Finding Something You Remember You Love!

Soooo, by Dec 14th, 2012 I was almost 100% sure I didn't want to be a neuro-physio and was re-considering if this was the right choice in career.

Christmas vacation was great. Lots of family time, rest and a fantastic chest flu. 2 weeks of no responsibilities and absolutely nothing to do with school, except a small, quiet and sophisticated class social. It was a great holiday season, and I wasn't exactly looking forward to returning on the 2nd to start the next practicum at 7:15 am after a couple of weeks of sleeping in and eating bon bons.

But on Tuesday I was reminded how much I actually do love being a physio (student).

My placement is basically a private practice but on the military base in Esquimalt.

I feel competent and I feel like I am able to use the technical skills we have learned in class.

But its more than that too, its the and problem solving nature of orthopedics. You have to find out what is causing the pain from what the client is telling you and what you find in your objective assessment. This takes piecing together and using your clinical experience (which I have little of) to determine what the problem is then base your treatment on your findings. As a logical individual I find this extremely gratifying, especially when the treatment is effective. Even if its not, I like that you can try again with a different theory or have another look for something you have missed.

And then I was thinking to myself, well, why should I like this placement more than the last one? Maybe its because my preceptor is a more think out loud person who verbalizes and talks me through the steps of determining the problems with a client. In hindsight this is probably the reason. I didn't realize it at the time, but we rarely talked through what we were doing and why during the session. Its a little awkward for the patient, but I feel like its how I am going to learn a lot this placement that way. And maybe it is because of the natural light that comes into the clinic instead of the basement fluorescent light area I worked in last.

Physiotherapist or psychiatrist?

There is something I have noticed this week about neuro outpatient that hasn't happened before in my other placements. People want to talk. Mostly about themselves or their impairment.

In paeds the kids communicate with body and facial expression and aren't concerned or interested about the condition too much, they just want to play the game and learn the new skill or want to know that they are doing well and how many points they have in the game. Once in a while if they are really comfortable they will tell you about their family life (usually an embarrassing story the mom or dad cringes over)

In acute care a lot of the time the patients are pretty out of it or they just want you to go away. There is the odd one now and again who will divulge their entire history of how they came to be in the hospital. But usually the visit is so short that there is just not enough time.

But in outpatient rehab there is a lot of time the model we are set up with allows us to spend up to an 1 hour with the patients.

And so these patients who have usually been through the acute ward and rehab wards in which you see several health care professionals a day. Usually the staff doesn't have too much extra time to chat and sincerely ask the question how are you really doing and even when they want to they may not have time to hear the answer. They they are discharged and have appointments here and there with GPs and specialists who are very busy, so when they come to us they are really looking for someone to listen to them and to gain reassurance from.

That's where public out patient physios come in (an the rest of the out-patient team as well). Now that they have you to themselves for an hour. Many of them want to relay their story. I once asked my sister why people do this and she said its for a couple of reasons:
1. Maybe you have had a similar experience to them and will be able to share in your common experience
3. Many are looking for acknowledgement and validation of their experiences.
2. You know about their condition and will be able to assist them.

In the case of the physio its usually the latter 2 points the clients are looking for. And so I have had patients tell my preceptor and myself things beyond the scope of a physio's practice and beyond the scope of the team's practice (ie. psychiatric issues).

This is part of the job, right. Listening to the patient, validating their feelings, bulding rapport, establishing trust, letting them know what you can address and what you can refer them to for their other concerns. I am finding that this is part of the job, if it take a client 15 minutes to tell you all of the information that they want to tell you, you have often gained their trust. Afterwards the sessions flow more smoothly as the patient feels a connection and is more likely to buy into the exercise program because they feel like the physio understands them and is in tune to their needs and concerns and has their best interests in mind.

If physios aren't psychiatrists, they still can provide some comfort and reassurance simply by listening and providing thoughtful responses for the patient.

Barriers

While reading a paper on Parkinson's Disease this week, I came across this gem:

"Research demonstrates that people with disabilities are less physically active than people without disabilities, although the reasons for this are unclear." - 2009

Really?!

Thinking of my patients I can think of several reasons for each of the patients I have seen in the past few weeks as to why they would be less physically active than the non-disabled population. Maybe this is demonstrating a gap between researchers and clinicians. I am sure there are other researchers that are well aware of the barriers to activity for disabled people.

From these past two weeks alone I can think of several reasons
1. Fatigue - usually a symptom of brain injury like stroke or traumatic head injury. People with these types of injuries require more sleep and have barely enough energy just to get through their activities of daily life, let alone go for a walk or participate in a community exercise program.
2. Mobility - people with disabilities often have a more difficult time getting around from place to place. If they feel like they can't exercise or be active in their home or neighborhood for safety concerns it is an extra effort or expense or burden on a family member to get them to a place where they can participate in an activity.
3. Stigma - Firstly, there is the idea in many cultures and the older generations that once you are injured or sick that you should rest and take it slow. Secondly, there are the stares when someone with an impairment is in public.
4. De-conditioning - after an injury there is often a certain amount of time spent in hospital or physically unable to participate in usual activities. This leads to a decrease in cardiovascular capacity and a decrease in strength. This makes it harder to get back to doing the same thing you were doing previously.
5.Physical Impairment - its possible that the physical impairment itself is inhibiting participation and activity. For example, if a person has difficulties balancing, walking is going to be a lot harder for them and so they may not be able to walk as far as an able bodied person because walking even a shorter distance requires a lot of effort.

These are just a few examples.

As physios its our job to help the patient overcome these barriers. We can do this by minimizing the impairment, encouraging activity and participation.The optimal situation would be to help repair their impairment, however, this is not always possible, so we help them find ways to adapt activities so that they can fully participate and be active members of their communities.

Exam Week ... By Special Request

Imagine my delight as one clear autumn afternoon in October I was riding the #99 home with Krista and Alison when I got this email on my blackberry:
Needless to say I was overjoyed.... not.

Anyways since Paeds is and Adult Neuro are tow different tests we technically wrote 6 exams in 4 days. That includes the infamouse OSCE on Tuesday.

So to prepare for exams, I basically became a hermit along with the rest of my classmates for the better part of 3 weeks... maybe more. I was certainly unpleasant to spend time around. Now, for those of you who don't know our class schedule is already pretty intense. We are in class from 5-7hrs on most days. Meaning we  start class at 8am and get off at 4pm with an hour for lunch on a longer day. Maybe get off at 3 on a earlier day. So this means you only have from 4pm onwards to study for 6 exams as well as eat, bathe, exercise, grocery shop, etc.

Busy.

One of my classmates pointed out that "studying" is just student and dying put together.

This is why I am cranky around exams. Lack of sleep, exercise and the overwhelming feeling that if you don't pass your exams you could potentially be kicked out of the program (or at least your year) wont get to go on placement, will have to repeat a placement and not get to go to Sri Lanka. And of course, endure the shame of failure.

So exam week came around:

1. Electro - good times. Its always great to open to the firs page and be like "oh man, I have no idea even what you are asking" for 2 questions. It didn't get better after that. Although I can say I nailed drawing a leg, however, the placement of my electrodes on my hand-drawn leg....

Then after that I studied like a demon for 10+ hours for the practical exam the net day. Studying for a practical is sort of fun? But it really drains the energy out of you. Thank goodness I had Disney Princess Alphagettis to get me through the evening... (note to self: alphagettis are not as good as you thought they were when you were 6).

2.  OSCE - Objective Clinical Standard Exam
When you get the email a week before telling you your time for the OSCE and you are shaking and your bowels loosen, its not a good omen. I am sure I made several mistakes during the test. I made up a name for a patient in one station. Actually I am going to go ahead and blame it on the first station, I opened up the card for the question/objective outside the door and it was Laser. I ruled Laser out definitely as a possibility to be on the test. But there it was, with its stupid clinical-evidence staring at me in the face..... I babbled on and on in the cardio station giving the patient  a million ways to avoid raising their heart rate too high I fumbled through sit to stand and for got that raising the plinth not lowering it made it easier for the patient. I was re-directed by the examiner a couple of times "Please, re-read the question." Nobody likes to hear that. So I was pretty anxious while stu-dying in the library for my net exams, waiting for the ominous email that I had failed and would have to come back on Thursday.

But the email came and I passed. So I was able to focus more on studying for the next 4 exams.

3. MSK -
I felt like a King writing this exam.

but after we studied for patho, not to fun.

4. Patho
not going to brag, but I wrote the answer key probably, just saying. It was nice to get a nice gentle lob during exam week.

5. Paed neuro
Thank sweet nectar of the gods that this was multiple choice, otherwise this could have been a trainwreck. This being one of the last exams of the session, I had not focused a lot on it previously and felt pretty nervous going in, but had the feeling that I did enough to pass walking out.

6. Adult Neuro
If your patient is struggling and getting frustrated doing up small buttons on his shirt after a brain injury and doesn't want your help, what do you do?
That was seriously a question, and that is why this was the best exam ever. It was really fair and sooooo practical. Who cares about specifics of pathways and exact location of this centre or that structure? I don't. I don't even care that much about clinical neuro, but this exam was really good at not focusing on the nitty gritty, but looking at practical application of knowledge.

p.s. I made him take a break, put on another shirt and try it later when no so frustrated. I also got a piece of cloth with bigger buttons to practice.


We ended exam week with a trip to the Bimini, where else, where after a looooong semester our very own Dill-Owl-Mouse-Killer Jen-WOO-WOO-Woo bought the Dillweeds a round of burbon. That pretty much sums it up.


Schools out!

I have never been happier to resume exercising and eating vegetables.

Next blog we get serious.

A semester in retrospective

I am so glad I survived that semester. It was a long one.

For those of you who don't know it has been an unusually long semester. We started school back up right after the end of our last placement. In July we had a few weeks of research and a case-based study week.  3 pretty intensive weeks, I don't know what it is about it, but those week long courses always seem to take the mickey out of me. (especially when you have a prof for one of them who tells you that there will be a few of you who will not pass the course on the very first day of class. Nothing like a good old spirit crush during the first lecture, but I digress.



Working hard, or hardly working? A much needed study break.

After our spirits were most definately crushed, we had 2 glorious weeks of freedom, I almost went to Mexico, but instead ended up having a few relaxing days at home,

Then I went on an awesome bike trip with Levana and Karen (two friends from the program). We biked to Ruckle beach the first day and stayed the night. After traversing the island on day 2 we spent the second night at Ganges. We drank far to much wine and ate far too much cheese and our non-cyclist friend Levana vowed to never ride a bike again because "she almost died" at the summit of Salt Spring Islands many hills.

Karen and Chelsea drinking a bottle of wine @ Mistaken Identity Vineyards

 Then wen to Victoria to visit my very pregnant sister for a few days. It was nice to have a little bit of time with her before Levi arrived. We spent a lot of the time setting the final touches to the nursery to get ready for baby and watched a lot of Olympics :) We were enthralled by "Shuttle-gate".


Kristen at nearly 9 months!


After that we spent the August long weekend in the hospital as Kyro (Taura and Spencer's son) decided to keep everyone on their toes by playing peek-a-boo. Luckily though, he decided to stay in a little longer and make sure he was ready to face the world.

August 8th rolled around and it was time to head back to the class room. On the first day back I was hit by a car on my bike on my way to school. Ouch! I ended up not breaking any bones! But scared the living daylights out of my boyfriend and Mom as they both arrived at the ER looking for a bag of bones I think. Note to self: on next ambulance ride give injury details and LOC info to person you call.

The accident made August a bit harder I have since been attending physio 2 times a  week and massage 1 time per week. It ate into my recreation time and my studies.


In mid-August we had 2 new additions to the family. We welcomed Kyro Alexander on August the 21st. Kyro surprised us a a little by how quickly he came. I was on the way to the hospital when I got news from my brother that he had arrived. Taura did great and recovered well after the delivery, Spencer took a little longer to get back to normal.

Kyro 1 day old with Aunty Chelsea

Then 5 days later we welcomed Levi Atticus. Kristen ended up having a C-section after 24hrs of hard labour and a week of labour on and off. She took a little longer to recover, but is doing well now. Both babies are growing so quickly under the care of such loving and attentive parents.




Levi with Aunty Chels on his birthday :)

As August drew to a close it was time to get ready for the next incoming class of Physio students. Brooke (classmate) and myself were the head orientation officers. We organized a welcome potluck, a mid-week scavenger hunt and a BBQ (all in one week) for the incoming students. Needless to say it was a blast as well as being a gong-show. I believe our prof on the Thursday after the scavenger hunt were most of us stayed out long past out bedtimes said he was impressed how many of us showed up for an 8am class given what occurred the night before.




Chelsea and Brooke dressed up as "Social Sheriffs" for the scavanger hunt.


The semester started to get a lot more tough after the Labour day weekend. Electro picked up we learned how to safely apply electrical current and ultrasound and laser. We also had a pathology midterm that layed some serious smack down on the class.

A few weeks into September after I had been away for a bit and Cameron had been away for a bit, Cameron took me on a walk one afternoon. We never go for walks. I thought nothing of it though, just thought he wanted to spend some time together. We walked down to the water and talked for a bit about nothing in particular and then all of a sudden he was down on one knee! I said yes and since that day we have been engaged.


My beautiful ring :)

 
The semester continued to march on as we selected placements and were introduces to Adult Neuro, Peadiatric Neuro and Manual therapy. This semester was super practical and all of the classes added something to my physio tool belt. It was lots of hands on!

Then there was the Dillman. We spent almost every Monday afternoon working on our "research project" and pasting each other's heads on animals to make the time pass more quickly.



 This pretty much sums it up.


Exams came to quickly and as per usual the PT department put all of our exams in a 4 day period. Including our practical exam. 6 exams in 4 days. Studying was my world for 3 weeks. 3 weeks I will never get back.... I would like to take this opportunity to thank all of my friends, family and new fiance for putting up with me during these grumpy days.


Dark days of studying.

Then we started placement a mere 4 days after finishing exams.... more to come on that.

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!