Things I Learned

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

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

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

Gender Games

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

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

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

How to continue receiving listserv emails

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


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

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

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

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

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

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

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

Merry File Sharing Day!

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

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

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

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

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

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

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

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

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

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

OT Connections

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

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

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

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

Doubts

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

More thoughts in the full post...

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

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

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

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

OT Web Gems- Research Edition

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

On to the web gems!

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

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

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

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

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

SNF productivity

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

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

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

ChChChanges

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

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

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

Some interesting cases

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


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

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

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

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

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

More Voting Info

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

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

Sharing Politics

While trying to score a sensory profile in my 'office' Tuesday, I was distracted from the columns of numbers by a heated conversation from the adjoining treatment room. It involved 3 pt's and 1 therapist, arguing over the coming election, all in a seriously irrational manner. The "one issue voter," "crazy partisan voter," and "completely crazy voter" were all represented. And as I groaned audibly and closed the door, I was reminded of how against my beliefs of pt. care this situation really is.

It's a common social more in the US that religion and politics should not be discussed in polite company. While I don't think that these conversations should be totally off limits, it is something to tread carefully around. Coworkers often engage in brief conversations about these topics (possibly expanding as they work together longer) but people are usually careful to ease into these discussions so that they don't strain what is a comfortable working relationship. However, I believe that despite politics and religion being important parts of an individual's occupational profile, therapists should not discuss these topics with their clients. Here's why...


While people must make their own decisions about how much information to share on these topics with coworkers, they should be very cautious about what or any information is discussed with clients. No matter how often we try to empower our clients during the therapeutic process, we still often hear, "do what you think is best, you're the expert." This is not a relationship with equal footing. You, the therapist, are billing the client for the time that you are spending together. The client is agreeing to pay for your expertise to assist them in working toward their goals. They are not paying to be proselytized, and they should never be confused into feeling that is what they are getting for their money.

Part of OT is the universal respect you must hold for your client to enable them to "Live life to its fullest." If you are disparaging his political party's beliefs, will they really believe that you hold full respect for them? If you are constantly talking about your opinions and beliefs, will they feel defensive when their views differ from your own? Some might say that they only have these type of conversations with clients who are receptive, but do you yourself instantly come down on everyone who shares an unwanted opinion? It would be difficult to assess how receptive a person forced to sit through your therapy small-talk really is, and whether they are just trying to be polite, conclude their appointment, and go on with their life.

Full disclosure: I am very immersed into politics. I make a concerted effort for my pt's to feel free to discuss that interest, but not know in what way I will be voting. I was very concerned in making sure that they would be able to vote, despite being hospitalized, as that is a critical occupation for many. (sidenote- our Care Manager on the SNF floor directed all the efforts in that direction, getting absentee ballots and representatives from the various counties to appear and verify voters. It's very doable, make sure your residents maintain their rights) Even though I consider intrusive conversations about politics to be inappropriate, I have a way to discuss the topic with those who seem interested. If they are watching election coverage, I can ask them what's happening, what's interesting them. When they express a belief, I don't contradict it, even if it's not founded in fact. I can ask about their speculations, such as, "our state voted Republican both times for Bush and Democrat both times for Clinton. Which way will we vote this time?" This is nonpartisan and doesn't ask about their own views.

If you really needed convincing that you should tread lightly involving politics and patients, consider this in your conversations: how often is the person pushing their value statements on you, extolling the virtues of their candidate, and trying to convince you to vote similarly? How would you feel if they constantly were doing that instead of listening to your instructions or doing the work they needed to do to get better? And you would stop their conversation because it would be detrimental to their progress, and you, as the therapist and 'authority figure' are responsible for helping them achieve progress. Keep it in mind and keep your opinions in check as the election season winds down.

OT Webgems- Kids and Wellness

All the jet-setting this falls has left me with less time to update, but I have still been collecting interesting web articles to share. This edition focuses on some issues in children's wellness, like nutrition, fitness, and fun.

Portion Sizes- A short discussion on how children learn to fill their plates. I was always taught "you can come back for more," but that didn't stop me from overloading my plate, especially at times like thanksgiving.

Kids and Sports- A brief report of findings on a study about kids who participate in sports. There's some notes on how the kids felt about bodies, but one of the key findings was that children with disabilities and girls in general had less access to sports. There's always room to help with Special Olympics, Challenger baseball, and able-bodied sports teams. Get out there and volunteer!

First Year Survey- A sampling of findings about the typical first year of life in a US infant.

School Lunches- while this is too late to mesh with National School Lunch Week (who knew?) here is some info for parents on learning more about school lunches. The author does make mention of one of my personal favorites- flat square pizza.

Music w/o Pain- A few brief tips from an OT on preventing repetitive strain injuries in musicians, hopefully your local school still has a music program. I have a few handouts and other information on this topic from poster presenters at various conferences- check the link relating to the 2005 AOTA conference to see exactly what I had... hopefully it is still around somewhere.

That's it for now! Enjoy a fun-filled pre-Halloween week. I know I'll be looking for costumes when they go on sale so that I have some fun stuff to practice dressing with in the clinic.

New Toy!

Found a cool new toy at the bargain outlet today... "Monster Under My Bed." Kids (4+) stick their hands underneath to try to find out what gross objects are left under the bed... like rotting orange, dirty diaper, sticky sucker, hamster. Then you see if your object matches on your bingo card, trying to get 3 in a row. If you take too long, the monster under the bed will get aggravated and pop up to reclaim what's his!



I am looking forward to using this with the kids... I have several who working on basic hand use and finger prehension. I can see that the hand therapist may steal it away to work on stereognosis. And this could be quite nice for cotreats w/ speech therapy... work on prepositions, descriptive words, colors. Lots of fun ahead!

Of course, this doesn't mean you have to spend big bucks to have great therapy... my coworkers laughed at me for making a paper bag puppet during my lunch break, but it has been the favorite toy several times now with different kids. One of my teachers at the conference last weekend said that pediatric therapy was about being goofy and selling it to the kids that they were having fun... so either a novel toy or a simple one with a silly therapist will probably work well. :)

Frustration

I haven't been able to post lately due to different time constraints... finished a big long post on hip fracture but it won't post right, something is wrong with the "continue reading" link and it is way too large to appear uncut. Very frustrated by that.

short update- went to my state association conference over the weekend, got to visit w/ some OT buddies and my teachers. Got a few bugs in my ear from the weekend... things to make our SNF better, ICU treatments, a recharge on advocacy, thoughts on early intervention. Also got an update on the status of my research paper. All these seeds and ideas... so diverse. I started listing the logical conclusion of these paths and there are 4 very different end paths, and probably no more than 2 can be carried out. I will probably start taking little steps into these different directions and see how far I can go before I have to give one up, by which time I hope to have more concrete direction in my life.

I am getting caught up on my OT reading... I am down to only 3 OT Practice magazines and 1 AJOT (to scan) on my reading list. Spent the afternoon watching "Observations Based on Sensory Integration Theory" and had quite a sense of deja vu... I may have seen (slept through?) this in peds class 2 years ago. Obviously my mind wasn't ready the first time around. But this time, at least, I saw where these simple motor activities could fit into an extended eval to get a better idea of sensory processing. Of course, the observations in the video are narrated by an SI expert... if she could arrange to narrate the evaluations in my clinic to continually guide me, that would be even better than my in head thinking of "ok... write it down and figure it out later."

Although I have had moments where I feel like I was much smarter about OT right before I graduated than now, I know that I have more confidence in what I do and a better handle on all my OT responsibilities (especially evals). I can't stay current on all the knowledge I had, even though different topics interest me a lot, since I don't use it all everyday. I am trying to feel better about the level of OT stuff that I know, as I have been responsible for job-shadow students all fall, and now have been practicing long enough to take a student. 66% of my official supervisors were new practitioners, and now that I am that professional age, I wonder if I could handle the responsibility of shaping another practitioner. I guess I am aware of the things that I don't know... which is why I really wish I had a mentor (both for rehab and peds!). That's also part of the reasoning for trying to stay up on reading, so that I don't fall behind while in veritable isolation.

quotes of the day

3.5 y.o. child w/ SPD (who rarely talks) is distracted by the stinkbugs in the clinic room.

"Goodness gracious! Look at the buggies!"
followed by...
"If my dad was here, we'd open up a can of whup-ass on those stinkbugs!"

They continue to surprise and exhaust me...

seesaw

There is such a seesaw pattern in much of life, but in this job in particular. We have busy days, slow days, few kids, many kids. Ups and downs and all arounds.

We have a speech therapist now, which is excellent. I look forward to not being responsible for all the communication boards needed in the hospital, and to getting my kiddos the treatment they have been waiting for.

The insanely busy SNF floor and acute care floors have calmed down a bit, at least for a few days. Nice to have less on my plate for the mornings since they are short and the evenings are long with kids. The elderly lady w/ thalamic stroke from this post has now landed down my hallway... she is doing considerably worse since acute care, sadly. We played cards today and I was happy that she had moments of understanding and initiating action on her own.

Laid down a VERY hard line with a pt. the other day... he has been quite uncooperative since his arrival and keeps insisting that he's independent or will be independent soon without assist. 2 weeks ago I needed to reevaluate how close he was to meeting his goals and needed to see him don shirt and pants on a Friday afternoon. "I don't need to do that, I'll do that when I go home." I basically said, "prove it." We stood w/ MAX Ax2 for 3 seconds, which was not enough time for him to pull his pants up, but was (I thought), enough time for him to realize that he needed to work on ADL tasks. Gave him a brief talk about how he needed to keep working... it didn't take. He made the COTA cry when she was trying to work with him. So, when I came back to that little mess, I said, "Mr. B, you made the other girl very upset, and I have to tell you that she's the nicest person on staff. Now you're stuck with me. You can pick which chair you sit in and where it is in the room, you can pick out which pair of pants you're wearing, but you will sit up and get dressed, and you will not get rid of me until that is done." His son was skeptical, but proud that his dad was able to do so much for himself. Saw him again today and he had a much better attitude about the whole thing, and is now a CGA w/ LE dressing.

New kid eval tomorrow... tried to do a Peabody on my fresh eval from last week and he was a total terror today. His mom about cried when I gave her the report on his behavior. She has some majorly off-base assumptions about his development as well, thought that his FMC was at normal developing range and reported that he "graduated" from speech therapy. I suspect that he "graduated" because he ran out of visits under medicaid, b/c his main statements of "I tell mom" and "you not my friend no more" were not age appropriate. He has sensory and behavioral issues (always a combo) and he will be a considerable challenge.

Get to go w/ my PT coworker to a Civitan Club meeting to explain our grant request for some new equipment and supplies. Fingers crossed for support in an expedited fashion!

Busy busy busy

been running around a lot lately... 2 weekends traveling in a row coming up, busy census at the hospital, and 6 OT practice magazines just piling up on my reading list. I also have to prep for girl scouts since I have another kid eval and will miss the meeting. I will update again... someday!

brief update note

Some updates...
After a long fought afternoon, I finally managed to get the cut links to work so I can shorten posts. The 6 subscribers from google reader will still have to deal w/ walls of text, but the rest of you got life a little easier. I don't think that I'm going to go and retro-edit the other posts, they'll be off the main page in a few weeks anyway.

Also, I think I am going to start uploading things to google documents for file sharing, since it doesn't require an account and there hasn't been any outcry from the OT Advantage community begging for files over there. (Yes, I recognize google's domination over my internet life, and I'm ok with that)

Now I just wish there was a way to make it so that when you clicked on the tag link (like "students") that it would show you the titles of the posts instead of all the relevant posts. I am somewhat of an organization freak. A free internet cookie to the one who figures out how to do that, and writes it in a way I can understand.

Case Example with Goals

A review of "recent keyword activity" leading to the blog indicates that there's a lot of people out there looking for example goals and treatments for different diagnoses. I'll try to do some posts in this direction, please don't plagiarize them for your school assignments.

Here's a walkthrough case to see the clinical reasoning behind the goals that are written, and a few example goals.


CASE: Mr. X is a 65 y.o. s/p THR on the acute orthopedic floor. He lives alone, has a tub/shower, and was previously independent with all I/ADLs. He would like to return to full independence.

SETTING BACKGROUND: Heads up- in an acute hospital, your basic joint replacement patients w/o significant comorbidities or post-op complications will leave the floor in 3-5 days. Case management will look to therapy to determine where this person will go (home, SNF, acute rehab). The lack of time for intervention means that your treatments need to cut to the point, so you can give an accurate expectation of how the client will perform in the continuing days, and whether they must have continuing care.

IMPORTANCE: Goals at this level of care have to reflect the quick pt. turnover. What are the most important things for Mr. X to learn and demonstrate before he discharges to maximize his safety and independence?

My ranking: hip precautions; basic mobility; LE dressing; advanced mobility (tub transfer, standing tolerance); home safety. Your clinical reasoning may place importance in a different order, here is my reasoning. He must know hip precautions before moving, to prevent dislocation and repeat surgery. He must be able to stand and take at least 1-2 steps so that at the very least he can get from w/c to BSC, and to facilitate dressing. We have no evidence from our brief case that this man would have any difficulty w/ UE dressing, but he cannot be independent unless ADL retraining is performed for LE dressing. He needs to be able to put on pants and shoes, or he is not going to have anything resembling independence upon discharge. At the point that he can stand up long enough to put pants on, he is probably ready to progress to advanced mobility, and I consider tub transfers to be especially important. It's better to review this in a controlled environment before the pt. goes home and decides to do it anyway. And home safety is always a good thing to work on with your patient, to try to prevent falls and maximize independence. If you, like me, do not get to leave the hospital to investigate the home, you will have to get creative with this.

GOALS
In 3-5 visits, pt. will...
1. verbalize and demo 3/3 hip precautions (we are assuming he doesn't have the extra 'no active abduction' precaution)
2. transfer to BSC w/ CGA and assistive device
3. don socks w/ sock aid independently
4. don pants w/ AE prn and CGA (I almost always use the "AE prn" phrasing since different devices work better for different people, and I have actually seen a person don pants independently w/o any device while observing hip precautions)
5. perform safe tub transfer to extended TTB w/ CGAx1
6. verbalize/demo 3-5 home safety techniques



The best way to get better at writing goals and treatment plans is to practice and get feedback from a trusted advisor- professor, supervisor, etc. The best exercise I know for this is detailed in this simple document. I have not completed an example there as this was an assignment from one of my teachers, and surely others are using it as well.

notes from the listserv

As an AOTA member, I subscribe to a couple of special interest listservs in an effort to get smarter semi-randomly. Yet, I often want to unsubscribe for one of two reasons:

1. Failure to observe internet/listserv etiquette. Perhaps I'm a spoiled person, having had internet access since I was 10, but there are some basic rules that people should observe online when their words come into my sphere. Please!!! Don't type in caps! Use a subject in your emails! Send a direct reply to the sender if your message does not contribute to the entire discussion (e.g. "thanks" or "can you send that to me too?").

2. OT Trolls. Yes, they exist. They seize on an opportunity to argue, in detail, about whether Person A is doing OT, what the difference between OT and PT is, whether the original poster was being a good OT or not... ad nauseum. I've wondered about suggesting that a new listserv be created just so that people can keep their biased partisan arguments about OT ("OT's can't walk people! That's PT!" vs "It's better to walk them than to do a stupid craft or game!") somewhere else. Perhaps I wouldn't be so irritated about this fight about the OT domain if we didn't have a practice framework that detailed an outline for therapy, or if this exact same fight didn't already happen a few months ago when the last RA motions were up for debate, or if it didn't all look suspiciously like one person stirring the pot in an effort to get more attention to their website and ideas.

An open call to stop this foolhardy "debate" if you can call it that. Functional mobility is part of the OT practice act. Enabling and Prepartory activities are part of our treatment framework. Crafts and games are at the foundation of the profession from the Reconstruction Aides. All of the arguers are right. And wrong, because limiting your practice to only one of these areas is not OT either. OT is a beautiful profession because at its core is the belief that engagement in meaningful occupation will promote health. Don't limit yourself as a practitioner, or you will limit us all, and our clients.

Predictions

Everyone makes predictions. Doctors give a prognosis, based on how they think the pt. will heal. Therapists set goals, which they believe the pt. will achieve in a set period of time with skilled intervention. This is part of the professional's training, and if they are not reasonably accurate with their predictions, they will not be very respected by their peers or able to do the job as well. (sidenote- it is perfectly reasonable as a student to not make these predictions very well. it is all about developing experience, understanding reasonable expectations, understanding probability, creating new schemas, etc)

So we all make predictions about our patients. These can be helpful- if you predict that your pt will not use AE at home, it's helpful to plan your interventions otherwise. Sometimes they cause us to be jaded about our patients or their capabilities. Right now, I have a pt on the skilled floor that the general consensus prediction is that she is going to die. Soon. She's 92 s/p hip fx & ORIF (thank goodness that she doesn't have hip precautions). MAX Ax2 for anything resembling mobility, during which she moans and cries. She won't eat anything except pudding/applesauce to take her pills. She has a distension the size of my fist, protruding from her abdomen. She has been talking to her deceased relatives. Unable to don a button-up sweater due to weakness and confusion. Medically, her H&H is quite low, but she has religious objections to blood transfusion. I seriously worry every time I see her that she will die while I am there. Sometimes joint replacements and orthopedic surgeries can be the beginning of the end for a person, which is awful. A few months ago, a Mrs H had a second TKR which started her downward spiral... last time she was on her feet was on our skilled floor. I hate to watch people go downhill, I hate to know that there's nothing I can do, I hate that I don't know more medical information so that I could understand what is causing the decline and fix it!

Predictions can be quite depressing... maybe it's better sometimes to just not worry about the future.

Very busy days

7 evaluations yesterday, 1 full blown ADL, and 5 other short treatments. What a day.
It was most difficult because many of the evals were complex. Allow me to demonstrate...

1. L TKA. Very basic. Started off in pain and then walked into the hallway. No problem to write up, will likely go home from acute care.
2. 95 y.o. thalamic CVA. A very unreliable historian. She understood yes/no only. Once to the EOB, however, she did jump up with a walker and head right out the door. (sidenote- physical recovery almost always comes quicker than cognitive recovery. Frustrating, and potentially dangerous. Reminds me of a TBI story)
3. Frontal lobe CVA. Dysarthria, flaccid RUE. Frustrated at not being able to communicate with nurses and dietary staff. Promised her a communication board, which I really didn't have time to make that day, but she really needed.
4. Pneumonia w/ complications that landed pt. in the ICU. Some minimal spontaneous movement w/ agitated, but not able to respond to commands. Just extubated that a.m., so no comment from the pt.
5. Elderly man w/ THR after falling. No memory of hip precautions. No social support system. We were able to stand at the EOB w/ MAX Ax2 for a minute or two, but that was it. Usually at this many days out from surgery, a pt. can at least walk to a chair.
   
6. R TKR that I knew from acute care. An interesting case, as she is able to do many of the basic functional tasks that are required by OT before discharge. However, she has very little knee flexion, and it is always a PT goal that a pt. have at least 90* knee flexion after surgery. It's a strange part of the OT/PT relationship, as I'm not grabbing legs and bending them, but it won't matter how "functional" she is if she has to get a surgery redone.
7. The last of the day transferred from another hospital and was quite exhausted. Pneumonia, GI Bleed, Renal Failure. He's super weak.

So that left a lot of complicated goals to write up (on top of the 3 peds notes from the previous day that I didn't have time to write). I did end up forgetting a treatment and having to document at the nurses' station since I had already locked up the office.

My ADL was with Mr. A, a pleasant, but lonely gentleman admitted w/ CHF and COPD. He doesn't want to go home w/ O2, but right now is struggling to do anything without it. We worked w/ the pulse oximeter on doing short bursts w/o the O2. His O2 cord wasn't long enough to go into the bathroom, and the nurses were saying that he'd only been using the O2 intermittantly over the weekend. However, an O2 % rating in the 70s (should be 90% or above) after a trip to the bathroom warranted getting after the nurses to get him a longer cord. The hour moved very slowly due to rest breaks as he rollercoastered up and down the O2 saturation levels. He is getting better w/ energy conservation techniques. I was a little depressed because the nurses were talking about him going downhill and that he was going to "go quick, when his time comes." I hope he can get better and also go home to a better situation.

Peds practice is picking up again. Getting another few evals and busier evenings. The peds + girl scout tuesday combination is getting hard on me... still working on finding a balance.

OT WebGems- Aging Edition

HOO-HA, I am nearing the end of my blog-related bookmarks (for now)! This edition focuses on those who are lucky enough to become elderly, with one crazy note thrown in at the end.

Architectural Updates- I have some links about aging-in-place and universal design on the sidebar, as it was the original reason I got into OT. Here's a retirement community that has incorporated some of those principles to help their residents live more independently.

Retirement Communities- The later pages in this article offer some great questions to ask before choosing an over-55, assisted living, or continuing care facility.

Balance- Here's some info and products to improve balance at any age! We should probably all start now, since our proprioceptive system starts declining around age 12.

Cognitive- As high tech pushes devices to boost your cognition and keep your mind sharp, people continue to wonder about what long-term effects all those crosswords, sudokus, and Brain Age games have.

Unrelated-- I saw a video of this car on Disaboom, and had to share. I am not a claustrophobic person, but this makes the Smart Car look spacious. However, I support the idea that a wheelchair user could have relatively easy access to their local area. I see a disproportionate number of pedestrians along high-speed roadways driving scooters than walking, and an enclosed way would be safer. I give you- Kenguru! Arriving in England soonish, US... another 15 years?

Danger Zone Sports

Title LGT an article on the hidden injuries in cheerleading. Bonus points for the author, as the main character overcame years of physical therapy to become a physical therapist.

My mom used to work in vocational rehab and would always cross off cheerleading and football on my high school physical forms so that I couldn't participate in those. Same reason that ATV riding and some other typical fun teenager things were verboten. High risk of SCI and/or TBI. Since I had followed other paths, these forbidden activities weren't high on my interest checklist anyway. But, I did enjoy diving, and loved to do so at every opportunity. I did a lot of flips and acrobatics, at least as acrobatic as someone with no gymnastics training or natural grace. I had an incident where I hit the bottom of a hotel pool hard with both feet and jarred my whole back... thought I was going to have a serious problem but walked away from it. I dove into a friend's pool that was 2 feet shallower than I expected and scraped everything but my head on the bottom.

But even though my mom had always discouraged dangerous activity, and afterwards I always resolved to be more careful diving, the danger never sunk in until I became a lifeguard. That's when I got all the information about exactly every way you could hurt yourself in a pool, and how badly. Simultaneously, I learned that those who are being paid to protect your safety may or may not act appropriately to maximize your recovery. One little shake while putting you on the backboard, not stabilizing the head properly when retrieving someone from the bottom of the pool... there's a million opportunities to screw up. It ruined diving for me, and also ruined being a bystander. I hate to be at a public pool or riverside that's out of control... I don't want to feel responsible to help when the inevitable (to my jaded eyes) accident occurs.

I don't know how to best decrease injuries in kids who play sports, but I do think that you need a combination of parental interference and personal education. Parents can insist on safety measures for the child or team, and can ingrain good habits in kids (like seat belts and helmets). Until the child recognizes that yes, they can get hurt and need to be careful, there has to be a parent or responsible adult to step in and insist on safety.