Compensatory Strategies

For memory:
Young man with head injury, starting to initiate using a "memory log" because he has an emerging awareness of his appalling memory deficits. Overheard the speech therapist talking about a "compensatory strategy" to a different patient in our meal prep group and wanted to know what a "compensatory strategy" was. She explained, then I used the example of him using a memory log being a compensatory strategy for a poor memory. He jokingly wrote that explanation down in his log. I think it's a sign of progress when you are aware enough of your limitations to joke affably about them.

For poor oxygen saturation (O2 sats):
People on my unit often have difficulty breathing with full effectiveness. They take shallow breaths, using only their shoulder and intercostal muscles, not engaging their diaphragm. This causes a lot of problems:

1. Air never fully circulates in the lungs, so fluid can collect in the lower lobes and cause pneumonia.
2. Inefficient use of lungs makes people who are already weak fatigue even more easily, so they don't recover quickly.
3. Can lead to poor oxygen saturation which can cause dizziness or fainting- putting people at risk for falls or other injury.
4. Low O2 sats make you dopey, can't learn stuff, can't do stuff safely.

With people like this we do a whole training on diaphragmatic breathing and pursed lip breathing. It's prety cool. The biggest take home message for people is to exhale ALL THE WAY. We teach them to practice by breathing out for twice as long as they breathe in. E.g.: "breathe in while I count to 2, now breathe out while I count to 4". For some reason, putting the emphasis on a fully exhaling has better results than emphasizing breathing more deeply. And, if you let people wear the O2 monitor while you do this then they can get instant feedback of the difference this makes, so they can better internalize the technique. Pretty cool, right?

Surprisingly, many people have difficulty with the slow, controlled, exhale concept. They really struggle with it. I had a recent patient who was having difficulty with this, so we kept practicing for about 5 minutes of every session with moderate success.

On Friday, as I checked his O2 sats, I saw his lips moving. Knowing he was a religious human I asked him if he was praying. He said no, that he was reciting poetry. I asked him what he was reciting and he told me "'The Naming of Cats' by T.S. Eliot", and started to recite it for me in ringing, stentorian tones. As I listened to the long, drawn-out phrases, I was struck by the way he was taking short deep breaths between lines and exhaling long and controlled breaths as he recited each line. It was my breathing technique- easily accomplished through this meaningful occupation of sharing a favorite poem. I checked his O2 sats again, he had started at 89% (normal folks are at 99%-100%, the alarm on the machine goes off below 90%), and was up at 95% by the time he was done.

I pointed this out and we talked over the reasons why this might be working for him. He was very amused, so we spent the rest of the session reciting poetry and psalms together while he did activities. His O2 sats remained at 95%-97% throughout our session.

Also, it was fun. Here is our playlist:

1. The Naming of Cats- TS Eliot
2. When I Was One and Twenty- AE Houseman
3. Disobedience- AA Milne
4. TiddleyPom- AA Milne
5. The Lord's Prayer
6. The 23rd Psalm