Tuesday 29 September 2015

Y3S2W12: Paediatrics

Paediatrics was the theme for both CVP and integrated studies. In the integrated studies lab we critiqued a research paper written by the guest lecturer in terms of a family centred approach and the ICF framework. It was then on to another text, a 'children-style' book focused at debunking cultural beliefs that disability is caused as a result of you or your family doing something bad. These books took a surprisingly long time to ready, but had clear messages without being too confrontational or disrespecting the cultural beliefs. The simplicity of the books was also great! The author was a graduate of UoO physio school, and is working in the Philippines as a physio. The second lab was a lot of fun and involved real infants... the running joke was that for the females' in the class, their 'ovaries were working overtime'... fair to say they especially enjoyed that lab. We had three infants in our lab (with their parents), the age range was between three months to 12 months. We got to observe them play and interact with them. Also, we were able to complete the Alberta Infant Motor Scale (for diagnosing developmental delay in infants)... this was much better than completing the outcome measure by watching infants on a video clip like we had in semester one.

CVP paediatric tasks included teaching parents how to mobilise their child's secretions (percussion etc), modifying PEEP (positive end expiratory pressures) by blowing into a glass of water through a straw (with dish washing detergent), manual handling skills for infants with appropriate chest physio interventions (including games for children!). We practised glossopharyngeal breathing "frog breathing"... because this is legitimately how frogs breathe and it legitimately works for humans. We practised a lot of patient education for the caregiver / parent of our patient too!


Business planning was the topic our PHTY355 lecture... it basically took us through the pros, cons and process of creating your own practice (or venture that may require business planning). Here's an insight... we're probably not going to become millionaires from private practice (or from physio in general)... after all, 'health care shouldn't be there to make profits, right?' Ha! Apparently New Zealand has one of the highest rates Kick Start (new) businesses in the world... and one which has one of the most new business failures.

Third year dinner is one of the biggest, if not the biggest, physio event. This year the third year dinner was held on Sunday at LoneStar. It's a night of reflection on our journey through undergraduate physio. Time to share our highs, laugh through our lows, and thank the student exec committee for their long hours. There are some social awards, performances, good food and even better company. This is quite possibly the last time we will all be in one place (other than exams) before we graduate... because next year we're pretty much on our own. Below is a pic taken, prior to our entrées being served, of my good physio class mates (and Gill - a wonderful lecturer who took us in first year for some MSK, and most of integrated studies this year). Professional looking bunch.


Integrated studies individual community assignment was handed in on Monday... I last mentioned this around mid-semester break, but I wasn't sure where the assignment instructions were... we got those a week or so after the mid-semester break... I linked osteoarthritis of the knee, quality of life and physiotherapy from data collected from our community visit.


Clinical studies requires SWATs, clinical diaries and reflective statements from all four placements be submitted as a final 3rd year portfolio. These portfolios were due on Friday. I'm all up to date - no more assignments or portfolios to submit this year... Time to focus on external exams!
One week of lectures to go!

Wednesday 23 September 2015

Y3S2W11: Old Dog, New Tricks

Fear not of old age, for physiotherapy is here to help. Older adults... or 'elders' if they're especially wise, are trainable - like old dogs, their bodies can learn new tricks. When you are struggling to open the jar of jam or need to leave 15min earlier to get to the bus stop because you're now walking slower - call a physio. We'll set you up with an exercise programme to make you buff, strong and fit. 

The 'older adult' was the theme of integrated studies this week. The first lab was self-directed and consisted of eight stations. After the lab, we were able to get a case study from the reception to present about in lab two. The older adult is likely to have multi-morbidities (many diseases / health conditions) and we're expected to help them manage these whilst improving their physical function.

Phty355 series from ACC continued... it is reasonable to assume that deciding whether a client can claim under ACC is not always a black and white process. We had another 'prep for 4th year lecture' and the key messages came from current 4th years. Most of these messages are encompassed by the phrase "fake it until you make it". 

I see you Intensive Care Unit (ICU) Syndrome is a psychological syndrome some inpatients acquire in an ICU. We were going through a different psychological syndrome (but one that's familiar to us... study stress) in our CVP lab on the role of the physio in an intensive care unit. This was an intense lab, but us per usual we had some fun. Key stations in the lab had us practising suctioning... this involved putting a catheter with a vacuum into the part of the lung where it branches into two i.e. left and right lung, to suck up secretions in an unconscious patient. For added amusement, the unconscious patient was hooked up to an ECG monitor that would 'randomly' flat-line (i.e. the patient's heart supposedly stopped), so we appropriately managed the patient's airways (put them back on the ventilator) and perform chest compressions. Good fun. We also taught self-suctioning to our patient with a tracheostomy whom had a 'Swedish nose'. 'Dressing up' in personal protective equipment (PPE) during the lab whilst suctioning was important and quite amusing too. To top off the lab, most of us had a ride on the tilt-table! Good fun! This lab also had us working on a patient with burns and another patient after a heart transplant, both in an inpatient setting.


CVP lecturer on Thursday had extensive experience as a ICU physician in New Zealand. This presenter had an immense passion and enthusiasm for intensive care. He shed light on the importance of the physio in ICU. He was excited to have worked with Margot Skinner (current lecturer at the School of Physiotherapy and current executive board member of WCPT) and J. Pryor (a graduate of Otago, world renowned CVP physio and co-author of our CVP textbook) during his time in the intensive care profession. He described the shift in medical philosophy and use of technology over his time in practice, in particular a shift to non-invasive ventilation. He joked that his colleague had described non-invasive ventilation as "ventilator foreplay... preparation for the big event" at a time when using non-invasive ventilation first became available. However, today with modern non-invasive systems we can support patient at an appropriate level without robbing them of the dignity of being able to speak etc when previously patients were given a tracheostomy tube or endotracheal tubes for ventilation straight away.

Some inspirational quotes from this lecturer:
  • 'Fall in love with all areas of physiotherapy that you encounter'. 
  • 'I see a lot of physiotherapists wearing a stethoscope, but the most important tool you bring into the ICU is your hands... stethoscopes only give you a fraction of the information... physiotherapists feel the physiology happening with their hands'.

Thursday 17 September 2015

Y3S2W10: Death & Taxes

PHTY354 was split between occupational  health (integrated studies) and palliative care (CVP).
  • Our CVP lecture/lab concentrated on the physio role in palliative care. We had a guest lecturer from Dunedin's hospice describe the philosophy of assisting people to live a quality life right up to their death... not prolonging death or prolonging life. The hospice works with the patient and their family to plan how the patient wants to die. The physio role is to keep the person as well functioning and with the least amount of symptoms as possible (if the patient wishes for this service). During the lab we watched a local Dunedin person's documented life leading up to his death and the involvement of the hospice and hospital. This tugged at a few heart strings. Our second lecture of the week saw an oncology physician talk to us about cancer. Thus, in our lab we also covered lymphatic drainage for lymphoedema, post mastectomy management, and care for people with other end stage disease and cancer.
  • Integrated studies lectures had two guest lecturers, the first was a clinical educator from the School of Physio clinic in Dunedin, the other a clinical educator from the School of Physio clinic in Christchurch. These two lecturers were experts in the area of occupational health. In New Zealand, physiotherapists can specialise in Occupational Health... this has a large overlap with the work done by Occupational Therapists... (so that's neuro rehab, hand therapy and occupational health that physios and OTs share similar roles in patient rehab!) The first lab was case based and looked at different factors that affect occupational health (such as workplace layout, biomechanical analysis, environmental/individual factors, organisational/policy, and psychosocial factors) and putting together a rehabilitation plan (return to work plan) for a patient. The second lab was more hands on, this involved setting up work stations (chairs, tables, correcting postures etc) and recapping strategies for lifting/transfers (then problem solving for different occupational demands).
We had the first lecture in a series from ACC (accident compensation corporation) representatives for PHTY355. ACC is New Zealand's 'insurance' system whereby everyone (including visitors to NZ) are covered by the government if they are injured as a result of an accident. It's a 'no fault' system, removing the right to sue (therefore, less psychosocial factors and generally people recover quicker). We looked at how a client is entitled to compensation under different categories of the 'Accident Compensation Act, 2001' such as 'Personal injury caused by accident' (PICBA) and 'Work related gradual process, disease or infection' (WRGPDI). The lecture took the form of case studies; we split into small groups and were given case studies to debate whether it was reasonable for the patient  to be entitled to compensation, and if so under which cover policy (if any... there are some legal requirements and medical 'grey areas' to interpret).

So I've now finished my last clinical placement for the year. I must admit that it was probably my favourite placement of my undergraduate degree so far. Without saying that one area of physio is more important or better than another (each area is equally awesome), here's why you might enjoy this placement.
  • If you like responsibility, making semi-critical decisions, complex health conditions, medical jargon and monitoring vital signs then cardiorespiratory physio is for you.
  • If you enjoy seeing a transformation of the patient from their most vulnerable health status to a threshold where the patient can usually resume or cope with their life demands, and know you've played a large role in their recovery, then cardiorespiratory physio is for you.
  • If you enjoy taking patients for walks around the ward in their PJs (or hospital gown), giving out red socks with grippy bits on them, or drag-racing people in wheel chairs (in slow motion) then cardiorespiratory is for you.
  • If you don't mind rogue mucus missiles, practitioners stealing your patient, decrypting handwriting, holding your patient's pants up as they walk, frequently washing your hands, teaching people to breathe or having the same patients' most days of the week, then cardiorespiratory might be a well suited option for you.
During my placement I got to treat people with pulmonary fibrosis, pneumonia, COPD as well as those having undergone CABG and lung lobectomy. Most of my clients were discharged upon finishing my placement - everything appeared to be running smoothly. Interesting points of this placement included CT imaging of a patient with subcutaneous emphysema caused by a CPAP/drainage accident following a pneumothorax, an xray of the pneumothorax itself, the effectiveness of physiotherapy techniques are easing work of breathing, and normalising SpO2 with principles of physiology (such as ventilation-perfusion matching, minute ventilation etc). For example, one person I saw had a blood saturation (of oxygen, SpO2) of 90% in sitting. The person had pneumonia in the right lower lobe and a non-productive cough. The combination of left side lying and diaphragmatic breathing increased the SpO2 to 96%. Magic (science)!

Right now (as I think ahead and start dreaming about future employment) I feel that an ideal job would be to work as a physiotherapist in a hospital during the work week 8:30am-5pm (cardiorespiratory ward would be great thanks!), then run musculoskeletal clinics in the evening 6-8pm and work as a sports physio on the weekend... oh and then start a petition to have the 7 day week extended to a 10 day week so I can have some time to go tramping (... is there an outdoor recreational activity that involves both physio and tramping? Adaptive outdoor neuro-rehab and/or chronic disease adventures through exercise perhaps?).

Thursday 10 September 2015

Y3S2W9: Celebrate Physio

World Physiotherapy Day occurs every year on the 8th of September. It is a day to celebrate and raise awareness of physiotherapy in the community and what better way to do this is than to offer neck/shoulder or calf muscle massages  to the public. All funds raised were donated toward maintaining Dunedin's Physiotherapy Pool.


The world confederation for physical therapy (WCPT) is a large promoter of physical therapy world-wide. They produce posters and banners for clinics  to display - below are two pictures from posters - very cool!


The regional physiotherapy body celebrated world physiotherapy day with a treasure hunt around Dunedin!! What better way to be physically active!


Integrated studies looked the role of physiotherapy in the mental health area. Dementia, depression, anxieties, psychosis etc. The first lab for IS was great! When we got through the patient assessments (questionnaires etc) we were invited to join in a mindfulness activity and a yoga-like relaxation activity. For whatever reason I was not settled and displayed some poor mindfulness and self-control (might have been the stress of resitting my presentation the next day). Anyway, here's what happened. The mindfulness activity involved taking two raisins. We had to see it as a unique shape, as possibly having a smell (yes we smelt it), we noticed how salivation had begun, after putting it in our mouth we felt its texture, taste, etc. The second raisin was to be eaten as we usually would... automatically. My problem begun right from the get go... after not having any lunch my automated response was to put it straight into my mouth, chew, swallow... bugger! So I had to get another two raisins. Anyway, this made a bit of a scene (we were sitting in a circle). Having demonstrated my inability to be mindful I should have known better than to complete the next activity next to somebody who snores. This second activity had us lying relaxed on yoga mats, we were to follow the instructions of the lab demonstrator (who was a specialist in the area of physio and mental health). Instructions guided out attention around the classroom and inward on our body sensations. The guy I was lying near begun to snore, he snored right in my ear and I struggled to suppress my laughter. After the class I apologised to the lab demonstrator for my lack of mindfulness (and self-control). What a lab!! The second lab was nice and short. It concentrated on the physio role in a dementia patient ward.

So I mentioned that I had to resit my clinical presentation. I was happy with this opportunity given that my 'winging it' before the semester break had not paid off... probably because I rambled about my patient and had little/no literature to back up anything. Cool, so round two was on Wednesday and I wasn't alone. It turned out another student had focused too much on the client case too (and rumoured to have put his slides together after waking at 5am the day of the presentation)... he's a smart guy and can usually ramble his way through anything. Anyway, I was prepared with a script and had re-jigged my powerpoint presentation. I kept to the same topic, answering the question "what is the best manual therapy for mechanical neck pain, given that the literature suggests they are equally effective?" So, how did it go Round Two? Well I got it all out in the end, even if I was over time (again) and wishing I had a bit more drool in my mouth to keep things running smoothly.

Our two hour CVP lecture on Monday was nicely split between our usual lecturer (topic: non-invasive ventilation) and a guest lecturer (another surgeon from Dunedin Hospital) on vascular surgeries and peripheral vascular disease. It was very interactive (very!) - the presenter didn't have a powerpoint, rather he just systematically go around class asking each of us questions and filling the gaps when needed. The third CVP lecture of the week (on Thursday) was on general surgery, presented by a general surgeon (actually, he was a breast surgeon specialist). He recognised that ERAS (enhanced recovery after surgery) lead to better patient outcomes, and physiotherapy plays an important role in this strategy.

In the labs we were able to experience some of the non-invasive respiratory devices (CPAP and IBBP). In addition, we discussed respiratory management for patient's with spinal cord injury and some last resort techniques for unconscious patients based on primitive reflexes. I enjoyed the CPAP and IBBP aspects of the lab the most. The CPAP (image below) is similar to sticking your head out the window of a moving car (not recommended...) or walking outside on a windy Wellington day... essentially it is a machine that blows air (or gas, possibly humidified - depending on the model) into your mouth or nose. The high pressure splints open the airways and is normally used on patients with sleep apnoea. I had a go talking with a nasal CPAP and found that it was most odd because the air rushes from the nose and back out of the mouth as you talk. This was entertaining. The other machine was a IBBP... like a CPAP this machine can be set to blow air into the mouth or nose, however it switches off when the flow rate stops (e.g. when the lungs are full) so the patient can breathe out easier. Put simply, this machine is interesting in that the machine does most of the breathing in for the patient!


Due to the success of the first cultural dinner (good job student exec!) we had Cultural Dinner 2.0. This was again at the Hunter Centre at 7pm on Wednesday. Again, there was a plethora of cultural dishes both mains and pudding! The personally think one of the key highlights is having the staff mingle with us, even with their busy schedules! Some staff are actually pretty dedicated to the cultural dinner cause, one staff had his cultural dish slow cooking on his office bookshelf from midday!

I've discovered elevator humour (sort of). On Wednesday we took the elevator down from 7th floor. When we got on, one of the overhead lights must have blown and we remarked that "the mood lighting was fairly effective" given that we were all standing closely in silence. The elevator then proceeded to stop on most floors on the way down as more people squeezed on. We decided the 23 person capacity was very optimistic given that 11 people was a stretch! One of the medical staff mentioned that they'd hate to be the 23th person, but I claimed that they would be lucky to be the first one off. The hospital staff are (mostly) very friendly, the pain team dropped in on a patient we were having a consultation with and reminded the patient to "be sure to press your PCA (patient controlled analgesia) button, especially when you know the physio is coming". Not only is this a good thing for the patient to do, as it allows them to perform respiratory and mobilisation exercises in less pain, but it is a funny inside joke that seeing the physio is an overall painful experience... great humour! The patients are allowed a sense of humour too, one patient I saw retorted to the question "how are you feeling today?" with "Well, I don't feel well enough to take you out dancing". We'll take that as a compliment. For some people, there are things on the respiratory ward that are not pleasant to do. Respiratory physio involves encouraging phlegm expulsion, and then looking at its quality/quantity. My physio peer (we were working in pairs) looked moderately disturbed when listening to the very wet sounding phlegm coupled with the sound of hard-work of bringing it up... then quickly turned away quickly when we were assessing the phlegm in the specimen container.

Thursday 3 September 2015

Y3S2W8: Chest physio & womens health.

This week was the start of my final placement for the year - 7th floor at Dunedin Public Hospital (cardiorespiratory). The weather was a little bit drizzly, so there was a clear trail of wet footprints on the carpet to follow as I walked through the front entrance to the hospital at 8:45am. A potent aroma of coffee greeted me, and I wasn't surprised to see a number of staff and patient's family cuing for this elixir. On the elevator, waiting areas and on the wards themselves, the hospital is generally a quiet place... until you listen more carefully then you hear the murmur of healthcare, patients and families - it's like the walls of the hospital breathing, but we shouldn't listen too hard. On the 7th floor we have a very small cupboard to store our personal items, then we're drawn to the nurses station - the morning begins. We receive a patient case file, decrypt the previous notes (not only are some people's handwriting illegible, but there are new abbreviations) and decide what our role is with this patient today. The pace in the hospital is not very fast, thus it's not at all like a MSK placement (which resembles speed dating in comparison). CVP requires you to give the patient time, and of course many of the other staff will be in line to visit your patient too. Then there's the unpredictability of the patient - their condition is usually less stable and if the physio is scheduled to see them but they have a hypoglycaemic episode, their family arrives, etc, then it becomes a juggling act towards the end of the day. We need not worry though, because provided they don't check themselves out then we'll see them the next day (or monitor them as needed). Another difference between MSK and CVP is the day/date awareness. MSK people are very aware of what day of the week it is, but often are unaware what the date is (you discover this when the patient fills in forms or when rebooking) - however, in hospital the date no longer matters and patient's start getting the day of the week mixed up! This is fair enough too because everyday must be the same for patients' in the hospital.

On day one (Monday) of placement three other peers and our educator introduced the placement with a discussion about our online case study and the wiki that we completed. Afterwards, we worked in pairs to treat our patients with a modest amount of supervision from our clinical educator. The main case I worked with on Monday was a man ready for discharge. We assessed his walking ability on the flat and with stairs and deemed him fit to return to his home. There are commodes at the hospital which can be used for transporting patients - I got to drive this to the orthopaedic gym on 4th floor with the patient in it... it turns out that it's a rear wheel turning chair, which means that we have to drift the chair around corners. Drifting chairs around the hospital sounds like fun, but we had to remember that crashing wasn't an option (they're not easy to steer) and my patient was >80years of age (I'm sure he wouldn't have enjoyed this).

On day two (Wednesday) I got to see a patient with idiopathic pulmonary fibrosis. The poor patient had an acute infection affecting the right lung, more than the left... as a part of our subjective/objective/treatment we needed to auscultate. We heard fine crackling in basal area of his left lobe with end inspiration, and throughout the breathing cycle and evenly distributed through the right lung - interesting! We were invited to have a look at an xray of another patient who had had a complete right lung pneumothorax... apparently the person had put up with what they thought was an exacerbation of asthma - ha!

On day three (Friday), I got to see a patient two days post CABG - he was still in phase one of the road to recovery plan. In this phase, the physio will assess his respiratory health (our patient had pneumonia a few weeks before his surgery), after treating his lungs (with breathing techniques) we mobilised him from one chair to another chair about two metres away. Our patient was a little bit unstead on his feet, so we decided that was enough exercise at the time. The physio will visit him over the weekend to help him continue clearing secretions effectively and mobilising him a bit further. The second patient I saw required a pre-op consultation with a physio (heart valve replacement) - so we got to do this without our supervisors attendance. We discussed his living situation, physical capacity and goals following treatment, then taught him the breathing techniques and educated him about the post-op plan (from a physio perspective) i.e. lung health, gradual mobilisation/walking, advise about wound care (bracing the chest when huffing), and lifting precautions.

CVP focused on physiotherapy for managing a patient pre- and post-operatively from surgery on their chest or abdomen. Key points to note were the management of patients presenting with restrictive versus obstructive chest conditions and the effect of incision location on our rehabilitation plan. The lab put this knowledge into action and we completed case studies, practised physio-patient interaction with some techniques. The School of Physio has a few full body manikins, and the manikin working with us today was Heartly. He wasn't looking to good (or feeling too good either... lightheaded due to low BP etc), with a chest drain in his pleural cavity following a lobectomy and nasal prongs to improve his oxygen saturation. It was our job to safely get Heartly out of bed and into a chair. During the lab we got to have a play with incentive spirometry, mainly because it is useful for people with a restrictive lung presentation, such as many people after chest surgery. Incentive spirometry requires the patient to breath in with enough suction to lift a ball off the bottom of a container - the ease of this can be changed via a dial on the device.

Incentive Spirometry 10s challenge.

The Integrated Studies theme of the week was Womens Health. We covered the role of physiotherapy through pregnancy (antenatal and post-natal care) including appropriate exercises for abdominals and pelvic floor, as well as strategies to assess and reduce posterior pelvic pain. We discussed postural strategies for minimising low back pain during pregnancy too. On the note of pelvic floor training, we investigated the high level evidence for reducing stress and urge incontinence and prolapse too. We were lucky to have a physiotherapist who is a specialist in Women's Health during labs and lectures. In the lab we got to lay around on mats (or plinths) and practice abdominal and pelvic floor training - good fun! And, hear about pregnancy education (using a pregnancy atlas) - not so much fun, especially for the pregnant ladies out there! Oh, and we got to see our classmate's bladder and abdominals with an ultrasound imaging device!


PHTY355 lecture was about running our own private practice. After listening to the business talk I left the lecture thinking that I'd like to focus my future of physio on health rather than earning big money through owning my own business.