OTNotes Greatest Hits Volume I: 2008-2012

As part of my blogiversary, I wanted to celebrate entries that have gotten lots of views, lots of comments, or that I felt were particularly good writing. I've tried to group these thematically to make for best reading. If there is an entry that you remember and isn't listed, or something you wanted to say about one of the pieces listed, please feel free to share your thoughts in the comments!

Entries for Students - I started this blog originally to help people in OT school, so it should be no surprise that I have lots of popular entries for students.

How to get into OT school

Writing goals -I need to update this since my approach has changed somewhat since I wrote it

Writing Sensory Goals 

Case example with goals - This is an acute care joint replacement case

NBCOT study tips -please take note: this was written several years ago, has no info on simulation questions, and I cannot legally update it until 2014.
giving an inservice - should help you pick a topic and some basic presenting tips
searching for an OT job - short plug here, I have gotten 3 jobs from AOTA's OTJoblink. Consider it.
interviewing tips 

the importance of asking questions

Acute Care - How many hours have I spent in the hospital? A lot. Sometimes people in this area are very reductionist, but there is a lot to learn and improve upon if you're an OT in acute care.

How to compile a relevant past medical history
prioritizing evaluations - a few different methods
Acute Care Tips and Tricks - some essential tips learned after many years
who gets to go home? - 3 short case studies of "similar" people who all discharged to different locations
Adventures in serial casting - this is a review of the research surrounding serial casting efficacy
Patterns - a couple of patterns observed in admissions based on weather and other external factors


Pediatric- I'm still getting my sea legs in the land of peds, but here are a couple of good entries. As I start to feel more confident, there will probably be an uptick in this category
Mat Man  -maybe my favorite photo entry
infant toddler trauma awareness  -a lot of really good information on trauma training
starting in Early Intervention: assessment -how I picked my EI assessment


Energy Conservation- this is a fondness of mine. At one point I had a whole EC series planned... may still do something along those lines sometime.
energy conservation in the summer
energy conservation for holidays

Professional Issues- Various issues that I think are relevant to the profession in an overarching way

collaboration with Girl Scouts - I really want to see a greater connection between OTs and Girl Scouts
Malcolm Gladwell thoughts - remember when Malcolm Gladwell's books were really popular? here are some of his ideas applied to OT
OT twitter chat - some advice on getting started in twitter chat, which I would definitely encourage. Check out #OTalk2US if you haven't yet
thoughts on a Glee episode -the OT connections mirror version of this got picked up by AOTA's 1 minute update and really exploded. People were very opinionated over this issue, or just the show.

Personal Issues: glimpses of my more inner life

struggling to be an ot for family
reading without getting carsick -there really should be more information online about how to accomplish this
unanticipated blessings related to presenting at conference


Uncategorized- some of the randomness that is truly me
chicken dance - a little inspirational story that showcases my favorite strategy- make a fool out of yourself.
OT quotes -these are not quotes from OTs, but more meant to be generally inspirational. I should have renamed this or actually found real OT quotes, but it is what it is.

podcast with AOTA presenter -I did my very first podcast!

aquatic exercises -specific treatments for aerobic pool exercises. I now do several of these myself since I am doing prenatal water exercises
metacognitive analysis- how I approach puzzles



I think this is a pretty good list and definitely shows that I have some seriously diverse interests that I've been writing about the past five years. I think that I will probably make this an annual event, and reflect back on the best posts of the year. 

Pregnant in Healthcare: diseases to avoid

This is a hard article to entitle. Obviously, no one wants to be exposed to contagious diseases at any time, but by virtue of working in a hospital, there will be sick people around. This is a list of infections and diseases that should be avoided by pregnant women working in healthcare that was compiled by a former coworker of mine. Explanations of some of the possible effects of exposure to the fetus are directly from the links and citations noted. It's not my intention to cause anyone to worry, but just to give a little information to be used when building your caseload.

Please don't debate with me about the frequency of these complications or ask whether your child is at risk- I'm not a doctor, you should definitely discuss your concerns with your own OB. But this is information that I think is hard to find in one place and beneficial to many women trying to work while pregnant.

Herpes varicella/ Herpes Zoster (chicken pox, shingles) – exposure in the first 20 weeks or last 5 days of pregnancy can cause congenital varicella syndrome with a spectrum of musculoskeletal and visual birth defects.

Rubella (German measles) – Early exposure can cause congenital rubella syndrome, characterized by eye defects, heart defects, and mental retardation. Also raises the risk of miscarriage or stillbirth. This is covered by the MMR vaccine so you should be immune if you received it as a child.

Toxoplasmosis – early exposure is less likely transmitted but can mean more serious results, late exposure is more likely transmitted but has less serious results. This can cause eye, hearing, and learning problems.

Cytomegalovirus – transmission is rare, but possible effects of CMV on a baby include learning disabilities, mental retardation, and vision or hearing loss after delivery.

Parvovirus (slapped-cheek disease, fifth disease) – Can cause severe anemia which raises the risk of miscarriage or stillbirth.

Herpes Simplex – (STD) Exposure at birth may result in brain damage, blindness or death for the newborn.

Hepatitis B – this infection can be passed to the infant at birth, which poses the risk for developing chronic Hep B.

Pt with AIDS with mental status change (can be Cryptococcal Meningitis or "crypto") - this is a fungal, opportunistic infection. It can be transmitted to the baby and both of you could need to be treated. Certain drugs to treat this can cause miscarriage, so obviously inform your doctor if you are pregnant.

Bacterial Meningitis – can cause brain damage, hearing loss, or learning disabilities.

It has also been recommended to me that pregnant women avoid contact with people who have the flu. And it's always good practice to avoid contact with anyone with a fever or new unexplained vomiting or diarrhea. This article from Nursing Center has some additional information on risks that pregnant healthcare workers are exposed to, with some suggestions for how to mitigate these risks.

As a currently pregnant, currently recovering from very mild illness person, I can attest that it's pretty miserable being sick when you don't have many options for medication, are already tired, are at greater risk for dehydration, and are worried about the development of your child.

Knowledge is power- hope this list helps you feel more empowered as a pregnant healthcare worker!

Adventures in Scheduling

With all the crazy scheduling that is required as a therapist, you'd think they'd make you do logic puzzles as part of an entrance exam. Here are a few general thoughts on the mishaps inherent to scheduling. (this is a bit scattered since I'm still jet-lagged, so please forgive any dangling modifiers or unresolved thoughts)

First off, I think that there is this cultural norm of what a "workday" entails. If your parents worked non-medical white-collar jobs then you can probably identify with a 9-5 workday as we see in so many shows and movies (at least those that actually indicate that people WORK for a living, as opposed to being independently wealthy enough to just sit around and talk). Even in college, actual "working" time for me did not get up to 40 hours/week until the end of OT school (at which point we raced right on past 40 and never looked back). I know that there's tons of people out there doing simultaneous job and college, or 2 jobs regularly, all I can say is more power to you. But I had this expectation that a "normal job" would have normal hours and that the schedule would not be that bad.
I have realized that was complete BS.

This enlightenment took its time coming. On my phys/dys fieldworks, I had a hard time adjusting to a 7-330 schedule, especially with a nonexistent lunch that was dominated by meetings and paperwork. Despite that, people almost never left on time, needing to stay for one reason or another. It was frustrating as a student, waiting at the end of the day to get your notes signed and be told to have to redo them (now) when it was already past "quitting time." The woes of being a salaried employee- you will often work over the expected time.

Scheduling within your day is another insane proposition. In acute rehab, we had to work as a team to make sure (each day) that the client had their required time in all services, minimal time wasted sitting in the gym between services, at least one ADL per week, and so forth. In the hospital, coordinating cotreats was the biggest scheduling portion, and knowing that your whole day was likely to be derailed by patients going to tests and whatnot. The hazard of hospital work is ending up with a back-heavy day because not enough could get done in the morning. School scheduling had to work with the class schedule to make sure that they weren't being removed from important learning opportunities or special classes or being overbooked in a day. (We did pull-out services and I could not even conceive of how to schedule push-in during my year balancing so many different schools. I would love to hear experienced therapists' tips on that.) However good your schedule is, it is likely to get derailed by an IEP meeting or school assembly or lockdown drill. Outpatient scheduling might be assumed to be the easiest, but often you are dealing with people who need to be seen outside of their own working hours or school hours, so fitting in times can be tough.

I'm great at logic puzzles, but daily scheduling is a monumental frustration to me. One of the few beauties of being a prn employee is that I can just show up and do what is already assigned... and if the patient needs to schedule for their next time, I usually turf that to someone else.

Good coworkers will also adjust their schedules to help one another, even if it means balancing inpatient and outpatient work in the same day, or taking something difficult. But that is another thing that will wreck your schedule... and productivity if you have to track that.

My most common work now is as an independent EI contractor. I'm still trying to get into a good groove for getting the kids scheduled out right. Part of me doesn't want to over-analyze it because I don't have a huge caseload (yet?) or time demand, but my left brain would love to just have regular times for each kid each month. Evals have to be scheduled within 15 days of hearing about them, which is not really a lot of time to work people in if you do have a lot of other engagements... like holidays, which we have a few coming up.

Holidays are a whole issue all their own. Remember getting days off in school for holidays? And long Christmas breaks? That does tend to go out the window. Hospital and SNF people have to rotate through holiday coverage... when you start out, especially if you're young and childless, expect to work some of the biggies. I remember a boss telling me when I was interviewing that they paid so well for big holiday coverage (it was good- effectively 3x normal pay plus a PTO day to be used later) that they never had to force people to work major holidays. 6 months later, when those of us who were under 30 were all sitting there on Christmas day, I found those words to be particularly irritating.

Another fieldwork instructor would be laughing at the turn my life has taken. She had her own business, and I remember being aghast when told that we would be working on a major holiday. To student-me, I could not even conceptualize why you would be working on a national holiday. Well, now that I am mostly self-employed, I get it. I just scheduled a kid on a major holiday without even thinking twice. Major reasoning- I no longer get paid to take holidays... or paid regularly at all. If I have a "day off," it's just another day making no money whatsoever, and I've had plenty of those days for awhile. 

Now with my EI kids I would like to schedule multiple visits in a day in a geographically sensible way, but it hasn't worked well yet. If I do a community outing, it's hard to say exactly how much time that will take, so planning the next visit can be tricky. Accounting for travel time is hard sometimes as well. But there's just the general Murphy's Law that comes into effect here also: the people who live near each other will have opposing personal requests, one will want morning and another will want evening; one can only do Thursdays and another Tuesdays; everyone will want 10am; on and on it goes.

Is there a moral to these scheduling woes? (is there anything logical written by someone whose personal time changes have zapped her ability to do anything but stare like a zombie?) I guess the overriding theme would be that you have to be flexible. No matter how nicely laid out your schedule is, it is likely that it could all go to pot anyway. No matter your personal preferences for workdays, if you want to get paid and your employer decides you're working weekends or holidays, that's what will happen. Until you go into business for yourself, and then you'll probably work those days anyway. And if you like the freedom of "set your own schedule" prn work, it's probably good if you have a backup income and a good budget. 

Acute Care Tricks

There are so many OTs in the Acute Care/Hospital setting, and yet sometimes it's as if we're the black sheep of the OT family. There's not a lot of OT research done in the field, we must work within the medical model, and turnover of patients and therapists is high. I remember when I was getting started, I borrowed books on PT in acute care to try to bridge some knowledge gaps and vowed that there should be more on the role of OT. (click through to continue)

After spending four years in the hospital system, I had made up a list of topics that were relevant to OT in acute care that weren't covered well in my textbooks and had decided to do a series of serious blog entries covering these topics. Of course, this was in my +50 hour work week and long commute days and just never got it started. That is about the time that I saw this book coming out, and while I was excited, I was also really depressed about not doing my series ahead of time, and I stopped writing on the topic for awhile. (I haven't been able to see the book yet, but based on the contents I think that it would be really good for people new to the acute care setting)

Anyway, that's a really long intro, but I wanted to share some of the off-book tips for acute care therapists (many of these would be relevant to physical therapists as well) that I've developed (or stolen from smarter people) over the past few years.

- learn to get good at manipulating equipment. If you don't know what it is, what it does, or what happens if it gets disconnected- ask and figure it out. A good nurse friend will come and disconnect IVs, foleys, and PEG tubes if they're able to per order. Ask people to show you how to pop the ICU monitors off the wall. Stack your O2 tank on the IV pole, hook a chest tube on a walker, pin loose drains to the patient's gown... possibilities are endless. Pay attention to what the good nurses and techs do and take a page from them.

- double up on everything. Think you need 2 washcloths for your ADL? Better bring 4. Because one will drop on the floor or get really dirty and you'll need another.

- Be creative with what you have. You can't carry a lot of items with you in acute care, so nothing can be a unitasker. A mitten (used to keep people from pulling wires) can be a ball, which is a good early purposeful activity in the ICU. Objects like a safety pin and comb can be good for fine motor and stereognosis testing.

- speaking of the ICU, if you are working with someone (particularly male) who isn't able to stay covered with a gown and is kicking the covers off, the sleeves of a gown can become leg holes to help keep some modesty.

- Try to make it easy for the next person who comes along. This is a list of things you should return to place before you leave the room. If your patient is anything less than 100% ambulatory, make sure the bed is right beside the chair. Don't leave all the cords tangled up in a corner. And if you can make the bed fresh (or even get the tech to help you during the tx) then it will very much be appreciated. When you're working with someone on their first day after an orthopedic surgery, or any time that you don't feel very confident that the person will actually make it to a chair, you need a different bed changing strategy. As a person is sitting EOB, (maybe as you're taking vitals or the PT is checking something) pull the four corners of the sheets off the bed. Then your helper can put the new fitted sheet and a folded draw sheet on as close to the patient. When your patient stands up, the helper pulls off the old and moves over the new stuff LICKETY SPLIT. Voila! new bed, ready for your person to collapse back onto if needed.

- In a pinch, the back of a sturdy chair can serve as a walker for standing. This usually ends up happening in the ICU when you weren't expecting a person to do any standing, but they surprise you in a good way. Not such a good way that they start cartwheeling across the room, but good enough to get a short stand in.

- lastly, there's one accessory you should never be without. Jumbo safety pins. Stick 10 of them on your lanyard or off your badge tag- they are so often useful.



What's the trick that makes your life in acute care easier?

random thoughts of an insomniac OT

Can't sleep and it's before six a.m. on a day I have off. Awesome. But here are some of my thoughts on things that have been happening recently.

First off, and rather obviously to anyone who has been with me in person, I am under a lot of stress lately. For an OT, I certainly exhibit a lot of poor patterns in dealing with stress when it gets to a high level. I retreat into comfortable things, procrastinate on other tasks (hello blog), and have a thousand questions running through my head all the time. I'm also increasingly more distracted, which feeds back into the procrastination. I've been waking up around 5 for the past several weeks, but for the most part I just stay in bed in a semi-dozing anxiety spree until the alarm actually goes off. Very stressed. Likely to get worse before it gets better.

Since I'm not concentrating well, I haven't been reading as much lately. But I have been attempting to get through a couple books that may be of interest to others. One is strictly a book for work: Yes/No Medical Spanish. I haven't had a chance to use it in person, but I love the concept and found just about everything I would need for an eval (adult or pediatric) included. Since I haven't had the time/motivation/follow through to sit and intensely improve my Spanish (and it would take a lot of classes before I could be fluent for medical things) this is a great resource. I may eventually make a master sheet out of several sections so that I could just carry a small paper for home setup and basic questions and hopefully by that time the interpreter would show up! But definitely a useful book, though not therapy based. The other book I picked up because I saw an interview on Daily Show or Colbert and thought it would be thoroughly interesting: Beyond Boundaries: The New Neuroscience of Connecting Brains with Machines---and How It Will Change Our Lives. The interview was very interesting, and the scientist discussed his research using brain-machine interfaces and talking about how they would make it possible for paralyzed people to walk using their brain power, really innovative stuff. I don't think it's only due to my attention problems, but I have been really struggling through this book both with the reading level and finding things that are interesting in it. I have renewed it twice at the library, it's do or die time now. I finally just skipped several chapters and am reading only about the actual experiments, so it's a little better that way.

I feel proud since 2 of my completely not related to OT goals that I set for myself are coming along nicely. I am progressing well as a user of chopsticks (still much better with wooden ones than smoother surfaces) and I have been able to complete 3 medium difficulty sum sudoku puzzles. Everyone needs something to aspire to and in this instance, something that has nothing to do with a career. But yay... good achievements thus far since I started as a complete novice with both this year.

I had a really interesting person s/p TBI the past few weeks, and he would make a great case study if I can strip enough identifiers eventually. I had a man with a severe hemorhage that was hospitalized for several weeks and made terrific progress exponentially near the end of his stay. I also saw a man with an intriguing stroke presentation (basically a subtly expanding stroke over >1 week) who is now at the local IRF and doing wonderful per report. These people made me actually sad when they were discharged, since they were great people and their cases were interesting. It's difficult in acute care since stays are so short, ability to do treatments is rare, and you get no follow up on what has happened to the person. It's nice when you get to see someone make progress. And speaking as someone who has interests across the lifespan, it's nice to have something so interesting because I need some beacons to figure out where I need to go and focus with my career.

Some odd moments of feeling out the boundaries between therapy comrades. I was scheduled to see a child with torticollis and was interested to try out a new approach I had seen online. But then I found myself wondering if there was good OT justification for that approach. Usually, I don't feel that I'm the 'infringer' so to speak on the other practice domains, but that case made me wonder if it was a treatment true to OT practice. I think there are probably some ways that it potentially could be (use as a feeding position, etc) but it was odd to get that squeamish feeling. Kid never showed up anyway, so really a moot point, but made for some pondering.

I had several moments lately that made me proud to be an OT and do what I do. Despite being the 'young pup' of our current floor group, I am pretty much the only one with an interest in neuro, and people have been counting on me to various degrees for their own education, which makes me feel really great to have that level of respect from others. I got a nice sincere thank you from an elderly man whose wife had a stroke... he had been disappointed that I couldn't see her daily in the hospital but so grateful that I came back. I was not expecting it since the session had been very difficult for the pt and he had watched her struggle along with BADLs. I spent a lot of time with the family of the man with TBI, and they seemed appreciative of the resources given, and even mentioned to the SLP that they felt really prepared following our sessions. I was able to make a connection with a young Hispanic couple really unfamiliar with the health care system and things like inpatient rehab, and I could tell that they were happy to see me even passing in the hallway, so that was great.

I'm trying to really enjoy these happy and proud moments, really appreciate the little things. I have a tendency to be so pessimistic and do want to remember that there are good moments even when I'm in the midst of mounds of work and disappointing myself on other fronts. I'll get a semi-needed computer respite this long weekend and see if that helps things. Words of encouragement appreciated, and I hope to be through the rough spot soon. :)

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.

Adventures in Serial Casting Part II: Review of the Evidence

The term "serial casting" refers to the use of plaster casts applied over time to gradually increase PROM, decrease abnormal tone, and hopefully therefore increase functioning. Typical population for this intervention is either for children with cerebral palsy or adults post stroke or TBI. This (really long) entry aims to examine the evidence behind the intervention by answering multiple questions regarding the intervention.

For this review, I looked at 3 systematic reviews and 1 prospective uncontrolled intervention that was not included in the prior reviews. Of the reviews, one was from an OT publication, one from a PT publication, and one from a physiatry publication, so I feel that all relevant parties were represented. I focused only on articles that emphasized adults, and preferably the lower extremity since that was most relevant to my case. Annotated bibliography at bottom of page.


WHAT IS THE RATIONALE FOR SERIAL CASTING?
There are multiple theories for the effectiveness of serial casting and as per Lannin, Novak & Cusick, there is no strong evidence to state clearly which is the correct reasoning. (Categories by Lannin, Novak & Cusick though 1 or more are expressed in each article, further references as noted)
1. Neurophysiological (includes NDT)- casting prevents changes in muscle length, which eliminates excitatory input of muscle spindles and decreases spasticity. The concepts of neutral warmth, proprioceptive input to the limb, and even/constant pressure are also considered to play a part (Saracco Preissner). Per Mortenson & Eng, little evidence exists for the concept of neutral warmth providing the decreased spasticity.
2. Biomechanical- a low-load, long-duration stretch can prevent or correct contractures. By stretching, the Golgi Tendon Organs are stimulated, which stimulate the Ib afferent fibers and then inhibit the alpha motor neurons (Mortenson & Eng).
3. Motor Learning- support proximal joints until control is gained distally. Per Mortenson & Eng, no evidence to support this. I question how this can be applied to LE casts, since they are predominantly applied to the ankle and toe ROM is not a desired outcome. Also, though I have never casted a knee, it seems that if you were working off of this principle to give support proximally until distal control is given, then it might be easier to apply a bledsoe brace locked in position than a serial cast.


WHAT OUTCOMES ARE EXPECTED TO IMPROVE WITH SERIAL CASTING?
Mortenson & Eng outlined these well as: reducing abnormal tone, increasing ROM/reducing contracture (usually PROM is what is measured), and function. Measurement of these effects has been inconsistent across studies. Some studies give a very subjective therapist rating of tone, others use tools such as the Ashworth Scale. ROM was typically measured using standard goniometry, though Mortenson & Eng bemoaned the reliability of ankle goniometry. Mortenson & Eng also disucssed that increases in ROM do not necessarily correlate with increases in function, similarly, Saracco Preissner mentioned that abnormal tone did not necessarily indicate lack of function. "Function" is defined very loosely between studies and various outcome measures are used. Singer et al used the Transfer Dependency Scale, and other studies referenced the FIM. From my own limited experience in research, it would make sense that you would need an adequately sensitive measure and control for confounding factors (concurrent therapy, practice effect, time) to truly indicate whether improvement would be due to casting. I can think of several appropriate measures for UE functional improvement but don't know what has been researched in this direction arleady.



WHAT IS THE ACCEPTED PROTOCOL FOR SERIAL CASTING?
As indicated in the systematic review articles, there is no consistent protocol for serial casting. Lannin, Novak & Cusick identifies a key problem in a consistent protocol- namely that your background rationale will affect your decisions regarding casting time and limb positions. This article listed known indicators and contraindications to tx along with the level of evidence for each, however, a confounding variable to this information is that some factors that were exclusion criteria for some studies were inclusion criteria for others. Given the wide variability, comparison of RCTs was unable to be performed in this review.

Timing is a decision that has wide variability in each study. Saracco Preissner states (but does not reference) that there is no indication how long after injury casting is effective or when a person is too far removed from injury to benefit. It is stated that "most" advocate casting sooner for increased effectiveness, but again this is unreferenced. Length of time wearing the cast was highly variable as well, with the most relevant results being from a study by Pohl in 2002 (referenced in the following section) that showed no difference in results when casts were worn 1-4 days vs 5-7 days.

Protocol was specified for the Singer et al study, and stated to be "standard guideline." Briefly, casts were applied by 2 therapists w/ pt. in prone and knee flexed to 90* after gel pads were applied to bony prominences at risk for breakdown. They were able to insert a custom molded support for metatarsals if clawing of the toes was present. Casting was postponed if pressure areas or skin breakdown was present. Casts were discontinued when no change in PROM was seen over 3 casts, skin breakdown present, or if there was a need to emphasize other treatment prior to discharge.

INDIVIDUAL STUDIES AND RESULTS OF NOTE:
*Singer et al performed a prospective uncontrolled intervention with 16 adults after aquired brain injury. Statistically significant increases in PROM were noted, and 13/16 improved their transfer ability. However, transfer skills were measured by "4 randomly selected scores" not admission/discharge scores, and could have been affected by concurrent cognitive increases. Of note, 3/4 patients who had limited response had brainstem dysfunction and decerebrate positioning. I believe it is clinically accepted that decerebrate and decorticate positioning is an indicator of poor prognosis medically and with therapy, but I can understand including these patients in this study to just add to that evidence. The authors suggested that the severity of injury rather than the severity of the ankle deformity was the more important predictor of success.

(The following articles were referenced in one or more of the main articles, but I did not follow up to read the full article. Slightly irresponsible, I know, so just take this info at that level)
*Pohl 2002- this study compared 2 groups who were casted for different lengths of time between cast changes- 1-4 days vs 5-7 days. All groups showed an increase in PROM with no difference between groups. Gains were maintained 1 month after cast removal. The Lannin, Novak & Cusick review stated that since there were slightly fewer complications with the group who got casts changed more frequently, there might be an advantage to more frequent changes, however, cost does not appear to have been considered as a factor.

*Mosley 2006- this was an RCT focused on adults with serial elbow casts vs PROM for 1 hr/day. The casting group decreased contracture 22* compared to stretchers when casts were removed, but this decreased to 11* the next day, and the improved effect had almost disappeared by 42 days.

*Booth 1983- This was a retrospective study of 39 patients who had casts s/p head injury. 37% showed and increase in ROM and decreased tone. They observed that pts with brainstem lesions got their casts longer out from injury and took longer to show progress than those who had cortical lesions. Per this study, traditional treatments (PROM, splinting, weight bearing, and PAMs) did not do enough to make an impact on spasticity compared to casting. I'm not sure why this study was given such prominence in the Saracco Preissner article since it was a retrospective study, a bit dated at this time, and its rather unclear how they drew such sweeping consclusions, but again, I did not review the actual article

*Hill 1994- a double-crossover design between traditional tx (PROM, static stretching, splinting) and casting. Improvements were seen for ROM in 14/15 participants and spasticity in 11/15. Stated conclusion is that casting was more effective than the traditional tx, but the gains did not translate into functional gains.


WHAT ARE THE OVERALL RECOMMENDATIONS FOR SERIAL CASTING?
Per Lannin, Novak & Cusick, "There is insufficient evidence to either support or refute the effectiveness of upper limb casting ... There is no evidence of long-term benefits or long-term adverse effects." But this article also stated that there is Level Ib evidence that casting an adult's elbow s/p brain injury increases available extension 1 day after cast removal.

Per Sarraco, since immobilization (such as with spasticity) can cause physiological changes that would impair ADLs, and these changes are reversible, we should treat as able for spasticity. Serial casting has shown some effectiveness in improving ROM and spasticity.

Mortenson & Eng issued "grade" ratings for practice, which I am not familiar with. They say that there are inconsistent measures of "function," so no recommendation can be made on that front. A "Grade C" rating is given to using casts to reduce spasticity secondary to decreased rigor in measurement tools. A "Grade B" rating is given to using casting to improve or prevent loss of PROM, and they state that this is the only outcome with enough evidence to be considered a "best practice." Their studies showed gains of 10.4-26* improvement in ankle ROM, which is statistically significant, however they cautioned that ankle goniometry is not always reliable.



WHAT SHOULD BE ADDRESSED IN FUTURE RESEARCH RELATED TO SERIAL CASTING?
As with nearly all therapy research, there are many questions that need to be addressed. A summary from all articles would include the following, but it is not an exhaustive list:
How does casting work? Is it a biomechanical effect, neurological effect, or both?
What is the best protocol for serial casting? Included in this would be inclusion criteria, positioning of casts, length of time worn, concurrent therapy, post-casting program (including splints and exercises).
What is the comparison to other treatments or lack thereof (especially no stretching)?
How long are gains maintained?
How do improvements after casting translate into function? What specific functinoal gains are seen? Are these gains cost effective and best practice?
Randomized controlled trials comparing the above are also needed.



FULL DISCLOSURE: I am not a professor or professional researcher and do not claim that this is an exhaustive review of the literature surrounding this topic, but a review that I undertook relevant to a specific case. I am not an expert clinician. I do not intend to diminish the efforts or quality of research produced by any of the referenced articles. I would encourage you to do your own review and get necessary training prior to performing this intervention, which may not constitute entry-level practice for all practitioners. Please feel free to comment on additonal relevant research.


References
Singer, B. J., Jegasothy, G. M., Singer, K. P., & Allison, G. T. (2003). Evaluation of Serial Casting to Correct Equinovarus Deformity of the Ankle After Acquired Brain Injury in Adults. Archives of Physical Medicine and Rehabilitation, 84, 483-491.
A single study in Australia looking specifically at casted ankles in an adult brain injury unit.

Lannin, N. A., Novak, I., & Cusick, C. (2007). A systematic review of upper extremity casting for children and adults with central nervous system motor disorders. Clincal Rehabilitation, 21, 963-976.
A review focusing on UE casts but somewhat confounding as it includes many studies on children with CP

Mortenson, P. A. & Eng, J. J. (2003). The use of casts in the management of joint mobility and hypertonia following brain injury in adults: a systematic review. Physical Therapy, 83(7), 648-658.
Looks at adults after TBI and CVA only but includes studies involving wrist and elbow casting as well.

Preissner, K. S. (2001). The effecs of serial casting on spasticity: a literature review. Occupational Therapy in Health Care, 14(2), 99-106.
This review focuses mainly on management of spasticity, less on ROM gains.

Looking forward to 2011

Goodbye 2010. I don't have the energy for a LONG year in review, but...
I will touch on a few ups and downs of the year.

Firstly, let me thank all readers. I really appreciate the comments (that aren't plugging fake universities or spam in other languages) because I like to see that there has been an effect from my efforts. I don't look at the stats often, but glancing today, I see that since I started tracking in 2008, pageloads have increased by 20,000- more than 300%! WOW! And the cross-posts in the sister blog on OT Connections have brought in an extra 50-350 viewers each time, with one anomaly (thank you 1-minute update). It's really exciting to see how this blog has grown and spread, and gets me thinking about some plans for the future (more on that later). So a BIG THANK YOU to each of you, and please always feel free to comment or email me with suggestions.

Most popular pages on this site continue to be Writing Goals and a Case Study With Goals, which is understandable since this is one of the more difficult skills in OT that is not hands-on. I do intend to spend some time getting back to the 'roots' of this blog and posting about decision making, goal writing, and treatment plans. Perplexingly, a rather random What a Week post is the most read on the mirror site, with the exception of my post about Glee that got picked up by 1-minute update. Ironically, some of the posts I spent the MOST time on (e.g. Metacognition and Serial Casting Case Study) don't seem to be as popular, but I don't have tracking to that degree so I can't be positive. I did get several thoughtful comments on my most emotional post (Struggling as an OT for my Family) so I appreciate that deeply.

2010 was the first AOTA Conference I've been to as a practitioner, and even the first I saw after fieldwork. It was great to re-energize and network with other therapists. I think that as you are in the profession longer, you become more aware of others in the field, so I spotted dozens of OT Celebrities this year and got to talk with many, which was awesome.

It was interesting to see all the uproar in AOTA this past year with the potential organizational changes. As we are heading into election season again I see the new blogs and OTC memberships cropping up and it's always notable to see who sticks with it. Props to Bill Wong for continuing to post, and also to Florence Clark for taking up the mantle of the President's Blog.

There were some serious downers last year. We lost my husband's grandmother to Alzheimer's Disease in the summer, which was very difficult for the family. Then over the holidays, we had several additional hospitalizations of our family members, which have yet to completely resolve. Health is so very fragile and some families are like a house of cards... I am learning to take pleasure in contentment and tranquility, because it can all be very fleeting.

I struggled on my final rotation of the year on the cardiopulmonary floor, made extra difficult by the chronic nature of those diseases. It is hard to watch others' independence fade as their bodies fail, and I felt like the efforts I made brought about little change. There were some truly tragic stories in the ICUs that even made attending rounds difficult. I did my best for them, but I am so thankful to be back with a more stable patient base.

As the year ended, I realized that I am no longer really a "new practitioner." Granted, most of my experience is consolidated in one practice area, and I certainly don't know all there is to know about the acute care setting, but I now have a valuable level of skill. I feel like I could go to any adult hospital confidently and be a skilled member of their team. I caught multiple strokes and other medical problems, which makes me feel bad at the time (I hate to see people doing poorly) but it makes me feel that I am a competent professional doing my best to look out for my patients. I progressed with treating pediatrics by taking on outpatients for a few months and doing some feeding interventions for the infants. I was really proud to recognize self-soothing in the baby I evaluated my last day, because even though it's simple, it shows that I am retaining what I've learned though my time to practice is sporadic. I also had my first true fieldwork student, and I don't think I screwed up too badly or she would not have sent beignets. :)

I have a lot to look forward to for 2011. My goal is to spend less time typing notes at home (which is awful!) and more time being able to participate in my "OT extracurriculars"- this blog, OTC, twitter, association stuff. I am now the VP of Advocacy Relations for the Maryland OT Association and things are already in full swing. We are planning for Lobby Night in Annapolis, and would certainly love your company if you're able to attend. I am looking forward to the AOTA Conference in Philly (a mere 2 hours away) and the MOTA Conference (a mere 15 minutes away). I really enjoy how close Baltimore is to fun and excitement, so I know there will be more trips to DC and NY this year too.

Happy, healthy, awesome new year to all.

It's a Christmas Miracle!

So at rounds today, I was rushing in late and trying to get my computer set up to look things up. They had already started on the first patient (not one of mine) and wanted to know if OT and PT agreed on discharge plans. I asked for a minute to get everything settled, and in that time, the resident looked up the notes and had the answers. I was shocked! I said, "wow, I didn't think you guys ever read our notes!" and got rousing responses from around the table (resident, PA, social work and case management) who stated that they DO read them (even if it's just the summary paragraph at the bottom). It was like a present with a big red bow.

Neuro floor humor

Saw this was today's Crankshaft comic and couldn't help cracking a smile. If you come into a hospital with a headache, be prepared for neuro checks Q4!

Working on the neuro floor means that I have to suppress my natural propensity to be a worrywart- I start thinking about word finding problems, clumsiness/tripping, and hope that I'm not ignoring signs of a tumor or aneurysm! It's hard to listen to all my patients' stories of symptom onset w/o getting a little paranoid.

Just finished a biography of neurosurgeon Keith Black who has very compelling personal narrative and his life story is certainly an object lesson in encouraging the learning interests of your children. He described that his parents got him a dissection kit and chemistry set from a young age and encouraged curiosity in a number of ways- it's certainly a great story of parents helping a child achieve exceptional outcomes.

Thanks for being patient with the slow updates- had a very withdrawn week and have also finally resumed regular workouts (plus it's FOOTBALL SEASON), so time has been spread.

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?

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.

Yikes!

Holy cow... it's been almost a month since conference. Where has the time gone?
I would say that I want to go back... but the time since the conference has been pretty rough as evidenced by the scarce/nonexistent updates. And at such a terrible time, after handing out those nice business cards haha. So, some brief updates.

- I took no time off after the conference, and that was not smart. Next year, I take a day to recuperate and absorb info. I still need to print out handouts- both for sessions that I attended and others that looked interesting- and then compile my notes.

- I went to some great sessions and met more "famous" OTs than ever before. I think that the quality of presentations was very high this year.

- I hope to get a submission in so that I might present next year in Philadelphia, Pennsylvania, April 14–17. I've had a gigundously large and cruddy list of things to do lately, and it's been pushed aside, but I really must do it.

- Speaking of cruddy things to do, I have been documenting at home almost every night, including tonight. I continually wonder how people meet productivity standards and get documentation done.

- April and May definitely kicked off my season of concerts and travel. I have had 1 weekend at home since conference and will not have another uncluttered weekend until July. Obviously I am mixing in some fun times, but it's wearing me out.

- had my first pt. with what I consider a contemporary popular name. I have been mildly wondering what it will be like when nursing facilities have hoardes of Jennys, Kelseys, Chelseas, Kaitlins, Stephanies, Kimberlys and Lindsays... not to mention when the following phase of names ages, leaving us with Tylers, Taylors, Collins', Houstons, Austins and the like as patients.

- I got a really nice bag at conference... messenger bag in a pretty blue with lots of cool features. Got it on the last day of conference. Went to pack it in the taxi to the airport the next day and a clip snapped off. Packed it to work the following day and the snaps holding the strap broke. I was so mad at the people, I said to myself, "I'll show you, I'll go back to my crappy tote bag from before." I noticed later that day that the tote bag, which I had gotten at previous AOTA conference, was from the same darned nursing home. And the zipper is trying to break. Darn you unnamed NURSING HOME!

- Posted on the Acute CareOT Forum about ICU evals. Hope to see that forum stay active. I have been tardy in adding friends I made at conference to my OTC list, but it is very hard to search for people. Feel free to add me.

- Less than a month left of doing outpatient pediatric work. As it was before, part-time peds work is difficult. Been reading up on Developmental Coordination Disorder, want to take our unit blocks (small, interlocking squares) and make lego-like designs with picture instructions to use as a clinic tool.

So, times have been busy and will only continue to get busier. The blogging break was good, if unplanned and ill-timed. I will try to be a little more active before my real vacation comes. Things I intend to do before then (OT related):
-write proposal for AOTA conference
-post more videos from conference
-post all 80-some photos from conference
-write a post on energy conservation for summer travel

Until then... here's hoping there's not too many more late nights documenting from home!

Reflection of the week

A few reflections from the past week, which has been very hard.
First off, I would just like to say that the AOTA conference was great, but I was very foolish to stay for the entire time and then head right back to work the next day. Because as fun as it is, it is also exhausting, and I didn't get any time to process the new information before heading right back into my crazy daily life. I was looking forward to today, my day off, to do some of that. However, I neglected to remember that we're traveling AGAIN this weekend. So that has added to the stress, and I won't really get a "me day" to process stuff until next Saturday. Very difficult on a personal level, and also because I would like to do some recaps about the cool sessions I attended and to give a glimpse of conference awesomeness to the holdouts who didn't make it this year.
In my stress, I decided to let go of thinking about presenting at a state conference this year, since all the deadlines were very close. However, I will be applying to present at next year's AOTA conference in Philadelphia. I will be trying to do a Tech Day session on hands-on optimization of OT Connections and the web in general using tools such as RSS readers, email filters, and aggregators. Basically an in-depth and hands-on version of my presentation to WVOTA last year. I feel like many people shy away from using online OT tools because they don't know the ways to make it less time-consuming. Any thoughts, or people who want to join in?
This week, work has over-dominated my life, preventing a normal occupational balance. Carved out some time for friends, but it went poorly too. So I'm trying to focus on some of the more positive or interesting things of the week.

- With the brainstorming help of some PT buds, I made a really cool splint. Our plastic surgery dept has been writing some crazy orders of late, and this time they got a crazy splint as a result, but they liked it. A woman had a skin graft on the anterior and posterior sides of her calf, and they wanted all pressure off of this to heal. However, she only had about an inch from the sole of her foot before the graft started, and then it was almost to her knee. So if you think about supporting an entire leg from those 2 points, and you've had basic physics, you know that's just not an awesome idea considering the stress and strain that would be present. And thinking about orthoplastic splint construction, I was really at a loss of how to create a solid object to accomplish this. Then the idea of using an abduction pillow came up, cutting a large piece out of the blue foam and reorganizing the straps so that no part of the graft would touch, but greater support would be available to the leg. Not having a knife, or razor blade, (either of which would have been better, more appropriate tools) I set out with scissors and my BARE HANDS to rip the foam as needed, providing a much-needed laugh to my pt. And it worked! Props to combined creativity!

- I spent a fair amount of time explaining standard developmental tasks for 3 year olds this week. They just aren't made to be perfect yet at that point.

- Happened to have the AE cabinet open, which sparked some ideas during an outpatient session. Gave a teenager a rocker knife, which she absolutely loved. Steak is a favorite food. We spent several minutes chopping up theraputty with me hovering nearby to save the other hand. Obviously, she'll have to use it with supervision, but I think that it was truly helpful for her to have a tangible skill at the end of the therapy session. (This is part of a much larger thought process right now, but that will be a very long blog post at another time)

- Spent time crying the other night over one of my pts who went home instead of to rehab because his wife is dying. Lately our sessions have just been getting him to a wheelchair so he could go visit her in another part of the hospital. Very sad situation, but luckily they have family support to make the end of life time better.

- I think the newborn nursery can sense when I'm overstressed AND happen to be the only one to cover the area. Got 2 referrals yesterday, but got my second really conscientious and involved family in 3 weeks, which is really nice. It makes up for the stress of getting everything else covered when the parents really want to get your opinion.

And that's about it. I'm behind on my online readings, but am just simplifying things by deleting several that are either too frequently posted or not compelling enough. I went from 300 unread to 74 through that method. I'm behind on my library books... really can't get into the current book and am more excited about the other one I checked out, which is about Asperger's Syndrome. I'm behind on my professional reading- I ordered a book about developmental coordination disorder and am now afraid that the child I'm treating will be out of visits before I even get it open, and I borrowed a NICU book from a colleague several weeks ago that has not even been flipped through yet. And now I have piles of notes from conference to compile, and also have to print out my handouts before they expire off the site. I also promised to add new acute people on OT Connections and work on making some awesome acute-related posts but I haven't been able to start yet. Can anyone spare some extra eyeballs and brains to help me with all that? lol. I did read a very good post by "the OT Nerd" about the worth of conference for re-energizing, and I hope that I haven't wasted that feeling by rushing back to work.

Time to jet off on another trip... I will get to everything eventually!

Almost Over

Our conference time is almost at an end...
Saturday was a long day, but still had some highlights. I got some good videos and pictures, which will all be uploaded to the OT Connections Conference Gallery either at the airport or Monday after I get home. So if you're not already on OT Connections... get there! I have been talking especially to acute care practitioners at conference trying to get them involved w/ OTC because I feel that we are very isolated in our practice and need to connect so we can determine what is best practice and what is just "facility tradition." It's hard after conference to maintain the same energy and excitement, and I feel that using OTC can help keep that feeling alive longer in the face of everyday work.

Time to go to my last workshop... these Sunday sessions are hard to get motivated for since all the fun and most of the people have gone. Then the exciting time of 6 hours at the airport!

Podcast with AOTA Presenter Kelly Casey

Welcome to the First-Ever OTNotes podcast!


Featuring Kelly Casey, Occupational Therapist from The Johns Hopkins Hospital in Baltimore, who is presenting multiple topics at the AOTA Conference. (Get it? That's why we're using the special "speakers-only" badge for this entry) The audio is 22 minutes, please forgive the technical quality and instead focus on the awesome discussion points offered.



Here are some links to helpful information in case you're not taking notes:

Kelly's Topics:

Thu, Apr 29, 9:00 - 10:30 AM Short Course 105

Culture Change In Acute Care: An Interdisciplinary Approach to Creating Respect For Therapies

Thu, Apr 29, 1:00 - 3:00 PM Poster 207

Movement Towards The Centennial Vision: Steps Of Post-professional And Entry Level OTDs

Fri, Apr 30, 2:00 - 3:30 PM Short Course 223

Assessing Cognitive Disorders: Integrating Standardized Assessments In Acute Care

Cognitive assessments discussed:
- Cognitive Assessment of Minnesota
- Executive Function Performance Test
- JFK Coma Recovery Scale


Centennial Vision Statement

We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs.

Crazy Life

Been going through some crazy busy times lately.

So, work kinda blew up recently (2 weeks ago? I don't know it's getting hard to keep up), going from a manageable, reasonable, daily activity to a "what the heck happened here" type experience. Earliest I left all week was 1 hour overtime. YIKES. Here's a little recap. Got my first Level 1 student, and I think we had a pretty good week. Tried to arrange for some interesting stuff everyday (hard to do when we started the week with 5/5 pts having severe dementia). Most amusing moment may have been the kitchen assessment with the man who required step by step instructions and multiple interventions for safety. He wanted to make oatmeal by pouring milk into the oats canister, then tried to fill the pot with water while the pot still had a lid on it, then had to burn it a bit... fun stuff. A good time to demonstrate how hard it is to remember all the details of your treatment.

It was also my first week with the pediatric outpatients, which went pretty well. But it was a little awkward getting to know them both, do a reassessment on the first day. I had prepared for the time that outpatients would take, but I hadn't counted in the other pediatric crew- the NICU. I've been moonlighting up there a bit, and the OT that normally covers left for vacation with a very large caseload left behind. Had to weasel out a few hours each day for babies, and also antepartums on Friday.

Now I'm looking at my outpatient peds caseload growing EXPONENTIALLY in the coming days. I'm turning into a morning inpatient / afternoon outpatient person again. I even got swept over to take a hand patient last week (definitely not my thing) which at least wasn't hard, but did prove that OP is starting to climb into my schedule a lot. It's odd, like reliving my old job... deja vu all over again. We're also switching floor teams again soon and I will be moved to surgery, which is ok for a switch but I worry about seeing all their priority patients (especially when they don't even end rounds until after 9, 930) and then making all my OP appts. There is also a limit to how much I can write in a day, as evidenced by me STILL working on an eval from Friday. I'm out of practice, and the templates for kids are very un-helpful. I will basically have to make my own peds template before Wednesday. I had just wanted to help out a little... I just forgot that with school ending the outpatient caseload would grow grow grow... oy.

In other OT news, I have been actively observing the continued RA-related debates on OTC, and hope that others are too. I'm disappointed to see that many people are choosing to abandon the discussion for one reason or another. I did start a group for Millennial-aged students/practitioners in support of the Participation Committee's suggestions, primarily as a way for newer members to voice their opinions on the matter. I've also been working on arranging an interview and podcast for the blog, I suspect it will be harder to schedule a time than to do the editing and whatnot. Kinda fun to branch out in that way.

Other demands on my time lately have been: trips to play with friends' babies (so big compared to my guys in the NICU); the NCAA basketball tournament; Healthcare reform; seeking out concerts for the summer; and planning a fun weekend getaway. I believe we're coming into a time where I will be traveling or at an event almost every weekend, which does make it hard to get other stuff done. Got to have that occupational balance though ;)

Pre-CI Jitters

I'm getting my first Level 1 student and trying to beat a case of the pre-CI jitters.

I'm growing out of the "new practitioner" label. I'm on my second job, practiced in multiple settings (sometimes daily) and I'm pretty sure that I pay "big girl" OT prices for AOTA membership now. But of course there are still "firsts," and I am now, finally, getting my first real OT student. I've played hostess to several job-shadow candidates before, but those were usually just for a couple hours. Most of those also came from the local high school and had to rotate through multiple healthcare jobs and were not particularly interested in OT. I missed out on students at my last job because state law required that you have 1 year experience before being a supervisor (or Clinical Instructor... same dif) and the offers for students after that first year didn't coincide with my availability. My current job requires that employees have 1 year experience at the hospital before taking a Level 2 student, and I definitely feel that it is a complex enough environment to learn in the year allotted without additional pressures. But now I feel pretty confident in my navigation of the hospital, finding the right people, getting the right supplies. Onto the next challenge!

I was to get 2 students, one for 1 week straight and another just once a week for several weeks. But we had some shuffling of schedules going around to best allow for shared responsibility and best experiences for students, so now I will just have the one. It does make me a little nervous... the feeling of having to bring the A GAME all day (especially early morning, ugh), be on my best behavior, be smart, and most importantly facilitate learning for the student. I don't usually have a problem with imposter syndrome, but the thought of having a person watching my every move and asking me to then JUSTIFY each one is a bit frightening. There are many things that I understand that I don't know well enough to teach.

So I borrowed a book- a handbook for acute care PT (I know, I KNOW, but there aren't any OT ones available to my knowledge) to brush up on things and try to feel more mastery on the material. It did make me feel better... as my supervisor says "you know more than you know" but there were some frustrating points. I brushed up on causes of common ailments and meanings of lab values since those sorts of imbalances (plus weakness and dementia) make up most of my medicine-floor caseload. I know that I came across a lot of that information in biology classes and physiology class but I didn't retain ALL the implications of certain things. Was I not paying attention the first time or did I just need something practical to relate the knowledge to? Is this comparable to suffering through higher level math with no explanation offered except "you'll use it in calculus/physics," which -while true- is not really a motivating factor? It was a relief to know that I did know the concepts in the book... I'm not just faking it everyday :)

I think that being a CI will be a good time for me to question my skills in a constructive way. Am I educating patients and staff on the role of OT? Am I conducting a thorough evaluation? Are my goals client centered, SMART, and varied? Are my patients getting what they need to facilitate the best possible discharge? It will be a good exercise, but undoubtedly a stressful one.

High levels of critique and reflection would be enough, BUT I'm also changing my schedule again for a short time. I will be covering 2 outpatient pediatric clients while another OT is on leave. It will be good to revive those skills, but it's hard acting as a fill-in. These clients are also older than my former clients (who I still miss *sniff*) so it will be tapping into different occupations- chores, computer use, hair care instead of blocks, buttons, and 1 step commands.

Wish me luck! I hope that I am smarter and more capable than I sometimes think I am. If not, I'm sure my student will let me know :-/ haha

Acute Care Courses at AOTA Conference

I feel that it's difficult to find OT courses on acute care topics. It's also hard to apply evidence from those courses to the everyday fast paced world. Here are some parts of the AOTA conference especially for Acute Care OTs (places where you're almost guaranteed to find me!)
Links go to full course description on the Create Itinerary page for conference.

Poster PO 623. The Role of Occupational Therapy With Pediatric Oncologic Patients Who Undergo Complex Orthopedic Procedures in the Acute Care Setting Sat, May 1, 12:30 - 2:30 PM

Poster PO 408. An Interdisciplinary Approach to Acute Care Using Standardized Patients and Human Patient Simulators Fri, Apr 30, 3:00 - 5:00 PM

Poster PO 226. Mind-Body Interventions for the Inpatient Acute Care Oncology Population Thu, Apr 29, 1:00 - 3:00 PM

Short Course SC 105. Culture Change in Acute Care: An Interdisciplinary Approach To Creating Respect for Therapies Thu, Apr 29, 9:00 - 10:30 AM

Short Course SC 223. Assessing Cognitive Disorders: Integrating Standardized Assessments in Acute Care Fri, Apr 30, 2:00 - 3:30 PM

Short Course SC 338. Acute Care Management of Shoulder Replacement Patients Sat, May 1, 3:30 - 5:00 PM

Short Course SC 306. The Acute Care Perspective: Occupational Therapy's Role in Early Management of Traumatic Brain Injury and Spinal Cord Injury Sat, May 1, 9:00 - 10:30 AM

Workshop WS 205. Doing With Not To...Occupational Therapy in the Newborn Intensive Care Unit (NICU) Fri, Apr 30, 8:00 - 11:00 AM