End of year wrap up

Things have been pretty crazy lately. Here are some recent and end-of-year reflections, semi-structured, semi-sensible.


I should begin with an apology. I have been terribly behind and under-participatory in the online realm since October. I attribute this in part to an over-focus on getting my conference presentation ready. I am a terrible procrastinator and felt that I had to restrict my access to other endeavors to ensure that it would get done. After that, getting back on the horse, over the various RSI, over the burnout and back into the swing became a mountain I couldn't climb. My google reader page is finally down to 0 unread items for the first time in months... sweet success. I have some good trips coming up- family time for Christmas and a Vegas vacation in January. My husband may be going to France in February... don't know if I can swing that one too. At any rate, it's good to have things to look forward to, it's helping me keep my mind out of the dingy early winter blahs that try to seep in.

The job change this year was a new experience that defined most of my year. I've never left a job before that wasn't already predetermined by the end of a semester. I could have handled a lot of things better, however I do feel that this was a good choice. There have been lots of good opportunities that opened up at this position. I've already gotten to work with people who had unique diagnoses, lots of people in more critical condition than I was used to, gotten to learn a lot. I've also gotten to eat LOTS of Greek and some Indian, some Egyptian food, which we do not have back home. Hummus is my new goto snack... I really don't think I've ever seen any in the grocery stores before. Also, there are franchises of many more different chains than I've had access to before. I get a little obsessed about the food sometimes.

I feel that the blog has grown well this year. I like getting feedback from readers and statcounter tells me that there have been more than 10,000 MORE page views than last year. So, THANKS!! I do occasionally look to statcounter for what people have searched for to get to the blog to get ideas, but if you have something you're curious about or want to see, dropping an email is more likely to get a response. I had hoped to do more entries and different topics, but inspiration is fickle. Room for improvement to be sure.

So life goes on and hopefully things will get a little more under control in the upcoming year, but I won't count on it. I'm working Christmas day and then off for over a week... couple weeks off until the Vegas trip. Happy new year everyone!

Additional clock drawings

Sometimes I think these clock drawings are revealing, sometimes just plain confusing.

This one is from a man with dementia. I don't remember much else about the case since it was awhile ago. I do remember leaving him tucked in bed, call bell in hand, last words out of mouth "call the nurse, don't get up on your own" and before I could wash my hands he was already up on his feet on the way to the bathroom. I don't remember what time I asked for, but I have to assume that it was 7:40 and we get the numbers instead of hands.

This was my first experience with the Montreal Cognitive Assessment, which is becoming my preferred pencil/paper tool. However, it does start off with alternating trailmaking and has a 5 words after 5 minutes recall section, both of which are rather difficult for many people. But it's free and more discriminating than the Mini-Mental. The MDs wanted a KELS on this lady to determine if she could go home or not, but our manual was missing so I went with a basic functional eval and the MOCA. (could have stopped after the functional eval... if you can't get your pants on, you can't go home) This lady got 2/3 points for the clock since she does have numbers and a full circle, but again has just drawn a location on the rim of the clock for the time.


Finally, my most recent, which was another attempt at the MOCA but the woman almost swung at me when I brought out the paper. So we administered the test by walking around the unit and intermittently asking questions. I find it interesting that the numbers here are counterclockwise, also semi-dyslexic with the 10 as a 01. She kept becoming confused at the time... first it was 11:10, then 3:00, then 5:30 and her hands are closer to that than anything. Ironically, she was wearing a dial watch at the time.

Overcoming my Sensory Battle with Lotion

Is "Sensory Battle" a phrase yet? If not, you heard it here first! As a person who lives on the spectrum for Sensory Processing Disorder, and has experience working with children in the field, I can easily admit that my life has been full of sensory battles. Here's the story of one such encounter with lotion.


I have been fortunate in my life in that I have had pretty good skin. Sometimes oily, but since I don't wear makeup, I would say that I have had only a moderate amount of breakouts (lifetime average). But in the past few years, since I have been employed and in a dry hospital environment for the duration of the winter, my skin has gotten drier. Last year I had to start using a facial moisturizer, which was difficult but made easier by the fact that I could wash my hands off to rid of any extra lotion-feeling. This year the dryness is spreading... meaning more lotion all over my hands and body. Best summed up as: EWWWWW

I am very sensitive to tactile stimulation. Velvet=good. Tags=bad. Sweatshirt=good. Lotion=AWFUL!!! The cold, slimy, gooey feeling makes my skin crawl all over. And then it sinks in and it sticks and you can't get it off... ack. My husband and I got massages last year for our anniversary and the lotion almost ruined it for me... laying flat, unable to run or scream as lotion was poured all over me was a very tense experience.

Imagine for a moment, the strain that my struggles placed on my parents. If you have a child with SPD, you are probably familiar with the scene. Your child needs to put on sunscreen but screams, pulls away, and starts crying in hysterics when the goop is applied. Maybe you give in and don't put on so much sunscreen, then the child gets burnt and has to have aloe gel applied and the whole scene is repeated again. (Of course, this is not my only tactile difficulty, and I have processing difficulties in multiple sensory arenas).

But now I am older and understand my sensory needs better. I have managed to make great strides out of necessity- I am now able to apply chapstick multiple times per day (I find that lots of lip smacking afterward makes it better), and apply the facial moisturizer every morning (winter only). I have sought out the least flavored and scented of all products. I spent 10 minutes in the drugstore yesterday sniffing multiple "unscented" lotions trying to find the most agreeable one. The texture is impossible to try out. I am trying to start small... only apply a small amount to a controlled area and then leave my arms free to wipe off all excess. It has been a struggle thus far, but getting better. By concentrating on mastering this, I think I can finally suppress the EWWW and add another item to my List of Can-Dos: lotion.

Fighting Frustration and Fatigue

This has been a hard 2 weeks.
It is my impression that the hospital staff was stressed and unpleasant last week due to the impending holiday and just wanting to leave work and go eat copious amounts of gravy laden food. However, they seemed to bring their bad moods BACK with them after Thanksgiving, which is just not fair. Get a grip people- it's holiday season for everyone, not just you. I'm working Christmas day, so that leaves 16 more working days before I can really rest. I'm already so tired... spent this a.m. in a fog since I fell asleep on the bus, and then was ok until I walked through my apt door where I have now crumpled into a semi-lifeless blob. My eyes and brain are fatigued... I can't even begin to think about learning more about Google Wave even though I have OT buddies on there now because it is literally overwhelming to me at this moment.

A vast majority of my pts on the cardiopulmonary unit this week have been people with volume overload following dietary indiscretions over the holiday. COPD and CHF exacerbations as well for related reasons. Interesting how things move in patterns. Unfortunately, since ice and snow is coming up there will be more broken hips and the like.

The next thing I write will probably be about the difficulty getting an IRF/ACIR placement for a pt... we've been discussing this a lot at work, there are new insurance rules going into effect, our documentation has extra scrutinization coming its way. It's a detailed issue that I care a lot about but I need to be a little more coherent before I try to address that. So I'm taking some time to rest, though that time does include traveling to a football game on Saturday and likely Christmas shopping (possibly even at crazy IKEA, yikes) on Sunday.

Just trying to keep afloat...

Energy Conservation for the Holidays

Energy Conservation is a favorite topic of mine. It involves a combination of strategies designed to let you save your energy on the multitude of tasks in a day so that you can save it for the things that matter most in your life. Holidays can be very draining, but here are some ways to save your energy. Please add your own suggestions in the comments section.

Tips for Family Get-togethers
-Try to limit excessive travel (I speak from experience- last year was a 10 day 8 location trip).
-When you do travel, make sure to take rest breaks at least every 2 hours to get out of the car and stretch. Rotating driving responsibilities is also a good idea
-Rotate hosting responsibilities within the group so that no one person has to bear the brunt of continual entertaining
-Consider meeting friends at a restaurant or other gathering place
-If you're doing the entertaining, ask for setup and cleanup help
-Try to take a nap before any gathering that will go into the evening hours

Tips for Meal Prep
-Spread the responsibilities around the family or group. Have people volunteer to make a specific dish so that the host is not saddled with the entire meal
-Prepare some dishes ahead of time if possible
-Use tools to save you time and effort. This includes mixers, microwave, and the crockpot
-Try to prepare more foods in the crockpot or bake them in the oven instead of cooking stovetop, since it requires less tending
-Keep a stool or extra chair in the kitchen so you can take breaks during cooking time. A higher stool can be pulled up directly to the stovetop for stirring pots, or to the sink to wash dishes
-Oven Bags can cut the cooking time for a turkey down substantially and decrease basting needs
-Perform prep tasks seated at table if possible
-Split large tasks between a group

Food Substitutions
-Several stores offer completely catered meals
-A rotisserie chicken can be substituted for making a full turkey
-Steam n' Mash Potatoes by Ore Ida are pre-cut potato pieces that you add to your own milk, butter, and spices. Saves the trouble of peeling and cutting the potatoes.
-Betty Crocker and Bob Evans both have instant mashed potatoes that can be heated up in the microwave. They also offer sweet potatoes and stuffing.
-Many schools offer cookie batter in large buckets as fundraisers, making cookies into a scoop & bake operation

As always, I have no relationship, financial or otherwise, with any of the aforementioned companies or products. However, I have used them myself frequently.

Post from the Alzheimer's Reading Room

The Alzheimer's Reading Room is not my favorite blog, but I do follow it regularly. I was impressed at this recent entry that described the author's change in his caregiving style as he learned about Alzheimer's Disease. The emphasis on the power of DOING is great, and I wish that this would become well-known. The case is similar for adults with Alzheimer's, people with disabilities, children, ANYBODY- "Let me do."

A "very special" episode of Glee

I have been occasionally watching "Glee" and trying to decide whether it's worth my viewing time. However the most recent episode and its after-school-special sugaryness has exposed a lot of controversy.

There are 2 main issues here, one with the show for casting a non-disabled actor to play a student in a wheelchair, and one with the episode itself, which featured terribly contrived dialogue to try to make the other glee-clubbers understand Artie's plight of being in a wheelchair.

Let's start with the immersion exercise episode where the self-centered glee clubbers were relegated to spend a few hours each day in a wheelchair. The students' teacher rolls out wheelchairs that he supposedly bought at a tag sale from a local nursing home. Of course these were all sleek, more stylish chairs than that bear no resemblance to the standard industrial type chairs seen in hospitals and nursing homes. A nitpick, admittedly, but that's how I am. The whole episode was painful to watch as the glee geeks were more mistreated than usual now that they were wheelchair users. Cool kids are now... uncool! Feeling left out over a week leads to... increased empathy 4-evar! We even had time to learn that ex-quarterback kid couldn't manage to find a job... until he was in a wheelchair and had pity and fear of litigation from an employer! It just didn't feel like an empowering week. And this may also be part of a commentary on how poorly defined this show is... is it made for children and tweens or is it made for adults? The fake pregnancy pentagon storyline is surely not made for the young crowd, but you'd expect older viewers to rant about the terrible plotlines in general. Confusing.

However, the meat of this discussion should be about the casting of the role of Artie, and some of the controversy was addressed in the USA Today. Why wasn't a legitimate actor-singer-wheelchair user cast to play Artie, glee club geek in a wheelchair? Here's a second, perhaps more telling question- how many such actor-singer-wheelchair users auditioned? From the way that actor Kevin McHale describes his audition, I find it questionable that the role was ever advertised to indicate that the actor would be in a wheelchair. It sounds like this was a plot twist to increase diversity that got thought of after the casting and got shoved onto an already created character. I have the impression that the role was created around the actor, so perhaps the casting calls were not worded in a way to invite wheelchair users to audition.
sidenote- if you watch the McHale interview, how does a kid who plays an adolescent have no idea what time schools are in session? "From 8 to 12 or whenever"?

I don't think that the character of Artie is a great ambassador of teenage wheelchair users anyway. As a member of the glee club, he is often hanging out on the sidelines with the band instead of participating in the show. If he is worked into the routine, it often involves another character pushing him around. The writers went out of their way to end this episode with a big musical number that had everyone swooshing around in wheelchairs, but did they consult a wheelchair dancer for choreography tips? I have my doubts. And if my earlier suppositions about the wheelchair being thrust onto a character after the actor had already been selected, why not put Mark Salling, who plays buff ne'er do well football star Puck into a wheelchair, to be a buff ne'er do well wrestling star? Artie could have continued to be the geeky guy who plays the guitar, he also could have been the much-mocked kicker on the football team. Wouldn't that have made for some better, more original storylines than putting the dorky kid in the wheelchair?

Should an able-bodied actor ever play a character that has a disability? That is the main question. In one sense, all acting is fakery. Hollywood does not always hire sports stars, drug addicts, or serial killers to play themselves. But certainly a capable actor who has the same abilities as his character would have a better understanding of how to play the role well. The real issues in this question are-1. are disabled actors being considered? and 2. are non-disabled actors giving an unfair portrayal to disabled characters? The Iris Center, out of Vanderbilt University, has a catalogue of movies about disability or featuring disabled characters. Some of these movies feature great performances, but are they demeaning? One mother in the UK is starting a group
criticizing portrayals of characters with mental or neurological impairments (nothing about physical impairments, oddly) who are played by actors who do not have a disability. One thing that I worry about though is if there becomes a taboo on non-disabled actors playing disabled characters, will disabled actors ever be allowed to just be actors, and not be identified first by a disability?

Some sad times

My time at work has been sad lately.
My current rotation has been a mighty mishmash of cardiopulmonary pts on intensive and progressive care units, orthopedic pts, and frequent floating back to the neuro floor and ICU. In short, my pts have been much more acutely ill than on my other rotations.

It's very depressing seeing pts on multiple admissions for severe COPD or CHF exacerbations. People who are far past where cardiopulmonary rehab can be beneficial. I've had several pts travel back and forth from the regular floor to the ICU, but I have a couple that I'm concerned aren't likely to come out. I've had to get much more diligent about checking with nurses even for follow up sessions since my pts fluctuate considerably from day to day. Got as close as I care to get to a pt coding... me throwing on a contact isolation gown and slapping a vitals machine onto a lady who was hyperventilating, desatting, and gasping in pain. Fortunately the doctor and charge nurse were right behind me, so I was able to excuse myself and let them perform the rapid response and take her to the ICU.

My neurology pts aren't faring much better. Someone I evaluated several weeks ago while on that rotation is now nearing a full 2 months hospitalized and has just gotten progressively functionally worse. I wonder if she would have been happier if the surgeons left her brain tumor in and let her live out the rest of her life still able to walk and talk and recognize her family. Her shoulder now has a finger width subluxation that I feel personally responsible for.

She is one of several people we've had with GBMs lately, a particularly nasty type of brain tumor with very poor prognosis. Also had the readmission of a young CA pt that I worked with prior, who was intubated, had to get a PEG tube, and generally declining. I couldn't even look toward the back corner of the unit without choking up.

I've also had some personal disappointment lately, and have felt pretty bad for being swayed by that at all, having any negative emotions over this minor speed bump in life when I still have life and many of my pts are losing theirs. So it's been a very emotional time, a lot of tears at home, some at work. Not such a great time lately, but it will improve, I hope.

Back From Conference

State OT conference was this weekend and I had both an enjoyable time and very energizing time.
Finishing and presenting my topic at the state conference were both great feelings. I haven't given a formal presentation since school, and it was even longer since I'd given one in front of (mostly) strangers. I felt a bit like a motormouth and know that I set out to cover too much for my 30 minutes, but it was a good experience. The official title was "Growing as an OT Through Online Resources" but it was basically a quick overview of multiple types of online tools (with several plugs for OT Connections, haha). Only bummer was that my presentation was last so people were tired and quiet by the time I came up to talk.

Got to spend some good time catching up with fellow alumnae of my program, quick chats with a couple of professors as well. Serendipitous moment was seeing a car with license plate "OTHELPS" as we were driving back.

Love the energizing feeling that comes from being with other OTs, hearing about legislative victories, hearing some inspirational stories of rehab at its best. Have some ideas about helping our conference continue to grow, and I enjoyed presenting and think I can do that again with less stress. Have another project that I'm working on this week and then will be working the next 3 Sundays due to holiday scheduling so life continues to be very busy. Learning a lot on the cardiopulmonary floor and will be passing it along soon! :)

On my way to WVOTA 09

I know I haven't posted much this month, mostly because I was trying to finish my presentation for the annual conference. I'm going to be presenting on social networking and OT and I am really excited. Wish me luck!!

Virtual Reality Survey

Passing along a survey for student research, link on the full post.
I am a student at Thomas Jefferson University and I am currently doing my master's research project on virtual reality program usage in therapy. Whether or not you use these systems, I would really appreciate if you were able to complete the following survey and pass it along to any OTs you know!

Survey link:

http://www.surveymonkey.com/s.aspx?sm=l12ANB490U1A2oAercLlpQ_3d_3d


Thank you in advance!

Sara Jasin, OT/S

Tis the season for changing

3 months has gone by, neuro rotation is over.
This month, I begin on a new floor, the last "new" floor possible (NICU/peds does not count into the rotation). So I will now be working with cardiopulmonary pts, some in ICUs, and orthos. I don't find any of these superbly interesting but hope to find some fun stuff to do. Little worried from a productivity standpoint since I suspect we'll be taking a lot of rest breaks, lots of breaks to check vitals, and probably a lot of advance planning to separate OT/PT sessions into morning/afternoon. I haven't ventured fully into the ICUs yet... we are starting an effort for early mobility and decreased sedation (similar to this) so that will be interesting but it is also stressful to make sure that I know enough about what is going on and protecting my pts, not pushing them too far.

My neuro rotation was good... it was split with surgery, which was not so much fun. Rounds for both are kind of demanding, and first thing in the morning which can make it hard to get a jump start on the day. I did learn a lot on the rotation... I am no longer scared to be in the neuro ICU despite intra-ventricular catheters and pts who have to be monitored very closely. Worked with one lady for 5-6 weeks in total over 2 admissions, she might make a good case study later. I got over my splinting fears for the basic stuff- had a period of 2 weeks where I felt like I made at least one splint everyday. Luckily there are good experienced people around me who are willing to give advice on whether to splint or not, whether adaptations need to be made. even made a resting hand splint around an arterial line.

Had several interesting cases, but lately it's been more sadness and disappointment. Some people really stick with you and it's hard to leave at the end of the day knowing that there's really no reason your pt wound up in the hospital, and that same freak accident/diagnosis that happened to them could just as easily happen to you. Life can seem random when otherwise healthy people wind up hospitalized for something no one could have seen coming. I had a lady in her 80s who had never had any illness before, but had neuro symptoms, came to the ER, and found that she has had a large brain aneurysm that was leaking. What are the odds? It's not right, but there's other diagnoses where you assign a fault, make yourself feel better- I won't get this, I don't smoke/use drugs/I wear a seatbelt- but too many things on this rotation could happen to anyone. It's a scary world out there, and unpleasant to have to contemplate mortality so often.

The switch has me working with some new OTs/PTs that I'm not familiar with so that is interesting. At least one is working on clinical ladder for cardiopulmonary, so I expect to learn a lot. I am reminded of when I was playing on a basketball team with 9 players and I was the 5th player, so there were times when I was the worst player on the court, and times when I was the best player on the court. I remember asking my dad about that situation and he said not to feel bad about being the worst player because everyone around you can teach you and make you better. So that's sometimes how I feel right now, being the newest OT hire and only 2 years experience, but I do feel that I'm learning and getting better.

I've gotten better at writing goals for ICU pts and conducting tx sessions, suspect that will continue to improve during this rotation and hopefully I will have a good update with ideas for everyone.

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.