stares 1 rotation 2 2010

Stares Entry One – Placement 2 2010

Situation:

I was asked to see a Mr H was day 2 post CABG. He had been transferred from ICU the previous day. PMHx: smoker, HTN, previous MI. Today he had not yet been mobilised on the ward. Mr H had only sat out of bed with the nursing staff.

Task:

Ax & Rx of patient. I was aiming to mobilise according to day 2 post CABG path way.

Action:

After doing a thorough Ax (- chest screen and checking obs, pain , SOB, ecetera) and giving this patient breathing exercises to help airway clearance and decreased lung volumes, I deemed this him suitable to mobilise. I told the patient I was going to get him out of bed as I was on one side of the bed preparing the attachments. Before I had a given clear instructions, the patient began to get out on the opposite side to the one I was on. He had on support from me and I was not able to probperly monitor him as he sat up out of bed. After checking he was ok to get up and mobilise, I told him we will be going for a walk soon. As I went to place the trolley in front of Mr H and hook up all of his attachments, he stood up on his own without any support. Once again he was ok, however it was not good practice that I hadn’t been there ready to give full support if necessary. Once the patient was ready, we walked 70m up and down the ward. Mr H had quite a fast walking pace and I had to keep asking him to stop to get his heart rate down as it was rising above 100 BPM. When the walk was finished Mr H felt fine, although a little tired. After a reassessment and some patient education, our session was finished.

Result

Patient was able to ambulate a good distance. I achieved my goals for the patient on that day. Although nothing negative happened to myself or the patient, the session did not run very smoothly and because of this the session was not optimally safe for the patient.

Evaluation

My Rx was not very safe because my instructions to the patient were not clear enough. This patient was very eager to do everything all at once. If you are not there on standby when the patient is mobilising for the first times after major surgery, there is a high possibility the patient could have an accident and undo all the hard work of the surgical team. After trying to run an Rx session with a patient when I was not familiar with the attachments and not clear enough with my instructions, I know this is something I need to improve.

Strategies

• Practice verbal communication on someone who is not a patient – making sure I am absolutely clear about when they are to move.
  
• Get more practice with supervision setting up trolleys with attachments ready for the patient to mobilise.
• Always give the acute surgical patients more assistance than necessary for the first few times you see them until you are familiar with the patient.

Rotation 2 Initial Entry

Initial entry

At the moment I am both nervous and excited about my next clinical rotation. I am excited that I have successfully completed rotation 1 and that I am moving onto something new. I think one of the best things about this year will be an opportunity to sample everything before making a decision about which area I would like to start working in. I hope this placement will give me the chance to broaden my understanding about the role of physiotherapists in acute settings. (I was in a community health setting on my previous rotation.)

At the same time I am nervous because I am aware that my patients will probably be sicker than any patients I have had in the past. Not only might this make them harder to motivate and treat, they might be less reluctant than your average person to place their health in the hands of a student. Though this is understandable, I anticipate it to be very frustrating. To combat this I will have to be very well prepared to treat these acute patients. By developing a rapport quickly and showing my supervisor that I am competent and confident hopefully this problem will be overcome.

I am also nervous because I know that Fremantle is such a large teaching hospital. There will be 6 students from Notre Dame doing cardio rotations alone! I am worried that it will be difficult to get guidance from my supervisor because this clinical setting is likely to be very busy. In previous practical experiences, although I have had the opportunity to be independent, there was always someone on hand if I was really unsure. Again, I think being very well prepared and confident will help with this problem..Thank goodness for clinical prep week.

I have not had a chance to speak to any other students about a cardio placement at Fremantle Hospital. I am not sure how independent I will be expected to be, however I expect to be supervised/observing for the first few days at least. After that, depending on which ward I get placed on, perhaps I will start getting my own patients and as I progress, work up to a full patient load.

This is my cardio prac, however I could be working in any on the following areas: General Medical, General Surgical, Cardiothoracics, Intensive Care Unit, Ambulatory Care (Including Pulmonary, Cardiac and Functional Rehabilitation), Haematology or Oncology. I am not going to get my hopes up about with one I would prefer to go to, they all have their positives and negatives. I anticipate that my preparation will need to be broad. I hope to expand my knowledge of cardiorespriatory physiotherapy assessment and treatment in one of those areas during my time at Fremantle Hospital.

Final Entry

Final Entry

Looking back at my initial entry I realise how clueless I was about the type of facility I was going to! It was my understanding initially that Mandurah Community Health Centre would be connected to Peel Health Campus as they were right next door to one another, In fact MCHC is a multidisciplinary facility. There is a wait list for patients seeking the services of the centre. GP’s as well as Dr’s and surgeons from hospitals are able to refer patients to the centre. The physios’ see between 8 and 10 patients per day on average, with group exercise classes run every day.

My Time at MCHC was structured the same as the other physiotherapists working at the centre, roughly 70% one on one patient time, 30% class work. My case load at MCHC was not that varied. I saw many people with neck, back and shoulder problems. This was good as it has provided me with a strong foundation to treat these types of problems in the future.

I saw my own patients independently from week two. This provided me with a great opportunity to learn independently. I found myself really having to reason, rather than just go to my supervisor straight away. This was challenging but I think it brought out the best in me.

Though I was a little uncomfortable with the sudden responsibility I was given I believe it was necessary. This placement provided a good chance for me to build on my clinical reasoning, assessment and treatment capabilities. Some examples of these opportunities are listed in my previous stares entries.

Perhaps the most important thing I gained was confidence with treating real, live patients. Looking back, one of the main skills I think I was missing was confidence. Much of this confidence I feel was gained from the large number of patients I was able to treat while on placement as well as running group classes, in particular hydrotherapy. I have learned that you can be well versed on all the theory in the world, but if you aren’t good at selling that knowledge it’s hard to get patients on your side. To sum up, confidence in what I know and what I tell patients is the best and most important thing I have taken from this placement.

Stares entry three

Stares Entry Three

Situation:

Mrs H is a woman in her early 50’s. She attended physiotherapy for her first appointment last week, 4 weeks post rotator cuff repair. The post op orders stated there is to be no glenohumoral joint movement for 6 weeks. I asked Mrs H about this, according to her she was told not to so take the arm out of the abduction sling or move the arm at all during this time. At this stage she had not even had an appointment to see her surgeon since discharge from hospital.
I am thinking there are a few problems with this situation. This seems a very odd protocol to me. I had thought that most post op treatment protocols called for at least passive range of motion in the first 1-2 weeks of rehab, but was not confident with my knowledge.
I felt conflicted because I got the distinct sense that this lady had been lost in the surgeons system, she had told me that she was meant to have an appointment at two weeks, however when she went to make the appointment she was told she would be contacted to make an appointment when she needed to be. There was no reason I could think of in this lady’s history for such a restrictive post op protocol.
What was my role to be if the only exercises I could give this lady, she had already had on a sheet of paper given to her at discharge.

Task:

1. Try and provide this patient with the best possible treatment given the surgeons restrictions.
2. Find out more about the usual rehabilitation protocol post rotator cuff repair and any possible reasons for this surgeon’s post op orders.

Action:

I spent great deal of time of time talking to this patient regarding her ongoing management, what she needed to do and what would likely happen in the future. She was very distressed at how long the whole process was taking and how she seemed to have been lost in the system.
After reassuring the patient and setting a plan in place, I checked her elbow and wrist stretches as well as adding in a scapula stetting exercise.
After this I went home and did a search on rotator cuff rehabilitation protocols. I did a quick scan of PEDRO and ebsco. I found that in most of the control groups in studies testing various rotator cuff rehab protocols had the patients doing at least passive range of motion from day 2 or so. The experimental groups often had accelerated progression to static contractions and active assisted. Most of the evidence seemed to suggest that there was no difference in approach, also that a generic exercise approach was as good as a specific one.
Some reasons for adhering to a more limited post op program of exercise were specific problems with instability, poor bone strength or repair integrity. To my patients knowledge she had none of these. Perhaps this lady should have received a more accelerated program.

Result:

Hopefully the overall result for the patient will be good. Although her path to full function has been delayed, I convinced Mrs H to take a more active role in ensuring that she was receiving the best care possible. She will see her Dr as soon as possible, hopefully when he sees her he will give her the all clear to go ahead with physio as he was the person who referred her in the first place. Hopefully the surgeon had strong reason for the delay in GHJ ROM.
Seeing this patient has been a positive experience for me as seeing this patient prompted me to do some research. I have acknowledged that there are some holes in my understanding of standard rehabilitation protocols.

Evaluation:

It is important to keep up to date with the latest EBP. One of the positive things about musculoskeletal physiotherapy is that this is one area of physio where there is usually ample resources to keep up to date on the latest research. This experience has brought to my attention that I am not 100% confident with post op protocols of many orthopaedic procedures, (including rotator cuff repair). In order to understand why a surgeon may have given certain orders, or when someone needs further follow up I think it is important for me to have a better understanding of what the surgeon has done in each procedure and the standard path of rehabilitation. Because I wasn’t really sure of the norm compared with what this surgeon had asked, I was not confident with what I was doing.

Strategies:

• 
  Set myself the goal of revising general rehab protocols from orthopaedics.
  
• Keep up to date on EBP. Set the goal of choosing at least one case from my patient list each week and research the most up to date information about relevant treatment techniques and prognosis.
  
• If unsure, in the future try and call the surgeon. I might not get an answer straight away but at least I might get some more understanding about the patient from a surgical perspective.