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.