I Heart Neuro

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.

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.

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.

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).

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.

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!

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.

Bonding Time

One of my new patients has an amputated right leg. Now, like any professional in the health profession, whenever you receive orders for a complex case, the first thing you think of is how interesting it will be. What a great learning experience. In a way, that may seem a little selfish. But I'm sure we see it as a chance to provide skilled service to someone who really needs it. So when I met my new patient last week who had his right leg amputated, I was excited to start my eval and treatment.


Let me tell you, that was one of the most physically draining 75 minutes of therapy I have experienced. My patient, who I will call Frank, required moderate to maximum assistance for every transfer -to get out of his wheelchair, out of bed, on and off the toilet, on and off the shower chair. And we had to do all of that since he needed to use the toilet as soon as I walked in and since I told the CNA that I'd help him with his scheduled shower. After the draining task of showering himself, which many people take for granted until they can no longer do it independently, I had to call the CNA to help me lift Frank back to his wheelchair. Despite all this, I am finding that I really enjoy working with the physically challenging patients. Because the way I see it, there is really no other direction for them to go but up (at least that it what I hope for my patients even though it is not always the case). And when they do "go up" or make the slightest bit of progress, I get excited like a little girl opening presents on Christmas morning.

I usually take a lot of time thinking about how to best position my patient and his environment (his wheelchair, the height of his bed, to recline or not to recline) so that he can safely perform whatever it is he needs to do in the easiest way possible. In working with Frank last week, he would discover easier ways to do things, and I would learn from him. When he'd ask me if he could do it a different way instead, I would tell him, "You can do whatever you feel works for YOU. I will give you my suggestions and if I feel your safety is at risk, then I will jump in." He likes that I listen to him. He told me once after his shower, "WE did pretty good!" I like that he includes me in his accomplishments.

There was one day that Frank did not want to participate in therapy. He layed in bed till 10:00 AM and the CNA came in to ask me if I could help him get up and dressed because she had been trying since 8:00. Well that was not going to happen. When Frank decides he doesn't want to do something, he DOESN'T want to do something. I learned later from his nurse that his family had just sold his home that he absolutely loves and will be moving in with his daughter when he gets discharged. He needed an anxiety pill. That broke my heart. I went in to see him and we talked for awhile. He told me he felt that if he layed in bed and rested that day, he would be emotionally and physically prepared for therapy the next day. I told him I was ok with that. I walked in at 9:00 AM the next morning and Frank was ready to go. He told me, "I am going to get out of this bed and into my wheelchair and you are just going to watch me because I did it all by myself last night". Uh, you did? That made me nervous. I stood there with my hands an inch away from Frank's skin and every time I slightly brushed him, he'd stop and tell me to back off. "I am just killing you right now, aren't I?" he said, laughing. "Yes, Frank. Yes you are." He made me so nervous, it took every ounce of me to stop myself from helping him. I trusted him, but I felt that if he accidently slipped, I would not be fast enough to catch him. "Can I AT LEAST put my arm under yours? I won't help. It'll just be there if you need a little oomph." "No." I wanted to pout and stomp my feet. Frank thought it was hysterical. But you know what? He was right. Given time, and excessive perspiration on my end, Frank carefully (and safely) made it to his chair with no help. He sat there with a big smile on his face. Awesome. He sang the whole time he was in the shower that morning.

Today, Frank made my Monday by telling me something I will always remember. I wrote it down as soon as he said it because I knew that if ever there was a day that I doubted myself or felt down in the dumps, I could read it and remember why I love doing what I do. Frank told me, "You are one of the highlights of my being here. We talk, we have conversation. You are not just my occupational therapist. You are also my shrink." I almost cried.

Elderly Children

I went into occupational therapy school dead-set on working with children and graduated, still with a passion for pediatrics, but with a new-found love for the adult population. Little did I know, my first (well, technically second) job would be with the geriatric population -the one population I said I'd never work with. But, to my surprise, after an exhausting weekend experience, I learned the many similarities between the pediatric and geriatric population. Let me tell you how my weekend went down.

It started at 1:00 in the afternoon -the time I was scheduled to watch a 6-year-old who I've known since she was 2, and a 3-year-old who I've known ever since the time their mother took a pregnancy test. I wasn't just there for the afternoon. Heck, I wasn't even there till late evening. I was there for the next 27 hours. I walked in with a venti skinny vanilla latte and their mother said to me, with a smile on her face, "If you need more, there's freshly ground beans in the freezer. Feel free to brew yourself a pot." I laughed but found out later that evening she was not joking.


Similarity #1 between children and the elderly: They value their independence.

But doesn't everyone? In my attempts to give the girls their independence, I let them pick out their daytime outfits in the morning. The 6-year-old did pretty well color-coordinating, but the 3-year-old came out of her room in her full-on fairy costume. Wings and everything. The whole shibang. Nonetheless, her dress was backwards and in my attempts to make her look somewhat appropriate for our walk with the family lab, she stomped and cried, "KAFWIN, LET ME DOOOO IT!" Until she took it off later on that day, she was knocking walls and counters with her wings.

With one of my patients, adaptive equipment is not an option. Despite my countless explanations that it actually helps him be more independent till he can do things on his own without it (put socks on by yourself with your sock aid, reach for something out of your closet with your reacher without asking for assistance, pull your shirt down behind you with your dressing stick), he saw it as a label that he was incapable. And that was fine. People view adaptive equipment in different ways. For him, being independent was being INDEPENDENT. Not independent with modifications.

Similarity #2: Despite the many times they will attempt to convince you otherwise, they require supervision.

Usually the girls spend a good 15 minutes in the tub playing together with their bath toys before getting ready for bed. Once the tub's filled and they're sitting safely in it, allowing them to play what they call "tidal wave" is a bad idea. I could hear them laughing as I washed the dishes in the kitchem and figured everything was fine. But when I walked in the bathroom after their 15 minutes was up, the tub was filled a quarter of the way up. And the other three-quarters was everywhere BUT in the tub. "Girls! What are you DOING?!" They looked up at me laughing -"We're playing 'tidal wave'!" Duh.

A few weeks ago at work I walked out of my patient's room and noticed my co-worker's patient attempting a wheelchair to bed transfer unsupervised. From our weekly meetings and the few times he's been put on my schedule, I knew he wasn't suppose to be doing functional transfers unsupervised. I jumped in right before he could face-plant off his wheelchair and asked him what he was doing. He said, "I'm trying to get back in bed!" Duh. I told him he was not suppose to get out of his chair or out of his bed unsupervised. I knew he understood me. Even though all he did in response to my 1-minute safety education was laugh.

Similarity #3: Sometimes there is just no reasoning with them and you have no choice but to pick your battles.

Come naptime, the 3-year-old stomped and cried yet again, not wanting to take her fairy costume off. Despite my reasoning that the wing's wires will poke her in her sleep and that the flower in the front of the dress will most likely fall off, she wanted to sleep in it "like Thumbellina". One thing was for sure. She was not taking that thing off. She stomped and cried and even though I absolutely refuse to give into fits and tantrums, I figured she was tired. And quite frankly, I was tired too. So like Thumbellina, she took her afternoon nap in her fairy dress. Wings and everything.

A couple weeks ago I had a patient who absolutely hated rehab. In fact, I was pretty convinced up until the day she was self-discharged that she hated the world. I spent the first 45 minutes of every 60-minute treatment session explaining to her WHY she was in rehab and why we were doing what we were doing. She would apologize to me at the end of the session and I would go home thinking we had built rapport and that they next day would be a different day. It was not. I went in her room at 7:00 AM one morning because she was upset with me the day before for walking in at 8:00 because she said she was waiting for me since 7:00. So there I was, standing over her bed, asking her if she was ready for therapy and all she did was yell, "It's 7:00 in the morning! Why are you here so damn early?!" I was a millimeter close from walking out of her room and putting her on someone else's schedule. When I told her, obviously frustrated, that she was upset with me the day before because I WASN'T in at 7:00, she got up and decided to "get it over with". I spent the next 60 minutes of the session in silence, while she jabbered away at how she hates rehab and did not understand why she was doing what she was doing. I explained it to her once more, giving her the benefit of the doubt. Maybe she has poor short-term memory. But she would not stop. So I picked my battles and did not argue with her. I was just there to help her with her self-care that morning and supervise her exercises. I left her room after the longest 60 minutes of my life.

Similarity #4: With some encouragement, sillyness, and a little give-and-take, they will do whatever you ask of them.

Sunday afternoon, the house was a disaster. There were crayons and papers scattered all over the floor, along with their stuffed animals. They were playing "school". I had just made them popcorn and under-estimated the size of the bowl the popcorn was flowing into. On top of that, the girl's drawers were opened and emptied out in their attempts to "independently" dress themselves. Now we all know, clean-up is never as fun as playing, no matter what the situation. Getting these girls to clean up was like pulling teeth. But the less I demanded and the more I encouraged, the more toys per minute they seemed to pick up. When I joined them and made it a game, they started picking up two toys at a time. And when I told them we were going to the dollar store afterwards, all the toys and clothes miraculously disappeared off the floor.

At work with my elderly patients, it is never suprising to get a patient who complains when you ask them to do something they find difficult or fatiguing in therapy. I find myself constantly saying, "You can totally do that!" or "How will you know till you try it!" When my patients are grumpy, I dish it back. And then they end up calling me a "happy booger" or a "cheery little one" and all is good. I have learned that if I respect what they ask, they have to respect what I ask. In other words, we meet eachother halfway. If they do a couple sit to stand transfers for me or attempt to put their pants on, I will go over handouts with them the last 10 minutes of our session so they can take a long rest break.

Similarity #5: Working with children and the elderly means there will be special moments that, as corny as it sounds, I will cherish forever.


Getting the girls in bed early so I can relax for the night means they will be up at the butt-crack of dawn the next morning. I pulled the covers off my head and found them standing in the doorway of my room, half asleep. I raised my arms up and we layed there together -me, the girls, and the lab. I looked at the clock on the nightstand. It was 6:50 AM. Holy crap. After 20 minutes, we went on a "pajama" walk with the dog. And that morning, we made chocolate chip cookies. I felt like a kid again.

Last week at work when I walked in my patient's room at 8:00 AM, she told me she was feeling so nauseated, she did not think she was up for a shower that morning. She is one who worries about her body odor due to her feeding tube inserted in her abdomen region, and unfortunately she had a doctor's appointment at 10:00. If this were a rare circumstance, I would've re-scheduled for later that day. But this patient of mine was always feeling nauseated and worried and sleepy. So I gave her a few minutes as I gathered a few things, came back, and encouraged her to attempt this shower no matter how long it took us within our 60-minute treatment session. When she got it done, her husband turned to me and said, "Thank you, Katharine. If it weren't for you, she wouldn't have gotten in the shower today". Appreciative family members always make my day.

So there you have it! The few similarities between children and the elderly that I have discovered this crazy 27-hour weekend.

Baby Steps -Part III

**Must read Part I and II to fully understand the magnitude of this post**

11am. I walked into Kate's room, fully gowned, masked, and gloved to take on Kate's long-term goal -the shower. She told me she was sore and paying for what she did yesterday, but she was ready to do it. She mummbled, "I can do it. I can do it. I can do it", took a deep breath, and stood up from the edge of the bed with her walker. And just as I was in the process of getting her wheelchair positioned to wheel her to the bathroom, I looked up at her and said, "Can you WALK to the shower?" She looked ahead of her to the bathroom and said, "Well I walked to the commode and back yesterday, so I should be able to". She was able to all right -with me following behind her with her chair, praying her knees wouldn't buckle. With some cuing on hand and feet placement, Kate was IN the shower. Standing. Once she sat down, I started frantically laying towels on the floor to soak up excess water, saying repeatedly, "This is great. Kate, this is awesome. This is so great. Oh my gosh I am so excited." Kate just sat there, not saying a word. I looked up at her and asked, "Aren't you excited about this?!" She smiled and said, "Oh I may not look excited, but I am WAY excited. I cannot believe I just did that". She went to town with her washcloth, and I helped her with her feet, back, and peri area -all the while mummbling the same this-is-great-this-is-awesome-oh-my-gosh-this-is-so-great rant the entire time. I almost cried, I was so happy. After she dried off, got dressed in her gown, and sat back in her wheelchair, I told her, "This is one of those amazing moments that I will remember as a new grad for the rest of my career, Kate." It was the best shower ever. And I wasn't even the one taking a shower.

Baby Steps -Part II

**Make sure to read Part I before reading this post. It'll make everything make so much more sense.**

I came to work excited to see what Kate could accomplish today, and left work with her exceeding all my expectations. She was all ready for me when I poked my head in her room at 11am, despite laying supine in bed, staring at the ceiling. I gave her my game plan. We were going to bust out a tricep workout with her sitting on the edge of the bed, she was going to comb her hair since she looked like she just got electricuted, then we were going to have her attempt standing with the wheelchair backed up in front of her so she could hold onto the handles as if it were her walker. Kate fears using her walker to stand because she feels like it will slide out from under her. So we were going to adapt with what we had and ease her into it. Baby steps.

Without me saying a word, she lowered the head of her bed, scooted up to the top of it while laying supine (something she needed max assist x2 with when I first met her), log-rolled with use of the hand rail, and pushed herself up into a sitting position at the edge of the bed as she swung her legs over. I knew it was going to be a great session already. I asked how she felt today and she said, "I am excited to see what new things I can do". So I handed her her theraband and she started on her tricep exercises. She asked me how many she had to do. I told her since she looked pumped today I wanted her to do as many reps as she could till she felt a burn. Then we'd stop, take a breather, and do the same amount of reps two more times. She was up for it and she did them like a pro. We did a few more exercises with dumb bells (1 lb heavier than last week) since she was pretty much being a rockstar. After that, she combed her hair and I pulled it up into a pony tail for her.

Then it was time to stand. I backed the wheelchair in front of her so she could hold onto the handles. With the brakes locked, I leaned into the front of her chair with one knee on the seat and my hands planted on her arm rests to make sure it was stabilized. I must admit, I was a little scared considering it was just us two in the room and she told me her emergency call-button was apparently not working. But I knew she could do it. I wouldn't have asked her to if I didn't feel she could. I told her to take her time -she took a couple deep breaths with her eyes closed, and up she went. Once she was up, she looked at me and smiled. She sat back down and said, "I want to try it with the walker". Sweet. It took her a few seconds to get her mind in gear, but I knew that once she did it a few times, she'd be one step away from conquering her fear of falling when using the darn thing. She did it and I was so proud of her.

On top of all this, she said she wanted to stay standing for four whole minutes. She made it to three and a half when she told me she had to pee. Now typically, she'd be in bed, flat on her back. And all I'd have her do is roll to the side so I could stick her bed pan under her. But she was already standing so I asked if she felt like she could walk to her commode, which sat right outside her bathroom door (about 20 small steps). She said, "Might as well". I followed right behind her with her wheelchair and told her that if she felt like her knees were going to give way, to fall BACK. Not forward. Or better yet, just don't fall at all.

She got to the commode, pivoted, sat on it, realized she wasn't entirely on it, did a partial-stand, and re-adjusted. I may or may not have done a little victory dance. She looked up at me and said, "I did it!". Yes, she did. If she didn't have C. diff, I would've hugged her. On top of all that, she was able to get off the commode, and walk back and get herself into bed at the end of our session. That called for a high five. I told her how proud I was of her as I was leaving work today since her room is one of the last ones on the way out. She was sitting up in her wheelchair, watching television. I told her, "No more bed baths, my friend. Tomorrow you're getting in the shower." She was stoked.

Baby Steps -Part I

I always end up with the patients who have some kind of virus that requires contact isolation precautions -meaning I treat them in their room, doors shut, fully gowned and gloved and masked and dying of heat. On Monday I evaled a new patient, who I will call Kate, who had these same precautions. Kate is in her late thirties, morbidly obese, and was diagnosed with Clostridium difficile, otherwise known as C. diff. C. diff is an infection of the colon that occurs primarily with people who have been using antibiotics.

Typically when we get a new admit, they are scheduled for a 15-min occupational therapy and physical therapy evaluation, followed by 60 minutes of treatment for each discipline. Sometimes if admits arrive later in the day, we do the 15-min eval and treat the following day. But I like to do the whole 75 minutes because I feel that the 15-min eval time does not give me a clear picture of what my patient can do in terms of their daily tasks. With the 60-min treatment following the eval, I get to see their bed mobility, how they transfer out of their wheelchair with their walker, on and off the toilet, toilet hygiene, how they manage and don their clothes, how they transfer in and out of the shower, can they reach their feet and lower back to wash, can they locate their grooming materials while standing at the sink, can they balance well when reaching for things at the sink, put their pants on over their toes, pull them up in standing, how is their safety awareness?, are they impulsive, distractible, inattentive... At the same time, I get to converse with them and build rapport for a whole 75 minutes. I leave the eval having a pretty good sense of what they can accomplish. With a 15-min eval, I am in and out and my documentation sucks for whoever has to read it the following day.

So with Kate, I did the whole 75-min treatment, which was definitely needed. Because, due to Kate's generalized muscle weakness, she needed a bed bath. And half the time she was crying so we had to stop and give her room to breathe. Kate was, for the most part, max assist x2 -me and the CNA (my new bestfriend). I gave her a washcloth and had her do what she could on her own, which was wiping her face and chest. With what seems like the simplest task, Kate needed rest breaks. In the middle of it all, Kate needed to use the bed pan. I thought to myself how I'd feel if I were laying flat in a bed, unable to move my legs more than an inch, with two people completely gowned and masked hovering over me, helping me with the most intimate of tasks. Oh how we take things for granted. I told Kate that I hated being fully gowned. She told me she didn't blame me and that her son even refuses to visit her because it's such a pain to get all gowned up. I said, "That's not what I meant. I feel very impersonal in this. Like I'm here to conduct experients on my patients". We laughed.

Despite Kate's situation, she was a very pleasant lady. Our long-term goal was to get her in the shower. But first we had to get her to transfer safely into her wheelchair. The physical therapy assistant (PTA) and I did a lot of collarborating this week. Whenever she'd come back to the gym from her room, I'd chase after her and ask her how Kate did. There was always progress being made. She was able to get Kate up in a static standing position for one minute. Her main problem was pushing herself up from the bed with her arms. Her triceps were so weak and she had so much weight to carry. So we started with tricep exercises with her semi-reclined in bed. Then we progressed to her holding herself up in bed with her elbows locked and pumping herself up and down as best she could (even if it was just a centimeter) during bed mobility tasks. Kate broke down once during that session because she said her son came in to celebrate his birthday with her but she couldn't do anything for him. She couldn't be a mom. But that motivated her even more to continue with her exercises.

When I walked by her room the other day, one of the CNAs was getting all gowned up to go in. Kate's door was slightly open and I could see her sitting in her wheelchair, watching tv -her hair braided back. I stopped in the hall and called her name. She had a BIG smile on her face and we waved at eachother. She said in her cute, nasally voice, "Hello world! ..I'm suppose to say that to everyone who sees me today sitting in my chair". I loved it. And I told her I liked her hair. She stayed in that chair for 5 and a half hours, which I think was a little too much after being in supine for so long, because the next day she was worn out.

She had the energy the next day to go from supine to sitting on the edge of the bed. But when I got the CNA to help me assist her to do a partial-stand-pivot transfer, Kate freaked out. With time, we attempted it twice, but there was no way I was going to risk her falling on her face and going back to square one. So we decided to do a bed bath with her sitting on the edge of the bed. I gave her a couple washcloths and told her to go to work, and I'd be there to help with what she couldn't do. She was able to wash down to the top of her feet, part of her peri area, her chest and armpits, and her face. She was doing great. She combed her hair and I braided it. She put her gown on and rolled back in bed, lifting her legs up with just a few verbal cues on hand placement. I raised the head of her bed and then, out of nowhere, Kate started crying. I asked what she was so sad about. And she said, "I feel like I disappointed you. We were so excited to get in the shower today and I thought today was the day that I could do it". I told her, "Kate! I am going to tell you FIVE things that you did GREAT today". Here was my list that I pointed out to her (literally):

1. You got yourself up to the edge of the bed, where you sat with no assistance for about 30 minutes.
2. You washed your own legs and feet! Remember how I had to do that for you with you laying flat in bed the other day?
3. You washed part of your privates! How awesome is that?! (We laughed)
4. You got yourself back in bed with NO help from me to get your feet up.
5. Your hair's all combed! Granted I did the braiding. But I couldn't have done it if you hadn't have combed it! (We laughed again).

I told her that yes, she may not have gotten in the shower today, but to put her focus on what she COULD do today that she COULDN'T do yesterday. It all brings her one step closer to reaching her goal of getting in the shower. Baby steps. She was getting there.

I am hoping that once she is able to safely transfer to her wheelchair and her C. diff sample comes back negative, I can take her on an outing to the store. That was her long-long-LONG term goal. And I really want to make it happen to lift up her spirits. I told her yesterday how proud I was of her and that I was looking forward to seeing what we could do Monday. She was all smiles.

Goodbyes

I usually don't like saying goodbye to people. But at my job, discharge (upon therapist recommendations, of course) is always a good thing. I like to tell my patients, "I've enjoyed working with you, but I hope to never see you in this environment ever again".

I have a patient who is going to be going home on Wednesday. She had back surgery recently and also presents with cognitive problems, which makes recalling (and following) her back precautions next to impossible. She would impulsively twist to reach for a pillow, bend to put her socks on or pick something off the floor.. And I'd find myself telling her, "No- Stop- Wait- Don't do that-", as if I were babysitting a 2-year-old. At one point she didn't even remember having precautions. And when I attached the tab alarm to her, so that nursing staff would be called if she ever attempts getting out of bed unsupervised, I caught her taking it off and hiding it under her pillow when she thought I wasn't looking. I have caught her performing wheelchair-to-bed transfers all alone in her room (brakes unlocked I might add) as I was leaving another patient's room across from hers. I have told her time and time again to use her call button before doing that, but of course when you think you don't actually have precautions, why on earth would you need to call for assistance with anything? Good grief.

I figured that the best thing I could do was have her remember her precautions. She has horrible macular degeneration so posters with big contrasting letters was not an option. So that idea got scrapped pretty quick. Plan B. She did have a talking clock that I've noticed around her neck. Her friend gave it to her on her second day at the facility. With time, she was able to remember and initiate using it to tell the time without asking me. This told me that, with repetition and practice, there was hope that she could remember her back precautions.

I began each session asking her what her three precautions were. BLTs. No bending, no lifting, no twisting. She told me, "That is not going to stick out in my mind because I don't eat BLT sandwiches". She'd remember 2/3 after about a couple minutes of staring at the ceiling. Then I would have her repeat them in her head as I left her room to grab towels for her shower or theraband for her exercises. I'd come back and she'd remember, once again, 2/3. We'd start an activity and before any sort of movement, I'd ask her again. Or on the way back to her room from the gym or before out session ended. 2/3. Then one morning, I went to see her and, when asked what her precautions were and expecting the same 2/3 answer, she told me all three! I jumped for joy, I was so happy! Now the trick was getting her to actually follow them. But we were making progress. Baby steps. This was good.

She could now verbally tell me her precautions, but her impulsivity would always get the best of her. I told her that before she even attempts to move, she needed to stop and say her precautions outloud. This took time and there were days when she would get overwhelmed and emotional and all we'd do was sit together with her rubbing my forarm gently to calm herself down. She told me she just really missed her home. So what did I do? I scheduled a home evaluation.

I love doing home evaluations because, not only does it allow me to assess my patient's home safety and give my recommendations to allow for easy access, but it let's my patient be back in their natural environment and have something to look forward to. There's nothing like home. I scheduled it with her daughter who picked up my patient -sitting all ready to go in her wheelchair and oversized neon green shades nonetheless. I helped her with a car transfer and followed them to my patient's home sweet home. I could see how happy my patient was to step foot into her front doors (Well, back doors. Her front steps didn't have any railings and I absolutely refused to put myself in a situation where there'd be a chance for me to fill out another stupid incident report). We stayed no more than 30 minutes. We went over a few functional transfers -in and out of the shower, on and off the toilet, in and out of bed.. I gave my recommendations for adaptive equipment and things I'd re-organize in the home to make it easier and safer for my patient. The next day, the PT told me she had an amazing session with my patient -she remembered all three precautions, showed more energy, more strength and endurance... She told me she thinks seeing her home and knowing that's where she will be discharging to has picked up her spirits. I couldn't agree more.

I saw her in the afternoon that same day. When I told her I'd be taking her to the gym, she scooted over to the head of the bed to reach for her vaseline. Now I know this may sound a little strange but that was the best thing EVER. And I'll explain why. My patient would continuously twist her entire trunk (BIG no no) to get her vaseline on the night stand at the head of the bed. I always asked her, "What could you have done differently so that you're not twisting?" We'd talk about moving her entire body over, asking for help, using her reacher... The fact that she moved her entire body to get her vaseline that day was a HUGE accomplishment in my eyes. It told me she's remembering SOMETHING. I have no idea what and it could have been mere coincidence. But I'll take it. I was so happy and she was so proud of herself.

So she leaves on Wednesday. She will have 24-hour supervision, which is what her PT and myself have recommended, and home health services for continued therapy. She told me last week during her shower, "What would I do without you?" and I told her, "You're doing all the work. I'm just watching you do it." She took my forarm and started rubbing it gently. I am going to miss her.

Incident Report #1

I filled out my first incident report the other Friday for my first hip patient. In tears nonetheless, I filled it out as best I could. Here's what took place:

My patient, who has had screws implanted into his hip, was pulling his pants up in standing while holding his front wheel walker with one hand. He is currently toe-touch weightbearing status. Well I was right beside him providing contact gaurd assistance because he told me he felt sleepier than usual. His pants must have caught on his foot or something because he spontaneously let go of his walker to use both hands to pull his pants up. He lost balance (did not fall though thank goodness) and leaned into his right leg. I held onto him and pushed him upright. I asked him if he was ok and all he said was, "I felt it snap". I about passed out. He was able to walk back to his bed with his walker and lay down. I sat on the edge of his bed and just stared over him. He kept saying, "I'm ok. I'm alright. Don't worry." He said he felt just fine, he just felt a snap. Shit shit shit shit shit. So I left to talk to physical therapy and nursing. They said they'd monitor it but they weren't too concerned since he wasn't in pain and could walk back to his bed.

I saw a couple more patients after him and then visited him on my lunch break. I walked in to find him ambulating to the bathroom with his walker. So of course I thought, he must be fine. I asked him and he said, "I'm in a lot of pain". He said it was a sharp pain. An 8/10 pain level. Shit shit shit shit shit. I then went to our rehab director, who is also our OT mentor. She gave me my first incident report to fill out, just in case a complication occurred, and told me she'd follow-up with nursing to make sure they get an x-ray done. I went back to the gym and filled it out in tears, with Andriana and Dani, my two ex-classmates/co-workers, comforting me (these are the times when I am so thankful that I work with my friends). I prayed for him to be ok. The PTA who works with him told me there was nothing I could do to prevent it from happening and that if I wasn't there to catch him, he would've fallen to the ground. The director told me, it happens. It's just the population that we work with.

I went to see my next patient once I got myself together, 30 minutes later than planned. As I walked down the hall, the x-ray tech was leaving his room. Towards the end of the session, Andriana knocked on the door to tell me that the x-ray results were in and that everything was normal. She purposefully searched for me to tell me that so I wouldn't continue my treatment session worrying. What a great friend. It was a huge weight lifted off of me. I went back to see him after my session to tell him I was so glad he was ok. He said, "Yeah I was getting worried because the pain was getting so bad I almost cried". "You're gonna make ME cry!" I told him all teary-eyed. He said, "You didn't do anything wrong. It's not your fault". I told him, "I know, but you're my patient and I don't want you to be in pain". "Me neither". We both laughed.

I'm assuming he just pulled a muscle or something. But where did the SNAP come from?! Who knows. His nurse saw me leave his room and asked me, probably knowing I already had an emotional breakdown earlier, "Did you hear his hip is alright?". Ah this is definitely something I never want to experience ever again.

Go Stand

Ever since I was little, I was always so easy to please. I would get excited over the smallest things, maybe even just as much as things of greater importance. Well now that I am not so little anymore, nothing has really changed. Sometimes I think I need to not let my emotions get the best of me and be a little more, I don't know, withdrawn. But welcome to the life of an occupational therapist. Or any therapist for that matter. Where everyone's business unpurposefully becomes your business. And everyone's struggles become your struggles. And everyone's little successes become your own. If I didn't like connecting and helping people take more control over their own lives, then I would've chosen a different profession.

The other day I assisted my patient in a shower. He is slowly but steadily making progress in building endurance and strength in order to perform his morning ADL routine independently. We've been working on fine motor skills a lot because, for what seems like the longest time, he could not button his shirt on his own or fasten his belt. I've always encouraged him to try his hardest and when he gets to the point where I feel like he is getting so frustrated and mad at life, I intervene and do it  for him -telling him that we will try again tomorrow and that it's frustrating, I know, but I'm happy he tried his best for me. My patient is such a sweetheart. He takes a deep breath, sighs, and mumbles, "Ok". Well the other day, I handed him his shirt and told him, as I do every time, to try his best and I'll help if need be. He sat there for a minute so I went to grab my clipboard from his room, dreading the thought of having to document the same assistance level as I had the past few notes. When I got back, he got the first button on! He was working on the second. And pretty soon he was on the third, then the fourth. No rest breaks. No signs of fatigue or frustration. He finished in about 5 minutes but he got it done. Independently, too! I jumped up and down clapping and demanded a high-five. My patient laughed. I'm not sure if he was excited that he finally buttoned his shirt on his own or if he was just amused at how strange I was. Today I had the exact same reaction to my patient who donned his socks independently using his sock aid. He was a proud man, let me tell you. He told me his family came over to visit the night before and gathered around so he could demonstrate how to use the silly piece of adaptive equipment. That was a good moment.

I have also done a few more firsts these past two weeks. I did my first solo home evaluation. The facility driver took me and my patient to her daughter's house (where my patient will be discharged to) to assess safety and accessibility, and to give any recommendations for continual progress at home. We went through each room, laying out what daily tasks my patient would be participating in and how that may look like within this home environment. At the rehab facility, we get to work on so many things and train and educate patients on what to do once they go home. But it is so beneficial to actually observe and see the patient in their home environment because that is realistically what they will have to deal with once discharged. I thought that home eval went pretty well. The family was very supportive and accepting of my recommendations -which were not very many since their house is already really accessible.

I also got my very first shoulder case. She had a total left shoulder arthroplasty done and was admitted from the hospital on Monday. The doctor's orders say only pendulum exercises on her shoulder, and active movement allowed at her elbow, wrist, and fingers. Her sling can only be removed 3x/day and her surgical area must always be wrapped during showers. She is doing well and I'm pretty sure she will be discharged home some time next week, depending on what nursing and physical therapy agree upon. I remember when I first evaled her, I asked her to perform a sit to stand transfer for me as I searched for her walker. Well she had none. Duh. Her legs were just fine. I have been so used to patient's with hip and knee surgeries that I automatically think "Where's the walker?".

Last week I did my first group session with my friend/ex-classmate from grad school (we now joke at the fact that we are "colleagues/co-workers"). Our patients were ones who needed more functional transfer and proper body mechanics training. So we played "Go Fish", which actually turned into "Go Stand". We went around the table and every time someone did not have the card another patient asked for, they had to perform a sit to stand transfer and reach for a card from the deck. It was fun and the patient's enjoyed the company of others with the same diagnoses. Two of them now meet up in the dining room for meals instead of having them brought to their individual rooms.

I have also had to do a lot of research these past two weeks, which is fine with me because I like being able to explain why I'm doing what I'm doing and learning more in the process. I had a patient who had sensation problems in her right first and second digits so I taught her some desensitization techniques. I knew what to do, I just didn't quite know how to explain them in laymen's terms as to WHY they work. I have also had to research the rational behind pendulum exercises because there had to be a more in-depth explanation than simply regaining range of motion in the shoulder joint. But no. That's pretty much it. I have also had to explain to a patient the reason for continued skilled services and give my professional opinion as to why I think they are not safe to return home. That has been the hardest part so far because I understand that patients don't want to be here and want to sleep in their own bed and cook in their own kitchens and watch TV on their own living room couches. But if I don't keep my patients' best interest in mind, then I am not doing my job. And it will be most likely that patient's who are advised not to return home quite yet, fall and end up back where they started. Nonetheless, patient's leave when they want to leave, and refuse therapy when they want to refuse therapy. So all I can do is give them and their caregivers the best recommendations and home safety program I can so that returning to rehab is prevented.

Quote of the day: 

Occupational therapy assistance says to nurse administering pills to patient undergoing therapy in the gym: "If you make him nauseated, I'll kill you."

Rehab Planking

In getting through my week, I have realized how important it is to not only document my experiences with being a new occupational therapist, but to write down some of the funny comments that come out of people's mouths. Because these are the kinds of things that will help get me through the day when things aren't as amusing. So here we go:

80ish-yr-old patient during a cooking activity: You pinched my boob!
COTA: Sorry, I didn' realize they were down there.
Patient: Oh yeah, they're down there alright. Like lemons in socks.

Me: Did your wife leave?
Patient: Yeah. And frankly I don't give a damn if she ever comes back.
*awkward silence*
Patient: She ticks me off.

Me: You didn't shower yet this morning did you?
Male patient: No. I told the nurse you had first dibs on me. I don't know what it is with you and watching me shower.

Me, walking in my patient's room: MORNING!!
Patient: Oh no.  

PT: I like planking. Wow that sounds dirty.

Patient sitting in gym across from another patient: WHAT'S WRONG WITH YOU?!

Patient during fine motor activity: Now when am I ever going to use PEGS? I don't have PEGS!

Patient sitting up in bed: I'm pooped.

Me: You POOPED?!

Patient: Oh god I hope not.

Patient: I finished the plane while you were gone. In standing, too! I won't mind if you document that I did even though you weren't really here.

Me: Uh, no.

The New Job

I'm on my second week at my new job and I love it. I love how fast-paced it is, how many resources are available, how we can do community outings with patients, the mentorship, and the entire rehab team. I am especially excited to be working with two of my ex-classmates from grad school. I am excited to learn and grow together. I found this one and only picture of us three together. Now looking at this picture, how can rehab NOT be fun?! Apparently the staff outside the rehab team call us the triplets since no one can quite get our names straight just yet.

The setting is definitely challenging, but I have learned so much within the first week and a half. This setting feels like a mixture of a whole bunch of settings. It feels like acute rehab in that we work on ADLs in patient's rooms, it feels like inpatient rehab with our gym to bring our patient's to, and it feels like outpatient rehab with our community outings and home evaluations. I am never bored or complain that the day is dragging.

My schedule pretty much starts at 6:45 AM. I get the list of patients that I need to see. I visit my patient's rooms to schedule when to see them that day and then I start my treatments at about 7:00 AM (if I'm lucky and fast enough). Treatment usually involves assisting patient's with showering, dressing, transfers on and off the toilet -that sort of thing. If a patient does not need a shower that day or has been showered already by a CNA at the crack of dawn, we usually go into the gym to work on endurance in standing while doing a functional activity in dynamic standing. That could be anything -a puzzle, a board game, cooking in the kitchen, theraputty exercises. Or we'll do bilateral upper extremity exercises with theraband, weights, the machines -depending on the patient's goals, of course. Then there's always energy conservation or home safety education with patient's and families. I'll take a 30-minute lunch break, catch up on paperwork, see one or two patients more, finish my paperwork (daily notes, weekly progress notes, eval reports, discharge reports), bill, and clock out. Some times we'll get new admits around noon. If that's the case, then I'll do an eval for fifteen minutes. I go home, get to bed some time between 9:00 and 9:30, and start my day all over again.

So far I have had some pretty good experiences. My first ever patient with an orthopedic injury happened to be a simultaneous bilateral total knee arthroplasty. Yes, SIMULTANEOUS. Both knees. Toe-touch weightbearing on the right, weightbearing as tolerated on the left. I walked in, planning to evaluate for fifteen minutes and then treat for another sixty, but walked out a little short on my time because of my patient's pain level. We agreed on a treatment session at 7:00 AM the following day once his pain is properly managed. I prepared that night, thinking of how to exactly assist this patient in transfers from his bed to his wheelchair to the toilet to the shower. I'm surprised I didn't wake up at two in the morning re-thinking the scenario in my head. When I walked in that morning, the CNA tracked me down and told me he was waiting up in his bed for me. Here we go! Every transfer was going successfully with assistance from one of the CNAs, up until we got the patient out of the shower in his wheeling shower chair to the side of the bed. He looked at me and said, "I don't know how you expect me to do this transfer. I have never tried standing up from a surface as low as this." Well, shit. I stood there thinking I need to figure this out QUICK, I have to make it seem like I know what I'm talking about, and I need to actually KNOW what I'm talking about so that he doesn't fall flat on his face and traumatize me from bilateral knee patients for the rest of my life. So I figured, ok, it's all about body mechanics. I had him scoot to the edge of the chair, bring both legs out straight as far as he could, push off of the shower chair arm rests (that would NOT come off, which is why we did not do a sliding board transfer onto his bed. That would have been nice), grab a hold of his walker and push down into it to lift himself up after the CNA and I pulled him up far enough under his armpits with max assistance. From a standing position, we did a pivot, raised his bed to his butt, and had him ease onto the edge of the bed. Success! He looked at me and said, "That went a lot smoother than I thought". I think I gained his respect that day. Before I left, he asked me what my name was since I did not have a name tag yet. I told him Katharine. He said, "Can I call you Kathy?" That was fine with me. Since that day, he has been making slow but steady progress. He performs his transfers with contact gaurd assistance now, some times stand by assistance. Today, after working out in the gym, showering, donning his very uncoorperative ted hose, and discussing potential adaptive equipment he may need at home, he was ready to transfer from his wheelchair to the bed and call it a day. I bent down to help lift his legs, but he put his hand out and said proudly, "Nope nope! Just watch!" He did the transfer on his own. I was so excited for him! Then he asked if he could go home Saturday. Aw crap. Double shit. In our meeting yesterday we decided he needed another week. I did not tell him that because I was advised not to just yet, but I did tell him that I felt Saturday is too early and that I want him to be 100% safe in being alone at home. He wasn't happy. But he didn't give me a hard time about it. Thank goodness.

For The Birds

Lola, Tania, and I used this last week of mine to really get the most important things done. For Lola, it was arranging the corner of her apartment that was crammed with so much stuff that she couldn't get to her birds to feed them. And for Tania, it was painting her birdhouse.

Before Lola and I started, she wanted me to help put her pain patches on. She turned around, hunched over, and blurted, "Put it above my crackademia". Then she laughed, turned around, and said, "The crackademia. What's that mean? Phobia of the butt crack!" This was going to be fun.

This was the task at hand: Lola wanted to remove the big file cabinet sitting under her book shelf sitting under her two bird cages. She wanted to replace it with her chested drawers and bring the file cabinet out to the dumpster. The first thing to do was to figure out how to even start. There was no room in that little corner of hers or anywhere else for that matter. Lola's apartment was full of clutter and she was the first to admit it. We stood there, staring at everything, when Lola said, "I have a dream. As soon as we get our shit together, the dream will come true". We ended up piling things on top of more things and inching our way around the furniture -with me all the while demonstrating and teaching Lola about good body mechanics. With Lola's impulsive tendencies, I had to stop her many times because she would pull instead of push, or not bend her knees, or lift boxes away from her body, or not initiate rest breaks when she was clearly fatigued and out of breath. It took a good hour and a half to get the job done, to sweep all the bird seed away (until Lola knocked over the cup she swept the seed into and had to start all over again), find a dollie in the building, and wheel the file cabinet to the dumpster. Lola was so happy she gave me the biggest hug as she said, "Thank you, baby girl. You're my girl."


From the first day I met Tania, I couldn't help but notice her wooden birdhouse on top of her kitchen shelf. When I asked her about it, she told me she always wanted to paint it but couldn't open her paint bottles. So that's what we did on my last visit with her. She's been doing so well with her theraputty exercises -doing them at home twice a day when not even asked of her. I can tell because when I have her demo them to me, she knows exactly how to do them and it almost looks as if she's using a less resistant putty than she started out with. Tania was now able to open her paint bottles by herself.


Tania's stroke affected her fine motor coordination but not as severely as I have seen in past clients on fieldwork. The great thing is that, even though Tania stopped arts and crafts after her stroke, she still loves the thought of doing them and using her hands as much as possible, which gives her excellent rehab potential.  Tania was able to paint her birdhouse on our last visit in about fifty minutes. It was slow, but she got it done. She told me, "When I do crafts, I get lost. I can go on for hours." I told her I was the same way. We cleaned up together -Tania putting the caps back on the paint bottles, rinsing out the brushes, crumpling the newspaper to throw away, walking to and from the sink and trash can and table. It was all great therapy and she knew it. I was so proud of her. She listens and follows-through with everything asked of her -a therapist's perfect client. The past few days she's been walking by the gym using her walker instead of her powerchair. She's been walking faster and appears more stable. The PT assistant says she's been making so much progress. I told Tania I was so excited for her and that I can only do so much in outpatient therapy. Progress is seen when clients carry out and follow through at home. Tania does just that.