P4R1W8: Lessons learned.

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.

"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:

1. Being eaten by ants
2. Thinking they were in prison for a pseudo-real crime they had done.
3. 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.

Premixed brownie from the supermarket is a winner!!

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.

Treatment room, Active Body Centre based at City Fitness in Stoke!

P4R1W7: The long and winding road

With a few road works around, traffic has been a bit slow.... more time to enjoy the view!

On Monday an older female patient was discharged after three or so weeks in the hospital. On a daily basis (not weekends), she would spend time receiving physiotherapy with me. This is the lady that I joined for morning tea in her room to have a general catch up a few weeks ago. Anyway, she was discharged today and stopped by the AT&R gym to specifically say goodbye, thank me and wish me well (and she gave me a hug). I wished her all the best with her return to home. What a heart warming moment - all that work had paid off.

I've got another nice older lady that I'm working with, and we've established a good love-hate relationship (in a comical sense). She would spot me and give me the look like "you had better not be getting me up". I would, naturally, go do the opposite - we would have a joke about it. She's awesome because she is very motivated to get herself down the long hallway to the gym - her room is the furthest away from the gym on that corridor. Once in the gym, she would walk herself down the long parallel bars. Good on her. ...later in the week my supervisor and I were discussing her de-conditioned legs. The patient said "deconditioning, you just made that up - it's probably not even in the dictionary" to which my supervisor replied "deconditioning is in the dictionary... it's right next to air-conditioning".

On Tuesday I attended an evening seminar "How to walk off your Parkinson's symptoms" by international guest and author John Pepper (book tittled Reverse Parkinson's Disease). John has PD, but has used high intensity walking and conscious movements to overcome his parkinson symptoms. Although I didn't learn anything new, it was nice to hear this man's story - it always appreciated more coming from a person with first hand experience. The AT&R crew (physios and physio aids) all attended this seminar. Following the seminar we popped out to The Free House for a beer.

Sitting in the AT&R ward lounge, looking through to the dining room...

Wednesday was a quiet day. We had quite a few overflow patients from the medical ward which we agreed made the AT&R ward look like a retirement home village. I had the community physiotherapist sit in on a session with a patient whom I have referred to him. We will hopefully have a home visit with her next week (I'm just tagging along). Otherwise, I took my patients for extended sessions in the gym.

Backtracking to Wednesday morning after hydrotherapy, I returned a patient to her room. She was sharing a room with another lady who usually does hydrotherapy with us, however she was being discharged in an hour or so (thus not at the pool with us). As I was wishing her well for her return home she told me how she was scared the first time she went into the hydrotherapy pool, in particular using the water controlled hydrolic hoist (it rattles and shakes sometimes). She had a very sore hip and hadn't been in the pool for a long time. Between those three things, she was a little bit anxious. Anyway, she recalled a firm hand being placed on her back and a sense of safety for what was happening. That firm hand was mine, I was in my togs, in the pool along side her. Her thanks was very sincere - that firm hand on her back had made all the difference, that first day of hydrotherapy. Yay, another heart warming moment!

A date scone baked by our wonderful physiotherapy assistant... the delicious Wednesday tradition! Yum!

Things to watch out for on AT&R

1. Catheters and patient's exercising can be a recipe for disaster.
2. If you stand on the sensor mat by accident, you can rest assure it won't be a secret and the nurse will come. P.s. a sensor mat alerts the nurses that a patient has probably fallen or is trying to wander without assistance.
3.  Hand hygiene audits... On Thursday we were all under the watchful eye of a nurse carrying out the monthly hand hygiene audit. Early in the morning I walked passed my supervisor who was being followed by this nurse. He was firing cheeky comments her way until I happened to walk passed. He then said "follow him", and she turned around to follow me down to the patient's room. I was taking a patient back from the pool to their room thinking 'it's going to be a good day, this nurse is ready to take the patient from me to give them a shower'. I was wrong.

Thursday was St Patricks Day, and only one person dressed in green with a big green hat...that was our ever so cheerful morning toast lady. We call her bubbles and she volunteers each morning to cheer up our patients and give them toast. Today she gave me a green mint, egg-shaped, piece of chocolate. And on the discussion of chocolate, there was another patient's birthday and the family brought in two cakes of white choc for us to nibble at whilst we write our notes.

I had my clinical educator in on Thursday. With minimal new patients to practice new assessments with over the week, all I could do was to try my best with a Medical Ward overflow patient... a patient in AT&R just because we had an available bed. ...Another non-neuro patient to assess. I've had a poor run with very few new patients to assess this placement. I've done my best, but there's no way I'm up to the standard the assessors are after. I've decided it's not all my fault, there's nothing I can really do about it. The clinical intervention really has not helped at all - I feel that it's all very well having an intervention, but with no consistent new people to practice new assessments on there is little point. In addition I've had a confusing few patient assessments with my clinical educator - a few communication and expectation mismatches, so really I'm at a point where I know there is no coming back from this situation. I'm now prepared to fail this placement... having talked to my clinical educator and my supervisor about it, I have put my mind at ease. I feel a little hard-done-by, but I'll get on with the last week, next week, and try and finish on a high note (I'll dedicate this week to myself and my neuro patients...) Failing a paper means that I will be back for another neuro placement next year.

Friday was a fairly good day. I had my usual patients in the morning, two amputees in the afternoon (both of these patients have recently received their prosthesis from Wellington Limb Clinic) and I had my peer review (again... because it was recommended that the physio student watch me do an initial assessment). This was done without too many problems. Initially I wasn't sure whether I was going to get to do the assessment... due to it being an afternoon admission to AT&R and my supervisors finishing earlier on in the afternoon. Anyway, we got there in the end.

...Bring on my last week of neuro placement for the year... lets end it on a high note!

Next week I will also be providing an in-service presentation and probably a plate of food to share to say thanks to the healthcare team and my supervisors in AT&R.

P4R1W6: Brighter on the otherside.

Shipwreck in Motueka.

I've had to create myself a clinical improvement plan. Basically I've got to prompt myself to ask myself 'why'... What am I observing, why is it doing this? Why can't the person do this? (Make a problem list). Is it important to do something about it, why or why not? Why, why, why!?! ...I actually thought I was doing this already, but not to the extent that I should be (apparently). I'll keep trying my best and hopefully pass this neuro paper. Only two weeks to go, and lots to improve on!

On Tuesday I got to be a guest physio and help out at a falls prevention programme run by the PHO (Public Health Organisation). The main educational session took place in another room, and we had took individuals one-by-one to discuss their recent falls, home/life situation and to preform a timed up and go test. As you'd expect, most of the attendees were older persons. One key message that I got from them is that they are truly frightened of having another fall. (Also, they don't know how to correctly fit their walking sticks). There was some irony in holding a falls prevention programme in a pub. Maybe we could balance their anxiety of falling with some liquid courage (...might put them at a higher risk of falling though).

Timed up and go setup in the restaurant!

Hospital mysteries

1. Wheelchair wheels getting flat... there are no sharps lying around!!
2. Wheelchair cushions... not many on the ward now... they must grow legs and walk out.
3.  The lift that randomly opens on the ground floor with nobody on it and nobody waiting.

A patient lied to me (again... sort of). I asked them about their past medical history and specifically asking whether they had any problems with their heart. They said no. They mentioned that their legs get swollen, and sometimes their stomach does too - fluid retention. Looking at their legs, they were pretty swollen! Fluid was indeed retaining. The patient said they had been previously quite active, but when asked specifically they walked 10-15min most in one go, once a week. So, not as active I would like. I didn't think too much of all of this... the person was so very kind or 'lovely' as we call kind older persons (this one was >95years old). After the consultation I have a look at the patient's notes... it turns out they have chronic heart failure, with atrial fibrillation, hypertension, gastro-osophageal reflux disorder, epilepsy, have had a transient ischaemic attack and total knee and hip replacements.... it goes to show that patients don't share all that we need them to. Moreover the person said their clavicle had fractured... turns out it was their neck of humerus! Close, but no gold star!

A former patient delivers apples to some departments in the hospital every other week during apple season!!

A family member of a patient brought a dog in to visit the patient... We were lucky to get a bit of 'dog therapy' in the nurses station between writing up patient notes.

We had issues with keeping patients on the ward (alarm bells were ringing from all corners of the ward this week). We give some patient's sensors that cause alarms to go off when they wander out, or if they open a door that's suppose to be closed. I caught one leaving the ward via the main entrance  mid-week with a frame that I suspect was taken from another patient... it was miles to small for this very tall gentleman. This happened as I was leaving, so I had to take him back, slap a red ticket on his frame, adjust it (with no other name tag on it, it was his for the taking) and inform the nurses about this before I left.

I've started a job in Motueka. It's a support role for a young patient in the community. We're hitting up the gym in Mot and accessing the community every second weekend.

This week flew by so fast, so that's it - a very short blog post.

P4R1W5: Trouble in paradise

This week was a bit of a roller coaster. We're halfway through our first rotation, and I'm not ashamed to say that all is not always well. I'll detail this in a paragraph at the end. Anyway, here's a spiel about the week that has just been.

But before I get into it all, you should all check out Touch Compass dance company. 

https://www.youtube.com/user/touchcompass

http://www.touchcompass.org.nz/

I got to observe a treatment by an OT specialist in skin care. I also got to sit in on a doctor's neurological assessment. My supervisor loaned me a DVD "The brain that changes itself" to have a look at in my own time (it's about neuroplasticity). I got to sit in on an Allied Health meeting, which unfortunately had a theme of 'underfunding and coping with under-resourced services'. We had a physio team meeting too, which was pretty interesting to sit in on - a wide range of topics were covered (too much to go into). All of these experiences were pretty cool - as a fly on the wall!

Multidisciplinary team (MDT) meetings are a bit of an emotional roller coaster. Each team member usually has some input for each patient, and we all really get involved to understand the patients life - how best to get them home and to understand the requirements / constraints of their life situation. There is usually a good laugh about somebody, usually a family member of a patient or the patient themselves, who has a good sense of humour. Then there are the heart felt discussions about patients who have a less optimistic prognosis. The team really cares for each patient. It's such an inspiration to be involved in the rehabilitation, although I'm dreading growing old!!

On Monday we spent some time with a Richmond Physiotherapy Clinic recapping Mechanical Diagnosis and Therapy (also abbreviated as MDT). All of the physiotherapists at this clinic have done some training in MDT, in fact it's fair to say that this is a speciality clinic of MDT therapists. One physio there has her diploma in MDT, which is a lot of additional training! Only two people had their Diploma in MDT in the South Island; her and a staff member at the UoO School of Physiotherapy. MDT was developed by Mr  Smith and Robin McKenzie - he's the 'Treat your own back' legend... I've mentioned him in a previous blog post before. I hope to spend some time during my community placement at the clinic.

Physio banter.

• There is a lot of banter that goes on at the hydrotherapy pool. The quote of the week is from an older lady to the older gentleman (another patient using the pool) within ear shot of us staff (two females and myself) "Why do you get two lady's and I only get one man? to which the gentleman replied "it comes with experience". Classy! 
•  I had a patient with expressive dysphagia. When asked how they thought their walking was, their reply was "looks stupid", then they back tracked and they really meant to say "looks good"... their sentences are all jumbled up.
• I heard from another physio who receives semi-precious rocks (gem stones) from a patient. The patient makes the rocks shiny by rubbing 'nose fat' on the rocks.... I think we all know there's no such thing as nose fat... 
• It was entertaining to briefly join a group of Drs sitting out in the sunshine and exclaim (with a joking undertone) that you've lost a patient... they generally like a bit of humour.

Top five fashion accessories for physiotherapists

1. Walking (transfer) belt... a bit like hand-cuffs, watch out! We might take you for a walk!
2. Personal protective equipment... whole body camouflage / blending in with other health professionals
3. Stethoscope... when worn around the shoulders, it is like wearing a very smart suit jacket.
4. Stopwatch... the sports medallion, hanging around your neck on a piece of string.
5. Pens... they fit nicely into shirt button holes or clipped on pockets.

I'm a karate black belt, red tip... naa, just got my walking belt on!

Lunch out in the rehabilitation outdoor area is always nice, sunny and we bring out the walking frames with the built in seats. Perfect! Morning tea is usually had on the go. On Wednesday I caught up with a patient of mine in her room before her rehab session, taking the time to make myself a hot Milo and yarn with her whilst she had her own morning tea. I joked that I was hidden, and that I should use her room to escape doing any work. The other quiet spot on the ward is the Breakfast Club room.

Breakfast Club room!!

And sometimes food or hot drinks are left on my desk - I love it!

We're half way through rotation one now (week three of placement in AT&R). We've had our mid-way review from our clinical supervisors (the people on the ward with us everyday). In addition, we have completed our peer review (our peers observe us perform an assessment or treatment and provide feedback too). I haven't really had the opportunity to assess many new patients with my supervisors watching, so I hope to cram as many as I can in to the last three weeks! In order to fill my working day up, I've made a timetable which will stay on my student desk so I can book in outpatient and inpatients there, and my supervisors can add more patients (if I haven't already done so myself). That way, we all know that I'm experiencing lots of new stuff, managing my time effectively and have the opportunity to improve my clinical and professional skills.

To elaborate more on my progress so far... three weeks in and I feel that I haven't learned much at all. The team; my supervisors, physio aides, OTs, medical staff including nurses are super kind. They make turning up for placement each day worthwhile. The patients, the ones I can effectively communicate with, are lovely too. The main bee in my bonnet is that the quality of new patient assessment experiences I have had have been poor (or non-existent), especially with people that cannot communicate effectively. I would love to get better at this. Although neuro isn't my favourite aspect of physiotherapy, I would still like to be a pro - one day I would like to work in a hospital. Lets hope I can bring myself back on track to pass the paper and more importantly assess and treat people with severe and acute neurological conditions... I'm feeling pretty glum, which isn't like me at all. I'm choosing to filter the details out of this blog to keep everything above board, other than to say let me watch few real new patient assessments, talk me through why you're doing what you're doing, and then let me complete a new patient assessment myself (then give me feedback). I've had enough patient follow ups - I'm already good at these! Frustrating stuff, lets sort it out already.

We farewelled a new graduate physiotherapist (she's been working for NMDHB for over a year). We went out to Stag and Fern on Thursday for pizza and drinks, and on Friday (her last day) we had a morning tea for her. She's our sock poster girl! Best of luck in Wellington Alex!!

I might need some red socks for this neuro rotation...


This weekend I'm volunteering as a massage therapist at the Nelson Relay for Life.

7pm Saturday to 1am Sunday, non-stop massage. ...And there were 10 of us massaging!