Before the week began, I made a trip over to Marlborough Sounds and had a swim at Cow Shed bay, near the Queen Charlotte Track. Apparently there is phosphorescence from plankton in Marlborough Sounds... I'll have to investigate this further.
The week is over & I've finished my first placement. I haven't passed the placement. I will need to repeat this paper at the end of the year or early next year. All that said, I have learned a lot from this placement. But before I tell you about my experience, let me say that fourth year really is about making yourself a safe and effective physiotherapist. Reflections in action and reflections on action are the pillars on which we improve. As a fourth year physiotherapy student, you will be faced with a lot of reflecting. Most of the time, we have no idea how to cypher through, analyse and interpret these reflections... and if we do, we don't really have time to do it. But once a placement is over, it becomes easier to see the details in your own performance to improve upon - knowing this, we can seek strategies to improve (I've already done some reading around my own identified areas where I lack specific knowledge).
The art of rehabilitation.
- Managing risk versus making gains. It's the balance between killing a patient and getting them better quickly.
- Reflections & personal growth. ...we need both experience and expertise.
- Understanding the patient-condition-treatment nexus. How can we treat the patient as a person? What does their condition(s) mean to us? What treatments can we provide that are safe and effective? Easier said than done.
Community Physiotherapy: On Monday I went with a community physiotherapist to visit an outpatient of mine... to allow for better continuity of treatment and for me to experience the community physiotherapy perspective.
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| "English is hard, but it can be understood through tough thorough thought though" |
On Tuesday I emailed the Nelson physiotherapy team (it was also forwarded to the occupational therapy team at some point) with a note to say I was providing an in-service training session on the topic 'aphasia in CVA (stroke) - a better approach to communication'. The aim of my presentation was to bring awareness to our communication strategies with people who have aphasia. I'll sum up my powerpoint in the following bullet points.
- Aphasia is an impairment of speech affecting the Broca's and Wernicke's areas of the brain i.e. the frontal lobe and superior temporal gyrus, respectively, connected via the neural structure arcuate fasciculus. The Broca's area functions to help us express language, so when it is affected we tend to only express basic words and incomplete sentences. There is usually accompanying difficulty understanding simple language like 'left and right'. Wernicke's area helps us to understand language, so when it is affected we have difficult understanding and our sentences become an apple, banana, orange word salad - our sentences become jumbled with meaningless words... but it otherwise sounds like a sentence should. These areas are on the dominant hemisphere of the brain, usually the left side.
- Based on data collected ~5years ago, stroke was reported to be New Zealand's third largest killer (new brain insults occurring in ~2500 people every year). It's a major cause of disability. Data suggests that 1/3 of all stroke patient's, particularly those with middle cerebral artery insult, have some form of aphasia.
- The whole point of the presentation was to have each practitioner reflect on their own experiences, how did they communicate and what strategies did they use / did they find helpful. I then compared the strategies raised with strategies that I found by scouting through the literature. Some of these strategies were (common sense):
- And if the communication broke down then it was best to let the person know, but also let them know that it's not their fault and it's okay to be frustrated by the difficulties they're facing to communicate (be honest but sensitive about the communication). Try rephrasing or using another communication mode - ascertain whether they have a communication preference. Recap and confirm what has been communicated. Communicate at an appropriate intellectual level for the person in their current state. If all else fails, then return to the topic later.
- Aphasia does not reflect intelligence, memory or hearing.
- I had a look at qualitative studies that examined discrepancies between what patients with aphasia want and what physicians do (in terms of communication style) - and it turns out that although we can identify strategies, we don't always utilise them.
- Another qualitative study found that these patients preferred to have a conversation, rather than no conversation. I had a chat to the speech language therapist in the AT&R unit about a patient of mine with aphasia and the SLT recommended encouraging them to practice speech, whether it be by counting, or asking for the pair-word e.g. 'fish and ... chips', 'knife and ... fork', or getting the patient to identify objects or movements e.g. left, right, left, right. It sounds basic but it's a way for patient's to practice their speech - our feedback would then support speech, rather than judging their intelligence. Another tip is for the patient to watch our mouths when we speak.
- One story a physio gave about their experience observing aphasia in the community was set at a petrol station where he identified a patient who had aphasia paying for their petrol. The service person asked whether they wanted to accumulate or redeem their loyalty credits (Smart Saver Fuel Cents). It was agreed that at the best of times, even us people without aphasia find this difficult to comprehend (why don't they just say 'do you want to save or use your points?')... so imagine how this person with aphasia felt. In the end they just turned around and left the petrol station.
Ethics in-service training on Wednesday... basically it was a case study that had progressive ethical dilemmas. A hypothetical patient was going to have an elective cardiac surgery but refused pre-operative physiotherapy (patient education, prophylactic chest physiotherapy) saying they knew what to do and it was going to go without complications. How would you, the physio, ethically respond - and what do you legally have to do? The patient had post-operative complications, pneumonia and became unconscious, so the patient was put on a ventilator. What ethical and legal considerations would prevent us or encourage us to treat this patient? The patient then had a stroke, and was unresponsive - what would we, the physio, present to the MDT meeting. We had a few laughs, dark humour is actually quite funny when situations are hypothetical.
Delirium, hallucination and dementia make for interesting
patients... there were incidences from patients over my placement where
some patients believed some pretty strange things. Here's my top three:
- Being eaten by ants
- Thinking they were in prison for a pseudo-real crime they had done.
- Getting
angry because the staff wouldn't let the person walk to the shops
around 2am (said person has a flaccid leg and can no way walk... was
using a hoist to transfer at the time).
Most of my experience throughout the placement was through the AT&R ward (inpatients). That usually kept me busy until lunch time (often after that too). After lunch I usually had a patient or two booked in. One thing that has really struck me as important is to work with the doctors, nurses, patient and family. I am a bit guilty of doing physiotherapy with a patient, but not talking to the nurses about the patient's state / progress to ensure the patient is both safe and is well looked after once I finish with the patient for the day. Yeah, lots of things to improve on now that I have reflected with my supervisors.
My last neuro new patient assessment with my clinical educator was a rush. We had two patient's coming down in the afternoon, one from ward nine, the other from the medical ward. At the handover meeting it was decided between my supervisor and the other physio on the AT&R ward that I would take whoever was ready first. Anyway, it turned into another retrieval exercise after lunch (not because the orderlies weren't doing a good job, rather I had to be assessed with a patient within a certain time that afternoon). So I picked up the patient, brought them down to AT&R ward, dropped off their belongings to their room, helped with a toilet stop and then it was off to the gym for their initial assessment. And it went alright, not perfectly, but I got the information I needed and had a good rapport with the patient. We were a bit pushed for time, and key information was not mentioned by the patient (I hadn't been able to read the patients notes)... when I say this, I refer to asking the patient whether they had any heart or lung problems now or in the past and they said no! I check their feet... pitting oedema... I suspect the truth will be in their notes.
On my last day, right before I was going to leave a patient called for me from their room, asking me to ring their wife - they wanted to go home. Obviously I had to reason with them, they were not medically ready to be going home. But I did emphasise to the nurse that the person should be allowed to make a phone call, just to catch up with their family. Goes to show, building rapport is a powerful thing.
It's tradition for 4th year students to bake on their last day of
placement, so I whipped up a batch of chocolate brownies for all the
staff in AT&R to enjoy. I also said goodbye to my patients & the staff - nurses, doctors, OTs & cleaners, they were thankful for my contribution and enjoyed the brownie that I had brought along.
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| Premixed brownie from the supermarket is a winner!! |
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| Lloyd is a historic patient of AT&R Nelson who brings in apples from his orchard |
Easter break... time to update our portfolios and then relax for a week!
I've started some more casual hours working, this time continuing as a massage therapist with a local physiotherapy clinic in Nelson 'Active Body Centre'. I'll be available Monday, Tuesday and Friday evenings from 6pm.
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| Treatment room, Active Body Centre based at City Fitness in Stoke! |
