A brief interlude with snow

Lots of things happening around here. I woke up this morning to find an inch of snow on the ground- good packing snow too!!! It was gone by the time I left work this afternoon though :( Most of you probably know I absolutely love snow, so unfortunately this was just kind of a tease. Guess I'd better put together a ski weekend in Austria or something if I want to really see some snow this winter. It's finally starting to act like winter, what with this small bit of snow, and I actually had to wear my winter coat one day this week. I suppose it's too much to hope for a real snow storm around these parts.

I've got some more pics from my birthday weekend, although I've realized I didn't take any at the pub on Friday night. Oops. It was such a crazy day at work, with me running around like a chicken with its head cut off, I guess I was just too busy relaxing with friends and colleagues to think of my camera at the bottom of my bag.

Speaking of birthdays, my blog is officially one year old today. Who knew I'd keep this up for that long?! It certainly helped to keep me sane during my day hospital rotation. I don't blog as often now as I did whilst working there, but I still look forward to writing, and getting emails with people's responses and comments. Although, y'all do still remember you can click on the word "comment" and leave a comment right on the blog, yeah? ;)

Oh, and speaking of birthdays again, my Dad's is coming up. He and my mom were in Florida this past weekend for a surprise 60th birthday for Jenn's mom, at the Disney World resort. Yup, whilst I was partying here in London, they were partying in Orlando. Oh yeah, and Tress was partying in DC since she is still hanging around home for medical treatment of her arms (poor thing, she's bored stiff and can't wait to be cleared to go back to Africa). We get around as a family, eh? So my mom, sister, and I arranged for a luxury bass fishing trip for my Dad whilst he was down there-- I initially wanted to send him deep sea fishing, but for various reasons, we switched to bass fishing closer to Orlando. I think that's probably the first original gift I've ever thought of for my Dad. I always try to get personal when I give gifts, and I'm usually pretty successful, but I've been stumped for as far back as I can remember with my Dad. Oh, he's a Terry Pratchett fan, so I always buy the latest books, he loves puzzles, so I get interesting puzzles for him...but I was very proud of this fishing idea, and apparently he had a great time. Yay!

Tomorrow begins the second module of my Bobath course, which I am very excited about, so I'll just post a few more pics now, and then I need to read through the material we were given for tomorrow. One of my patients has been chosen to be our patient model, so I'm really looking forward to getting normal movement treatment ideas for her!

The down side

I've been struggling today with the recent development of clinical depression in one of my patients, and the role we played in "causing" it. This lady is 85, presents with right-sided neglect, and decreased sensation on the right side, but she has full range of motion and good strength. In certain routine daily activities, the right side automatically comes into play, as it also does during therapeutic intervention that we structure to bring her awareness to that side. However, there is more on this patient's problem list. We believe there may be some visual field problems and referred her to the orthoptist- we're waiting for the appt. There are definitely some visual perceptual problems including figure ground, object constancy, and depth perception deficits. She perseverates a lot, and cannot easily divide or alternate her attention. And as if all that weren't enough, she has both expressive and receptive speech aphasias, although she gets the general idea during conversational speech, and sometimes manages to get out what she actually means to say.

Put all of this together, and we had to have a case conference last Thursday with her family to say that the prognosis is not good-- that even if she makes improvements with functional transfers and walking, she will need 24 hour supervision due to the cognitive deficits. Although she'd only been with us a little over 3 weeks at that point, we felt it only fair to give her family time to absorb this, ask any questions they might come up with, and begin to make a very difficult decision about whether they could look after her as a family, or tell us to begin the process of finding her a place in a residential or nursing home. Now, although this patient did not by any means follow along in the meeting, point by point, it was clear she understood the concept that we were discussing a "home" for her, and were saying she could not go back to her own home. She was very distressed by this, and kept repeating "But they love me, we all love each other. " (Referring to her family.)

Prior to the case conference, she was always motivated for therapy, always bright and pleasant. On the Friday following the case conference, she came with us to the gym for therapy, but was rather agitated. She then had the weekend with no therapy, and apparently, according to nursing staff, her family has been visiting a lot less frequently. So this poor lady knows we were talking about a residential/nursing home for her, probably doesn't understand why, doesn't understand why she can't go back home, has little to no control over her environment due to her long list of problems, and may very well feel like her family is pulling away/abandoning her. On Monday, she was a completely different person. We were told by the nurses she wasn't sleeping at night, she's not eating, she can't sit up straight in a chair, is tired all the time, couldn't be roused to keep her eyes open let alone get her transferred into a wheelchair to come to the gym for therapy, and kept repeating "I wanna go home, I wanna go home, they love me." Tuesday, the same, at which point I said to the nurses, the SHO, and anyone else who would listen, this lady needs help urgently, she's showing signs of clinical depression directly related to what we told her in the meeting. Today, the matron of the ward came to me for an update on all the patients, and I repeated myself again, and apparently today this lady's been delirious, so they finally paid attention to what I was saying.

Although I've been reassured that we did the right thing by including her in the case conference, it would not have been right to keep her ignorant of discharge plans because she would have to have been told eventually and would have had the same reaction then, I still feel awful. Just horrible. It's night and day, her emotional health and personality before the case conference, and now. But I guess even if we'd only told her family, so that we could continue to make progress in therapy, all that progress would have been lost when we did tell her. Well, that and we could never have predicted she'd have this reaction in the first place. You just never know with stroke patients, the brain can be such a delicate thing, and maybe the only thing she was holding onto in what is now a confusing world for her was going back home, where everything would be alright. Seems to be how a lot of our patients feel, actually, although for very few of them is it actually the case that they go home and everything is alright.

The integration of knowledge and clinical practice (finally)

There's a fairly regular neuro teaching/training group that happens on Mondays, and was previously physios only until I gate-crashed when I started on the stroke unit. And today I brought Cecilia's OT student with me as well. Today's topic was assessment of dyspraxia, and we met a patient that one of the group's members is currently treating (she's an outpatient physio) and who had agreed to perform some functional tasks for the group. First of all, the sad news...this guy could really have benefitted from a stint on a specialised rehab stroke unit but unfortunately slipped through the cracks. He went from an acute admission to hospital (where he was indeed diagnosed with CVA) to being denied admission to our stroke unit (I have no idea what the neurologist who made that decision was thinking) to going to a generalised rehab unit where the staff was temporary and his treatment was inconsistent to being discharged home with his wife. Thankfully a referral was made to outpatient physio and she realised this was an urgent case and picked him up right away. The good news...we generated a lot of new ideas today as a result of our group session, which in the end was really more of a brainstorming session than a teaching on the assessment of dyspraxia. There are no formal assessments for dyspraxia, I think at least in part because it's so hard to tease it out... you must first eliminate any other possibilites including muscle weakness, motor problems, decreased sensation, etc. And after watching this guy stand up, sit down, walk, talk, and have wild resting tremors with his left hand, we were able to pick up on several things that the physio (through no fault of her own) had missed- she doesn't work on a stroke unit after all, and it's hard to keep your eye on everything when you're working solo with a patient. We decided that the dyspraxia he's experiencing now may very well be the manifestation of other problems rather than be a true dyspraxia. He will be getting a referral to an orthoptist because we suspect possible vision problems. He also seemed to be exhibiting a fair amount of inattention to his left side. I was able to suggest graded bilateral functional activities for both arms, with facilitation from the therapist to make sure the activity is successful (for example, washing hands with hand-over-hand from the therapist to control the tremors) because I suspected he's given up on that hand since it doesn't do what he wants it to do most of the time, and he never had intense input from a stroke rehab team to work on that hand. For the first time in a while, it felt like a synthesis of what I've soaked up since arriving on the stroke unit, with things that I learned at Tufts, such as the importance of a "Just Right Challenge" balanced with making sure the patient experiences success. And boy did it feel good to contribute!!! :)

Physios: OTs in disguise?

Well, blogger is doing its thing again...I posted a few photos early this morning, but have thus far been unable to post the rest tonight.

I am exhausted, but no rest for the weary! I've been cleaning house, because Carla arrives tomorrow morning for her UK-blink-and-you'll-miss-it adventure... we're going to cram as much in as possible, including a day trip to Bath and Stonehenge on Friday so that she gets to see more than just London. Unfortunately, I have to be on the tube at 7am tomorrow to meet her at the airport, so no sleeping in for me. Guess I'll just have to indulge in a nap on Sunday.

Gripe of the day...what's with the physical therapists moving in on our turf?! It used to be that physios were the joint and muscle experts, very straightforward stuff. And OTs, well, we were able to claim that what made us unique was our focus on purposeful, meaningful activity, or functional activities if you prefer. And yet these days, physios are pretty much across the board incorporating functional activity goals in their treatment plans. Professional niche stealers! Get back on your side! We were here first!!

Sometimes families need more intervention than the patient

I spent 45 minutes of an hour-long session with a patient on the ward this afternoon, listening to the patient's son, rather than assessing the patient. The son (55) is on the verge of a meltdown due to the stress and strain he's under dealing with his father (and apparently other issues going on in his family as well, including as he said at the end, the fact that his marriage has been strained for some time). He insists that his father has memory problems which lead to safety issues at home, including but not limited to the fact that the patient has left the gas grill on before by accident. The son was saying there is no way his father can come home, carers won't make any difference at all since they don't provide 24-hour care, and his father needs 24-hour supervision. (Although the patient is insisting he manages, and wouldn't have carers anyway). The son was basically saying he gets no sleep and is on the "edge." Meanwhile, when I was able to actually work with the patient for a bit, he was able to respond to questions appropriately and scored a 24/30 on the MMSE (which ain't that bad). Now, I don't not believe the son-- his father has cancer of the lungs and a brain tumor that causes seizures, and having been told it will be terminal eventually, ideally the son would like his father to be in palliative care (the patient is currently against anything that involves leaving his home). I only met the patient today and was able to spend only about 15 minutes talking with him. I did see part of his session with the physio, and he is able to walk with a frame, get up out of a chair, etc. However, I do think the son is going to have a hell of a fight, because his father could be cared for at home (and social services won't support an application for residential care unless a patient cannot be sufficiently cared for at home), and if the patient does have the cognitive deficits the son is describing, he hides them well. And as far as palliative care-- well, that initiative would have to come from the doctor, and to override the patient's wishes, again it would have to be proven he is not of sound mind. Ai-yai-yai. I let the patient's son just get it all off his chest, he so needed to, but in the end, I had to tell him it will be the social worker and/or doctor who may or may not be able to help him get 24-hour care for his father.

And then, a really scary sight on my way out the door, a patient with an oxygen mask on at the end of the ward was getting attention from the SHO because his face had literally turned mustard yellow behind the mask. I've never ever seen that before.

On a lighter note, the domestic staff and porters are on strike again, and Annette was helping out with the afternoon tea. One of the Day Hospital patients asked her, "So what do you do here?" And Annette told her she was an Occupational Therapy Assistant. And the patient said, "Oh, you're one of them." I died laughing over at the nursing desk.

Back later on tonight with a more upbeat topic.