Exodus

There have been so many farewells here lately, and it's quite frustrating!

In the space of ~1-2 months, we are losing a lot of people at work. One of the front office staffers, 3 PTs (who all sit in my cubicle row) and likely 3 great rehab techs. Also, one girl from my row is likely to go out on maternity leave any day now. I don't want it to get quiet and lonely in my area, or lose contact with good friends. And now, I'm seeing goodbyes in the blogosphere. One of the leaders from Hospital Impact is onto other projects, though the blog will continue. OT Advocacy made what was to me a shocking announcement of retirement, after a relatively short but productive run and a feature in OT Practice. And debate continues for the future of OT Students... though understandable, I would hate to lose access to the outlook of a cherished virtual friend.

And another thing! What happened to our OT Blog Carnival?! 2-3 issues and then poof?

I don't really think of fall as a time for changes... more as a time to hunker down and stay the course. Plus, I'm usually too distracted by football season to want to shake up life in any other way. Maybe some new and interesting things will pop up, but it's no fun to be saying goodbye all the time.

My First WiiHab

So our hospital has a Wii (actually 2, one lives solely in the burn unit) which I have thought was interesting since I didn't know how well it could be used in acute care. I missed the inservice but figured I could go ahead with my session since I have a Wii at home and am somewhat familiar with the games.

The way I see it, for the Wii to be used in acute care, you have to have a client who is sticking around for a few days, has the required cognitive capabilities to understand the system, and has deficits that can be addressed using the system. We currently have 3 games- the basic sports game, Wii Play, and Wii Fit. The first client that I had who would have been appropriate (since the program starting) was a cute little lady who was extrememly active prior to her stroke- walking 3 miles a day. Her only deficits were upper-level balance issues, but I was off after her evaluation so I didn't get to implement that plan. But I was able to use the Wii with another lady on the stroke floor. Sorry the case study isn't more in-depth, but several weeks have passed now...

Ms Z was getting an extensive neuro workup for several symptoms, including visual dysfunctions, L-sided paralysis, mental status changes, seizures. Original possible diagnoses were PRES vs an unlikely conversion disorder. Her visual problems were very odd, starting out where she could only see shadows, then she could identify broad swaths of color and light/dark, to where her acuity was markedly improved at which time the optometrist diagnosed a L hemianopsia. She also had a L hemiparesis. As our sessions progressed, she regained hand movement progressing to intermittant elbow and shoulder control. She also progressed to verbal cues only for supine to sit, and was then able to transfer to a chair with min assist of 2, needing her L knee blocked. Once we could transfer her to an appropriate chair, she could come down to our gym to use the Wii.

I thought she would be a good Wii candidate since her controlled ROM of the LUE was intermittant. I hoped that given a distracting BUE task that the control might become more consistent. This was my plan on Friday... when I came in on Monday we had to cut the session short due to LP, and then on Tuesday Ms Z had full ROM of her LUE! Not from anything I did, but just part of the strange waxing and waning of symptoms. She then had some RUE control deficits. I decided that since her coordination was still off that the Wii session could continue. We worked on Wii boxing to address standing balance, endurance, and UE ROM control. Our first day, Ms Z was unable to tolerate a full "round" vs the computer opponent (3 minutes) while standing. However, she persevered while seated and did complete 2 bouts. Our second day, she was able to complete a full bout while standing (10 minutes in parallel bars with contact guard support from PT). We then added in additional challenges, using different punches (inspired by TurboJam), and trying to better facilitate weight shifting both front-back and right-left.

I was happy with how the boxing activity worked out... my next session was going to be more visually-spatial based and require more refined isometric control of the shoulder, but Ms Z was discharged that night to rehab. Even though her initial reaction to the wii was "this doesn't apply to me because I do not play sports," she did get very active and involved in the activity, progressing on performance components she needed for independence. The novelty of the activity was also good since she was getting frustrated with an extended hospital stay. It was a worthwhile therapy experience for both of us.

I feel that I learned a lot from these sessions, and I went home and reevaluated my wii games (sports and play... don't have a wii fit). That brought me to a gigantic list of things that could be better about the games from a therapy perspective. It is a LONG list, I will share it hopefully this week and would love to hear others' thoughts on using the Wii in rehab. For more thoughts on the subject, you can check out a blog dedicated to WiiHab here.

Thoughts Spurred by Malcolm Gladwell

At the suggestion of my dad, I read Malcolm Gladwell's books over the summer, and have some OT-related thoughts from them.

As a disclaimer, before someone jumps in to attack my lack of critical reading skills, I am well aware that none of the concepts in Gladwell's books are his own research, but there is a limit to how many individual research articles any one person is going to read in a given lifetime. So these are distilled stories with ready-made inferences, but interesting and thought provoking nonetheless. Here are some OT-related thoughts from the books The Tipping Point (TP), Blink (B), and Outliers (O).

Reading the Face (B 197) The final chapter of Blink discusses the work of Paul Ekman and ability to read emotions through expressions and micro-expressions. While I think it would be interesting to see when people are lying, frustrated, or scared, I think I would have better use to just be more aware of my own expressions and the message that I am subconsciously sending.

Fusiform vs Temporal gyrus (B 219)- After discussing visual tracking during a movie between persons w/ and w/o autism, he touches on a study indicating that most people picture and view faces using the fusiform gyrus. However, an autistic individual uses the inferior temporal gyrus to view faces, which is the same location that most people use only for objects. I wasn't really aware of that specific neurological difference but think that it would make an interesting principle to guide treatment.

10,000 hour rule (O 35)- This concept is presented as one of the precursors to mis-named overnight success. Several examples were given of people who started working in an unpopular field and had logged 10,000 hours of practice by the time that the field was ready for rapid growth. This number is referred to as the number of hours of practice needed to become an expert in the field. This would be a little over 5 years of full time work. How many OTs work their first 5 years uninterrupted, let alone in the same practice area? Just a thought. Also makes the hours needed for board and specialty certification seem almost doable.

Culture of Honor (O 161)- There was a mention of how a cultural importance of honor in highland areas has continued into the Appalachian region, giving some reasoning behind the number of feuds in the past century. This concept is also of high importance to many urban residents, especially in places where gang culture is rampant. I just thought it was an important tip to promote developing rapport with your clients and deferring to be more formal and respectful until you have a well developed relationship with your client and can be more informal.

Parenting styles (O 104)- A study is referenced that talks about 2 parenting styles: "concerted cultivation" vs "accomplishment of natural growth." I don't have full definitions for these, but they are associated with high and low SES families, respectively. The former is where the parent would encourage social skills and talent development through modeling and empowering the child. This was associated with higher confidence and better interactions with adults. The latter is a style that is more passive, leaving some of the development left up to teachers, coaches, therapists, etc. I definitely saw both types of parents when I was working with peds. In my experience, the latter style makes it hard to have home program carryover.

Levels of mitigation in speech (O 194)- The levels are restated here, and were discussed in the book in relation to studies about plane crashes. The author of that link also references an article from a person in a different power-index culture, which was interesting. I would be very interested to see a study on what terminology was used in ERs for trauma or in ICUs in critical moments between the various staff members. I may write up my observations on the language that is used at the interdisciplinary care meetings. But as far as client-therapist interactions, I think you have to balance your styles based on the client and family cultural and learning preferences. As an OT I want to give options, not take them away, however as safety concerns become larger, I do get more commanding.

Transactive Memory (TP 187) I scoured my in-depth books on cognition and found no mention of this concept, however, there is some research on this concept in the fields of relationship studies and also in computer science. This is where a couple or a group have certain tacitly designated tasks or things to remember. I never know where the various charger cords or electronic devices are, but/because my husband always does. This can happen sometimes in workplaces as well, where you have specialists and go-to guys/gals for specific tasks or theories. I think this also accounts for some of the memory impairment that I see in hospital patients as well. If you're used to sharing memory tasks it's not the same when you're out of your environment and out of touch with those you are close to.

The Tipping Point (TP 9)- Obviously this is the main idea of the first book, the idea that at some point change becomes unstoppable due to the momentous force behind it. My question here is- when is OT going to reach a tipping point? When are we going to be highly demanded in multiple fields? When are we going to be the go-to professionals for daily living, low vision, home mods, driving rehab, etc etc ad nauseum? When are we going to be respected by legislation, hospital policies, and other professions? I AM READY TO TIP! I know this is implicit in the Centennial Vision, and I would love for us as a profession to tip by that time. So I guess I'm still at the phase of tipping that I am becoming the best OT I can be so that when consumers have my services they come away with a great message about the purpose and power of OT. Just important to try your best every day since you don't know who you encounter that will be talking about you later.

Hope that's enough inspiration to help me get through the week! Anyone else have Gladwell-related thoughts?

Layout Updates Complete (?)

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

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

New find from twitter

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

Trying for a better week

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

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

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

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

Miracle Treat Day

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

drawings from a client w/ impaired vision post CVA

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

Clock Drawing: I found this interesting since the numbers are running counterclockwise, and he did draw them in descending order. I couldn't find any information on other cases with the numbers running backwards.
These pictures are his attempts to reproduce the above drawings. He was able to describe the shapes in the drawings somewhat, but unable to figure out what the whole picture was.

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

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

Progressing in Pediatrics

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

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

How to prioritize a full day and other stories

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

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

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

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

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

hiatus

No updates this weekend, I'm visiting with my family! Have to get my webcam working so that some other things can get done too. :)

Long term care calculator

Saw this calculator (thanks to the Alzheimer's Reading Room) to figure up long term care expenses for different regions. I can't seem to make it work since I can't select cities, but this may be a function of firefox, hopefully not of the program. Anybody who can work it, let me know if it's a reasonable estimate compared to the real world.

Adaptive Equipment- a different view

I've had a few thoughts about Adaptive Equipment (AE) lately
I saw this post on OT Advocacy and read the second reference, a diatribe on the lack of utility of a sandwich holder which the author's OT wanted her to use. This was interesting to me on 2 counts, first: this entry reflects an unfortunate client-therapist relationship, since there is no point in forcefully recommending devices that the client does not want, and this should have come up during a session; second: I consider myself well versed in various AE items, even some that are obscure, thanks to a tech-based fieldwork and my mother's old texts (1977?) on facilitating independence in homemakers, yet I do not believe that I had ever heard of the sandwich holder. My first reaction was "how pointless," and I had been thinking of devices that could be permanently put out to pasture. Other nominees would include the button hook (how often do you really have to wear a shirt with buttons on it?) and the oven stick (hello microwave).But instead of starting a chronicle of useless devices, I had a second thought. Just as it does a client injustice to insist upon their purchase and use of a device, it is also inappropriate to know of AE that could be potentially helpful and desireable and not allow the choice to be theirs. Despite my knowledge of AE, I am a minimalist and a Mcgyver-ist as well. Never a reacher and a dressing stick when the reacher will suffice. Never a sock aid if we can put socks on using a footstool. But if someone expresses an interest or a problem that I know of an AE solution for, no matter how outlandish, then I feel obliged to discuss it with the client and let them make the final choice. For example, I had been working with a lady in her 80s who had a tibial plateau fx and was either non or toe-touch weightbearing. So her main transport was going to be a wheelchair, using a walker for transfers. She really, really, really wanted wheelchair gloves. I didn't think that it was necessary for her to spend money on those, but she enjoyed being able to propel herself around the facility at her own will.

Another story that comes to mind is from my very first fieldwork, when an OT had constructed what she termed "claws" out of splinting material and strapping that compensated for decreased grip in a pt who'd had a spinal cord injury. The specific pt that it was crafted for loved being able to use the claws to pull up his pants. My supervisor tried the same idea with one of her outpatient clients (who'd also had a high level SCI) but was in his 20s and wanted nothing to do with pink claws. I guess what I am taking a long time to say is 'different strokes for different folks'- there will be devices that are appropriate and wanted by some clients that will not be appropriate or wanted by others. And that should be a choice left up to the client.

On a PS note, the picture above is from one of my mom's texts, of which I believe the copyright is long expired. I may look through the collection and see what other illustrations and instructions can be shared for homemade adaptations, just in case anyone is curious.

What I'm Reading Now

Current reading pile

• Mansfield Park, Jane Austen- trying to finish this so I can get on with everything else. The first 200 pages were not particularly exciting, but now it's picking up
• The Tipping Point, Malcolm Gladwell- borrowed this from my dad and my husband now picked up the audio book. I'm a little competitive, so I'll have to keep up while he's reading.
• Stroke Rehabilitation: A function-based approach- I bought this quite a while ago, but now need to get around to reading it since I will be on the neuro side of the floor quite soon.
  
• OT Practice 7/13- did take a break from the novel to go through that. Have to browse the OT Connections Forum to see what the conversations are about that... the main article was interesting, I just need to process it in relation to my own life.
• Rehabilitation of Traumatic Brain Injury in Active Duty Military Personnel and Veterans: Defense and Veterans Brain Injury Center Randomized Controlled Trial of Two Rehabilitation Approaches (Archives of Physical Medicine and Rehabilitation Vol 89, Dec 2008)- Saw this referenced in the previous OT Practice and it referred to 2 different treatment approaches that I wanted more information on. Haven't set out to tackle it yet.
• Self-care, productivity, and leisure, or dimensions of occupational experience? Rethinking occupational "categories" (Canadian Journal of Occupational Therapy April 2009 Vol 6 Num 2)- Saw the abstract on Karen's blog and had my library buds pull it for me. Should be an interesting challenge to daily practice.
• Validation of a New Coma Scale: The FOUR Score (Annals of Neurology 2005; 58:585-593)- I saw this in our new employee handbook in the 'preparing for neuro' section. I can't remember if I learned about this before or not. I know that we did the Glasgow Coma Scale and the Rancho Los Amigos Scale for Brain Injury, but I thought I would look into this. Not sure if it is used on our floor or not, but it's worth learning about.
• 17 files from my neuro professor/coworker- piles of powerpoints, buckets of documents, all in preparation for the scary neuro floor. eeep!
  

So that's what I'm up to. I love reading, but sometimes there is too much... this doesn't even take into account my Google Reader list or daily newspaper browsing. Anyone know an electronic reader that will transport the information into my mind?

information overload

As usual, I panicked over the wrong thing, this time, it was continuing education, of all things!

Earlier this year, as I contemplated job changes and whatnot, continuing ed was far away on my back burner. But when I had to get a license in a new state, I had different, more confusing rules to learn. The main, biggest, worst difference in the 2 states is that you cannot "roll over" CE hours in Maryland. But in February, that was not my concern. The worry was how I would manage to fill in the hours well, and options seemed limited. I did get 2 hours from my jurisprudence exam (required for license) and had a coupon from AOTA for a free CE article (1 hour, but not as of yet cashed) and prospects for further ed looked bleak. I am saving my monies for the 2010 AOTA conference as a dual education/reunion opportunity with some of my classmates and know that I can pull a whole year's worth (and some) of CEUs at that event. So knowing that, and knowing that I get no roll over (Grr grr grr) that just left me with 10 hours to figure out for this year.

My main difficulty was balancing educational benefit and financial cost. I attended a seminar on stroke at the facility (couldn't beat the rates and a friend wanted to go) which was good. I will be presenting at a local state conference as well, so I will get credit to attend and to prepare, but I have to look into the rules to see how that will shake out. So everything appeared to be taken care of... however...

That's when cool offers started pouring in. First was the guilt that I should attend 1 state conference and not another. That would be an extra event in November. Then our NICU therapist introduced me to the Developmental Therapists in the NICU conference which would be in Phoenix this year. I got an offer for 13 hours to learn therapy Spanish over 2 days... I got another NICU conference pamphlet in the mail today (16 hours w/ optional pre-conferences) which also advertises an online CE library... enticing. The quality of solicitations that I am getting is improving, which is bad, since there's already too many choices!

The 2 NICU conferences are tempting... one since it comes recommended by a coworker who has NICU-know-how, the other since it is close by. But as to be expected with a conference that earns you so many hours, they are each quite expensive. It's also a bit prohibitory in my mind, since there are only so many things I can keep in my head at once and I don't know if it's worthwhile to expend a lot of effort on NICU learning when I probably won't get to practice it much.

Therapy Spanish hits me in a sore spot... I feel like languages are one of my strong suits, however, my language skills (other than English) are really underdeveloped. 2 years of concurrent Latin and Spanish in high school was fun, but didn't give me a strong basis in either language, and college Latin proved even more futile. ASL was fun, and I can still sign Journey songs, but I don't have a functional usage. While I can cheat while reading Latin/Spanish and decipher somewhat, there's no way to do that in sign. And there's no way to learn any language without a lot of practice... which I just haven't set aside the full time for.

It's hard thinking about all the things you could learn, all that you could use, all that you could grow to be... especially on days when time seems limited even for the daily mundane tasks. So much potential, and too many other things in the way. Sigh.

(by the way, I have no experience w/ any of these CE companies or the specific courses, so I can't offer any comment on their overall worth. I have no relationship with any of them, monetary or otherwise and this is not an endorsement.)

As if people needed excuses NOT to use mass transit

hearing loss? back injury? and what else?

A medline release about subway stations being loud enough to damage hearing has been heavy on my mind of late. I notice that I can often hear the music from my fellow travelers MP3 players- they are cranking it up to hear it over the other noise, which only feeds into this probability of hearing loss. It's also pretty commonly acknowledged that bus/truck drivers are at risk for chronic back pain from the vibrations of the vehicles (here, here, here for a few quickly obtained (if not most definitive) sources). A student project looked at vibrations as well as "measuring “impulsive shocks,” which occur when a bus driver hits a speed bump or a pothole." I have been starting to wonder seriously about the effects of constant vibrations from the metro and the forceful impact of "impulsive shocks" from Baltimore's potholes.

Personally, I feel like I am rolling the dice enough against sustaining an injury in some way: Recent AJOT article highlighted potential for work-related injuries in OTs; I am constantly dancing on the edge of RSI in my wrists, elbows, and shoulders; and I have yet to see the effect from my sports playing, but the possibility of hip, back, ankle or shoulder OA remain highly in the future. Lousy to be thinking about this in my 20s. It's a scary world out there.

first day back

First day back... first day on the surgery floor.

It's hard returning from vacay anyway, but trying to get a feel for a brand new floor at the same time is double hard. Added into that is a factor I had not previously considered- July 1 marked the transition from classroom medical students to residents. So not only do I not know the ropes, but the people who are writing the orders don't know the ropes either. I didn't realize when I accepted a job at a teaching hospital that part of my job would be teaching doctors. But we are all teachers, and we are all students...

I had a sad realization today when I realized that a PT student who was present before I left must have completed her rotation. Already in just three months there have been 3 different OT/PT students in the office that have come and gone, I've had minimal contact with any of them. I've never had my own fieldwork student yet since I hadn't been licensed long enough to take one at my previous job and now at my current job they have a (needed and appreciated) requirement that you have to work a year in the facility before taking a student. I have had several job-shadows before, but it's different, being that they were all just for a few hours and all high school students except for one pre-OT.

Anyway, first day was a comedy of errors and minor misfortunes. First eval of the new rotation, a (thank goodness) cotreat w/ PT was of a gentleman who was quite agitated and upset, who basically tried to run down the hallway away from us and was working very hard at pulling out his IV and chest tube. He later left AMA, though he did allow someone to remove the tube properly before running off. Second guy kept having low O2 sats and no rebound despite cranking up the oxygen. Saw a lady before lunch who was quite limited in cognitive and physical abilities. Mod assist for feeding, Max assist for grooming. Nice though, and later walking by I saw her son, which was crucial since no one has been able to get ahold of family members. So I had to go on a mad dash to find the MD and case manager so that discharge plans could be made, but that actually worked out well.

Last guy, I had tried to see multiple times throughout the day to no avail. Half started an eval twice and had to leave for different reasons. Finally came back to finish it following a wound vac replacement, at which time the new docs announce that he has to go to the OR tomorrow for surgery. I say, what are you doing? and the response is "we don't know yet." It apparently will start as a wound debridement and then based on the amount of muscle loss and damage to the fascia may have to be an ampuation of his leg. Which is, of course, majorly distressing for him and effectively renders my evaluation useless, since he will need new orders and a reassessment once he's medically stable following the procedure. Pretty impossible to make reasonable goals or discharge plan when you don't even know the impairments yet.

Hopefully it'll get a little easier tomorrow.

back in the saddle

It was so nice to have some time off from everything!!
I love the beach, and I did some real disconnecting this year, only checked email twice and facebook once in a week, and did not bring any OT materials either. Left my phone turned off for several days (no one to call me anyway since I was at the beach w/ all my top callers). My husband was not as prudent and accepted a call from my office... ack. But other than that slip, a total unplug. I so often feel out of balance in my occupations, a point brought sharply home by realizing that I opened up all my puzzle books this week for the first time since LAST year's vacation, despite the fact that I really enjoy that. I read a good novel and a crummy nonfiction book, played Rock Band with the family, just relaxed. It was good to be away from everything. This evening I got to check my mail (so satisfying to have a whole box full for a change!). I cleared through a list of 354 google reader items pretty quickly this evening (skimming many, real reading a few, and just deleting a bunch including 125 medline notes).

So Monday takes me back to the day-to-day worklife, since I did not hit the lottery and cannot as yet retire to my own beach house. This may be difficult since I am naturally nocturnal and have slipped closer to that schedule in the past week... waking up at 6 is going to be harder than usual. I really need a job on afternoon shift... too bad no one wants to do therapy at night. I have ended my medicine rotation and am moving to the neuro/surgery floor, so that will be new and interesting.

I did start a twitter account before vacation which I will be primarily using to share interesting articles right away instead of letting them languish for ages in my bookmarks until I find enough similar for a webgems post. I held out on twitter for a long time, but I need to figure it out since I will be presenting on using social media effectively and efficiently as an OT for a state conference this fall (!!yay!!). For now, these updates will be funnelled into the much too long sidebar... I am looking into getting a new layout, 3 bar or otherwise and maybe more specific to OT if possible.

First twittered link is an article from Gretchen Rubin about how to make meetings better. Different sites have vastly different numbers/types/procedures for meetings. My last job held monthly OT meetings, and sporadic as-needed meetings for the inpatient and outpatient staff, all of which were informal. My inpatient rehab fieldwork felt like there was a meeting everyday at lunch. We had inservices, all rehab, all OT, specific team meetings, strategic planning from the upper management, etc. And during my 3 months I think we tried to do rounds reports 3 different ways. My other fieldwork supervisor was a consultant, so there were LOTS of meetings we went to during that time. Currently I have daily rounds (depending on the floor), a monthly OT meeting, a monthly acute care meeting, a weekly floor meeting, and a bimonthly all rehab meeting. With the exception of the dailies, it's not too bad. It's hard to balance the good you can do by being at a meeting and representing OT and advocating for various clients vs actually being able to go see and treat and document those clients instead. It's no secret that I am not a big fan of meetings, so anything to make them a little better is appreciated.


Happy 4th!!

Aerobic Exercises in the Pool

I've had interest in aquatics since I finally conquered the water (6th grade?). My research project in OT school was on aquatic therapy for CVA pts at a local rehab, and I also spent a fair amount of time lifeguarding. But the spur for this article is more personal... my dad had a heart attack 2 years ago at a young age and has been working hard at galvanizing the men around him to be proactive about heart health. My uncle has been resistant, saying that he can't do regular cardio due to his knee replacement... so here's some low impact cardio exercises you can do in a family sized pool. As always, consult a doctor before beginning an exercise regimen of any kind, especially if you have risk factors for cardiac disease. Seriously. Also, be careful in the heat, since that could aggravate a cardiac condition. Again with the checking with doctors.

Treading Water- an easy exercise that can be done for a long time. For variation, try arms only, legs only, or holding a weight above your head.

Walk Laps- good for a shallow pool, you can add resistance through leg bands, such as these from Speedo

Jumps/Skips/ Bobs- simple enough, more demanding than just walking. Jumps or skips in the shallow end, you can do bobs up and down in the deep end trying to get high into the air and deep to the bottom of the pool. Be careful not to over exert, especially if you are holding your breath.

Underwater Laps- build lung capacity by swimming progressively farther underwater. Slow your breathing during your rest breaks.

Side push ups- plant your hands on the pool wall and practice lifting yourself out of the pool. Be careful with this, keep your head back and away from the wall or your teeth are in peril. As an alternative, if you have a diving board, you can do pull ups while in the pool, you can also do these from starting blocks if your local pool has them and allows them to be used for this purpose.

Crunches- with your back to the pool wall, stretch your arms so they support you and let your feet dangle straight down. (this is 90* shoulder abduction for those who are anatomically inclined) Then, you can do oblique (side to side) crunches.

Stepping- if you have an aerobic stepping program that you are familiar with but have a hard time tolerating the impact level, weighted steps can be used in a shallow pool.

If you have access to a lap pool in your community, swimming laps is good cardiovascular exercise and can also help you work on expanding lung capacity and strengthening. To mix up the routine, consider using a buoy to force you to swim only with your arms, or a kickboard for the opposite. Also, many local community centers offer aqua aerobics... if you're already paying for membership, you can take advantage of the class.

Some resources:
http://www.exercisegoals.com/water-aerobic-exercises.html
http://squidkid.org/2008/03/19/water-aerobics-for-very-smart-dummies-pool-workouts-101/

ps- again, go to the doctor!! use these tips at your own risk.

Gaining ground

so I'm not such a newbie anymore. I even turn in the right direction now when getting off the elevator...

In fact, we're getting near to floor rotation time, so soon I should move on from medicine for awhile and into a new frontier. The medicine floor is sometimes a drag... I hate seeing people with multiple admissions or trying to tell people that they aren't safe to go home. However, I have seen some cool things in the past months, including one lady who had a neuro disorder so rare that they were collecting her CSF for research and a guy recently with an unknown tick-borne illness (learned a new word, Rickettsia). I have definitely had some times where I wondered whether I was smart enough to work at this hospital, but everyone makes mistakes and I am learning. Definitely taking a closer look at lab values, figuring out more about those.

I have gotten to take 2 visits into the NICU in the past couple of weeks. I work with a girl who is really experienced with feeding and so I got to see the different units and today I got to see a baby intervention in the feeder/grower area. It's interesting stuff, but unfortunately I don't get to devote a lot of time to learning this (since they're kinda paying me to do other things too) and it's such a specialized area that it seems that it would 1. take a lot of time to learn and 2. be best to learn in person from an expert as opposed to on your own.

The whole peds/NICU interest causes me internal unrest, as I really don't know what areas of OT that I want to go into. Yes, I know that I am young, but I have such broad scattered interests that I have no idea where I'm going. Early this year, I had made out different possible career tracks and things connected to each... there were at least 4 and I had programs and interests on each card that I'm not willing to give up, so the range remains broad. In similar news, I just volunteered to do my first home mod evals as an OTR/L... don't know what will come of this, if anything. don't even know if it is volunteering or consulting for money, which I will definitely have to figure out :-P

I have been stressing out the past couple of weeks, it's been busy at home and work and I have been dancing on the edge of tweak out. I have a wonderful (albeit unpaid) vacation that I am leaving for this Thursday after being at work everyday for 11 days (1 was a conference). I truly need a vacation at this point. I had planned to schedule blog posts ahead of time, but I don't know how many I will get done. The other thing that I have thought of doing on vacation is reviewing info for my next rotation (neuro or ortho & ICU) but I think I am coming up on a point where I just desperately need a break. I have been pretty devoted to reading OT stuff for about 90 minutes each day (metro ride) and I just want to move to something less taxing on my brain. I have lots of ideas right now but I think that my mental health needs me to not overwork for a week. Should be a good time with family, actually try to relax for an extended period instead of running around like a vagabond. Have to learn how to balance life.

Donate Bone Marrow!

You can sign up to donate your bone marrow for free (there is usually a registry fee attached). This site also allows you to donate umbilical cord blood if you're having a baby. You could save a life!!

A few notes on Alzheimer's Disease

Been reading some more on Alzheimer's lately. I have HBO's "Alzheimer's Project" on my DVR but haven't gotten around to watching it yet... but here are some other notes of late.

I have been reading about the Home Environmental Skill Building Program during my metro trips, which has been interesting. I can't use it very well in the hospital environment, but it would be good in home health as long as you could justify the billing. It has had some good insights for me anyway, namely, the understanding of different priorities between OT and caregiver.

If this article about early-onset Alzheimer's doesn't scare the crap out of you, you don't worry like I do... yikes. I have a lot of word finding difficulties, so my paranoia is bumping up now.

Stumbled onto The Alzheimer's Reading Room while looking up something else, it will probably become one of my top blogs in the scrollbar. I found it because I had read about the Test Your Memory exam on a Medline press release and wanted to see what was included in the test. However, after looking at it, I think we need an adaptation for the US... don't tell my history teacher father, but I'm not sure that I remember when WWI started. I would pick the JFK assassination as a seminal date in many of the current elderly individuals' minds, however, I don't know if there is a reasoning behind the date that it shouldn't be something the person actually lived through.

Saw 2 clients w/ dementia today, one early-stage and one end-stage. Depressing. Early stage lady was faking it pretty well but had severely decreased short and long term memory. Independent w/ BADLs though, so I am recommending adult day care, hopefully that will work out well. My end stage lady was a social admission... 92 y.o. husband came in w/ a cardiac emergency and she can't care for herself. Sweet lady, but gets confused in the middle of her sentences. She was good at ADLs too though. Long term care for her. No one likes to see their mother's mind crumble.

Quickie Acute Care Stories

It's hard to remember the stories from my job now since I pass in and out of peoples' lives much quicker and can zombie zone-out trying to make it through a ridiculously scheduled day. Like yesterday morning, when I found myself staring at 11 potential evals with no one to share. In the zone. Anyhow, here are some memorable moments...

3 Primary Runners for "Patient of the Day!!"

- Mr. X is 1 month s/p CVA that was not treated well at his hospital and received no rehab, now presents w/ visual deficits. He talks about his eyes dilating in and out, changes in light and dark, and not being able to see well. Finally he says, "I can only see half your face." Trying to figure out if this is a hemianopsia or other field cut, I ask which side. And his reply is, "the one with the big pimple."

- Mrs. Y is s/p fall and starting to have some memory problems, but is well tended to by her family. She says, "my daughter diagnoses me very accurately. She knew I had kidney failure while my doctor was still running blood tests." The PT asks, "is your daughter a doctor?" and she replies, "no, she uses the internet."

- Mr. Z is admitted for COPD, but apparently has no functional deficits and the shortness of breath isn't kicking in very quickly during activity. Unable to evaluate him during the morning as he had eloped out of the hospital, off the campus, and down to the gas station for a coffee and a newspaper. (independent community mobility- check!)

I just don't think you can write fiction to accurately display the craziness of the real world.

I was happy about Mr. X though because I happened to be sitting in on rounds and the PA was saying what a good vision workup OT had done with him, which made me feel good as vision is not my specialty. (Thank you Gutman and Schonfeld, I never would have remembered it without you). Later in the week, I was attending a different set of rounds and they were discussing a pt. w/ eyesight that had deteriorated due to cancer and suggested a low vision consult, and it was a good opportunity to educate the case manager, social worker, and doctor, as none of them had any idea that OT could do so much in the field. So, a few vision victories there.

Touching on the original point again, it is hard to blog after work now. The acute care life can be quite stressful and there's such pt turnover that I do mind-dump a lot. That and the use of the laptop all day makes it difficult to work on it in the evening as well. Really trying to avoid repetitive strain injuries, and it is becoming quite difficult. I do have a lot of good jotted down ideas that will get typed up eventually, but I've been restricting my blog access until I get a (for now) secret project accomplished. I am also in the midst of 7 straight weeks of full weekends- either I travel or someone traveling to me- and that leaves less time for other stuff too. Like my exercise goal, which is now back somewhere in the precontemplation phase... GIANT sigh.

Until next time- enjoy the crazy things life brings you today!

Slow on the Updates

Some busy times lately...
So for the first time in 2 or 3 weeks, I finally was able to discharge a patient on the evaluation. I have been so busy lately and working over a lot because every person I have seen has needed subacute rehab or nursing home placement, which means that they all needed goals written and follow ups done... very time and thought consuming. Wednesday we only had 7 new evals (only!) for 3 OTs, so we actually got to the follow up cards... one of the other girls said, "did you pick up? You still have cards in here" and the answer was yes, I have a full load today, but I just have too many people to actually see them all in a day. Been exhausted all week really. Sleeping on the metro instead of reading.

Trying to answer a Call for Papers for my state conference... haven't decided whether to submit for AOTA as well or not. Having a hard time following through on the requirements to write it up, very pathetic as I have no trouble writing on here, but once there's a deadline my brain is locked and procrastination sets in. I am obviously not going back to school any time soon.

I am going to Orlando in 2010 for the AOTA conference, and hopefully will get reimbursed for it from our continuing ed funds. I'm actually in a strange CE situation... I was a little panicky earlier in the year, but picked up 2 hours just applying for my new license. If I present at my state conference, that's 6 hours (have to pay to register anyway) plus a few as credit for the presentation, and my hospital is offering a stroke course for 6 hours that is super cheap for employees, so I could finish the rest of my hours right there no problem. But I am interested in the AOTA course Integrating Mental Health Into OT Practice with Older Adults... it is another 6 hours and still priced very fairly for members. I think it would be very helpful for me, but from a financial or efficiency standpoint, it doesn't make sense. I can't carryover extra CE hours in my new state, and I will have more than enough from the AOTA conference for 2010. In theory I guess I could order it and then just hold off on submitting the exam until I need it (2011?) if it is active that long. I am also holding onto 2 completed CE articles from OT practice on contemporary motor control that I hadn't submitted since I can't find my coupon.

A world with many options is simply a world filled with too many decisions...

I do have 2-3 interesting case studies I will post soon. Busy set of weekends coming up- worked last 2, had a visitor last weekend, at my parents' house for a wedding this weekend... Even though we always try to cut back to have relaxing time we always get large stretches of weeks in the summer and fall that are heavy on travel. Hope everyone is enjoying summertime before we hit triple digit heat on the East coast. :)

Update on Reading Without Getting Sick

After ~2 months of efforts, I have reached my conclusions on reading on the metro train without getting carsick.

I have found that a combination of strategies allows me to read almost nonstop while on the metro.
- Choosing a front facing seat: I will take back facing seats over sideways facing... if forced into sideways seats, I turn so that I am taking up more space and oriented toward the front.
- Front Car: I try to get a seat near the front of the overall train. There isn't a big difference between car 1-2 or 2-3 but there is a major difference between front most and rear most in amount of sway.
- Don't touch anything: I avoid contact w/ the walls of the train, since they vibrate.
- Eliminate degrees of freedom: I hold the book close to me, pinning down one page w/ both hands if necessary.
- Periodic rest breaks: If I feel the train going into a turn, shaking extra, or going faster than normal, I close my eyes. I had been looking up away from the book, but closing my eyes forces me to feel when the situation has calmed down.
- Accupressure: I couldn't find my sea-bands, but when I went to the store, I remembered what i didn't like about them. The elastic does have give, and the little pressure balls can cut too tightly. However, I found psi bands, which are doubly adjustable both at the wristband and at the dial. Pretty cool, hopefully the plastic won't break.

And there you have it! I've been knocking out important articles and texts with ease.

DISCLAIMERS
1. I am not a doctor and cannot advise you on best remedies for your individual situation... go get a checkup.
2. I am not going to try these remedies while in the car. I think that cars are too bouncy, and given to too many directional shifts in both left-right and up-down (at least where I am from). It's enough for me to just not get carsick in the car, I won't be pushing it there.
3. There is one known remedy for motion sickness that I have not tried, which is eating ginger. It's not feasible for me to do that nonstop for 2 hours everyday and I hate gum of any kind more than any non-SPD person could possibly understand.