Standard Precautions

If you don't feel like counting, sing the alphabet, that's about the right amount of time for a proper hand wash.

The increase in cases of swine flu (aka H1N1) is making the news regularly this week. Most notably in central Texas where the Dell Children's Hospital has actually had to roll out their emergency triage plan- complete with giant tents!


This scenario, and an employee's potential role in it, is given a quick overview during hospital orientation, and reviewed briefly once a year as part of a "self-taught learning module" that we all must complete to keep our jobs, like a TB test and CPR certification. It has always sounded so fantastical: the tornado and the terrorist, the power outage and the pandemic. All these scenarios have blended together in my imagination to form a dim image of tents in the hospital parking lot, illuminated by flashes of lightning, all conversation carried out in a bellow to override the sound of the generators, while the frightened populace makes a run on the local hardware store for N95 rated masks.


I wasn't really picturing irate mothers bringing in their kids with 101 degree fevers to sit in the sun in a hot parking lot with no other indication of disaster. Just waiting to be told if their kids have flu. It's sort of anti-climactic.


In this blog I am definitely NOT going to weigh in on whether or not you should bring your kid to the hospital, or what you should do if you think you have swine flu, etc. If you're worried I recommend calling your hospital's information line and asking what their recommendation is for being prepared. Believe me- LOTS of people in your community have spent LOTS of time planning to minimize the impact of this on your community.


(However, IF you choose to make a swine flu preparedness kit- like one friend I know who has stocked up on masks, purell, and Nuun electrolyte replacement tablets- have a hospital friend show you the right way to put on the mask.)

One of My Better Moments

NOTE- this post has some swearing in it. Originally I had a big ol' disclaimer at the beginning but I decided not to worry about it after all.

I had a patient die this week. He was a quadriplegic, had been for years, and his body was finally shutting down. Like many people with quadriplegia he had some arm movement, but not even wrist extension (meaning he couldn't bend his wrists back toward his arms). So, just so you know, that's a high level injury.

This guy was a really difficult patient. Like many of my patients who have lived with limited independence he had developed a personality trait... er... to be blunt, he was an asshole. He was a Vietnam veteran who probably had issues even before his injury, after his injury he had only his voice as a tool to get what he needed. If up in his wheelchair he could, of course, motor around on his own. But he was dependent to get up in his chair at all.

With his limited lung function he'd been fighting a losing battle with pneumonia for several months. The docs brought him to our unit once they thought he was stable enough so he could get back to his prior level and go home. It was evident from day one that this was not the case. For one, his blood pressure was often really low (65/34) - one of the therapists refused to enter his room without knowing his code status. This made it very hard to work with him on account of if you raised his head above his heart he would die. The big indicator though was the edema (swelling/fluid retention) in his legs. It was the dependent/stasis kind (e.g.: not a problem with his lymphatic system). When I called the lymphedema OT in to screen him she explained that it's the kind of swelling you see when someone's body can no longer handle it's own fluids, and they are literally pooling in the lowest part of you.

This kind of pooling is also seen in dead bodies.

When not barely conscious due to low blood pressure this guy was a persnickety, demanding, sarcastic, asshole. There is literally no other way to put it. I get people like this maybe once every 4-5 months. When I first started I watched the other staff break their heads against the wall of this intractibility: getting offended, getting angry, getting flustered, trying to fight back. All to no purpose. And until I figured it out I kept walking in and doing the same thing. Until I figured it out. Talking with other therapists we figured out that there is a strategy for working with these people and this is what I had planned to write about before he died. It goes like this:

1. Identify that this patient is one of those. The simple method for identification is as follows- walk into their room and start chatting, casually move something insignificant on their tray table (such as a sugar packet) about 1 inch. If the patient stops you, demands that you put the packet back where it was because they had a specific reason for it being there, then makes 5 other tiny detail requests in the same sentence... you have your ID.


2. Understand, nay accept, that your plan is secondary, tertiary even, to whatever this patient has in mind. When you walk into the room you must be saying in your head "submit, submit, submit. Nothing will happen here that this patient does not want to happen."And by want I mean think up themselves and dictate every step of.
   

My coworker says working with this kind of patient is like being "fucked in the ass. And you have to like it." I realize this is terribly crude, but it's so completely apt. It's weird, but when you walk in preparing yourself to just bend over, it doesn't feel so bad anymore. And, ironically, this is how the patient establishes rapport with you, so you can almost always get something functional done in the end (no pun intended). I had fun watching nurses and doctors get so frustrated and angry, then pulling them aside and telling them the submit/ass-fuck theory of patient interaction. Their eyes would get huge, then they'd glance furtively from side to side, then they'd say "oh my god, you are soooo right", then they'd look relieved and not mind so much anymore.

Interestingly, he could play the lap steel. He had this custom instrument with custom adapted strap on bar and picks. He could play the blues. One evening at about 5:45, just as I was leaving mind you, I could hear him shouting at the CNA. He was all angry and snarky because no one would get him up to his wheelchair. He had his heart set on getting up to his chair that day but it didn't happen because his blood pressure was so low that he missed all his therapy times on account of being in Trendelenberg all day (bed positioned with head lower than feet). Now he was feeling better and just super pissed that he couldn't get up. He kept saying "I just want to play my guitar, dammit!"

So I did something I never, ever do. I clocked out, then I went back in on my own time. I spent 30 minutes getting him setup in bed with his guitar (I didn't want to get him up because he'd been so unstable all day). You can imagine all the finicky details of positioning the guitar with blanket rolls, getting the angle just right, strapping on his picks properly, then adjusting it all again and again. And again. He played me some simple 5-bar blues, and he was pretty good. I didn't know they had adaptive setups for guitar playing, but I was happy to see it, and he was stoked to show off after weeks of being completely helpless.

He lasted 2 more days before going back to the hospital. He died in the ICU the next day.

I was so glad that I had gotten to the point of not minding this guy. Because once I was fully willing to submit I could suddenly see that he had no power to make me do so. I no longer had any irritation or anger towards him, so in his moment of need I was able to pull out some compassion. In a way his jerkiness pulled me out of my role as a "professional therapist", and it allowed him a chance to be seen on his own terms, as a guitar guy. And you guys, he got to play his guitar one last time. I did that. And I'm proud of it.





The photo is NOT of my patient's guitar, but another adapted lap steel I found on the interwebs. Click on the photo for a link to the forum where it was discussed. Also, here is a link to another adapted musical instrument website:
http://www.disabled-musicians.org/equip.html

Snippet

Patient with new below knee amputation (BKA):

"My toes hurt that I don't have."

Meritocracy- Part II

Philosophically:
Sweety pointed out that the big tech companies that use merit-based systems successfully are for profit. Everybody there is there for money. At sweety's job, when they made bonuses commensurate with how much product got sold (good product, that didn't need to be recalled or repaired), everyone really was motivated to work harder. There was a direct correlation between the work and the purpose of the company. Also, the reward was for the whole team. If the team worked together effectively to create more good product to sell, then the team got more profit from the sale of that product.

Contrast that with the new situation at my work. Everyone is individually rated on a scale, there is a finite amount of money in the therapy budget allocated for raises. HR will decide based on your rating, relative to everyone else's, how much of that money goes to you.

There are two glaring problems with this:

1. Our company is non-profit, and though we all really like getting paid, profit or production is not the reason we come to work each day. Don't get me wrong, I'm not saying we don't like making money, just that "profit" isn't in line with the hospital's goals in the same way that it is for the companies our CEO is using as a model.
2. The new reward system is competitive vs cooperative. Health care right now is pushing hard to move toward a team approach to everything. Interdisciplinary teams are the buzzword of a good organization. We are encouraged daily through modeling, trainings, and motivational banners to promote teamwork and work together. And the teamwork works REALLY well. The team aspect of my job is easily the most effective and most satisfying, and patients get better care. It's a huge part of why I like the unit I work on, and what motivates me to work harder. The new system is a jarring, discordant note - it's a weight dragging at the progress toward this excellent goal.

Nonviolent Communication:
Okay, these people are a little fruity- and, like lots of people who are passionate about an idea, come off as a little preachy as well. That said, my shrink had me watch a DVD of a seminar by the guy who started this, and there were definitely some ideas that worked for me.

1. That the common relational strategy of using rewards/punishment to get what we want from people, is coercive and inherently violent. Instead of seeing people as people, it sees them as a means to an end. We dehumanize them, even if only a little tiny bit, and this is a violent mindset. (This idea echoes something Jesus says about the commandment "thou shalt not kill". He points out that hating someone in your heart is qualitatively the same as killing them, inviting us to move beyond simply following rules of conduct to transforming the way we think about others.)
2. Another idea that I like is that the nonviolent communication mindset is generalizable- it should enhance peace, effectiveness, communication across contexts. I'm a simple creature and I much prefer generalizable tools over a highly varied and complex skill set.

Here is a pretty representative quote from their website:

"This approach to communication emphasizes compassion as the motivation for action rather than fear, guilt, shame, blame, coercion, threat or justification for punishment. In other words, it is about getting what you want for reasons you will not regret later. NVC is NOT about getting people to do what we want. It is about creating a quality of connection that gets everyone’s needs met through compassionate giving."

So grab your grain of salt, and go check 'em out. Here is an article on their website about using NVC at a psychiatric hospital, it made me happy so I'm recommending you start there.

Meritocracy- Part I

Or: how to turn the economic downturn into an opportunity to torpedo morale.
So my hospital just switched from regular step raises to "merit-based" raises. They've been talking about it for a while, in a vague sort of way, then suddenly went for it. Under the new system both the step raises and the regular cost of living raise are rolled into one raise. Also, the highest increase you can get is less than what we used to get for cost of living. Additionally, the standards have been changed so that most people are not likely to be able to earn a raise in the course of their everyday work (to get "exceeds expectations" in a given category one has to somehow be promoting departmental or interdepartmental improvement in that category). It was presented as an opportunity for people who are motivated and work hard to get rewarded and recognized. This was communicated to us in a single, peppy email.

Also, did I mention that the biggest raise you could get, if you change/improve hospital policy in every category, is still less than the cost of living increase you got last year for just showing up and working hard?

How I used to feel:
The way I was compensated before this change made me feel like the hospital took my job really seriously, and like they expected me to be a grown-up. I've been pretty bought-in to the mission and values of the organization, and more motivated than in any previous job to bring my best self every single day.

How I felt when I first heard about the change:
We all assumed that the change had to do with the economy, and was a way to avoid giving raises without saying that outright. I felt like upper management had just decided that the most rewarding part of my job is money. And like they think we're stupid and we wouldn't notice a crappy deal if they put a positive spin on it. I heard the message: All new increases are based on merit and, by the way, you don't merit crap. I definitely do not feel that I've been "given an opportunity to be recognized".

Most notably, I felt a sudden, sharp decline in my motivation to work hard, and a decrease in my sense of connection to the hospital and its mission and values. I'm pretty sure that wasn't the intended goal of the new policy.

After the explain:
My PT cohort, a proactive and direct sort of human, told our lead therapist that we needed a manager to come explain the policy and the reasons/details to us in person, because morale had tanked as soon as we got the email. There was a lot of grumbling.

One really helpful piece of information was that the decision to switch to merit based raises was made before the economic downturn. The CEO is trying to bring the hospital in line with some of the successful business practices of big companies. Specifically mentioned were some tech companies that give merit-based bonuses and raises. He wants us to operate like those successful businesses.

The decision regarding how much the raise could be was made seperately and is based on the economy and will vary from year to year. Another helpful piece of info was that all management, residents, and non-bargaining employees are having the same change.

Two Firsts

First student:
I had my first student today. Okay, she's not an OT student doing an internship, she's just doing her OT-program pre-requisite volunteer hours shadowing an OT. It was really fun to have a gopher. It was also fun, in a challenging sort of way, to have a person that I needed to explain things to. What I am doing, why I am doing it, what I am looking for with certain questions and activities. It's cool because it makes me think very specifically about my specific goals for a specific session, as well as my overall rehab plan for a specific patient. I always do this anyway, but it's usually half sub-conscious. It felt good to do it out loud, like a little refresher course in "best practice".
(Okay, so no prizes for unexcessive use of the word specific in the preceding paragraph.)

First time I've been surprised into embarassment:
This awesome old guy is having his anniversary today, at rehab. He has Parkinson's, complicated by a broken hip from a recent fall. His super-groovy wife is around a lot and helps with all his care. She's preparing to take him home, no matter what. They brought us, like, 3 cakes from the local swanky bakery to celebrate their anniversary.

Anyway, my patient recently had his catheter pulled. Like often happens after having a catheter, he has to 1) relearn how to control the sphincter at the end of his urethra, 2) get his bladder to reaccustom to being full, so he can hold his urine a bit instead of peeing the second he gets the urge.

Anyway, he peed himself. I came in for therapy right in time for cleanup, student in tow. We worked on strategies for taking off the pants (weight shift, forward lean, etc). Then I gave him a wet washcloth to clean up. He starts in with the washcloth then, after a moment or two, stops and laughs, turns to his wife and says: Hey honey, wanna give me a hand here!? It is our anniversary after all.

These Truths Can Coexist

FYI:

The therapists at your loved one's rehab facility can sincerely care about their patients. They can be prepared to advocate aggressively on your loved one's behalf. They could be taking copious notes about every detail of every treatment. They might pore over the chart, drinking in each med and status change. They are probably prepared to give you lots of time to talk about all your concerns, observations, fears, and frustrations.

Also, they might REALLY like you to not follow them around the cafeteria on their lunch break reiterating all of the above.

Seriously, don't do that. We have rules about professional behavior, and we have patient satisfaction goals. I even have personal, up-with-people, ethics. All of which preclude me from saying what I'm thinking, which is that you should f-ing leave me alone during my lunch break.

Seriously.