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Samantha Schambach Ankle Unit Post
This past week during clinic I was able to do a full treatment session on my own. From start to finish. I was not fully aware of this before going into it because my CI was very sneaky about breaking it down step by step and saying look over this patients chart and tell me some key concepts about it and then what you would do before we go in. As she was saying this I figured it would be a treatment like we always do where I am the facilitator but she is there right beside me in case I need anything or if I forget a step/leave something out. During this treatment I walked into the patient’s room and per usual my CI was right behind me. In between getting the patients permission to work with them and me setting up the room, my CI had stepped outside. Later I found out she was keeping an eye on me from afar but where I could not see her. After talking a couple minutes with the patient I felt it was time to get her up and walk her then do her therapeutic exercise one we got into bed as she had just seen OT and gotten up to the chair. I turned to get the go ahead like usual from my CI and I saw her sitting outside the room working on notes. This was slightly nerve racking as this would be the first time I was alone with a patient and doing the whole treatment by myself. The rest of the treatment went fantastic though. I was able to walk safely with the patient in the hallway. I remembered the gait belt and all the lines and tubes. And when we were done we did some bed exercises that I told her she could do on her own. These were all the things my CI and I had discussed doing prior to treatment. I enjoyed this learning tactic that my CI tried as in my midterm I stated that I tend to look for approval before doing things even though I know it is appropriate to do them and that I wanted to work on this. By her not being in the room with me, I did not have that “crutch” and had to be a big girl PT and make my own clinically/evidence based decisions. Now that I know I can do this, I look forward to working with more challenging patients with more co-morbidities and seeing where my confidence levels can go. Overall I am greatly for this scary yet very rewarding experience.
Pete,
I think this encounter was very similar to mine, and its so important to connect on a level thats not necessarily all about PT. You did a great job explaining to her what you can do for her, however, knowing you im sure you made her laugh or even told her a story which made her much more comfortable working with you. PT is so much more than just glides and mobs, but its a personal connection that you make with patients on a daily basis. You did a great job at that, keep doing you!
Andrew
Andrew Lamont (Third Post)
The other week in clinic, we arrived at the last patient of the days house, which was a beaten down, tiny house in the outskirts of Winchester. A man and a woman are sitting on the porch as we pull up. What ive learned from Home health is to never judge a book by its cover, and its been a valuable lesson to me throughout this semester. We walked up to the porch where we were greeted with nothing less than top notch treatment. After getting a quick history on this patient, I could tell that not only was he losing hope in himself, but showed a variety of depressive symptoms when talking about his family life. He mentioned being an alcoholic for about 10 years, drinking upwards of a fifth of a handle of vodka each day. I felt as though this person may need our services more than ever, however, may also need other types of therapy as well. Taking that into consideration, I wanted to bring up a lighter topic that may get him in a better mood to get up and move with us. I noticed him wearing a RealTree hat and asked him about hunting. This sparked about a 10 minute conversation about hunting and his past encounters with deer, however, he seemed to become much happier and more open to our treatment. We ended up working on crutch training since he was s/p femoral endarterectomy, which he picked up quite easily. He has a loss of sensation on his left and right feet from his diabetes which had left a sore on his left toe from dragging it on the ground. We talked about the importance of moving his feet consistently throughout the day, even when sitting. There was very little PT that I felt like we did, other than education, but what I feel like we did do was allow him an hour or so of an escape from reality. He kept talking to us to the point where we almost could not leave, but it felt so good to make an impact on this guy the way I felt like we did. I spoke to my CI who claimed that he had never opened up to anything before this treatment and also asked me how I knew he hunted. PT is not all about the physical aspect, but many times the emotional connection you can make with someone, that can ultimately lead to them getting better. This is one of the biggest reasons I chose PT, and it played out perfectly in this scenario.
11/12
Peter Cradduck
In the time since I last posted on here I have come to the conclusion that prerequisite, clear communication and patient rapport is foundational in administering effective treatment.
It was your typical tuesday in the Nursing home; loud TV’s, people sleeping in wheelchairs, a strange and inexplicable amalgam of smells… The patient was a 96 y/o woman who refuses to get out of bed on her own despite her adequate strength and ability. She had limited knee flexion, she had some balance issues when walking… I talked to her for the first 10 minutes about how great getting up might feel as we performed a “warm up” including ankle pumps, heel slides and SLR. I then told her about my ability to help her knee bend more without pain if she would allow me to help her. She allowed it. I did a condylar MWM. I emphasized the increase in flexion she got exclaiming “Would ya look at that? I think that might be just what you need to get up!” All this excitement worked for this individual. Through trial and error I recognize that each communicative tactic must be in the right time and right place with the right spirit. Luckily, this was all three.
To my surprise she swung her legs off the bed and prepared herself to stand up. She was still apprehensive, but she was willing to get up now as opposed to when we first arrived to her room and she recoiled at the mention of getting out of bed… Now let me be clear, I don’t believe I have magic hands that sweat essential-oils and permeate rays of divine healing, but as long as the patient believes they do (thus helping them be well), I won’t say anything.
Reply to Mary,
Mary, if I didn’t know your serious nature, I would have assumed you were kidding. This is interesting. Very cool though that this was utilized as a treatment. I am curious as to the specific utility and background behind this suggestion, I understand I am in no position to denounce this exercise/game as a treatment, but I am curious as to how this works. Nudge me in class sometime and explain.
Nice post!
-PeteLevi Perry
In the acute care setting, we were working with a lady that received a TKA the previous day. She was relatively young and healthy, headstrong, tough, and wasn’t going to let anything get in her way. Basically, not the type of patient you would normally worry about. However, she hadn’t had much sleep, was on pain medicine, had received some sleeping medicine the night before, hadn’t eaten breakfast yet, and just had major surgery. She had normal vitals, so we got her up and did some exercises, ambulation, visited the bathroom, did some more exercises – although unhappy, she was doing quite well with the activity. We checked her BP and it had dropped a bit. It was time to eat breakfast, and she wanted to sit in her chair and eat, so we transferred into the chair from bed. She complained of increasing dizziness and nausea. My CI quickly got her back into the bed and she practically collapsed into supine. Her BP had dropped even more. It was theorized that her BP was dropping in sitting and if she didn’t return to supine, then she would have crashed and passed out. After lying there for a bit her BP increased and she felt better. It was just a lesson that things can change quickly, and it’s not always the people that you would textbook think to have the issues.
Rachel Lenz
Post #2This week in clinic, I saw a patient who had just received an ORIF due to a fracture just below her greater trochanter on the L side. She was very nervous to get up and move however she wanted to move and knew that it was better if she was able to move more. We gave her some strategies to use AAROM (with the use of the contralateral leg or a sheet) to enable her to move the affected leg and reposition herself. She was very grateful for this. We also demonstrated and explained what her weight bearing restriction was. This was TTWB which I find to be difficult for a lot of patients to comprehend and abide by. She however did very well. At first, she struggled with the walker and how far to hop forward but after some practice she was able to ambulate with only slight difficulty.
Once she was seated in a chair, we were talking with her about how important it is for her to get up and walk with the nursing staff, however she got very nervous all of a sudden. It was obvious that she was much more apprehensive about the TTWB restriction than she had showed while working with us. This had surprised because of how well she did walking with us. Because of this we educated her on the process and asked what scared her the most, which was falling, and ensured her that as long as she walked with the nursing staff or us, that she would be safe and that she would not fall.
This showed me that even when someone performs and exercise well, that does not mean that they are comfortable doing so or that they will perform it the same way when you are not with them. Therefore it is really important to talk with your patients and make them feel safe to express concerns that they may have, otherwise you may miss some valuable information that may help the patient be more successful throughout the treatment process.Austin Wernecke
I was working with an individual who is currently going through dialysis in the home health setting, and today highlighted to me the importance of the physical therapist. He is an older male who is generally unmotivated, in pain because of his back or his headaches from dialysis and is known to cancel treatment sessions. This last visit was canceled because the pt had refused dialysis treatment and was in the hospital, my CI saying he was not sure that our pt would make it through. Fast forward to next week we are seeing him for a visit, after his hospitalization. Going into the visit I had mixed emotions, as I was not used to thinking that a patient I had seen that week may not be there the next. I was not sure what to think or how to think. Once in the visit, though I was able to put my mixed thoughts, feelings, and emotions aside and focus on the reason for the visit, the pt. It was in this visit that the pt expressed how no one is every helping with his exercises, he feels like he won’t get better and that even though he wanted to be better he did not know how to or even the belief he would. He was very negative about his standing, to say the least. I spent part of that visit not only providing therex but also working on the pt’s mindset. Talking him through that he may not get better right away, but if he kept working he could see progress in his strength. I talked to him about having a good mindset and doing his HEP as both those things would help determine where he ends up function wise. Looking back on this interaction what I took away is that we are physical therapists. Sometimes our emphasis is physical and sometimes its therapy and we have to be ready for both. We can give all the therex, manual therapy or modalities to help a patient, but if that pt is not onboard, positive and doing their HEP gains will be minimal. Going forward I plan to be positive and encouraging with the pt but also tough on his HEP. I want to stress that I am invested in him and that I can see an improvement in him even if he cannot see it himself. Maybe this way he can start to believe in himself and get better.
Tiffany Reynolds
I worked with a patient in the hospital who has COPD. Upon discharge I was able to see how respiratory care normally assesses the patient to determine how much oxygen they need to be sent home with. They try to have the patient ambulate with as little oxygen coming from the tank as possible while still maintaining adequate perfusion. We were monitoring his O2 sats the whole time during ambulation. He ambulated about 100 feet and then we went to stairwell to practice stairs as he has 10 to get into his home so we did that many. Once he ascended the 10 stairs he said that he needed a break so we had him sit in a chair at the top. As he was seated his O2 sats dropped below 80 so we bumped up his O2 to 6L/min, then kept dropping until 65 at which point the nurse had her phone dialed to call the respiratory team but then it started to go up. That was the lowest oxygen saturation level I have seen thus far. This made us more hesitant about his discharge plans for home since he has the stairs. We decided to still say home with supervision as he has his wife at home and we instructed him on energy conservation techniques and taking appropriate rest breaks. We told him he will have to keep a chair at the top of his stairs and sit immediately for a few minutes once inside.
Mary Davern
I was working with a 17 year old girl who was 3 months post op from a surgery to treat patellar subluxation. She was focusing on increasing quad and hamstring strength.. I was feeling excited to work with a younger patient but when asked to think of new exercises to give her, I was having trouble being creative. After suggesting hamstring stool pulls and wall sits, I was running out of ideas so my CI suggested playing ‘crab soccer’. We set up goals on either side of the clinic and had to kick the ball while being in the reverse bridge/crab position. This exercise not only targeted her hamstrings and quads but also involved stabilizing the core especially when one leg lifted off the ground to kick the ball. This exercise kept the patient interested in therapy and demonstrated the importance of incorporating exciting exercises especially for younger patients. Next time I work with a young patient I will be sure to think of games or sport related activites to use as therex.
Reply to Katie Woelfel
Katie –
What a great experience! I was actually in women’s health last semester for ICE 1 and was also surprised to treat multiple male patients with urinary incontinence and testicular pain. Women’s health/pelvic floor is a specialty that is often marginalized, however, serves a population with significant quality of life changes.
It’s awesome that you were able to use referral patterns to treat this patient’s chronic pain. For a patient with a significant medical history, it is important to bring it back to the basics. Did your CI perform any spine manipulations to improve his hypo-mobility?
Alyse Nierzwicki
For the past two weeks, I have had the opportunity to treat a 55 yo woman with a T8 SCI. This patient was diagnosed with stage 3 cancer and had a malignant tumor removed from her spinal cord, resulting in an acquired T8 incomplete spinal cord injury. Upon eval, her ASIA showed she did not have any sensation or motor function below T8. We thus, worked on improving her trunk control, sitting/dynamic balance, and w/c to mat transfers. This past week, however, she showed some motor return in her quads, hip flexors, and tibialis anterior (how exciting!). We utilized gravity-eliminated positions (i.e. powder board) to initiate strengthening and motor re-education of these muscles. She is, however, undergoing chemotherapy and consequently experiences a significant level of fatigue. It has been a challenge to try and implement multiple strengthening exercises, while catering her treatment around rest breaks.
This next coming week, we will incorporate the FES bike to improve muscle activation and prepare her for the standing frame. Depending on her level of fatigue, I plan to work on her static and dynamic standing balance, promoting carry over from her seated exercises. Due to her increased motor return, this patient has been extended for another four weeks. I am excited to see what improvements we make within the next month to increase her level of independence and possibly implement a home d/c.
Katie Woelfel replying to Melissa,
What an awesome case to have after finishing up the knee unit. That was great you could look proximally and distally to put the puzzle pieces together in order to better understand what the patient needed. I wonder if the patient would benefit from intrinsic foot strengthening giving his present pes planus. Can’t wait to hear more about his progress and response to the manual given.
Katie Woelfel
This semester I have the opportunity to be working with pelvic floor patients. Recently, we had an increase in male pelvic floor we’re seeing. I feel lucky to be able to advocate for this speciality / patient population. A specific patient that had me reflect on this was a mid 65 year old male patient that had been experiencing intermittent testicular pain since his teenage years. My CI decided to take a purely musculoskeletal approach for the initial evaluation rather than focusing on the medical diagnosis / suggestion of pelvic floor dysfunction. She made this decision based on his history of failed interventions from a multitude of different disciplines.
During the evaluation we observed his very obvious hypomobility in all directions of his spine, especially lumbar spine. We were able to replicate his exact pain L testicular pain with having him perform R lumbar rotation. We were then able to hypothesis that his pain was a referral from his pain and were able to treat accordingly to there.
The major significance of this was that when dealing with what seems like a complicated case to treat or something that might be out of our line of expertise, it’s always helpful to go back to the basics. Don’t get overwhelmed, and treat what you find.
Alex Gett response to Bailey Long,
You have the best of both worlds, as you are learning the newest trends in PT where your CI has most likely seen more that I could forget. I encourage you to keep challenging yourself to lean on your CI to learn from their experience while also integrating what we are currently learning. As future PT’s, we must understand that there is more than one way to approach the job. If we can take pieces of info from everyone we come across, while integrating our own personalities and strengths, we will set ourselves up to be well-rounded clinicians.