The end is only the beginning!

Merry Christmas everyone!! Well how quickly time fly’s I feel I have only just started a new post and  I am now moving on. On the 6th of January I will be starting my new permanent band 5 post at Derby Hospitals NHS Foundation Trust and I can’t wait! As promised I wanted to give everyone an idea of what my first experiences were as a band 5 . I have been fortunate in some respects because although I have not yet completed a full rotation, I have had 2 mini ones, which has meant I have seen and learnt a lot in a short space of time. The downside to this is I have learnt a little about a lot and I now need to build on my experiences to progress my development.

So starting from the beginning my first rotation was on Critical Care Rehab. It was difficult coming onto this rotation as it had only just been made available to band 5’s and it was ideally suited to someone who had done a rotation on ITU previously. Luckily for me I had been on the same area as a second year student so at least I knew some of the team. The rehab team mainly worked with patients who had been ventilated for more than 10 days or who were likely to be a slow wean. Due to me not having completed my respiratory competencies it was difficult for me to be just given a caseload and the majority of patients we were working with were complicated rehabs. At the beginning of the rotation my senior and I set realistic objectives to be achieved by the end of the 6 weeks (It was almost like having another placement except I was qualified and no one to countersign my notes).

The sort of objectives we set were:

To be able to carry out a basic baseline respiratory assessment of a ventilated and non ventilated patient.

To have an understanding of the complex needs of critical care patients during and post admission.

To be able to formulate a problem list, treatment plan and goals for rehab patients.

To be able to develop competencies on specialist equipment.

It doesn’t seem like I had many objectives but I had to be realistic in the time I had. Throughout the rotation I was fortunate to attend weekly in service training, one to one teaching sessions with my senior and I was able to observe more senior physiotherapists in practice as well as treating my own patients. I found the one to one teaching sessions very useful as it gave me the opportunity to clarify points in my own mind. When initially setting my objectives I was asked on a scale of 1-10 how confident  I was  in carrying out a respiratory assessment which I answered 4/10. I find respiratory quite difficult because the problem is internal and not particularly visual. However following completion of my rotation I am now able to take a backwards step from my patient and work through my assessment systematically.

  • Firstly what has lead the patient to end up on critical care?
  • If they are post surgery did they have any risk factors pre- surgery i.e. Past medical, smoking, obesity, trauma, previous exercise tolerance.
  • Were there any complications during surgery?
  • Were they an emergency admission and is there any contraindications to my treatment?

So this is the sort of stuff going through my mind before even reaching the patient. Next I would spend time to read the notes thoroughly to see what lead them to be on critical care. After reading the notes you can already hypothesise reasons contributing to the patients condition.

Reduced FRC

  •  Anesthetic- reduced mucocilliary clearance
  • Pain- are they reluctant to deep breathe
  • Sputum- due to past medical condition or due to reduced mucocillary clearance
  • Position
  • lung consolidation
  • lung collapse
  • respiratory muscle weakness
  • Drowsy from sedation or opioids

So what can we help with?

  • Analgesia for pain and assistance with supported cough.
  • Sputum- ACBT, manual technique, suction etc..
  • Re-positioning to assist with V/Q matching
  • Ventilator support
  • reduction of sedation.

So we have a few things we can adopt as treatment options and this list is not exhaustive.

On critical care patients are normally under hourly observations so the next step of my assessment would be to interpret them. When writing my first initial assessment I would document:

Subjective

  1. Presenting Complaint- what did they come in with?
  2. History of presenting Complaint- why did they end up on critical care?
  3. Past medical history. Is there anything relevant which will affect their PC?
  4. SH- What was there pre-admission state what support do they have at home?
  5. What has been said by the MDT or any critical events?

Objective

  1. Temperature- every degree increase in temperature increases the patient oxygen demand by 10%
  2. Cardiovascular system: Blood pressure,Heart Rate, CVP and MAP . Are they stable does this restrict or treatment?
  3. Respiratory- Method of ventilation what support are they using? Why are they on this mode?
  4. Respiratory rate do they look distressed or have increased Work of Breathing? Why do they have increased WOB?
  5. Oxygen Saturation. Why are saturation’s low? is it due to shunt? diffusion problem? V/Q mismatch? hypoventilation?
  6. Arterial Blood Gas . What does it show? What is compensating if any?
  7. Renal- Urine output and fluid balance. Are they in organ failure? Are they overloaded with fluid?
  8. IV drugs. Is there blood pressure or heart rate being supported? Are they sedated? Do they have an epidural need to be careful of postural hypotension.
  9. Abdomen- is the gut absorbing nutrients? Is the abdomen distended?
  10. Neuro- Glasgow coma scale?
  11. Auscultation- Air entry? Added sounds? tactile fremitus? Thoracic expansion.

Treatment

  • What is the problem? What are your treatment options?

Analysis

  • What is the patient limited by? What were the results of the treatment?

Plan

  • Physiotherapy treatment plan
  • Recommendations for staff

I have not attempted to go through modes of ventilation and treatments as I could write for days but a clear understanding of the reasoning for different ventilator modes and treatments in essential to formulate and clinically reason an appropriate treatment plan. So the above is the method I would use to assess a respiratory patient. By being systematic it means you are unlikely to miss something critical as a band 5 and with experience your clinical reasoning will become stronger.

So in summary of my first rotation I can now say my confidence has gone from a 4/10 to a 7/10 however, I think I would benefit from having a further rotation on critical care to consolidate my learning.  From completing my rotation I am now able to perform multi system assessments of ventilated critical care patients to generate problem lists and appropriate plans for treatment. I have demonstrated effective skills in the respiratory treatment of ventilated and non ventilated patients. I have also gained experience of treating longer term ventilated patients, developing rehabilitation programmes and acting as the patient’s key worker at weekly goal setting meetings.

Onto my Second Rotation Medicine. I was prepared for a change in culture but the first week really was a shock to the system. Compared to critical care we had a big case load to get through each day and there was a real need to prioritise your time. At the QE we work through a traffic light system (without having the sheet in front of me this gives a basic outline of prioritising patients)

Red= Acute respiratory, Discharges, Falls.

Amber= new patients, patients who have had a decline in mobility or those requiring ongoing rehab.

Green=  Patients safe with or without aids being monitored.

From coming from critical care this was a bit of a shock because I was used to seeing all of my patients daily but on medicine it is impossible to see everyone as the priorities must get done. So my objectives for the four weeks I was on medicine were:

  1. Effective prioritisation of medical caseload using prioritisation tool.
  2. Timely and Seamless discharge planning or patients in line with multidisciplinary team goals.
  3. Appropriate referral to other services and MDT.
  4. Appropriate use of physiotherapy paperwork and documentation in line with CSP and trust standards.

Again my objectives would be a lot different if I had been working on the area for 4 months but I had to be realistic to get the most out of it. Through the 4 weeks I have developed my skills in prioritisation ensuring all patients were seen in a timely manner, I am able to contribute to MDT meetings and I have referred patients on to relevant services. Again I believe I need another ward based rotation to consolidate my skills but I feel in the short space of time I have achieved the objectives I have set.

For anyone who is about to embark on there first physio job or to any qualified physiotherapist my top 5 tips would be:

  1. Don’t be afraid to ask questions, you’re not meant to know everything
  2. If you have a complicated patient don’t be afraid to ask your senior to review them with you remember you need to be within your scope of practice.
  3. Don’t be afraid to say no if people are putting too much responsibility on you straight away or you are feeling overwhelmed.
  4. Take up opportunities to observe more senior physiotherapists.
  5. Make sure you read patient notes thoroughly to carry out an effective assessment and treatment. You don’t want to cut corners.

Thank you for taking the time to read my blog, I will be starting my new job in Derby soon which will allow my blog posts to continue. Please feel free to leave any comments or tweet me @LCphysio

 

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