OT Web Gems- yet another random edition

OT Web Gems is back! (because I'm aimless and have collected a lot of links!) Some of the absolutely random things (with emphasis on a few blogs) that have caught my eye recently.

-CPR performed by those with physical disabilities- yes, it is possible, I'm glad that the author posted it as there seems to be a dearth of info on the topic. I've just found the blog through twitter and will be following her posts with interest- she's an OT, you should too!

-Fidget toys explained- I have been following this blog with interest for some time now and really respect that the author is prolific not just in blogging but also on wikis, really helping to get the word out about OT related issues. I'm a little bummed because I've had a script and everything ready to make a video on fidget toys for 2 years or more and just kept putting it off- scooped again! Oh well, I may still make it anyway, and this is definitely another OT blog you should be following.

-TherExtras- another blog I have only recently discovered with lots of interesting topics, author is an OT/PT/PhD

-World OT Day Poster- Mark your calendar: OT Wikiflash October 25-29

-What's happening in Obama's brain? -an interesting little piece which I find more interesting due to my current neuro-related reading, The Shallows: What the Internet is Doing to our Brains. I won't start talking about that now, but it's been an exciting little spur to my curiosity and knowledge quest.

-Motor Skills Games- a good resource if you need some fresh ideas, gross and fine motor included

-"Socially Awkward Like Me" -I really identified with this blog post that I found through someone else's twitter feed, discussing how she sees shades of her own behaviors in her autistic child's behaviors

-Backpack tips from PTs- Is it wrong that I feel that PTs are horning in on Backpack Day? I've been feeling under attack lately anyway and this just frosted my cookies in all the wrong ways. This was also featured in the WaPo, with no comment on the OT event. :(

-Tots-n-Tech- I stumbled across this newsletter and thought it was very well written with good ideas. Some great, simple, kid-friendly AE included. I will have to be following them in the future as well.

tips?

So this is just a very brief thought I had over dinner tonight. OT is by definition a service profession, we are paid to provide a service to others. Waitstaff who provide good service receive (in theory) increased compensation from their customers, and those who provide subpar service are not as well compensated. However, OT is basically "flat-rate" pay, with some increased compensation for experience, but no financial recognition of competence or above average performance. (at least in my experience- is anyone being compensated for specialty certification or other signs of advanced practice??) The only fiscally-related judgment of competence is whether you continue to be employed. We've had a lot of cuts at our hospital lately, particularly in the employee recognition department, and I think it's fair to say that morale is down. We have ways for patients to recognize excellent staff, but one of those methods is tied to the Press-Ganey survey, which doesn't go out to the patient until they have already been discharged for several weeks. By that time, I feel that our impression on the pt. and family may have faded a bit. Anyway, my idea is that during the discharge session with the RN, the pt. and family were handed a paper asking them which services they had received that had a checklist of various ancillary hospital services, and then gave them an imaginary$10-$20 to spend on "tips" for the staff members/departments they felt offered good service. Accumulating "tip money" could either result in an incentive reward or an actual dollar reward, which I think would be cool. I've never worked in another service profession that gets tips, but I have to imagine that it is somewhat motivating to see a reward immediately after your service was provided. Good feedback and all. Any thoughts?

Just breathe

I'm in a little bit of a rut right now, with an associated (OT related) writers' and readers' block. I'm working on a couple of entries, but it's moving slowly. I usually never have an unread OT Practice for longer than a day, given my 2 hour commute is so conducive to reading, but I now have 2 piled up along with the latest 2 AJOTs. My google reader list has been perpetually overflowing for months now, causing me to unsubscribe to several items just to decrease the counts. I know we all get behind on that stuff, and that I used to get much more behind on it when I didn't have scheduled reading time. But I'm in a little bit of a funk right now, so patience is requested and encouragement would be appreciated. :)

Adventures in Serial Casting, Part I

Image from BBC

I recently worked on serial casts for a patient with brain injury to improve PROM and tone of the ankle. Here is the case study which will be followed by an entry of some of my own research into the topic.

Pt. is a ~60 y.o. female s/p multiple CVAs who was referred to OT for splinting assessment while in the neuro ICU. Pt. was connected to typical ICU monitors plus arterial line, was breathing comfortably on room air. She presents at a Rancho 3-4 level, depending on the day. Her L foot demonstrates increased tone, plantarflexion, and inversion. I was not able to passively stretch her ankle into neutral position and she demonstrated no AROM. I did not splint her per normal protocols (pre-fabricated multi-podus boot or individualized foot boot constructed from splinting material and cushioning as necessary) because I worried that she would not fit well into even an individualized splint due to the inversion and would be at risk for skin breakdown. I asked the doctors to consult PM&R at rounds, and the PM&R doctor injected the patient with a phenol nerve block (I'm not going to go into the differences between phenol and botox because I really don't know anything about it and that decision lies outside the OT realm. There is research on it if you're interested) which he said would be effective for 2-3 months.

After the nerve block, I was able to range pt's foot out of extreme inversion but not quite to neutral and she still had deficits in dorsiflexion PROM. At this time we were able to begin serial casting of the ankle. I can't say that I had experience with the specific technique, my previous casting experiences involved the elbow (in retrospect, this is much easier to cast in my opinion). However, I did take an athletic training class back in high school which involved many sessions of ankle taping (and after spraining my own ankle I got several years of experience taping my own ankle daily) so I did feel that I had a good concept of the necessary design (stirrups, figure 8s, heel locks and a general circumferential wrap).

Our first cast was applied after 15 minutes of a heat pack. Pt. was positioned on her non-affected side with L knee in flexion and L great toe in extension to inhibit tone and allow for the PT to get best stretch from her ankle. Gel pads were applied to bony prominences, cast padding was applied to the whole lower leg, and 3 layers of plaster were applied. This first cast was applied on a Friday, (only because I was on day 2 of 8 working days and would be there over the weekend to monitor) and removed on Monday with gains in PROM noted. I had forgotten the confidence that you need to operate a cast saw, but it came back. Her inversion problem was gone after this first cast. A second cast was applied on Monday afternoon and removed the following Friday by another therapist who decided to try out a standard multipodus boot at this time as the pt. could be ranged to neutral. However, when I saw her on Sunday, she still had the PROM to get to neutral but her increased tone was still pushing her into plantarflexion and thus she was pushing herself out of the boot.

We decided to do 1 additional cast in attempt to reduce the spasticity, but something was not right about this attempt. When following up the next day, there was an indentation on the medial portion of the leg that was concerning for increased pressure, and it was unreachable by tools to attempt to correct, so it had to be cut off. It still seemed wet, and I don't know why, but that made it harder to cut. I bivalved it in the hope that I would be able to fix it from the inside and make a long term splint. This was my last day before vacation and afterward they tried kinesiotaping to reduce tone as well but I was not present for that part. Thus ends the chronicle of the serial casting.

(Please stay tuned for an entry focusing on the research behind serial casting)

Bye bye July

So July should probably just be labeled the month that got out of control.
I had an additional 5 days off on top of regular weekends, (I did work a holiday) and had lots of days switched from normal schedule. It makes for an interesting new rotation when life is all topsy-turvy. I'm not sure that my coworkers would say the same, but don't worry buds I'll be back with a vengeance in August.

So I switched to neuro coming off my vacation, had some personal issues come up mid-month and then capped off by entertaining friends last week. In addition to trying to make some changes in my personal life and reading extra novels, that has made less time to update on here. (sidenote- I read The Eyre Affair by Jasper Fforde and am completely hooked on the Thursday Next novels) But there's been plenty of interesting happenings. Neuro is always a challenging rotation since the deficits can be minute or mind-blowing and you truly have to fight to get your patients into the right rehab setting on discharge. I have been trying to improve my skills in evaluating visual deficits and splint fabrication. I finally made a hand cone without getting the orthoplast stuck on the plastic cone, which was a victory in itself.

I return to work tomorrow after several days off which were much needed. My caseload has been taking a turn for the worst lately. A patient that had been improving coded and recoded. Several are hanging in limbo- stable but not improving. My strongest candidate for acute rehab wound up getting a femoral line placed and landing on bedrest. I regretfully had to recommend inpatient rehab for a young lady due to safety concerns. I've spent a lot of energy fighting for TBI rehab for a patient only to have the family refuse. I've had a patient that has made me terribly homesick and I know that she is going to be one of the people whose life sticks with me for a long time (shout out to MM and all my peds) so I've been very emotional over her case. We have many very very sick people on the unit right now so it has been a bit depressing.

Upcoming Entries (if any of these interest you, please comment and I'll try to move it along quicker)
- Adventures in Serial Casting
- Failures in being an OT for the family
- A case study for a patient with multiple CVAs

I hope to have some more good case studies in the near future, but people need to start improving. Any well wishes much appreciated.