Last week my 10-year-old daughter pointed to her leg and asked "What's this bone called, Mom?" Specifically, she was pointing to a bony prominence on the lateral aspect of her lower leg and wondering why her friend had a "bigger bump" than herself. I quickly responded "Well, that's your..." and in that moment I realized two facts: I could name all the muscles associated with the lower extremity but I could not recall the name of that bone.
As a parent, when confronted with a question that I don't readily feel I can answer sufficiently, I try to spin a "teaching moment" for my kids and myself. In this case, "Let's look it up!" I told my daughter and her friend. As luck (or positional irony) would have it, I had recently unpacked a box of my physical therapy textbooks from school including a beloved original anatomy text that was sitting in the kitchen.
As I fished through the pages looking for the knee chapter, I remembered how arduous the anatomy class was for me back in my first semester of PTA school. The rote memorization of the OIAN of muscles and general frustration of trying to understand the shoulder joint. As if by osmosis of simply holding the anatomy book, I recalled the bony prominence in question: fibular head.
That's right -- I had completely forgotten the name for the fibula. More than disappointing considering I've been a PTA for a number of years now. I did a quick checklist of all the major bones of the extremities and spine that I could identify -- not too bad. But I wasn't going to pat myself on the back -- I forgot the fibula after all. The fact is my anatomy skills are rusty.
Just like I tell my patients, if you don't use it -- you'll lose it. In their case, I'm referring to the ability to walk if they don't attempt to stand, but the same can be applied to anything including anatomy knowledge. I simply don't treat many orthopedic patients in my SNF/long-term care facility. My focus is improving balance, transfers and gait safety. The majority of my patients are end-of-life and/or have an advanced dementia diagnosis. My approach and communication skills are strong because they have to be to work with that particular population. My recall of the carpal ligaments? Not so much.
I now have my old anatomy textbook at the ready at work, including a very helpful anatomy app on my phone that was reviewed and recommended by ADVANCE recently. I also plan on taking a few continuing ed courses that focus on specific joint rehab I feel the need to review. The "unidentified bump" debacle was an important reminder that I'll need to be responsible for maintaining my knowledge and skill level regardless of the setting where I work. As well, I won't have to pause when locating the fibular head anytime soon.
I have found there are a few skill sets PTAs might find useful in their careers that are not covered in the PTA program curriculum. The techniques relate mostly to skilled nursing PT, as that's been my setting since I graduated, but can certainly translate to home health or inpatient/acute physical therapy.
The first and most often demonstrated (during my typical day) is toilet transfer training. I would also include bedside commode (BSC) transfer under this skill. Perhaps due to occupational therapy's ownership of bathroom ADLs of all kinds, this particular transfer was never discussed in class. That's just my theory and I'm probably completely off the mark (side note: I love OTs!). As it turns out, I perform toilet transfers multiple times a day to work toward a safer, functional transfer. Quite often, the primary PT will set a toilet or BSC t/f as one of the patient's short-term goals.
Speaking of transfers not discussed in PTA school: car transfers. Again, here is a functional transfer I regularly include in therapy sessions that involve the patient and family/friends. Typically everyone involved is eager to learn and motivated since the result is the patient's increased safety and independence (and ability to leave the facility -- which is a huge incentive for them).
Last but certainly not least, wheelchair management training. Although we did indeed have thorough training in wheelchair fitting in class, I was never taught how to adjust the brakes, attach anti-tippers or raise/lower the wheel height. All of which I've had to learn and perform on almost a daily basis. Disclaimer: both SNF rehab departments I've worked in did not employ a rehab aide who could also perform these maintenance services. However, I find knowing how a wheelchair is constructed and can be modified only makes me a better clinician for my patients. Not to mention, sometimes I'm the only person there to fix it.
Let's face the facts: On-the-job training post-PTA program profoundly trumps the basic skills you learn in school. An accredited PTA program offers a stunning amount of information in a concise, accelerated time frame. I still recall my instructor stating that it was impossible to teach us every skill we'll require for our patients and he was absolutely right, of course. But a few extra optional labs in the handicap-accessible bathrooms might've been beneficial.
"I have a positive attitude and I surround myself with positive people. I eat cleanly and have a bowel movement every day -- it makes a difference (wink)."
This wise statement was given to me by a 98-year-old patient when I asked her, "What is the secret to aging gracefully?" This particular person did not use an assistive device, walked faster than me and had better posture than anyone I knew, regardless of age.
Over the past few years, my PT caseload had been predominately made up of the geriatric population. Since I started in skilled nursing therapy, a day hasn't gone by where I haven't learned something from my patients about the human condition. Whether witnessing the steadfast resiliency of an 80-plus-year-old recovering from a pelvic fracture or the gentle wilting of spirit with a person suffering from dementia -- each day holds lessons that I might not have been able to experience if not for physical therapy.
I find treating the geriatric patient as rewarding as a high-level athlete. Typically, my patients are dedicated, respectful to their plan of care and tough-as-nails (there are always those exceptions to the rule, though). As well, there's an absence of the sense of entitlement many other younger patients from different generations carry to their treatment session.
Working in a skilled nursing/long-term care setting with this age group has enabled me to take a hard look at my lifestyle and attitude. What can I do today that will improve my health and quality of life when I'm 90? That is if I'm lucky enough to reach my ninth decade. Personally I've attempted to reduce the level of stress I allow in my life, move my body as much as I can and, as my 98-year-old patient sagely stated -- stay positive.
Summer is in full swing as we head into July. The kids are out of school, the sun is out (even in the drippy Pacific Northwest that I call home) and everyone has earmarked their week/s of vacation in the coming month or two. Working full-time in any job, really, warrants at least a week of mental and physical relaxation outside the "office." In the skilled nursing setting -- between efficiency scrutiny and challenging patient caseloads, those vacation days can be a lifeline or at least an oasis to recharge my energy and outlook.
This year, however, I've accrued no vacation days due to starting a new job a few months ago and having to wait a year before I can take a "paid" vacation day per contract outlines. Although I do get paid holidays, those days are considered typical working days if they fall on Monday through Friday. This means, other than taking a sick day when I am or (more often than not) my kids are ill, I won't see a paid vacation day until the summer of 2015. Let me just emphasize that taking a few days off to nurse a sick child is no vacation, by any stretch of the imagination.
Do I appreciate that my employer offers paid vacation? Absolutely! In fact, post-one year of employment, I'll receive 15 days to enjoy throughout that following year. In the interim, I'm monopolizing my weekend days with mini road trips and "stay-cations," kids in tow. A few extra days tacked onto these weekends would be ideal, but for now I'm finding the peace and reenergizing rest I need close to home. As well, this is giving me the time and motivation to schedule the next big family trip. When summer rolls round next year, this PTA will be relaxing far from home or facility pressures, preferably on an uneventful beach that only follows island time.
Recently, in the middle of a treatment session, I had a patient worriedly ask me if the skilled nursing facility where we were working was "going out of business." Considering how random the question was, but more importantly how concerned the patient seemed, I attempted to ease his mind with the truthful answer of the facility's stable future.
I followed this up with a question about where he heard this information. The patient then stated he knew of employees' hours being cut and general nervous malaise spreading throughout the staff.
How would a patient know of staff members having garnished hours? Either an employee of the facility felt the need to share this type of information to the patient or (more likely than not) the patient overheard a conversation between staff. Whichever might have been the case, this additional stress is the last worry a patient should be concerned with.
When in the therapy gym or the busy hallways of the SNF, information between therapists and other healthcare staff is exchanged constantly. How easy is it to "vent" frustrations to each other -- whether about a specific patient, colleague or facility practice? Very simply human nature, of course. I find "discussing" my day with colleagues to be an imperative stress reducer -- when patients are not present and in the privacy of a closed therapy gym, that is. One unguarded and disparaging comment in front of an unassuming patient can potentially lead to days of confusion and anxiety for him.
Working in healthcare can be incredibly stressful -- as we all know. In addition, our patients can be compromised with pain, depression and anxiety of their own. Guarding our private conversations from patients is just another safety measure to insure patient comfort and confidence in their care team. Not to mention, avoid those awkward conversations.
There are many motivating techniques as PT/PTAs we can utilize with our patients to encourage participation and compliance with their plan of care. I like to think my ability to discuss a wide range of topics (Halibut fishing? NFL stats? Crochet patterns?) can angle me into getting an extra ther-ex set of mini squats. Despite my varied repartee with patients, I've found nothing as truly motivating as having family present during a session.
Having worked with the young 18-30-year-old to the end-of-life geriatric patient, I can tell you from my experience, when a spouse, parent or child is observing or in many cases participating during the treatment, the patient (in most cases) exerts more energy and simply tries harder than if it were a regular one-on-one session. This does not exclude patients with cognitive impairments. I've seen patients with advanced dementia, who are typically agitated and nonverbal become (physically and emotionally) calm and even carry on conversations with their family members. This results in a vastly more productive therapy session than the average with that person.
With a few beautiful exceptions, most patients don't have family members present during their daily treatments because it just isn't realistic. Most patients have therapy 5-7 days a week and their close family members work or often don't have transportation to the facility (this is a major obstacle for spouses who don't drive anymore). When the opportunity arises and a family member happens to visit during the patient's scheduled therapy hour, I highly encourage that person attending. Often family and friends feel like they're "intruding" or "disrupting" their loved one's therapy session. I'll take that opportunity to educate the family on the importance of their presence and encouragement.
Unfortunately, there are instances where family members are so incredibly uncomfortable witnessing their loved ones weak and ill -- they can't leave the patient's room fast enough as I enter to begin therapy. But when the opportunity arises, those family and friends can be incorporated into a therapeutic session. I never pass up the chance to suggest they observe or, even better, encourage them to participate in the therapy session. The cathartic love that family brings into therapy can be the most successful tool for a person's recovery.
Once upon a time, not but a short few months ago, I worked in a large corporate-run skilled nursing facility where the productivity of the rehab staff was considered top priority. Even above the recovery of the patients, you may ask? Almost -- with productivity expectations a very close second. Every week our rehab meeting would lead with our director addressing our "team" productivity percentage average.
My days were spent running from one patient to another -- furiously, scheduling my patients back-to-back, so I would only "lose" 2-5 minutes between each treatment session. An unexpected family visit or unscheduled out-of-facility MD appointment for one of my patients could sabotage my productivity for the day. I would half-joke with my colleagues that I could pinpoint the exact time of day when my productivity dropped from 90 to 70%.
With that type of atmosphere, I would get anxious during my "downtime" between treatments, sometimes breaking off a quick casual conversation with a patient or family member because I had to track down my next patient. When spending just a few extra minutes with a person can be the highlight of his session or at the very least build a rapport of trust.
You can imagine my shock when I began my current job at another skilled nursing/long-term care facility where I was told productivity was not their driving focus. Due to the fact that this rehab department was "in transition" -- the expectation was to deliver quality therapy as they build up their rehab unit over the next few months. As the only PTA and one of only three therapists making up the team, there's still quite a lot of building to be done.
Although I don't have the "productivity police" looming over my head on a daily basis anymore, I continue to be shrewd with my timing and often feel my pulse quicken when a treatment is delayed unexpectedly. I have no doubt when the new rehab department is in full swing and the gym is bustling with patients and therapists, our productivity will be scrutinized more than it is now. But until then, I'll enjoy rapport-building and helping patients reach their goals vs. my minutes reaching 90%.
Last weekend I ran my second half-marathon. In hindsight, I'm pleased with my performance, having finished 4 minutes faster than last year's half. When I signed up for the run this year, however, I originally set the lofty goal of running the full marathon. I gave myself four months to train and established a week-by-week running regime to reach my goal. The first two months went well -- I didn't miss a training run and was easily increasing the mileage. Then life happened. Between unexpectedly switching jobs and a hard-hitting flu bug sweeping through the household, somewhere between week 8 or 10, the plan jumped the tracks.
When I came to terms with the fact that I would have to "downgrade" to running the half-marathon vs. the full, I was initially disappointed in myself. It was then I realized there are many times in the physical therapy setting when I have to recommend that a patient downgrades a short- or long-term goal. Despite the concerted efforts of the patient, the primary PT and myself, sometimes reaching a particular functional goal becomes unrealistic. If a patient has to return to ambulating with a front-wheeled walker versus the four-wheeled rolling walker due to increased weakness as a result of a health decline -- that's simply the more realistic and safer choice.
I'll explain to the patient that goals are established in the plan of care by the PT to reach his highest function and independence. The goals are assessed weekly and adjusted accordingly. There are even times when patients far surpass a short-term goal and surprise everyone on their rehab team, including themselves. Whichever the outcome, the only way to "fail" is to give up and not participate entirely. Perhaps a gait goal was never fully met and maybe I'll never run a full marathon -- but when the effort was made and the goal modified and reached, people should not be disappointed in themselves.
I recently had a routine but painful dental procedure performed by my good-natured dentist. As I sat, gripping the armrests of the exam chair, the dentist attempted to distract me (in vain) with small talk about my family and the "crazy Spring weather we're having" -- as he proceeded to insert a sharp tool into my gum line.
His distraction techniques did not work on this patient, however. As I knew how uncomfortable I was about to become and the last thing I wanted to part take in at that moment was casual banter about the increased rainfall.
It's moments like these that help me reflect on my own ability to distract patients in moments of therapy-induced pain. Patients with ORIF procedures or hip and knee replacements maintain a steady, high level of pain for many days and sometimes weeks post op. Despite diligent pre-medication, therapy can seem like necessary torture at times.
My therapeutic style is brutal honesty with the patient. Before we do the first ankle pump, I like to give the "game plan" for the therapy session, so the patient knows there will be a beginning (bed exercises), middle (transfer training) and end (gait training -- then ice!). I find that if patients feel like they have some control over their therapy, they can persevere and complete the session.
Without a doubt, I also distract with conversation. Supine exercises and seated rest breaks between gait-training bouts are the perfect opportunity to engage patients on their favorite interests, whether it's family, job, sports or their dogs. I have many, many in-depth discussions about people's pets. I think patients feel more at ease when disclosing details of their lives that are most important to them, especially if it brings them comfort and pride when they're feeling the most vulnerable.
Personally I think ignoring or not recognizing someone's pain, whether in the role of clinician or patient, can strain the relationship and ultimately the outcome of the therapy session. I've found that learning how to finesse the art of distraction (and honesty) has had positive outcomes for my patients throughout the years. How do you "distract" patients through a tough therapy treatment?
Last month I was lucky enough to celebrate turning the age of 40. One would assume, as I did, that working with the geriatric population on a daily basis for years by this point would give me a healthy perspective on aging. In general, I like to think it has -- especially experiencing the resiliency of the human body and spirit. However, reaching this personal milestone came with a large dose of unexpected anxiety and stress.
I've always felt age is a subjective description of one's self -- having met 30-year-old patients who behave like they're in a 75-year-old body and 90-year-olds who don't look a day over 65. As we all know, lifestyle and genetics hold a tight grip when it comes to "aging gracefully." Maybe this is the reason I, for lack of a better description, "flipped out" as my birthday drew near.
My midlife crisis at least had a healthy theme to it. A few months before my birthday, I began swimming laps three times a week, which I hadn't done in 20 years. I also learned to rock climb and signed up to run a full marathon. I was obviously feeling energetic and very ambitious... also compensating for not having enough funds to buy a cute sports car.
For me, turning 40 was "the beginning of the end of life," which is a completely ridiculous and naive way of viewing age. But alas, that's how I felt. Luckily, working with my patients -- the above 75 set -- left me feeling humbled and appreciative. When a few patients learned it was my birthday and asked my age, I received a lot of: "Forty was the best time of my life," "If I could only go back to that age" and "You're still so young, dear." One of the best pieces of advice I received was from a 90-year-old resident, who told me "just don't stop moving." Frankly, those are some of the wisest words I've heard in all my 40 years to date.
I'm pleased to report, my birthday panic has completely gone -- funny how that happens when you learn to accept the inevitable. The good news is that I'm still training for that marathon and continue my swimming every Saturday. Best of all, working in skilled nursing every day allows me to keep that healthy aging perspective in check -- and appreciate life.
Every week I'll perform therapy screens on long-term care patients at the skilled nursing facility where I work. Often, this is a result of a patient's recent falling episode or general decline in transfer safety. Typically the patient, whether modified independent with his walker or wheelchair level, is a fall risk. We just have to assess if therapy services can reduce injury to the patient and staff during functional transfers.
After discussing the patient's current physical condition and transfer status with staff, I'll submit my recommendation for a possible evaluation by a physical therapist if the patient's insurance allows or if a restorative program is more appropriate. Many times, a patient will be picked up on caseload who has just experienced a recent health decline (fracture, pneumonia etc.) and will be seen in therapy a few times a week for increased strength and functional transfer safety.
It's exciting when we see a patient progress from a dependent sling lift transfer to a minimal assist with aide staff within a short few weeks of therapy. Even more rewarding is helping a patient walk the length of the parallel bars after being non-ambulatory for over a year. The one potential drawback we find is that with the increased strength and self-assist the patient is gaining, so is the potential risk of these folks attempting to self-transfer.
Whether the patient has cognitive issues or not, with increased practice and familiarity transferring from a wheelchair to his bed with therapy, the temptation to attempt the transfer himself increases as well. The nursing staff describes this phenomenon as "just strong enough to fall." They're right, of course, but we're also just effectively doing what the therapy department was asked to do -- improve the physical strength of the patient. Along with this increased self-assist, we also educate the patient in safety strategies and waiting for staff to arrive to provide continued assistance when necessary.
Unfortunately, there will always be a few patients who attempt transferring and walking on their own that will result in a fall -- despite all the education provided by their therapist. In my opinion, the prevented falls and injury to patients and staff due to exercise and training in physical therapy far outweigh the risk.
Having worked in the skilled nursing setting for a number of years now, I'm always struck by how much I have to communicate with the nursing aide staff. Whether it pertains to a patient's transfer status or what time a shower is scheduled, I'm constantly "grabbing" a CNA for information.
One of the first pieces of advice a veteran PT gave me when I started my career in skilled nursing physical therapy was "be friendly to the aide staff -- you'll need their help." This advice could not have been more productive. Numerous times a week, I'm seeking an aide to assist me with a two-person transfer or requesting a patient be up and ready for therapy at a specific time.
Often, I'll have to discuss the patient's transfer safety and complete training with the aide staff when a patient's transfer is upgraded. This can be hard to negotiate during the day as aides are constantly on the move assisting patients and most often understaffed.
I've found the most compassionate and bright CNAs do not last long in the facility. No surprise, these ladies and gentlemen are on the RN nursing track and ultimately leave to go back to school. This leads me to the baffling question of why do nursing assistants make minimum wage? I agree that a six-week certification program should not garner a six-figure salary, but I don't think I'm far off when I say they deserve to make more than say, retail -- selling shoes.
Another PTA friend who worked in the SNF setting suggested that CNAs make $15 across the board, which would help with maintaining good quality staff and job retention. Considering the physical labor and importance of their clientele, I have to agree.
I consider aides to be working on the "front lines" of healthcare. A position that is notoriously and inexplicably underappreciated. An observant CNA can alert the nursing staff to a potentially serious health decline of a patient. As well, aides are assisting patients more than any other staff member. In many ways they represent the facility or hospital in the patient's view. Many of my patients can't stop extolling the virtues of an excellent CNA who is working with them.
However, an apathetic or "moody" aide encounter can affect a patient's day and even his focus in a therapy session. If I were the administrator in a healthcare facility, I would take a hard look at this fact. But in the meantime, I assist my CNA friends as much as I can on the floor.
Recently, I approached one of my patients for therapy participation and was quickly given a decline. Up to this point, the patient (who newly arrived to the skilled nursing facility a few days prior) had been agreeable to therapy. The refusal was quick and adamant, which included the following myriad of reasons: she was in pain, did not sleep the previous evening and felt she "overdid it in yesterday's session." Pain and fatigue are the most common reasons a person will not be enthusiastic at the prospect of daily gait training.
In further discussion with this particular patient, I found out she was also anxious with aide staff, feeling frustrated with her family and she was constipated. After hearing these additional details and educating on the importance of physical movement and healing, the patient really looked at me for the first time during the conversation and stated that she felt depressed.
Having been diagnosed with clinical depression more than once in my life, I take that statement with the weight it deserves. Depression can sneak into your life and steal all of the energy and motivation that you think you might possess. When you need physical activity the most, every fiber of your body resists. Depression in patients is common and comes as no surprise considering the increased stress and fatigue associated with hospitalization. By the time patients arrive to a SNF, they have already experienced major surgery or illness and most likely have been isolated from their home for quite a while. It's crucial that patients get out of bed and physically start moving at this point -- for their body and mind.
If I suspect depression or, as in this case, a patient verbally states the fact, I will alert the nursing staff and primary physical therapist. Once recognized, each department can address the depression before it can completely sabotage the patient's recovery.
Luckily, physical therapy plays a key component in overcoming or avoiding depression altogether. Armed with this knowledge, a successful therapy session becomes as important as an anti-depressive medication. Maybe even more effective.
A few weeks ago, I began a new PTA position at a long-term care/skilled nursing facility. Although the setting may be the same as my former job, the facility is run completely different. Transitioning from a large established rehab team to a small, newly formed therapy department has had its highs and lows, as I'm finding out.
Due to a smaller caseload of patients, I'm currently one of only three clinicians (including the rehab director) who make up our fledgling team. Initially, I was expecting this to be a disadvantage, as working with multiple PT and PTAs was something I always considered a strength in a therapy team. If I had a question or sought advice with progressing a patient, an experienced PT or PTA would be there to offer help. As well, with a deep pool of OTs/COTAs making up the other half of the department, discussing shared patients and planned co-treatments would happen daily.
The downside to having such a large rehab staff is that the patients would be seen by two, three or sometimes four different therapists within a week or two. As well, a few of the primary PTs worked part-time, so consulting about the patient's plan of care could get difficult (when in doubt, I would consult with my DOR, of course). At times, this would leave me feeling disconnected from the primary therapist and frustrated with the process.
As I'm discovering in my new facility, working under just one primary physical therapist solves many of the problems I faced in the larger team atmosphere. This therapist is present every day and each patient is discussed to some degree or another throughout the day. If I have questions or thoughts regarding the plan of care, I know she will be able to field the discussion within the same day. Having a single "PT-PTA" team seems to be working on our small rehab department and I only expect it to grow stronger as we gain more experience with each other and our clientele.
Do you work in a large clinic or a smaller private setting with less staff? What advantages do you see with the size of your rehab department? I'm interested in your input and I'll let you know how it continues in my setting. Thanks!
Although having only been a PTA for three years, I've found myself in conversations with many potential future SPTA candidates. Quite a few have been with bright and hardworking CNAs who I work with in skilled nursing and others have been with folks my age or older (that would be the 40+ set if you were wondering) looking into PTA as a second or third career.
For those seeking direction about entering the physical therapy field -- I say this: The accredited PTA programs available are incredibly challenging, so be prepared to study and be tested weekly for almost two years without a significant break. I don't mince words or sugarcoat the process because people need to understand the commitment level you take on as a SPTA. However, when you've earned your degree and pass the state board -- you'll be working in a vastly varied field where your choice of setting and patient type can range from the local gym with a 12-year-old soccer player to the hospital with a 90-year-old recovering from hip surgery.
Whichever setting and patient group they ultimately choose to work with, I tell them they have to love it. If you're passionate about orthopedic PT but working in a skilled nursing setting with little exposure to ortho conditions, maybe it's time to make a job switch. Patients will know if your heart's not "in it" and frankly, you've worked too hard to just "phone it in" at work daily. Having said that -- give each PT setting a try, whether job shadowing a PTA or when choosing your clinical affiliations.
Personally, I find discussing the PTA profession with other interested parties to be one of my duties as a licensed healthcare professional in this field. Physical therapy has given me a profound insight into the human condition as well as myself. Providing advice and mentoring future PTAs can only support the long-term strength of the profession.