blind leading the blind

We made a train leading to the therapy gym. In front was Mrs. C in her wheelchair, I was pushing her, followed by her son who held onto the walker I held out behind me as a guide for him. Mrs. C is 84 and was admitted for a COPD exacerbation. Today our treatment focused on training her son to be her 24 hr caregiver/supervisor. She needs help to stand, walk, and transfer and will be returning home on oxygen. Her son is blind. I didn't ask how he began blind as I wasn't there to begin treating him too and I knew that asking probing questions would inevitably lead to that. Again, my purpose today was to train her son how to safely assist Mrs. C from the wheelchair to the commode over the toilet. He passed the test, even when I tripped her to see how he'd react to a near fall. He'll be back Monday and all of next week to continue training. Amazing to imagine what some people are dealing with out there! But somehow they survive and hopefully this pair of blind leading the blind- will make it happen.

splitting time

One of the greatest things about where I work is that every 4 months we rotate units. This keeps me from getting too comfortable anywhere. Just when you've figured out where the extra oxygen tanks are kept and which nursing aide to approach with a "messy" situation, you're packing up and moving on. This also keeps our clinical skills sharp. Just when you're burnt out on the neuro unit, you switch gears to hips, knees, or COPDs.

By now I've rotated through every unit, seen it all. So I opted to be the "splitter", working half the day at the main hospital and half the day at our sattelight unit at a hospital in Dorchester. I don't really have my own caseload, I basically do evals or cover patients when their primary therapist is off or unavailable. And while it can get crazy seeing over 50 different patients a week, it has it's benefits... you don't have to do as much treatment planning, following up with surgeons you can never get a hold of, or go home thinking worrying about that patient you've been treating for the last 3 months. It's a breathe of fresh air. Instead of jumping in the deep end with a few patients, I'm just wading up to my knees with a couple dozen. This may free up some energy to put into some other areas... writing and research! Stay tuned...

weighing in on the healthcare debate

work has been very stressful lately. it's feeling like, well, work. and here in lies the problem with healthcare. it's people's work, jobs, and it's a business. i make a salary based on treating the sick. if there were no sick people, i wouldn't be employed. recently we've been having meetings regarding how to increase our productivity, as an outside company audited our hospital staffing and determined that our department was overstaffed by 3. HA! and here we are working through lunch, unpaid overtime, and have a waiting list to see patients. Yet, the physical therapy department was quoted as being accurately staffed, even though they have 3 additional positions than OT. How can this be?

Well, the auditors looked at units billed. A unit represents 15 minutes of treatment. Not time spent educating, talking with families, or whipping up some crazy piece of adaptive equipment. During those 15 minutes the patient must be participating in an activity. A lot of time is not billable. And it's often during that time that I feel like I'm doing my best work. We don't get paid to think. Only to do.

Doctors work on the same payment system, it's called fee for service. They are paid by how many tests and procedures performed. So guess what the incentive is? Treat more, do more. Quantity, not quality is rewarded. Even if the time and energy might be better spent sitting with a patient and family and discussing the patient's risks for surgery or plans for end of life care. Until the reimbursement system is redesigned, our country is not likely to get any healthier.

OPA!

"Opa. Opa. Opa!" we chanted together moving from lying down to sitting at the edge of the bed. Mr. B moved here from Greece when he was 22 and found a job working in construction. His high school sweetheart followed him out here. They married, had 3 children- all now working as lawyers, married, with their own children. They all still speak Greek.

"Borro!" was his other mantra through therapy. His wife told me it meant to persist, to hope. After his stroke, Mr. P lost the ability to understand language and verbalize. Yet, he was able to speak these 2 words in greek and he never lost his ability to connect with people. His eyes were able to communicate exactly what his mouth could not say. He wanted to try.

And try we did... I'd be with him 2xday for 30-45minutes each working on sitting, standing- learning to move in his new half-paralyzed body. We also tried to manage his severe pain and tone (spasticity) developing in his right upper extremity. Some days I would just look at him and want to cry, but then he would remind me, "OPA! Borro!"

"She can't go!"

"I will not let an insurance company dictate how well my wife recovers from this stroke! I'll sell the car, my house... I don't care what it takes, she's not leaving here to go to some nursing home where she'll get a measley 2 hours of medicore therapy at best!" Mr. B's rage left me shaking. My head spinning in the emotional storm but also left me struggling to grip on to some sense of truth. Who or what's to blame here? America's disconnected healthcare system? The patient and husband for having her hypertension go untreated for 10 years? The insurance company who's insisting she move on?

Her husband is there every morning before we get in and at night he leaves after she falls asleep. They are living the words they said to each other 40 years ago, "For better or worse, In sickness and in health." But could his emotional response be clouding his judgement? Is it clouding mine?

What really is the best solution? Allow her to move through the continuum of care, moving down to a less expensive, less intense rehab facility. Perhaps she'll continue to progress at a SNF and eventually be able to go home. But what if she doesn't? After 6 weeks of steady progress with us, what if she starts regressing somewhere else? What if she never makes it home? Wouldn't that be more expensive for the insurance company?

all in a days work

work can appear so random at times, for instance... today I helped someone get dressed, taught someone learn how to use a cell phone, cooked rice and beans aruban style, and gave a massage. And that's all in between reading charts, lab values, chasing down doctors, and speaking with family members about their loved ones. Man, no wonder why I'm exhausted at the end of the day!

can't fix 'em all

It's difficult to accept, but true. I'm not a super healer. I can't make it all better for everyone. Not to say that this was ever my assumption, but some days it's just more apparent than others. Like today, the look on Mrs.'s P's face said it all. Her husband sits in his hospital bed staring out the window to the right, unaware of the left side of the room. He needs two people to help him with washing in bed, someone to clean up his bottom several times a day as he cannot control his bowels, and someone to feed him. His mind is clear, he knows and is able to say where he is and what time it is. He knows he's impaired, but wants to get home so he can help his wife. He's concerned about her, asking her "Who's helping you take out the trash? I gotta get home so I can help you with the bills." She's called asking her husband for directions to her doctors office. They have no children and few friends have come to visit or show support. All they seem to have is each other and I'm witnessing the slow painful awakening that their lives are completely changed. I want to do more. I want to make it all better.

goodnight moon

She started crying sitting at the edge of the bed combing her hair. I sat next to her, hiding my own tears. Such a simple task, now such an achievement. No one would have imagined this 38 year old woman's life being turned upside down the way it has been over the last two months. On January 18th 2009, she gave birth to her second child, a perfectly healthy baby boy. Then after two weeks of being home with her growing family, she started to not feel well. Her doctor recommended that she go to the hospital, just to get checked out. A few days later she was comatose, vented, on dialysis, and receiving final blessings from family and friends as she went into multi-organ failure due to a pneumonia and sepsis.

After swift medical interventions including a course of IV antibiotics, she began winning the uphill battle- her lungs and kidneys returned to function and she became stable enough to be transfered to our hospital for rehabilitation. Initially she needed all of our help to bring her sitting to the edge of the bed, the next day she needed half help, and by day 3 she was sitting up on her own! Sure signs of her body's resiliency, but emotionally she was struggling. Imagine being away from your newborn for over one month!

So we began the "books on tape" project, (can't take credit for this one, thanks Colleen!), voice recording my patient's voice reading stories and special messages to her children. Her family at home then included this into their bedtime routine so they could be used to hearing their mother's voice. Like brushing your hair, reading a bedtime story has never carried so much meaning.