Emotional de- attachment

By Mariel | Published February 1, 2012

I don’t know what it is about me, but I have never been so attached to my pts that I have cried at work or cried at home for them. Don’t get me wrong, I care deeply for my pts. It always makes me so sad when I hear of someone dying, or I know they have a terrible prognosis. I love my job and I love OT. I look at pts holistically, but I know that it can be a big emotional burden. I have written about this before. Thank goodness, I do not have as intense a caseload currently.

I was talking to one of the volunteers and she has never experienced death in her life. My grandpa died when I was 5, my uncle when I was 11, and my dad when I was 23. I know what value life has, the memories that someone leaves with you, the imprint they have on this earth. That being said, I mourn for my pts, but on the inside. I don’t outwardly show this to my co-workers and I don’t really talk to my husband about it. I internalize it, for better or worse. I belive in reflection, which I do often. I think about my dear pts that have passed away or have a terrible prognosis. I care for them with compassion, but I cannot let it bother me so much that I cannot go on living. I would be a terrible therapist if I let that happen. You need to be able to appreciate humanity but also respect the circle of life. It’s the only way you will survive being a therapist.

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Large and in charge!

By Mariel | Published January 12, 2012

I’ve got a few pts on my caseload right now who probably weigh about 350 pounds each. That is about 3x my body weight. Something that I know is true when working with obese people is that they have decreased bed mobility. They have extra girth around their body that limits the ability to get in and out of bed. As an occupational therapist, this also applies to other activities of daily living. Some pts are so large that they cannot do post-toilet hygiene or tie their shoes. The hospital bathrooms are too narrow for the pt to comfortably use. I am not prejudiced against obese people. My whole immediate family is obese. I am simply acknowledging that as an occupational therapist analyzing the abilities of people to do activities of daily living, being morbidly obese hinders independence in occupational performance. It especially makes it more difficult to recover more easily from a life saving surgery.

One pt had abdominal surgery. He has a large belly, bigger than Santa Claus. It is getting in the way of getting in and out of bed. He has no problem walking. He’s steady on his feet.  Another pt has abdominal pain and bloating. She is also very weak from cancer. She is so bottom heavy that it’s hard to get the right momentum to get out of a chair. The extra poundage is hard to move against gravity and the less you move, the harder you have to work to get better. I’m doing my part by seeing these pts daily and encouraging to move around more. It’s working but not without its challenges. You can seriously injure yourself trying to move a heavy pt. Do not do it by yourself. I usually have the pts do as much as they can for two reasons: 1. it’s therapeutic for them and 2. I want to limit my exposure to injury as much as possible.  Nursing staff, on the other hand, feel they are limited in time so they try to do more of the work, instead of giving the pt a few minutes to do it on their own. As a healthcare worker, you need to protect yourself first, before the pt.  If you hurt your back trying to move someone, you would be no use to them or yourself.

It’s important to have good problem solving as a therapist, to be able to get yourself out of a jam when needed.

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You better watch your back!

By Mariel | Published September 26, 2011

Wednesdays have not been good days for me. I don’t know what it is, but the last two Wednesdays, I have tweaked my back at work. Ugh! Terrible. Last week was really bad. I was with a very needy pt. I was in his room for about 90 minutes (which is way too long!). He has been in the hospital for over 5 weeks and his anxiety is through the roof! At this point, he just can’t stay still or get comfortable. One minute, he wants to sit up…the next, he wants to sit down. It was like that for the whole session. I did my best to encourage him to take steps, to sit up in the chair, to do his ADL while seated in the chair….it was really like pulling teeth. His poor wife! This man was encumbered by IV lines, telemetry lines, oxygen. I should not have let the hospital equipment get in my way. I should have really gotten further down, squatted more and used better body mechanics. But I didn’t. So, my back hurt by the end of the session. And that was the beginning of my day! Oh, I hurt! It wasn’t super terrible. I could still feel my legs. I didn’t have any numbness or tingling down my legs. But oh, the pain to just move or walk around. I was uncomfortable for the rest of the day. I did lay on ice and that helped. I also did yoga that day to help re-align myself. But even 5 days later, my massage therapist mentioned, “This side of your back is much tighter than the other side.” By then, my back felt back to normal but to have her tell me that I was still tweaked was not a good feeling.

As a health care professional and being in the helping profession, I still have to remind myself that I need to take care of myself. As much as I care for my pts…they don’t care about me. They really don’t. They don’t care if I herniate a disk, tear a ligament or break a bone….just so long as I can help them to get better. And that’s wrong. Above all else, I need to take care of myself. Because if I don’t, who will take care of me?

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Empathy

By Mariel | Published September 21, 2011

According to Merriam-Webster’s dictionary: empathy |ˈempəθē|noun   the ability to understand and share the feelings of another.

As a therapist, you need to have empathy. I feel like that’s a non-negotiable. However, there are tons of therapists who do not think that. If you had a therapist who didn’t have any empathy, he might just come right into your room and say “We’re getting you up now.” And you’re thinking, “Wait! I’m not ready!.” Obviously, part of being a therapist is educating the pt on how to work the body to their advantage and make things easier.

On the other hand, I just worked with a pt with metastatic prostate cancer. He sustained bilateral pathological fractures of his femurs requiring bilateral hip replacements. He was in great pain, literally coming from his bones. My job was to get him out of bed and into a chair so he could participate in some ADL. I understood that this man was in great pain. His wife was in the room and very encouraging. She wanted him out of bed, following doctor’s orders, doing more normal things than just staying in bed all day.

We started the session going very slowly. I educated him to take deep breaths and how to position his body to get him in the bed position to swing to the side of the bed. We were only able to move his legs about 5 inches before he started getting mean. Two RNs showed up to assist me and to change his bed linens after he was sitting in a chair. With the help of me, two RNs, the pt’s wife and a whole lot of mean things being said from the pt, he was able to sit at the edge of the bed for over 30 mins and finally stand up on his own two feet twice, post-op day 2. It wasn’t perfect but we had accomplished something. Needless to say, he was not very happy with me. He was in a lot more pain.  I remember telling him during the tx, “I don’t care if you hate me, but if I can get you back to sleeping in your own bed, it was worth it.”

To a certain extent, I feel like I was that therapist who just came in and said “We’re doing this.”  I know that my pt agreed to the therapy, otherwise, we would not have done what we did. That session was over one hour of me sweating, positioning the pt, educating his wife and the RNs on where to position their bodies so we could accomplish this task. I certainly had empathy and could appreciate that this man was in a great deal of pain.  But was I being too pushy? In my mind, I was helping this man. I know his attending MD and his wife wanted him out of bed. Was the means to the end justified here? I mean, he did agree to do therapy. I guess what I’m concerned about is that halfway through the tx session, he didn’t want to do it anymore. He just stopped working with us, which was really hard. And it made me feel like I was forcing him to do stuff. In a way, I had to force him, because I couldn’t let him just slide off the bed. I needed to end the session with him in a comfortable position.

Working with pts can be tricky and working with people who have cancer makes it that much harder.  I guess you just have to look at it from all the angles. What the pt feels, what’s best for the pt medically, what the pt and family want to do, what is meaningful to the pt. So many variables!

 

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Eye sea ewe

By Mariel | Published September 7, 2011

These last two weeks I have been spending a lot of time in the intensive care unit. More than half of my patients are there; with tubes sticking out of every orifice (or newly made ones!). It can be kind of scary and intimidating to walk into the ICU. The nurses there are very passionate about what they do. They love their patients and love their jobs. Medical doctors are talking a mile a minute about what’s wrong with pts.  Someone’s CPAP’ing here or she’s draining there, wound vac here, he’s extubated today, sprinting (it’s not what you think!), too many drugs and catheters, Fentanyl, hospice consult….that’s just part of what’s going on in the ICU.

It’s possible that the pts just look like blobs laying in bed. Respiratory therapy is trying to get pts to breathe on their own while the pts are trying not to lose hope that one day they will walk out of the hospital. Sprinting is after extubation-when respiratory therapy is trying to get the pt’s intercostal and respiratory muscles to work how they used to, before the pt was intubated. So, try to imagine that in your mind: You had a tube shoved down your throat so that you could breathe. They pulled the tube out. Now your mouth and throat are sore and your lungs, ribs, chest are so weak, that you can’t even breathe on your own. You need to exercise your respiratory muscles! I don’t know about you, but I just breathe. Some times, I tell myself to take a deep breath, but I can breathe without really thinking about it. Breathing doesn’t really bother me. I just do it. For my ICU pts, breathing is a workout that needs to be finely balanced with other exercises.

So what role does occupational therapy play if the pts can’t even breathe? This is where it can get confusing because occupational therapy can start to look like physical therapy here. Preparatory methods of intervention are used to prepare the pt for purposeful or occupation-based activity. How can someone start dressing himself or transfer herself to the toilet if he/she can’t even sit up on the edge of the bed without help? This is when OTs just start with rolling in bed, bed mobility, range of motion and general strengthening. It’s not very glamorous and it gets kind of boring, but you have to do it to get to the end goal. Usually people want to be independent, which is why OT is so important.

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9/5/11

By Mariel | Published September 5, 2011

I just found out that one of my pts died. One of the young guys with testicular cancer. I know that as an occupational therapist, I am poised to be a very special figure in the last days, weeks, or months of someone’s life. My boss had said in a staff meeting that years ago, therapy was denied near the end of life because insurance companies thought something along the lines of, “What’s the point? The person is going to die.”  Nowadays, occupational therapy is not denied and is valid because it improves the pt’s quality of life in those last days. I think that makes a world of difference. Would you want to be as independent as possible, up to the end?

 

 

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Therapeutic use of self

By Mariel | Published September 1, 2011

In my miscarriage post, I mentioned therapeutic use of self. Does it sound weird? As a therapist, you can use yourself as a tool for therapy. And it’s true. You develop a rapport with your pts, you learn what they like, strive for, live for, what motivates them. And you use that to your advantage.  According to the “Pedretti’s Occupational Therapy, Practice Skills for Physical Dysfunction,” therapeutic use of self means that the OT uses own self and all that entails (knowledge, personality, and experience) conveying empathy, active listening, and establishing trust.

It’s quite fascinating how important it is for you to be confident in yourself and your skills to be an effective therapist. As one of my favorite psychiatrists said, “It’s all about the delivery.” If you exude that confidence, your pt will have confidence that the therapy will help him/her, in turn boosting the effectiveness of the therapy. It’s not just the physical part of therapy that will get results, it’s the mental component too.

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