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.

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This time last Year!

How crazy around this time last year I was starting to write my blog. Now a year qualified looking through my posts it is crazy to think how much I have achieved in that time. So this blog post is going to update people on my progress through rotations and will also touch on a recent course I have been on for Strength and Conditioning combined with Physiotherapy.

Currently I am working within the Specialist Medicine team at Derby, covering one of the acute respiratory wards and the High Dependency Unit. My first impression of starting my respiratory rotation was although respiratory physiotherapy isn’t my comfort zone, it was a skill I needed to develop. I naively thought “well at least I won’t have the same level of social sort out as elderly medicine….” (How wrong I was). You forget that elderly people may also have a respiratory condition and even if they are not elderly you may have to deal with breathlessness management, oxygen requirements and anxiety to prevent people being readmitted to hospital. Initially I found myself being very slow with my assessment an acute ward is very different from ITU. On ITU a lot of the patients did not necessarily have predisposing respiratory conditions (not all of them) or they were intubated so management was focused on chest clearance and early rehab. Whereas on an acute ward you are looking at how patients will manage at home with ADL’s, the need for long term oxygen therapy, occupational therapy involvement and  the need for social services involement. On the ward we work closely with the OT, one of the things we look at is equipment to help with energy conservation, as this can help to maintain a patients’ independence.

On the ward we have around 28 beds including a 4 bed High Dependency Unit. The high dependency unit has 1 nurse for 2 beds and is mainly for patients who are needing Acute NIV, Tracheotomies who need regular management, patients who have the ability to deteriorate who need escalation to ITU and patients who have reached there ceiling of care on HDU (so they are not for escalation to ITU if they deteriorate likely because their respiratory function is limited due to predisposing lung condition). The sort of patients I have been exposed to on HDU are Spinal cord injuries, Stroke, Neuro-muscular conditions such as GBS , acute exacerbation of COPD, vasculitis and severe pneumonia (So a range of conditions to get stuck into). In HDU all the patients have the ability to go off quickly so you have to keep your eye on the ball, however, it is worth noting that not all of the patients in HDU need physio. For example the patients dependent on NIV who do not have sputum retention normally just need time for their blood gases to normalise so we would hold off unless they need us for mobility Ax.

So objectives I have set myself on Respiratory:

1. To be able to carry out a Subjective and Objective Assessment on a:  i)Critically unwell patient ii)Ward Based patient iii) create a problem list and Rx plan.

2. To be confident using different Rx techniques and demonstrating clinical reasoning. i) Mechanical devices ii) Manual techniques iii) Suction iv) Advice and Education v) Postural Drainage.

3. To be confident in interpreting observations i) HDU charts ii) Auscultation iii) ABG’s

4. Prioritisation of a respiratory ward. i) HDU II) Ward Management iii) Discharge planning.

5. To be on call competent and safe

Through this rotation I will spend half of my time on the ward with HDU and half of my time on a general respiratory ward. To become on call competent through supervision sessions I am slowly working through my competencies. So far I have been fortunate for the experiences I have gained which will set me up for going on call.  However, I don’t think you can ever be prepared for the adrenaline kick of an on call situation. I think the best advice I have been given is always to go back to basics and question why someone has ended up in the situation they are in. What can we have an effect on? And what can’t we have an effect on? What is the main problem: Lung volume, Sputum or work of breathing or both? (This is how I would look at my patients but obviously everyone has different methods you would also complete a thorough respiratory assessment to reach your conclusion).

So slowly but surely my confidence with respiratory is slowly increasing and I am hoping to be ready for the September rota eeeek!! I will try to keep you updated with my progress.

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So very much away from respiratory physiotherapy. I recently attended a course: The Integration of Strength & Conditioning and Athletic Screening to the Management of the Sporting Client: Recreational to Elite Level. The course was run by Harborne Physio and was taken by Simon Noad (West Brom Physiotherapist) and Ray Jackman (S+C coach based on Uni of Birmingham). I wanted to attend this course because there is a known gap between physio and S+C. We should be working in partnership to help athletes or clients achieve their goals. So I wanted to gain a bit more knowledge of S+C and how this would fit into my practice. Just to say people may have differing opinions regarding this process this is just one example. How I have written this up may be a bit jumpy because I have jumped through different principles discussed on the course.

The course was fantastic and it is the first combined S+C/ Physio course in the UK. Simon and Ray were great teachers and explained the principles and practical elements very clearly. The course highlighted that we should be focusing on training athletes not specific “Footballers, rugby players or runners”. The process of S+C is to help develop an individual to perform at the best of their ability.Obviously you will reach a point where you need to be looking at sport specific requirements but we must create foundations first. Is the athlete fit to undertake a training regime without breaking down. There are many elements which must be incorporated into a training regime to account for this for example: Nutrition, Speed, Strength, Power, Recovery,RSA, Endurance, Injury prevention, Flexibility, Anaerobic, Research. If we just breakdown recovery we should be looking at: Sleep (10 hours for an athlete), Hydration, Nutrition, Foam rolling, Mobility work, compression, ?Ice Baths so all of the elements can be deconstructed to create a comprehensive Ax and Plan.

So back to athletic profiling things to consider?

1: When do we screen:Pre season, End of season, following significant injury, return to training or objective Ax. There is no right or wrong answer.

2. Where?: Where do you work, what are you trying to measure?

3. How?: Single station, multi-station, single practitioner or multiple, number of athletes.

After devising a plan we should be doing a medical screen, if you do not have  medical support. This may highlight risks such as Cardiac problems which may need to be screened. http://www.c-r-y.org.uk/ . If in doubt refer to a Doctor or advise client to seek GP advice. (No your scope of practice).

The Screen

Habits/ Daily activities- may lead to motor control restrictions. This links to Poor training regimes which may cause soft tissue restrictions and finally previous injuries which may lead to movement dysfunctions linking back to habits.

How we are born to squat

Some of the things we may include in a initial screen are a Squat, Lunge, Single leg dip, box drop, forward hop and a combination. We should be marking these against normal movement to pre-empt restrictions and weakness. The testing must be standardised and you don’t have to include all of the movements to get what you want (look at the specifics of the sport).

Then we would move onto NMSK assessment some of the tings you might look at. (Not an extensive list)

  • Spinal position
  • Spinal AROM
  • Ankle ROM
  • SIJ mobility
  • Prone internal rotation
  • Thoracic Spine AROM
  • Hamstring AROM
  • ITB length
  • Hip flexor lengthon
  • Groin Strength
  • Quadriceps length
  • Hyper mobility
  • Motor/Core Control- looking at timing of muscle activation

There was a lot of practical elements looking at exercise prescription and how you would take your data forwards into a profile. The process I will incorporate into my practice will look at:

  1. Mobility
  2. Motor Control
  3. Functional Patterning.

We can incorporate this method into practice to formulate a comprehensive treatment or exercise prescription. It is difficult to demonstrate this in a blog post but basically the rational for this is because quality stability is driven by quality proprioception. And Quality functional movements cannot occur with restriction. So we should be addressing restrictions in RX, fire up the NMSK system and then consolidate learning with functional patterning.

For mobility we should be addressing myofascial length and Joint Range this links back to muscle slings which may impact of an athletes training. I am not going to go through the different slings and predisposition to different injuries as I will be here all day but some good examples can be found here: http://www.mobilitywod.com/#[/

or in the book “How to become a Supple Leopard”

After Mobility we can address motor control which is looking at stabilisation working in the new range of movement you have achieved. Some of the things which may be included are: Rolling, Dead lifting and chop and lift. This element demonstrates perfectly how much of MSK physio can relate to Neuro physio.

Finally we look at motor patterning using new control and range and incorporating them into functional movements. Something people might want to read around is Reactive Neuromuscular Training.

Your client should now be ready for S+C training however the whole process falls under the broad umbrella of S+C so there are links between the two, highlighting the need for more integration and a holistic approach.

The second part of the course focused very much on the principles of S+C incorporating RAMP principles into training. Work by Ian Jeffery’s comes into this. Elements we should be including within S+C are :

  • Needs Analysis: Requirements of the sport, movement Ax and Physiological Ax.
  • Warm Up: Raise- Increase HR etc, Activate- key muscle groups, Mobilise- look at movements not muscles and  Potentiate- sport specific drills.
  • Have an understanding of SPORT and FITT principles (not just giving 3x sets of 10)

So this was just a whistle stop tour of the course and this blog is not an exhaustive program of what you would consider but may give you some prompts to look at different elements of your practice. The main learning points I took away from the course are:

  1. When, Where and How to conduct an athletic screen and profile.
  2. The importance of looking at Mobility>>Motor Control >> Functional Patterning
  3. RAMP principles
  4. The importance of specific and tailored training regimes.
  5. The importance of understanding the needs of your athlete.

Thank you for taking an interest in my blog.  Next week I will be attending the CSP industrial relations committee meeting at CSP head quarters so my next blog is likely to be centred around that.

If you have any comments please post to my wall or tweet me @LCphysio

Take a chance rather than make a plan!

For the last couple of days I have been at Physiotherapy UK. It was a fantastic conference but I must say I am quite happy to be now on the sofa writing this in front of X factor! This post is going to hopefully give an insight into some of the talks I went to and maybe inspire people to attend next year. The problem I find every year I go to Physio UK is I want to see everything so its difficult to make a choice on which talks you go to see especially since I haven’t really specialised in a specific area yet. However it really makes you a appreciate the power and diversity of our profession!

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For those who haven’t been to Physio UK lectures go on throughout the day but there are also lots of trade stands (lots of freebies to be had!) and opportunities to network. The first day kicked off with the Founders Lecture by Dr Emma Stokes! It was such an inspirational start to the day, the thing that stood out to me was the statement “Take a chance rather than make a plan”. This is so true we create our own luck and you really just have to latch on to any opportunities  that come your way(This blog is credit to that) . Take a chance even if you can’t see where it will take you because then looking back you won’t have to say what if…. I think the other main point to take from the lecture was that we need to allow ourselves time for creative thought. Sometimes as physios we make ourselves so busy we don’t have time to open our minds (I am one to say I need to make time for myself sometimes). Please find the link for a further summary of the founders lecture. http://www.csp.org.uk/news/2013/10/11/physio13-founders-lecture-calls-physios-think-creatively You can also follow Emma @ekstokes and watch out for her up and coming blog!!

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Just to highlight that this is my interpretation of the lectures I went to see as I don’t have the slides in front of me and I will only be covering a select few to keep everything concise. Each one will have a title so you can pick and choose which you read if you wish.

Lecture 1: Tendinopathy By Dr Dylan Morrissey

I have not read much about tendinopathy except for my undergraduate training and a few odd posts from twitter but this lecture gave a really good view of current practice and where we need to take it in the future. Now this was a surprise to me but a third of people with tendinopathy are sedentary! I had always assumed that running or elite sport were contributing factors.

So current practice currently involves:

  • Progressive loading- based on theories of mechanotransduction probably. This load needs to individualised to the client so it is appropriate and needs to be slow.

Conservative management of mid-portion Achilles Tendon.

Younger Active people:

  • Reasonable strength, high load- Rx: isometrics- reactive stage. Eccentric exercises, con-ecc, power.

Middle Aged recreational people:

  • Reasonable strength lower loads-Rx: eccentric exercises, concentric- eccentric, Strength and Endurance.

Elderly sedentary people:

  • focus should be to get them moving I missed this part of the slide but Rx: Concentric eccentric exercises.

Some of the top tickets for treatment,

  • Tendon Loading- tendon loading= tendon health. Potentially need to avoid casting to allow for appropriate loading to take place.
  • RSWT- Radial shockwave therapy. The ASSERT trial showed immediate and long term effect with shock wave.
  • Diagnostic suspicion- need to be aware of Intra-tendinous Tears this may be seen in younger, athletic people, presenting with impact related pain who fail with eccentric loading. Another would be Fascia Cura Tears as above but a subtle difference in client group.
  • Prevention
  • High volume image guided injections- reduce pain and allow for loading.
  • Educate and reassure.

So what should be our potential treatment time line?

  • Clinical diagnosis- Week 1
  • Stick with the manual therapy- i.e mobilisation, massage etc.
  • RSWT or HVIGI if the first doesn’t work try the other a couple of weeks later.
  • It is not until 20 weeks you would be considering minimally invasive surgery and 24 weeks for open surgery.

So what are some of the risk factors for tendinopathy:

  • Hamstring / calf strain
  • Tight hamstrings
  • back pain
  • hypertension
  • tight calf muscles.

Lecture 2: Surgical Outcomes for Achilles Tendinopathy and Tendon Rupture- Mike Carmont

So the biggest thing to get across is surgery is normally a last resort! The incident of mid portion Achilles Tendinopathy in the general population is Prox: 9-25% Mid-portion 55-66% and Insertion 20-25%. Patients are normally quite good at locating the problem subjectively during an objective assessment. The main thinks to look for during objective assessment are a gap in the tendon, compare alignment and squeeze calf.  A treatment Algorithm can be found here  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#!po=28.1250 which links to the main article http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#!po=28.1250 by Alfredson (2007).

Mike went onto say that the best treatment is exercise however other surgical options are:

  • Stripping
  • Percutaneous-  Day case, the problem with this is pain normally returns.
  • Tenotomy- open debridement sometimes with plantaris release.

All of this is all well and good but you now need to select your patients.

  • Do they need to return to sport or work quickly.
  • Surgery decreases the chance of re-rupture

However some of the complications are:

  • re-rupture
  • deep infection
  • DVT
  • Sural nerve injury
  • adhesions
  • prominent sutures
  • superficial infection

So like with any surgery the risks and benefits must be weighed up as some patients may still be in pain post surgery.

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Lecture 3: Demonstrating Improvement: how neuro-physiotherapy services are leading the way forward- Jill Lockhart

I have to admit I was a bit late for this one but what is on the horizon? :

  • Patient experience
  • Integrated Care
  • Personalised budgets
  • 7 day service
  • Emergency care challenge
  • SPOA
  • Open referral
  • Strategic approach- pathways cross boundaries
  • Workforce changes
  • LTC- Prehab, self management and integrated care.
  • Year of care.

Lecture 4: Bastion to Birmingham: Lessons learnt + future aspirations Sir Keith Porter

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I have to say that after this talk I was so unbelievably proud to say I work at the Queen Elizabeth in Birmingham, especially now I am currently working on intensive care. The talk was based on the fact that a trend had formed where on matched injuries the military appeared to have better care and outcomes for their patients. At the point of injury the main thing integrated into the military was the self help and buddy help so the soldiers knew what to do in time of crisis. It is a real shame this didn’t go through as part of the national curriculum as teaching people early may mirror the training of military personnel.

So to compare:

999 response to injured casualty:

  • First Responder- who will typically have to still wait for an ambulance to arrive for serious cases.
  • Ambulance who can either be manned with a paramedic+emergency care assistant, technician + emergency care assistant or voluntary aid.

Military

  • Helicopter
  • Consultant in emergency medicine or anesthetics
  • Military paramedic
  • Military Nurse.

In the military emergency department there will be an emergency 24/7 consultant who is exclusively trauma. There are dedicated theatres and a  massive transfusion policy (there has been shown to be a reduced mortality in patients receiving the transfusion policy). At the moment places like the Queen Elizabeth are trying to mirror this in hospital.

The main things to be aware of in serious injuries is the lethal triad:

  • Hypothermia
  • Acidosis
  • Coagulopathy

Damage control resuscitation is then implemented. This is to prevent a secondary hit  from Systemic Inflammatory Response Syndrome. So in resuscitation medics will be permissive of hypotension, blood products will be given for volume and surgery will be limited initially. The more critically injured you are the bigger capillary leak you may have which may lead to multi organ failure through second hit SIRS.

So the critical factors to look out for are:

  • Severe metabolic acidosis ph <7.3
  • Hypothermia
  • More than 10 units of blood.

And the aims of treatment should be:

  • save life maximise function
  • manage infection
  • repair damaged structures
  • achieve soft tissue cover and stable skeleton.

There was plenty  of other lectures I attended on the day but hopefully this will give you an insight into some of the talks going on. Keep looking to the CSP website for updates of some of the presentations as they normally get posted online here is the link from last years presentations http://www.csp.org.uk/purchase/video-access

The final talk of the day was looking Physiotherapy: Post Francis. There was some great discussion which can be reviewed on the #physio13 or from posts collated by the CSP twitter feed @thecsp or follow this link http://www.csp.org.uk/frontline/article/mind-your-ps-send-us-your-qs

So overall the conference was great, I got to network with lots of physiotherapists, students and companies (which is another key reason to go to Physiotherapy UK and for students your University normally has a few funded places so take advantage whilst you can). It was great to catch up with some of the main physios on twitter to finally but a face to their name and it is likely that I will be returning next year.

I am sorry I have not been able to cover all the sessions in my blog but I hope you find the post useful. I have had lots of positive comments in Birmingham over the last 2 days so I will continue to keep updating my journey as a newly qualified physiotherapist.

As always any comments either post on here or tweet me @LCphysio.

Day 1 of the rest of your life!

I have had a pretty hectic week in all fairness and writing this blog has become quite therapeutic to help me find time for me (which is so important whether you are qualified or student, don’t burn yourself out!).  So all of my checks have now gone through so I am now officially employed by UHB! I spoke to my manager yesterday to confirm a start date which is now MONDAY!!! Scary times. Now if that wasn’t scary enough my first rotation is on critical care!! (better get the respiratory books out!) I am very lucky because as a student I worked in the same area so at least I have some idea of where things are. One thing I will be doing is writing down some of the keys things like ABG’s, contraindications and indications for certain treatments as I know that in a new environment sometimes your mind can go completely blank so better to be prepared. I also did this as a student which was useful if I was quizzed by an educator. The things I included were:

  • blood gas values
  • Normal HR, BP, MAP values etc…
  • auscultation sounds
  • mini neuro assessment
  • contraindications for suction
  • contraindications for manual techniques
  • contraindications for manual hyperinflation
  • weaning protocols
  • decannulation protocols
  • Areas of the brain
  • Manchester Mobility Scale.

This is not an extensive list but it really helped me during placement. Alternatively you can now get mini pocket books from Flipio which has the same sort of things in a published book. See link below:

http://www.flipio.co.uk/

I am very excited to get started so I will update you on how my first day goes !!

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So last weekend I was running Seth O’Neil’s LBP: Using Sub classification to Achieve Better Patient Management course. The course gave a great insight into LBP classification which could be implemented into practice. I am going to talk about some of the stuff I took from the course . However,because it is my interpretation I will try to reference some of the main sources if you want to learn more as I think I need to go away and read around the topic myself to get a wider understanding. A great place to start would be to listen to Kieran O’Sullivan’s podcast on chronic LBP http://physioedge.com.au/pe-022-chronic-low-back-pain-with-dr-kieran-osullivan/ and the Pain Education Group website. Obviously this is not the only way to treat Lower back pain as there are many other theories but is good to attend courses so you can make an informed choice.

So as pre course reading we were given 2 papers one by Fersum et al 2012 and the other by O’Sullivan 2005. The reasoning behind classifying back pain is similar to any joint, we wouldn’t necessarily treat an OA ankle the same as an inversion sprain? So if we could why would we not classify a patient’s specific LBP problem to help direct our treatments? It is little bit more complicated than that but a good place to start is what pain mechanism is causing the patient’s pain?

So in this case we are going to look at three:

  1. Nociceptive/Mechanical Pain
  2. Peripheral Neuropathic Pain
  3. Centrally Mediated Pain

Nociceptive Pain is from activity in tissues such as muscle, joint,  skin ans viscera and can be classified by pain which is local, sharp/dull, normal aggs and eases (mechanical), predictable, antalgic pattern, absence of dysesthesias i.e. pins and needles or numbness.

Peripheral Neuropathic Pain is caused by a primary lesion or dysfunction in the peripheral nervous system. Symptoms include dysesthisa, allodynia (pain on non-painful stimulation), hyperalgesia, dermatomal pain and aggs and eases in line with neural tissue. eg. CRPS, Pain generated from the nerve. Physiology of a nerve can generate pain.

Centrally Mediated Pain is caused by a primary lesion or dysfunction in the central nervous system this can be seen from diffuse/ non anatomic areas of pain on palpation. It may be unpredictable, pain disproportionate to the nature of lesion, strong association with maladaptive psycho-social factors. e.g. fibromyalgia

A great way that Seth explains chronic pain to his patients’ is by stating:

“Firstly your pain is real!! If you can imagine doing a crossword everyday for a year- you get very good at it. This is because your brain gets bigger and creates more neurones in this area due to repetition. Therefore if your brain constantly receives pain signals your brain learns to feel pain better and becomes hard wired. So we need to think of strategies we can use to retrain your brain.”

or you can try this video how to explain pain:

There are many classification systems however this event was focused on O’Sullivan Classification (CB-CFT). Through the Fersum et al study the CB-CFT approach had far superior results compared to normal physio (MT + Exercise).

With AQP affecting MSK services in the UK it is vital we have statistics to back up our treatment effects. To begin patients should be screened using either the StartBack or Oreobro tool (these also have mobile apps).  These tools allow us to see who needs secondary intervention i.e  pain team and it also helps with prioritising  patients. One of the biggest risk factors for chronic back pain is psychological screening. One outcome measure which can be used to monitor LBP is the Oswestry Disability Index (which can be downloaded for free on if you search on Google).

The O’sullivan Classification addresses whether Back pain is:

  • Specific or non- specific
  • maladaptive or adaptive
  • movement impairments vs control behaviour

To understand this you might want to read: Diagnosis of classification of chronic low back pain disorders: maladaptive movement and motor control impairments as underlying mechanism. Peter O’Sullivan 2005.

http://ac.els-cdn.com/S1356689X05001104/1-s2.0-S1356689X05001104-main.pdf?_tid=f8c3a4f8-2c7b-11e3-b396-00000aab0f26&acdnat=1380839851_1c7b2129e94ab33b2cc108d229937340

When assessing a patient why is it that some of us ignore passive movements of the spine whereas if we were looking at a knee joint this would not even cross our mind? So if we don’t assess passive movement of the spine how do we know whether the problem is a movement disorder so loss of movement or a control disorder full ROM but painful. It is is difficult to explain this with out providing images but please refer to the resources available.

Movement Impairment Classification- Management

  • education- regarding pain mechanism
  • reduce fear
  • CBT approach
  • restore movement impairment
  • graded movement restoration
  • graded pain exposure
  • functional restoration
  • normalise movement behaviour

Control Impairment Classification- Management

  • Education- regarding pain mechanism
  • Cognitive behavioural  motor control
  • intervention
  • pain control
  • retrain faulty postures and movements
  • self control of pain
  • functional restoration
  • normalise movement behaviour.

So at large the treatment should be direction specific, control or movement specific and should take into account psych profile.

This post is more to create awareness of the classification as I am aware I need to clarify some of my knowledge so I can further implement this approach into my practice. I think as a new graduate it is difficult to reason through some of these processes without actually getting the chance to assess patients in an MSK setting on a regular basis. One thing I will be trialing will be looking at passive movements to see how this affects my clinical reasoning in practice.

Seth was a fantastic teacher and he had great feedback from the course. Seth is one of the key Physiotherapists on twitter and his feed attracts a lot of UK and international physios so it is well worth a follow @Seth0Neill.

Some other useful resources below are:

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Comments are welcome especially if it involves discussion around Sub-classification of LBP or tweet me @LCphysio

Thank you for taking an interest.

Grab Opportunities With Both Hands!

I just wanted to start this post by saying a massive thank you to everyone who has taken an interest in my blog. So far, I have had over 4000 views which is amazing and totally appreciated.

So this week I went to the CSP West Midlands Regional Network Study day in Worcester (Keep looking on the CSP website for the presentations under West Midlands Regional Network). I am going to discuss what I took from the event. See a few pictures below.

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When I was a student I was the student representative on the West Midlands Regional Network, which I have now passed onto Daniel Jackson (3rd Year Keele who kindly provided the photos). The West Midlands is a very active network and I have continued to have some involvement since qualifying which will be easier now I am staying in Birmingham. At the moment my role on the network is part of communications team which involves engaging members (mainly new grads with what goes on). The network are very welcoming and always like to know what is going on in your work place, so any issues can be fed back to the CSP through our chair Janet Davies or Rep to Council Philip Hulse. The study day kicked off similarly to a normal network meeting, so work place reports were discussed and key points in the CSP council papers and key messages were highlighted (For more information and minutes please go the West Midlands Regional Network http://www.csp.org.uk/nations-regions/west-midlands. The network meetings are great to find out what is happening in the real world of physio (for students)  and it is great way to share good practice or discuss work place issues for (qualified). For me the network meetings are a great opportunity to network and to find out first hand what issues are facing our profession.

I have highlighted presentations in bold so you can pick and choose which sections you read as there is quite a lot to talk about.

Presentation 1-“Professionalism in Today’s Regulatory Climate” Sue England who is the CSP Treasurer and Council Representative (@SueEngland10)

I believe slides will be put on the CSP website. I am not going to discuss everything in the presentation but this is what stuck with me: Firstly discussion of what defines your Scope of practice. Sue suggested it was a good thing to actually write down your scope each year. So what are you trained and competent to carry out? This changes with experience so it is good to know what the limits of your practice are. For me personally by writing down my scope this will highlight areas I need to focus my CPD to aid my career progression.

Secondly was the fact that as a physiotherapist you are an autonomous practitioner, this means any clinical decision you make you must be able to justify whether during assessment, clinical reasoning, treatment plan or record you are involved in. The first line of defense you have if you are pulled up by the HCPC are your notes, this mean they must be accurate, comprehensive and comprehensible ! As a full CSP member you have comprehensive public liability insurance (if you are working within your scope of practice). CSP membership is a bit like RAC/AA cover you don’t want to have to use it but that time you do the costs that would be covered would be equal to a lifetime cover so personally I think it is a small price to pay (fingers crossed I never have to face this!!)

Finally I found a good link to read  is :  http://webarchive.nationalarchives.gov.uk/20130402150350/http://ahp.dh.gov.uk/2012/02/27/voicepiece-karen-middleton-chief-health-professions-officer/ . Karen Middleton, Chief Health Professions Offcier, wants AHP’s  to be transparent following recent findings from the Francis report (although most of the findings were centred around nurses, physios need to ensure we don’t miss out on funding for leadership programs or CPD opportunities) . As physio’s we generally are not very good at challenging each others practice, so Karen’s aim is to encourage AHPs to talk about the issue of professional behaviour in a more open and constructive way, which I believe was the main message behind Sue’s presentation.

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2nd Presentation: A Personal Experience of Completing the HCPC CPD Audit- Jane Toms- Communication Lead WMRN and lecturer Coventry University.

I think one of the scariest things to think about as a qualified physiotherapist is being called up by the HCPC for CPD Audit. Each year the HCPC select 2.5 % of the profession to have their portfolio reviewed. Now lets face it physiotherapists are very good at doing CPD, however, if someone was to come and raid you’re house one evening, would it be in an organised manner? If you’re like me I have 3 folders which store everything but I wouldn’t necessarily think it was appropriate to hand into the HCPC. Jane Tom’s presentation gave a great insight into the process and revealed some relieving points.

How she completed it:

  1. Read carefully what was required: Guides,videos and examples from HCPC.
  2. Look at online resources from CSP, HCPC.
  3. Read carefully what is required again
  4. Look at the assessment criteria!!!
  5. Look at portfolio and select most appropriate CPD
  6. Keep cycling through 1-5.

Jane brought in a copy of her submission and it was quite a relief to see a very thin A4 folder!!!  So what was needed in the submission.

  • 500 words about current roles and responsibilities
  • 1500 Words on how she addressed standards 1-4 with evidence to support it.
  • Standard 5 submit it!! You do not need to use all 2000 words!

So a lot less work than you thought? However, do you write the dates of any CPD activities you do?

Standard 1: Maintain a continuous up to date, accurate record of CPD: Basically write a timetable for the last 2 years of things you have done and the nature of the activity, for example formal course, discussion, peer review.

Standard 2: Demonstrate that CPD activities are varied and relevant: so link to nature of the activities you have recorded and then link to why the activities are relevant to your current role (so link this to summary of role).

Standard 3: CPD has contributed to quality of practice and service delivery: Link evidence to a form of evaluation you can do this yourself or by external feedback you may have documented. How has CPD helped your practice.

Standard 4: Seek to ensure CPD benefits the service user. Who are your service users? Basically it could be anyone you come in to contact with so patients, students, staff etc. Try to link to service user feedback eg. cards, emails, patient feedback etc… This is probably the most difficult standard.

So what would Jane do differently next time?

  • don’t feel guilty if portfolio is chaotic
  • endeavor to be less chaotic as this would save time e.g write down CPD in diary.
  • Ask people who give positive feedback to email her- emails provide dated evidence.
  • email colleagues appreciation
  • even more collecting of positive emails, cards and feedback.

Presentation should again be uploaded onto the WMRN page.

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Presentation 3 Achieving CPD Excellence- Sophie Wickens CSP Fieldwork Officer for CPD

So following the previous presentation I think the importance of CPD has been highlighted. CPD is an ongoing process. My CPD has very much focused on how my CPD activity has affected me but I haven’t integrated it into how it has affected my service users, I have said it will but I haven’t evidenced it. A way I could demonstrate my CPD in this way could be what I learnt from working with England Cricket, followed up by documenting an email from Steve McCaig who gave me positive feedback for the work I did and how the players and coaches responded to me.

What are the benefits of demonstrating excellence in your CPD?

  • encourages further learning.
  • HCPC requirement
  • Role model to others.
  • Job satisfaction
  • Become critical about own practice.
  • Make the case to employers of the benefits of attending courses. i.e. applying for funding.
  • a way of influencing commissioners.

What resources are available to you from the CSP?

  • Pebblepad/ eportfolio proformas
  • Frontline
  • ICSP- Case discussions
  • Twitter
  • Championing CPD Scheme
  • CSP Colleagues
  • CPD Champions- reflective cards
  • QA Audit Tool
  • Physiotherapy Framework
  • CPD Syd
  • Specialist physio through professional advice service.
  • Links to specialist library
  • Network meetings
  • Annual Reps Conference
  • Clinical interest groups
  • Physiotherapy UK
  • Physio Journal
  • CSP Briefing papers
  • Website.

So there are a few things to be going on with.

Presentation 4 Top Ten Things you didn’t know about NICE Naomi McVey.

I am mainly going to bullet point some of the things I learnt from this presentation as I don’t have the slides in front of me.

  1. Maybe its just me but did you know the codes on NICE guidelines symbolise the type of paper you are looking at, for example CG- Clinical Guideline QS- Quality Standards PH- Public Health.
  2. The full NICE Guideline provides an in depth report of all the evidence and a summary whereas the web format provides recommendations. Naomi advised to go to the web format first and then follow up with the full guideline if you require more detail.
  3. NICE Quality Standards provide markers of high quality care from the best available evidence, so good to use when looking to implement a quality service.

CPD Opportunities and Resources available from NICE.

Presentation 5 Moving into the driving seat- how physiotherapy can benefit from this current climate Sue Browning CSP Dep Chief Exec.

Change in the NHS is here to stay as we cannot afford to keep doing what we are doing. There is increased competition to provide services, there is a shift to primary and integrated care to promote self-management and there is an increasing demand for quality to be monitored.

Change does bring opportunity: Commissioners are looking for more efficient and better ways of working and there is strong evidence that physio is the answer to many of the major current changes. However, we cannot assume that people know the key role of physio in preventing unnecessary admissions, providing alternative pathways and keeping people independent. Therefore it is our job to go out and take control of this agenda. Everyone has a role we need to understand and look to improve our role, sell ourselves, look for opportunities round local joint strategic needs assessments (JSNA), build support with patient groups (they will be your allies), learn from others and look to the CSP website. Tell the CSP what you need to do this? As a profession we are a team and need to work together.

Finally moving into the driving seat.

  • Physiotherapy has a strong future.
  • We all have a role in creating that future from student to qualified member.
  • Services will change.
  • Seize opportunities
  • Network, network, network and access the support.
  • Regional Networks have important roles.

So as you can see I have taken a lot from one study day I hope you may find some of it useful.

Finally what is happening with me, I recently went to help out at an extra session with West Brom using Functional movement screening to assess players. This worked in my favor as I am now going to be doing some paid work for West Brom, as one of the physios was unable to cover a day so I stepped in (It shows sometimes grasping any hint of opportunity can lead to others). I will do a follow up post for all of this as I feel I have I overloaded this post with information.

Thank you again for taking the time to read my post. Again any comments please leave on the page or tweet me @LCphsyio

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:

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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.

Everything happens for a Reason!

So I have now written this post 3 times because things keep changing so quickly. So just to catch up on what I have been doing the last couple of weeks (I hope I can remember everything).

Last week I attended my first training session with West Bromwich Albion, which was more of an induction to get to grips with how things were run. I was working with a physiotherapist called Mel as Nathan the main man was called out with another player in hospital. As a physiotherapist I was involved in the Prehabilitation of players during their warm up, this involved:

  • Sport specific skills including proprioception some of the exercises included were:
  • Hopping to four points with one foot, at each point volleying a football back to the feeder on inside foot, laces and knee/volley. On the return to the middle point the player had to head the ball.
  • Using a wobble cushion dribbling the ball to four cones whilst standing on one foot.
  • Jumping onto wobble boards with cushion upmost. Jumping two feet and one foot.
  • Foam Rolling, quads, hamstrings, ITB, gastroc’s

It is important to encourage injury prevention within the academy and to illustrate its importance. The activities involve challenging core stability and sports specific proprioception. I really enjoyed the session as I haven’t had the opportunity to work on prehab before and I think me and Mel were both thankful for the extra pair of hands as more players turned up than usual. Having enough physiotherapists to players is key to ensure form is correct throughout.

There is now good evidence that a prevention program consisting of a mixture of: Balance training, landing with increased flexion at the knee and hip, controlling body motions especially in deceleration and pivoting manoeuvres, can significantly reduce the number of ACL injuries. So for these players who are at the start off their careers it is vital to educate them on the use of prehab (Brukner, 2012).

http://www.peterbrukner.com/acl-injuries-preventable/

Since my induction I have been on my first proper session which was fantastic. Again the session focused around Prehab at the beginning, some of the exercises we used were:

  • Hopping on one foot onto 6 wobble cushions in a line.
  • Hopping onto on a wobble board cushion side up, jumping onto the ground same foot and then bounding a mini hurdle.
  • Using an agility ladder each player tied their legs together with an elastic band and side stepped through the ladder.
  • Hopping over hurdles in a zigzag pattern and volleying a ball back to the feeder.

We then were able to follow up certain players who needed specific rehab which was great to learn about some sport specific. Next week I will be leading on prehab with another physio and will be assisting with injury prevention screening using Functional exercise movement patterns. So I will follow up with a post on this.

With regards to job interviews I have had two recently, one for Bank work with Nottinghamshire Healthcare NHS trust and one for a private company called APOS Therapy. So first for Nottingham, I really was feeling a bit deflated about NHS interviews but I knew it was an opportunity for interview and although it was bank it covered all the rotations I wanted so I knew I had to give it everything. The night before I organised my CPD folder to match the person spec for the job (but of course they didn’t look at it…. Sods law) but anyway, I went in to the interview feeling a lot more relaxed than previous ones (I think it was because I was a bit half-hearted about it all… but it somehow calmed me down). The questions I got asked were:

  • Tell us about your biggest achievement to date?
  • How do you cope with stress? And how does it affect you personally?
  • Tell us about a time when you didn’t meet a deadline? What were the repercussions?
  • Why this trust?
  • What would you assess objectively for a patient with anterior knee pain?
  • How would you go about assessing a patient who has been admitted following a fall? What would you need to know subjectively? Objectively? And what would your management plan and goals be?

There was a few more which have slipped my mind.

From previous interviews I have realised the importance of not getting your hopes up.  On this interview I ensured I paused and composed my thoughts before speaking and I provided comprehensive answers for the two clinical questions. I got home that afternoon and looked at my phone; I had two missed calls from an unknown number followed by a voice mail. It was the therapy lead asking if I could call her back….. So of course I did and was subsequently offered the position! I was so ecstatic, the job was close to home and they were very positive with my feedback which was a real confidence boost. Of course I accepted the offer and then tried to prepare for the next interview still grinning.

Apos Therapy is a fast growing international company which focuses its treatment on correcting biomechanics by wearing some special boots. The product is fantastic and has had some great reviews see website for more information: http://apostherapy.co.uk/en/home . The interview was ok but it did demonstrate the simplicity of my knowledge for biomechanics but it was very interesting. Apos Therapy are very good at investing in people and providing intensive training but I was concerned as a new graduate that specialising to early would not help me to develop my hands on skills as a physiotherapist. So I decided that although I had got through to the second stage of interview at this time the job was not going to work for me, but if an opportunity arose at a later date it would definitely be something I would consider.

So I had decided the Nottingham job was for me and even though I had secured some bank work at Walsall healthcare. Nottingham would mean I could save some money. But then you will never guess what happened next….. Me, Gerard Greene and Tom Astley were just about to head out for drinks in Harborne (about 9pm) when I got a phone call from an unknown number. It was Janet Hallam from the QE ringing to say they could offer me a fixed term contract until the end of January, which could become more permanent if funding became available. I was in complete shock!! So I said I would call back in the morning! Of course I took the job it was the place I wanted to work for from the start and even if nothing comes of it, it is 6 months of NHS work on my CV J!!!

So although I have written this post three times due to circumstances changing, I can honestly say that everything happens for a reason! So hopefully my future blogs will now consist of my experiences as an employed graduate!! On a final note who’s to say networking won’t get you anywhere. Next weekend I will be working with England U19’s Cricket to assist with their injury prevention screening so hopefully this will open even more doors.

Thank you for taking an interest in my blog, feel free to comment or tweet me @lc_physio.

Pictures from the final Rugby Camp at Ellesmere College:

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