Fingertips

Gross Stuff

It's day 3 of acute care physical therapy in a busy, regional, level-one trauma center hospital. We serve all of Alabama, east Mississippi, and the pan-handle of Florida. We are also a regional disaster center, meaning if some place in the southeast US is overwhelmed because of some type of disaster, we are prepared to take overflow patients in the event of a crisis.

Every hospital has emergency codes. The rehab hospital I had during my previous rotation had color-coded emergency codes. The University Hospital uses alphabetical codes. So, in the event of a disaster, we would be alerted with Code D. Of course, I had to crack up during the orientation tour, while being treated to the sights and smells of the hospital environment, my CI alerted me to a Code Brown. The smell of bowel movement wafted down the hall. I said, "Ah, that's nothing!" recalling a bowel accident that fouled half of the gymnasium one morning during in-patient rehab. "Well, I can see that we're not put off by smells," my CI observed.

In my short time here, I've been exposed to gangrenous toes, a fasciectomy, edematous scrotum, and weeping legs. When I attended lymph drainage therapy classes, I heard about people who had so much edema in their legs that it would literally ooze out of their skin. For that reason, therapists specializing in treating edema were discouraged from having treatment offices with carpeted floors. Thanks to the acute care setting, I have now witnessed this phenomenon.

Ah, bodily fluids -- so many opportunities to come in contact with it. Or step in it -- as with the previous example. Something else that's easy to step in is urine. PTs are often put in close proximity with what is known as the "dump zone." This presents a wonderful opportunity for a slip and fall hazard. Add to that scenario: contact precautions. Contact precautions are in place when a patient harbors bacteria or other infectious agents that can be contagious to others. Does custodial staff put anything in their mop water to neutralize bodily fluids that may carry MRSA, C diff, or VRE? I certainly hope so.

So what do I do with my shoes? I wish we had a trough we could walk through with a disinfecting agent, the way that cattle farms do when transporting steer from one barn to another. When I get home, I take my shoes off immediately. I'd leave them outside my door, if I thought they'd still be there in the morning. After this internship, maybe I'll just burn them.

A Sampling of Acute Care

It's day two of my acute care rotation. Today I went around with my clinical instructor and got a taste of what acute care practice is like. In acute care, we start off with a patient list and plan our day according to the rooms that are clustered together. The University Hospital consists of 4 or 5 building connected by above ground crosswalks (like Minneapolis!), at least 20 wards, and 900+ beds. It takes 15 minutes to get from one end of the hospital to the other.

Treating therapists rotate through 4 units -- Unit 1 or general surgery, which offers a variety of patient types from renal patients to plastic surgery patients to transplant patients. These patients offer the widest variety of conditions -- some are very sick and some are up and walking independently, having had relatively minor surgery compared to some others.

Unit 2 is neurology and cancer patients. These folks will include neuro-ICU, strokes, spinal cord injuries, brain tumor surgeries, and, of course, all kinds of cancer patients. Many of the cancer patients will be on contact precautions, not because they pose a threat to a healthy hospital environment, but because we pose an infection risk to them! Many cancer treatments create reduced immunity and put patients at risk for contracting all kinds of bugs that healthy individuals can usually avoid.

Unit 3 are the cardiac patients. Some in the department argue that cardiac patients are the most difficult to treat because they are seriously ill. Obviously heart attack patients end up here, but also patients with heart transplants, circulation problems and often lung problems because these systems are so closely intertwined.

Unit 4 is trauma and burns. UAB department of physical therapy is working with the University Hospital to research an early mobilization program for burn patients. Early results look promising. Of course, trauma also includes stabbings, gunshot wounds (we are in the inner city -- just watch First 48), and motor vehicle accidents.

Preparing For My Next Clinic

My next clinic starts Monday in acute care at our local University Hospital. Acute care means that I be working with people who have just come out of surgery or who are in one of the various Intensive Care Units (ICUs). What I know about this type of clinic setting is that I will learn a lot about medicine and that is interesting to me.

The importance of physical therapy during this time in a person's life is to prevent problems from occurring. Inactivity can lead to serious and life-threatening conditions such as deep vein thrombosis, embolism, and pneumonia. The other side effects of prolonged immobility include, but are not limited to, weakness, decreased tolerance for sitting or standing, tissue contracture, and other factors that can lead to functional limitations.

So I'm boning up on things that I may run into in this setting. For instance, heart and lung issues are big in this setting, so I'm reviewing cardiopulmonary techniques. Also, memorizing normal lab values will be helpful in having me spot abnormalities quickly. recognizing significant changes in EKG patterns will also help me to know when to ask for assistance or cease treatments such a walking.

I found a really good website from Brigham and Women's Hospital that has all kinds of physical therapy standards and protocols. I've focused on the in-patient standards of care to help me get an overview of the type of work I can expect to do. Of course, it's my responsibility to fill in the gaps (such as those lab values and being able to read EKGs), but the details will come with training.

I'm excited about this clinic. My previous exposure to this setting once a week during my first year of study left me fascinated and wanting to learn more. I am hoping that I discover that this setting may be the one where I want to practice.

Fix Common Postural Problems

The Columbia Daily Tribune, in Missouri, has a nice article called In Balance. Physical therapist, Jeff Bridges, and athletic trainer, Ryan Baird, agree that most that most postural problems occur due to muscle imbalances.

Common problems include rolled shoulders, toes that point too far out, and knee that track together when squatting. If these postural and strength problems are happening to you or your clients, this article gives you exercises with pictures and descriptors to help correct them.

Evaluation

Every semester at our clinical internship, we have mid-term and final evaluations. The APTA has developed an evaluation tool called the Web-CPI (Web clinical performance instrument) which both the student and clinical instructor must fill out in order to complete the course. It involves 18 items ranging from safety to communication and professionalism, to the five elements of patient/client management, to utilization of support staff.

It takes hours to fill out. That is, if you are thoughtful and thorough in your evaluation. Joy. Since my last day of clinic was this past Friday, I must finish this behemoth and meet with my clinical adviser so we can go over it together. I must also fill out an evaluation of clinical site itself, get signatures and turn a copy in to the school. As I write this post, I recognize that I'm procrastinating.

After this particular clinic, I'm so over paperwork. Most places are automated with computers to record documentation. My first clinic with the VA Hospital had computer documentation, and while it was time consuming, documentation was entered on a client, maximum 4 forms and we were done. At my most recent clinic, all documentation was written by hand on paper forms. I touched on this topic in my post about "A day in the life . . . ." Much of the information was recorded on several forms, making for redundant documentation that requires consistency (how many ways can a question be asked? -- this is the way they trap people in lies!) which is where computers excel. I actually have a list that is almost 2 pages long outlining all the documentation I need to handle on a patient at any given time during their stay at this facility.

Why do I mention all of this? If I'm evaluating the facility, "ridiculous amounts of documentation" is going to be one of the more critical items of feedback they are going to get from me.

Staying Focused

I stumbled upon this little piece from Massage Today about remaining focused.

When you notice that you lose focus or drift, quietly bring yourself back to what you are doing.

Being present was a message that was repeated frequently in massage school -- not a word of which was mentioned while I've been in PT school. Maybe there is an assumption that remaining focused and present is a requirement of a physical therapist. But I see a lot of needless chatter about personal lives and favorite college football teams. However, we are working with people, and we need to find a way to engage them. creating a rapport encourages cooperation and can pave the way for educating people about their health while they're being treated, an important aspect of physical therapy.

As a student, the demands of the job and the environment make focus incredibly difficult. There are time management and safety issues to keep in mind. Circumstances occur that require changes in treatment plans, and everything we observe must be documented accurately. Therapy interruptions such as meetings, phone calls, and peer interactions must all be juggled without losing focus about what your patient is doing. Treating multiple patients at a time requires switching your focus, while maintaining attention on what your patient that is not being attended to directly is doing, such as poor exercise form. These things all become second nature with experience.

So in massage school, twice a week we were on the tables practicing new techniques in a quiet environment where presence and mindfullness were encouraged. In PT school, bright lights, circulating assistants and lots of conversation were the norm. In the clinic, wide open spaces make for lots of activity, noise, and distractions to both the patient and the therapist. The focus there becomes blocking out distractions from outside of ourselves AND inside our heads.

Research Summary for My In-Service Presentation on Hip Replacement vs. Hip Resurfacing

Every semester, as part of my educational requirement, I have to ask a clinical question that related to the clinic setting that I am in and find research articles that answer that question. Following is my research question:

In patients with hip osteoarthritis, are there advantages in hip resurfacing compared to total hip replacement in terms of life of the appliance, surgical procedure, and rehabilitation time?

I have included my summary of the articles that I researched:

The demographics of patients who undergo hip replacement surgery are getting younger and more active than ever. These factors test the life of the appliances, increase the likelihood of revision surgery, and affect length of rehabilitation and final outcomes. More research is needed to compare the pros and cons of hip resurfacing and total hip replacement surgeries.

At Lakeshore, our patient population is generally elderly, often with comorbidities that compromise bone density. However, as the baby boom generation ages, more and more patients under age 65 arrive having had hip surgery and complicating comorbidities. As hip arthroplasty surgeries become more innovative, it is helpful to discern if these new procedures create advantages or change the way we rehabilitate patients of all ages.

References:

1. PA Vendittoli, M Lavigne, J Girard, AG Roy. A randomised study comparing resection of acetabular bone at resurfacing and total hip replacement. J Bone Joint Surg. 2006;88-B:(8):997-1002.
2. Cooke NJ, Rodgers L, Rawlings D, McCaskie AW, Holland JP. Bone density of the femoral neck following Birmingham hip resurfacing: A 2-year prospective study in 27 hips. Acta Orthopaedica. 2009;80:(6):660–665.
3. Nantel J, Termoz N, Vendittoli PA, Lavigne M, Prince F. Gait Patterns After Total Hip Arthroplasty and Surface Replacement Arthroplasty. Arch Phys Med Rehabil. 2009;90: 463-469.

My In-Service Presentation - Hip Replacement vs. Hip Resurfacing

Every semester, as part of my educational requirement, I have to ask a clinical question that related to the clinic setting that I am in and find research articles that answer that question. Following is my research question: In patients with hip osteoarthritis, are there advantages in hip resurfacing compared to total hip replacement in terms of life of the appliance, surgical procedure, and rehabilitation time?

I found three papers to critique on the topic. One contrasts the two surgeries, titled: A randomised study comparing resection of acetabular bone at resurfacing and total hip replacement. Another discusses bone density following hip resurfacing surgery, titled: Bone density of the femoral neck following Birmingham hip resurfacing: A 2-year prospective study in 27 hips. Another discusses quality of bone following the surgery, titled: Xxxx. And the final paper compares gait patterns in both patient populations, titled: Gait Patterns After Total Hip Arthroplasty and Surface Replacement Arthroplasty.

After critiquing the articles, I had to write a summary paper for my two of my classmates and one instructor to read and give feedback. Following corrections to my summary, I am to put together a presentation and convene an in-service meeting discussing the topic for the therapist who work at my clinic. This topic requires finding information over and above the research studies, because appliance life and rehabilitation time have not been compared in a research study. Following this in-service presentation, the clinic gets to keep a copy of my work for their resource library.

Wish me luck, my presentation is today. Hope the AV equipment works so I can show my PowerPoint presentation!

Inexpensive Massage Music

When I was a practicing massage therapist, I kept a stack of CDs in my office to play during my sessions. There were a handful of soft rock popular albums, several new age music albums, but the majority of my massage music collection consisted of classical music. Mozart, Bach, and others provided the backgound music for my clients to relax, and rarely got in the way of my own critical thinking while planning the treatment.

These days, as CD sales drop and digital music becomes the standard, many therapists are using their iPods and other digital music players to provide the soundtrack to their sessions. The advantages are many: ecological savings (no packaging), size (thousands of songs in a package smaller than a CD case), and customizable,. on-the-go playlists.

My husband is a big music fan (you can tell from his music & literature blog), and is always looking for a bargain. Lately he pointed out Amazon MP3, and the music bargains they offer, including:

Free albums: Amazon MP3 offers over 120 free album downloads, several classical albums.

Free songs: Amazon MP3 offers over 1,900 free song downloads.

Over 1,000 MP3 albums for only $5: These include 100 classical albums.

Daily and weekly specials:

Including:

The 99 Most Essential Haydn Masterpieces for $2.99
The 99 Most Essential Mendelssohn Masterpieces
More classical bestsellers

I like Amazon MP3 because I can play short snippets and test-drive the music before I download it. The free compilations are also wonderful ways to discover new music, both for your practice and your free time.

Of course, burrowing through these offerings can seem daunting, but a little time could help you save a fortune in building you massage practice music library.

A Day In The Life Of A Physical Therapy Student

At the rehabilitation hospital where I am currently doing my clinical internship, patients must be well enough to withstand 3 or more full hours of therapy a day. The goal for the patients is to be seen by physical therapy for an hour and a half, and an occupational therapy for an hour and a half. Also, patients may go to speech therapy for a half hour to an hour and music therapy for a half hour, if they qualify for it. To qualify for these therapies, the patient usually has experienced a stroke or a brain injury. If a patient does not qualify for speech and music therapy, they are assigned to group therapy. During the patient's first week at the hospital, if they assigned to group therapy, they will rotate, learning about energy conservation techniques, wheelchair mobility, and upper and lower body strengthening. During their subsequent time at the hospital patients may be assigned to exercise to music, upper extremity strengthening, lower extremity strengthening, or pulmonary group depending upon which is most appropriate for them.

For physical therapists, our day starts at 8:00 am, and we generally are expected to see six patients a day. We treat two patients at a time. Therapy sessions start at 8:30 am, 10:00 am, and the two afternoon patients are staggered, starting at 1:00 and 1:30 pm. We treat for 1-1/2 hours or 6 15 minute increments or "units." Holes in the schedule are 8-8:30, 11:30-12, and 3-3:30 (unless it's our day to lead a group therapy). These "holes" are opportunities for documentation, making up missed units, or tying up loose ends from the previous day or planning the upcoming day. 3:30-4:30 is set aside for evaluations and the obligatory documentation that goes with them.

As part of our daily treatment plan, we choose an activity based upon a functional goal such as walking. These activities take more time for some patients than others, for example, exercise therapy for a high functioning patient may only take 1 unit whereas it may take 2 units for a more debilitated patient. Sounds straight forward enough.

But when treating two patients, their differing level of function dictates how much one-on-one time the therapist needs to spend with them doing skilled therapy. A low-functioning patient may take 15 minutes to transfer from their wheelchair to a mat in order to perform exercise therapy. What do you do with your high-functioning patient when that is happening? A patient needs gait training; what do you do with a low-functioning patient needs to practice sit to stand? The services of an aide or tech is warranted here, but in order for services to be billable, the therapist must be careful what they ask the tech to do. A Hoyer lift transfer performed by a tech is not billable, but keeping the patient on track for their exercise program is billable, because the therapist created the exercise plan.

Twelve weeks is plenty of time to get this juggling act down. However, there are other tasks we are expected to perform and these responsibilities alter our treatment plan. A list of these other of these include new patient evaluations, patient discharges, equipment ordering, family education, functional status updates, weekly staffing meetings for each patient, group assignments, and, on Fridays, preparing weekend treatment assignments. For each of these responsibilities documentation is required which can number anywhere from 1 to 9 different forms that must be filled out or updated. None of this paperwork is computerized.

Remember those "holes" in our schedule that I mentioned earlier -- this list gives you an idea of they types of things we may do to fill those times. To throw a monkey wrench into the works, family education takes 45 minutes or 3 units during a patient's treatment time to discuss the patients functional abilities, safety and equipment issues, and discharge setting. During this time, we must figure out how to treat our other patient and meet their goals during the time we spend with family education. Four days per week staffing meetings with an interdisciplinary team interrupt our treatment flow. These meetings take anywhere from 3 to 10 minutes and are usually an opportunity for a patient to take a rest break. Problems arise when you have cognitively impaired patients on wander guard who need constant attendance if they are left alone, impulsive, and do not want to cooperate with application of a pelvic restraint belt in their wheelchair.

Amid the noise and chaos, the phone rings, faxes need to be sent. Patients may leave their gait belt, their glasses, their grippy socks, orthosis (or you name it) up in their room and you cannot work without it. Vendors cannot locate the needed equipment, or insurance does not cover products from a particular company and the hunt is on to find a compatible source. Communication is essential between professionals and must occur with patient privacy and HIPAA laws observed. Patients miss units because they come down from their room late, they feel sick, or they need to be changed due to an incontinence episode. Some are confused or belligerent, most are sweet. Nearly all have issues surrounding cognition and those that don't have serious co-morbidities to account for. Safety is paramount and the most amazing things that we take for granted can become a serious hazard to a patient who at risk for falling or is cognitively impaired.

It's easy to feel overwhelmed. I have 2-1/2 weeks left. I will make it through this clinic. Maybe, after many years of experience, I will feel compelled to challenge myself with a neuro-rehabilitation setting. However, after this experience, I believe that this is probably not the area for me.

This Week's Health-Related DVDs - August 3rd, 2010

Finally, there are enough health-related DVD releases this week to warrant a post.

If the weather in your city is anything like mine (95+ degree highs for the past two weeks, and at least a week more of this heat spell), exercising indoors is the best option, and utilizing DVDs and videos is a great way to add variety to your fitness regimen.

This week two DVDs are especially impressive, Yoga Emergency The 12 Minute Workout: Arms & Shoulders and Yoga Emergency The 12 Minute Workout: Back. Both utilize a short yoga routine to combat pain and soreness in specific areas, arms & shoulders and the back respectively. I have long been intrigued by the use of yoga as both an exercise and treatment tool, and am looking forward to checking out these videos.

The week's other exercise DVDs are a bit more mainstream, but could be useful nonetheless, especially the popular Leslie Sansone: Walk Off 10 Pounds and another yoga video, Tara Stiles - Yoga Anywhere: The New York Sessions

What new health-related releases are you picking up or adding to your Netflix queue this week?

This week's health-related DVD releases:

also at Fingertips:

other health-related DVD release lists

Physical Therapy and Cognitive Impairment

One of the most challenging aspect of my clinical internship this semester is working with patients who are cognitively impaired. Different kinds of brain injuries, such as stroke, yield different challenges to communication. Aphasia is an acquired communication disorder that impairs a person's ability to process language, but does not affect intelligence.

One type of aphasia is called receptive aphasia which affects a patient's ability to understand what is being told to them, as though everyone and everything around them is suddenly in a foreign language. They can speak, but what they produce is called "word salad," a combination of words that do not make any sense. When a patient has expressive aphasia, they can understand most of what is being said to them, but they may not be able to talk at all. Verbal apraxia is a type of speech difficulty where a person knows what they want to say, but they have little or no control over the muscles needed to form words. It must be horribly frustrating for them, and that's just the communication aspect of cognitive impairment.

Inattention and motivation are other aspects of cognitive impairment that challenge the therapist. The frontal lobe of the brain, the big part found in humans, is in charge of executive function, motor planning, and, in part, personality. The closer you get to the center of the brain and the brain stem, the more basic the functions, such as breathing, basic emotions, and motivation which is linked to neurotransmitters and brain chemicals like dopamine and endorphins.

Lack of dopamine, implicated in Parkinson's disease, is causes slow movements, tremors, freezing, dementia, rigid muscles, loss of automatic movement, speech changes, and impaired balance and posture. It's important to know when working with Parkinson's patients that simple, one-word commands, usually helpful when working with cognitively impaired patients, can cause freezing.

I tend to take the polite tack when working with people. So I ask them, "Can you pick up your leg (or would you like to walk, or whatever)?" This usually elicits an "I can't" response from patients. So I've had to learn to get a little bossy. "Let's walk," I say, and, voila, they walk. If you ask someone to think about what is automatic, they may not be able to perform automatic movements that they've been doing all their life. Parkinson's patients require less staccato commands to prevent freezing episodes, such as, "Why don't we take a walk?" in order to tap into those automatic movements. This is not something I likely would have remembered in the classroom discussing theory, which is the purpose of clinical education.

Top Massage Blogs

Fingertips is listed on this list of the top massage blogs.

Check out the other sites listed, the list is a great resource not only for massage therapy and building a massage practice, but also for general health information.

Even though I blog more these days about general health issues and my studies in physical therapy, I continue to keep my eyes open to massage news. You never know what bodywork techniques may come ion handy in physical therapy as well as massage therapy.

Medical Graphic Novels

The Guardian Science Blog shares a list of its favorite medical graphic novels, and discusses medicine in comics in another article.

A couple of weeks ago, my husband shared a list of books he recommends to healthcare workers, and one of two books appear on both his list and that of the Guardian, David B.'s Epileptic and David Small's Stitches.

I have just started Epileptic, and find it an incredibly visual perspective of living with a sibling who has epilepsy. I was riveted by Stitches. The book is much more than a medical history, and Small's portrayal of his own personal history in words and pictures captures his life perfectly.

Aside from newspaper comic strips, I have to admit rarely reading comics as an adult. When my husband started discovering graphic novels, he would occasionally share ones he though I might like. Comics deliver their content both visually and verbally, and can be effective tools to learn about health issues, especially from the perspective of the patient.

Continuous Passive Motion

I've learned how to use a nifty machine. It's called a continuous passive motion machine. The purpose of this machine is to help prevent the knee joint from becoming stiff and develop scar tissue following surgery. I've seen these machines used on people who have had knee replacement surgeries and they are also used for people who have had ACL repairs.

Studies show that the use of continuous passive motion in the first days and weeks following surgery improve range and help reduce scarring (and conceivably, pain) during early healing. However, after about six weeks, it shows no advantages in knee range of motion over never having had it.

How do we use it? As PT we use a goniometer to measure the angles of the knee in extension (when the leg is straight) and flexion (when the knee is bent). So a patient may lack 15 degrees of extension, which means they are 15 degrees away from having their leg fully straight (0 degrees). And they may only have 55 degrees of flexion (90 degrees is what we look like when we sit in a chair).

So I get the patient set up in the machine and see how far they can straighten and bend their knee with the machine helping them. We want the patient to feel challenged, but no so far into discomfort that it would prevent them from sleeping. So I may start with 0 degrees to 75 degrees -- definitely a challenge! Then I watch their face and eyes closely as the machine tests their end range. Basically, they say "Uncle!" and we back the machine off 2 to 3 degrees on either end of the range. Then we run the machine through several cycles of movement making sure the patient can tolerate it.

Ideally, at patient should be able to increase their range on the machine 2 to 3 degrees every 2 days or so. Some people progress faster. Some people progress slower. Patients who opt for joint replacement surgeries have been in pain for a long time. Folks have good days and bad days. Generally they know they have a rough road ahead, but are motivated to work through the pain in order to get to the long await reward of getting back to living their life.

"Tender" days are ones where a patient's pain does not seem as well controlled. On these days, we still push them in therapy, but as therapists, we need to recognize their limits so as not to break their spirit, or encourage them to holler stop prematurely as a protective mechanism from pain, which would serve to rob them of valuable therapy. This requires trust which comes from doing what you say you are going to do. It's also important to engage the patient actively in the movement which, while painful, encourages them to take some control of the pain.