Final Entry

Five weeks at Osborne Park Hospital on the stroke and general rehab ward are over and I’m pleased with my efforts over this time, but glad that it’s over. I found this placement to be a very beneficial one, as I predicted in my initial entry and feel that I’d be performing at a graduate level for working with stroke patients. I believe that most of my initial entry predictions were fairly true and I definitely started off pretty nervously, but I certainly grew into the position as time progressed and become more and more confident that I could handle the different scenarios that were thrown my way. I found I was able to call on my knowledge from PHTY 314 pretty well, although at times I was able to call on the knowledge but not able to put it to good use with my treatment, which I was disappointed in. My supervisor identified this as well, so I will definitely be making a greater effort in the future to know clinical implications or relevant treatment techniques for situations where I am able to identify specific abnormalities about a patient. Overall though, I was very pleased with how I performed on this placement.

My predictions about the nature of the placement were close to spot on, where I started off with a smaller case load and more supervision and progressed in the final weeks to a larger more complex case load with minimal supervision. For example, in my first week, I would see on average around 4 patients per day, consisting of 2 stroke unit and 2 general rehab patients. My stroke patients had all been on the ward for quite a while, but my tasks in the first week were to conduct initial assessments on them as if they were new admissions. This was also done with my supervisor present. By the end of the placement, I was generally seeing 3 or 4 stroke patients and 3 or 4 general rehab patients a day, plus attending up to 2 meetings a day, so my case load increased significantly, meaning that my time management skills had to improve as well, which they certainly did. In my final weeks, I was entrusted to perform initial assessments independently, which was a good indicator for me of my growth over the placement.

I had 2 supervisors for this placement, 1 for my stroke patients and 1 for my general rehab ones. Both made sure that my progress was tracked well along the guide for the placement that has been provided on blackboard. It was very well set out and focussed initially on assessment techniques, then on treatment techniques in the 2nd week and on improving and progressing these areas in the final weeks. This was shown by the SOAPIERs that I had to hand in at the completion of my first 2 weeks. The first was quite short and focussed more on the objective assessment and then analysis sections. While the second that I handed in was almost 3 times as long as it was much more detailed in the O and A, but also included a comprehensive plan, intervention and evaluation. My supervisors told me at this point that my growth and improvement were fitting in well with the placement guide and their expectations of me. One of the things that was very much consolidated in my mind during this placement was the importance of accurate assessment. I learnt that through a thorough and effective assessment you can easily identify what the patient needs help with, consequently making your treatment objectives very easy to identify. This is definitely something I will take forward with me into the future.

My prediction that I would feel like a part of the team as time progressed also turned out to be correct, which was demonstrated well in my final journal entry. It wasn’t just because I knew people’s name or that they knew mine by the end of the placement, it was the fact that I was able to make valuable contributions to the team, enabling better patient care for both my stroke and general rehab patients. The example I used in my third journal entry was a good one, where it was my confidence to feed my findings back to the medical team that enabled them to get a better understanding a patient’s thoughts and feelings and subsequently help manage her treatment the way she wished for it to be handled. Although on this occasion it wasn’t really a favourable outcome, as the patient essentially had decided to decline any further treatment, it was still a good lesson for the positives of an effective multidisciplinary team.

My initial concerns about starting a neuro placement were not a great issue in the end. As I previously mentioned, I felt I did well when recalling on required knowledge, but at times it was just the application of this knowledge that let me down. I didn’t really have any problems with my neuroanatomy because I found that an accurate assessment will outline your treatment goals irrespective of the anatomical site of damage in stroke patients. I also learnt that in a neuro setting, the patient will often have impairments that you as the physiotherapist cannot treat directly, but that we do have strategies that can help to reduce the implications of these impairments. For example, visual field defects, inattention, dysphasia and dyspraxia are all impairments that have considerable implications for providing treatment, but by identifying them, you can incorporate strategies into your general treatment to try reduce the impact of them. By being aware of them, you can use single commands for dyspraxia or encourage the patient to turn their head and be aware of the side where they may have visual defects or inattention. All of these things can be identified through simple assessment techniques, but play large parts in the structure and methods you use during treatment.

My final concerns about case load and time management, weren’t large issues in the end either. They both increased and improved pretty naturally as I became more confident and familiar in the environment and developed good routines. For example, many of my general rehab patients would be in pain before physio treatment, so if they were written up for pain relief medication then I would advise them to get some to enable rehab effective time with me. I learnt that by checking on the patient and their pain levels 20-30 minutes prior to your scheduled session time with them, you can get them to have the required relief and come back when it has begun to act. This minimises the amount of wasted time spent waiting for the patient’s pain levels to be manageable. In the time in between I could either see another patient or write up my notes. It was little things like this that I picked up over the duration of the placement that improved my time management.

The initial concern of supervision also proved to be something I need not have worried about. Both of my supervisors were always there to lend support whenever I needed it, but at the same time left me to be quite independent as soon as they felt I was capable. I mentioned previously that the level of supervision was initially very high, which was good while I found my feet, but then as time progressed I saw more and more patients on my own. I felt I handled these situations well, but was also able to call on assistance whenever I felt I needed it, which was good for my development as a student therapist.

At the end of the 5 weeks at Osborne Park Hospital I am pleased with my performance on the stroke ward, but I am also glad that it is over. I found it to be pretty challenging and a different environment and certainly different patients to what I was used to. At times I found it hard when I was seeing such little progress with my patients because of the extent of their impairments. I found it even harder when patients that had worked so well for an extended period of time, only to move backwards in terms of their rehab status. This was the case with one of my patients who was almost ready for discharge, when they had another stroke in my final week and subsequently were set back a long way. I suppose I just have to get used to difficulties such as this being present in areas of the physiotherapy and general health care line of work. It also continues to surprise me how tired I am at the end of a working week, but I am slowly getting used it. I will certainly enjoy some quieter time this week plus extra time to prepare for my next placement.

Entry 3 - Intervention (25/04/2010)

Situation: I had been treating a very elderly woman for about a week and a half, when out of no-where she refused physio treatment 2 days in a row. I thought this to be very strange as she was a very pleasant woman who had previously been so enthusiastic and always enjoyed her rehab physio sessions with me. The woman was at Osborne Park Hospital for ongoing rehabilitation following a left hemiarthroplasty, performed because of a fractured neck of femur (NOF) suffered from a fall outside her home. The first 2 days that the woman refused treatment I didn’t really think too much of it. On those days she reported feeling very tired which I didn’t feel was unreasonable as she’d had multiple investigations such as CT’s and X-rays on each of the days and told me she had slept poorly on each of the previous nights. After the second day I did have a quick chat with one of the members of the medical team regarding the investigations that were being performed, his response was that some of the patient’s symptoms such as her abdominal pain could have been linked to cancer, so they were investigating this further.
When I went to continue with the rehab the following day and the patient refused again, I wanted to look into this more, so asked some additional questions to ones from the previous days. During a lengthy discussion with the patient I discovered that the she had basically had enough, did not want any further treatment and just wanted to go home. She told me that she felt her “time was up,” referring to her life, suggesting that she didn’t feel she had much longer to live. She told me multiple times that she had “lived a good life” and as such was “happy to go.” She also explained to me that she felt she may go unconscious soon and if she did, she did not wish to be resuscitated. After the events of this conversation I knew I had to relay my findings back to the medical team.

Task: My ongoing task for this patient was to provide rehabilitation for her hemiarthroplasty to get her a point where she would be able and safe for discharge home from the hospital. She was living with her son at home and this was to be her planned discharge destination, so I had to get her to a state where she was independent with transfers and mobility so she could go home.

Action: After becoming aware of my patient’s thoughts and feelings, I was quick to assure her that the doctors and the whole team were doing their best to try and help with her pain and recovery. I explained that the tests that had been performed were necessary to try and ascertain what was causing her problems. I also reminded the patient of her sons and all the stories she had told me about them and asked her if they knew about her current state of mind and if so what they thought about it. She responded by saying that they were fully supportive of her decision, a response that I was not utterly convinced about, but nonetheless took on board. Apart from what I had already said and explained to the woman, I felt that I was out of my depth to say much more on the subject to her, so I headed straight to the doctor’s office to let them know about my conversation.
I explained to the team that was present all the events that had occurred prior to the conversation and exactly what was said during the conversation itself. The registrar said that they were aware of the patient’s low mood over the previous few days, but were not aware that the patient did not wish to be resuscitated in the event of an emergency. They thanked me for my findings and went straight in to have a further discussion with the patient about the matter.
When they had finished with the woman, they came back to me, thanked me again for my efforts and we had another lengthy discussion concerning the patient. In summary, the patient informed the team that she’d decided not to have any further investigations performed and that she wanted it officially put on the record that she was not to be resuscitated if it came down to it. They explained to me that their goal was to get the patient medically stable to enable her to be discharged home as she wished. Until then she was to remain in the hospital and I would still continue to be her treating physiotherapist. I was told, that I could try my absolute best to get her to do some rehabilitation exercises, but if she refused, then I had to respect this decision and there was nothing that they or I could do about it. I made sure that I documented precisely and thoroughly the events that had transpired, so that there was clear records of exactly what had happened over the previous few days.

Result: In my final week, I managed to get the woman to go for a short walk on just 2 occasions, but there was no additional rehabilitative therapy to go with these. She was still in a fair bit of pain and having bowel problems on my final day at the hospital and it had not been confirmed as to exactly why her symptoms were present. During the week I was trying most mornings and afternoons to get her to go for a walk or do some exercises and tried many different approaches, most to no avail. I tried saying that she may feel better after a walk, referred to the doctors saying they felt she may feel better, said that she could relax for the rest of the day after a walk or that she could sleep better if she does a bit of exercise. When it did come time for me to finish at the hospital she was still medically unstable and consequently was waiting to be discharged home.

Evaluation: I feel I did really good, learnt the importance of liasing with the whole team, although in this incidence it wasn’t the best outcome, I still learnt that its good to do it, coz u don’t know what u might get out of it, I strongly encouraged her to at least go for a walk with me if she wouldn’t go to the gym, but at the end of the day it was her decision and there wasn’t much that I could do about it
On reflection, I feel I acted appropriately under the circumstances and actually performed pretty well. The unfortunate part of the situation was that I couldn’t get the patient to attend physio treatment sessions as often as I would have hoped, but I feel that I did as well as I could to try and make this goal of rehab a reality. I learnt the importance of effective liaison with other members of the multidisciplinary team, which in this case were the doctors. I felt I showed I could be a responsible member of the team who had vital information to present and this was fully understood and acted upon by the doctors. I also felt that by going to them after the second day, to try get an understanding of the situation was a wise move as it prepared me well for the conversation that I had with the patient the following day, that resulted in me being able to abstract so much important information from the patient for the first time. By attending to the patient twice a day where possible it gave her every opportunity to come with me for her physical rehabilitation, which is why she was initially transferred to Osborne Park Hospital. At the end of the day, I left it up to the patient to decide if she wanted to participate or not, as per the medical team’s advice, however I felt I did all that I personally could to make this achievable. I was pleased with my performance, despite a less than desirable outcome for the patient personally.

Strategies: Above all, this situation taught me that I personally can contribute and be a valuable member of the multidisciplinary team, despite my status as a relatively inexperienced student therapist. I realise that I should have known I still play an important role in the team despite being a student, but this experience just proved to me more than anything that I do belong and do have worth in that environment, which was encouraging. By liaising with other members of the team so much, it also showed that I can learn a lot of important information from others, which will help me when treating my patients, but also that I can in turn provide information that can help others. In the future I will definitely be trying harder to get more out of the others members of the team, plus contribute by passing on what I know. I was also reminded of the fact that you can’t force a patient to engage in the treatment routine. It’s ultimately their choice and if they are refusing treatment, then you have to respect this decision and move on. I feel that giving my patient two opportunities per day was appropriate as it was important that she try to participate in rehab, however, spending any more time than this probably would have been a waste of my time. It really is important not to dwell on a patient who has refused treatment because you invariably have plenty of others who would appreciate your time and efforts much more. Finally, I discovered some new ways of trying to get a difficult patient to agree to treatment, both from my own accord and from my supervisor. These include the ones mentioned previously such as feeling better, doctors, sleeping better plus movement helping if needing to go to the toilet and multiple attempts in a day. None of which were particularly successful with this patient, but were on others that I treated during this placement and that I could see myself using in the future when encountering difficult patients.

Entry 2: Assessment (11/04/2010)

Situation: On Monday afternoon I was told by my supervisor that there was a new patient on the stroke ward. She told me I was to be his treating therapist and to start with an initial assessment. I had 2 hours until I would be seeing the new patient and I had two of my other patients that I had to see before then as well, which would leave me very little time to prepare. In the very brief amount of time that I did have to review the patient’s history, I found out that he had been transferred from Sir Charles Gardiner Hospital (SCGH) to Osborne Park Hospital over the weekend but had not yet received any physio treatment. I did have the patient’s SCGH notes that came over with the discharge, however it was missing many relevant and important sections, such as discharge documents and investigation results. I basically had the progress notes to skim over within a few minutes. From them, my main findings were that the man was very dysphasic, both receptive and expressive, and was dyspraxic too. I knew immediately that these would play a large part in how I went about conducting the assessment, because it becomes very difficult to conduct an assessment on someone with whom it is difficult communicating. This was to be my first initial stroke patient assessment and with the limited preparation time and a communication barrier looming, the lead up wasn’t ideal, however I still approached the situation with confidence and wanted to do a good job.

Task: My task was to perform the initial neurological assessment on this man with the aim of completing it in one session, and then to complete the necessary initial stroke outcome measures the following day. My supervisor would be present for the session, however I was told to conduct the assessment as if she was not there and that she would only have input if she felt I required it.

Action: When I arrived at the man’s room I was surprised to find that his mobility chart had already been filled out. As it turned out the weekend physio had completed this when the man was admitted over the weekend. He was written as ambulating without aids with a standby assist, so I introduced myself, explained what my plan was for the session and walked with him to the physio gym. Having been with the man for less than 5 minutes at this point, it was already evident to me the extent of the dysphasia and dyspraxia. The man’s only response to my questions was a yes or no answer and even these did not correlate appropriately with what the man was doing. This lack of response to many of my initial questions was a sign of the breakdown in communication ability. I very quickly learned that there was going to be no point in trying to get any kind of subjective history out of this man, because he simply could not communicate effectively. I began objectively assessing the man, with things such as his vision and cranial nerves. This again proved to be very difficult, but also time consuming and I had large questions over the validity of the results I was obtaining from the man. I began assessing things such as his volitional movement and range of motion using methods such as demonstrations and beginning the movements passively for the man, who could not comprehend what I wanted him to do. It got to the point where I had about 10 minutes to go of my 45 minute session and I was still looking at these same kinds of range of motion assessments. I then decided to turn to my supervisor to ask for her thoughts about the situation and how I should finish off. Her response was that I was doing well with what I had done thus far, especially with the use of demonstrations and passively moving the man to initiate movements to perform the assessment. She then went on to say that if I was to continue as I was then we would both be there until Friday afternoon trying to complete this initial assessment and advised me just to do what I could easily assess for now and then finish up. I took this on board and looked at tone, which is more of a therapist guided assessment, but then went onto functional abilities of rolling, supine to sit, transfers and eventually gait, all of which required demonstrations and heavy hands on guidance and facilitation to achieve the desired movements. This worked well and was much quicker as it was not relying on the man’s comprehension of the spoken word. It was for this reason that I abandoned testing things such as sensation, strength, cerebellar signs and balance, as I would not have obtained true results due to the patient not being able to understand my instructions for the testing. I was now out of time, and hoped that the man would be a bit better the following day when I would continue my neurological assessment.

Result: The result of my actions was that I had a very patchy-looking initial neurological assessment sheet when I had finished the session. I documented all that I had found, as best as I could in the notes, which again was difficult with the subjective history due to lack of transfer notes and the state of the patient himself. I did the best that I could with my documentation though, and left the assessment ready to come back to it the next day.
My session the following day with the man did turn out to be much better than the first. I was able to complete the majority of the assessments I had left from the previous day and also began with some outcome measures such as the Gowland and motor assessment scale. It was still very difficult however, to verbally communicate with the man, but I persevered as best I could. One thing that I did observe was a difference in many of the findings from the previous day, for example active and passive range of movements and some differences in posture. What this meant was that I had to alter some of my findings from the previous day in the notes, which I did under the objective heading in my SOAPIER. Although it took me about twice as long as it was supposed to, I achieved my task of performing the initial neurological assessment.

Evaluation: On reflection, I was quite dissatisfied with my performance, even under the circumstances. I felt that I was far too slow, which was both a product of having a difficult patient, but also a reflection of my ability to perform the different assessments. I found myself constantly having to stop and think about exactly what I wanted to do next with the assessment procedure, which proved to be costly in terms of time management. I felt that if I had have known some of the assessment techniques better, then it would not have taken me as long to complete the process. Despite this, I was happy with my decision to turn to my supervisor at the point when I did because it guided me in the right direction to finish off. I knew in my own mind that this was not a plea for help from my supervisor, but more a quick comment on how I was actually going and what I could do to be better. I hope that it came across this way and not as me struggling to cope with the situation. My thoughts about the performance were eased a little when my supervisor explained to me that it was a very hard patient to perform my first initial assessment on and complimented me on the effort that I did put in. However, I was still disappointed in myself as I felt it could have been done much better and more effectively, particularly on the first day, when things seemed to go so slow. I was glad to have the practice though and hopefully after having a difficult case first up, it will put me in good stead for my next new patient and if it is a difficult case again, then I will be all the more prepared.

Strategies: On reflection, I became aware of many new strategies from this experience. Strategies that were identified by both myself and my supervisor, but all of which I intend to utilise when assessing and treating in the future. The first of which is very important when assessing any population, but particularly stroke patients, is that of being very observant and in this case, the more informal observations. My supervisor and I had a lengthy discussion about this after my initial session, where she felt that many of the things that I was attempting to assess, but was having difficulty with due to dysphasia and other impairments, had actually been demonstrated by the man whilst he was doing other activities. She advised me that with good observational skills you can mark the patient down as having the ability to perform a certain skill or movement because you have seen them do it elsewhere, even if you have not formally assessed it. From this, I definitely intend to become more observant, and improve this very important skill of an effective therapist.
The next strategy was easy to identify because I had a fair bit of trouble with it initially and that is, knowing the tests, assessments and outcome measures well enough to execute them effectively and efficiently. I have found that knowing these well can increase your efficiency dramatically, as it means you can chop and change the assessment you are performing, according to the position that you currently have the patient in, minimising time wastage from constantly changing position.
Thirdly, I learnt that to get the desired response from the patient may require using a number of different communication methods. Due to this particular patient’s difficulty in comprehending what I was saying to him, I had to resort to demonstrations and hands on guidance and facilitation to initiate movements. For most people I will obviously have to use more verbal communication, but it is important to know that there are alternative methods such as the ones afore mentioned, as well as sensory, written, including written words and pictures plus videos or photos and sometimes more. Having these different methods of communicating and showing the patient what you want them to try and do means that you will be able to conduct a more comprehensive and effective assessment and get correct results.
Finally, from this particular situation, I learnt you can only ever do so much under particular circumstances. With this patient, there were still some parts of the assessment that my supervisor and I discussed and decided were not even worth doing due to the patient’s comprehension difficulty. In this instance, I was experiencing difficulty during the initial session, but I did what I could in the allotted time frame and then came back to continue the following day and thankfully things were slightly improved. I found that there was no point in getting flustered and worked up over the situation, because as I later discovered, you may be able to be more effective in future endeavours.