No Ordinary Therapy

Update on Joel

Joel had a tough week. He began the week with bilateral LE DVTs, which not only made his legs feel heavy and swollen, and gave him a lot of pain, but also meant standard bed-rest precautions, and  consequently, Joel was extremely frustrated with the halt in progress. Still, he was in fairly good spirits and was willing to participate in some UE neuro-re-ed and fine motor control work.

By Tuesday, I began to notice some different behavior in Joel. Having been initially very well-mannered, compliant, motivated and willing to engage, suddenly Joel would no longer make eye-contact, he stopped initiating conversation, only provided minimal responses to questions, and was unmotivated for therapy. As staff, we began to consider a delayed but normal stress response and some expected frustration in the light of the DVT development. Having been up and about and making excellent progress the week after his stroke, suddenly finding himself on bed-rest was understandably cause for irritation and disappointment. Joel was also being seen by neuro and vascular students several times a day, and we believed that the invasive nature of these tours was causing this otherwise private man to become even more disgruntled with the hospital in general.

In the meantime, Joel's doctors ordered some standard tests in the light of his past history of lung cancer, which had been clear for the past six years.

However, Joel became increasingly rude as Tuesday passed into Wednesday and his behavior often bordered outright belligerence. He also seemed to get less of what we were saying, required more verbal cues for sequences, and appeared more impulsive than before. Then Joel also admitted to changes in his vision and all those little red flags that had been waving at us for a couple of days began to signal more strongly.

It turns out that apart from a cva, a state of hypercoagulation and bilateral DVTs, Joel's lungs are full of masses. When I left on Friday afternoon, there was an investigation under way to find out if the sudden changes in Joel's behavior was a result of a new stroke or mets to the brain.

As I said in the beginning... it was a tough week for Joel.

2 Minutes for Molars

It was my turn to work Saturday this week, so after recovering from dish rag syndrome last week, I've just completed (and survived) a six day working week. Thankfully, one of my favorite therapists was the other person called into action and Saturday went by pretty smoothly with a few laughs along the way.

I have a very interesting caseload right now, which is pushing my creative buttons. I also find myself in the exquisitely uncomfortable position of leaning rather heavily against the boundaries of my existing knowledge base and experience. The great thing about this profession is that just when you think you've found your stride and you vaguely know what you're supposed to be doing, someone shows up on the unit with a rare disorder... or a strange mix of co-morbid factors... or an atypical presentation of a condition you know well.

Right now, I have a patient (I'll call him Joel) who has just experienced a cva and has some right-sided deficits, but he also presents with some significant OCD-type behavior (pre-stroke, apparently). In many ways this makes him the ideal candidate for therapy because he does everything you ask him to do, in exactly the way you've shown him, but it also means that I have to tread very carefully when giving directives or setting up a session. For example, in a typical session with many stroke patients I might address neuro-re-ed, coordination, fine-motor control, and visual-perception via a sink-side grooming task... brushing teeth, shaving, combing hair, make-up etc. This is an ideal, purposeful 30-45 minute session. However, with Joel I've learned that apart from needing to perform these tasks in exactly the same thorough way every day, it's also extremely difficult for him to just perform grooming tasks at the sink without completing every other aspect of his morning self-care routine, which includes toileting, full-body bathing, and dressing. Isolating any one single task from this routine, or even selecting a couple of tasks, is painfully out of context for Joel, yet the entire process takes approximately an hour and a half.

My problem is that I have a list of other things that I really need to address with Joel. The obvious solution would be to direct the nursing aides to set up and assist with his morning ADLs, and explain that it's important that Joel perform certain tasks in a certain way in order to help him recover from his stroke, but from experience I'm afraid this rarely gets carried through. For a start, the nursing aides have a tight schedule and are usually overworked (and underpaid) as it is, which is why they so frequently ignore any requests to allow the patient to perform ADLs in a therapeutic way and instead will provide the in-bed-car-wash-special while the patient just lies there passively. They just don't have an hour and a half to devote to one patient and Joel still needs supervision and assistance at this stage. Sometimes, we can educate family members to assist with this type of routine, but Joel's family all work or live outside the state.

Anyone have any thoughts or suggestions?

Dish Rag Detox

Hmmmm... been down and out with a recurrence of trigeminal neuralgia these past few days, so I haven't been to work. It's not often that I take time off for health reasons but this was getting me down, and with a six day week looming, I decided to be proactive and do some self-care stuff. I slept for about 12 hours straight, which is unheard of these days. I haven't slept that long since I was about 17 when it's obligatory to sleep like you're under a spell.

There's nothing worse than trying to givegivegive to sick people when you feel like a wrung out dish rag yourself, especially if you're also in severe pain, so I decided to do the honorable thing and get out of there before I said something totally inappropriate and unsympathetic (hey, don't tut and look at me disapprovingly - I'm human!)

The time off has done me the world of good, although I think I would really benefit from a few days by the ocean, with some fresh air and sunshine... or from a spa getaway with a steam room, massage, and mineral springs... or from getting a lungful of fresh mountain air and exposure to some negative air ions after hiking for an afternoon...

Ah well, soon enough. For now it's BJs and laundry this afternoon, but I can still dream... right? 

Bed Crumbs

Sooooooooo cold today and scrubs are definitely not warm. In fact, I may as well have been standing on the railway platform in my pajamas this morning. I also forgot my hat and now I have an earache.

Monday in a hospital can sometimes be hard. Patients have often succumbed to weekend inertia and a break in routine, and after two days of clock watching, reading the menu from cover to cover, and picking the crumbs out of their beds, they're often lethargic and a little glum. Not always, of course, but a lot of the time. Rather than pick up where we left off on Friday, it often feels like we have to take a few steps back and slowly gather momentum again as the new week begins. Even patients who are appropriate for the Saturday schedule and have had that extra day of therapy will often report that Sunday in a hospital feels like a week and can be torturous.

So, what can we do to a) prevent our patients from dying of boredom at the weekend, and b) keep our patients on track with therapy?

There is an easy answer to each of these questions but no easy application. I'll write more about the solutions when I don't have an earache and a compulsion to watch Supernanny.

Later...   

I'm Back... I Think...

Good grief! I can't believe it's been so many months since I last posted. November? NOVEMBER?? I guess I needed a rest or something.

It's been busy as usual, what else can I say? Students, Christmas, New Year, new rotations, new patients, going back to school, extra trainings, as well as all the other stuff that keeps us from spending our time on the sofa re-reading the Harry Potter series.

One of my main reasons for not posting is that at the start of the new year I began a rotation at our satellite unit in Boston, which involves taking the train. This means being at my local commuter rail station at 6:20 AM so that I can fend off all the SUVs and Volvos and get a place to park for the day, and sometimes, I don't get home until 6:30 PM because of the stupid return schedule. On Thursdays, I go to Tufts for an OTD class and don't drag my weary butt through the door until 9:00 PM! As you can imagine, by that time I'm not at my creative best. I check email, look for clean scrubs, wash out my travel mug, and look forward to bed...

Anyway, despite all this I'm hoping to start writing again on a more regular basis.

"Once More Into The Breach, Dear Friends..."

Crazy week... Even more than usual...

My Monday lecture went well - at least I enjoyed myself. I was teaching about the role of narrative and narrative reasoning in the clinical reasoning process to a class of second year grads at Tufts. I know sounds like a yawn but how we think is the essence of OT so this stuff is important. The yawn-free you can make the better though. I didn't actually see anyone falling asleep but having been a grad not so long ago I know that it's possible to sleep with your eyelids strategically taped open for a couple of hours.

On Wednesday, five members of our department called in or were on vacation. It just so happened that we also had 98000 new admissions. We had another of those Henry V speeches from our team leaders and we all strode off into the vortex of hospital chaos for a day of blood, sweat, tears, long-handled shoe-horns, and the occasional round of balloon volleyball. At this point, I have to give public praise to my student who somehow coped with two discharges, one AMA, three complex evals, treatment of our own patients, and coverage for the absent therapists.

At the end of the week I discovered that I'm supposed to give an OT/PT inservice on the subject of pain meds next Wednesday, so rather than completely allowing my wee brain to recover this weekend, I'll be cranking out the quick and dirty on the most commonly used analgesics in our particular setting. I also have my student's midterm eval to complete. And there was me thinking I'd leisurely start my Christmas shopping this weekend...

A Few Extra Brain Cells...

Today I had one patient go out acute for respiratory distress and two leave for surgical follow-up sessions, which meant 7 unproductive units (that translates to an hour and forty-five minutes). Doesn't sound like much, but when you're usually slammed because you're carrying a full caseload and training a student an hour and forty-five minutes can feel like a whole glorious day of emptiness stretching out in front of you. Of course, there are always things to do...

Today my student and I took a little more time to go over documentation. It was a big milestone - documenting straight into the chart without copying from an edited draft (yes, we're transitioning to Meditech and computerized charting but until then we still rely on ink, quill, and parchment). We also discussed how to cope when a patient is non-compliant and how to strike deals so its a win-win situation (I'm convinced OT is just all about cutting deals). I also made a copy of the student evaluation form because her midterm assessment is looming and I want her on the same page right now re. areas that need improvement.

We also achieved a rare milestone for a Level II internship - we both left work on time with a few brain cells in tact. Now that's worth celebrating...

The Exciting World Of OT

I almost fell asleep during a treat today.

One of my most medically complex, long-term patients had identified the goal of being able to independently open her make-up bag and retrieve items. She's lost a lot of fine-motor control so although being able to snag some lippy without help might sound like a meager goal to some, it's quite a feat for this particular patient.

Bless her, she was really pleased with her achievements. Unfortunately, there's only so much peppy cheer leading you can do while watching someone happily zip and unzip, zip and unzip, zip and unzip...

I had to kneel on the hard floor to create some discomfort and keep myself awake.      

Worthy Blagh

I know that I've mentioned the amount of talking we do as OTs a few times in the past, but when you add a student to the mix the daily blagh level goes through the roof, so here I am mentioning it again. Given the circumstances I think it's hardly surprising that I'm barely keeping this blog going these days. On the whole, I have to admit, I'm really enjoying working with a student but I'm definitely ready to zone out by the time I've waded through the mail and had my welcome-home-from-work-cuppa.

The student and I have had a couple of interesting patients though, so the extra blagh has been worthwhile. One guy who had a left CVA was a perfect candidate for CIMT (Constraint Induced Movement Therapy), so the worthy blagh included discouraging the use of his unaffected arm while providing intensive training of the weaker arm via functional and vocational tasks (basically, putting his non-affected hand in a mitt while he struggled to do everything with the weaker one). It was an amazing process - very messy and frustrating at times, but with wonderful results, and after almost two weeks of therapy our guy will go home tomorrow able to perform 95% of his basic ADL tasks independently. He's an artist and the family breadwinner, so he'll continue to work on increasing grasp and fine motor control via outpatient services, and hopefully, he'll be able to get back into his studio soon and eventually resume work. Bloody marvelous.

Yeah, yeah... sometimes I love the blagh.

Do I Really Work Indoors?

Two days of being back at work, two days of being a Clinical Supervisor, and two days of wondering where the time goes. I'm all talked out tonight. Having spent a week ambling around the coast of Maine breathing in fresh air and enjoying some tranquility, I'm having to work hard at readjusting to the craziness of hospital life. I'm also kind of shocked by the stale the air that we're exposed to daily, and I'm blown away by just how much talking we have to do. It's a lot! Really a lot.

Last night I got home, changed into my sweats, set my ipod to shuffle, and went for a run - the first one in months and months (and maybe a few more months). It hurt but it felt so good to be out in the fresh air. It also felt really good not to have to talk, and to marvel at the sheer randomness of Dashboard Convention followed by Il Divo, The Indigo Girls, Abba, Rutter, Bonnie Raitt, Puccini, Dusty Springfield...