Final Entry

This placement has been an immensely rewarding experience for me. Although I had a setback with illness in the second week, I was able to contact the personnel and get the documentation necessary to help me focus on my health and not put anyone else at risk. There was the increased pressure on my return that I was unable to miss any more time so I was extra cautious with hygiene and my energy levels.

Working in gerontology rehabilitation feels like a different style of physiotherapy is required. The healing process is longer and there are many more co-morbidities to take into consideration. Nothing can be rushed. The physiotherapist needs to be involved in communication with the patient, with the surgeons, doctors and other health professionals, as well as family members in order to give effective treatment.

Assessment needs to be narrowed down to specific functional tasks and pre-admission function clearly understood as a starting point to rehabilitate the patient. Full assessments may not be practical and even though the student may want to go through every objective measure, the patients were not usually capable before admission and therefore it is not necessary.

Professional behavior is essential as patients and their families are expecting a certain level of care. At a time when loved ones are in medical crisis there is potential to be caught up in emotional situations that require the highest professionalism. The physiotherapist needs to develop a rapport with the patients but when there is a large case load these interactions need to be succinct and relevant so as to keep clear professional boundaries and remain time efficient. The limit of your knowledge has to be made clear and any questions referred to the relevant health professionals.

Safety, safety, safety. When everything else is taken into account, at the end of the day we were treating elderly patients that were a high fall risk. Footwear, walking aids, mobility boards and clear communication were the name of the game. DO NO HARM. It was unfortunate that a patient did fall while in rehabilitation for a hip replacement the day before discharge, which set her back by one month. Every precaution was taken and these events can happen, but must be minimized.

Before the placement I was overly concerned with time management but the routine of the job becomes ingrained quickly and the importance of the work means that you cannot afford to run late, or be tired or carry stress from home. The patients need you to be focused. The other staff members rely on your commitment. Anything that shows a lack of team dedication will show through and the work will become overwhelming.

Looking back at my initial entry I can see how shallow my thoughts extended into the actual workings of a gerontology placement. I am pleased that once I had taken control of my time management I was able to have an extremely rewarding experience and be viewed as a useful and reliable member in the rehabilitation team.

STARES Entry Three - Assessment

• Situation – Having missed out on week two because of illness, I was starting to get my confidence back with patients. The clinic had gone through a very busy time and I had been involved in many hours of patient rehab based on assessments from the physiotherapists. I had become proficient in this area and had my own caseload to manage and reports to present and the allied health meetings. I had been involved in discharge planning including RITH referrals. Where I was lacking in experience was with initial assessments. The form that the physio assessments are conducted on contain many of the tools that we have learnt about in our Gerontology unit and I was keen to have some initial assessments so as to go through these in some detail. At the start of week 5 I was to be supervised by my clinical tutor and I was given a new patient to conduct an initial assessment on. 

• Task – Conduct initial assessment on a 70 year old female patient with an ORIF on fractured neck of femur secondary to a mechanical fall, day 7 post-op on transfer to rehab hospital.

• Action – I was handed the patient in the morning to conduct initial assessment on with clinical tutor in the afternoon. During lunch break I went through patients file to get information on the initial trauma, the surgical procedure and precautions, past medical history, current medication list and the patients social history. There were no previous notes from the physio or an official hand-over. Having struggled with past attempts to record all relevant information I made a concerted effort to source all the data that could be used for analysis and planning, including a mention of foot pain from a past accident. X-rays of the foot only reveal arthritic degeneration.

• Result – Having geared myself up to see this patient I was flustered when we entered the patients room only to find them in a deep, peaceful sleep. We approached my hospital supervisor to adjust schedule for the afternoon and we attended to other patients in the meantime. We were successful in our second attempt to start our initial assessment. We encouraged the patient to be transported by wheel chair to the gym for the assessment, as the shared ward room is busy with visitors. Consent was given and the patient was happy and compliant. On arrival in the gym I transfer the patient to the plinth to assess range of motion, strength and considering ending the assessment with a timed up and go (TUG) as a baseline evaluation. Once on the plinth the patient began to demonstrate extreme pain on mobilization of the knee joint that radiated up to the groin. My tutor suggested we conclude the assessment. The patient’s knee is swollen and bruised and she still complains of foot pain. The patient mentions that she feels that the pain in her foot caused the mechanical fall. We had noted that the patient’s crutches were too long so we made adjustments to improve the patients gait stability. I my documentation I noted that the source of the patient’s foot and knee pain would have to be addressed to correctly rehabilitate the patients mobility. Following up with the doctors on the patient’s pain led to another X-ray on the foot and a Doppler on the knee for a possible Deep Vein Thrombosis. A missed fractured metatarsal was picked up on the X-ray and the Doppler results had not been received as yet.

• Evaluation – A number of issues were raised by my tutor and helped explain why I felt the assessment had not gone well. Having prepared as well as I thought I could have for the afternoon, I had not informed the patient of our intentions and had not organised for her to have her pain medication. I was so intent on completing the assessment the way I wanted it I forgot to consider the patient. This wasted valuable time trying to reorganize the patient list and made me less confident.

• Strategies – Planning is a very important part of the health care professional’s day, but being able to change the plan at short notice and still maintain composure seems just as important. At the centre of all treatment is the patient, and the health care provider should work backwards from there. My need to conduct a full assessment comes second to the patients needs. Reading notes does not replace a face-to-face conversation.  A patient’s pain needs to be controlled in order to treat their impairment and this needs to be organised in advance with the nursing staff. In this case the unexpected pain led to further investigations, which were valuable information, but could have been achieved with a conversation and visual inspection.

Make a plan

Make a back-up plan

Have alternative ideas

Think on your feet

Be ready to change direction

Be well prepared

Be flexible…

This list could go on and on but the main outcome that I have learned is that the patient comes first and time, energy and resources can be saved to being less focused on paperwork on more focused on the person. Then be a damned good physio to back it up.

STARES Entry Two: Professional Behaviour

Situation

73 yo male patient presents with partial lower limb paralysis following emergency T9/T10 laminectomy. English is not the patients first language but can communicate clearly. Patient having difficult time after multiple hospital transfers and incontinence as a result of the surgery. He was extremely upset about his condition as he had been in near perfect health prior to the disease in his spine, and had received some poor care from some medical personal prior to arriving at this ward.

Task

Conduct an initial assessment of patient’s lower limb muscle capabilities using the oxford scale attached to official hospital assessment form. Supervisor in attendance.

Action

I reviewed the patient’s file and noted his social and medical history, but the real extent of his condition and his distress was not realized until we introduced ourselves. Having felt prepared to do the assessment prior to entering the room, I was flustered and needed prompting and guidance to remain objective and conduct the assessment. We tested isometric contractions of the gluteal muscles, hip flexors, hip abductors and adductors, knee flexors, knee extensors, ankle dorsiflexors and ankle plantar flexors, and toe flexors and extensors.

Result

All the key muscle groups that the surgery had affected were tested and we made the patient as comfortable as possible during the test, as well as expressing empathy and ensuring his emotions were cared for and concerns addressed.

Evaluation

I felt my ability to conduct an initial assessment lacked confidence at a time when the patient really needed to be shown he was in good hands. My supervisor guided me through and had to help me to prioritise the assessment. As the patient could not be rotated (surgical precaution), some muscles could not be tested against gravity. An estimate was made by the supervisor whether the patient would be able to do this based on resistance with gravity. This was a very worthwhile experience as it showed me how important it was to remain objective and adapt procedures to fit with patient’s specific impairments/limitations.

Strategies

Although our task was to get a baseline assessment of the patients muscle strength, there were many other factors that needed to be addressed to care for this patient in a holistic manner, specifically his emotional state. In any field of professional medical care there will be people in great distress that need your professional medical knowledge, but very importantly need to be treated like human beings and reassured and given the time to express their concerns. In future I will try to be prepared for the flood of emotions that can come from initial meetings with patients, give that patient enough time to fully express themselves and conduct a professional, objective assessment. I feel that in that particular circumstance I should have excused myself (like I needed to get something) and taken a moment to compose myself. Having watched my supervisor handle the situation so well has given me confidence that I would be able to at least duplicate this performance in the future.

Minor setbacks

Well, here I am at the start of week four. I missed the whole of week two with viral conjunctivitis so it doesn't feel like I have passed the half way mark yet. I felt my first week went well and was in control of my learning experience, but since then it has felt a little rocky and some new patients have tested my ability to stay objective. Caring about people and wishing them well only goes so far. Having the knowledge and putting it into practice is what will really help and it is something to continue striving for.