Start of week 3

Today marks the start of week 3 of my outpatient affiliation.  The time warp of school persists, though now the days go by fast and pleasantly.  I cannot remember which author in which I first read of the "whoosh effect," wherein good times strum along almost faster than you can keep up while rough times become strung out.  For some reason I want to say Douglas Adams or John Irving or Kurt Vonnegut, but usually such a lapse in memory recall gives a clue 3 stages away from how I think they present.  Meaning, my mind will say "their name starts with an F!" where in actuality there in an f-sounding ph in part of the book's title and their name actually has a T in it somewhere (as in some letter that gets crossed).  This may sound familiar to those whom I have described my astronomical difficulty with extemporaneous writing assignments.  Regardless, I may not ever know the date or day of the week correctly, but I am pleased by the greater state of whoosh-ness.  [Oh yes, I went there with my suffix.  Credit owed to performance theorists like bell hooks and Judith Butler.]

The outpatient setting is fun, but has its drawbacks.  Patients are only seen in 30 minute blocks, and that is assuming that transportation outlets for these neurological patients works like its supposed to (har har, good luck with that one...).  Patients are in chronic states of injury at this point, but long-term disuse and negative neuroplasticity create replicable patterns from patient to patient.  Furthermore most patients did not receive proper care during any stage of their injury, including chronic stages for as much as 18 years before coming to this facility.  Not that we are doing anything ground breaking, we just try to give whatever level of actual care we can rather than just a hot pack and ultrasound modalities before sending them on their way.  I previously described Mr. B, a chronic stroke patient with Parkinsonism characteristics.  His family didn't realize he had continual low-dose strokes until they had accumulated over a year and he was resultantly bed-ridden, and once given medical care nothing was done for his paretic and high-tone arm except a hot pack and elbow range of motion.

I have treated Mr. B a couple times now, which has been a very interesting process.  He is cognitively affected, so that he'll answer any question agreeably and doesn't understand verbal cues.  Thankfully he does follow gestures well, which I discovered today, so pointing while saying "lift up!" will yield actual results.  His tone is hard to decipher because you cannot use any patient descriptions within your assessment because the patient has none to offer.  The feel of his tone and range of motion could indicate any of three things: rigidity, massive muscle guarding against pain, or stage 1 of adhesive capsulitis (the "freezing stage" of a frozen shoulder).  I worried about the latter during my first assessment of him, particularly since I found restriction in a capsular pattern including nil external and internal rotation.  Mentally I was freaking out about whether my assignment to perform range of motion exercises on his shoulder would exacerbate symptoms.  Thankfully, it turns out to be an initiation block that correlates more with the premise of rigidity, where his body resists movement internally or externally initiated until some axonal threshold is crossed and he can finally move.  The tricks to cross that threshold -- that is the task at hand.  Mr. B is a patient from which I will continue to learn boat loads (metric sh*t tons!).

Ms. C is a bariatric patient with joint pain and major loss of functional independence.  She is incredibly motivated, and is quite practical with her personal goals of cleaning herself independently after using the bathroom and getting out of bed independently.  Seems like an acute bedside type of goal set, but her main limiting factor is her morbid obesity; she is over 500 pounds, but by how much is beyond my knowledge.  My first two sessions with her were performed in her wheelchair, as the clinic does not have a Hoyer Lift to transfer her to a mat and at the time the clinic had a bariatric walker (i.e. rate for patients up to 700 pounds) on order.  Lots of upper extremity motions with an emphasis on endurance, very reminiscent of the upper extremity class held daily by the occupational therapists on the spinal cord injury rehabilitation floor at Mount Sinai Hospital.  Then the walker arrived.

Thankfully, Ms. C is stable on her feet.  I still have to guard her when she walks, but the impending doom is much, much less than when I was first presented with the task.  For those who don't know, falls are NEVER okay during therapy.  Any falls at home are taken very seriously, a risk of falling can be the primary block for a patient who wants to regain independence, and every precaution is taken during session so that patients never hit the floor.  It is rare for such an opportunity to strike in outpatient, but sometimes knees give out or fatigue overtakes the patient's control.  If so, as the therapist (with a license and with malpractice insurance) you guard them, you catch them and you get them safely onto a seat or a table mat.  What do you do when the patient is >500 lbs?  You assess their ability before the attempt, if needed have a wheelchair follow (still dangerous, as she can and has nearly tipped her 300+ pound power wheelchair by accident before), and if she goes then you have to let her fall.  Otherwise you sacrifice your own health and your ability to treat the rest of your patients.  It is a unique case, where even if you had four people giving contact guard it still would not be appropriate to catch her during a fall.  I am happy to say that in the three sessions that we have walked, she has improved every time.  The distance remains the same -- 60 feet -- but she can speak a word or two mid-ambulation now.  That's a huge jump in stamina.

Then comes Mr. D, who has bilateral knee osteoarthritis and a script for therapy twice weekly, yet never reports pain, has no functional limitations and practically skips into and out of each session.  After so many patients, even the orthopedic cases, who need genuine help to restore normal life it can be difficult to respect his need for services.  Mr. D is super sweet, never argues, is more motivated to participate than 80% of the other patients, and yet I continually must remind myself that it is not my place to judge patients -- that any level of discomfort deserves a full course of treatment.  Perhaps his initial prescription was intended to jump start a home exercise program for long-term self-administered conservative care.  I was not yet at the clinic when he was evaluated, so cannot say for sure.  If we are given a script then we do our best to show a need for care within initial evaluation documentation and sometimes hyperbole can help our case.  I recently spoke with a classmate about the differences between her outpatient sports/orthopedic affiliation and my outpatient neuro/ortho affiliation.  She wonders the same thing regarding need of care, having spent her first affiliation in acute rehabilitation and now working with weekend warriors who have a slightly tender ankle.  I would and do have the same initial reaction as she does, but, again, must remind myself that any pain or limitation equates with some difference in how a person spends their time and thus affects quality of life.  We are not there to judge whose case is of more need; we are there to help resolve any and all limitations to a patient's normal life as best we can.

On that note, time for some whoosh sleep....