A Field Trip

An interesting article in Newsweek about how scientists have used the DNA of body lice (a misnomer, since they actually live in clothing) to determine that 114,000 years ago, humans lost body hair for good and had to make up for it with clothing. Huh. I'm telling you, it's the New Science of Human Evolution.

It was another lovely day, so the new physio Sarah and I took the opportunity to take out one of our patients who is very functional physically but with a lot of higher level cognitive problems. We took her off hospital grounds and across one pretty busy road to a very pretty pond on the edges of Epping Forest. She was able to order some drinks for us from the little shack with moderate prompting and produced the correct change from a palmful of coins independently. After we sat down near the pond, we noticed she was watching the birds. She was able to identify jackdaws and magpies, although we had to take her word for it given our lack of knowledge in that area. We asked her about birds in her garden at home, and she named starlings but then got stuck. We waited for a bit, and then I said we couldn't help her out unfortunately by offering names of birds as we didn't know much about birds. This lady's personality is showing up a bit more these days, and she immediately responded by rubbing her hands, and saying "Well then!" as if she were about to make up a whole list of birds because we wouldn't know the difference anyway. Only she got stuck at starlings again. We were all very loathe to return to the hospital, it was so beautiful, but had lingered long enough we all missed lunch (don't worry, the nurses kept some for her!).

I'm very excited, I get to go along with her for an assessment on Friday morning at the Homerton RNRU, which is a regional unit specialising in working with people who have higher level cognitive deficits. I've heard a lot about it, and am looking forward to having a look at the program in person. Actually, they are currently advertising for a Senior 2 OT, so shhh, don't tell anyone, but I'm going to apply ;)

This lady's husband came in at the end of the day, and was very excited to hear that she could come home this weekend for an overnight visit (she's only been doing short day leaves to home thus far). I took advantage of his presence to introduce both my patient and her husband to the OT who will be taking my place in three weeks' time. And my patient, bless, began to cry because "You're leaving me." I felt my eyes watering up, I was overwhelmed at seeing such emotion from her because she has been fairly blank in terms of emotions up until this point as a result of her brain injuries...I had to rush into the good news about her weekend overnight visit coming up to keep from crying myself.

Man, I really don't want to leave this unit!

"Go shorty, it's your birthday...

We're gonna party like it's your birthday. We're gonna sip on Bacardi like it's your birthday"
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"Oh, what a beautiful morning, oh what a beautiful day. I got a beautiful feelin', everything's goin' my way"
# # # # # # # #

I know, I know, it's a horrific mix of genres, but it is my birthday, and for the first time in a while, it is a beautiful day. The sun is shining, and although there are setbacks happening on the stroke unit this morning, it seems like nothing can get me down. Many thanks for the birthday messages and e-cards I have already received earlier today!!!! I woke up and stumbled downstairs as the zombie I normally am in the mornings, only to find a big sign plastered onto our hallway mirror that said "OVER THE HILL" highlighted in bright orange with a picture of an old lady knitting. I think I woke up both Nicole and Leeanne, I was laughing so hard. It is such a typically American way to take the piss, I knew immediately it was Nicole who put it there.

I have two sad stories this morning-- one of my little elderly ladies was scheduled to go home on Monday, which was already a delay from the original date of discharge this past Wednesday. She is the first person I have ever met who was "in service." She was a maid in the household of a posh Welsh family, and has loads of fascinating stories. She now can't leave on Monday, because they want to do an MRI and see if she needs surgery for a blocked carotid artery. If I were her family (and they are very unhappy about this), I would complain, because her D/C had been scheduled, she'd had a previous scan where they told her they thought everything was ok, and now at the last minute have changed their minds. And then there's another lady in her 60s, ready to go home for a visit this weekend, and then be discharged a week from Monday, but she did something very unsafe last night (poor insight and safety awareness can be such a problem with patients who've had a stroke), fell, and fractured her femur. So, no weekend visit, and she's being transferred to the orthopaedic ward.

But at the risk of sounding uncaring (which you all know I'm not), the sun is still shining, and I am not going to be brought low today. I will deal with these problems as they arise, comfort my patients, and keep my sunny mood. Happy Friday to you all, and Happy Birthday to me! Lots of love, Allison.

News from the world of CVAs

Hardly feels like 2007, eh? Not all of 2006 passed in a flash for me, in particular those bits related to my rotation at the day hospital. Unfortunately now on my stroke unit rotation, it's like my life is on fast forward. I have less than 3 months left, and I try hard not to think about the withdrawal I'll probably experience once it's done. Everyone on the team would love to have me repeat the rotation, but it's too popular of a rotation- there's no way the Head OT will let me do that. So my only hope to stay in stroke world is the acute unit, which is on the Senior II rotation. I'm still waiting on word from the Head OT as to whether she'll be allowed to hire to that rotation. If the answer is yes, I'll probably be interviewing in late February, and assuming I were to get one of the posts, I'd most likely be slotted into Orthopaedics until the Senior II rotation changes in early July. At that point, fingers crossed, I'd be assigned to the acute stroke unit. In the meantime, I'm still looking at all the job adverts I can find, as what I really want is to be on a stroke rehab unit. Since I can't continue on the unit here after March, I have to look at other hospitals, and hope they don't count my need for a work permit against me, like the Homerton did (very famous regional hospital in East London, with specialisation in assessment, diagnosis, and treatment of higher level cognitive disorders-- for example, Dysexecutive Function). I have a guy on my caseload right now as a matter of fact, who is fully functional on a physical level, but unable to cope with problems/new settings/changes/novelty because of higher level cognitive deficits caused by his stroke. He's been accepted to the Homerton, but there's a long long waiting list for a bed, and we're pulling our hair out because we're not specialised enough to provide him with the treatment he really needs whilst he's waiting for a Homerton bed. Which could still take more than 2 months. Argh.

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.

Sex

Knew that title would get ya! Haha! Read on...It was an interesting day at work today-- half the team was out on annual leave for one reason or another, so it was just myself and two physios trying to manage the whole unit caseload.

For the first time as on OT, I addressed the subject of sexuality today. We had a case conference with a patient (who is going home Dec 21) and his spouse to discuss the details of his discharge. He is 57, and I believe she's 10 years younger, and by the time we'd come to the end of our conference, I just felt like I had to bring it up. For those of you non-OTs, although we aren't really told how to do it, it is stressed as part of our OT training that since we focus on holistic treatment, we should always be aware of how important sexuality is. Even more so because no other rehab professional will address it with the patient. And when you think about it, it's true, if everyone on a rehab team ignores such a major issue as sexuality, your patient may go home with lots of questions and no answers, because it wasn't something they felt comfortable bringing up. So it's our job as OTs to break the ice, and make it ok for them to ask questions. I have not had to figure out how to do this until now, as I've dealt mainly with elderly, frail patients. But today, when everything else had been said, I told M and his wife that although I'm not an expert, I'd be happy to provide information and resources if they had questions about their intimate life with each other, considering M's post-stroke deficits...and as I said this, I could feel myself going bright red. Which they and Bettina, the physio, thought was hysterical. This couple is very down-to-earth, very straightforward, and I don't know why I flushed as I was speaking, they were the perfect people to help me start figuring out how to address the subject. But on the other hand, to illustrate my earlier point, even being such a "hip" couple, they had not brought up the subject with anyone on the team, so it really is my/our responsibility to open the lines of communication so that people know they can talk about it or ask questions if they want. I just have to figure out how to have the conversation on a clinical, professional level, so that my face doesn't keep giving away the fact that I feel like I'm pushing my boundaries!

The word, on Sunday night

So, this weekend...I cancelled my plans for Friday night, came home and slept. I have yet another cold (after finally getting rid of the one that lasted more than a month, I was "healthy" for maybe 3 days before showing symptoms of this one)...I've been such the social butterfly for so long now, saying yes to everything and thus having really late Friday and Saturday nights every weekend (involving alcohol, naturally, see my previous post on how over here, social event=alcohol), I think my body just decided enough is enough. I slept for a solid two hours after work, woke up, sent my apologies to the people I was supposed to meet, had dinner, and went back to bed. However, I did join up with Nicole and Rob and a whole bunch of their friends, plus housemate Nicole and her boyfriend Dave, last night for a great meal and then drinks...it's hard to say no when you're having fun, so it ended up being a late night once again. Luckily, today being Sunday, there was plenty of time for a lie-in.

In other news, let's see...I've been a busy bee getting together Christmas gifts, both homemade and bought. It's a bit more difficult to come up with ideas for things you know people really want or will really like, when you're not around to pick up the hints they drop in daily conversation. And I've always been someone who hates to say, "Ok tell me what's on your list, give me an idea..." But I think I'm managing! However, housemate Nicole's birthday is coming up in a little over a week, and I'm a bit stumped on that one, even though I live with her. And Dave has not been of much help, grrr. Hopefully I'll think of something really soon here...I've got a bit of a grace period since we're not actually celebrating her bday until the 16th, even though it's really on the 12th.

And at work, I am still very happy, which still seems to continue to amaze my supervisor. I guess in the past, she's been used to some basic grades being really stressed out, not liking the rotation for some reason, or only really settling in and realizing that they like it when the 6 months are almost over. Apparently, she heard ahead of time how much I was looking forward to starting on the stroke unit, and she was afraid it wouldn't live up to my expectations. But I'm a little different from the other basic grades, given how much experience I already had in rehab world before moving across the pond, and I already knew I wanted to specialize in stroke, had worked with stroke patients, knew what I was getting myself into. I explained to her that, professionally, doing this kind of work is why I made the move. And I'm loving every minute of it, even the hard parts of it. Nothing like taking on a challenge, and overcoming barriers. I wrote a little bit earlier about how much I enjoyed my first Bobath module, which took place on Thanksgiving and Black Friday. I am so looking forward to the next two pieces, plus I am putting in my application for the three-week Bobath course. Apparently, even though it is supposedly offered worldwide, there are no Bobath courses presently in the States...and I am now looking into the Senior II position at Whipps, which has a rotation on the acute stroke unit, and apparently I have a very good shot at securing. There are only two basic grades with enough experience to apply, me being one of them, and there will be some vacancies shortly. Good thing too, as with my work permit situation and the current OT job shortages, I can't get a Senior II job anywhere else.

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!!! :)

News

The sad news today was that the tube was completely incapacitated, on top of which there was also a bus strike, and the stroke unit was therefore in complete disarray. I was there on time since I had walked, and an OT student who drives in every day was also there. But everyone else was at least an hour late. Although, I'm just now getting to the sad part of it...the central line had been shut down because there was not one, but two jumpers today. And we come back around to the topic of perspective, because I can't imagine where people must be in their lives to do such a thing-- and I also can't imagine being someone on the platform seeing this happen, or god forbid, the driver of the train.

On a much less dramatic note(perspective), but still emotionally draining and life-changing for this particular family, we had a case conference today for one of my patients. When asked what his current big goal, or number one goal, might be, he replied in this meeting he wanted to get back to work. (He's only 57, and was a self-employed painter/decorator.) We asked him to try again, and to try to think realistically, given the fact that he still has no movement or sensation on the left side of his body. He came up with walking, with a stick, or perhaps a frame at first. And it broke my heart, but we had to tell him we didn't see him being able to walk by the time he goes home, and that going back to work might very well not be on the cards for him. We asked him when he thought he might be ready to go home, and he named June of next year, but we had to tell him it would be early January at the latest. And we had to tell him that doing a good transfer with assistance, and standing well, would be the goals we'll try to accomplish before he leaves. His family is having to re-locate to wheelchair accessible housing, and he'll be getting a powered wheelchair eventually. His family is very "switched on" as they say, and none of this was a big shock to his wife, but I think he was pretty surprised by the news. His insight has definitely been affected by the stroke, and while he will say straight away he is making slow progress in therapy, and has good days and bad days, he's very unrealistic about the big picture. I think that's the hardest part of therapy some days-- being brutally honest with our patients about what we think they'll achieve before they go home. And even harder is dealing with patients who have no insight into their capabilities and limitations, and don't believe you no matter what you say. The one I'm talking about from today, he's not as bad as that. We've currently got two patients who think that they could walk with a stick if we'd just let them, even though they need 2-3 people just to help them stand in therapy.

Ok, so enough of the sad talk...my happy stuff today: Let's see, going to the gym (always feels even better than usual after an emotional day at work), I'm all booked for a yoga and hiking weekend in the Brecons in Wales in February (yay!!), and I got my first Christmas gift!! I got the shock of my life this morning when I picked up a parcel from my Mom on my way to work, which I thought contained some items I'd asked her to get from the drugstore. But it was bigger than I expected, yet still lightweight, so I couldn't guess what else might be in there. Turns out it was a pair of black Crocs (clogs) that was on my Christmas list, which she'd sent over early, thinking I could use them in hospital now. They are the coolest! And so comfy too... thanks Mom!!!

An emotional drain of a day

Ooh, I just love it when Blogger won't cooperate with uploading photos. Love it, love it, love it.

I've had a crazy day today where everything went wrong with my patients I've actually currently got, plus two patients who had already gone home. "M" was badly handled by a nurse yesterday morning apparently, and now fears retribution from the nurses if he complains-- I heard about it from his wife, and I am now obligated to speak to the matron (essentially Head Nurse)-- unfortunately what happens on the ward with nursing staff has a huge impact on progress in therapy. "F" is scheduled to go home tomorrow, and though I specifically said to the nurse at our multi-discliplinary meeting last week that she would be going home that day and an ambulance needed to be arranged to take her home, today we were told that the nursing staff had no idea "F" was going home, and no ambulance had been booked. "G" is a story of his own, which I will get into when I have the energy for it-- in a nutshell, he's a 52 (or 62, we're not sure which, he's got two different birth dates, I'll explain another time) year old man who's had a stroke, past medical history of heavy smoking and drinking for 30 years (read alcoholic), who still thinks after 12 weeks of rehab that he can go home and be fine on his own. Meanwhile he can't walk, but tries to get up every day and falls, is incontinent, and has absolutely no problem-solving skills, no safety awareness or judgement, and no insight as to capabilities and limitations. But he's very good at covering things up, so the psych has assessed him to have the capacity to make informed decisions. Wheeee. It's a long story, I'll tell it another day. Meanwhile, the son of a patient who was recently discharged was calling me up on the phone, telling me his father is impulsive, aggressive, shouts at everybody, and does things he knows he is not safe to do, now that he is at home. And he wanted me to tell him that eventually his father will be back to normal, and told me he thinks the sleeping pills his father is on are causing the aggressiveness and impulsiveness. The son apparently wasn't listening while his father was a patient, when we talked about the behavioral side effects of having had a stroke, and I don't think he really took it on board when I explained this to him again today. In addition, though our discharge plan specifically called for this patient to be set up for living on the ground floor, and the family agreed, the son told me on the phone today that his father has gotten up at least three times during the night and tried to go downstairs. What?!!! I said to the son, we agreed that your father would be living downstairs, he is not safe on the stairs, we had everything delivered that you needed to have him downstairs. And the son said yes, but we're currently having a toilet and walk-in shower installed downstairs, it's too messy for his bed. And all I could say was please, please, clear a space for him to sleep and for his commode, he cannot be upstairs, his behavior is not going to change, he will do things he knows he is not supposed to do, and all we can do is keep him as safe as possible bykeeping him on the ground floor! For the icing on the cake, though the family insisted on having this man back home, and stated that as long as there were carers to help with personal care, his spouse would always be home with him, and everything would be fine, the son was now saying today he wanted 24-hour supervision for his father. And I had to say I'm sorry, but you either have to pay for that yourself, or if you want social services (i.e. the government) to pay for it, he will have to go to a residential home.

Geez, it was like the hits just kept coming today. That's not everything, but that's enough for now.

How things stand on a Wednesday night

Things that are making me happy and/or laugh tonight:

I met a really fun Australian girl on the pub crawl, and sent her a text on Sunday to say I'd like to hang out again in future. I heard back from her tonight, and I'm quite pleased at the prospect of a new friend :)

My Aunt Sue's comment on my previous post...it would seem sibling rivalry shines through whether you're a teenager living at home, or an adult with your own family ;)

Dinner plans tomorrow night!

This weekend I'm visiting Jo- checking out her new place in Rugby and partying it up. Plus some shopping-- something I never do over here because it's not in the budget. But I have a little left over this month.

I have signed up for a Halloween weekend in Kent-- haunted house, hay ride, pumpkin carving, costumes, and a chance to wander around Leeds Castle. Not to mention, more opportunities to make new friends.

I ruined a chicken roast on Monday, trying to make it up as I went along, but managed to turn it into a very tasty chicken soup last night.

And last, but "soitenly" not least: I'm working on the stroke unit and loving it!!!!

What a difference a job makes...

Yes, it's a Friday night and I'm home. But I've actually already been out for three hours immediately following work- drinks for a colleague who's leaving. AND the Guiness World Record attempt for biggest pub crawl is tomorrow. One drink at each of 10 pubs between 11:30am and 6pm. Our picture will be in the paper and everything, although with 2700 people, I doubt you'll be able to pick out individual faces.

Anywho...I feel like a different person. As I titled this entry, what a difference a job makes. I'm so incredibly happy, it's like night and day between the last rotation and this one. I feel at home on the one hand because rehab is familiar and satisfying work for me. I'm also rather intimidated at all that there is for me to learn, and me being me, I'm setting ridiculously high standards/goals for myself as to what I am to accomplish in a short 6 months. All that I want to do is impossible really, and I'm trying really hard to remind myself that I always aim too high...I cannot become an expert in the care of stroke patients in 6 months. My supervisor is very laid back, extremely so, which although I'm sure I will find trying at times, should be very good for balancing me out, and keeping me realistic. I had supervision yesterday afternoon, and told her that in general I am very happy (because she wanted to make sure I wasn't dreading coming into work everyday-- I told her "No way!!"), but that I'm worried time will fly by too quickly and I won't be able to learn everything. To which she said simply, you won't. And she's right. Even the Senior Physio that I'm working with for 3 of my 6 patients is still learning, and she has a lot of knowledge and skills. But as flatmate Nicole and I were discussing tonight, when you've got the right job, or are on the right unit over here in England with skilled teammates, there really are career-oriented reasons to be working in the UK. Woohoo!!

It's not just the job though. I've also slowly slowly started to make new friends and connections, through work and other means...one of those things that just takes time, and can seem like it's never going to happen when you've moved to new country on your own. But I can see now after 7 months that things are starting to happen, a new life is coming together. I know from past experience that moves like this, whether it's to a new country, or just simply away from family and friends, makes me stronger, makes me a better person, helps me to know myself better...but every time I do it, it's still just as hard, and it can initially be easy to forget that the fact that it is hard is what makes me grow. But enough of my soapbox-- I'm going to go practice my chugging technique ;)

Time has started to fly by again, thanks to my new rotation

I am having the best professional week I've had since moving here. I will be learning about normal movement from some pretty skilled therapists on my stroke unit. I will be attending a 6-day Bobath Course, to learn some more about normal movement, and learn specialized intervention techniques for working on good alignment with stroke patients. I will be having one-on-one training sessions once a week with my Senior OT who is also the Rehab Stroke Team Leader, on anything my little heart desires...from seating to dyspraxia to cognitive assessment and interventions. I will have six patients just about every day, with whom I will have the chance to build a therapeutic rapport as I carry through on rehabilitation treatment plans I have helped to establish. I will be setting problem-based treatment goals, with client input. We have an electric standing frame for use with "heavy" stroke patients, who barely have sitting balance...one man's wife was almost in tears today, seeing him for the first time in a vertical position, rather than just laying in bed.

I do NOT have to attend department business meetings anymore. I WILL be presenting to my new stroke rehab team on kinesio-taping of the shoulder, since I took a course about this time last year.

And finally, anyone out there have any suggestions on interventions addressing attention? I have a patient who is an alcoholic, and as a result of his stroke, currently involuntarily sober, and he forgets that he cannot walk, he wants a drink so badly. As he joked to me (coping strategy!) on my first day, he has the attention "of a goldfish". We have no way of knowing if there were cognitive issues due to the alcoholism before the stroke, and generally speaking, he's good on perception, orientation...but there is no safety awareness, no insight, no judgement. I'll be working this over with the Senior OT, but as I need to start with attention on the perceptual/cognitive hierarchy, I would appreciate it if any of you OTs have suggestions on interventions addressing attention.

I am a happy, happy girl.

Apologies, I know I've lost most of my reading audience by now, guess I've just been too busy and I'm still struggling with the whole sitting in front of the computer thing-- I do have lots to write about, and I will, just not tonight. I'm exhausted, and am going to bed early. And probably not tomorrow night, because I'm in London in the afternoon for an AMPS update meeting at the National Hospital of Neurology (or quite simply, Queen's Square, to those in the know), and then will pick up my RunLondon 10K tshirt at the Niketown on Oxford St. in time to have dinner and attend at play at the final week of the Globe Theatre season-- A Comedy of Errors. In a note to self sort of spirit, I will be blogging about Halloween, fall in general, hospital fashion, my new rotation, and some of my new patients, by Thursday at the latest. But for a quickie-- I'm very excited about my new placement, and I think there is the potential to learn a lot. Night, night everyone, love to all.

In which I learn about my next rotation

I had a mini-tour of the stroke unit this afternoon, once I finally found it, that is. There was a mis-communication between myself and the other basic grade OT who is finishing up her rotation there, and she forgot we were meeting this afternoon. And with all the ward closures that have happened at Whipps, due to the dire financial situation they are currently sorting out, I was directed to three different locations before I finally found the rehab stroke team. It was a bit overwhelming, but then any new job is (right up there with moving and death for most stressful life experiences) and I've learned to cope with it pretty well, with all the new OT placements I've done thus far. I would not say it was intimidating because the staff is all really lovely, and I'm familiar with rehab work...I get to do manual transfers again, yay! (Funny, but I really do mean it, I'm not being sarcastic there.) However, I will have a lot of adjusting to do, what with the new procedures and time schedules and assessments I need to start using. Apparently I will have 6 patients pretty much at all times, hallelujah, I'm moving back toward normal caseload numbers.

In other news, I'm rather upset. I used the only yellow cake mix I'd brought back with me in July to make my family's special peanut butter chocolate chip brownies for a lunch we had today for the basic grade who resigned (she's the reason I actually did get the stroke unit, click on the stroke label for previous posts with the whole story). The recipe calls for 350 degrees Fahrenheit in the oven, but our oven only has gas marks, and I obviously got it wrong. I left them in for the normal amount of time, and the top was lovely and golden brown, but the inside was just goo, and there was no way of saving them (I tried putting them back in for a bit). Shame. Only the edges were salvageable. The only consolation last night was that I made such a good panne and tomato pasta sauce from scratch that Leeanne was literally drooling over it. You win some, you lose some.

Karma, karma, karma, karma, karma chameleon

Continuing on the karma band wagon, I have also secured a place on the 6-day (spread out in 3 two-day chunks over several months) Bobath course...in essence we will learn about "normal movement" and using the specific Bobath physical rehabilitation techniques/method of normalizing movement with patients who are hemiplegic. So this training is pretty much specific to working with stroke patients. I have to contribute to the cost of the course, given the current state of things in the NHS (at a meeting yesterday we were told that on top of the current £33 million the Trust is currently trying to cut, they have determined they need to come up with an additional £11 million!!), but I don't mind, they are still paying the bulk of the cost for me. I do mind that the first day of the course falls on Thanksgiving, but not so much that the second day falls on Black Friday, since I won't be in the US for it anyway.

While I'm on the topic of the current state of things in the NHS: I get Therapy Weekly magazine, and noticed that in the latest issue, where when I first started there used to be 6-8 pages of adverts at the back for OT posts, this time there was one page with a grand total of 2 adverts on it.

I'm safely back

Man, fall out of internet contact for a week and a half, and major things happen in the lives of the people you love!!! Let's see...Amanda Aveyard-Elo and her husband Darin have a new baby boy, Cooper, in their family. Jean and Bob Aveyard (Amanda's parents) are my set of Mom and Dad #3. And yes, it does stop there, I only have 3 sets of parents, lol. Jennifer Flory, sweetest girl in the world, someone I have known for 13 years, and someone I am happy to count among my closest friends, is finally engaged to her Chris! Apparently it happened in Philly, on the steps of the Museum of Art ("Rocky", anyone?). She waited and waited for me to show up on msn or skype and finally sent an email, to which she received my krappy automated response that I was on holiday. I am SOOO sorry hun, and I am absolutely overjoyed for you both! I am overcome with the news, and I thank my lucky stars for you that you've found the right person-- he knows I'd kick his ass if it ever came to that, but I know I'll never have to, because I have had the privilege to see in person what is between the two of you. It's a rare thing you share, I know you know that, and I feel blessed that thus far family and friends have all had the wisdom to hold out for what is right. All of that being said, please, please pick a date after April of next year. I've also come back to find out that Rob and Nicole will be tying the knot on 31 March next year, right smack in the middle of my Thailand/Phillipines jaunt. :(

Let's see what else, what else...the brother of one of my closest childhood friends (thought not someone I'm really in touch with anymore unfortunately) has gotten married also. Tressa, who has now been in Rwanda for almost a week, forwarded some pics. This is a boy I have adored for most of my life. However, not someone I would have imagined getting married this young. Funny how almost everything is opposite of what I thought would happen, in terms of people who are already married or will be getting married, and those who are single. I wonder if those who get out all their wildchild stuff in early adolescence and college are therefore those who recognize what a gift it truly is when they find something special. Meanwhile the rest of us are still just struggling to find ourselves.

Speaking of adolescence and by implication, high school, I also got a message from my friend Wes, with whom I have kept sporadically in touch since graduating from high school. He has been in and out of London for work, and wrote last week to see if I'd be around for dinner and drinks. Doh! But he's in Oxford this week, so I've written to see if he'll be around for the weekend as well, because it's been a good long while this time since we've caught up.

And last, but most definitely NOT least-- I have been assigned to the stroke unit for my next rotation, by some complete and utter mystifying twist of fate. WOOOOHOOOOOOOOOOOO!! There is some serious karma working in my favor, or something!

I am too tired to begin on the trip, too much to say and I couldn't begin to do anything justice, but I'll be back tomorrow night with the first of my stories, and maybe some photos too. My love to all, and my heartfelt congratulations to all of you with new beginnings of one sort or another.

Another Anniversary (mine)

I just had a phone call from my placement agent in the US...she was calling to congratulate me on my 6-month anniversary today. I hadn't really thought about it, other than that when this rotation ends at the end of September, it would be about 7 months. But I started work on February 22, so she's right, today is the day.

And speaking of the end of the rotation, I've had some pretty good news today. The girl who was to definitely get the stroke unit has apparently handed in her resignation. And I'm so envious, because she has resigned to go traveling in Australia with some friends. I had my end of rotation meeting with Barbara (Head OT) today, which was fine (no backlash about my taking a holiday, thank goodness). She took one look at my list which had stroke unit in capital letters in the number one spot, and said, yes, well obviously that's your absolute first choice. And I said, "Yes it is, so I had to put it there even though I know Lizzie will get it" -- which is when she told me on the DL that Lizzie had already turned in her resignation for end of September. However, she went on to say that stroke is a popular rotation, and there is already one other person who has asked for it (I've mentioned this person before, she's not very reliable, but she's been here longer than me), plus other people may ask for it as well who have not yet had their meeting with Barbara. But she said she's pretty sure I'll get a rehab post since most of the acute posts are already filled. Apparently if you've just finished a rehab post, you're theoretically supposed to get an acute one next, in Barbara's "I've got to be fair to all the Basic Grades" scheme. And it's too bad, she said if she'd finished with all the meetings, she would have told me before I left what my next post will be, but she's got the last meeting on Thursday, which is my travel day. That's okay though, I've assigned Nicole to text me with the news. Therefore, I am crossing my fingers and everything else for the next few days that as Barbara works things through, I get the stroke unit...she was very careful to warn me about it being a popular choice though, so I'm only cautiously optimistic.

I do think I managed to convince her of how quiet it is at the Day Hospital, and got her thinking that maybe this should be a split post. For whoever gets the very next rotation here, it will still be full time. But after that, she may have a Basic Grade split their time between the Day Hospital and the main department, as I have been doing anyway. I know Ann and Annette would appreciate that too, since with me around, they quite often don't have enough to do either.

Crash Team

For a slow morning, it was a pretty action-packed afternoon. Shortly after 1pm or so, one of our consultants rushed into the day hospital, followed closely by 5 or 6 other out-of-breath people who turned out to be members of the crash team. Apparently they had been called to the Day Hospital for someone who was in cardiac arrest. We looked around at our 4 patients, who were all enjoying their lunch, and said, well, we certainly didn't call in a cardiac arrest. So they all filtered out, only to come rushing back in a minute or so later, and this time there must have been at least 15 of them. They went tearing toward the back where the consultants' offices are, and we were told they weren't after a patient, it was Dr. K--- (one of our consultants) who had apparently collapsed. We did a thorough search of the building, sent one of the secretaries to walk around the outside of the building, called over to his acute ward...no one had any idea where he was. We all sort of stood around in shock, knowing there was nothing we could do, and I finally left at 2pm to go up to the acute wards. As it turned out, one of the other OTs had more need of me today than Jodie, so I was sent to Chestnut ward. I hadn't been there 10 minutes when I heard some of their staff talking about it-- apparently he had collapsed downstairs from Chestnut ward, and one of the crash team found him there. I called over to the Day Hospital to let them all know and carried on. I returned to the Day Hospital around 4pm, and as I walked over to the desk, the head nurse thanked me for my information, and pointed over to the main secretary's desk...there was Dr. K---, practically shouting down the phone at some poor soul. I've no idea what happened in those couple of hours, or how he got out of being at least kept under observation for a while, but all in all, it was a very wierd, stressful set of events, for apparently everyone but Dr. K---.

On Chestnut ward, I tried to see a patient who had come to us with radiation burns...he was at St. Barts Hospital only about a week ago for radiation treatment for epiglottal cancer. He now has burns on his neck and can't really speak. But that didn't stop him from shouting in a whisper in my face (he stepped closer every time I took a step back, nothing wrong with his balance or walking abilities), with the accompanying spittle naturally, about how he's tired of everyone asking him things and not telling him anything, and all he wants to know is when he'll get his voice back. I didn't get anything accomplished with him, almost needless to say, but I did go wash my face when I was finally able to make my retreat. After that I inserted myself into a family grouping surrounding another man, and had a very pleasant conversation with the poor chap, who had a stroke, and is currently without the use of his right arm. Ah, if only I were rehab! He is someone who has apparently always had a good sense of humor, and is coping very well, although I'm sure the fact that he doesn't really have any other major deficits (besides the arm) from the stroke helps quite a bit. I'll do the whole functional assessment with him tomorrow, but he appears to be very functional indeed.

No word from Bristol yet...

"Love is in the air"

Thought a little Barry White was appropos with the mood of things around here this weekend. Dave turned up with a poem he'd written for Nicole about how she's the one he wants to be with for the rest of his life. He framed it with dried flowers and everything. Made me cry, reading it. Then the two of them took off for their posh night at a five star hotel in central London, just one part of the gifts that Nicole showered on him for his recent birthday. Still to come- a spa day together in October. Meanwhile, Leeanne's Italian stallion has been wandering around the house since Wednesday with his shirt off. She has announced that she is in love, will be going to visit him before her visa runs out in October, and that she may try to get a new visa altogether if he decides he is going to move to London. Haven't seen much of her today, ever since he left for the airport this morning. And as for me, well let's just say I had a good weekend too.

I have to say, I have been having a blast going out dancing since I've been here. Shake it like a salt shaker!! You can get a lot of great house music, reggae, lounge and all of that going out in NYC. Call me cheesy, but I love all the top 40 you get in clubs here, set to a house beat or whatever...you can dance and sing and basically have a ball. And being an OT, I love any opportunity to put on a little bling- dressing up, make up, the whole nine yards. I almost miss needing to wear business casual to work- almost. Cuz it feels good to look good!

Ok, so as for the interview...it went very well for the most part. As I wrote earlier, my presentation was probably more generalized than they would have liked. And I guess I was answering questions that way too, because they redirected me after one answer to specifically address how I would work with patients exhibiting aggressive, emotional problems. And I doubt I gave a very good answer, because I really haven't had to work with patients like that before. The facility was impressive, built in 1999, with its own therapy pool and everything. It's a jointly run venture, both NHS and private. I liked the feel of the place, I liked the staff, I liked the resources available...but they mainly have patients who have suffered some sort of traumatic brain injury. Not really stroke or SCI or anything. I will find out the results tomorrow, but I'm not so sure it's a good fit for me regardless. I'm not working in mental health because I realized it wasn't a good fit for me...traumatic brain injury patients are as much mental health patients as they are physical health, and more to the point, I'm specifically interested in working with stroke patients.

It's been an interesting day today, raining hard on and off all day, with a couple of brief rumbles of thunder thrown in midday. Great day for sleeping in, making phone calls, getting stuff done around the house, and cozying up with a DVD, as I plan to do now. I'll let y'all know the official word when I get the phone call tomorrow. Night!