I have been working in both inpatient (IP) and outpatient (OP) lately. What I like about inpatient is that the schedule is more flexible. If I get through all my pts, I can have down time to check my email, do work projects, clean or go hunting for items from the rehab dept that have mysteriously disappeared.  I see pts in their most acute state. I get to see someone the day he had a stroke, the day after she had brain surgery, the day after a hip surgery. I converse with other healthcare professionals (RNs, MDs, RTs, CNAs, NPs, PAs) on a regular basis to talk about discharge plans or pt status. I don’t like how physically demanding it is. It can hurt my back, if I have a really hefty or anxious pt. But on the other hand, it could be really easy, if I have pts who can move around well. I don’t like how boring it can get. It can be pretty monotonous some times, seeing joint replacements, back surgeries and brain tumors, cancer. It just gets to be the same old thing, at least to me. Another thing is that the pts are barely wearing any clothes. They might poop, vomit or faint on you. Or the pt may not be available because the pt is having an echocardiogram, cardioversion, PEG tube placement, wound vac placement, anything.

In outpatient therapy, the pts come to you. You don’t expect them to vomit on you, so you can wear nicer clothes. It can be monotonous….carpal tunnel, tennis elbow, forearm pain. Or it can be really challenging….Parkinson’s disease, hemiplegia, oculomotor difficulties, post-op hand pts. It just depends. As the occupational therapist, I set the treatment plan and I choose the interventions. You could argue that therapy is only as boring as you make it.  I don’t like the ergonomics of outpatient. My upper traps  always seem to tense up and then I am in pain…in need of therapy myself. The scheduling is terrible. I have pts back to back, without time for a bathroom break. On the other hand, outpatient therapy lends itself to specializations. There are tons of specializations/certifications that would serve you well in outpatient, if you were interested. Certified lymphedema therapist, certified hand therapist, vision rehab therapist, driving rehab, assistive technology practitioner, the list goes on.

Someone asked me if I like inpatient or outpatient better. They both have their ups/downs. I do like the variety of doing both. I don’t have a favorite because I think either IP or OP, my mantra still applies:  You need to take care of yourself, because no one will take care of you. The patients don’t care if you are sick. All they want is for you to take care of them. This goes with having good time management (because you want to do your documentation and get out of work when there is still light out), setting limits (if you have to pee, you better do it), and realizing that as the therapist, you are in control of the interventions and tx plan. Don’t have boring therapy if you don’t want boring therapy. And always, take care of yourself!

So for now, I can’t decide if I like IP or OP more. I’ll just stay flexible and keep my options open.

Something I have noticed with my student is that I forget all the things I know as an OT.  I just feel like some things are common sense, “duh!” type of things. However, my student has never worked in a hospital before. She doesn’t know what a Foley catheter is, or what telemetry, A-line, cordis, IJ catheter, chest tube, JP drain, ICP, TLSO, cardiac chair, venodynes, nasal cannula, CPAP, sprinting or I&D are. Even though she is in OT school, she might not know what sternal precautions are, or what spine, hip, or abdominal precautions the pts must follow. She might not know about contact precaution rooms. She doesn’t know that working in an acute care hospital, there are A LOT of rules. Rules that you must follow.

If I just systematically go through my day (which I know all you pre-OT/PT students will like) this is what I do:

7:30 AM- At work. Check the number of evaluations that need to be completed that day. Count the number of pts already on OT service. Prioritize and assign pts to therapists depending on diagnosis and need for therapy. Joint replacements, spine and neuro (stroke, brain tumor, brain injury) pts are going to be top priority. 

7:45 AM- Talk with PTs and other OTs re: pt status of all pts receiving therapy.

8 AM- Up on the floor. Going to see my first pt. Must do a chart review on every pt to see what new things are going on: discharge plan, change in mental or medical status, if the pt will go for tests that day, chemo, etc. Because this is acute care, you must always check with the nurse. What if the pt has orthostatic hypotension? I don’t want the pt to faint on me. What if the pt’s platelet count is low and if the pt falls, the pt might bleed to death? Scary things that you need to think about.

From 8-12, I try to pack in as many pts as I can. I must remember to wash my hands or use the alcohol gel before and after I see each pt. Asides from being good hygiene and illness prevention, that is a mandated rule by The Joint Commission on hospital accreditation. If a pt is on oxygen, I need to find a portable O2 tank before we walk around. If the pt is on telemetry (measuring heart waves, beat, respiratory rate), I need to put the pt on a portable monitor if we leave the bedside.  If the pt is dependent for mobility, I need to find help before I try to move the pt  (I don’t want to hurt myself). Does the pt have non-skid socks on (hospital policy)? Does the pt have diarrhea? If so, I better get an adult diaper and put it on the pt. Before all of this, is the pt even mentally with it to follow directions and be safe out of bed?

12-1PM- LUNCH.  I need to eat because I just burned a ton of calories walking all over the hospital and helping move pts around.

1-4PM- See more pts. Sanitize my walker after every pt use. I need to document on every pt (this is an insurance/legal thing), preferably as soon as I am done with each treatment so that I don’t have paperwork piled up at the end of the day. Touch base with other healthcare providers of my pts, so we are all on the same page re: discharge plan, treatment plan in the hospital, etc.

4PM- Go home.

Yay, my day is done and now I can have “me” time. Time to eat and exercise, so I can keep myself healthy so I can do the routine all over again.

I think it is very important for the pt’s family and friends to be involved and helpful, especially in times of brain injuries or serious hospitalizations such as organ transplants, near end-of-life, new cancer diagnosis.

What do you do when the family or friend of a pt is just a little to pushy during your treatment? There’s a difference between being a pt’s advocate and being overbearing and rude. Being an advocate is helping the pt navigate the system and to make it easier on the pt. Hassling the medical staff will get you nowhere.  Something you have to understand is that you don’t know what the pt or family is going through. Some people have better support systems than others. Some families are tight like glue, others are non-existent, by choice or circumstance.  Someone who the pt does have is you.

The big thing to remember is to have empathy. Look it up in the dictionary. Read it, understand it and be it. You will be a better therapist just by doing that.

It should be common sense that you do not date your patient. However, I have heard stories of therapists having inappropriate or sexual relationships with patients. Seeing as that I am married, I doubt I could have an inappropriate relationship with a pt….or could I?

When you think about the population that the Veterans Affairs hospitals serve, it was no surprise that some pts were really inappropriate. It is mostly men and a majority of them are single, varying in age range from World War II-era to Operation Iraqi Freedom-era. A lot of them have frontal lobe brain injuries, which affects your impulse control and inhibitions.  If you think about it:  you are a young therapist, willing to assist the pt to reach maximum independence….the pt starts to grow on you and like you (for various reasons). I made a point of wearing a wedding band (which I do not normally wear even though I am married) just so that I could have a subtle hint to say, “stay away!” So, yes, pts at the VA did try to hit on me and ask me out on dates, which I politely refused. Yes, the pts were hurt, but would I risk my job and license for a guy? No way!

Alternatively,  I made friends with one of my former pts. This is a different kind of pt/therapist relationship. She is young and had a stroke. She was seeing me to regain function in her previously dominant hand. Part of occupational therapy is therapeutic use of self.  During our therapy sessions, we talked about things and I cheered her on and we ended up having a good pt/therapist relationship.  I suggested things to her to help her acheive her goals, and she complied. Everyone wants a pt like that! Well, medical insurance has a funny way of working. We got to the point that her insurance would no longer pay for visits, and I needed to make sure she could excel in a home exercise program. After her last visit, I didn’t know what happened to her. We had exchanged email addresses some time during our therapy sessions, I think for therapy homework or something like that. Well, since she was no longer my pt, we met for lunch. I was curious to see how she was doing and by that time, we were genuinely friends. Now, I see her a few times a year and we just pick up right where we left off. She is a former pt who I consider one of my good friends. Yes, Disney princess, I am talking about you!

I don’t think being friends with someone who is no longer my pt is wrong.  I do think that going on a date with someone, who you are actively treating, is wrong. If someone wanted to date you, they shouldn’t be your pt. It’s about ethics. What do you think? This goes back to understanding that as a therapist, you are put in a lot of ethical dilemmas (not just pt/therapist relationships), so you always have to think what is right and what is not?

I have really been mulling this over. I work in a somewhat physical job. I have to get people from supine to sit, sit to stand, on the toilet, in the shower. It can be quite demanding on your body. One of the reasons I became on OT is because I’m just not that into going to the gym all the time. I like getting my physical activities through other, organic things like walking to the grocery store, yoga, dancing. I’m definitely not a gym rat. However, as I mentioned in other posts, I have issues with my neck and back. So moving pts really works my muscles but I have come to the realization that I NEED to work out..regularly. I need to do something else, beside work my 40-hour-a-week job. I need to stay healthy. Because, like I’ve posted before, if I don’t take care of myself, no one else will.

My co-workers all love to run. I hate running. I can’t relate when everyone talks about whatever race they are doing next. Someone else swims, some play tennis, some lift weights, some bike. One guy surfs. I do yoga. That really is the thing that I do that helps me with myself, my body, my life. I don’t do the Americanized version of yoga, where you try to do all these crazy poses in a limited amount of time. I like to do gentle, restorative yoga. I like to calm my mind. I like to lie on my back, do spinal twists, breathe, stretch my muscles that get worked out from doing maximum level assistance transfers. It’s important to have good posture and breathing techniques, especially as a therapist. For 2012, I look forward to deepening my yoga practice and taking care of myself more than I take care of my pts. It sounds selfish, but it’s the only way I’m gonna make it to be an old OT. I have to make sure my body can last in this type of physically demanding job. I don’t want to end up like one of my pts and have spinal surgery or a hip replacement. I want to stay as healthy as I can.

Mrs. M was the pt that was having a stroke in the Rehab dept. Her brain and body haven’t been handling the shock so well. Her family put her on comfort care and PT/OT/SLP are no longer working with her. She is/was a very feisty, independent lady. We’re sorry that she is nearing the end of life. I think her family agrees that her 87 years were so full of life. No one ever wants to go, but it’s the circle of life. Some times, you just have to remind yourself that everyone dies and to make the most out of your life. She’s such a sweet lady. Those good memories are what help people go on.