#Physio14: Where will the next 100 years take us?

This post has been slightly delayed partly due to me gallivanting in Vietnam for 2 weeks but also due to my change in shift pattern on Trauma and Orthopaedics I have less time in the evenings to sit and write my blog. This post will mainly cover my trip to Physiotherapy UK and will touch on future exciting developments in the pipe line.

Attending Physiotherapy UK was a relatively last minute decision. I had been to the conference for the last 5 or so years as a student and newly qualified, however this year with me going to Vietnam for a couple of weeks I was definitely counting my pennies.

I can tell you the decision not to go did not last long as everyone kept messaging me  asking “Are you going to Physio UK?” and in the end I just didn’t want to miss out! It was a great 2 day event which was credit to the organisers  and council, a truly inspiring event with lots of learning to take away. I have written this blog  in blocks so you can skip to the presentation summary you want,( I have not included all of the presentations as I would be here all night). Each one will be divided by a horizontal line.

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Rob Webster- Meeting the 201 Challenge: Opportunity and Threat. NHS Confederation.

It was great for Rob Webster, Chief Executive of NHS Confederation, to come and deliver a talk at Physio UK. Rob really did set the scene for the challenges faced by the NHS in the near future and where Physiotherapy can play its part.

So the current Challenges:

  • Generational Challenge- A society becoming dependent on the health service.
  • Ageing Population- An increasing demand on the Health service.
  • NHS Reform
  • Funding Cuts
  • A population with multiple issues.

We have a leadership role to be optimistic: 7 Themes the NHS needs to address.

  1. The Need challenge-changing population
  2. The Culture challenge
  3. The Design Challenge
  4. The Finance Challenge
  5. The Leadership Challenge
  6. The Workforce Challenge
  7. The Technology Challenge.

So we need ambition for the future- Where is the NHS going?

The vision and asks: The 2015 Challenge Manifesto a time for action.

  • Start with Prevention
  • Long Term Conditions- supported self care
  • Seven day services- local hospitals
  • Hyper acute trusts to save your life in need.

Things we need to remember as Physiotherapists and other Health Professionals.

  • We are guests in other peoples lives. We need to put ourselves in our patients’ shoes to truly understand what they are going through.
  • Our outcomes should be theirs.
  • We should organise around them and not our professional egos.

The Opportunities.

  • Integration working as one team across community and across organisations
  • Cost effective- using and promoting the work being done by Physio Works.
  • Right Person, Right Care.

Threats

  • Misunderstood Role- we need to learn to shout a bit louder about our profession.
  • The Heft of Status Quo.- “If you always do what you have always done you will always get what you have always got”
  • Visibility- Do commissioners know what we can do?
  • Unintended consequences of safe staffing
  • Plurality.

My take home message: We are facing a challenging environment within NHS whether it be cuts, increasing pressure to meet demands or trying to make Physiotherapy heard. We could easily just sit on our laurels and wait for someone to make a plan for us however we all have a responsibility to push our profession forwards and demonstrate how we can be a major part of the transformation of the NHS.


Centenary Founders Lecture 1912-2014 Karen Middleton.

I think I must have done 3 blog posts including a speech from Karen but each time I take away something different. The lecture was focused on how Physiotherapy has transformed over the last 100 years. How we take for granted our Autonomy and need to look back at how our founders over came the challenges to achieve this. Physiotherapy has a great future if we continue to push the boundaries of our profession.

Karen’s Leadership Lessons.

  1. Take Responsibility for your own development- I have taken this forwards by finding a mentor to guide my development.
  2. Things that Karen reflects on: What are you known for? What do you want to be known for? What challenges you? What have you learnt? What have you recently added to your CV? Why should anyone be lead by you?
  3. We need to be flexible! Learn to live with a bit of mess!
  4. What level of risk can you accept? What can you get away with?
  5. Learn to act quickly but not rashly. Don’t over think.
  6. Leadership takes guts
  7. Speak out when others are silent when integrity is at stake. Would you stand up for Physiotherapy?
  8. Everything in your body will tell you you can’t do it. Imposter syndrome we diminish our own value.
  9. We must be authentic
  10. People need a reason to follow you. People need to feel empowered.

If you want to see the video to Karen’s inspirational lecture please click the link below.

http://www.csp.org.uk/news/2014/10/10/karen-middleton-calls-action-stop-physiotherapy-sleepwalking-obscurity


Supporting People with Long Term Conditions- Prof Ann Ashburn

Patients need:

  • Support, Information, choice- patient preference, self-management, Information about their condition, prevention+ health promotion, psycho-social, point of contact when things go wrong, feedback from patients for service improvement and Training for all.

The Strengths of Physiotherapy

  • Active participants
  • Targets set and agreed
  • Collaboration
  • People views of Physiotherapists.

Challenges

  • Limited Research
  • Psycho-social aspect
  • Leisure activities- health promotion
  • Utilising Technology

Disempowerment and Psycho-social factors in long term conditions

  • Attention
  • Diminished concentration affects learning
  • Not being given enough time to think
  • Too many instructions
  • Background noise
  • Fatigue
  • Day to day variability, medication cycle & sleeping patterns. Affected by dehydration (as a result of slowness to swallow,concern about bladder control) so could have headaches, fatigue, constipation all of which will affect performance.
  •  Answering phone – better face to face

Empowerment

  • Allow patients to achieve
  • Recognition of previous life and the patient as a person
  • Choice
  • Support

The final part of Ann’s presentation looked at some of the health promotion activities that Physiotherapists could be involved in such as a scheme called Life after Parkinson’s. For example they set up a dance group for patients with PD . This was just one example of how we need to be creative to improve patient experience and that there is life after a diagnosis of a long term condition.


Assessment and Treatment Planning for MS- Dr Jenny Freeman

Symptoms of MS

  • Fatigue
  • Weakness
  • Poor Coordination
  • Spasticity
  • Sensory Disturbance
  • Visual Disturbance
  • Poor Swallow
  • Bladder and Bowel etc

Some questions and top tips for people with MS.

What are you currently doing to manage your health? What exercise?

Is there anything putting you off?

Do you ever Fall? Impaired  balance during Transfers, STS, Turning./Delayed motor response/Alteration of 2 sensory inputs/use of walking aids.

Exercise is proven to be beneficial and is not associated with relapse. Transient symptoms should settle down.

Should be aiming to complete Resistance training 2-3/week at mod intensity 60-80% 1rep max 1-3sets for min 8 weeks. Aerobic training 2-3 times a week 30 mins 4x a week.

Some of the balance interventions: Increase sway in quiet stance, delayed anticipatory + autonomic postural adjustments. Evidence suggests the benefits for balance interventions.

Current Outcome Measures Used.

10m Timed Walk, Single leg stance, lateral reach, confidence scale ABC, MS Walking scale, Activities specific MS, Grip strength, 9 hole peg test.

Useful Resources: Rehabilitation Measures Database- Neurology/ MS edge outcome measures database.


Measuring Respiratory Symptoms in Advanced MS? What’s the point? What’s the evidence? What are the options? by Rachel Moses.

This was a regular problem when I was working on an acute respiratory ward, MS patients being picked up too late for respiratory Ax. If these patients are caught early there are many interventions which can be taught to prevent admission to hospital but the new NICE guideline for MS have removed speech/swallow and respiratory management from the guidelines even though anecdotal evidence suggests there is a need.

MS pulmonary dysfunction and function 

  • Marked expiratory dysfunction – poor cough
  • Severe diaphragm weakness ? Indication or higher cervical cord lesion.
  • Limited ability to maximally exhale
  • reduced vital capacity for patients who desaturate over night.
  • MS- abnormalities in breathing control, resp muscle weakness, bulbar dysfunction.

What’s the Point?

So when we are assessing a patient we want to be looking at their peak cough flow. If the patients peak cough flow falls below 270ml then it is likely they will need some support to have an effective cough.

  • Lung Volume recruitment bags would be the first port of call this aids breath stacking to increase lung volume for a more effective cough.
  • If LVR isn’t enough some patients may need a Manual assisted cough as well.
  • The final port of call would be manual Insufflation: Exsufflation. This is a machine which delivers a volume and then switches the pressure release the volume and augment a cough. MI:E has been shown to be a cost effective admission avoidance strategy for patients with advanced NMD.

From this presentation it reiterated the importance of early respiratory assessment to prevent acute admissions. It also highlighted a need to educate commissioners on the benefit of respiratory management for patients with MS.


The Dementia Challenge- Iain Lang

What is Dementia?

  • A set of symptoms, progressive condition.
  • Not easy to differentiate between different types of dementia
  • variable condition day to day.

Why is dementia important?

  • Common
  • It’s frightening- most feared health condition, reliance on others
  • £26 billion cost to UK Economy
  • people with dementia stay an average five days longer in hospital.

How can we respond to the challenge?

  • Diagnosis more than 1/2 of people with dementia are not diagnosed.
  • Treatment- drugs are used to reduce symptoms and deal with psychosis, anxiety or depression. No current drug developments.
  • Understand how to communicate with patients with dementia- now mandatory training.
  1. Prevention- managing other commorbidities  HTN, Diabetes.
  2. Don’t smoke this increases the risk of dementia
  3. Eat a Mediterranean diet
  4. stay engaged prevent social isolation, learn new things
  5. Exercise best evidence to prevent dementia

Implicit memory- how you do things?

  • Evidence suggests the way forwards
  • error less learning
  • positive experience
  • repetition guiding what you want.

Implicit vs Explicit

  • Priming
  • errorless learning
  • repeated constant practice
  •  avoid multitasking

Dual Tasking

  • Capactiy overaload
  • Structural interface- sensory overload- for example during standing use fingers instead of hands to support patient.
  • be patient
  • don’t overload senses
  • one thing at a time
  • may choose to do this as part of rehab.

Communication

  • Dementia questionnaire inpatient- what do they enjoy?
  • Smile
  • Understand where people come from.

Pain

  • Very overlooked
  • most unable to verbalise
  • unable to process pain
  • unable to identify pain
  • unable to understand why they are in pain
  • What were they taking before?
  • Pain scale- Abbey pain scale.

People with dementia should be given the opportunity to maximise their potential.

  • Approach from the front good eye contact
  • think about what they are called
  • short commands and being courteous
  • keep hand movements open
  • use positive tone
  • goal based- lets go and look out the window
  • stand up tall
  • use gesture or tap where
  • avoid jargon
  • use of equipment be aware may not understand how to use.

I have been able to take this learning into practice in the acute setting by adapting my communication and limiting sensory bombardment, in turn I have found my patients with dementia have made good progress. Sometimes you need to be patient and try and build rapport  before asking them to do something but if you can get them on your side you will make your job a lot easier. I have also found that by reducing my handling has encouraged patients to be more active during the treatment session which has limited the manual handling load for me.


So that was just a review of some of the presentations I attended whilst at Physio UK. During the event I was able to catch up and network with many different people who I aim to stay in contact with. Physio UK always offers a great opportunity to speak to new people who share a similar interest to you whether that be Management, Education, MSK, Respiratory, Neurology and more. Whilst at the drinks reception I got talking to Paula Manning, outgoing Vice Chair East Midlands Regional network and Catherine Pope, Vice Chair of council. They asked me whether I would be prepared to stand as Vice Chair for the East Midlands Network. I was ecstatic to have been asked but I suggested that I would need to confirm this with my manager. My manager has now agreed to support me and I have been selected to run as Vice Chair of EMRN. The role will be a challenge but it will give me valuable experience which can be transferable to my professional developent. I have lots of people to support me so I am looking forward to taking the role forwards into 2015.

One final thing in the pipe line, I have been asked by the CSP student reps to speak at the annual rep development weekend.  I am really looking forward to sharing my experience as a new graduate with reps and hopefully inspiring them to do great things and take the future of our profession forwards.

Apologies for the length of this blog, but Thank you for taking an interest. Wishing everyone a Merry Christmas and a Happy 2015! Any comments or questions please leave a message below or tweet me @LCphysio.

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Respiratory Rotation Tick!!

This post has taken me so many attempts to write, I am not sure if it is because the last couple of weeks have been a bit relentless mainly with me flapping thinking “Oh God this week I am on call”. It doesn’t matter how much prep you do or how much everyone tells you that you’ll be fine you still don’t feel ready. Being quite a reflective person I like to analyse every possible option before doing something (which I think enhances my anxiety of on call thinking will I ever make a decision!), however, I am also a born pragmatist which means once I know what I am doing I get things done and with the fab support I have had from my team during supervision sessions and clinical work I now feel I could reason through my options and make a sound clinical judgement! So this post is going to look back on some of the success’s and challenges I have faced on this rotation. I am now on-call competent and I have just completed my first on call (pheeewww) so I will try to explain the things which were going through my head and how I came out the other side!!

So Firstly the competencies, to be competent on call there are certain skills which need to be reviewed to ensure safe practice is maintained. These include:

  • Understanding of Arterial Blood Gases.
  • Interpretation of Auscultation
  • Interpretation of Chest Xray’s
  • Understanding of Oxygen Therapy
  • Ability to use cough assist and clearway
  • Ability to use Intermittent Positive Pressure Breathing.
  • V/Q matching and positioning
  • Humidification
  • Use of Manual Hyperinflation
  • Suctioning
  • Assessing an acutely ill patient
  • Tracheostomy care
  • Time on ITU/Paeds/Surgery/HDU/Medical Wards

I have to say I was glad to see the back of them, doing more work after work meant sometimes feeling mentally and physically exhausted but I had great support from my supervisor Emily Stranney and team throughout which made things a hell of a lot easier. I am not going to go into each competency as I will be here all night but these are some of the things that would be expected of you at Derby.

I think one of the best ways for me to sum up my experiences is to give you my Top 10 tips on how to survive your respiratory rotation. For me I was fortunate to have experience on ITU on placement and when I worked in Birmingham but I can understand how daunting it can be if you were going in blind. For example on my first day of my the rotation I was quite happily being showed around to familiarise myself  when one of the nurses called us over to say a patient needed urgent chest physio… So off we went straight into a emergency situation good job I had already had experience in suctioning and my supervisor was taking control…way to break me in gently or throw me into the deep end I am not quite sure :-). So my tips based on my experience on medical respiratory wards and I hope some of them may be useful.

1. Take a 24 hour approach to your patients. For patients with long term respiratory conditions they may physically be able to complete the tasks separately but when you put everything together washing and dressing themselves, making breakfast, walking to the shop even they may be exhausted for the rest of the day or even the next. This is where you may need to liase with occupational therapists, oxygen nurse, rehab coordinators or pulmonary rehab to assist with formulating a seamless discharge for your patients.

2. If they need oxygen therapy have you considered it as a tripping hazard? Many patients will be elderly and you don’t want a long line of oxygen tubing to be another reason for another admission to hospital. So maybe trial a long lead of oxygen as part of your treatment session to carry out a risk assessment?

3. You sometimes need to wait a bit longer before you pick up a physio referral. For example sometimes some of the COPD patients come in with type 2 respiratory failure and they need  NIV to rectify blood gases before you start pushing their exercise tolerance to the limit. (This may not always be the case speak to the nurses are they productive of sputum or not?)

4. If opportunity allows opt to do some joint treatment sessions with more senior physiotherapists and get them to compare what you are auscultating etc to see if your treatment plans match up. Different physiotherapists work in different ways so it is good to work with a variety to aid your own clinical reasoning.

5. Get into the habit of checking patients Chest Xray’s, if a recent one has been taken to help guide your treatment. Also the more practice you get the easier they will become to interpret… as no one wants to be scratching their head at 3am in the morning.

6. Know your indications and contraindications for treatment this will help formulate your treatment plan. I would advise to carry around a notebook with these in because if your mind goes blank you have something to back you up. My on call book has useful phone numbers, door codes, equipment locations, indications and contraindications for treatment, typical patients for each treatment and some of the useful values you may need as part of an assessment.

7. Break each respiratory patient down simply. What is the main problem? Sputum retention? Reduced Lung Volume? or Increased work of breathing? What can you change or help with and this will formulate your treatment options.

8. As always don’t be afraid to ask questions or your seniors or Doctors question their clinical reasoning so you are understand why you are doing something. You will be amazed at how many times as a physiotherapist you are the first one to notice that a patients target SpO2 need adjusting.

9. Like with anything in physiotherapy if something is outside of your scope of practice ask for help. For example I have been faced with the situation where a patient has aspirated on their vomit and I asked for my senior to treat the patient with me because I had never dine nasal suction before. ( You are not seen as incompetent you are seen as safe)!

10.Be aware of the neuro-muscular patients, they have the potential to go off spectacularly due to poor lung volumes and cough effort. And just because you can’t hear anything doesn’t mean secretions aren’t lurking. The likelihood is that secretions can’t be heard due to poor lung volume creating turbulence.

Finally just relax… easier said than done I know, but, you are better to take a deep breath take your time and reason through what you are doing.

I hope some of these tips will be useful, I feel so much more confident with my respiratory skills post rotation and I would advise anyone to develop the skills as you never know when they may come in handy ( it will probably be me reviewing the odd respiratory patient when I move to T+O next :-S)

So those were my top 10 survival tips for your respiratory rotation. I will now go onto my first on call situation and some of the tips which brought me out the other side.

I can honestly say this day had been looming for a long time…. but I kept thinking oh it’s fine I’ve got ages yet (it won’t happen to me)! To oh wait I am on call tomorrow oh Cr*p!! The night before I definitely did not sleep at all waking up every hour thinking am I meant to be on call tonight? when I wasn’t. So the day finally arrived, I had arranged to stay with a colleague as we have to be at the hospital within  40 mins, so from Chesterfield I would be pushing it! I was lucky in someways to be completing my first on call during my time on respiratory as it meant I had the opportunity to talk things through with my supervisor and also suss out if there was any poorly people lurking about on the wards. Through the week there had been no call outs so I was testing my luck not to be called out but I guess I kind of wanted to be called in just to get the whole thing over and done with. So I settled into bed about 9pm… set my alarm for the morning, straightened out my uniform next to bed alongside my on call book and a pen. As I did the night before I wasn’t sleeping well looking at the clock every hour…. but by the time I got to 3AM I thought you know what maybe I have been saved and tonight is not the night so I drifted off to sleep.

04.30AM The phone rings!! ” Hello this is the switch board can we direct a call through to you”

Me: “Urghh urghh Yes hold on let me just find a pen”

“Hello its the registrar …. The patient has this, this, this and this can you come in for emergency physio”

Me: ” Hold on a second  can you just repeat that I have just woken up” So by this point I had found my little book and was able to take some details down. One thing I would say is make sure you take the time to slow the referrer down and clarify the patient in your head (Don’t forget to find out the patient’s name and location as you don’t want to be running round the hospital at night)

So I had got the details I needed, got dressed, got in my car and drove to hospital all the time thinking should I be doing this or this. By the time I had made it to the hospital I headed to the patient’s location took a deep breath went through the notes, looked at their Chest X-Ray, asked if they were for escalation for a higher level of care, checked blood results and then started to conduct my assessment. I went through logically my treatment options and formulated my treatment plan. As a first on call it wasn’t really a physio problem to solve but it allowed me to reason this through and at least I got called out and lived to tell the tale.

So my top tips for on call based on my limited experience:

1. Make sure you are competent! There is a reason we are set competencies and this is to make sure we are safe and clinically effective.  So take the time to put the work in so when it comes to being called out at 3am in the morning you are prepared.

2. Be organised! Have everything ready so that the only thing you have to do is get dressed and turn up at the hospital.

3. Don’t be afraid to challenge the referrer for the reason for the call out. Not all call out’s need a physio so you may be able to offer advice over the phone to rectify the problem.

4. Take your time read through the notes, check the patients observations, check blood results (INR and platelets especially), check recent X-Rays and breathe.

5. Familiarise  yourself with your environment, take the time to have a walk around the areas you don’t normally work in. Or if it is area you haven’t had much experience in ring the ward physio’s in the morning and see if they have any patients you might want to treat before you are on call to get to know them.

Finally breathe, the best piece of advice I have been given on the run up to my on call is to look at it as you are only offering an opinion. At the end of the day it is the consultant who has the final say on the patients care and sometimes as a physiotherapist you cannot do anything more and have to step away.

I hope this piece has reassured physio students and new grads that being on call isn’t as terrifying as you think and the hardest thing is just that initial thought of waiting to be called out!! But once you have done it you have a real sense of achievement  that you have been able to help someone in need and the fear disappears. I mean if I can come out the other side then anyone can!!

So my next rotation takes me to Trauma and Orthopaedics in a couple of weeks time. I have only ever done T+O outpatients so I am intrigued to learn more about it and see where it takes me. My next blog post will focus on the recent Physio Works locally event I attended in Nottingham for the CSP and I hope to share with you some of the keys themes of the day!

Thank you again for taking an interest. Any comments please feel free to leave one below or tweet me @LCphysio.

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

 

Opening New Doors!

I have been really busy this week. Firstly, from finding out I have been offered a job at the QE, I have been house hunting like crazy.  I knew I wanted to live in Harborne because it was walking distance to the hospital, the area was great to meet other young professionals and with Gerard also living in Harborne, communication would also be easier regarding organisation of CPD courses.  The unfortunate thing is that because it is such a popular area, houses become available and go like hot cakes so I have struggled to even get a viewing on some. But I  have found one which is only a couple of mins walk from the high st and 15 min from the hospital which will be perfect. I will be living with a 2 girls and 1 guy which will be great to meet some new people (can’t wait to start a new adventure!!!)

So after I had been to the house viewing on Thursday night, after training with West Brom, I had to drive to Loughborough University. Through networking I had been given the opportunity to assist Steve McCaig at the England Cricket U19 Profiling camp. Steve is looking to complete his PHd on causes of throwing arm pain in cricketers. The work was expenses paid so I was provided with accommodation and food which suited me. Now baring in mind that on the Rugby camps I have been sleeping in the school dorms, I kind of expected the same for the cricket (which would have been fine for me as long as I have a bed and a shower). But I turned up on the Thursday evening about 9pm to be presented with a lovely hotel room, I was thinking by this point maybe cricket is the sport for me :-)!

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First day of the Camp I had to meet Steve at 7am at the ECB cricket centre. With Steve being an Ozzy it was difficult not to gloat about the previous ashes test but I soon recognised he completely backed the England team through and through. In the morning he quickly ran through the screening program and told me that we would only have 15 mins per player so it was going to be tight (I was thinking oh my god I hope I can keep up) . So the things we were looking at were(some were extras that needed to be covered for his data collection for his PHd pilot study): Scapula position at rest, elbow carrying angle, combined elevation, shoulder internal/external rotation, straight leg raise, hip rotation ROM, Sit and Reach and Knee to wall angle and distance. Steve wanted to know if any of the previous limitations predisposed players to certain injuries or arm pain.

The most common injuries seen in cricket are: Lower back pain, Side strain, Posterior ankle impingement, hamstring strains, lower limb tendinopathy and throwing related shoulder pain. From unpublished data Steve suggested that some of predisposing factors for injuries were.

  • Throwing arm pain- elbow : Reduced total ROM Gleno-humeral Joint and External Rotation on dominant side, reduced Combined elevation, reduced grip strength as a % of Body weight, strength shoulder internal and external rotn, back extension, calf raises.
  • General LBP: Reduced Back Extension and Side Plank times, L to R imbalance on Side plank, reduced Add Squeeze (Look up muscle slings that act on the pelvis to understand reduced adductor squeeze.)
  • LBP fast bowlers–Similar trunk muscle endurance scores but difference not as great, decreased Combined elevation, Dorsiflexion and Sit and Reach.
  • Posterior Ankle impingement: Reduced Dorsiflexion Rom and > L and R difference

So these were some of the reasons we were screening the players so we can look back in retrospective to see whether these limitations are the cause of problem and so players can be given appropriate management plans. Steve has been working in Cricket for about 9 Years so he was really knowledgeable of his sport. You become to realise that each physio at the top has their own ideas and clinical reasoning. At west brom there is a strict focus on prehabilitation, whereas England cricket would focus on physical Preparation. So I think when you get into the area you want to work in you have to ensure you make decisions about how you manage your players/ patients using your own clinical reasoning and judgement, whilst basing practice on evidence. I really enjoyed the first day of the camp because Steve took the time to explain his reasoning and provided some teaching on the Shoulder complex.

On the second day a lot of the drills in the morning were focused on batting, fielding and throwing. Each player was filmed using high speed cameras so their  technique and biomechanics could be recorded. Cricket is not necessarily a sport I follow but it was good to see a break down of skills and to see the difference between the spinners and fast bowlers. I was manning one of the cameras for the batting so I got a real close up of the players. In the afternoon most of our screening was based on muscle endurance so we were looking at Back extension, side planks, calf raises, bridges whilst the strength and conditioning coaches  also carried out other functional movement and strength tests. Again we were looking at imbalances and factors which may predispose players to injury. It was great to see that the physios and strength and conditioning coaches working closely together off the same page as I believe there is a real gap in everyday practice between health professionals and the fitness industry.

So what is in the pipe line for me now, well I am attending the CSP West Midlands Regional Network Meeting on Monday to see what is happening in the region. Regional network meetings are great for networking with qualified clinicians and most are very welcoming to students and new grads. Visit your individual region on the CSP website to see when their next meeting is.

http://www.csp.org.uk/nations-regions

After having so much backing for my blog there is a potential it will be promoted on the CSP website in the blog section so watch this space.

See some pictures below from the ECB Profiling Camp:

IMG_0588  IMG_0590 IMG_0589IMG_0587IMG_0591

Thanks for taking an interest in my blog, if you have any comments please feel free to leave them on this page or tweet me @LC_physio.

Make your Weaknesses your Strengths!

I am writing this post following a roller coaster of a week. I feel completely emotionally and physically drained, and I even started question why I am putting myself through this. I know that is stupid I’ve only had 4 interviews (which I am completely thankful for) , but I think after 4 rejections in such a short space of time it does knock your confidence.  But as the title of the post claims you need to make your weaknesses your strengths and carry on.

Tough-Day-At-The-Office

So  I started on Monday with an interview at Derby Hospitals NHS trust. Due to me working with Worcester Warriors Community again this week, I had arranged my interview for 8.30 am so I could do both. Most people who know me, know I like to be organised and on time. I think I got a bit excited as I appeared to be waiting outside the interview room at 7.30 am (but better to be an hour early than 5 minutes late). So the Derby interview was based on a series of scenarios. There were 4 rooms, 3 scenarios and 1 personal interview , each room had 2 practitioners (I felt like I was on the apprentice and Lord Sugar was going to come out and say your fired or hired!!).

The first room I was in was the personal interview which I was thankful for to break the ice. Some of the questions I got asked were:

  • Tell us about you?
  • What do you think about customer service?
  • Tell us about a situation where you have had to motivate a team?
  • How do you deal with stress?

There was a few more questions but I can’t remember them all. From my previous interview at the QE I felt I shut off and needed some prompts to keep speaking (I think the nerves probably got the better of me). So on this interview I tried to keep speaking until they shut me up.

The second room was a respiratory case study (resp and neuro tend to be my weaker areas mainly because I have had less experience in them) but I felt I was able to work through the case study fairly. There were things when I came out that I could have included but I suppose when your under pressure some things don’t always come to the front of your mind.

The third was MSK, which if do say so myself I blasted. Typical presentation of a frozen shoulder but with a past medical history of a mastectomy (which can have an impact on the shoulder due to radio/chemotherapy sometimes causing tightness) so they wanted some discussion around this.

Finally was a neuro case study. They wanted to know what you know about stroke? What your goals for discharge would be? What would you do if a patient was being discharged by a doctor but you weren’t happy? Again there were some others but I can’t remember the rest.

So overall I felt a lot more comfortable in this interview but I sometimes felt I deviated from the point in the personal interview. So we were due to hear feedback on the Wednesday but I didn’t hear anything. One of my friends had already received an email to say that unfortunately they had been unsuccessful, so due to not hearing anything I thought I would be in with a chance…..But no phone call…..I rang the trust today to find out the decision but unfortunately I had been unsuccessful.  I think I had got my hopes up as I had felt comfortable in the interview and due to others receiving emails… but they just hadn’t sent mine. So as you can imagine I was pretty gutted. The feedback I got was that sometimes I was not concise in my answers for the personal section (which at the QE I was too concise and closed) so I need to find a happy medium. The only other point they made was that I could have been more evaluative in my respiratory case study (which I suppose comes with experience). They were positive in saying I was employable (BUT THEY DIDN’T EMPLOY ME GAHHHH HAHA) but unfortunately they said it was very competitive. On the other hand I did get the offer of bank work off the back of it so fingers crossed that might lead to something else (fingers and toes crossed).

I have another interview for Nottingham CIC bank 4th September so I can let you all know how that goes (I think soon I will have had an interview at every trust it feels…. so I will be the guru of interview questions).

From my previous post, I had discussed my interview at the QE, which I received feedback for on Monday. I scored 23/51 on the question paper again did well on MSK (but lacked some detail, for example I might have said ROM exercises but not specified which ones) and to my surprise respiratory was OK but I wasn’t detailed enough in the orthopaedic question.  They said I came across well in the personal interview but just missed some of the buzz words and sometimes required some prompts (more nerves than not having enough to say). But again I am on reserve list for 3 months so hopefully something might come up.

So for my next interview things I will be working on:

  • Preparing points for generic interview questions so I can be more concise.
  • Ensuring my CPD folder is linked to the post.
  • Learn to relax!!!
  • Finally work through some more respiratory and neuro case studies.

Like I said above I have been back at the Worcester Warriors this week, but working with under 12’s. It is fair to say under 12’s are a lot more demanding, not necessarily in relation to injuries but more in relation to their behavior, but we have great staff at the camps and  everything got done in the end. I am back at the camps again next week for a final week so I will update you then. Tomorrow I will be up very early to head over to West Bromwich Albion Football Club for an induction, so I am looking forward to that (but maybe not the early start after this week). But again you have to embrace opportunities that come your way.

Thank you again for taking the time to read my blog. If you have any questions feel free to comment or tweet me @LCphysio !

Time to Reflect!

So I am feeling in a reflective mood following a hectic week  (I have to apologise to my boyfriend as he told me to reflect a bit to early on when everything was a bit raw and I wasn’t very grateful for his advice, but I have come round). When I last posted I had one interview at Birmingham. Since then I have received 3 more! At Nottingham, Derbyshire Community and Derby Hospitals NHS Trust.  This week I have had one at Nottingham, one at Birmingham  and a telephone interview with Derbyshire community. Fair to say it has been quite stressful and I feel physically and emotionally exhausted. I am going to talk about my Nottingham and Derbyshire community interviews as those are the ones I have heard back from which unfortunately have been unsuccessful, but like the title of the blog is it’s time to reflect.

So I had my Nottingham interview on the Monday, luckily for me my mum volunteered to drive me so I could chill out and focus on the interview. With the interview being in the afternoon I had spent all morning pacing up and down so I had kinda wished my interview had been in the morning to get it over and done with. When I got there I had to go straight to HR to give in documents which was a fair distance to walk and not very easy to find so I was glad I gave myself plenty of time, though I was so flustered when I finally got back to the reception to wait for my interview.

So the interview came around, I had two female interviewers who were both very pleasant and took it in turns to ask questions. The questions I can remember were:

  • Why did you want to work for the trust?
  • What attributes would you bring to the post as a band 5?
  • How would you differentiate between acute hamstring and sciatica? Treat one of them.
  • You have a patient who has a left sided infarct. What would you expect to find on assessment and what would you tell your colleagues to help them if they were going to be treating them?
  • What are your learning needs to be able to go out on respiratory on call?
  • Questions on trusts values and behaviours.
  • You have a patient who has dementia the team is happy for him to go home but you have concerns how would you deal with it?
  • How would you show a patient they were cared for?
  • What would you do if your senior wasn’t using the proper hand washing technique?
  • You are on an orthopaedic ward with 28 beds. What would you do if you were the only qualified member of staff because your senior is off sick?

I’m sure there were more but these are the ones I can remember. I am yet to receive feedback as I have to wait 2 weeks, but on reflection one of the big questions I messed up on was the orthopaedic ward one! (which I will be gutted about if that was the only thing I didn’t do right as I have been having nightmares about it). Basically I answered it by talking about getting handover, having a team meeting to see who could help out and then work from there. If I had my brain switched on I would have talked about the importance of prioritising patients and delegating to the physio assistant which I didn’t gahhhhhhh!!!!!!!!

Another question I could have gone into more detail about was my learning needs to go on call. Not only do I need more experience in dealing with respiratory patients along with the mandatory training. But I also could have talked about being trained on equipment such as mechanical ventilation etc. Hind sight is a great thing!!! There maybe more things I could have done but I will await feedback and will post as soon as I do.

This Thursday I had 2 interviews. I had Birmingham in the morning and a telephone interview in the afternoon as part of a short listing process for the community post. Like I said before I will talk more about the Birmingham interview when I get feedback not holding out too much as there was only 1 post available and 8 candidates were internal!!! Urggh physio is sooo competitive. So for my telephone interview I was asked 4 questions. This job would have been ideal as it is 5 minutes from my house but anyway. All candidates were asked the same questions the first 3 I coped with fine and the interviewer didn’t have any comments to make on them and because they were OK I can’t for the life of me remember them. I think there were:

What makes a good band 5 physiotherapist in the community?

How would you go about maintaining safety in the community?

I can’t remember the 3rd one!

But the 4th one I remember clear as day because I completely fluffed it!!! I was asked to talk about a neurological patient I had seen and to talk about there management and treatment. Now this sounds a straight forward question and it would have been if I had been asked it again but at the time I was so drained from my previous interview that my brain yet again failed me. My pure neuro placement had been my first 2nd year one and I felt I would have been to vague with my answer to discuss one of my patients because it was such a long time ago so I decided to go with one of my patients I had seen on my second to last placement (who actually really wasn’t a true neurological patient so I really shot myself in the foot). This was the question that prevented me getting shortlisted and if I was asked the same question again I would have answered it completely differently. I would have talked about one of my stroke patients, the patient’s symptoms, physio treatment, outcome measures, and MDT involvement but my brain wasn’t quick enough to process the question.

So all in all I was pretty gutted about the Nottingham post as it looked a great hospital to work at, but a better physio was found on the day. I still have the QE to hold out for which is my number one place to work but after hearing there is only one position I am starting to doubt myself :(!

So anyway lets end on a positive so apart from interviews today I have had the opportunity to attend a meeting with West Bromwich Albion Football club with Head Academy Physiotherapist Simon Noad. My role with the club will be on a voluntary basis and will involve assisting the part time physiotherapists with any of the U16 players… a foot in the door you might say. I am really grateful to Gerard Greene for passing on my CV to Simon and I look forward to telling you about my experiences.

So although I am not telling you how happy I am about securing a job I am back on a positive mind set after writing this piece and I am just taking that those jobs were not meant for me. I start the camps with Worcester Warriors next week so watch this space 🙂 !! Again if anyone has any comments please post them on here or tweet me at @LCphysio xx

You get out what you put in!

Woo Hoo, I finally have an interview at University Hospitals Birmingham NHS trust, which is the trust I wanted to work for if I was to return to Birmingham.

 

I had previously done my ITU placement at the Queen Elizabeth Hospital and was amazed at the variety of areas physios were working in. I can remember on my first day walking into the QE staff room, after having a placement at Evesham,with 5 physios, to be met with hundreds of physios and feeling a little overwhelmed. However, the team I was working with were great and I learnt so much in the 6 weeks I was there. So with regards to the interview I will keep you updated with how it goes, I am currently in the process of organising my CPD folder and revising my whole degree in one week :-S!!

As you may remember from my previous blog post, I have secured a position working with the Worcester Warriors on their summer camps. I have just had the timetable for the first week and it sounds great. I am really looking forward to taking part in the injury prevention screening and I will write up a piece so you can see what I learnt from the experience.

Throughout my time as a student I have been heavily involved with the CSP which has opened many opportunities for me. For people reading this with no background in Physiotherapy, the Chartered Society of Physiotherapy is the largest membership organisation for physiotherapy. The CSP is a member-led organisation governed by an elected Council. They provide a wide range of member services and campaign on behalf of all physiotherapy staff and the physiotherapy profession. A misconception by many is that the Health and care professions council (HCPC) will stand up for physiotherapists if a complaint has been filed against them, this is not the case as the HCPC looks out for patients. So if you did face a situation where your practice was under scrutiny it would be the CSP who have your back!!

When I was a student, a lot of students could not see value for money by joining  the society, however, I am a firm believer of you get out what you put in. As a CSP student member you get access to the CSP library, iCSP (which professionals use as a forum to discuss relevant issues), you can become part of professional networks, get access to pebble pad, receive a fortnightly magazine, get many discounts at different retailers and  much more.  As a student I was helped out by the CSP at University. During my return to second year (as I had a year out due to injury), I was going straight back out on placement. On the first day of my stroke placement I got a phone call from University saying “you can’t be on placement as you are not registered as a student “. At this point I had already worked myself up for this day in returning back to University and had re-registered online but there was obviously a problem with their system. Luckily for me after discussion with the CSP I was allowed to remain at the hospital because I was a member phewww!!

So the whole point of me talking about the CSP is to show you what I got out of it, there are so many opportunities within the CSP website to get involved in (although you sometimes have to look as although the website is improving is still not great). For any prospective physiotherapy student reading this becoming a student representative for the CSP enabled me to to contribute to policy, present at conferences, sit on the West Midlands Regional network and set up an Unemployed Graduate Scheme which helps you stand out whilst looking for a job.  As a student representative you don’t have to do as much as I did but the skills I have developed such as communication, leadership and time management are all transferable for the benefit of my patients and future career.

From above I mentioned I was involved in the West Midlands Regional Network.  Each region of the UK has a regional network which are always looking for students to be involved. Last Friday I had a conference call with the communication team which is a  new role for me on the network . My role will try to communicate messages and integrate newly qualifieds’ into the West Midlands Regional Network. The meeting was initiated to discuss strategies to improve the West Midlands Network and how we would achieve this. My contribution was that although the website has improved we are still missing a huge market by using social media (i.e Facebook and twitter) which I will be looking to peruse for the network alongside Daniel Jackson who has taken over my role of Midlands Regional Coordinator for students.

I hope you have taken away something from my blog and If you have any questions about being involved with the CSP  drop me a message on here or twitter @lucycocker1.

Links below:

CSP Website: http://www.csp.org.uk/

West Midlands Regional Network: http://www.csp.org.uk/nations-regions/west-midlands

Look out for the West Midlands Network Study Day: http://www.csp.org.uk/network-events/monday-16th-september-2013-cpd-study-day-930am-4pm-worcester?networkid=447