and mechanism of every single drug on patient’s medicine chart.
I could only answer some of her questions and she was very impatient after a while. I was threatened and not motivated after the first hour. I confess my knowledge in neurology is limited but I do look up things which I don’t know. I tried hard to revise my neuro every night after clinic, but some skills (e.g. Observation) really come with experience.
I am planning to get some extra supervision next week and do you guys have some strategies to deal with this? I would love to hear your advice,thanks!
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