FINAL ENTRY - Fremantle Hospital

All over red rover! It has been an extended journey, and have come out the other end with invaluable experiences and a much extended repertoire of knowledge and skills.

At Fremantle Hospital I was designated to work within the intensive care unit and cardiothoracic ward. These fields of cardiorespiratory, having highly dependent patients with added responsibility on therapists to perform to the highest standard, gave me fantastic insight into the skills and requirements of a cardiorespiratory physiotherapist. Being some of the most acute and unstable patients of the hospital, you had to be 100% on your game at all times, and constantly monitoring your patient’s status.

Having done suctioning and basic cardiorespiratory techniques on prior placements, as well as having seen the intensive care unit at Fremantle previously, this mentally prepared me to be quite comfortable in that environment.

On this placement, the initial week was mostly observational and noting considerations and precautions that need to be constantly monitored to avoid the dreaded “code blue.” By week three, Kendall and I were running the cardiothoracic ward, seeing patients of our own within ICU and conducting the pre-operation education for patients about to be admitted for heart surgery. This independence gave me great confidence in my ability to embark on a career as a physiotherapist and be able to manage a clinical caseload of my own.

For majority of our placement the hospital was running on a “code green,” indicating that the hospital needed to discharge patients as efficiently as possible in order to free up the emergency department. This is a policy only recently introduced as a result of the 4-hour rule. As we were treating un-medically stable patients, this rarely impacted our ward, though for the few patients on the ward who were borderline, discharge planning needed to be undertaken and occasionally the assistance of the RRAD team was required.

Prior to commencing this placement I was concerned about the four-hour rule impacting time with patients and discharge planning, which did occur on other wards, though within the area I was delegated too, this was not a major issue.

Another concern was my past experience of Fremantle hospital impacting on my placement. Initially it was daunting, though my supervisor was brilliant and demonstrated outstanding patient care which put my mind at ease and resurrected my faith in the Fremantle hospital staff.

Overall I thoroughly enjoyed my experience at Fremantle hospital and only wished that other students had the same opportunity as I did in working in ICU. The patients are much more dependent with a greater intensity in what we do as cardiorespiratory physiotherapists, rather than just the daily mobility review on a general medical ward.

Otherwise I am grateful for the opportunities I have had over this final year in my degree, have learnt a great deal of interesting techniques and have consolidated a lot of our theoretical knowledge as well as meeting some fantastic people along the way.

STARES 3 FH

Situation

A 79 year old male patient was admitted to the cardiothoracic ward 8 days post booked right thoracotomy. The procedure involved a resection of the middle and lower lobes of the right lung to remove a malignancy, a significant mass that was easily identifiable on his pre-operative chest x-ray. Prior to admission the patient had a 6 week history of coughing, productive of creamy white sputum and increasing shortness of breath on exertion. This patient had a background of previous myocardial infarct in 1989, hypercholesterolaemia, hypertension, type II diabetes myelitis, gastric ulcers, arthritis and asthma. The patient had a delayed progression post operatively secondary to multiple complications including episodes of tachycardia of greater than 200bpm and acute renal failure resulting in an extended stay in the intensive care unit.

On the day of admission to the cardiothoracics ward the patient’s blood results were unremarkable except for a low haemaglobin reading of 90, the chest x-ray showed marked decreased volume of the right lung field and a significant trachea deviation to the right. This is to be expected following a lobectomy of the right middle and lower lobes. The patient currently had an inter-costal catheter insitu, on 5kpa of suction, an in-dwelling catheter, oxygen requirements and intravenous drugs being administered regularly. With a right thoracotomy, his incision was postero-laterally on the right.

Previously the patient had managed all activities of daily living independently, living with his wife in their own home. He was independently ambulating with nil aids required. The patient was an ex smoker of 21 years with an 80 pack year history, resulting in poor overall lung health and integrity.

Task

In this particular clinical situation I was to see this patient with my clinical supervisor, conduct a full cardiorespiratory and mobility assessment and complete the relevant treatment session.

Action

Prior to seeing the patient I gathered the relevant information regarding medical history, current medical progress, nursing obs, most recent chest x-ray reports and blood results. Using this information I developed a rough idea for treatment and planning of the session. I then proceeded to see the patient. As the patient was attached to an IV drip that the nursing staff informed me would be finished in 10 minutes, I completed my assessment in this period. This involved the regular auscultation, cough assessment and evaluation of patients chest expansion. After completing the assessment I explained my findings to the patient and how we could best address these and optimise his recovery. By this stage the IV drip was complete, which the nursing staff detached. As the patient was on suction, the patient had about 5 metres of tubing allowing him to walk 5 metres from the bed. As I had not yet seen a patient with this set-up, I proceeded to ambulate the patient as any other with the tubing coming behind, keeping an eye on the catheter to ensure it didn’t become disconnected. My tutor instructed me to drop the tubing and then pick it up again as we walked. This then made it difficult to bring along a monitor and hold the patient, so I did not take the monitor so I could have hands on the patient in the case of a fall. After ambulating I positioned the patient in bed and demonstrated some breathing exercises, which I encouraged the patient to carry out independently.

Result

After this session I discussed the outcome with my tutor. I was unhappy with my performance as I felt under-prepared throughout the session and under-pressure as I had not been assessed one on one since 3^rd year exams, the thought of an assessment threw me off. On discussing with my tutor I pointed out the things I felt I could have improved on and would have normally done had I been more prepared. The tutor felt I was unsafe in this instance as the patient could have potentially tripped over the tubing had I left it dragging and as a result of holding the patient, was not monitoring.

Evaluation

Overall a poor performance on my behalf and I knew I could have been doing / done a better job which was most disappointing, especially considering it was my assessment with the tutor.

Main point – don’t be afraid to ask for help. My tutor had told me to ignore her presence and act as if I was the ward physio seeing a patient independently, which I took to mean that I couldn’t seek her help. Mistake number one. Had I requested her assistance, the session would have run a lot smoother and been safer for the patient.

I also needed to plan ahead to familiarise myself with the patients environment, plan my treatment and organise attachments and equipment I needed for the session.

To optimise my session, having the patient sitting out of bed in a chair would have been optimal, again emphasising the planning of the session.

Otherwise, I was able to quickly build rapport with the patient, despite my lack of confidence in my performance, I still had the patients full participation and support. I was able to effectively translate medical jargon to simple language and answer any questions the patient had.

Strategies

- Ask for help when needed

- Plan ahead – equipment, environment, attachments, expectations

- Aim for optimal treatment session

- Continue effective communication

STARES 2

SITUATION:

A 69-year-old patient was brought in by ambulance to the emergency department, presenting with infection of a pacing wire, left insitu following heart surgery in 2009. After removal of the wire in theatre, he was transferred to the cardiothoracic ward for monitoring. The patient was initially flagged by the nursing staff for a physiotherapy mobility review only. My supervising physiotherapist reviewed the patient and deemed him inappropriate for further physiotherapy input prior to discharge as the patient was complaining of significant pain that limited any mobilisation. As this patient was of low priority it was documented that he would only be seen by physiotherapy on request or for discharge planning.

The following day the patient was reviewed by occupational therapy that requested a mobility assessment from physiotherapy as the patient’s pain was now controlled at a manageable level and was now able to mobilise and actively participate. The patient was normally ambulant indoors with a walking stick and outdoors with a 4ww. He lived with his wife in a single storey home and had nil complaints of pain, SOB or coughing during my assessment. His main complaint was a marked tremour in his upper limbs that was a new presentation since being in hospital and had increased significantly over his admission. He also appeared mildly confused, repeatedly asking what day it was, mixing up his wife’s name and unable to remember his address.

TASK

It was my task to use my assessment findings to establish the patient’s mobility and level of assistance required and to undertake this in the safest possible manner. From this I was to begin appropriate discharge planning in collaboration with the other members of the disciplinary team.

ACTION

After gathering relevant information from the medical and nursing notes, as well as subjectively from the patient, I then gathered relevant aids including a portable IV pole, SpO2 monitor and WZF in anticipation of ambulating the patient down the corridor to assess his mobility and ambulation tolerance. I began formal assessments with a quick cardiorespiratory assessment, which was found to be clear. The patient’s main complaint throughout his stay had been pain in his lower limbs, which was unremarkable at the time of my visit. From gathering this information I deemed it appropriate to further assess the patient’s mobility and attempt a walk. For cautionary purposes, I had Kendall assist me in getting the patient up for the first time. We first got the patient into sitting, where he displayed good independent sitting balance, though had an evident tremor in his upper limbs at rest. The patient remarked on this as abnormal, though felt comfortable to continue. On standing the patient’s tremor increased and now incorporated the trunk. The patient tolerated standing for less then 10 seconds before his legs gave way and we guided him back onto the bed. I reassured the patient that he had done nothing wrong and that I would consult the medical team in regards to the increasing tremor. We got the patient back into bed and reassured him once again. I then consulted the medical team in regards to the origin of the patient’s symptoms and documented my actions and findings.

RESULTS

As a result of my assessment, I deemed the patient unsafe to be transferred at this time as the tremor impeded his ability to stand independently or even with the maximum assistance of 2 people. I notified his nurse of what had occurred and my suggestions for transfers. I then consulted the medical staff with my supervisor to discuss potential causes for the patient’s symptoms. I deemed it appropriate to regularly monitor the patient to report back on any improvement or decline in status to aid the medical team in their treatments. The nursing staff and medical team found my findings and input very helpful in their treatment of the patient. My supervisor was also satisfied with my consideration of safety and my collaboration with the team to benefit my patient.

EVALUATION

In this situation my emphasis on safety of the patient and my decision to proceed with caution and recruit Kendall to assist me, was appropriate and necessary. Also my communication with the patient and ability to establish trust and rapport was to my credit in that the patient felt confident in my ability, confidence that was maintained even after the patient had lost his strength in standing and was guided back into sitting.

Working in collaboration with fellow members of the team was fundamental in this situation, as it required a combined understanding and effort in order to identify the underlying cause of the patient’s symptoms.

One thing to work on is awareness of medication side effects, in that this patient was on a few medications that could potentially have the side effect of shaking. Even though the patient had been on these drugs long term, other new drugs could be influencing their action.

STRATEGIES

Obviously emphasising safety in every situation, especially with new patients on their first time out of bed as with drug reactions and illness it is unknown whether the patient will be as able as they report.

Finally, always including and utilising the strengths of all the team members to allow for optimal outcome for the patient.

STARES 1

SITUATION:

A 19-year-old female patient was admitted to the ICU at Fremantle Hospital following an overdose of Seroquel, an anti-psychotic commonly prescribed to people suffering from bipolar disorder. Within the patient’s notes was a detailed psych examination from her psychologist. This patient had an extensive history of family sexual and physical abuse, neglect, drugs and alcohol, witness to suicide of a close family relative and episodes of insomnia and paranoia. On presenting to ED she was intubated and administered charcoal in an attempt to preserve her organs and bodily functions. Within the ICU the patient had multiple attachments including; invasive SIMV with constant PEEP of 8kpa and 100% FiO₂, cardiac monitoring, Noradrenaline to support heart function, Morphine and Midazolan for pain and sedation given through separate IV lines, an oxygen saturation monitor and an indwelling catheter. Her resting heart rate was at 105 bpm with a mean arterial pressure of 136 and her saturations on 100% FiO2 were at 92%. On auscultation there was clear bronchial sounds in the posterior upper segments of the right and audible crackling throughout the upper lobes. The lower segments of the lungs had poor airway entry and therefore minimal breath sounds were heard. Her assigned nurse reported that she was de-saturating significantly overnight to extreme lows of 48% and required frequent suctioning via the ETT in an attempt to maintain clear lungs. By her 2^nd day in ICU, it was deemed that she was in single organ failure involving the lungs.

TASK

My task in this clinical situation was to gather all relevant information from the patient’s medical notes, nursing observations and relevant staff, as well as conduct a thorough assessment of the patient’s cardiorespiratory function to then present this to my supervisor and discuss optimal treatments.

ACTION

Firstly I gathered all relevant past medical history, the presenting complaint and her current admission journey as well as brief summary of her social background from her medical notes. I then consulted her nurse to gain any additional information about recent observations, information and objective measures noted. With all of this I deemed it necessary to do a screen of tone, reflexes and ROM to assess any potential neurological deficits or pre-morbid restrictions as well as cardiorespiratory assessments such as auscultation, breathing pattern analysis, effect of positioning on saturations and blood pressure as well as cough reflex.

I reported all of my findings to my supervisor with a clear analysis of impairments, a prioritized problem list and a plan of treatment.

RESULT

From the notes I was able to gather a fair amount of information, which made my patients background and pre-morbid status clear in my mind. I then had a good idea of a baseline as to compare my clinical findings with and identify a worsening progression.

The nursing staff acknowledged that I asked appropriate questions in a clear manner, enabling them to easily provide me with the answer I needed.

My supervisor also acknowledged that I had shown initiative to consult the nursing staff and the medical notes, prior to seeing the patient. She agreed with my reasoning behind my choices of assessment, analysis of the findings and my prioritized problem list with just a few additional notes to add. We then collaboratively came up with a plan for that day’s treatment to best address the identified problems that we could potentially impact on.

EVALUATION:

In this clinical situation, my greatest strength was my communication. My revision of specific cardiorespiratory terminology enabled me to express my findings, to my supervisor, in a succinct, informative and educated manner, while my broader understanding of the meanings allowed me to then translate this to nursing staff.

As this is my final placement, I am confident in communicating with various team members and find this a very useful means of gathering information when the correct question is asked. Being my only cardiorespiratory placement, I was initially unaware of the information required in a good patient handover and in this instance, my supervisor needed to ask a couple of additional questions to draw out information.

This situation particularly tested my ability to remain neutral and unattached. The patient was around my age and had been through such a hard life struggle, to now be in ICU with multiple attachments, organ failure and no family support, seemed so unjust and almost cruel. Something I will undoubtedly be exposed to often in ICU and will gradually come to terms with.

STRATEGIES

After being in this situation I will endeavour to plan my handover by writing down all elements I need to know about a patient to then handover to a fellow physio or team member. From this I hope to develop an individual method of doing this and hope it becomes more efficient.

Exposure to clinical situations offers experience and knowledge, which can only benefit me the next time I am presented with something similar.

INITIAL ENTRY - Fremantle Hospital Cardiorespiratory

Fingers crossed, last and final placement. Fremantle Hospital to signify the coming to an end.

At Fremantle hospital I will be undertaking my cardiorespiratory placement. This field of physiotherapy is one I enjoyed at university and found simple to grasp concepts and treatments, therefore I feel confident in my ability to perform well at this placement. As majority of my prior placements have incorporated some element of acute care cardiorespiratory or post surgical rehabilitation, this will hopefully help in my success on this placement.

Fremantle Hospital itself is an older facility, on a small location, though being the only public tertiary hospital south of the river has extremely high demands to meet. With the additional pressure of the four-hour rule, there is added stress on staff, which will undoubtedly be translated to students as well. This could play out two ways, being given a greater degree of independence to share the clinical case load or having a greater degree of supervision to ensure more efficient and quality care.

In terms of the nature of this placement; we have not yet been informed of the specific area of cardiorespiratory physiotherapy that we will be assigned to, whether it be cardiopulmonary rehabilitation, oncology or general surgical, there is great variety in the nature of each of these wards.

The structure however would be similar in that it is largely acute inpatient care where we will be designated patients to treat and assess throughout our placement. It will be my role to integrate into the team, assess and treat the patients I am designated, attend relevant meetings and professional development sessions and assist my supervisor and other staff members in any way possible to improve efficiency and quality of patient care. Meanwhile as a representative of Notre Dame Fremantle and a student looking to be employed as a physiotherapist in the near future, I will act professionally and acknowledge workplace policies and procedures as well as build good working relationships with the staff of Fremantle Hospital.

Prior to commencing this placement I have only a few concerns:

- The impact of the four-hour rule, specifically to cardiorespiratory patients. I found in previous placements, especially Neurology at Royal Perth, that the four-hour rule put added pressure on the emergency department to delegate patients to relevant wards quickly. This then meant that patients were placed wherever there was a free bed and often ended up in units not specialised for their care. Also as many patients have an element of cardiorespiratory, the variety of patient presentations may be overwhelming.

- Fremantle Hospital has featured in my past, and from previous experience, was not a satisfactory hospital with poor facilities, limited resources, mainly staff and a low standard of patient care. I am hoping that since this time, the standards have much improved and that my past experience doesn’t bias my opinion of the placement.

Overall I am excited to be on the home stretch and have my final placement in a field of physiotherapy that I feel confident with.

FINAL ENTRY - Royal Perth Hospital Stroke Unit - WSC

Looking back over this five week placement I feel I have come out stronger, and more confident. With such poor and negative expectations originally, it couldn’t have been worse then what I prepared for. With the main objective of gaining as much information that I could and passing so that I could continue the degree, I had little concern about how I was treated as a student. I have a strong exterior and can handle bullying without the need to retaliate, and in this situation this definitely played to my advantage. After being so confident from my last placement, this also helped a great deal in maintaining my interest in physiotherapy as a potential career.

My supervisor was originally hard to approach and seemed quite rigid in her ideas, though over the weeks, getting to know her I was able to adapt my style to work with hers, which worked to benefit us both. I was a bit disappointed that at the end of 5 weeks, the supervisor was still adamant on attending all assessment and treatment sessions with us students and was reluctant to allow us to do things independently. On a few occasions I attempted to show initiative and commence an assessment, or collect a patient on my own accord, though this did not fly well with my supervisor. So as a result we were constantly supervised, which was mildly frustrating. Overall though, she was definitely an expert in her field and had a lot of knowledge in the field of neuro physio, her explanations could occasionally be hard to interpret, though watching work with patients offered invaluable learning experiences that I will retain and employ in the future.

Royal Perth in general is a public hospital and like expected, is run like the other hospitals I have been to, though as it is a tertiary facility, the demands are just that one step higher. Staffing is an issue and patient’s presentations are that tiny bit harder so the workload can be an issue. Our stroke ward wasn’t particularly busy during our stay, so this wasn’t too evident in physiotherapy, and we often felt it pertinent to assist our fellow staff members with their duties.

My study prior to the placement had been useful, though more practical practice and knowledge wouldn’t have gone astray.

My concerns were evident, especially in the first week or two, though as the placement progressed I was able to figure out a way to adapt to my supervisors methods, which aided in my learning. The barriers to students was clearly evident, not so much from my supervisor, though other staff expressed this attitude, which originally dampened my confidence, though I soon came to realise that in a few months I would no longer be a student and that if they had such low expectations and value for students I would make it an aim to prove them wrong. This provided a drive and incentive to work hard and demonstrate my skills and knowledge to the best of my ability.

Experience is always a concern, though this is obviously something that I can’t impact on and will only take time.

Overall I found neuro physio highly interesting and valuable to translate skills to all areas of physiotherapy. My experience wasn’t the best, though was highly rewarding nonetheless. I feel the skills I have learnt will be integral in my career and would consider pursuing this area or physiotherapy in the future.

STARES 3

SITUATION

A 27 year old female was admitted to ward 8A under the neurology team for further investigation and treatment after presenting to the emergency department with signs and symptoms in her left lower limb including abnormal sensations, decreased active motor control, proximally greater than distally and increased tone of the classic extensor pattern. A CT scan of her brain and spine had been taken, as well as a lumbar spinal tap to determine possible causes for symptoms. All of these tests were negative.

On physio assessment it was found that she had an abnormal sensation pattern and experience in her left lower limb with a clearly defined areas. Normal awareness of sensation was graded 10/10 and using this as a reference, a specific sensory assessment was conducted to determine the most affected areas. According to the patient she had near normal awareness at her knee and on the plantar aspect of her foot with 8/10, though at her hip region and back of the thigh and calf she reported 2/10 awareness. Also noted was the description of as being “pins and needles” type sensation to all touch. In terms of active motor control there was decreased strength throughout the left lower limb in comparison to the right with impaired coordination. Tone wise, there was evident fatiguable clonus in gastroc and soleus on the left, as well as rigidity with passive movement into dorsi flexion. On standing, the left lower limb went into extension pattern with plantar flexion and inversion of the foot, adduction of the hip and hyperextension of the knee. Functionally she was independent with bed mobility and sitting balance, supervision for transfers and non ambulant on initial assessment. Her right lower limb, trunk and upper limbs were unaffected.

Subjectively, it was noted that the patient had catastrophising behaviours and was concerned about the lack of a diagnosis and prognosis.

The medical team, from lack of a clearer picture, and inability to find anything on clinical tests, diagnosed this patient with transverse myelitis, or inflammation of the spinal cord. For this she was started on steroid therapy to decrease the potential inflammation and hopefully alleviate some her symptoms.

TASK

In this situation it was my role to investigate this patients past medical history and relevant information from her medical file. From this I was too conduct a full neurological and mobility assessment to help develop an appropriate rehabilitation plan in the future.

ACTION

From reading the patient’s medical notes, it was unclear as to the cause of her symptoms and there was no indication of a diagnosis. To clarify this I met with her medical team to discuss her notes and their point of view of her situation before I went and had a look for myself. The medical team confirmed that all tests had so far been negative and they thought this could potentially be an acute attack of multiple sclerosis, though without evidence of plaques or prior episodes, this diagnosis could not be made. They felt that with a thorough physio assessment, the symptoms would be clearer and they could get a better understanding of her presentation.

I proceeded to conduct my assessment of the patient. On subjective questioning of the patient I gathered the relevant information about onset, history, current understanding and feelings and goals. This also helped me develop rapport with the patient as she was quite concerned and anxious about her pending diagnosis and sudden onset of muscle weakness with abnormal sensation. Being on a specialised neurology/stroke ward didn’t reassure her in the least, fearing she had experiences a stroke or had developed a brain disorder of some kind. I explained the process of assessment and how this would aid the medical team in the diagnosis, which would further help her rehabilitation, as we would understand how to manage her symptoms.

The assessment was carried out, with constant explanation and reassurance to the patient, as she was concerned about the impairments and their potential meanings. This included; muscle power, tone, detailed assessment of sensation, coordination, reflexes and functional capacity.

From my findings I had a feeling that this could potentially be an acute episode of multiple sclerosis; the patient reported that she had experienced clonus in her lower limb in the past and had tingling sensations in her upper limbs though didn’t think anything of it, the symptoms were unilateral and of quite an original nature and the symptoms seemed to have changed rapidly from onset to admission to the time of the assessment. This thought was not expressed to the patient and instead I discussed my findings with the medical team who agreed that they felt the same way, though as it was the first recorded episode, the diagnosis could not be made. Therefore they were planning to diagnose her with Transverse Myelitis. I received the okay to commence rehabilitation.

From this I then explained the diagnosis to the patient who had been informed by the medical team earlier that day, and also explained the effects of the steroid treatment she was to commence. We then collaboratively developed short term and long-term goals and a rehabilitation plan.

RESULTS

As a result of my assessment, the medical team was able to confirm the patient’s presentation and get a better understanding of her clinical picture. I was also able to develop an effective and targeted rehabilitation program with the patient to impact on her impairments.

Through effective communication I was able to develop a good relationship and rapport with the patient, which gave her confidence in my ability as her therapist and my future planning. My explanations also helped the patient understand her symptoms and treatment and she was better able to participate and grasp the concepts of her rehabilitation, making it easier to undertake treatment.

EVALUATION

With this particular patient, my biggest strength was communication. Coupled with this was compassion. Without being able to relate to this patient and truly portray empathy for her situation, I feel assessment and treatment would not have been so effective and the patient would have been swept away by her catastrophising beliefs. By giving her understanding, this gave her a sense of control, which gave me confidence in that she would be proactive in rehabilitation and motivated to participate at 110%.

Another strength was my thorough assessment and efficiency of conducting this. This also benefitted the patient as it built her confidence in me as her therapist. As it was my 5^th week and probably my 30^th full neuro assessment, I had developed a method that came naturally and easily.

A noted weakness was confidence in communicating with the medical team. In this particular situation I felt they handled the patients catastrophisation poorly after recommending she take part in a medical student study and be a case study they examined, which involved a room full of medical students trying to guess her diagnosis. After which the patient was clearly distraught by the suggestions made and spent an afternoon in tears. They also explained the findings of tests, eventual diagnosis and steroid treatment. I expressed this to my supervisor who said it is often left to the allied health team to translate medical information to the patients as they are often pushed for time.

STRATEGIES

Some strategies that were / could be useful in similar situations are:

- Building rapport with your patients through understanding and empathising. Also having good prior knowledge of their situation and researching elements of their history prior to seeing them gives an extra head start before seeing the patient.

- Planning assessment before going in, though avoiding having expectations as this could bias your interpretation of results.

- Utilising the knowledge of the whole multidisciplinary team and having confidence in own background to backup and present your argument in any open discussion.