Fun with OT

Wonderland

2010-02-23T19:38:00.000-08:00

Drink Me
My first patient today was a very large man. Not obese, mind you, just extremely tall. Like Yao or Shaq. His head is easily twice as big as my sweety's (in case you're wondering, my sweety has a big head), the footboard on the hospital bed had to be taken off so his feet wouldn't shove up against it, sitting in our largest power wheelchair his knees are still higher than his hips... and that's with the footplate off, feet on the floor. The hospital pants (one size fits all) barely cover his knees. Nothing in our donated clothing closet fits him. I have to use 2 hands to move one of his legs, when usually I can move both together with just one arm.

I found that I kept having to rethink the things I normally do for a patient to improve their mobility. Or not so much rethink them, but rethink how to achieve them. For example: when sitting at the edge of the bed one's feet should be flat on the floor to optimize balance and decrease risk for falls. This is a problem as most hospital beds are notoriously tall, out of habit I lower a bed almost all the way everytime I'm sitting someone up, it's a reflex. Wait, stop... raise it, raise it.... wow... okay, raise it some more. When the bed's right about at my hip, his feet are flat on the floor.

His hands are probably the most striking. Enormous paddles, he holds his 8 ounce milk carton delicately, with thumb and forefinger, the way I might hold a shot glass. He sees me staring and lets me place my palm against his to compare sizes. My fingertips barely reach to the base of his fingers. He laughs at the look on my face and has me measure my middle finger against his pinky- my longest finger is as long as the 2 end segments of his littlest finger.

Eat Me:
My next patient was a tiny woman in her 40's. Shy, quiet, earnest, she is not frail or bird-boned, just very small. I can't get the bed low enough for her feet to even touch the ground, let alone be flat on the floor. The hospital pants (one size fits all) have a third of their length rolled up so she can use them. Nothing in our donated clothing closet fits her.

Her tiny hands barely extend to the first knuckle of my fingers, and she uses both hands together to do things that most of us do one-handed: hold a cup, carry a shampoo bottle. She can't really carry multiple items easily, or gather the top of a sock into her hands so that she can put her toes right into the toe of the sock. She has a funny strategy of hitching her bottom up high on one side every time she sits, so that she'll be able to get it into the chair.

Steadying her, for balance, my hands engulf her shoulders, my palm takes up her whole belly.

Through the Looking Glass:
I realized that I have ways and means of doing things: moving a limb, threading a foot into a pants leg, steadying someone. I have done them so much that my body has a plan and a memory and it just gets going without a lot of instruction from me. These two patients were so surreal because my goals were the same as always, but my body didn't know how to do them. I had to plan and think over each movement. With the first guy I was tiny, I had to set everything up for maximum leverage. With the second patient I was gigantic, I had to scale way back on strength, speed, and contact area. And having them back to back was just plain trippy, I felt off-balance the whole morning.

This Day Must End With Beer and Chocolate

2010-02-01T20:43:00.001-08:00

First: When this dude showed up on the unit he was so lethargic, requiring so much cheerleading to get up at all, that my PT co-troublemaker and I told the physiatrist on duty this week that we figured he was depressed and could benefit from a psych consult. He is one of several patients on the unit right now whose needs are primarily psychosocial versus basic self-care and functional mobility.

He's a homeless dude with a prior spinal cord injury whose bindle and wheelchair were stolen when he came to the hospital, he comes to us with nothing. My OT activities have involved community outings to purchase cell phone chargers and to the local bank to problem solve how to get access to his money as he no longer has an ID. Over the weekend he swung from completely depressed to monkey-hanging-from-the-chandelier manic. You guys, he is seriously off his nut right now.

I go in to his room to find the urinal on the floor- beside a yellow puddle, his breakfast tray on the floor- beside about 50% of his breakfast, and he has no pants on. He takes a swing at me, throws his water at me, and shouts at me to take his teeth out of my mouth and give them back. He's very jovial about it, but completely off. Because of my last quadriplegic patient, I remember that he has no power at all, he's paralyzed, he can't even get out of bed without me. I finally got to where I don't mind one of these guys, not even from the beginning. I finally learned: I have all the power in this situation, so- you know- I can be magnanimous. His nurse is relieved to see me because patients like this get under her skin.

Here's what I do:

Limit visual stimuli- close the curtain to the hall, remove clutter from trays and floor, remove all trash and miscellaneous items from view and from within reach.
Pick 2 very basic self-care tasks that I know the patient can do- put on a shirt OR brush teeth and ask him which he would like to do. He picks brush teeth so I set up the task so that I can hand him ONE ITEM AT A TIME, providing 2-3 word instructions until he can complete it. This takes 45 minutes, but by the end he is definitely calmer and no longer combative.
Before leaving the room I ask him if I can get him water or soda (with most patients we leave this as an open ended question- but he was needing forced choice questions or he would just ask me to suck his dick- seriously).

Throughout the interaction I keep my movements clear and predictable, stay mostly out of arm's reach, limit my eye-contact and my verbal output. He is lost in his own world and does not need me to add stimulus to this. He successfully brushed his teeth. Then they gave him a bunch of ativan and he slept the rest of the day... nice.

Second: Sweet young old dude whose body is really having trouble. Different organs are failing and being managed by different doctors, plus he had a mild stroke about 10 years ago with mild residual balance deficits. Wracked by anxiety he is thinking about his aging self and how it is time to change how he's living because he can't do it on his own anymore. His family wants to help him out, but he is tortured and paralyzed by memories of childhood traumas. He keeps reliving these experiences, as well as some bad decisions he made as a young adult, and which he's never told anyone about. He says he's boxed it all up but that it's been eating away at him for all these years. He is torn between wanting to unburden himself and the terror he feels that anyone would know his secrets. As he tells me some things and dances around the others, his shame and fear are palpable, like a corrosive syrupy tide that rises over me as I listen, filling my own mouth and nose until my breathing becomes as jerky and shallow as his own.

On paper this guy is at rehab for a variety of medical reasons, in practice he is trying to make the biggest decision of his life, and it has nothing to do with his medical condition. Will he be able to let go of his shame, be brave, and tell someone (family, friend, therapist) about himself? Or will he keep his mouth shut and sink back into his ocean of misery and loneliness? And until he makes this decision he won't be able to make the other decision about which discharge option to choose. He is paralyzed. He talks to me for almost 2 hours, then spends the rest of the day crying.

Here's what I do:

Put down a taproot like a pesky oak seedling in my garden. On the surface it looks like a 3 inch sprout with one oak leaf, just under the surface is the acorn, but try to pull it up and you find 18 inches of taproot growing straight down. I sit in his chair and send down a taproot of my own to the bones of the earth and to the bedrock of my faith. I picture it through and past my own shame and fear and trauma, through my own physiological response to his woundedness, to the spinning axis of the earth, to an archetype of peace and stillness that I believe in but have only experienced in dreams. Then I listen.
Make sure he's already had a psych consult. He has. In addition to medication, the psychiatrist has recommended psychotherapy/counseling. I ask our social worker if he can follow up with connecting him to resources. He hedges- per usual. I brilliantly think to call my own shrink and ask him how one would go about connecting a person on medicare to a counselor. He is extremely helpful in providing information and specific names. Hurray for crossover of resources!
Check with the physiatrist of the week to make sure it's okay to pursue counselors as an inpatient. Of course it is. I make a plan with the patient to start calling people on the list tomorrow.
Spend way too long figuring out how to write this note so that my activities fit within the OT scope of practice... access to resources? Problem solving for dishcarge with emphasis on psychosocial barriers to same? Good lord, writing that note is almost the worst part of the whole thing.
Wish I had more skills. I can build a rapport and listen like a pro, and for most of my anxious or depressed patients this is the level of support they need. Y'know, acknowledge the stress of their functional change, encourage them to talk to their families, recommend follow up with a counselor when they leave, connect them to the chaplain or help them contact their own support people. We do this and move on to other therapeutic activities. But this guy can't move past this state, can't calm himself, and can't be redirected... by me anyway. Time for a second degree?
Run around the building a couple of times to clear my head.

Third: I'll keep it short. This guy had a seizure in the shower. Finished the shower, grabbed the grab bar with his right hand, stood up, turned halfway towards his walker, and suddenly couldn't move. I'm standing at his left side facing the same direction as he is, I've got my right arm around his back for balance and support, and my left hand holding his bum left hand onto the walker. He goes all stiff and starts pushing backwards- he tells me he can't let go with his right hand. I let go with my left and pull the "Help!" cord. But of course no one comes, then he gets stiffer and starts to push backwards even more, then starts to shake. I think about how I really don't want him to fall and wreck my perfect record of no falls. I think about how he has recently had a head trauma (stroke or injury or tumor- take your pick) and that this may be a change in condition. I think about how he is on coumadin and I REALLY don't want him to fall.

Here's what I do over the course of the next 30 seconds (try to keep up):

Keeping my right arm around his waist I reach behind him with my left arm and grab onto the grab bar by his right hand- now my left arm is also supporting his back.
Still supporting his back with my left arm, I pin his hips to the wall with the left side of my body so I can let go of him with my right arm to grab the shower seat and pull it up behind his butt. At this point he has started to shake and has slumped against the wall on his right side.
I reach around his waist with my right arm again and bring my left across his chest so I can guide him back into sitting on the chair, then I protect his head from the tiled walls until he stops convulsing.
As soon as he is still I jerk open the door to the hall and shout, loudly, "I need help in the shower RIGHT NOW!". Within seconds I've got a PT, two nurses, and a CNA all helping to get him in a wheelchair and back to bed.
He opens his eyes and tells everyone that he's fine. No idea what we're all stressed about...

It's always fun to have one of those adrenaline experiences where you're all cool, collected, and problem solvey in the moment, then as soon as it's over you are shaking like a leaf and your legs will hardly hold you up. What IS that? Literally, as soon as the nurses showed up to help, my legs almost gave out. What's the mechanism for that? I know it's some adrenaline thing but why does everything keep working until the second it doesn't have to?

.....

2010-01-11T21:23:00.000-08:00

The lady from the last post just died. I still have a memory, in my body, of holding her up on her bed. I have a clear image, because it was so recent, of the challenges, struggles, eye-rolling, and joking- she was really quite droll. I keep being surprised, when a memory of a session with her intrudes into my thoughts, that she doesn't seem any more faded than my other former patients, as though my memory of her should diminish as her presence on this earth recedes.

But my memories continue to ebb and flow at their own rate, according to my own rhythms. And this, apparently, is outside the realm of the literal and actual world.

Midline Orientation

2010-01-06T16:02:00.001-08:00

This week a patient's son asked me if there was a way to strap, bolster, or otherwise "manhandle" (his word, not mine) his mother into an upright position. She'd had a pretty severe stroke, the most functionally limiting effect of which was a severely impaired midline orientation, with pusher's syndrome.

Just to review, your brain is getting signals from your whole body about it's relationship to the environment: muscles and joints send signals about where each piece is in space and in relation to each other, pressure receptors in your skin send signals about weight distribution, your semi-circular canals (in your ears) and your optic nerves send signals about the orientation of your head to the environment and to the rest of your body. A stroke interferes with one or more of these feedback systems, impacting your ability to sit upright.

If hemiparesis or hemi-weakness (paralysis or weakness on one side) is the only issue, then it's usually a simple matter of training you to check your orientation with each position change until you relearn what middle "feels" like. Unfortunately, it's rare that a stroke will effect only the muscles on one side without also interfering with the brain's perception of that side as well. A person with pusher's syndrome has an impaired midline, and the sensation that they are off balance causes them to try and hold themselves upright with every ounce of strength available to them. However, because there are perceptual deficits in addition to the hemiparesis, what ends up happening is that every muscle on their unaffected side works overtime to push them over to their weak side.

This is where we were at with my patient when her son asked about positioning. He was having a hard time watching his mother struggle to be comfortable and upright.

So, with his mother seated at the edge of the bed, I explained it all to him (all while working with her of course). How your body perceives its middle. How the more you try to prop up the weak side, the harder the strong side pushes against you (I learned this the hard way, after many sessions that ended with my back or arm sore and me sweating like an olympic distance runner). I asked my patient to explain what it feels like when I tried to push her upright (she said, they all do, that it feels like I'm trying to push her over). I pointed out how, if I blocked her arm from pushing, you could see her strong leg inch out to the side and start to push her also. I explained the strategy of not resisting her and letting her push herself over until she could feel that she wasn't straight, then helping her correct. I had her lean onto her strong elbow, in hopes of reducing the fear of falling to that strong side (after all, she's seated on a bed, there's no real danger). I brought out the long mirror so that she could use visual cues to help orient herself. I showed him what I call the "more flies with honey than vinegar" technique of sitting on the strong side and asking the patient to lean against my shoulder. Then I had him sit next to her and play along, so he could feel it for himself. If a picture's worth a thousand words, then an experience must be worth its weight in gold.

His mom and I have been doing this balance training stuff for the for first 20-30 minutes of every session since she got here- she has the worst post-stroke balance I have ever seen since I started this job. But she's really sharp, so she understands what's going on and she works hard, cognitively, to fight against the reflexes that aren't working for her. I could tell that she enjoyed being a part of this educational moment for her son, that she enjoyed being able to explain to him exactly what was going on for her. After 15 minutes or so, she found her midline, and she maintained it with only verbal cues for the rest of the session. Her son was able to take over cueing and prompting instead of me. It was totally fun and successful. Yay.

Throughout this treatment there was an observing part of me that was suddenly stunned that I knew all this. Because the thing is that I didn't learn ANY of that in OT school. I didn't even learn about impaired midlines at all. (Though this is how I spend so much of my time with any stroke patient.) I learned all of it on the job. Through observation, through asking questions of doctors, through asking for some mentoring assistance from more experienced therapists. The weird thing is that there wasn't one moment when I put it all together and came up with a theory or a framework. I just kept putting it together. Trial and error, an answer from a senior therapist here, an observation there, stuff I learned about neuro-plasticity, casual lunchtime conversations with co-workers; wait two years and voila- knowledge! Practical knowledge that I can use, and even share with others. Freaky. Just imagine what I'll be surprised by in two more years. Or twenty.

The Rehab Reality

2009-11-23T20:35:00.001-08:00

After a week, this stroke guy had our number.

When I first saw this shirt I didn't even blink, it seemed perfectly straightforward to me. If that's not a testament to its rehab aptness I don't know what is.

Ghost Story

2009-11-22T13:34:00.000-08:00

I had this really nice old lady off and on for like, 6 months, as she went back and forth between our rehab and the nearest fancy teaching hospital for abdominal surgeries.

She is a lovely lady, and we totally hit it off, got along really well. We talked life, love, future, philosophy, and faith. I met her daughter and her aged and demented beautiful sisters.

But by her last tour I could tell that she was over it. She was so bored with the hospital and with being sick. She was ready to go home, or die, whatever came first (she went home and is actually fine). She just couldn't keep a perky attitude anymore- here's what gave it away:

On the third day of her last stay I came to get her up for a shower. She told me she didn't feel like it, she complained of being tired, she actually pouted. She said: "the doctor told me 'no activity whatsoever'". This, of course, was nonsense, the doctors never say that to rehab patients. So she says "fine!" Then she folds her arms, glares at me, and delivers the following curse (she's from a foreign country, and I speak her language of origin, so you have to imagine it in like, village Polish, or hill country Mexican Spanish, with proper spooky crone invective):

"Fine! But if I die I'm going to come back as a ghost. I will travel this county until I find you, and I will haunt you. I'll haunt you in your sleep, when you're alone. I'll say 'oootgiiiirllll (imagine spooky haunting voice), oootgiiiirllll, cooomme wiiith meeee' and then I will take you back with me to beyond the grave, and you will never see your family again. ALL BECAUSE OF A SHOWER."

Compensatory Strategies

2009-11-22T11:57:00.000-08:00

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:

Air never fully circulates in the lungs, so fluid can collect in the lower lobes and cause pneumonia.
Inefficient use of lungs makes people who are already weak fatigue even more easily, so they don't recover quickly.
Can lead to poor oxygen saturation which can cause dizziness or fainting- putting people at risk for falls or other injury.
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:

Come On, Get Serious

2009-11-19T21:10:00.001-08:00

You guys, anti-depressants work best when used in conjunction with psychotherapy or counseling of some kind. Seriously. The difference in effectiveness is shocking when you read the research (like this article, and this article, and this one)

I'm so sick of doctors just prescribing that shit, willy nilly, and not also referring to counseling. It's not like they're magic pills, and lots of them also have side-effects that really suck. If you are depressed and taking medication, get some other help too.

And doctors, shame on you for not insisting on a wholisitic approach to address the distress of your patients.

Right now I have a woman on my caseload who was so depressed this year that she ended up being treated with electroshock therapy. Electroshock therapy! And is now taking several anti-depressants to maintain her mood stability. These medications have really extreme side-effects that are significantly affecting her fine motor and balance functions, now she's had a stroke. When I asked her if we could contact her therapist to provide support during this difficult time she said that she didn't have one. That she'd never had one, that her doctor had never recommended she see someone.

Do you KNOW how crazy this is? Depression so severe you need electroconvulsive therapy and major psych meds with awful side-effects, you're travelling across two counties to work with the best psychiatrist you can find, but NO ONE recommends a shrink.

I just don't even know what to say... gah.

Redefining Indigence

2009-11-18T22:39:00.000-08:00

In the last 3 months I've had 5, count them, 5 patients with a new diagnosis of diabetes. They came to me because they had a severe diabetes related medical emergency, and needed rehab to recover.

4 people who had strokes
1 person who had a cut on her foot which never healed (diabetes interferes with healing processes), and which she didn't realize was bad (diabetes interferes with sensation). Her brother talked her into going to the hospital 3 weeks later, and it turned out that she had gas gangrene all the way to her knee and needed an emergency amputation of her whole left leg! I already posted about dry gangrene, so I am not going to talk about gas gangrene but you can read about it here.

None of these people had health insurance. All of them were either self-employed and could no longer afford the rising cost of insurance, or had recently had their hours cut due to the tanking economy and could no longer receive health coverage through their jobs. All of them were independent, hard working, responsible individuals who had never imposed on anyone in their lives. The epitome of the American bootstrap ideal.

They were all between the ages of 57 and 64, keeping their fingers crossed that they would make it until they were 65 and could get on Medicare. In the absence of annual checkups/physicals none of these individuals knew that they had diabetes, they didn't know until they had a major medical emergency and presented at the ER. Then they get rehab at the most expensive place in the county, all courtesy of the taxpayer.

I grew up with the belief that responsible adults had health care, yet all of these folks are responsible adults. 15 years ago, I was working my first real job: a staff member at a group home for children with disabilities. As a full time-minimum wage- employee I got full benefits for myself AND my husband at no cost to me. I have the same quality of benefits now- working for the only hospital in town. Other than my co-workers, I don't know anyone else who has this level of awesome benefits. It is unheard of. But 15 years ago it was common place.

The real kicker though is that despite the changing demographic of the uninsured, our perception of people who are uninsured remains unchanged. They are "indigent", irresponsible, low class, "not planning ahead". I wish you could all be flies on the wall at some of the rounds meetings to see the eye-rolling and hear the thinly veiled derisive comments and assumptions made about "these people".

Lately there's been an increase in this type of uninsured patient at our unit, so what's happening? It's easy to assume this change in demographic is a result of all the economic and health care related problems facing our country right. But it could also just be a local issue- the competing medical group in town that has no ER, so they can cherry-pick the folks with insurance, leaving the rest to use the ER as a primary care physician (by the way, I call shenanigans on this sucky practice. It is not in the best interest of your community). Probably, these are all factors- I don't know.

But it seems to me that we have 2 options:
A) Either we become a culture that gets comfortable with allowing people to die in the street if they don't have money/insurance.
B) We decide that we'd rather spend taxpayer money on prevention (at the very least yearly physicals) than on constantly picking up the pieces from major medical emergencies.

The one option we don't really have is to keep telling ourselves that only the "indigent" and irresponsible don't have healthcare. Don't get me wrong, I understand the temptation. As long as we keep telling ourselves that we don't have to acknowledge the extent of the problem. But guys, these people are your aunts, uncles, mothers, neighbors, and friends. They may not even be telling you about it because they believe they have failed and are ashamed.

I, for one, still want to live in the culture where we don't let people die in the street. So I'm willing to take my courage in hand and face the reality of the current healthcare system. I don't pretend to understand all the implications of the proposed health care reform plans, but I'm clear that things cannot go on as they are. In fact, they won't. I'm thinking that the sooner we face that, the better chance we have of creating reform that might actually make some kind of difference.

Standard Precautions

2009-09-22T21:52:00.000-07:00

If you don't feel like counting, sing the alphabet, that's about the right amount of time for a proper hand wash.

The increase in cases of swine flu (aka H1N1) is making the news regularly this week. Most notably in central Texas where the Dell Children's Hospital has actually had to roll out their emergency triage plan- complete with giant tents!

This scenario, and an employee's potential role in it, is given a quick overview during hospital orientation, and reviewed briefly once a year as part of a "self-taught learning module" that we all must complete to keep our jobs, like a TB test and CPR certification. It has always sounded so fantastical: the tornado and the terrorist, the power outage and the pandemic. All these scenarios have blended together in my imagination to form a dim image of tents in the hospital parking lot, illuminated by flashes of lightning, all conversation carried out in a bellow to override the sound of the generators, while the frightened populace makes a run on the local hardware store for N95 rated masks.

I wasn't really picturing irate mothers bringing in their kids with 101 degree fevers to sit in the sun in a hot parking lot with no other indication of disaster. Just waiting to be told if their kids have flu. It's sort of anti-climactic.

In this blog I am definitely NOT going to weigh in on whether or not you should bring your kid to the hospital, or what you should do if you think you have swine flu, etc. If you're worried I recommend calling your hospital's information line and asking what their recommendation is for being prepared. Believe me- LOTS of people in your community have spent LOTS of time planning to minimize the impact of this on your community.

(However, IF you choose to make a swine flu preparedness kit- like one friend I know who has stocked up on masks, purell, and Nuun electrolyte replacement tablets- have a hospital friend show you the right way to put on the mask.)

One of My Better Moments

2009-09-13T20:49:00.000-07:00

NOTE- this post has some swearing in it. Originally I had a big ol' disclaimer at the beginning but I decided not to worry about it after all.

I had a patient die this week. He was a quadriplegic, had been for years, and his body was finally shutting down. Like many people with quadriplegia he had some arm movement, but not even wrist extension (meaning he couldn't bend his wrists back toward his arms). So, just so you know, that's a high level injury.

This guy was a really difficult patient. Like many of my patients who have lived with limited independence he had developed a personality trait... er... to be blunt, he was an asshole. He was a Vietnam veteran who probably had issues even before his injury, after his injury he had only his voice as a tool to get what he needed. If up in his wheelchair he could, of course, motor around on his own. But he was dependent to get up in his chair at all.

With his limited lung function he'd been fighting a losing battle with pneumonia for several months. The docs brought him to our unit once they thought he was stable enough so he could get back to his prior level and go home. It was evident from day one that this was not the case. For one, his blood pressure was often really low (65/34) - one of the therapists refused to enter his room without knowing his code status. This made it very hard to work with him on account of if you raised his head above his heart he would die. The big indicator though was the edema (swelling/fluid retention) in his legs. It was the dependent/stasis kind (e.g.: not a problem with his lymphatic system). When I called the lymphedema OT in to screen him she explained that it's the kind of swelling you see when someone's body can no longer handle it's own fluids, and they are literally pooling in the lowest part of you.

This kind of pooling is also seen in dead bodies.

When not barely conscious due to low blood pressure this guy was a persnickety, demanding, sarcastic, asshole. There is literally no other way to put it. I get people like this maybe once every 4-5 months. When I first started I watched the other staff break their heads against the wall of this intractibility: getting offended, getting angry, getting flustered, trying to fight back. All to no purpose. And until I figured it out I kept walking in and doing the same thing. Until I figured it out. Talking with other therapists we figured out that there is a strategy for working with these people and this is what I had planned to write about before he died. It goes like this:

Identify that this patient is one of those. The simple method for identification is as follows- walk into their room and start chatting, casually move something insignificant on their tray table (such as a sugar packet) about 1 inch. If the patient stops you, demands that you put the packet back where it was because they had a specific reason for it being there, then makes 5 other tiny detail requests in the same sentence... you have your ID.

Understand, nay accept, that your plan is secondary, tertiary even, to whatever this patient has in mind. When you walk into the room you must be saying in your head "submit, submit, submit. Nothing will happen here that this patient does not want to happen."And by want I mean think up themselves and dictate every step of.

My coworker says working with this kind of patient is like being "fucked in the ass. And you have to like it." I realize this is terribly crude, but it's so completely apt. It's weird, but when you walk in preparing yourself to just bend over, it doesn't feel so bad anymore. And, ironically, this is how the patient establishes rapport with you, so you can almost always get something functional done in the end (no pun intended). I had fun watching nurses and doctors get so frustrated and angry, then pulling them aside and telling them the submit/ass-fuck theory of patient interaction. Their eyes would get huge, then they'd glance furtively from side to side, then they'd say "oh my god, you are soooo right", then they'd look relieved and not mind so much anymore.

Interestingly, he could play the lap steel. He had this custom instrument with custom adapted strap on bar and picks. He could play the blues. One evening at about 5:45, just as I was leaving mind you, I could hear him shouting at the CNA. He was all angry and snarky because no one would get him up to his wheelchair. He had his heart set on getting up to his chair that day but it didn't happen because his blood pressure was so low that he missed all his therapy times on account of being in Trendelenberg all day (bed positioned with head lower than feet). Now he was feeling better and just super pissed that he couldn't get up. He kept saying "I just want to play my guitar, dammit!"

So I did something I never, ever do. I clocked out, then I went back in on my own time. I spent 30 minutes getting him setup in bed with his guitar (I didn't want to get him up because he'd been so unstable all day). You can imagine all the finicky details of positioning the guitar with blanket rolls, getting the angle just right, strapping on his picks properly, then adjusting it all again and again. And again. He played me some simple 5-bar blues, and he was pretty good. I didn't know they had adaptive setups for guitar playing, but I was happy to see it, and he was stoked to show off after weeks of being completely helpless.

He lasted 2 more days before going back to the hospital. He died in the ICU the next day.

I was so glad that I had gotten to the point of not minding this guy. Because once I was fully willing to submit I could suddenly see that he had no power to make me do so. I no longer had any irritation or anger towards him, so in his moment of need I was able to pull out some compassion. In a way his jerkiness pulled me out of my role as a "professional therapist", and it allowed him a chance to be seen on his own terms, as a guitar guy. And you guys, he got to play his guitar one last time. I did that. And I'm proud of it.

The photo is NOT of my patient's guitar, but another adapted lap steel I found on the interwebs. Click on the photo for a link to the forum where it was discussed. Also, here is a link to another adapted musical instrument website:
http://www.disabled-musicians.org/equip.html

Snippet

2009-09-05T10:50:00.000-07:00

Patient with new below knee amputation (BKA):

"My toes hurt that I don't have."

Meritocracy- Part II

2009-08-23T11:28:00.000-07:00

Philosophically:
Sweety pointed out that the big tech companies that use merit-based systems successfully are for profit. Everybody there is there for money. At sweety's job, when they made bonuses commensurate with how much product got sold (good product, that didn't need to be recalled or repaired), everyone really was motivated to work harder. There was a direct correlation between the work and the purpose of the company. Also, the reward was for the whole team. If the team worked together effectively to create more good product to sell, then the team got more profit from the sale of that product.

Contrast that with the new situation at my work. Everyone is individually rated on a scale, there is a finite amount of money in the therapy budget allocated for raises. HR will decide based on your rating, relative to everyone else's, how much of that money goes to you.

There are two glaring problems with this:

Our company is non-profit, and though we all really like getting paid, profit or production is not the reason we come to work each day. Don't get me wrong, I'm not saying we don't like making money, just that "profit" isn't in line with the hospital's goals in the same way that it is for the companies our CEO is using as a model.
The new reward system is competitive vs cooperative. Health care right now is pushing hard to move toward a team approach to everything. Interdisciplinary teams are the buzzword of a good organization. We are encouraged daily through modeling, trainings, and motivational banners to promote teamwork and work together. And the teamwork works REALLY well. The team aspect of my job is easily the most effective and most satisfying, and patients get better care. It's a huge part of why I like the unit I work on, and what motivates me to work harder. The new system is a jarring, discordant note - it's a weight dragging at the progress toward this excellent goal.

Nonviolent Communication:
Okay, these people are a little fruity- and, like lots of people who are passionate about an idea, come off as a little preachy as well. That said, my shrink had me watch a DVD of a seminar by the guy who started this, and there were definitely some ideas that worked for me.

That the common relational strategy of using rewards/punishment to get what we want from people, is coercive and inherently violent. Instead of seeing people as people, it sees them as a means to an end. We dehumanize them, even if only a little tiny bit, and this is a violent mindset. (This idea echoes something Jesus says about the commandment "thou shalt not kill". He points out that hating someone in your heart is qualitatively the same as killing them, inviting us to move beyond simply following rules of conduct to transforming the way we think about others.)
Another idea that I like is that the nonviolent communication mindset is generalizable- it should enhance peace, effectiveness, communication across contexts. I'm a simple creature and I much prefer generalizable tools over a highly varied and complex skill set.

Here is a pretty representative quote from their website:

"This approach to communication emphasizes compassion as the motivation for action rather than fear, guilt, shame, blame, coercion, threat or justification for punishment. In other words, it is about getting what you want for reasons you will not regret later. NVC is NOT about getting people to do what we want. It is about creating a quality of connection that gets everyone’s needs met through compassionate giving."

So grab your grain of salt, and go check 'em out. Here is an article on their website about using NVC at a psychiatric hospital, it made me happy so I'm recommending you start there.

Meritocracy- Part I

2009-08-23T11:25:00.000-07:00

Or: how to turn the economic downturn into an opportunity to torpedo morale.
So my hospital just switched from regular step raises to "merit-based" raises. They've been talking about it for a while, in a vague sort of way, then suddenly went for it. Under the new system both the step raises and the regular cost of living raise are rolled into one raise. Also, the highest increase you can get is less than what we used to get for cost of living. Additionally, the standards have been changed so that most people are not likely to be able to earn a raise in the course of their everyday work (to get "exceeds expectations" in a given category one has to somehow be promoting departmental or interdepartmental improvement in that category). It was presented as an opportunity for people who are motivated and work hard to get rewarded and recognized. This was communicated to us in a single, peppy email.

Also, did I mention that the biggest raise you could get, if you change/improve hospital policy in every category, is still less than the cost of living increase you got last year for just showing up and working hard?

How I used to feel:
The way I was compensated before this change made me feel like the hospital took my job really seriously, and like they expected me to be a grown-up. I've been pretty bought-in to the mission and values of the organization, and more motivated than in any previous job to bring my best self every single day.

How I felt when I first heard about the change:
We all assumed that the change had to do with the economy, and was a way to avoid giving raises without saying that outright. I felt like upper management had just decided that the most rewarding part of my job is money. And like they think we're stupid and we wouldn't notice a crappy deal if they put a positive spin on it. I heard the message: All new increases are based on merit and, by the way, you don't merit crap. I definitely do not feel that I've been "given an opportunity to be recognized".

Most notably, I felt a sudden, sharp decline in my motivation to work hard, and a decrease in my sense of connection to the hospital and its mission and values. I'm pretty sure that wasn't the intended goal of the new policy.

After the explain:
My PT cohort, a proactive and direct sort of human, told our lead therapist that we needed a manager to come explain the policy and the reasons/details to us in person, because morale had tanked as soon as we got the email. There was a lot of grumbling.

One really helpful piece of information was that the decision to switch to merit based raises was made before the economic downturn. The CEO is trying to bring the hospital in line with some of the successful business practices of big companies. Specifically mentioned were some tech companies that give merit-based bonuses and raises. He wants us to operate like those successful businesses.

The decision regarding how much the raise could be was made seperately and is based on the economy and will vary from year to year. Another helpful piece of info was that all management, residents, and non-bargaining employees are having the same change.

Two Firsts

2009-08-12T21:37:00.000-07:00

First student:
I had my first student today. Okay, she's not an OT student doing an internship, she's just doing her OT-program pre-requisite volunteer hours shadowing an OT. It was really fun to have a gopher. It was also fun, in a challenging sort of way, to have a person that I needed to explain things to. What I am doing, why I am doing it, what I am looking for with certain questions and activities. It's cool because it makes me think very specifically about my specific goals for a specific session, as well as my overall rehab plan for a specific patient. I always do this anyway, but it's usually half sub-conscious. It felt good to do it out loud, like a little refresher course in "best practice".
(Okay, so no prizes for unexcessive use of the word specific in the preceding paragraph.)

First time I've been surprised into embarassment:
This awesome old guy is having his anniversary today, at rehab. He has Parkinson's, complicated by a broken hip from a recent fall. His super-groovy wife is around a lot and helps with all his care. She's preparing to take him home, no matter what. They brought us, like, 3 cakes from the local swanky bakery to celebrate their anniversary.

Anyway, my patient recently had his catheter pulled. Like often happens after having a catheter, he has to 1) relearn how to control the sphincter at the end of his urethra, 2) get his bladder to reaccustom to being full, so he can hold his urine a bit instead of peeing the second he gets the urge.

Anyway, he peed himself. I came in for therapy right in time for cleanup, student in tow. We worked on strategies for taking off the pants (weight shift, forward lean, etc). Then I gave him a wet washcloth to clean up. He starts in with the washcloth then, after a moment or two, stops and laughs, turns to his wife and says: Hey honey, wanna give me a hand here!? It is our anniversary after all.

These Truths Can Coexist

2009-08-10T23:12:00.000-07:00

FYI:

The therapists at your loved one's rehab facility can sincerely care about their patients. They can be prepared to advocate aggressively on your loved one's behalf. They could be taking copious notes about every detail of every treatment. They might pore over the chart, drinking in each med and status change. They are probably prepared to give you lots of time to talk about all your concerns, observations, fears, and frustrations.

Also, they might REALLY like you to not follow them around the cafeteria on their lunch break reiterating all of the above.

Seriously, don't do that. We have rules about professional behavior, and we have patient satisfaction goals. I even have personal, up-with-people, ethics. All of which preclude me from saying what I'm thinking, which is that you should f-ing leave me alone during my lunch break.

Seriously.

Dumbledore's Hand

2009-07-26T14:27:00.000-07:00

It is hard for me to imagine going on living in a world where this is true-

In the 6th Harry Potter book something strange has happened to Dumbledore. In attempting to destroy a cursed ring containing a fragment of Lord Voldemort's soul, he sustains a bizarre injury to his right hand. Here are some of the ways it is described in the book:

"... his hand was blackened and shrivelled, it looked as though the flesh had been burned away."
"... he shook his sleeve away to reveal the tips of those burned and blackened fingers."
"... Dumbledore's right hand was as blackened and dead-looking as it had been on the night he had come to fetch Harry from the Dursley's."

It turns out there is a real thing like this. It happens when there is an injury to an extremity- usually a finger or toe- in such a way that the blood supply is cut off and the body part dies.

Often what happens is that then it starts to rot, this is called gangrene, and if it is not taken off the rotting tissue will cause a systemic, very deadly infection- sepsis.

Occasionally the dead body part will not rot, it will just sort of ... ummm... shrivel up, dessicate. It pretty much looks exactly like a a body part that came off one of those Andes mummies. This is called "dry gangrene" and, you guys, I am not going to post an image of it.

I have a patient right now with a finger like this. The last third of her ring finger is just ... well it's just a shriveled mummy finger. She injured it a few months ago and it has been shrivelling ever since. It is black, and it is now the size and shape of the bone and knuckle underneath. Where it joins to the living part of her finger the skin is sort of pulling back and away in layers.

My patient says it doesn't hurt. "I kind of like to absent-mindedly drum with it", she says casually. "It makes a nice tapping noise." And, indeed, if you look closely at her fingertip you can see the blackened and smoothly polished end of her finger bone glinting, visible through the hole she's worn in the skin.

One wonders (if one is like me) why she hasn't had it removed. Answer: "it's not causing a problem, it's a closed wound. The doctor said cutting it off would create an open wound and since I don't heal well (she really doesn't), it was better to leave it unless it became a problem..."

Up to this point I've been keeping my cool, trying not to look at it but unable to keep from staring furtively. Y'know, casual and matter of fact on the outside, horror and rising bile on the inside.

Then she finishes her sentence. She says the final phrase casually and my brain processes it too quickly for me to attempt any sort of protective maneuver. I don't even hear the words themselves. Instead, borne in upon me is the kind of feeling you have when you are just waking up from a nightmare, when the unformed shadows of wraithlike horrors stray, for an instant, from dreamland to briefly populate your moonlit bedroom.

"...or it might just break off on its own."

Neuro Rounds July 21

2009-07-21T22:22:00.000-07:00

This week's diagnoses:
1) Entertaining IT guy- weakness, tingling on one side for the last 2 years, then sudden loss of all sensation below the neck. Answer: cavernous malformation. In the spinal cord. Surgery relieved most of it. And the guy appears to move fairly normally. Best line: "I don't have legs, I have logs. I can't feel anything below my waist."

2) Very well spoken 30-something with (most likely) Lyme disease. Told a great and entertaining story. Bullseye rashes, muscle weakness, neck stiffness (meningitis), Bell's Palsy. He researched online and kept track of his symptoms. Didn't come in until he stopped getting better 4 weeks into it. Best line: "I was keeping a score card between spider bite and tick bite. I really don't think it was a tick. I'm pretty sure it was a spider with a twist of lyme."

Success? A Discharge Plan in Two Parts

2009-07-15T07:55:00.000-07:00

The patient: A few months ago I had a patient. Obesity, diabetes, and high blood pressure had taken their usual toll, and she had been just barely getting by in her tiny senior apartment.

The obesity caused aching joints and fatigue, so her mobility had become increasingly limited. Her sleep had been poor thanks to the extra weight that makes it difficult to breathe fully when lying down. The diabetes, poorly controlled, had led to poor circulation and neuropathies in her feet and legs, meaning she had very little feeling down below her ankles.

You can imagine: poor balance and bad falls, cuts and scrapes that go unnoticed and untended, etc. The long and short of it is that the combination of these factors led to two massive heel pressure wounds. One on each foot. She didn't notice because they didn't hurt. Truthfully, her heels were falling off. Especially the left one. Folks, it was gross.

So, her sister drags her to the ER, she gets admitted and seen by the wound care specialist. They decide: 1) admit her to rehab to try and get diabetes and blood pressure under control (this will help healing), 2) Apply fancy dressings and regular cleanings for a week and then decide whether she needs surgical debridement (yes, in the end, she did), 3) NO WEIGHT BEARING ON HER HEELS, FOR 2 MONTHS.

My part: Okay, I'm going to give the short version. She wanted to go home, not to a skilled nursing facility (SNF). Our original plan had been for skilled nursing because she lives alone and can't get around on her tiptoes because, not to put too fine a point on it, she weighs 400 pounds. Also, she can't feel her feet well enough to know if she is actually staying off her heels. However, she was adamant. No SNF.

So we thought up a plan: Bariatric (medi-speak for obese) hospital bed, bariatric drop arm commode at the same height as the bed, setup of the home with computer, tv, food, water all accessible from the bed. Then hire help for 1-2 hours in the morning for wound care, light cleaning, help with toileting. Then, train her to do safe scoot transfers from the bed to the commode. Then recommend home care until her wounds healed. That's it. We did pretty good.

But then, the local home nurses association (HNA) said that they absolutely refused to take her on as a patient. "She belongs in a SNF" they said, "she needs way more help than 2 hours a day" they said. They were surprisingly pissy about it. So we went back to the drawing board, we enlisted the sister to be a caregiver 5 hours a day, we got her in and trained her to do everything from butt wiping to wound care, we argued, we got Doctor Smith to call the head of HNA and insist that they follow through on the doctor's orders. In the end, they did, gracelessly. It was clear from their eval note that they were looking for problems and they planned to have her taken to the ER at the first sign of anything off. They wanted her to fail.

So 3 weeks later, when she still hadn't turned up at the hospital again, I naturally assumed that all our efforts had paid off.

The rest of the story: So just last week I was talking to one of the lovely charge nurses. She is an evening shift nurse and I was telling her about some current patient whose discharge plan I am worried about. She responded "yeah, we don't want another one like 'X'" referring to my no-heels patient. I was stunned and asked her what on earth she was talking about. This is what she told me.

6 hours after arriving home "X" calls the rehab unit complaining that her catheter isn't draining and she is having pain and cramping in her abdomen. This charge nurse answers and gives "X" instructions to feel along the tube until she finds the kink, then unkink.

"X" calls back 10 minutes later, couldn't find a kink. Charge nurse says to call her sister, the one we all trained to be an excellent caregiver (guys, we worked REALLY hard at this). "X" sounds dubious but agrees to try this.

10 minutes later she calls back saying her sister isn't coming and she's just going to call the ambulance and go to the ER. The nurse says to wait a few minutes, hangs up, and calls the doctor (at home because it's now 9 o'clock at night)

Nurse: Dr. Smith! We can't have our discharge go to the ER, THE SAME DAY, because of a kinked catheter.
Dr. Smith: Oh shit, fucking shit... [more swearing].
Nurse: You know what, I'm just going to go over to her house and see what's going on.
Dr. Smith: yeah, go do that, please.

So she goes. She finds "X" in a sweltering hot room, windows closed, drenched in sweat. She explains how you might not have anything to pee if you're sweating everything out. She opens windows. Around the time she arrives the sister also shows up. 3 sheets to the wind. She drove across town to help out, stumbled in and sat down to watch our charge nurse fix things up. So our nurse gets water, she gets a cool washcloth, she checks the catheter. Everything's working out... so she thinks.

But then, as the nurse about to leave "X" says (are you ready for it?): "oh hey, since you're here, could you help me with this bedpan? I've been on it since I got home." That means 7+ hours guys, lying on a bedpan, that her sister had apparently put under her and then left. For the night. (This raises so many questions for me I just don't know where to start... what were they thinking? why didn't "X" remove it herself- which, incidentally, she could have done? wha.. whe... I.. uh...)

"X" rolls onto her side and, to the nurse's consternation, the bedpan goes with her. She goes to remove it but can't. Because in the last 7 hours gravity and liquid (squeamish people should stop reading now) have successfully suctioned it to "X's" butt.

"Ot-girl, I could not get it off" she says, pantomiming prying at something with a foot and both hands. In the end she resourcefully dug out a metal spatula from the kitchen and used it break the seal. She said it went off with a shot-like report. And a spray of poo instantly decorated "X" and her bed. The sister watched impassively.

At this point our nurse sort of lost it. Thrusting the steaming full bedpan at the sister she starts reading them the riot act about getting their act together. She talks about how everyone has gone out on a limb to get "X" home because this is what she wanted, she talks about our hard work. And she talks about their hard work. She finishes by reminding them that HNA will be out there the next day looking for an excuse to fail "X" at home and send her to a SNF. Then she makes the (drunken) sister empty the bedpan and clean everything up.

She gets back to work at 11pm.

As I'm listening to the story I'm thinking: "Oh my God, HNA was right. How could I have been so wrong? This chick should NEVER have gone home!" I'm horrified.

On the other hand, she's still at home, 5 weeks later.

So actually, I have no idea what lessons to draw from this adventure.

I'm Just Gonna Say It

2009-07-10T22:52:00.000-07:00

OT Rocks.

So today I had my weekly meal prep and lunch group. I do it with a speech therapist and we use this great functional, normal activity to work on both OT and ST goals.

Some Objectives:

- get patients out of their rooms
- get patients talking to other patients
- increase endurance for seated activity (it's a LONG group)
- problem solving for multi-step activities
- problem solving how to do familiar activities given your new physical/cognitive limitations
- one-handed techniques for opening jars, chopping vegetables, etc.
- attention to complex tasks
- social interaction
- more complex food trials for people with swallow deficits

We always make a simple meal- either personal pizzas or sandwiches, and fruit salad- because these are the kinds of meals people might actually make at home. Time and time again we see people who fatigue easily suddenly able to tolerate 2 hours of seated activity without complaint, we see people who have been depressed or unmotivated brighten and begin participating, we see patients discussing the ups and downs of their illness and rehab- offering comfort and support to other patients.

Since many of our patients have dysphagia, everyone on this unit has their swallow evaluated by a speech therapist. Often someone with a neurological deficit will be unable to manage the full gamut of food textures and are at risk for choking or aspirating their food. To prevent this the speech therapist tries them on a sequence of difficult to easy textures and liquid densities, and determines which diet is appropriate for them. They post signs and everything because it is ABSOLUTELY ESSENTIAL that no one vary from this diet unless the patient has been upgraded to another level by speech. Nobody likes a dysphagia diet.

When we first started this group we used to make sure that any swallow-restricted patients had their regular lunch brought in because our meal is usually too high a level. Until we realized that for some reason patients who participate in this group meal preparation activity will suddenly be able to manage a more regular diet. Now if the ST has someone they want to try and upgrade they make sure to schedule them for this group. Meaningful occupations wins again!

But I digress. I was short on patients to bring this week, so I decided shove my Wake-O-Lepsy gal into a wheelchair and drag her down there to hang out while the rest of us got busy. I knew she needed to eat, and the nurses were short so I thought at worst we could help out by feeding her (she hasn't been eating for herself). At best I thought we might get one of her 10 minute alertness windows and if that happened she might like to see some other people.

She slept through the transfer (LIKO lift), she slept through being wheeled down to the kitchen. But the moment she was at the table and I was doing introductions she woke up, opened one eye, and started talking. Yeah, okay- so she sounded a bit drunk and she needed lots of help figuring out what was going on. But, I'm not kidding, she peeled and sliced bananas, passed items to other patients, answered questions, and ate her own sandwich without any help. She even tuned in long enough to ask us "What is this place? Where are we?"

This lady has been asleep for 2 weeks, with no more than 10 minutes at a time of wakefulness. With our social interaction and meaningful, familiar activity, she stayed up and active for 90 minutes. She only started dropping off again when the other patients left to go back to their rooms.

So I put in my note that this lady needs to be up and participating in every group we offer, clearly that is the level of stimulus that she needs. Her kids say she is a social person so this makes sense. However, the frustrating bit is that Insurance does not consider groups to be the same level of therapy as individual treatments. So we can only sign patients up for groups if they also have enough time to get their three hours of 1 on 1 time. On a certain level, I see the Insurance's point, but I would love a little freedom to use my clinical judgement, to say: screw 1:1 treats, this patient sleeps through 'em, if you really want her to get better get her up and in a room with other people, as much as possible. Her nurse happened to come check her out in group and we decided that she needed to be up and parked in front of the nursing station, with all the chatter and bustle, for as much of the day as she can tolerate. We'll see what happens.

Like I said. OT Rocks.

Wake-O-Lepsy

2009-07-07T20:19:00.001-07:00

My new patient had a stroke.

Now, I know what you're thinking: "but OT-girl, don't most of your patients have strokes?"

And my answer is: yes, of course they do. And I've seen a bunch. I've seen almost everything that Oliver Sachs writes about in "The Man Who Mistook His Wife for a Hat".

I've seen the stroke standards:

hemiplegia (half your body is some degree of paralyzed)
hemianopsia (one half of your visual field is cut)
hemi-neglect (you've forgotten that there is such a thing as one side of your body- say the left side)
I've seen people shave only half their face, and not be able to look left even when they're running into something repeatedly on the left side.
Impaired midline orientation (when you can't figure out where the middle of your body is, so you keep falling over)
Aphasia (speech and language deficits)

I've seen the more unique stroke presentations:

anosognosia ("there's nothing wrong with me, why do I keep falling over?")
apraxia (impaired motor planning- this can be ideational, e.g.: using a comb as a toothbrush, or just mean that you can't figure out how to get your toothbrush into your mouth)
impaired spatial awareness
cortical blindness (your eyes work fine, but your visual cortex can't interpret anything they send it- so automatic things work fine, you won't run into stuff in the hallway but as soon as you have to think about it you have no idea what you're seeing)
ataxia (you can't smooth out your movements- usually results from a cerebellar lesion)

I've seen the guys who don't know that their leg or arm belongs to them and folks who can't turn left and learn to compensate by making full right circles every time they need to go left. I've seen many people try repeatedly to pull their pants up, unable to figure out that the reason their pants are suddenly too small to button is because they've got their stroke arm shoved into their underwear.

Most of these symptoms are a result of strokes that occur at some place in your cerebral cortex, which is the outer layer of your brain. They affect some combination of sensation and motor (right side of the brain affects left side of the body- the fancy word is: contralateral), if it's on the left you may have some speech deficits as well. The cortical blindness guy had a stroke in occipital lobe (back of his head) which is where your visual cortex is (incidentally, this is why "shaken baby syndrome" often presents with visual deficits. The brain smashes into the back of the skull repeatedly and the visual cortex is damaged).

The cerebellar stroke is a little less common, and results in some combination of jerky movements (ataxia), chronic dizziness, and nausea. Because it's in your cerebellum the effects are on the same side of your body as the stroke (the fancy word is: ipsilateral).

Anyway- My new patient had a stroke. Not in her cerebral cortex. Not in her cerebellum. Not even in her occipital lobes. It was in her brainstem and thalamus. She has no hemiparesis, no hemineglect, no apraxia, no ataxia, no aphasia. If you can get her to move and respond, she has no noticeable deficits whatsoever. She just can't wake up. See, the thalamus and brainstem mediate arousal. They tell you when to be awake, and hers isn't working. So she doesn't wake up. Much. Or often.

When I first evaluated her she would half answer any question- eyes closed, and half-attempt any instruction given (e.g.: raise your right hand). She mumbled answers to yes/no questions, she even allowed me to drag her to sitting at the edge of bed to be fed some lunch. Which she ate. Without ever waking up or opening her eyes.

This is arguably more trippy than anything I've ever seen. The part of me that's seen all these other strokes is like "she's fine, she just needs to wake up". Then the other part of me is all "yeah, but she doesn't wake up, because her stroke was in the 'wake up' part of her brain".

To make things more trippy in the last couple of days she has started having periods of awakness in which she just sits up and does stuff: carries on a conversation, feeds herself, etc. They last less than 10 minutes, then she drops back asleep like it never happened. It's like reverse Narcolepsy.

Dude. It's so trippy.

A Lake of Poo

2009-07-04T19:45:00.000-07:00

He's 92. It took me and my PT co-treating therapist 45 minutes to clean him up.

Happy Independence Day to me.

A First

2009-07-03T09:35:00.000-07:00

I got to make my first APS referral today. My patient is a friendly, fairly healthy, old guy who had a mild stroke.

Now, let me just say, it is not uncommon for caregivers to be strange. AND it is not uncommon for people to have very weird relationships worked out to make their life work (I mean, who doesn't?). Generally speaking, I don't expect to change anyone or "fix" their personal life and dysfunction. I just use my background in special ed and mental health to try and work within the limitations of all the parties involved. My successes vary.

But if I take you for a home eval at your retirement apartment, and you can't get your mail because the people at the front desk say your caregiver has your keys, that's a tiny red flag and I'm going to start to wonder. Also, if when we get into your apartment, you say "oh great, she's got the credit cards out again, and she's been using the computer." Well, that's more like a shot across the bow than a red flag. If, in the course of probing conversation, you then say that A) she's been using your credit cards for a while, so what's the point of starting to argue about it now, and B) she's the only one who cares about you so you guess you have to put up with whatever "strange things" she does. Well, this is something I can't really ignore.

So I got to call Adult Protective Services. Yay.

New Learning

2009-06-25T20:14:00.000-07:00

One interesting patient

I wrote about this one last week, the new quad with advocating family member. This is only my fourth spinal cord injury patient, so I was surprised when I realized that I had a really good handle on where to start with this person. Don't get me wrong, I'm definitely struggling to make sure I cover everything that needs covering. But for the first time I was totally confident about where to start. And, maybe more to the point, when to bring in some of the other OTs with more experience.

Quadriplegic does not necessarily mean that you can't move your arms or legs at all, like Christopher Reeve. In fact, the most common spinal cord injury is at cervical vertebra 5-6 (C5-6). Above the lesion (injured part of spinal cord) are the nerves that innervate some or all of the muscles that move your shoulder, bend and straighten your elbow, and bend your wrist back. Below the lesion are the nerves that innervate your hand and fingers, that bend your wrist down, and... well... everything else. Many people with spinal cord injuries can feel some part of their affected limbs and often have spasticity (muscle tone) in their legs which can sometimes be utilized to help with mobility. Of course, at times this spasticity is a real detriment, inhibiting positioning and even causing pain.

My patient has a classic quadriplegic right arm (lots of arm movement, no hand movement), a much weaker left arm, and some useful spasticity in the left leg.

Goals for the first few weeks:

1. Get the bowel regulated by setting a bowel routine: suppository at 8am, breakfast at 8:30, mechanical lift to be hoisted over the bedpan (or onto a commode) at 9am. Sometimes a person with a spinal cord injury has a spastic bowel, meaning that it doesn't empty unless stimulated. In this case a person will need digital stimulation (dig stim) to cause the peristaltic reflex in the intestines to begin moving stool out of the bowel. This involves inserting a (gloved and lubricated) finger about 1 inch into colon and moving it in a circular motion around the wall of the colon. Fortunately, this falls under the category of Things That Are Not In My Scope of Practice. So I get it all setup, do the grunt work as it were, and call a nurse for the dig stim. As an OT I focus on best setup- lift to a commode? lift to hang suspended over the bedpan on the bed? Can the patient insert own suppository? I also focus on getting the routine totally set so that the patient can learn to direct their routine. Once they can do this, we pass the baton on to nursing and move on to goal two.

Click on the image for a link to spinal cord injury (SCI) bowel routine info site

This is a LIKO lift. We use it to transfer people from one place to another. This picture makes it look easy. Do not be fooled.

2. Increasing the strength of the arm muscles still innervated so that my patient can eventually feed himself. Some of this is done through functional activity, some with resistive exercises, some by setting up this fabulous arm support on a spring that provides some resistance against gravity.

It's such a small thing, but the combined look of relief, pride, and smug achievement on this person's face the first time he fed himself lunch was totally priceless.

mobile arm support attached to wheelchair to facilitate self-feeding

Redemption

2009-06-17T20:32:00.000-07:00

Today I had an opportunity to advocate for a patient in the face of strong cultural impetus to keep quiet.

I took it.

The cultural cues to do otherwise came both in the form of general societal cues governing confrontation and power dynamic, and the doctor-on-down hierarchical cues specific to the hospital setting (I've talked about these a little in the culture of safety posts).

The situation was a family conference of some importance to one of my patients. He has a new, permanent, life-altering disability and has been waiting anxiously for his aunt to arrive from out of state so that she can help advocate and take on responsibility for his care. We do conferences with each patient every week, but the aunt had just arrived and this was our first conference with her present.

The aunt was ready with questions, a little anxious, and quite insistent. She was the type of family-member turned patient-advocate that come across as suspicious and demanding. I'd say about 25% of our patients have family like this. This can be annoying but is not necessarily bad or good. It's just useful to be aware that this person is likely to bring up some irritation in me, then I can be mindful of my reaction and look for ways to bring the person onto the patient care bandwagon instead of falling into the trap of being at odds with them.

Doctor Black was on today, and confessed he was in a foul mood. It was obvious he wanted to just get in and out of the conferences, as quickly as possible, without any hassles or difficulties. I totally understand, sometimes work is draining.

In the conference Strident Patient Relative started trying to ask questions in that slightly irritable-and-pointed-but-indirect way. I'm sure you've heard this kind of thing, maybe from your mother, or some smarty-pants TA back at college. Then Irritable Doctor Black started trying to answer the questions in the same oblique style. Not actually communicating anything and, unfortunately, conveying a sort of shining-on attitude toward patient and relative.

So I took a deep (mental) breath, put on my most innocent and conciliatory face, and started to interpret. "Oh Strident Patient Relative", I said "it sounds like you're wanting to know... (insert clear rephrasing of oblique questions here), is that correct?" and "Dr. Black, I understood you to be explaining ...." Strident Patient Advocate looked relieved and tried again. Dr. Black shot me a look that would strip paint. And also tried again.

They failed. We went through the whole thing again. I ignored the doctors-run-the-show rule. I ignored the clear social cues that Dr. Black was trying to leave the room. I ignored my own pathological need to keep everybody happy and make them hold hands and be friends (this is my issue). This time, when the social worker started answering a question, Dr. Black looked right at me with lips pursed and wide, angry eyes. "Stop. Now." He told me under cover of the other conversation. I looked back and smiled innocently. "Maybe" I said.

They both tried again. And this time they did better. It took a long time, and it wasn't all pleasant. But honest questions got asked and clear answers given. As soon as we were done I snuck off to chart in the therapy office instead of at the nurse's station. I think I'll stay out of Dr. Black's way for the rest of the day...

An Interesting Lady

2009-06-14T13:38:00.000-07:00

Last week I had a patient in her mid-90's, though she didn't look a day over 82. Which, at 95, is saying something. She was remarkably healthy and strong, and was totally cognitively intact as well. She had a straight back, no arthritis, and could still put her shoes on by bringing her foot up to the surface she was sitting on. Her sparkling good health was unusual for her age, and very unusual for the demographic I usually see at rehab. I mean, she didn't even have hearing aids.

She was there because she'd had a stroke. A very mild one, whose effects were already resolving. By the time I evaluated her she was nearing her prior level of function (PLOF, from an insurance perspective this is what we are aiming for, to return people to PLOF, we can't set goals that someone be more independent than they were prior to their hospitalization). Indeed, her only limitation was a general decrease in energy level, resulting in her being too easily fatigued to successfully run her own home. So her daughter had recently placed her in a local group home for seniors. This is the conversation we had:

Me: Man! You've got to be the healthiest patient I've ever had. What did you do to keep yourself so strong and sharp?

Patient: (drily) I'm not sure, but it wasn't worth it.

Me: Really?

Patient: Really. There should be a pill you can take when you turn 85 so you can just die in your sleep.

Me: (Awkardly) Ummm... so you're kind of tired of day to day life then?

Patient: You could say that.

At this point I start asking some probing questions about her daily life. She's obviously a little, perhaps not unreasonably, depressed. But I want to make sure that she is being adequately cared for at her group home. I am a mandated reporter after all. I also, as an OT, wonder if there are any resources I can introduce her to (community resources, hospital sponsored exercise or support group, maybe even transportation options) that would give her more to occupy her time. She tells me that the home is clean, the staff kind and efficient. They help her with bathing and any other small needs she may have. Her daughter takes her out every Saturday, and visits one other night during the week so they can have dinner together. "But there isn't really anyone to talk to" she says. "The other residents have dementia and can't really carry on a conversation." In response to my question about the staff she states that they are all Phillipino, English second language, and engage only in perfunctory and pragmatic conversations with the residents, while carrying on lengthy and rapid conversations in Tagalog with each other.

Me: Geez. It sounds like you'd have good reason to be lonely and, ah... a little bored, perhaps?

Patient: I am definitely a little bored, and maybe lonely.

Me: (half joking) me, I'd probably be trying to learn Tagalog just so I would have someone to talk to!

Patient: (with a sheepish grin)... well, I did get the "Teach Yourself Tagalog" tapes from the library

This lady? Seriously, one of my new heroes. However, in the end she declined offers to help her get setup with the local handicapped bus service, declined information on local community classes and group activities (it costs too much, I don't wan't to bother my daughter, etc). She left after about 5 days, back to her boring life. Too soon, really. I had hoped to meet the daughter and have some of that same conversation with her present. I had hoped the daughter could assuage some of her mother's concerns about being a burden. But the opportunity never materialized.

She reminds me a little bit of another patient I had in her late 80's. This one had so many things going wrong with her body, 2 strokes, kidney failure, diabetes and subsequent neuropathy, she was going down bit by bit. In her late 70's she had a pacemaker put in. She told me, quite frankly, that this had turned out to be a terrible idea. "I should've died 4 times already since then!" she told me. I had never thought about possible downsides to pacemakers before...

A Disheartening Compliment

2009-06-13T09:12:00.000-07:00

High census- Right now our census is really high. I'm now following the rehab progress of 10 patients. That's 10 weekly summaries, 10 equipment orders, 10 home evaluations, 10 sets of caregivers that need to be trained, 10 people to report on in rounds, and 10 families to educate and console. It's 1000 questions for nurses and doctors, and in infinite number of details to coordinate with other staff. And that's just MY team.

Normally my brain starts to overload at about 5 patients, and I can keep it together with about 7. But 10 is too many. Obviously I can't see all these people every day, so we have per diems and other float therapists come fill in. The floats generally won't do weekly summaries, and they can't schedule home evals or do equipment orders. So I still have to keep on top of all those details.

Scheduling- About half my patients at any given time have cognitive deficits or complicated neurological deficits such that their rehab course is improved if they have a consistent therapist. Others have simpler needs that can easily be met by different floats every day. To coordinate all this involves the Insanely Byzantine Scheduling Binder and Phone Message System. In the binder's different compartments you write down each patient's needs. One compartment for primary therapist, if they need consistency, how much speech therapy, which groups, when they poop every day, ad infinitem. Another compartment for specific scheduling needs for a particular day- family training, home eval, early or extra long treatments, if you need a long lunch or are leaving early, the possiblities are endless. Because there are so many details that need to be considered for scheduling many of them get ignored/missed by the scheduler. So if you really care about your specific scheduling need you have to call the scheduling line and leave a message repeating it clearly, and it doesn't hurt if you sound a bit threatening or reproachful either.

That's scheduling from the therapists' perspectives. From the scheduler's perspective you also have to find out the wildly varying availability of the therapists (who's coming in when, who likes a long lunch, which people you can pull from different units if you need more staff, and the intricate and mystifying lacework of the speech therapists' schedules), you also have to check with nursing to find out if anyone has any tests scheduled, the intake coordinator to see if there will be new patients for evaluation, and the discharge coordinator to find out if anyone will be leaving. I do not enjoy doing the schedule. It uses the same part of my brain as trigonometry.

Double Whammy- When the scheduler goes on vacation during a high census time and I'm the only one available to do it. Under normal circumstanstances, 10-12 patients, it takes me about 3 hours to do the schedule. With 20 patients and 3 extra therapists... when am I supposed to see my patients? Coordinate their discharges? Eat lunch?

So imagine my dismay when the lead therapist on our unit complimented me on my excellent scheduling skills. Apparently my schedule had no double-booked therapists or patients, no one scheduled for overtime, and no lunches or breaks missed. Unfortunately, this is unusual. "You're the best fill-in scheduler so far!" she said. She told me I'm going to have to royally screw up the next one if I don't want to get stuck doing with it every time the regular scheduler is on vacation.

Culture of Safety? The Joke's On Me

2009-06-01T23:02:00.000-07:00

So, as I stated before, I've been trying to go to neuro rounds regularly. Neuro rounds is great because I learn lots of interesting things related to my current field of practice. Also, it counts for CEUs, or Continuing Education Units, which I need to keep my license current.

Last week they presented on this old lady who had some interesting neurological deficits (duh). She also had some dementia. The nurses rolled her in on a gurney, raised to about waist high, with guard rails up and the head raised so she was sort of half sitting. Then they left her, covered in a sheet, in front of a room full of lab-coated strangers.

Immediately the doctors plunged into their discussion of reflexes, neurological disorders, and strength measurements. The patient occasionally was called upon to answer a question, or to stare blankly while the sheet was pulled back for an impromptu test of reflexes or examination of foot drop (when, for neurological reasons, you are unable to pull your toe back toward your shin). You could see that because of her pre-existing dementia the lady was not quite clear on what was going on, she was clutching her sheet nervously and glancing vacantly around the room. It was a little awkward, and I felt a little bad for her as the doctors were sort of treating her in a very detached way.

Then it got worse. The lights went down, the projector came on, and the radiology tech (he comes to every neuro conference so he can interprete CT scans, MRIs, etc) started going through the woman's MRI, showing her brain to us and describing the "obvious wasting" and other deficits. The doctors then started discussing this in the most dry and exagerated way, all "well no wonder she has dementia with cerebral wasting like that" and "honestly doctor, why even bring her down here? In a case like this you don't really think there's any hope, do you?" With the lady sitting there clutching her sheet and looking anxiously and dementedly around the room. I was horrified and so were the other therapists sitting by me. But what could we do?

THEN they were done with her and ready for the next case. They called up to nursing to come and get the lady. Then, I'm not kidding, they pushed her into a corner at the front of the room. And left her there. For 25 minutes she sat there, perched above the seated crowd and craning over her shoulder at us, trying to hear what was going on and looking more and more pathetic and confused by the moment. In that moment, there was no culture of safety, no patient care. That patient was not a human, and the whole group of doctors was acting out the very worst of the doctor stereotype. They were demonstrating exactly the culture which prompted the JCAHO regulations for creating a Culture Of Safety in health organizations.

But here's the thing, I was there too. And I didn't do anything either. I wanted to, I felt ethically called to by my professional and personal code of ethics. Yet I didn't. Don't get me wrong, I didn't feel the need to interrrupt proceedings and call out the whole room full of doctors. But I did feel that I should be sitting next to the lady and holding her hand, or offering her water and calmly re-orienting her to what was going on.

But since she was up at the front of the room I couldn't do it without everybody seeing me. I couldn't have done it unobtrusively. I didn't want my actions to seem pointed. I didn't want to draw attention to myself by violating the custom of the moment.

In the words of T.S. Eliot: In short, I was afraid.

So I sat there, unable to listen to the next case, anxiously wishing I had the balls to go provide compassionate patient care to a scared and helpless octogenarian. I wondered how many other people in the room were thinking the same thing, lacking the same guts to violate the tacit code of behavior. I wondered if people would be relieved if I did go up there. I tried to talk myself into it, but in the end I chickened out. All that shock at Grand Rounds, and laughing at the doctors for their poor social skills and poor bedside manner. All that snooty speculating about medical school and residencies creating a culture of arrogance and lack of compassion or respect for others. But when the moment came I just got in line. Against my better judgement and fully aware of what I was doing, I signed up to be part of the problem.

The joke's on me.

Culture of Safety? Epilogue

2009-04-24T22:02:00.001-07:00

This post is the third in a 3 part series

Appreciation: I talked to many therapists and nurses after my day at Grand Rounds, and I heard many stories corroborating this aspect of doctor behavior. One from a therapist who was told by a doctor to get out of the chair he had been sitting in (not marked, no charts or papers around, not logged into the computer), he said "I didn't go to medical school for 12 years to be kicked out of my chair by a therapist".

As a result of these conversations I have realized three things: 1) The 3 doctors that I work with are not like this. This stuff sounds appallingly foreign to me because it is. In the year and a half that I've been working I have had maybe 3 interactions with docs where I felt even slightly condescended to or belittled, and each time I have felt totally comfortable calling the doc on it, with no adverse consequences or fear of retaliation. These docs really do try for a team approach (which is the new direction of healthcare) and, while I still find their social skills lacking, they apparently do a pretty good job. 2) I may be in for a rude awakening when I eventually move on to another setting. 3) The cultural standards are changing, and my oblivion to the old way combined with my overall respectful and friendly attitude could contribute to this change.

The Problem With Knowledge: Sitting at that table in Grand Rounds I found myself wishing that I hadn't been told about the "physician's favorite table". As long as I didn't know, I was oblivious to the situation, and their disapproval crashed against me like waves against granite and I was unmoved. Once I knew, then my staying there was a self-conscious statement of sorts. Like I was taking a stand against something instead of just being myself. I felt like Eve after eating from the tree of knowledge of Good and Evil. Suddenly, I cast my eye back over my last 2 vists to neuro rounds, when the two docs I work with wouldn't acknowledge me. I thought it was a fluke, like they were distracted. Now I suspect it was a part of that dumb culture, they won't say hi to me in front of their doctor friends. I'm not asking for a conversation, just the most minimal socially appropriate acknowledgement of someone you know- an eyebrow lift, or the two finger wave.

What I Wonder:
1) Do the doctors have a special table because they feel like awkward, geeky, junior highers and they need somewhere to sit so they don't feel like dorks standing around looking for a place with their lunch tray (flashback, anyone?)?
2) Do I take the cue and pretend I don't see my docs at neuro rounds? Or do I just keep making the basic gesture of recognition and see what happens? Can I do that without being pointed?

Culture of Safety? The Conclusion

2009-04-24T17:38:00.000-07:00

This post is the second in a 3 part series

So last Friday I went to Grand Rounds.

Presenting: Dr. Black, the Chief Medical Officer of the hospital, a psychiatrist.
Topic: Culture of Safety: Managing Disruptive Behavior.

I went to get perspectives on managing difficult patients, hearing any new hospital policies about managing difficult patients, and gathering some tips to bring back to my team over at rehab.

I walked in, got my lunch, picked up a copy of the powerpoint for the presentation, and sat down at a mostly empty table near the back. I picked this table because the doctor sitting at it smiled at me briefly.

My first clue comes as I'm waiting for Dr. Black to start, killing time by eating my lunch and browsing the handout. The first page is all anecdotes about bad doctor behavior. With a sense of foreboding I look at the next page which turns out to be all statistics about disruptive physician behavior. Turns out the presentation is about disruptive doctors. Hmmm...

Anecdotes include stories of drunk surgeons refusing to check operation sites prior to the procedure (this is STANDARD protocol for any surgery), doctors screaming at nurses or patients, and examples of physicians throwing things at people. Statistics include such notable numbers as "23% of nurses experience a physical threat during their career" and "49% of hospital workers feel pressured to do something they believe is not safe or appropriate for their patient". Apparently this has become such a problem that JCAHO (Joint Commission for the Accreditation of Healthcare Organizations) now requires a hospital policy to deal with this from any hospital seeking accreditation (incidentally, Medicare will not pay for any unaccredited hospital expenses, so accreditation is a big deal). At the end of the handout is a copy of the hospital's new policy and procedure on this topic.

By the time Dr. Black begins, two of my therapist co-workers have joined me, but the rest of the table is full of muttering doctors glaring darkly at their handouts. Then the fun begins.

Dr. Black starts by asking for stories of bad doctor behavior from the audience. We hear a few stories of people having things thrown at them during their residency, or surgeons screaming at nurses and throwing charts, one notable story of a doctor peeing on a patient when no one was looking (no one believed the patient so he left AMA). Everyone is looking shocked and muttering, so I'm assuming they are all thinking along the lines of "Oh my goodness, how terrible, of course I would never do something like that."

He starts to outline the statistics on the bad behavior, and includes more covert disruptive behaviors (such as eye-rolling, condescension, using medical records to vent irritation, talking trash about staff to patients or families), and gives a couple of statistics about the link between disruptive behaviors and "adverse events" (such as operating on the wrong site). The muttering gets louder, and the dark looks get darker. Finally one old and respected doctor raises his hand to ask "Come on, what was the study that actually linked this stuff to adverse events? Was there a control group? In your opinion, doctor, was this a truly scientific study?" A loud swell of approval muttering meets this question, but Dr. Black doesn't falter, he just keeps on with his presentation. "People remember these events" he says and "we got here by not policing ourselves". And when he mentions that 23% of nurses have had a physical threat during their career (usually items being thrown at them), the doctor across from me mutters sarcastically that people remember their perception of the event. It is with a combination of shock and something like unholy glee that I realize these medical professionals are so defensive that they are actually defending a doctor's right to be a jerk. "Don't underestimate the power of anger to make people try harder" one says. I feel like I'm in the twilight zone, my OT friend leans over "I feel like a voyeur" she whispers. The doctors across the table glare at us.

Ironic sub-plot:
When my therapist friends first sat down next to me one of them said "I'll sit here for now, but we might have to move." Apparently, the table I had chosen was the "physicians' favorite table", and my friend whispers to me the story of the time a mucky-muck doctor stood and gave her stink-eye until she got up and moved. Apparently the doctor then said "it's a fine day when a therapist gets to sit while a doctor has to stand".

From the moment she tells me this I become more and more aware of the social dynamic at the table. Doctors come in, get their food, stand at my table, looking pointedly for empty seats, then eventually move to another table. Some doctors pull up chairs until the end opposite from me is fully crowded while our end is so sparse that my friends and I may as well be radioactive. I decide to ignore it, the table's not marked, and rounds are open to everyone. For the next few minutes I focus assertively on Dr. Black at the front of the room, when I next glance around my two friends are gone and in their chairs are two doctors. Looking around the room I see them standing at the back, the OT mouths to me with a grin that she was kicked out of her chair so I grab my stuff and jump up to join her.

We spend the next ten minutes standing in the back, trying not to giggle at the rising ire of the room and the perfect object lesson of us getting kicked out of our table at the conference about doctors learning not to be jerks. We left, fists in mouths, when we couldn't keep from laughing any longer.

Culture of Safety? Part I

2009-04-24T16:54:00.000-07:00

At the hospital there are several kinds of conferences that take the name of "rounds". There is the regular rounding of the team on specific patients (such as the weekly rounds that I participate in). There are case presentation rounds such as "ortho" or "neuro" rounds in which doctors take turns presenting an interesting case in their specialty. Finally, there are educational presentations, known as Grand Rounds, in which a doctor presents on new research or procedures in the medical world. These last are big lunchtime affairs with upwards of 100 doctors and other staff attending and free lunch provided.

Rounds are open to all staff, though it is primarily doctors who attend them. I went to Grand Rounds a couple of times when I was an intern, and recently I have been going to neuro rounds because many of the patients presented on end up at my rehab unit. Also it is totally fascinating. I have noticed, with some amusement, that the doctors display shockingly poor people skills and turn these conferences into pissing contests.

I wish I could describe it: the basement room full of white coats, the nervous patient watching the projector displaying his own skull/spinal cord/carotid arteries to a crowd of strangers, the sarcastic tones as doctors challenge each other's methods and research, followed by rolling eyes and folded arms and disruptive stage whispers. A hierarchy emerges as one observes over time. The new guy from India is hesitant, awkward, afraid of his own decisions. The youngish, handsome doctor is sycophantically trying to get the respect of the older doc who is head of neurology by smirkily agreeing with everything he says. The up and coming young doc is trying to stay out of it all by not having opinions either way. The various other docs who ask questions referencing specific obscure research "... haven't you read so and so et al?". If this doesn't somehow evoke junior high to you then I am not doing it justice. The feel is qualitatively the same, and is simultaneously appalling and enormously entertaining.

Recommendation

2009-04-16T00:07:00.000-07:00

When you are a patient at rehab, do not listen politely until your physiatrist has spent 5 minutes telling you that he is on your team, then tell him to fuck off.

This is not a nice thing to do.

Also, it reflects poorly on you as a person.

Perhaps you have some impulse control deficits from hypoxia (mild), or a right hemisphere stroke (also mild). Perhaps you are still working the steps as you recover from your (pre-existing) alcoholism. If this is the case, then I agree that these are mitigating factors.

If this is the case then a good place to start with in therapy is impulse control. Not only will this make you seem like less of a big jerk, it will also enhance your safety because you will be thinking before you move.

Medicare Doesn't Cover That, Sir

2009-04-07T20:22:00.000-07:00

Okay, I'm going to try to paint a picture here. Bear with me because I think it'll be worth it.

There will be a punchline.

I have this new patient who has been on a steady decline for several years due to a complicated cornucopia of medical problems. He's living with his very dedicated daughter who has been doing all his care. Care which has become increasingly difficult and time consuming. The guy is somewhat demented, very weak, he has edema in his arms and legs, and he has recently stopped eating all but 5%-10% of his meals.

His course is complicated, he had an old stroke, then aneurysm surgery with complications. He never recovered from the surgery due to chronic orthostatic hypotension (gets dizzy everytime he's up). His daughter says if only they could get that worked out he'd be able to recover from everything else... Maybe that's true. But, from a therapist's perspective I see a guy with a stage 4 bed sore (this means it's down to the bone and would need surgery to heal). I see a guy with contractures in every muscle group from prolonged bedrest. I see a guy who can't even move his own arms while lying in bed, let alone participate in his own transfers. Our goals for him are that he would go from dependent to maximal assist with grooming and washing his chest and stomach. Our other goal is to train his daughter on using a lift for his self-care/toileting/etc.

Further, he doesn't like therapy (doesn't want to move) and doesn't have the memory to understand why therapy or the purpose of therapy, so it's like we're harassing him every time we're in there. His level of motivation to do anything related to his own care is so low that if he wants a drink of water I have to hold the straw up to his mouth AND literally tell him "suck harder" to get the water up the straw. He is capable of sucking on the straw, he just wouldn't unless I told him to.

So you can imagine we're having a hard time coming up with reasonable and realistic goals for him. We're also having a hard time walking the line between what his daughter wants and what he wants. As he is now, with his current intake and activity level, his wound will never heal. He'll probably continue to have increasing swallow problems, get pneumonia again... in short, he's not long for this world. The daughter wants everything done, no hospice, no palliative care consult, no "making him comfortable". In her heart he's still going to make a full recovery. And it's hard to figure out what the patient wants because he presents as uninterested and apathetic.

SO. With all this in mind I go in to his room. We do some bedlevel hand and arm exercises (as long as he doesn't have to move his body he's happy), I repositioned him and elevated his edemitous arms, I asked him if he wanted water. He did (see above).

Then he reached for my arm and held it, he told me about his wife who had died several years ago. And he told me about the church he used to go to. He said he had a headache, so I rubbed his forehead.

I took his hand, the one on my arm, and I held it in silence for a moment. Then I asked him what he wanted. What, if anything, he wanted. Right now. In his life. Was there anything he could think of that would make him feel comfortable, or at peace, or whatever.

He gripped my hand, looked right at me, opened his mouth, and said:

"Pussy"

Stream of Consciousness On the Tilt Table

2009-04-06T08:28:00.000-07:00

A tilt table is a padded table with a foot plate; it goes from horizontal to vertical with a handy electric remote. You strap someone onto it with a strap around their knees and one around their waist and you slowly raise them to an upright position. The purpose is to give their very weak (or paralyzed) body a chance to experience vertical without making any physical demands on their strength reserves in hopes that they will quit having syncopal episodes whenever you try to stand them. You go up to say, 30*, then wait a few minutes, then up to 60* wait a few- check BP, up to 70*- check BP, wait a bit... you get the idea. It takes time.

The other day I had my old guy from the previous post, the combat medic. As he's hanging out on the tilt table he starts telling me about his war experience. Not stories of events, but more like stream of consciousness of the experience itself.

Battle of the Bulge:
-I feel like I'm earning my bronze stars all over again. (Me: how'd you earn your bronze stars, patient: I was never really sure).
- I sn't as cold as most guys because early on I found a dead German. They had good winter gear because our army decided to spend money on ammunition instead of clothes. So I took his boots and his overcoat, wool.
- You'd hear shooting somewhere and just cringe waiting for someone to shoulde "MEDIC, Medic, medic". You just tell yourself, "okay, I've gotta go out there". Crawling on our bellies through the snow.
-We learned that morphine freezes, so we had to keep it strapped to our bodies. We learned pretty quick that you can't do much for a headwound or a belly wound. So we'd just give 'em morphine and mark an M on their forehead with iodine, so other medics would know we'd done what we could. 88,000 casualties in that battle. 6 weeks.
-All we had was morphine, sulfa powder, and bandages. You go to a guy and patch him up, then play God. Did he get to go back behind the lines for better medical care? Or did he have to stay up front and keep fighting.
-I still have the dreams from all that. People shouting "Medic!"

Dachau:
-We were there right after it opened, just hours. We saw the ovens, and the bodies... Even now, if someone's barbecueing meat, if it burns. The smell.... I'm right back there.
-I couldn't believe all the people living nearby saying they never knew. You could smell that place for miles around.
-We only stayed a week, doing what we could, that was all we could take. Then they moved us somewhere else.

He said he'd never talked about the war this much before. Not even with his wife and kids. "It's just not something you talk about." Why talk about it now? He doesn't want to die without having told someone, and he's planning to write it all down before he goes. Also, this rehab time is the most scared he's been since the war. "Apparently" he says, "they've diagnosed all us vets with that post-traumatic stress disorder."

He made it to 70* degrees and hung out there for a couple minutes before having a drop in blood pressure. Later in the day he stood for 5 minutes, in a standing frame.

Two More World War II Vets

2009-03-31T22:15:00.000-07:00

The first guy was a seaman on a battleship in the Pacific theatre. He says he didn't see a lot of combat up close and personal, but they did shoot down some Japanese fighter planes. He says he was 17 when he signed up. Got his mom to fill out the papers to let him enlist as a minor. In addition to the standard Navy man's anchor tattoo, he also has a tattoo of what looks like a green spider on his right bicep and a clear one on his left. When asked he says that they are actually ship's running lights, what looks like legs are rays and that the clear one used to be red, but it faded.

Green is for Starboard (right arm), Red is for Port (left arm). In my opinion, this is one heck of a good idea for a tattoo.

The other guy was a combat medic in Europe (I can tell by the medic pin fastened to his WWII vet ball cap that he is wearing in his hospital bed). When I asked him about it he says he was a combat medic at the Battle of the Bulge (also called Battle for the Ardennes if you're German, or the Ardennes-Alsace Campaign if you're an ally). For those of you who don't know, the Battle of the Bulge was one of the pivotal battles of the war in Europe. It took place in the middle of winter near Bastogne and the troops were underprovided for in every way (my other patient who was there got trench foot and has neuropathy to this day as a result).

I ask him if he was attached to a specific company. He says normally yes, but during the Battle of the Bulge they were told "you guys are medics, pair up and go do your thing. If you hear shooting or explosions, go there and try to help". So he and his buddy just ran around in the snowy woods looking for wounded and dying people to help. For 6 weeks. The 6th episode of the HBO Band of Brothers miniseries, called "Angels From Above", follows a combat medic, one Eugene Roe, during this battle. What it depicts is very like what my patient describes to me. The noise, the cold, the confusion, the fear, the futility. "That's where I lost my eye" he says. "Had it shot out and didn't even notice 'til later".

I asked what he did after this battle and he said that he "bummed around Europe for a while, ended up at Dachau". I asked if he was among the liberators and he said he was there with some other medics, "we were just trying to do what we could for them" he said. Then he sits up straight and looks me in the eye, this guy who is so weak he can't lift his arms against gravity (he's got the critical illness myopathy), and he says fiercely "it's true, it really happened. Hitler's final solution was a real thing. It just makes me so angry hearing those people say, like that bishop, that there weren't death camps. I saw it. I was a medic there." When he slumps back into his chair he is not crying exactly, but he's not dry-eyed either.

Now here's the cool thing: when the allies realized how many death and concentration there were, the extent of the horror, Eisenhower made a decision that showed an amazing level of foresight. He gave an order that as many troops, companies, divisions, as possible should go see the nearest camp. Even if it was out of the way, even if they had somewhere else to be. He made local villagers comes see the camps. He made photographers and congressmen and Generals come see. His reason was that the atrocity was too great to be believed and he was afraid that someday someone would say it was a lie or exaggerated propaganda. He wanted a massive body of evidence, from photos to footage to thousands of eye-witnesses. So that it couldn't be realistically denied.

Eisenhower, Bradley, and Patton at Ohrdruf. The first concentration camp discovered by the allies.

When my patient tells me his story about Dachau he is fulfilling this purpose and now that I have it from an eye-witness I am a part of the memory and I get to help guard the history. And now so do you.

American soldiers at Dachau

*Note* In putting this post together I searched for images of Dachau prison. The one above is nothing like the most awful. But I found myself squeamish about putting the more stark photos on my blog. I am surprised by this as I think their existence is important and I don't have a problem acknowledging the holocaust. Yet when it comes right down to it, I want to sanitize it a little, just for my own... well... sanity. It makes me sad to think of all those guys who can't sanitize it because they were there.

Short and Sweet

2009-03-31T07:24:00.000-07:00

Another home evaluation last week. This lady has some memory and judgement issues, and has to be independent during the day while her partner is at work. Before coming to rehab she had multiple falls trying to do transfers during the day so we spent a lot of time practicing how to do 'em better.

The home eval was sort of a classic one. Much more textbook than probably any so far. She had a very small space and just needed me to problem solve where and how to arrange the furniture. Y'know, so she wouldn't have to wheel around in her power wheelchair dragging furniture out of the way every time she wanted to use the can. To compensate for the memory problems and to counteract the force of habit I had fun labeling the footprints of the rearranged furniture with duct tape on the carpet. I also made a duct tape hash mark for where her wheelchair needed to be for a safe transfer.

Patient: (indignantly) Hey OTgirl, do you have tape all over your carpet?!
Me: Not yet, but then I can still remember where to put things.

(This interaction ended up with her signing a piece of tape and me promising to put it on my floor until she discharged. I took a picture with my cell phone to prove I'd followed through on my end of the bargain. Hey, whatever it takes to get buy-in.)

Even better, her best friend was there and helped rearrange furniture and clean things. She said "if we don't do it now, Jane will never get around to it". It was fun to actually get to arrange things instead of just make recommendations.

Disturbing The Sleep Or Things To Remember

2009-03-27T13:27:00.000-07:00

So yesterday morning I'm working with my first patient of the day. We're having fun AND getting things accomplished so I'm feeling pretty good about my morning. At one point I'm jogging down the hall to find a piece of equipment and I pass the room of my next patient. He's sitting up in his wheelchair napping, which makes sense as he has not been getting enough sleep. On my way back I glance into his room again and he's still sitting there, waiting for me, napping. But he's just really still. As I look at him I have an odd feeling of foreboding, like maybe he's dead. So I step inside his room and watch for a few moments and I can see that his chest is rising and falling rhythmically. "Okay", I think. "He's napping." And I continue on back to my other patient.

10 minutes later I am finishing up my note and getting ready to head into the guy's room. It took a while to do the note because I kept having to answer the phone and talk to patient's and families. This is because none of the nurses were to be found (low census so only three nurses were on today). Not even the charge nurse. The CNAs and the other therapists are starting to get irritated. "Where're the nurses?" we wonder.

Did you guess? That's right, they were ALL in my next patient's room. He wasn't napping, he was unconscious. The therapist who saw him before me, who had left him up in his chair to wait for me, like me passed his room and saw him "napping". Like me, she also had a sense of foreboding, like he might be dead, tried to rouse him and was unable to do so. Turned out he was having a syncopal episode.

A syncopal episode is a sudden drop in heart rate, resulting in a drop in blood pressure, resulting in loss of consciousness. When you stand up quickly and get a headrush this is a syncopal episode. Basically, your heart has to work certain amount to get oxygenated blood to your head when you are lying, a little more when you are sitting, and more still when you are standing. Little pressure sensors (called baro-receptors) in the arch of your aorta right where it exits the heart, cue your heart to step it up when you stand, or relax when you sit/lie down. However, there can be a second or two of lag time, hence the headrush/dizziness. If you have low blood pressure to begin with (dehydrated, genetic predisposition, taking beta blockers, etc) you might pass out, which will correct the problem, though it may leave you with other problems such difficult to explain bruises. If, however, you are strapped into a wheelchair, you don't get to hit the ground and self-correct, you're just stuck in your syncopal episode...

Click on this image to visit a site detailing how your body maintains arterial pressure.

So. The nurses and the therapist throw him in bed, get the EKG going, get the oxygen on him, suction his upper respiratory tubes to clear the vomit (yah... vomit). He comes to and doesn't know what the big deal is all about. So he's fine, he didn't crash all the way, he didn't aspirate (inhale) his vomit, he's just sleepy. Then they moved him to the room directly across from the nurse's station.

I am thinking that I am glad I'm not the one who left him in his wheelchair. I am also thinking "ohmygodohmygodohmygodohmygod! Why didn't I check on him?! Why did I assume he was okay?" I talked to the therapist that did find him, she is my boss and has been doing this for 15 years. She knows stuff.

Me: I saw him napping and I could see he was breathing evenly so I left him alone!

Therapist: Yeah, I hear you. This guy is really complicated medically. The Thing To Remember is, with those cardiac patients, don't assume they're fine. If they look funky just go in and check.

Now in all fairness, we don't usually have people on rehab who are terribly medically unstable. When I work on the telemetry unit at the main hospital, I'm totally paranoid and absolutely check on everybody. I check with nursing before going into a room, I take blood pressure and heartrate with them lying down, then sitting, and I keep the BP cuff on them when they're standing so I can check it anytime I want. If someone's sitting in their chair "asleep" I wake 'em up just to make sure. But it's not generally an issue on the rehab unit, so I didn't generalize...

Sometimes I feel like the stakes of my job are just really high.

People on telemetry are hooked up to a heartrate monitor with cables like this.

The monitor transmits wirelessly to a screen in their room like the one in this picture.

It also transmits wirelessly to the nursing station. These nurses can see the heart rhythms of EVERY PERSON ON THE UNIT from their nursing station.

The Good, The Bad, and The Jackass

2009-03-24T21:05:00.000-07:00

The Good- One of my patient's this week had a mild stroke in her right occipital lobe. The result is left visual field deficits, some left neglect, and some impaired balance. Her memory is not what it used to be but she says this is not new since the stroke. She is friendly- "jolly" is how she describes herself- knowledgeable, and motivated. Her balance is improving, as is her reading and writing, and incorporation of her left hand into activities.

Today she came to our dining group and did a great job explaining left neglect to a couple of our newer patients. Then she told them about our cooking group tomorrow and we talked about how she was going shopping for ingredients. This prompted a group discussion about how a trip to the grocery store might be therapeutic (practice balance, attention to task, visual scanning, bimanual coordination). This is why I like groups.

I pushed her in the wheelchair to the store, once there she walked pushing a grocery cart and I followed in the wheelchair. She did great: reaching, bending, bimanual produce bagging, didn't get tired. Just great. Yesterday she had said that she couldn't see a point to going shopping- that it didn't seem like therapy. After we got back from the store she said "I did much better than I thought I would, I'm not even tired" and, "it feels really good to do something normal instead of just exercises". This is why I like therapy through functional activities (AKA occupational therapy).

At the store, while I was wheeling around in the wheelchair, I had an opportunity to see the world from a (slightly) disabled point of view. I haven't done this since I was in school when we had to go around campus for half a day in wheelchairs. On campus everyone was trying so hard not to stare, they wouldn't even acknowledge you unless you needed something, and even then they wouldn't look at you. They were amazingly helpful, considering. Hold a door, stand aside in the elevator, even push you up a ramp. But they wouldn't make eye contact. It was extremely surreal. Today, in my hometown, I got a very different reaction. Being in a wheelchair was like an invitation to interaction. Fellow shoppers smiled and greeted us, employees went out of their way to make sure we had everything we needed, everyone worked around us without a hint of impatience. I go shopping at this store with patients at least every other week and this week stands out as the friendliest visit ever. This is w

hy I like my hometown.

The Bad- Incredibly sweet, keen, youngish gentleman, who turned up at rehab following brain surgery to biopsy the tumor wrapped around his left motor cortex. Turns out to be metastatic cancer, inoperable. He's another one on the make 'em comfortable-train the family-order equipment plan. He came to our dining group and was so darn friendly to everyone, listened great to other patients explaining things (see above). The whole time I was thinking "wow, so nice to meet you, you're cool. You'll be dead soon". Bleah.

The Jackass- Dr. Smith choosing to wax pedantically on, as he occasionally does, about some social ill. In principle I like a good discussion and in practice I like Dr. Smith. But sometimes he can be a little condescending, a bit finger-waggy, and he likes to posture for the other male doc (who is a decent human) and assert his dominance which I find so unbecoming. He also likes arguing and tries to bait people so he can have a little I'm-bored-let's-tease-each-other-like-12-yr-olds fight. Which I also find unbecoming.

Previous topics have included The Moral Bankruptcy of Walmart, Why The Local Theatre Company's Recent Production of ______ Was No Good, and What People in Europe Think of Americans. Today's topic was People in the Rural Midwest Are Either Stupid or Intentionally Milking FEMA For All it's Worth. There is no reason for this conversation, it's not productive, it's not nice, it's not on the front page of the paper, it's not related to our patients. I could see him looking sidelong at me out of the corner of his eyes, wondering if I would bite. But no, I've gotten better, I haven't risen to the bait since How Firefighters Are A Drain on Their Communities. Still, it was hard to keep my mouth shut when one of the kiss-asses in rounds quipped that people in the rural midwest have no common sense, "after all, they vote Republican".

Here's what I didn't say: "Oh right, they're dumb because they don't think like you" and "of course, if only everyone voted democrat the country would be perfect" and "I feel good when I make fun of entire demographics, especially in a context in which no representative of that group is present to make things awkward." He totally reminds me of Homer Simpson from the episode when he makes up his own religion. The quote is "everyone is stupid except me", and the cautionary tale is to pay attention so you don't end up talking, then thinking like Homer.

Ack! Communication! Ack!

2009-03-20T08:35:00.000-07:00

Background- A pulmonary embolism is a blood clot that has traveled, usually from your legs, to your lungs. A big risk factor for blood clots is being immobile. You spend a bunch of time in bed, the blood pools in your legs, the pools clot. There you go. Then therapies come and get you moving, blood pumping, clot dislodges and starts zooming around your body. So we make everyone wear TED (support) hose, if they're really immobile they wear these things called sequentials.

Sequentials are 3-chambered air pillows that velcro around your lower legs. They are connected to a small air compressor that inflates the chambers in sequence from distal to proximal, lowest to highest. Above is a picture of the air compressor, below is a guy wearing thigh-high sequentials. You can see the blue tubes coming out of the base by his toes and heading down to the compressor.

When a clot travels to your lungs it prevents the blood gases from being exchanged, you're still breathing in and out, but you're not adequately changing your CO2 for O2. You might feel shortness of breath, fatigue, coughing. Or you might just drop dead. If it keeps on going it can get to your heart and cause a heart attack or it can go to your brain and cause a stroke.

Many people at rehab are at risk for emboli. Partly because they are immobile, but also because often they've had a surgery, or because they've just had an embolic stroke which means that they may be more clotty than the average bear. What the medical staff do is check blood for clottiness, and give medication that thins the blood. (This can be complicated because if someone had a bleeding stroke and they're taking blood thinners to dissolve a leg clot it could create unwanted bleeding elsewhere again). What the therapists do is watch for any leg or arm swelling, discomfort, aching, and check with docs and nursing before doing anything to relieve that swelling. We make sure people are wearing their TED hose, and report any new swelling in risky patients to docs and nurses. I DO NOT take these people out of bed and get them exercisin'.

Story- So I'm working last weekend, the census has jumped up and we're pretty busy. I'm charting on my last patient while the Doc and one of the nurses are talking about another patient. I'm only half listening because he's not my patient.

Nurse: Excuse me doctor, Mr. Jones, is saying he's feeling tired and short of breath.
Doctor: Oh man, this guy is constantly complaining about everything. He's driving everyone nuts. (Pauses and thinks) You know what though, I think it's a case of the boy who cried wolf because I checked him out and I think he might have a PE (pulmonary embolism). Let's send him to the main house for an ultrasound.

I finish my note and go to my next patient. It's some guy named James from the other team who I've never met. He's in bed and tells me he's tired but wants to work. We get up, we practice a couple of transfers. 30 minutes into treatment the medical transport people show up to take James off for his ultrasound... James was Mr. Jones that the nurse and doc had just been talking about. I just, hmmm. I don't even have words for how horrified I was. I mean, this is actually the best way to have someone drop dead in my arms. No exaggeration. That's it, I have nothing else to say.

The Commute

2009-03-13T08:24:00.000-07:00

Things I think about my commute-

Evening- During the evening rush hour I am a little disturbed by the number of commuters who, along with the usual exhaust fumes, leave a cloud of pot smoke in their wake. (I am also disturbed by the quantities of beer cans, keystone of course, littering the sides of winding mountain roads I ride on my day off).

Morning- The furious rain of the last few weeks has subsided and we have been enjoying the other kind of winter day that characterizes our area. You know, the crisp, clear, endless-deep-blue-sky kind. I've noticed that it gets colder between 5am and 7am, I've noticed the difference in the thermometer from when I wake up to when I leave (usually about 3 degress). But I really feel it on the days I get up early and ride my bike to the pool, the ground is icy after I get out when it wasn't when I got in. Then I get to ride the 8 miles to work with wet hair.

*WOMEN SPECIFIC SIDEBAR [OPEN]*
I would like to say a word here about cold nipples. These happen occasionally but their direct cause is difficult to pin down. I think it is a combination of cold and maybe an overly tight sports bra restricting circulation. Anyway, cold nipples is an excruciatingly painful phenomenon, just excruciating.
*WOMEN SPECIFIC SIDEBAR [CLOSED]*

But there's something about riding in that cold, with the sky just lighting up, sun still behind the mountain. I see everyone in their warm cars with their travel mugs of coffee, parading past me at the red light. They all have the same look on their faces, like they're still waiting to wake all the way up, but I feel like I'm already in my day. Partly it's that my body is working and moving already, but mostly it's that I'm in my environment instead of seperated from it by metal and glass. If the air is cold I am cold, and I breathe cold air and watch my breath steam away from me. When it's hot I am hot, and the sweat slides down my back and evaporates off my arms, covering me in fine salt dust.

But I digress. This year I have been taking a slightly longer route to get to work because it is so much more fantastic. It is a winding mountain highway that runs down the west side of a heavily wooded river gorge, eventually making its way to the river bottoms of the city where I work. The wall of the gorge slopes up steeply to my right, and continues sloping down on my left. At some places the road is right up to the edge of the cliff, other places have several yards of sloping wooded hill before it drops down. Because of the steepness I can see many layers of trees in my foreground. Trunks of trees growing at road level, and tops of trees growing 30 yards away and down the cliff. Then there is nothing. Just a broad, empty space where there should be a midground. Then, distantly, the shadowy purple silhouettes of the eastern ridge of the gorge make up the background. When I leave in the morning the sun usually has not yet crested the eastern ridge, so the light in the gorge is diffuse and slightly glowing.

As I ride, the background of the eastern ridge appears to stay still and motionless while the trees in the foreground slide back and forth across its face. Sometimes the road and the river curve so that when I look left I can see back up the valley, sometimes down toward town. Mostly though, I can just see foreground trees sliding past background mountains. It reminds me of the movie sets in old Westerns. A painted backdrop with some real trees up front for effect. I used to think those backdrops were hokey, but now I think there was something real they were trying to capture. About halfway down the sun clears the ridge, thrusting uncompromising spears of rosy-orange light between all my foreground trees, lighting up first the hillside to my right and eventually the pavement under my wheels, piercing me as well. The earliest dawn light seems so stark. It's not ugly or sinister, but it's also not full of promise or hope. It is the distilled essence of the next 24 hours. It seems to say: this is a day and in 24 hours it will end, there is nothing you can think or want or do that will change anything about that. I find this reassuring. Sometimes the gorge is full of mist, then all you have is the foreground, and as the sun rises, reddish misty auras surround the trees.

By the time I get to the flats just before town, the sun has risen to a gentler angle, and the trees- deciduous now- are a softer green than those of the evergreen woods I have just left. This phase of the morning is like a transition time to when I will get out into the populated parts. The morning becomes softer and fresh in a more personal way. The trees are smaller so the sun can warm me up, and the birds have started singing. Now I am passing the homeless folks who live in these woods as they make their way to the highway for an early start on panhandling, in another mile I will pass the homeless shelter, and the early risers in its population will join me at the stoplight as we all head to town. I feel like I am walking a tightrope between the cars of the enfranchised, and the cold, grubby day-to-day coping of those less fortunate. I am glad for my cold commute with the sunrise and the trees, and I am glad that I wouldn't have to do it if I didn't want to.

You Are At The Right Blog!

2009-03-08T09:15:00.001-07:00

If you were looking for "Reflections of a Rehab OT" that is. Returning visitors will notice that I've changed the name, layout, and "about me" section of my blog. Mostly I've been irritated by the visually busy nature of my blog and the cheesy name. Also, I'm no longer completely "newly licensed", and other than the occasional weekend shift, I don't really float between facilities anymore. Instead, I am solidly ensconced as the lead OT for one of the two teams at rehab, and all my energies go into making that work. I have written about that role in the post called catching up.

Misunderstood and Righteously Indignant

2009-03-06T17:47:00.000-08:00

So I'm on a home evaluation with patient, spouse, Gallant Adult Son. The first obstacle is a sloping path with several short steps. Gallant Adult Son insists on pushing patient up the path. He starts without waiting for my suggestion on the easiest way to do it, so struggles more than is necessary. I let it go because I think trial and error is a really effective way to learn (this is part of why home evals are so useful, as in "really, it'll be easier at home? Let's try it"), and I plan to demonstrate on the way down the path when we leave. High-srung spouse spends this time yelling at Gallant Adult Son to be careful and not hurt his back, and asking me why I'm not doing it. I'm not going to tell her that Gallant Adult Son won't let me, besides I'm not coming home with the patient, so me doing it for them is not a long-term solution. We do the home eval and on the way out the spouse tells Gallant Adult Son to "make that girl do it". Which, for the record, I was going to anyway for teaching purposes. I ignore my irritation, bite my tonge, and start bringing the wheelchair down the pay, explaining the physics of the Best Method as I go. But Gallant Adult Son is funny, he's anxious about what he perceives as making me do it when he is a big, strong, capable guy just standing there. As soon as I've finished my spiel and gone about 4 steps he is insisting on taking over, he just can't leave it alone. So I say go for it. Like I said before, I'm not going to be there anyway. It all goes fine, of course, it's not rocket science.

The next day the discharge planner tells me she had a conversation with the patient's very angry and upset spouse who is convinced her husband is not ready to come home. "He can't even walk!" she wailed, and "he's too much work, why that girl couldn't even get him up the path, she had to make my son help!" She tells me this in rounds, in front of the whole team. I just had to get up and leave for a moment.

How To Be A Smart Old Cannibal

2009-03-04T21:43:00.000-08:00

Critical Illness Myopathy-What it is- If you someday have a severe accident or an illness, you might end up in the hospital. Maybe even the ICU. Perhaps you will barely be conscious, maybe even in a coma. You might not be able to eat sufficient quantities of food or get up and keep your muscles moving. If this goes on long enough your protein starved body will start cannibalizing your large muscles to get protein. At least this is how the doctors explain critical illness myopathy to my patients. This condition presents itself in a really strange way. In addition to the low energy, weakness, and quick fatigue time that anyone who's been sick and bedridden will experience, there is a unique pattern of muscle weakness. In a nutshell, the large muscles of the shoulder and pelvic girdles become proportionally much weaker than your other weak muscles. (Myopathy= muscle weakness)

Critical Illness Myopathy-What it means to you- Your pelvic girdle muscles are the ones that stabilize your pelvis and move your femurs. Especially during transition type positions (such as going from sitting to standing and back) when the weight of your body/limbs is somewhat cantilevered out in various directions against gravity versus just being stacked in a gravity friendly way like when you are standing or sitting. What this means is that you can't stand up. At all. If I get you to standing using skill and equipment, you can maintain standing, maybe even walk a few steps with a walker, but you cannot go from sitting to standing unless the surface you are standing up from is high (think stool height or higher). You also can't sit down in a controlled fashion, once you get partway down your legs just collapse and down you go, flop!

Now normally when someone has weak legs we teach them compensatory strategies for transferring from one surface to another by using their arms to push up so they can scoot a bit. Unfortunately, with critical illness myopathy your shoulder girdle muscles have also been cannibalized and therefore are as unable to lift you as your legs are. Again, once standing you can support your weight through your arms, on a walker say, but they can't provide sufficient force to lift your 100+ pounds up from resting.

So we do a lot strengthening exercises. One of the best ways to get those muscles back is to try to stand, even though you can't. You scoot forward to the edge of your chair, tuck your feet back so they're under your center of gravity, lean out "nose over toes" and push up with arms and legs. Another way is to get help getting into standing, then just be standing for a while, like in a standing frame so that you can't collapse when your legs get tired in 90 seconds. And the crazy thing is that it works. Within a week you can scoot safely and push up enough to clear your ass so that you can drop your pants and sit on the pot; and, what is maybe more the point, you can pull them back up again. You can also stand up from a tall chair, stool, or bed that has been raised up. Over the next 3-5 days you keep getting stronger, and we work on standing from progressively lower surfaces. After 2 weeks you probably can do all your own self-care, but it takes you twice as long as it used to and you have to take lots of rest breaks. You can get up from a tallish regular chair, sometimes, depending on how tired you are and what time of day it is. You can probably walk household distances with a walker, but again will need lots of breaks.

You're not 100% (the rule of thumb is 1 month recover for every week of bedrest) but you are ready to go home. We do a home eval and make recommendations to get you safely through the first few weeks, we train your family, we order any equipment you might need (walker, w/c, commode, etc), we schedule home health to follow you at home. Then you're off.

Pet Peeves Related to Old Guys with Critical Illness Myopathy
-When you tell me, after not being able to stand/reach your feet/wipe your ass: "I think it'll be easier once I'm at home."
-When your wife tells me "oh come on, he doesn't need a ramp!",
-When your caregiver tells me "I'm not moving the throw rugs/area rugs, he'll be fine".
-When you, in response to my insistence that dogs be behind a closed door whenever you are standing/walking, reply "well, we'll see how it goes".
-People wanting to get up in the middle of the night, not turn on a light, and walk to the bathroom to pee, instead of using a urinal.

My last CIM patient plus one was one of those convinced it would be fine when he went home, he didn't want a urinal at night, he didn't want to move furniture to make better access to his bathroom. He fell his first night and was unable to get up. When his daughter called the fire department they suggested that he move some furniture to make better access to the watercloset or use a urinal at night. He was delighted with the suggestions and told my boss that they really made a difference...

My patient with CIM who left last week had the disbelieving spouse, the cavalier caregiver, the giant dogs, and a determination to "see how it goes". I educated him, I educated his "number two son", I typed up safety tips and put them in his go-home packet (I actually taped them to the front of his go-home packet). I did fall recovery where I made him get on the floor and learn the strategy for getting up- even with best efforts he needed me AND the biggest CNA on the floor. I even told him the story of my last CIM patient. He laughed and said "so if I fall I should be sure to tell your boss that you didn't warn me?"

The best moment came after the home visit. This guy's adult son was there to help make suggestions and problem solve, he'd been the one coming to every conference and available on the phone to answer questions and keep track of stuff, really the responsible go-to guy. But he was very reserved and hard to read. The whole two weeks I couldn't tell if I was annoying the crap out of him or if he was just taking it all in and sort not talking unless he had something to say (this is how my husband is). At the home eval the disbelieving wife and cavalier caregivers had been downplaying any suggestions and expressing terse disbelief that he was still needing a walker. Between my patient and his wife I had some real concerns about my patient's safety. So the next day I asked the son if he thought his mom would be able to support her husband in being safe at home. The heretofore reserved and hard-to-read guy suddenly busted out with the most eloquent eye-roll I've ever seen and said, in a voice heavy with unmistakeable sarcasm "you've met her, what do you think?" Then we both laughed. He actually laughed with me.

Euphemism

2009-02-26T07:40:00.000-08:00

Elderly (90+) gentleman in the shower. Referring to his johnson as his "dangling participle". I made him laugh when I told him after he was done washing that I'd help him stand so he could wash his split infinitive. I can't believe they pay me for some of this stuff.

Although, given the previous post it all evens out in the end I guess.

OT Circus

2009-02-24T19:55:00.000-08:00

It's 5pm, the end of a long Monday. My right knee is firmly pressed into the dirty orange carpet, while my left knee is jammed securely against the slightly damp behind of a crying 250 lb woman in her early 70's. She too is on her knees and we are both leaning against a comfortably used 80's sectional sofa. Behind me, anxiously hovering, are the patient's adult children, spouse, and siblings. They are immobilized by their indecision: do they jump in and rescue my patient who is used to ruling everyone's life with her anxiety, or do they wait and let me, the "professional" direct the rescue.

In my mind's eye I am picturing the various options for recovering from this situation. The classic up-to-knees-roll-onto-couch maneuver for people with mediocre leg strength is not an option as this patient has neither the physical nor psychological stamina for such an activity. Nor does the gather-all-the-relatives-for-a-group-weight-lifting-project option really fit the bill as the main reason this patient came to rehab was that the above mobility strategy had become less and less useful as the patient's leg weakness progressed. I settle on the Hoyer-style lift in the patient's bedroom. The lift I had ordered for this family for just such a situation as this. The lift I had been in the middle of training the husband on using. The lift he had declined to practice with not 10 minutes before, stating "I think we can figure it out if we need it". The lift whose specific model I have never seen before. I am not looking forward to reading through the lift's manual with crying patient on the floor and anxious family looking on. After all, I'm trying to inspire confidence.

Meanwhile I am also trying to do some quick mental triage. Most home evaluations happen several days before discharge to give you, the patient, and the family some time to make adjustments and set some very specific mobility goals. They get to try things at home, see what works and what doesn't, then go back to rehab and practice, order equipment, etc. For some patients there is too much attached to being at home and it's not a good psychological idea to take them home and then bring them back to rehab. This lady is one of those, so I'm doing a quick and dirty home eval on her day of discharge. The equipment is there, I'm planning on doing a run-through of Optimal Setup and How To Use, then I'm leaving her there with her family. Now, kneeling with my patient on the floor of her home, I am trying to decide on the most important bits of information to leave them with. Given the anxiety level and distractibility of patient and family, I probably will only be able to impart 2 things, at the most.

I settle on 1) modeling problem-solving how to use the hoyer lift in awkward situations, and 2) prevention of future falls.

Step 1) get the patient all the way down to the floor. This is performed simultaneously to asking the husband what he thinks caused the fall. This is also performed simultaneously to the pre-school aged granddaughter walking back and forth across my patient's legs as she lies on the floor whimpering for someone to bring her milk (yes, my patient wants someone to bring her milk). I tell my patient (let's call her Gina) that she is is not allowed to have milk during Get Off The Floor Project Time, I tell her to focus. The husband tells me that he was trying to do a slideboard transfer onto the couch (which we have practiced ad nauseum at rehab) and the wheelchair "just tipped forward". Patient now successfully on the floor, granddaughter still walking back and forth across her legs, patient now moaning for a pillow. I glance over at the wheelchair and see that the footrests are still on it. In position to support patient's feet. I point this out and the husband says "oh, that must be it, she must've put her weight on those instead of on the floor". I agree. Gina angrily demands a blanket. Again, I tell her to focus.

Step 2) Get the hoyer lift's sling under her. Of course the vendor has sent the wrong sling. Of course the picture in the manual for how to place the sling shows a docile man lying supine in a bed with two competent staff rolling him side to side. It definitely does not show a whimpering lady with her legs half under a couch and a grandkid walking up and down on the sling. I go over how to place the sling, I go over how to use the manual to figure out how to place the sling, then I dog-ear the relevant pages in the manual. Gina asks for milk again. Her son rushes to get her some, but I glance at the husband and he tells their son no. I tell Gina to focus.

Step 3) Get the lift and use it to hoist the sling and the patient. At this point grandkid's mother tells her to give grandma some space. She does. From this point forward music for this adventure is provided in the form of toddler style piano-key-mashing scales. Do-Re-Mi-Fa-So-So-Fa-Mi-Re-Do. Now this is where it gets hairy. First of all, ideal practice states you place the lift at the patient's feet, Gina's are under the couch so we have to go headfirst. Second, I'm not familiar with this lift so I am having difficulty finding the various controls. Don't get me wrong, I'm not worried about safety as they all work the same way, it's just that I can't find the right buttons/release valves to make it work. Fortunately (depending on how you look at it) my patient's brother has used one of these with his father-in-law, he helps get it set up. I reframe by saying "see, you have a lift expert right here in your home". We start hoisting Gina. When she is dangling about 1 foot off the ground she begins again asking for a blanket. At this point I ask her if she is planning on living in the sling, because if she is then getting comfortable makes sense. She is offended but I don't back down. I tell her to focus, then I demonstrate the proper technique for getting back into the wheelchair. This is new information to them, so I feel useful.

My patient is not this big, and neither she nor I are anywhere near this smiley.

At this point the family is feeling good about using the hoyer. So I gather them around for a lecture on how to prevent falls. Gina interrupts to ask for some milk. I talk about anxiety, about how it can interfere with decision making and judgement. I talk about how they all love and care about Gina and want to make sure she has what she needs. I am not judging this, I don't expect or need them to change this. This is their life and their relationship, they should feel free to do it the way they want. EXCEPT during transfers. "During transfers" I say, "you all need to say no to distractions, and to the demands of anxiety. You need to say 'right now I am helping you move safely, when we're done I'll get you ...' or someone is going to get hurt". They solemnly nod, they nudge each other and say "did you hear that?" and "You have to do that too". I am secretly amused, and I make them practice saying this out loud to Gina. It is 6:30 by the time I make my escape. My shift ended at 5:30.

As I reflect on this situation I have a lot of different thoughts. One is that it's really useful to see someone in their home environment because it is so different from the hospital. And not just the environment, but the person and their behavior/attitude. But I also find myself reflecting on what it means to be holistic. On the one hand, this patient has been anxious and passive for years and years, I recognize that there is little I can do to change her, and realistically I shouldn't even try. I try to recognize that this is the reality and the limitation that I am working with, the context, if you will. We offer a psych consult, we offer better medication and support groups, she declines. I document that these were offered and refused and I move on. What else can I do?

Yet another part of me wonders if I shouldn't be more forceful. A part of me feels slightly disingenuous or even maybe less holistic when I don't call out the ridiculous mindset as it presents itself during treatment. As though I'm passing off the responsibility to other "experts" who don't have the opportunity to see the psych dysfunction in practice, but only in theory. When we work toward your stated goal of toileting independence for 3 straight days until you can do it with only a little help for setup and then you refuse to do its again and demand a bedpan, would it be reasonable for me to insist? When you state, as your reason for refusing, that you've lived a full life and worked hard and now it's your time to rest and let others take care of you, can I say flat out that it is ridiculous to apply this thought to wiping your own ass?

I wonder how much of my hesitation to call this spade a spade has to do with my own anxiety over upsetting people. I mean, I am quite persuasive and can usually get people engaged with all kinds activities by calmly and reasonably downplaying refusals and excuses. Generally this works very well. I make my minutes, patients learn things, and they all report a positive experience with me. Read, they like me. Occasionally these strategies are not effective long-term, and my tendency is to sort of tell myself that this is my patient's limit and it's not going to change so it's not my problem. And it's likely that I'm right. In contemplating this situation I am starting to think that part of the reason I don't call patients on this crappy mindset is that I want them to not get upset. And I can get so much done without upsetting people that I hesitate to see a value. So I was surprised to find myself feeling slightly remiss, like I had not done everything I could, when I hedged during the toileting discussion. I felt like I had squandered, out of fear, an opportunity to use the rapport I had built. It likely wouldn't have changed anything, it's just a question of what has more professional integrity, and what is more honoring to my patient: Just go with what their thinking, or treat them like a grown-up capable of making informed decisions about their life?

Death and Pragmatics

2009-02-11T22:11:00.000-08:00

This week I have a sweet 93 yr old lady who has Parkinson's and was recently hospitalized following a sudden loss of consciousness. Turned out she had a gastrointestinal (GI) bleed. She is slowly getting stronger but the odds of her going back to her retirement community at an "independent living" level are slim.

Independent living means that you are safe on your own behind closed doors. The community provides housekeeping services and meals in the cafeteria, but you do all your own self-care, toileting, etc. This facility is pretty good, for an extra fee they can bump you up to "assisted living" which means providing assistance for bathing and dressing, and occasional other assistance with transfers. This would probably be appropriate for my patient. Probably. For the first few days she was totally against having extra help, stating "I've never needed any help with that". I would say that I know she CAN do it, but if getting dressed takes 2 hours (literally) why not get some extra help and save your energy for other things?

Today I asked her if she was going to go back home. She said she didn't think so. I asked what she thought we should do with her if she didn't go back home. She said "bury me". I asked her if she was done with life, had enough, finished. She said "Yes! I'm 93 years old!" I didn't know whether to laugh or feel sad. Instead I told her that she wasn't going to die tomorrow, and asked if she would consider hiring extra help to make life easier for whatever time she has left. Surprise! She laughed and said yes.

Googling for Narcissism

2009-02-09T21:22:00.000-08:00

Okay, I totally weirded myself out by Googling OT and some of the diagnoses I work with. Here are the results:

OT and Broken Hip- 1st of 38,000
OT and hemidressing- 1st of 502,000
OT and visual field cut- 1st of 24,000

OT and bicycle commuter- nothing
OT and stroke CVA- nada

Best Story So Far and a Spot of DIY

2009-02-08T22:40:00.000-08:00

Best Story So Far

Me: Are you ready to get up for therapy Mr. Abaroa?

Mr. A.: Maybe, did you bring me any whiskey?

Me: I didn't know you wanted any, what's your favorite kind?

Mr. A.: Just kidding, I don't really drink. I'll tell you something though. You know back during the Prohibition days my dad was a bootlegger.

Me: Really?

Mr. A.: Yeah, in Utah. Those Mormons... they sure love their (makes drinking gesture and winks at me).

Me: They do? That's surprising 'cause it's like in their rules or something that they can't drink.

Mr. A.: (drily) Is it?

Me: So, was your dad a Mormon?

Mr. A.: No. Basque.

(He delivers this piece of information as though it is self-explanatory that his dad would be a Basque bootlegger in Utah. I, however, have never actually met a Basque person or any of their friends and relations, and am fascinated by this tiny people group from the Pyrenees spanning the France/Spain border. Not least because they are an ancient people group who do not speak an indo-european language -which is the language group that includes almost every other European language. Except for Hungarian and Finnish- which are related to each other in a group known as the "Finno-Ugrik" group, it looks like troll. In fact, their language is not related to any other known language. Don't ask why I am fascinated by them, or why I know about their language. I am a nerd, and I have a book called "The Encyclopedia of European Languages" which I have read like a Choose-Your-Own-Adventure book. I once wrote my sweety a message in Oggam, carved into the edge of a stick of course. Look it up.)

Me: Did you say Basque?

Mr. A.: That's right. Okay, here's how it worked. They made the whiskey up in Canada, then they'd smuggle it in to the Basque sheepherder's camp in Montana. Then those guys would bring it to the Basque sheepherder's camp in Wyoming. From there it would come to us. We were the endpoint.

Me: Did you by chance live in a Basque sheepherder camp in Utah?

Mr. A.: Yep. And what we'd do see, is my dad would butcher some sheep to sell to the local restaurants, and he'd put them on clean hay in his wagon. But it was a special wagon that he'd built with a false bottom, and the whiskey was all hidden in the bottom of the wagon. Then he would sell the fresh sheep and the whiskey to the restaurants. He'd let me ride with him. I was about 5.

This story starts cool with "my dad was a bootlegger to lushy mormons" and just gets better from there. Basque sheepherder camps all over the US? Basque sheepherder liquor smuggling operations?? Butchered sheep and false bottom horsedrawn wagons full of illegal Basque-sheepherder-smuggled booze?? I have nothing to add to that. Nothing.

A spot of DIY- It has been raining cats and dogs lately which has got me thinking about the ups and downs of being a bicycle commuter. Riding in the winter brings its own challenges. There's the early evenings. There's the mornings that are so cold I get an ice cream headache bombing down the first hill. Then there's the rain. The rain's not so bad once you're prepared with the right gear. Very important: visor so that it won't rain into your eyeballs. Also very important: shoe covers. Without shoe covers all the water from the sky and your wheels rolls down your legs into your shoes rendering your feet instantly as squelchy and uncomfortable as if you were creekwalking.

I have some nice shoe covers that cost me $50.00. I can't find my shoe covers. Sweety can't find my shoe covers. They are nowhere. It turns out that I absolutely cannot ride my bike in the pouring rain without my shoe covers. It turns out I have a limit to what I will do on my bike and this is it. Yet I can't bring myself to shell out another $50.00 bucks because a) they might turn up any minute, and b) the only bike store in town that sells the ones I want is staffed by snotty bikier-than-thou semi-competent boobs. Unfortunately I also can't bring myself to ride my bike in the rain, even one day, without them. Prune feet is no way to start the day. So I decided to try my hand at a spot of DIY. Here is a picture of my fabulous new shoecovers made from plastice grocery bags and white duct tape. They have a hole cut out for the cleats on cycling shoes, and I can use the handles to tie them snugly around my calf and under my rain pants. I wonder if they will work, I wonder how they will hold up, I wonder if I will slip and fall the first time I try to put my plastic covered foot down on the wet pavement at a stoplight... I'll keep you posted.

Fun With Visual Field Cut and Hemiparesis

2009-01-26T21:02:00.000-08:00

I've been working on this for a while. Now you too can get a glimpse of what it's like to put on a shirt after you've had a stroke.

Go get a short sleeved t-shirt, the plainer the better. No ringers, no big silkscreened design on the front, just plain.
Pick a side of your body to be your hemiparetic side. Let's say Left.
Close or cover your left eye. If you are really fancy you can use a pair of glasses frames (or just use your own specs) and just cover the left half of each lens.
Now sit on the edge of your bed, or a comfortable chair. Make sure both feet are on the floor for stability. Visualize your paralyzed left side. It's your left leg, it's your left arm, it's also the left side of your trunk, so don't forget to slouch a little to the left. You can enhance the left visual field cut by turning your head all the way to the left so that you have to look out of the right side of your eye/s.
Now you are ready to put on your shirt. You can try this anyway you like. Have fun trying to find the bottom and distinguish the two sleeves one from the other. Oops! Did you leave your shirt somewhere out of your reach? How will you get it? Remember, your left leg does not work. Also, when you are trying to get your shirt on over your left arm be aware that it is probably floppy not stiff, or it is stiff with a flexed elbow and shoulder tight against your body, hand fisted.
Perhaps you would like to try the standard hemi-dressing protocol. It states that it is usually easier to dress the affected side first. So arrange that left sleeve so that you can put our left arm into it, hike it up way past your elbow so it won't slip off while you trying to dress your right arm. Finally, gather the whole back of the shirt in your right hand and pull it over your head in one fell swoop. Straighten. Another way to dress your left arm is to thread your right hand backwards through the left sleeve and out the bottom, grab your left hand and shimmy it through, then carry on as above.

You can see that while the hemi-dressing technique does help, it does little to address the visual and trunk balance deficits. It also does little to address the likely spatial awareness deficits, sequencing, and impulsivity deficits you may have. You can also see what a complex piece of machinery is a t-shirt. The pants aren't nearly so difficult (except that you can't bend over and lift up that left leg simultaneously).

Finally, you can see the amazing coordinated systems that allow us to get dressed. Vision, coordinated trunk balance, synergistic patterns of arm movements and arm on trunk movement. A mental image of the archetypal t-shirt allows you to keep track of which part of the actual t-shirt you are manipulating, a practical connection to the passage of time allows you to know when to move on to the next ste, and a philosphical connection to your culture, social norms, and values- gives you a reason to get dressed (and in those clothes) at all.

We're wacky and fascinating.

Positive Feedback

2009-01-26T17:31:00.000-08:00

One of my patients had some nice things to say about the rehab doctor that I find both most entertaining and most cocky. My patient felt that this doc really took time to listen and was working with the patient to provide excellent care. It's funny because while I know that this doc is very intelligent, and really does care about the patients, my experience of her is not one of good listening and collaboration. She is, however, excellent at BS'ing and saying what you want to hear. She's been known to make promises about what rehab can deliver that are totally not within her scope or ability to make happen. Occasionally she hangs us therapists out to dry by telling patients and family members what we will/can do without checking in with us. I hate looking like an asshole because someone else doesn't have an edit button on their mouth.

So the question is: Is the doc actually having a good EQ moment? Or is she just happening to pull out her fabulous people skills in a way that worked for this patient. And what should I do? I generally believe in the passing along of positive feedback, but I hesitate to add any fuel to this particular doctor's ego.

Not much of a question really. I decided that I don't need to judge genuine EQ vs good bullshit, and there's no reason to let someone else's questionable personality cause me to behave in a manner inconsistent with my beliefs. I passed along the positive feedback.

Pop Quiz Answer

2009-01-21T21:59:00.000-08:00

The mysterious tool pictured in the post: "Pop Quiz" is a measuring guide to help you determine which size of condom catheter is appropriate for a given patient. It's a tool for measuring tools. The charge nurse said the guys always tell her "Oh, I'll need the extra large", then she whips out the tool(s), measures, and says witheringly "I think average size will be fine". Actually, I'm sure this charge nurse doesn't say anything of the kind because she is nice and sensitive and caring. And has probably seen a million johnsons and could care less about how big a given Junior Member is.

Another Smarty-Pants Smack Down Courtesy of the OED

2009-01-16T18:18:00.000-08:00

full-size OED

The other day I was reading another OT's evaluation of a patient who had been admitted following a mild stroke, and I came across this sentence: "...patient has history of dementia which may have been exasperated by the stroke."

"Oh my good Lord." I thought. "How can this person not know the difference between exasperate and exacerbate. Next I showed it to someone else who also laughed. Later I told it to sweetie who helpfully rolled his eyes, and we discussed the philosophical implications of not having different words for these different concepts. We felt smugly sorry for the poor person. Finally I looked it up in the Ultimate Resource of English Language: the Oxford English Dictionary (OED).

The OED is a venerable tome that contains every word ever used in print in English since the year 1000 on. It is 22 volumes large. We have the shrunk down version which is bigger than a vintage family Bible, has 9 tiny pages per page, and comes with a gigantic magnifying glass, and costs $400 suggested retail price. We bought the OED a few years ago because we are such word nerd-snobs, and we wanted to have the pleasure of being smarty-pants authorities on every verbal dispute (even if only in the privacy of our own home).

Shrunk version of the OED with 9 tiny pages per page.

The actual experience of the OED turned out to be different than we had hoped. Far from reinforcing our feeling of being extremely word savvy, we were constantly astonished at the kinds of words that are recognized by the OED as proper English. It turns out that pretty much any word that you can make up by sticking a suffix or prefix onto an existing word is probably in the OED. Actually, not probably, almost certainly. For example: if you have an annoying friend who thinks that poets are the greatest type of being on earth you could, with perfect accuracy, describe them as a poetolater, or prone to poetolatry - a word which the OED defines as "an immoderate veneration of poets".

So the OED got me again. Turns out that the number 2 definition of exasperate is exacerbate. Part of me still thinks maybe the therapist in question used the word exasperate because they didn't know any better. Or, as sweetie put it, they're using all the right words for all the wrong reasons. But the reality is that if you use the right word in the right context then it's the right word... right? And me thinking I'm so smart.

Power Dynamics and Pop Quiz Hint

2009-01-16T09:48:00.000-08:00

Power Dynamics- Took NFP to a dentist appointment as his ill-fitting dentures are further contributing to his swallow and food management woes (imagine that the left side of mouth, tongue, and esophagus are also weakened and neglected as a result of the stroke). It was interesting to observe the difficulty of managing his stroke symptoms in a community environment. There were the small doors and narrow hallways, not to mention the small exam rooms cluttered with odd bits of equipment and chairs poorly designed for transfers. For a person who has difficulty with visual-spatial perception and is distractible, he suddenly was much more dependent on me for wheelchair mobility than he is in the hospital. Add to that the forms that needed filling out (left neglect had him only filling out the right side, I had to point to each item in the left column).

Maybe the most difficut aspect though was the expectation of a reasonable pace that exists in the real world. NFP probably could have been more independent except that things in the real world move at least at triple rehab pace. The dentist isn't trying to be rude, the hygienist is very patient. They are all waiting probably double the time they would normally wait for somebody before they jump to help, but it's about 2/3 the amount of time that NFP would need to do it himself safely.

I was impressed that he was able to stay focused at least for transfers, he would not let anyone rush him and remembered all his steps for safety. But other than that he needed a lot of help. Hoping to facilitate as much autonomy as possible, I insisted he put on clean clothes before we left and made a point of leaving him alone with the dentist during the actual appointment. I mean I'm not his caregiver, and NFP is an intelligent adult (a PhD in fact) who has been taking care of his oral needs without help for years. And it seemed to help. For the initial paperwork the dentist was asking me questions about NFP, for the concluding paperwork it was like I wasn't even there.

Interestingly, there was also a subtle change in NFP's demeanor. For the last week-ish he has had a tendency to keep his head down a bit, make limited eye-contact, with us he has been deferential almost to the point of submissiveness. On the surface this makes my job easier because he works hard at whatever we tell him, but on a deeper level it could make the transition back to home and life harder. Think about it, who's going to tell him what to do at home? His wife? You married people know that this is a sub-optimal way to have a relationship. At the end of the appointment my NFP was back to how he was the first week at rehab. Sitting up a little taller, better eye-contact; it was clear that he saw himself as an equal with the dentist in this exchange of services for financial remuneration. And he carried that back to rehab with him. So I'm calling it successful community re-integration and will try to capitalize on it in future treatments, and with other patients.

Pop Quiz Hint- This is a photo of a condom catheter

Pop Quiz

2009-01-14T21:32:00.000-08:00

I learned something new today, it is about the tool pictured below. One of the charge nurses, who as it turns out has an intrinsic understanding of comedic timing, described it to me.

Cyber Props to whoever succesfully guesses what this item is. Tune in next week for the answer.

NFP and the Fabulous Home Visit

2009-01-14T21:05:00.000-08:00

He lives a long ways away in a rural area, and it was a very lovely day. Sort of unseasonably warm with a blue brassy sky. So as not to waste potentially therapeutic time during the drive down I had NFP pay special attention to sitting upright (not slumping away from his affected side), mobilizing his scapulas, and attending to his affected upper extremity. During the drive he tells me about the opportunity to come to the US and how he had to leave his wife and children behind, hoping that he would someday be able to get them visas. He is crying as he tells me this.

Gracious and friendly, if a bit stressed, wife meets us in the front yard. Patient is distractible so the evaluation takes a little longer, not least because he also benefits from actually trying things out instead of just discussing them. This is because he has some totally messed up spatial awareness and assumes that he can do things that are actually not that simple. Here are two home eval tips for a person with mobility deficits: 1) get rid of area and throw rugs, 2) shut the dogs in a different room before doing any transfers or walking.

People's homes are such a fun window into who they are outside of the medical condition that brought them to me. And NFP's house had this in spades. Fancy copies of several patents adorn his walls (did I mention he's a scientist, and a practical one at that?). A photo of his private audience with the old Pope. Portraits of saints, and home made nativity backdrops (don't ask, I can't even describe it) dominate a corner of the living room. A wall full of dozens of photos of the grandkids, on their own and with NFP looking all hale and hearty.

Like many foreign born patients, these two viewed my appearance at their home as an opportunity to return some of the care and kindness, hospitality if you will, that they feel they have received from myself and other therapists. Cue fabulous, traditional, gigantic home cooked meal from the old country. One time, months ago, I tried refusing such hospitality because I felt it was inappropriate to take anything from my patients. I kicked myself for weeks. I now think that people need to feel human, to put themselves back on equal footing after a ground-shaking experience. One way of doing that is by giving something to someone. I think that maybe we are most able to give/share/serve when we ourselves feel in control and powerful, when we feel at least equal to those around us; thus the act of giving or serving has the power to elevate the giver, to shift a power dynamic (at rehab there is always a power dynamic, no matter how respectful. I mean, in what other situation would I get to nit-pickily boss around a scientist with a PHD?). Maybe this is why subversive Jesus is always telling people to lead by serving. I accepted their hospitality without qualms, and I was touched. And stuffed.

They are hoping that sweety and I will come over for dinner sometime after he goes back home. Maybe so.

Waste Land

2009-01-14T21:00:00.000-08:00

The Hollow Men
Mistah Kurtz -- he dead.
A penny for the Old Guy
T.S. Eliot

I

We are the hollow men
We are the stuffed men
Leaning together
Headpiece filled with straw.
Alas!Our dried voices, when
We whisper together
Are quiet and meaningless
As wind in dry grass
Or rats' feet over broken glass
In our dry cellar

Shape without form, shade without colour,
Paralysed force, gesture without motion;
Those who have crossed
With direct eyes, to death's other Kingdom
Remember us -- if at all -- not as lost
Violent souls, but only
As the hollow men
The stuffed men.

II

Eyes I dare not meet in dreams
In death's dream kingdom
These do not appear:
There, the eyes are
Sunlight on a broken column
There, is a tree swinging
And voices are
In the wind's singing
More distant and more solemn
Than a fading star.

Let me be no nearer
In death's dream kingdom
Let me also wear
Such deliberate disguises
Rat's coat, crowskin, crossed staves
In a field
Behaving as the wind behaves
No nearer --Not that final meeting
In the twilight kingdom

III

This is the dead land
This is cactus land
Here the stone images
Are raised, here they receive
The supplication of a dead man's hand
Under the twinkle of a fading star.

Is it like this
In death's other kingdom
Waking alone
At the hour when we are
Trembling with tenderness
Lips that would kiss
Form prayers to broken stone.
IV
The eyes are not here
There are no eyes here
In this valley of dying stars
In this hollow valley
This broken jaw of our lost kingdoms

In this last of meeting places
We grope together
And avoid speech
Gathered on this beach of the tumid river

Sightless, unless
The eyes reappear
As the perpetual star
Multifoliate rose
Of death's twilight kingdom
The hope only
Of empty men.
V
Here we go round the prickly pear
Prickly pear prickly pear
Here we go round the prickly pear
At five o'clock in the morning.

Between the idea
And the reality
Between the motion
And the act
Falls the Shadow For Thine is the Kingdom

Between the conception
And the creation
Between the emotion
And the response
Falls the Shadow Life is very long

Between the desire
And the spasm
Between the potency
And the existence
Between the essence
And the descent
Falls the Shadow For Thine is the Kingdom

For Thine is
Life is
For Thine is the

This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper.

The endearingly grouchy Old Guy, who during therapy last week described his current life experience by drily and sadly referencing the last stanza of this poem, died unexpectedly two days later.

New Favorite Patient, and Other

2009-01-06T21:44:00.000-08:00

I have a N(ew) F(avorite) P(atient), which feels a little weird because it's almost like I'm comparing patients, which is just not that useful. In reality though, I still treat everyone with the same respect and professionalism, it's just that I have more fun with NFP. Having just had a right hemisphere stroke resulting in left hemiparesis, left neglect, some impulsivity, some difficulty with pacing his movements (like rushing to the next step of an activity before finishing the first), and difficulty with interpreting visual/spatial relationships, NFP is a perfect rehab candidate.

Right hemorrhagic stroke. Photo credit to SSCF Stroke and Circulation Fund

This guy is fun to work with because he is so smart. A scientist from Eastern Europe (he came here years before the fall of the Iron Curtain, and had to work for several years before being able to bring his family), he is a senior who was still working full time at the time of his stroke and he looks about 55. He approaches his rehab with a clinical eye and a scientific mentality. If you tell him he needs to attend to his left side and hand/arm to help reconnect it to his brain, the next time you see him he'll be oriented with his left side to the mirror in his room so that he can practice interpreting visual information that way; he'll also be massaging his left arm and hand and holding it up where he can see it. After we told him that he is at risk for falls because of impulsivity he decided that he will never try to stand unless he is actually working with a person who has asked him to stand on "3", AND they have counted to "1-2-3". He stands out to me as the only patient who has ever commented specifically on the "physics" of transfers, something I think about all the time but don't usually mention as physics to my patients, and he can relate concepts and strategies in therapy to other things he has learned or observed during his life. During therapy he discourses intelligently on such diverse topics as genetics, obscure mythology, European history, theology, and philosophy (okay, he's a little distractible), and he's a polyglot- speaks 5 languages, including a hefty portion of my second language. In his off time he prays the rosary for the therapists and nurses.

The other reason he is fun to work with is that he is kind and gallant in an old school kind of way. He kisses everyone's hand at the end of a session, and tells his wife that we are his "best professors".

My other patient right now is the opposite of fun to work with. To start off with he is totally inappropriate for acute rehab, too high-level (read independent), and has no neurological deficts- being here to recover from hip replacement surgery; this type of patient usually goes to a short term skilled nursing facility. I'm not sure why on earth the docs thought acute rehab was a good idea, and though this is not the patient's fault, it means that every session I am wracking my brain to try and figure out something useful to do with the patient. I mean, everyone at acute rehab has to have 3 hours per day if we want to get reimbursed. But if that person doesn't really need me how do I ethically treat them?

To make things worse he is one of the most negative people I have ever met. Like my NFP he is from Europe but this is where the similarities end. He started our first session by talking trash about everyone from residents to therapists at the hospital where he had his surgery, they were all unprofessional and time-wasting. During a session with my PT colleague he and his neighbor expended energy in mild xenophobic ranting about the information in the halls being written in both English and Spanish, and how "those people" should be deported. He is not particularly venomous (to one's face) but is generally demanding and regimented, running the nurses ragged and wasting everyone's time with long stories about how he has been wronged in the past and why all the people he knows are not up to standard.

Everyone is rolling their eyes at this patient, but the special hell is reserved for me. He is a retired occupational therapist ... from an acute rehab setting. That's right folks, he knows his hip precautions, he knows how to use adaptive equipment to get dressed, he already measured his whole house and got the equipment that he wants, he's already arranged his kitchen to maximize energy conservation and work simplification, he's hired a 1xweek housekeeper, and has a couple friends helping with meals. The other day I was scheduled for 2 hours with him, an exquisite form of psychological torture. I mean, what exactly am I supposed to do with him? In the end that's actually what I asked him- after he told me knows all the ways that OTs waste time just to "get their minutes". I told him that (as he well knew) he wasn't really appropriate for 3 hours a day of acute rehab, and asked him what sorts of goals he thought I should write to be ethical within the constraints of the situation. Surprisingly, he was not offfended. He went home yesterday. Thank goodness.

War Is a Black Hole

2009-01-01T17:42:00.000-08:00

Women GIs marching at Des Moines. Image credit to "The Wac", click image for link.

During a recent low census week at rehab I had the opportunity of floating over to the main house for a couple of days. While there I did about a million quick and dirty evaluations, during the course of which I happened to meet a very unusual WWII vet. A woman! That's right folks, a female GI who goes by the name of Joe (okay, not really Joe, but another name that is usually a man's name but in this case is short for a more neutral or female name). Joe wasn't a land-girl, or working for the armed services here in the States. No, Joe was attached to Ike's headquarters in North Africa as a switchboard operator. She took French in High School and so was selected to be a translator. After a quick basic training in Des Moines, where she and some other women learned to march and took more French classes, they hopped aboard the troop ship Santa Rosa and sailed off. She was in North Africa until Italy surrendered or switched sides or whatever, then she was transferred to Italy. On their arrival a crowd of Italians cheered for them, and she and her fellow servicewomen were all blessed by Pope Pius XII.

Photo taken from "The US Army Transport, Santa Rosa" site. Click image for link.

85th Div. enters gates of Rome. Photo from SearchBeat.com. Click photo for link.

The other WWII veteran that I've worked with recently is an 88 year old man with a distant stroke and some recent health complications. He is tired. He is afraid of falling. He is a very friendly person, but seems a little depressed. I asked him, as I ask all my octogenarian patients, if he was in the service in World War II. He said that he was, in the Navy in the Pacific. I asked him a few questions about it but he said he doesn't think about it much anymore. He said: "I used to like looking at photos from the war, but I find I don't care for them anymore. That recent NOVA documentary was wonderful though". "Oh yeah?" I said, "what was it about?". "The most recent discoveries about black holes" was his reply. I guess he didn't want to talk about it.

Representation of a Black Hole from"black holes and quasars". Click image for link.

Contemplation

2008-12-22T21:17:00.000-08:00

I know I haven't posted in a while and I'm trying to think why that is. When I started this blog I was new at the job and overwhelmed by the intensity of human interaction. Also, every diagnosis was new and interesting. I found myself transfixed by the combination of fascinating new information about cancer, stroke, Parkinson's, dementia, addiction, obesity and the fascination of the intimate workings of people's lives. Work every day was like a supersolid version of life. Like heavy water (H3O), or suddenly suddenly being able to see the infrared spectrum on plant life. And my response to it was apiece. The raucous chorus of human emotions... joy, affection, fear, grief, pride, pleasure, curiosity, frustration, anger, love... turned up to an almost unbearable deafening roar. Or maybe more like a frenetic high-pitched whine, the kind spinning machinery or motors make before breaking into flying pieces of shrapnel. I think I needed to write so that I could stop rehashing the cases with my friends, my husband, my mother, myself.

Almost a year later this job has become a commonplace. It is not that I don't have all these feelings, it's not that I no longer find the diagnoses and symptoms fascinating, and I'm certainly still fascinated and honored by the opportunity to enter into the lives, fears, and hopes of these people- my patients. But the whole thing is tamer, not so intense. I no longer feel that something inside me is going to burst and take out half the room. I've managed to synthesize the experience to become an enriching and enjoyable part of my everyday life. So the need, the drive, to write it down has dissipated.

Is there is another reason for writing now that self-preservation is no longer an issue? I think there must be, because I miss seeing it and I feel vaguely guilty or like I'm missing out by not writing it down. What purpose could it serve, now that I don't need it in the same way?

A Word of Explanation

2008-12-22T21:07:00.001-08:00

To all those who read my blog: I get all my photos randomly from the internet so as to protect my own anonymity and that of my patients. They are loosely representational of an image I am trying to convey and in no way are literally connected to any story, anecdote, person, or place mentioned my blog. If you find yourself on my blog and you object then please write a comment and I will remove the photo the next time I log on.

On the Corner of Good Samaritan and Deliverance

2008-12-03T09:06:00.000-08:00

Okay, this is not a work story but it IS a story about bicycle commuting and it happened on the way to work.

On the second rainy day of the season I am riding to work down a fairly rural road (for my area). It has limited cell phone coverage. Of course I run over a medium sized rock while going about 30 MPH and instantly flatten my front tire. No problem, I carry a spare tube. Turns out I have the wrong spare (for my cross bike) it is too big and won't fit in road tire. Crap. Plan B is to repair the leak, not a problem as I have the supplies, it just takes a little longer. Turns out the flat is not caused by a hole but by a damaged valve stem. Not reparable. Crap.

Front wheel in hand I stand forlornly on the side of the road, looking pathetic and sticking my thumb out for a ride. Small cars pass and don't stop- who can blame them. Modern miniature, earth-saving SUVs pass and don't stop. Grrr... I feel judgemental. I snidely think to myself that these are certainly the kinds of people who bought their cars just to primly feel that they are doing their part to save the planet (let's not get into my feelings about "morality through consumerism"). These are the kinds of people who gaze at me in awe and assume that I am a more holy environmentalist than they are when I mention that I ride 9 miles to (and 9 miles back) work every day. They should stop for me. (For the record, this sentiment is totally hypocritical. While I won't go so far as to say that I could care less about the planet, the fact is that I ride my bike because a) I love to ride, and b) I use daily aerobic exercise to help stabilize my mood and mitigate the effects of mild ADD. I ride to work for ME, and if I ever stop riding to work I will feel no guilt whatsoever about the planet). Now, lest you think that people aren't stopping because it's "scary" to pick up hitchhikers let me just say that I didn't look like your average hitchhiker. I am a smallish woman, I have a nice bicycle, I am wearing my bright green cycling-visibility jacket and my rain gear, I am clearly a "normal"and nonthreatening person in distress. Plus the people on this road see me every day riding to work (which may be the actual reason they didn't stop, they all hate me for slowing down their commute every morning!).

Enough of that- the above paragraph serves simply to catalogue the thoughts running through my mind as I stood on the side of the road in the rain. After about 5 minutes and 15-20 cars someone finally stops for me. He is an archetype of the kind of person one should never hitch a ride from. In the horror movie about hitchhiking this guy would be cast in the role of the Bad Guy. But he's stopped in the middle of the road waiting so I say a quick prayer and toss my bike in the back of his pickup. Picture this: 1970's gigantic and battered blue Ford truck. With Confederate flags. The man is well over six-feet tall and built like a tank. His unkempt, long, and greying hair extends beyond his shoulders to mingle with his unkempt, long, and greying beard. I climb into the cab and the first thing guy says to me is: "you really have to slam that door, but there's not really a handle so people usually just stick their fingers through the crack in the window and yank (the window is slightly down)". I close the door. The next thing the guy says to me is: "My sister, God told me to stop for you. Jesus said if you got food you gotta feed the hungry, and since I got a truck and you need a ride I have to stop and help you out. I've got an opportunity today to do something for someone else". He said he could drop me wherever I needed to be "I'm homeless" he said, "I have no demands on my time today, so you tell me where you need to be and I will take you there". He drove me all the way to work and when he found out I worked at the hospital he showed me the big scar on his stomach where he had been stabbed. "I forgave the guy" he told me, "Jesus said to forgive and love your enemies, and he's right. If I kept that hate inside me I don't know if I could have healed, I don't want that poison in my mind and my body". He also told me a story about how 3 years ago he picked up another young woman cyclist who had just crashed her bike on the train tracks, "see, it's come full circle now" he said. Most of us think of "come full circle" as meaning that I did something nice for someone and now I get something nice done for me, can you imagine what the world would be like if we all thought of it like this guy? "I did something nice for someone and oh look! Now I get to do the same kind of nice thing again."

When he dropped me off I tried to give him some gas money but hepolitely refused saying that he had no needs or wants right now.

A Blast!

2008-11-20T11:11:00.000-08:00

I'm having more fun than I could possible have imagined being back at work. I work with great people and I love the patient care. Also, my patients this week are really fun.

One: Classic new york Jewish guy with appropriate old school New York Jew accent. Had a stroke, symptoms of which mostly are resolved. He's considering his end of life issues (though he's not dying, he is thinking about the fact that he doesn't have as much time ahead of him as he's had behind him). He's a little forgetful but very motivated to get home safely. He also has a very capable and supportive family who participate energetically in family training and carefully write down our every suggestion- I have to be very careful what I say and not prattle on humorously at them. The best part is that he croons Frank Sinatra songs in the shower, loudly. I enjoyed a pleasant morning this week, upon determining (through my expert clinical judgement) that he had progressed to a supervised level for bathing, just sitting on his wheelchair outside the shower curtain listening to throaty crooner tunes echoing through the bathroom and hallway.

Two: Middle aged man with metastatic melanoma (we get a surprising number of these folks). We're doing our same old song and dance: maximize independence, family training, functional mobility training, etc. But the guy is so at peace, willing to learn what he can, and he is so supported by wonderful family and friends. It is a real honor to work with them to make a solid discharge plan that is taking this whole support system into account. Incidentally, this guy has chronic dizziness seconary to a tumor recently removed from his cerebellum- I was able to teach the visual anchoring technique that I learned months ago from one of our other OTs. It worked! I feel effective.

Three and Four: Two, count them, two local oldsters with recent heart surgery and subsequent complications. Both fascinated by work simplification strategies, energy-conservation and self-pacing techniques, and diaphragmatic breathing. They go through their morning self-care routines or a spot of light housework/meal prep, following my guidelines then look at me in delighted surprise and say "wow, that certainly feels a lot better!" or "I didn't know I would be able to do all that". Ahhh... satisfaction.

Five: Older woman with Downs Syndrome (I know it has a different name now, but I don't feel like looking it up) who has had a stroke. Aphasia and hemiplegia. Really difficult. But I was surprised to discover that she is almost easier to work with than someone who was more cognitively intact to start with. She is used to following simple instructions, trusts her family caregivers implicitly. She also doesn't seem to have the ability for complex fears/anxieties related to distant perception of self-in-the-future so she doesn't seem to get paralyzed by depression or a sense of "what does it matter". More than many patients she is very much "in the moment" and is therefore surprisingly able to participate in therapy and try things. She also has more carryover/recall than I would have expected. Very interesting and engaging case, not least because my background is with young adults with developmental disabilities so I get a chance to combine my old knowledge and skills with my new ones.

Perplexing: You've maybe heard that communication is 10% words and 90% non-verbal. I was shocked to observe this in practice during our case conferences with patients and families this week. Dr. Jones was on, we were having a conference with a man whose son was coordinating all his care upon discharge. They were a family of finicky, detail oriented, somewhat anxious people. They asked very good questions and wrote everything down, but it was clear that the son was worried we would discharge dad too soon. Dr. Jones answered all his questions carefully, gave clear reassuring information, explained the rehab process, described the thorough home follow up he could expect, everything clear and thorough, all reassuring information. Yet somehow managed to give the impression that he was shining them on. In fact, everything about Dr. Jones' interactions screamed "I am not telling you the whole story, I am just trying to say what you want to hear so that you will take your dad home in 3 days". But he wasn't. He was telling the truth, the whole story, the dad really will be ready in 3 days, and he really will have sufficient support once he gets home. It was so weird to watch the misunderstanding and irritation growing on both sides and not be able to redirect it.

I've been puzzling ever since about how a person can communicate truthful and positive information while managing to convey haf-truths and a total lack of interest in a positive outcome... I mean, imagine if Dr. Jones could figure out how to invert that... In the meantime, we're going to fix this guy up and do a great discharge plan and probably still get an angry letter about a bad job. I am really perplexed by this.

Home Again

2008-11-16T08:55:00.001-08:00

I've just finished my first week back at work. Interesting perspective one gets after being gone for a while.

I got a little boost to combat my imposter syndrome as all co-workers, doctors and therapists and nurses, very vocally delighted to have me back. Saying nice things about my presence tangibly improving the positive atmosphere and sense of collaboration between disciplines. Very nice to hear as this is part of my plan at work. I try to explain this to people but they think I'm kidding. "Oh, that's good to hear" I say, "I spend the whole ride into work reminding myself to hum and sing in the halls, smile at all my co-workers, and refrain from sarcastic joking (all too easy if one forgets oneself)". You may think this is all a little too sicky-sweet, but I'm thinking that if I lay a foundation every day of pleasant mutual respect it will encourage interdisciplinary cooperation as well as facilitate big changes that need to be made on the unit. Or at least I won't be bringing people down...

Some administrative drama when I got back, one co-worker in particular (lots of experience, floated over to the unit to support them while I was gone) very pushy about his ideas of what should change- equally agitated about all problems/concerns, and starting lots of hares simultaneously without consulting other therapists or the lead on the unit. Sincere and intelligent man, skilled therapist, sometimes pain in the ass. That's the most flattering assessment. Slightly less flattering assessment involves control issues, wanting to be the most important person in a given setting, and liking to have fingers in every available pie whether appropriate or not. Suspected this therapist would like to split me off my team as my team is working really well together and having an influence. Before I left I requested that my boss, my lead, my PT team co-leader, and this therapist wait until I returned before making major decisions about my career. I was totally nice about it, and felt a little embarassed for being so paranoid. But according to my PT team leader he did try, in a nice "wouldn't it be better for everybody if..." way. Tried to rearrange all the teams without talking to the lead therapist. Nobody went for it so my job is safe for now.

Anyway all this drama to hear about the moment I got back, mildly entertaining, but not very inspiring. Then I got to go start treating patients...

That was fun. I've been getting so into the daily routine of work that I hadn't stopped to think about how much I like the actual one on one patient time. I mean, I know I like it but I get busy. So I've been enjoying myself all week with my interesting people. Pulled all my research about sleep cycles out to help a guy get back on a regular sleep schedule, trained a reticent husband to help his wife walk safely, educated a whole family about shower setup. Little stuff, but total nuts and bolts of the trade. Super fun. Fufilling. Glad to be back.

Lag

2008-10-01T23:28:00.000-07:00

Sorry to all my faithful readers about the dearth of posts, I'm leaving for an extended foreign vacation in a few days and have been spending much of my time in planning etc.

Here are some snippets:

The whole increase-productivity-but-don't-work-overtime plan is going along swimmingly. It's like I've had a total epiphany and can now work efficiently. I'm not sure what happened, but it is such a relief. Other good news: we've finally hired another OT, she is super sweet and very perky (more so than I am, in fact), she is also a new grad thus very gung-ho. She will ease the workload further. Fun-fun.

Last week's cooking group: Friendly and sociable head-injured-alcoholic lady, totally not oriented to place or activity, attempting to carry out conversation with ridiculously gregarious spanish-only patient. Translation of non-sense to not-listening and back again provided by very introverted bilingual patient. As I speak spanish and was able to hear all sides of this conversation, I of course had to step out of the room before I embarrassed everybody with my uncontrollable giggles.

Conversation at rounds:

Background: I have gotten several impressed comments from the docs about my vocabulary. I don't normally mind this kind of thing except that they act so surprised that I would use words like "infirm", "pique", and "cognate". My dillemma is that these are such mundane words that I don't know if I should feel insulted or sorry for them, and I definitely feel tempted to simplify my speech. After much soul-searching and a few conversations with my PT co-team leader about Being Oneself I decided to just go ahead and talk like I want to talk and let people ask questions or be impressed as appropriate.

Thus I found myself in the following situation in rounds. Doc Jones talking about our new patient and explaining what a craniotomy is- surgery removing part of your skull, which is then stored in the cryogenic freezer for 6 months or so until the swelling in your head goes down enough to stick it back in- I say "oh I get it, like modern day trepanning". Crickets. 9 blank stares. "What?" says the doc. "Modern day trepanning", I say into the silence. More crickets. "You know", I plead desperately, "the ancient practice of drilling holes in the head to let out the evil spirits". After a slight pause Doc Jones says witheringly "I guess, except there's no evil spirits". Now what could I possibly say to that? I mean, duh. So I stick my nose in the air and say huffily "well obviously not anymore, they removed half his skull". Doc Jones was not amused, but the speechy and my PT co-team leader were turning red and tearing up trying not to laugh, so it wasn't a complete loss.

Oh, I almost forgot! I recently had multiple back and forth emails with the head of security and the editor of the hospital newletter (he wrote an article encouraging more staff to bicycle commute in which he quoted the head of security as stating that bike parking at the hospital is totally safe- I, of course, had to take issue). In one of my emails I suggested a bicycle cage with access only availabe to certain people as a safe option that was less expensive than bike lockers for all. And it's happening! It just came out in the most recent newsletter. Now, they're not crediting me, but I don't care as long I don't have to fight with security guards about where to put my bike anymore. Yay!.

Challenges

2008-09-23T20:46:00.000-07:00

New spinal cord injury patient OR the longer I work here the less I think motorcycles are a good idea

Here is one reason I am so glad that I work where I work: support. This guy has a diagnosis I have never worked with before. He's an incomplete quadriplegic. What this means is that he does not have a total loss of sensation and motor function to all extremities. When he first had his accident he had not sensation or volitional movement below a shoulder shrug. We're talking ventilator and feeding tube. But he has what's called a "central cord syndrome" so some sensation and mobility is starting to come back, mostly in his legs. Imagine how weird that would feel- Dr. Smith called it "classic 'man in a barrel'".

This is a cross section of the cervical (neck) spinal cord. The red area is what is damaged in someone with Central Cord Syndrome

He presents a real challenge for me because I don't know what to expect, and I'm having to think way outside my box for things to do with him therapeutically because he is so completely dependent. I mean, I have some ideas, but I'm not totally confident that I'm not barking up the wrong tree. So in addition to googling things and reading some journals, I call my boss (who used to work at Rancho Los Amigos), and she comes down, helps me plan my goals, and gives me 1:1 assistance with the guy. I am learning SO much. One thing I've gotten to use is a deltoid aid or mobile arm support to suspend his arm against gravity, then he can use the tiny bit of muscle strength that he is getting back to do stuff, functionally. Or at least he can start moving his arm so that it can get stronger.

Something I learned about myself is that I can get annoyed by dependent people. I mean, this guys is literally dependent. As in, "can you scratch my nose", as in "I can't actually spit out the phlegm I've just coughed out of my lungs without help". After an hour treatment, no matter how polite the guy is, I find myself irritated by all his needs. Isn't that funny? (That's funny weird, not funny ha-ha). Maybe it's a part of the American "bootstrap" cultural value, that we really don't respect being needy. Or maybe I just have issues. In any case, now that I'm aware I can be on my guard and so remain professional and non-bitchy. A worthy goal.

This is the only picture I could find of someone actually using a mobile arm support (not a deltoid aid, but similar idea). See how it supports his forearm, and has a little counterbalance action so that he can bring his drink up to his mouth.

Other Challenge: Resist the urge to become wittily sarcastic just to show off my vocab and repartee smarts to the wittily sarcastic doctors who like to think that they are the only ones with repartee smarts. Just don't do it. It is not my best self. It does not foster teamwork. But I am really good at it... just, you know, for the record.

It's Working!

2008-09-20T09:50:00.000-07:00

My plan to be more efficient worked out great. Even though I still have 9 people on my caseload I only worked overtime 1 day this week. I'm so stoked. It CAN be done. Here are some things I did with my spare time: sushi with a friend, rock-climbing with a co-worker, swimming, coffee with my honey.

Learning Curve II

2008-09-13T08:53:00.000-07:00

With keeping up with my daily treatment schedule- I am allotted 7 minutes from every treatment session for charting. (The fact that this is not really enough time is a subject for another post). If I'm scheduled for half an hour I can leave the room after 23 minutes, an hour- 53 minutes, etc. What really happens though is that I end up staying the whole half hour or hour or whatever, then end up behind and having to do all my charting at the end of the day... when I can barely remember what happened. Substandard charting ensues. The solution came to me three days ago while I was riding my bike: Treat each session like it's 15 minutes shorter than it really is, then when it takes me another 7-8 minutes to get out of there I still have that 7 minutes left to chart.

With using my skills- I had a patient this week who had just suffered a third stroke. Not only that but he has an old brain injury. He's been fairly independent at home, and wants to go home independently again. He probably can, but a combination of disorganized thinking (from his brain injury), a somewhat manipulative personality, and a tendency to cover both by displays of snotty irritability and casual joking, have made planning a safe discharge confusing to say the least (and a serious pain in my ass to say the most). It took me a week and a half to figure out that he is telling a different story, or different pieces of the story, to all the different therapists/nurses/doctors. And he tells it all with the implication that whoever he is talking to now will be able to help straighten it out, then tells it differently the next day to the next person. When I finally figured this out I pulled out my skills from working with the teens with behavioral disorders and brain injuries/developmental delay/etc. Before working with him I talked to his nurse and read carefully the nursing notes from the day before: thus all staff on same page. Then when I worked with him I wrote down every point that he wanted resolved and the solutions we had come to. Each time he got off track or angry (intentional obfuscation? doesn't matter) I found my happy center and waited 'til he was done, then back to the topic at hand. At the end we reviewed what I had written, made a copy for the nursing station, then taped the original to his wall. Thus all staff still on same page. It helped.

With delegating and collaborating- Same patient. I need to order equipment for him. Couldn't/wouldn't give me consistent information about his home setup, declined a home visit, refused to let me call friends or family to get information about his home setup. Technically, I have done all I can- people can refuse treatment, I just chart these interactions to cover my own butt. However, covering-my-own-butt is not, shall we say, a noble goal. It is not a feather in my therapeutic cap. Plus, as team leader I am supposed to be coordinating a safe discharge, and it seems weird to say "well the head-injured guy with the frontal lobe stroke (affecting judgement and planning) told me it would be fine... so how was I supposed to know there might be a problem?" A flash of brilliance, I asked the discharge planner what I should do, can I call family anyway, etc. He was able to follow up on one detail, then reminded me that the pt. would be followed by home health, not just shipped out to fend for himself. That was a start, then I remembered: "hey, I'm part of an interdisciplinary team here". So I met with my boss (a PT) and the speech therapist who is on my team (speechies also work with cognition), and asked them what was the best way to follow up. Conclusion- speak directly with the home health therapists who are going to be working with him, explain the situation, and ask them to follow up on the specific concerns. Done in 5 minutes, documented in the discharge summary. No stewing at night, no worrying that I let a ball drop.

I'll figure out how to not work overtime yet!

Things I Heard at Work this Week

2008-09-13T08:34:00.000-07:00

From a little old lady who fell and got a head injury. She comes to us following surgery to relieve pressure from the bleed in her brain. She is nice, but very confused. Earnestly:
"Yesterday was a hard day because it was the anniversary of my husband's death. My son and I spent the day together. So if you see him in the hall here would you tell him I need to ask him some questions?"
Me: "See who? Your son?"
Patient: "No, my husband."
Me: "I thought you said he passed a year ago."
Patient: "That's right, so if you see him make sure he knows what room I'm in."
I tried two more times, then let it go.

Older gentleman with a stroke. He is pleasant enough, but defnitely tired and just a little flat affect. In making conversation, I asked him what he thought about the presidential campaigning going on right now. His response:
"I think you'd make a terrible president."

...hmmm.... compliment? we'll take it as such.

Defining My Terms

2008-09-07T21:41:00.000-07:00

Homonymous Hemianopsia: The visual field from one side or the other is cut. Not the view from the right or left eye, but the right or left visual field- from each eye-

Paris as seen with full visual field

Paris as seen with right homonymous hemianopsia

Receptive aphasia: Difficulty understanding speech, spoken or written. May be complete, making it impossible to understand words at all (and by extension, many abtract concepts), or only partial just making comprehension difficult. It could even affect only visual comprehension, such as happened to Howard Engel, The Man Who Forgot How to Read.

Ranging: Short version of "Range of Motion" (ROM). A term used to describe putting a joint through it's paces . It can be done Actively (AROM), so that a person can increase strength, flexibility, and neuronal connections between body and brain. It can be done Passively (PROM) to prevent contractures (shortening of the muscles resulting in decreased flexibility). Anyone spending too much time in bed should be sure to range their ankles to keep their toes from getting too pointy, their hips so that they can sit upright, and anyway... they just shouldn't be allowed to stay in bed for so long. PROM is especially important for the affected side of a person who has suffered a stroke. The stroke often creates abnormal muscle tone, usually in the form of excessive flexor tone, which means the curling up muscles go unopposed by the opening up muscles, resulting in a fist, flexed wrist, bent elbow, internally rotated and adducted shoulder. It's called a flexor synergy. If a person goes unranged the flexor muscles will shorten and it will become difficult and painful to regain flexibility. If/when the brain comes back online with that side of the body, the patient will have lost significant functional use of the arm, the back and shoulder will be out of line at risk for injury and definitely painful. This is how a person ends up with that classic stroke arm look: hand and wrist flexed, elbow bent, and the whole arm stiffly pulled awkwardly in front of the chest.

Pusher's Syndrome: Someone with a stroke often can't find their midline. When sitting upright they might feel like they are leaning over too far to one side (usually the good/unaffected side). Afraid of falling over and forward, the person will push hard with the unaffected arm to keep themselves upright, they usually push backwards too by straightening their legs. This ironically makes them fall over to the affected side and backwards. Gentle support on the affected side usually triggers increased pushing until you find that you are fighting the patient with all your own balance and strength just to keep them upright. As a newbie, I usually wait until my back muscles start to scream and I'm dripping sweat before remembering that the best thing to do is let a person push themselves over, then have them straighten up, then the other way, then straighten up, then remind the person about how their brain is getting incomplete and incorrect signals from their body. Try to retrain their sense of balance, midline, spatial orientation.

The Tao of OT

2008-09-06T09:18:00.000-07:00

Some interesting neuro patients-
It's one thing to know all about homonymous hemianopsia and hemi-neglect, it's another thing entirely to work with a person who has both, coupled with mild receptive aphasia making it very difficult for her to tell herself a story about what she needs to do to compensate ("scan, look right, go slowly, look before you walk..."). And it's really strange to watch someone peering intently at where they think the right side is, when really they've just barely managed to look straight ahead. We put her in a right facing room so that the majority of the stimulus would be coming in from her affected R side. A week later they needed the room for someone else and switched her to a L facing room. Should have been fine right? Her L side wasn't really affected... Ha! Not even, poor lady couldn't find anything at all, she was so turned around and backwards she was nearly in tears. She was worried she was regressing or going crazy, maybe having another stroke. We spent an hour practicing finding your way around in a new environment, safely (good thing we switched her room). Then I did some family training about the same thing. She said I made her day, so that was nice. :)

Guy who came to us six weeks after onset of major stroke. The notes from the original hospital's therapists say that he was too impaired to be appropriate for therapy for the whole six weeks. It looks like nobody ranged him or even worked that hard at positioning. His R side flexor tone is so strong, especially upper extremity, that it's work to open his hand, and his shoulder is stuck in internal rotation and adduction, with an totally immobile scapula. Moving his arm more than 30-40 degrees in any direction hurts him. I'm so glad I have two OTs in outpatient with neuro-ifrah experience to call on for support.

And finally: Pusher's Syndrome... Good Lord! I get my morning workout just having someone sit at the edge of their bed.

Another *obvious* thing that I knew-but-didn't-know
People don't come to neuro-inpatient rehab with a pure heart, only focused on therapy. They come with their baggage, and their learning style, and their awkward family dynamics, and their mental illness/personality disorder, and their varying levels of mistrust about authority/the man/bureaucracies/etc. People are rude and demanding, and scared and frustrated and depressed. They know their bodies and lives better than you and they may or may not be interested in working with you on any given day. The doctors occasionally wag their fingers admonishingly and say things like: "We're too nice to our patients, they need to treat us with respect and just focus on therapy." Silly doctors. If only it were that simple. Some patients have the emotional tools to play along and stay focused. But for others building and maintaining a rapport, helping a patient interact more effectively with other staff, is absolutely essential to getting them to participate in the "real" therapy. You can't fight it, you just have to flow with it. The Tao of OT.

Overtime

2008-09-05T21:45:00.000-07:00

WORK: work work work work work work work work work work work work work work Work work work work work work work work work workwork work work work work work work work work work work work work work work work work work work work work work work work work work work work WORK WORK WORK chart chart toilet toilet dress dress transfer transfer Shower shower shower shower evaluate evaluate evaluate work work work work work work work work WORK WORK work. Shoot me now.

Now THAT'S How it's Supposed to Work!

2008-09-03T21:14:00.000-07:00

About 2 months ago my team had an elderly man with paraplegia to work with. He had his accident about 30 years ago and had been living independently in a small apartment ever since. Like most elderly folks, his ability to do things safely and independently was decreasing as he got weaker and heavier. 6 months before he came to us, James had fallen transferring into the shower and broken his leg. He went to a nursing home to recover and ended up there for the next 5 months. By the time he got to us he had major pressure sores on his butt, and seriously believed he would never be able to go home. He was too old, it was too hard, he didn't think he could return to his old routine (his slideboard transfers were a major cause of all the sores because the arthritis in his shoulders meant he was no longer able to lift himself enough to protect his heinie during the transfer), he doesn't have any family that can help...

Now, we have lots of possible solutions to these types of situations (that's why we're rehab), but this guy was looking at his future through the wrong end of the telescope and the light at the end of his tunnel was very far away and not that bright. Prone to depression, and very detail oriented, he was easily overwhelmed with all the new things he needed to learn and new people he needed to coordinate. Also, the new skills (lift transfers instead of slideboard, power chair instead of manual chair, etc) represented a tangible loss of independence and function that he found depressing. At least every other day James would ask me if I thought it was even worth bothering with, "Maybe I should just give up", he would say "I don't see how this can work".

Bit by bit we talked him into trying 1 new thing at a time, commode chair instead of toilet, power chair instead of manual, hiring help for morning and evening to save his energy, using a timer to remember his pressure reliefs (so he would not get new sores). My coup-de-grace occurred when his first hired caregiver quit 2 days before discharge because she was a lazy and money-seeking individual who didn't really want to do all the work he would require (she wanted to do laundry and cooking, but not help with a bowel program, for example). That same week we happened to have another patient who had just suffered a 3rd stroke, his highly competent caregivers (a mother and son team) were there for training, and I grabbed the young and energetic son, introduced him to James, had them both talk to the discharge planner/case manager, and voila- they were there for training and went home with James as a new client.

Now, 2 months later his power wheelchair has finally been approved, and my PT co team leader went out to his house for a fitting. James is doing great! He has no new sores, he has no depression, he is up and excited about life. The young caregiver guy was there and it was obvious that they are actual friends, they go to movies, they hang out, they like each other. James apparently kept saying "you said this would happen, I just couldn't imagine it working so well". He was already planning tomorrow's outing in his powerchair. "I'll finally be able to get my own groceries again" he said.

The interesting part for me is that as he got older his life really had been getting narrower and narrower. He wasn't going out much anymore, daily activities were getting harder and harder. Then he finally hit the moment that represented rock bottom, needing to hire help to get dressed and out of bed in the morning, and it turned out to be a door that opened his life up to fun and people and possibility again... there's gotta be some kind of moral here.

Super Powers

2008-08-31T09:39:00.000-07:00

An unexpected consequence of working at rehab is that I now have 2 new superpowers.

The first one is a sort of ESP or premonitory awareness. When I see you on the street I get an immediate sense of how hard you will be to transfer when you have your stroke. I don't think about it, it just comes to me. I simply observe your size, how you move, probably a whole bunch of other factors I'm not aware of, and there it is.

The second one is X-ray vision. That's right, I can see you naked. This is not as great a superpower as it might seem to be. Especially because it works best on those of us who are, shall we say, past our prime. When I see you I know what you are hiding under that flowing dress, where the extra roll is under those high-waisted pants (and what it looks like), the extra flappy skin and dangly bits are as obvious to me as if you weren't wearing any clothes at all. The wrinkles and stretch marks, how low your boobs actually hang, everything but the particulars of your moles. It's not gross, people are interesting, but it's extremely not exciting.

A word of warning:
Working at rehab has also made me aware that most of us engage daily in a very dangerous activity. When I see my husband do it I have to bite my tongue to keep from warning him to be careful. That's right folks, I'm talking about showers. Every morning we stumble, half-awake and barefoot, into a poorly lit and cramped space. We run hot water- making the floor slippery and putting ourselves at risk for a dizzying drop in blood pressure. We cover our bodies in a variety of substances which when rinsed off add to the slipperiness of the floor, then increase our dizziness and disorientation by stumbling around with our eyes closed tightly to keep these substances from getting in our eyes. With no concern for safety whatsoever, we will even stand on one foot just to ensure that we've managed to rub slippery soap on the very bottoms of our feet, first one and then the other. But worst are the women, who stand on one foot with conditioner in their hair, soap all over their bodies, hot water running, and play with razor blades. Sometimes I wonder how any of us live long enough for an OT to even get the chance to order us a shower chair.

Unexpected

2008-08-22T09:53:00.000-07:00

One of my patients this week is a 70-something, wizened, little old Chinese lady. She and her very cute husband have been in the U.S. for 30 years. They dress to the nines, really like each other, have stereotypical accents, and are very polite. She's in end-stage organ failure (I won't say which organ), and is on the list for a transplant. But it probably won't happen in time. Anyway, she is already weak from her condition, then was recently made weaker by a prolonged ICU stay. She's with us for a week or two to get some strength back, and for her and her husband to learn strategies and solutions to simplify her care so she can go back home for as long as she has. She is very sweet and fun to work with. Yesterday she heard me whistling and commented that she likes music and likes to hear people sing and whistle. "You can trust someone who likes music" she said. When I asked her what kind of music she likes she paused and regarded me seriously for a moment, head tilted to one side, before pronouncing decisively "ABBA".

Then she sang a couple bars of "Chiquita". I 'bout died trying not to laugh.

You've Been Warned

2008-08-20T23:00:00.000-07:00

When you, otherwise healthy and with no stroke risk factors, have a sudden and inexplicable hemorrhagic stroke (for those of you tuning in late that's the bleeding kind, not the clotting kind), do go ahead and get that follow-up MRI recommended by the doc for several weeks after discharge. It turns out that sudden and inexplicable strokes are often actually quite explicable (though still sudden), but their causes are obscured in initial MRIs by the mass quantities of blood pooled in your nervous tissues.

Some causes of hemorrhagic stroke:

aneurysm

arteriovenous malformation

brain tumor; basal ganglia

As it happens, my really cool patient from several months ago, the one whose family sent the awesome brownies, had the basal ganglia brain tumor. I just found out he died. Here is what I wrote about this guy back when I had him:

May 18, 2008
A new addition to my caseload. Older guy who came to town from distant parts to visit relatives, then had a massive L hemisphere hemorrhaegic stroke, and now is stuck at rehab for a few weeks until he is strong enough to fly home with his wife. For review: L hemisphere of the brain means aphasia and R side weakness/paralysis, and neglect (he actually only shaved the L side of his face, something I've only read about but never seen), as well as some general apraxias and some difficulty with problem solving. This guy is getting some tone back in his leg, but so far his right arm is almost completely flaccid, though he is starting to get some shoulder muscles back. He can accurately nod yes/no until the questions get really complex (like double negatives or questions with syntactical complexity such as "is your neck above your head?"). According to the speech therapist only this guy's expressive communication is messed up, his receptive communication is fine and the reason he gets confused by complex questions is that to answer them one must repeat the question in one's head, thus using expressive communication.
Anyway, this guy is really cool and nice. He is getting better at taking care of his arm when sitting or lying down, but he still really struggles to remember it during activities like bathing, dressing, or transfers. After multiple reminders to guard his arm I told him that some people with stroke say that their affected arm doesn't feel like it belongs to them, that it's hard to care about what happens to it because it is not theirs. He nodded so vigorously I thought he might give himself whiplash. I suggested that he think of his arm like a puppy that needed to be taken care of and watched to make sure it didn't get into trouble. He laughed.
I also asked him if he was pissed about having a stroke. He nodded vigorously at this as well, gritted his teeth, and rolled his eyes. I usually ask people about this aspect of recovery because I think it easily goes unaddressed in a rehab setting. Most patients are very eager to acknowledge their feelings about their condition. Even if they have aphasia and can't really say much about it."

May 28, 2008
"New left hemorrhagic patient is making lots of gains. He can spit out a few more words spontaneously, and is now able to answer forced choice questions if you supply the choices and give him lots of time, for example: "when you put on your shirt, which arm will you dress first, the right or the left?"(this is relevant because dressing with hemiplegia is easier if you dress the affected side first). I've also noticed that if I just say "put your shirt on" he's thinking about getting dressed and gets a bit frustrated if it takes a long time. On the other hand, if I point out that putting on a shirt is also brain training for sequencing, spatial awareness/relationships, and problem solving- and that it is helping to reconnect a variety of neuronal passageways- he is thinking about the process of recovery and has much more patience and greater success. Health through occupation, baby! OT is awesome!"

I am sad.

Groups

2008-08-18T21:37:00.001-07:00

Tried my hand at running a group last week, along with the speech therapist. I was a little intimidated by the whole thing, but it was actually pretty fun.

My previous experience with running groups was exclusively in a mental health setting, where the clients had to attend or lose their housing. As you might imagine, they were less than willing participants and getting them engaged was a lot of hard work for me (coercion is not a good motivation strategy). I have dim memories of 60 minutes of working like a dog to keep people engaged, and focused, then also having to initiate every conversation for them. I am an extrovert, but that was way beyond my powers, not to mention energy level.

So, I was nervous about the group. But it was definitely a bird of a different feather. It was a cooking/light meal prep group with 6 folks who had all had strokes except for one guy who had a brain injury. Some of the things we worked on in the group were:

sequencing
problem solving
attention to task
safety awareness
incorporation of neglected/affected side into functional task
introduction to adapted kitchen utensils and kitchen setup

This went great, and the group folks were definitely interested and actively involved. But the best thing was how they all talked to each other. "Why are you here?" they asked, and "how did you get help when you realized you were having a stroke?", then on to a discussion of hemi-neglect and the frustration of not being able to move one arm, the fear of not being able to be how they were before their stroke. They didn't need me to keep the conversation going, and in the end they were all really excited to have met other folks in their same predicament.

I can't wait to do more groups.

Saving Face

2008-08-15T20:38:00.000-07:00

It seems that work this week has been rife with opportunities to change, along with all the accompanying awkwardness, embarassment, and defensiveness that often precedes change.

Myself and a patient- I had a patient this week who I really struggled to connect with. It was the first time since I started at rehab that I had my buttons pushed by someone. Dealing with a chronic illness complicated by a stroke, he second guessed everything during the evaluation, and ended up shouting at me that I should quit my job because I am a terrible therapist- in the middle of a transfer (moving from one surface to another). I felt my blood pressure rise, I felt my chest tighten with anger, I felt that the middle of a transfer was no time to respond. I stayed calm, we completed the transfer and the shower. At the end of which we had managed to establish a shaky kind of rapport. I found the guy difficult and demanding. I considered doing a staff switch, setting the patient up with a different primary OT. But the next day I realized that the patient felt confident with me, that remaining calm the day before had allowed the patient to save face, and given him time to begin re-evaluating his goals for rehab. I decided to suck up my own irritation and give it another try. The patient's confidence in me allowed me to save face and gave me a chance to change my attitude.

Interestingly I started seeing how the guy was pushing a lot of buttons, CNAs, nurses, even one of the doctor's. Then he was getting the ol' eye roll/lecture treatment strategy which was exacerbating his distrust of the system, and subsequent negative and argumentative attitude. I talked with the ST and the PT about approach and communication strategies that might help, then the three of us took the responsibility of casually bringing it up with other staff as appropriate. Not like we're telling them what to do, but like we're letting them in on a secret tip (which I guess we are). Patient is now bought in, no outbursts in 5 days, participates actively in therapy. It's not perfect, but it's going much better.

Dr. Jones
One of the patients reported feeling weird that the Dr.'s all stand behind a podium (it's actually a little cart full of charts) when they come for rounds. They said it made them feel like the doctors were keeping themselves seperate from the patients and also that they had some sort of major ego trip going on (no comment). I brought it up in rounds for two reasons: 1) it's really funny that the patient thought that the chart cart was a portable podium, 2) maybe we could stand next to the cart, since it's not really a podium and we don't need it in front of us. Dr. Jones laughed it off dismissively saying "it's only one person, and basically... I don't care". I'm irritated at being dismissed, but I drop the subject. Dr. Jones goes into the first room for patient conferences, leaves the cart behind, and walks right over to the patient. By not belaboring the point I allowed him to save face, then consider changing without having to admit that this is what he was doing.

Discharge planner - This guy is really hard for me to figure out, and to work with. He doesn't like to put himself out or work too hard. He's managed to delegate huge portions of his job to other disciplines and acts all long-suffering when asked to do things like contact social services for the subject of my previous post. So: homeless guy with brain injury and no local family is needing some help with a discharge location. OT happened to have information from local homeless health services (HHS) representative who contacted us regarding this patient and are willing to do some quasi supervising of him for a few weeks after discharge. Passed this info, along with the guy's card, on to discharge planner during rounds, at which point he says "Oh, so-and-so from HHS (eye-roll), I already talked to him, he's not helpful at all". Totally dismissing me in front of the doc and acting like I'm stupid for bringing it up. I'm annoyed, but I let it go. Next day, discharge planner tells the team that he spoke with "so-and-so" and they are willing and able to provide some supervision and assistance with meds so we might be able to do a safe discharge to the shelter. Like it was a brand new idea and plan he had just worked out. The doctor was all excited, congratulating the guy on some good discharge planning. Are you kidding me?! I let that go too. If I let the discharge planner save face he does his job better.

Sometimes I feel that allowing people to save face is dishonest. Sometimes I feel like it's just politic. Sometimes I get frustrated that letting people save face often involves some self-effacement on my part. Sometimes I think letting people save face is a gracious act, made easier by self-confidence and a genuine positive regard for the humanity of others. I certainly feel that way when others allow me to save face.

A Bad Discharge Plan

2008-08-15T20:25:00.000-07:00

Newly disabled, requiring assist with most self-care, no insurance. Adult children willing and able to be trained to help out regularly. But only if patient moves back in with ex-spouse. They won't have anything to do with the patient if patient stays with new significant other. Patient left spouse several years ago when could no longer tolerate being battered. New functional status forcing patient to choose between family and significant other... patient chooses family. Family educated on legal responsibility to dependent adult. Social services to follow.

Denial

2008-08-05T21:26:00.000-07:00

With Drinking- In addition to its other detrimental effects, long term alcohol abuse has a negative effect on your immune system. I did not know this. Apparently, while you are busy pickling yourself your body quietly stops working. What this means is when you bash your shin on the step ladder in the garage,you don't simply get a nasty gash and bruise, maybe a hairline fracture. No, instead you develop multiple abcesses (abcessi?) which eventually require surgery and major anti-biotics, and weight-bearing precautions (ie: don't put any weight on that foot). This is a problem if you live alone in a house on a hill with 20 steps to get into it. It also means that when the doctor tells you that the excessive drinking is preventing you from being able to heal, you adamantly insist that you only drink a couple of beers a day. This is what you tell everyone who will listen. "I don't know why they keep saying it's the alcohol" you glower, "I only drink a couple of beers a day". To keep this denial going, it is crucial to disallow visits by friends who know your habits and will say things like. "Yeah, Bob only drinks a couple of beers a day, but you know Bob, I don't think it's the beer, I think it's the gin... and the wine."

I told the guy he would die a painful, limb-falling-off death if he didn't stop drinking. I told him that his body couldn't compensate for the abuse anymore, that it wasn't an issue of right or wrong, but of being aware of his options and facing the consequences of his decisions. "No one can tell you what is right for you" I said, "only you can decide if it is time to get help or not". Then I left him with his tattletale friend. It would be a funny story, except it isn't.

With Smoking- Lady with recent back surgery and poor safety awareness keeps sneaking outside to smoke. Nevermind that she is taking meds for smoking cessation ("why do I keep feeling nauseous after I smoke?"). Chatting with her nurse and me about smoking and quitting, the nurse says something about how she quit after watching her grandfather die slowly from emphysema secondary to smoking. "It was awful to watch" she said, "it's like he was literally suffocating". Smoking lady responds with "Oh, I know. That's how my husband died. After he got sick I wouldn't let anyone smoke in the house. Even if it was raining I would go outside to smoke".

With Work- I really like my job, I really like my co-workers, I really like my patients. So I don't mind when the census is high and we're understaffed and I end up working overtime everyday for 2 weeks. And it certainly doesn't bother me to work 10 hours with no lunch break on rounds day.

Exercising Restraint

2008-07-29T22:15:00.000-07:00

Haldol- From the first generation of antipsychotics, Haldol (haloperidol) is a drug with a lot of history- good and bad. Haldol does provide relief from some psychotic symptoms, but it also has a huge sedative effect. Haldol often works for people when other anti-psychotics don't. People on too much Haldol stand there and drool. 10 inch strands of spittle. Just hanging out of their mouths. Haldol also has some major unpleasant side effects (besides the gorked-out drooly one) such as stiffness, tremors, decreased attention, lethargy. Like some other anti-psychotics, people who take Haldol for an extended period of time (like months or years) may have permanent nervous system effects called tardive dyskinesia. Haldol is not inherently evil, many people take it because it is more effective for them than other anti-psychotic medication. And Haldol taken in the short term doesn't have long term negative effects (as far as I know).

That said, in my setting Haldol is very occasionally used as a chemical restraint. In other words, if someone is agitated, combative, or non-compliant to the point that they are a danger to themselves or to someone else, restraints might be appropriate. Like other kinds of restraints, chemical restraints are only supposed to be used if someone is in danger, or endangering. For example, Haldol might be used with someone disoriented in ICU who keeps trying to pull out their trach tube.

That said, in my setting what constitutes "dangerous" is somewhat subjective. Thus, the woman with anoxic encephelopathy (brain damage from extended time without oxygen), who is constantly confused and has a short term memory of about 5 minutes, might end up being chemically restrained simply because we do not have enough staff for someone to keep an eye on her and engage her when she starts to get freaked out. It probably comes as no surprise that the physical restraints do not generally help decrease agitation, fear, confusion, or violent behavior.

After the wheelchair seatbelt, this bed is our second most common form of restraint. My friend N-Dawg refers to it as a "special jail bed".

It's not that restraints are always unnecessary. It's just that it's often too easy to just say "Oh, I can't redirect that person, where's the Haldol". It wouldn't be so bad if we weren't constantly paying lip service to the idea that medicating for our own convenience is not something we believe in. It's easy to talk big during rounds about not medicating people into submission (Dr. Smith), it's another thing to tell the Friday night charge nurse to brush up on her patient redirecting skills when she calls you at home at 11 pm asking if she can give Haldol to an agitated patient.

I can see a better way to do things, but then I have had special de-escalation trainings through my previous job with emotionally and behaviorally disturbed teens (I know, which ones aren't...). I guess the only way we can really effect a change is if we do more than just say we don't want to resort to chemical restraints. We have to actually make some changes, like have trainings, and budget money for sitters or extra CNAs to keep people occupied; actually spend time and money to explore other options.

To be fair, it doesn't happen that often. In 5 months of working on that unit, I have only been concerned about overmedicating 2 patients. Out of probably 100, give or take. The first was a man with Parkinson's who had suffered a stroke. The stroke, while minor, interfered with delicate (and deteriorating) balance of brain chemistry, Parkinson's symptoms, and Parkinson's medication. We struggled for several weeks to help him regain this balance, while he slipped farther and farther into tremors, stiffness, retropulsion (leaning/pushing backward when standing or sitting), and Parkinson's dementia. He became agitated, one of the docs prescribed Haldol (albeit a very small dose). Unfortunately, one side-effect of Haldol is parkinsonism. The next morning the patient was so stiff he looked like he was in rigor mortis. Lying rigid in bed, face mask-like, barely able to respond to questions, or express discomfort. At the very least, not conducive to therapy. The second was a woman with anoxic encephelopathy. She came to us totally disoriented, no short term memory, terrible attention span, and with balance so impaired she could hardly walk. Balance, attention, and strength slowly improved, orientation and memory less so. A difficult case of a totally confused, but fully ambulatory adult. The poor woman frequently became frightened and frustrated, requiring regular attention, redirection, and reassurance to remain calm. Normally we would try to have family stay with the person during the night, but this person's family is not around much. I come back after a 3 day weekend, and this patient is so out of it that her balance has worsened, her attention span is decreased, motivation out the window. She went from requiring supervision, to requiring actual physical assistance. Again, not conducive to therapy.

Nobody is evil, or capricious, or cold, or drunk with power. It just seems like our ethics are ahead of our skills and resources. I don't know what the answer is, but I suspect that my fellow therapists and I may be spearheading the R & D.

Real and Surreal

2008-07-23T23:28:00.000-07:00

Real- I worked an extra morning this week to make sure that, following a recent epidemic of scheduling fiascos, a specific patient's home evaluation wouldn't fall through the cracks. The patient is an older gentleman who lives with his middle aged daughter and son-in-law. The guy is really sweet, had pre-existing Alzheimer's dementia, and comes to us with a mild stroke whose biggest impact is on balance and speech. I have no worries about the discharge plan, the family is great and are ready to keep dad at home. Said home is a small house in a rural area of the county set on largish piece of property complete with plenty of sunshine, 2 horses, a large vegetable garden, half-wild cat, and flock of laying chickens. I spent a billable morning enjoying some nice sunshine with some nice people, giving positive feedback for the home modifications already made, and doing some extremely basic cooperative problem solving about other modifications. I came home with a half-dozen farm fresh eggs, all sizes and colors. I felt like James Herriot.

these are the actual eggs

Surreal- From the Dream Archive- About a month after I started working at rehab I woke up gasping for air. In my dream my entire workplace was under water. All the patients were in their beds, submerged. All the halls and rooms were covered in clean, still water. Otherwise everything was normal. I still had my tight schedule, and all my paperwork, I still had all the concerns for safety and transfer logistics. Everything was normal except that I had to swim everywhere. The tight schedule was stressing me out, and to make matters worse I was continually delayed by running out of air and having to hunt down pockets of trapped air every few minutes. Under the bed, up in a corner of the room, I would start a patient moving, then swim furiously toward an air pocket (the actual surface of the water was, of course, somewhere outside and above the building), stick my lips in it and suck down some air, then swim back to my patient for another 3 minutes. The whole time I was treating patients my mind was on where I could find the nearest air pocket. At the peak of my exhaustion I am swimming madly down the corridor to the charting station, wondering if there is an air pocket under one of the desks in there, wondering why work has to be so hard... when suddenly I am passed by Harold, the oldest PT who works at the rehab campus (before he was a PT he was a professional art glass blower, he says he quit because it was too messy), he is swimming with a leisurely, Seuss-style, breast stroke, in no apparent distress. Upon closer examination I realize he has gills. I am struck immediately by two thoughts, first- it's not fair to expect me to work under water if I don't have gills, second- the extra time I have spent looking at Harold has caused me to run out of air, no pocket in sight. I wake up gasping.

Who needs Jung?

Hitting the Wall

2008-07-22T22:45:00.000-07:00

About a month ago I was suddenly gripped by the icy hand of futility. "What am I doing here?" I asked myself, and "I suck as a therapist, nothing I do makes any difference", and "I just know all my co-workers are wondering when I will realize my mistake and just quit". The therapist version of an existential crisis, also known as "impostor syndrome". One of the outpatient therapists pointed out that as I've only had my license for about 6 months I was probably hitting the six-month wall. "You see" she said over lunch, "six months is just long enough to have forgotten all the minutiae you learned in school, but not long enough to feel at all competent with the new learning here at rehab. Give it a couple of weeks, you'll be fine."

1 month, 15 rehab patients, 2 sets of rounds, a-week-and-a-half stint at the main hospital, 1 dialysis-refusing patient in end-stage renal failure (she died), 1 patient who died of complications from diabetes (his family sent us 5, count them, 5 gigantic baskets full of pounds of chocolate- kind gesture? or passive aggresive gesture intended to send the whole staff into diabetic shock in one fell swoop?- you be the judge....), 5 discharge plans, 7 bouts of caregiver training, and 60,000 chocolatey calories later... it turns out she was right. I am so exactly where I want to be.

An orbital complication of the impostor syndrome is related to my recent wrist injury. I hurt myself doing excessive yard work, caused major pain and swelling in my forearm, dramatically limiting it's functional use. My ability to seek help was limited by my fundamental conviction that there was no point in seeking treatment, that the doctors don't know anything and all therapists are hacks anyway. I spent two weeks in terrible pain, charting one handed, and getting sweetie to help me fasten my bras, before I went to the doctor. She said "you're an OT and you're coming to me!?" I said "I knew it, that's why I didn't come in for two weeks... well could you just write me a referral to the hand clinic?" She thought that was a great idea. I also asked for a Rx for anti-inflammatories, she kindly obliged. Here's what I learned: splints designed to remedy a particular type of problem are really helpful, strong anti-inflammatories are really helpful, tried and true strategies such as alternating ice and heat are really helpful, hand therapy is really helpful. Turns out all therapists aren't hacks after all (not even me).

Hand Therapy

2008-07-18T09:45:00.001-07:00

I recently hurt my wrist and am at Hand Therapy right now. The therapist wants to know how I add lots of pictures to my blog. Also she is showing me some tricks to reduce strain when typing/mousing.

Here is a picture of a compressed carpal nerve. Get it Hand Therapist? That's how it's done!

Warning Signs

2008-07-16T23:13:00.000-07:00

Of Heart Trouble
During my low-rehab-census induced stint at the main hospital last week I had the opportunity to treat people in the ICU. Always fun. One, very friendly, patient was there recovering from an emergency quadruple bypass (commonly referred to as a "cabbage" or CABG - Coronary Artery Bypass Graft). I asked him how he ended up at the hospital and this is the story he told me:
"Well, it started about 5 days before I had my... I guess I'll call it a heart attack. On the first day I noticed that I was feeling really tired while trying to do fairly lightweight home maintenance. Then on the second day I noticed that I was feeling really tired and also some chest pain even from just walking around and getting dressed. On the third day I found that I was feeling fatigued and having chest pain while I was just sitting in my chair watching tv and not doing anything. On the fourth day I felt like I had someone sitting on my chest..."
"Oh right" I interject, "That's a classic sign, the old elephant-on-the-chest".
"Well yeah" the guy replies, "I'd heard of that too, but I thought 'this doesn't feel like an elephant, it's more like a big guy' so I decided just to rest. But the next day it really did feel like an elephant so that's when I came in to the ER."
At this point I raise my eyebrows and say drily "So you went 5 days with fatigue, chest pain, and pressure on your chest before you decided to do something about it?!"
"I know" the guys says sheepishly "for someone with a 150 IQ I'm not that smart".

Of Mets to the Brain
Man gets pulled over by the police for drunk driving. He spends 2 days in the clink before they realize that his apparent drunkenness is not clearing... and besides, his blood test comes back negative for alcohol, so they bring him in to the ER. Turns out he has metastic cancer to the brain, pushing on his cerebellum, and causing ataxia, poor balance, and slurred speech. He sounds like a totally drugged out guy when you listen to him talk, but he's totally all there. He wanted a shower, he wanted to do as much of it on his own as possible. He's still hoping to get stronger and feels that some of his limitations are weakness from being in the hospital bed for a week. He's probably sort of right, but it also seems like he's not quite ready to accept the long view of things. That he's not going to get much strength back, that's it's downhill from here. And who am I to disabuse him of the idea, he'll figure it out soon enough and people need time to adjust to this sort of bad bad news. Or maybe he won't figure it out, and who can blame him, after all- he has mets to the brain.

I read this post to sweetie and asked him if he thought it sounded cold, the part about mets to the brain. He said maybe just a little. It's just that the whole thing was so matter of fact. He's going to die. Soon. I know it and he knows it, and he knows I know it. But the man wants a shower and I can offer him a shower. And the man wants to wash his own feet, so I can set him up on a shower chair and put soap on his washcloth and squat on the floor by his knees with my hands on his shoulder and skinny chest so he won't fall over, and give him some information about how not to pass out while laboriously bending over to use every bit of balance and strength he has to wash his darn feet. Then I'll help him sit up again and when he apologizes I'll tell him it's no problem that my shirt is getting wet, that I wear clothes that are okay to get wet. Maybe this will be his last shower ever, so I'm happy to help. Or maybe it won't and now the guy will know how to not pass out in the shower.

Irony

2008-07-08T23:43:00.001-07:00

Irony- inherent in the system The census is low at the rehab this week. "What does this mean?" you ask, well I'll tell you. It means that I have been floated over to the main hospital for the week. I find myself irritated by the move. And no, the irony of said irritation is not lost on me. The irony also will not be lost on those of you who have been faithful readers since this blog's inception, as you may remember how I felt about being transferred, without being asked or warned, to the acute rehab unit several months ago. (For those of you who don't remember, please review such posts as: The direction the feet are pointing, success!, a week at rehab). It's actually not bad at all as I love the main hospital and all the therapists therein.

*Snapshot* Head of OTs at the main hospital (also my supervisor when I was an intern) managed to get an interdisciplinary team of 6 different therapists (including the usually very proper and single-minded head of all therapists at the main hospital) to crowd into a single stall bathroom with a bag of wintergreen lifesavers for a "sparking party". Hey, we're all entitled to two ten minute breaks per day.

Irony- When saying what you don't mean makes you look like a moron. Charting in the nursing station at the rehab campus last week, with my PT team co-leader and Dr. Smith. It's been a frustrating week, super low census means most of our patients are difficult; difficult to treat, difficult family situations, difficult discharges to plan. It also means we have fewer successes and positive patients to offset the disapointment and frustration. Suddenly Dr. Smith turns away from his computer and states vehemently: "I can't stand talking to room 217 (large brain injury man), he can't even pay attention long enough to make a plan, and if I try to get him to focus he just rolls his eyes and tells me I'm getting ahead of myself (Dr. Smith here does a passable imitation of 217's voice and facial expressions)!". Just as vehemently, I reply ironically "I know, it's almost like he has a head injury or something!" At this Dr. Smith looks at me witheringly and says pointedly that 217 does, in fact, have a head injury. Fortunately my PT buddy laughs histerically at Dr. Smith, clueing him in and saving me from a career-non-enhancing-lose-lose situation in which I either 1) allow the doctor to believe that I have treated a guy for a month without reading his diagnosis, or 2) successfully convince the doctor that he is, in fact, a moron.

Smoking and your... health??

2008-07-01T21:56:00.000-07:00

Phil of the Cornelia Marie

I was just watching an episode of Discovery Channel's "Deadliest Catch". You know, the show about Alaskan crab fishermen. It was the episode where Phil, skipper of the Cornelia Marie, ends up in the hospital because of a blood clot in his lung. According to his doctor, the clot (AKA: embolism) started in his leg, passed through his heart, and ended up blocking some lung action. This is usually fatal. At the end of the episode Phil hauls himself out of his hospital bed in the ICU, drags on his boots, and staggers outside for some "fresh air". Next shot is of him smoking.

arrows point to pulmonary emboli

This is obviously a bad idea, man with difficulty breathing should not be out smoking, right? Especially when you consider that smoking may have increased his risk of developing blood clots in the first place. And, while I am NOT IN ANY WAY advocating smoking, I would like to offer the gentle reader a montage of images to add to their automatic disdain for nicotine.

The people at rehab (both the skilled nursing, and the acute rehab) often struggle with depression and poor motivation. Often, just getting them to be willing to engage in therapy at all is like pulling teeth, let alone getting them to walk for any distance or go outside. Ironically, it is the people who smoke that I see dragging themselves out of bed several times a day, getting dressed, walking and standing, going outside. Smoking is not necessarily worse for you than the creeping weakness and dissipation of not getting up, of not being able to think of a reason to go outside.
Some research suggests that nicotine reduces the frequency and intensity of psychotic hallucinations and delusions, that it provides some legitimate relief for people with schizophrenia. In terms of the health risks associated with smoking... have you seen some of the side effects of common antipsychotic medications? It could easily be argued that this is a 6 of one, 1/2 dozen of the other kind of thing.
Recently I worked with a guy who had the critical illness myopathy. He was totally weak and pretty tired, but he got up, got dressed, put on his shoes, and walked with me all the way down the block to the quicky-mart to buy cigarettes. Yes he took lots of breaks on the way. Yes the cigarette smoke escaped creepily from the hole in his throat left by the recently removed trach tube. But I tell you what, after that day he knew that he would get his strength back, he knew that I was on his side, he could see his trajectory landing him at home instead of at a nursing home. He discharged to his home today.

The Power of Your Real Life

2008-06-28T09:28:00.000-07:00

Part of our job is helping people to transition back into regular life, and out of an environment where trained professionals take care of everything. 2 ways that we do this are home evaluations and community outings.

Home Evals This is when we go to a patient's house, usually with the patient and some family member/s. We look at access to the home, access within the home, whether or not the wheelchair will fit through the doorways, bathroom setup, etc. We make suggestions and commend the changes that have already been made. Something interesting often happens on these home evals: people who have been languishing at rehab, maybe depressed, maybe only partially emotionally invested, often suddenly perk up and come back ready to work. I think that maybe they have been subconsciously or secretly scared, afraid they will never go home, or unable to envision their home and their place in it. They can't quite picture all the things at rehab superimposed on their previous life. Suddenly they have a vision of how it will be, and they see a light at the end of their tunnel. I also think that these people have spent weeks dependent on the hospitality (such as it is) and kindness of others, and at the home eval it's as though we're on their turf. They offer us water and cookies. We always accept.

I recently did a home eval at cancer lady's home. Her children and grandchildren were there. Her daughter-in-law was so invested in making things work, her fiance showed me the room where the patient would be setup. They were curious, excited, anxious, proud of themselves, happy to see their loved one sitting at home. The house was full of the patient's art and sculpture work, "let me show you my mom's website" the son says animatedly, while my patient sits nearby and pets her dog. Fantastic.

Community Outings People at rehab, especially those with no family, still have to take care of their outside business. Often, as soon as they are healed enough to start worrying, they worry about their bills, their cars, their bank statements, their business... pretty much all the same things you worry about. Over the last few weeks I've had the opportunity to assist several patients with errands of this nature and I was amazed at the results.

The first guy was large brain injury man, he has made a lot of progress but still can't always tell the difference between the call bell (to summon the nurse) and the telephone. Like many people with a brain injury he can be impulsive, distractible, and quickly abandons all but the most concrete of tasks. On our trip to the bank he gave me solid directions, had an appropriate and succesful (if brief) interaction with the bank teller. Then he politely requested a stop at the post office and a nearby taco bell which he handled with independence and more or less appropriate social interaction. He still has needs and I'm not sure he should be living alone yet, but man, did he outperform my expectations.

The second guy is older and recovering from a prolonged illness with encephelopathy (essentially he came down with sick-for-way-too-long-dementia). Poor memory, cantankerous, not quite sure where he is half the time. This poor guy owns his own business and has been baching it for 50+ years. He doesn't get why all these strangers just get to tell him what he can and can't do. He also wanted to go to the bank, the post office, and to check on his cars. It was so cool. To prepare he worked with speech therapy to get his bank deposits ready, then with the social workers to get his po box key and find out where his cars were (at his mechanic's shop). Finally he and I went on a long outing to take care of this stuff. Just like the other guy he gave me great directions, but as an added bonus the people at each stop recognized him and were happy to see him. He was able to take care of his business without any help from me at all. Like the independent grown-up he has been up until 3 months ago. The best part was his mechanic who treated him like a friend, an uncle maybe, and told him straight-up that he couldn't leave in his car because he wasn't well enough yet. My patient finally believed that he still had a way to go to recover "This didn't go quite like I planned" he said. But he was present, ready to move forward.

mediocre analogy for how the brain works

FIMs

2008-06-24T14:01:00.000-07:00

The Functional Independence Measure, or FIM, is used by rehab facilities around the country (and possibly other countries) to track the ability of a given facility to produce measurable functional improvement.

The FIM is used to assess each patient within the first 72 hours of admission, then again at discharge. The facility is rated based on the difference between the two scores. We only get paid based on the assumption about the client made as a result of the first score. (Does that seem weird to you?) The idea is to score the person at their absolute lowest moment within the first 24 hours, the lower the initial FIM score, the more money it theoretically costs to rehabilitate them, and the more we get reimbursed.

Areas assessed:

Motor- bed mobility, transfers to/from bed, wheelchar, toilet, shower, locomotion for walking or in a wheelchair, and locomotion for going up and down stairs.

Self-care- eating, grooming, bathing, dressing (upper body), dressing (lower body), toileting, bladder management, bowel management.

Cognition- including comprehension, expression, social interaction, problem solving, and memory.

Patients are scored by PT, OT, ST, nursing, and psychologists. We all have to be trained to use the FIM and pass a little FIM using test. This test does go with me to other facilities, even within the same organization... So yes, I have to take it once for the SNF, and once for acute rehab.

On each category a person is rated on a scale from 0-7. Zero means the activity did not occur, and you almost never use it. The other numbers rate the amount of assistance a person needed thus:

7- Independent

6- Modified independence (uses adaptive equipment, but does not require assistance).

5- Supervision or Setup (supervision or cueing for safety, initiation, completeness, encouragement; setup assist including item retrieval, package opening, placing items in a person's hand. Note: for a score of 5 there must be NO PHYSICAL CONTACT).

4- Minimal Assist (patient performs at least 75% of the task.)

3- Moderate Assist (patient performs 50%-74% of the task)

2- Maximal Assist (patient performs 25%-49% of the task)

1- Dependent (patient performs less than 25% of the task)

There is some attempt to break down each activity into countable steps, especially the self-care ones, making it easier to identify what percent of the activity is done independently. It only sort of works.

Benefits: Uniformity, quick shorthand for safety and time planning (e.g.: I can glance at the white board on the patient's wall and if the last person who worked with him put a 2 down for incremental scoot toilet transfers, I know better than to try and stand 'em up with no walker.), everybody's using it, reimbursement, people who like to quantify everything are happy.

Downsides: Uniformity (patients are not uniform), quick shorthand does not have room for details, no way to represent small increments of progress, really complicated decision trees for each category.

A helpful perspective: the person who did the last training said to think of it as assessing the "burden of care". This paradigm was helpful to me as I had been struggling with feeling like "oh, that person's made so much progress, I just want to round up..." - irrational, I know, and only semi-conscious. Thinking of it as assessing the burden of care helps me keep focused on the purpose, to whit planning an effective and safe discharge including where to go/what kind of training the family or caregivers need/what kind of equipment and supervision/ etc.

*Note* In web research done for this post I discovered that the people own the FIM, now refer to it as the FIM(TM), and have decreed that acronym "FIM" no longer stands for anything... It does, however, still refer to the same assessment tool, technically known only as the "Guide for the Uniform Data Set for Medical Rehabilitation". Whatever.

Some Toilet Transfers

FIM(TM) score: 6- MOD Ind toilet transfer

FIM(TM) score: 1- Dependent toilet transfser with Liko lift.

Revisited

2008-06-19T22:34:00.000-07:00

Top Down or Bottom Up?
I keep thinking again about the whole medical/healthcare system and what isn't working about it. It seems like there is a ton of pressure in the system. Insurance, no insurance, good insurance, bad insurance, price inflation, scamming insurance companies, reimbursement, needy patients, equipment purchasing, home health, ad infinitum. It seems as though the top down people like bean counters and insurance company reps are only thinking about the big picture (how to keep their business afloat, how to make a profit), and not considering the (other than in the abstract) the individuals involved. From the bottom up, the individuals involved are only thinking about their needs in the immediate moment: (how to get reimbursed, how to afford a shower chair, how to work the system to get as much as they can because this is their life, scheduling therapy for the requisite 3 hours, etc). All the tension and torque in the system needs an outlet and, unfortunately, the point of friction- the steam release- is often at the bedside. The doctors/case managers often end up feeling adversarial about the people they're trying to treat. Rationally, we all know that at the time a person is at rehab for a stroke/paralysis/head injury they are not being a freeloader, but there is no other point along the way where discrepancy between healthcare mandates and healthcare provisions is addressed. Thus the pressure for reimbursement falls to the people at the bedside- both patient/family and doctor/staff. And this is not fair. Doctors don't like being in this position, they don't like to look like money grubbers, none of them want to be reduced to cold, calculating judges of a patient's worthiness to receive help in their hour of need. Patients, for their part, are dealing with dramatic life changes and are in no position to think philosophically about the big picture of healthcare in America.

With this on my mind I've been paying attention since my last post on the subject and I've noticed something interesting. For all that the doctors get grumpy about the patients with no insurance or that don't make their therapy hours, they keep admitting them to the unit. I realize now that the doctors really believe in the benefit of rehab and they want to provide it to as many people as they can. There are always at least 2 uninsured people on the unit, and some people who will not participate in a reimuburseable amount of therapy (but can still benefit). They may get grumpy with the patients and they may pressure us therapists to try to drum up units with an inappropriate patient, but they will still bring the people to rehab because it's a good thing to do and it will help a person. So at the point of friction the weight of a screwy system rests on the injured and the needy and the sincere and the noble and the flawed and the human. And most of the time it works out. But, not efficiently, not as well as it could, not as affordably as it could... What is the answer?

Learning Curve
New patient with metastatic cancer to the spinal column. She is really cool, about my folks age, engaged to a nice man. She has recently become paralyzed from the waist down because of the location of the new tumors. She and her fiance live in a room in her son's house. She will probably die within the year, probably painfully. (Incidentally she has no insurance). She is here to learn to manage as a paraplegic including transfers, skin care, self-catheterizing for urination, and for caregiver training and home setup. This patient is really cool and is learning fast, her caregivers are also cool and have great safety awareness and problem solving skills. The patient is faced with thoughts like "do I want to hope for a prognosis of less than six months so that I will qualify for hospice care (which is free)? Or do I want to hope for a prognosis of a year or two so that I, well can have a year or two...? What would you want? This is a sad story, when I told sweety about it I could hear how sad it was. Yet I do not feel sad in the way that I would have 3 months ago. I mean, I am sad for her and I feel empathy, but I am not distressed or torn up like I was before. At first I thought: "oh no, I have become jaded". But now I do not think so. I think I have some emotional distance, I get that these people are not me. I can care, and I can listen, but it doesn't have to keep me up at night. Also, it helps that I get to make a significant and practical impact on how enjoyable their last days are. My boss tells me that this will go in waves, she's probably right. That's okay too, just part of the process.

Patients
Have been seeing bicycle guru man, and cortical blindness lady coming in to outpatient. They are both walking and have made dramatic gains. The bike guy calls me "kiddo". Cute, funny.

Final note
Doing my first solo home evaluation tomorrow. A little nervous about it. I'll keep you updated.

See You At Rehab!

2008-06-11T21:19:00.001-07:00

I love my job, and I really and truly love and enjoy my patients. If you come to rehab I will be delighted to work with you. If you don't want to come to rehab here are some suggestions of activities to avoid:

Falling off of a donkey
Aggressive mountain biking on an unfamiliar bicycle
Riding a bike without a helmet
Riding a bike with no brakes
Drinking and riding a bike
Drinking and driving
Drinking and climbing on a roof
Drinking and going to your construction job
Drinking and walking on top of a freeway soundwall
Drinking and jumping off a bridge
Smoking so much meth that you give yourself a stroke
Smoking anything
Smoking through your tracheostomy

These are just a few examples of some of the avoidable reasons why people turn up at rehab (I have actually seen all of these in the last 8 months). There are also lots of unavoidable and unpredictable reasons people turn up at rehab. Antoher reason to avoid the above: the people who have practiced good judgement and basically healthy living have an easier time with recovery than the others. It's just easier, everything from problem solving to physical endurance.

A Bad Day

2008-06-11T07:36:00.000-07:00

Apparently this is the internation symbol of Parkinson's. Who knew?

-Right when I came in on Friday one of the PTs asked if I could help her do a transfer with Parkinson's Man. Parkinson's Man had symptoms that had been manageable (not fixed) with medication until he had a tiny stroke that screwed up his whole brain chemistry. The meds still help but they are not as effective as they once were. Parkinson's makes it hard for people to initiate movement, advanced Parkinson's symptoms include stiffness, rigidity and some dementia. The meds that you give people (Sinemet, parcopa) begin to work really fast and last only a few hours. Friday morning, secondary to dementia, Parkinson's Man had refused his meds and was sitting at the edge of the bed, mostly frozen, and disoriented and rude. What should have taken 5 minutes ended up taking 25.

-I went in to my first treatment 15 minutes late. This is a lady who has been very sick for 6 months and is finally starting to recover. She is a real trooper and participates as much as she can with therapy. This day she had not slept well and was not able to participate much. She still stayed engaged with the process and tried, but I did a most of the physical work. (We call this dependent care, if someone is at a dependent care level one day- or initially- that's one thing, but if that level doesn't change then the person is not considered appropriate for therapy. Basically, I can't justify billing for rolling and wiping and changing someone. They have CNA's and rehab techs for that.)

-Next I go into Parkinson Man's room. 15 minutes late (or 1 unit). I'm scheduled for 4 units with him. He is lying in bed and saying he wants a shower. I think about it, I try to help him move to sit up at the edge of the bed again. He is rigid like a corpse. Seriously. Parkinson's Man shouldn't be here. He fluctuates dramatically but his overall condition is decline, he is not appropriate for rehab. Yet his family is having trouble finding a placement for him, they are still adjusting to his new status. The doctors have empathy and are allowing him to stay longer. This is fine except it trickles down as pressure to fill 3 hours of therapy minutes a day with him. So yes, more dependent care. There's also -very slight- pressure to write creative notes that make therapy look productive. This is called "unethical", so I don't do it (which is fine at this job, I would never get in trouble for holding to my own professional ethical standard). So I spend 45 minutes doing dependent care. Again, I don't exactly mind, I mean it's a mitzvah. But it is not really my job and I worry because people already don't know what OT does. I don't want to confuse them any further. As I take off his diaper and clean his periarea (nice word for ass) I notice that he has some redness on his scrotum so I pause in my labors to tell nursing that he may have a new fungal infection. They immediately send Dr. Brown in to look at it, he says that the problem is that nursing and OT are not doing a good enough job at cleaning him up (Okay, A- I'm not done, B- It's not really my job anyway). After several deep breaths I leave Parkinson's Man to go chart. I also take the time to note on the big schedule that he is down 1 unit so that other therapists can try to make it up. As I note this, the scheduler lady looks over and says "you have to make those minutes up you know". Never mind that he's not appropriate for therapy, Never mind that the only reason I'm behind is because I was being a second person (which I can't bill for) on this same guy!

-I leave to go to our weekly therapy meeting for unit-kink-working-out. In which we get the news that we're filling out our initial Functional Independence Measures (FIM) wrong, thus decreasing our reimbursement. It's apparently only OT though, PT and ST are doing it right. I will totally write another post about the FIMs.

-Lunch

-I go back to work and the charge nurse (a guy with years of experience, very good at his job) asks me if I will get on the phone and talk to the rehab doctor. He wants to know if Parkinson's Man is doing any better since his most recent med change. The nurse told him "no" and he said, "let me talk to therapy because they don't agree with you". So insulting! Plus, he's splitting us, pitting us against each other. I don't think he's malicious, just tactless and I don't want to play along. I don't get on the phone with him, instead I tell the charge nurse to tell him that "the team has discussed it and that we all agree there is no functional change". Then I remember that the day before this same doctor came in during therapy and asked me if there was a change. At that time I told him "it might be slightly easier for me to forcibly bend him than yesterday". Now I know that I actually have to say "NO FUNCTIONAL CHANGE". I mean, I think my statement makes that obvious, but.... anyway.

-Next was large brain injury man, covered in poo, with either no initiation or impulsivity, leaping naked out of bed and staggering around the room in a panic because he's covered in poo. He's unsteady and has poor balance, but doesn't know it, and can't calm down enough to listen to instructions. I have to hold him so he doesn't fall, he's agitated and doesn't want me to hold him. I got him calmed down and cleaned up eventually. Oh, and once he sat down he was able to do a lot of his own self-care. So that was something.

-We'll finish the day with small brain injury man who told me to "get the fuck out of this room, and don't come back".

Visual Anchoring

2008-06-09T22:01:00.000-07:00

Got a comment from a Dr. on a previous post about the lady with chronic vertigo and nausea following a cerebellar stroke. He read the bit about the palliative care consult and was hoping for information about which meds were recommended. See that comment thread for an explanation of why I won't post them here. However, I will happily post an effective OT compensatory strategy called "Visual Anchoring". Attend:

Before you move, find a vertical line somewhere in your vicinity. For example: a door jamb, the side of a picture frame or window, the edge of your fridge, etc.

Focus on this vertical line while you move from lying to sitting, sitting to standing, etc.

Now that you are on your feet let's try walking: Find a vertical line in the direction you wish to go and focus on it as you walk.

Ready to change direction? Stop moving while you scan for another vertical line in your new direction. Now focus on that as you turn and keep walking.

This was suggested by the super old school OT lady who works 2 days a week. She is awesome. She taught it to my patient and then explained it to me. The patient told me it made a significant difference. It didn't "cure" the problem but it made the difference between having the energy to get out of bed or not on any given day. Go OT!

Oh, this is the same old school OT who explained about the gastrocnemius (calf-muscle) being the second most powerful pump for venous return in your body.

Crystal Skulls and Other Mysteries

2008-06-02T08:05:00.000-07:00

As part of the media hype around the new Indiana Jones movie there was a show on, I believe, the Discovery Channel about the bits of Indiana Jones lore that are rooted in real legends, myths, and bits of history. One thing they talked about was a South American Legend that describes 13 crystal skulls scattered throughout the world that will eventually be brought back together. According to legend these skulls have mystical/magical properties and powers. Interestingly, about 6 crystal skulls have been found, most are in museums, 1 belongs to an American lady. This lady said she got the skull from a guru in India? I can't remember exactly where. Anyway, she saw this guru while her daughter was dying of cancer and after she died the guru gave her the skull. Now the lady takes the skull around on tour (at first it was just in a box in her closet, then it came to her in a dream and said it's name was "Max", after which she decided she had to share it with others). The show included interviews with people who see Max every year on his tour. They talked about the feeling they got from meditating with Max, touching Max, gazing into Max's eye sockets... They described a feeling of peace, and of being deeply and truly connected, special. There were maybe a dozen people, gathered there, feeling a bond with each other because of their connection to the skull. Now, don't get me wrong, it's not like they were pointing their noses up at those of us who haven't (or wouldn't) meditated with skull, but there was definitely an air of endorphiny "I've had a special, unique, deeply moving, and impossible to explain experience".

As I listened to them talking I found that the feelings they were describing were very familiar. I realized that I had had them myself that same day at work while eating brownies. You see, earlier in the week we had another teleconference with New Stroke Patient's children who live in distant parts. The plan is for New Stroke Patient and his wife to live with the kids for a while as he continues to recover. On the phone, one of his kids told him he'd better work on his swallow with speech therapy because she was making him her special brownies. We joked with the family that she should send them here to rehab and he could work on eating them now instead of waiting. "We'll make sure he gets one" the doctor said. Laughter all around. 2 days later New Stroke Patient's wife catches me in the hall to tell me that the daughter has made said brownies, and FedEx'ed them overnight. "They'll be here tomorrow at 3" she says, "she wrote 'FRAGILE' all over them. She's never shipped her brownies before". The next day they arrived, individually wrapped, different flavors and toppings. Beautiful brownies, enough for all the staff to share, a note for the staff, and one brownie marked "Dad" with toasted nuts on top. It was a beautiful thing, impossible to explain. Brownies appear and suddenly a tired and worried spouse plays hostess in a nursing station, we have a mystical connection to 3 unknown people thousands of miles away, and an impossible-to-misunderstand-shared-experience with a man who cannot speak. How can something as simple as a brownie even the playing field between a whole team of medical professionals and the people they are serving? How could brownies have such power that my friends get choked up just hearing about them? Christ in a baked good.

The funny thing though is that this is almost a common place. The brownies were special and this family is special, but less extreme examples of this same thing happen all the time. Last week the mystical was embodied in a flat of organic strawberries, before that it was the divine in 2 dozen cookies from the absolute best local bakery. Weekly we have Jesus delivered to us in the form of chocolate, cards, cakes, and flowers. And every time, every last one of these gestures feels like a crazy, inexplicable mystical connection to my co-workers, my patients, my fellow humans, and to something fundamentally true and indescribable about the universe. But the real fantastic thing is that these moments turn me so that I start to feel that way about making jam with my sweetie (no that's not a euphemism) or helping my godchild take a bath, text-messaging my brother or riding my bike. So I don't begrudge these guys their crystal skull experience, but I also think that in pursuing the divine and mystical in the esoteric, we run the risk of missing out on the holiness of baked goods.

Some Patients and A Good Book

2008-05-28T10:04:00.000-07:00

Professor guy and Bike guru guy both went home last week. Lots of progress made by both. If you had seen them when they first showed up you never would have guessed that 4 weeks later they'd be walking out, with a quad cane and supervision, but walking nonetheless.

New MS patient found a nursing home that would take him. His state insurance didn't come through yet, but his family pulled together and will pay for the nursing home until it does. An interesting answer to that particular puzzle.

New left hemorrhagic patient is making lots of gains. He can spit out a few more words spontaneously, and is now able to answer forced choice questions if you supply the choices and give him lots of time, for example: "when you put on your shirt, which arm will you dress first, the right or the left?"(this is relevant because dressing with hemiplegia is easier if you dress the affected side first). I've also noticed that if I just say "put your shirt on" he's thinking about getting dressed and gets a bit frustrated if it takes a long time. On the other hand, if I point out that putting on a shirt is also brain training for sequencing, spatial awareness/relationships, and problem solving- and that it is helping to reconnect a variety of neuronal passageways- he is thinking about the process of recovery and has much more patience and greater success. Health through occupation, baby! OT is awesome!

A bariatric patient (read morbidly obese). Nice lady, not circus sideshow overweight, but quite heavy. Her weight is mostly in her legs and abdomen, due in large part to very poor circulation and lymphedema. Your heart pumps blood away from it into your (muscularly-walled) arteries, the blood flows into your extremities pushing the other blood before it into your (non-muscular) veins. It is the pressure of the new blood coming through that forces the old blood up the veins and back to the heart. Your lymphatic system does something similar by having lymph fluid circulate throughout the body, be processed by lymph nodes, and filtered by the kidneys. The hardest part is getting lymph or blood up from your feet and lower legs because of the distance. One way that we keep things flowing is by being active, as we move around our muscles literally squeeze blood and lymph out of our extremities, keeping it moving. The less active you are, the harder it is to circulate your fluids. With lymphedema what happens is that lymph and blood don't move through, fluid pools in the tissues making them big and heavy, making it hard to move around. A bit of a vicious cycle. Fluids keep circulating to the legs, then not being able to make it out. I've heard stories of patients losing 60 pounds in a matter of weeks, all water weight. Here's how it's done. You give a person diuretics, watch their fluid intake, and make sure they have easy access to the bathroom. But you have to be careful because all the excess fluid is processed by the kidneys. That is a lot of work for kidneys so you have to go slowly. Furthermore, fluid that hangs out in the legs for too long can become fibrous and gelatinous, so it doesn't move readily to the kidneys to be processed, thus putting even more strain on the kidneys. Something I learned: the gastrocnemius, or calf-muscle, is the second biggest pump for venous return in your body (the heart is the first). Ankle pumps, ankle pumps, and more ankle pumps to all you edemitous lower-extremitied people!

A Good Book
Written by a neuroanatomist who had a stroke, "My Stroke of Insight" is a book about the experience of having a left-sided stroke (with aphasia and right hemiparesis) coupled with an understanding of what was happening on a technical level. She also has a bunch of information about what kinds of attitudes and approaches were the most helpful. Obviously not to be taken as an instruction manual for working with stroke patients, but totally interesting all the same.

Top Down or Bottom Up

2008-05-20T20:43:00.000-07:00

Top down:
I was at an inservice last week put on by the hospital's chief financial officer. He was giving us the lowdown on the hospital's financial situation and some problems facing health care. Here are some things I learned:

As you might have suspected, the cost of a given hospital stay does not reflect the actual cost of services rendered or goods used.
All insurance companies, MediCare and your state medical insurance included, refuse to pay any given bill in full. Private insurance companies pay the most, but still not all.
To counter this hospitals inflate their bills. To counter this insurance companies agree to pay less than the bill. (Does this look like a vicious cycle to you?)
If you don't have insurance and you show up at the ER, the ER is required by law to treat you. If you have crappy insurance that will not reimburse the hospital, the hospital will eat the costs.
To try to make up the difference for uninsured and poorly insured and MediCare patients (MediCare pays, on average, 75% of a given medical bill), hospitals inflate the cost of every good and service.
A decent insurance company pays most of that bill (80%-95%), then tries to make up their loss by, that's right, raising insurance premiums until your employer can no longer afford to cover you fully, forcing you to contribute more to your insurance or forego insurance thus becoming one of the uninsured people who is driving up the cost of health care. Whew.

To sum up: We currently have a universal health care system in which the uninsured use the ER for their primary care physician, and people with health insurance are basically providing health coverage for the uninsured. It is inefficient, it is poor health care, it is a vicious cycle. The chief financial guy said that he views it as basically a health care tax that the government is not calling a tax.

Bottom up- At rehab this week we have a person with a new diagnosis of MS, the progressive kind. This man was previously homeless, living in a tent in the local woods, until he could no longer get up off the ground. He has family who are involved, but they don't really feel like having him live with them (and he doesn't want to live with them anyway). This guy has no insurance. He is hoping to be placed in a nursing home as MS is progressive and he will continue to decline. Unfortunately no nursing home will take him because he does not have the state insurance in place that will cover his nursing home costs. Our social worker helped him apply for it, but it hasn't come through yet.

In rounds today the doctor said that he could stay at rehab for five more days and then his options were to figure out how to get along with his family, or the hospital would give him hotel vouchers for 5 days while he figures out what to do next. The patient was really upset, and who can blame him. He doesn't have money, he is newly disabled, and we're basically threatening to send him out back to the street. Now, I know that the doctor is trying to bluff the family into acting, and we probably will not send this guy back to the street, but I am uncomfortable playing on a person's fears like that. I am glad that we take people with no insurance to our rehab unit and give them care. I advocate heartily to increase their length of stay and try to get them a good discharge plan where they will be safe and have their needs met.

??? But what is the right answer here? Who is responsible for this person? Is it his family? If we say it is not his family then we are saying that all of society is responsible. Even if he gets on state insurance and lives in a nursing home, we pay for that with our taxes. And maybe that's okay, maybe that's better than saying we don't care about the other humans, poor and irresponsible though they may be. But maybe we should all know that this is what we are saying. See, when you hear about a charity hospital taking patients with no insurance just remember that you the insured, are the main contributor to this charity. And that it is getting more expensive all the time. I mean, I could say that I won't pay for my ridiculously expensive hospital bill, but it doesn't really solve the problem. It doesn't change the fact that a smaller and smaller number of insured people are paying for an ever growing number of poorly insured folks.

I found out today that in the microcosm that is the rehab unit, the doctors do not get paid by the hospital but directly through the patient's insurance. So at rehab the doctors have to eat the cost of uninsured or poorly insured patients. I get paid when I come to work, no matter whether the hospital gets reimbursed or not. But not the doctors. Is it right that a doctor should carry the weight of a crappy healthcare system? Is it right that poor people should not get care? Is it right that someone should work their own ass off so that they can do pro bono work, whether they want to or not, for someone who never got their own life together? Is it right that health care should be so expensive that even 3 stitches in my hand cost $400? Makin it so that even basic healthcare cannot be paid for out of pocket?

So in this election year, when candidates are talking left and right about Universal Health Care, note that none of them are actually talking about what that might look like. They don't have an actual plan, and they're certainly not talking about the crappy universal health care system that we already have. I intend to follow up with the chief financial officer guy and try to find out what he thinks would work, because I feel a little discouraged and very curious.