Create Foundations First!

It has been a while again since my last blog! I have been very busy with work, gym and trying to tame a new ex racehorse I have obtained!! Most people who know me know I like to keep myself busy! The last time I wrote my blog I had just started my job at Derby Hospitals NHS FT, moving onto elderly medicine. I am now talking to you on my second to last day oN my rotation and I am now going to talk a little bit out my progress and some of the things I have come to realise on my journey!

From past experience working at the Queen Elizabeth hospital, on a medicine ward. I had identified I needed to continue to develop my ward prioritisation and management skills to be successful on my new rotation of elderly medicine. It was difficult coming to Derby because having only experienced physiotherapy in Birmingham there were different policies and procedures to follow. For example in the morning we have a daily board round to discuss patients with the MDT whereas in Birmingham we had a weekly MDT meeting. I have found the board round has worked quite well because it creates an opportunity to discuss problems and identify patients earlier who are becoming medically fit for discharge. Although I am from Derbyshire, I never realised how huge the county is, so figuring out where patients are located was initially a challenge however this was made easier with the fantastic nurses completing  inpatient rehab forms for us after completing goals (what a luxury!).

So I wanted to talk about some of the things I have learnt along the journey which I hope will be useful to all physiotherapists not just students and graduates. My opinions are not gold standard they are just an opinion so please formulate your own clinical reasoning.

Prioritisation 

This is a skill I have really had to refine. In day to day life I am a very organised person however  my problem in terms of the ward management were I wanted everyone to have daily physiotherapy sessions. But unfortunately i realised this is not always possible due to the complex busy caseload . I Initially I found it difficult to lead the caseload partly because there was more than one physio  on the ward, my supervisor (which is great for learning). So we tried not to tread on each others toes. Further more I also lacked confidence and experience to challenge some of the views of the MDT with regards to discharge planning which hindered my initial development. With the complexity of some of the cases on the ward it took me a bit of time to demonstrate my full prioritisation skills, but over the last 4 months I have progressed to the point of feeling confident that I could transfer my ward management skills to any acute ward based setting. 

 

So below are some of the things I have learnt along the way:

  • Everyone has different methods for prioritising, but the way I have gone about it in a simplistic view due to the many factors which interplay : Respiratory patients not managing their own secretions, new patients who need a full assessment (prioritising patients who are requiring chest physio and those coming up to be medically fit for discharge), patients who are medically fit for discharge without a plan for discharge, patients at risk of deterioration if they are not seen and finally patients who are being monitored on the ward.
  • Prioritise patients who require assistance of  2 to ensure staffing can match the need in the afternoon.
  • Unfortunately when you want to see patients on the ward most of the time they do not always fit in your specific time slot so you have to be flexible with your management. 
  • Don’t be afraid to delegate you are not alone (hopefully). If you work with a physio assistant is there any patients that they could see for you on their own? Is there any admin needs they could complete for you?
  • And finally relax! You can only do what you can do! You are not superman or woman! (although I try to be),,, you are better to complete assessments thoroughly to create a plan rather than coming out of your assessment thinking what information have I gained from that?

Multidisciplinary Team Working

I have been very fortunate on my ward to work with a fantastic MDT who are very pro therapy to facilitate discharge. Coming onto my ward I initially felt the high bed pressures looming! However, this has encouraged me to devise a plan earlier and ensure I was continuously liaising with members of the MDT to create a discharge plan with the aim of preventing readmission. Working with the Frail elderly you will be presented with some complex cases such as patients at risk of falls, cognitive impairment, patients refusing social services or patients who do not meet social services funding, patients with complex commodities and finally patients with varying conditions.

Sometimes you are presented with some very emotive cases and you can feel as though you are playing with peoples lives. From our point of view we can only recommend what a patient should do to maintain there safety. However, if patient has capacity to accept risk or go home ignoring recommendations then that is their choice to make. We should be facilitators not dictators. I sometimes felt quite stressed with some of the situations I was faced with, with some patients being border line whether they are safe at home or not. However that stress is important because it ensures I am conscious of my decisions to strive for the best care for each individual patient. I think if you don’t have some form of internal stress and are going through the motions in your job this may come back and bite you in some point of your career. For patients we should be assessing them holistically and taking a 24 hour approach to theIR discharge…. Are they able to manage hygiene needs between care calls? Are they able to sit between care calls? Do they have any pressure sores? Do they have a cognitive impairment? Are they safe with there mobility? Are they able to complete bed/chair and toilet transfers? and finally Are they any safety hazards or risks for the patient returning home? These complex discharges cannot be completed seamlessly without an MDT approach so get to know your team and start communicating!

Preceptorship

It wasn’t long ago I was talking about starting my preceptorship! I am pleased to say I have now completed it to 6 months and have gathered evidence throughout my rotation to support my objectives, The objectives I was set were:

Working with patients and groups: I demonstrated this through joint sessions with my supervisor and a self evaluation form,

Working with colleagues and other agencies: I demonstrated this through a complex case study with a reflective piece and copies of some of my record keeping demonstrating liaison with different members of the team.

Written Communication: I demonstrated this by taking 5 sets of notes and analysing what was good and bad about them.

Using Local and clinical policies relating to working practice: I completed a reflection on infection control and completed a notes audit for the team.

Aside from my preceptorship I was set rotation objectives which interlinked with the programme. It might be a bit geeky but lets face it not many people spend time to document their experiences like me anyway ,but, the preceptorship process really did hone my reflective skills which will support a career long commitment to reflection and CPD in future practice. 

I have loved my time working with the elderly medicine team and I have had ample opportunities to develop my clinical reasoning, prioritisation and overall ward management. I now feel confident that I can transfer these skills to another acute ward based setting, to deliver a quality service to my patients. It was fed back to me that I sometimes set my expectations too high of myself. This has been the case for many years but it is the driving force which allows me to strive for the best. On the other hand, I realise that it is important to get the foundations right first to  develop a solid base for development and that there is no need to rush, at the end of the day I am only still in my 1st year of graduating :-S!

 

Action Plan and the Future.

So in the pipe line for me…. next Tuesday I will be starting on my respiratory rotation (eek), I have completed the 2 week intensive training given by the trust so it is now up to me to get my head in the books to get my head back into respiratory management! Aside from this you may be aware from my last post I wanted to find a mentor to help refine my leadership skills…. well I am pleased to say I have found one and not just anyone. Sarah Bazin OBE has happily agreed to help me and we will be meeting next week :-). Sarah is the current chair of the European Region of the World Confederation for Physical Therapy (ER-WCPT) so I am honored to be working with her over the coming months!

My latest action plan…

  • Revisiting my respiratory assessments
  • Thinking of objectives for my respiratory rotation
  • Creating a 5-10 year plan with the help of Sarah as appropriate

I think that will be enough to keep me going for now. Thank you for taking an interest in my blog! Please feel free to leave a comment or Tweet me @LCphysio . 

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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

 

Decisions, Dilemmas and Diversion

It has been a while since I wrote my last post. I have been very busy since starting my new job at the Queen Elizabeth Hospital Birmingham and I have also continued to  work at West Bromwich Albion FC and Harborne Physio at Barefoot Birmingham. So I have barely had time to sit down never mind write my blog. As you may be aware from my last post my first rotation has been critical care rehab which has been incredible. I have been able to see some of the long term rehab patients who are ventilated and non-ventilated and I am getting to see some of the post operative patients which all will stand me in good stead when I come to complete my respiratory competencies. It has been great to get stuck back into respiratory as I only had the one placement in my second year and everyday my confidence is building as the team I am working with is great!! We do a lot of doubles together, teaching sessions and in service training.

Now this all sounds all well and good but the last couple of weeks have been pretty stressful for me, a couple of weeks into my job at the QE I got an email through from a manager at Derby Hospitals. As you may know from previous posts I had been for an interview there but was unsuccessful (which I was disappointed with as I had done my best on the day). The email read along the lines of:

Dear Lucy

I hope you are well.

We have had some extra movement in the trust and I would like to offer you a permanent contract at Derby Hospitals…..

Image

At this point I read the email about 50 times before I made sense of it! Due to my interview being within 3 months they could recruit me straight away! Of course at this point I accepted but was wary that a permanent post was coming up at the QE so I was still hopeful to remain in trust so I attended the interview to give myself options.

I turned up at the QE interview consciously fine, I went in sat the written paper which asked questions on Chronic non-specific lower back pain and what the management would be? Prioritisation of a list of patients, a respiratory patient assessment, treatment with relation to the on call rota and another question which I can’t remember. I came back to sit down after the paper feeling relatively calm and waited to be seen for the individual interview…. I was being interviewed by the head of therapies and a band 7. I went in and the first few questions were absolutely fine and then it hit me….. My nerves suddenly took over me and I couldn’t physically speak the further questions weren’t particularly ambiguous and if you had asked me later that day I could have gone on for hours but instead I felt like I was outside my body looking in and couldn’t do anything to help myself…. So unfortunately I can’t recall any of the questions from that interview and you can guess I didn’t get the permanent contract…. however they were very understanding of how much the job meant to me on the day and did extend my contract if I wanted.

Now for most people this would be a simple decision to take the permanent contract, but for me not so much. I really had to sit down and right the pros and cons of each hospital and location which did keep me awake most of the night. In the end I chose the permanent contract although I have settled into the QE and I love the hospital I had to be selfish in thinking about my further development…. so I opted for continuity. So as you can imagine I am ecstatic!!! I am now a proud owner of a permanent band 5 contract and all the events and opportunities that have lead to this day have sometimes been hard but totally worth it in the end. I just wanted to say that if you are newly qualified physiotherapist looking for an NHS job don’t give up! I have had several interviews which have been unsuccessful but you can’t take it personally and you have to move on to the next one. Eventually something will come your way and it will be the reason you didn’t get the previous jobs you applied for, because everything happens for a reason.

So since I have now got a permanent band 5 post as promised I wanted to give students and new grads tips on how to write their supporting information. So firstly here are my top 10 tips for writing an application and attending an interview:

1. Read the PERSON SPECIFICATION….. this is the point all managers come back to that applicants haven’t done what they have asked. Sometimes there will be hidden questions to how they want you to approach the application. Basically don’t give them a reason to turn you away, use buzz words that are included in the person spec.

2. Make it personal to the trust, show them how you meet their vision and values if you don’t do this you might as well not even submit your application.

3. Demonstrate your transferable skills. If you have been involved in other activities outside of physiotherapy… what skills have you developed and how can you transfer them into practice.

4. Include your HCPC number and CSP membership number at the top. This means the recruiters don’t have to look through your application when it is staring them in the face.

5.Make sure you review the NHS jobs website daily. The website sends emails of new jobs at the end of the day not when a job goes out.

6. Get your application in early some NHS jobs can close within a couple of hours like the QE. Have a basic template for your application ready so you are ready to go when the job goes live.

7. Don’t make it any longer than 2 pages A4 treat it as a CV otherwise the recruiters will get bored if you are not keeping everything concise.

8.Attend interviews that you don’t want, you might change your mind when you get there and have a look around (and lets face it we can’t be fussy). Try and book an informal visit before the interview as this is something you can talk about during the face to face interview if you have one.

9. Prepare but don’t over prepare. Try and practice questions by answering them out loud as this is how you will be responding in the interview. But try to relax at the end of the day it is not the end of the world if you don’t get the job, nobody died and it is their loss.

10. Finally take in your CPD folder and make it relevant to the post you are applying for, that way they know you are dedicated to that specific post.

I can’t give you any real tips for interviews as they are all different but it is a skill you do develop…. so if you have a shocking one don’t beat yourself up about it. Below I have posted one of my applications with the name of the trust removed, I hope some of you may find it useful.

Physiotherapy BSc: Class 1 (Hons)

HCPC Registered: PH101564

Full member: Chartered Society of Physiotherapy.

Full driving license.

As a very enthusiastic, driven, and dedicated person I believe I would provide a valuable contribution to the teams within X Hospitals NHS Foundation Trust. I believe X Hospital would facilitate me to achieve excellence, whilst allowing me to gain a firm grounding for a successful career in physiotherapy.

I wish to emulate the trusts vision of “……”. I believe I am a very personable, polite and enjoy taking the time to take a holistic approach with my patients. I feel the best outcomes are achieved when patients feel empowered and listened to. On clinical placement one of my patients lacked confidence and I felt by taking the time to understand their goals, this aided my treatment and their outcome. Conversely, I had a situation where I had to break bad news to a patient. The gentleman was likely to remain wheelchair bound due to him demonstrating no improvement over several months. Although I was presented with the harsh reality of stroke, the process was made easier due to the patient and family trusting me as I always aimed to answer any of their concerns and provide information when they required.

Through clinical placements I have been fortunate to gain experience in Intermediate Care, Acute Stroke, MSK x 2 and Orthopaedic Outpatients, Intensive Care at a major trauma centre and Elderly Rehabilitation. During this process I have been able to demonstrate my strengths in communication, time management and ownership of my own caseload, whilst also ensuring I am providing patient-centred care. This has been evidenced by feedback from my clinical educators in my CPD portfolio.

On my last two placements I demonstrated safe, effective and autonomous caseload management in an inpatient and outpatient setting. In both cases I was responsible for discharge planning and referral to appropriate services following MDT meetings or by written communication. I have been able to successfully demonstrate this through positive feedback received from educators, patients and from the wider MDT.

Clinical placement has allowed me to develop my problem solving skills. This can be demonstrated from my experience on intensive care. Coordination of care is essential in all settings; however, in intensive care it is vital due to patients being prone to fatigue. To ensure the MDT were working in a coordinated way I helped to implement the idea of writing a treatment timetable.  The timetable allowed for patients to feel empowered by them deciding when they wanted to be seen and it allowed staff to work together efficiently.

Data protection and patient confidentiality is a requirement for any practicing physiotherapist. I have demonstrated my awareness of this in my portfolio following completion of information governance modules: Patient Confidentiality, secure handling of confidential information and Records management and the NHS codes of practice.

At University I have maintained my manual handling training which I have applied to a practice setting. An example of this was when a patient had slipped out of her chair. To resolve this I autonomously worked with a physiotherapy assistant and used a slide sheet to ensure safety and dignity was maintained by the patient.

With the new changes being implemented in the NHS, it is important for physiotherapy services to provide evidence of positive outcomes. In light of recent failings in the NHS, it is essential for a practicing physiotherapist to adopt clinical governance to ensure patient safety remains the priority. Furthermore, I understand I have a personal responsibility to provide a clinically effective service by basing my practice on evidence and working within my scope of practice. As part of my elderly rehabilitation placement, I conducted a documentation audit using the quality assurance tool and presented this to staff. The audit highlighted shortcomings in record keeping which needed to be addressed, as it had the potential to impact patient outcomes. If I was to gain this post, X NHSFT would gain a physiotherapist dedicated to the profession who is flexible, proactive and who takes a positive approach to managing change and challenges.

Alongside clinical experience, I have been an active member of the CSP. For the last 4 years, I have been a student representative and I have served as Midlands Regional Coordinator for the Student Executive Committee (SEC) from 2011-2013. This role required the ability to organise and coordinate meetings between student reps at Coventry, Keele, Nottingham, Leicester and Birmingham. The meetings discussed relevant physiotherapy issues within the student population and ensured student input was applied to the wider society. Through this role, I have had the opportunity to present at conferences, contribute to policy, sit on the West Midlands Regional network and set up an Unemployed Graduate Scheme. The scheme was set up by myself to provide free evening CPD lectures for new graduates who were in the transition between graduation and employment. These opportunities have allowed me to develop my leadership, communication, organisational and presentation skills. My contributions to the society have been recognised this year as I was nominated and received highly commended CSP student representative of the year 2013.

I am an active learner and seek out any opportunities to further enhance my professional development. An example of this was applying to work with the University Rugby League team as their pitch side support .To enable me to take on this position I had to complete a pitch side first aid course and show further evidence of CPD activities related to the post. During this role I have had to work alone in high pressure situations which have enhanced my lateral thinking skills. I have had to negotiate with players and coaches on a regular basis to ensure players who were unfit to play remained on the side line. This role has highlighted my diplomacy skills to achieve ‘win win’ situation.

Outside of physiotherapy I have a passion for horse riding, which has continued through University. For the last 2 years I have been elected as 1st Team Captain, for the University Equestrian Club, and I have represented the University at British University and College Sport over the past 4 years. This role has enhanced my leadership and teamwork skills and has demonstrated my dedication to activities I am involved in as we were crowned national champions in 2013.

I enjoy being challenged in my work and I believe that physiotherapy should remain a seven day service for the benefit of the patients. Recent news discussing how patients who have elective surgery on a Friday are more likely to have complications highlights this. I would be willing to be flexible in my work as I believe my time management skills have ensured I can create a work life balance, evidenced by my commitment to my hobbies.

As a newly qualified graduate, I am aware of my scope of practice; which includes recognising personal weaknesses and critically appraising my performance and learning. I welcome the opportunity to discuss cases with colleagues, to share best practice and further develop my clinical reasoning skills. I am excited about the new learning opportunities X NHS trust would bring.

Thank you for this opportunity and I look forward to hearing from you.

And that is really it I hope to keep you all updated with my progress as a new band 5 at Derby. Thank you to everyone who follows the blog, the support has been great and has really kept me going when times have been tough.

Feel free to leave me a comment or tweet me @LCphysio