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.