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...