I am trying to type this as my left ring finger swells up ridiculously despite Benadryl and ice. I hate yellow jackets. HATE them.
Anyway, I successfully completed my third week of shadowing and wanted to share a few highlights like I did for Week 2:
1) A female burn patient and her pre-adolescent son. I did not have the temerity to ask how they were burned, but did ask when it happened (a month ago). The therapist was so, so good at talking with them while she worked. She examined Mom's burned hand, put some lotion on it, gently stretched it a little, and then wrapped it in bandages dipped in warm paraffin. Next, she examined the son's skin grafts on his back and said they were healing very well. She discussed some exercises he could do at home. Then she removed the paraffin wraps from Mom's hand and had her do some exercises before presenting her with a hand-stretching tool for her to use at home and detailing some exercises for her to do. I was very impressed with both the nuts and bolts of the treatment and the therapist's bedside manner.
2) I saw two OTs working together on a SHUEE (Shriners Hospital for Children Upper Extremity Evaluation) for one of the day rehab patients. It is an interesting test with a variety of tasks to measure upper extremity function. Usually one OT administers the test while the other videotapes it. Later, an OT watches the tape and scores the evaluation. After the test, one of the OTs took us back to the casting area and made the patient a constraint cast (very simple--it's basically a removable clamshell with the closed "hinge" end over the child's hand). She will be in the next Constraint Group starting at the end of this week.
3) I played the most awesome game of dominoes EVAH. The therapist got the patient (a girl with CP) into a hammock suspended from the ceiling. The hammock ran under her midsection so her upper body and her feet were free. She had to push herself forward to a table where I sat to play dominoes with her. Every time one of us had to draw another domino, the patient had to swing 90 degrees to the left of me where the therapist held one end of a rope. The patient had to grab the other end and pull herself toward the therapist hand-over-hand, then extend one arm into the domino bag, which the therapist held high and off to one side. She had to draw a lot of dominoes over the course of the game, so the girl got a very good workout. And it was fun--she was giggling the whole time! This session really made me appreciate the therapist's creativity.
4) I got to see a TENS (transcutaneous electrical nerve stimulation) unit at work and experience it for myself. In OT, TENS units are used to stimulate damaged nerves in the hope of helping them regenerate. The idea is that since nerves are a two-way street (they can receive impulses from the brain and transmit impulses back), stimulating the "return" side might also improve things on the outbound (brain-to extremity) side. The patient in question had some nerve damage in one of his hands, so TENS was applied before the OT and the patient worked on dressing skills (the patient was about to go back to school). When the session was over, the OT taped a lead to my left hand on the fleshy part of the palm just below the thumb and turned up the level until I felt a little tingling. You can actually make the thumb twitch involuntarily if you turn the unit high enough (which she did -- it felt a little staticky, but it didn't hurt per se).
5) The Myelo Clinic. No, not the Mayo Clinic, the Myelo Clinic. I never really understood just what a [insert name of disease or disease grouping here] Clinic was until I saw it for myself. As the PT the OT and I were waiting in the hall with put it, "It's a great idea -- in theory." The idea is that a number of patients with similar disorders all come in on a certain morning and get seen by a whole bunch of specialists in a shortish (2 hours or so) time window. The specialists include everything from OT and PT to orthopedics, gastroenterology, urology, a nutrition specialist--you name it. Each patient gets a little sheet on the exam room door, and each specialist checks his discipline off the sheet after he/she has seen the patient. "Myelo" refers to the spine and/or bone marrow, and both of the patients I saw my OT work with had spina bifida. One was the most developmentally normal kid I saw the entire three weeks--one of her hands was a bit floppy and she had some issues with sitting/standing/walking, but intellectually she was doing quite well. The OT had a fun time working with her. The second patient had a more severe form of spina bifida and was pretty much dragging himself around by his arms instead of crawling like a normal kid. She tried everything to convince him to pull himself to a stand, but he just couldn't manage it. He had tremendous grip strength, though.
So, there you have it--three weeks of observation from the Land of Peds.
Wednesday, August 24, 2011
Monday, August 15, 2011
Peds Shadowing, Week 2
I'm not going to list out every patient I saw last week because it would just take way too long, and because some of the stuff was the same (two more screaming kids in serial casting, for example). So let me just give you five "highlights":
1) I watched a treatment session with a young girl who had Aicardi syndrome, characterized by an incomplete or missing corpus callosum, the structure that allows the two hemispheres of the brain to communicate with each other. You can imagine how devastating it would be to a baby's growth and development to have the two halves of the brain forever separated. In this session, the focus was on having the patient sit up with less support (unassisted was still not possible), reach for and grab small objects such as cones or toy penguins (she sometimes knocked them over but was rarely able to pick them up), and grab suction balls stuck to a mirror (again, several knock-offs, but only one grab that I remember). The patient had pervasive severe developmental delays, but was indeed progressing, if only in very small increments.
2) I got to watch and then try out a fluidotherapy machine. An adolescent male with arthritis in his hand and wrist inserted his forearm into the machine and performed squeezing/stretching exercises with some spongy blocks that the OT had inserted into the machine while the warm air was blowing the corn husk bits (the size of large grains of sand) over and around the boy's hand. The OT indulged my curiosity and let me try it after the boy was done. It felt much nicer than I expected. The air is warm but not uncomfortably hot, and it blows the corn husk material all around so it is making contact with your hand from all different angles and directions. I was expecting the corn husks to be quite abrasive and pelt my hand like pea-sized hail, but they were actually gentle and soothing.
3) I learned about a new kind of casting. Last week I wrote about serial casting, which aims to straighten or fix a limb. This week I went to Constraint Group, where there were several kids being treated with constraint casting. Constraint casting involves putting a removable cast over a child's dominant arm/hand so that he/she is forced to use the weaker hand to do things. I guess it's the equivalent of putting an eye patch over your good eye so you have to use the weaker one. Some kids actually end up in Constraint Group after they finish serial casting, which makes sense when you think about it: you've had your left arm in a cast for six weeks to straighten it, so it is now weaker because you haven't been using it. So you get a cast put on your right arm to force you to use Lefty again. (I love that pediatric OTs constantly refer to Righty and Lefty, i.e., "I want to see Lefty help pull your shoe off, okay?" This morning a little boy even said to the therapist, "Righty's tired. He stayed up late watching SpongeBob last night!")
4) The zipline. In addition to the Rehab Apartment, there are two gyms in the rehab area, and one of them has an honest-to-goodness zipline affixed to the ceiling. It runs about ten feet across the room and ends over a pit filled with fluffy padding. As part of the afternoon social skills group (I wrote about it last week), the kids all used the zipline to simulate blasting through space. We also read a Dr. Seuss book about space and made planets with a spaceship and an astronaut orbiting them, and we practiced pretend zero-gee walking (where you have to move reeeaaaallllly slowly), which provoked many giggles. I paired up with one of the "my engine is running fast" kids and engaged him for pretty much the whole hour. I think it helped.
5) I got to see an initial hand evaluation on Thursday. The patient was a preadolescent boy who had suffered a friction burn by sticking his hands in a treadmill belt as a baby. (Not uncommon, apparently. Be careful with your treadmill if you have small children!) He had fairly thick scar tissue along the sides of his pointer and middle fingers, and since he had been experiencing a growth spurt, he had difficulty straightening those two fingers. The fingers were growing, but the scar tissue wasn't budging. You can see how this could create a problem. The OT examined the boy's fingers very carefully, asked about his ADLs (he was still able to do everything he wanted to do, fortunately, including throwing a baseball and taking tae kwon do), tested his strength and range of motion (good), and finally decided to make him a splint for night wear in addition to recommending regular massage and application of lotion to the scar tissue to loosen and soften it. I talked to the boy and his sister and mom while the OT made and fitted the splint. It was a very interesting and enjoyable session.
It's hard to believe this is my last week already. I've seen and learned quite a bit and hope to experience a few more things before it's over and done with.
1) I watched a treatment session with a young girl who had Aicardi syndrome, characterized by an incomplete or missing corpus callosum, the structure that allows the two hemispheres of the brain to communicate with each other. You can imagine how devastating it would be to a baby's growth and development to have the two halves of the brain forever separated. In this session, the focus was on having the patient sit up with less support (unassisted was still not possible), reach for and grab small objects such as cones or toy penguins (she sometimes knocked them over but was rarely able to pick them up), and grab suction balls stuck to a mirror (again, several knock-offs, but only one grab that I remember). The patient had pervasive severe developmental delays, but was indeed progressing, if only in very small increments.
2) I got to watch and then try out a fluidotherapy machine. An adolescent male with arthritis in his hand and wrist inserted his forearm into the machine and performed squeezing/stretching exercises with some spongy blocks that the OT had inserted into the machine while the warm air was blowing the corn husk bits (the size of large grains of sand) over and around the boy's hand. The OT indulged my curiosity and let me try it after the boy was done. It felt much nicer than I expected. The air is warm but not uncomfortably hot, and it blows the corn husk material all around so it is making contact with your hand from all different angles and directions. I was expecting the corn husks to be quite abrasive and pelt my hand like pea-sized hail, but they were actually gentle and soothing.
3) I learned about a new kind of casting. Last week I wrote about serial casting, which aims to straighten or fix a limb. This week I went to Constraint Group, where there were several kids being treated with constraint casting. Constraint casting involves putting a removable cast over a child's dominant arm/hand so that he/she is forced to use the weaker hand to do things. I guess it's the equivalent of putting an eye patch over your good eye so you have to use the weaker one. Some kids actually end up in Constraint Group after they finish serial casting, which makes sense when you think about it: you've had your left arm in a cast for six weeks to straighten it, so it is now weaker because you haven't been using it. So you get a cast put on your right arm to force you to use Lefty again. (I love that pediatric OTs constantly refer to Righty and Lefty, i.e., "I want to see Lefty help pull your shoe off, okay?" This morning a little boy even said to the therapist, "Righty's tired. He stayed up late watching SpongeBob last night!")
4) The zipline. In addition to the Rehab Apartment, there are two gyms in the rehab area, and one of them has an honest-to-goodness zipline affixed to the ceiling. It runs about ten feet across the room and ends over a pit filled with fluffy padding. As part of the afternoon social skills group (I wrote about it last week), the kids all used the zipline to simulate blasting through space. We also read a Dr. Seuss book about space and made planets with a spaceship and an astronaut orbiting them, and we practiced pretend zero-gee walking (where you have to move reeeaaaallllly slowly), which provoked many giggles. I paired up with one of the "my engine is running fast" kids and engaged him for pretty much the whole hour. I think it helped.
5) I got to see an initial hand evaluation on Thursday. The patient was a preadolescent boy who had suffered a friction burn by sticking his hands in a treadmill belt as a baby. (Not uncommon, apparently. Be careful with your treadmill if you have small children!) He had fairly thick scar tissue along the sides of his pointer and middle fingers, and since he had been experiencing a growth spurt, he had difficulty straightening those two fingers. The fingers were growing, but the scar tissue wasn't budging. You can see how this could create a problem. The OT examined the boy's fingers very carefully, asked about his ADLs (he was still able to do everything he wanted to do, fortunately, including throwing a baseball and taking tae kwon do), tested his strength and range of motion (good), and finally decided to make him a splint for night wear in addition to recommending regular massage and application of lotion to the scar tissue to loosen and soften it. I talked to the boy and his sister and mom while the OT made and fitted the splint. It was a very interesting and enjoyable session.
It's hard to believe this is my last week already. I've seen and learned quite a bit and hope to experience a few more things before it's over and done with.
Saturday, August 6, 2011
Peds Shadowing, Week 1
Week one of three of my peds shadowing is over. I celebrated by coming home and taking a two-hour nap. The constant barrage of new information is simultaneously exhilarating and exhausting.
I started Day 1 observing a TBI patient who is only about 6 weeks out, but making an incredible recovery. She did some visual perception exercises ("circle the one that's different from the others" sort of stuff) and then copied down a text about jellyfish at our local zoo. After having the patient self-check her text for errors, the OT asked her a few questions to test her comprehension. The OT also talked to the patient's mother and me while she was working to test her ability to handle distractions (distractability and difficulty focusing are quite common following a TBI).
Next, I got to check out the Rehab Apartment. It's a fully functional apartment right inside the hospital that has a full kitchen, living/dining room, bedroom, bathroom, and laundry area. It even has curtains on the windows, a standard front door, cedar siding on the outside walls, and a mailbox mounted near the front door. It is furnished with consumer furniture so it feels homey and not so hospital-like. Patient #2 was practicing toileting and dressing in the Rehab Apartment. She asked me to wait at the dining room table while she and the OT did the toileting stuff, so I poked around and looked at everything else in the apartment while I waited. The next task was dressing, so the three of us went into the apartment bedroom. The closet is full of really cute costumes that the OTs use for dressing exercises. The patient picked out a costume, and then she and the OT worked on methods for getting clothes off and on while working around the patient's strength limitations. Finally, she and the OT played Connect Four at the dining room table.
My final observation on Day 1 was of a two year-old girl who was undergoing rehab following cardiac surgery. She crawled through a play tunnel, collected blocks and stacked them up on a table, strung wooden farm animals on a long string, crawled through the padded pit to retrieve the farm animals, and put plastic rings into vertical and horizontal holes.
Day 2 started with my first exposure to splinting. One of the treatments the hospital employs is "serial splinting." It's sort of the same concept as using braces to straighten your teeth, only they use casts. Let's say you have a child who can't straighten his elbow. They start by measuring the initial range of motion (ROM) and note the extension they can achieve; say, 30 degrees away from normal extension (I think that's -30 in OT-speak, but don't quote me on that). They splint the arm at whatever level of extension they can manage, and the child comes back a week later, has the cast cut off, gets a new set of measurements, and has a new cast applied. This process is repeated for 4-6 weeks, hopefully resulting in the ability to completely straighten the elbow.
This all sounds pretty straightforward, but it is not so fun if you are the kid whose arm is being splinted. First, they have to use a very loud saw to cut off the old cast, and the child feels pressure and vibration as the saw cuts through the material. This resulted in the child I was observing screaming bloody murder and crying his head off. Then, they have to test the new ROM and see where they're at. All the kid knows is that the OTs are torquing his arm to the point that it hurts at least some. This sent my kid into a renewed fit of screaming and crying. Then, the new cast has to be applied. The kid had to hold pretty still for a while and was not happy to see his arm disappear again. However, he did like the cool bears-and-balloons pattern he picked for his cast, so that was some consolation.
The splinting theme continued as two OTs and I went up to an inpatient unit to assess a 16 month-old girl with weakness on one side. First of all, do you know how hard it is to assess someone who can't follow any kind of spoken commands and generally wants you to stop messing with her? She made her wishes known by exercising her vocal cords in a semi-tearful monotone. The OTs continued gamely on, singing nursery rhymes to her to calm her down. (Note to self: brush up on your nursery rhymes. Singing "Shake your booty" is not going to make you any friends.)
They actually have a portable splinting machine that they wheel around on a cart, and I got to see them make a splint for the girl's weak hand. First, they made a rough template by tracing her hand on some paper. Next, they cut the template shape out of a sheet of orthoplast and laid it in a hot water bath to make it malleable. Then they went through a process of shaping it, trying it on the girl's arm (after it had cooled a little, of course!), noting where further adjustments were needed, cutting off a bit here or flaring a part there, and so on until it was finished. All the while, the girl was voicing her displeasure, especially when the medical team came in and made several unsuccessful tries to get an IV in, but the OTs were unflappable and just kept doing their thing.
It was with great relief that I fled to my final observation of the day. Two days a week, there is an afternoon group session for kids with sensory processing issues and social issues where they do some motor activities, practice good turn-taking behavior, and work on "slowing their engines down" or "speeding their engines up" as needed. The group started with everyone talking about whether their engines were running "fast," "slow," or "just right." There was a "fast" kid who was a textbook sensory seeker, a "slow" girl who complained she was tired but seemed to perk up as the group went on, a boy who said he was feeling "just right" and had the behaviors to match, and a boy who was so shy he spent the first half hour hiding inside a foam castle. A real eye-opener--it was like The Out-of-Sync Child come to life. After some wheelbarrow walking, the group talked about nursery rhymes and acted out Humpty Dumpty (falling backwards into the pit) and Jack and Jill (putting weights in a bucket for the pail of water, walking up a foam bridge, handing the bucket to the OT, and then sliding down a foam slide to "tumble down the hill"). Then we sang The Itsy-Bitsy Spider, complete with hand motions, and made our own spider webs out of paper plates and yarn.
Day 3 began with the same TBI patient I saw at the beginning of Day 1. The OT brought out a game called Make N' Break that the patient (and I) had never seen before. She asked the patient to read the instructions and tell her how to play, asking occasional questions about various aspects of gameplay to make sure that she was understanding what she was reading. Then they played the game, which was a great exercise in hand-eye coordination and spatial thinking skills. The OT cleverly exploited one of the obscure rules in her last turn to make sure the patient won. Then they did Mad Libs (remember those?), which is a great activity for an older child like this patient who is preparing to go back to school.
Next, I got to spend another hour in the Rehab Apartment with a cerebral palsy (CP) patient. Under the supervision of the OT, the patient baked brownies, including retrieving the ingredients and measuring cups from the cupboards, mixing the ingredients together while standing (one of the session goals was to work on standing endurance), and getting the batter into the pan and into the oven safely. The child's nursing aide was there as well and kept up a constant annoying stream of chatter with the OT, who was very polite about it, but it bothered me a lot. The brownies smelled wonderful, but we didn't get to eat any of them because the hour was over before they were done baking.
Finally, I observed a COTA (that's short for Certified Occupational Therapy Assistant) work with a boy who had been taken from his biological mother after she tried to kill him. (Wow.) He had many developmental delays and other issues. They worked with a Filo lacing set ("Aah, a kid-friendly version of leather lacing!" I said when I saw it in action) and then looked at a "how to draw" book for kids that the COTA had brought in specifically for this patient because he likes to draw. He successfully followed the instructions to make a pretty good-looking spider. "Let's go scare my mom with it!" he said happily as they left the room at the end of the session.
Day 4 started with an evaluation. A new patient was brought in for testing. Only OTs are allowed to do evaluations; COTAs can do treatments, but not evaluations. The OT asked me to play with the patient while she talked to his mom. She gave us a Connect Four game ("It's the universal game!" she said brightly) and some wooden people pieces that fit together in different ways. The boy was fascinated by the Connect Four game--he'd slide a piece in the top and then pull the retaining tab back so it would fall out. He did that fifteen or twenty times in a row before he realized that you could actually put in more than one piece at a time. We eventually filled up the whole screen with pieces and talked a little bit about red and black and rows and stuff, and then we played with the wooden people for a little while. I got silly playing with the people pieces (one of them looked the mouthpiece on the really really old phones, you know, sort of cone-shaped), so we pretended they were phones and had goofy conversations for a while.
Then the evaluation started. Wow, was it long. (Just like this post!) Considering the child already had an ADHD diagnosis, I was amazed he made it through the whole thing without pitching a fit. There were a whole bunch of block-building exercises, where the OT would build a little tower behind a screen and then show it to the boy and ask him to duplicate it, and flip books where he had to say which things were the same and which things were different, and an exercise where he had to draw a person, and writing exercises where he had to copy out shapes and letters from the flip book, and a cute exercise where he was given five cards and had to match them to pictures in the flip book (mitten goes with hand, bat goes with ball, etc.). There was much more, but that gives you the basic idea. I played with the boy again while the OT went over the results with his mother (We played with toy trucks and blew bubbles! Whoo-hoo!), and after they left, she showed me a little bit about how the test worked and why she had given him the test items that she had. Very interesting stuff.
Patient #2 was an inpatient evaluation of a girl in Oncology who couldn't have been older than seven. "She kind of runs the show," the OT warned me as we went up, and yikes, she certainly called it. We walked in the room to see the girl matter-of-factly unpacking her suitcase, putting her things into drawers. "I just need to look at a few things, and then we'll be on our way," the OT said brightly, to which the girl replied, "No! I have to unpack first!" She certainly wasn't having any balance issues, bending over easily to pluck things from the suitcase and twisting her trunk to the side to put them in the drawers. The girl's mom asked if she wanted anything from the cafeteria, and the girl yelled, "NO! I don't want anything!" The OT said she could run down and get herself something while we were there, and Mom promptly disappeared. After some persuasion, the girl deigned to catch a beach ball and throw it back, which she did quite handily, readily put together some sectioned dolls (a harder version of the wooden ones I had with Patient #1), and drew a very nice circle and rectangle, but refused for reasons unknown to give us a triangle. And when Mom came back, the girl screeched at her, "Why didn't you bring me anything?! I want my DONUT!!" (Wow.)
I now know why all medical wards have long sections of counter near the nurses' station. It's so OTs, PTs, SLPs, nurses, doctors, and basically everyone that comes into contact with a patient can write notes on what happened. As "my" OT wrote her note on the just-concluded evaluation of Miss Runs The Show at the counter, I counted no fewer than four other professionals standing there writing assiduously.
Patient #3 was also extremely interesting. Hand therapy! I finally got to see some! Woot! The patient was an adolescent male who had severely burned the palms of his hands as a baby, and had undergone many surgeries over the years trying to retain the function and flexibility in his hands and fingers. Unfortunately, a recent surgery had not gone well, and the middle finger on his writing hand had become nearly totally unusable--so the patient wrote a letter explaining why he wanted to have it amputated. His request was granted, and this appointment was his post-amputation follow-up. The OT asked some questions about how the incision was healing, was it swollen, was it oozing, was he in pain, etc. He and his mom expressed some concern about a particular spot along the incision, so the OT carefully unwrapped the bandage and took a look. She thought that particular self-absorbing stitch had just absorbed a little faster than the ones around it, but she called over to Plastics, and they said he could come by and they'd have a doctor look at it just to be sure. Then she had him do some exercises with his hand, and then she fetched him a pencil and paper and had him try writing. He actually wrote pretty well, all things considered, and the OT told them about possibly using some "fatter" pencils and pens for a few weeks until everything healed up a little more.
So, that was my week of peds shadowing. Quite a lot of different experiences, ages, diagnoses! It was absolutely fascinating, but I think you see why I needed a nap after all that.
Can't wait to see what happens next week...
I started Day 1 observing a TBI patient who is only about 6 weeks out, but making an incredible recovery. She did some visual perception exercises ("circle the one that's different from the others" sort of stuff) and then copied down a text about jellyfish at our local zoo. After having the patient self-check her text for errors, the OT asked her a few questions to test her comprehension. The OT also talked to the patient's mother and me while she was working to test her ability to handle distractions (distractability and difficulty focusing are quite common following a TBI).
Next, I got to check out the Rehab Apartment. It's a fully functional apartment right inside the hospital that has a full kitchen, living/dining room, bedroom, bathroom, and laundry area. It even has curtains on the windows, a standard front door, cedar siding on the outside walls, and a mailbox mounted near the front door. It is furnished with consumer furniture so it feels homey and not so hospital-like. Patient #2 was practicing toileting and dressing in the Rehab Apartment. She asked me to wait at the dining room table while she and the OT did the toileting stuff, so I poked around and looked at everything else in the apartment while I waited. The next task was dressing, so the three of us went into the apartment bedroom. The closet is full of really cute costumes that the OTs use for dressing exercises. The patient picked out a costume, and then she and the OT worked on methods for getting clothes off and on while working around the patient's strength limitations. Finally, she and the OT played Connect Four at the dining room table.
My final observation on Day 1 was of a two year-old girl who was undergoing rehab following cardiac surgery. She crawled through a play tunnel, collected blocks and stacked them up on a table, strung wooden farm animals on a long string, crawled through the padded pit to retrieve the farm animals, and put plastic rings into vertical and horizontal holes.
Day 2 started with my first exposure to splinting. One of the treatments the hospital employs is "serial splinting." It's sort of the same concept as using braces to straighten your teeth, only they use casts. Let's say you have a child who can't straighten his elbow. They start by measuring the initial range of motion (ROM) and note the extension they can achieve; say, 30 degrees away from normal extension (I think that's -30 in OT-speak, but don't quote me on that). They splint the arm at whatever level of extension they can manage, and the child comes back a week later, has the cast cut off, gets a new set of measurements, and has a new cast applied. This process is repeated for 4-6 weeks, hopefully resulting in the ability to completely straighten the elbow.
This all sounds pretty straightforward, but it is not so fun if you are the kid whose arm is being splinted. First, they have to use a very loud saw to cut off the old cast, and the child feels pressure and vibration as the saw cuts through the material. This resulted in the child I was observing screaming bloody murder and crying his head off. Then, they have to test the new ROM and see where they're at. All the kid knows is that the OTs are torquing his arm to the point that it hurts at least some. This sent my kid into a renewed fit of screaming and crying. Then, the new cast has to be applied. The kid had to hold pretty still for a while and was not happy to see his arm disappear again. However, he did like the cool bears-and-balloons pattern he picked for his cast, so that was some consolation.
The splinting theme continued as two OTs and I went up to an inpatient unit to assess a 16 month-old girl with weakness on one side. First of all, do you know how hard it is to assess someone who can't follow any kind of spoken commands and generally wants you to stop messing with her? She made her wishes known by exercising her vocal cords in a semi-tearful monotone. The OTs continued gamely on, singing nursery rhymes to her to calm her down. (Note to self: brush up on your nursery rhymes. Singing "Shake your booty" is not going to make you any friends.)
They actually have a portable splinting machine that they wheel around on a cart, and I got to see them make a splint for the girl's weak hand. First, they made a rough template by tracing her hand on some paper. Next, they cut the template shape out of a sheet of orthoplast and laid it in a hot water bath to make it malleable. Then they went through a process of shaping it, trying it on the girl's arm (after it had cooled a little, of course!), noting where further adjustments were needed, cutting off a bit here or flaring a part there, and so on until it was finished. All the while, the girl was voicing her displeasure, especially when the medical team came in and made several unsuccessful tries to get an IV in, but the OTs were unflappable and just kept doing their thing.
It was with great relief that I fled to my final observation of the day. Two days a week, there is an afternoon group session for kids with sensory processing issues and social issues where they do some motor activities, practice good turn-taking behavior, and work on "slowing their engines down" or "speeding their engines up" as needed. The group started with everyone talking about whether their engines were running "fast," "slow," or "just right." There was a "fast" kid who was a textbook sensory seeker, a "slow" girl who complained she was tired but seemed to perk up as the group went on, a boy who said he was feeling "just right" and had the behaviors to match, and a boy who was so shy he spent the first half hour hiding inside a foam castle. A real eye-opener--it was like The Out-of-Sync Child come to life. After some wheelbarrow walking, the group talked about nursery rhymes and acted out Humpty Dumpty (falling backwards into the pit) and Jack and Jill (putting weights in a bucket for the pail of water, walking up a foam bridge, handing the bucket to the OT, and then sliding down a foam slide to "tumble down the hill"). Then we sang The Itsy-Bitsy Spider, complete with hand motions, and made our own spider webs out of paper plates and yarn.
Day 3 began with the same TBI patient I saw at the beginning of Day 1. The OT brought out a game called Make N' Break that the patient (and I) had never seen before. She asked the patient to read the instructions and tell her how to play, asking occasional questions about various aspects of gameplay to make sure that she was understanding what she was reading. Then they played the game, which was a great exercise in hand-eye coordination and spatial thinking skills. The OT cleverly exploited one of the obscure rules in her last turn to make sure the patient won. Then they did Mad Libs (remember those?), which is a great activity for an older child like this patient who is preparing to go back to school.
Next, I got to spend another hour in the Rehab Apartment with a cerebral palsy (CP) patient. Under the supervision of the OT, the patient baked brownies, including retrieving the ingredients and measuring cups from the cupboards, mixing the ingredients together while standing (one of the session goals was to work on standing endurance), and getting the batter into the pan and into the oven safely. The child's nursing aide was there as well and kept up a constant annoying stream of chatter with the OT, who was very polite about it, but it bothered me a lot. The brownies smelled wonderful, but we didn't get to eat any of them because the hour was over before they were done baking.
Finally, I observed a COTA (that's short for Certified Occupational Therapy Assistant) work with a boy who had been taken from his biological mother after she tried to kill him. (Wow.) He had many developmental delays and other issues. They worked with a Filo lacing set ("Aah, a kid-friendly version of leather lacing!" I said when I saw it in action) and then looked at a "how to draw" book for kids that the COTA had brought in specifically for this patient because he likes to draw. He successfully followed the instructions to make a pretty good-looking spider. "Let's go scare my mom with it!" he said happily as they left the room at the end of the session.
Day 4 started with an evaluation. A new patient was brought in for testing. Only OTs are allowed to do evaluations; COTAs can do treatments, but not evaluations. The OT asked me to play with the patient while she talked to his mom. She gave us a Connect Four game ("It's the universal game!" she said brightly) and some wooden people pieces that fit together in different ways. The boy was fascinated by the Connect Four game--he'd slide a piece in the top and then pull the retaining tab back so it would fall out. He did that fifteen or twenty times in a row before he realized that you could actually put in more than one piece at a time. We eventually filled up the whole screen with pieces and talked a little bit about red and black and rows and stuff, and then we played with the wooden people for a little while. I got silly playing with the people pieces (one of them looked the mouthpiece on the really really old phones, you know, sort of cone-shaped), so we pretended they were phones and had goofy conversations for a while.
Then the evaluation started. Wow, was it long. (Just like this post!) Considering the child already had an ADHD diagnosis, I was amazed he made it through the whole thing without pitching a fit. There were a whole bunch of block-building exercises, where the OT would build a little tower behind a screen and then show it to the boy and ask him to duplicate it, and flip books where he had to say which things were the same and which things were different, and an exercise where he had to draw a person, and writing exercises where he had to copy out shapes and letters from the flip book, and a cute exercise where he was given five cards and had to match them to pictures in the flip book (mitten goes with hand, bat goes with ball, etc.). There was much more, but that gives you the basic idea. I played with the boy again while the OT went over the results with his mother (We played with toy trucks and blew bubbles! Whoo-hoo!), and after they left, she showed me a little bit about how the test worked and why she had given him the test items that she had. Very interesting stuff.
Patient #2 was an inpatient evaluation of a girl in Oncology who couldn't have been older than seven. "She kind of runs the show," the OT warned me as we went up, and yikes, she certainly called it. We walked in the room to see the girl matter-of-factly unpacking her suitcase, putting her things into drawers. "I just need to look at a few things, and then we'll be on our way," the OT said brightly, to which the girl replied, "No! I have to unpack first!" She certainly wasn't having any balance issues, bending over easily to pluck things from the suitcase and twisting her trunk to the side to put them in the drawers. The girl's mom asked if she wanted anything from the cafeteria, and the girl yelled, "NO! I don't want anything!" The OT said she could run down and get herself something while we were there, and Mom promptly disappeared. After some persuasion, the girl deigned to catch a beach ball and throw it back, which she did quite handily, readily put together some sectioned dolls (a harder version of the wooden ones I had with Patient #1), and drew a very nice circle and rectangle, but refused for reasons unknown to give us a triangle. And when Mom came back, the girl screeched at her, "Why didn't you bring me anything?! I want my DONUT!!" (Wow.)
I now know why all medical wards have long sections of counter near the nurses' station. It's so OTs, PTs, SLPs, nurses, doctors, and basically everyone that comes into contact with a patient can write notes on what happened. As "my" OT wrote her note on the just-concluded evaluation of Miss Runs The Show at the counter, I counted no fewer than four other professionals standing there writing assiduously.
Patient #3 was also extremely interesting. Hand therapy! I finally got to see some! Woot! The patient was an adolescent male who had severely burned the palms of his hands as a baby, and had undergone many surgeries over the years trying to retain the function and flexibility in his hands and fingers. Unfortunately, a recent surgery had not gone well, and the middle finger on his writing hand had become nearly totally unusable--so the patient wrote a letter explaining why he wanted to have it amputated. His request was granted, and this appointment was his post-amputation follow-up. The OT asked some questions about how the incision was healing, was it swollen, was it oozing, was he in pain, etc. He and his mom expressed some concern about a particular spot along the incision, so the OT carefully unwrapped the bandage and took a look. She thought that particular self-absorbing stitch had just absorbed a little faster than the ones around it, but she called over to Plastics, and they said he could come by and they'd have a doctor look at it just to be sure. Then she had him do some exercises with his hand, and then she fetched him a pencil and paper and had him try writing. He actually wrote pretty well, all things considered, and the OT told them about possibly using some "fatter" pencils and pens for a few weeks until everything healed up a little more.
So, that was my week of peds shadowing. Quite a lot of different experiences, ages, diagnoses! It was absolutely fascinating, but I think you see why I needed a nap after all that.
Can't wait to see what happens next week...
Wednesday, August 3, 2011
Peds, Baby!
This week has marked the beginning of a new adventure. Four days a week for 3-4 hours a day, I am shadowing at a large children's hospital. I have been a volunteer at this same children's hospital for several years now, but shadowing is a whole different ball of wax.
The OT Department is huge. There are about two dozen OTs and COTAs working there, and they have a fully decked out rehab apartment complete with cedar siding and a mailbox outside the front door, two gyms, a rock climbing wall, cabinets and cabinets of toys, games, and fidgets, a pit filled with fluffy mats...it's like a toy store on steroids. They also have a Day Rehab section, a whole area devoted to splinting, a seemingly endless corridor of treatment and exam rooms, and probably several other areas I haven't even seen yet.
Unfortunately, I have to head out shortly for my third day of shadowing, but I'll try and fill you in on what I've seen so far ASAP (before it all falls out of my brain!).
The OT Department is huge. There are about two dozen OTs and COTAs working there, and they have a fully decked out rehab apartment complete with cedar siding and a mailbox outside the front door, two gyms, a rock climbing wall, cabinets and cabinets of toys, games, and fidgets, a pit filled with fluffy mats...it's like a toy store on steroids. They also have a Day Rehab section, a whole area devoted to splinting, a seemingly endless corridor of treatment and exam rooms, and probably several other areas I haven't even seen yet.
Unfortunately, I have to head out shortly for my third day of shadowing, but I'll try and fill you in on what I've seen so far ASAP (before it all falls out of my brain!).
It's Official!
The Great Eight is now the Great Seven. I finished my Abnormal Psych class last Friday and my grade posted this morning! I got an A in Abnormal Psych!! Woot woot! I enjoyed the class a lot and was glad to take it with a nice small group during the summer. So, as I promised, here is the newly revised Great Eight list:
- Medical Terminology. Thankfully, there are no prerequisites for this class. And it's offered on-line! ENROLLED FALL 2011 (on-line class).
- Abnormal Psychology. COMPLETED SUMMER 2011. GRADE: A!!
- Lifespan. This class is about human development from birth to death. ENROLLED FALL 2011.
- Social Science Statistics. This class is about understanding the math used in scientific research studies so you can tell if a study is bogus or believable. Could come in very handy. If I take this class at BCU, Intro to Psych is the only prerequisite.
- Human Anatomy with Lab. At last, my chance to cut up dead people! And don't forget the opportunity to smell like formaldehyde. I must have a 200-level biology class with lab before I can take this class. I think I read somewhere that one should take anatomy before one takes physiology.
- Physiology with Lab. No cutting up dead people here. I'm not sure about the smelling like formaldehyde part. The 200-level bio class is also required as a prereq for this class.
- Pathology. This class is all about disease and things that can go wrong in body and mind. You can't take this class until you've taken physiology. (Which sorta makes sense, since you should have an understanding of how things function normally before you can really appreciate what constitutes abnormal/pathological function.)
- Neuroscience with Lab. This class should be called Zombie Class, because it's all about braaaaaiiiins. Specifically, it's about the structure and function of the central and peripheral nervous system, which of course includes the braaaaiiiin.
When Worlds Collide
Believe it or not, OT is not my entire life...at least not yet. I still make pathetic attempts at pursuing other interests. One of those interests is dog agility, where a dog and handler run around a big obstacle course. The dog actually does the obstacles, but the handler has to direct the dog and tell him where to go, so there is also considerable human hustling involved.
At any rate, I agreed to do an agility demo last weekend at one of these typical Midwestern small-town summer festival weekends with a friend. He and I arrived with a car full of equipment and dogs, set everything up, and ran through a few practice rounds. The actual demo went off without a hitch, and people were appropriately impressed. We then offered to take other people's dogs and try them out on some of the obstacles. It was hot and we only had a few takers.
Just as we were preparing to pack things up and call it a day, a lady in a power chair with a service dog came up to us. The dog was a leggy black lab mix named Diego, very gentle and sweet, and the lady said she was looking for something to do with him to give him more exercise. She easily called him over a jump to her, and he also quickly got the hang of going through the tunnel to her. I told her that people in power chairs can and do compete successfully with their dogs in agility, and that I thought she and Diego would love it.
When I told her I was going to school for OT, she opened up quite a bit. She was a former nurse who had been put in a chair by multiple sclerosis and now struggled with energy management issues. In addition to the usual sorts of things like putting her cell phone in her hands and activating switches for her, Diego could actually do most of the work on her transfers from the chair to her bed or the chair to the tub! He actually drags the transfer board into place for her and then helps her pull herself onto and across the board. I thought that was really amazing.
She got her dog from Assistance Dogs of America, Inc., and unlike many other organizations, she was not required to raise $10,000 or more to have a dog placed with her. ADAI regularly pulls dogs from pounds and shelters to train as service animals, so they save lives in the process, too. They sound like a good group. If I ever hit the lottery, I am definitely going to send them some coin.
At any rate, I agreed to do an agility demo last weekend at one of these typical Midwestern small-town summer festival weekends with a friend. He and I arrived with a car full of equipment and dogs, set everything up, and ran through a few practice rounds. The actual demo went off without a hitch, and people were appropriately impressed. We then offered to take other people's dogs and try them out on some of the obstacles. It was hot and we only had a few takers.
Just as we were preparing to pack things up and call it a day, a lady in a power chair with a service dog came up to us. The dog was a leggy black lab mix named Diego, very gentle and sweet, and the lady said she was looking for something to do with him to give him more exercise. She easily called him over a jump to her, and he also quickly got the hang of going through the tunnel to her. I told her that people in power chairs can and do compete successfully with their dogs in agility, and that I thought she and Diego would love it.
When I told her I was going to school for OT, she opened up quite a bit. She was a former nurse who had been put in a chair by multiple sclerosis and now struggled with energy management issues. In addition to the usual sorts of things like putting her cell phone in her hands and activating switches for her, Diego could actually do most of the work on her transfers from the chair to her bed or the chair to the tub! He actually drags the transfer board into place for her and then helps her pull herself onto and across the board. I thought that was really amazing.
She got her dog from Assistance Dogs of America, Inc., and unlike many other organizations, she was not required to raise $10,000 or more to have a dog placed with her. ADAI regularly pulls dogs from pounds and shelters to train as service animals, so they save lives in the process, too. They sound like a good group. If I ever hit the lottery, I am definitely going to send them some coin.
Tuesday, August 2, 2011
Catching Up, Part 1
I hate doing these kinds of posts where it's basically a laundry list of what I've been up to, but things have been so dang crazy around here! Rmph!
So last week I had another observapalooza, this one with Molly. We got to see three clients. (I have changed the details as always, never fear...) Client #1 had a TBI (traumatic brain injury) due to an MVA (motor vehicle accident) more than a decade ago, apparently had a Glasgow score of 4 or 5 (which is very low, very bad, and connotes a very poor prognosis), and is really in amazingly good shape, all things considered. She speaks quickly, which is very unusual for someone with a TBI, and has to be told to speak more slowly and loudly. Since I had not heard her history, Molly asked her to tell me about her accident, which she did. It made the little hairs stand up on the back of my neck....another one for the "just slap me if I complain about anything" file.
We were working mostly on her trigger finger, a pointer finger that was stuck in flexion. Molly taped it with kinesio tape and had the client pick up some dice of various sizes and move them around, and then the client pulled out her clarinet and played a little bit. It's a terrific therapeutic activity because it requires you to hold your trunk upright, breathe deeply from the diaphragm, focus the breath into the instrument, and move the fingers over the holes and stops, including that pesky pointer finger. (The client called it "ornery," which made me laugh.)
All in all, the client was very appropriate in her emotions and speech, although she apparently still has some fairly major memory deficits (she still forgets she has a clarinet unless she leaves it in plain sight). Her one quirk, which I found adorable and endearing, was that she kept throwing in little phrases in Italian. She spent a year as an exchange student in Italy less than two years before her accident and spoke Italian pretty well. She loved the experience, and even the accident and TBI could not knock the Italian out of her. Instead of saying "thank you," most of the time she said "grazie" instead. Same thing for "you're welcome," "hello," and "goodbye," as well as a few other affectionate phrases ("I'm so proud of you," "You're very nice," etc.). It was very cute, I thought.
Our second client was the lovely Janet, Molly's ALS client. More kinesio tape for Janet's own ornery stuck-in-flexion pointer finger, discussion of an ALS support group that Molly was scouting out for Janet, and some issues with emotional lability (Janet was very perplexed that she could go from happy to crying and back again at the drop of a hat, and Molly reassured her that this is actually pretty common with ALS and does have a biological origin). And oh yes, the bed maker. Janet had ordered this gadget because she was having trouble tucking the sheets under on her mother's bed. She didn't want to leave them hanging because she was afraid that her mother, who is quite elderly, would trip on them and fall. So Janet, Molly, Janet's sister-in-law who was up visiting from Georgia, and I all crowded around the bed to try out this wondrous-sounding device. Well. It might have worked if the mattress weren't made out of lead bars. Seriously, it was quite possibly the heaviest mattress I have ever struggled with, and it was only a full-size bed! Anyway, Molly tried it a few different ways and finally decided sitting in a chair was the easiest way to use it, but she really had to lean into it and still could barely get the sheets tucked. Janet tried and made an I-give-up face after about ten seconds. Her sister-in-law gave it a whirl and was equally defeated. Janet pointed authoritatively at me, and I too gave it a shot. I did manage to get it to work, but I sounded like Hulk Hogan in the WWF World Championships. The noises that came out of me were anything but ladylike, and everyone had a good laugh over it before we sadly put the bed maker back in its box to return for a refund.
Client #3 was a gentleman who was actually more or less housebound and on oxygen. He had a long list of medical issues, most of which had been exacerbated by a stroke that had left him in a nursing home for months. He had been thrilled to finally come back home and even more thrilled when Molly started working with him about six weeks prior. Understandably, the man had been quite depressed at his feelings of neediness and helplessness. Molly gave him a whole series of strengthening exercises that he could do right in his bed, and as I watched, she had him work on rolling himself over so that his legs hung off the side of the bed, first on one side, and then the other. Then she even had him do it without using his arms to pull himself over. The man was so amazed and happy when he found that he could do it with just his core and lower extremities! It sounds like a small thing, but being able to get yourself to a seated position over the edge of the bed makes it so much easier to get into a wheelchair! And likewise, when you transfer out of the wheelchair and back into the bed, being able to swing your own legs over instead of having your grandson lift them makes a huge difference; it gives you some of your dignity and independence back.
Total time observed this session: 5 hours
Total time observed thus far: 20 hours, 10 minutes
I have so much more to report, but I'll have to come back later...
So last week I had another observapalooza, this one with Molly. We got to see three clients. (I have changed the details as always, never fear...) Client #1 had a TBI (traumatic brain injury) due to an MVA (motor vehicle accident) more than a decade ago, apparently had a Glasgow score of 4 or 5 (which is very low, very bad, and connotes a very poor prognosis), and is really in amazingly good shape, all things considered. She speaks quickly, which is very unusual for someone with a TBI, and has to be told to speak more slowly and loudly. Since I had not heard her history, Molly asked her to tell me about her accident, which she did. It made the little hairs stand up on the back of my neck....another one for the "just slap me if I complain about anything" file.
We were working mostly on her trigger finger, a pointer finger that was stuck in flexion. Molly taped it with kinesio tape and had the client pick up some dice of various sizes and move them around, and then the client pulled out her clarinet and played a little bit. It's a terrific therapeutic activity because it requires you to hold your trunk upright, breathe deeply from the diaphragm, focus the breath into the instrument, and move the fingers over the holes and stops, including that pesky pointer finger. (The client called it "ornery," which made me laugh.)
All in all, the client was very appropriate in her emotions and speech, although she apparently still has some fairly major memory deficits (she still forgets she has a clarinet unless she leaves it in plain sight). Her one quirk, which I found adorable and endearing, was that she kept throwing in little phrases in Italian. She spent a year as an exchange student in Italy less than two years before her accident and spoke Italian pretty well. She loved the experience, and even the accident and TBI could not knock the Italian out of her. Instead of saying "thank you," most of the time she said "grazie" instead. Same thing for "you're welcome," "hello," and "goodbye," as well as a few other affectionate phrases ("I'm so proud of you," "You're very nice," etc.). It was very cute, I thought.
Our second client was the lovely Janet, Molly's ALS client. More kinesio tape for Janet's own ornery stuck-in-flexion pointer finger, discussion of an ALS support group that Molly was scouting out for Janet, and some issues with emotional lability (Janet was very perplexed that she could go from happy to crying and back again at the drop of a hat, and Molly reassured her that this is actually pretty common with ALS and does have a biological origin). And oh yes, the bed maker. Janet had ordered this gadget because she was having trouble tucking the sheets under on her mother's bed. She didn't want to leave them hanging because she was afraid that her mother, who is quite elderly, would trip on them and fall. So Janet, Molly, Janet's sister-in-law who was up visiting from Georgia, and I all crowded around the bed to try out this wondrous-sounding device. Well. It might have worked if the mattress weren't made out of lead bars. Seriously, it was quite possibly the heaviest mattress I have ever struggled with, and it was only a full-size bed! Anyway, Molly tried it a few different ways and finally decided sitting in a chair was the easiest way to use it, but she really had to lean into it and still could barely get the sheets tucked. Janet tried and made an I-give-up face after about ten seconds. Her sister-in-law gave it a whirl and was equally defeated. Janet pointed authoritatively at me, and I too gave it a shot. I did manage to get it to work, but I sounded like Hulk Hogan in the WWF World Championships. The noises that came out of me were anything but ladylike, and everyone had a good laugh over it before we sadly put the bed maker back in its box to return for a refund.
Client #3 was a gentleman who was actually more or less housebound and on oxygen. He had a long list of medical issues, most of which had been exacerbated by a stroke that had left him in a nursing home for months. He had been thrilled to finally come back home and even more thrilled when Molly started working with him about six weeks prior. Understandably, the man had been quite depressed at his feelings of neediness and helplessness. Molly gave him a whole series of strengthening exercises that he could do right in his bed, and as I watched, she had him work on rolling himself over so that his legs hung off the side of the bed, first on one side, and then the other. Then she even had him do it without using his arms to pull himself over. The man was so amazed and happy when he found that he could do it with just his core and lower extremities! It sounds like a small thing, but being able to get yourself to a seated position over the edge of the bed makes it so much easier to get into a wheelchair! And likewise, when you transfer out of the wheelchair and back into the bed, being able to swing your own legs over instead of having your grandson lift them makes a huge difference; it gives you some of your dignity and independence back.
Total time observed this session: 5 hours
Total time observed thus far: 20 hours, 10 minutes
I have so much more to report, but I'll have to come back later...
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