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Journey of a DPT Student

Trust Your Instincts

Published July 1, 2013 4:36 PM by Lauren Rosso

If there's anything I've learned in the past few weeks, it's to trust my clinical instincts. It's going to take a long time for me to identify adverse events with certainty and confidence, but for now, I need to rely on that "gut feeling" I get when something doesn't seem right. And for now, that's been enough.

Twice in the past month, I got a bad feeling about the way a patient was presenting. In the first case, I had been working with a patient who sustained multiple subdural hematomas and facial fractures after surviving a pretty bad car accident. To put it kindly, he was not the friendliest nor most cooperative patient; however he would agree to treatment with encouragement.

One day, he looked like his normal self, but he wouldn't respond to me with anything other than a shoulder shrug and a sigh. Even though this wasn't far from his baseline, something just didn't feel right. After speaking to other members of the team who noticed similar changes, we informed the doctors. As it turned it, his subdurals had re-bled and he had another craniotomy to evacuate the masses.

The second time, I was working with a patient who developed encephalitis due to Lyme disease. By the time he got to us in rehab, he was a superstar. His balance, endurance and cognition were all near baseline, and we anticipated his discharge within a week. Then one day, he was complaining of low-back and anterior thigh pain, as well as paresthesia and weakness. It wasn't presenting like radicular nerve root pain, though.

My first thought was that there was intra-articular hip joint pathology, and I feared it was some sort of systemic process as a result of the Lyme disease. Unfortunately, the cause was a polyneuropathy and demyelination of his peripheral nerves, similar to a Guillain Barre presentation. I'm not saying that my "early catch" changed anything, but at least it sparked the conversation and subsequent examination.

I'm glad to know that somewhere in the depths of my knowledge, I know what's "right" and what's "wrong." I'm excited to grow as a clinician and be able to confidently identify these types of adverse events when they begin.

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This was a great read. I am about to embark on my first clinical affiliation as a DPT student and I can't say enough about how this simple post helped to placate some of my unease about clinical. I have often thought worriedly about the nature of my place as a DPT student in terms of suggesting interventions or initiating dialogue about a patient with my CI. I'm somewhat divided in that whereas I feel moderately confident in my knowledge from the classes I've been taking this year, my CI has been working in the clinic for a while now and possesses many of the "street smarts" I can only hope to one day myself obtain.

I fully appreciate the value of good instincts. I've often failed to act on  or second-guessed myself out of listening to my instincts and it has come back to hurt me in the long run. I feel that even though right now I'm worried I'll be unprepared for what's expected of me on my first clinical, I might know more than I think I do and may begin to somewhat unconsciously string concepts together in clinical practice. Also, the fact that you were able to instinctively act on subtle behavioral and physical changes within your patients shows me the importance of heightening all senses at all times to a patient's words and actions and of familiarizing oneself with the patient's "norms".

I'm happy to hear you listened to your own instincts and they served you well. I do wish more clinicians and students would sometimes eschew common and accepted practice for the sake of patient safety when they as physical therapists feel something is not quite right. Too often I hear of cases in which a therapist followed protocol through a therapy session, but acting rapidly on clear signs of distress would have served the patient much better. Although we learn about many interventions, history-taking questions, patient care techniques, etc., it often is the most basic of neural connections which leads us to the right decision in clinical practice and even in life.

Elisabeth Flannery, , SPT ECU March 11, 2014 12:06 AM
Greenville NC

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