final entry

1. Part of me is pretty keen to finish and get busy with holidays and summer... but another part of me is really going to miss the people I've become friends with over the past 5 weeks. I think I've made the mistake of becoming too close with some of the patients. Oh well. I'm so glad we've finally has some proper prac time and i't's been great hearing eveyone's interesting stories. I've learned heaps about long-term management of people with neurodegenerative conditions, and I have such respect for the people who work here. I've definitely come to appreciate the influence of family dynamics when dealing with paeds patients. There's no substitute for clinical experience - I'm already looking forward to my next prac where hopefully I'll have a completely new and different experience, and build on what I've learned here.

2. Family-centred practice in paeds
Some of what's involved in living with these conditions- carers, transport, feeding, toileting, wheelchair maintenance, effects of the weather, pressure care, EWC sport, surgery, work, therapy, applications to funding bodies, relationships.......
Importance of knowing your anatomy and what a difference that makes to the effectiveness of your Rx
Effective communication with coleagues and patients
Time management
That sometimes you've just got to be a bitch and make them do it, even if they don't want to

wed week 5

Today I worked with a young woman during her hydro session. She has some sort of myotonia that the doctors can't specifically diagnose. Her father had the same condition and recently passed away, and "Mary" has been quite depressed ever since. She spends most of her time in her wheelchair but does standing transfers. The challenge I had today was dealing with her severe lack of motivation, bordering on laziness, and fear of water (always a good start in aquatic physio).

I found that boundaries and goals made a real difference to Mary's enjoyment of the session. I made a big deal of her achievements because for every new exercise she'd laugh at me, give up before she'd even tried it and say "I can't do it". As we soon found out, she could do it, I think she just didn't like the challenge, and has a bit of a fear of pain. I've met a few patients on this prac who are like that- just obsessed with pain and always talking about how they want to avoid it and how it's so bad for them. I was quite confident and pleased with my performance in the water today. Instead of giving her choices and options like I did the first time I saw her, I took real control of the session and I think it was far more beneficial for her. I won't be here to see her again but given the chance, I'd like to incorporate a few more balance exercises into her programme.

mon week 5

Today we had news that one of the clients had a fall yesterday while transferring. Her boyfriend was helping her get from bed to chair and she stacked it, twisting her ankle, landing on her bum and cracking her head on the way down. They wen straight to hospital, x rays of ankle NAD, and she was vomiting that afternoon. When we saw "Shelly" today she was in a lot of pain sitting on her coccyx, and was quite worried about having to continue doing standing pivot transfers while her ankle and calf were still swollen, TOP and painful on WB. We did a bit of an assessment of her ankle and put on a compression bandage. Bcause she is in a wheelchair most of the day it is pretty hard to get the benefits of elevatting the limb. The PT and OT decided for her own safety that she's going to have to transfer in a sling for the next week or so.

Sounds silly but this experience really highlighted for me how a simple thing like a sprained ankle has completely changed this woman's handling and management programme. A fall that shouldn't have happened has made her already difficult daily transfers just that little bit more tiresome for everyone involved. She's a trooper, she'll be ok in the end, but in the meantime her confidence is battered.

fri week 4

On Friday my palpation skills were put to the test. We were measuring this lady's leg length so we could give the orthotist at Shenton Park the right info for him to measure up her new calipers. Problem was, this woman (like 90% of Rocky Bay patients) is very overweight. It took us forever to find her greater trochanters. We still weren't 100% sure in the end. I was pretty confident in what I thought I was palpating, and made a few suggestions about positioning her and moving her that really helped. I was happy that I stuck to my guns when I thought I was on the right spot, and Brendan (the physio) aggreed. Made me realise how important your basic anatomy knowledge is because at uni we're all pretty easy to palpate but in situations like this you have to know what you're looking for...it's not right in front of you.

fri week 4

Today I did my first assessment of a client. Most of the clients have annual reviews, or 6-monthly reviews if they're young kids. I was doing "Brad"'s annual assessment, a 17yr old boy with DMD. It's the end of week 4 and this is the first subjective and objective assessment I'm taking. I should have done better but I haven't had the experience, and I was a bit disappointed with how I went. I think these things come with practice - I know how to measure ms strength and ROM and all that, it's not rocket science, but the practicality of managing my time and holding the goniometer and this contractured limb in the right place, and asking questions right so the conversation flows well... all that stuff is why we're on placement because doing it at uni is so different (well that's been my experience anyway). I got most of the info we needed no worries... I just felt I made a few amateur mistakes.

Next time I assess a patient I'll concentrate more on asking open-ended questions. Like most teenage boys I've encountered on this prac, he almost always answers "I don't know", so it wasn't a very dynamic conversation! On Monday I'll ask my supervisor how I went. I understand that I'm not expected to hit it out of the park every time on this prac but I know there's room for improvement, and it's a matter of 'when' not 'if' :)

tue week 4

Today I supervised one of my regulars for his exercise session. We have a really great rapport and talk pretty much non-stop from the minute he rolls in the door, which I was very grateful for today.... I went to see 'Mark' to start his PT and immediately I thought he seemed not quite himself. I asked if he was ready to got to the gym and he said something along the lines of "i'm having a bit of trouble, do you mind if we start a bit later, once i've sorted this out?" I thought he was a bit uncomfortable and I decided not to press him for answers or clarification. I had no idea what he was talking about. Instead I just accepted this and said no worries, I'll be in the physio area whenever you're ready.

After about 10 mins he appeared, saying he was very tired. He was getting a bit depressed about his situation, disability (Acute disseminated encephalomyelitis... good words for a spelling bee), recent broken ankle, how he ruined his life in his youth... I think I did the right thing by changing the subject to the Melbourne Cup/ Red Bull/ his church group/ anything other than his past when he was able-bodied. He certainly appreciated the conversation not being so "autobiographical" as he put it. A few mins later Mark told me the real reason why he was feeling so crap- he was constipated, so he had a really sore tummy and it was also affecting his BP. Furthermore, he'd spent the day filling out paperwork for an insurance claim regarding how he broke his ankle (he got hit by a car - for the third time), and he's really down about not being able to walk. I reckon he wouldn't have told this to just anyone and I'm glad he felt comfortable enough with me to tell me what was really going on. I modified a few of the exercises and made sure he got plenty of positive feedback, and thanked him for even rocking up today when he could have just stayed at home.

In hindsight I'm glad I picked up on Mark's unease when I did, and didn't question him for clarification in the begnnning. It did leave me a bit confused/ in the dark but it sorted itself out in the end and it minimised Mark's potential embarassment in front of his mates. He seems quite sensitive and I think that if I had confronted him or asked "why", it may have dented some of the trust we've built up. In the future I'll continue to trust my gut and empathise. I was lucky in this situation because I wasn't stressed for time... if I were up against the clock I'd definitely have been more firm, more rushed, and had less time to empathise fully with what he was going through.

fri week 3

Today I accompanied a PT and OT on a home visit to this 14yr old kid ('Luke') with DMD who'd recently had spinal fusion surgery. The purpose of the visit was to check out his transfers, fit a corset that he has to wear in the shower, make up an instruction sheet for the carer who was starting on monday, make some adjustments to his chair and just see how the family was coping generally.

It was pretty tough and interesting trying to manage this sullen/ sad kid and his narky grandma. His mum had to go to Shenton Park to pick up some pain meds, and had to wait there for ages so she wasn't even at home. As a result of that, his grandma had to stay home and be with him/us and not go to work, so she was pretty edgy. From what I could gather the entire family unit was at breaking point - Luke seems verging on depression, no one can sleep for more than a few hours at a time because Luke needs to be rolled or repositioned so many times during the night, Luke's dad works most of the time, and they have had zero home help/ carers for about 10-12 days. They didn't really want to see us, and it took a bit of explaining to get them to understand the purpose of the visit. There were a few firey words exchanged and it wasn't a very pleasant situation.

I think I did all right in the circumstances. I was the only one in the room trying to talk with Luke and not at him. His entire room was covered from floor to ceiling (including ceiling) with Ford stuff so I tried to get him to tell me a bit about his obsession with Ford ("I don't know" was his response most of the time). I didn't want my supervisor to think I wasn't paying attention to what she was doing but to be honest I think it was just as important to try cheer Luke up and try to diffuse a bit of the tension in the room. It was just a really stressed, exhausted, frustrated family.... The experience really opened my eyes to the influences of family dynamics, patient compliance and showing empathy.