Would a splint be contraindicated in this case?

We all know that one of the purposes of splinting by occupational therapists is for joint protection and to preserve function and range of motion.  I have blogged before about my experience with fabricating below knee amputation (BKA) splints, used to preserve knee extension for being able to fit orthoses at a later date.

Sometimes, however, I wonder if a patient really needs the splint.  For example, I once had a 85 year old patient who had severe Alzheimer’s dementia, was completely bedbound at a nursing home at baseline and had a BKA due to gangrene.  While normally I would make a splint, I wasn’t sure that it was indicated in this case.

First, the patient was bedbound at baseline, and therefore an unlikely canditate for a prosthetic.  Second, a patient is very likely to develop skin breakdown and sores from a splint if the splint schedule isn’t adhered to, or frequently monitored.  Third, splints aren’t generally the most comfortable things.

Providing a splint would not increase or improve quality of life, and so it would seem to me that a splint would not be indicated in this case for the reasons listed above.  What are your thoughts?

Can a family be too involved?

One thing that I have always observed while working in the hospital setting is that the patients who have family and friends that come to visit tend to fare better when it comes to physical rehabilitation and overall attitude towards the outcome.  They are better able to laugh through their hospital stay and they have a strong support system.  The patients who are alone during their entire hospital stay tend to be more depressed, less motivated to participate in therapy, and have a poorer affect.

As a result, I have always advocated that when possible, patients should encourage family and friends to visit.  I recently had a situation where I questioned this for the first time.  The patient was an older person who was completely independent with all her activities of daily living and participating in the community.  She suffered a fall, fracturing some bones and having aches all over.

Once stable, therapy was called in to see the patient.  On a typical patient, we would normally ask if the patient would be willing to get up, and work towards getting her out of bed and to a chair, at least for the first time in therapy.  Patients usually complain of pain, but we try to coordinate with the nursing staff so that the patients can be fully medicated and ready to go.  Usually, this is enough, and we can proceed with therapy.

However, with this patient, we saw that there would be problems from the start.  Upon arrival, the patient’s son was in the room.  Right away, he told us that she was sleeping and that he doesn’t think she should have therapy so that she could rest.  If a patient is alert and oriented, I like to at least ask the patient their opinion on participating in therapy, which is what I did.  The patient was quick to say that she would welcome sitting at the edge of the bed, so I’m happy I asked.

Then, when approaching the bed and reaching out to shake her hand and introduce myself, the son audibly gasped, worried that my touch would cause more pain.  This went on throughout the entire 40-minute long evaluation.  Any time I touched the patient in any way, the son could be seen and heard wincing and gasping, as if my touching the patient was actually hurting him!

Now as an aside, I completely empathize with the son, and I fully understand that his mom is in pain.  I could not even begin to imagine what it would be like if that were my own mother.  However, the son took this to an extreme that I had never seen before.

In moving the head of the bed upwards, the son demanded that we be “gentle” several times.  Unfortunately, there is no gentle button, just an up and down button, but I managed to get the head of the bed situated in a way that was agreeable to everyone.  Before removing the patients waffle boots (used to prevent heel sores), the son made us wait and ask the patient to make sure that it was ok to remove them, as her legs were very sore.

With literally every single movement, the son was involved, asking his mom to tell us to stop when it became too much.  To get to the edge of the bed, we have to move one leg, then the other, adjust the shoulders and hips, move both legs again, adjust the shoulders and hips, sit her forward, etc. until she can sit at the edge of bed appropriately.  Even then, we had to manage her sitting balance and control her dangling legs.  Imagine for a moment getting stopped by the family member for each and every single one of those movements!  I’m honestly quite surprised that we completed the evaluation in only 40 minutes.  We had to reassure the son over and over again that we were being as gentle as possible, explaining exactly what we were doing, and why we were doing it.

Take note that I have spent most of this post discussing the son, and not the patient.  When a family member gets so involved that we can barely pay attention to the patient, I think that there is something wrong.  When the son asks the patient repeatedly to tell therapy to stop if it becomes too painful is absolutely detrimental to the patients ability to recuperate.  Patients need to be encouraged to do more so that they can get stronger and healthier.

Once again, I empathize with the son and I think he is the greatest son a mother could have for his ability to be at her bedside throughout the day and worry about her.  But there comes a time when it can be too much.  I had actually heard rumors that when the patient was in the ICU (where they have very specific visiting hours), the patients heart rate and blood pressure was noted to be higher when family members were present!  So, while I normally advoate for patients to welcome family members and friends to visit, I also think that there is a time when they need to step back and let the patient get therapy so that they can get well and go back to being independent.

Fundamentals of Clinical Instruction

One of the great things about the place I work is the fact that we have a vast amount of opportunities to attend inservices and continuing education classes.  A class I recently attended that was put together by therapists at the hospitals was regarding clinical instruction, and how to be a fieldwork educator.

The class was broken up into two parts.  The first part was just with the occupational therapists, and laws and regulations related specifically to occupational therapy were discussed.  The second part went over how students learn, various learning methods, and how to handle the problem and exceptional student.

Hearing about ways of handling the problem student was especially interesting, as we got to hear stories about various students who did all sorts of things that I could never imagine doing myself as a student.  But we also got to hear about some creative ways of working with students who have a hard time with certain skill sets.

For example, if the clinical instructor (CI) sees that the student has a hard time managing the patient and the IV pole at the same time, the CI should attach a blood pressure cuff to his arm, and use the vitals machine as the IV pole.  A clean chest tube drain can be used a Foley catheter.

Overall, it was a great class, and it was nice to see that my hospital takes teaching students so seriously.  At any given time, there are always at least two students somewhere in the hospital, whether it is a phsyical therapy student, occupational therapy student, or a speech-language pathology student.  While I did already have a Level I student, I hope to soon be able to take a Level II student and use some of the principles I learned in this class.

Celebrating Occupational Therapy month

This year, I joined the OT Month Committee at my hospital to see what kind of ideas we could come up with to spread the word about OT. In past years, we had a booth set up near the cafeteria, but few people stopped to look at what was being presented at the booth. Since we wanted to reach out to a larger group of people, we decided to send out an all-user email.

In the email, we talked about how April is occupational therapy month and we had a link to an online quiz inviting people to test their knowledge about occupational therapy. Additionally, we offered a $20 giftcard as an incentive for people to take the quiz.

I was pleasantly surprised to see that a total of 67 people had successfully completed the quiz! There were plenty of wrong answers, but the fact that people took the time to try the quiz shows that we helped spread the word. As an added fun tidbit, one of the questions we asked was for people to name an occupational therapist that they knew. Many people left that last question blank, but it was interesting to see which therapists got mentioned.

Here are the questions from the quiz:

Splints I have Fabricated

Here’s a list of some of the splints I have either fabricated myself or got assistance in fabricating:

• Several below knee amputation splints
• Resting hand splints (actually, these are pre-fabricated)
• Humeral fracture brace (two pieces; protects the humerus from getting bumped by others; limits some shoulder range of motion if the doctor chooses)
• Several posterior gutter splints (usually for protection of an elbow status post ORIF; often, the splint starts along the forearm and extends down to the carpals)
• Yesterday, I helped with two splints (both on the same person, one for each hand): Ulnar gutter splint that involved providing slight MCP flexion for the 4th and 5th digits; and a resting hand splint that only provided ‘rest’ for the index finger through the MCP, but allowed for free range of motion of the PIP and DIP, and the rest of the fingers.

Sometimes the orders can be very complicated and specific, such as the ones highlighted in the last bullet above.  But I really enjoy making the splints, and am more and more strongly considering to specialize in splinting.

Acute Care is Intense

I started working in acute care as a student on my Level II fieldwork, so I never realized just how intensive it can be. I recently had a friend of mine who is an OT express interest in working in acute care. She wanted to follow me for a few hours to see how my day was.

Here is how I do a typical chart review before seeing a patient for the first time:

• Go on the computer
  • Check out the therapy orders, as well as their activity orders (out of bed, ambulate with assistive device, etc.) I also check what other services have been consulted. Is physical therapy on board? Social work? Rehabilitation? etc.
  • See what diagnostic tests have been ordered. A CT scan of the thorax may be ordered to rule out pulmonary emboli, ultrasound may be ordered to rule out DVT, x-ray to rule out fracture, etc.
  • Check on specific patient care orders – do they need a brace when out of bed? how many liters of oxygen should they be on?
  • Patient alerts – What kind of precautions are they on? Contact isolation? Are they on aspiration, neutropenic, or seizure precautions?
  • Diet – Are they NPO?  Stage I, II, III, or IV diet?  Knowing a patient’s diet can help with the education part of what they can and cannot do in the hospital
  • Code status – Are they DNR? Some patients have specific instructions as to whether or not they can be intubated
  • Lab values – The most common things I look for are hematocrit, hemoglobin, potassium, sodium, creatinine, PT/INR. Are the lab values high? low? Which way are they trending? All these are factors into whether or not a patient should be on hold. For example, if a patient has a hemoglobin of 7.5 and a hematocrit of 22.6, I would probably not see the patient, since they are below critical and are probably going to be too weak to see me anyway.
  • Vital signs – Check the latest blood pressure readings, heart rate, temperature, and sometimes the respiratory rate.
• Next, I check the physical chart:
  • I first go through the History of Present Illness section to see what led up to the hospitalization. Often times, I’ll find most of the patient’s past medical history.
  • Then, I check the consultation section to see what medical services have looked at the patient. This can include Medicine, Neurology, Orthopedics, Nephrology, Infectious Disease, Oncology, Cardiology, Pulmonary, and more. This section helps give a nice, complete picture of what is going on with the patient.
  • Next, I look throughout all the notes that everyone wrote. This includes mostly nursing notes, but also notes from doctors and from any of the above mentioned services giving updates. You see a progression of status as you read the notes.

I am only comfortable going into a patients room when I’m done looking up everything mentioned above. And now that I typed it all up, I can see why my friend who was shadowing for a few hours was so overwhelmed when she left! Working in acute care is intense; there is no question about it. But since I was brought in as a student and learned things slowly at a pace that a student would learn, I have no problem doing it today.

One of the great things with acute care (which others may specifically not like) is the fast pace. Going in to work, you never know who your new patients will be, making each and every day very unique. Often times, there are lots of new evaluations that need to be completed, so just the rush of trying to get everyone done makes the day go by very fast.

Acute care is definitely not for everyone, but if you can handle some of the minor stresses and be willing to learn a LOT about anything medical related, then it is for you!

Open Heart Surgery

I really want to see an open heart surgery. Until that happens, I’ll have to be happy with treating patients that have had open heart surgery; the most common of which I see is coronary artery bypass grafts (CABG).

Patients undergoing CABG usually have complicated heart problems and arteries that are blocked. The procedure basically reroutes some of the blood vessels, thus enabling better blood flow to the heart. Chest pain is also reduced.

As occupational therapists, one of the big things we do with open heart patients is review sternal precautions (I just wrote that paragraph on the precautions for this blog post – yay for Wikipedia!). It is amazing how people are so different in this area. For some people, after hearing the precautions once, they automatically start following the precautions with no difficulty. These patients tend to recover much more quickly than patients who do not (that isn’t scientific, just something I’ve picked up on. Then, there are patients who no matter how many times you go over the precautions, they still don’t follow them. It can be very frustrating at times.

While writing this, I was struck by an interesting thought. When working with hip replacements, I almost never have a problem with people not following their precautions. I have the most difficulty with sternal precautions. People with spinal precautions tend to be very good about their precautions, unless they’ve had a minor spinal surgery, such as a laminectomy. If I had to guess, I’d say the reason is that with hip and spine surgeries, doing the things that you’re not supposed to do directly impacts the joint/vertebrae, and is therefore a lot more painful, which is why they usually adhere to the precautions. However, with sternal precautions, patients do not necessarily feel anything wrong with what they are doing, so they’ll be more likely to not adhere to the precautions.

Addendum: Here is the paragraph I wrote on Wikipedia:

Patients undergoing coronary artery bypass surgery will have to avoid certain things to avoid opening the incision. These are called sternal precautions. First, patients need to avoid using their arms excessively, such as pushing themselves out of a chair or reaching back before sitting down. To avoid this, patients are encouraged to build up momentum by rocking several times in their chair before standing up. Second, patients should avoid lifting anything in excess of 5-10 pounds. A gallon of milk weighs approximately 8.5 pounds, and is a good reference point for weight limitations. Finally, patients should avoid overhead activities with their hands, such as reaching for sweaters from the top shelf of a closet or reaching for plates or cups from the cupboard.

Working with comatose patients

Luckily, I don’t work with too many patients who are comatose, but I’ve had weeks where I will suddenly see 3 or 4 patients in one week who are comatose. This usually happens because the patient is for the most part medically stable, and they now need placement. Most facilities won’t accept patients without having some sort of level of care, so they call upon the therapists to determine what the patients can and cannot do.

What I find interesting is that for the most part, the exact same evaluation will take place from OT, PT, and SLP. My hospital seems to favor the JFK Coma Recovery Scale, and both the OTs and PTs use the scale as their evaluation. What ends up happening is that we both do the exact same thing based on the exact same scale, yet bill differently. And Medicare accepts this. If the patient was not comatose, Medicare would never pay for two disciplines to do the exact same thing. Go figure.

When the patient is comatose, it is obviously hard to complete ADLs, but we end up usually seeing what stimuli work to arouse the patient. Can the patient follow a 1-step command consistently (i.e. give a thumbs up)? Do they respond to pain? The link to the scale is here (pdf) and is for the most part self-explanatory, should you want to know more information.

Working with Doctors

I recently had an interaction with a doctor that I wanted to share, as I think that it is important to understand our own role and how we need to educate and interact with doctors.

• I was getting ready to see a patient, but noticed that in the OT orders (everything is on the computer), the order said that the patient was on bedrest. I couldn’t find anything in the chart that would indicate why the patient was on bedrest. Usually, it is obvious; they’re being ruled out for DVT or PE, they’re scheduled to go to the OR, etc. But for this patient, I could not find any reason in the chart as to why the patient was on bedrest, and the nurse herself couldn’t figure it out. Finally, after a half an hour of trying to figure this out, I was able to track down the doctor who had put in the order. Turns out, she was in a lot of pain, and he figured it would hurt even more to get out of bed, so he ordered bedrest. In my mind, I was thinking that if every single patient we saw was put on bedrest because of some pain, I wouldn’t have a job as every one of my patients would be on bedrest. Instead, I had to explain to the doctor that as therapists, it is our job to get them out of bed and be able to work through their pain to be able to ambulate and complete their ADLs. I went on to explain that when we see an order for bedrest, the therapists don’t touch the patient. Needless to say, the doctor was a new grad, but I was happy that I was able to educate and explain our role as therapists. Combined with the fact that I did it nicely, the doctor didn’t feel insulted, and he even asked a few further questions regarding our role.

Identifying Yourself

It is important to always properly identify to your patients who you are, what your role is in the therapeutic process, and what you plan on doing during that treatment session. Sometimes, however, that just isn’t enough.

I am taking a graduate elective that allows me to have 60 hours of extra clinical time so that I can further gain experience in the setting of my choosing before graduating. I have liked acute care for a while now, and I therefore decided to do another clinical in acute care.

My last day was earlier this week. We went in to see an 80+ year old lady who had been admitted for CHF and also had a diagnosis of dementia. While the patient agreed to let me treat her by walking from her bed to the bathroom to do a toilet transfer, she kept asking me over and over again why I was doing this “procedure.” I explained each time that the doctors wanted to know how safe she was so that she could go home. However, no matter how many times I explained it, she kept asking me about the procedure. Before leaving, she asked that we come back so that we could speak to her daughters.

A few hours later, we went back to her room as requested, and her daughters were now there. Turns out that since I wasn’t wearing a formal identification from the hospital (because I was only there for 60 hours), she thought I was someone from some random nursing home. She was afraid that I was assessing her for a nursing home. No matter how many times I told her that we were occupational therapists, she was still worried.

So even if you identify yourself as an occupational therapist, that isn’t always enough. I think it was great that the patient was cognizant of the fact that all hospital employees should have identification, and that she realized that I wasn’t wearing a hospital ID.