Things I Learned

Full title: Things I learned in school that I didn't think were important at the time.

Part of the reasoning for making this blog was to share information from school with other students. Here are some things that snuck up on me and I later realized were important.

• Don't take it personally- In preparation for Level II fieldwork, we had to read "The Four Agreements."I did not enjoy this, at all. Thought it was worthless. However, agreement 2 (Don't take anything personally) has proven several times to be very worthwhile. Often, things that people say or do that irritate us were never intended to do so, yet we take them as an intentional personal affront. By learning to not take the little words and actions personally, you can save yourself a lot of headaches, especially those that can come if you are in a catty workplace.
  
• Leave it at the door- As a corollary to the first point, there is a line between your personal and professional life (especially on fieldwork). Sure, you can share information about yourself and interests, but your main focus has to be getting work done or it will come back to getcha. And of course, you have to be careful about what and how much you share w/ whom... does your supervisor need to know about your hangover?
  
• Act interested- One of my teachers used to say this was key to keeping instructors happy. No matter where you are, this is crucial. Make eye contact, nod approvingly, ask questions. People respond to this, and they respond to the opposite as well... I think that one of my professors is still a little icy to me because of this.
  
• It's not about the site- I spent a lot of time obsessing about fieldwork sites... pretty much from the time that I got into OT school. I pursued a few specific ones like a trained attack animal wearing blinders. And, in consequence, I had a few experiences that could have been better, more challenging, more relevant to my daily practice. You can obsess about the name or prestige of a certain place, but you have a find a good fit for you and a place where you can learn. Get a heads up from older students about different locations. Talk to your fieldwork coordinator about your goals and desires, but trust that in the end, it will all work out.
  
• It's not about specializing- This is hooked to the previous point. I remember in first year of school we were all getting to know one another, and most people had a specific setting or population that they already wanted to specialize in. Many people wanted to work in a pediatric setting, but some of them found out that they truly preferred geriatrics. It's getting harder not to find out about specialties early, as OT is becoming filled with deep niches (that's a separate entry), however, don't cling too hard to these ideas you have about your career early in school. Be open to the possibilities.
  
• It's not about money- It's always hard to believe as a student, but one day, someone will pay you to work! There will come a day where student loans no longer matter and you can buy brand-name food! However, there always seems to be someone on the listserv asking about their choice for first job... great money or supervision? The consensus answer is always to take the better overall experience and not worry about the money. It's hard to believe that the money will come, especially when everyone loves talking about the economy, but a good base of experience is something you can't buy. Admittedly, I let the money factor into my first job decision more than it should have (separate entry- negotiating and money management) but the position did have a mix of experiences and I have been learning a good deal. This is also why many teachers advise against taking a traveling position right out of school, get the supervision and assistance when you first start, and then go for the lucrative placement if you want to.
  
• You get what you give- It's hard to find energy sometimes at the onset of a day, especially if you're a "morning eeyore" like me. But you can't expect to get great things from minimal effort. In school, we organized a study guide sharing effort between classmates and then passed these down to the underclassmen. I certainly don't know how everyone's tests went, but there does seem to be a correlation between putting in the effort to make your own guide and doing well. This translates into the work environment as well. If you show your clients that you care and want to understand what matters to them, they will try more during therapy sessions. It's hard to be "on" all the time, and those that don't work in direct consumer interaction don't always understand that. But give the best you can, as often as you can, and don't expect more from those you work with than you are willing to give.
  

Gender Games

So I had a strange week, though it was several weeks ago now (I'm a little behind in blog posting). My hallway on the SNF floor has four 'semi-private' rooms. I would say that my 'average pt' is a 78 y.o. female with a condition causing general weakness and mild dementia. However, I had a set of weeks where it was all... men.

We rarely get ANY men on our SNF floor (staff or pts). And in this situation we had 9! My hallway had Mr. H after his hip fracture; Mr. R who was terribly deconditioned and had very little shoulder flexion either side; a man receiving IV antibiotics; Mr. L w/ confusion after UTI; Mr. N with mild dementia and THR; and Mr. Z w/ advanced dementia. It was interesting working with an all-male caseload for the first time ever... these guys had some good stories and some were very willing to work hard. I think in general they did have some apprehension about ADLs, probably more than my 'average pt' but I try to be respectful of such things.

I spent a lot of time working with both Mr. H and Mr. R, and can happily say that they improved greatly and are at home. The others, unfortunately, did not have the same result. I guess basically it worked out as it does when I have an all femme hallway, some worked hard, some wouldn't work at all, and some couldn't overcome their deficits in the time we had together. Hopefully they'll all continue to improve.

How to continue receiving listserv emails

Several individuals on one of the listservs that I subscribe to were irritated/perplexed at the change from emailed listservs to forums on the OTConnections site. In reality, I think that this will operate much like everything did on the AOTA site, as you always had the opportunity to access the listservs in forum format (check out that alliteration!). But if you're having trouble changing over and would like to continue receiving emails of the new topics and discussions, here's a step-by-step process.


When you first go to http://otconnections.aota.org/ there is an option to sign up or log in. You use your same old AOTA.org name and password to log in.

At this point, you will be redirected to your 'homepage.' This page shows your latest activity and that of your friends. When you first sign in, the only friend you will have is "OT Connections." You don't have to get anymore if you don't want to. This is the page that you can go back to by clicking the "home" tab at top, and can help you navigate to other areas of the site.

To edit your public profile, click the link under the funny picture. This is in the top left. In this section you can upload a photo or pick a different clip art picture to be your 'avatar.' This is just
for what other people see when they look at your page. It's not necessary. You also have an option to add a public biography. What you DO need to do is go to the "Site Options" tab; put in your correct email address, and save the change at the bottom of the page. You can also choose what you get messages about and who can contact you in this tab.

Now, click the "forums" tab on the red bar at the top of the screen. On the right, under "shortcuts," is a link for "Forum Subscriptions."

Now you can scroll through the list and choose which listservs to receive by email. Simply click on the "No" beside the chosen listserv, and it will change to "Yes." And voila! Your listserv emails should return to your inbox unfettered.

If there is a problem with this, let me know and I will try to correct the directions.

And no, I don't work for AOTA, though I totally would if I had the chance. I'm just an OT who is also a computer nerd and thinks that being active in the state and national association is a good benefit. :)

Merry File Sharing Day!

So I finally took my memory key to work and got my files off of there. Browse as you wish, I only ask that you do not plagiarize or submit works as your own, but feel free to print for patients. Burst ahead for file-sharing goodness!

OK... so apparently, you cannot upload text files or pdfs to OT Connections. Therefore, it cannot be the prime sharing source. Please let me know if the google documents do not show up correctly and I will email the item to you.

Homemade Adaptive Equipment- instructions for making sock aid, dressing stick, and long sponge in English and Spanish. I ran it through a translator, please don't blame me for the grammar. Speaking of long handled sponges & shoehorns, I always send people to the drugstore or dollar store for these items.

Potential Friends Worksheet- I made up this simple sheet for a child w/ Asperger's who was really upset about not being able to make friends. He liked to plan things out, so we tried breaking down introductory conversations step by step, and then practiced one of these with a PT on break.

Heavy Work Handout- Here's a handout on different heavy work activities, it's mostly for parents but does have a few ideas for classrooms. I did borrow and compile from different sensory resources, the main 2 are referenced.

Yoga Exercises for your Back- I copied and pasted out selected yoga exercises that work on back muscles, unfortunately, I cannot remember the source site.

Tips to Decrease Back Pain (for children)- Here are some child-specific strategies to reduce back pain.

UE AROM handout- goes through basic arm stretches in layman's terms.

I have a hip precautions handout, but only in pdf... I'll have to copy it into word format before sharing.

As an extra bonus for those of you who have read so far down the page, I will tell you that I found ALL of my files from school on this magical memory key, and will share them as quickly as I can, but it will be difficult as I am probably busier this time of year more than any other. There's some great stuff, and one early post will have to be on old-school homemade AE. For other great pediatric handouts, try Super Duper Publications and of course AOTA has great consumer tip sheets.

OT Connections

So I am on OT Connections now (Title links to the homepage). I uploaded a new picture for that avatar, so I will probably change this one to match. Obviously my wedding photo wasn't very OT-related, but I really don't have pictures of me doing OT-things. Someone should have been taking pictures in class, but even when our school did publicity photos of "OT class" they were always very staged.

Can't promise how much time I will spend on there, but hopefully some good networking and information sharing will come about. I haven't tested the file upload yet, but if it works well I will throw over Google Documents and share things over that network.

My inservice went well today, shared some updates about opening our state practice act and the changes that are intended... tried to bug my colleagues into joining our state association. It actually costs less than dinner for 2 most places, so for OTs who make 5 figures, it doesn't really seem like a big sacrifice. We'll see if my 'prodding' had any result. Also at work today, I got some sensory profiles graded and papers filed away (Coworker: "I can actually see the formica on your desk! There is a desk there!") AND I took my thumb drive and copied all my files, so hopefully I can spend a little time this weekend sharing some of the things I've been working on.

Also on the list of things to do is to make a handout for simple modifications to make a home w/c accessible, since I have my first amputee since fieldwork and this will likely be her discharge disposition. I have ample resources, I just need to combine them efficiently in handout form.

Doubts

I am a person who worries, doubts, and has times of self depreciation. This is probably evident to many people already, but a disclaimer to anyone else. On the plus side, I likely have those traits due to an urge to be better at the things that I do. Part of the duty of being a member of a profession is a continued commitment to improvement, and I feel that is especially important to be the best I can be so that I can best facilitate goal achievement in my clients. So it hurts when others suggest that OT is not effective, not science-driven, not worthwhile. I found this post linked from another blog, and was disappointed in many of the comments I saw. It also made me wonder if any of my clients or their parents are writing about me. If not writing, they may be talking... one of the things that I have noticed w/ my peds caseload is that some come in for an evaluation and a couple of treatments and are never heard from again, despite phone calls and notes. I often wonder what has happened in these situations when a kid disappears from my schedule and isn't heard from again. Some I know are for financial or personal family reasons, but I know that there's been at least one who didn't come back because mom didn't like me or the therapy session that she observed. It can make you a little paranoid, and I don't need help finding things to worry about.

More thoughts in the full post...

One specific problem that I have is that I feel I'm doing pretty well at evaluating kids and spotting a sensory processing difficulty, and I know that I can pick treatments that challenge them, but I'm not seeing these kids improve as much as I would like. Also, it's difficult to best know what to do for some kids.

I've had more parents observing sessions recently, which I don't mind most of the time, but would rather have a 2way mirror other times. I wish I had better answers for their questions sometimes. I can see in some of their eyes that they don't find me smart enough, or good enough to work with their kids. One set of parents was whispering back and forth to one another as I let their child engage in free play during the eval... they were very upset at her for 'not following directions.' Though I haven't had anyone confusing me with a high school student lately, I don't know that I'm giving off the vibe that I need to best interact with the kids and their parents.

I really wish that I had a fieldwork in peds, or someone else that would share the caseload and give me ideas, or (ideally) a mentor to help me grow as a practitioner. That is on my list of things to do this week... finding people to reach out to online as the ones that I have attempted to reach out to in person have not panned out well. Also on my list of things to do, and gaining priority with each passing second, is preparing my 'inservice.' I have to present it tomorrow. It's not a big thing, more like a five minute thing, but I need to get it done.

Haven't had a chance to check out the OT Connections site... also haven't been on OT Advantage for awhile anyway. Hopefully one or both of these will work out... I am already on the computer too much w/ reading interesting things. And my only network is Facebook, I try to avoid all the other stuff. I already need at least 24 more hours every week, I can't imagine trying to cram in a 'second life' of any sorts.

OT Web Gems- Research Edition

Ok, update first. I have not been intending to neglect the blog of late, especially when Karen was nice enough to include me in her OT Practice article. However, I have had a few complications this week. One, I am procrastinating preparing for my inservice (11/21) and have been trying to do that before doing fun things. Two, I am having a lot of shoulder impingement problems and while I don't know what is causing them, I know the computer isn't making it better, so I've been online less. Anyway, I have several entries half-started and other ideas brewing, so there will be updates once I get my life in line.

On to the web gems!

OT Student Survey on working with adults with developmental disabilities. I can't remember if I posted this already or not, but I'm guessing that since it's in my inbox that I have not. Oops.

Kessler Rehab Research- this site will make it to my sidebar when I next update that. Research on SCI, CVA, TBI

NIH Clinical Trials- can't really remember why I bookmarked this, as I don't deal in pharmaceuticals, but it may be relevant to those in research

StrokEngine- love it! lots of good categorized info on the latest CVA research. Another to be added to the toolbar

MOHO Clearinghouse- an alert reader on one of the AOTA listservs (holiday time is a great time to renew your membership- new practitioners get 2 years reduced rates!) pointed this site out. Has some good free MOHO based stuff, as well as some research links and products you can buy. I intend to use the play inventories with some of my older kids when I have time to print them out.

SNF productivity

Title link goes to a recent Advance article on SNF productivity which is very aptly timed for me. I haven't gotten any feedback from other SNF therapists, but I know that we are getting a lot of urging to maximize therapy minutes for all patients. As I've said before, we get a lot of medically compromised pts and are responsible for all SNF pts, all acute care pts, and an outpatient caseload with not very many OTs to share this burden. Our inpatient therapists are expected to by 70% productive for SNF and acute floors, and outpatient is expected to be 90% productive. With my days split between 2 buildings, that is not often a reality for me, which puts pressure on my boss, but she has been pretty understanding of the situation.

I suspect that as long as health care is dependent upon the payors that there will be a push for high productivity and high billing. I don't expect a radical change in health care any time soon, despite the campaign talk, as we have a whole host of other problems going on.

Feedback definitely wanted from SNF therapists:
- Do you have productivity standards? Is there a strict expectation to meet them?
- What levels are your patients meeting? Is there a push for more minutes?
- What fun things are you doing? How are you getting your pts interested in completing high levels of therapy?

ChChChanges

Our SNF floor recently had auditors come in and evaluate what we were doing and how we could improve our care and (I assume) finances. We are still waiting on their report, but at this point, I think everyone knows that there will be changes and there's considerable tension, worries, and defensiveness in the water now. I am not totally alarmed by this prospect however, and am hopeful that we will make some good improvements. I think that I welcome the outside influence more than the others, as they've all been working on the floor for 10-30 years, and let things wear a bit of a rut. Don't get me wrong, we all work very hard at getting our pt's better and more independent, but there is more that could be done. I think that it is also a bit harder on our floor, since we are connected to a rural hospital and do not have a lot of pt's willing to pursue acute rehab. We get a lot of pt's that are sicker and more complex than I think the average community SNF gets, which makes it hard to do more advanced treatments, such as IADLs and endurance draining activities. Also, our OT staff is limited to 1.5-2.5 therapists for the skilled floor (16 beds) in addition to the rest of the hospital acute care. Since our outpatient practice is in a separate building, this limits the amount of help those therapists can lend.

I feel the constraints of this situation, but I always have a push to do more, and really hope that we will make some improvements. I would like to see pt's out of their rooms more, get more help from nursing, and make home visits. I am looking for suggestions for what others do to keep their SNF therapy fresh, interesting, and therapeutic for their pt's. I'd love to hear about it- except for comments related to 'wiihab.' There is no funding for it at our hospital, and our pt base is really not at a level to actively benefit. Also, no way to secure it safely. But anyway, let me know about the awesome things you're doing to take your pt's from SNF to home.

Also- how many people working in a SNF or rehab facility frequently recommend home health therapy upon discharge? I was taught to do this for most pts as a CYA measure, but our MDS director thinks that this is a sign we're not keeping our pts long enough. Thoughts?

Some interesting cases

The hospital has actually been slow for a little while, but I couldn't catch a break during that time since my pediatric caseload was simultaneously growing. The peds caseload will require a separate entry, as it has exploded a bit. Anyway, the circle of hospital life always comes back around from slow with only a few pts to overfull with referrals coming out of our collective ears. We've managed to fill up again just in time for us to be shorthanded as a colleague takes a weeklong trip. But, before I get totally overwhelmed again, here's some stories on a few of the interesting people I've seen recently.


I have been working with Mr. H for the past 2 weeks. A great elderly gentleman who is mentally extremely sharp. I believe that he remembers absolutely everything I have ever told him (so hopefully he will remember to get those grab bars installed at home!). Really nice guy, good sense of humor, and absolutely tries his hardest to work with us. He came in with a hip fracture and a previous dx of Parkinson's Disease. Thank goodness that he had an ORIF, as he has a special method of mobility that would not work at all if he had hip precautions. He's become one of my favorites, which is good, because since he moves slower it takes considerably more time to do a treatment. He has progressed from being MAX Ax2 to stand, also for LE dressing, to being CG-SBA. Terrific progress.

Mr. R has also had a strange journey that I've gotten to share. He had a history of problems with his shoulders and had 1 rotator cuff surgery a long time back. It had taken him a long time to recover, but he did get a lot of UE motion back. Then, over the course of a couple months, he gets run down, stops exercises, has some cardiac issues and pneumonia and winds up in the hospital. When he first arrived on our skilled unit, he had such minimal ROM in his arms that he could not use them to help stand up, and was MAX A 1-2 for all ADL tasks. We had really made some progress, and he was able to dress upper and lower body w/CG-MIN Ax1 and was looking ready to discharge soon. Unfortunately, he had a bowel obstruction, wound up back in acute care for a week. He's been readmitted to the skilled unit now and hopefully hasn't deteriorated too much in the interim.

Most complicated evaluation of the week goes to Mrs. MA, who had a very intense CVA. She had multiple infarcts in the L MCA distribution in the frontal, parietal, and temporal lobes. This also resulted in mass effects, which usually happens in hemorrhagic CVAs, not ischemic. First thought: Holy cow!!!! This lady has expressive aphasia, and is limited mostly to the word "okay." On the day that I saw her for the eval, she was doing a little better, using a few more words appropriately and trying to construct sentences that would start out intelligble. Us "Thurapee Girls" descended en masse- OT, Speech, PT. We got her OOB and into a chair, at which point the telemetry nurses descended upon us freaking out- Mrs MA's heartrate was 190. So, back to bed, PT exited stage left, and I did my first cotreat with our new speech therapist. It's terrible to say that I've had fieldworks and been practicing over a year and never cotreated with speech, but it's a situation of coincidental circumstances and not out of some crazy "no teamwork" philosophy. I do cotreats w/ PT all the time, but really had to switch my brain channels for working with speech. Challenging, but fun! We worked on communication briefly, and worked feeding and groming into the bedside swallowing eval. Also, I learned a new fun fact- no cranberry juice for people on Coumadin. Good to know. I hope that this interesting lady makes a good recovery while she's with us... she'll likely discharge to community SNF or maybe acute rehab if she starts doing better.

Also have another TKR pt. who is going to recover function much faster than knee flexion or mobility. She's mobidly obese, but has excellent flexibility (way better than me) and can do lower body dressing in bed. That's not usually something I do with people who do not have a spinal cord injury, but it works. However, she's still struggling a lot with basic mobility and knee ROM. We will likely see her on the skilled floor.

Here's hoping we don't get TOO busy... since that takes away the time that we can spend on each person and simultaneously takes away my sanity. :)

More Voting Info

Here's some more information to pass on to those in the hospital... good luck getting people to come to the hospital though as they may be swamped doing regular poll-stuffs.

http://www.slate.com/id/2203670/