Fourth Year - Rotation 2 - Communication STARES

Situation 
A new patient was assigned to my client list who was a 63 yr old female who was referred to the outpatients clinic for assessment and treatment of her right knee pain. An x-ray report depicted a suspicion of osteoarthritis in bilateral knees and the patient’s GP was considering sending her to a specialist to be placed onto the total knee replacement waiting list. This patient was also a migrant who had lived in this district for many years and who predominantly spoke Lebanese and conversed very little in English. Fortunately, she was accompanied to her initial assessment with her daughter who spoke fluent English and Lebanese and acted as our translator throughout the assessment. It seemed that this was a role the daughter played regularly as she was able to give a good medical history on behalf of the patient and also question her mother further on specific questions. At this point in time, a normal initial assessment by me should take 1 hour to complete the subjective, objective as well as provide adequate treatment to address the patient’s presenting problem or to build a foundation for subsequent treatments.

Task
To perform an initial assessment and provide treatment to the patient with language difficulties within the 1 hour time frame.

Action
I began with my usual questioning that we’d been taught in uni to try explore the presenting pains. This tactic was not so successful as the patient was unable to describe her pain besides using the words “painful” and “sore” and grabbing her right knee with a pained expression on her face. This is where I started employing hand gestures as well to coax further describing words out of her such as ‘stabbing’, ‘hot’, ‘swollen’, ‘clicking’ and ‘locking while doing activities’ as well as getting the daughter to try and explain my questions in Lebanese. I was able to establish that she had exactly the same ‘glowing’ ‘occasionally stabbing’ pain without locking, clicking or giving way in both knees for the last 2 years with a gradual onset. Unfortunately I was unable to use the VAS to get a pain score from the patient as even with both the daughter and my effort together we could not get her understanding the concept of using the scale to rate pain.

Result
With lots of hard and slow work, I was able to finally complete my initial assessment and review a home exercise program suitable for the patient. I used the help of already drawn exercises to help speed up the process of explaining the position the patient had to be in to perform the exercises as well as doing a lot of demonstrating myself. The patient was able to leave the clinic with a satisfied feeling of knowing that her knee problem was being dealt with and with the reassurance that she was performing the exercises correctly and her daughter was able to also correct her if she had trouble doing the exercises at home. Communication with the patient had only being a minor issue that slowed down the whole assessment but I was still able to complete all relevant aspects of the initial assessment within the 1 hour assigned to the patient.

Evaluation
It was difficult initially to work out the best way to gather all the information I needed to complete the subjective as I kept trying to ask certain questions like “how would you rate your pain out of 10, 10 being the worst imaginable pain ever and 0 being pain free” without getting the answers I wanted. It was only when I realised we weren't getting anywhere with these sorts of questions that I decided that it wasn’t too important to actually have an actual number for the VAS but just ensured that my treatment would decrease her pain from her point of view. I realise that communication with the patient is very important especially in regards to getting a detailed subjective and also with motivating the patients to do the exercises. I was relieved that the objective part the assessment wasn’t made too difficult by the decreased ability of the communication between the patient and me as lots of demonstrating was able to get us through it. Although I still think this initial assessment and treatment session was a success, it could have been much better with appropriate communication.

Strategies
My supervisor advised me that the VAS is very difficult for a certain population of the clients we have presenting here in the outpatients and I was correct in abandoning it after trying to rephrase it a couple of times. The supervisor approved of my decision to use the strategy of asking if the treatment I gave the patient decreased her pain instead of getting a numeral value.
The idea of using pictures and giving them to the patient to take home was also another good way of improving the communication between us as in combination of my demonstrating and explanation of the exercises from the daughter, the patient was able to reproduce the exercises perfectly with minor adjustments here and there.
Having the daughter as a translator was very effective rather than using a hospital translator as the daughter visited her mother at least once a day and was able to ensure that she could perform the exercises and stretches with her mum. This extra support and encouragement is going to be very beneficial for this patient’s recovery/maintenance. Also by having the daughter as the translator, I believe the patient was able to recall a better history and the daughter could fill in any gaps.
Next time I will keep in mind that there are ways around communication with a patient and also talking slower and waiting for an answer before shooting the next question is beneficial to every party involved!