Fourth Year - Rotation 3 - Communication STARES

Situation
I was asked to continue the rehabilitation of a 37 year old female patient who last week experienced multiple seizures and developed expressive dysphasia. She was bought into the hospital via an ambulance after an episode and was found to have a left frontal glioma. She underwent a craniotomy and excision of the frontal tumor on the 24/05/10. This woman has only recently moved here from China and does not speak or understand any English. Her supportive husband has become a boarder on the ward but unfortunately speaks and understands limited English also. The medical team have also been struggling with communication but have organised an interpreter to be available during their visits and meetings when interpretations are required and are also using the bilingual skills of one of the student doctors. This patient has been seen previously by another physio whose assessment revealed the patient requires work on her high level balance as she tends to veer to the right when ambulating and walks with a ‘floppy gait’. She also has a slightly weaker right side strength in her upper and lower limbs but does not seem to notice a difference between the two sides herself. It was documented in the patient’s notes that she “responds well to actions”.

Task
To continue this patient’s rehabilitation.
Perform a treatment session with a patient with complex communication problems.

Action
After checking the patient’s integrated notes and checking her obs chart (BP=115/70, SpO2=97% on room air, afebrile) I went to visit her room where I found her resting in bed with her husband. I knew I had to keep my language simple and use as many actions as I could. I indicated “Hello! I’m Dorianne, one of the physios” while pointing at myself and “that we would be going for a walk and do exercises” while acting out marching on the spot, doing bicep curls and pointing down the corridor to the gym. These actions were met by a blank stare from both the patient and the husband. I felt like an idiot and a clown but I persisted and pointed to the patient and myself, made a ‘rise up’ actions with both my hands and pretended to march out of the room. That seemed to work as the patient began getting up and the husband got her a dress robe and shoes to wear. Usually with all patients I would ask them about symptoms and complaints they had like pain, headaches, nausea and dizziness. With this patient I tried grimacing my face and rubbing my temples/head, my stomach, indicating throwing up and dizzy/fainting. The patient responded with rubbing the left side of her face and stomach. According to her integrated notes she is having period pains at the moment so I assumed that this is what she was indicating. I got her down to the gym and proceeded with her exercise rehabilitation by first demonstrating the exercises and she was able to copy and follow them all. I realise that most patient’s don’t tell you symptoms they are experiencing during treatment unless constantly questioned so I was taking extra care in monitoring her non-verbal expressions and body reactions. It was through this that I noticed the colour in her face suddenly fade and her eyes shut but the patient remained standing. Her husband did not seem to realise but was able to grab one of the high back chairs in the room when I pointed at it while I held onto the patient who was still standing but not opening her eyes on command or when I applied a sternal rub to her chest with my hand. We sat the patient who then opened her eyes and I was able to get another physio in the room to find me a sats monitor. Her obs were BP=113/66 and SpO2=96% on room air. This was similar to her most recent obs so I was not too worried except I did not know what happened at the patient indicated that she felt fine. I was unwilling to continue treatment and returned her to her room via a wheelchair and informed her nurse of what happened.

Result
The inability to properly communicate really affected my ability to treat this patient. Everything seemed to take triple the amount of time and I was never sure if she fully understood the exercise or reason for treatment. The treatment session was poor as I was unable to determine if I was challenging her balance enough and there little work done. Having her husband around was more useful than a distraction as I assume that he was explaining exercises in Chinese and encouraging her to perform them. Unfortunately it also seemed as if he did not understand anything I was saying as they both looked confused for most of the session. It was only with demonstration and pointing that I was able to communicate exercises or actions properly. Even then, getting her to march on thick foam without upper limb support and walking heel-toe on a straight line I felt as though she did not understand the benefits of these exercises and why she was with me.

Evaluation
Before walking into this patient’s room I didn’t realise how much communication is just verbal! The majority of the time I spent with this patient I felt like an idiot with my over the top actions and had to remind myself to not get frustrated with the lack of communication between the husband, the patient and myself. I think my strengths with this patient would be with my demonstration abilities and how I was able to correct the patient. For example when the patient was marching on the foam, I was able to indicate to her to lift her knees higher by pointing to her legs and then demonstrating little steps and then pointing to my own legs and demonstrating big steps. I was also impressed with my ability to notice her non-verbal reactions like her eyes shutting and face draining during the treatment session. My weakness would be how I dismissed the stomach and head gestures the patient made at the beginning of the session – maybe there was something worse going on then period pain and post head surgery pain. I thought I dealt with this patient well by staying close to her throughout the treatment but it would have been better to organise a better way of communicating before or during the session.

Strategies
This was very different from all other cases of communication/language barriers I have had with other patients. After seeing this patient, I had a talk to my supervisor who said I had acted in the best possible way for this situation. Using different actions to get my point across is important even though you may feel silly sometimes. I think it is vital to not just second guess what the patient may be indicating, especially for this one who had expressive dysphagia. I had to try read the patient’s facial and body expressions and act accordingly to the reactions I saw.
I went home and printed out a list of Mandarin medical terms from http://mandarin.about.com/od/vocabularylists/tp/medical_terms.htm incase this can help me with the treatment or question of the patient in the future.
Getting an interpreter would be ideal but it is not possible in this environment for an interpreter to be around 24/7. If I know when the interpreter will be around maybe I could tee up treatment times accordingly.
Don’t get angry at the patient as it is not your fault or their fault!
Don’t just give up! They need rehab and should be treated like every other patient.