Home: To Go or Not to Go...

"Just please let me go home. I don't care if I die, at least I'll be in my own home." Her words still haunt me. We did not follow her crying pleas to go home, instead we sent her to a skilled nursing facility. Her primary care physician admitted her directly after an appointment in his office. The arthritis in her knees was not benefiting from outpatient treatment and she could barely walk around her apartment. She refused to live with her children or have additional paid caregiver assistance even though finances were not a consideration. Her family was also concerned about her living alone but could not imagine a nursing home, "She grew up an orphan in an institution and we cannot imagine sending her back to one at the end of her life."

So here's the dilemmia... do you allow someone to go home as they wish despite knowing that they will likely die? Or do you send them to a place where they can live safely and yet potentially miserably?

In this case, the skilled nursing facility (SNF) felt like the right decision as the patient continued to demonstrate decreased insight into her deficits and ability to care for herself. "I'll be fine, I don't need anyone there," she's say despite spending less than 8 hours out of bed per week and needing an assist to walk or transfer to a chair. Her primary care physician will follow her and if she is miserable, she can... go home.

my good buddy

I sobbed driving home from work yesterday. They let him die. Okay, no, he was going to die. They let him suffer. For the last 5 days Will Ferninger has been telling me and the other therapists/nurses that he feels like he's dying. "I just know it's happening. I can feel it." As a child survivor of the Dresden during WW2, his lung disease began by inhaling particles in air released during the bombings and its aftermath. It worsened over the years as he spent hours/day inhaling flour, working as a baker in the US. Although his lungs were developing pulmonary fibrosis (scarring of lung tissue), the disease never manifested itself until recently. This is how PF is often described, like walking towards a cliff and then one day you just fall off. Once it's symptoms present themselves, it happens fast.

So when Mr. F went from being able to shower himself on 6 liters of oxygen to showering with total assistance the next week and struggling for a breath on 15 liters, we knew it wouldn't be long. And he openly discussed this, but not with everyone. He would not tell the doctor or his family. "How you doing today Mr. F?" "Oh fine really, hope to get better." I overheard this conversation with the doctor the day before he died. But why? Why wasn't he able to tell the doctor how he was really feeling? Machoism?

It happened in the middle of the night, he couldn't breathe. DNR, DNI means there's no turning back. They put him on 100% O2 with a non rebreather and shipped him off to the emergency room at a local acute care hospital. He died in the hands of strangers when we could have made him comfortable. His family was called in the middle of the night when we saw this coming on through the whole day.

But then again, maybe he died in the hands of more kind strangers like the ones he met at our hospital and was able to share so much with. Maybe that's just what he needed at the end of his life- to see so many strangers caring, when early in life he saw so many strangers being cruel (as a child during WW2). And maybe I wasn't crying just about Mr. F. Today my mom is gone 13 years ago. She died in emergency room and my family was called in the middle of the night.

"Will, why are you crying?" Mr. F's girlfriend asked him as tears rolled down his face after he introduced us. "I am crying because she is such my good buddy." Holding back my own tears, I said, "Yes, Will we are good buddies." May you forever rest in peace, Mr. Ferninger. Hope you meet a lovely lady up there who might also call me her good buddy.

Mojo Found!

It is hard for me to remember how or when I lost it. My mojo somehow slipped away over the last two years. I started serving decaf OT and occasionally found myself going through the motions of ADLs. Perhaps it was the overwhelming caseload, the new emphasis on productivity, or the chronic stressful hospital environment. Somehow I lost the enthusiasm that I had when I graduated and I had a feeling I wasn't not alone. Many new grads enter the field full of hope for their potential to create a systemic change, make a good wage, or at least to constantly give their best everyday to their clients.

Yet slowly over time, after consistently hearing, "No, you can't do that" or "Sorry, but we've put a hold on raises for the year" or "I just wanna know if they can go home alone" your career satisfaction begins to dip and you forget the real meaning and purpose of our work. Especially in this economy where the drive is to do more with less. This can be the beginning of a very dangerous slope filled with apathy, unprofessional behaviors, and contagious malcontent. However, I found the antidote. This week in Orlando, I found my mojo.

It has been two years since I've been to an AOTA conference and I had forgotten the inspiring power of this 4 day event. Dancing in the aisles at Opening Ceremony with 3,000 other OTs, meeting and sitting in lectures with Trombly, Fleming, and Gillen (celebrities in the world of OT), testing out the latest inventions at the expo and talking with the inventors, learning the cutting edge evidence for our practice- it certainly has all the elements necessary to recharge one's OT battery. Now I hope to bring this new found energy and rediscovered passion to work with me tomorrow morning!

he's in there

Switched back to the mothership last week (that's what I call the main hospital). So I'm back to carrying my own caseload which I really missed by the end of four months. While it was a nice reprieve to not be so involved in patients' stories, I was reminded how much I gain out of investing myself in my patients. And ask and you shall receive... little did I know that a story was about to come along that would completely require all my attention and energy.

At 26 years old, Mark was on top of the world- living with friends in southie, working in boston, close with his family. Everything changed January 16th when he went skiing with his family and tested out some new skis. He went over a mogul, fell, skis popped off, and he just didn't get up. His dad and sister were immediately behind him and were able to get ski patrol and medics to the scene. He was medi-flighted to the nearest hospital, intubated, and CT showed an intercranial hemorrhage. Somehow his helmet was unable to protect him from sustaining this traumatic brain injury. He remained unconscious for 1 week and was unable to be extubated, so his parents had to decide- to let him go or continue with life saving measures placing a trach and feeding tube. The wild part of this story is that this family has been here before. In 2003, Mark acquired a TBI (traumatic brain injury) requiring bilateral craniotomies. He made a dramatic and full recovery. On one hand, his prognosis may not be good because it's the second time, how much can the brain/body handle? However, on the other hand, perhaps this means Mark is a very resilient person. He may have what it takes to recover, his body/mind may known how to heal itself.

"Unresponsive, but family feels he is responding to their voice and blinking on command." The neuro report did not offer much hope. I went into the room and took a deep breathe, seeing such a young handsome person attached to ventilator just didn't seem right. His eyes were slightly open, but staring blankly, right through you. Looking into his eyes felt like looking into the night sky- filling me with wonder of what lies beyond what my eyes can see. I spoke softly into his ear, introducing myself and my role. Then I said, "If you can hear me, I want you to blink once." And he did. To be sure it wasn't just a coincidence of timing I asked him to repeat, and he did, slowly but intentionally closing both eyes.

So now, I know he's in there. Now I know somebody's home. So I went a little further, explaining to him that he could relax and to let go of some of the tension he was holding onto. I told him not to try so hard. I told him he was in a good place with good doctors and nurses. I told him he didn't have to worry about his family. I told him to just "let go." And with those simple commands, the tension in his muscles began to relax and urine began to flow into his catheter. The nurse was concerned that he hadn't urinated all day! I laughed, "Good you're peeing, see you can let it go!"

This week we will trial sitting him up at the edge of the bed and check his positioning in a wheel chair to get him out of bed. I'm also going to attempt to do a relaxation session with Mark and his mother. See if they can both begin to relax and allow some healing. If it happened once already, why not again? Let's do it!

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.

talk to me

I always thought I could talk to anybody about anything. When I was little I even imagined I could talk my way out of a bad guy kidnapping me. (Never tried to test this one out). And especially the hard stuff, the personal stuff, the down and dirty, & wild and crazy. But not today. Today the patient that I've building a trusting relationship with for the past 3 months, told me he couldn't talk to me, "It's personal."

There's obviously more to the story and this patient's story is one of the tougher ones. 53 year old male with history of schizoaffective disorder (schizophrenia + bipolar) fell at his group home and developed shortness of breath and bilateral extremity weakness after a few days. He presented to the ER was intubated and sent for a CAT scan, which revealed a C4-5 fracture. Basically- he broke his neck during the fall and its amazing he's not paralyzed from the neck down. Doctors stabilized his head and neck with a halo and he transferred to our hospital for further medical management and rehab. During his 16 weeks in the halo, we were able to build a solid relationship- a true achievement for someone with his history of mental illness. I introduced him to the internet, we baked pies for the nurses, and exercised him back into shape. He told me stories of what it was like living with his disease- surviving 14 years of institutionalization. His parents came to visit him everyday through every hospitalization.

Symptoms of his schizoaffective disorder presented initially as emotional lability and difficulty with appropriate social engagement. Later on he developed episodes of mania- "I'm gonna sell my coin collection and go back to college, get my degree in writing!" and negative thoughts, talking and crying a lot over war and killing. At times he was difficult to redirect, often going off on tangents with thoughts that didn't really connect. Generally he was pretty easy to treat given his boundaries and I really felt like we were getting somewhere.

But once the halo came off, anxiety began to rise regarding his discharge plan. During those 16 weeks he was receiving nutrition via a feeding tube since he was unable to swallow with his neck immobilized. Once that was removed he had a swallow test performed by speech therapists to determine if he would be able to eat or drink anything. And here's when his behavior really began to fall apart... he failed the swallow test. No eating or drinking allowed, probably for the rest of his life. Worse, he won't be able to return to his group home because they won't take him with a g-tube. Stuck. And stuck with schizoaffective disorder. Who's to say how a person without this mental illness would behave? Hi, um yeah, you can't ever eat or drink again and you can't go back home.

Well needless to say, he may be leaving the hospital tonight via Section 12. He's been screaming profanities at the nurses, flooded the toilet, rummaged through his roommates belongings, and hiding scissors, drinks, and food. His affect looks entirely different- drawn, lost, and empty. "I can't talk about it Amanda, it's personal." Come on buddy, talk to me!

CODE D

It's not too often you hear this code in a hospital, but Friday, December 12th we entered disaster mode. After 2 days of serious rain and ice, three telephone poles came down in the middle of the entrance to the hospital. There's only one way in and out, and that road was blocked. No main power and no one in, no one out. The generators kicked in right away, so no one had to ambu the vent patients all day. Thank god. The road was cleared by 2:45pm, so luckily the 3-11 shift could come on. My day was pretty much business as usual, a lot quieter though with having to talk to my patients over the roommates blaring TV or interrupting families visiting. Unforgettable- CODE D, hopefully the first and last. I called my OT buddy Mike to tell him the story and he told me his "fire story." Basically a patient was about to be discharged to a long term psych facility, so he lit his hospital room a blaze. Mike ended up evacuating 123 patients out into the parking lot. Now that is crazy! See anything can happen on any given day. Gotta stay focused.

i love my job.

"work is love made visible... and to love life through labor is to be intimate with life's inmost secret."
-taken from the prophet by kahlil gibran

the art of listening

It's 11:38am, 22 minutes until lunch and my stomach is rumbling. I'm running late to my next treatment session which will be focusing on solving my patients insomnia. I've asked him to think about a good night sleep verse a bad night sleep and the type of day that leads up to each. Upon arriving to his room, I see that he's asleep. Seems silly to wake him to talk about his sleeping or lack thereof, however, allowing him to sleep through our therapy time won't really get to the bottom of his insomnia.

He awoke grouchy and slow moving. I knew we needed a quiet place to talk, despite the temptation of saving time by staying in his room and battling with the bells and beeps of the unit. He's not too thrilled either to be leaving now 10 minutes before lunch, but I have a hunch that this what we need to do.

So we pull up to a quiet section in the simulated living center, he's in his wheelchair and I'm sitting in the red restaurant booth. I ask, "Did you think about your sleep? What do you think makes the difference between a good night's sleep and a poor night's sleep?" He's missing his hearing aides, so I have to repeat the question. My patience is wearing thin. His response is slow and I'm holding myself back from giving him the answer. "Stress."

"There's a reason why I can't sleep at night. I can't turn off my mind. It runs through a million thoughts. You see I didn't really have a good life." He went on to tell me about his horrific childhood- stories of terrifying abuse. How his mother left him crying in a crib for 3 days until his grandmother found him with his head stuck between the rails of the crib. How his father stomped on all of their Christmas gifts one year for twenty minutes in a fit of rage. How his mother wrote him out of her will just weeks before her death after they had finally reunited and begun to stabilize their relationship. How his father convinced him to leave the Navy and come work for the family business, but then underpaid him so much that he could barely afford to put food on the table. It was sickening to hear, but I know that he had to tell me. I could tell by the sound of his voice that just by speaking these injustices out loud he was beginning to free himself of them. I could almost see the weight being lifted off his back.

I didn't offer him any advice. I merely listened and supported him through the telling. I offered him a place to be heard. And it was in hearing himself say something that I believe he really began to heal... "When I asked my mother, 'Why'd you do it?' She simply responded, 'I didn't know any better." He held back tears, obviously still hurt by her answer. Then later in the conversation he said to me, "I didn't lead a very good life myself. I drank. I divorced my wife. I cheated. I gambled. But now I think I'm ready to go back to the people I've hurt and tell them, 'I'm sorry but I just didn't know any better." I smiled and pointed out to him that that was exactly what his mother had said to him. The revelation shook him. He paused for a moment and it began to sink in. "Now can you forgive her?" I asked. "Yeah, I think I just did."

By the end of it, he couldn't thank me enough and said he immediately felt much better. He admitted that at first he was annoyed at my insistence of going to another room, but he also admitted that now he thinks he was finally going to get a good night's sleep. When we got back to the room both the nurse and the respiratory therapist made remarks about how good he looked, "You must be close to going home?" "I am." He said as he winked at me.

the power of occupation

"I'm a little out of practice." Jim leaned over the side of the piano which he played and whispered this in my ear for the sixth time, unable to recall the five times earlier in which he did the same thing.

Jim is the reason why I'm coming out of a 3 month writing hiatus. He has reminded me of the power of occupation.

Jim is a bit out of practice. For the past month this 58 year old man has been at the hospital, lying in bed "recovering" from multible strokes affecting various areas of his brain. These include the cerebellum, disturbing his sense of balance; the temporal, disrupting his sense of time; the hippocampus and pre-frontal lobe, erasing the ability to form new memories; the hypothalamus, disabling him from regulating his emotions; and finally the occipital, destroying his vision. Basically, he is now blind, confused, unable to remember anything from one minute to the next, dizzy 24/7, and emotionally unstable. He says it feels like a nightmare, it IS a nightmare!

That's the bad news. The good news is... he can walk, talk, and remember how to do things like tie his shoes, get dressed, and play the piano. His strength, coordination, tone, and proprioception remain basically intact. So when I walked in yesterday and we sat up at the edge of the bed without crying or complaining of dizziness I knew we had a breakthrough moment. "Come on Jim, we're going to the piano."

Darlene, his girlfriend, mentioned briefly that he could play and we had tried once before but to no avail. Dizziness and headaches spun Jim into a panic attack and we had to head back to bed. But not this time. He sat on the bench and began to clumsily play a few chords. "It feels different. I can't see what I'm doing." I responded to Jim's anxiety with a calm voice, "Just close your eyes and keep doing it. Just let it flow out. Don't judge it." And suddenly it came out! It was beautiful. Beautiful melodious chords and rhythmns, classically composed. Just as I was nearly in tears, he leaned over and whispered to me, "Do you know what this song is called?" "Amanda." He remembered my name and I burst out crying!

For over an hour and half Jim played consistently, gathering a crowd of doctors, nurses, therapists, patients, and families. Dr. Wirtz, his primary physician, walked by, paused, then remarked, "Better than any medicine." It is the longest time he has sat upright and not cried or complained of dizziness or fear. A truly powerful example of the power of occupation.

"Man, through the use of the hands as they are energized by mind and will, can influence the state of his own health." Well said, Mary Reilly.

Happy 1 Year Anniversary!

It's officially been one year and 6 days since I began this blog in June 2007. Looking back at some of my first entries, I realize how far I have come in one year. One of the greatest things I appreciate from my work is learning to shift gears quickly and be present in each moment for each patient. Taking care of the needs of one patient then moving on and taking care of the needs of the next patient. Moving through my day in a flow-like state, yet maintaining a mindful connection to the clock, paperwork, and equipment.

Perhaps I'll give you a snapshot of my day today to celebrate this anniversary! Began at 7:30am looking at the schedule, designing my dailty treatment plans, and reading through the charts for updated doctors orders and nursing notes. Then off to my first patient...

9:00-10:00 In to see a 78 year old woman admitted for failure to thrive secondary to small bowel obstruction, which began evident when she began vomiting fecal matter at home. Yes, it's possible. We sat at the edge of the bed for some ADL magic a la sponge bath and dressing into street clothes. Hopefully that does that does the trick!

10:00 Next off to Mrs. Pistol, a 76 year old woman who recently had a massive hemmorhage (stroke). She is the most pleasantly confused person I've ever met. If my brain ever bleeds (knock on wood) I hope to be as delightful as she. She has been making gains in terms of initiating and sequencing functional activities, but continues to require cueing throughout due to decreased attention and distracting hallucinations, which may be a side effect of Provigal, a medication used to increase alertness.

10:30 3rd patient of the day, Mrs. J another 76 year old woman, but with a very different situation. Within the last month she has survived a flatline via CPR and weaned off a vent, now ready to go home with supervision and minimal assistance only due to her fluctuating blood pressure. Orthostatic hypotension remains her primary limiting factor, meaning her BP dramatically drops when she stands, making her very weak. Luckily her spirits have not dropped along with it, she remains very positive and realistic through it all.

11:00 Off to see Mrs. G. A 78 year old female presented to us after breaking the proximal end of her femur (very close the the hip) and is having difficulty getting back on her feet. She's making gains, slowly but surely. But will she be able to go home as she's hoping to? Only time and her determination will tell.

11:30 Last patient before lunch, Mr. Lyon. An 82 year old going on 65 year old. This man truly does not look or act his age. He's always asleep when I go in and after waking him, he teasingly tells me to take a long walk off a short pier. Yet he's always up for whatever I have up my sleeve... be it doing some laundry to work on his balance and activity tolerance or playing catch to build up his endurance, he's willing and ready.

During the afternoon I revisted Mrs. G, Mrs. J, Mrs. Pistol, and Mr. Lyons. A little bit of cognitive assessment here some pacing and energy conservation teaching here and voila- there you have it... a day's done!

I'll admit it's been a while since I've written, I've just been overwhelmed with the thought of sitting down at the computer and thinking about work outside of work. I'm getting better at really leaving work at work. I still love it just the same, but am aware of the potential for burnout by bringing it home and chewing it all over again. Instead I've gotten into some really good reading... Waking by Matthew Sanford, Anatomy of the Spirit by Carolyn Myss, and Eat, Pray, Love by Elizabeth Gilbert. Also really deepening my yoga practice. Attended the Yoga Journal Conference and am looking into becoming certified as a yoga teacher. Om, baby, om.

"i know too much"

How often does this happen? The eval begins and you conversation with the patient goes like this, "Show me supination. Okay good, do you have any external rotation in your shoulder. Hmm, how's your proprioception?" Never, right? We're constantly translating for patients... but not with this one.

Introduce Bill. Bill's a 47 year old male- very athletic, musician, gymnast coach, father, husband, and CLINICAL SPECIALIST PHYSICAL THERAPIST! He knows the lingo. He knows the hospital course. He knows the long road he has ahead of him.

I am so glad to be walking this road with him.

exhausted

I'm babysitting, the kids just all settled in bed, finally. While giving the youngest of the three his bath, I realized this was the 6th person that I've bathed today! Began with a 72 year old woman and ended with a 2 year old. And now one more bath to go- mine!