On returning after the weekend, my C.E. and I learned that Mr A had deteriorated over the last two days and had been transferred to a side room. Mr A’s SpO2 had dropped again and was unreponsive to stimuli on either side. On auscultation, Mr A had minimal breathing sounds in the lower aspects of his lungs and crackles higher up. It was also during auscultation that I noted the patient had an increase in temperature, indicating infection. I suggested repositioning the patient and attempt to suction him in order to remove the fluid within his lungs. When applying suction, the fluid coming out was thick and cream coloured, leading myself and my C.E. to suspect that Mr A had again aspirated. During suctioning, Mr A began to cough continuously, so I withdrew the suction catheter and replaced it with a “Yankauer” suction tube in order to remove any expectorated into Mr A’s mouth. However, Mr A’s coughing led to copious vomitting at which point I applied the “Yankauer” suction in order to reduce the risk of any vomit entering the lungs. Two nurses then arrived and took over caring for Mr A..
The aftermath was a compulsary in-service training event on how to feed a patients with NG tubes in situ. Mr A’s SpO2 did improve that day and he was awake to see visitors, though he was fatigued and drifted in and out of consciousness. Unfortunatley, his condition deteriorated over the next few days due to a severe chest infection and a suspected second stroke affecting his right side. After assessment by the medical physicians and other senior members of staff, the family agreed to place Mr A on the Liverpool Care Pathway, which is a form of palliative care. Mr A passed away in his sleep after two weeks, during the weekend before my last week of placement.
With regard to the overall case, I was deeply saddened by the result and shocked at how quickly a person’s status can change over a relatively short period of time. I chose this experience due to my presence throughout the whole case and that it is where I believe I will be able to learn and develop the most during relection.
For example, I felt that my first meeting with the patient probably did not leave a good impression with my clinical educator as I was very disorganised and unprepared at the time. I found it frustrating that I was spending more time trying to remember the phases of the assessment than actually performing it. Also, when it came to using the bird, the presence of a mask and high-flow oxygen was distressing to Mr A and at the same time made me uncomfortable as I felt I had to force something upon him. When it was decided that suction had to be performed, I was hoping that I wouldn’t be asked to part of the procedure as my experience was extremely limited. I had previously observed two procedures and practiced once on a model at university, and I did not feel confident to perform one at this time. My C.E. understood my reluctance and took over, but kept me involved in the treatment process, allowing me to still learn from the experience.
Following the incident, I realised that I could have been more prepared and that if was able to remain calm at the time I could have performed better. Over the next few days, I decided upon an action plan to address the issues that arose. I began relearning the assessment process with the help of other staff who offered advice. Initially, I still took a bit longer than expected to perform assessments, but as I gained more experience and became more comfortable process, it became easier. The same could be said about my practical skills. Since I came to realise that at some point I would have to be able to suction a patient, I decided to practice my skill on a model with advice given by other practictioners and health professionals who perform the procedure. With regard to my reaction to the patient’s discomfort where I had to fix the mask onto Mr A’s face, I decided to discuss it with my C.E. and another practitioner who regularly performs the treatment. Both were understanding and said they felt the same way when they first started. They explained that it was necessary for some uncomfortable treatments to be done for the longterm benefit of the patient. After seeing the results of the treatment the next day, I finally came to understand what my C.E. and the other practitioner were trying to explain.
After returning and meeting the patient after the weekend, I was worried that our decision to allow Mr A remain sat out in his chair had fatigued him and contributed to his decline. I then reflected on the fact that as a student, my C.E. would be accountable for my actions. However, my C.E. assured me that it was the patient’s choice to sit out and there were any number of factors attributed to his decline. She also noted that she agreed and cleared my decision to let him sit out.
My C.E. concurred with my suggestion of suction and as she knew I had been practicing during the past few days on the dummy, suggested that I perform the procedure under supervision. After preparing all the equipment and repositioning the patient in long supported sitting, my C.E. told me to say what I was doing as I was doing it and I found it did help to calm me down. I managed to get the suction catheter down after two attempts, which caused some minor discomfort to Mr A, but he did not seemed distressed. At the time, I was pleased that I was able to complete the procedure but I became annoyed when I saw that feed being suctioned out. There had been clear instructions about feeding the procedure yet someone had ignored them. I was shocked when the patient vomitted as, initially, I was only expecting some minor secretions in his mouth, but due to being prepared I was able to adapt and use the yankauer suction to remove the vomit.
At the time, I was constantly worrying about what the repercussions of my decision would be and my confidence decreased. This directly affected my decision making skills for the rest of that day. However, using my own personal notes I was able to assess my feelings at the time and evalute reasoning behind my decisions. I was then able to draw from the experience of what happened on a personal level to aid in my future practice.
Throughout the experience I found my C.E. to be very supportive, giving me advice, time to reflect, and directing me toward resources that would aid in my learning. I also discorvered, on a practical level, that simulated practice was extremely effective, giving me more experience and increase my confidence in my own ability. Tuttle et al. (2007) further explains the beneficial nature in which simulated practice allows students to become more competent in practice. Baker et al. (2012) also supports this and also outlined the benefits of collaborating with other professions to practice skills.
On reflection I find that a positive aspect was that I was present throughout the whole length of the case with my C.E. guiding me through allowing me to observe, given time to practice and then asked to perform suction on a patient. I was also fortunate in that I was able to witness and contribute to make decisions with regard to which treatments would be suitable for the patient.
On the other hand, I found that there were times when there was too much to learn, which was quite stressfull. As well as the practical aspect of my learning, I had to supplement that with factual knowledge. However, I was reminded by my C.E. that it wasn’t possible to learn everything at once and the most effective way was to learn as I work.
On analysis of the treatments given, I found sufficient literature to support the decisions made. First of all, was the use of the “bird”. In 2001, Berney and Denehey concluded that even though the use of IPPB was contreversial and inconsistant, there was a general agreement on physiological effects such as ability to decrease work of breathing to produce a more effective cough, which was our goal for Mr A. However, I felt that instead of holding the mask in place I could have found a mask with and elastic strap, freeing my hands for other jobs. When it came to suctioning, Law (2008) stated that “alternative air clearence techniques should be considered first”. However, I was reminded that this was classed as an emergency situation and “the purpose of tracheal/endotracheal suction is to remove pulmonary secretions in patients who are unable to cough and clear their own secretions effectively. The patient may be fully conscious or have an impaired conscious level” (Endacott, Jevon and Simon, 2009). With regard to the decision for Mr A to sit out for a long period of time I looked to Askim et al. who summarised that it is feasible for patients with a severe stroke to sit out. However, they also noted that most patients with a moderate to severe stroke spend between 31.0%-59.2% of a nine hour period out of bed. Even with Mr A’s stroke status downgraded from severe to moderate, he still spent more than the recommended amount of time sat out of bed.
As discussed previously, practical skills and factual knowledge are intergral to a physiotherapist’s practice. I’ve also come to realise during this reflection that as the case prgressed, my C.E. had allowed me to make more decisions, regarding the patient’s interventions and tested my knowlegde by asking me to clinically reason them. As time went on, she became more passive and was only present in order to supervise, aid and intervene if needed. My C.E. supported me from a learning perspective as well, ensuring that I had enough resources to further my development of which I am grateful.
Overall, I believe that this was a valuable learning experience for me in that I feel like I have grown on a personal and professional level, as well as had the ability to improve my practical skills. It has also made me realise what my limits at the time were, and exposed my weaknesses. I have determined that there are a number of factors that determine how confident I am. For example, if I have knowledge of an upcoming situation, I can prepare by asking questions then learning the relevent information or practicing the required skills. If the situation is unforeseen, remaining calm and drawing from past experiences will help me through. If I have deemed that I do not have the means to deal with the situation, I can always ask for help. However, one of the main things I will take away from this placement and reflection is something my C.E. told me. That in physiotherapy it is not possible to fully prepare yourself for every situation and that it is an ongoing learning experience. As a second year physiotherapy student who has just completed his first placement, I know that there is a lot more to learn.
Askim, T., Bernhardt, J., Løge, AD., Indredavik, B., 2012. Stroke patients do not need to be inactive in the first two-weeks after stroke: results from a stroke unit focused on early rehabilitation. International Journal of Stroke, 7(1) pp. 25-31
Baker, C., Medves, J., Luctkar-Flude, M., Hopkins-Rosseel, D., Pulling, C., Kelly-Turner, C., 2012. Evaluation of Simulation-Based Interprofessional Education Module on Adult Suctioning Using Action Research. Journal of Research in Interprofressional Practice and Education, 2(2) pp.152-167
Berney, S., Deneby, L., 2001. The use of positive pressure devices by physiotherapists. European Respiratory Journal 17: pp.821-829
Denehy, L., Berney, S., 2001. The use of positive pressure devices by physiotherapists. European Respiratory journal, 17(4) pp.821-829
Endacott, R., Jevon, P., Cooper, S., 2009. Clinical Nursing Skills: Core and Advanced. Oxford: Oxford University Press
Law, C., 2003. Using mucociliary clearance methods that do not require an artificial airway. Nursing Times, 99(41) pp.57-59
Penuelas, O., Frutos-Vivar, F., Esteban, A., 2007. Noninvasive positive-pressure ventilation in acute respiratory failure. Canadian Medical Association Journal 177(10) pp.1211-1218s
Tuttle, R., Cohen, M., Augustine, A., Novotny, D., Delgado, E., Dongilli, T., Lutz, J., DeVita, M., 2007. Utilizing Simulation Technology for Competency Skills Assessment and a Comparison of Traditional Methods of Training to Simulation-Based Training. Respiratory Care, 52(3) pp.263-270
by
maximus2210 (student)
