Morning at the Improv

Sometimes things don't go as you'd planned. Sometimes the plan and the reality are not even on speaking terms with each other. This is what OT shadowing session #2 was like.

I met Molly, who is Kay's partner OT, at their office. She introduced me to the facility owner, Bill, whom I did not get a chance to meet last week. He has been a therapist almost as long as I have been alive, and I am no spring chicken, so this gentleman has really been there, done that, and bought the T-shirt. Something about OT must keep you young, because neither Molly nor Kay nor the facility owner look anything like their chronological age. Molly and Bill were discussing some sort of legislation governing Medicare reimbursements in other states and most of it went sailing right over my head.

After faxing in some paperwork, Molly drove to the client's home with me following her in my own car. The client recently came to live with her daughter, and the daughter had just finished cleaning out her mother's old home. Molly was there to meet a contractor who was coming to discuss installing a wheelchair lift outside the front door so that the client would be able to enter and exit the house more easily. The contractor was supposed to come during a two-hour window.

While we waited for the contractor, Molly showed the patient, whom she's been working with for a couple of months, a pot and some baking supplies. "I thought since we've talked so much about how you love to make cookies, that we could bake some cookies while we wait for the contractor to come."

The client, who was warm and friendly, just a very nice woman, suddenly shut down. "No cookies!" she insisted.

Molly tried to persuade her, but the client was firm in her conviction that she wanted absolutely nothing to do with cookie baking today. Realizing the cookie thing was just not going to fly, Molly worked on getting the client walking around in her walker. The house had extra boxes and things lying around from the client's old home, including some lovely old-fashioned hat boxes (the round kind with fancy corded handles). The hat boxes were right in the client's intended path, so we started talking about them.

"I LOVE my hats," the client told us, and before you know it, we had an impromptu hat show in the living room with the client sitting in a regular chair rather than in her recliner. It was fun! The client opened each box, removed the paper from inside each hat, and told us about it--where she'd worn it, the outfits she had that went with it--it sounds silly, but it was a great exercise for her and fun for us. She even modeled a few of them. And the hats were gorgeous. Most of them were very elegant leather-trimmed suede or velvet pillbox hats from the early 60's. Very tasteful.

By the time the hat show was over, we had burned through a little more than half of the two-hour contractor window, so Molly called and left a message. Then we found a bag with wooden letter cutouts shaped like things that began with that letter (for example, the E was cut in the shape of an elephant). Molly asked the client to check and make sure the whole alphabet was there (we really weren't sure--another item from the attic of her old house), and the client laid the letters out in order on an adjustable rolling table placed in front of her chair. We talked about the items pictured on each letter (she apparently didn't play dominoes growing up!) as we went. Then Molly told her to close her eyes (I played along by turning my back) and removed a letter. The client had to find the gap and then name the letter that was missing. We did this 8 or 10 times, and then Molly noticed that the client was leaning toward her weak side, so she got to go back to her recliner after that.

Still no contractor. Molly left another message and then took me upstairs to show me the modified bathroom. It had a tub transfer bench with a cutout and an extra grab bar affixed to the outer edge of the bench. There were also three grab bars fixed to the enclosure itself and a nubbly bath mat inside the tub to prevent slippage. Molly demonstrated how to use the transfer bench, and then she showed me the chair lift on the stairway. You get in at the bottom of the stairs and flip a switch, and then you ride up the stairs to the top. I'd never seen one of these in person before and I was very taken with it.

Shortly thereafter, the two hours were up and the contractor was still nowhere to be seen. Oh, well. Molly had to go to another appointment, so I drove to a local BBQ place and took home some tasty pulled pork for lunch.

This visit: 2 hours, 15 minutes Total observation time: 5 hours, 15 minutes

My Very First OT Shadowing!

I am happy to say that I am no longer a strictly-theoretical-only-knowing-what-I-read-on-books-and-blogs aspiring OT. I have SEEN OT! With my own two eyes! And lived to tell (you) about it!

I spent a wonderful morning with OTR/L Kay. Despite being an OT for nearly 20 years, she's not much older than I am. We got along just fine. She had a domestic emergency, so we met a bit later than originally planned.

Kay starts by showing me around the office and introducing me to everyone. She just says I'm an OT student rather than explaining, "She's two years away from even starting OT school and is only a couple of weeks into her first prereq." (Plus her option is a lot quicker.) Then she shows me the room she and her partner OT Molly work out of. It's a good thing they work mostly in patients' homes because the place is a closet. It's smaller than the bedroom I use as an office at home. The windowless space consists entirely of two desks, a table with a phone, a filing cabinet, and some wall-mounted cabinets.

Kay has to call Molly and straighten out some insurance issue (we haven't even started and insurance is already rearing its ugly head!), so I amuse myself with the MVPT, the Motor-Free Visual Perception Test. It consists of a series of placards where you are shown a shape, number or three-letter sequence, and have to find the same one among four drawings below the test item or on the next page following the test item. (I guess we're also testing ST memory a bit there.) There are also items where the "match" may be smaller, rotated, darker, etc. and a few final items of "Which one of these is not like the others?" The test seems very easy, but I guess that's just soothing reassurance that I don't have a visual impairment.

Soon, we're walking to Kay's car to go see the client. She makes a quick call on her cell phone to tell them we're coming and programs the client's address into her GPS, noting that the cell and GPS are her two best friends. She hands me the client file and pulls out of the parking lot. I am pleased that I can actually understand the file. I check a few acronyms with Kay, but my guesses are all correct.

Kay is going to do a "wheelchair eval" -- to see if the client can get a scooter or power wheelchair. The client's insurance will pay for a chair if certain conditions are met. It is Kay's job to interview the client and see if he meets those conditions. As we drive, Kay explains how several components of the client's medical history speak in favor of a powered chair.

Soon, we pull into the driveway of an older small but well-kept home and walk up a long wheelchair ramp to the front door. A lady about my mom's age opens the door, cigarette in hand, and gestures us into her living room. The client, her husband, sits at one end of a leather sectional couch, gaze fixed on the TV tuned to some morning hosts chittering and laughing about nothing in particular. Pictures of adult children and cherubic grandchildren adorn the walls and the shelf above the TV. The client has a splint and some ice over one hand.

"Oh, no, what happened?" Kay says, immediately concerned with the man's injury. His wife tells us he fell yesterday and had to go to the ER. The man had a stroke a few months ago, so his speech is slurred and sparse, yet his wife is able to interpret his grunts and mumbles. He interjects himself into her narrative as she describes what happened, and she takes it with good humor. He even allows his wife to take off and re-apply the sling (quite a painful process) so Kay can look at the injury.

Kay takes some time trying to make the client as comfortable as possible: extra pillows behind his back, replacing the hard ice pack with some frozen vegetables (they don't have peas, but soon he's sporting a bag of California Blend), and pillows to rest his lower arm on so his hand isn't hanging down. The client's wife explains that she wants him to eat before she gives him his pain meds, but he can't eat right after he wakes up. This is why he's so uncomfortable right now.

Kay opens her laptop, balancing it across her knees, and begins her interview by discovering that both the patient's first and last names have been misspelled on the file. Heh.

What really impresses me is how amazingly well Kay multi-tasks. She's typing into her laptop, she's talking to the client and trying hard to understand his replies, she's talking to his wife, she's incorporating all the extra information they are throwing in that is not directly related to the question at hand, and the evaluation doesn't even feel like an evaluation. It feels like a conversation. Meanwhile, I have the important job of holding the client's cane. :-) He does actually say that he likes me the best since I'm the only one not causing him pain. He even asks me if I'd like a cold Pepsi from the fridge, which is so sweet. I politely decline, but thank him for being a good host.

Kay gets to the part where she needs to measure the range of motion the client has in his hips, knees, elbows, shoulders, etc., so she pulls out her trusty goniometer. I've never seen one of these in action before--my inner geek is turning cartwheels. She carefully instructs him where to hold what and takes some measurements. She does a full set of measurements for his uninjured arm and shoulder, but obviously can't do a whole lot with his injured hand, so she mostly leaves that side alone.

Next, she helps him stand and sees how far he can walk. He is able to go about ten steps before turning and coming back to the couch. She makes some notes about how far he lifts his feet off the ground and the evenness of his stride, things like that, and then we take a little "field trip" with his wife to look at the bathroom doorway (wow, is it narrow) and the bedroom arrangements (tight turns required to get a chair in and out). Kay explains that a scooter requires better motor control and upper body strength because the controls are forward of the user on a handlebar-like arrangement. A scooter is also more difficult to mount and dismount and is longer than a power chair, so it has a wider turning radius. A power chair is controlled by a joystick very close to where the user's right hand would normally rest, so it doesn't require as much upper body strength or balance. Kay is leaning toward recommending a power chair for this client over a scooter.

We return to the living room. Next, the client's wife helps him get into the manual wheelchair he currently uses, and Kay asks him to wheel himself a few feet in the kitchen. He mostly uses his feet and is not able to make the chair move very effectively.

All the while, Kay is talking with the man and his wife and listening carefully to what they're saying, and the man just comes to life. His grunts and mumbles turn into words, then phrases, even a few full sentences. He enunciates clearly enough to make a joke as Kay finishes up his medical inventory. She says, "OK, so you have pain here, there, there, and there. Is there anything else giving you pain?"

"Yeah," the man says, a glint in his eyes, "that one (he points to his wife) and that one (he points to his home health aide)!" Everybody bursts out laughing.

We were there for about two hours. Kay had never laid eyes on the client or his wife before, but by the time we left, she had built a sincere rapport with them. And the client, whom the case manager had described in his file as "non-verbal," had shown himself to be a likable, charming man who could still speak fairly well. His speech improved quite a bit just while we were there.

I made sure to thank the client and his wife for allowing me to observe. It is a humbling thing to be welcomed into someone's home, and for a stranger to let you see his weaknesses and vulnerabilities--and still have the presence of mind to offer you a cold drink.

This visit: 3 hours
Total observation time thus far: 3 hours

Abnormal Psych: 1 Exam Down, 2 to Go

So the prof walks in on Friday and says, "I have your exams graded." Most of the students look stiffly away or down at their feet, like he just said, "I have your AIDS test results back!"

"I guess I made this test a little harder than I should have," he continues, and I blink. What? I studied for a 10, and his exam was a 3. Totally un-sneaky, straightforward questions covering exactly what he said he was going to cover. We had an hour to finish, and I was done in 20 minutes. Maybe there were backs to the pages and I didn't see the questions on them, so I only did half the test? Christ, that would be just the kind of boneheaded thing I would do!

"The grades were really kind of all over the place," he says apologetically, like it's his fault, "so I did curve the exam."

Uh-oh. If he had to curve it, we didn't do very well. Maybe he nailed me on my short essay. I knew I shouldn't have said the therapist was implanting false memories!

He stands at the front of the room holding a big stack of papers. "OK, I'll hand these back now. Add fifteen points to the score marked on your paper."

"FIFTEEN points?!" I blurt out. "That means we sucked!" Panic mode!

"Well, no, actually two people aced it," he says, looking directly at me, and I immediately feel better. My money is on me and the ex-cop. He and I studied together for two and a half hours the day before the exam, and we eventually got to the point where we couldn't stump each other any more no matter how hard we tried.

"You might be wondering if your score is capped at 100 with the curve," he continues, looking back at the class, "and the answer is no. So if the curve puts you over 100 points, just think of it as getting a little ahead on your next exam." Boy, that would be sweet to get a 105 or 107 or something like that.

I finally get my paper back and glance hastily at the top of the first page. It's the only red ink on the entire exam: one word, underlined twice. It says perfect!

That means I got a 115 on my first exam.

There are not enough smilies on the Internet to express my delight.

First Exam Looming...

I've been so quiet because my first Abnormal Psych exam is today. It is worth 30% of my total grade. Once it is over, I have several nifty things to tell you about!

Cute OT Joke

Q: How many OTs does it take to change a lightbulb?
A: None. They teach the lightbulb to change itself.

Be Careful What You Wish For

A not-atypical day three months ago:

• Walk dogs
• Check e-mail, putter around on the Interwebs
• Realize I'm hungry because it's lunchtime (oops)
  
• Eat in, or call a friend to go out with, or walk downtown for lunch
• Realize it's afternoon and I have done nothing constructive
• Do something constructive for about two hours--work, or go for a run
• Walk dogs
• Ponder domestic chores and maybe do one, or cook dinner if necessary
• Probably more puttering around on the Interwebs

A day I am probably going to have next week:

• Walk dogs insanely early
• Make sure there's nothing violently urgent in my e-mail
• Drive through rush-hour traffic to a large city
• Meet an OT and shadow her for 3-4 hours as she drives around to patients' homes
• Drive home, stuff some food in my face
• Get half an hour to study if I'm lucky
• Abnormal Psych class
• Participate in hour-long psych study for extra credit
• Run home, walk dogs who are mad at me for being late
• Throw dinner together
• Go to Pilates class
  
• Try and write some coherent notes on OT observation
• Study until I slump over from exhaustion

Having places to be. Having goals and structured time. Having something to work toward...all very nice things that make me happy, but yowza, the days are just PACKED.

Why Freud is a Quack

According to my professor:

You bring 50 ten year-old boys into a room, and Freud says, "Okay. My theories say that they should all feel erotic desire for their mothers. For every one that admits that, I get a point. And for each boy who denies having such urges, I say he is experiencing repression. Score another point for me. Lookee, I score 50 points! I win!!"

A theory that claims to explain everything actually explains nothing at all.

All I can add is AMEN.

Everyone Has a Story

The guy to my left was overseas killing people for the military. He was concerned that he wasn't particularly broken up about it. The guy to my right was a big-city cop until he was severely injured on duty and took early retirement. The prof readily admitted to suffering from PTSD.

If everyone else in my Abnormal Psych class is that interesting, it's going to be one heckuva ride.

After the syllabus/policy housekeeping song and dance that I have given any number of times, we talked about abnormality and how problematic it is to define. The DSM-IV-TR has this incredibly long, totally useless definition that reads like the guy at the end of the car commercials murmuring a mile a minute about lease terms and payments.

There are four major components that can render a behavior abnormal. Unfortunately, for each criterion, it's pretty easy to come up with examples of things that meet that particular criterion, but are not pathological. Likewise, there are plenty of abnormalities that do not meet at least some of the criteria.

First, there's deviance: behavior, emotion, or thought that deviates from established behavior and norms. This one's super-easy: go to India and loudly proclaim the miracle of the Immaculate Conception. They will think you are deviant, all right. Or talk to the Ice Breakers, those people that go swimming in icy waters every winter. Deviant? Yes. Abnormal in the abnormal psych sense? No. Also, deviance is always relative to a particular culture and time--it would have been quite odd for me to be taking college classes a century ago as a woman.

Next, bring on distress: the behavior, emotion, or thought is unpleasant or upsetting to the sufferer. Seems clear enough. However, people who suffer from mania are clearly experiencing abnormal behavior despite the complete absence of distress involved. And the guy who's convinced he's Jesus Christ is probably happy as a clam.

Third, we have dysfunction: the ailment makes it difficult for people to care for themselves, maintain social contacts, and hold down a job. Again, a counterexample: people going on hunger strikes to achieve better conditions are dysfunctional in the sense that they are not meeting their basic needs, but this is not abnormal behavior in the clinical sense of the word.
So feel free to get your Gandhi on.

Finally, there is danger: the ultimate in psychological dysfunctioning is behavior that is dangerous to oneself or others. Clearly, the alcoholic who drives around drunk all the time fits the bill, but most people with mental health problems are not dangerous at all.

So, in conclusion, people continue to argue about what "abnormality" actually is. There's more gray here than in the skies over Cleveland in February.

Right Place, Right Time

The traumatic brain injury workshop was, in a word, amazing! There were two speakers, both of whom were terrific. The neuropsychologist went first. I could go on and on and on about what she said, but I'll confine myself to 5 things:

1. The brain is full of white matter tracts that create a sort of neuron superhighway. As a matter of fact, if you put all the white matter end to end, it would span the globe three and a half times!
2. Traumatic brain injury often tears the axons that connect neurons, throwing up roadblocks on the white matter superhighway and forcing dead-ends and detours (diffuse axonal injury). This results in disrupted communication within the brain. She compared it to heavy snow bringing down phone lines.
3. She highly recommended a book on traumatic brain injury called "Where Is the Mango Princess?" It's written by the wife of a successful attorney who suffered a TBI and was never quite the same afterwards.
4. Memory symptoms are extremely common after a TBI. TBI tends to mess up memory by making it more difficult for information to "make the leap" from working or short-term memory into long-term memory. However, things that were well known before the TBI will not be forgotten because those memories are stored all over the brain.
5. Changes in social competence and executive planning skills are some of the longest-lasting and highest hurdles that make it difficult on family members and hard for patients to successfully re-integrate into their home, work, and school environments.

The second speaker was a PT who talked about the continuum of care for brain injuries. Basically, the continuum of care goes like this:

1. Shock Trauma/Neuro Intensive Care Unit: All about survival, prevention of secondary complications such as ICP, decubitus, aspiration pneumonia, etc., and stabilization so the patient can move on to #2.
2. Neuro Floor: More stabilization and work on increasing endurance to three hours, which is the minimum required for acute rehab. Patients will get out of bed and work on walking and sitting endurance.
   
3. Long Term Acute Care (LTAC, pronounced EL-tack): Increase endurance, allow for continued cognitive clearing, wound and infection management, and vent weaning if necessary.
4. Skilled Nursing Facility (SNF, pronounced "sniff"): Step up prior to acute rehab or down following acute rehab when the intensity of acute rehab is not tolerated/no longer required. More wound and infection management if necessary.
5. Acute Rehabilitation: Gain independence in mobility and ADLs (activities of daily living). Address behavior issues. Train family to provide safe care at home.
   

These steps are followed by home health (if housebound), outpatient treatment, and a residential community re-entry program that will enable patients to re-integrate into their community.

The speaker also showed some amazing before-and-after videos of people who had made tremendous progress with their mobility and movement. Of course, the time between before and after was years in some cases, but there was significant improvement. She also talked about using a baclofen pump for spasticity and tone management.

So, after all that meaty goodness, the VP of the company from which the speakers came spoke at the mic and said his company is opening a new TBI community re-entry residential facility this fall...ten minutes from my house!! I beat feet up to speak to him and ask about shadowing, and he went one better, saying I might even be able to get some paid hours as an assistant who helps patients get to the therapy room and back. In my case, I'd take patients to and from OT and watch the whole session as it was happening. Nifty, eh?

But the faboo networking didn't end there. I also talked to a woman who does home health, home assessments for aging in place, and senior driver assessments, which I also find very interesting. She gave me her brochure and asked me to get in touch with her about shadowing.

Needless to say, both of these lovely people got e-mails from me today.

That clunk you just heard is my life falling into place.

She's a super geek...super geek (she's super geeky)

I am the biggest geek ever. (Just thought I'd warn you now.)

Since my class starts in less than a week (aaagghhh!), I went up to Local College today to get my Student ID, an item I have not possessed in more than a decade. Technology has made this chore much easier than it used to be, although the pictures still suck. They just suck a lot faster now.

Then I...went and found my Abnormal Psych classroom. I'm so embarrassed to admit I did that. I can't remember the last time I went somewhere in advance just so I was sure I knew where it was. But yes, this Super Geek did just that. It is a windowless room with no notable qualities whatsoever. I've seen coffins with more personality than this place. However, I did notice that just behind it, there is a closet-looking thing. I couldn't help but wonder if our class will be secretly observed or experimented on in some weird way. We are in the Psych building, after all.

To top off my geekery, I am printing out directions and gathering business cards for a half-day seminar I'm going to tomorrow. When I saw the title, I knew I had to go. It's called "Brain Injury 101." How awesome is that?! The only way you could make it any more welcoming is if you called it "Everything You Ever Wanted To Know About Brain Injuries But Were Afraid To Ask." (Although that wouldn't fit on a poster very well.)

I expect I will be doing a lot of scribbling and post-seminar clarification since I had to look up half the initials after the presenter's name, but eeeeeeeeee! I am excited to go learn about brain injuries!