Layout Updates Complete (?)

I think, for the most part, that the layout updates are complete. There were a lot of trials, especially since I was reluctant to check and re-add each link on these pages one at a time, but hopefully there is a better collection of links now and a more efficient design. May have to update my photo, but it's hard to get an OT-relevant pic. So, thoughts on the 3 column design? I wanted to go totally custom but haven't been able to get that going yet. Haven't put the code back in to shorten all the entries again- do people find that useful?

Now that the drama of recreating the homepage is over I hope to get some more regular entries going, but one reason I'm not sad they've been slow is that I have been trying to get a better balance to life. So we've been going to some concerts, getting ready for football games this fall and visiting family over the holidays. Nice to have some fun stuff to look forward to. Also, I've been working on my presentation for the state conference, since I can't very well just show up and say, "yeah... I have a blog." Not going to cut it :)


New find from twitter

Twitter time has been semi productive!
Found a link to an OT blog I hadn't been following- Info Spot 4 the Special Tot. The author also has a website on sensory processing in infants. I haven't had time to explore the whole thing yet, but the author has definitely been profuse in publishing and has also acted on something that I had discussed with another blogger- producing entries for wiki-how related to OT. So, props for that. It is on my list of things to do, but ... in unrelated news, I am getting a few other things adding up on my list. My research from school is actually getting near to being published (!!) and so I have some things to finish up for that. I have been reading my stroke textbook 1 chapter at a time on the metro rides, when I'm not falling asleep from exhaustion. And I am swinging my occupational imbalance in another direction, going to be attending several upcoming concerts and 1-2 football games before Christmas, hope to keep peppering my sometimes dull life with a little fun :)


Trying for a better week

Goals this week are a little morbid.
So I had multiple pt deaths last week, 2 expected, but 1 not. None due to receiving
OT services or lack thereof but still not a pleasant thing. I did get one lady up to the chair about 5 hours before she coded, didn't do much else since her O2 sats were not stellar. So I've been a little depressed and I would just like for people to stay alive this week.

Saw a cute-as-a-button 89 y.o. lady on Friday who had a pontine CVA (blessedly mild) but told me "I've never been sick all my life, so if I die it's ok" and I am just thinking NOOOOOOOOOO!!!!!!!!! The COTA saw her yesterday and she met all her OT goals, but after that she transfered into intermediate care for continually BAD blood pressures (222/101 etc) which is not good. Went in and talked to her today...hopefully they will get her heart under control. She is totally asymptomatic and does great from a functional standpoint, however she keeps having these skyrocketing BPs. Everything would probably be under better control if she had come to the ER right away but she arrived 4 days s/p onset of symptoms and only came in when her MD called and noticed her slurred speech. Worse- she lives with an adult child... how can you not notice that your mom has major weakness on one side, slurring speech, and struggling to walk? Seriously, better to come in sooner than later.

Saw a bunch of pts with multi-trauma today... one guy I saw OOB for the first time in 3-4 weeks, an older lady with dementia who we presume fell down the stairs and refused to put on her TLSO, and a man who was involved in a head-on car crash- now in the ICU only seen for splinting. He has BUE intrinsic plus/resting hand splints and BLE foot boots now. Probably has a TBI as well that can't be evaluated yet so he will have a long recovery road ahead. Been learning (and relearning) a lot of stuff about splinting lately.

Really hope week 2 on neuro floor is better than week 1. Not making a lot of progress on the stroke textbook but I have gone through several AJOTs and other research articles, hope to have a summary post soon. Also still working on a Malcolm Gladwell related post. In other work news, am now on the documentation committee following our strategic planning meeting so I hope to make that both comprehensive and quicker, if possible. Added a bunch of new 'tweepz' on twitter, hopefully that won't cause any brain overload but may be helpful resources, so if you do the tweet thing, go ahead and check it out. :)


Miracle Treat Day

August 13, 2009- Dairy Queen Miracle Treat Day!! Since you can't eat those paper balloons that get hung up in stores.


drawings from a client w/ impaired vision post CVA

These pictures were drawn by a client with an interesting and complex history of CVA.
Mr. R presented to our general medicine floor a few months ago after a fall, and had been unable to stay home unattended during the day without problems. He had experienced a stroke 1 month prior to admission, outside the US, and as far as we learned had received nothing but the most basic treatment to stabilize him, no rehabilitation whatsoever. While this gentleman had virtually no motor involvement, he had MAJOR deficits in short term memory, to the point where he had what I would call "5 questions a day," which varied slightly day-to-day, but would be repeated for the duration of that day no matter how they were answered. He retained very little of the answers that were provided, though this ability waxed and waned. This would have been a great enough barrier to home discharge, however, he also had severe visual involvement. I appealed for a neuro-ophthalmology consult but they declined to participate since this was not an acute event. So I did what I could to evaluate this issue.

Clock Drawing: I found this interesting since the numbers are running counterclockwise, and he did draw them in descending order. I couldn't find any information on other cases with the numbers running backwards.

These pictures are his attempts to reproduce the above drawings. He was able to describe the shapes in the drawings somewhat, but unable to figure out what the whole picture was.

We had a similar issue when he was trying to '"cross out the m's" or reproduce written letters. He could write letters accurately but couldn't read them effectively unless directly cued to trace the example and trace the letter in question.

Mr R's decreased vision was really a secondary problem to the decreased short term memory. He would occasionally report new, altered visual symptoms which made evaluation difficult, and functionally, his vision was less limiting than other deficits. For instance, he needed help to find his way to the bathroom, but needed only verbal cues for perseveration to shave his face. I believe the family had to pursue nursing placement since they couldn't provide 24 hour supervision, which is sad, but between his memory and visual deficits he did need that level of care.


Progressing in Pediatrics

Got my official badge access to the OB/pediatric/NICU areas today, now I can stop annoying security by paging them every time I want on or off the floor.
Got to observe a baby with a pronounced cleft palate again today, this time made it in time to watch the feeding process. I learned about the Haberman feeder, which is a special nipple that requires you to squeeze along with the baby's attempts to suck. Very interesting and I got to hold the baby for awhile. Also saw a girl admitted for preterm labor today... have to get less nervous on the new floor, I heard myself talking extremely fast when doing her eval. It's hard to absorb all this new specialty information for peds, especially since I am starting on the neuro floor next week and will have to be ready for that. Trying to learn fast and not have my brain explode...

Did my first real ADL in a long while... 7 units with the same lady. Didn't have an excess # of orders today anyway and almost all of my evals and followups were cancelled for one reason or another. We'll see what tomorrow brings... hard to tell what will happen


How to prioritize a full day and other stories

9 hours today, and it was JAM packed. So much so that it will span into tomorrow morning.
Mondays are always difficult for me since every name and face is fresh. To top it off, we were shorthanded today which adds the task of prioritization into the mix. There are many methods for this, some of which are mutually exclusive, and some of which aren't applicable when you need them to bed. Regardless of what I choose, it is hard to pick and know that a certain amount will not get done.
Here are a few of the ways that you can prioritize evals-

- Pathway patients first- this is an overriding rule in my facility. Gastric bypass, new stroke, spinal surgery, and joint replacement patients are on a "pathway" and need to be seen on day 1.
- Highest priority first- this is common sense, but we have a box on the referral form to indicate whether the pt is supposed to discharge in 24 hours. These pts become top priority, however, these forms are not always marked to facilitate this. You can meet with the medical team though, and ask them who is the biggest priority (and also ask which referral was inappropriate and can wait another day). I have been told that I can say, "I can only see X# of your pts today, who should it be?" if there is no distinguishing factor between them.
- Oldest orders first- this is what I did today since it's the first day after the weekend. We try to see everyone within a certain # of hours of the referral being written, so I just started with oldest orders.
- Divide and conquer- when we are swamped as a department, sometimes I find it best to meet with the PT in my area and split our mutual list. This way ALL the pts are seen today by at least 1 discipline and have a discharge recommendation.
- Least likely to leave last- as a corollary to highest priority first, the patients who are sickest and least likely to be discharging soon can usually wait a day. So pts in the intensive care units are lower priority for evaluation unless the need is for splinting.
- Most complicated first- sometimes it makes the day better if the most difficult pt is tackled first. Plus if this pt requires a time-consuming eval or intervention such as splinting, at least it's done and out of the way.

Does that cover it? I don't know. There will still be days when there are so many evaluations in the box that your eyes begin to spin and glaze over. I had a few weeks like that on the medical floor where I went through each day in battle mode- just taking the 6 evals I could handle and throwing my hands up at the rest. The other thing that these models don't take into effect is the need to do follow-ups. I don't know how to get a good balance there, and need to figure it out pronto since people stick around longer on the neuro floor, and I will be there in .. a week? Any tips on managing the mix of evals/followups?

So after sorting today, I started off at 930ish with pt #1 who had a gastric bypass. #2 was an older lady who was a turnaround discharge/admission, both times with pneumonia. #3 got derailed since he was meeting with his boss. #4 was in the ICU but also got derailed since he was moving to the floor that second. #5 was supposed to be a quick re-eval of a lady that I didn't even pick up pre-op, but she is doing much worse now and required over an hour. She had to have the wound care nurse come see her before our treatment could continue, so I grabbed a sandwich in that time and also went to see a little newborn w/ cleft palate. #6 was an ICU followup that didn't work out very well but was done at request of a PT I was working with. Then I hopped back upstairs to see pt #4 which went ok, and finished the day with pt #3 which was fair. In the midst of this, I also had to do another 2 chart reviews that didn't turn into actual billable events. Wound up with great productivity but will still be typing up #5 and #6 tomorrow morning. That will probably be a slow starting day since it is my turn in rounds and we have our weekly team meeting right after.

(By the way, I'm not trying to be patronizing about my patients by numbering them, but it's hard work to come up with aliases for everyone, and I don't anticipate touching on any of these stories again.)