Finishing the cardio placement tomorrow... and it has been good. For some reason, cardio seems to be lower stress, even though some of the patients have been a lot closer to death's doorstep than any I saw on the neuro prac.
One of the arts that I have learnt by doing is that of getting the patient to 'cough it up': 'harvesting the prairie oyster'. Here are my top tips for harvesting good gob:
1. Adapt the ACBT:
At school, we were taught a standardized version of the ACBT; but in practise, it gets modified quite often. For instance, if a patient goes through the first cycle of TEEs and you can hear the rattle of a good goober in the pipes, why would you go through another set of TEEs, huff and cough? What is the patient going to do, balance the little jewel on his tongue while he goes through the rest of a standard cycle? No, she will swallow it! And what a pity, you lose the chance to see how the lungs are doing (is it like pea soup?... infection! White & frothy?... possible pneumothorax!), to say nothing of that satisfying entry in the notes: "E/ pt produced 14 Tbsp.s thick++ creamy golden" (it is all about volume...).
2. Listen for the loogie:
You can hear when a patient is hiding treasures in the airways (even without a 'scope). Just think back to how L.R. , a 26y.o. female PT student, presented in the first year of the programme: you knew she was packing. So when you hear that rattly, 'chunks-are-coming' tone to a pt.'s exhale, skip the rest of the ACBT and go straight to the cough. (it's funny, thinking back to visiting the Dr. for a sore throat and being asked to cough, you wondered 'Why?' - now it is so obvious).
3. Grease the wheels:
To move anything, you need lube. If a patient has a dry throat, you aren't gunna get anything out of her. Imagine my chagrin when they put A.S., my top producer, on thickened fluids - he went from being an easy Tbsp. per-session-man to "np" (that's 'non-productive' for you musculo-heads). And then the Doc wants three sputum samples! The solution was easy. A.S. is a compliant, reasonable man: he understood that he wasn't safe to swallow water, but given how dry his throat was, he happily promised not to swallow in exchange for a sips of water to wet his whistle and then spit. Sure enough, the Doc. got three specimen jars of premium caramel custard.
4. Watch for the swallow:
Early in the prac, I often found that patients who had a moist++ cough and audible secretions on Ausc. would not produce. After a while, it seemed obvious that they were swallowing the goods. Many patients won't admit it, thinking it is too disgusting. So the trick is to watch their throat after a cough - you can see if they are swallowing.
5. The secret weapon:
Apple juice. For some reason, a sip or two of apple juice and the pt will double their production. The once thing you have to watch for is that it changes the colour of the final product.
Which brings me to my reflective question: more than one pt. reported that they always have more secretions after eating or drinking. What have the rest of you found? Is the after-lunch harvest better?
(dedicated to T.G., GEM 2008's very own sputum queen).
Thursday, January 31, 2008
Tuesday, January 29, 2008
the gap
Hi guys,
when reading ABGs, have you come across the term "anion gap"? well, i've always wondered what it meant and how it relates to our patient so i thought i'd share it with you guys so you guys can get a better picture of our patients status.
The anion gap represents the concentration of all the unmeasured anions in the plasma. It is calculated from the following formula:
either [Na]-[Cl]-[HCO3] or [Na]+[K]-[Cl]-[HCO3]
The optimum value is about 10-12mmol/L. Some of the major clinical uses of the anion gap include signalling the presence of a metabolic acidosis, helping to differentiate between causes of a metabolic acidosis and to assist in the assessment of the biochemical severity of the acidosis and following the response to treatment.
An elevated anion gap is commonly die to ketoacid overproduction due to fat metabolism (diabetes, alcohol, starvation), lactic acid overproduction due to respiratory failure, inability to excrete acids due to renal disease and dehydration.
A decreased anion gap then might be due to hyponatremia, primary hypothyroidism and hypoalbuminemia.
I think this is a pretty useful number as by working backwards from the ABGs then we would be able to detect the associated problems with the patient and thus adjust our treatment and approach accordingly.
Also, i think knowledge of this gap gave me a better understanding of why my patient (whose anion gap is abnormal ) was so lethargic. In fact, i think that the reason could possibly be attributed to insufficiency of the electrolytes which in turn compromises energy production and cellular function.
when reading ABGs, have you come across the term "anion gap"? well, i've always wondered what it meant and how it relates to our patient so i thought i'd share it with you guys so you guys can get a better picture of our patients status.
The anion gap represents the concentration of all the unmeasured anions in the plasma. It is calculated from the following formula:
either [Na]-[Cl]-[HCO3] or [Na]+[K]-[Cl]-[HCO3]
The optimum value is about 10-12mmol/L. Some of the major clinical uses of the anion gap include signalling the presence of a metabolic acidosis, helping to differentiate between causes of a metabolic acidosis and to assist in the assessment of the biochemical severity of the acidosis and following the response to treatment.
An elevated anion gap is commonly die to ketoacid overproduction due to fat metabolism (diabetes, alcohol, starvation), lactic acid overproduction due to respiratory failure, inability to excrete acids due to renal disease and dehydration.
A decreased anion gap then might be due to hyponatremia, primary hypothyroidism and hypoalbuminemia.
I think this is a pretty useful number as by working backwards from the ABGs then we would be able to detect the associated problems with the patient and thus adjust our treatment and approach accordingly.
Also, i think knowledge of this gap gave me a better understanding of why my patient (whose anion gap is abnormal ) was so lethargic. In fact, i think that the reason could possibly be attributed to insufficiency of the electrolytes which in turn compromises energy production and cellular function.
schatzki's ring
hi all, that's a picture of "schatzki's ring"
I used to think that dysphagia largely meant difficulty swallowing liquids, and i never expected the patient to have difficulty swallowing solids and not liquids till i met this old lady.
This lady patient has GORD and intermittent difficulty swallowing solid food which the medical team attributed to the 'schatzki's ring'. As i've never seen that term before, i thought i'd share what i found with you guys to expand our knowledge.
the schatzki's ring is an abnormal ring of tissue in the lower esophagus located at or near the border of the lower esophageal sphincter. It is also known as a lower esophageal ring. The causes for this is unclear and it is hypothesized that it could be a consequence of GORD or be congenital or even pill-induced.
A barium esophagram followed by an esophagogastroduodenoscopy is usually done to diagnose the condition and dilatation with intention to fracture that ring is usually the first course of action. If that does not work, the medical team might resort to surgical excision, all the time keeping in mind aggressively treating any existing reflux diseases.
Although this is not directly physio-related, i hope this piece of information comes in useful for you guys at some point in time, especially if your patient has GORD and has difficulty swallowing things like bread and steak but not water (like my patient).
Monday, January 28, 2008
the 'Blue Tab' & resusc. instructions
During my cardio placement, I have seen a few sets of patient's notes with a blue tab attached to one of the pages.
The blue tab marks the page in a patient's notes where there are instructions about DNR (do not resuscitate) if there are any. Maybe I was asleep when it was discussed, but I don't recall learning about this crucial bit of info at school.... My supervisor told me about it after I had been on prac.s for >5 weeks.
This, and the very poor health of some of the pt.s we see got me thinking about the balance between keeping people alive and minimizing suffering. There is no doubt that, for some patients, there comes a time when the two goals not aligned. One patient we were treating was discussed by one of the health care team as "...just needs to die". Not at all out of callousness; quite the opposite: it seemed plain to these experienced practitioners that there was no point in prolonging the patient's life, as he didn't seem likely to live and was suffering.
Of course, that doesn't make any difference to us: we would never decide not to treat a patient. However, I can't help wondering about the whole thing: when i finish giving some patients chest physio, they are exhausted and look worse that when I started even though they are breathing easier and are perfectly capable of declining treatment. I guess they do feel better and / or they blindly trust that what we do is good for them.
My reflection on the matter is this: how do we take patient suffering / will-to-die into account? All of our treatments are supposed to be evidence based practises, but how do studies take into account the balance between prolonging life and prolonging pain? Has anyone seen any studies that try to incorporate these factors?
The blue tab marks the page in a patient's notes where there are instructions about DNR (do not resuscitate) if there are any. Maybe I was asleep when it was discussed, but I don't recall learning about this crucial bit of info at school.... My supervisor told me about it after I had been on prac.s for >5 weeks.
This, and the very poor health of some of the pt.s we see got me thinking about the balance between keeping people alive and minimizing suffering. There is no doubt that, for some patients, there comes a time when the two goals not aligned. One patient we were treating was discussed by one of the health care team as "...just needs to die". Not at all out of callousness; quite the opposite: it seemed plain to these experienced practitioners that there was no point in prolonging the patient's life, as he didn't seem likely to live and was suffering.
Of course, that doesn't make any difference to us: we would never decide not to treat a patient. However, I can't help wondering about the whole thing: when i finish giving some patients chest physio, they are exhausted and look worse that when I started even though they are breathing easier and are perfectly capable of declining treatment. I guess they do feel better and / or they blindly trust that what we do is good for them.
My reflection on the matter is this: how do we take patient suffering / will-to-die into account? All of our treatments are supposed to be evidence based practises, but how do studies take into account the balance between prolonging life and prolonging pain? Has anyone seen any studies that try to incorporate these factors?
fun therapy
Hi all,
I have been seeing a 24 yo woman with Cerebellar Syndrome (her main impairment is ataxia) in neuro outpatients, twice a week for three weeks now. We have been doing mainly trunk stability, balance and gait work with her and although our sessions were different each time, I felt like the sessions were a bit boring and wanted to make them more interesting for her. I discussed this with my supervisor and he showed me some really good ideas for making core stability work interesting and fun for both me and my patient.
My favorite exercise was ‘the airplane’ which I’ve done with my kids at gymnastics quite a lot but would never have thought to do it with patients. The airplane involves the patient lying on a plinth with their knees bent up to their chest and their feet in the air. I stand on the plinth facing the pt and place the pt’s feet on my ASIS, then lean fwd and hold onto the cage/frame in front. The pt then straightens their legs to lift my feet off the plinth so that it looks like I’m flying (hence the name of the exercise). To make it hard for the pt you can let go of the cage and hold onto their hands, or move slightly form side to side to make their trunk work harder. My patient really liked this exercise as it was something different from what we normally did, and it made her have to work really hard.
Obviously this isn’t the sort of exercise you would do with everyone and you have to choose the pt’s you do it with very carefully. But for those pt’s that it is suitable for I think it is a great thing to do as it works whole body strength, stability and balance all at the same time… and its really good fun!! If anyone ever has a patient like this that is capable of doing this exercise, I really recommend giving it a go.
Tara
I have been seeing a 24 yo woman with Cerebellar Syndrome (her main impairment is ataxia) in neuro outpatients, twice a week for three weeks now. We have been doing mainly trunk stability, balance and gait work with her and although our sessions were different each time, I felt like the sessions were a bit boring and wanted to make them more interesting for her. I discussed this with my supervisor and he showed me some really good ideas for making core stability work interesting and fun for both me and my patient.
My favorite exercise was ‘the airplane’ which I’ve done with my kids at gymnastics quite a lot but would never have thought to do it with patients. The airplane involves the patient lying on a plinth with their knees bent up to their chest and their feet in the air. I stand on the plinth facing the pt and place the pt’s feet on my ASIS, then lean fwd and hold onto the cage/frame in front. The pt then straightens their legs to lift my feet off the plinth so that it looks like I’m flying (hence the name of the exercise). To make it hard for the pt you can let go of the cage and hold onto their hands, or move slightly form side to side to make their trunk work harder. My patient really liked this exercise as it was something different from what we normally did, and it made her have to work really hard.
Obviously this isn’t the sort of exercise you would do with everyone and you have to choose the pt’s you do it with very carefully. But for those pt’s that it is suitable for I think it is a great thing to do as it works whole body strength, stability and balance all at the same time… and its really good fun!! If anyone ever has a patient like this that is capable of doing this exercise, I really recommend giving it a go.
Tara
Sunday, January 27, 2008
Treatment for weakness vs altered muscle activation pattern...(Daria's Post)
Hi all,
I am currently on my neuroplacement at SCGH. One of my patient is 65 year old male who had PCI. Patient's gait is ataxic and his balance vary significantly from day to day or even between morning and afternoon of same day. Patient showing lack of insight and often overestimates his abilities.He is really compliant with physio treatment and wants to work hard to improve his functional level however, he is stubborn personality and very inpatient and attempts to do things before full explaination/demo is finished. It is my third week of placement and last two monday's morning I find very upsetting as patient had 2 falls when he was trying to get to toilet on his own even though his "mobility chart" says "ambulation 1 A - close supervision".I was trying to explain to the patient that he needs to call for help, that he could fracture his leg ect. My clinical supervisor said it is qiute common problem that patient is trying to experience his abilities.Hoverever it does not make me feel better. My treatment first consisted of: balance exercises ( static,dynamic with all possible variables), walk, protective responses training and exercises to decrease ataxia AI's and RS's. I've noticed that balance even vary improved whereas I was not satisfied with patient's gait especially his trunk moving forward and backward with preference for backward (the patient tends to fall backward). So after consultation with my supervisor I added more abdominals exercises and moved toward building endurance in walking by increasing distance. Additionally, I noticed some weakness (not significant) in LL and decrease the ability to produce fractionated movements in LL (L>R). Can anyone give me some suggestions what sort of treatment can be used to improve ability to fractionate movements.
Thanks,
Daria
I am currently on my neuroplacement at SCGH. One of my patient is 65 year old male who had PCI. Patient's gait is ataxic and his balance vary significantly from day to day or even between morning and afternoon of same day. Patient showing lack of insight and often overestimates his abilities.He is really compliant with physio treatment and wants to work hard to improve his functional level however, he is stubborn personality and very inpatient and attempts to do things before full explaination/demo is finished. It is my third week of placement and last two monday's morning I find very upsetting as patient had 2 falls when he was trying to get to toilet on his own even though his "mobility chart" says "ambulation 1 A - close supervision".I was trying to explain to the patient that he needs to call for help, that he could fracture his leg ect. My clinical supervisor said it is qiute common problem that patient is trying to experience his abilities.Hoverever it does not make me feel better. My treatment first consisted of: balance exercises ( static,dynamic with all possible variables), walk, protective responses training and exercises to decrease ataxia AI's and RS's. I've noticed that balance even vary improved whereas I was not satisfied with patient's gait especially his trunk moving forward and backward with preference for backward (the patient tends to fall backward). So after consultation with my supervisor I added more abdominals exercises and moved toward building endurance in walking by increasing distance. Additionally, I noticed some weakness (not significant) in LL and decrease the ability to produce fractionated movements in LL (L>R). Can anyone give me some suggestions what sort of treatment can be used to improve ability to fractionate movements.
Thanks,
Daria
Saturday, January 26, 2008
A lesson learnt in safety procedures
Hey guys, this week my neurological placement was turning out to be pretty similar to the previous two weeks until Thursday morning. Together with my fellow student and clinical supervisor we were scheduled to see a new patient ‘James’.
James is a 28 y.o. male who was in a car accident approximately 7 years ago. James suffered brain damage mainly to his cerebellum and the fronto-parietal lobe resulting in impairments of motor deficits for the muscles that produce speech, and hemiparesis and spasticity to the right side of his body. James biggest impairment though was the ataxia he has in his trunk which means he spends most of his day (waking hours) in an electric W/C which has bilateral supports at the trunk to keep him in his chair. He is a 2 person max assist for transfers (W/C to SOEB) and is a 1 person max assist for SOEB balance.
The aim of this session was to assess James’ static sitting balance and dynamic sitting balance if appropriate, his bed mobility, and the amount of voluntary movement he has in his limbs. Based upon assessment appropriate treatment techniques and exercises were to be implemented to assist James.
James was T/F to bed via a slide board where we assessed his sitting balance and instigated some sitting exercises which he initially had some difficulty with but improved. This lasted approximately 20 minutes before James was T/F to supine. Through out the whole session James was constantly monitored; he responded that he was feeling good with no problems. Then James bed mobility was assessed and he was asked to move from supine to side lying. After 3 rolls to the right then three to the left I noticed that James was starting to look increasingly tired and fatigued. Each time he came back to supine there was an audible rattle in James’ throat that he tried to clear himself via a tracheal rub.
James movement pattern moving into side lying (esp. left) was quite poor with a lot of neck extension and rotation as opposed to flexion and rotation. James was asked to roll to his left again to try and clear his throat as his rattle was still present. In left side lying James appeared to be losing consciousness. The clinical tutor was very concerned for James’ state and decided to hit the alert buzzer. It started to become clear that James was passing out (probably due to hypoxia) or he was having a seizure (less likely as patient has no Hx of seizures and he was not shaking). The medical emergency team responded very promptly and O2 therapy was required as James O2 saturation had decreased. After about 15-20 minutes James condition started to improve and he returned to an alert state of consciousness.
While this was quite distressing for the patient I found it a fantastic learning experience as the speed with which my supervisor responded was fantastic. She picked up on the signs that were indicating that James may have been drifting out of consciousness very quickly. This reinforced to me the importance of continued monitoring of your patient. Her quick reaction made a big difference to the outcome of the patient.
The other important factor highlighted to me through this event was that neither myself nor my fellow student had been given instructions or the protocol on what to do in an emergency. Considering that this was the third week of our placement it should have been done by now. The message I would like to get across to everyone is to make sure they know the protocols in their department in case of emergency. As initially I was asked to get a mask and suctioning equipment and we had not been shown where they were.
Thanks
James is a 28 y.o. male who was in a car accident approximately 7 years ago. James suffered brain damage mainly to his cerebellum and the fronto-parietal lobe resulting in impairments of motor deficits for the muscles that produce speech, and hemiparesis and spasticity to the right side of his body. James biggest impairment though was the ataxia he has in his trunk which means he spends most of his day (waking hours) in an electric W/C which has bilateral supports at the trunk to keep him in his chair. He is a 2 person max assist for transfers (W/C to SOEB) and is a 1 person max assist for SOEB balance.
The aim of this session was to assess James’ static sitting balance and dynamic sitting balance if appropriate, his bed mobility, and the amount of voluntary movement he has in his limbs. Based upon assessment appropriate treatment techniques and exercises were to be implemented to assist James.
James was T/F to bed via a slide board where we assessed his sitting balance and instigated some sitting exercises which he initially had some difficulty with but improved. This lasted approximately 20 minutes before James was T/F to supine. Through out the whole session James was constantly monitored; he responded that he was feeling good with no problems. Then James bed mobility was assessed and he was asked to move from supine to side lying. After 3 rolls to the right then three to the left I noticed that James was starting to look increasingly tired and fatigued. Each time he came back to supine there was an audible rattle in James’ throat that he tried to clear himself via a tracheal rub.
James movement pattern moving into side lying (esp. left) was quite poor with a lot of neck extension and rotation as opposed to flexion and rotation. James was asked to roll to his left again to try and clear his throat as his rattle was still present. In left side lying James appeared to be losing consciousness. The clinical tutor was very concerned for James’ state and decided to hit the alert buzzer. It started to become clear that James was passing out (probably due to hypoxia) or he was having a seizure (less likely as patient has no Hx of seizures and he was not shaking). The medical emergency team responded very promptly and O2 therapy was required as James O2 saturation had decreased. After about 15-20 minutes James condition started to improve and he returned to an alert state of consciousness.
While this was quite distressing for the patient I found it a fantastic learning experience as the speed with which my supervisor responded was fantastic. She picked up on the signs that were indicating that James may have been drifting out of consciousness very quickly. This reinforced to me the importance of continued monitoring of your patient. Her quick reaction made a big difference to the outcome of the patient.
The other important factor highlighted to me through this event was that neither myself nor my fellow student had been given instructions or the protocol on what to do in an emergency. Considering that this was the third week of our placement it should have been done by now. The message I would like to get across to everyone is to make sure they know the protocols in their department in case of emergency. As initially I was asked to get a mask and suctioning equipment and we had not been shown where they were.
Thanks
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