2012 - Final Entry - I'm Still Standing

It seems like a really long time since I wrote the initial entry. The routine of work can become a bit of a grind at times. Although I am sad to be leaving the placement, the patients and the staff, I am satisfied with my efforts and the confidence that grew in me. The daunting nature of a neurological placement seems distant as well – although not nearly mastered, certainly well apprenticed.

As always I made communication my first goal. I feel it is an imperative part of being a therapist and all situations are improved if used effectively. Poor communication can lead to countless errors, poor safety and resource wastage. On this placement I was exposed to direct communication with patients, allied health professionals, family members and the general public. There is a great art in being able to slide into different roles. Health professionals need succinct information that is relevant without the chit-chat. Family members require a more friendly, approachable professional who is also able to deliver top-notch service. The level of communication then varies greatly when it comes to patients who have suffered a stoke. Some patients are able to comprehend their condition and are either fully communicative or have a flat effect. Others have a vague awareness of what is going on and can only follow one stage commands. Some can become emotional if given too much praise while others depend on the positive feedback. Being able to cover all these bases within a morning can be exhausting but becomes easier with time and reflection. Starting each day with a warm, friendly and humble attitude seems to go a long way in the right direction. Another important aspect of this is good written documentation from other professionals in contributing to the understanding of the patients communication needs. It keeps everyone on the same page, as it were. When you read in the integrated notes that a patient becomes emotional when speaking about their condition but calms if distracted by the footy, this can save much needed therapy time. Recorded conversations with family members or consultants can piece together the structure of how this patient is being supported.

This placement has gone a long way to showing me what a physiotherapist can be to a patient and how fragile that relationship is. Working so hard with someone and finding out their medical and social history, meeting their families and getting them to place their trust in you and your colleagues – and then having to leave – it almost seems neglectful to assume that others can fill the void. A good hand-over needs to include a social aspect that may get lost in the medical jargon and it is why the S in SOAPIER is so important. It can be used for more then “Valid verbal consent”. It should express the patients mood, their feelings and their complaints as these really are the ultimate goals – improve their mood (and health), improve their feelings, minimize their complaints.

I was going to write a whole bit on time management and safety awareness but these seem to have taken care of themselves. My shoes held up, thanks for asking. Good form, good function. Building a great physiotherapist from the ground up.

  

2012 – STARES 3 – Presentation

Situation - Week three of our five week placement at a stroke rehab hospital ward. My fellow neuro student and I were settling in to a routine. We each had a couple of patients to make plans and give treatment and assist the other during their sessions. Life was good, life was predictable…

Task - Having initially been told that students would not be required to give a presentation, our supervisor decided it would be worthwhile if we reviewed some literature, made some notes and delivered it to a room full of physios…like a presentation. While they gave it a friendly sounding name “Journal Club”, it may as well have been called “Torture Club” or the “Sympathetic Nervous System Club” – yes – that’s the “Fight-or Flight Club”.

Action - In week one we had attended a presentation on dyspraxia that was a little hard to follow.  Since that time we had been given a patient with severe dyspraxia and were constantly looking for alternatives to assess their function and give treatments that they could follow. We decided that our research time would be best spent looking up some articles to further our understanding and perhaps help other therapists who may also need some information. We found three relevant articles and a supporting assessment form to present to the group. I spent the week making up a table from the articles that gave treatment ideas for therapists treating dyspraxic patients. My student colleague would handle the assessment side of the presentation and demonstrate how other conventional assessments could fall down when a patient may have other problems like receptive dysphasia. We tested the suggestions with our patient with positive results. It required us to keep the treatment area free from clutter, breakdown tasks into simple sequences and keep conversation to a minimum. We found these elements hard as physio areas can be quite cluttered, simple tasks have many different pathways and cutting conversation out of a session can feel a little unfriendly. Nether the less, the patient was responding well.

Armed with all this information and three hectares worth of photocopied journals to hand around (one of the requirements)

Result - The main outcomes from this task was that it showed us that not all conditions are well understood by health professionals, having a relevant patient can motivate research and understanding and being well prepared can take a lot of pressure out of a presentation. The room responded well to our presentation and although our photocopying skills left a lot to be desired, the therapists felt better equipped to assess and structure a treatment session for a patient with dyspraxia.

Evaluation

I felt our presentation was delivered professionally and with confidence. We gave the other therapists a workable frame of ideas to structure appropriate assessments and treatment sessions for patients with dyspraxia as well as differential diagnosis if the patient didn’t fit the picture. Our supervisor was impressed with our research and allowed us more freedom to plan treatment sessions with the patient with dyspraxia.

Strategies - In the future, if asked to present a journal I would definitely ask for more instruction on how to use the photocopier. A double-sided print that was collated would have saved lots of time and resources.

Have confidence in the material you are presenting and the resources you add to it. I had not included the table I had made up as a handout to the group. They all requested a copy that, while making me feel positive about the presentation, made me realize that further time has been wasted and I looked like a student lacking confidence in my work. I made my table look fantastic and emailed it around with much gusto.

Having someone else to present with makes it a lot easier. I also spoke with several other physiotherapists during the week prior to our presentation asking them about their experiences with public speaking. This made me feel a little more relaxed when I stood up in front of them to present. They knew what I was going through and I felt connected with the audience.

2012 - STARES 1 - Transfers

Situation: Day one of placement at Neurology Stroke Unit. Supervisor has arranged meeting with university tutor. Patient to be organised to help introduce the 3^rd year neurology physiotherapy students to conducting an initial assessment.

Task: Assess mobility and give treatment to 90 yo female with Right MCA infarct.  Patient presents with left side neglect, dysphagia and mild confusion. Guidance given from university tutor and main assessment role shared with 3^rd year physiotherapy student.

Action: We had been given a brief account of the presenting condition with the major obstacle being the strong contralateral push when transferring the patient. We introduced ourselves and our tutor to the patient and her daughter, who was present. The patient was sitting in her wheelchair but was slumped in an uncomfortable position. A nasal gastric tube was in place as the patient had been aspirating her food due to dysphagia. Patient had a mild cough and complained of the tube irritating her throat. The tape securing the tube had lifted and there was some discussion as to whether the tube was still correctly fitted. We assisted the tutor in repositioning the patient and transporting to the physiotherapy gym via wheelchair. On arrival at the gym my student colleague conducted the chest auscultation to clear the airways as a possible cause of the cough. The airways sounded clear and the cough noted as being due to the feeding tube. We prepared to transfer the patient to the plinth to begin our assessment. We removed footplates and the patient’s socks and compression bandages. The brakes were checked and the patients support table was removed. Our tutor took the lead role as she had been warned about the patient’s tendency to push. The other student and I positioned ourselves to give assistance from the plinth and from the left side of the patient. The patient was assisted to shuffle forward in the chair until her feet touched the ground. Instructions were given to lean forward and hold the therapist for support. As soon as the transfer started the patient tried to get her right hand to the plinth for support. This created a strong push from the right side that the therapist found difficult to control. Attempts were made to straighten the patient up but the very strong push made it difficult and the frail condition of the patient made it difficult to return the force to stabilise the patient. The patient began to slide toward the floor and the therapist gave instruction for a 3 x max assist to get her back to the wheelchair. We all lifted on “GO” and returned the patient to her chair. The pushing ceased and the patient was safe.

Result: The initial attempt to transfer the patient was unsuccessful and dangerous for the patient and the therapists. A second attempt ensured the patient was unable to get her arm in a position to push by placing a pillow on her right side. A mirror and strong verbal prompts throughout the transfer assisted to get the patient upright and transferred to the plinth.

Evaluation: Even though there was a clear plan, and the senior therapist was prepared for the problem, the patient was able to get into a position that extenuated the pushing and created an unsafe situation for all. However, because we had cleared our area, revised some basic communication and handling techniques, we were able to return the patient to a safe position and make a new plan.

Strategies: Being more familiar with the techniques to reduce the effects of pushing would have made me more prepared and confident to suggest some ideas prior to the transfer. All the literature and lab work seemed to go out the window when a real patient demonstrated the real effects of the condition. It was a rapid learning curve and one that kept me up most of the night. The importance of preparatory techniques and planning for the worst were the main strategies that came to the fore and were utilized successfully on future transfers of this patient.

Initial Entry 2012

The Shoes do not Make the Man

On my last placement I was introduced to rehabilitation in the gerontology area, mainly focused on post-op orthopaedic rehab. This was a good opportunity to understand the increased demands of the aging community, possible co-morbidities and the influence of a wide array of medications. When reflecting on my time at that facility I fondly remember the staff and the patients and their understanding and help in my learning. This is all very well and good, but after this next prac I want to be looking back and remember how good I was at my job and how many people I was able to help.

The positive that I can take from my last prac was that I felt I had good communication skills and was able to speak with other health professionals, with patients and their families. I was aware of my limitations and of my strengths. In the past year, however, one a whole new set of challenges and information has made me once again unsure of what I know and has again presented the mountain to climb back to a level of confidence in what I know and what I don’t know (staying clear of what I think I know and what I think I don’t know).

Another big positive from my last placement was my safety awareness. My shadowing, wheelchair braking and patient handling, I felt, was spot on. My hygiene awareness was possibly not as good and I contracted viral conjunctivitis from one of the patients after the first week. This is an area that I will most definitely not be taking for granted in the future. Daily charts need to be closely read to see what the patient may be currently suffering from (on top of the main condition) that may be contagious to myself and to other patients and staff that I interact with. I have also purchased a new pair of shoes that will only be used for hospital work. They are much more comfortable than my last pair and don’t have laces as this can be a source of contamination (lack a bit of cool factor though).

I was always punctual for my last placement but had a tendency to cut it fine. This next placement is a little further away so I will have to be prepared the night before and stick to my designated departure time come hell or high water. A coffee mug for the car may help this department considerably. My new Velcro shoes should save around 30 seconds as well!

My biggest hurdle is putting the knowledge into practice. Knowing the assessments and how to conduct them, writing SOAPIERS and other documentation is what I will be focussing on this placement. I feel these are my weakest areas and when conquered will help boost my confidence and time management. Speaking of big hurdles, did I mention my new shoes.

I start my new placement tomorrow armed with maps, workbooks and a pre-packed lunch. Even though I will be eating chicken I will not shy away from the daunting task of working on a neuro rehab ward. The butterflies in my stomach will be replaced by beetles of enthusiasm and ladybugs of dedication. Hopefully this will lead to a colony of other helpful insects working towards the common goal of helping me not make a complete fool of myself. At least I have new shoes.