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
- Use of Manual Hyperinflation
- 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.