Wow, I haven't written a post in over a month. It just goes to show how busy I've been -with work and everything else in between. Last Wednesday, I realized how much I missed writing and reflecting upon my job when I evaluated my new patient with a diagnosis of "multiple CVAs". I will call him James.
I had read in James' chart that he had aphasia as a result of his multiple CVAs. But I was not aware of the severity of it, and whether it was expressive or receptive aphasia. I knelt down by his bed, which was as low to the ground as the bed controls would allow, and told him I was from occupational therapy. "I'm here to evaluate you. Do you know what occupational therapy is?" Nothing. "James, are you in any pain?" Nothing. He just looked at me, with an occasional grumble here and there. But nothing that made any sense to me. I decided to be as simple as I possibly could be and ask him yes and no questions. I took his hand and told him, "James, squeeze my hand twice if your answer is yes, and once for no". I demonstrated and repeated the instructions again. Then I had him try before asking anymore questions to make sure he knew what I was asking him to do. He just rubbed my hand in his. For one, there was no sequence to what he was doing. And two, he was not squeezing at all. I looked at him and his eyes were tearing up. He looked helpless and almost as if he felt bad for me. I said to him, "I know this is frustrating. We'll just have to find a better way to communicate with eachother." I tried writing "yes" and "no" on a piece of paper and told him to point. He just slapped the paper and growned. Holy cow. This man has global aphasia. Not only can he not express himself verbally, he cannot comprehend language.
I left the room really fast to grab Jason, the physical therapist who was scheduled to eval James that day. He came in with me and, with very direct physical cues and hand-over-hand demonstration, James understood the tasks we were asking of him. We got him sitting up on the edge of the bed, and with max assistance (times two), we got him into his wheelchair. Unfortunately, global aphasia wasn't the only roadblock James had to deal with. Because of his multiple CVAs, James had major flaccidity in his right upper extremity. It was just there -as if it were not part of his body. If you were to lift it up and let go, it would drop back down in full force. He was, however, able to initiate movement in his right lower extremity, which showed great potential for bed mobility and transfer training. On that first day, sitting in his wheelchair, James needed all the force I had pushing against his right side so he could stay sitting upright. If I let go, he'd be on the floor. We had to get him back in bed.
I left that evaluation, baffled. What was I going to do? I felt the same way leaving the next day's treatment, which consisted of 10-minute increments throughout the day to get him sitting on the edge of the bed and back into bed so he wouldn't get bed sores. I wasn't entirely sure what was going on. Some times he seemed like he understood what I was verbally saying. At other times, he looked like he wasn't quite all there. He'd respond well to direct physical cues one time, and the next time, stare at me frustrated. We were going to have a family meeting the next day to figure out the plan of care. I was set on discharging him to an inpatient neuro rehab facility. That was till the next day (Friday) happened.
I was walking down the hall to join the PRN physical therapist's session with him, when I saw her pushing James towards the gym in the wheelchair. At first I was mortified. He is going to tip over and land on his FACE! But then I was excited! He's sitting up! Granted he's leaning off to one side, but he's sitting in the chair without anyone pushing to keep him up. I knelt down beside him and said, "James! How are you?" He looked at me and said awkwardly, "Good". My jaw dropped. How this was happening, I have no idea. And to be honest, I really didn't care.
I joined the PT for half of the session. We got him standing at the parallel bars with max assistance. I got him holding onto the bar with his right hand so he could do some weightbearing to initiate some sort of proprioceptive input into the arm. Then the PT helped me get him onto a mat with his left side (the strong side) leaning against the wall. The PT told me to have him lean against it for a few seconds to give him the proprioceptive input that he needs to be "more towards his left side" (I don't know how else to explain it), then slowly move his shoulders towards midline. Then I'd slowly let go and get him to look up at the full-body mirror in front of him. His feet were planted flat on a wooden block and his right hand was placed open-faced on the mat, allowing him to weightbear through his right side as well. He sat in a static position for 1 minute. This was great! Occasionally, I'd have him reach with his left hand for an object. He would wobble and throw himself off-balance, but this was still progress compared to the day before. I was so happy. I did not understand what happened neurologically between that day and the day before, but it really did not matter at that moment. When James rested again on his left side, he held my hand and rubbed it. It's weird to say, but when I'd look at him, it was as if he was speaking with his eyes and I could tell how he was feeling. He was exhausted. But he was proud of what he did that day.
The family meeting was an hour later that day. And the physical therapist and I decided to continue seeing James for skilled services at our facility, letting our rehab director know how much progress he made overnight. I learned two things that day: 1.) Sometimes things don't make any sense in rehab (or in life for that matter) but, in some circumstances, it really doesn't matter. And 2.) Neuro is where my passion is.
Sunday, December 18, 2011
Thursday, November 10, 2011
Bring It On, Chemo!
With every patient who does not understand the purpose of therapy or despises the idea of getting out of bed for rehab, comes a handful of patients who think and feel quite the opposite. My patient, who I'll name Pam, is one out of that handful of patients. I am writing this post for the sole purpose of saying how proud I am of Pam.
Pam is a 70+ year-old lady with leukemia. When she was first admitted to our facility, she could only stand to brush her teeth or comb her hair for 58 seconds. It took her a whole 70 minutes to get through an exercise routine that would normally take my average patient 20 minutes to complete. And it took all her strength to open the cap on her creamer bottle for her morning coffee.
Within 2 weeks, Pam was making slow but steady progress. She was standing longer, completing her exercise routine in a shorter period of time, and having more energy and strength to bust open her coffee creamer. The main concern her physical therapist and I had was that Pam was starting up again with chemo treatments. Five days in a row, Monday through Friday, mid-day, for an hour and a half. We were worried that, including preparation and traveling time, Pam would be too exhausted for therapy and end up regressing.
We came up with a plan. I would see Pam first thing in the morning at 6:50 AM to get her ready for the day doing ADLs, take her to the gym, continue occupational therapy, then she would have physical therapy from 8:00-9:10 AM. She'd have her breakfast, an hour to rest, and then off she'd go to chemo. By the time she'd get back, she would not have to worry about therapy and could relax for the day. This routine would start up all over again the next day. Monday to Friday.
Well, it's now Thursday. And Pam has shown no signs of decline. I show up to her room at 6:50 on the dot every morning and she greets me from her bed with a weak smile on her face. She does everything asked of her, no complaints. One thing that has become part of our routine is stopping by the dining room on the way to the gym to make her a cup of coffee with her special caramel machiatto creamer. That makes her happy. And everytime I think of how hard she is working and how pleasant and positive her attitude is with everything she is going through, I almost want to cry just watching her. I am so proud of her. And I have told her that time and time again.
Tomorrow is our last 6:50 AM occupational therapy session. If I make it up in time, I'm planning on surprising her with her favorite Starbucks latte to celebrate her last day of chemo and making it through a challenging week! On Monday, with her chemo done, I promised to schedule her later in the day so she can enjoy sleeping in again.
Pam is a 70+ year-old lady with leukemia. When she was first admitted to our facility, she could only stand to brush her teeth or comb her hair for 58 seconds. It took her a whole 70 minutes to get through an exercise routine that would normally take my average patient 20 minutes to complete. And it took all her strength to open the cap on her creamer bottle for her morning coffee.
Within 2 weeks, Pam was making slow but steady progress. She was standing longer, completing her exercise routine in a shorter period of time, and having more energy and strength to bust open her coffee creamer. The main concern her physical therapist and I had was that Pam was starting up again with chemo treatments. Five days in a row, Monday through Friday, mid-day, for an hour and a half. We were worried that, including preparation and traveling time, Pam would be too exhausted for therapy and end up regressing.
We came up with a plan. I would see Pam first thing in the morning at 6:50 AM to get her ready for the day doing ADLs, take her to the gym, continue occupational therapy, then she would have physical therapy from 8:00-9:10 AM. She'd have her breakfast, an hour to rest, and then off she'd go to chemo. By the time she'd get back, she would not have to worry about therapy and could relax for the day. This routine would start up all over again the next day. Monday to Friday.
Well, it's now Thursday. And Pam has shown no signs of decline. I show up to her room at 6:50 on the dot every morning and she greets me from her bed with a weak smile on her face. She does everything asked of her, no complaints. One thing that has become part of our routine is stopping by the dining room on the way to the gym to make her a cup of coffee with her special caramel machiatto creamer. That makes her happy. And everytime I think of how hard she is working and how pleasant and positive her attitude is with everything she is going through, I almost want to cry just watching her. I am so proud of her. And I have told her that time and time again.
Tomorrow is our last 6:50 AM occupational therapy session. If I make it up in time, I'm planning on surprising her with her favorite Starbucks latte to celebrate her last day of chemo and making it through a challenging week! On Monday, with her chemo done, I promised to schedule her later in the day so she can enjoy sleeping in again.
Saturday, October 29, 2011
The Things We Take For Granted
Because my last internship was at an outpatient neuro rehab facility, I have developed great interest in neuro rehab. Which is why everytime we get a new-admit slip placed on the rehab desk at work that reads "CVA", I ask to have that patient put on my schedule. My patient, who I'll call Kelly, got admitted last Friday, having had what the doctor believes was a stroke to the occipital portion of her brain. According to her chart, nothing has been accurately diagnosed yet. In this case, and in any other case, you treat whatever you see. My ex-fieldwork supervisor in neuro rehab told me on my internship that, because the symptoms patients present vary with every CVA, it is important to not just rely on what the book tells you the symptoms are, but to explore the patient in depth, and treat what you discover during the evaluation and throughout treatment.
So here's what I discovered about Kelly. She was very weak. She could perform a toilet and shower transfer with me simply guiding her at her hips, but at any given moment, may need maximum assistance from two people because she can have muscle spasms in her legs in a split second. She can be in the middle of drying herself while sitting on her shower chair, and then collapse onto you because everything around her starts to spin. That was a little scary. She wears a black eye patch with a garter strapped around her head because she has double vision, and in order to focus on something and see it accurately, she has to have one eye closed. She has difficulty and fatigues easily with circular and vertical eye movements. She has poor short-term memory and divided attention. She will be walking to get clean clothes out of her drawer, get there, and forget what she walked over there for. Or she'll attempt to don her jeans in the morning and forget to take her pajama bottoms off.
With every limitation Kelly has, she has a million strengths. She is highly motivated. She is willing to try anything and everything I ask her to. One morning she was so nauseated after breakfast and kept apologizing for having to re-schedule, almost in tears, because she really wanted to do therapy. She goes to the afternoon recreational activities in our facility -attempting to play Bingo and Keno even though she tells me it's frustrating at times. Kelly also has a lot of hobbies and a thirst for learning new ones. She loves brain-teaser activities that are perfect for working on improving short-term memory. She has amazing family support. The posters, cards, flowers, pirate hat to match her eye patch, Winnie the Pooh and Snoopie stuffed animal in her room say it all. And whenever I recommend getting a portable grab bar or a vision stick or large-print playing cards, her daughter, parents, or husband will have it for her the next day to show me in therapy.
I look forward to working with Kelly every day because she makes me do treatments that are different from the typical ones I do with our more common patients with orthopedic injuries. It allows me to pull from what I've learned on my internship and be creative to find ways for her to re-learn new things or compensate for skills that may be difficult to regain. I've done visuomotor exercises with Kelly with her vision stick from the home exercise program she was given upon discharge from the hospital. But then I thought of ways to vary the exercises and make them more functional. We've scanned and read through the grocery newspaper which I really liked not only because Kelly loves grocery shopping, but because it has a lot of contrasting color and bigger font that make it easier for Kelly to read and maintain visual focus. I've taped a vertical and horizontal list of letters and numbers to the wall and had Kelly read them up and down, side to side, with her head facing the front and only moving her eyes(alternating the patch). I explained to Kelly that when she is discharged, she will have to be able to read signs being out and about in the community. At times I'd take out the middle portion of the list so she would have to jump back and forth to the first letter/number on one side and then to the first letter/number on the other side. Not only is she again working on her eye movement, but she is also working on her short-term memory and divided attention, because as she is going from one letter/number, she has to remember where her placement was and where she left off. I've played the memory game with Kelly and emphasized the importance of repetition, repetition, repetition. The more she reminded herself over and over again of what picture was beneathe the cards, the easier it was for her to finish the game. I printed an article on activities for short-term memory (http://www.livestrong.com/article/187149-activities-for-short-term-memory/) in large font and had Kelly read it during one of our sessions while, at the same time, teaching her how to use a rular to mark her place or use her finger to jump from one word to the next. It's amazing how one simple compensatory strategy can help.
In the meantime, we've also worked together to build Kelly's strength for safe transfers and shower tasks. On Thursday, almost a week after she was admitted, she asked if she could attempt shaving her legs because she hadn't for three weeks now. Why not! She was in the shower for, not kidding, a good 30 minutes. Hunched down, reaching for her ankles with her razor, she started laughing. When I asked her what was funny, she said to me, "I'm just laughing at the little things that are making me so happy right now". I grabbed my clip board and wrote that special quote down, thinking to myself, "That's what OT is all about". After her shower, she pulled out a pair of new jeans out of her drawer. She told me they were new and she couldn't fit into them when she bought them. She told me she lost 20+ lbs since before the hospital and wanted to try them on. She pulled them up over her legs all on her own, saying, "They feel so nice against my smooth skin! Amazing the things we take for granted." She layed supine, sucked her stomach in, and buttoned them shut. They fit. She sat on the edge of her bed and said to me, "I will never take things for granted ever again. Never."
On Friday, she mentioned she couldn't continue reading her novels on the kindle application on her iPad because the font was so small. So I saved the last 10 minutes in our therapy session to mess around with it. Surprisingly, my technologically-retarded self, discovered how to maximize the font. Kelly sighed and said wtih a big smile, "I can read now!" Next week, I'm going to print out large Sudoku sheets for her to work on since she told me she misses doing them. Then we are going to visit her home to give Kelly ideas on how to make her environment safer and more accessible. That should be a good session. And one to motivate her even more towards discharge.
So here's what I discovered about Kelly. She was very weak. She could perform a toilet and shower transfer with me simply guiding her at her hips, but at any given moment, may need maximum assistance from two people because she can have muscle spasms in her legs in a split second. She can be in the middle of drying herself while sitting on her shower chair, and then collapse onto you because everything around her starts to spin. That was a little scary. She wears a black eye patch with a garter strapped around her head because she has double vision, and in order to focus on something and see it accurately, she has to have one eye closed. She has difficulty and fatigues easily with circular and vertical eye movements. She has poor short-term memory and divided attention. She will be walking to get clean clothes out of her drawer, get there, and forget what she walked over there for. Or she'll attempt to don her jeans in the morning and forget to take her pajama bottoms off.
With every limitation Kelly has, she has a million strengths. She is highly motivated. She is willing to try anything and everything I ask her to. One morning she was so nauseated after breakfast and kept apologizing for having to re-schedule, almost in tears, because she really wanted to do therapy. She goes to the afternoon recreational activities in our facility -attempting to play Bingo and Keno even though she tells me it's frustrating at times. Kelly also has a lot of hobbies and a thirst for learning new ones. She loves brain-teaser activities that are perfect for working on improving short-term memory. She has amazing family support. The posters, cards, flowers, pirate hat to match her eye patch, Winnie the Pooh and Snoopie stuffed animal in her room say it all. And whenever I recommend getting a portable grab bar or a vision stick or large-print playing cards, her daughter, parents, or husband will have it for her the next day to show me in therapy.
I look forward to working with Kelly every day because she makes me do treatments that are different from the typical ones I do with our more common patients with orthopedic injuries. It allows me to pull from what I've learned on my internship and be creative to find ways for her to re-learn new things or compensate for skills that may be difficult to regain. I've done visuomotor exercises with Kelly with her vision stick from the home exercise program she was given upon discharge from the hospital. But then I thought of ways to vary the exercises and make them more functional. We've scanned and read through the grocery newspaper which I really liked not only because Kelly loves grocery shopping, but because it has a lot of contrasting color and bigger font that make it easier for Kelly to read and maintain visual focus. I've taped a vertical and horizontal list of letters and numbers to the wall and had Kelly read them up and down, side to side, with her head facing the front and only moving her eyes(alternating the patch). I explained to Kelly that when she is discharged, she will have to be able to read signs being out and about in the community. At times I'd take out the middle portion of the list so she would have to jump back and forth to the first letter/number on one side and then to the first letter/number on the other side. Not only is she again working on her eye movement, but she is also working on her short-term memory and divided attention, because as she is going from one letter/number, she has to remember where her placement was and where she left off. I've played the memory game with Kelly and emphasized the importance of repetition, repetition, repetition. The more she reminded herself over and over again of what picture was beneathe the cards, the easier it was for her to finish the game. I printed an article on activities for short-term memory (http://www.livestrong.com/article/187149-activities-for-short-term-memory/) in large font and had Kelly read it during one of our sessions while, at the same time, teaching her how to use a rular to mark her place or use her finger to jump from one word to the next. It's amazing how one simple compensatory strategy can help.
In the meantime, we've also worked together to build Kelly's strength for safe transfers and shower tasks. On Thursday, almost a week after she was admitted, she asked if she could attempt shaving her legs because she hadn't for three weeks now. Why not! She was in the shower for, not kidding, a good 30 minutes. Hunched down, reaching for her ankles with her razor, she started laughing. When I asked her what was funny, she said to me, "I'm just laughing at the little things that are making me so happy right now". I grabbed my clip board and wrote that special quote down, thinking to myself, "That's what OT is all about". After her shower, she pulled out a pair of new jeans out of her drawer. She told me they were new and she couldn't fit into them when she bought them. She told me she lost 20+ lbs since before the hospital and wanted to try them on. She pulled them up over her legs all on her own, saying, "They feel so nice against my smooth skin! Amazing the things we take for granted." She layed supine, sucked her stomach in, and buttoned them shut. They fit. She sat on the edge of her bed and said to me, "I will never take things for granted ever again. Never."
On Friday, she mentioned she couldn't continue reading her novels on the kindle application on her iPad because the font was so small. So I saved the last 10 minutes in our therapy session to mess around with it. Surprisingly, my technologically-retarded self, discovered how to maximize the font. Kelly sighed and said wtih a big smile, "I can read now!" Next week, I'm going to print out large Sudoku sheets for her to work on since she told me she misses doing them. Then we are going to visit her home to give Kelly ideas on how to make her environment safer and more accessible. That should be a good session. And one to motivate her even more towards discharge.
Friday, October 7, 2011
Room 104
I can't help but feel a sense of failure (even if it's slight) when a former patient of mine returns to our facility after a fall. I felt that for the first time on Wednesday morning. I was in room 104, doing a room treatment, when my patient's phone rang. It was not long until I realized that the person calling was someone my patient did not know. She said, "Here. Talk to my therapist" and handed me the phone. To my surprise, it was my ex-patient's daughter. That patient used to be in room 104 and was discharged a couple weeks ago. What her daughter told me broke my heart.
My patient fell on Saturday in the middle of the night, tripping over the wheel of her four-wheel walker as she was getting out of bed to go to the bathroom. She had not gotten out of bed since. It was already Wednesday. And according to her daughter, home health never arrived. First thing I asked was, "Did you take her to the hospital?" No. I was so confused. So I told her I'd see what I could do, never having this situation happen before, and that I was glad she called when she did. I talked to the physical therapist who also worked with this patient and our social worker, who was in charge of getting home health services set up prior to discharge. She took it from there and sent a home health nurse over to the house.
At 4:30, as I was getting ready to leave and was walking down the hall, I saw my patient's name outside one of the rooms. I stared at it for a second to make sure I was reading it correctly. Then I knocked, opened the door, and peeked inside. My patient (let's call her Connie) was attempting to sit up in bed with a big, gasping smile on her face. She opened her arms up to me. I made my way past her daughter, who was on the phone and ended up taking her call in the bathroom, and gave Connie a big hug. "What happened?!" I asked her. She told me how she fell and that she feels she has declined and has been depressed since she's been home and does not understand why. Then she hugged me again. I told her I was glad she was back under the circumstances and that we'll talk tomorrow and figure out what's been going on and how we can fix it. I told her, "You were READY to go home, Connie. In fact, you were more than ready." And she knew that.
When I first met Connie, she became very special to me right away. Connie used to be on hospice care, which was shocking to me. Because even though she fatigued easily when bending over to put her socks on and needed me guiding her into the shower, she had so much potential. With Connie's Rheumatoid Arthritis (RA), we adapted her writing utensils and found easier ways to allow her to open packages in the kitchen. With her Chronic Obstructive Pulmonary Disorder (COPD), we went over energy conservation strategies and did endurance training. With her decreased strength, we did bilateral upper extremity exercises and functional activities, keeping her RA precautions in mind. And with her depression, we talked. Mostly about family and baking and what she wishes she COULD do.
When her endurance finally picked up and her physical therapist gave me the go-ahead with walking long distances with her front-wheel walker, I planned a trip to the dollar store. When the facility driver and I went into her room to get her ready, she was sitting on the edge of the bed, with a big smile on her face, and a list of almost 20 items she wanted to purchase -all listed in her squiggly handwriting, that she told me she did with her adapted pen. Here's what she came up with:
3 birthday cards - one for my grandson, one for my sister, and one for my brother (this one has to be extra special).
Hairbrush
Hair color
Hair curlers (2 packs)
Hair spray
Mirror
Floss (2 packs)
Hot tamales
Pantyliners
Non-slip mat (The main reason we were going to the dollar store in the first place)
Mascara
Shades
Reading glasses
Small notebook
I wasn't sure if we could find all this stuff at the dollar store, but Connie reassured me we would. We got there and she looked like a kid in a candy store. On top of getting all the items on her list, she found more things she wanted. She demonstrated good endurance in walking for a long period of time, good safety with positioning her walker when reaching for items, and good fine motor skills as she manipulated her wallet and money. As we walked out, Connie said to me, "I haven't been taken to the store in 8 years". I felt happy and sorry for her all at the same time, I almost cried.
That same week we baked sugar cookies in the kitchen in the rehab gym. Connie told me she used to bake all the time but that she stopped because it became too difficult for her with her RA and COPD. But there she was! In control. Opening packages with minimal assistance and adaptive strategies, obtaining everything she needed, stirring ingredients in standing, managing the oven, and washing dishes. We stood there and ate a cookie (or two) before I walked her back to her room.
The following week, Connie told me she needed a smaller pair of black sweat pants because she had lost a lot of weight. She wanted to go to Ross for their Senior-20%-off-Tuesday. I scheduled it with the driver, which almost became a disaster because I wrote it on the Wednesday calendar by accident. Connie said if we couldn't go, she would've cried. Connie would've hated me (well, not really). The driver, by luck, showed up to her room at the perfect time to replace her oxygen tank and was greeted with Connie asking, "Ready to take me?" Luckily, he had no appointments scheduled and we were able to make it to Ross for our therapy session. She bought a pair of black sweats, a bunch of socks, and a cute turqoise blouse that I picked out for her. The only thing that she didn't find that was on her list was a wallet. She did amazingly well considering how huge Ross was. The only little scare we ran into was when we were in the dressing room and she told me that she was having BM accidents lately. Luckily, she did not have one under my watch, on a community outing nonetheless!
And now here she was. Back in transitional rehab because of falling at home. In a way I felt responsible because she was my patient and my job was to keep her safe. But when I told the physical therapist the situation and how I randomly, but thankfully, received a phone call in room 104 that morning, he told me we did our part. She was more than ready to go home. Among all the patients I've had, she's been able to do the most -bake, go on outings, walk through an entire store and try on clothing.. There was nothing more we could've done as a team.
I missed Connie so much when she left. In fact, I considered doing PRN work in home health to possibly be her home health therapist. But that was just a thought. I know I say this a lot in my posts, but I had a true bond with Connie. I am not happy of course about the circumstances, but I am glad that she is back in an environment where she can get the skilled service and support she needs to get back to where she was the day she left. It seemed as if Connie was excited to be back. She hugged me again for a third time before I told her I had to go clock out because I was done working for the day and that I would see her tomorrow. As I walked out the door, Connie called out, "I love you, hun".
Today, I saw her for a 70-minute treatment session. She was in the gym, just finishing up her physical therapy session, when she whispered that she'd like to start our session in her room because she wanted to talk to me. In her room, she told me she wanted to get out of bed since Saturday but her daughter told her not to because she didn't want her to fall. She told me all her frustrations and hurtful feelings towards her family. All I could do was listen. Then, as she sat on the toilet, she broke down into tears and said, "I just wish somebody wanted me". My heart broke once again and I felt for her. There I was, hugging my patient who was sitting on the toilet thinking, "I don't know how sanitary this is but I don't give a crap" (no pun intended).
My patient fell on Saturday in the middle of the night, tripping over the wheel of her four-wheel walker as she was getting out of bed to go to the bathroom. She had not gotten out of bed since. It was already Wednesday. And according to her daughter, home health never arrived. First thing I asked was, "Did you take her to the hospital?" No. I was so confused. So I told her I'd see what I could do, never having this situation happen before, and that I was glad she called when she did. I talked to the physical therapist who also worked with this patient and our social worker, who was in charge of getting home health services set up prior to discharge. She took it from there and sent a home health nurse over to the house.
At 4:30, as I was getting ready to leave and was walking down the hall, I saw my patient's name outside one of the rooms. I stared at it for a second to make sure I was reading it correctly. Then I knocked, opened the door, and peeked inside. My patient (let's call her Connie) was attempting to sit up in bed with a big, gasping smile on her face. She opened her arms up to me. I made my way past her daughter, who was on the phone and ended up taking her call in the bathroom, and gave Connie a big hug. "What happened?!" I asked her. She told me how she fell and that she feels she has declined and has been depressed since she's been home and does not understand why. Then she hugged me again. I told her I was glad she was back under the circumstances and that we'll talk tomorrow and figure out what's been going on and how we can fix it. I told her, "You were READY to go home, Connie. In fact, you were more than ready." And she knew that.
When I first met Connie, she became very special to me right away. Connie used to be on hospice care, which was shocking to me. Because even though she fatigued easily when bending over to put her socks on and needed me guiding her into the shower, she had so much potential. With Connie's Rheumatoid Arthritis (RA), we adapted her writing utensils and found easier ways to allow her to open packages in the kitchen. With her Chronic Obstructive Pulmonary Disorder (COPD), we went over energy conservation strategies and did endurance training. With her decreased strength, we did bilateral upper extremity exercises and functional activities, keeping her RA precautions in mind. And with her depression, we talked. Mostly about family and baking and what she wishes she COULD do.
When her endurance finally picked up and her physical therapist gave me the go-ahead with walking long distances with her front-wheel walker, I planned a trip to the dollar store. When the facility driver and I went into her room to get her ready, she was sitting on the edge of the bed, with a big smile on her face, and a list of almost 20 items she wanted to purchase -all listed in her squiggly handwriting, that she told me she did with her adapted pen. Here's what she came up with:
3 birthday cards - one for my grandson, one for my sister, and one for my brother (this one has to be extra special).
Hairbrush
Hair color
Hair curlers (2 packs)
Hair spray
Mirror
Floss (2 packs)
Hot tamales
Pantyliners
Non-slip mat (The main reason we were going to the dollar store in the first place)
Mascara
Shades
Reading glasses
Small notebook
I wasn't sure if we could find all this stuff at the dollar store, but Connie reassured me we would. We got there and she looked like a kid in a candy store. On top of getting all the items on her list, she found more things she wanted. She demonstrated good endurance in walking for a long period of time, good safety with positioning her walker when reaching for items, and good fine motor skills as she manipulated her wallet and money. As we walked out, Connie said to me, "I haven't been taken to the store in 8 years". I felt happy and sorry for her all at the same time, I almost cried.
That same week we baked sugar cookies in the kitchen in the rehab gym. Connie told me she used to bake all the time but that she stopped because it became too difficult for her with her RA and COPD. But there she was! In control. Opening packages with minimal assistance and adaptive strategies, obtaining everything she needed, stirring ingredients in standing, managing the oven, and washing dishes. We stood there and ate a cookie (or two) before I walked her back to her room.
The following week, Connie told me she needed a smaller pair of black sweat pants because she had lost a lot of weight. She wanted to go to Ross for their Senior-20%-off-Tuesday. I scheduled it with the driver, which almost became a disaster because I wrote it on the Wednesday calendar by accident. Connie said if we couldn't go, she would've cried. Connie would've hated me (well, not really). The driver, by luck, showed up to her room at the perfect time to replace her oxygen tank and was greeted with Connie asking, "Ready to take me?" Luckily, he had no appointments scheduled and we were able to make it to Ross for our therapy session. She bought a pair of black sweats, a bunch of socks, and a cute turqoise blouse that I picked out for her. The only thing that she didn't find that was on her list was a wallet. She did amazingly well considering how huge Ross was. The only little scare we ran into was when we were in the dressing room and she told me that she was having BM accidents lately. Luckily, she did not have one under my watch, on a community outing nonetheless!
And now here she was. Back in transitional rehab because of falling at home. In a way I felt responsible because she was my patient and my job was to keep her safe. But when I told the physical therapist the situation and how I randomly, but thankfully, received a phone call in room 104 that morning, he told me we did our part. She was more than ready to go home. Among all the patients I've had, she's been able to do the most -bake, go on outings, walk through an entire store and try on clothing.. There was nothing more we could've done as a team.
I missed Connie so much when she left. In fact, I considered doing PRN work in home health to possibly be her home health therapist. But that was just a thought. I know I say this a lot in my posts, but I had a true bond with Connie. I am not happy of course about the circumstances, but I am glad that she is back in an environment where she can get the skilled service and support she needs to get back to where she was the day she left. It seemed as if Connie was excited to be back. She hugged me again for a third time before I told her I had to go clock out because I was done working for the day and that I would see her tomorrow. As I walked out the door, Connie called out, "I love you, hun".
Today, I saw her for a 70-minute treatment session. She was in the gym, just finishing up her physical therapy session, when she whispered that she'd like to start our session in her room because she wanted to talk to me. In her room, she told me she wanted to get out of bed since Saturday but her daughter told her not to because she didn't want her to fall. She told me all her frustrations and hurtful feelings towards her family. All I could do was listen. Then, as she sat on the toilet, she broke down into tears and said, "I just wish somebody wanted me". My heart broke once again and I felt for her. There I was, hugging my patient who was sitting on the toilet thinking, "I don't know how sanitary this is but I don't give a crap" (no pun intended).
Thursday, October 6, 2011
I Can Use a Wrench!
Yesterday, I decided to play the role of handyman. Considering the only tools I know how to use are crochet and knitting needles, I think I did a pretty good job and I am proud enough to write a post entirely on my experience fixing my patient's wheelchair brakes!
I was working with one of my patients, doing a room treatment, when I noticed her wheelchair moved as she performed a sit-to-stand transfer. This surprised me at first because for one, I did not want her to fall, and second, she has always been my A-patient when it came to safety during functional transfers. Lord help me if I had to document that she all of a sudden had poor safety awareness. I checked her brakes and they were locked. But they were loose and just barely touched the wheel. She told me the PRN physical therapy assistant noticed it yesterday and that someone would tighten them today. I had her sit on the edge of the bed and looked at the clock. We had 10 minutes left. Now in 10 minutes, could I really figure out how to fix this thing? Why not. The physical therapist taught me how to do it my second week on the job when my patient's brakes were loose. But it took me a good 20 minutes to get it done because saying "yes, I can do that" after being shown how, does not necessarily mean, "yes I can do that" once you try it yourself. But I figured I had to figure it out eventually. And my patient cannot go through the rest of the day with loose brakes.
So I went to the gym, grabbed the toolbox, went back to my patient's room, gave her some theraband to do her exercises with in the meantime as she watched me.. layed out the tools on her floor, tipped her wheelchair on it's side, and crouched down. I told my patient, "So here's the thing. I know what I'm SUPPOSED to do-", as I pointed to the nut and bolt I was suppose to take apart, "-I just don't know if I remember what I'm suppose to do it WITH", as I held up the different little hollow cylindrical silver thingys. "I REALLY don't wanna have to call Jason" (her PT). But after a couple minutes of being unproductive, I had to give in.
Jason was sitting at the computer. I grabbed him and off we went back to her room. He laughed at all the tools on the floor. Once he picked out the tools I was suppose to use, I was good to go. I fixed the first wheel and clapped once it locked tightly into the wheel. Then I flipped the chair over and started unscrewing the other. When I was close to finishing, the nut got stuck in the cylindrical silver thingy. Panic. My patient laughed. I was glad to provide entertainment as she was doing her exercises on the edge of the bed. "I am NOT calling Jason back here. You cannot tell him this happened." We laughed. I figured out that if I attached it back onto the chair, it stabilized the nut well enough for me to unscrew it from the other side. I got it! Done! I was so excited and proud of myself. There's a first time for everything.
I was working with one of my patients, doing a room treatment, when I noticed her wheelchair moved as she performed a sit-to-stand transfer. This surprised me at first because for one, I did not want her to fall, and second, she has always been my A-patient when it came to safety during functional transfers. Lord help me if I had to document that she all of a sudden had poor safety awareness. I checked her brakes and they were locked. But they were loose and just barely touched the wheel. She told me the PRN physical therapy assistant noticed it yesterday and that someone would tighten them today. I had her sit on the edge of the bed and looked at the clock. We had 10 minutes left. Now in 10 minutes, could I really figure out how to fix this thing? Why not. The physical therapist taught me how to do it my second week on the job when my patient's brakes were loose. But it took me a good 20 minutes to get it done because saying "yes, I can do that" after being shown how, does not necessarily mean, "yes I can do that" once you try it yourself. But I figured I had to figure it out eventually. And my patient cannot go through the rest of the day with loose brakes.
So I went to the gym, grabbed the toolbox, went back to my patient's room, gave her some theraband to do her exercises with in the meantime as she watched me.. layed out the tools on her floor, tipped her wheelchair on it's side, and crouched down. I told my patient, "So here's the thing. I know what I'm SUPPOSED to do-", as I pointed to the nut and bolt I was suppose to take apart, "-I just don't know if I remember what I'm suppose to do it WITH", as I held up the different little hollow cylindrical silver thingys. "I REALLY don't wanna have to call Jason" (her PT). But after a couple minutes of being unproductive, I had to give in.
Jason was sitting at the computer. I grabbed him and off we went back to her room. He laughed at all the tools on the floor. Once he picked out the tools I was suppose to use, I was good to go. I fixed the first wheel and clapped once it locked tightly into the wheel. Then I flipped the chair over and started unscrewing the other. When I was close to finishing, the nut got stuck in the cylindrical silver thingy. Panic. My patient laughed. I was glad to provide entertainment as she was doing her exercises on the edge of the bed. "I am NOT calling Jason back here. You cannot tell him this happened." We laughed. I figured out that if I attached it back onto the chair, it stabilized the nut well enough for me to unscrew it from the other side. I got it! Done! I was so excited and proud of myself. There's a first time for everything.
Wednesday, September 21, 2011
A Little Bit of Rummy & A Touch of Cowboy
I swear that whenever one of my favorite patients discharges (because let's be honest, everyone has favorites even if it's a patient), another one miraculously appears. I evaled a gentleman yesterday who fell off his horse and fractured his ribs. I will name him Bud.
Bud is a gentleman in every sense of the word. In the two sessions I've worked with him, he's called me every nickname your father, boyfriend, grandfather, or husband has ever called you -sweetie, sweet pea, sweet thing, honey, hun, purdy lady, baby girl, babe, darlin. You name it, he's called me it. Sometimes I think it's because he can't quit remember my name just yet. But I think it's really because he's just a gentleman born and raised in the good ol' southern United States.
When I first met Bud, he told me he was originally from Texas. I told him my parents were moving to Austin in November. As soon as I said "Austin", Bud laughed, shook his head and said, "You gotta get down and dirty with it honey. 'AWE-stin'. Not that California talk you sayin there." As we walked to the gym from his room, he proceeded to teach me how to use "yall" and "yonder" in my sentences. I told the other therapists, "I'm learning how to speak Cowboy!" I'm sure Bud thinks I'm nuts.
When I told Bud I grew up in the Philippines, he blurted in his southern accent, "OH so you speak Filipinian!" I knew we were going to have a blast in therapy already. So far, all we have been working on is Bud's endurance. He is able to shower, dress himself, do his grooming and hygiene standing at the sink, etc. with only stand-by assistance. It just takes him forever to do it because he fatigues so easily. And on top of that, Bud does not understand the concept of pacing. So we've gone over energy conservation strategies on the first day after the shower and have been focusing on building his endurance for functional activities.Today, we did nothing but play cards in dynamic standing. Bud was able to stand for about 15 minutes tops (which is great) before having to sit down. The one problem is that Bud likes to work, work, work and doesn't initiate sitting down and taking a rest break. I constantly have to ask him, "Bud, how does your body feel right now? Are you doing ok standing there? Are you starting to get short of breath?" This is what we're working on. The good thing is that he's aware of this concern of mine and is trying to make these energy conservation strategies a new part of his routine.
So we played cards for a good part of our 60 minute treatment today. Bud loves playing cards, which makes it a great activity to use when working on standing tolerance and functional endurance. Bud taught me how to play 21, Poker, and Rummy. Rummy was my favorite. I would try to jump ahead and "hit" and "draw" when I wasn't suppose to and Bud would tell me to hold my horses and listen to his instructions because I was getting ahead of myself. Sometimes I felt like I was the patient. But I only jump ahead because I don't understand Bud half the time he's talking to me because of his heavy southern accent. At times it feels like he's eating his words under his moustache. So I ended up learning how to play Rummy from my next patient who also likes playing cards. When I went back to see Bud for the second half of our session in the afternoon, he commented on how fast I picked the game up.
Bud has already stated his goals for me (yes me, not him) while he is in our facility and when he gets discharged. He says, "Imma make a cowgirl outta you before I leave this place!" Here is his goal list for me, which isn't very client-centered considering all I want to be able to do is beat him at Rummy:
1. Learn how to ride a bull. If this were a real therapy goal, I would be discharged due to insurance reasons (because I would refuse therapy sessions until Medicare denies reimbursement for skilled services), or I would be discharged straight to the hospital for a fractured EVERYTHING.
2. Learn how to rope a calf. I think I would much rather pet the calf than rope it.
3. Get me a pair ah dem cowboy boots. This I don't mind.
4. Eat his buffalo chili. I don't know where he's planning on getting us buffalo meat for this cooking task. Other than that, I'm all about kitchen safety and self-feeding!
Bud is a gentleman in every sense of the word. In the two sessions I've worked with him, he's called me every nickname your father, boyfriend, grandfather, or husband has ever called you -sweetie, sweet pea, sweet thing, honey, hun, purdy lady, baby girl, babe, darlin. You name it, he's called me it. Sometimes I think it's because he can't quit remember my name just yet. But I think it's really because he's just a gentleman born and raised in the good ol' southern United States.
When I first met Bud, he told me he was originally from Texas. I told him my parents were moving to Austin in November. As soon as I said "Austin", Bud laughed, shook his head and said, "You gotta get down and dirty with it honey. 'AWE-stin'. Not that California talk you sayin there." As we walked to the gym from his room, he proceeded to teach me how to use "yall" and "yonder" in my sentences. I told the other therapists, "I'm learning how to speak Cowboy!" I'm sure Bud thinks I'm nuts.
When I told Bud I grew up in the Philippines, he blurted in his southern accent, "OH so you speak Filipinian!" I knew we were going to have a blast in therapy already. So far, all we have been working on is Bud's endurance. He is able to shower, dress himself, do his grooming and hygiene standing at the sink, etc. with only stand-by assistance. It just takes him forever to do it because he fatigues so easily. And on top of that, Bud does not understand the concept of pacing. So we've gone over energy conservation strategies on the first day after the shower and have been focusing on building his endurance for functional activities.Today, we did nothing but play cards in dynamic standing. Bud was able to stand for about 15 minutes tops (which is great) before having to sit down. The one problem is that Bud likes to work, work, work and doesn't initiate sitting down and taking a rest break. I constantly have to ask him, "Bud, how does your body feel right now? Are you doing ok standing there? Are you starting to get short of breath?" This is what we're working on. The good thing is that he's aware of this concern of mine and is trying to make these energy conservation strategies a new part of his routine.
So we played cards for a good part of our 60 minute treatment today. Bud loves playing cards, which makes it a great activity to use when working on standing tolerance and functional endurance. Bud taught me how to play 21, Poker, and Rummy. Rummy was my favorite. I would try to jump ahead and "hit" and "draw" when I wasn't suppose to and Bud would tell me to hold my horses and listen to his instructions because I was getting ahead of myself. Sometimes I felt like I was the patient. But I only jump ahead because I don't understand Bud half the time he's talking to me because of his heavy southern accent. At times it feels like he's eating his words under his moustache. So I ended up learning how to play Rummy from my next patient who also likes playing cards. When I went back to see Bud for the second half of our session in the afternoon, he commented on how fast I picked the game up.
Bud has already stated his goals for me (yes me, not him) while he is in our facility and when he gets discharged. He says, "Imma make a cowgirl outta you before I leave this place!" Here is his goal list for me, which isn't very client-centered considering all I want to be able to do is beat him at Rummy:
1. Learn how to ride a bull. If this were a real therapy goal, I would be discharged due to insurance reasons (because I would refuse therapy sessions until Medicare denies reimbursement for skilled services), or I would be discharged straight to the hospital for a fractured EVERYTHING.
2. Learn how to rope a calf. I think I would much rather pet the calf than rope it.
3. Get me a pair ah dem cowboy boots. This I don't mind.
4. Eat his buffalo chili. I don't know where he's planning on getting us buffalo meat for this cooking task. Other than that, I'm all about kitchen safety and self-feeding!
Friday, September 16, 2011
Group & Storytelling
At 6:45 AM, Thursday morning, I walked into the rehab gym with my sweats and O.T. softball shirt on (because it is sports day or physical health day or something like that) and the desire to curl up in bed because it is so cold and still dark outside and none of my current patient's appreciate 7:00 AM wake-up calls for therapy. So why the heck am I awake right now? But then one of our physical therapy assistants had a brilliant idea. We decided to group all our patients since the therapy department was in charge of doing some sort of sports activity with all the patients. We did not really think through this carefully because the two ideas we came up with were dodgeball or flash mob. Dodgeball was not going to work because we have three halls in our facility, not enough rubber balls or therapists to span the hallways, and many of our patients do not have the strength or range of motion to throw a ball very well. Flash mob was not going to work because the only dancer we have on our team is Andriana. And she already refused to chereograph any type of routine and we did not even have music planned that morning. So we decided to group our patients from 10:00-12:00 that morning and do fun sports-related activities. 10:00 AM would consist of two groups: the high-level OT group and the low-level PT group. At 11:00 AM, we would switch. We made sure each therapist had no more than 4 patients in each group so that we could bill for services. We printed handouts, came up with a rough outline of what we were to do, then did a couple individual treatments and caught up on paperwork.
At 10:00 AM, the CNAs brought all the patient's in one at a time. It was going to be a riot. Organized chaos. I was already getting sensory-overload. Our first group, the high-level patients, were a lot more energized. We did theraband exercises to work on bilateral upper extremity strength, balloon volleyball to work on range of motion, hot potato with weighted balls for core strengthening and sitting balance while weightshifting, and finally, a healthy aging discussion. It was fun. And our discussion was hilarious because we had patients who would not stop giving long, elaborate examples that, by the end of their story, I had no idea how it related to our topic.
Then we had our low-level group, who had just finished physical therapy. I realized that Frank, my patient with the amputated leg, got placed in the wrong group. Oh. No. Because as all the people in our low-level group needed several physical cues to do the theraband exercises, did not notice the balloon coming to them till it landed on their heads, and stared off into space when asked questions during discussion, Frank looked around wondering what was going on. I was doing the same. One of Andriana's patients fell asleep while doing the group exercises and almost slapped Frank with his theraband. Another patient with a very thick German accent was doing the exercises way too fast while yelling, "I need my oxygen! But I'm going to do these exercises anyway!" She started laughing and heeving -we had to physically take the theraband away from her. "Deep breaths through your nose, Marg. Smell the schnitzel!" Frank, who was sitting next to me as I talked about healthy aging, would smile and wink at me every time I looked over at him.
This morning I woke Frank up at 8:00 AM to get him ready for his 10:30 AM doctor's appointment. He looked at me, closed his eyes, and sighed, "Oh it's you". I said, "Frank, we're going to do a shower for therapy today". His eyes opened wide up and he said, "I can't do therapy this morning. I have a doctor's appointment!" When I told him we had plenty of time and that I was helping him get ready for it, he said, "I look forward to the day that I can win an agrument with you." We laughed. I sat on the cushion by the window sill and told him I was going to let him get himself out of bed and into his wheelchair. If you have forgotten or haven't read my previous posts, Frank is almost 90 years old (probably one of our sharpest patients) and has had a right amputated leg for quite a few years. After a few attempts and sounds of intense effort coming from Frank's end to get him in a long-sitting position, I suggested raising the head of the bed to make the transfer less demanding because Frank's family told me that he will have a hospital bed at home when he discharges. Frank told me to just let HIM do it. I laughed. I can't take things personal with Frank because he knows me well and I know him. When he got to the edge of the bed from a supine position, I crouched down on the floor and looked up at him saying, "Take a rest break -that was a lot of work". Frank said, "Let me tell you story". Oh boy, here we go.
Frank told me that when he was younger and moving around pretty well with his amputated leg, he started volunteering at the Utah State Rehabilitation Center. He told me that there were several young kids with the same disability as him. He would show them how to get on and off chairs, move around, and do daily activities like nothing was different about him. Frank told me they would enthusiastically cheer after he did things but that when they tried it themselves, they struggled. Frank said that as he watched them struggle, he would cry like a baby. When the coordinator asked him if he could come help regularly because the kids loved watching him do what he could do, Frank told him that he could not let these kids see him crying just because they could not do the same things he could. He never went back again. The reason why Frank told me this story was not just because he was able to get to the edge of the bed without my help now, but because he said the group session yesterday reminded him of that experience. I thought to myself, Well that's because your occupational therapist is an idiot and did not realize you were placed in the low-level group. Frank said, "I watched those ladies yesterday and how they were trying so hard to do the activities and it took all of me to prevent myself from crying . . . I have a picture of Christ in my home and beside it is a quote: 'I never said it would be easy, I only said it would be worth it'. I will keep trying. I just hope it's worth it". Holding back tears, I told Frank it was so worth it. He smiled looking down at me and knodded, "Ok. Now let's go." He completed the transfer, with no help, both of us in silence.
At 10:00 AM, the CNAs brought all the patient's in one at a time. It was going to be a riot. Organized chaos. I was already getting sensory-overload. Our first group, the high-level patients, were a lot more energized. We did theraband exercises to work on bilateral upper extremity strength, balloon volleyball to work on range of motion, hot potato with weighted balls for core strengthening and sitting balance while weightshifting, and finally, a healthy aging discussion. It was fun. And our discussion was hilarious because we had patients who would not stop giving long, elaborate examples that, by the end of their story, I had no idea how it related to our topic.
Then we had our low-level group, who had just finished physical therapy. I realized that Frank, my patient with the amputated leg, got placed in the wrong group. Oh. No. Because as all the people in our low-level group needed several physical cues to do the theraband exercises, did not notice the balloon coming to them till it landed on their heads, and stared off into space when asked questions during discussion, Frank looked around wondering what was going on. I was doing the same. One of Andriana's patients fell asleep while doing the group exercises and almost slapped Frank with his theraband. Another patient with a very thick German accent was doing the exercises way too fast while yelling, "I need my oxygen! But I'm going to do these exercises anyway!" She started laughing and heeving -we had to physically take the theraband away from her. "Deep breaths through your nose, Marg. Smell the schnitzel!" Frank, who was sitting next to me as I talked about healthy aging, would smile and wink at me every time I looked over at him.
This morning I woke Frank up at 8:00 AM to get him ready for his 10:30 AM doctor's appointment. He looked at me, closed his eyes, and sighed, "Oh it's you". I said, "Frank, we're going to do a shower for therapy today". His eyes opened wide up and he said, "I can't do therapy this morning. I have a doctor's appointment!" When I told him we had plenty of time and that I was helping him get ready for it, he said, "I look forward to the day that I can win an agrument with you." We laughed. I sat on the cushion by the window sill and told him I was going to let him get himself out of bed and into his wheelchair. If you have forgotten or haven't read my previous posts, Frank is almost 90 years old (probably one of our sharpest patients) and has had a right amputated leg for quite a few years. After a few attempts and sounds of intense effort coming from Frank's end to get him in a long-sitting position, I suggested raising the head of the bed to make the transfer less demanding because Frank's family told me that he will have a hospital bed at home when he discharges. Frank told me to just let HIM do it. I laughed. I can't take things personal with Frank because he knows me well and I know him. When he got to the edge of the bed from a supine position, I crouched down on the floor and looked up at him saying, "Take a rest break -that was a lot of work". Frank said, "Let me tell you story". Oh boy, here we go.
Frank told me that when he was younger and moving around pretty well with his amputated leg, he started volunteering at the Utah State Rehabilitation Center. He told me that there were several young kids with the same disability as him. He would show them how to get on and off chairs, move around, and do daily activities like nothing was different about him. Frank told me they would enthusiastically cheer after he did things but that when they tried it themselves, they struggled. Frank said that as he watched them struggle, he would cry like a baby. When the coordinator asked him if he could come help regularly because the kids loved watching him do what he could do, Frank told him that he could not let these kids see him crying just because they could not do the same things he could. He never went back again. The reason why Frank told me this story was not just because he was able to get to the edge of the bed without my help now, but because he said the group session yesterday reminded him of that experience. I thought to myself, Well that's because your occupational therapist is an idiot and did not realize you were placed in the low-level group. Frank said, "I watched those ladies yesterday and how they were trying so hard to do the activities and it took all of me to prevent myself from crying . . . I have a picture of Christ in my home and beside it is a quote: 'I never said it would be easy, I only said it would be worth it'. I will keep trying. I just hope it's worth it". Holding back tears, I told Frank it was so worth it. He smiled looking down at me and knodded, "Ok. Now let's go." He completed the transfer, with no help, both of us in silence.
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