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.