Learning the theory

As with any clinical specialty, it is absolutely essential for students to have a thorough understanding of normal structure and function, before being able to identify and consider the abnormal or pathologic. You wouldn’t go to an outpatient setting to assess a patient with acute knee pain without knowing the structural anatomy of the knee joint and the interaction of the muscles acting over it. How can you decide which treatment technique is appropriate if you are unable to identify where and at what level dysfunction has occurred? In the same way, it is essential to have a good understanding of the structural anatomy of the thorax, heart, lungs and vasculature.

Physiotherapy students tend to fall into one of two camps: those who enjoy learning anatomy and find it easy to remember and those who prefer learning and understanding physiology. But like most aspects of the human body, the anatomy of the thorax, heart, lungs and vasculature is intrinsically linked to its physiology or function. Simplistically, anatomy is generally learning a fact, e.g. the heart has four chambers, whereas physiology requires a level of applied understanding, e.g. the four chambers of the heart contract and relax in a co-ordinated manner in order to move deoxygenated blood from the body through the lungs for oxygenation and carbon dioxide removal, ready to re-enter the systemic circulation. So you could say that anatomy provides the structural basis on which to understand physiology and therefore must be learnt first.

Tips for learning anatomy

Unfortunately, unlike the skeleton you got in order to learn musculoskeletal anatomy, you won’t be given a heart and a set of lungs to keep in a box under your bed! Shame, because the visual memory of actually being able to handle something is a great aid to learning. It’s much easier to remember the structure of an organ and how individual components interact when you can physically take it apart and reassemble it. This is particularly true of the heart and lungs, as most imaging of these organs provides a two-dimensional representation of what are three-dimensional structures. You may be at a university which offers you the chance to watch human cadaver dissection, which is a memorable event, to say the least; mainly as the smell of formaldehyde stays on your clothes for several hours after you leave, no matter how many times you wash your hands or spray your uniform with Febreze!® Alternatively, students have found exhibitions such as “Bodyworks®” useful for visualizing human anatomy. Virtual or three-dimensional interactive images are often available on the internet (e.g. www.anatomy.tv) but often require a license or subscription, which make them expensive for an individual but they may be available on campus. However, most universities have access to models of the heart and lungs which can be taken apart to reveal both external and internal structure.

Try drawing and labeling the anatomic structure of the heart, lungs, thorax and vasculature to reinforce learning and utilize visual memory. It is also a great way to self-test your understanding and recall. Use a skeleton to help understand how the typical and atypical ribs are different, and how that relates to their function. Look at the shape of the thorax and relate its structure to the normal mechanics of respiration.

When you start clinical placements, take every opportunity to watch any surgical procedure or clinical intervention. Cardiothoracic surgery is fabulous if you can watch, especially if you are able to stand at the “head end” and peer into the chest cavity. This is a wonderful way to visualize and consolidate anatomy; there is actually very little blood and it really helps to put structures into context. Don’t touch anything covered in green surgical cloth or you will incur the wrath of the surgeon and his team, and if you feel faint or sick, always move away from the operating table as quickly as you can! Other clinical interventions such as bronchoscopy are also invaluable; being able to actually see inside the bronchial tree really helps to reinforce the structural anatomy of the airway and mucosa plus how these structures relate to function.

There is a wide range of “normal” in the general population, so the more “chests” you can review, the more familiar you will become with normal variation. Practice surface marking the heart and lungs on as many different people as you can and make sure you recruit both male and female models to practice on so you learn to accommodate for additional soft tissue! One good landmark to remember is in most cases the bra cup follows the line of the sixth rib.

Tips for learning physiology

Before embarking on learning physiology, remember to familiarize yourself with the anatomy first, as the structure of the cardiopulmonary system directly relates to its function. Remembering physiology is all about understanding; it is often sequential and may tell a story. Once you understand the story, remembering it becomes easier.

Writing your own flow diagrams of the key principles and points is a great way to condense the core information and also provides a fabulous revision tool for later on. This also works really well for learning pathology. Alternatively, read through each physiology lecture and pick out the top 10 points and bullet them in order. Learn the bullet points, which then act as a memory prompt to aid recall of the additional information.

The internet is an invaluable resource for learning normal physiology, pathology and dysfunction. Websites provide a wealth of simplistic explanations which have been written for the lay person. If there is an area you have difficulty in understanding, start by reading literature at this level. Once you have learnt the basics, increase the depth of your knowledge by using a more informative website aimed at undergraduate nurses or other allied health professionals. As your understanding grows, utilize literature and texts at a higher level, increasing the depth of your knowledge and understanding. Most physiology texts come with an accompanying CD which often provides a more visual approach to learning.

Tips for learning physiotherapy

All effective physiotherapy intervention aims to affect or reverse underlying physiological dysfunction. Therefore, in order to be able to use clinical reasoning to select an appropriate treatment, a thorough understanding of normal and abnormal physiology is required. You can’t get away from the fact that you have to know the anatomy and physiology! Once you understand how an intervention, technique or adjunct works, then it can be “matched” to the physiological dysfunction identified on assessment. One textbook which students find very useful (Cardiopulmonary physiotherapy, Jones & Moffatt 2002) is written in this format; firstly common physiological dysfunction is identified and described, then possible intervention modalities which may be used in treatment are outlined with their key physiologic principles, supported by an evidence base.

Many universities have access to mannequins which can be used to practice manual hyperinflation and endotracheal suction, nasopharyngeal and oral suction and other physiotherapy intervention. Where available, use these resources to practice technique, because often the hardest aspect of something like endotracheal suction is actually getting a glove onto a nervous sweating hand, while holding the catheter under one arm and maintaining “aseptic or clean” technique, all under the scrutiny of the clinical educator!

Interactive DVDs, web-based sites and other media packages are very useful tools for learning physiotherapy techniques and skills; many DVDs and interactive CD-ROMs are available for loan from the BMA library or other similar outlets. Medical equipment manufacturers often produce fabulous interactive “teaching” packages to accompany their products. Try using a search engine to find an interactive site which may help you. Littmann® provides a comprehensive guide to auscultation and breath sounds (http://solutions.3m.com/wps/portal/ 3M/en_US/Littmann/stethoscope/education/educational-cd/lung-sounds/); similarly Dräger Medical® offers several excellent interactive teaching packages and down loads covering use of their mechanical ventilators (www.draeger.co.uk/MTms/internet/site/MS/internet/UK/ms/lib/Demos/int_lib_demo_evita.jsp).

BENCH TO BEDSIDE

Cardiopulmonary physiotherapy is an area where students often find it difficult to relate theory to practical application. It’s hard to visualize the problems of a breathless patient if you have never seen one, never mind understanding how changing the patient’s position may be of benefit. But most students report that as soon as they have used this knowledge on clinical placement, it all fits into place.

Preparation for clinical placement

This is where it gets really interesting! Analyzing the assessment of a cardiopulmonary patient is like doing a jigsaw, putting all the different pieces together to produce a clinical picture. Try to visualize the patient as a whole, thinking about how the body systems interact, rather than just thinking about the heart or lungs in isolation. Currently, cardiopulmonary physiotherapy is much more rehabilitation focused compared to the “shake ‘n vac” image of old! Although physiotherapists tend to choose an area of clinical specialty, one of the skills of being an effective clinician is being able to think outside a diagnostic label and treat all presenting problems, whichever body system they may affect. All therapeutic intervention and clinical skills are transferable and can be applied as indicated.

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