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.

P4R5W2: Orthopaedic Physio

My tertiary physiotherapy placement will be divided into two main areas. The first week was on the orthopaedic ward. The next five weeks will be spent on the surgical ward. As an added bonus, I've shadowed a paediatric ward patient (we played games in the AT&R gym), and had my first medical ward patient. I have also spent some time on the surgical ward earlier in the week. It seems like I might get a bit of everything in small quantities over the next few weeks.

I've got back into the swing of things. The 8am rounds with the surgeons / orthopods and charge nurse (printing off my own handover sheet and annotating it from the previous day). Teaching people how to use frames and crutches. Liaising with the nurses and checking obs charts. Patient education. Listening to patients and their lungs (not at the same time). Writing notes and entering in the days work in Trendcare (a statistical software that tracks patients and the services they have received).  

I've had plenty of great moments with my supervisors, and other staff at the hospital. My supervisor has a great sense of humor, she introduced me to the 'Care Principle', an acronym that stands for 'Cover ass, retain employment'. Simply this means to tie up all loose ends (figuratively) and do a thorough job.

I've had some experience with the Arjo and standing hoists, ROM knee braces, ERAS (enhanced recovery after surgery) total hip replacements... I even encountered an Airvo humidifier. There's a continuous passive motion device that I'm eyeing up for next week (maybe)! I was fortunate to join the Occupational Therapists for a half-hour excursion to deliver home equipment to a patient's house ready for their discharge in the weekend. This opened my eyes to the amount we assume when a patient tells us there is a ramp or stairs in their house. The patients house we visited had a nice ramp that led directly onto small pebbles, with a step down to the driveway... we didn't hear about the pebbles, which will make using the low walking frame interesting! Another patient we saw lived in a house-bus and another patient wasn't able to safely use crutches up the stairs, so we taught one to bottom shuffle up and down the stairs and suggested the other find alternative accommodation for a few weeks.

All fourth year students will have received an email that looks like this and feel quite excited! I've got neuro to repeat, so that will be done next year in Feb (so I won't be graduating this time around).

Not all fourth year students will have received an email that looks like this. I'm hoping the CHCH based research group members decide to go along - it'll be great for them!

The weekend was spent studying and seeing more of the scenery around Nelson... My flatmates and I went to Cobb Valley for a day tramping excursion!

P4R5W1: PSW Tertiary Edition

Beginning of St James Walkway, Lewis Pass.

This is our last professional studies week (PSW) of the year (or for the degree, for those graduating in December). This week begun with presentations from student's who had community placements in the last rotation. We had a range of presentations including: use of acupuncture for tennis elbow, effect of respiratory muscle training for patients with spinal cord injuries, psychosocial factors impacting return to work, appraisal of clinical guidelines for management of spasticity and associated MSK conditions in children with cerebral palsy,  elbow extension restoration in tetraplegics, adverse neural tension in hamstring strains, and physio management of fatigue for patients following mild traumatic brain injury or concussion. My presentation was on Cupping therapy in MSK and Sports Physiotherapy... I came in feeling prepared, but I'm not the most confident public speaker (especially when there's a clock ticking and a few dozen eyes beaming back). 

Tuesday began early with an area preparation tutorial for my next placement, physiotherapy in a tertiary setting. Christchurch students were given placements in paediatrics, orthopaedics, medical respiraotyr, burns and plastics, cardiology/cardiac surgery, general medicine and surgical wards. Nelson students are privileged to get a mixture of surgical and medical wards... I'm not exactly sure what my placement will look like, so I'll tell you more about this next week. A highlight of the tutorial was listened to a mannequin's chest to identify different lung sounds, both normal and abnormal. I'm excited to get to put my stethoscope to use next week.

Later that morning we had a three minute presentation on our PHTY459 research project. Again, there were some interesting studies done by my 4th year peers and their supervisors. One included evaluating public spaces, namely gyms/pools, for usability for persons with a disability. Another project evaluated the use of a Troidometer II in measuring elbow extensor strength in tetraplegia. Tagged onto the end of this was a presentation about post-graduate study opportunities at the University of Otago (acupuncture, neurorehabilitation, occupational health, sports physiotherapy, orthopaedic manipulative therapy as well as research pathways)

Tuesday afternoon was especially entertaining and informative; we had two presentations. The first was from a neonatal acute care physiotherapist about "navigating the teenage brain". One key message from this presentation was to target your communication to the stage of brain development. Fun fact, the female brain matures at the age of 23, whilst the male brain matures at the age of 25. A mature brain can better 'access' the prefrontal cortex and 'over-ride' the earlier-developed limbic system. This explains differences in risk-taking behaviours and logic thinking between males and females during teenage years. We also discussed how stress (catecholamines) can influence how easily we can access our prefrontal cortex (i.e. a mental block). The second presentation was on the physiotherapy management of haemophilia. I hadn't given much thought to managing haemophilia until this lecture... and I was surprised how important the physiotherapists role was in diagnosis of a bleed vs other injury (particularly chronic or severe bleeds... arthritis in joints or myositis ossificans in muscle tissue!)

Wednesday was likened to job shopping. There were a number of representatives from private practices pitching potential jobs for their clinics to us, as well as describing what they expected from new graduate physiotherapists. Next up were representatives from the Physiotherapy Board of New Zealand, they gave us a run down on registering as a physiotherapist and obtaining an annual practicing certificate. Then the Board ran a session on ethics. There was one hysterical moment from a class member who made a fairly inappropriate joke given the seriousness of our ethics discussion. I'll elaborate. In groups, we were given situations where a physiotherapist was in a bad situation that had professional consequences. The group in question had a situation like 'a physiotherapist treated an 18 year old female for a shoulder injury. The day after the client was discharged, they were engaged in a sexual relationship. The mother of the client found out and lay a complaint with the Physiotherapy Board of New Zealand'. What ethical concepts are woven into this situation? Well, it's unlikely to be justice (fairness), but my peer had a crack at making it relevant (for humerus effect; nobody should be offended by this). My peer suggested that there was an injustice made because the physiotherapist did not share sexual relationships with all of their clients. I'm not going to get politically correct, the joke is what it is. You can reach your own conclusions as to what the most relevant ethical principles are that makes that a poor situation.

Thursday morning we had a session on the cervical spine from an orthopaedic manipulative physiotherapy approach which reinforced what the Nelson placed crew had learned from Michael Monaghan. The lecturer from Otago had recently been to a workshop / conference in the US led by Stanley Paris. Thursday finished with a group of first year graduates working in a range of physiotherapy practices came to share their experiences from their first year working as a physio, as well as sharing the inside scoop on selecting a job.

Back to Nelson for round five!

P4R5W0: North Island Adventures (Holiday!!!)

Quick catch up from my week break... I had a second attempt (first attempt was earlier this year) at reaching the summit of Mt Holdsworth (via Powell Hut) in the Tararua ranges, this time with success. It's a much easier walk when it's not pouring with rain, gusting like a hurricane or lighting up with lightening. It was a stunning sunny, clear day and at the summit both East and West coasts of the North Island and the top of the South Island could be seen. As a bonus there was some snow that had not yet turned into a slab of ice.

Powell Hut

Trig point of Mt Holdsworth in background

Mt Holdsworth Summit

P4R4W7: 100th Blog Post

My blog has reached a milestone, it's my 100th blog post.

Celebrations? I think I'll take the week off next week... ha!

It was my last week of my Community Physiotherapy Placement at Sports Therapy and I was busy setting myself up to pass the placement - prepping for clients, preparing an in-service presentation and finishing off my written project (with additional powerpoint + script for the next PSW week).

My Tuesday session with Michael was, as always, insightful. Apparently skeletal models made out of real human bones could be brought and were used by medical, physiotherapy and osteopathic students (historically). Michael happened to own a set of joints - I didn't think I'd see any more real tissue models since anatomy in second year. We used these joints in a between-patient time to examine the foot, neck and elbow. A few more manips for the foot were taught, one in particular had the patient in prone lying, with the foot placed and pronated flat on the plinth... the practitioner uses a manip similar to the screw technique for thoracic spine, the manip is to the calcaneous and talus to gap the sinus tarsi / subtalar jt. The elbow was another interesting jt to manip... here's a Youtube video that is similar: https://www.youtube.com/watch?v=-FKNdj0UmTk

Book & dvd on Monaghan's techniques!!

Sessions with Michael were most valuable. He offered a 'less is more' approach, with great handling skills, consideration of alternative positioning for older patients and irritable conditions, a fine-tuned biomechanical approach with techniques utilising a sensing hand for joint interplay, and of course osteopathic manipulations! I am very privileged to have met and had some hours with him over this placement. I think he should update his book / DVD to include his techniques for the peripheral joints so that his wisdom isn't lost.

My placement at Sports Therapy has been equally rewarding. I feel that I have begun to developed a better, more relaxed approach of chat with my clients. My supervisor has challenged my thinking on political correctness within physiotherapy practice, which isn't necessarily a bad thing - it's a realistic view on physiotherapy practice. It's fair to say I have almost had a laugh a minute there.

World Physiotherapy Day on the 8th of September!!

I had my presentation on cupping therapy on Friday and it was a little bit rushed, but I think the physiotherapists there already knew a lot about cupping anyway, so they got the brief version. I was able to show some fire cupping, that's all that mattered in the end, haha! I also got my project submitted to my educator on time and within the word limit. I've got a formal presentation to give on cupping in the next PSW week. I might dedicate some of the break to write a post about cupping therapy specifically.

On Friday I baked brownies (again... you'd think that was all I knew how to bake... you're not far wrong there!) I also whipped up some bacon and onion cheese rolls (a Southland delicacy) for my supervisor who is shifting to Invercargill. A client mentioned that cheese rolls and Speights beer will soon become the norm for his breakfast. I wish my supervisor Phil all the best in the deep south.

And that is the end of my community placement. Time for a week break (after I finish my clinical portfolio for this placement haha! Due before Monday).

P4R4W6: Sports Outtings

This week there was a South Island Secondary Schools womens soccer tournament at Saxon soccer fields in Nelson and in my non-clinic hours I was down at the soccer fields (it's been a full on week). There was a range of acute conditions, as you would expect. The highlights from this would be watching new ways of strapping, learning more about K-tape (I'll describe this soon), hearing about physiotherapy business and what to aim for in an employment contract. I had some practice with ACC read codes and having clients add extra details or fill in missing boxes on the ACC45 form. In the clinic we completed an online ACC32 form, request for further treatment, for a client and we had it accepted within the week.

Prior to this placement I understood K-tape to increase proprioceptive input (due to its adhesion to skin and elastic nature), or facilitate the reduction of swelling (jellyfish cut k-taping, with the tentacles/tails draped over the area of swelling towards the body of the jellyfish... best I can describe it). This week I learned that k-tape "in theory" can be used to facilitate or inhibit muscle activity depending on the amount of stretch and direction of elastic recoil. Cool idea, but I don't feel entirely convinced...

• To facilitate muscle activation: Apply the tape proximal to distal, aligned with the muscle fibres with 25-50% stretch - the elastic recoil pulls the skin towards a shortened muscle position.
• To inhibit muscle activation: Apply the tape distal to proximal, aligned with the muscle fibres with 0-25% stretch - the elastic recoil pulls the skin towards a lengthened muscle position with the idea that a muscle is more relaxed under stretch.
• To apply a mechanical correction, such as a medial glide of the patella e.g. applied from a bent knee position with  maximal stretch in a horse-shoe shape  on the lateral boarder of the patella, as the client straightens their knee you taper off the stretch (the ends of K-tape shouldn't be under any stretch... so it won't peel itself off). A mechanical correction could also be an AP glide on the GH joint.
• A decompression technique acts to lift the skin and fascia to minimise irritation from additional tape applied over-top (rigid tape). For example, to decompress the skin over the achillies tendon, apply one strip along the length of the tendon itself, stretching 25%, then a second strip is applied at 25% stretch directly over-top of the first strip (the ends can extend passed the first tape to adhere to the skin). Rigid taping, such as an ankle lock can then be applied over-top of this.

I then stumbled upon an article by Lee K, Yi C & Lee S (2016) The effects of kinesiology taping therapy on degenerative knee arthritis patients' pain, function and joint range of motion. The authors applied K-tape applied to the hamstrings, tibialis anterior on patients with pain on knee flexion OR quadriceps or gastrocnemius on patients with pain on knee extension. The control group of patients got a heat pack and some interference wave therapy. Results? Those older persons who had degenerative, painful knees had significantly less knee pain, increased range of motion and improved WOMAC scores (better function, reduced stiffness). Interesting stuff.
 

Tuesday Michael taught us how he goes about examining a foot. The main points that captivated my interest was how to manipulate (grade V mobilisation) the ankle & foot. One of particular interest was the talonavicular joint and talocrural joint. Dorsiflex the ankle into a closed-packed position (end range), then slightly plantarflex it (so it isn't quite at end range). With one hand on the calcaneous (heel), other hand on the talus with hand rolling the navicular away from the talus (gapping the talonavicular joint). Take these joints into a grade 4+ distraction / mobilisation in a caudal direction, then thrust. Amazing! Tuesday was also the first client that I've assessed and treated that required an interpreter.

This weekend I'll be frantically writing up my community project / mini-review for presentation at an in service training session on Wednesday and submission on Friday. Coincidentally, the group research project about falls (my research placement) is due next Friday too - it'll need to be printed and submitted sometime next week.