Clinical Education I: Integrated Clinical Experience

Today I finished my first clinical experience!

Simulation week:

While heading into the virtual simulated activities, I was overly confident in my ability to concisely evaluate and treat the given patients. However, this sense of extreme confidence began to decline once I realized that it’s a daunting task to remember and mentally reorganize everything I have learned within my first year of PT school while also reacting to the patient’s situation. Even though the virtual simulations were frustrating at times, I appreciate the challenges I was able to think and work through.

The “Molly” simulation was the first time I had been able to watch and think about how to interact with a patient that truly does not want to be doing physical therapy. Throughout the session, Molly made small comments about how the PTs were bothersome and how she wished they were not working with her. During the session, she also refused to do the ther-ex activities. I enjoyed being able to watch the videos of how the PTs handled the situation in a respectful manner while also explaining to the patient the importance of physical therapy to reach her goal of going home. This aspect of the simulation emphasized the importance of actively listening to a patient’s feelings and fears while also educating the patient on how the therapy will make them stronger and safer to return home. Another important lesson that I noticed throughout the Molly simulation was the impact that a patient’s comorbidities can have on their present status. It wasn’t until doing the simulation that my brain fully grasped, we, as therapists, have to consider all aspects of a patient’s health and not just the current issue that we are there to treat them for.

The primary takeaway from the Alex simulation was that just because a patient/case appears to be clear and easy, it doesn’t necessarily mean that it will be. Instead, I learned that PTs should enter the patient’s room prepared for the unexpected especially in the acute care system. Additionally, I think that this simulation emphasized the role that therapists have in educating the patient in a way that he/she can truly comprehend what is going on with one’s body.

There were a few things that really stuck out to me in both the Molly and Alex cases. Since I haven’t had the opportunity to do much shadowing in acute care, it became extremely clear that it is essential to thoroughly read the patient’s medical chart before going to see the patient. It hadn’t really become clear to me before the simulation how vital it is not only to read the chart, but to understand how the information may impact the patient during the session. Furthermore, I really enjoyed the collaboration part of the simulation with various healthcare professionals. I haven’t been able to do this sort of interprofessional collaboration before, so I struggled with knowing who to talk to and what sort of questions should be asked.

Things that I think went well for myself and my group members during the live simulation include treating the patient in a respectful manner, communication when there were multiple people in the room during the session, asking for help when it was needed, and instantly integrating the feedback that was given during the debriefing sessions.

There were so many things that I learned during the live simulations. Some of the primary takeaways from the live simulations that I believe I could improve on include:

  1. How you interact with the patient can fully alter how the therapy session will precede. Small actions such as getting down on eye level while speaking with the patient, asking preferred name to be called, and turning on a smaller light in the room rather than the large overhead one can have a huge impact on the patient and the rapport that is built. Additionally, use the session as a space where the patient can speak about their fears and anxiety about medical changes and provide education to mitigate those fears.
  2. Taking a small pause during the session to just think and take a deep breath can ensure that safety is maintained and the session goes smoothly.
  3. Be flexible and willing to pivot your plan based on how the session is going. Especially in acute care, things will not always go as planned so its important to be able to adapt what is being done, wording of instructions, etc. Along those lines, good communication with others in the room helping during the session is vital in order to keep the patient safe.
  4. Pay thorough attention to vital signs and what the vitals are actually telling you about the patient’s health status. It’s extremely important to not just read the numbers but to consider what is going on with the patient’s body at that moment. Thus, vital signs can be used to dictate what happens during the session—does the patient need to take a break, are breathing exercises, is the patient about to pass out, should the treatment session be ended. However, therapists must consider the best times to actually take vitals instead of constantly taking them and having the patient constantly thinking about numbers or their pain level.

 

After being able to participate in the simulation week, I feel much more confident going into my clinical even though some nervousness is still present. I believe that the simulation week was extremely beneficial in the sense that it allowed us to work in teams to think through how best to treat the live patient. This allowed me to start piecing together how all the information I learned this year all connects and impacts one another during treatment sessions. A few things that I would like to work on next week in clinical include: safely completing gait training while guarding the patient, management of lines and leads, and cueing the patient in a way that is more conversational and easier for the patient to grasp and conceptualize.

Heading into the clinical week, the behavioral objectives I set for myself were:

  1. By the end of the week, the student will be able to write a SOAP note with all essential information included within 15 minutes with supervision by the clinical instructor.
  2. The student will be able to safely manage lines and leads during a patient transfer and mobility with stand by supervision from the clinical instructor by the end of the week.
  3. The student will actively seek feedback on her performance from the clinical instructor at the end of the first day and each following day of that week.
  4. The student will be able to safely ambulate a patient down the hospital hallway with minimal assistance from clinical instructor by the end of the week.
  5. The student will be able to thoroughly conduct the initial patient interview in a timely manner with supervision from the clinical instructor by the end of the week.

Clinical week: VCU Surgical and Trauma ICU

Heading into the clinical, I was anxious and nervous. This was my first time as a PT student that we would be going into a real clinical experience. Furthermore, I had never shadowed a PT in the acute care setting due to COVID except for the two half day experiences from Rehab I during our fall semester. I had no idea what to expect and was worried I wouldn’t be able to treat patients in such critical health conditions.

Throughout the week, I was lucky enough to be able to see a wide variety of patients—post transplant surgeries, intubated patients, those that had experienced trauma, and so many more. My CI, Leah, did an amazing job at gradually leading me to do tasks more independently. Throughout the week, I went from mainly observing on the first day to doing a subjective history with a nonverbal patient and managing multiple lines and leads while walking a patient down the hall. Each day, I had the opportunity to practice writing SOAP notes about the patients we had seen. My CI took the time to go over my notes with me each day to help me see how each could be improved. As the week went on, I was able to get through writing quicker while also integrating the feedback that I had gained throughout the week. Throughout the week, I additionally learned a ton of information about lines and leads that went beyond just how to manage them during transfer and gait. I gained an understanding of which lines/leads could be disconnected during the session (when and how long), how to put a chest tube on/off suction, how to gauge a patient’s vitals to see when a tele/pulse ox should be removed before gait, and what information about lines/leads should be communicated with nursing staff before and after a session. While I was extremely nervous the first time or two mobilizing a patient with multiple lines and leads attached, by my last day, I was able to ambulate a patient down the hall with just the supervision of my CI.

The greatest challenge I faced during my clinical experience was being confident in myself and trusting what I have been taught during my first year of PT school. I think that this was challenging for me because during school we had only practiced on each other (all of whom were healthy) and the lines and leads weren’t actually attached to one’s body. Thus, stepping into the ICU, I was extremely nervous that I would hurt a patient who was already in pain. While I knew my CI wouldn’t let anything bad happen, I struggled with trusting myself when making decisions about the patient in front of me. Additionally, another challenge that I faced this week was trying to find a balance between caring for a patient without becoming attached. Several of the patients were so incredibly kind and understanding that I was a PT student; therefore, it was frustrating to only be able to see some of these patients once due to them moving to out of the ICU. Obviously, I was thrilled that they were improving enough to move out of the ICU, but also sad that I wouldn’t be able to see the progress they would make.

The thing that surprised me the most was understanding that you never truly know how a patient is going to react before going into a session and your premade plan may be completely altered. There were many patients who surprised me with how they actually presented compared to what injuries they had. Two examples of this include a liver transplant patient who was up and walking without any assistive device after only 3 days post-surgery and a gunshot victim to the head who was able to walk with little to no assistance upon eval.  I was often amazed with what the patients were able to physically achieve while they were in the ICU and despite the intense pain he/she was in. This really emphasized the concept of treating what you see compared to treating what you think a patient should present based on his/her diagnosis.

Throughout the week, my CI demonstrated two of the APTA core values exceptionally well: altruism and caring & compassion. Leah always went out of her way to help her patients in any way she could—whether this was listening to concerns and fears, making a joke to lighten the mood, explaining what one’s diagnosis truly meant, and brushing and braiding a patient’s hair to make the patient feel better. Leah consistently made her patients feel safer and respected by showing them that she was a real person. Additionally, Leah was always willing to help other hospital staff to aid in patient care. This included helping other physical therapists or the nursing staff on the floor—whether it was seeing a patient who required higher levels of assistance or cleaning up a patient and the room after a bowel movement. All of her actions throughout the week demonstrated her genuine desire to help others while also considering one’s fears, emotions, and needs.

I absolutely loved my week-long clinical experience in the STICU at VCU. I wish that the clinical experience had been longer, and I could have spent more time there! Going into my second year of PT school and future clinical experiences, I really want to improve my level of confidence and trust in myself. While there will be clinical instructors present during my clinicals, I need to learn to trust my abilities to treat patients based on the knowledge that I have been taught up to that point. I also want to work on my ability to be more assertive during PT sessions with patients in which I am confidently leading the session and taking initiative. Even though I still have so much to learn, I am also extremely proud of myself for the progress I made throughout this week. I went from being terrified the first day while just observing to being able to complete line/lead management, bed mobility, transfer, and gait with a patient with supervision of my CI. If I learned anything, it’s that PTs must be extremely flexible in acute care and be able to be able to pivot one’s plan ASAP.

Virtual Gallery

Hurt by Johnny Cash

While I believe that the entire song Hurt is representative of physical pain, there are certain lyrics that stand out more than others. I believe that the song expresses how individuals with chronic health conditions or constant physical pain start to view him or herself and one’s life.

I focus on the pain, the only thing that’s real. The needle tears a hole, the old sting.”

For those with chronic or intense symptoms, pain becomes a part of who they are as individuals- whether this is how they view themselves or how they believe society views them. Physical pain can be immersive and all consuming. If the pain is constantly present, it may begin to take over one’s thoughts and lead the individual to obsess over it. Thus, the presence or absence of the pain can impact one’s view of reality since it has become his/her norm.

 Try to kill it all away but I remember everything. What have I become? My sweetest friend.” 

Pain can take a toll not only on one’s physical health, but additionally one’s emotional and mental health as well. While the pain may lessen or subside, those with chronic conditions are constantly aware of the impact the disorder has already had. Such impacts may include friendships, family relationships, education, and employment. Therefore, while the patient may be willing to do anything for symptoms to be relieved, he or she will still remember the influence that such pain has already had on one’s life.

Additionally, pain and chronic conditions have a huge impact on self-image. A change in self-image may be due to physical alterations, loss of confidence, hopelessness, or how much other members of society attempt to understand the pain. The reference to “what have I become” may also relate to how the individual has chosen to cope with the pain or any changes in one’s life due to such coping.

Full of broken thoughts I cannot repair. Beneath the stains of time, the feelings of despair.” 

If pain cannot be relieved or subsided, a person can be driven to feelings of hopelessness, anxiety, and depression. These emotions strongly impact one’s thoughts about the situation and the ability to continuously suffer through the pain. Therefore, I believe the lyric relates to how a person will progressively lose hope of recovery as more time passes without success.

While interpreting the song Hurt by Johnny Cash, I became aware that pain is a consuming experience that can impact a person’s self-image and self-confidence. For those with chronic conditions or long lasting pain, the feelings of pain can become one’s sense of reality; since the pain is constantly present, having pain allows the person to know that he/she is awake and alive. Furthermore, for many, pain is not a single experience that ends without having an impact on one’s life. Instead, people are reminded of how the pain impacted their lives physically, emotionally, socially, and mentally. Lastly, the song demonstrates the concept that if left untreated, such pain can lead to despair, desperation, and depression.

Questions: As healthcare professionals, what role do you believe PT plays in impacting how physical pain impacts a patient’s self-image? What are ways PT can help prevent feelings of despair in patients with continuous pain or chronic conditions (especially those that are uncurable)?

Welcome to my page!

Hi! I’m Shannon Cash, and I am a student physical therapist at Virginia Commonwealth University (VCU) in the class of 2024. I’ve lived in a small town in North Carolina my entire life, and I’m excited to undergo this new adventure. I received my B.A. in Exercise and Sports Science at the University of North Carolina-Chapel Hill in December of 2020.

I initially knew I wanted to go into a profession that helped people after my grandfather was diagnosed with Progressive Supranuclear Palsy (PSP). I watched him undergo the emotional and physical hardships of losing muscle control, the ability to walk, and eventually the ability to feed and care for himself. However, it wasn’t until I met my friend, Wallace, in undergrad that I knew that physical therapy was the career for me. Wallace suffers from a rare autoimmune disease that has taken a toll on her body for around ten years. After suffering from seizures during her junior year, Wallace lost the ability to walk completely. By having the opportunity to watch her relearn to walk, a basic skill that each of us take for granted daily, and the dedication that it took, I knew that I wanted to be part of the career that gave my friend her independence back. Today, Wallace is able to walk independently without a wheelchair or walker.

The purpose of this site is to showcase my professional and personal development throughout my physical therapy training at VCU. Hopefully, it becomes a tool that will allow me to reflect upon my journey of entering into the PT profession. I plan to add and publish updates throughout my education and future career. I hope this is a beneficial way for others, and myself, to observe both my professional accomplishments and personal reflections. Thanks!

 

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