P4R5W5: A good variety.

This is the end of my fourth week, and I'm still working toward running the surgical ward.

The week started with two of the acute physiotherapy team members on unplanned sick leave. This somewhat stretched physiotherapy resources. Tuesday and Wednesday were a little different on the wards too (normal physio staffing resumed) - the junior doctors had their strike against the DHBs for better working conditions.

I saw a variety of conditions this week, so I'll briefly mention them here.

There was a patient in ICU who had had a cardiac arrest. The patient was intubated and suction was performed to stimulate a cough and remove secretions. As this patient's status improved, they were extubated and put on airvo (high flow oxygen device). The supervising physiotherapist encouraged vibrations with deep breathing and oral suction (having checked the CXR, chest x-ray). The nurse also showed me how we collect sputum samples using suction. Physiotherapy encouraged movement of arms and legs, then sitting etc too. Patient comfort is obviously very important; one thing I learned this week was about identifying other means of ensuring the patient is comfortable. One aspect I overlooked was addressing the patient's dry mouth by using water from a sponge on a stick (I'm sure it has a proper name) - these are good tips and ticks that I hadn't thought of. Having a cold wet flannel on the forhead is another trick that can make a patient feel more comfortable.

Another thing I learned this week was: when a member of the MDT request for you to see a patient, particularly for a mobility review, you need to make your own informed decision about whether you need to see the patient, and what you will do / offer for the patient, and then justify or inform the MDT about your decision... it may well be that all the information they need about a patient's mobility is described by the hospital level residential care facility that the patient resides in, in the patient notes already. All that is needed is for the patient to confirm this information and a wheelchair to be brought up (...because the residential service didn't send it in with the patient).

Bird flu? Parrot fever? Psittacosis? This was the suspected diagnosis for a chest infection for another patient I saw this week. Other than the odd [potential] source of infection, the main reason I'm mentioning this case is because the physiotherapist performed 'induced sputum' to (as the name suggests) get a sputum sample for laboratories to examine. The process involves hypertonic saline (9%) in a nebuliser and the ACBT (active cycle of breathing techniques i.e. deep breathing, huffing and a cough or two) to be performed. The patient breathes in these vaporised droplets for about 20min to moisten secretions and produce a productive cough.

Mountain biking is a dangerous sport. We've had two patients with injuries sustained from mountain biking this week. The first patient had a contusion of the lung and a concussion, the second patient had fractures of their first six ribs, clavicle and scapular. Yikes! After an orthopaedic sling was fitted, I encouraged them to use a towel or wall to brace against to take deep breaths and cough to manage their pain and gave advice about returning to mountain biking.
 

The whitebait are running ?swimming and the seasonal tramper will be gearing up for another year in the wilderness (labour day / long weekend this week). A word of warning, be careful with gas canisters. We had a patient with burns to their hands, chest and face following an incident earlier in the week. As there were no burns to the airways or grafts needed, I encouraged deep breathing through incentive spirometry (given they had lower blood SpO2, probably pain related), and gentle hand/finger range of motion exercises.

In an interesting experiment with a patient who lacked touch sensation and was not able to voluntarily walk as a consequence of a back injury, but had reflexes intact, good muscle definition after weeks post-injury, could get themselves into standing and use a cross-trainer at home (not to mention, unremarkable imaging)...  a physio had a genius idea of tieing each of the patient's feet to a high walking frame with a theraband and pushing them down a ramp to get a gait pattern / walking movement going. Of course, there were plenty of hands on board to ensure the patient's safety. The set-up showed potential as the patient was able to continue stepping on the flat surface having gained momentum.

The last interesting case of the week involved a patient who had a tibial plateau fracture. There were a few unexpected post-surgical events that delayed their recovery. Anyway, the short story is the team is trying to get his knee straight. A range of motion brace was trialed and found to be a nuisance for the nurses to put on and off, so there was a collaboration between a few physio team members, and a thermoplastic brace was made to encourage knee extension. I was fortunate to watch the designing and making of the thermoplastic device.

It's Labour weekend, so I'll get an extra day to get my portfolio up to date!

Flat photo!

P4R5W4: Used with good effect.

The third week on the wards rolled around pretty quickly. I've listened to some interesting sounds through my stethoscope, including wheeze, creps, heart murmurs, people talking to me whilst I try to listen to their lungs, as well as the rare burp & hick-up that coincidentally occurred whilst auscultating! I am more often finding myself excited for my patients when they clear secretions from their lungs. I even had an exciting conversation with an older lady who, after a few days, had finally passed some wind. The excitement continued later in the week when she had a bowel motion. Exciting stuff!

There are some great patient attitudes out there. One patient stopped me in passing to tell me a joke. I was somewhat busy, but I stopped to listen (who wouldn't pass up an opportunity to share a laugh). The joke was about an elderly person who took their neighbors 'dog' for a walk down the street when a passerby asked why the person had a cabbage on the leash, to which the elderly person retorted that they would go back to their neighbor to apologise for not walking their colly.

On the ward I've had the opportunity to perform a bit of chest physio, there have been a range of patients with a range of conditions; post-abdominal surgery under local and general anaesthetics (some following the ERAS enhanced recovery after surgery protocol... different booklet to that of normal notes), traumatic injury (mountain bikers beware, your sport is dangerous!), pneumonia and upper respiratory tract infections. Incentive spirometers seem to be the flavour of the month - from my short experience, these devices really do motivate people to breathe deeper more often each hour! I've had many patients demonstrate their improvement with such pride. I've also made some DIY bubble PEP devices out of unused saline bottles (rinsed and filled with tap water) and unused catheter tubing (cut to size!) stuck together with some sellotape, with a post-it note covering the saline bottle label (instead showing instructions for bubble PEP). Bubble PEP is not just for paediatrics... geriatric patients enjoy it too.

There are plenty of wound drains, IV lines, PCA (personal controlled analgesia) line, catheters, telemetry lines, nurse-buzzer button, SCDs (sequential compression device i.e. calf pump machine), Airvo/nasal oxygen tubes, blood pressure cuffs + pulse oximeter lines etc to be cautious of and searching for. I have noticed that patients are often put on supplementary O2 via nasal prongs by the nursing staff on their arrival, this is something that physios commonly remove from the patients soon after they are assessed and deemed safe to have the oxygen removed (these patients are relieved, as the oxygen nasal prongs reportedly dry out their throat). 

I had some friends visit over the weekend, so we made a day trip into Abel Tasman national park!

P4R5W3: Tertiary Physiotherapy

Last week I failed to talk about the role of the physiotherapy in the acute care setting... obviously, we don't have a set client list so we print a handover sheet like we did on the AT&R ward. Patients are then prioritised based on their health status and rehabilitation goals, the risk for chest infections/falls/pressure sores/ability to self-manage, and with consideration of their planned date of discharge. We liaise with other healthcare professionals and services about their physiotherapy management, often getting information that makes our input more effective or safe. 

The typical day on the wards starts with printing off the handover sheet and annotating it with notes from the previous day's handover sheet (otherwise I might forget what I've done or going to do with the patient). We then scope out likely candidates for physiotherapy services from the list, check their notes and cross-reference the ward patient board (which is a large whiteboard with patient names, their room/bed number, nurse + Dr, planned discharge date and a list of services (OT, PT, SLT, Nutrition, Social work etc) that may have had input requested for a given patient. There's a triangle system: one side of the triangle symbolises a referral/input needed. Once the healthcare professional sees the patient, they can add another side of the triangle. When the healthcare professional has discharged the client from their service, they can add the final piece to complete the triangle... they can also put a red or green dot in the triangle to indicate that the patient is safe and ready to discharge or not. Of course, communication extends beyond the whiteboard and we discuss patients status / our findings with the healthcare team as well as reading their notes/making note entries into their medical documents. Depending on the ward, there will likely be some form of ward rounds... the ortho ward has a round at 8am every day, the surgical ward has two rounds during the week and a grand round on Friday, the medical ward will likely have daily rounds too (I haven't really observed this yet).

So we've got a list of patients to see, time to get on with the job! We start by visiting the HDU (high dependency unit) to see whether we can offer physio input there (at other times people at the HDU will page/ring for us). We take a couple of flights of stairs up for a fleeting flyby through the ortho ward to see how that's looking, and up another set of stairs to surgical.  At morning tea time the acute physiotherapy team regroups in the acute services office to ensure there is adequate cover across all wards (if one ward is particularly busy, then another physio will take on a couple of patients from another ward for the day). At lunch, the PTs regroup again to discuss how the morning has gone. By the end of the day, we are likely to somewhat regroup and tie up loose ends of paperwork etc.

Our role ranges, but generally we aim to have patients stay physically conditioned and mobilising safely (walking) and effectively for returning to their home environment (ie. do they have stairs with a rail that we need to see them complete before discharge) and performing chest/respiratory physio (assisting patients to clear lung secretions, breathe easier or otherwise maintain good lung health for their stay in hospital). There is, of course, a lot of patient education and information collecting (i.e. patient's previous level of function & home situation).

These are the common wards that are covered by the physiotherapy acute care team.

• General Surgical ward
• HDU/ICU
• Medical ward
• Orthopaedic ward
• Paediatric ward
• Emergency department

This week was very quiet on the Surgical and Orthopaedic wards, so I got to hang out on the medical ward and revamp patient information sheets for Bubble PEP and Incentive Spirometry. I also took to Snapchat whilst the draft copy was being sent to the printer! 

By all accounts, it was a very enjoyable week.