Hello fellow colleagues,
I am currently working on my placement in the surgical and medical wards. This past week I have had a few interesting patients in which we were required to suction.
One of these patients was a post laparotomy and the other had come in due to a bad fever.
These patients were in need of suctioning as they had ineffective coughs and you could hear their secretions being transmitted audibly and UATS were heard on auscultation. These patients were not intubated- they were however drowsy. Due to them having ineffective cough my supervisor and I decided to use an oropharyngeal airway (Guedel) and then suction via this. We treated both these patients in the morning and returned in the afternoon for a second treatment session due to the copious amounts of secretions in the lungs. On the 1st visit both patients did not like the experience and found it very uncomfortable as well as tiresome but we still managed to suction a large amount of secretions. On the 2nd visit both these patients refused the Guedel airway. As you can’t force a Guedel in on a conscious patient without their consent we decided to try the nasopharyngeal route instead but the patients nostrils were too small and we were unable to gain entry.
The situation that then arose was that we had two patients who clearly needed suctioning however were both refusing and were unable to clear independently and effectively. I was concerned as to what you would do in this situation because you can not force someone to give their consent however there would be a large likelihood these patients would deteriorate over time due to the large amounts of secretions still present. In the end my supervisor told me that all we could do was leave these patients and try at a later time as the extra stress placed on them via forcing suctioning could be detrimental to their status. I was however concerned that by not treating them that would also be detrimental to their status.
I thought I would just share this incident with you as I found it an interesting situation as I would have thought that it would be a priority to treat someone presenting like these two patients did. Has anyone else had any interesting suctioning issues on their placements??
Debs
Saturday, January 19, 2008
A Serial Patient!
Hi all,
I am currently treating a patient with severe muscles tightness and secondary joint hypomobility (leading to limited ROM) in the lower Cx and mid/upper Tx spine. The client has had these episodes (that usually last for a couple of weeks) periodically over the last couple of years and has come to the clinic each time (a few trees have been cut down to build her file!!). They are very much related to her study habits as a med student where she says she often studies up to 14 hours straight with no breaks.
The client maintains that she comes to the physio clinic when these episodes occur, as a preventative measure, because if she doesn't she begins to feel disabling pain in her neck and between the scapulae. The client is always happy with the treatment she receives at the clinic which includes STM, myofascial release, PAIVMS to Tx/Cx spine, stretching and education. As a private paying client the client is obviously very lucrative for the clinic.
So you may ask what is Nico going on about here?!!
It just seems that all the education in the world reguarding her study habits, posture and ergonomics can't seem to change her behaviour. The client knows that if she adopted some of the advice including frequent breaks, getting a better chair etc.. her symptoms would disappear. For instance I mention that she should break from study every 20 min and walk/stretch and she responds with "yeah I know, I've been told all this before". The client is just a very driven person and is so busy in other areas of her life to implement the strategies given to her. The client would rather deal with the symptoms when they occur than deal with the root problem.
Does anyone have experience with a pt/client like this and what strategies did they use to affectively get their point across?
Something to think about too. Is it ok to keep on taking this clients money knowing that you are making her happy but not effectively dealing with her loading/postural disorder? I can imagine this kind of client would be a common occurance in private practice. Anyway something to think about if you want to.
Take it easy.
Nico
I am currently treating a patient with severe muscles tightness and secondary joint hypomobility (leading to limited ROM) in the lower Cx and mid/upper Tx spine. The client has had these episodes (that usually last for a couple of weeks) periodically over the last couple of years and has come to the clinic each time (a few trees have been cut down to build her file!!). They are very much related to her study habits as a med student where she says she often studies up to 14 hours straight with no breaks.
The client maintains that she comes to the physio clinic when these episodes occur, as a preventative measure, because if she doesn't she begins to feel disabling pain in her neck and between the scapulae. The client is always happy with the treatment she receives at the clinic which includes STM, myofascial release, PAIVMS to Tx/Cx spine, stretching and education. As a private paying client the client is obviously very lucrative for the clinic.
So you may ask what is Nico going on about here?!!
It just seems that all the education in the world reguarding her study habits, posture and ergonomics can't seem to change her behaviour. The client knows that if she adopted some of the advice including frequent breaks, getting a better chair etc.. her symptoms would disappear. For instance I mention that she should break from study every 20 min and walk/stretch and she responds with "yeah I know, I've been told all this before". The client is just a very driven person and is so busy in other areas of her life to implement the strategies given to her. The client would rather deal with the symptoms when they occur than deal with the root problem.
Does anyone have experience with a pt/client like this and what strategies did they use to affectively get their point across?
Something to think about too. Is it ok to keep on taking this clients money knowing that you are making her happy but not effectively dealing with her loading/postural disorder? I can imagine this kind of client would be a common occurance in private practice. Anyway something to think about if you want to.
Take it easy.
Nico
Thursday, January 17, 2008
Frustrating communication
Hi all!
I’m currently doing my Neuro Outpatients placement.
This week I saw a patient who was a new admission to the neuro outpatient clinic. The patient had a L MCA infarct approx 7 months ago and was a late addition to my case load and I hadn’t had a chance to read over his medical notes before seeing him. Because of this, I had no idea of his history and what to expect. When I finally met the pt and started chatting, I was faced with a person grunting and gesturing at me in an attempt to tell me that he couldn’t talk. The pt had only mild receptive aphasia and could understand simple instructions, however he had severe expressive aphasia and was unable to communicate other than indicating yes or no through nodding his head. Even then, his yes and no answers seemed all over the place and not at all consistent which made it really hard to get a clear picture of what was really going on. My subjective Ax was pretty much non existent and my objective was very sketchy. Some Ax such as tone and ROM were relatively normal to complete, however the pts physical responses and facial expressions to this had to be monitored closely, rather than relying on a verbal response to stop. Other Ax was seemingly almost impossible.
This whole process had to be done so slowly to be as accurate as possible and was extremely long and yet at the end of it all I felt like I had gotten nowhere and had more questions than answers which left me feeling extremely frustrated and useless…
Later that day I was buying lunch at the cafeteria and saw the same pt eating lunch with his wife, daughter and 3 of his grandchildren. They were all chatting, laughing and looked like a happy family having a nice lunch together. As I watched this family, my patient looked like he was really happy to have so many family members around him and yet I couldn’t help but feel like he was missing out on something. He had so much going on around him and he couldn’t contribute at all… all he could do was sit there and listen.
I thought back to how I had felt at the end of our session that morning and how frustrated I was with the situation… then I thought, how must this guy feel? 7 months ago this guy was a seemingly normal, happy, working man who could interact with his family and environment around him. Now all he could do was nod his head and grunt. At that point my morning didn’t seem so bad after all.
I’m currently doing my Neuro Outpatients placement.
This week I saw a patient who was a new admission to the neuro outpatient clinic. The patient had a L MCA infarct approx 7 months ago and was a late addition to my case load and I hadn’t had a chance to read over his medical notes before seeing him. Because of this, I had no idea of his history and what to expect. When I finally met the pt and started chatting, I was faced with a person grunting and gesturing at me in an attempt to tell me that he couldn’t talk. The pt had only mild receptive aphasia and could understand simple instructions, however he had severe expressive aphasia and was unable to communicate other than indicating yes or no through nodding his head. Even then, his yes and no answers seemed all over the place and not at all consistent which made it really hard to get a clear picture of what was really going on. My subjective Ax was pretty much non existent and my objective was very sketchy. Some Ax such as tone and ROM were relatively normal to complete, however the pts physical responses and facial expressions to this had to be monitored closely, rather than relying on a verbal response to stop. Other Ax was seemingly almost impossible.
This whole process had to be done so slowly to be as accurate as possible and was extremely long and yet at the end of it all I felt like I had gotten nowhere and had more questions than answers which left me feeling extremely frustrated and useless…
Later that day I was buying lunch at the cafeteria and saw the same pt eating lunch with his wife, daughter and 3 of his grandchildren. They were all chatting, laughing and looked like a happy family having a nice lunch together. As I watched this family, my patient looked like he was really happy to have so many family members around him and yet I couldn’t help but feel like he was missing out on something. He had so much going on around him and he couldn’t contribute at all… all he could do was sit there and listen.
I thought back to how I had felt at the end of our session that morning and how frustrated I was with the situation… then I thought, how must this guy feel? 7 months ago this guy was a seemingly normal, happy, working man who could interact with his family and environment around him. Now all he could do was nod his head and grunt. At that point my morning didn’t seem so bad after all.
Wednesday, January 16, 2008
Rib troubles
Does anyone have experience with rib troubles?
This pt presented with pain & TOP ++. Based on the presentation, I thought it was a broken rib... but thinking about it, there was not sufficient trauma to explain this.
PC: pain in back & chest
Hx:
3 week history of sleeping in different bed (travelling).
Possible contribution of connubial activities.
Functional problems:
pain 5/10 sneezing / coughing centred on L post / post-lat rib #4
pain 4/10 deep breath same location
TOP ++ area of L rib #4
AROM:
L SF 5cm < style="font-weight: bold;">PAIVMs:
bilateral (transverse processes):
R2: no noticeable diff. in T1,2,3,4,5
pain 3/10 T2; 4/10 T3; 5/10 T4; 5/10 T5
ribs:
P2: at 1/3 range R & L ribs 3,4,5
pain 8/10 L rib 4
pain 7/10 L rib 3 & 5, R rib 4
pain 6/10 L rib 2, R rib 3, 5
Any ideas about Dx or Rx?
In retrospect, I am thinking I should have checked for trigger points / muscle tightness of the paraspinals, traps and rhomboids to see if they were contributing to the global soreness & TOP around the costovertebral joints - it seems to me more likely that one structure (e.g. rhomboids) would be so sore rather than any separate structures (i.e. 5-6 underlying costovertebral joints). Perhaps the go is to relax overlying muscles before doing PAIVMs?
This pt presented with pain & TOP ++. Based on the presentation, I thought it was a broken rib... but thinking about it, there was not sufficient trauma to explain this.
PC: pain in back & chest
Hx:
3 week history of sleeping in different bed (travelling).
Possible contribution of connubial activities.
Functional problems:
pain 5/10 sneezing / coughing centred on L post / post-lat rib #4
pain 4/10 deep breath same location
TOP ++ area of L rib #4
AROM:
L SF 5cm < style="font-weight: bold;">PAIVMs:
bilateral (transverse processes):
R2: no noticeable diff. in T1,2,3,4,5
pain 3/10 T2; 4/10 T3; 5/10 T4; 5/10 T5
ribs:
P2: at 1/3 range R & L ribs 3,4,5
pain 8/10 L rib 4
pain 7/10 L rib 3 & 5, R rib 4
pain 6/10 L rib 2, R rib 3, 5
Any ideas about Dx or Rx?
In retrospect, I am thinking I should have checked for trigger points / muscle tightness of the paraspinals, traps and rhomboids to see if they were contributing to the global soreness & TOP around the costovertebral joints - it seems to me more likely that one structure (e.g. rhomboids) would be so sore rather than any separate structures (i.e. 5-6 underlying costovertebral joints). Perhaps the go is to relax overlying muscles before doing PAIVMs?
Monday, January 14, 2008
A lesson in patience
Hi guys, i'm currently doing my cardiopulmonary placement. This incident didn't happen to me personally but it definitely taught me alot about taking time to do the right thing.
Last week, there was a patient who came in after surgery (laparotomy) and had a drainage tube connected to him. This tube basically was for the drainage of waste matter and had a little balloon attached to the end of it to prevent it from getting yanked out accidentally.
What happened was that one of the doctors was trying to remove the tube from the patient. However, he didn't want to wait for the nurse to run out to grab a syringe to deflate the cuff first. Instead, he pulled on the tube till the balloon was showing and then stabbed the balloon with his pen, thereby causing all the waste matter to splatter on him, another doctor and everywhere else.
As a result, he had to spend the rest of the day getting tested for the different diseases that could he could be infected with and even had to draw up an accident report. This incident maybe funny as we're not the doctor who made that mistake but it really taught me about how tempting it is to take shortcuts (especially when we're tight for time) yet how important and how much more efficient it is to do the right thing and in the right way.
For example, it might only take us 2 secs to check if our patient is nauseous/dizzy on standing but it'd take us alot more time and effort trying to ambulate someone who is or happened to faint or vomit halfway. Therefore, I'm reminded that it's always worthwhile to take some time to do it right, especially when our patients are involved.
Last week, there was a patient who came in after surgery (laparotomy) and had a drainage tube connected to him. This tube basically was for the drainage of waste matter and had a little balloon attached to the end of it to prevent it from getting yanked out accidentally.
What happened was that one of the doctors was trying to remove the tube from the patient. However, he didn't want to wait for the nurse to run out to grab a syringe to deflate the cuff first. Instead, he pulled on the tube till the balloon was showing and then stabbed the balloon with his pen, thereby causing all the waste matter to splatter on him, another doctor and everywhere else.
As a result, he had to spend the rest of the day getting tested for the different diseases that could he could be infected with and even had to draw up an accident report. This incident maybe funny as we're not the doctor who made that mistake but it really taught me about how tempting it is to take shortcuts (especially when we're tight for time) yet how important and how much more efficient it is to do the right thing and in the right way.
For example, it might only take us 2 secs to check if our patient is nauseous/dizzy on standing but it'd take us alot more time and effort trying to ambulate someone who is or happened to faint or vomit halfway. Therefore, I'm reminded that it's always worthwhile to take some time to do it right, especially when our patients are involved.
Sunday, January 13, 2008
Neuro Clinical Reasoning Problem for you
Had an interesting case during the Neuro placement which brought up an intriguing clinical reasoning problem - you can have a read and see if you would crack the nut yourself.
The patient was a 68 year old gent with transverse myelitis and a PMH of R MCA stroke.
Transverse myelitis (TM) itself is interesting in that it is similar to Guillan Barré, but presents like an incomplete spinal cord injury (SCI). Specifically, TM involves demyelination (like Guillan Barré) of the spinal cord across a specific spinal cord level (so there is partial or complete loss of motor control below a segment, like an SCI).
The clinical course is similar to Guillan Barré in that there is an extremely rapid decline followed by long, slow recovery. However, the prognosis is not as good as Guillan Barré: 1/3 of patients recover with a mild to moderate disability; 1/3 of patients recover with a moderate to severe disability; and 1/3 of patients don't recover appreciably. Thankfully for our patient, people with TM who show early signs of some recovery (as he did) are much less likely to fall into the last group.
Another positive aspect is that, unlike Guillan Barré, TM leaves with patients with wholly intact function above the affected level of the spinal cord. Our patient was a C7 TM case, so he had complete control of triceps, etc. - but not the best finger grip for pens, etc.
This brings up the clinical reasoning question. Our patient was starting to lose ROM for wrist flexion. The questions was: do we stretch out the long finger flexors to retain muscle length & avoid a flexion contracture; or do we leave it alone so that he will still have a tenodesis grip?
What would you do?
We debated the question before asking our clinical supervisor. The answer she came up with was: Consider the likely clinical course... While there is any chance for recovery, we should try to aim for optimal function and not go for compensations - which is what a tenodesis grip is. We therefore instituted a 'HEP' stretching program so that the patient could maintain his wrist ROM.
The patient was a 68 year old gent with transverse myelitis and a PMH of R MCA stroke.
Transverse myelitis (TM) itself is interesting in that it is similar to Guillan Barré, but presents like an incomplete spinal cord injury (SCI). Specifically, TM involves demyelination (like Guillan Barré) of the spinal cord across a specific spinal cord level (so there is partial or complete loss of motor control below a segment, like an SCI).
The clinical course is similar to Guillan Barré in that there is an extremely rapid decline followed by long, slow recovery. However, the prognosis is not as good as Guillan Barré: 1/3 of patients recover with a mild to moderate disability; 1/3 of patients recover with a moderate to severe disability; and 1/3 of patients don't recover appreciably. Thankfully for our patient, people with TM who show early signs of some recovery (as he did) are much less likely to fall into the last group.
Another positive aspect is that, unlike Guillan Barré, TM leaves with patients with wholly intact function above the affected level of the spinal cord. Our patient was a C7 TM case, so he had complete control of triceps, etc. - but not the best finger grip for pens, etc.
This brings up the clinical reasoning question. Our patient was starting to lose ROM for wrist flexion. The questions was: do we stretch out the long finger flexors to retain muscle length & avoid a flexion contracture; or do we leave it alone so that he will still have a tenodesis grip?
What would you do?
We debated the question before asking our clinical supervisor. The answer she came up with was: Consider the likely clinical course... While there is any chance for recovery, we should try to aim for optimal function and not go for compensations - which is what a tenodesis grip is. We therefore instituted a 'HEP' stretching program so that the patient could maintain his wrist ROM.
Gains made in treatment and intensity of rehabilitation
Hey crew,
In December this year I had my Neurology placement. I was working on an acute neurology ward. One of my patients was a 64 year old female who had had a R MCA stroke. Her main impairments were left sided weakness and abnormal motor control patterns of her left arm and left leg. This lady was fairly dependent and initially required 2 x moderate assist to sit to stand and do any transfers. Our main goals for this patient was for her to achieve independence in sit to stand (with the assistance of a rail) as well as independent transfers such as w/c to bed such that she would be able to return home to live with her husband. The doctor gave us 2-3 weeks to try and achieve this goal as after this they wanted to transfer her to Osbourne Park for further rehab and then return home or a nursing home.
Initially in the first week of Rx with her we focused on muscle strength of her legs and core stability. After this week I found out that if she didn’t achieve close to independent status she would have to go to a nursing home. This upset me as you could tell she did not want to go to a nursing home and her husband did not want her to either- however, he would not of been able to cope at home unless she improved her status. This situation really motivated me to assist her in regaining her functional status. From this day, I changed my Rx ideas to focus on transfers from w/c to bed and back as well as sit to stand practice. Everyday I saw her twice and spent 45-60minutes with her- I found her to be a very challenging patient as she was very inconsistent with her progress. One day she would have a great session and do the tasks really well and then the subsequent day it felt like we were back to basics and where we had started. She also had some memory problems which affected the way she performed tasks as she would forget the sequence of movements to achieve the goals. On her bad days I felt very frustrated as I felt my treatment was being ineffective and I wasn’t progressing her- these days really tested my patience and motivation to her Rx. Personally, when I’m treating patients I like to see the patients progress and improve as this shows that I am being effective and helpful in the patients function. I guess with this patient I realized that you’re not always going to get fast results and patients will progress and then regress on their bad and good days. I think I thought that everyday I would see progress and then when this wasn’t the case and she was fairly inconsistent it opened my eyes to the rehabilitation in stroke and how it can take a long time for someone to regain function.
Overall though, in the 2-3 weeks I was treating the patient I learnt a lot from her and she made some good gains although not as significant as I had hoped as she still required lots of cueing for each task she performed. For me, this patient raised 2 issues; the first being that I realized that rehabilitation can take a long time and you’re not always going to get fast results however its still important to prosper on and keep trying to achieve improvements by using various Rx technqiues, the 2nd issue that it raised for me is how much rehab is necessary for patients to improve? As we are students we were able to see this patient 2 x per day however I doubt that we would have this opportunity in the clinical world with a full case load. It concerns me that if this patient had of received less Rx would she of been in an even worse functional status? I worry that when we get into working in the clinical setting we wont always have time to achieve all that we want to achieve with patients and we may have to settle for a reduced functional status of the patients.
Just let me know if any of you feel the same way as me in this situation. Thanks.
In December this year I had my Neurology placement. I was working on an acute neurology ward. One of my patients was a 64 year old female who had had a R MCA stroke. Her main impairments were left sided weakness and abnormal motor control patterns of her left arm and left leg. This lady was fairly dependent and initially required 2 x moderate assist to sit to stand and do any transfers. Our main goals for this patient was for her to achieve independence in sit to stand (with the assistance of a rail) as well as independent transfers such as w/c to bed such that she would be able to return home to live with her husband. The doctor gave us 2-3 weeks to try and achieve this goal as after this they wanted to transfer her to Osbourne Park for further rehab and then return home or a nursing home.
Initially in the first week of Rx with her we focused on muscle strength of her legs and core stability. After this week I found out that if she didn’t achieve close to independent status she would have to go to a nursing home. This upset me as you could tell she did not want to go to a nursing home and her husband did not want her to either- however, he would not of been able to cope at home unless she improved her status. This situation really motivated me to assist her in regaining her functional status. From this day, I changed my Rx ideas to focus on transfers from w/c to bed and back as well as sit to stand practice. Everyday I saw her twice and spent 45-60minutes with her- I found her to be a very challenging patient as she was very inconsistent with her progress. One day she would have a great session and do the tasks really well and then the subsequent day it felt like we were back to basics and where we had started. She also had some memory problems which affected the way she performed tasks as she would forget the sequence of movements to achieve the goals. On her bad days I felt very frustrated as I felt my treatment was being ineffective and I wasn’t progressing her- these days really tested my patience and motivation to her Rx. Personally, when I’m treating patients I like to see the patients progress and improve as this shows that I am being effective and helpful in the patients function. I guess with this patient I realized that you’re not always going to get fast results and patients will progress and then regress on their bad and good days. I think I thought that everyday I would see progress and then when this wasn’t the case and she was fairly inconsistent it opened my eyes to the rehabilitation in stroke and how it can take a long time for someone to regain function.
Overall though, in the 2-3 weeks I was treating the patient I learnt a lot from her and she made some good gains although not as significant as I had hoped as she still required lots of cueing for each task she performed. For me, this patient raised 2 issues; the first being that I realized that rehabilitation can take a long time and you’re not always going to get fast results however its still important to prosper on and keep trying to achieve improvements by using various Rx technqiues, the 2nd issue that it raised for me is how much rehab is necessary for patients to improve? As we are students we were able to see this patient 2 x per day however I doubt that we would have this opportunity in the clinical world with a full case load. It concerns me that if this patient had of received less Rx would she of been in an even worse functional status? I worry that when we get into working in the clinical setting we wont always have time to achieve all that we want to achieve with patients and we may have to settle for a reduced functional status of the patients.
Just let me know if any of you feel the same way as me in this situation. Thanks.
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