Self-Reflections

CE 1 - Week 1 (OP Ortho, Worker's Compensation, Manual Therapy)

• Why didn't anyone show us to measure external & internal rotation using the level where the patient's finger lands on their spinous process?!
• The patients improve their ROM after a small bout of manual therapy by my CI. I want to learn that magic.
• We talked about traction in class but never set it up before. Now, at least 2 patients/day are on the mechanical traction tables for a portion of the session.
• These patients seem so independent and living pretty functional lives - why on earth are they in PT 2-3 times per week and been here for so many weeks?

CE 1 - Week 2 (OP Ortho, Worker's Compensation, Manual Therapy)

• I'm proficient in administering passive modalities such as: TENS, ultrasound, NMES, and iontophoresis. I now delegate these interventions to PT Aides. Reflecting back to this, not sure if that is a role/responsibility for a PT aide.
• After the inflammatory phase was over on one of our patients, I did edema measurements - at the malleoli, navicular, and metatarsal. No Figure 8's!
• Not too difficult to administer isometrics of the shoulder: flexion, extension, abduction, external & internal rotation to all of our patients with shoulder conditions...
• It's only a 2-week clinical, & I'm a bit emotional saying good-bye to our patients. Yikes! How am I going handle my 12-week clinicals?

CE 2 - Week 1 (OP Ortho, Vestibular, MDT)

• Patient education is pivotal. To share your wealth of knowledge in patient friendly terms, use analogies. For example, when helping a patient to decide whether or not to progress their current walking regimen (Let's say they currently walk 2 miles/day), they must get three days of green lights. Example: A day with pain or soreness is a red light. A day of walking 4,000 steps without 24 hrs of those symptoms is a green light. After 3 days of green lights, they can increase it up to a new goal, a 5-10% step increase. This is covered in A World of Hurt.
• It's vital to test Single Leg Stance & 30 Second Chair Test to assess for fall risk.
• We as providers must share unbiased information to our patients to allow for patient autonomy for their health. For example, Carpal Tunnel Syndrome surgery or conservative PT; we must present both sides of the coin if they ask for our opinion.
• The Triad of Evidence-based Practice is: best scientific evidence, clinical experience, and patient preferences. Providing the BEST care for patients takes into consideration all 3 components!
• From the subjective & objective assessment, there's 6 Pain Mechanism Classification System Categories: 1)Nociceptive: inflammatory 2)Nociceptive: ischemic 3)Peripheral neurogenic 4)Central sensitization 5)Afferent/Cognitive & 6)Motor/Autonomic. Again, this is covered in A World of Hurt.
• Working with patients who are elderly and want to improve their quality of life? Incorporate 6 seconds of vigorous exercises into their therapeutic exercise (>5 METS). Resource: http://www.bbc.com/news/health-28400968

CE 2 - Week 2 (OP Ortho, Vestibular, MDT)

• There are 2 speeds a person can walk: self-selected gait speed (the pace you normally walk) & reserved gait speed (the pace you can safely walk as fast as possible). For men over 70, the Grim Reaper walks at 2.0 mph. Thus, we want our patients to walk faster for longevity. We incorporate this in the clinic by: 1) educating our patients why this matters & 2) improving their self-selected gait speed by increasing brief bouts of reserved gait speed. Reference: http://www.bmj.com/content/343/bmj.d7679
• Hug Syndrome is real symptom that patients with Multiple Sclerosis can experience. Yes, it blew me away to learn about that!
• It is fair to educate (& even over-educate), but it gets tricky if you over-administer interventions to a patient. Too many variables may backfire, and you won't know which one helps & hurts the patient.
• My heart still breaks a bit every time I make a patient shed some tears.

CE 2 - Week 3 (Aquatic Therapy, OP Ortho)

• It's incredible what a few water barbells, pool noodles, and kick boards can do to make an entire aquatics therapy session worthwhile.
• Aquatic therapy exercises apply resistance to the opposite motion, thus you are strengthening both sides of the muscle pair - Doing hip abduction? You feel hip adduction resistance.
• Whether you like it or not, several of the aquatic exercises involve core muscle strengthening!
• To provide hip distractions, you add several pounds of ankle weights & go into the deep end (hold onto the corner, otherwise you become an anchor!)
• It is starting to become far too often that I hear from a patient "I wish I knew about all of these [hip precautions, activity restrictions, etc.] before surgery."

CE 2 - Week 4 (Aquatic Therapy, OP Ortho)

• Aquatics can and will help to achieve many patient goals: sit<>stand, balance, strength, ROM, walking/standing tolerance, etc.
• Some patients who would've likely cancelled PT on-land can tolerate an entire session of aquatics with just extra help to get in/out of the pool.
• It's a remarkable & eye-opening experience to see patients with a myriad of conditions (such as Parkinson's Disease, chronic low back pain, fibromyalgia, and cerebral palsy) meet & exceed their goals after a few visits in aquatic therapy.
• Did you know there's Ai Chi for the water? Learn more here: http://aqua4balance.com/aquatic-exercises/ai-chi.html

CE 2 - Week 5 (Wound Care, Lymphedema, Pelvic Health)

• Nothing in this world can prepare you for the odor of exudating wounds. Those wounds are weeping & so is your sense of smell.
• According to one of the PTs, it's a sin for other healthcare providers to be the sole wound care providers. PTs provide interventions such as: debridement, pulse lavage, ultrasound, e-stim, & lymphatic draining. We are part of a team.
• Diabetes can be so cruel and cause not only neuropathic wounds but also big toe, partial foot, or ankle disarticulation amputations. If you're diabetic, please watch your blood sugar & examine your feet.
• Lymphedema is a common side effect post-cancer or cancer treatment and can effect 1 extremity or bilateral extremities. The chances of having lymphedema gets slimmer 2 years post-cancer remission.

CE 2 - Week 6 (Wound Care, Lymphedema, Pelvic Health, OP Ortho, MDT, Vestibular)

• Vitals are Vital! If patient 1 is presenting with perfuse sweating and complaining of shortness of breath, take vitals - BP, HR, and SpO2. Same if patient 2 is presenting with lightheadedness and blue lips. One patient's BP and HR may be normal but SpO2 be 63% (patient 1), or they may be hypotensive (patient 2). Both of these were sent to the ED this week - beyond our scope of practice.
• When giving patients graded exposure interventions of walking, your goal is to have them increase just 5-10% of steps every 3 days of green lights. Too much can undoubtedly set them back for days of soreness and potentially noncompliance with HEP.
• Ice is indicated for the first 72 hours during inflammation. Ice, however, stiffens the joints. Heat, on the other hand, loosens up the joint. Thus, after an initial injury - choose heat over ice when you're looking for a band-aid.

CE 2 - Week 7 (OP Ortho, MDT, Vestibular)

• The Dynamic Visual Acuity Test (DVAT) is highly specific and sensitive to UVH and BVH. If a patient tests negative for the DVAT, you can rule out BVH (sensitivity = 1.00), but still has UVH ruled in (sensitivity = 0.87).
• In PT school, we somewhat brushed over G-codes for Medicare. It's a big deal when 75% of your patients utilize Medicare.
• It seems that many patients come in sharing a not so ideal home health PT experience. Thus, I asked my CI what does it take to become a home health PT. He said a heart beat. Although we were taught that it requires a few years of experience & critical thinking in order to provide quality care in a stand alone setting.

CE 2 - Week 8 (OP Ortho, MDT, Vestibular)

• Claudication versus derangement: how do you rule one out versus the other? Bike test. Symptoms dissolve immediately after stopping the bike points toward claudication.
• Some incredible reads that we recommend to patients (but I am now reading!) include: 7 Steps to a Pain Free Life & Treat Your Own Back - both written by the late & great Robin McKenzie.
• The first few visits for the patient is a constant evaluation to see how patient responds to exercise. Once the patient's symptoms present in a predictable manner in the clinic, then you can progress the patient forward, know what exercises to send them home with, and educate them on how to reduce or turn off their pain.
• I really started to put the pieces together of the Mechanical Diagnosis & Treatment (MDT) classifications of derangement vs. dysfunction after numerous discussions with my CI PLUS a case report example.

CE 2 - Week 9

CE 2 - Week 10

• I never realized how important it is to have a positive environment for our patients. It might sound obvious, but one sour apple in the bunch can completely affect the mood of the entire clinic. Those apples will likely need a private treatment room.

CE 2 - Week 11

• Networking with PTs from across the U.S. is as vital as doing vitals on our patients!

CE 2 - Week 12

• That was an incredible eye-opening 12-week clinical. Thank you to my primary CI for
• During interviews for my PT job, I promise to: shadow at the clinic prior to making a decision/deal, interview the staff PT on site on their experience working there,

CE 3 - Week 1 (IP Acute)

• The biggest safety concerns for PTs and seeing patients includes INR levels, troponin, scheduled doppler exams. Other than that, we are likely seeing the patient if cleared by nursing staff!
• Either I snoozed during this portion of class, or we never learned that for total knee replacements, they either receive an adductor canal block or femoral nerve block during surgery. We care about that in the acute care setting to assess for sensation post-op.

CE 3 - Week 2 (IP Acute, Vestibular)

• Vestibular Evaluations in the acute care setting should really not be gravely different than outpatient. HINTS Exam is put on a higher priority to immediately check for central vs peripheral cause.
• I think the record for number of lines/tubes in a single patient was 10 this week with NG tube, foley catheter, rectal tube, pulse oximeter, BP cuff, tracheostomy tube, IV, telemetry, colostomy bag, and hemovac. Nonetheless, we still were able to perform bed mobility with the patient.

CE 3 - Week 3 (IP Acute)

• You know you're in acute care when...you hear "Texas" & instantly think of the worst catheter in the universe.
• Evaluating/treating a patient in the ICU is not super scary despite the occasional DNI/DNR orders. In fact, it's probably the safest place to treat. They have constant monitors & a personal nurse on staff ready to help.

CE 3 - Week 4 (IP Acute)

• Do not forget, PT peeps, that nursing/CNA staff are not trained as vigorously as us for transferring patients and providing various levels of assistance. Education them - we are the movement experts!
• Training the support staff in different transfers can make everyone a bit more comfortable...and possibly improve keeping the patients mobile in the hospital!

CE 3 - Week 5 (IP Acute)

• It's surely a worthwhile experience to see how the Rapid Response Team (RRT) run through a Code 33 (Cardiopulmonary Arrest).
• Edema from CHF or ESRD significantly impacts even the most basic activities such as sitting with upright posture, standing, and movement of arms/hands!

CE 3 - Week 6 (IP Acute)

• Some patients require a ton of active listening / TLC while others just need a distraction and able to showcase their physical abilities. It boils down to the original comment of not administering a cookie-cutter intervention to the patients.

CE 3 - Week 11 (IP Acute)

• Finally, I was able to observe surgery this week! I spent the entire day in the operating room.
• I observed: anterior cervical laminectomy (w/interbody fusion), total knee replacement with Mako, and a total hip replacement. What a thrilling time!
• The neat part was seeing the patients post-op on the ortho floor test driving their new knees and hips!