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.

STARES 2

SITUATION

A 37year old female was diagnosed with multiple sclerosis at the age of 27years old. This patient had suffered frequent relapses in multiple sclerosis with a variety of presentations, including complete blindness, paralysis and incontinence. She presented to Royal Perth hospital under the recommendation of her neurologist when her latest episode failed to relinquish and seemed to be progressing. Early in May she reported waking up with loss of strength in her right lower limb. This further progressed in the week to a radiating “electric shock” sensation to touch, throughout the left side, below the T4 dermatome. On admission, an initial mobility screen and assessment was completed. From the subjective it was found that she had struggled with multiple sclerosis for 10 years. In this time she had had numerous relapses with some residual deficits including impaired sensation in her upper limbs. As well as this struggle against the unknown, on her journey she had discovered that she is immune-deficient and has severe life threatening reactions to most multiple sclerosis control medication. Her lifestyle choices like smoking and unhealthy diet, regular hospital admissions, steroid treatment and past wheelchair dependency for periods at a time, she had become obese. With the additional weight and regular steroid treatment, rehabilitation became very difficult and limited severely by fatigue. She had also had bad experiences with rehabilitation in the past, with little input and persistence, she had been deemed wheelchair dependent by her therapists. She then taught herself to walk independently at home, which resulted in shattered knee-caps and hip injury from repeated falls. Coming to Royal Perth she was astounded at the amount and quality of input she was receiving. On admission she was ambulating with a family walking stick and one assist for short distances, otherwise she used her wheel chair. On ambulation she had a poor pattern with excessive compensation. Rather than using the walking stick as an effective aid, it was used like a tripod to extend her base of support. From this we incorporated gait re-training as a fundamental component of her rehab. Upon discharge she was referred to Shenton Park campus for further inpatient rehabilitation.

TASK

For this patient, my task was to conduct a thorough subjective and objective examination to ascertain the full clinical picture. From this I was to develop a treatment plan with options to modify as her clinical presentation was changing slightly day by day. After 2 weeks of rehabilitation I had the task of planning her discharge and referring her to Shenton Park Campus.

ACTION

On commencement of the examination, I discovered through the subjective that she had a poor history with her therapists. I therefore took a sensitive approach to her history and struggle with her condition and thoroughly explained the process of examination and rehabilitation offered at Royal Perth. After gathering a clear clinical picture of this patient, with extensive questioning I conducted a brief neuro screen, assessing tone, sensation, proprioception, strength and coordination. I then began a mobility screen, starting with bed mobility, transfers and finally ambulation. I found she was independent with bed mobility and transfers, though required excessive effort to complete the tasks. On ambulation, I had to educate her on technique and aid use. From observation of her pattern I deemed it more appropriate for her to use a wheeled zimmer frame to provide the additional support and balance that she required to demonstrate a more efficient gait pattern. This mobility screen fatigued the patient. I discussed fatigue with the patient and educated her on knowing her limitations. We then organised an appropriate time to begin treatment the following day, at a time when she felt she had the most energy.

I devised a treatment plan to address her fear of the forward space, lack of trunkal dissociation and control, standing balance and foot awareness. With this treatment plan was a few other options or avenues we could try if the first idea wasn’t optimal. We commenced treatment the following morning, ensuring all treatments were related back to functional gains to provide motivation for participation. The patient worked well and at the onset of fatigue I took the patient back to her room. I prescribed her with an exercise program to continue in her room throughout the day when she was feeling up to it.

We continued rehabilitation throughout her stay, progressing her exercises to continually challenge her. I developed good rapport with the patient and we worked well together.

The multidisciplinary team discussed her discharge options and it was globally decided that further rehabilitation at Shenton Park was optimal. I discussed this with the patient and she was eager to begin. I completed her discharge summary and contacted Shenton Park to relay the relevant information.

RESULT

As a result of my assessment, I was able to coordinate an effective treatment plan and carry this out with my patient with success. With constant re-assessment and regular input we were able to progress her rehabilitation throughout her stay and improve her independence with transfers and her effectiveness in gait. We developed a good rapport and understanding and I feel this helped with her rehabilitation and acceptance of therapy input. She participated in her therapy sessions and from what I gathered, carried out her exercise program, this optimised her chance of recovery. My supervisor was satisfied with my performance with this patient and was confident with my approach, therefore allowed me to conduct majority of sessions independently. She was also pleased with my discharge planning and supported me in the decision to refer this patient to Shenton Park for further input.

EVALUATION

In this clinical situation I feel I communicated well and my ability to build rapport and understanding with this patient was good. With prior experience and knowledge of multiple sclerosis, this gave me an advantage in understanding the patients struggle and I was able to adequately relate to her difficulties.

My treatment plans were appropriate in their level and difficulty. They were challenging yet achievable, therefore the patient was satisfied with their performance and motivated to continue with therapy.

Elements I could improve on would be my questioning throughout the subjective as I feel there were crucial elements I didn’t thoroughly explore and gain a clear enough picture of. Throughout our treatment sessions, I was able to ascertain this information.

Also my confidence in the multidisciplinary team meetings could do with improvement. During the meeting I was asked for my input on the patients status in physiotherapy. I gave an overview of her mobility, her key issues that we were working on, and what we were doing specifically in treatment sessions. My supervisor then provided the additional information that I failed to mention of rehab potential and our plan to recommend Shenton Park.

STRATEGIES

Having multiple treatment strategies worked to my advantage, as I was able to modify my treatment sessions depending on the patients level of symptoms and alertness. An independent exercise program for the patient to do independently is also a strategy I will employ in the future as this gave my patient a degree of control over their rehabilitation and gains and I feel also improved the gains we made as she was practising what we did in our sessions throughout the day.

Breaking the subjective down into components that are easier to comprehend and handle would improve my efficiency in questioning.

Lastly preparing fundamental information that needs to be relayed in the team meeting for each of my patients would be handy to improve my confidence in these situations.

STARES 1

SITUATION:

A patient was transferred from the ED department to the neurology ward for further treatment. She had presented to the ED department complaining of a severe headache behind her right eye and a sense of vagueness and confusion. This was later diagnosed on CT scan as a haemorrhagic stroke in her right frontal lobe. On initial admission, the patient was medically unstable, therefore only the necessary mobility screen could be carried out on day one. Initially she required two people to assist transfers and could only step stand transfer over the right side. Her sitting balance was poor, standing balance almost non-existent and she was not ambulating. By day two, there was lingering drowsiness, though she was now medically stable and her headache had eased. A neuro assessment was commenced and it was found that she had a low affect, significant rigidity throughout her right side, lower and upper limb, mild problem with initiation of movement, reduced ROM in her right shoulder secondary to a rotator cuff repair a few months prior, poor postural control and poor pelvic, lower limb and trunk dissociation. On the Gowland assessment she scored level 6 on most parts. Day three her presentation had changed again. She was now requiring one assist to transfer and ambulating in physiotherapy only with maximal assist of one.

TASK

My task in this situation was to conduct the initial mobility screen of this patient, complete a full initial neuro assessment and plan and carry out daily physiotherapy sessions.

ACTION

After I had conducted the initial assessment and developed a problem list for this patient, I developed some ideas for treatment and presented this to my supervisor. We were in disagreement in the approach to this patient as I was adopting a more functional approach, where as my supervisor wanted to address the impairments specifically. I carried out a fairly standard treatment session addressing impairments, which incorporated bridging and trunk control activities in supine, encouraging glute activation. I then finished this session with a facilitated walk. As she had a haemorrhagic stroke, her presentation was highly variable and by day four, Friday, she was requiring moderate assist of one for transfers and ambulation. My treatment focus then turned to addressing her pelvic control in standing and her confidence towards the forward space to bring her centre of mass in front of her base of support, making sit to stand transfers and walking easier.

RESULTS

My supervisor didn’t encourage walking this patient, though after seeing me walk her in my treatment session with the tutor, she identified that with appropriate facilitation, her gait pattern was near normal. I was able to show my supervisor that my observation of this patient’s ability was good and the treatments I had chosen were suitable. Focusing treatment on a functional task involved the patient more as she understood the relevance of the activity. This also boosted her confidence in recovery and physiotherapy.

EVALUATION

It has been difficult to build rapport with my supervisor on this placement as I feel a functional approach in some cases is more appropriate than addressing impairments specifically. When the functional ability of a patient is high, I feel that the impairments can be addressed through fine-tuning of the functional tasks rather than taking the patient to a non-specific task that addresses the impairment in isolation. In this particular situation I had this difficulty. Though I was able to see this patient with my tutor who agreed with my decision to walk this patient, which was fairly successful. Something I could perhaps improve on is my confidence in my ideas and ability to translate this to my supervisor.

Also my neuro assessment wasn’t systematic and it was obvious that this was my first experience with this. This is something I will need to work on and practice to improve my efficiency in assessment.

My communication to my patient was appropriate and effective. I found it easy to develop rapport and engage the patient in treatment. Another element I need to work on is facilitation. This again comes with experience.

STRATEGIES

- Relate all treatments to tasks that the patient find relevant to their goals. This helps with engagement of the patient in treatment sessions

- Confidence in observations and treatment ideas to relay this to my supervisor.

- Planning assessment in order of position eg. Supine tests, sitting tests, standing etc. This improves the flow and efficiency of the assessment process.

Initial Entry - Royal Perth WSC Stroke unit

In anticipation of my third clinical placement at Royal Perth Hospital I have begun preparation for a highly demanding five weeks. From my peers I have heard that generally placements at Royal Perth are challenging, in that expectations of knowledge and ability are of the highest standard and that staff tend to derogate students. Combined with this feedback, is a pre-warning that my potential supervisor can appear to be “a bully.” With this in mind I am anxious, again. The sense of unknown is un-nerving and with the feedback I have received about this placement, it has not been comforting. As I am coming into this placement on such a high from my last placement, I feel this could work to my advantage as this has built my confidence.

Royal Perth is a hospital in the public sector. I am assuming this will be run like most hospitals in that there will be a high focus on the multi-disciplinary team and a more or less blanket referral of patients to the wards physiotherapist. As I have had prior placements on wards in hospitals, I am confident that I will know the structure and procedures in how the ward operates. I have also had practice in writing inpatient notes etc, so this should alleviate some initial pressure.

For this placement specifically, I have revised my neuro, in particular stroke symptoms and presentations as well as neuro assessments. I am hoping this is sufficient to get me through the first couple if days, until I get an idea of specific knowledge that is required from me.

I feel my role in this placement will be to support the existing structure, participate in the multidisciplinary treatment of patients and conduct myself professionally as a potential future physiotherapist.

Prior to commencing this placement I have the following concerns:

- That I will not be able to establish a positive learning relationship with my supervisor.

- There could potentially be barriers in terms of negative attitudes towards students, impairing my ability to gain a lot from the placement through interaction with colleagues.

- With little experience with stroke patients, I may appear inexperienced and uncoordinated in this area.

Overall I am most nervous about this placement, as it is a field I feel I have the littlest experience with and from the feedback I have received I will have barriers to overcome. I am also anxious that if I feel overly intimidated I may be less inclined to take advantage of learning opportunities, as I will be afraid to ask. With the support of the Notre Dame staff, that I can rely on if things become too overwhelming, hopefully I will be able to overcome any unnecessary anxiety and awkward situations I may fond myself in.

FINAL ENTRY - AMR Physiotherapy

Five weeks of rural physiotherapy in Margaret River has been a blast! The placement gave me invaluable experiences in a broad range of physiotherapy fields, including musculoskeletal, gerontology, neuro, paediatrics and cardiorespiratory, in both a private clinic and public hospital setting. Having such a vast array of clinical presentations kept me on my toes, always wondering what would be next.

Three days of the week were spent in the private sector at AMR physiotherapy, a private practice. Here the case mix was broad, from children with trampoline injuries and wine makers with low back pain to yoga students with knee strains and surfers with complete gastroc tears. The rest of the week was spent in Augusta, housing a somewhat older population. I got close with the members of the community, having one on one physiotherapy sessions as well as weekly exercise groups and outings.

Looking back at my initial entry, my perception of this placement is the same, if not better. I have thoroughly enjoyed the atmosphere and the unpredictable nature of the rural setting whilst expanding my clinical experience greatly. My initial anxiety subsided within the first week, after meeting my friendly and supportive supervisor and treating some amazing patients who appreciated the extra time spent with them, as well as learning a lot themselves from my learning.

The issues I had to prior to commencing this placement were dealt with throughout the five weeks and by the end I felt very comfortable, reluctant to leave.

To start with I had concerns about my ability to recall information from my studies to apply this to my patient. In the clinical setting, it seems to come naturally and the lectures become clear and relevant. My supervisor was also very supportive with a broad knowledge base and over 30 years of experience in physiotherapy. Even if I was unsure of a test or technique, he would always be close by to assist, or show me a completely different approach to broaden my skills. The close supervision was nerve racking for the first couple of days, though as my confidence grew, so did my supervisors confidence in me and he took a back seat in the sessions, only giving input if I asked or he felt it was absolutely necessary.

The only issue that I had throughout the placement was physical ability. I often came against the problem that I could not overpower my patient in a strength or muscle power test, nor did I have the arm span or size to perform some techniques. My supervisor was very understanding and supportive in this area and taught me some strategies to overcome this, which I employed throughout my time there and this gradually became a less evident issue. I also found that some of my own physical faults, for example internally rotated and valgus knees, became evident when trying to teach a patient how to perform a certain task correctly, like squats. This is something I will continue to face, and hopefully with live what I preach and correct such postural anomalies.

Overall I have enjoyed this experience and have restored my confidence as a physiotherapy student. Having a supportive and welcoming supervisor makes all the difference when on clinical placement and I feel this is 80% the reason I have enjoyed this prac as much as I have.

Musculoskeletal private practice physiotherapy is a great area to work in, and I felt comfortable in my skills and performance in this area.

STARES 3

SITUATION

In my final week at AMR physiotherapy I was acting as an independent practitioner, seeing my own patients individually. A particular patient I saw, referred to physiotherapy by his school, was a 5 year old boy complaining of knee and hip pain when running and walking. Informally observing his posture and gait, the following was noted; bilateral pronation of the feet, internally rotated hips bilaterally, valgus knees and wide stance. By questioning the mother and son it was evident that the pain was worst with running and had been gradually worsening over the past month. The boy felt his left was sorer than the right and that it was mainly his knees that hurt. On formal examination it was evident his feet were over pronated with complete loss of arch, though he was able to actively achieve one, his knees were in valgus; left greater than right, he had adopted an abnormal gait pattern and there was no evidence of a leg length discrepancy. The mother had been in correspondence with the school in regards to the complaints of pain and teacher had observed the flat foot posture and recommended physiotherapy as an appropriate place to seek advice for treatment. The mother had also done research into flat foot posture in children and had become quite anxious about potential surgical treatments and outcomes.

TASK

My task in this situation was to ascertain the source of the pain by acquiring information from the teacher's referral as well as the young boy and his mother and perform a thorough examination. I was also required to establish the activity limitations and goals to make future treatment as functional and meaningful as possible.

ACTION

On subjective examination, I initially spoke directly to the child, building rapport by asking about school etc. From this I gradually became more specific, asking about what he was experiencing when he ran and exploring his thoughts. From the information I gathered from the boy, I then proceeded to confer these details with his mother and her perspective of his pain. This provided me with valuable information about where the pain was, what aggravated the pain, what had already been done and what the mother felt would help. Using the information I had retrieved, I began my objective assessment. This included postural and gait analysis, as well as specific tests of the knee, hip, ankles and feet. My supervisor assisted me in this element of the assessment, and he performed additional tests he had acquired over his physiotherapy career.

After the examination, we concluded that the main source was the altered foot posture, overly pronating affecting knee and hip alignment. I then instructed the boy through active supination by trying not to squash an egg that he had to keep safe under his foot. This was a game that I showed the mother to continue at home as often as possible.

On speaking with the mother I noticed her anxiety towards the pain her son was experiencing and possible surgical interventions that had been suggested on the internet. I reassured her that considering she had noticed it so early, children can change and adapt rapidly, so with correct input we would be able to make significant improvements. This alleviated some of her anxiety and she left feeling confident that she was on the right path to resolve the issue.

RESULT

As a result of this session, we had a clear understanding of the issue at hand and had a rough plan of our future treatment approach. I had also reassured the mother to reduce her anxiety, which also reduced anxiety in the child.

EVALUATION

In this session I was able to effectively build rapport with the mother and child through effective communication and a good approach. This rapport then translated into the assessment, and the boy was willing and trusting to allow me to do the assessments I needed to do.

My objective examination was less fluid, as I was unsure of which assessments were applicable. I also found it difficult to keep an open mind to any other underlying impairments, as the pronation and altered posture was so obvious.

In this situation I had a few treatment ideas that I had acquired from Notre Dame practical lessons, so was able to instruct the boy on how to perform these and give a few suggestions of running at the beach and wearing thongs as other strategies to encourage altered foot posture.

STRATEGIES

A strategy I found useful was starting the session with general conversation about school and friends to build rapport with the child. It is important that the child feels comfortable with you, especially when you will be asking the child to de-robe and be performing assessments on them. In future I will have a better knowledge of this impairment as I have now seen it presented clinically, so will be able to perform the objective examination in a more efficient and effective manner. Another strategy crucial to a good clinician is keeping an open mind, to discover all underlying impairments and get a whole picture of the patient in front of you rather than putting all presentations to text book as everyone is an individual.

STARES 2

SITUATION

A middle aged male artist presented to the physiotherapy clinic with left hip pain being his main complaint. On subjective examination I was able to uncover that he had recently sprained his right ankle and consequently ceased his normal activity for a period of 3 months. After his 3-month break he had rejoined martial arts class on a Wednesday afternoon. He found this activity to be aggravating, particularly falling to the ground onto his hip and the jarring of landing was most painful. The morning was stiff and sore with slight improvement after some movement, though excessive exercise also aggravated it. He also reported a prior diagnosis of arthritis in his hips, which he is currently taking medication for. When asked further about any other pains, he reported symptoms in his shoulders bilaterally that became most prevalent with driving. On a long drive the shoulder pain progressed to pins and needles in his hands, in the median nerve distribution and shaking his hands alleviated the pins and needles temporarily, though not the shoulder pain. He had no troubles with painting. He no longer had pain in his ankle. From this subjective examination, the relevant objective examinations were carried out on the hip, shoulder and wrist joints. It was found that the left hip had significantly reduced ROM, especially into flexion and was painful on Quadrant and Faber’s test. On muscle power testing it was found that he had mildly reduced EHL power on the left indicating an L5/S1 nerve root issue. The shoulders both demonstrated positive impingement signs, particularly of supraspinatis as well as a lack of correct scapular stabilisation and posture. Finally from the subjective and objective examination of the wrists, he was found to be positive for carpal tunnel syndrome.

TASK

In this clinical situation I was to undertake this patients full initial examination and treatment independently with background supervision. This also included writing a letter back to the referring GP explaining my findings, treatment and recommendations.

ACTION

On subjective examination I proceeded to thoroughly investigate not only the referring and presenting complaint but also all other pain experiences and retrieve all relevant information to guide my objective examination. From this I developed theories on each of the pains and their source of symptoms, which I would confirm or negate through my objective. I undertook the relevant tests of the hip, shoulders and wrists with occasional hints and suggestions from my supervisor. From this I made an clinically reasoned diagnosis of what was causing each pain experience; arthritis in the hip joint and tightening of the hip capsule, decreased mobility at the left L5/S1 facet joint, bilateral shoulder impingement and carpal tunnel syndrome at the wrists. I explained these to my supervisor who agreed with my findings and told me to proceed with treatment of these. My treatment incorporated mobilisation of the L5/S1 facet joint, mobilisation of the hip joint, instruction on scapula setting and posture as well as a home exercise program including hip stretches, rotator cuff stretching and strengthening and carpal tunnel stretches. After treatment, I wrote a letter to the referring GP, firstly thanking him for the referral and then proceeding to explain my findings, treatment and recommendations.

RESULT

The patient felt better and re-assured following his session. My supervisor was happy with my performance of the subjective, objective and treatment of this patient and felt confident in my clinical reasoning to identify the source of symptoms and treat accordingly.

EVALUATION:

Overall I feel I performed well in this case. I was able to thoroughly examine the patient as well as apply sound clinical reasoning to determine a diagnosis and treat this appropriately. In particular, I feel my subjective examination ability has thoroughly improved while on this placement and I am able to structure questions as well as drawing from their answers to get information that I previously would have missed. I also felt my ability to recognise possible source of symptoms from the subjective examination to narrow down my objective tests has improved and was effective and more efficient, again paying credit to my subjective examining ability. Throughout this session though, I had a few difficulties, which I would like to work on and improve my technique for future patients that may have similar presentations. Firstly, on examination of muscle power, I initially missed the EHL weakness, due to lack of experience in identifying poor quality of movement, as well as a poor technique. Secondly I lacked the endurance or strength to apply the hip mobilisations for an extended period. My supervisor then showed me a different technique that was easier, though still taxing. This is something I would like to practise and improve on. Lastly, I have had little experience in writing letters to fellow health professionals. My supervisor assisted me in writing the letter to the GP, though in future I would like to be efficient in doing this independently. My main issue with this was the language and terminology that would transfer to other health professions as well as what to include and what to leave out of the letter.

STRATEGIES:

As mentioned time and time again, having good background knowledge is the key to success in any situation. Being able to explain yourself to a fellow clinician, as well as to a patient is a skill that develops over time, though having a prior understand the concepts yourself, helps a great deal. When questioning a patient, I find asking more questions rather then less helps significantly in understanding the patient’s experience. Strategies I will employ in the future will include; practising techniques and working on techniques that I find more efficient and effective, especially for treating male patients that are a lot bigger and stronger then myself, as well as getting experience in writing letters to other health care providers and members of the community.

STARES 1

SITUATION

A young woman had been referred by her GP for physiotherapy assessment, treatment and advice. Her presenting complaint was right-sided pain in her neck, shoulder and arm along with some pins and needles in her forearm. The onset of symptoms had been associated with her task at work, and consequently a workers compensation claim was undertaken. To qualify for workers compensation she required proof from relevant medical professionals as to the relationship between her injury and her tasks at work. The task was working at a supermarket checkout which involved reaching and lifting objects placed on her right side, just over arms length away and some weighing up to 3kg. This involved extending her right arm and twisting to the right repetitively. In the 2 years she had been with this employer she was rarely switched to an opposing till that would require her to use her left, evening out the demand on the body, rather she remained at the same till for about 90% of her employment. This had resulted in a gradual wear and tear of her right side and a consequent injury in her neck and upper limb. On examination it was found that she had sustained significant damage to her rotator cuff with positive impingement signs and tenderness on supraspinatus and supscapularis tendon palpation and stretch. Her neck was tight throughout with muscle spasms, decreased left rotation and left side flexion and her neck pain was reproduced at C3, 4 and 5. She also complained of pins and needles on abduction and elbow extension with left side flexion (stretching the nerves) and had a positive neurodynamic tests for median and ulnar nerves. From this information we agreed that the injury was work related and that the claim should be pursued. We then applied appropriate treatment to mobilise the neck into the direction of restriction, used electrotherapy to settle the swelling around the shoulder and provided stretches for the neck and shoulder.

TASK:

In the above described situation I was working with a fellow physiotherapy student from the Curtin GEM program, under the supervision of Robert Lane, the Margaret River physiotherapist. The two of us has to assess this young female, apply the relevant treatment and then present our findings to the GP and the supermarket manager to be documented on the workers claim report.

ACTION:

During this session we discussed appropriate assessments and treatment ideas and both had an attempt at applying these. I noticed that the Curtin student approached things differently and had a different understanding of the application of both assessments and treatments. For example they were doing the neurodynamic tests in one movement by putting them in the end position and then asking the patient to move their neck to change the level of pain, whereas we are shown to slowly add the components of the movement to further stress the neural tissue. I demonstrated our approach to neurodynamics to the student and the supervisor and it was shown that our method was far more sensitising. Another difference I noticed was the treatment of the neck. The Curtin student applied a side flexion PPIVM with the patients head on the pillow and swinging it from side to side as well as general PA to C3,4 and 5 with the patient in supine as they were unable to apply anything to the right side as it was too painful. Again I had to opportunity to show my clinical reasoning in this situation. I demonstrated a cradle hold PPIVM of side flexion as well as applying a side glide at EOR side flexion specifically at C3, 4 and 5.

RESULT:

From this session it was clear that there were differences in education in between the Curtin GEM program and the Notre Dame Physiotherapy course. In this situation I was able to demonstrate my learning and application of knowledge, which my supervisor was pleased with. We were able to improve our patient’s pain and available movement, as well as effectively translate our findings to the GP and supermarket manager. It was also a learning experience for both the Curtin student and myself as we were able to teach each other different approaches to assessment, treatment and clinical reasoning.

EVALUATION:

When evaluating my performance in this situation I feel I had a few strengths. Firstly I was able to demonstrate my ability and knowledge effectively to my supervisor, as well as to my patient and peer in a confident manner. This was a new experience for myself, as I have not yet felt confident in my ability to correctly assess and treat a patient. Secondly, my best strength was being able to demonstrate my approach to the Curtin student in a non-derogative way and combine it with her treatment and assessments as another option rather than a better one, even though my techniques proved to be more effective I was able to then teach the Curtin student how to do it and gave her the chance to try it. My weakness in this situation was efficiency. I have not yet established the experience to know what tests are needed and which can be disregarded in particular situations, therefore I am often very thorough, though this works to my detriment, as I am unable to see the patient in the 20minute slot provided.

STRATEGIES:

I think knowing that clinical placement is not only a learning opportunity for yourself, but also for your supervisor, patient and fellow students from other institutions changes your whole outlook on your clinical placement. Your teaching skills become just as important as your ability to learn. Also being confident in the way you present yourself and conduct the session has a large impact on how the patient perceives your ability and how they respond to your treatments. Be confident, learn and teach.

Initial Entry - Margaret River

Now to embark on a rural placement based in Margaret River and Augusta, I am both intrigued and nervous. Intrigued by the environment, both physical and social as well as the exposure I will have to a vast array of presentations. Nervous about the demands of musculoskeletal physiotherapy in a private practice setting and the extensive background theory required to stay afloat in this rural situation. I am hoping I have the knowledge required and am able to utilise what I have appropriately to excel in this placement, as from my last I have grown very anxious towards physiotherapy and feel my success in this placement could be vital in me continuing physiotherapy as my chosen career path.

AMR physiotherapy practice in Margaret River is a single treatment room private practice. Being rural, I expect the nature of this placement to be quite different to those in the metro areas. From peers I have learned that rural placements offer different patient-therapist dynamics, such that rapport is easily established and patients are open and accepting to any therapy on offer. Also, that rural covers an extensive field of treatment areas, mainly musculoskeletal based and movement dysfunction related, though the occasional patient (human or animal) may arise with something different.

In terms of the structure of this placement, I have discussed this with peers as well as the physiotherapist based at the Margaret River practice and have established that I will indeed be thrown into the deep end and shown how to swim. Initially I will be seeing patients at my own pace, with full supervision. I will be sharing the one treatment room between myself, my supervisor and another Curtin student; I will also have opportunities to observe. As the placement progresses, I will need to develop efficiency to be seeing my patients in 20 minute time intervals, and supervision will grow scarce.

My role in this experience will be to act as a professional physiotherapy student, with all the relevant knowledge of a new graduate. I will be expected to apply, expand and share my knowledge while in this clinical setting so as to develop myself as a physiotherapist.

Prior to starting this placement I have the following concerns:

· My ability to recall information from my knowledge base when it pertains to the patient opposite me.

· My physical capacity in musculoskeletal physiotherapy could be limited.

· I tend to get flustered when under close observation and find this quite intimidating. Having close supervision in the initial weeks could impair my performance, which would limit my supervisors faith in my ability and therefore lead to further close supervision, vicious cycle.

· Rural setting, being somewhat disconnected from my supports in Perth could have an impact on my overall performance. This could swing both ways, flourish with independence or crumble under it all.

Overall I am looking forward to a fresh start and a new opportunity to restore my desire to become a physiotherapist. I am hopeful that this field will be something I enjoy as it seemed that the musculoskeletal aspects at PMH, such as hip surveillance and BOTOX clinic were the areas I enjoyed the most.

FINAL ENTRY

Looking back at my five week placement at PMH I am disappointed. With such large expectations for this placement I have not achieved all that I would have liked too. I feel this is for two reasons;

Firstly, the placement structure was hard to familiarise myself with as I had different supervisors each day, as well as attending many clinics throughout each week. Often my schedule was not planned until the Monday of each week. This left a lot up in the air and I found it hard to prepare for the upcoming days. To a degree this made me feel slightly unnerved as I prefer to be organised and prepared for the upcoming week.

Secondly, I was rarely given the opportunity to demonstrate my skills. I understand that it is a matter of the family’s wishes and our involvement is largely dependent on the family’s acceptance of student participation, though certain supervisors allowed for minimal hands on experience and as a result I was marked low in this area. Given consistent opportunities I feel I would have been able to learn and develop skills in this area though as my main supervisor only treated complex presentations, it was rare for such an opportunity to arise. Also having no consistency in patients was difficult as I was unable to gain familiarity with the family or the child.

In hind sight I should have taken a more proactive role and asked to have my schedule done in advance. Also getting hands on by coming forwards and requesting to try everything that the supervisor demonstrates.

This is a very difficult placement. The most difficult element would have been the instability and variability of the placement structure. In terms of the paediatric physiotherapy I feel I could have done well given the opportunity.

I was able to come out of this placement with a few new experiences such as, suctioning, facilitation, working with children and exposure to a very broad range of patients. Particular areas I enjoyed were Hip Surveillance clinic on CP children of all ages and plastics clinic. I also enjoyed working with the older children and teenagers as they were able to take on board my feedback and respond appropriately. You can also gain a clearer subjective from the child directly rather than through the parents.

Recapping on my initial concerns;
- The emotional attachment issue did crop up on occasion and at times it was a challenge to stay composed. PMH has the worst paediatric presentations from the whole of WA in the one location and this can be overwhelming but I managed control this majority of the time.
- Communicating with families wasn’t a strong point for me as I often found it hard to try and gain handling opportunities as well as relating to the families.
- The barrier to students treating children was a prominent issue. This was evident in most treatment sessions and it was obvious when the parents changed their tone and general posture when I went to try a treatment. When asked a question by myself, they would often answer by addressing my supervisor which I found frustrating at times.
- And as previously mentioned, getting hands on experience was difficult.

From my initial expectations and desire to do paediatric physiotherapy my plans have changed somewhat. I enjoyed the musculoskeletal side of paediatrics and found these patients were more willing to have student input, though when medical complications were added to a substantial history of complaints, this is when student input is less welcomed. Community based paediatrics would be an area I would consider.