New roles & responsibilities

I have taken on some additional OT tasks this year, and it's getting to be an interesting balancing act.

A flashback to begin the story: when I was in high school (not all that long ago) I often had this feeling of being overextended, existing in a state of mild panic at most times. Totally unassigned time (especially that which was not merely procrastination) was rare. Looking back, I was doing A LOT. Probably too much. As a sampling (just of items I can quickly remember, which probably neglects a few) I was involved in 2 sports, at least 5 extracurriculars (not including special events such as talent show) and a part time job while carrying a not-wussy list of classes. I say this not to brag, but to give some perspective of who I was/am. My freshman year of college was completely opposite- I went to class, I goofed off with my friends, I took midday naps, maintained my (very) part time job, and I did not care about much else. This actually had a reverse effect of sometimes making me feel anxious and somewhat empty at times.

I added activities back in and out around the MOT program. I added in AOTA and SOTA my first year in the program and my state association soon after. Responsibilities grew over time. After graduation, I was again pretty inactive at first, which was justified in my mind by moving to a new town, starting a new job, and getting married all in quick succession. But again, I added items back in, even doing extra program development for work in my free time.

So as the years have passed, I have added activities in and out as it suits me. Things tapered off with the move to Baltimore but have increased again now that I've been settled awhile. The most noticeable time commitment is work, which with my poor balancing act between productivity and completing notes has led to me taking work home frequently.Inpatient staff is doing more covering of outpatients while also handling staffing shortages of our own. This has created a baseline level of stress for me, trying to stay on top of the daily grind and being unhappy that I can't seem to squeeze it all into an 8 hour day. I also had a level I student recently, which was fun despite the time involved and seemed to work out even a little better than last time. Just leaving me at a baseline level of exhausted.

In addition to work, I have taken a more active role in my state association. I was 'elected' as VP of Advocacy Relations for MOTA and have been involved in monthly business meetings and bimonthly legislative reviews with our bill review team and our lobbyist. It is a great group of individuals, I feel like we have a diversity on the group that allows to have insight into almost all the issues. It seems that no matter what the bill of concern, if we say, how do the OTs in that field feel, we will always have a representative. Our Lobby Night event went well, we've also had several members present testimony to various committees in support of bills. Legislative activity rolls by quickly, so it's kept me quite busy trying to keep the pace.

My other new OT activity is very concentrated in the amount of effort but will only be officially meeting twice a year. I got to go to California last week for a 2 day NBCOT conference developing simulation questions. First of all, I did not even know that they had added these type of questions to the exam since I took it. It is truly a challenge for your critical thinking skills. Looking at the example I was sent, I wasn't sure that I could take the test, let alone write it. I met a great group of OTs, in and out of academia and in all ranges of practice. Everyone I met was intelligent, friendly, and committed to giving back to the OT community. If it's any consolation to the students out there, as hard as you will work studying to take the exam, others are working just as hard to write it according to the blueprint and keep it fair for entry level OTs. I haven't had the feeling of brain jello for a long time, but we worked to exhaustion on those items.

Last major OT activity is the upcoming AOTA Conference. I am certainly looking forward to it, but I've got enough stuff on my plate that I'm not frequently thinking of it as a 'getaway' or anything like that. I'm excited because it's close enough to drive, and I will get to go with my best friend. I've gone to 3 conferences in past years, but never with a buddy, so that will be nice. I'm trying to cool it on the overscheduled program and see if I can take things at a calmer pace for once. I think that it's interesting in how things are scheduled at the conference. Last year, I felt like there were more NICU courses, so it's hard to tell if that was a passing trend, more people holding out for the NANT conference, or just a random event. This year, I saw 4 interesting acute care courses- all scheduled at the same time, so that's a major bummer. I've noticed that I selected more stroke related courses this year, including one that I tried to attend LAST year and the presenter didn't show up for. I'm disappointed that I didn't do more with my new-found knowledge last year, so I'm going to take off the day after to see if I can synthesize some things before heading right back into the workplace.

With all these new roles and responsibilities, I have had difficulty keeping up with other tasks. My google reader has completely overflowed to something like 500 unread items, I haven't been able to get the state association legislative webpage up and running yet, and I won't even tell you how long this post has been sitting in drafts. I have 2 AJOTs that haven't even been opened, let alone read. I have about 300 pages left in The Count of Monte Cristo and really would like to spend a solitary day finishing that. Concert season is coming up too. Obviously, there will be things that get left behind. I'm trying to prioritize and find a dozen extra hours in the day. Until then, I'm just doing what I can and hopefully will stumble into some occupational balance.


Who gets to go home? 3 short case studies

One of my biggest responsibilities from a hospital standpoint is providing discharge recommendations. Hospital stays are notoriously short and it is a priority of the case management staff and doctors to determine discharge location, for which they recruit OTs and PTs to assist. But determining discharge readiness and placement is more of an art than a science, no flow chart can be easily developed to guide a novice through the process. So here are 3 case examples of similar patients and situations, whom I saw on the same day, and my rationale for their discharge locations.

All three of the individuals were over 80 years old, with moderate dementia. They were all admitted with altered mental status caused by pneumonia and concurrent urinary tract infections. They were all living with family members prior to admission, who have each made a goal to keep the individual at home as long as possible. They are each oriented only to person at this time, but recognize their family members who were at bedside. Each person required max assist for bed-chair transfer and max assist for ADLs during OT eval.

Patient “Alan” lives with his also elderly brother. They have been living together almost their entire lives, and until about 5 years ago were very active in several community activities. I think it is fair to say that they are brothers and also best friends. Alan has been declining in recent years however. He is normally able to walk at home but is very unsteady, requires a lot of assist on the steps to the upper floor, and has had multiple falls at home endangering him and his brother. Alan's brother tearfully states that he is unable to help him after falling, which is becoming more frequent. Alan has not been able to leave the house for some time, and his brother is only able to go out for short trips to the grocery store, which he recognizes still poses a safety risk by leaving Alan alone. They have a 2 story home, good DME setup, and some rare support from friends (no remaining family).

Patient “Betty” is a very pleasant woman, always smiling, happy and friendly. Her daughter is a retired pediatric nurse, but is frustrated with herself for not knowing more about geriatric care. She noticed a cough developing earlier in the week but did not expect that illness would cause such a drastic change in her mother's personality and abilities. Normally Betty is able to walk w/o device and perform ADLs with supervision. However, Betty is very afraid of falling in the hospital environment, actually fighting the transfer, and requires max assist of 2 for chair to bed. She is still able to follow 1 step commands as long as they are not about transfers. Betty's daughter is well educated on devices, but has a bad back and cannot lift >10 pounds. Per pt's daughter, Betty did well in rehab previously after a hip replacement.

Patient “Carol” is lethargic and minimally responsive during the evaluation. She responds best to her daughter, and will follow 1 step commands from her. She has severe retropulsion in sitting. I could not transfer her, but her daughter was able to in a less than fully safe method. Daughter reports that there are multiple family members that live in the home with Carol, and others that assist in rotating care duties. They have good DME setup at home and 24 hour assist with various caregivers. Carol clearly responds best to her family members over the staff at the hospital.

Who gets to go where? There are few hard and fast rules in discharge planning. Because OT is committed to being client and family-centered (and because care for a person with moderate dementia requires a high level of commitment from the family), discussions regarding each option were provided to the families of the patients. These are the decisions we made together, though it is certainly possible that other therapists or case managers may have tried to elicit a different response.

Alan was recommended for a trial of inpatient rehabilitation at a subacute level to attempt to progress in ADLs and transfers. The plan was to select a facility that also provides long term care, as Alan's brother could no longer care for him at home. Special consideration was given to make this place close to their home so that Alan's brother could make frequent visits.

Betty was recommended for inpatient rehab at a subacute level at a facility she had been to previously. Betty's daughter would not be able to care for her currently, but was open to the idea of family training and purchase of lifting devices if needed to allow for her to return home after rehab. She also had a good connection with home therapists as well.

Carol was recommended to return home with home health therapy to address safety in transfers and additional adaptive equipment assessment for best safety at home for her and the family. She was unlikely to fare well in any facility cognitively or with physical progress. The family was ready to continue 24 hour assist and try whatever was necessary to provide for Carol.

Discharge planning is not always easy. Therapists, MDs, case managers and the family do not always reach agreement. But this was a situation where even though there were difficult decisions, each family unit got what was best for them, I think.