Everyone makes predictions. Doctors give a prognosis, based on how they think the pt. will heal. Therapists set goals, which they believe the pt. will achieve in a set period of time with skilled intervention. This is part of the professional's training, and if they are not reasonably accurate with their predictions, they will not be very respected by their peers or able to do the job as well. (sidenote- it is perfectly reasonable as a student to not make these predictions very well. it is all about developing experience, understanding reasonable expectations, understanding probability, creating new schemas, etc)

So we all make predictions about our patients. These can be helpful- if you predict that your pt will not use AE at home, it's helpful to plan your interventions otherwise. Sometimes they cause us to be jaded about our patients or their capabilities. Right now, I have a pt on the skilled floor that the general consensus prediction is that she is going to die. Soon. She's 92 s/p hip fx & ORIF (thank goodness that she doesn't have hip precautions). MAX Ax2 for anything resembling mobility, during which she moans and cries. She won't eat anything except pudding/applesauce to take her pills. She has a distension the size of my fist, protruding from her abdomen. She has been talking to her deceased relatives. Unable to don a button-up sweater due to weakness and confusion. Medically, her H&H is quite low, but she has religious objections to blood transfusion. I seriously worry every time I see her that she will die while I am there. Sometimes joint replacements and orthopedic surgeries can be the beginning of the end for a person, which is awful. A few months ago, a Mrs H had a second TKR which started her downward spiral... last time she was on her feet was on our skilled floor. I hate to watch people go downhill, I hate to know that there's nothing I can do, I hate that I don't know more medical information so that I could understand what is causing the decline and fix it!

Predictions can be quite depressing... maybe it's better sometimes to just not worry about the future.


Very busy days

7 evaluations yesterday, 1 full blown ADL, and 5 other short treatments. What a day.
It was most difficult because many of the evals were complex. Allow me to demonstrate...
  1. L TKA. Very basic. Started off in pain and then walked into the hallway. No problem to write up, will likely go home from acute care.
  2. 95 y.o. thalamic CVA. A very unreliable historian. She understood yes/no only. Once to the EOB, however, she did jump up with a walker and head right out the door. (sidenote- physical recovery almost always comes quicker than cognitive recovery. Frustrating, and potentially dangerous. Reminds me of a TBI story)
  3. Frontal lobe CVA. Dysarthria, flaccid RUE. Frustrated at not being able to communicate with nurses and dietary staff. Promised her a communication board, which I really didn't have time to make that day, but she really needed.
  4. Pneumonia w/ complications that landed pt. in the ICU. Some minimal spontaneous movement w/ agitated, but not able to respond to commands. Just extubated that a.m., so no comment from the pt.
  5. Elderly man w/ THR after falling. No memory of hip precautions. No social support system. We were able to stand at the EOB w/ MAX Ax2 for a minute or two, but that was it. Usually at this many days out from surgery, a pt. can at least walk to a chair.
  6. R TKR that I knew from acute care. An interesting case, as she is able to do many of the basic functional tasks that are required by OT before discharge. However, she has very little knee flexion, and it is always a PT goal that a pt. have at least 90* knee flexion after surgery. It's a strange part of the OT/PT relationship, as I'm not grabbing legs and bending them, but it won't matter how "functional" she is if she has to get a surgery redone.
  7. The last of the day transferred from another hospital and was quite exhausted. Pneumonia, GI Bleed, Renal Failure. He's super weak.
So that left a lot of complicated goals to write up (on top of the 3 peds notes from the previous day that I didn't have time to write). I did end up forgetting a treatment and having to document at the nurses' station since I had already locked up the office.

My ADL was with Mr. A, a pleasant, but lonely gentleman admitted w/ CHF and COPD. He doesn't want to go home w/ O2, but right now is struggling to do anything without it. We worked w/ the pulse oximeter on doing short bursts w/o the O2. His O2 cord wasn't long enough to go into the bathroom, and the nurses were saying that he'd only been using the O2 intermittantly over the weekend. However, an O2 % rating in the 70s (should be 90% or above) after a trip to the bathroom warranted getting after the nurses to get him a longer cord. The hour moved very slowly due to rest breaks as he rollercoastered up and down the O2 saturation levels. He is getting better w/ energy conservation techniques. I was a little depressed because the nurses were talking about him going downhill and that he was going to "go quick, when his time comes." I hope he can get better and also go home to a better situation.

Peds practice is picking up again. Getting another few evals and busier evenings. The peds + girl scout tuesday combination is getting hard on me... still working on finding a balance.


OT WebGems- Aging Edition

HOO-HA, I am nearing the end of my blog-related bookmarks (for now)! This edition focuses on those who are lucky enough to become elderly, with one crazy note thrown in at the end.

Architectural Updates- I have some links about aging-in-place and universal design on the sidebar, as it was the original reason I got into OT. Here's a retirement community that has incorporated some of those principles to help their residents live more independently.

Retirement Communities- The later pages in this article offer some great questions to ask before choosing an over-55, assisted living, or continuing care facility.

Balance- Here's some info and products to improve balance at any age! We should probably all start now, since our proprioceptive system starts declining around age 12.

As high tech pushes devices to boost your cognition and keep your mind sharp, people continue to wonder about what long-term effects all those crosswords, sudokus, and Brain Age games have.

Unrelated-- I saw a video of this car on Disaboom, and had to share. I am not a claustrophobic person, but this makes the Smart Car look spacious. However, I support the idea that a wheelchair user could have relatively easy access to their local area. I see a disproportionate number of pedestrians along high-speed roadways driving scooters than walking, and an enclosed way would be safer. I give you- Kenguru! Arriving in England soonish, US... another 15 years?


Danger Zone Sports

Title LGT an article on the hidden injuries in cheerleading. Bonus points for the author, as the main character overcame years of physical therapy to become a physical therapist.

My mom used to work in vocational rehab and would always cross off cheerleading and football on my high school physical forms so that I couldn't participate in those. Same reason that ATV riding and some other typical fun teenager things were verboten. High risk of SCI and/or TBI. Since I had followed other paths, these forbidden activities weren't high on my interest checklist anyway. But, I did enjoy diving, and loved to do so at every opportunity. I did a lot of flips and acrobatics, at least as acrobatic as someone with no gymnastics training or natural grace. I had an incident where I hit the bottom of a hotel pool hard with both feet and jarred my whole back... thought I was going to have a serious problem but walked away from it. I dove into a friend's pool that was 2 feet shallower than I expected and scraped everything but my head on the bottom.

But even though my mom had always discouraged dangerous activity, and afterwards I always resolved to be more careful diving, the danger never sunk in until I became a lifeguard. That's when I got all the information about exactly every way you could hurt yourself in a pool, and how badly. Simultaneously, I learned that those who are being paid to protect your safety may or may not act appropriately to maximize your recovery. One little shake while putting you on the backboard, not stabilizing the head properly when retrieving someone from the bottom of the pool... there's a million opportunities to screw up. It ruined diving for me, and also ruined being a bystander. I hate to be at a public pool or riverside that's out of control... I don't want to feel responsible to help when the inevitable (to my jaded eyes) accident occurs.

I don't know how to best decrease injuries in kids who play sports, but I do think that you need a combination of parental interference and personal education. Parents can insist on safety measures for the child or team, and can ingrain good habits in kids (like seat belts and helmets). Until the child recognizes that yes, they can get hurt and need to be careful, there has to be a parent or responsible adult to step in and insist on safety.

Sharing Time!

Karen suggested that I share some of the handouts and treatment tools that I had worked on over the past year. I have been meaning to upload some handouts to some neutral site that would hold them nicely for others... haven't decided on the best method for this. Some text files could be posted to Google Documents, but it won't hold pdf files... OT Advantage also holds files but I'm unsure of a space restriction and it requires a (free) membership. Thoughts?

So, until I have a go-to site for file sharing, here are some of the other things on my list that don't require seeing the actual file. One thing that I did that was sorely needed by the clientele was creating Spanish handouts. I took Spanish, but I don't know enough to actually write it. But a 2-second internet search yields several sites that allow you to enter a paragraph or more of text and get an instant translation. So, I was able to translate several existing handouts in 10 minutes, which is very handy.

In a variation of a project I did for fieldwork, I collected a bunch of medicine bottles with various opening mechanisms for people to practice functional hand skills, and contained it nicely so that it could easily be taken to any room in the hospital. Another easy thing that I did during a slow day at work was to compile fine motor kits. We already had a handout and several existing supplies, but it just took time to do. Another activity that requires only time was cleaning out our supply closet. Just figuring out what we owned saved us money- we had 10 top quality walker bags just collecting dust!

Another easy project completed out of already existing materials was to create a pill sorting activity. We had dozens of colored beads in a small container and pill boxes (and also medicine bottles from my previous project). So I made a small chart with days of the week and the numbers and colors of beads for that day. It's a combined fine motor and cognitive activity. For a higher level client, I used a medication chart (made up by a pharm student) and correlated each real medication with a color of bead.

Something that I didn't put on my annual review sheet, but try to do, is just to fill in and be useful where needed. Paperwork, fixing things, doing the small tasks can have a positive impact on your coworkers. Sewing a button back on the Peabody kit during lunch got me a great review from the OT I job shadowed. The little things can make a big difference :)


A Thankfully Slow Day

Our skilled unit has had a mass exodus over the weekend, leaving us with only 8 people, only 5 receiving therapy. The acute care side is busier, however, and I have learned how this pattern will end. We will go from being underbooked to dreadfully overbooked in 1-2 days, most likely at a time when I am the only OT and will get stuck doing all the evals. But, until then, I appreciate what we have now. It was a fortunate occurrence since the COTA was only working a half day, I had peds in the afternoon, and we got several evals in the course of the morning.

Mr. H went home with his daughter. He improved quickly in a short time. Hopefully, she will get him some good outpatient and driver rehab. She was a home care nurse, very good about asking questions and continuing therapy work, so I think it will go well.

My new pt. is Mrs A, who fell and sustained an L4 and pubic ramus fractures. I have a terrible time with elderly ladies with compression fractures. 1) they are in a lot of pain; 2) most of the ones I see were living independently but... 3) they have to wear a brace when out of bed and 4) have to be able to don it independently in order to live independently. For those of you who have not had a compression fracture, the braces all wrap around the torso and fasten on the sides or the front. They may need to be tightened considerably, and this is very difficult to do on yourself, especially if you have arthritis or other ailments. The usual prescribed brace is a hard or soft TLSO (turtleshell) or a corset brace. I have tried and tried teach this to different pts without success- they just can't gt the braces tight enough to be supportive. Anyone have a foolproof idea for this?

Had my annual review today- yay, they're going to keep me! ;) My supervisor loved that I had made up a list of handouts I had made, treatment tools I had made, continuing education, networking and service activities. It was a really informal bulletted list, but it made her job easier. It's an easy thing to do, and good to do as a student for your Level II placements. When I was a student, I made a sheet of pts I had evaluated, written evals or notes for, or just filled in for treatments. It also made it easier to fill out my university's form evaluation of the fieldwork site, which required you to answer caseload questions and specify diagnoses treated.


OT WebGems- Autism Edition

Welcome back! It's time for more OT-related WebGems! I'm still hoping that this phrase is not copyrighted! As I have previously acknowledged, I and everyone else have a lot that we need to learn about autism. Hats off to the millions of parents who know far more about what works and what doesn't from their practical experience than I do from books and work. Here's a few newsclips about some up and coming autism research.

Genetic social skills- These researchers looked at the social skills of parents who had children with autism. 15% of the parents were classified as "socially aloof," and the researchers wonder if this is a genetic link to some of the social skills deficits in children w/ autism. I just hope it doesn't bring back the "refrigerator mom" theory.

Early Intervention- Researchers from the University of Michigan have started a 5 year study looking at how early intervention can effect social skills and language development of toddlers with autism. Study participants get 25 hours/week of therapy for 2 years, including ABA treatment and parent training.

Fever as a productive time- Researchers studied children with autism before and after having a fever, finding improved concentration, language skills and eye contact immediately following a fever. They offer this as "an exciting lead" in autism treatments, and offer anecdotal evidence for this reaction as well.

Robot Playmates- A group of engineers studied how children with autism interacted with a robotic playmate that was equipped to blow bubbles. This was a very small study, but an interesting lead. A little odd, but interesting nonetheless.

Susan Senator- This woman has raised 3 children, including a child with autism. She is the author of "Making Peace with Autism," which I would like to read. Here are two of her essays- one on kids using the word "retarded" in an inappropriate way, and one on the difficulty of choosing a residential school. I know that if I would have used "retarded" as a putdown, my mother would have taken in out on me as if I had used the N-word, F-word, etc.


Play Ball!

Had a really fun treatment today. Props to Mr A for withstanding over 2 hours of therapy today and to my pseudo-boss for being willing to listen to my ideas. Mr H is in his upper 80's and had a basilar artery stroke. When I first saw him in the hospital last week, he had poor sitting balance, very poor standing balance, and couldn't hold onto a walker w/ his R hand. Since then, he has made some great progress. (sidenote- spontaneous recovery is a frustrating concept to me. I wish that you could predict why some people get great recovery from cerebral events quickly, and others never do. me=control freak)

I had spent 45 minutes before lunch working with him sitting EOB while doing resistive clothespins and reaching in all planes, also did the extreme fine motor kit. No sitting balance issues. Sitting balance is the precursor to standing balance, so yes, this is relevant to his continued independence. Teaming up w/ my experienced PT friend and a rehab aide, we later found Mr A game to try our sitting balance game. We got to sit him on a ball, where he did great with dynamic sitting balance, even after incorporating throwing and catching another ball. Great BUE coordination. The only thing he didn't do well was the cognitive portion of this that we eventually worked up to- naming a different major city with every throw. We did try some dynamic standing at the end of this exercise, but that is still in the future.

This is the 2nd time in a year of employment that I have seen/heard of the ball being used. The first time, I was sitting on it to eat lunch. It makes me miss the rehab center, makes me find a commonality with a non-particularly-liked employee of said center who told me during my fieldwork that she could never NOT work on the stroke team, as the other diagnoses were boring. It certainly is interesting and sparks my curiosity over my future again... I have strong interests in CVA and SCI but they are generally separated and very specialized.


I HATE mornings. I would much rather stay up til 3 or 4 than ever get up before 9. I really hate it. And in the past few days, it's started to turn more into fall, which means that it's dark and cold when I wake up. As if I needed extra motivation to stay in bed. I had a terrible time making it to my one fieldwork on time, since it was darkest winter, and I ended up walking through the snow half the time. Being roused unwillingly out of bed and then having to tramp 1 mile in snow boots is not how I like to start the day. I just hate mornings... if only I liked outpatient better, then I could sleep in later.


OT WebGems- Edition #1

I routinely bookmark articles or websites with the intent to blog on them... sometimes they either get outdated or I just don't have enough to say on the article to be a whole legit post. So, in a shameless act of thievery from ESPN, I bring you the first installment of OT-Related WebGems! Today's theme: Back to school. Several selections for parents, and 1 for therapy students.

Motivating Students- Jay Matthews writes a summary of tips for teachers on motivating students, with better strategies than just grades. I think there's some good tips here that parents and teachers should discuss together.

Bike Safety- Somewhat of a tenuous link to school, but I'd like to believe that in some small town America, there are still kids that ride a bike to school. This set of articles was a nice comprehensive look into safety that includes video on how to properly adjust a helmet. Teach your kids safety and prevent injury!

Family Manager- Kathy Peel offers free tips on home organization. This is a set on getting out the door on time in the morning. She has also authored The Busy Mom's Guide if you are interested in further information.

Day Care Research- A short review of a study that should allay some fears of dropping your child at day care. Doesn't resolve anything, but if it helps your debate, I spent my first 5 years in a family-run daycare with no lasting negative outcomes.

Choosing a Partner- This was written about Presidential candidates choosing VPs, but it can be easily generalized to other working relationships. Attention therapy students: know thine research partner, before committed to years of work. I picked a friend that I knew was conscientious about deadlines and would get the information we needed from our adviser. I didn't pick my best friend, because we had studied together before and I knew that I would just spend research time chatting about irrelevant things instead of working. Research is a big part of most schools' graduation requirements, so choose wisely.


Past Medical History- what are you looking for?

While taking the medical history doesn't often fall to the therapist, it should be part of any evaluation and chart review. But sorting through a thick chart can get complex. Here are some important conditions to look for in your PMH. (not necessarily in order of importance)
  1. Cardiac conditions- this includes prior MI, HTN, A-Fib, CHF, TIA, CVA. Important for pacing of activities and planning exercise programs. From my experience, many people who have had a prior cardiac event continue to remain at-risk instead of taking the steps toward lifestyle change necessary to decrease their risk factors.
  2. COPD and other respiratory conditions- Is your pt. on oxygen at home, or should you be working on weaning to room air? Is this person prone to quick desaturation? Will you need a pulse-oximeter or portable O2 tank for this person? You may need to do endurance building activities, and be especially wary of hot showers!
  3. Cancer- many sources advocate against aggressive strengthening programs for individuals with active cancer, and especially metastases. Also, a woman with a mastectomy should never be lifted by that arm or have a blood pressure taken in that arm.
  4. Orthopedic surgery- obviously, a recent joint replacement will have a weight bearing status and appropriate precautions to note. But hip precautions are in effect for 3 months, and some of the hospital clientele will certainly be readmitted during that time period. If a person didn't receive adequate therapy following a joint replacement, they may still lack ROM in that joint.
  5. Falls- many hospital patients are labeled as at-risk for falls. But it's important to know how often and where your patient has been falling. Does this person need extra practice on tub transfers? A home evaluation and education on modifications? An assistive device? Increased supervision and physical assistance?
  6. DVT/PE- If your patient has a history of clots, you should be extra vigilant of preventative measures implemented by the MD and nursing staff. This includes the sequential compression devices for legs and the TED hose. Our facility has guidelines for usage of these and documentation to accompany it. You should also be aware if your patient develops a pain (particularly in the leg), and talk to the nursing staff about the possibility of this being a DVT. Pt. may need to rest that day, get a doppler study just to clear everything up. Better to be safe than sorry.
  7. Diabetes and other diet restrictions- important to note especially for cooking activities or just to have a quick answer for "Can I have a Coke?"
  8. Current UTI- this may not mean much in the history column, as most every person in the world has had at least one in the lifetime. However, a current UTI can cause a decrease in your pt's cognition, endurance, and balance. If there is a history of frequent UTI, that can be connected to incontinence, which is a good thing to take note of prior to getting someone totally dressed for ADLs.
So this is the short list that I came up with... there's lots of other relevant information to make a full chart review, but here's a good start on a medical history relevant to your acute care therapy clients. Perhaps another entry can focus on the pediatric medical review.


Threshold of Thursday

Doing my scrubs washing tonight so that I can go into work tomorrow (my day off) and Friday, and Saturday. bummer. Actually got some new, cool, non-kid tops that I can wear and be fashionable in at the hospital (not that the elderly don't get a kick out of my Land Before Time, Rugrats, and Spongebob shirts). Anyway, I usually don't go in on Thursdays as long as everyone is healthy and happy. But this week is our first week of evening pediatric schedule. Since it's been a short week, I can't say that I've really learned a whole lot yet (except for the fact that a 530 pt makes it very hard to get to your 600 meeting). I've been handling the peds on my own now since last December, and tomorrow marks the handoff of twice-weekly kids to the COTA. I am not worried about this, for the following simple reasons 1) her slots will be used primarily to see the "twice-weeklies." By definition, I will also be seeing these kids at other times during the week, and will be reviewing their notes weekly by necessity. I have been seeing both these kids for many months, they have great involved parents, and they are both OT/PT cotreats. 2) I trust the COTA. We're in the same office at least 3 days a week with ample time to discuss treatments or issues.

I'm confident that the COTA has the basic skills to easily succeed in this. My only worry is whether the girl who has autism will adapt to seeing different faces Tues/Thurs. She, however, is not as confident. As she pointed out today, it is a totally different world going from the inpatient environment to pediatrics. There is really very little transfer between the two worlds. Yes... we're still OT, still client centered, still focused on ADLs. Still, VERY different. One big difference is that even when our adults have comorbidities, it doesn't change your overall treatment plan too much. A person with a knee replacement often has the same general treatment course as a person with a knee replacement and a typical comorbidity. Yet the comorbidities that the kids have generally have a profound impact on your treatment activities. Think co-occurring SPD with autism; TBI and CP; dyspraxia and dyslexia. Both environments can be overwhelming until you're adjusted. We've chatted about the different kids, discussed goals and treatment ideas, but I think she's still a bit nervous. So, we're teaming up tomorrow as a reintroduction to peds, and then next week (due to massive scheduling problems) she'll do all the cotreats solo.

I expect the whole fall transition and dealing with vacations will be hectic, but not overlly problematic. My main problem is getting (certain) parents to be responsible and make appointments. The pediatric PT is bemoaning her full schedule... I wish I had that problem. Can't really get all into peds if I don't have the caseload to do it. We do finally have a speech therapist, but I don't know if she is interested/able to take on pediatric outpatients. And until we have someone to do that, we have been discouraged from actively marketing our pediatric services. So we're basically left to whomever wanders in. I did make a good connection with a family therapist who specializes in Asperger's Syndrome, and she said that she would be speaking with the doctor about OT referral for sensory issues. For now, we wait.