Cardioresp is awesome?!?!?!

Its been 5 weeks already.

At the beginning of the 5 weeks I was not pumped about being in the AMU. I was definitely thinking of strategies how to make it through and learn what I can to apply it to other areas of practice.

And the first couple of weeks were rough. I was not really liking it, and the skills and working through everything was challenging.

But near the end of the placement things got a lot better. Firstly, the hospital itself became a lot less intimidating. I feel more confident interacting with patients from a therapist-patient relationship. As I gained more confidence in my skills I noticed my confidence with the patients also improved. If a patient is putting up resistance to my questions or treatment I have strategies to work around it and deal with it without becoming flustered and thrown off.

Over the 5 weeks I have also gained a lot of medical knowledge. I am comfortable with a patient's chart and getting the medically relevant information to physio from it. I am also more comfortable with some of the more common conditions and the contraindications to treatment that go a long with them.

My charting has vastly improved and what was once a struggle to get all the patient's information from the session down on paper after has become much much easier.

My suctioning and chest physio skills have also greatly improved. I remember seeing a suctioning on my second day and being worried that I would never be able to do one that quickly and effidciently. And I remember having to suction a patient on my own for the first time. I was pretty hesitant and worried that I was missing a step or doing it wrong (I wasn't), but now I am suctioning without a hesitation.

The main theme here is that with more exposure to the environment and situations I was able to build my clinical reasoning skills, technical skills and general confidence. By doing so a whole new world was opened up. I was in the camp previously that thought all acute care was just getting somebody up to walk and subsequently that doing that day in and day out would be pretty monotonous and boring. But after having a rock-star-physio preceptor, it so much more. Yes, patients that come in can be pretty boring and all they need is a balance assessment and a walk.  But there is a lot more to be involved in. The complicated patients are the best because there is no protocols to follow in the AMU. Basically if you can reason it out that the treatment you are doing for the patient would be beneficial then you can go ahead and do it. There is a lot of problem solving and applying knowledge in clinical reasoning, which makes it way more interesting.

Beyond that there is chest physio. Before this placement I had about zero interest in it. I didn't like the though of pounding on chests and sucking out gunk from people's lungs. But there is something about it that is pretty satisfying. Its awesome to see the difference immediately you can make with a treatment. for example you hear coarse crackles when you listen to a chest then you do some percussions and suction and Voila! they are breathing better their chest sounds better and their oxygen levels have increased.

I am not sure if I want to work in the AMU when I graduate, but this clinical placement has shifted my perspective on acute medicine.

Beyond the AMU

This week my preceptor arranged for me to visit other areas in the hospital.

BPTU = Burns, Plastics and Multiple Trauma Unit
Wednesday Morning
 As the name suggests they handle the burns, plastic surgery patients and those who have experienced multiple traumas. And sometimes a patient may have a burn and a multiple trauma and requires plastic surgery to graft skin to their burn sites.
This is a really awesome unit. Maybe just because its something totally different then what I have been seeing for the past couple of weeks.

The physios are responsible for getting the patients up and out of bed and making sure they maintain their mobility like they do on the floor I am currently on. In addition they also get to do a bit of wound care and wound education. I got to see a couple of burn patients with pretty significant 3rd degree burns and a faciaotomies (when they cut open the fascia (the connective tissue that wraps the skin and the muscle together) to let the pressure off from all of the swelling. So it was pretty awesome to see people's muscles moving around (not awesome for them because this means they have lost a ton of skin) and to see the new skin grafts starting to grow where they had been placed.So we bandaged a few people up and took them for a walk and one patient we just did some passive range of motion (read: we moved his arms and legs around for him while he lay there in pain and agony) to make sure that when the sores healed that the skin wouldn't be tight and constrictive like Freddy Kruger and limit their future potential for range of motion.

Also the BPTU patients have the most interesting HPI's (history of present illness). Just sayin'. I was reading some of the charts and the scenes were playing out in my mind of how they managed that. The people that end up in this ward also end up in the headlines a lot of the time because of their crazy stories. (Note: nobody that I saw that day was in the news)


ICU
Wednesday Afternoon
I think a lot of people are familiar with ICU = intensive care unit. This place was how I used to imagine hospitals to be like. It looks like what hospitals on TV are made out to be in terms of how many doctors and nurses and other staff are involved in their care and how many machines are in the room and the general hustle and bustle and beeping and other noises going on. As for the patients its sort of like TV a bit in that there are some rooms that have the glass walls like in"House" and some are just curtained off. At VGH there are 27 beds in the ICU and that day they had an extra 2 ppl in the auxillary area.

The ICU is unique from the rest of the wards as most of them are on ventilators getting help with their breathing and  oxygen intake. The nursing is 1:1 because a lot of the patients require a serious amount of care as suggested by the name of the ward. A lot of the patients are also on dialysis requiring that little bit of extra help to clean out their system. A lot of them also are trached (tube in their neck to help them breathe). And a large amount have Foley catheters to drain the urine from their bladders.

Lots of people wonder what can a physio do for people in the ICU? Pretty much the same as what they can do for people in other parts of the hospital. They mobilize the relatively "healthier" and more stable patients and get them sitting up in bed or sitting at the edge of the bed. Some are even able to go for a short walk down the hall. And yes, apparently you can walk while you are on a ventilator if your conscious enough. They also do chest physio: percussions, vibrations and suctioning for those with chest pathologies.


CESEI
 Thursday Morning
I am not sure what this stands for I think something like "Centre of Excellence in Surgery and blah blah". Its not important. The important thing is that there are human robots that can be programed to react to your interventions. We weren't doing surgery but we were suctioning the robots in a few different ways. We suctioned them via  a trach tube, mouth and nasaly and we also listened to their fake breath sounds and we bagged them too. (Bagging is getting that air bag thingy like on tv and pushing some extra air into their lungs to help dislodge a mucous plug, thats the hope anyways.)

This was done with several of my classmates. It was good to see some of them again and talk about our experiences. Of course the conversation came down to the grossest stories, and I am glad to say that I didn't win that one. Lets just say I haven't been pooped in yet... yet. They day will come I am sure. knock on wood.

Pulmonary Rehab Lab
Thursday Afternoon
I spent an hour in a Pulmonary rehab class. People with COPD (emphysema, chronic bronchitis etc.) or who have recently undergone transplants come here. A physio teaches the class which consists of strength exercises and cardio. My main job was to teach a few exercises and run around with the SpO2 monitor to take readings of peoples blood oxygen levels. I am happy to report I have a great SpO2 baseline!

The class was really fun. It was nice to be in the rehab setting and see people who are committed and motivated to making their lung function better. The instructor was also hilarious and had a great rapport with the patients. That was really good to see for me because sometimes on the ward I think I get a little to serious.


All in all it was a great week getting to explore the other bits of the hospital somewhat. I think that my preceptor was sucessful in proving her point that even if you don't want to work in internal medicine there is a lot more you can do as a physio in the hospital!

Moving Quickly.

This past week, I almost pulled out an IV. Almost.

How did this happen? I was setting up a patient to sit in their wheelchair for a bit as I usually do after walking some of them and was moving quickly. I was trying to take vitals with the dynamap and sort out the call bell and make sure the catheter bag was clipped on and the IV was plugged in while talking to the patient. It was at that point my foot got tangled in the IV tubing and I tugged on the patient’s IV line and cause them to scream out in pain. I apologized profusely directly to the patient of course and thanked my lucky stars that it had not come all the way out which would have made me a marked woman as far as nurses are concerned. 

After finishing up with the patient and hurrying out of the room I began to reflect. What events lead to me tugging on an IV line and causing a patient undue pain.

I realized it all comes back to what my mom used to say, “A stitch in time, saves nine.” Words of wisdom I am sure her mother passed on to her as well. 

When I was with the patient, I was hurried and unfocused. I was focused on being quick as to be done with the patient so I could move onto charting or see another patient. But would I really be saving any time if I pulled out an IV. Indeed not. I would have to find the nurse, explain what happened, possibly write and incident report and probably have a lengthy debrief with my preceptor.

I sometimes have found myself rushing since then, bumping into things or walking too fast with equipment. It’s better to slow down and take a moment to avoid a dangerous situation rather than rush ahead and try to do something quickly while compromising safe practice. 

I think I have improved since the IV incident and I am lucky that it only was a close call and not a complete disaster that caused me to take a step back and reflect, because now when I am with patients and I find myself moving too quickly I think back to the patient with the IV and my mom’s voice pops into my head.

Acute Medical Unit

So what actually do physios do in the hospital on the AMU?

Miracles.

Just kidding. We leave those to the doctors and nurses.

Basically when a new patient comes to the unit they come with a medical chart. The physio on that unit will look over their chart and gather what is called a “Database”.

This includes:

Diagnosis

-what the Docs have decided that they have in term of illness

Relevant Information

-usually looking for Dr’s orders for either ‘Bedrest’ or AAT (activity as tolerated)

HPI (Hisotry of Present Complaint)

-a lot of the time the patients on the AMU come through the ER and so we get things like “Head ache for the past 3 days accompanied by shortness of breath and fever. Patient also complains of blah blah blah…..”

PMHx (Past Medical History)

- this includes things like if they have had surgery before, if they have been hospitalized before, hypertension, heart disease, stroke, diabetes, spinal cord injures

SHx (Social History)

-who they live with, where they live etc.

Once that is all gleamed from the patients chart its time to actually meet the patient. Sometimes you have to get all dressed up to go see a patient. This includes putting on blue gloves and a yellow gown. This is done for patients with diarrhoea or something infectious. If they are coughing and infections you get to put on surgical mask with a shield. The shield is also handy if you are doing some suctioning.

 

Less like this

more like this

Then you go in and have a chat with the patient while taking blood pressure and measuring their oxygen saturation levels. You find out how many stairs they have to get to inside their house and if they have any within their house and if they live alone. You also want to know if they used a cane or a walker prior to admission and how far they can usually get around on their own.

After that you might assess their range of motion and strength based on their previous level of mobility and the state they appear to be in now.

Then after that you get them sitting at the edge of the bed if they are able. Then standing then maybe transfer them to a wheelchair for some sitting upright time or go for a little walk for some exercise.            

Sounds pretty easy but there is actually a lot of clinical reasoning involved in knowing what exactly to do with the client. Should this person just sit at the edge of the bed or should you get this person up and out for a walk and if so what sort of equipment are you going to use if you do want to move them.

Then there are the “chest” patients. With these ones are tops priority. They may require suctioning. This is when you stick a tube with suctioning power down their trachea via trach tube or nose or mouth to get the gunk out of their lungs that they cannot cough out themselves. Its really awesome to see someone do better and breath better after a good suction, but man does it look uncomfortable then its going on. 

 <--This guy looks a little more comfortable than my patients

There is also the percussions. Which is the drumming on the chest of a person who has secretions in their chest and this helps to loosen the mucous from the small airways and get it out. The percussions are sometimes followed up by suctioning to get the gloop out.

percussions

Now I can say that I am fairly proficient in describing the gunk that comes out of the lungs. I can describe texture, color and amount. Also its important to note if it appears to be bloody or infected. This week alone I have seen several types of mucus, including an entire mouthful of yellow thick mucus into my (gloved) hand.

Everybody's working for the weekend

In a recent study.

This was the first time in a long time that I have had to work a weekend. Actually most of my former jobs have been with kids and camps and strangely enough they usually never involved working both Saturday and Sunday 8-4.4

My preceptor gave me plenty of warning about working the weekend. Like, a month I think so I was prepared mentally... people work the weekend all the time, I am not sure why I am making a big deal out of it.

Its really different than working during the week though. First of all there is just a lot less staff at the hospital so only really emergent test get done. So the patients are all in their rooms so that is awesome. The less staff also means easier access to the charts! Also my preceptor was covering 4 wards so we only had to see the high priority patients. 

I was also given a lot of responsibility this weekend. Which was a great learning experience. I was given patients and told to assess them and make decisions about there care and where they stood on the priority list and what they should receive as treatment. When you are left on your own you are forced to think things through critically and rationalize your actions because there is no preceptor to bail you out or correct a misstep. My preceptor didn't give me anything I couldn't handle in terms of patient complexity. But its always (for me at least) a bit unnerving stepping into a room collecting a social history, ausculatating or doing a balance or walking assessment and knowing that your findings are going to effect their treatment. I always worry that my assessments are wrong or invalid or I am finding something that is not there or missing something important. And without that piece of information am making sub-par decisions for their treatment. I sometimes wish my supervisor would follow me around to confirm everything. But in a way its good that she doesn't as this really makes me OWN my clinical findings and subsequent decisions.If she was checking up on every little thing I did I might feel like I was being micromanaged, I also might not become as confident in my clinical reasoning skills. 

Barillium Swallow Assessment

My preceptor is pretty into getting me into other wards and units. So she sent me down to Radiology.  

The "BAS" is to see how people are forming the ball of food or whatever that they are going to swallow and see how co-ordinated their swallow is and also to see if any is tricking down the wind pipe. Because (fun fact) some people are eating as though their lungs are a second stomach and don't cough it up...

 The assessment was run by the radiologist and the SLP. The SLP makes up the food. The food is interesting as it ranges in textures from water to honey to pure to chunks of fruit to a sandwich to a  cookie. Then he adds radioactive substances to them so that on the X-Ray they show up black. Then the machine is positioned so that the area of interest is visible like the pharynx or the esophagus or whatever. It was awesome to see all the bones in the head and the teeth working to chew and swallow. And then to see the bolus move from the mouth to the throat and hopefully into the correct tube. On the one I got to watch a little bit of food was hanging out near the windpipe but then it didn’t enter.

It was awesome to see the mouth and throat in action and the epiglottis moving to cover the windpipe! It was a huge geek moment.

Taking your work home with you

So my placement is at VGH. The biggest hospital in BC. Many people from  all over the province go to this hospital for care.

I am working on the Acute Medical Unit or “AMU”. My preceptor refered to the ward as a leftover pile, basically if you don’t fit into any of the other wards like: surgery, cardio-pulmonary, transplant, spinal cord, stroke, orthopedics or the ICU you get place in a bed in the AMU. So its awesome that I have been exposed to a lot of different patients. I have seen a wide variety of medical conditions, even though its only been a week.

However, patients are not only a set of vitals, or lab results or a pair of lungs or a low white blood cell count, they have complex social histories to go along with their illness. I found this hard to deal with at first working Peds in Penticton too; the foster kids who had a low chance of being adopted, the kids exposed to alcohol in utero, the kids who were born to really young parents who were trying to give their kids everything they could.

The patients at VGH are causing me to empathize as well. A lot of them have been dealt an unfair hand in life. They are just going a long doing fine and a series of really bad things happened to them and that’s how they ended up in hospital. That is not always the case though, they sometimes bring it on themselves through lifestyle choices, but still its hard to judge when you don’t know their entire life history and what had cause them to make those decisions.

Anyways, I guess it’s a part of my personality. Scratch that. I know it’s a part of my personality to care and to empathize. That is one of the reasons I chose health care and physio chose me.

Going home after the day is done I am finding it hard to switch off the empathetic part of my brain. Maybe its because its early days and I am naïve and un-jaded. Maybe also its because its all new to me and its sort of overwhelming. When my mind is not actively engaged in something else I am just thinking about the patients I saw that day and thinking about their social situation or their medical status and functional capabilities and how these things are going to play out for them for their future quality of life.

I think if this was to carry on for any length of time that I would burn out.

Hopefully it would end after becoming a little more seasoned, more experienced and less naïve.

In the meantime I am going to try a few strategies to see if I can have some brain time that’s “off” from physio.

·      Allow myself to talk about placement only until I have eaten dinner if my brain wants to go there.  After my dinner I will not dwell on any thoughts by bringing them up in conversation. I will let them go.

·      Cardio vascular exercise after placement hours to clear my head.

First week at the biggest hospital in BC

So the week didn’t start out so good. It was rainy all week and sort of stressful to be back in Vancouver knowing that I had to move on the weekend. Just ask Cameron, I get pretty stressed when it comes time to move.

Also at the beginning of the week I didn’t have my usual supervisor (she had a couple of days off in lieu of working weekends). The other supervisor I got was great though, she is one of our TAs in class and she is a fantastic teacher. That was fine, but the director of Physio for the hospital wanted me to know that once my regular supervisor showed up if I needed anything to let her know. Basically my supervisor is really smart and is very respected and wants her students to be top notch physios and sometimes her high expectations can be a little much, so I was stressing on Monday and Tuesday about having her and not being able to meet her standards and having a whole other “UVic Water Lab Incident 2007” again.

But so far its been awesome. She is super smart and a great critical thinker and had been working for a decent amount of time so she has consolidated a lot of knowledge. Her clinical reasoning skills are tops. I am really excited to learn from her. Sure, it might be a bit more stressful or not as laid back and I will be kept on my toes and busy, but its so much better than having a preceptor who doesn’t care.

Also for me too I think its good to have a preceptor with a different personality type than I have. Its good to have an assertive, very energetic, take charge type of preceptor so that hopefully I can learn some of her communication skills and use them when my usual approach fails.

Also I really hate presenting and public speaking, and my preceptor has her students do either a patient education project or an “in-service”. So I chose In-service. Really. I am trying to grow here. So in week #5 I will be delivering a presentation to all of the hospital’s physios who want to attend and the 5 of my peers who are also at the hospital on placement. I haven’t picked a topic yet, but its probably going to be some sort of acute medical condition that I will research and deliver the information on.

I think the saying goes: “You can’t always get what you want, but if you try sometimes, you just might find, you get what you need.”