STARES WEEK ONE: Assessment

Situation: I was asked to see a patient day one post elective surgery for the removal of an abdominal hernia. Her obs were stable, she was saturating at 100% on 2L of oxygen via nasal prongs, she was alert, orientated and afebrile but had not mobilised since surgery. She had an indwelling catheter and nasal prongs as attachments. It was documented that the patient had experienced no operative complications, her chest was clear and that she was previously independent with her mobility. The only possible complication to early mobilisation was that she was overweight. Although it would be important to see her day one post op I had planned to see her in the afternoon as she was not a high priority patient for physiotherapy. The patients nurse, however, wanted to get her up for a shower in the morning and so had asked for my assistance. The task would have to be quick and brief as there were other patients that were a priority for me.

Task: Together with my peer, perform a brief subjective and objective assessment, and with the nurse transfer the patient from the bed to a commode so the patient could be showered.

Action: We performed a subjective assessment asking the patient about pain, nausea and vomiting, dizziness, shortness of breath, cough, previous level of mobility and how she ambulated pre surgery. When it came to the objective assessment we decided it would be important to do a quick manual muscle test of the lower limbs so we could get an idea on the best way to transfer her. As she reported that she did not have a cough and she didn't have any shortness of breath we decided, with the limited time available, to not perform a routine cardio objective assessment today.

Result: The patient reported pain, 5/10, over the incision site, which increased with movement. She reported no chest pain, no cough, no production of sputum and no shortness of breath. The patient was previously independent with her activities of daily living and ambulated independently over indefinite distances with a quad stick. We decided to transfer her from supine to sit so we could perform the manual muscle screening. She was a 2 x max assist to get into sitting over the edge of the bed. This increased her shortness of breath score from 0/10 to 4/10. From the screening it was established that she had on average a grade 4 strength in the muscles of her lower limb and so it was decided that a step transfer would be suitable. Using a pulse oximeter we measured her 02 sats on room air (RA) as we would need to remove the oxygen to get her into the commode. Her sats were stable at 100% on RA so we decided it was safe to perform the transfer. With 2 x minimal assist and the patient using her quad stick, she took 5-6 steps forward so we could simply place the commode behind her to sit back down.

Evaluation: I felt the actual transfer itself was done efficiently and in a safe manner. It was performed in a way that did not put strain on us as therapists and that did not increase the pain of the patient. Reflecting back on the situation we should have performed the manual muscle test prior to positioning the patient sitting over the edge of the bed. This would have given us an idea that the patient had reasonable muscle strength so we may have chosen to perform a "supine to sit" transfer that was not a 2 x max assist and instead chosen one that encouraged a greater level of patient involvement.

Strategies: I think it's always important to encourage as much patient involvement as possible in our treatment sessions, after all one of the main aims of physiotherapy treatment is to get patients back to there previous level of function. I think an important strategy is never to assume that a patient is at a certain level of function based on initial observations. I think the best way to choose a transfer option is to consider the most independent transfer first and then if you don't think the patient is capable, consider the next most independent transfer and so on. This way you will promote patient independence and speed up their recovery.

Initial Entry 2nd Placement 2010 (Cardiorespiratory)

All of my placements to date have been musculoskeletal based so I am quite nervous about my upcoming cardiorespiratory (cardio) placement at Fremantle hospital. Not only this but it is also my first placement in a purely inpatient setting of a hospital, which is further enhancing my anxiety. Amongst this uncertainty I am excited at the prospect of working on a ward with a multidisciplinary team (MDT) and working with patients with more complex and critical conditions.

I expect that on my first day I will have a general orientation, be introduced to how the department works, how the ward functions and some of the types of patients that I may be seeing. I don't think I will have the same level of responsibility as early as I did with my musculoskeletal placement. I'm expecting that initially I'll be under the supervision of a physiotherapist because I will be dealing with patients in a more critical condition, but by the end of the placement I am sure that my supervisor will be wanting me to manage my own caseload. Speaking to students whom have already attended the placement it seems in some circumstances there are a limited number of patients that require cardiorespiratory physio and so they have been paired up to work with another student. This could possibly create conflict when a pair has contrasting ideas on the treatment of a patient but overall I think it would be beneficial to be able to "bounce" ideas of each other and clinically reason as a team. It would probably enhance our communication skills and facilitate our learning.

I expect that knowing the cardiorespiratory problem list is a must. I will need to be able to use my objective findings to justify my analysis and be able to document all the information appropriately in a soapier format. I suspect that knowledge of the various cardiorespiratory pathologies, types of surgeries, the effects of anaesthesia and the different types of interventions will also be vital.

The fact there is so much information compiled into out third year cardio unit is one of my major concerns. The idea that I could be presented with any one of the conditions we have studied, and possibly more, then have to interpret the vast types of objective markers and treat accordingly seems a little daunting. As mentioned before, I'm also a little concerned about working in a hospital setting when I have never really worked in one before.

Although it probably seems that I am quite fearful about this forthcoming placement I am looking forward to the challenge. As I have been based in the musculoskeletal setting for each placement thus far I have always felt that musculoskeletal physiotherapy was for me. I see this placement as my first opportunity to experience and discover another aspect of physiotherapy that I may enjoy.

Final Entry

Reflecting back on my initial entry for this musculoskeletal placement I feel that I was reasonably accurate with my expectations. From day one I was given the autonomy to see my own patients without having someone over my shoulder. Although it seemed daunting to start with I think that it was the best way for me to learn and I have gained valuable skills from being put in that situation. For the first two weeks I needed to report back to my supervisor after both the subjective and objective to show that I was conducting a safe and relevant assessment and that my clinically reasoning was valid. By week three I was completing my assessment and then discussing the treatment with my senior and by week four I was assessing and treating my patients without having to consult my supervisor. I think it was in these last two weeks that I thrived and felt that I really improved. I think maybe it was because by him having the confidence in me to see my own caseload it gave me more confidence in myself.

The expectation that I was going to see an array of patients and those with complex cases was accurate. I treated patients with MRSA, pain dominant presentations, centrally dominant pain mechanisms, obesity, diabetes and cancer to name a few. It really made me have to take a holistic approach to treatment and consider issues of infection control, appropriate exercise prescription and education etc.

Time management was another key skill that was required and something that I feel I further need to improve on. As my caseload increased so did the paperwork and so being able to perform a relevant assessment then treat appropriately and document the session became a challenge. I learnt the key to time management is a thorough and accurate initial assessment, I think if this is achieved and assuming you have treated the diagnosis appropriately, it makes the follow up assessment easier. If you don't perform a thorough initial assessment the problem can become more complex than you initially thought and chew up time that don't have.

Overall I thoroughly enjoyed my musuloskeletal placement. Having the responsibility of seeing my own caseload has really prepared me for the future. Being put in the deep end at the start of the placment really challenged my assessment and clinical reasoning skills and I think I have really benefited from the experience. One of the biggest things that I learned on the placement is that although we learn a lot about common presentations and patterns for certain conditions, it is not always the case in real life. Patients are often more complex so it is important to have an open mind during assessment and restrain from looking for issues that you think make up the problem but are not there. I found that it's important to treat what you see and always ask yourself "why?" when there is an impairment. I feel that this placement was a truly valuable experience and one that has prepared me to step out in the workforce at the end of the year.

STARES WEEK THREE: Analysis and Planning

Situation: I had been treating a 60 year old female who had been referred for headaches. On presentation the patient reported that they had suffered from "migraines" for 20 years. The headaches sometimes came in clusters having 3 or 4 in a row every 3 weeks. She described the pain as an ache that started in the neck and worked its way into the head. The pain most commonly occurred on the right but could shift to the left between episodes. She complained of no nausea or vomiting and only had described an aura on one occasion. Aggravating factors included stress and fatigue.

On objective examination I was unable to reproduce the patients neck pain with active movements, over-pressures, sustained movements or combined movements. Passive accessory examination produced no asterisk level. The patient did have a chin poked posture so I decided to assess her deep neck flexor recruitment and sternocleidomastoid seemed quite overactive. Her neck pain was then reproduced on palpation of the sternocleidomastoid origin. She also had decreased muscle length of upper trapezius which could be a result of her stress.

Although I don't think the patient suffered from true cervicogenic headache, on examination it seemed that the neck pain could possibly be a trigger for a her headaches. Treatment therefore consisted on addressing the patients postural issues with deep neck flexor recruitment exercises, stretches for upper trapezius and education on pain management such as the use of heat and relaxation techniques.

Task: The patient had been progressing well and not suffered from headache since starting treatment so the task was to start organising her discharge.

Action: For discharge the patient would need a comprehensive home exercise program and learn to manage her own neck pain. I continued with postural activities and stretches to maintain muscle length. I also addressed her ergonomics when sitting at her computer. As her aggravating factors were stress I taught her some relaxation techniques and suggested the use of heat for pain management. Part of my intervention was to educate her on the different type of headaches that she suffered from. I had to explain the headaches that we could manage biomechanically but that if she suffered from another aura that she would need to take her medication for migraines. Overall I had to make sure she no longer suffered from her symptoms and that she would be able to self manage in the future.

Result: The patient was going on holidays for 6 weeks so I had to decide whether to discharge her or transfer her to another physio upon return. Although she had been progressing well I had only been treating her over a 2 week period and since she suffered from headaches in clusters every 3 weeks, I was unable to tell if my treatment had been truly effective. Hence it was decided to write a transfer summary explaining the clusters of headaches and that should she need a follow up she would book an appointment after her holiday.

Evaluation: Overall I think I made the right decision. The aim of treatment is to make improvements in a patients symptoms. I was unable to ascertain whether my treatment was effective or whether natural history was the reason for her not having suffered from a headache during the time I had been treating her. Therefore giving her the option of another appointment if she suffered from a cluster of headaches in a week or twos time seemed appropriate.

Strategies: Always consider a patients natural history of symptoms when considering discharge.