Week Five Entry: Presentation

Situation: The majority of the patients that I have seen on this placement have low tone. One of the first patients that I saw was a 3 year old Down Syndrome child who was at the stage where she was pulling to stand and starting to cruise along furniture, however with her lower limbs in external rotation. I had a strong feeling that this was a compensatory mechanism for a lack of stability around the hip joint and so it got me thinking more about the anatomy around the hip joint. From seeing many other patients with a similar presentation it became apparent that a lot of the activity limitations that children with low tone display are the result of impairments around the hip and trunk. Discussing this with my supervisor we decided that for my 5-10 min presentation that I was to give in my final week, a functional anatomy review of the trunk and pelvis would be beneficial.

Task: Give a 5 -10 min presentation on the anatomy around the trunk and pelvis and discussing the implications it has for paediatric physiotherapy on the child with low tone.

Action: I started getting back into the books, reviewing the anatomy. I decided that two of the major impairments that were evident in this type of of client demographic were muscle weakness and instability. Furthermore I felt that focussing on muscle tissue would be appropriate as it was what we as physiotherapists good impact with our treatment. Whilst reviewing the hip joint I noticed that all the textbooks state that glut med is an internal rotator of the hip joint in practice we always treat glut med weakness with clams. Clams is an exercise based on abduction and external rotation of the hip joint, so appeared to contradict the literature. I contacted my musculoskeletal lecturer to confirm the actions of glut med and felt that his would be a good discussion point for the presentation. I then planned to discuss when each muscle group becomes active during a child's activities of their daily routine, completing the presentation with the common compensations that child will display for weakness and instability.

Result: My lecturer highlighted that glut med can be divided into anterior and posterior fibres. The anterior fibres are internal rotators and the posterior fibres are external rotators. It is these posterior fibres that become weak an effect a person's function, hence why we prescribe clams, as an exercise for glut med. This became a good discussion point during the presentation. I wasn't too sure how to structure how each muscle impacts on function. I could have identified each activity of a child's daily routine (e.g. crawling) and then list the muscles that contribute to the task but decided to group the muscles according to their common action (e.g. hip flexors) and then highlight when they are important to function. I felt that highlighting the common muscles that are impaired in a child with low tone and then the compensations that are observed as a result created healthy discussion between listeners.

Evaluation: I felt that my presentation went better than expected. Whilst reviewing the literature I was worried about how to structure the presentation. It appeared that there was a lot of information to cover within 10 mins and I felt that grouping the information together so that it was relevant and engaging was going to be quite a challenge. I was happy to hear some positive feedback from my supervisors as they felt I was able to turn a reasonably dry subject into an engaging discussion. My presentation did go overtime though. Overall I was pretty happy with how it went.

Strategies: Something I learned from this presentation is to always question what you read. I guess this is a strategy that I will continue to use throughout my career.

Week Three Entry- Intervention and Education

Situation: I had previously attended a home visit to see a 12 month old girl with Down Syndrome. The purpose of that visit was to perform an initial observational assessment and discuss the role of physiotherapy in the service that the commission provides. The mother, being a single parent, worked full time and would drop the child off at daycare in the morning and pick her up at the end of the day. I was therefore asked to attend a visit to the child's daycare with my supervisor, the occupational therapist and speech pathologist. The plan was to observe the child in the environment she spends most of the day in.

On the day that the visit was planned my supervisor called in sick so I had to attend as the acting physiotherapist. On arrival the young girl was asleep and so what had planned to be a visit to observe her routine at the daycare became more of a discussion with the head of the daycare about the child's daily routine.

She was very interested in how she was able to help this child develop but had not worked with a child with Down Syndrome previously. From discussing about what aspect of the child's development she wanted more information about her priority was how she could help the child physically mature. Acting as the physiotherapist, this meant that I would have to educate her on the best ways to facilitate the child's develop. By this stage the child had woken up and so apart from giving education I would also be demonstrating possible handling techniques to progress her development.

Task: Handover the information from the previous visit to the head of the daycare, educate her on the possible strategies that could help facilitate the child's development and demonstrate a few intervention techniques that they could use in the child's routine.

Action: As I had already seen the child at a previous home visit I was able to handover some of the information about what I had observed in regards to the child's mobility. The girl was able to sit independently for greater than 20 mins and reach forward outside her base of support. When she wanted something that was left and right but outside the width of the base she was sitting, she would pivot around to face the object and then lean forward to pick it up. This demonstrated to me that she lacked strength and eccentric control in the trunk particularly in side flexion (left and right) and rotation. The girl was able to mobilise to get toys by rolling with a good segmental pattern. Occasionally when rolling from prone to supine she found it difficult to clear the underlying shoulder and so had create momentum by kicking her legs, performing the movement with less control. In prone lying she was able to prop onto her elbows and weight shift to one side so she could play with toys with the free hand.

It was interesting to collaborate what I had observed at the initial visit with the information they were handing over to me and what I observed when the child was awake at this particular visit. Something that I had not seen that the daycare workers reported was that girl had started commando crawling in the past week. This was not observed during the session but she was able to propel herself backwards using her arms to push off. They highlighted that this was also new.

I mainly educated the head of daycare about the rate of development in a child with Down Syndrome and the main impairments that contribute to there slower development. She reported she was concerned about how slow this girl was developing compared to the other children and appeared worried that they may be doing something wrong that is slowing her down. I reassured her that the girl was developing normally for someone with her condition and that in fact she was progressing well and that it was great to here she is commando crawling, wanting to move at her age. I highlighted that Down Syndrome children lack the tone, strength and endurance of other kids of a similar age and hence the reason that they tend to be quite flexible, which was another concern of the theirs. I described that children will develop trunk control with forwards and backwards movements first and then develop their "side-bending" and rotation last.

When it came to the intervention, as I knew that she was focused a lot on the child's rate of development, I highlighted the idea that we may not change the rate of development with our intervention rather impact on the quality of each milestone so that the next stage of development may be better. My intervention was directed towards areas in which they could incorporate it to their daily routine. I encouraged them to carry her in side lying and demonstrated the technique. Teaching them to lower her from sitting via side sitting rather than straight back was something I addressed and I also covered how to facilitate her to come into sitting by providing a downward force at the hip and tactile feedback at the shoulder. I also demonstrated how to block the hip when she wanted to pivot to reach for something left and right so to encourage rotation at the trunk when reaching. Each of these focused on improving trunk control whilst being simple enough not to disrupt the workers daily routine and limit their available time with the other kids.

Result: By the end of the session I felt the daycare workers understood the purpose of each technique and how to perform them. It was good to see that when for example, I demonstrated how to block the hip, the girl attempted to reach for the toy by rotating at the trunk as this reinforced to them how the technique can help. They appeared more reassured by the end of session that the girl was progressing normally for someone with her condition.

Evaluation: I think overall I handled the situation pretty well. I was particularly happy with how I delivered my education. I felt I was clear and concise, identified what was normal for someone with her condition and as well as what she lacks, which is causing her develop at a slower rate. I think my choices for the intervention were appropriate but where I think I performed poorly was in the demonstration of how to pick up a child in side lying and in the fact that I didn't get the daycare workers to demonstrate the facilitation techniques that I showed them. This was pretty disappointing because now I'm unsure that the intervention will be effective outside the treatment session. Fortunately the head of daycare had told me that have carried babies in side lying before and blocking the hip from pivoting is reasonably simple. Facilitating side lying to sit maybe something I will need to re-visit at the next session. Making sure that the person who is performing the intervention can perform it correctly is something that applies to all areas of physiotherapy and is a vital concept.

Strategies: I think it mainly comes down to remembering to always evaluate a patient's performance of the exercises I prescribe but always thinking about how my intervention will stay effective outside the treatment session will hopefully jot my memory. I also could practice my handling skills with my baby cousin or dolls.

Week One Entry - Assessment

Situation: I attended a home visit with my supervisor to see a 3 1/2 year old girl with Down Syndrome for a mobility review. She is an only child and from previous meetings it was noted that the team around the child included her stay-at-home mother, father, nanna, disability services commission and paediatrician due to the complications associated with the girl's condition.

From the latest individual family support plan (IFSP), which is the name given to the goal setting meeting at Disability Services Commisions, it was identified that the main goals for the family were to progress the child's mobility and more specifically for the child to begin cruising along the furniture. Other goals included the child verbalising action words such as "up" and "help". At the time of the last home visit the girl's main form of mobilisation was via bottom-shuffling and she had not yet been observed crawling with the correct technique. She was able pull herself into standing at the couch but demonstrated a lack of ability to weight bear through her lower limbs with increased hyperextension of the knees and large reliance on the upper limbs for support. She was not yet able to cruise along the furniture, hence the goal set at the IFSP meeting.

Another issue that would need to be discussed at the home visit is that the child is at an age that the family will need to start thinking about enrolling her in a kindy. The commision offers support through the local area coordinator and therapist if the family desires, so a discussion about the possibilities for kindy and whether they would like some support would be useful.

Task: To perform a subjective and objective assessment aimed towards the child's mobility development.

Action: The main aim of the subjective was to get an idea of how the child was developing. When working with children you are not always going to see their best performance on any given home visit so an effective subjective assessment with the mother/father is important to get an insight on how the child is going. I asked the mother about the child's daily routine and if there was anything new or whether there were any concerns. I wanted to find out how the child moves, when does she move and whom does she move for? I also asked about how her communication was going because this was a priority for the family.

As the Disability Services Commission is based on family centred practice I based the objective around observation of the child in their natural environment and looking at how they played and interacted with others. If there was something looked altered from normal I aimed to correct it and see if the child could perform the movement in the correct manner.

Result: The mother identified that the girl had been cruising along the furniture throughout the day but more when her father or nanna was home. Although it was not observed the mother also reported the girl was now able to crawl and did so on various occasions. It was reported that the child's communication was progressing and that the girl had identified on two occasions the need to use the potty with success at using the toilet. The mother voiced some concern in regards to the child's behaviour when playing and that to settle her down she needed to put her in her chair or in her room after persistent poor behaviour. The child would settle for 20 mins but then return to her previous actions. The father would punish her immediately after the poor behaviour was observed so when the girl returned to the room she would not regress back being troublesome.

It was observed that the child was able to pull into standing independently and cruise along the furniture, however each time she did so she led with the left foot from high kneeling with that limb in approx. 70 degrees external rotation. When we tried to facilitate her to lead with her right lower limb she was unable to perform the task. There was no hyperextension of the knees observed. She still used bottom shuffling as the main form of mobilisation and no crawling was observed.

The girl enjoyed turn taking and pretend play with her toy tea-cup set and telephone in cross legged sitting, prone lying and when cruising. She also liked imitation and was able to verbalise two syllable words such as "yellow" (pronounced "lellow") and "mummy". She enjoyed scribbling and attempted to copy straight lines and circles when prompted. The girl did however like to throw toys on occasions and she did not stop when told to do so. The mother identified that it was this type of behaviour that was becoming more common.

Evaluation: I don't think I performed as well as I would have liked to. It was the first time I led the assessment and I think I found it difficult to adapt to working with children. Moreover I found it difficult to communicate and ask the mother questions whilst trying to play with the child and build rapport with her. So although I got the information I needed it could have been a lot more neat, fluid and efficient.

I need to also work on my facilitation and handling skills but I think this will more or less come with practice. I found it difficult to try and facilitate the girl to lead with her right foot especially because she was trying to prevent me from doing so. Observation is something I also need to work on so I am better able to identify impairments and deviations from the normal. For example my supervisor highlighted to me after the session that when the child lowered herself from the couch she would come into sitting through a deep squat rather than controlling it through high kneeling, something that I hadn't observed. I think observation is really important as it seems that the physiotherapists at the commission base most of there objective around this skill.

One positive was that I was able to recognise the major impairments and activity limitations in regards to the child's movement and document it effectively. I feel I did this whilst building rapport with the child and mother so that hopefully I can perform better at the next home visit.

Strategies: As I mentioned I think both these skills are going to improve as I practice and see more patients. I think one strategy that would be useful would be to make sure that I know what normal is. Knowing my developmental milestones and being able to identify normal will mean that it's a lot easier to identify deviations from the norm and recognise impairments in movement.

Intial Entry

I am quite unsure about this upcoming paediatrics placement. Having never had any experience working with kids as a physio I am quite concerned about how I'm going to perform. Although we have been taught the techniques in class there has only ever been one opportunity to get "hands on" experience and so I hope I pick it up quickly. I guess my concern is further fuelled by the fact that not only am I dealing with the child but I'm also working with the family. Something that I seem to be thinking about is whether the parents are going to be happy with a student physio working with their child? I expect that a sceptical parent would be not uncommon and might be something that I will cross during my time at Disability Services. One positive is that I have worked with kids at football clinics before so I'm not completely naive to working with children.

I expect that my supervisor will ease me into this placement. I think she will already know that I lack experience working with kids and recognise that because paediatrics is such a special discipline that I will need some time to develop my skills.

I already know that I will be doing home and school visits so it will be really interesting and valuable to see how each child copes and performs in their normal environment. The way I picture the placement is that I will be doing a lot of observational work, watching how my supervisor handles, treats and communicates with the kids and predict that it wont be until later in the placement that I have more autonomy. Speaking to others who have had paediatrics placements this seems to be the case across the board and I guess its due to both our inexperience in this specialty area but also the concerns of the family.

In regards to my preparation for the placement I think I'll need to know a child's developmental milestones, have a background knowledge of the various conditions and be able to come up with a treatment program appropriate to the child's age and interests. Maybe even know a few nursery rhymes! To be honest though, because our paediatric units involved so much information and it was difficult to go into each condition in depth, I think I'm going to do most of my learning whilst on this rotation.

Beyond my concern is some genuine excitement for the challenge that lies ahead. Although I don't think that I will work within paediatrics in the future I think it is going to be a great opportunity to improve my interpersonal skills and my ability to build rapport. If I by the end of the placement I have improved my ability to talk with kids and their families I think I'll be more confident with communicating with any patient that I cross. Overall it's going to be interesting to see how the program works and the effect that it has on the lives of kids within the community.

FINAL ENTRY: Placement 2 2010

Reflecting back on my initial entry for this placement it appears there were a few expectations that were accurate but there were other aspects of the placement that i had not considered.

Having the ability to interpret your objective findings and create an appropriate problem list was a must, as expected. This ability not only provided the foundation for treatment but was also how our supervisors judged our clinical reasoning. Needless to say it was a necessary skill to have.

Teamwork proved to be an important part of my placement. As per my initial inclinations, there were times where there were a lack of high priority cardiorespiratory patients and so you would treat patients together with another student. Furthermore, working on an acute surgical ward meant that patients had many attachments and so most of the time there were at least two of us working with the patient. Having the ability to manage attachments was something that I had not considered prior to the placement and proved to be an important skill.

I was right when I thought that I would not have the same level of autonomy as with my musculoskeletal placement. My supervisor needed to be sure that I was safe in regards to interpreting obs and with my manual handling before I was able to see patients on my own. As mentioned before I often needed an extra set of hands with patients which meant that I also had to be able to communicate effectively and take control of the situation at hand. I also found it beneficial having the support of my supervisor in the early stages. I felt more confident dealing with patients and it was great having a another person there to "bounce" thoughts off each other when there were alarms going off and a medically unwell patient lying in bed. I think if I didn't have that support early on it would have been too overwhelming.

I thought that I would need an extensive knowledge of pathology for this placement. This tended not to be the case for me because I was working on an acute surgical unit. Although I needed to have a basic understanding of some cardiorespiratory conditions what was more important was having a knowledge of the various procedures and how that surgery would effect a persons risk of developing a post op complication. I also needed to know the various protocols for each surgery.

Overall I have really enjoyed this placement. I have learnt a lot about how to deal with complex patients and prioritise them appropriately. I enjoyed the opportunity to work with other health care professionals and work as part of a team to improve a persons wellbeing. As I previously expected by the end of the placement I was managing my own caseload and running the ward and I feel that having that responsibility has progressed my learning immensely.

Week Five Entry: Discharge Planning

Situation: I had been seeing a patient a couple of weeks ago who had been admitted to emergency via ambulance with respiratory distress. He had collapsed and was transfered to ICU with the diagnosis of an infective exacerbation of his COPD. The 68 yr old male underwent a surgical trancheostomy as he was heavily sedated and was therefore unable to manage his own airway and secretions. He was transfered to the ward I was working on after a length of stay in ICU of close to two weeks and upon removal of his tracheostomy.

After the initial assessment it appeared that his chest was clear and that his main cardiorespiratory problems were airflow limitation (as a result of his asthma) and decreased exercise tolerance. He was morbidly obese and was a full sling hoist transfer, when previously he was independant with a walking stick. Something that further complicated the situation was that he was experiencing significant memory loss in regards to some aspects of his lifestyle prior to admission. He was confident about his living situation at home and how many flights of stairs etc. he had but was unable to identify whether he drunk alcohol or whether he normally had a cough, to name a few. His confusion was gradually improving but he occasionally was inconsitent with his answers to subjective questioning and often responded inappropriately.

Task: As the patient was improving medically and his chest was clear it was time to start thinking about discharge planning. My task was to come up with an appropriate discharge plan for the patient and discuss it with my supervisor.

Action: As the patient was significantly deconditioned and nowhere near his baseline, as he reported to us, I knew that this patient would require some form of rehab. Currently he was able to stand with a wheeled zimmer frame with 2 x mod assist and was able to stand for 30 secs only. Because the medical team was close to discharging the patient I automatically thought that they were thinking of sending him home so I had decided that sending him with RITH and possibly a home care package would be appropriate.

Result: It was decided by the team that he would require inpatient rehab and that V5, the rehab ward at Fremantle, would be an appropriate option.

Evaluation: Reflecting back i felt like i performed this task poorly and my discharge planning requires significant improvement.Unfortunately up to that date I did not really understand all possible discharge options available. Being on a surgical ward most patients that I had seen were close to there baseline by the time they were medically stable, so discharge tended to be simple. I automatically thought that because this patient was independant beforehand that he would be able to return home with a program such as RITH and be fine. I never even asked myself the obvious question, "can the patient go home?". I think if I had asked myself this I would have planned a lot better. I guess I also didn't realise how quickly the medical team were planning on discharging him and did not consider factors such as his length of stay and confused mental state. Looking back it seems obvious that he required further intensive rehab so inpatient rehab would be appropriate.

As the patient was quite confused and suffering from considerable memory loss it would have also been appropriate to contact the next of kin to identify what his true baseline was and how he was coping at home prior to admission. This would have given me some valuable information to make an educated decision about his discharge plan.

Strategies: Whenever I attend a new placement or am working at a new facility I am going to make sure that I understand all the discharge options available. I think that now that it is week 5 of my placement that my discharge planning has improved significantly because I have progressed my understanding of each of the discharge options and the various packages and services available. I think that as I become more experienced this will naturally improve and I will be able to make better discharge decisions.

Week Three Entry- Analysis and Planning

Situation: I was asked to see a 80 year old female for mobilisation on 8.4.10 . She was admitted via the emergency department with the onset of severe abdominal pain within 24 hours and underwent a incisional hernia repair on the 30.3.10 by midline incision. She had a revision laparotomy and hernia repair 2 days later due to complications. The patient had a past medical history of unstable angina, myocardial infarcts, postural hypotension and multiple transient ischemic attacks. Between the time of her revision surgery and the day I was due to review her mobility she had had 3 codes, all for decreased oxygen saturations. I had already seen the patient for chest physiotherapy and she had been taught deep breathing exercises, a supported cough and techniques to relieve shortness of breath. The fact that she had not yet mobilised was due to her unstable medical condition. On the 8.4.10 it was handed over that the patient was now medically stable enough to commence mobilisation.

Subjective examination revealed no pain at rest, moderate dyspnoea and a productive cough as the main findings. O2 saturations were at 98% on 37% high flow nasal prongs, BP was 131/69 and other obs were stable. Cough was strong, dry, productive of minimal clear sputum and effective. Auscultation revealed early fine inspiratory crackles bibasally and fair breath sounds throughout. Basal expansion was fair bibasally and left equaled right.

Task: Plan an appropriate treatment for the patient.

Action: I decided that transferring the patient to a high back chair would be an appropriate intervention. This would help to improve lung volumes and encourage basal expansion. Mobilising the patient would also improve tidal volumes and help shear secretions off the airway walls. The plan was to sit the patient over the edge of the bed. I would expect that the patient would be dizzy from lying in bed for an extended period of time. Once the dizziness subsides, with a wheeled zimmer frame we would stand and perform a step transfer to a chair next to the bed. I would require the assistance of another physiotherapist/nurse throughout and due to the nature of her condition I would be monitoring her vital signs closely.

Result: The patient was a 1 x minimal assist with rolling onto her side and a 2 x max assist to sit over the edge of the bed. As expected the patient experienced substantial dizziness and nausea when sitting over the edge of the bed, which eased after approx. 3 mins. Sats were stable at 97% and HR was within normal limits. Even so my supervisor suggested that we take a blood pressure reading. It indicated a drop in systolic BP with a reading of 120/67. We still deemed it safe to attempt a transfer as the patients symptoms had subsided. Upon standing with 2 x max assistance and a wheeled zimmer frame the patient reported dizziness and nausea. The patient could only tolerate standing for 5 secs before the dizziness increased so we sat her back on the bed. This time the dizziness took 5-6 mins to ease, her saturations had dropped to around 90 and she reported some minimal chest pain. I decided that transferring her to a chair would be a bit optimistic. Hence once her symptoms eased I got to perform one more sit to stand and take a few steps sideways so that I could position her in a more upright position in bed. When she stood up the second time the patient was a lot more stable and her work of breathing was not as high so I encouraged her to attempt stepping towards the chair for a transfer. The pt was reluctant to do so, even with encouragement, so we sat her down and transferred back into bed, with it tilted in an upright position.

Evaluation: I think transferring the patient to a chair was an appropriate choice of treatment. I think where I needed to improve was my ability to quickly change my plan when things don't go as expected. I thought that the patient would be able to complete the transfer after the second standing attempt but because the patient was reluctant to do so we had to decide on the next best option. I guess I feel my ability to plan before treatment was sufficient but where I need to improve is my ability to quickly plan the next step throughout the treatment session.

I always need to remember to ask "why?" when symptoms appear and then think of what I can do to ascertain the cause of the symptoms. In this case I should have realised that taking the patients blood pressure would have been a appropriate measure to ensure safety with performing the transfer.

Strategies: I think this is going to take practice and will improve with experience. The more patients I see the better I'm going to get a planning ahead. It's important not to get flustered in situations such as these so taking a few seconds to pause, think and take a breath would be a good strategy.