Today i decided to reflect on reflections, as we all know we are required to reflect formally on our work as physio's not only for our self benifit but also so that the university can prove that we are all able to professionally self evaluate. So.... how many of you go home after a day of work or clinic sit down to your partners/ family/ pets/ plants or whatever and say nothing. Myself personally I reflect on my day with both my partner and my family, lucky for me i have a mix of professionals between these groups of being medical and non medical so that i am able to get a multi-perspective reflection on whether my apporach with patients was justified, what i could do in order to improve my interaction / Rx (I dont suppose that this would happen if you just had to chat with a plant).
Nevertheless, i find it quite frustrating to then come up with 1 blog that sums up my whole week when all my interesting stories/ grieviences/ concerns have all been aired prior. As well as finding to for researching clinical presentations, assignments for research and PCR review i seem to have run out of time to scratch my self or catch up on my beloved sleep.... I guess this blog could be retitled Ryan is tired and grumpy.. why cant we just do clinic???
Ryan
Sunday, January 28, 2007
Life is so Unexpected
Mr X is a 56y.o. and was admitted to hospital for urinary tract infection (UTI).
A few days after admission, Mr X was referred for physiotherapy for administration of BiPAP. According to the doctors, he had sustained a stroke during the stay in the hospital and the stroke resulted in him having difficulty in breathing. BiPAP was to help to decrease his work of breathing and to normalise his ABGs. Mr X tolerated BiPAP well and was weaned off the machine two days later.
However, things didn’t go well and he was back on the BiPAP the next day (Friday). His GCS score had decreased once again and the doctors suspected that he was most likely to have had another stroke. They are not able to come up with a definite diagnosis as the CT scan knows no signs of an infarct.
After the weekend, I was back to the hospital again and got to know that Mr X had passed away the night before, due to ?cardiac arrest. It was really shocking. A man who was just admitted for a minor problem of UTI, his status had declined so drastically to the point of death. Life is so unexpected. I spoke to the nurse taking care of Mr X. She told me she had learnt not to get too emotional with patients. It is important to build a good rapport with patients and do our best for them. However, it is also important not to get too emotional. If not, when incidents like this happen, it would affect our work and thus affect other patients.
For our profession, this is definitely an issue we would face in the future. I am glad that I experienced it now and learnt from it so that I know how to deal with it in the future.
A few days after admission, Mr X was referred for physiotherapy for administration of BiPAP. According to the doctors, he had sustained a stroke during the stay in the hospital and the stroke resulted in him having difficulty in breathing. BiPAP was to help to decrease his work of breathing and to normalise his ABGs. Mr X tolerated BiPAP well and was weaned off the machine two days later.
However, things didn’t go well and he was back on the BiPAP the next day (Friday). His GCS score had decreased once again and the doctors suspected that he was most likely to have had another stroke. They are not able to come up with a definite diagnosis as the CT scan knows no signs of an infarct.
After the weekend, I was back to the hospital again and got to know that Mr X had passed away the night before, due to ?cardiac arrest. It was really shocking. A man who was just admitted for a minor problem of UTI, his status had declined so drastically to the point of death. Life is so unexpected. I spoke to the nurse taking care of Mr X. She told me she had learnt not to get too emotional with patients. It is important to build a good rapport with patients and do our best for them. However, it is also important not to get too emotional. If not, when incidents like this happen, it would affect our work and thus affect other patients.
For our profession, this is definitely an issue we would face in the future. I am glad that I experienced it now and learnt from it so that I know how to deal with it in the future.
Tempting
Almost there in Neuro placement at Bentley. It is very tempting with time constraints to not assess everything in a Neuro Ax. There is obviously so much to do. I have a had a couple of patients where doing a full Ax and getting information I didn’t think I would do that much with has been turned out to be important. Pt presented TIA? No evidence on investigation. Reduced right sided upper limb voluntary control and diminished light touch and possibly proprioception. Expressive aphasia. Receptive ok. Pt was improving on the ward, main issues were balance unrelated to the TIA? and Gowland 4 arm. Over a period of a few days, aphasia was improving and arm improved to Gowland 5 with minimal PT as pt had refused. So all was going smoothly, good recovery was occurring. I had done a full Gowland on the pts arms as well as most of the rest of the Neuro Ax. The next day pt appears and verbalises he is unwell, aphasia is worse/same but arm has reduced obviously back to Gowland 4. The bells start ringing! Had a chat with my supervisor who suggested a chat with the RMO. As it turns out it was useful information for them as they were currently querying the possibility of another TIA. So in short, if I didn’t assess it, I couldn’t have reassessed it and I wouldn’t have had an objective measure telling me the pt was going backwards. In short I learned don’t cut corners, you never know what info you will need.
Agree to disagree
Hello all,
I have seen a lot of very complicated surg patients this week, in the ICU and on the ward. Have had a chance to do some manual hyperinflation and some suctioning, a neuro assessment on my day 2 CABG patient who had a stroke and a look at surgical emphysema.
Following my mid-placement assessment i asked to see some medical (COPD) patients as our CCT said they would be good for the PCR. I was given an end stage COPD patient admitted with a chronic exacerbation who I saw with the CCT. He was a textbook patient with all the usual problems: dyspnoea, airflow limitation, decreased ex tolerance. O/E widespread expiratory polyphonic wheeze, sats 88-90% fixed upper resp breathing pattern... you get the idea. Someone I thought could really have benefited from physio.
Well when i got to the treatment (breathing control, ACBT, amb etc) he let me know in no uncertain terms how useless “huffing and puffing’ was and that every physio in the last 25 years had tried the same treatment to no avail. I persevered, had him go for a walk then asked him to show me how he recovered from his dyspnoea. I suggested some fixed forward lean positions which he declined to try, but I did notice he was already pursed lip breathing and recovering quite well.
Following the treatment his sats were up to 96% and he was reporting less SOB, his wheeze was significantly quieter too. The frustrating part about this session was that by all objective signs my treatment had made a difference, but my patient refused to acknowledge this change, continuing to believe that physio could not help him. I have to admit, at the beginning of the session I was almost in agreeance with him, what could I offer him that someone else had not already tried? I guess just having confidence in your treatment and approaching this patient not claiming to cure or solve all his problems, but maybe just to offer some suggestions on how best to manage can be helpful. any comments on similar experiences would be appreciated!
I have seen a lot of very complicated surg patients this week, in the ICU and on the ward. Have had a chance to do some manual hyperinflation and some suctioning, a neuro assessment on my day 2 CABG patient who had a stroke and a look at surgical emphysema.
Following my mid-placement assessment i asked to see some medical (COPD) patients as our CCT said they would be good for the PCR. I was given an end stage COPD patient admitted with a chronic exacerbation who I saw with the CCT. He was a textbook patient with all the usual problems: dyspnoea, airflow limitation, decreased ex tolerance. O/E widespread expiratory polyphonic wheeze, sats 88-90% fixed upper resp breathing pattern... you get the idea. Someone I thought could really have benefited from physio.
Well when i got to the treatment (breathing control, ACBT, amb etc) he let me know in no uncertain terms how useless “huffing and puffing’ was and that every physio in the last 25 years had tried the same treatment to no avail. I persevered, had him go for a walk then asked him to show me how he recovered from his dyspnoea. I suggested some fixed forward lean positions which he declined to try, but I did notice he was already pursed lip breathing and recovering quite well.
Following the treatment his sats were up to 96% and he was reporting less SOB, his wheeze was significantly quieter too. The frustrating part about this session was that by all objective signs my treatment had made a difference, but my patient refused to acknowledge this change, continuing to believe that physio could not help him. I have to admit, at the beginning of the session I was almost in agreeance with him, what could I offer him that someone else had not already tried? I guess just having confidence in your treatment and approaching this patient not claiming to cure or solve all his problems, but maybe just to offer some suggestions on how best to manage can be helpful. any comments on similar experiences would be appreciated!
Vigilance at all times!!
Having thought about a range of topics this week I thought I’d chat about a particular patient who had an interesting, and encouraging story to tell in which a physio played a significant role.
This patient is a 48 year old man who I went to see post an Ivor Lewis procedure (done for cancer of the oesophagus) to perform a respiratory assess and treat accordingly. The second day or so we of course went walking, and in one of his breaks we were chatting and it came out that the only reason his ca had been diagnosed was because of a PT. He had hurt his shoulder at work earlier in the year and was going to a PT for that, who then wanted to start him on a gym/strengthening programme. The PT was concerned about his recent weight loss (10kg in a year) and referred him back to the GP. The GP said “it’s all ok” and carry on with treatment….but the PT referred him onto another GP who did a endoscopy and…yes he had very advanced Ca.
I found this story amazing in that not only did the PT pick it up, but persevered with getting it checked out despite one dct giving the man the all clear, and now this guy will probably live longer etc because of that. I suppose for me it hugely reinforced all we were taught in Musculo regarding special questions, and gave me a bit of a fright in that literally someone’s life can be changed due to our vigilance as physios, even for the supposedly simple shoulder presentation that arrives in our clinic. So vigilance, and confidence in our own assessment of the individual is the thought for the week!!
Saturday, January 27, 2007
We are all Magicians!
The magic of hands indeed!
Third week in, and one thing that I and my fellow colleagues am starting to notice when treating patients is something as simple as STM/mobs can decrease symptoms by half. Your probably thinking, yeah DUH!
Here is one example. A patient presents with Lx pain with bilateral buttocks pain (somatic referral), with the main aggravating factors being standing and walking. Pain levels range from 1-7/10, but it is mainly stiffness that is the main complaint.
All movements are restricted, with R SF, L rot, ext, and combined R SF/ext producing the pain in the R Lx area, so a typical ‘closing’ pattern.
My treatment has consisted of left rotation PPIVM in slight R SF (due to low irritability) of L3-S1, STM of bilateral ES, and HEP consisting of ROM exercises and PF/TA/MF act/endurance.
This pt leaves feeling fantastic with less stiffness/pain with walking and standing and is on ‘cloud 9’.
Here are my thoughts, let me know what you think.
Firstly, something as simple as 3 mins STM can decrease the Sx and promote correct movement, the gift of ‘touch’!
Secondly, and maybe a bit out there, BUT, when we mobilize (as in PPIVMS), I am starting to think that, at the symptomatic level, there is a BIGGER part in the spinal gate model, which decreases the pain. I understand that we are also mobilizing the soft tissue and joint, however, I think that the spinal gate model may attribute more to the pain relief than we think, which then promotes correct movement.
Here’s to the healing hands!
Third week in, and one thing that I and my fellow colleagues am starting to notice when treating patients is something as simple as STM/mobs can decrease symptoms by half. Your probably thinking, yeah DUH!
Here is one example. A patient presents with Lx pain with bilateral buttocks pain (somatic referral), with the main aggravating factors being standing and walking. Pain levels range from 1-7/10, but it is mainly stiffness that is the main complaint.
All movements are restricted, with R SF, L rot, ext, and combined R SF/ext producing the pain in the R Lx area, so a typical ‘closing’ pattern.
My treatment has consisted of left rotation PPIVM in slight R SF (due to low irritability) of L3-S1, STM of bilateral ES, and HEP consisting of ROM exercises and PF/TA/MF act/endurance.
This pt leaves feeling fantastic with less stiffness/pain with walking and standing and is on ‘cloud 9’.
Here are my thoughts, let me know what you think.
Firstly, something as simple as 3 mins STM can decrease the Sx and promote correct movement, the gift of ‘touch’!
Secondly, and maybe a bit out there, BUT, when we mobilize (as in PPIVMS), I am starting to think that, at the symptomatic level, there is a BIGGER part in the spinal gate model, which decreases the pain. I understand that we are also mobilizing the soft tissue and joint, however, I think that the spinal gate model may attribute more to the pain relief than we think, which then promotes correct movement.
Here’s to the healing hands!
Not quite a textbk case scenario
Howdie. Another week has gone by.
I’m going to keep my blog short this week so it will be more appealing to read.
This week I got to see this patient together with my supervisor. This pt, Mrs H, has got a subarachnoid haematoma in the frontal area. The first day we saw her, she was really drowsy and doped from the medications. She had difficulty performing on commands and her initiation to tasks are poor (e.g. rolling on her side). From observation, she seemed to have inattention to the left. We helped to sit her up and it was obvious that she had some perceptual issues. In sitting, she was leaning backwards as well as to the left. She was a “pusher” (i.e. pushing to the left), so the only way to correct her sitting alignment was to facilitate her to reach to the right as well as forward.
On the 2nd day that I saw her, she was more alert and she could follow commands better. She was also more attentive. Her sitting alignment was slightly better but was still leaning to the left and backwards. After a few repetitions of forwards and right lateral reaching, we managed to get an upright sitting posture. Then, my supervisor decided to try to stand her up. To our surprise, while standing, she did not lean to the left like we would have expected her to. She leaned significantly to the right instead. She couldn’t maintain upright due to her poor hip extensors strength as well as Quads strength and they had to be supported. My supervisor also thinks that she maybe weaker on her Right LL, as she was buckling more on the Right, thus probably the reason that she’s leaning to the ®.
On the 3rd day, I actually wanted to have a closer look at Mrs H, in terms of tone, strength and sitting & standing alignment. However, Mrs H was to be transferred to a rehabilitation hospital. Such a pity I couldn’t explore more to this interesting presentation. Has anyone ever come across such case scenarios? To give me some light on this?
Anywaez, hope everyone had a nice long weekend! One more week to go!
I’m going to keep my blog short this week so it will be more appealing to read.
This week I got to see this patient together with my supervisor. This pt, Mrs H, has got a subarachnoid haematoma in the frontal area. The first day we saw her, she was really drowsy and doped from the medications. She had difficulty performing on commands and her initiation to tasks are poor (e.g. rolling on her side). From observation, she seemed to have inattention to the left. We helped to sit her up and it was obvious that she had some perceptual issues. In sitting, she was leaning backwards as well as to the left. She was a “pusher” (i.e. pushing to the left), so the only way to correct her sitting alignment was to facilitate her to reach to the right as well as forward.
On the 2nd day that I saw her, she was more alert and she could follow commands better. She was also more attentive. Her sitting alignment was slightly better but was still leaning to the left and backwards. After a few repetitions of forwards and right lateral reaching, we managed to get an upright sitting posture. Then, my supervisor decided to try to stand her up. To our surprise, while standing, she did not lean to the left like we would have expected her to. She leaned significantly to the right instead. She couldn’t maintain upright due to her poor hip extensors strength as well as Quads strength and they had to be supported. My supervisor also thinks that she maybe weaker on her Right LL, as she was buckling more on the Right, thus probably the reason that she’s leaning to the ®.
On the 3rd day, I actually wanted to have a closer look at Mrs H, in terms of tone, strength and sitting & standing alignment. However, Mrs H was to be transferred to a rehabilitation hospital. Such a pity I couldn’t explore more to this interesting presentation. Has anyone ever come across such case scenarios? To give me some light on this?
Anywaez, hope everyone had a nice long weekend! One more week to go!
Friday, January 26, 2007
Referred pain
This week, a patient with sharp pain behind her left eye. This patient had a history of cervicogenic headaches that had responded well to physio treatments. This presentation was without neck pain or pain on the sides or over the back of the skull, just behind the eye. Slightly limited AROM into R SF and R rotation otherwise NAD. PPIVMS detected hypomobility at C4 on both sides and PAIVMS were P2 limited at C2, C3, C4 some unilaterals as well. Palpation was ++ tight upper traps, LS, scalenes and SCM. No active or passive testing so far had reproduced symptoms. I had a student with me who asked to palpated SCM, doing TPs along the muscle produced intense pain however not until approaching the bottom third did the pain in the eye start. Here we are a trigger point reproducing the exact pain the patient is complaining of.
So off we went to report the objective, soft tissue the main concern, tick, what will we treat, the soft tissue – but not SCM!! The reason being it is in the anterior triangle where all the vessels and nerves are. Indirect treatment by loosening the U.T.s, LS and posterior structures will help? Ahhh but the SCM reproduces the pain! So off I went treated the posterior structures, yes improved ROM, pt felt better, I bid her farewell with some SCM and Cx stretches feeling horrible as I am sure she will again suffer her eye pain.
So here is a dilemma, well not really, I have learnt that SCM can refer to behind the eye, there are indirect ways to treat it, hold relax, stretches, posture repositioning and if I am asked in the PCR to treat the anterior of the neck I will say no that is contraindicated or at least an area of high caution which should be avoided.
You can turn the patient’s head to the side in supine, support their head with one hand and with the other pick up SCM between your thumb and fingers to perform TPs without fear of compromising the neurovascular structures I believe.
So off we went to report the objective, soft tissue the main concern, tick, what will we treat, the soft tissue – but not SCM!! The reason being it is in the anterior triangle where all the vessels and nerves are. Indirect treatment by loosening the U.T.s, LS and posterior structures will help? Ahhh but the SCM reproduces the pain! So off I went treated the posterior structures, yes improved ROM, pt felt better, I bid her farewell with some SCM and Cx stretches feeling horrible as I am sure she will again suffer her eye pain.
So here is a dilemma, well not really, I have learnt that SCM can refer to behind the eye, there are indirect ways to treat it, hold relax, stretches, posture repositioning and if I am asked in the PCR to treat the anterior of the neck I will say no that is contraindicated or at least an area of high caution which should be avoided.
You can turn the patient’s head to the side in supine, support their head with one hand and with the other pick up SCM between your thumb and fingers to perform TPs without fear of compromising the neurovascular structures I believe.
Thursday, January 25, 2007
Week 3 - Schizophrenia (me or the pt you might ask?)
G'day,
Definately an interesting patient set this week! The patient about whom this blog is about is a 66yr old female with an admit diagnosis of R sided pneumonia. Her very relevant background Hx includes Schizo-Afflictive disorder. I was lucky enough to be given this, oh how shall I say....hmm "charming" lady for an assessment this wk. She was admitted the previous evening, had been refusing any treatment - namely 02 therapy - with Sp02 dropping to 57%. However some marvellous nurse had finally managed to get her to accept sometime before my visit. I was a little anxious reading her notes.....and readied myself a bit like I was preparing for combat. It was a pleasant surprise that she was quite calm and was able to reasonably answer my questions, even have a feel of chest expansion and auscultate a few ant aspects of her chest. Then all of a sudden the storm clouds rolled in. She became very angry and yelling for us to leave (perhaps a few insults thrown in for good measure...). So realizing the time had expired on our meter, I(we) retreated. Returning later on I met with the same resistance. There was no way I could even get her to position herself so a bit of drainage might occur. Patient very febrile and lotsa secretions. Tried later on - no way! The next day I was asked to do an induced sputum. I think the farthest I got was setting it all up. I attempted 5 times that day - obviously going to settle for even clearance from a cough without the induced sputum method.
I will spare you all my different ways of approaching this situation, but it is a little frustrating obviously from a communication point of view but also due to the fact that she could really use some physio! What I have noticed about this lady is that she is generally very calm and compliant (sort of) for the first 3-5 min that you are in the room and then it is like a button is pushed and she goes off. I guess this is the first Schizo disorder I have had to interact with in such a way and therefore do not know if there are any 'tricks' for dealing with these individuals. As I will likely be seeing her again this coming week, if anyone has had experience and could offer me an tips that would be great.
Definately an interesting patient set this week! The patient about whom this blog is about is a 66yr old female with an admit diagnosis of R sided pneumonia. Her very relevant background Hx includes Schizo-Afflictive disorder. I was lucky enough to be given this, oh how shall I say....hmm "charming" lady for an assessment this wk. She was admitted the previous evening, had been refusing any treatment - namely 02 therapy - with Sp02 dropping to 57%. However some marvellous nurse had finally managed to get her to accept sometime before my visit. I was a little anxious reading her notes.....and readied myself a bit like I was preparing for combat. It was a pleasant surprise that she was quite calm and was able to reasonably answer my questions, even have a feel of chest expansion and auscultate a few ant aspects of her chest. Then all of a sudden the storm clouds rolled in. She became very angry and yelling for us to leave (perhaps a few insults thrown in for good measure...). So realizing the time had expired on our meter, I(we) retreated. Returning later on I met with the same resistance. There was no way I could even get her to position herself so a bit of drainage might occur. Patient very febrile and lotsa secretions. Tried later on - no way! The next day I was asked to do an induced sputum. I think the farthest I got was setting it all up. I attempted 5 times that day - obviously going to settle for even clearance from a cough without the induced sputum method.
I will spare you all my different ways of approaching this situation, but it is a little frustrating obviously from a communication point of view but also due to the fact that she could really use some physio! What I have noticed about this lady is that she is generally very calm and compliant (sort of) for the first 3-5 min that you are in the room and then it is like a button is pushed and she goes off. I guess this is the first Schizo disorder I have had to interact with in such a way and therefore do not know if there are any 'tricks' for dealing with these individuals. As I will likely be seeing her again this coming week, if anyone has had experience and could offer me an tips that would be great.
Sunday, January 21, 2007
Dizzy patient
Musculo outpatients:
Week 2, I was presented with a young lady in her 20’s who said the world was swaying and she felt unsteady on her feet – this had been the case for the last 2 weeks. Being a scientist herself she had been mapping the symptoms but could not find a pattern at all, it could last for 30-60 min or more with no known aggravating factors. Sometimes when she was walking, sitting, standing, it was not relieved by lying down or being still. The patient had continued to play netball and volleyball and when dizziness came on she continued. After a couple of episodes where she felt she was going to fall over and then not falling, she now continues to walk, or play believing she will not actually fall.
She had been to see a Dr who said it wasn’t anything in her inner ear and was most likely the muscles in her neck – one side tighter than the other giving different proprioceptive feedback to the brain so one side indicates movement and the other not – the confused brain suggests the ground or the person is swaying!
On hearing all this I thought I would check her vestibular system and vertebral artery in addition to a Cx objective and go on from there. All were negative, I couldn’t make the already present mild symptoms worse or better.
AROM – ↓ lateral flexion R>L, flexion and a slight decrease in rotation. Pt reports always had a ↓ in flexion, has AS however managed well and in remission at present.
PPIVMS – nothing unusual, PAIVMS – tender C3 mainly also C2 and C4 centrally and R uni-laterals.
Palpation – tight upper traps, LS, scalenes, occipital insertion – nuchal line.
With such marked muscle tightness I treated with STM for 10-15 min in hope to reduce some of the tension and see if symptoms changed. When I had finished and the patient sat up from prone she felt much worse so suggested the chair with back and arms so she could hang on. After 5 min the symptoms had returned to pre Rx levels. The AROM had improved and the patient reported feeling much better – even though symptoms still present! Supervisor said the symptoms may get worse before getting better.
I am eager to see my patient tomorrow to see if my Rx had a good, bad or no effect on her symptoms.
I was not aware that tight musculature in the Cx region could make someone dizzy, my supervisor says it is possible so we will see if in this case it is true or otherwise have to refer back to the Dr for further investigation.
Week 2, I was presented with a young lady in her 20’s who said the world was swaying and she felt unsteady on her feet – this had been the case for the last 2 weeks. Being a scientist herself she had been mapping the symptoms but could not find a pattern at all, it could last for 30-60 min or more with no known aggravating factors. Sometimes when she was walking, sitting, standing, it was not relieved by lying down or being still. The patient had continued to play netball and volleyball and when dizziness came on she continued. After a couple of episodes where she felt she was going to fall over and then not falling, she now continues to walk, or play believing she will not actually fall.
She had been to see a Dr who said it wasn’t anything in her inner ear and was most likely the muscles in her neck – one side tighter than the other giving different proprioceptive feedback to the brain so one side indicates movement and the other not – the confused brain suggests the ground or the person is swaying!
On hearing all this I thought I would check her vestibular system and vertebral artery in addition to a Cx objective and go on from there. All were negative, I couldn’t make the already present mild symptoms worse or better.
AROM – ↓ lateral flexion R>L, flexion and a slight decrease in rotation. Pt reports always had a ↓ in flexion, has AS however managed well and in remission at present.
PPIVMS – nothing unusual, PAIVMS – tender C3 mainly also C2 and C4 centrally and R uni-laterals.
Palpation – tight upper traps, LS, scalenes, occipital insertion – nuchal line.
With such marked muscle tightness I treated with STM for 10-15 min in hope to reduce some of the tension and see if symptoms changed. When I had finished and the patient sat up from prone she felt much worse so suggested the chair with back and arms so she could hang on. After 5 min the symptoms had returned to pre Rx levels. The AROM had improved and the patient reported feeling much better – even though symptoms still present! Supervisor said the symptoms may get worse before getting better.
I am eager to see my patient tomorrow to see if my Rx had a good, bad or no effect on her symptoms.
I was not aware that tight musculature in the Cx region could make someone dizzy, my supervisor says it is possible so we will see if in this case it is true or otherwise have to refer back to the Dr for further investigation.
Analysis and Plan
I’m still on Neuro placement and starting to bring it together. From an early stage I think we all got a little frustrated with the expectation of a long analysis/problem list and plan whatever placement we were on. As we started to go through clinics we saw the time pressures and the amount of time PT’s had to write notes and thought “how could they possibly write a full A and P like we are expected to”. Well they have probably done A and P lists so many times its automatic in their head. This is what my supervisor suggested would be the case for most PT’s. In the last couple of weeks I have realised that after you have written a few A and P lists for one of the particular core areas it does come more planned in your mind. So I have found the continual requests to write full SOAPIER’s initially frustrating but also very helpful. I have found that it makes my treatment sessions more focused and efficient because I have my goals for the session very clear. So hopefully some others can appreciate the inconvenience as I have but are also able to see the benefits.
Communication is the Key to Success
Dear all,
It is now two weeks into my cardiopulmonary placement. I am starting to get the hang of everything but occasionally, I still have difficulty carrying out my treatment with some patients.
Mr X is a 70 year old/Male is having end stage renal failure and COPD and suffering from depression. He was admitted due to chest infection and thus referred for physiotherapy.
He SOOB in chair all day and refuses to do anything except to the shower. For the last two days, I have been trying to get him to do some UL and LL exercises but it just didn’t work. He commented that he knew doing exercises was good for him and he would do it when he is ready. I persisted and tried again to get him to do some exercises. This time round, he got very agitated and chased me out of the room. I was disappointed with myself for not being able to get the patient to do anything.
Today, I tried a different technique and it worked. Instead of telling the patient: “Mr X, I am going to get you to do some exercises”, I told him: “I am not going to get you to do much. I am here to just have a look at how you are sitting to standing, and to see how’s the movement in your arms and legs.” The patient finally got up from the chair, did some shoulder flexion exercises and also some knee extension in sitting. Although the patient did only one STS, it was very encouraging for me. If I had thought about this trick few days’ back, I could have gotten him to do more and definitely able to get more air into his lungs.
It is all about playing with words and changing the way I communicate with the patient. Having good communication is such an important asset in our profession and I will try different ways of talking to my patients till they start to get moving. I will try the trick again tomorrow with Mr X and hope it still works. If not, I just have to keep on trying.
Do any of you having any ideas of how to get my patients off that chair?? Thanks!!
It is now two weeks into my cardiopulmonary placement. I am starting to get the hang of everything but occasionally, I still have difficulty carrying out my treatment with some patients.
Mr X is a 70 year old/Male is having end stage renal failure and COPD and suffering from depression. He was admitted due to chest infection and thus referred for physiotherapy.
He SOOB in chair all day and refuses to do anything except to the shower. For the last two days, I have been trying to get him to do some UL and LL exercises but it just didn’t work. He commented that he knew doing exercises was good for him and he would do it when he is ready. I persisted and tried again to get him to do some exercises. This time round, he got very agitated and chased me out of the room. I was disappointed with myself for not being able to get the patient to do anything.
Today, I tried a different technique and it worked. Instead of telling the patient: “Mr X, I am going to get you to do some exercises”, I told him: “I am not going to get you to do much. I am here to just have a look at how you are sitting to standing, and to see how’s the movement in your arms and legs.” The patient finally got up from the chair, did some shoulder flexion exercises and also some knee extension in sitting. Although the patient did only one STS, it was very encouraging for me. If I had thought about this trick few days’ back, I could have gotten him to do more and definitely able to get more air into his lungs.
It is all about playing with words and changing the way I communicate with the patient. Having good communication is such an important asset in our profession and I will try different ways of talking to my patients till they start to get moving. I will try the trick again tomorrow with Mr X and hope it still works. If not, I just have to keep on trying.
Do any of you having any ideas of how to get my patients off that chair?? Thanks!!
Communication
Hello all, I have had an interesting second week of prac.
A few experiences have stood out above the others.
One such instance was when I went to treat a Croatian lady in her late eighties who was day one post Laparotomy plus small bowel resection. I read her notes which were brief as she did not speak English well and proceeded to plan my treatment. My plan was to ask the usual subjective questions, assess her chest and obs, teach some ACBT and supported cough and if all was going well ambulate.
When I got to the patient however, it was quite a different scenario all together. Luckily an interpreter had been booked as the lady didn’t understand any English and was feeling very frightened and frustrated. This was the first time she had ever been in a hospital and could not understand why after having the surgery she wasn’t completely better? Everything was completely foreign to her, she was terrified at the beeping of the IV or Feed as she thought something was going wrong with her. She also didn’t understand why she couldn’t eat or go to the toilet (IDC). She likened the last 24 hours to being held in an isolation cell.
As it turned out this was the first chance the patient had to properly communicate with the health and medical staff. A lot of my planned treatment was spent explaining and reassuring her that she was doing well and that some pain/dizziness is normal following surgery. I struggled however, to explain through the interpreter the idea of ACBT and a supported cough. The patient argued that it was her stomach that was the problem not her lungs, and she refused to cough as she didn’t feel she needed to.
All this just got me thinking about how I would feel if I was the patient in a foreign country where I didn’t speak the language, all sorts of attachments and someone coming in and telling me to cough and purposely increase my pain? It just made me realise that treatments which seem so normal to us can seem quite unusual to our patients without good communication.
A few experiences have stood out above the others.
One such instance was when I went to treat a Croatian lady in her late eighties who was day one post Laparotomy plus small bowel resection. I read her notes which were brief as she did not speak English well and proceeded to plan my treatment. My plan was to ask the usual subjective questions, assess her chest and obs, teach some ACBT and supported cough and if all was going well ambulate.
When I got to the patient however, it was quite a different scenario all together. Luckily an interpreter had been booked as the lady didn’t understand any English and was feeling very frightened and frustrated. This was the first time she had ever been in a hospital and could not understand why after having the surgery she wasn’t completely better? Everything was completely foreign to her, she was terrified at the beeping of the IV or Feed as she thought something was going wrong with her. She also didn’t understand why she couldn’t eat or go to the toilet (IDC). She likened the last 24 hours to being held in an isolation cell.
As it turned out this was the first chance the patient had to properly communicate with the health and medical staff. A lot of my planned treatment was spent explaining and reassuring her that she was doing well and that some pain/dizziness is normal following surgery. I struggled however, to explain through the interpreter the idea of ACBT and a supported cough. The patient argued that it was her stomach that was the problem not her lungs, and she refused to cough as she didn’t feel she needed to.
All this just got me thinking about how I would feel if I was the patient in a foreign country where I didn’t speak the language, all sorts of attachments and someone coming in and telling me to cough and purposely increase my pain? It just made me realise that treatments which seem so normal to us can seem quite unusual to our patients without good communication.
The unusal presentation
Hi guyz,
I’m in my 2nd week of neuro placement. I have a patient that I thought would be interesting to share about. So the information is as follows…
PHx: Was hit by an object in the face. A few days later presented with fluid coming out from the ears and had a salty taste down the back of throat. Saw GP--> CT head= cribriform plate #--> immediately admitted to the hospital. Stayed in hospital for 4 days-->NAD-->flown back home. Suffered severe headache & occ rhinorrhea still and worsening of gait and coordination. Has pre-existing symptoms of ® UL& LL hemiparesis, sensory deficits & ataxic gait.
PMHx: in ’05, first episode of severe headache. Began with fooginess of ® eye-->® cervico-occipital headache which radiated to frontotemporal region, lasted 2hrs. Was diagnosed with migraine. Has nil previous hx of migraine or family hx of migraine. 2nd similar episode in early ’06, but this time was assoc with ® hemiparesis & sensory deficits. Deficits never resolved. In all, had 4 episodes last yr. Nil neuro diagnosis was ever made.
SHx: lives alone. Works underground, was able to continue working despite deficits as was able to "hide" them.
Inx: MRI Cranial/ spinal cord—nad; CT head—nad; Lx puncture—nad, just ↑glucose of CSF; Indium scan: nil CSF leakage
S/E: c/o pre-exisitng weakness & sensory loss & clumsiness with gait got worse when was flown back home. Has increase headache with movements of limbs. Headache =6-8/10
O/E:
· CN III, IV, VI — nad. Eyes tracking√
· Gowlands stage of recovery— ®arm: stage 5; hand: stage4; leg: stage 5; foot: stage 4
· Ms strength— UL: ® Gr 3-4; (L) Gr 4-4+
LL: ® Gr 3-3+; (L) Gr 4-4+
(Had increase in headache with mvts of limbs, ? true strength)
· Sensation—Light touch: UL: ® ↓↓ palmer> dorsum of hand. ↓ lateral aspect> medial aspect of hand/ forearm/ arm (i.e. feels more on C8, T1 dermatomes). (L)↓ palmer surface of hand.
LL: ® plantar surface nil sensation. ↓on dorsum of foot. ↓ant surface> post surface of lower leg/ thigh (i.e. feels more on L5, S1, S2 dermatomes). (L) ↓plantar> dorsum surface of foot.
Sharp/blunt: ® UL& LL: absent. (L) UL/LL: ↓ (5/10)
Joint position/ jt mvt sense: ® big toe/ ankle—able to det mvt but not direction. (L) big toe/ankle—able to det mvt. Direction 6/10. very slow response. Knee & hip jts not tested yet.
· Sitting posture: slightly W.B on (L)> ®
· Sitting Balance: Static √
Dynamic—Int disp: √ ; Ext disp: slight ↑ resistance when disp to the ®. Efficient saving response. Safe in static & dynamic sitting.
· Standing posture: slight W.B (L)> ®. Tunk tone (L)=®
· Standing Balance: Int disp: slight ↓ to ®. AP/PA√. Tend to overestimates ability but able to recognize when told abt safety.
Ext disp: uses a stepping response for slow & fast disp. (i.e. when disp to ®, ® foot steps out to the ® instead of (L) foot crossing over to take a step to the right).
Safe in standing, static & dynamic.
· Balance: feet tog, EO=30s; EC=5s
Sharpened Rhomberg, EO, (L) fwd= 8s, ® fwd= 11s
SLS, EO, (L)=25s, ®=5s
· Gait: -↓ ® heel strike on initial contact
-® knee hypertext during loadingà mid-stance
-↓ hip E during mid stanceà toe off
-↓wt transfer (pelvis lat shift) during mid-stanceà toe-off
-↓ knee F when hip in E during swing phase
So far, what I’ve been able to do is part Ax with the patient each session as I did not want to aggravate his headache too much.
With no neuro diagnosis to be made and with a unique presentation of sensory loss deficits (e.g. deficits of L5,S1, S2 more than L1,2,3; deficits on bilateral limbs), I was quite thrown away by that. Besides, the weakness presented does not match the deficits in sensation. According to my supervisor, the presentation of the patient is unusual. The stepping response during external displacement in standing is also not the norm. She suggested for me to keep these unusual presentation at the back of my head and not to worry too much about it. She advised me to just address the problems like I’ve been taught to, and with more experience in future, I would be able to recognise the abnormal from the norm.
So I’ve been trying to put those doubts aside first & deal with the problems that I can address first. I’ve been working (2 sessions) on weight transference in standing, as well as gait re-edu. I’ve also gave pt some ex’s to improve vol. mvts e.g. DF with knee extension fr 90deg flx to 0deg ext. Pt appeared to have better gait (↑ heel strike) after each session. However, my supervisor thinks it is unusual for the pt to have that much of an improvement after each session.
Thoughts for this week: it is a skill to note the subtleness of abnormality from the normality, the unusual fr the usual. How do we know how much can the patient improve and if it is unusual or not?
Anyone has any thoughts with regards to Ax/ analysis/ Rx of this pt?
Sorry about the long blog. Hope I didn’t confuse anyone.
Have a great week ahead!
I’m in my 2nd week of neuro placement. I have a patient that I thought would be interesting to share about. So the information is as follows…
PHx: Was hit by an object in the face. A few days later presented with fluid coming out from the ears and had a salty taste down the back of throat. Saw GP--> CT head= cribriform plate #--> immediately admitted to the hospital. Stayed in hospital for 4 days-->NAD-->flown back home. Suffered severe headache & occ rhinorrhea still and worsening of gait and coordination. Has pre-existing symptoms of ® UL& LL hemiparesis, sensory deficits & ataxic gait.
PMHx: in ’05, first episode of severe headache. Began with fooginess of ® eye-->® cervico-occipital headache which radiated to frontotemporal region, lasted 2hrs. Was diagnosed with migraine. Has nil previous hx of migraine or family hx of migraine. 2nd similar episode in early ’06, but this time was assoc with ® hemiparesis & sensory deficits. Deficits never resolved. In all, had 4 episodes last yr. Nil neuro diagnosis was ever made.
SHx: lives alone. Works underground, was able to continue working despite deficits as was able to "hide" them.
Inx: MRI Cranial/ spinal cord—nad; CT head—nad; Lx puncture—nad, just ↑glucose of CSF; Indium scan: nil CSF leakage
S/E: c/o pre-exisitng weakness & sensory loss & clumsiness with gait got worse when was flown back home. Has increase headache with movements of limbs. Headache =6-8/10
O/E:
· CN III, IV, VI — nad. Eyes tracking√
· Gowlands stage of recovery— ®arm: stage 5; hand: stage4; leg: stage 5; foot: stage 4
· Ms strength— UL: ® Gr 3-4; (L) Gr 4-4+
LL: ® Gr 3-3+; (L) Gr 4-4+
(Had increase in headache with mvts of limbs, ? true strength)
· Sensation—Light touch: UL: ® ↓↓ palmer> dorsum of hand. ↓ lateral aspect> medial aspect of hand/ forearm/ arm (i.e. feels more on C8, T1 dermatomes). (L)↓ palmer surface of hand.
LL: ® plantar surface nil sensation. ↓on dorsum of foot. ↓ant surface> post surface of lower leg/ thigh (i.e. feels more on L5, S1, S2 dermatomes). (L) ↓plantar> dorsum surface of foot.
Sharp/blunt: ® UL& LL: absent. (L) UL/LL: ↓ (5/10)
Joint position/ jt mvt sense: ® big toe/ ankle—able to det mvt but not direction. (L) big toe/ankle—able to det mvt. Direction 6/10. very slow response. Knee & hip jts not tested yet.
· Sitting posture: slightly W.B on (L)> ®
· Sitting Balance: Static √
Dynamic—Int disp: √ ; Ext disp: slight ↑ resistance when disp to the ®. Efficient saving response. Safe in static & dynamic sitting.
· Standing posture: slight W.B (L)> ®. Tunk tone (L)=®
· Standing Balance: Int disp: slight ↓ to ®. AP/PA√. Tend to overestimates ability but able to recognize when told abt safety.
Ext disp: uses a stepping response for slow & fast disp. (i.e. when disp to ®, ® foot steps out to the ® instead of (L) foot crossing over to take a step to the right).
Safe in standing, static & dynamic.
· Balance: feet tog, EO=30s; EC=5s
Sharpened Rhomberg, EO, (L) fwd= 8s, ® fwd= 11s
SLS, EO, (L)=25s, ®=5s
· Gait: -↓ ® heel strike on initial contact
-® knee hypertext during loadingà mid-stance
-↓ hip E during mid stanceà toe off
-↓wt transfer (pelvis lat shift) during mid-stanceà toe-off
-↓ knee F when hip in E during swing phase
So far, what I’ve been able to do is part Ax with the patient each session as I did not want to aggravate his headache too much.
With no neuro diagnosis to be made and with a unique presentation of sensory loss deficits (e.g. deficits of L5,S1, S2 more than L1,2,3; deficits on bilateral limbs), I was quite thrown away by that. Besides, the weakness presented does not match the deficits in sensation. According to my supervisor, the presentation of the patient is unusual. The stepping response during external displacement in standing is also not the norm. She suggested for me to keep these unusual presentation at the back of my head and not to worry too much about it. She advised me to just address the problems like I’ve been taught to, and with more experience in future, I would be able to recognise the abnormal from the norm.
So I’ve been trying to put those doubts aside first & deal with the problems that I can address first. I’ve been working (2 sessions) on weight transference in standing, as well as gait re-edu. I’ve also gave pt some ex’s to improve vol. mvts e.g. DF with knee extension fr 90deg flx to 0deg ext. Pt appeared to have better gait (↑ heel strike) after each session. However, my supervisor thinks it is unusual for the pt to have that much of an improvement after each session.
Thoughts for this week: it is a skill to note the subtleness of abnormality from the normality, the unusual fr the usual. How do we know how much can the patient improve and if it is unusual or not?
Anyone has any thoughts with regards to Ax/ analysis/ Rx of this pt?
Sorry about the long blog. Hope I didn’t confuse anyone.
Have a great week ahead!
Saturday, January 20, 2007
Physio Works!!
It has been very interesting reading all your Blogs; it is great getting a bit of an insight into what others are up to and experiences on all sorts of different placements – thanks!!
Well this week was pretty quiet for me on prac, so I don’t have that much to contribute….and yes one does get a bit more confident in time about clinical judgments!!
Give me STRUCTURE!
Well, here I am, half way through my musculo placement, and loving it! It is great to get the hands on experience with patients in the area of physiotherapy soon to be my career.
Things are all starting to flow a lot easier with the assessment, patient handling, and treatment. One thing that is still taking a while to establish is 'time management'.
It is amazing how quickly time moves during your time with a patient. Those of you who have finished, or currently doing, your musculo clinic will know that we get 1.5 hr for new patients, and 1 hr for ongoing pts. I currently need all of that time, and it is scaring me, due to me starting work in a private practice in May. In a private practice 'time management' is essential, as an initial will only be 45 mins MAX, and a subsequent 30 mins MAX, and the rate I am going, I will only see 4 patients/day when working.
I am currently really trying to get the subjective (initial) completed within 15 minutes, and find a structure to complete it in this time frame. For ongoing pts, I am really only focusing on certain aspects of the objective to use to also save time
This is the main focus for the remainder of the placement, as everything else is going well, so any comments will be hugely appreciated. Ideas on how others have structured their INITIAL SUBJECTIVE (PHx, Current Hx etc) in the past would be great.
I guess all this comes with experience, but I would like to have this sorted as much as I can come May. My supervisor has given me some ideas, but is there any one who may have experienced what I am saying and have any wisdom on the matter?
Things are all starting to flow a lot easier with the assessment, patient handling, and treatment. One thing that is still taking a while to establish is 'time management'.
It is amazing how quickly time moves during your time with a patient. Those of you who have finished, or currently doing, your musculo clinic will know that we get 1.5 hr for new patients, and 1 hr for ongoing pts. I currently need all of that time, and it is scaring me, due to me starting work in a private practice in May. In a private practice 'time management' is essential, as an initial will only be 45 mins MAX, and a subsequent 30 mins MAX, and the rate I am going, I will only see 4 patients/day when working.
I am currently really trying to get the subjective (initial) completed within 15 minutes, and find a structure to complete it in this time frame. For ongoing pts, I am really only focusing on certain aspects of the objective to use to also save time
This is the main focus for the remainder of the placement, as everything else is going well, so any comments will be hugely appreciated. Ideas on how others have structured their INITIAL SUBJECTIVE (PHx, Current Hx etc) in the past would be great.
I guess all this comes with experience, but I would like to have this sorted as much as I can come May. My supervisor has given me some ideas, but is there any one who may have experienced what I am saying and have any wisdom on the matter?
ICU Ethics
ahhh the joys of the ICU....
This week I was again in the ICU treating patients with cardiorespiratory problems. we had 2 patients to see this day, however we were both under the direct supervision of our supervisor.
'The Patients'
This week I was again in the ICU treating patients with cardiorespiratory problems. we had 2 patients to see this day, however we were both under the direct supervision of our supervisor.
'The Patients'
- A 52 y/o lady who was found unconscious at a local beach floating face down. She was dragged to the beach by lifeguards who provided CPR and was then transferred to the hospital via ambulance. Currently she is in an induced coma, intubated and ventilated on Bipap. CXR show an ARDS picture with bilateral diffuse areas of opacity and bi-basal infiltrates. Chest expansion was obviously reduced as the Bipap was operating on pressure control of 12mmHg. The patient was unable to initiate BR so the ventilator was also set to allow this. Ausc- clear BS in apical, diminished BS in middle and barely audible BS in the basal lobes. I was unable to hear any additional sounds but according to our supervisor there was. Rx included Manual hyperinflation with a PEEP of 8 + vibes, 2 cycles of this for about 3 mins per MH and then suctioning. Positioning and repositioning was also critical for this patient however all we did was move from supine to an upright sitting position and back down to supine. our supervisor told us about Prone lying and side lying postures and that these were performed by the "turning team". As yet this patient had not been prone and was unlikely to even be put into prone.
- The second patient was a 29 y/o male who for some reason decided that IV drug using was a good past-time. However on this occasion he used a 'dirty needle' and had an epileptic seizure. He is HEP -B and HEP- C with a ?? on HIV. He is also in an induced coma and ventilated on BIPAP, he is currently unable to take spontaneous breaths so the ventilator is performing all the work. He has been on constant renal dialysis for the last week and has shown signs or cerebral injury due to a four beat clonus. CXR and Ausc both showed areas of the left mid and lower lobes having areas of consolidation or infiltrates. The Rx was very similar to the previous patient however positioning was altered due to the presence of femoral arterial lines were being used for dialysis and a upright posture would have "kinked" the lines ending in disaster.
Now I pose this question for response as I am still unsure myself, ethically and morally and medically both cases are similar in terms of chest physio (at current status) however the gentleman is unable to take spontaneous breaths and shows signs of cerebral injury, what is the likelihood that this person will either function as he would have prior to the incident, without intensive 24hr care as opposed to the lady? Now I'm not 100% clear with each patients SHx but I have never seen any family or friends visiting the gentleman in the last week.
Now over the duration of treating these patients I have reflected on the ethics of treating these patients. One who seems to have a loving family and a future outside to ICU and another who seems to have a bleak existence ahead of him if he is able to pull through. I know that ethically and professionally both parties are entitled to the same treatment and care but i wonder if retrospectively each party would choose it for themselves??
Ryan Ridley
Wednesday, January 17, 2007
Along a similar thread..
Hi guys,
Thought I would get my post for this week (#2) up. I guess this goes along with a common theme recently - clinical experience (something I am sure we are all learning and getting better with).
I had a patient today who was admitted for an exacerbation of COPD?, however the Drs also query the possibility of an MI. (This individual has previously experienced cardiac problems). While going for our first walk together on the ward (no contraindications according to medical staff), his heart rate was up to no good - in as far as me trying to interpret it! It was extremely erratic - from 90 - right up to 175, to 110 to 145, to 80 etc.....Now I am sure we have all experienced some glitches with our oximeters, so I at first attributed it to that - tried different fingers, a diff oximeter, palpation.... Now the only problem with palpation is that it is a little more difficult to do during amb - hard to get all that accurate. At rest, his heart rate seemed to stabilize (and palpation was obviously easier). Now this was a bit disconcerting to me as heart complications/incident may have been the reason for his admission. However, I did continue on with the ambulation but paid close attention to other signs such as facial expression, color, perspiration, breathing rate/pattern, posture and of course his sats. We experienced no problems and he may actually be for D/C tomorrow.
Now, I think what I did was ok and these pracs are supposed to start to teach us to use clinical judgement but like Claire had mentioned - at what point is experience enough/are we qualified to make these judgements. I don't know yet? Like I said, I feel comfortable with that, but who knows right (I guess that is something you could ask yourself about a lot of things though..). So, to put it out there - what would you have done? A) once discovering this aberrant HR, return to bed ASAP B) Do as I did C) Other.
PS - nobody had much to say about this abnormal HR. Pt mentioned later on he had experienced this before - no adverse complications.....
Cheers and good luck with the rest of the week,
Donelle
Thought I would get my post for this week (#2) up. I guess this goes along with a common theme recently - clinical experience (something I am sure we are all learning and getting better with).
I had a patient today who was admitted for an exacerbation of COPD?, however the Drs also query the possibility of an MI. (This individual has previously experienced cardiac problems). While going for our first walk together on the ward (no contraindications according to medical staff), his heart rate was up to no good - in as far as me trying to interpret it! It was extremely erratic - from 90 - right up to 175, to 110 to 145, to 80 etc.....Now I am sure we have all experienced some glitches with our oximeters, so I at first attributed it to that - tried different fingers, a diff oximeter, palpation.... Now the only problem with palpation is that it is a little more difficult to do during amb - hard to get all that accurate. At rest, his heart rate seemed to stabilize (and palpation was obviously easier). Now this was a bit disconcerting to me as heart complications/incident may have been the reason for his admission. However, I did continue on with the ambulation but paid close attention to other signs such as facial expression, color, perspiration, breathing rate/pattern, posture and of course his sats. We experienced no problems and he may actually be for D/C tomorrow.
Now, I think what I did was ok and these pracs are supposed to start to teach us to use clinical judgement but like Claire had mentioned - at what point is experience enough/are we qualified to make these judgements. I don't know yet? Like I said, I feel comfortable with that, but who knows right (I guess that is something you could ask yourself about a lot of things though..). So, to put it out there - what would you have done? A) once discovering this aberrant HR, return to bed ASAP B) Do as I did C) Other.
PS - nobody had much to say about this abnormal HR. Pt mentioned later on he had experienced this before - no adverse complications.....
Cheers and good luck with the rest of the week,
Donelle
Sunday, January 14, 2007
The ICU
Hi all,
Apologise for the slow entry was having some blogging issues!
I have just finished my first week of the cardio placement at a major teaching hospital. I am on general surgery rotation for the first two weeks. Felt like I was somewhat prepared for the pulmonary and various abdominal surgery patients, but didn’t know what to expect from the heart patients.
The second day of prac I was sent to the ICU to treat a day one CABG x3 pretty much on my own (my supervisor was treating someone else in the same room).
Having never set foot in an ICU before, I was imagining mass car crash victims and other horribly ill patients with staff furiously running around everywhere (probably in part due to my years of watching medical dramas on TV). Needless to say, I was a little apprehensive about treating this day 1 patient. When I actually got to the ICU everything was quite calm and my patient was already sitting out of bed reading the paper and looking fantastic only a few hours after heart surgery. The staff were really friendly, the patients appeared stable and there were lots of empty beds. As for my heart patient, I have followed his progress this week seeing him twice per day. I continue to be amazed at the rate of his recovery. With one flight of stairs on the agenda prior to discharge (approximately day 5 post-op). this patient is well on his way back to functioning in the community and enjoying life. Ahh the marvels of modern medicine.
As far as the ICU goes i was wondering if I just saw it on a quiet day or if this is the usual presentation? Would appreciate any experiences from other students who have treated patients in ICU
Jess
Apologise for the slow entry was having some blogging issues!
I have just finished my first week of the cardio placement at a major teaching hospital. I am on general surgery rotation for the first two weeks. Felt like I was somewhat prepared for the pulmonary and various abdominal surgery patients, but didn’t know what to expect from the heart patients.
The second day of prac I was sent to the ICU to treat a day one CABG x3 pretty much on my own (my supervisor was treating someone else in the same room).
Having never set foot in an ICU before, I was imagining mass car crash victims and other horribly ill patients with staff furiously running around everywhere (probably in part due to my years of watching medical dramas on TV). Needless to say, I was a little apprehensive about treating this day 1 patient. When I actually got to the ICU everything was quite calm and my patient was already sitting out of bed reading the paper and looking fantastic only a few hours after heart surgery. The staff were really friendly, the patients appeared stable and there were lots of empty beds. As for my heart patient, I have followed his progress this week seeing him twice per day. I continue to be amazed at the rate of his recovery. With one flight of stairs on the agenda prior to discharge (approximately day 5 post-op). this patient is well on his way back to functioning in the community and enjoying life. Ahh the marvels of modern medicine.
As far as the ICU goes i was wondering if I just saw it on a quiet day or if this is the usual presentation? Would appreciate any experiences from other students who have treated patients in ICU
Jess
Saturday, January 13, 2007
Getting used to craniectomy
Hi all,
I am currently doing my Neurosurgical Inpatient Placement. It has been quite an eye-opener for first week.
This is the first time I am in close contact with traumatic head injured patients. To tell the truth, I was a little taken aback to what I have seen this week. Comparing to the picture I had in mind (after sitting through those traumatic HI lectures and seeing pictures of them in the rehabilitation phase) of how they may behave or look, there is a vast difference to the reality.
There are some patients who have had craniectomy (skull taken out), where there is not just a hollow dip in the head. There may be cerebrospinal leakage, occupying the area where the skull has been removed, making it look boggy and it is really soft and malleable to touch. I really do not know how to describe it, but to say it seems really “squishy”. I got a little freaked out when I do see and feel the fluid move. Most of us have got something that “eeks” us out and probably this is it for me. Think I will need some time to get used to it.
I had to help to sit this patient with a frontal craniectomy up on the edge of the bed. As the patient did not have any neck control, it was necessary to support the head. Besides, patient has a trachy on, so it was crucial that his head was not in an overly flexed position in case he coughs on it. The tricky bit to it was that there was very little bony surface that I could hold onto. There was no bone at the forehead and I could only support 1 finger width above the eyebrows where the edge of the craniectomy was. Another hand had to be right above the mid of the skull. I then realized that a human’s head is really heavy to support. All those brain matter really weigh a ton, and in addition to that, the excess CSF fluid. It is an uphill task trying to keep the patient’s head up in neutral. By the end of the placement I would expect good development of my UL musculature.
Hopefully this will give those going into neurosurgical inpatient, who may be freaked out like I was, a little mental preparation. Although I am sure most would take it really well. Despite the not-so-appealing part of it, I think I will still have plenty to look forward to for the next 3 weeks.
I am currently doing my Neurosurgical Inpatient Placement. It has been quite an eye-opener for first week.
This is the first time I am in close contact with traumatic head injured patients. To tell the truth, I was a little taken aback to what I have seen this week. Comparing to the picture I had in mind (after sitting through those traumatic HI lectures and seeing pictures of them in the rehabilitation phase) of how they may behave or look, there is a vast difference to the reality.
There are some patients who have had craniectomy (skull taken out), where there is not just a hollow dip in the head. There may be cerebrospinal leakage, occupying the area where the skull has been removed, making it look boggy and it is really soft and malleable to touch. I really do not know how to describe it, but to say it seems really “squishy”. I got a little freaked out when I do see and feel the fluid move. Most of us have got something that “eeks” us out and probably this is it for me. Think I will need some time to get used to it.
I had to help to sit this patient with a frontal craniectomy up on the edge of the bed. As the patient did not have any neck control, it was necessary to support the head. Besides, patient has a trachy on, so it was crucial that his head was not in an overly flexed position in case he coughs on it. The tricky bit to it was that there was very little bony surface that I could hold onto. There was no bone at the forehead and I could only support 1 finger width above the eyebrows where the edge of the craniectomy was. Another hand had to be right above the mid of the skull. I then realized that a human’s head is really heavy to support. All those brain matter really weigh a ton, and in addition to that, the excess CSF fluid. It is an uphill task trying to keep the patient’s head up in neutral. By the end of the placement I would expect good development of my UL musculature.
Hopefully this will give those going into neurosurgical inpatient, who may be freaked out like I was, a little mental preparation. Although I am sure most would take it really well. Despite the not-so-appealing part of it, I think I will still have plenty to look forward to for the next 3 weeks.
Sats of 78% !!!
I think I am going to have to get faster at doing and reflecting and getting it down in written form!
I am on my Cardio rotation at present and have been working with mainly medical patients so far – lots of COPD with exacerbations and infections of, and have found judging clinical status very difficult.
Most of the patients I’ve seen have resting sats of 90 – 95% on oxygen via NP, are incredibly breathless, look very ill and need to be ambulated as part of their treatment. We were sent off to see patients by ourselves on the 2nd day and were given little direction, which made it a bit difficult but we bravely set out. We had been told that you can let the sats get to 85% in these types of patients and to monitor by symptoms more than sats to direct exercise prescription. For 2 of our patients after walking them about 6m their sats dropped to 88%, and so we sat them down after which they dropped to 76%. Needless to say we both almost had arrests ourselves and couldn’t believe we were about to have caused sudden death to trusting patients, and surely this could have been prevented if they had just stayed resting in bed…After a very long few minutes of us repeating incessantly “breathe deeply through your nose” and looking despairingly white – faced at each other as the accomplice to a murder, their sats did return to 90% and we joined them sitting down for a while. But then what next….was that alright….should we carry them back to bed and say never get out again which seemed like the most sensible option……so we went and found the PT who looked amusedly at our anxious white faces and said that was fairly standard, and not to worry too much about sats and watch for symptoms and why didn’t we turn up the oxygen…All of these comments for me did not clear up the situation at all; surely we aren’t allowed to just change the oxygen flow rate in COPD patients, how do you measure breathlessness and symptoms when they start by being incredibly breathless and looking pale and sick at rest??? All questions I am keeping for my Curtin supervisor…but in the meantime any experience or suggestions would be greatly appreciated!
The benefits of a little chit-chat
Hi all, trust you had a good 2-week break! I am currently doing my Cardio placement. As of yet I have not run into any noteable problems/situations, questions or queries. ( I believe we may still be in the "breaking-in" period). While the majority of patients have had very interesting (and complex!) medical histories, I do not believe that sharing them is the point of this blogging exercise. I have thus racked my brain trying to think about what to share with you. And then it hit me! - communication!
I'm not necessarily talking about open/closed questioning or analysis of body language - I am talking about the art of simply having a chat to someone. I guess in a way it can come down to personal preference, but I know that if I put myself in a patient's position I am much more receptive, feel more comfortable and willing to engage with the health professional if they simply take the time to have a few words with you other than your health. This makes them seem interested in you and therefore, from a patients perspective, I believe the fundamentals for trust and confidence in your health professional emerge. And this! - is absolutely critical to developing good relationship with your patient!
So here is an example: I currently have a pt with end-stage COPD. He was willing to tolerate the subjective/objective assessment but really was pretty much tired of the whole process at this stage. "I mean, whats the point?". So realizing this early on in talking to him, I made an extra effort to respond to comments he would make. Such as: he enjoys fishing. So I would recount a few tales of fishing in my youth and go on to praise the fishing skills of my father and brother - big fish tales included of course!!. And this would therefore get him going and soon enough we would be having a good ole chat and laughs. Now I know this is not very time efficient, especially if you have a large case load. However, I do believe that it can actually hasten further treatments down the road as your patient may actually be more willing to get up and get going with you because you have spent the time and effort fostering this relationship.
So, back to this individual. He really didn't have much interest to get up and walk nor any desire to do any other exercises. He in fact was more interested in charging me $$ for time spent with him. Yep got expensive, ausculation was in the $100's and a walk was really out of the question considering my budget!! (a joke - just to clear up any confusion). However, once a good open line of communication was started and we both got to learn a little about each other, I had no problems getting him to do whatever I wanted and he was actually more interested and motivated in doing his treatment.
I have encountered this type of situation more so in this placement more so than in any others. I guess by this stage, these resp. pts often have heard/seen it all and often are at a very progressed state of their disease. Thus, while there are still benefits to be had by doing treatments, the motivation may be lacking. By being friendly and being interested in the person themselves and not only their condition or the job you have to do - you may have the power to help restore some motivation and increase their compliance.
Note: there will always be those pts that will be difficult no matter what you try!
So, if you aren't having much luck with treatment, try changing tactics and having a little "idle chit-chat" instead and see what transpires!
Have a good week,
Donelle.
I'm not necessarily talking about open/closed questioning or analysis of body language - I am talking about the art of simply having a chat to someone. I guess in a way it can come down to personal preference, but I know that if I put myself in a patient's position I am much more receptive, feel more comfortable and willing to engage with the health professional if they simply take the time to have a few words with you other than your health. This makes them seem interested in you and therefore, from a patients perspective, I believe the fundamentals for trust and confidence in your health professional emerge. And this! - is absolutely critical to developing good relationship with your patient!
So here is an example: I currently have a pt with end-stage COPD. He was willing to tolerate the subjective/objective assessment but really was pretty much tired of the whole process at this stage. "I mean, whats the point?". So realizing this early on in talking to him, I made an extra effort to respond to comments he would make. Such as: he enjoys fishing. So I would recount a few tales of fishing in my youth and go on to praise the fishing skills of my father and brother - big fish tales included of course!!. And this would therefore get him going and soon enough we would be having a good ole chat and laughs. Now I know this is not very time efficient, especially if you have a large case load. However, I do believe that it can actually hasten further treatments down the road as your patient may actually be more willing to get up and get going with you because you have spent the time and effort fostering this relationship.
So, back to this individual. He really didn't have much interest to get up and walk nor any desire to do any other exercises. He in fact was more interested in charging me $$ for time spent with him. Yep got expensive, ausculation was in the $100's and a walk was really out of the question considering my budget!! (a joke - just to clear up any confusion). However, once a good open line of communication was started and we both got to learn a little about each other, I had no problems getting him to do whatever I wanted and he was actually more interested and motivated in doing his treatment.
I have encountered this type of situation more so in this placement more so than in any others. I guess by this stage, these resp. pts often have heard/seen it all and often are at a very progressed state of their disease. Thus, while there are still benefits to be had by doing treatments, the motivation may be lacking. By being friendly and being interested in the person themselves and not only their condition or the job you have to do - you may have the power to help restore some motivation and increase their compliance.
Note: there will always be those pts that will be difficult no matter what you try!
So, if you aren't having much luck with treatment, try changing tactics and having a little "idle chit-chat" instead and see what transpires!
Have a good week,
Donelle.
Friday, January 12, 2007
A bit of perseverance
One week into Neuro placement all of my patients so far have been at least a couple of months post stroke. As a student you have the expectation that if you spend a treatment session with a patient working on a particular activity limitation that the change you make will remain until the next session. This obviously is not always the case. It can be very disheartening to spend an hour on a patients impairments only to see that the change you made has been partially or completely reversed by the next treatment session. Almost like one step forward one step back.
A discussion with my supervisor reminded me that most of the recovery occurs early and then tends to slow so it sometimes takes a little patience. So I have learned so far that even though the change you keep from one session to the next may be small, if you are making a change within your treatment session your treatment is effective. It may be worth considering two shorter sessions per day with these patients. I am told this is what some Neuro PT’s choose to do.
I am learning to recognise that my patients progress may be slow and take this into consideration in my plan for treatment, my discharge planning and my education to the patient.
Is it just me? Please comment
Leslie
A discussion with my supervisor reminded me that most of the recovery occurs early and then tends to slow so it sometimes takes a little patience. So I have learned so far that even though the change you keep from one session to the next may be small, if you are making a change within your treatment session your treatment is effective. It may be worth considering two shorter sessions per day with these patients. I am told this is what some Neuro PT’s choose to do.
I am learning to recognise that my patients progress may be slow and take this into consideration in my plan for treatment, my discharge planning and my education to the patient.
Is it just me? Please comment
Leslie
How many physios?
At my outpatients clinic.
Here is my patient, right sided hip pain, pelvis, goes down lateral thigh, into the calf, medial three toes are numb, or P&N all the time. Pain is constant, increases from 3/10 to 8/10 randomly, no pattern of aggravating factors. Woke up one morning 6 weeks ago with hip pain and over following days the pain spread. The patient has had four private physiotherapy treatments over the last 2 weeks for hip, shoulder, Cx pain and migraines, with some benefit.
NTPT → Straight leg raise was +ve, sensitised with DF.
Light touch → had altered sensation on lateral margin of the foot.
All other neural tests were clear.
Hypomobility of the lower Lx segments was also found.
There are a number of facets to this patient. Having been to a physiotherapist she is telling me what she thinks I need to know, rather than allowing me to ask questions. Long and the short of it, the subjective took a long long time. Being overweight palpation generally was very challenging and I question the accuracy of my PIVMS/ PAIVMS.
I went on to treat the neural hypersensitivity by PIVMS lateral flexion in left sidelying.
She had a referral for a CT of her pelvic region however had lost it and was not interested due to the radiation exposure. This patient does not take medication and was not interested in taking anything, NSAIDS etc. She had an appointment at the end of the week with her other PT as the PT had suggested that he could work in conjunction with the Curtin Clinic for the best outcome.
Here in lies the debate, treatments from different PTs doing potentially contradictory treatments and having the patient paying and travelling all over the place. The patient understood that it may not be in her best interest to have different people treating her condition at the same time and was happy for me to speak to the PT.
The call was made, the PT knew the patient and expressed that he thought it a good idea if we treated the lower back/leg problem and he would continue to treat the neck, shoulder and migraines.
My supervisor and I are not convinced on the basis of continuity, however I can see that if either practitioner is only going to treat one area then for the patient to have her needs met then it may be necessary. Why doesn’t the private PT give her a double session and treat both, considering they are likely to be linked anyway? No vertebra is an island.
Here is my patient, right sided hip pain, pelvis, goes down lateral thigh, into the calf, medial three toes are numb, or P&N all the time. Pain is constant, increases from 3/10 to 8/10 randomly, no pattern of aggravating factors. Woke up one morning 6 weeks ago with hip pain and over following days the pain spread. The patient has had four private physiotherapy treatments over the last 2 weeks for hip, shoulder, Cx pain and migraines, with some benefit.
NTPT → Straight leg raise was +ve, sensitised with DF.
Light touch → had altered sensation on lateral margin of the foot.
All other neural tests were clear.
Hypomobility of the lower Lx segments was also found.
There are a number of facets to this patient. Having been to a physiotherapist she is telling me what she thinks I need to know, rather than allowing me to ask questions. Long and the short of it, the subjective took a long long time. Being overweight palpation generally was very challenging and I question the accuracy of my PIVMS/ PAIVMS.
I went on to treat the neural hypersensitivity by PIVMS lateral flexion in left sidelying.
She had a referral for a CT of her pelvic region however had lost it and was not interested due to the radiation exposure. This patient does not take medication and was not interested in taking anything, NSAIDS etc. She had an appointment at the end of the week with her other PT as the PT had suggested that he could work in conjunction with the Curtin Clinic for the best outcome.
Here in lies the debate, treatments from different PTs doing potentially contradictory treatments and having the patient paying and travelling all over the place. The patient understood that it may not be in her best interest to have different people treating her condition at the same time and was happy for me to speak to the PT.
The call was made, the PT knew the patient and expressed that he thought it a good idea if we treated the lower back/leg problem and he would continue to treat the neck, shoulder and migraines.
My supervisor and I are not convinced on the basis of continuity, however I can see that if either practitioner is only going to treat one area then for the patient to have her needs met then it may be necessary. Why doesn’t the private PT give her a double session and treat both, considering they are likely to be linked anyway? No vertebra is an island.
A Helpless Patient
Dear all,
I am currently having my Cardiopulmonary Placement. I saw a patient today who was admitted a couple of days ago after a motorbike accident, suffering from T1 fracture (tetraplegia).
The aim of physiotherapy treatment is to maintain and monitor the patient’s chest twice daily. As usual, I review the patient, Mr X first thing in the morning and was shocked to hear what had happened overnight.
Yesterday night, the call bell had been left accidentally at the end of the bed. During the onset of SOB, Mr X wanted to call for help but was unable to do so. Being unable to move his lower extremities, having weak intrinsic hand muscles, he was unable to reach for the bell. Mr X commented feeling extremely helpless and scared!! He had just started to cope with his disability and had absolutely no idea how to cope with this situation. This episode of anxiety increased his SOB. When the physiotherapist was finally called in to attend to him, what he needed was SOB positioning and some reassurance.
I learnt an important lesson through this incident. We come in contact with patients everyday, each with a different condition. Focusing on giving the best possible treatment is important but it is crucial to keep in mind that something as simple as ensuring that the call bell is in the reach of patients after treatment sessions can make a big difference to them psychologically. Although we see majority of the patients in the day, we never know when patients will need help. Now, after treatments, I always make the effort to ensure that I leave the call bell near all my patients.
I am currently having my Cardiopulmonary Placement. I saw a patient today who was admitted a couple of days ago after a motorbike accident, suffering from T1 fracture (tetraplegia).
The aim of physiotherapy treatment is to maintain and monitor the patient’s chest twice daily. As usual, I review the patient, Mr X first thing in the morning and was shocked to hear what had happened overnight.
Yesterday night, the call bell had been left accidentally at the end of the bed. During the onset of SOB, Mr X wanted to call for help but was unable to do so. Being unable to move his lower extremities, having weak intrinsic hand muscles, he was unable to reach for the bell. Mr X commented feeling extremely helpless and scared!! He had just started to cope with his disability and had absolutely no idea how to cope with this situation. This episode of anxiety increased his SOB. When the physiotherapist was finally called in to attend to him, what he needed was SOB positioning and some reassurance.
I learnt an important lesson through this incident. We come in contact with patients everyday, each with a different condition. Focusing on giving the best possible treatment is important but it is crucial to keep in mind that something as simple as ensuring that the call bell is in the reach of patients after treatment sessions can make a big difference to them psychologically. Although we see majority of the patients in the day, we never know when patients will need help. Now, after treatments, I always make the effort to ensure that I leave the call bell near all my patients.
Endure that Spine
I am currently completing my Musculoskeletal Outpatients placement. During my first week I saw a number of different patients (all of different sizes), with a number of different musculoskeletal problems.
Throughout our physiotherapy education we were constantly 'grilled' on the 'therapist's position', and how to look after our own body and therefore endure a lengthened physiotherapists career. Well, I was one of those students (as you all may have been), who thought 'Ill be fine, I'm fit and strong'.
I have learnt a valuable lesson week one of my musculoskeletal career. Throughout my first week, I have assessed and treated ankles, wrists, shoulders, and lower backs. Whilst assessing and treating these patients I didn't really pay much attention to my own position.
Monday and Tuesday I felt fine, and continued with my mentality of 'Ill be fine' when our supervisor corrected therapist position during tutorials. Well, by the end of Wednesday my mid - low back was starting to ache, something that I never usually suffer. On Thursday and Friday, I started to focus on ways I could assess (with the aid of my supervisor) and treat my patients in a more favorable therapist position. In doing this my ache disappeared and I actually felt a lot stronger whilst assessing and treating (eg: accessory mobilisations).
My lessons of the week, that I hope you can all learn from, is this: 1) Always look after your own position first 2) there is always a stronger position to assess and treat in; and 3) always take valuable advice from supervisors that are a lot smaller than you!
Any comments
Troy
Throughout our physiotherapy education we were constantly 'grilled' on the 'therapist's position', and how to look after our own body and therefore endure a lengthened physiotherapists career. Well, I was one of those students (as you all may have been), who thought 'Ill be fine, I'm fit and strong'.
I have learnt a valuable lesson week one of my musculoskeletal career. Throughout my first week, I have assessed and treated ankles, wrists, shoulders, and lower backs. Whilst assessing and treating these patients I didn't really pay much attention to my own position.
Monday and Tuesday I felt fine, and continued with my mentality of 'Ill be fine' when our supervisor corrected therapist position during tutorials. Well, by the end of Wednesday my mid - low back was starting to ache, something that I never usually suffer. On Thursday and Friday, I started to focus on ways I could assess (with the aid of my supervisor) and treat my patients in a more favorable therapist position. In doing this my ache disappeared and I actually felt a lot stronger whilst assessing and treating (eg: accessory mobilisations).
My lessons of the week, that I hope you can all learn from, is this: 1) Always look after your own position first 2) there is always a stronger position to assess and treat in; and 3) always take valuable advice from supervisors that are a lot smaller than you!
Any comments
Troy
Thursday, January 11, 2007
The Irrational Student
Hi guys,
I thought I would get this Blog reflection posting rolling with a problem that I have seemed to encounter on my Cardiopulmonary placement.
I am on the cardio-thoracic and surgical wards as well as a couple of patients in the ICU. Yesterday I had a patient in the ICU who was a day 1 AVR (atrial valve replacement) and my supervisor, let me have the reigns (so to speak). Which was absolutely great and i thoroughly enjoyed it.
So here I am in the ICU ward with a patient who has just had his heart out in the open 8 hours before and my supervisor, trusts me to assess, treat, and co-ordinate transfer with the nurse. there are leads galore, monitors galore, and there in the maze is the patient, who i must say, looked a lot braver than me. Then it hits me... the self doubt.... "Am i doing this right".... "what if i kill this man"....."is that machine meant to be doing that"..... "can i lift this drain".... "whats this guys name again".... "what am i doing again".....
In the end i was able to grab hold of the irrational psycho inner student and I completed the treatment session safely and without a hitch. (he is still walking today.... he should be having his dinner OOB as i am typing this). According to the feedback from my supervisor I did really well and my Rx was justifiable, and ill get another ICU patient tomorrow.
My question to you guys is, 1- does the irrational student ever show up in you on these placements? and 2- does it happen just in wards where we think that if we stuff up the patient is more likely to die (or is that irrational student again) or 3- is this fear just ingrained in us from university so that we are able to become more cautious and reflective with patients at risk.
Please feel free to comment
Ryan
I thought I would get this Blog reflection posting rolling with a problem that I have seemed to encounter on my Cardiopulmonary placement.
I am on the cardio-thoracic and surgical wards as well as a couple of patients in the ICU. Yesterday I had a patient in the ICU who was a day 1 AVR (atrial valve replacement) and my supervisor, let me have the reigns (so to speak). Which was absolutely great and i thoroughly enjoyed it.
So here I am in the ICU ward with a patient who has just had his heart out in the open 8 hours before and my supervisor, trusts me to assess, treat, and co-ordinate transfer with the nurse. there are leads galore, monitors galore, and there in the maze is the patient, who i must say, looked a lot braver than me. Then it hits me... the self doubt.... "Am i doing this right".... "what if i kill this man"....."is that machine meant to be doing that"..... "can i lift this drain".... "whats this guys name again".... "what am i doing again".....
In the end i was able to grab hold of the irrational psycho inner student and I completed the treatment session safely and without a hitch. (he is still walking today.... he should be having his dinner OOB as i am typing this). According to the feedback from my supervisor I did really well and my Rx was justifiable, and ill get another ICU patient tomorrow.
My question to you guys is, 1- does the irrational student ever show up in you on these placements? and 2- does it happen just in wards where we think that if we stuff up the patient is more likely to die (or is that irrational student again) or 3- is this fear just ingrained in us from university so that we are able to become more cautious and reflective with patients at risk.
Please feel free to comment
Ryan
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