Final Entry

Looking back over the last five weeks, I really enjoyed the experiences I have had on my cardio prac a lot more than I thought I would have. I now am aware that although in the acute phase cardio physio is predominantly about chest physio techniques, as patient’s progress the dominant treatment is mobilising a patient back to their pre-morbid level as this is a treatment patients can easily do themselves.

As I had anticipated, professionalism and time management skills were essential and especially professional behaviour was expected from day one. The time management practice developed as my patient load increased over the five weeks until I was finally running the ward when my supervisor was away for a day.

Developing a prioritised cardiorespiratory problem list was another area that I knew would be tested with this prac and it certainly was. I hadn’t quite expected the amount of detail my supervisor expected from me in my full SOAPIERs each week. Another aspect of this was also being able to adapt the problem list as the patient progressed, which is an area I hadn’t thought about that much prior to this placement but since gaining the clinical experience am aware of how important a consideration this is.

In terms of patient populations, I did not see as many COPD patients as I had expected, most likely because I was on a general medical ward, however I did get a lot of experience with pneumonia patients. These patients often had a lot of co-morbidities which led to their condition being severe enough for hospitalisation. I did gain some exposure to post surgical patients, especially abdominal and cardiac, although as I was not on the surgical ward it was only a small proportion of all the patients I saw. I did need to be aware of the effects of anaesthesia on the respiratory system, the effect of pain and side effects of narcotics often used to manage post-op pain, but my main role with these patients was mobilising them and giving them post-operative education which is an area I had not considered as a physio’s role previously but now I know that it is in fact a key element, especially in heart surgery patients.

With all patients, safety was a priority. I had some challenging situations early on in my placement with patients who had multiple attachments however as I became more aware of the environment I was much more equipped to safely manage this.
Unlike my last hospital placement where I was very vocal in team meetings with doctors and all allied health staff, on this prac, most meetings I was involved with were with only nurses and allied health. In these meetings I did have an important role in discussing patient’s mobility level and what my thoughts were on their options for discharge. Discharge planning was a major part of my role on this prac as very often patients were coming in from home but were not coping and so were requiring an increased level of services or residential placement. I was often having to discuss with medical staff which destination I thought was appropriate and why which I found initially daunting but an excellent way to improve communication skills with medical professionals.

I thoroughly enjoyed the variety of experiences I had on this prac from pneumonia patients to cardiothoracic surgery patients as well as ICU patients. I felt this was most beneficial for my learning as there were limited chest patients on my home ward. The most important thing that I think I gained from this prac was the ability to discuss a patient and their progress with medical professionals and also gaining the knowledge about the many options for patients on discharge to have continuing care.

STARES #3, Topic: Intervention

SITUATION:
My patient was a 39 year old male diagnosed with severe diabetic ketoacidosis and a subsequent pneumonia after a night of binge drinking combined with Type 1 DM, currently in ICU, sedated and mechanically ventilated on BiPAP. He required physiotherapy intervention to gain a sputum sample and minimise further respiratory complications as well as treating his suspected pneumonia. I saw the patient with my supervisor for a chest assessment and treatment indicated as his CXR showed bilateral infiltrates. Following the assessment we decided the patient would be likely to benefit from manual hyperinflation (MHI), to simulate sustained maximal inspirations (SMIs), and oropharyngeal suctioning.

TASK:
My role in the intervention was to do the MHI prior to suctioning (which my supervisor did) to pre-oxygenate the patient and afterwards as SMIs. It was the first time I had performed the technique on a patient so I was given plenty of practice prior to the treatment.

ACTION:
Initially I practiced 'bagging the bag', that is performing MHI to the bag attached to would to the end which would usually be connected into the circuit to get air into the lungs. This was to practice the action and well as the timing of the technique. Following that, I watched my supervisor MHI the patient for the first few cycles and she also showed me how to connect it into the ventilator circuit as quickly as possible. When I started to perform the technique on the patient my supervisor initially did the timing for me as I got the hang of the action and then I progressed to timing it myself. This was when I began to have a few difficulties. On a couple of occasions I gave the patient to great an inspiration and he began to make a gurgling type noise. Although my supervisor was not concerned and I continued 'bagging' the patient, it made me nervous to know that it was very easy to injure his lungs by giving to large a breath.

RESULT:

The result of my intervention was not harmful or unsafe for the patient as I only held the breath slightly too long and I was under close supervision the whole time, it was more so a good learning experience for me. The treatment did achieve the goal of improved gas exchange as oxygen saturations went up and the patient had greater tidal volumes during the MHI, however these were both only short term changes. There were no detrimental effects to the patient or changes to cardiodynamic stability.

EVALUTATION

As it was the first time I performed MHI on a patient I was not expecting to have perfect technique and timing. From my experience I have learnt a new skill and also learnt a lot more about potential complication of MHI such as barotrauma and volutrauma. As I continued to practice on that patient I was able to adjust my hand positioning to be more efficient and effective as well as improving my timing by getting immediate feedback from my supervisor. I think that my strength was in the position and handling of the equipment where as my weakness was definitely in timing the technique. The aim is for the patient to take deeper breaths than normal however maintain a normal respiratory rate, that is, aiming for 12-16 breaths a minute. By giving my patient too great an inspiratory volume continuously it could have reduced his respiratory rate and reduced his oxygen saturations or a more severe consequence would be permanently damaging his lung tissue. As I only made this mistake a couple of times the intervention was still effective.

STRATEGIES:

Strategies that I implemented at the time included gaining direct feedback from my supervisor and asking questions as I performed the technique to adapt my treatment as I went along. I also used the method of 'bagging the bag' the bag again to improve my positioning and timing which was helpful despite the bag having far more resistance than normal lungs. Another method I used was to count in my head as my supervisor was performing MHI on the patient to cement the rhythm in my mind. After I had finished treating the patient, that night I went home and revised my notes on MHI as well as ventilator hyperinflation (VHI), especially taking note of the signs and symptoms that suggest adverse effects. Furthermore I revisited my information on the complications of the technique and when it is indicated to perform it. For my few days left on placement, whenever I was given the chance to go down to ICU, I asked my supervisor if she had any patients appropriate for MHI as I wanted gain as much experience with this technique as I could and hoped to be able to feel a variety of different lung compliance on various patients. I was able to perform MHI again, however only a couple more times but I felt that when compared to my first attempts, my technique had definitely improved.