Final entry (placement #4)

Prior to beginning my placement at derby I was quite nervous because of environmental factors such as living away from home, in a town I had never been to before, with people I did not know. On reflection, these concerns seem fairly immature because I now realise that the above factors forced me out of my comfort zone and forced me to meet new people and thus contributed to the amazing experience that I had.
The main reason for me preferencing Derby for my rural placement was the opportunity to work with Aboriginal people and gain a greater understanding of their culture and of the issues they face. Although I understand that I only scraped the surface, I definitely feel I have a greater understanding of the culture and of the health issues facing Aboriginal people. My caseload was predominantly Aboriginal patients and I also worked alongside many Aboriginal colleagues and from these experiences I was able to learn many invaluable lessons.
My expectations on caseload were fairly accurate, as I saw inpatients in the morning and most of these were minor presentations, such as chest infections and mobility assessments. In the afternoon I managed an outpatient caseload which was predominantly musculoskeletal presentations. In both the inpatient and outpatient setting I encountered many paediatric clients and although initially I was very nervous with this, due to my inexperience, I became more confident as the placement progressed. I also was lucky enough to be involved in many remote community visits, including a three day trip two Fitzroy Crossing and two seperate day trips to remote indigenous communities. Although I had expected to be involved in these trips, I was not prepared for the social and environmental conditions which I experienced. These experiences were some of the highlights of my placement, both for the amazing people I met and the horrendous conditions they lived in.
As expected I was given almost complete independence on this placement and was presented with a very diverse caseload, from paediatric patients, to musculoskeletal, to amputees and finally to neurological patients. Everyday was a new experience and it was this aspect of rural physiotherapy that has increased my interest in working in such an environment.
I returned from Derby a changed person and am so grateful I was given this opportunity. I have so many stories to tell and experiences to share, however my key take home message relates to working with Aboriginies. Prior to starting the placement I had been given so many tips and so much information on how to manage Aborignial patients. However, what I learnt is that just like any other demographic you need to treat each patient as an individual and you cannot apply one method to whole demographic.

STARES #2 (fourth rotation)

Situation:

Each morning I attend the general ward at Derby Hospital to assess and treat any patients requiring physiotherapy input. When I first get to the ward I print off the bed list which contains basic handover information for each patient. The general ward has 16 beds and is generally very quiet, with physiotherapy mainly involved with mobility assessment and education. This entry relates to a 52 year old male inpatient who had been admitted with chest pain and dyspnoea, the day prior to me seeing him. He was admitted from a remote community where he is normally independent with all ADL’s.

Task:

I was to complete an initial assessment and then treat accordingly.

Action:

I completed my assessment and from this reasoned that it was appropriate for the patient to mobilize as tolerated. I then explained the risks associated with prolonged bed rest and the benefits of mobilizing and encouraged the patient to join me for a short walk around the ward.

Result:

I was unsuccessful in mobilizing the patient as he did not feel up to it. I told him I would return later to try again and in the meantime encouraged the patient to sit out of bed as much as possible. Soon after I completed my session the patients nurse pointed out that the medical team was querying DVT with this patient and as such it was currently inappropriate to mobilize the patient.

Evaluation:

Although I was unsuccessful in mobilizing the patient, my actions were effective in ensuring the patient understood the importance of mobilizing and would be more likely to do so when I next reviewed him. However, I completed overlooked the fact that the medical team was querying DVT and thus my plan to mobilize the patient was contraindicated, and potentially very detrimental to the patient. My greatest weakness in this situation was my failure to collect a thorough background before beginning my assessment. I didn’t speak to the patients nurse prior to beginning and when I read the handover for the patient, I did so very briefly; this meant my proposed treatment was completely inappropriate.

Strategies:

From this incident I have learnt some very important strategies that I have already adopted and will ensure to adopt in the future. Firstly, prior to seeing any patient I will now ensure that I speak with the nurse looking after the patient, or the nurse coordinator on the ward, to get a handover. This is a strategy I have used in the past but only inconsistently when the nurse is present and not busy doing something else. I now realize that just a very short handover from a nurse can provide very important information, and in the above situation it would have prevented me trying to mobilise the patient. Secondly, I will ensure that when I read a handover I actually do so with some purpose so I can identify any precautions, instead of just looking at age, presenting complaint etc. I feel that the above incident occurred only because of lapse in concentration from me and thankfully no harm was done, however I have learnt how important it is to remain vigilant at all times when managing patients, particularly inpatients.

STARES #1 (Fourth rotation)

Situation: The physiotherapy team from Derby Hospital assists with the annual 20km Fitzroy Crossing Fun Run by pushing three indigenous residents who are wheelchair bound. On Sunday morning at 4am we left Derby for the 2.5hr trip to Fitzroy. When we got there we were introduced to two of the people we would be pushing, while the third person (Mr. X) lived nearby and needed to be picked up. Mr. X lives in a very dilapidated area of Fitzroy, where only indigenous people lived.

Task: My task was to accompany another volunteer to Mr. X’s home and then assist him transferring from wheelchair to the car.

Action: I traveled with the local volunteer to Mr. X’s house and then assisted Mr. X to transfer from his wheelchair to the car.

Result: I successfully assisted Mr. X with his transfer.

Evaluation: Although I successfully assisted Mr. X transferring into the car, I later realised that I actually gave too much assistance with his transfer. This became apparent later when Mr. X transferred from the car back into his wheelchair with the assistance of a physiotherapist who knew his capabilities and allowed Mr. X more independence with the transfer. My failure to initially assess Mr. X’s capabilities, even by just asking him, was a glaring weakness in my handling of this situation. In hindsight, I realize that my willingness to over assist was due to my apprehension and astonishment with the surrounding environment. This was not because I felt unsafe but rather because I was so shocked at the living conditions and at that stage the only way I could show my empathy was by making the transfer as easy as possible. I have been reflecting on this situation repeatedly and maybe I have over analysed it, however if my reasoning is accurate then I’m actually quite embarrassed.

Strategies: I have learnt a very important lesson from this situation; that regardless of the surrounding environment my focus should always be on the patient and the task that needs to be completed. Because although in this example the action was only something minor, assisting with a transfer, if the action was something more important such as completing an assessment or treatment, at home, then the ramifications would be greater. I also understand that my reaction is pretty natural considering it was the first time I had been exposed to these sorts of living conditions, and apparently it gets much worse. Hopefully this experience will ensure that in the future I will maintain the focus on the patient and task at hand, when in a similar or worse environment.

Initial entry-fourth rotation

I am both extremely nervous and excited prior to beginning my rural placement at Derby Health Service. Unlike previous placements, my nervousness is not so much related to the practical component of this placement but more so related to the environmental factors, such as living away from home in a shared house in a town I know very little about. However, it is these same reasons that make me very excited for this placement and these are some of the main reasons for me putting Derby as one of my preferences for my rural placement. The other big factor in me preferencing Derby, was the opportunity to a work in a large Aboriginal population and to get firsthand experience of Aboriginal culture and also to get a better understanding of the health issues affecting Aboriginal people. From what I have gathered this placement will have a mix of inpatient, outpatient and community physiotherapy, as well as the possibility of a 4-5 day remote trip to Fitzroy Crossing. I am uncertain of the makeup of my caseload, however I am under the impression that there will be no critically ill patients as I imagine these patients would be transferred to Perth. I expect that I will encounter many subacute chest infections, and orthopaedic patients and some amputees, however beyond that I am really unsure. I really don't know if I will encounter stroke or musculoskeletal patients, however I have been informed that I will be managing some paediatric patients, and this is something I am quite nervous about as I have very little experience managing children. I expect that my role as a student will be to manage an independent case load, and as this my fourth placement I feel confident handling this, however unlike previous placements, my caseload at Derby will not all fit one physiotherapy sub-discipline but will be a large mix. I believe my other expectation as a student will be to fully immerse myself in the rural experience and get involved in as many extracurricular activities, and this is something I am very keen to do. I understand that I may never get an opportunity like this again and I fully intend to make the most of it.

Final entry (FH OPD)

When I look back on my initial entry for this placement I realise I was fairly accurate with many of predictions. As expected, the majority of my patients were over 65, however I did have one seven year old patient and a few twenty something year old patients which I was not expecting. Further, as expected many of my patients were post joint replacements or post fractures, however the majority of my patients were chronic lower back pain patients and this is something I definitely had not expected. On the contrary I had expected to see more acute injuries, ankle sprains and shoulder dislocations, which in reality I saw very few of. I now realise that due to factors, such as waiting lists, it is very rare to see acute injuries in outpatients and in fact the
chronic patients are the norm. Although, prior to starting the placement I was aware of the importance of an accurate assessment I still think I underestimated just how critical an accurate and thorough initial assessment is in a musculoskeletal setting. On several occasions, after completing an initial assessment I was still left with unanswered questions and holes in my analysis because my initial assessment was not thorough enough. However, I have also learnt that due to time restrictions an initial assessment may not cover all areas and that an assessment may continue over the first two or three consultations. On this placement I was given an independent caseload from the first day and although I had expected to be working independent midway through the first week, this was earlier then I had expected. However, although I had an independent caseload I always felt support was nearby if needed. My case load initially consisted of 4-5 patients per day however by the fourth week I was consistently seeing 7 patients per day, which is what I had expected prior to beginning.
Prior to beginning this placement the two areas that were causing me most concern was my ability to make a diagnosis and secondly, the pressure of time management. Having now completed the placement I now realise that forming a diagnosis is not the be-all-and-all but rather forming a problem list is more important. This is because regardless of the diagnosis, if an accurate problem list can be formed by the end of an assessment, then a treatment plan can be created to address each problem, such as pain, reduced ROM or misalignment. The second issue of time management, was something that I initially struggled with but gradually improved throughout the placement. My initial problems with time management were associated with spending too much time writing notes, however as my documentation improved and became more concise, my time management also improved.
I have decided that the number one take home message from this placement is related to evidence based practice. On this placement more than any of my previous placements, I understood the importance of having an up to date knowledge base, as in the musculoskeletal field treatment guidelines are constantly changing as new research is published to support or reject a particular idea. So I now realise just how critical it is to keep updated with the latest published research, as this can determine if my treatment is valid or not.

STARES #3 (FH OPD)

Situation:
This entry relates to a 62 year old female patient whose treatment I had taken over from a previous student. The patient had developed a unilateral 'foot-drop' following a L4-S1 spinal fusion, which the specialist acknowledged was a direct result of the procedure. The specialist referred the patient to physiotherapy to assess the effectiveness of therapy in improving the 'foot-drop'. Two months into fortnightly therapy, including a home exercise and hydrotherapy program, the patient situation had not changed, and the foot drop remained. Consequently the patient was becoming increasingly concerned about her long term prognosis and was requesting more information about the probability of her 'foot-drop' improving with conservative management.
Task:
My task was to undertake a literature review so I could provide the patient with relevant information regarding her prognosis.
Action:
I performed a literature search using the Notre Dame databases.
Result:
After reading through the relevant articles I was able to impart a considerable amount of information to the patient, who was subsequently very grateful. However, as I was not able to find an article directly relating to 'my' patients situation I was not able to give her the information she desired most, relating to her prognosis.
Evaluation:
On reflection, although I was not able to give my patient the concrete answers she was seeking I was able to provide her with a lot of useful information relating to her situation. I believe I conducted a thorough literature search and managed to collect most of the available relevant information. Further, I feel I was able to interpret the confusing terminology and medical 'jargon' used in the articles, into a much clearer form so that the patient could understand it. I believe this was my greatest strength as the patient admitted that when had tried researching the area but couldn't make any sense of the information. In hindsight, I probably could have expanded my search to include other sources such as the library at Fremantle Hospital, at the time of my search I was not aware of this resource. Another area I could have improved was my handling of the patients enquiries into my opinion of her prognosis. I tried to remain impartial and constantly reminded the patient of my lack of experience, however on reflection I should have been more assertive and possible instead referred her to the much more experienced head of department.
Strategies:
From this case I have learnt some very useful strategies which I can use in the future. Firstly, not only was this literature search useful for the patient, it was also useful for me. I should have conducted this search after my first session with the patient, rather than waiting for her to ask. In the future I am going to endeavour to perform a similar search when I have a case which I know little about. I know evidence based practice is constantly drummed into us at university, however it is only since I have had a real case/patient demanding such information that i have realised the importance of keeping up to date with the latest information. Another strategy which I can use in the future relates to answering patients questions about their prognosis, I have learnt that although you can never give concrete answers it is important to be confident with my responses, and I can only be confident if I am up-to-date with the latest research.

Week 1 STARES Prac 3 (Freo MSK OPD)

Situation:
This entry relates to an incident that occurred on my first day of prac, when my supervisor asked my a routine theory question relating to a patient who i had just assessed.
Task:
My supervisor asked me which nerve root was responsible for a certain muscle action.
Action:
After a quick period of thinking I answered the question with what i thought was the correct answer.
Result:
My supervisor informed me that my answer was incorrect and told me the correct answer.
I was fairly confident the answer I had given was correct and later when I checked it in a textbook I realised my answer was correct. After i had confirmed the answer in the textbook I was then in a dilemma whether I should approach my supervisor to discuss the answer. As it was still my first day I decided not to bring the subject up again, however two days later an almost identical incident occurred. With a little more confidence, I approached my supervisor to clarify the answer and clear my confusion, my supervisor was really good about it and apologised for any confusion she had caused and confirmed that my answer was correct.
Evaluation:
After the first incident I was frustrated and embarassed because I presumed my supervisor would build an inaccurate initial impression of me based on this simple question, which in fact i had answered correctly. On reflection, I feel I handelled the situation appropriately however I think I should have discussed it with my supervisor to clear my confusion and concern. The main reason for not discussing it was my lack of confidence on my first day and also I wasn't sure how to approach the situation without coming across as arrogant or confrontational. However, my reflection from this incident meant that when the identical incident occurred later in the week I felt more confident to discuss it with my supervisor and did so without causing appearing arrogant or confrontational.
Strategies:
When I approached my supervisor in regards to the second incident I did so in a very open manner and just told her i was a little confused and could she help me clear up this confusion. This eased any tension and just created a free flowing discussion on the topic without any sense of confrontation. Had I approached my supervisor, for example saying " I think you may have got that wrong..." it would have immediately created confrontation which is not what I wanted in my first week. A second strategy which I will continue to adopt in the future is to not let my emotions get involved in a discussion and the best way I found to achieve this is be going away thinking about the situation, confirming the correct answer, and then discussing later when emotions are not involved. Reflecting on this incident, although I am disappointed I did not discuss the initial incident with my supervisor, I am pleased that I learnt something from it which allowed me to approach the second incident with a lot more confidence and professionalism.