Sunday 28 February 2016

P4R1W4: Tough Love

On ye bike, it's Monday!
The DHB has two orientation days for all staff. This is very similar to what was done in CHCH for preclinical weeks. Here's an outline of some of the things we sat through for a second time... Health, Safety & Wellbeing, Fire training, Maori health, Infection & control, I.T. training, Policies/Procedures/Guidelines, Patient centred care, Smokefree training... I also went on the tour of the hospital (found that there is an underground passage between the clinical and administrative sides of the hospital)... and I managed to skip the first aid training (and zipped back to AT&R to work through the afternoon). 

"Would you treat them any different?" We should be empathetic in every interaction, whether it be in a healthcare or any other setting. Powerful message. Worth a watch.

So I've now got a @nmdhb.govt.nz email address! When I first logged on, there were emails sitting there from a few weeks back (... 22 emails in total).  There are a few perks to working for a DHB - staff discounts for example! There's a staff gym (with squash court) and pool for ~$100 per year (access is for staff families too!). We have online learning systems which I am pretty sure I will need to sit down some day soon and complete a module on smoking cessation and privacy. Apparently we can hire bikes at a cheap rate and get massages at work (for a reasonable rate). On the intranet there's a buy/sell/swap, a list of continuing professional development courses, and of course a link to our patients notes.

Most of the time we write on lined paper like this...

Wednesday I was full on busy. Starting with hand-over at 8:30, hydro-pool for half an hour (I didn't get in), three patients before lunch, a physiotherapy refresher course on emergency procedures in the hydrotherapy pool (I got to pretend I was having a seizure), I had a brief catch up with the Physiotherapy team leader whom I hadn't met until now, I had a DNA (did not arrive) and an outpatient in the afternoon (plus patient notes... I managed to leave them all for the end of the day). I caught up with my I.T logins and cleared out the unnecessary emails then I was off... by this time it was 5:30pm. It was a pretty cool day - the person I admitted to the ward last Thursday is set for discharge on Friday. I played a bit of Nintendo Wii (bowling) with a patient. And I fitted a boxia ankle support on a patients shoe. Cool eh!

Thursday was busy. We started with a manual handling session at Franklin Village seminar room (across the road from the hospital). Following this we all picked up our NMDHB ID cards / swipe to access cards. Then it was back on to the ward to treat two patients before lunch. I couldn't get a new patient for my clinical educator to watch me assess, so she watched me perform two treatments on patients I had seen yesterday - one was the person with the ankle support (we decided the support was doing nothing, so we discontinued its use). The second person had a code brown when we arrived, so there was a slight delay - bowel motions are a good thing. Earlier in the day I had taken this person to the gym to begin a programme but the person's catheter connection to the bag got caught when they were trying to shift, and it broke free leaving urine on my treatment table. Shit happens. This week my session with my educator went really well. I was challenged to clinically reason, and sure I didn't know some things, but I can now direct my own learning to know more about it. I was buzzing throughout the session, it was great!


On Thursday I also recorded my bike trip from my flat, to the hospital. 




Currently there is only one paid male physiotherapist at Nelson hospital (that I've seen). With two male physio students there we have increased the male physiotherapists there by 200%

Tough love is:
  • Mobilising (walking) a patient even if they've got severe pain linked to anxiety. 
  • Throwing you into the deep end of patient assessments for the growth of your professional and clinical skills.
  • Keeping a patient on a walking frame over the weekend even though they might be safe to walk without it.
  • Discontinuing an intervention when it's no longer indicated, even if the patient likes it.
  • Waking up a patient for physiotherapy.

Quotes & stories from the ward.
  • "We're losing fish faster than we're losing patients this week" Referring to the fish tank by the reception desk... " 
  • A nurse told me yelling down the corridor was the normal method for finding people (including staff) that you've lost...
  • One morning this week we had a laugh during the morning handover about a patient who had emptied their catheter into an empty large can of peaches at the OT's breakfast club...
  • A story from an OT about a home visit where they were given drinks of tea in large bowls the patient had provided. The OT apparently commented about the tea being in a soup bowl as 'quite a large drink'. A caregiver was present also, who mentioned that it was probably more soup than tea, given the dirty towel the patient had previously used to clean the bowls.

On Friday after placement I  drove down to attended my friend's wedding in Queenstown (Glenorchy). After a 10h drive (including torrential downpour, lightening, fallen tree on the road and waterfall gushing over the road between Haast and Fox Glacier) I made it by 4am for a few hours of sleep. The weather was perfect for my mates wedding, a stellar day! On Sunday I drove back up to finish writing this blog (final touches). [Pictures are not of bride or groom]. Time for some sleep!!




Friday 19 February 2016

P4R1W3: Assessment, Treatment & Rehabilitation

I'm back in Nelson, ready to begin my first round of placement.




In prep for the placement I had a glance over some notes from 2nd and 3rd year - I even thought about making some info cards with normative values / prompts and have them laminated. There was a neuro preparation sheet with case studies and procedures to practice saying and doing - I chipped away at that too.  The other thing I will need to keep on top of is my clinical portfolio (reflective statements etc). This year's portfolio is much more detailed and has a few new sections than in previous years.

Assessment, Treatment & Rehabilitation (AT&R) is my neuro placement at Nelson Hospital. AT&R has an inpatient ward for patients who have been discharged following an acute admission but whom are not quite ready to return to their previous living situation. AT&R also has an outpatient aspect, of which the patient is referred by their local GP. The AT&R team may refer the patient to a community service (community physiotherapist or MDT). We also coordinate with the OT's and send referrals for equipment. The current team tries to refer patients with ACC claims to a private physiotherapist to accommodate the growing patient waiting list for this service.


Okay, so the first day was really good. I was a bit overwhelmed with all the names of the staff I needed to remember - I've started a list on my phone. I shadowed the physio with two patients today; one I will see weekly for the duration of my rotation in AT&R, the other was a more complex case.

Physio is more than just assessing and treating, it is also involves organising and admin tasks. I got to organise a weekly shuttle for my patient (St John shuttle). In future sessions I will be doing a triage via phone call, then booking patients in to see me. One phone call I made was to a lady whom answererd the phone but was so hard of hearing she couldn't understand a word I said. She passed the phone to her husband whom had some level of dementia. This made for an interesting phone call. On the topic of phone calls... my student desk space is right next to the phone, so I'll get to play secretary for the AT&R gym too.

We had a shared lunch with all the physiotherapists and physio assistants - everyone is super friendly. There appears to be an infinite number of things to do, so it's important to stop for lunch - otherwise you'll only wear yourself down. On Wednesday one of the physio assistants made scones to share with the team! YUM! Lunch is usually had at the AT&R gym or up at the physio 'hub' on 5th floor.

On Tuesday evening I practiced writing a referral to the Community Care Coordination Centre (aka the C, C, C, C.... ) for a patient who needs a wheelchair upgrade, read an article on Parkinsons and research stroke rehabilitation specifically for regaining sensory input. Tomorrow I have my first solo patient encounter - I'd better bring a black ink pen!

There are some quirks around the hospital... such as 'Coffee Happy Hour' at the cafe, a 'breakfast club' (an OT kitchen set-up for assessing patients), a 'staff social club' and an emergency stash of chocolate for 'pick-me-ups' in the AT&R gym. 

I'm quite excited about utilising the hydrotherapy pool in treatments! There is also a staff gym with pool (not the hydrotherapy pool), underground bike racks (and we can use the shower at the physio department early in the morning if we are sweaty from biking to the hospital!) "When was the last time you were in a hot pool with a handsome young man?" There's a bit of tongue and cheek between staff and patients... the quote above was mentioned to a 98 year old lady on Tuesday when I brought my togs along.

There are in service meetings, and we're encouraged to be always engaging with staff and patients... leaving all our study and portfolio work to be done in our own time. This is probably a good thing because we've been challenged to be involved in everything... and if there's something we want to see or need to see more of, then all we have to do is ask. Pretty sweet deal!

AT&R gymnasium! View from my desk!
On Tuesday I got to see my first stroke patient and complete the subjective, objective & treatment. If all patients are like this one, then there'll be lots of clinical reasoning involved. I thought I done a satisfactory job, there were times when I wasn't in control of the conversation and my patient rambled on. I had to fight myself from rudely interrupting - rather I had to take some time to think how I was going to pull the conversation back on topic. There is skill involved to stay interested and keeping your patient on topic... otherwise you tend to zone out and seem disinterested. So that was my outpatient experience for the day.

Earlier I mentioned that there was an inpatient service through AT&R too (it is, after all, an inpatient ward in the hospital). My daily routine will mostly begin with a ward meeting, then working with patients in the hydrotherapy pool, then working with patients in their room (or the AT&R gym), an inpatient service (or an MDT meeting, or an allied health 'scheduling'... scheduling is to prevent the OTs and PTs fighting to see a patient at the same time). The afternoon will consist of outpatients and possibly the odd inpatient session. Today for example, the last thing I done was a dynamic gait index (assessment of falls risk) for an inpatient... we changed her red tag to a green tag!! That is, the tag we put on frames and walking aids to indicate whether they can use them independently (green), whether they need supervision (orange) or  assistance (red). To be upgraded to a green tag suggests that you're likely to be discharged from a physiotherapy perspective very soon. On Friday I completed the Dynamic Gait Index again on this person and they got 24/24 marks. Perfect! This was my first patient discharged from AT&R and I felt like I had been helpful having worked with her daily throughout the week.





The rest of the week went well. The fire alarm went off on Wednesday, an inpatient must have thought it was the emergency button for getting a nurse... anyway we had firemen come in to the gym. It's great how staff make a joke out of everything. In this case it was to a patient "look, we've arranged some handsome young men to come in just for you. We should make a calendar." 

My new inpatient consultation was a challenge, namely because I had some preconceived ideas about what my clinical educator wanted and conflicting ideas about what was necessary for admission onto the AT&R ward. I got through it, but I'm not at all happy with how I performed. The other small incident was a miscommunication between the patient and a nurse - I should have read the nurses notes before seeing the patient. My flatmate said this quote "Customers are always right, patients are always wrong" and it sums up that particular experience very well. The patient told me they independently showered in the morning so I wrote it in the patient notes. It turns out that the patient had not showered independently, and this nurse sure let me know. Next time I'll be sure to read the notes and check in with the nurse. This was a good 'first week in' lesson. You do not want to upset the nurses.

Patient education analogies. 
  • Your brain is like a tree. When you cut off a branch, energy is no longer transferred from the top leaves of that branch to the roots. A small clot acts like hedge trimmers.
  • Nerve receptors in the hand are like a flower garden - all closely planted together. Nerve receptors on your thigh are like an orchard, planted or spread more widely apart. 
Other lessons learned:
  • Explain everything to your patients, e.g. "We need to test your sensation, like your ability to feel pain, so we know you will be safe."
  • Demonstrate stuff to your patients e.g. exaggerate a demonstration of what might happen if the patient doesn't follow safe standing up using a frame protocol.

Quick tips & quirks!
  • If you scribble in your notes, you've got to sign your initials next to the scribble. One document I wrote up had lots of my initials on it! Turns out, it's best to put a simple line through any mistakes you write.
  • How do you adapt a walking frame for an older person with a humerus fracture? Duct tape a stick across the handles.
  • Patients will inspire you. I had an outpatient amputee patient who is writing a facebook blog about his recovery. He is super motivated. I also had an inpatient cerebral palsy patient who is also very determined to make a full recovery. Said person has an improving ataxia, so we played a game of checkers with a large peg board (I was gutted to have lost the game!), a bit of ping pong by sliding towels on a table to push a tennis ball between each us, and practised some dance movements 'standing to positioning on the ground'. Next week we'll build on the dance moves, as she's a professional dance teacher and I'm sure she would like to get back to this asap!

Leaving work on Friday, I'm ready for the weekend.
I've now got the pin code for the secure bike storage area and the men's showers (so I can bike to placement and have a shower before starting at 8:30am)!



I finally got around to becoming a student member of Physiotherapy New Zealand (it's free for physio students... how have I not signed up earlier!!)

On Saturday I updated my portfolio - clinical diary and reflective statement.
On Sunday I went in search of Whispering Falls, up the Hackett Valley in Nelson...

Climbed up the side of Whispering Falls, Nelson NZ







Wednesday 10 February 2016

P4R1W2: Snippet of Chch

 

Second week of pre-clinical started with Waitangi Weekend. I was fortunate to have my parents up for the Sunday. We made a trip to Akaroa, which is an hour away from Chch - I felt it was time to get out of the city. Akaroa is a beautifully located town. It was super busy and we struggled to get a carpark around the town area. Moreover, the streets were very narrow - making for an interesting drive through (damn, and we thought we had escaped Chch. Haha!)


We heard that the Wellington centre had a presentation from Brian Mulligan last week (I'm very jealous!!)

Between lecture snack at The Boat Shed


Here's a quick overview of the second preclinical week...
Tuesday: I had a tutorial with others in the same rotation to prep us for our neuro placement. At the beginning of this tutorial each of us done our MRSA swabs... we learnt another piece of anatomy, our 'Natal Cleft' - which is another name for buttock. Next up for the day was a group meeting with my research group and our supervisor - we have three supervisors, one was physically present, another away on study leave and the third (the dean of the School of Physiotherapy) phoned in and we had a very brief chat over speaker phone. In the afternoon us physio students were grouped with the 4th year medical students (whom are also on their second week of orientation in Chch) for a run down on infection control.


Wednesday: We had a lecture on presenting, which we will require for our community paper (PHTY458). There were lots of useful tips and a few humorous stories and strategies thrown in. "I don't have time to go in detail on that now, lets chat about it after the presentation" coupled with 'avoiding said person after the presentation' is the best strategy for avoiding a question whilst sounding professional. Representatives of the CDHB come and spoke about fire and emergency procedures - this included a demonstration of the fire extinguisher. I had a great chat to the hair dresser in the Christchurch Hospital ground floor 'mall' area (seriously, there's down-scaled / miniature mall there... and I did happen to need a hair cut). She was very friendly, and obviously customer service by means of chatting was seen as more important than quickly getting the job done, so I was there for an hour (the cut could have been done in 15min) - I was more than okay with this as I had the whole afternoon free. It occurred to me that her role was a lot more than a hair dresser, and  I got to hear about her experiences and a bit of her life story. I would definitely go back (in addition, it is a very convenient location!!)


On Wednesday I got myself a metro card (for the Chch bus system) and I went to visit a friend at New Brighton Pier / beach! It took me a little bit of time to figure out, but overall a very reliable and helpful service. It cost me $10 for the card and the minimum topup is $10. Each of the yellow and orange buses cost me $2.50 for the first two trips, and the third trip was free. If you're exchanging between two bus lines then you can get a slip to take on to the next bus to continue your journey for free too. We returned to the New Start area which is a shipping container mall built shortly after the 2011 Christchurch earthquake. Christchurch city centre has a lot of construction underway, it's going to look great once it's all rebuilt. My bus trip was interesting because I missed my 'get off bus stop' and ended up having a 10min run back to the place I was staying. The bus driver was helpful there giving me directions amongst some general Chch chat.

New Brighton Pier


Thursday we had tutorials on ethics, social media, performing patient hand-overs, an in depth discussion on our assessment rubric. In the evening we went to check out the noodle night market.


 

 Friday we made our way back to Nelson!



Thursday 4 February 2016

P4R1W1: PreClinical Week

Stolen off somebody else's physio blog - I can't remember which.

On the road again!

The students placed in Nelson made their way to Chch for the two preclinical weeks. Most of us carpooled, which for the cost of fuel and the 4.5h drive, made the trip a lot easier. We stopped at Maruia Falls - an epic waterfall, which seems to be popular with the white-water kayakers! Upon arriving in Chch (on the Sunday before class began) we had a group BBQ to catch up on the summer so far. Preclinical weeks allow us to complete administration tasks and tutorials ready for the clinical placement ahead. Preclinical weeks are usually last one week, however because there's a lot of administration things to get our heads around, this first one is two week duration.

Maruia Falls, on the way from Nelson to Christchurch
Sunday 31st Jan, BBQ in Christchurch at a peer's house.
It soon became apparent that cycling was the best transport option for commuting, however I didn't bring my bike (I carpooled). Christchurch has a superb bus system, however it isn't exactly cheap to use and some trips may take twice to thrice as long as it would take to drive. The main problem when taking your own car is parking around Christchurch Hospital. There is a lack of free parking spots. Deans Ave is usually a safe bet if you get there early enough, and Hagley Park carpark is free for three hours - this means that you can come back after three hours (say, during your lunch break) and shift your car (and rub out the parking wardens chalk markings from your front tires). This is how we managed parking on Monday.

Our 2016 student ID's were sent to Chch!

^Walkway through Hagley Park / Christchurch Botanic Gardens / by the Avon River.

 ^We spent a lot of time based at the Christchurch School of Medicine.

Classes on Monday were at Christchurch Hospital / Otago School of Medicine. The morning focused on administration stuff (those of us from Nelson had returned these forms to our DHB a few weeks ago) and introductions. We were given verbal instructions to locate the library, computer suit and cafes in close proximity to the School of Medicine / Chch Hospital. The afternoon was more of the same - we found out where we were placed for rotation one, and whom we were working on our research project with. I'm lucky to be placed on my neuro rotation at the AT&R (Assesssment, Treatment & Rehabilitation) unit at Nelson Hospital. We finished day one with a bit of team building challenge 'who can build the tallest tower out of spaghetti and marshmallows' (the winner wasn't my research group). 



Tuesday classes were located at St John of God Hospital and the theme of the day was learning about ourselves - we completed a few psychometric questionnaires about our personalities and learning styles. Furthermore, we discussed strategies that would open communication lines and build rapport with people of different personalities and learning styles. Useful stuff. The staff put on a spread for lunch. There were a few interesting points for me on this day:
  • The memory task we began the day with which put reading and remembering patient notes into perspective.
  • Taking the Myers Briggs test and learning how we can best collaborate with others of different personality types. We had a few good laughs and looked at Harry Potter characters purported to fit each of the personality types (I was Neville Longbottom). My personality is the ISFJ-A. Check out http://www.16personalities.com/ for a short version.
  • For the learning style we used the Index of Learning Style Questionnaire. I discovered that I sit around the 1a/b and 3a/b - pretty much on the fence as the continuum goes to either 7a or the opposite 7b.
Outdoor space designed specifically for people with disabilities.

Wednesday was again at a different location - Princess Margret Hospital. In the morning I was shadowing a neurological physiotherapist. This will be the only time I will be in a clinical situation and not have to do anything, answer any questions, etc - only have to fill out a form and fill in a reflective statement. In the afternoon, we focused on our observation skills with the aim to observe normal / abnormal movement strategies on our peers and with patients with neurological conditions.

Half of the physio gym on ward 3a
Princess Margaret Hospital
Another day, another location. Thursday was a boiling 32degC outside, and by 3pm we were feeling the heat inside too. Our location was on Mandeville Street in Chch. We shown what was expected for us to submit in our portfolios and had a workshop on documentation. I got to meet our clinical educator too - she flew down from Nelson.

 
On Friday we were back at the School of Medicine. The Christchurch group were given their internet and intranet access codes and shown how to access electronic public health records. Strict policies prevent us from deviating from privacy laws. Interestingly we aren't even allowed to access our own health records. Later we had a lecture from a doctor about introducing ourselves the patient. He made us aware of the campaign #HelloMyNameIs. Have a read about it here: http://hellomynameis.org.uk/
In the afternoon we had a clinical supervisor from the Barrington Clinic (branch of the School of Physiotherapy clinics) talk to us about their expectations for fourth year students. Following on from this, we had some new University of Otago graduates now working as physiotherapists for the Christchurch District Health Board talk to us about their experiences of fourth year - very reassuring.
Student lounge at the Chch School of Medicine... we have door access too!
Rolleston Lecture Theatre at Chch School of Medicine

We have five papers / rotations this year.
PHTY455 - Musculoskeletal
PHTY456 - Neuro-rehabilitation
PHTY457 - Tertiary care
PHTY458 - Community rehabilitation
PHTY459 - Research

The order of rotations, for me, are: Neuro --> Research --> MSK --> Community --> Tertiary.

Obviously there were many more important messages and processes for fourth year to get our minds around, but it's not within the scope of this blog.

Year four is about relationships: the relationships with colleagues, our peers, educators, supervisors, patients and of course ourselves.

Waitangi weekend antics to come!