5 weeks have just flown by!
I can barely believe how nervous I seemed in my initial entry about entering my musculoskeletal placement! This outpatient experience has definitely made me grow in my technical skills and confidence as a practicing physio. This was greatly a result of the amount of responsibilities and autonomy given to me and also the amount of confidence my supervisor and all the physios around me had in my abilities. I never had anyone hovering over my shoulder or second guessing any of my diagnoses or treatment ideas. I felt as though I was working at the same level as the other physios and was respected as a colleague. There were even times when they would bounce treatment ideas off me for my point of view or to find out what the newest techniques we are learning at university.
This hospital has the best continuing education program set up out of all the placements I have been to so far and I actually enjoyed coming in early to learn about and practice dry needling and other physio techniques such as the Feldenkrais Method.
Looking back at my concerns from 5 weeks ago, I am happy to say that I actually enjoyed the challenge of hopping from one diagnosis of lower back pain to something different like de Quervain's in the hand. I found this a lot more interesting than when I saw the same total hip replacement after total hip replacement on my ortho placement. In practice I never became anxious when treating a patient and coming up with treatment ideas was never a hassle especially because I always had my clinical reasoning to back myself up.
I remember when I first came to using the ultrasound machine I was so sure I would not remember how to correctly set the right dosage for the patient but again I was surprised with my own ability to recall what to do. Thank goodness I had a quick check of how to work EPAs before starting! Contraindications were not an issue either…except when the patient spoke little english and there was no translator! I became very good at acting out asking questions!
Addressing my concern of good technique, I actually learnt different ways to perform certain techniques which will help preseve my poor hands from getting too damaged before I qualify! In this last week I started using this tool called the “Superthumb” when trigger pointing patients. Greatest thumb/life saver ever! The physios surrounding me in this clinic were very experienced and were able to show me different techniques or quick ‘cheat’ tests to eliminate certain problems such as shoulder pain refferring from the neck with Mullagan’s cervical glide.
Communication was a big issue not only for me as a student but for the other physios also. I learnt how to communicate with easier words and also picked up a few foreign words here and there!
My crash course in studying anatomy and going over all tests during the study week did no harm as I never felt stuck with identifying what I was looking for with tests or knowing what I was feeling/looking at. It helped that there were always great diagrams around if I ever did need assistance or need help explaining things to patients.
With providing exercises for patients, I always asked them and discussed with them when was the best time of day to perform their exercises. Also I made sure I didn’t give them too many so they would actually be able to complete them at home. I also made sure they were able to perform the exercises correctly and self correct before sending them home WITH a copy/picture/instructions of the exercises on a sheet of paper.
Working in this outpatients setting I have some to appreciate that all patients are different and they all need their treatments to be unique. This may be because of their age, the amount of pain they are in, their injury or even the time they have to perform their exercises at home. There were many times when I started with trying to fix a certain injury with the ‘standard protocol’ treatment only for it to backfire in my face when the exercises were either too easy or too hard for the patient.
On this placement, I have also come to realise that with all patients you have to treat with the biopsychosocial plan in mind. This was especially evident in one of my patients a 55 year old woman who was experiencing chronic low back pain who had had a recent episode of excruciating back pain 2 weeks ago, the same time her husband started experiencing shoulder pain which caused him to take time off work. Yellow flags were jumping out everywhere! I knew that I was going to be unable to treat her pain with hands on physio alone so I took it into my treatment plan to discuss her home situation in her treatment sessions which lead onto getting her GP involved with setting up home help for this patient.
This hospital has been great as it is use to dealing with students like myself and understands the needs and wants of a student. It was not only my supervisor that pushed me to learn and encourage developing my skills with hands on practice but also the other physios would pull me aside and show me/let me take over their interesting cases. I really enjoyed working with this physio team and have been swayed to look into working in a hospital setting like this when I graduate now. The complexity of outpatients is definitely something I would like to pursue especially in this supportive and social setting of a hospital.
From this placement, I know I have developed my clinical skills including my interviewing techniques and time management - although these are things that I will continue to strive to improve on still. My confidence in myself, my actions and technique has increased substantially which can only lead to greater things in the future! Bring on Rotation 3!
Friday, April 23, 2010
Thursday, April 22, 2010
Fourth Year - Rotation 2 - Time Management STARES
Situation
In this last week in outpatients, I set my own personal goal of being able to complete initial assessments and follow up assessments in the same time as what the other physios in the department were working at. As a student, I am given 1 hour and 20 minutes for initial assessments and 40 minutes for follow up patients. This is double the time given to new graduates and by the end of this placement I would like to consider myself up to new graduate standard in musculoskeletal outpatients.
Task
Keep an eye on the time during treatment sessions keeping in mind that I have to include a subjective, objective - a baseline for treatment, choose an appropriate treatment, reassess the outcome baseline – evaluate the treatment and also write up patients notes.
Action
Before I gathered my patient from the waiting room, I would have a quick check over the patient’s notes to review previous treatment sessions and organise in my head what we did last time, if the treatment had been working, if I had planned to try another treatment or reassess anything this time. I would also try to prepare any information sheets/exercise sheets/hydro assessment sheets/equipment I might have needed during the session. This included goniometers, tape measures, checking if there was a treatment cubicle free and occasionally checking if the traction machine was available or would be available soon. I also invested in a fob watch to keep track of the time during my treatment sessions.
Since I had the whole 40 mins for follow ups, I tried to fit my treatments into 30 mins to give me time to write up notes and prepare for the next patient as well as to give me a bit of ‘give’ in case treatments didn’t go as planned or patients turned up late.
Result
I was unable to fulfil this goal, as I tended to take around 30 minutes for each follow up patient and 1 hour for each new patient. I found that there is only so much you can plan ahead before actually seeing a patient. Patients tend to arrive and present differently from what you were expecting, not react to the treatment as you had planned or even develop further pains that you need to address or investigate further. I also occasionally had the problem of patients arriving late or the equipment not being available when I needed it. An example of this was when there was a 3 patient wait to use the lumbar traction so I had to perform the subjective and objective assessment on the patient and make them wait in the waiting room until the machine became available. I also had to shorten their treatment time as I knew other physios were waiting to use the machine after me as well. With patients who presented with multiple pains, I found I had to treat what I could and set them up for another follow up session to assess their new pains.
Not all of my time management was bad though. There was this one situation when a patient arrived a day early but because of my good time management that day I was able to spend adequate amounts of time with her instead of just sending her away. I also found that during this week I didn’t end up staying back late to finish up writing patients notes as I was completing them during the day instead. This was a huge change from previous weeks where once I stayed back an extra hour to finish paperwork! I still found that patients with English as their second language harder to fit into my time restrictions.
Evaluation
When I started giving myself 30 mins for each follow up patient I found that I was able to keep in this time limit. I found this new ‘time restriction’ great for keeping up with notes so I was not spending an hour at the end of the day just catching up on paper work. I still feel though that I still could have been more efficient with my timing as I never quite made the 20 mins follow up times as I would have liked. On the other hand this is not really expected of a student, but at the end of the placement I thought I should have been as fast as a new graduate.
Even though I did not achieve my time limit goal, I took pride in the fact that at least I knew didn’t rush my treatment sessions and I hardly ever went over time with patients. I found this time limit was a good learning curve for myself as I like talking/building rapport with patients but in an environment such as outpatients, this is not as easy as when working on the ward. I also found my questioning for subjectives becoming more precise as well as choosing just the necessary assessments for the objectives and the objective outcome measures.
Strategies
You don’t need to ask EVERY SINGLE QUESTION on the assessment form.
You can gather information in different sessions not just in the initial assessment.
Sometimes you have to interrupt a patient if they are quite talkative and refocus on the question at hand
Having a fob watch is a great way to keep track of the time!
You can’t treat every thing in one session – patients are usually happy if you just do something about their pain!
If a patient is late you need to take that into consideration with their treatment or hopefully have stocked up enough spare time from other treatments
There are always other physios at hand if you need help!
In this last week in outpatients, I set my own personal goal of being able to complete initial assessments and follow up assessments in the same time as what the other physios in the department were working at. As a student, I am given 1 hour and 20 minutes for initial assessments and 40 minutes for follow up patients. This is double the time given to new graduates and by the end of this placement I would like to consider myself up to new graduate standard in musculoskeletal outpatients.
Task
Keep an eye on the time during treatment sessions keeping in mind that I have to include a subjective, objective - a baseline for treatment, choose an appropriate treatment, reassess the outcome baseline – evaluate the treatment and also write up patients notes.
Action
Before I gathered my patient from the waiting room, I would have a quick check over the patient’s notes to review previous treatment sessions and organise in my head what we did last time, if the treatment had been working, if I had planned to try another treatment or reassess anything this time. I would also try to prepare any information sheets/exercise sheets/hydro assessment sheets/equipment I might have needed during the session. This included goniometers, tape measures, checking if there was a treatment cubicle free and occasionally checking if the traction machine was available or would be available soon. I also invested in a fob watch to keep track of the time during my treatment sessions.
Since I had the whole 40 mins for follow ups, I tried to fit my treatments into 30 mins to give me time to write up notes and prepare for the next patient as well as to give me a bit of ‘give’ in case treatments didn’t go as planned or patients turned up late.
Result
I was unable to fulfil this goal, as I tended to take around 30 minutes for each follow up patient and 1 hour for each new patient. I found that there is only so much you can plan ahead before actually seeing a patient. Patients tend to arrive and present differently from what you were expecting, not react to the treatment as you had planned or even develop further pains that you need to address or investigate further. I also occasionally had the problem of patients arriving late or the equipment not being available when I needed it. An example of this was when there was a 3 patient wait to use the lumbar traction so I had to perform the subjective and objective assessment on the patient and make them wait in the waiting room until the machine became available. I also had to shorten their treatment time as I knew other physios were waiting to use the machine after me as well. With patients who presented with multiple pains, I found I had to treat what I could and set them up for another follow up session to assess their new pains.
Not all of my time management was bad though. There was this one situation when a patient arrived a day early but because of my good time management that day I was able to spend adequate amounts of time with her instead of just sending her away. I also found that during this week I didn’t end up staying back late to finish up writing patients notes as I was completing them during the day instead. This was a huge change from previous weeks where once I stayed back an extra hour to finish paperwork! I still found that patients with English as their second language harder to fit into my time restrictions.
Evaluation
When I started giving myself 30 mins for each follow up patient I found that I was able to keep in this time limit. I found this new ‘time restriction’ great for keeping up with notes so I was not spending an hour at the end of the day just catching up on paper work. I still feel though that I still could have been more efficient with my timing as I never quite made the 20 mins follow up times as I would have liked. On the other hand this is not really expected of a student, but at the end of the placement I thought I should have been as fast as a new graduate.
Even though I did not achieve my time limit goal, I took pride in the fact that at least I knew didn’t rush my treatment sessions and I hardly ever went over time with patients. I found this time limit was a good learning curve for myself as I like talking/building rapport with patients but in an environment such as outpatients, this is not as easy as when working on the ward. I also found my questioning for subjectives becoming more precise as well as choosing just the necessary assessments for the objectives and the objective outcome measures.
Strategies
You don’t need to ask EVERY SINGLE QUESTION on the assessment form.
You can gather information in different sessions not just in the initial assessment.
Sometimes you have to interrupt a patient if they are quite talkative and refocus on the question at hand
Having a fob watch is a great way to keep track of the time!
You can’t treat every thing in one session – patients are usually happy if you just do something about their pain!
If a patient is late you need to take that into consideration with their treatment or hopefully have stocked up enough spare time from other treatments
There are always other physios at hand if you need help!
Saturday, April 3, 2010
Fourth Year - Rotation 2 - Assessment STARES
Situation:
On the 30/03, a 56 year old woman presented herself to the outpatient’s clinic with a referral from her GP. One month ago, this woman woke up experiencing head spinning dizziness and nausea which came in 30 second episodes. She mainly got these symptoms on positional changes and especially when turning in bed. The patient reports that she is unable to do anything to prevent an episode or ease the dizziness when it occurs besides waiting the 30 to 60 seconds for it to disappear. The woman denied any trauma to her head or any incidents that could have triggered off the dizziness. She was not currently taking any medication to help with the head spinning symptoms but has found that the nausea has decreased in severity. The woman has found working at her family owned dry cleaning service difficult but has not taken a day off. Her GP suggested a referral to physio for assessment and treatment would be beneficial as she suspected that the patient had Benign Paroxysmal Positional Vertigo (BPPV) but did not explain the condition or possible treatments to the patient.
Task:
My task was to perform the necessary subjective and objective examination to determine if BPPV was the correct diagnosis and then treat the patient accordingly.
I also had to consider and attempt to eliminate the differential diagnoses of light-headedness, presyncope, migraines, Meniere’s disease, vestibular neuronitis or labyinthitis.
Action:
I started my assessment questioning the patient on the symptoms of her dizziness in order to rule out the other differential diagnoses. These specific questions relating to the onset and easing time are usually good indications towards the condition the patient is suffering under. Other like questions relate to any hearing loss, trauma to the head, recent infections, nausea, positional/movement triggers and world spinning dizziness vs. head spinning dizziness. Examples of questions were:
“When did the dizziness start?”
“Are there certain movements or positions you are in when the symptoms present?”
“Are symptoms episodic or continuous?”
“How long do the episodes last?”
“How would you describe the dizziness you feel? Fuzzy? Giddy? World spinning? Head spinning? Like you’re about to fall/tilt?”After I gathered the appropriate information, I went to discuss the case with my supervisor who referred me to another physio in the department who was more qualified in dealing with this presentation. This physio observed me as I performed part of the objective aspect of this assessment. Firstly, I checked if my patient had spontaneous nystagmus while sitting and staring forwards. Next I performed the smooth pursuit test where the patient had to keep her head still as her eyes followed my moving finger from side to side, up and down. Then I did the saccadic eye movements where my patient had to again keep her head still and look quickly from one of my right finger to my left finger and back again. I followed this up with the vestibulo-ocular reflex (VOR) suppression test where the patient focused her eyes on her thumb in the fixed position in front of her and rotated her body around. I then repeated this test with the patient’s eyes closed and when she opened them she had to be still looking forward at the same spot.
The physiotherapist then performed the following tests:
Head thrust test: thrusting the patients head around 30 while they focus on a forward spot.
Head shake test: rapid passive shaking of the patients head firstly with eyes closed then again with her eyes open.
Cover test: the physio covered one of the patient’s eyes with a blank white sheet of paper then revealed it again while the patient aimed to keep her eyes fixed forward on a spot.
With all of these tests, we were looking into the patient’s eyes for signs of nystagmus and trying to reproduce her dizzy symptoms. We were unable to do so in any of these tests so far.
Next, we moved onto the positional tests again trying to reproduce her symptoms and see nystagmus. This test in known as the Dix-Hallpike and the patient starts in long sitting, eyes looking down to either the left or right corner of the top of the bed while the head remains neutral. Then the physio supported the patient’s body into supine as the head turned to look in the same direction as the eyes. This movement is followed by the patient rotating their head and eyes in the opposite direction and then followed by the turning of their whole body in the same direction. The patient then sit upright. Through out the test, we were again observing for nystagmus and reproduction of dizziness and nausea. We were able to see nystagmus with the left Dix-Hallpike and the patient reported dizziness with the action also.
The physio then said it was unnecessary to perform any further positional tests as we could treat this patient now with the left Dix-Hallpike treatment.
Result:
Even though I did not perform all the tests, the physiotherapist working with me was able to show me and explain to me what we were looking at for with the tests she was doing. Later she let me practice them on her. With the assessment that took place, we were able to establish that this patient was most likely suffering from BPPV with her main symptomatic movement being the left Dix-Hallpike test. This lead us to treating this patient with the left Dix-Hallpike treatment, a habitual treatment which involves reproducing the provocative position and aiming to move the calcium crystals out of the semi-circular canals to be absorbed by the body.
Evaluation:
Overall, I was pleased with the subjective and objective aspects of the assessment that I did myself. I was able to eliminate the majority of the differential diagnosis with questioning and confirm it with my observations in the objective assessment. It was really useful to have a physio present to show me how to do the specific tests that we don’t get the practice at uni and I was really excited when I saw us reproduce the patient’s nystagmus! The physio explained to me the different direction of nystagmus can indicate a peripheral or central problem as well as the quickness of the up and down beat. I feel confident now to perform the above tests on a patient if they present with similar symptoms also when this patient returns in a week for re-assessment. I was able to give an appropriate description of BPPV to the patient and answer all her concerns of the condition but I did feel as though my understanding of the anatomical aspect could be improved. My clinical reasoning to come to the diagnosis was good but I did go look up further information and review my neuro notes of vestibular problems when I got home. It was good to see that in outpatients you are not only limited to seeing only musculoskeletal conditions!
Strategies:
Neuro revision of vestibular conditions!
Practice of the techniques I have just learnt.
Practice wording of the subjective questions. Getting the patient to use other words to describe their symptoms without using the word ‘dizzy’.
The physio told me about Freznel goggles which can help with magnifying the nystagmus movement in the patient’s eyes.
The assessment needs to be done with the patient’s corrective lenses if they require them in everyday life.
The physio with me provided me with extra reading material relating to the assessment of BPPV and suggested I do some research of my own, as BPPV patients are common, especially in the elderly. I will take on this advice especially since my next placement is my neuro rotation.
On the 30/03, a 56 year old woman presented herself to the outpatient’s clinic with a referral from her GP. One month ago, this woman woke up experiencing head spinning dizziness and nausea which came in 30 second episodes. She mainly got these symptoms on positional changes and especially when turning in bed. The patient reports that she is unable to do anything to prevent an episode or ease the dizziness when it occurs besides waiting the 30 to 60 seconds for it to disappear. The woman denied any trauma to her head or any incidents that could have triggered off the dizziness. She was not currently taking any medication to help with the head spinning symptoms but has found that the nausea has decreased in severity. The woman has found working at her family owned dry cleaning service difficult but has not taken a day off. Her GP suggested a referral to physio for assessment and treatment would be beneficial as she suspected that the patient had Benign Paroxysmal Positional Vertigo (BPPV) but did not explain the condition or possible treatments to the patient.
Task:
My task was to perform the necessary subjective and objective examination to determine if BPPV was the correct diagnosis and then treat the patient accordingly.
I also had to consider and attempt to eliminate the differential diagnoses of light-headedness, presyncope, migraines, Meniere’s disease, vestibular neuronitis or labyinthitis.
Action:
I started my assessment questioning the patient on the symptoms of her dizziness in order to rule out the other differential diagnoses. These specific questions relating to the onset and easing time are usually good indications towards the condition the patient is suffering under. Other like questions relate to any hearing loss, trauma to the head, recent infections, nausea, positional/movement triggers and world spinning dizziness vs. head spinning dizziness. Examples of questions were:
“When did the dizziness start?”
“Are there certain movements or positions you are in when the symptoms present?”
“Are symptoms episodic or continuous?”
“How long do the episodes last?”
“How would you describe the dizziness you feel? Fuzzy? Giddy? World spinning? Head spinning? Like you’re about to fall/tilt?”After I gathered the appropriate information, I went to discuss the case with my supervisor who referred me to another physio in the department who was more qualified in dealing with this presentation. This physio observed me as I performed part of the objective aspect of this assessment. Firstly, I checked if my patient had spontaneous nystagmus while sitting and staring forwards. Next I performed the smooth pursuit test where the patient had to keep her head still as her eyes followed my moving finger from side to side, up and down. Then I did the saccadic eye movements where my patient had to again keep her head still and look quickly from one of my right finger to my left finger and back again. I followed this up with the vestibulo-ocular reflex (VOR) suppression test where the patient focused her eyes on her thumb in the fixed position in front of her and rotated her body around. I then repeated this test with the patient’s eyes closed and when she opened them she had to be still looking forward at the same spot.
The physiotherapist then performed the following tests:
Head thrust test: thrusting the patients head around 30 while they focus on a forward spot.
Head shake test: rapid passive shaking of the patients head firstly with eyes closed then again with her eyes open.
Cover test: the physio covered one of the patient’s eyes with a blank white sheet of paper then revealed it again while the patient aimed to keep her eyes fixed forward on a spot.
With all of these tests, we were looking into the patient’s eyes for signs of nystagmus and trying to reproduce her dizzy symptoms. We were unable to do so in any of these tests so far.
Next, we moved onto the positional tests again trying to reproduce her symptoms and see nystagmus. This test in known as the Dix-Hallpike and the patient starts in long sitting, eyes looking down to either the left or right corner of the top of the bed while the head remains neutral. Then the physio supported the patient’s body into supine as the head turned to look in the same direction as the eyes. This movement is followed by the patient rotating their head and eyes in the opposite direction and then followed by the turning of their whole body in the same direction. The patient then sit upright. Through out the test, we were again observing for nystagmus and reproduction of dizziness and nausea. We were able to see nystagmus with the left Dix-Hallpike and the patient reported dizziness with the action also.
The physio then said it was unnecessary to perform any further positional tests as we could treat this patient now with the left Dix-Hallpike treatment.
Result:
Even though I did not perform all the tests, the physiotherapist working with me was able to show me and explain to me what we were looking at for with the tests she was doing. Later she let me practice them on her. With the assessment that took place, we were able to establish that this patient was most likely suffering from BPPV with her main symptomatic movement being the left Dix-Hallpike test. This lead us to treating this patient with the left Dix-Hallpike treatment, a habitual treatment which involves reproducing the provocative position and aiming to move the calcium crystals out of the semi-circular canals to be absorbed by the body.
Evaluation:
Overall, I was pleased with the subjective and objective aspects of the assessment that I did myself. I was able to eliminate the majority of the differential diagnosis with questioning and confirm it with my observations in the objective assessment. It was really useful to have a physio present to show me how to do the specific tests that we don’t get the practice at uni and I was really excited when I saw us reproduce the patient’s nystagmus! The physio explained to me the different direction of nystagmus can indicate a peripheral or central problem as well as the quickness of the up and down beat. I feel confident now to perform the above tests on a patient if they present with similar symptoms also when this patient returns in a week for re-assessment. I was able to give an appropriate description of BPPV to the patient and answer all her concerns of the condition but I did feel as though my understanding of the anatomical aspect could be improved. My clinical reasoning to come to the diagnosis was good but I did go look up further information and review my neuro notes of vestibular problems when I got home. It was good to see that in outpatients you are not only limited to seeing only musculoskeletal conditions!
Strategies:
Neuro revision of vestibular conditions!
Practice of the techniques I have just learnt.
Practice wording of the subjective questions. Getting the patient to use other words to describe their symptoms without using the word ‘dizzy’.
The physio told me about Freznel goggles which can help with magnifying the nystagmus movement in the patient’s eyes.
The assessment needs to be done with the patient’s corrective lenses if they require them in everyday life.
The physio with me provided me with extra reading material relating to the assessment of BPPV and suggested I do some research of my own, as BPPV patients are common, especially in the elderly. I will take on this advice especially since my next placement is my neuro rotation.
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