Along with all the chaos that accompanies a capstone project, additional pressing issues come to the front lines. Within the past few months, the subject of G-Codes has taken up a majority of time in regard to educating ourselves, clinical and ancillary staff, as well as a busy IT department. In preparation for a mandatory July 1 compliance date, many hours have been spent trying to configure an operating system that complies with all the necessary information in treating and billing our Medicare patients. Now that the deadline is just around the corner, it's time to test what has been set up to comply with the rules.

A new language was introduced to rehabilitation staff this past week, and although confidence in attempting to explain what needs to be done after July 1 was in the message being delivered, a hint of heightened insecurity was detected by all. As in most situations where major change is about to occur, questions arise about how the implementation will take place, rather than what the final product will look like. This is a time of great change, again, and as the saying goes, "what doesn't kill us will make us stronger." Soon, this too will be behind us, and the next major change is no doubt lurking on the sidelines.

As another weekend approaches, and a plan to complete the first rough draft of my capstone is at the front of my mind, I'm quickly reminded why we need to educate, document and research the reasons we do what we do. In times where reimbursement is becoming more complicated, we must become more savvy in the way we approach payers, by demonstrating a need for our skills and what we can contribute in the care of their clients. By doing so, we're investing in our future, as well as the future of our patients and new professionals in the field.

When it rains, it pours. That's the only thing I can think of as I write endlessly into the night about pelvic fractures, aquatic therapy, and my case report. Sentences are not scarce, and the time to condense the content of this paper is coming this weekend. Limited sleep and awakening to ideas in the middle of the night that I can include in this paper to finish my doctorate is what life is comprised of these days. At least that's all I thought I'd have to deal with in these final weeks.

As I sit at my desk at work, I frequently think of content to include in my report. Yes, I'm consumed at all times with this final project. However, today an event jolted me to the point where I had to step away and call it a day. Tangled in the manuscript in my head, I was startled by a staff member who asked to speak to me behind closed doors. What happened next was quite an alarming admission that her paycheck wasn't what she expected it to be, and that once she paid for part of her rent, she wouldn't have enough money for food for the next two weeks.

Dealing with patient care issues on a daily basis has been quite challenging over the past four months, including difficult patients, parents, and insurance issues. However, I never imagined that my own staff would have to deal with issues like this. Not knowing what to say or even suggest, all I could do was listen and support the employee's concerns. Surprisingly enough, I was able to come up with an idea that may help her situation, but not within the next couple of weeks. Now that I've had time to absorb the conversation, I've come up with other ideas as well.

Another mission is on my plate, to help those around me that need more than I. Rather than losing sleep for the next week, I'll exhaust my energy on others that need help, and continue the chaos of paper-writing during my waking hours. Changing the strategy may be what I need in order to finish the final project for my DPT.

Organizing a case report is proving to be more challenging than ever. Although my patient case is, in my estimation, a complicated issue, I thought for sure that I'd have more than enough to research and background information to present than I'd know what to do with. Interestingly enough, during the exhaustive literature search from last semester, I found minimal information in regard to acetabular and pelvic fractures that I could use to support the need for this case report.

However, as I sit down to begin the background information, I try again to find articles that may have been published on the subject. Instantly, there are four journal articles published in the past month on just the subject I was looking for! As I feverishly read the articles, I realize that this is just the starting position I need to be in.

Starting broadly on the different aspects of my patient case and then paring down to the specifics, I need to tie my patient's comorbidities together. The issues present in this case made the decision to place the patient in an aquatic environment almost a last-ditch effort to hasten her recovery with as little trauma as possible to her already traumatized, post-surgical pelvis.

Thankfully, this motivated and mentally prepared patient was the strongest person I've ever met in my practice to this day, and because of this, she was chosen to be the one I'd describe as my most successful case. As I admitted to her in the middle of her care, I wasn't sure how far she'd progress, but thankfully she took this admission as a challenge to prove my doubts wrong. To this day, she continues to amaze me with her energy, activity and social life (and this is years later).

This is what keeps me reading article after article, in an effort to support the need for this case report. The complexity of the situation, combined with the tremendous outcome due to the patient's personal strength and theoretical basis for the treatment chosen for this case, all play a major part in the development of this report. Now it's time to get back to writing, reading, reviewing and completion of this project.

What has helped me most with this task so far has been reading other case reports. I've learned writing styles vary greatly and each case report is significantly different from the rest. This is what makes even an "average" patient case more interesting and adds to our current body of knowledge. Trying different techniques on similar types of patients, applying techniques that may not be familiar to us, and describing patient case management are three areas I'm considering focusing on with my particular case. However, I believe I have to incorporate all these areas to complete a professional, publishable document for publication.

In an attempt to stay positive and relatively stress-free for the next couple of months, I arrange a busy lifestyle to keep my mind and body healthy. With hard work and determination, I'll end up with my goal being met, and come out with the reward: my DPT!

As the dust begins to settle from separating one department into two, this extended break from school allows me to get a grasp on what being a manager really entails in an outpatient rehabilitation facility. From balancing payroll to juggling hours in three disciplines to staying productive, to completing performance appraisals and performing chart reviews, I quickly realize why I absorb only five hours of sleep each night.

Just like other leaders around me, I thrive on being able to mentor, support and at times counsel staff in a positive light to promote a better system of healthcare. This has been a challenge as more duties are put on my plate. Perhaps five hours of sleep is all that's necessary, except for the fact that I can sleep like a bear on Saturday and Sunday mornings -- which, as a matter of fact, is the time I'll need come this weekend to write the final paper for my DPT.

Some of my most productive "thinking" for this final assignment occurs during the most unexpected times of the day. I find humor in the moments that I come across these productive thoughts, and wonder if I'm the only one who experiences random bursts of mental energy for what I'm about to initiate in this final quest. For example, I've been blessed with a new friend who meets me for coffee before work every morning. As a Native American, he provides such insight into how the universe is connected to us mentally and physically, along with sharing life experiences and influences.

In the midst of such a deep conversation, a flash of a table in a particular case report I read the previous night comes across my mind. Trying to take mental notes of thoughts for this project has proven to be less than successful, so I rely on modern-day technology to save these thoughts for my weekend project. Perhaps it's just the coffee stimulating these thoughts, or perhaps this friend has stirred something in my mind to produce little tidbits that will hopefully assist in building this case report. Whatever the reason, I find myself making an apology for pulling out my phone to keep track of what I may need to complete my project.

Another thought is that I may be burning the candle at both ends, where I keep myself so busy that I only have moments during each day of the week to review in my mind the subject at hand. But even if this is true, I'm determined to produce the end result gracefully. Once this is completed, I'll sleep endlessly, and undoubtedly be able to provide more to my family, friends, dreams and career. Time will tell, my friend explains to me, as the spirits and the universe work together to unfold what is yet to come. I don't know what this means, but I surely embrace positive energy to keep me on track for this journey.

Amazing what can happen in one week. In a major healthcare system of a large metropolitan area surrounded by water, we've successfully accomplished separating pediatric from adult rehabilitation in preparation for our growth as the Rehabilitation Institute of South Florida. Every day of this mission has started at 5 a.m. with communication with one of my best friends, the leader of this department (in addition to being the leader of several other departments). When I look back to the time we met more than 20 years ago, I remember thinking that this person would be someone I'd follow someday. Here I am, years later, reporting to her on a daily basis.

As I struggle with keeping our department productive and mentoring staff including physical, speech and occupational therapists, I'm comforted by the words of many friends that we're becoming a vision for the future of rehabilitative medicine. Not only does a comprehensive rehabilitative system provide every facet of care needed by the community, but also offers a link to other services not regularly affiliated with us (i.e. outreach programs).

Thankfully I'm able to support therapists' ideas to expand our care into the community, as well as continue my support on an individual basis with the Guardian Ad Litem program. Every day is an adventure at this point, between work and a fulfilling personal life with the Guardian program. Time will pass quickly during this transition, as my new semester starts this month.

A short break between semesters has proven to come at the best time for me. Today brings with it a major change in my facility, where one department is becoming two. Employees have been preparing for months for this change, with hopes that everything goes smoothly. In a large department where things don't always go smoothly on a regular day, we have great expectations that the preparation will pay off and a smooth transition will occur.

Starting today (and hopefully for only the next week), we'll be re-registering every patient who comes through our front door. Our first line of defense, the front desk, will be inundated with the process of obtaining signatures for financial and medical consents. We've already begun the process of changing patient accounts to be reassigned to either the adult or the children's hospital, whereas before today the patient's account was registered to only the adult hospital. In preparation for this day, we've assisted our front lines to make the transition as smooth as possible and reduce the chaos that's looming in the next couple of hours.

As I tossed and turned throughout last night about the impending change, I realized that the faith I have in our registration team is what would give me one more hour of sleep before the alarm clock went off. Thankfully, all of this change couldn't have come at a better time. It amazes me that these 11- to 12-hour days at work are only possible because I have two more weeks of break between semesters. However, I continue to gather information for my final paper, which I work on only during the weekend now. School has become my break from a busy work schedule. I welcome the thought of finishing my DPT and wonder what the future holds when I complete my goal.

Registration for the final two courses has taken place. Mental, physical and emotional preparation is next on my agenda. Although I have a pretty good idea about what my case report will be, I often question myself and my ability to develop a doctoral-level document capable of being published. The exhaustive literature search has been literally exhausting. Many nights my bedtime story has been "How to Write a Case Report."

I follow the subject of my case report on Facebook. She has accomplished so much in such a short time since her devastating accident, and is so supportive of my efforts to obtain my DPT. I'm honored she is letting me tell her story, our story, about the success in such a complicated case. She has no idea how thrilled I am to be able to share our treatment approach so that other professionals may use our case as another type of intervention in physical therapy.

In an effort to gain some strength for the final stretch, I take the time to reflect on everything I've learned so far in the past two years. Being out of the classroom for more than 20 years and among the new graduates for the past few years, I can definitely see how my approach to evaluating, examining and treating patients has changed. This cannot be done by reading journal articles alone, or continuing education, or even working alongside other DPTs.

The hours spent being guided by lectures of my professors, self-studies, projects and study groups have definitely enhanced my knowledge base and outlook on our profession. Of course, I continue to see PTs who are resistant to the thought of returning to school for various reasons. Only when they experience the amount of work and knowledge that's available to them at this level will they really come to understand the importance of such a degree.

The concern I had two years ago that I may not be able to make it even this far is hard to even remember. Not only have my four coworkers and I made it this far, but I've been able to raise my two teenage girls alone, rescue countless animals, get in three to four games of tennis a week, become a handler for therapy dogs in my healthcare system, become a Guardian Ad Litem and take on a larger leadership role in my healthcare system. What amazes me even more is what my coworkers have been able to juggle during the same two-year stretch, which only minimizes what I've achieved.

As the light at the end of the tunnel approaches, I must admit the most exciting thought is being able to spend a weekend with my classmates away from home again, as we did when we started the program in June 2011. A weekend away from our busy lifestyles to bond, breathe and just enjoy the accomplishment of such a task is what I'm looking forward to most. This is what I'll keep in mind as I begin the process of writing my case report.

A most disturbing week has occurred, once again, for the citizens of our country. As I look forward to starting a new semester once again and booking a flight to attend a weekend course for the final session in the quest for my DPT, I'm shaken by the latest attack on our fellow citizens. Although acts of terrorism occur all over the world and throughout history, this latest attack brings certain thoughts to my mind about our profession.

Physical therapists continue to be in demand, especially during times like these. Historically, we've been utilized to treat the acute as well as the chronically injured. There is a great deal of need for our assistance in the recovery of our citizens, especially in the long-term effects of such tragedy.

Even in these darkest days, there is a light in my department. She goes by the name "Lily." She's a service dog at my new facility, and I'm the proud "newest" handler on her team. As I sit here and write this week's blog, Lily sits at my feet, fast asleep after meeting the outpatient rehabilitation team at Memorial Regional Hospital/Joe DiMaggio Children's Hospital. She has brought light and life into our patients over the span of just two hours.

The life of this golden retriever is to provide relief to victims of tragedy, as well as relaxation and motivation to those who are rehabilitating in our facility. Thankfully, Lily has joined us at a much-needed time in our lives.

As we move toward the formation of a major rehabilitation provider in the region, meetings, conference calls and webinars fill my schedule. My new role is quickly becoming a challenge, in that therapists are being designated as working for the adult hospital, while others for the children's hospital. Still yet, there are those who work for both facilities, which only confuses the situation with documentation and billing. As a major provider of rehabilitative services, we will be converting to paperless documentation at approximately the same time we're scheduled to undergo major reconstruction of our facility.

This week comes to a close at a rapid pace. While going over the architect's drawings to provide the most space and utilize all the room that we have, many things come to mind. What kind of services can we provide to become the most comprehensive facility? Already we provide the most comprehensive services, but have become aware that a driving program would be something that's not available in the vicinity. This is definitely something added to the construction plan.

Additionally, having the services of a neuropsychologist in the building would add to our TBI and developmental programs (also being put in the works for the future). By far, the most amazing meeting this week has been with the most gifted neurosurgeon in the region, presenting to him and his colleagues a plan to become a comprehensive spine center. Utilizing our team approach to provide the best possible outcome for his surgical patients by "backing up" our designer protocols with the latest evidence-based practice, we've been able to start a comprehensive program for some of the most involved patients.

It has been a most productive, chaotic week, ending too quickly, but thank goodness. Time to recharge and focus on the summer semester, to arrange a flight for our final onsite class: "The Doctoring Profession."

After a long three-day weekend over the holiday, I was surprised to find in my school email in-box a quick response to the second submission of my abstract. I was sure to have a response that I completed the class successfully with this project. However, I quickly realized that I have more work to do in order to receive a passing grade in this first part of a two-part class.

Thankfully, each time the abstract returns to me, if comes with thought-provoking suggestions about how to improve the content. Although I review the email quickly each time for a phrase that looks something like "congratulations" or "this is what I was looking for," I must admit I get a little disappointed due to not finding anything similar to these phrases.

A few days have passed, and I've been contemplating how I can change my abstract to incorporate what has been suggested. The recommendations provided, I must admit, are making me change the way I'm thinking about my case study. This is more than I thought I'd gain from such a class, let alone such a project. I'm not even close to done with this project (which will be completed during the next semester), and the impending end of this semester with ongoing re-submissions is preparing me for what's yet to come.

For the next couple of weeks, I'll stay positive, focused and on task for completion of this class. In order to do so, I'll be starting to gather more information than before now that I'm learning what's expected of me in preparing the case report. The feedback provided to me thus far has impacted the process of pulling all the information together to complete an abstract, as well as prepared me for what's yet to come.

A big year is in the making. I've successfully completed training to become a Guardian Ad Litem. The next step is to wait for a case to be assigned to me. Quite often, friends and family question me about how I'll manage the guardianship of a minor or minors while completing my doctorate. Quite honestly, I'm not sure. What I do realize is that all things are possible, and as long as I take care of myself and get enough sleep, everything should be accomplished.

Besides graduating from the Guardian training program, just yesterday I registered for my final two classes, the first of which will be the most challenging to me, in that I must complete, successfully, my case report. I'm cautious to submit my revision of the abstract because I'm still not entirely sure of what my professor is asking me to include. The best that I can do will be done in the next few days.

Thankfully, my director is allowing me to take Friday off, so that I can "complete" the resubmission (in addition to preparing for the holiday weekend, spending time with my daughters, enjoying a visit from a friend and going to medical appointments put off for way too long).

With all this activity going on, I'm fortunate enough to admit that my new position of manager of outpatient rehabilitative services is going quite well. Supportive and appreciative staff continue to roll with the changes I'm implementing to become the very best in community-based rehabilitative services.

All aspects of this busy schedule are coming together, finally, with much loss of sleep, sweat and tears. Attending classes for the Guardian Ad Litem program after work twice a week, with one more week to go, I'm determined now more than ever that this will keep me focused on an issue that's so important to me. After this evening, I'll attend only two more classes in preparation for my certification to become a voice for neglected and abused children in my community. Yesterday morning I had a "moment" as I had to be fingerprinted in order to take on such a role. This had been, by far, the point when I took a deep breath and realized the importance of such a huge, voluntary role.

As for the abstract for my case report, I successfully submitted last weekend with pride and relief (the first draft, that is). Convinced I did an acceptable abstract, I didn't expect to have it returned so quickly with a couple of suggestions to improve the content. Just when I thought all was completed for this semester, I took a step back and realized it could definitely be worse -- I could have been told to start all over again. Think positive. Regroup, re-think and re-write. That will be the focus of this weekend, to prepare an abstract that's acceptable to my professor (and will give me a passing grade in this next-to-last final course).

Finally, as I try to figure out how to run the daily operations in an outpatient rehabilitation department, I'm handed a magazine this morning by my director. I come from a department that ran exceedingly well, and I expected the same as I transitioned to a sister facility. However, I've run into many different personalities, operations and challenges that have inclined me to take another step back. After reading an article I found in this magazine, I realize that most of the resistance encountered may be due to working in a multigenerational department.

Never before have I been exposed to such differences, but after considering the variances among generations in regard to loyalty, academic credentials and work ethics, I can appreciate the reception I'm encountering on a daily basis. This situation and the constant, major changes I'm implementing have combined so that I'm not always met with great reception. However, in the end, I know that everyone's needs and wishes will be met. We're making progress in all areas, and next I'll pursue encouraging all the Generation X-ers and Baby Boomers to further their education.

One thing most people think of my schedule is that I have a very well-balanced work and personal life. Unfortunately, this isn't true. When I think of balance, I think of a controlled environment, even as obstacles get in the way. This is definitely not the case with me.

Last week I realized that the week I'm in now would be one of the busiest I've ever had. On the schedule is a list of duties: work, research, Guardian Ad Litem classes after work (making my days last 13 hours long, but only two days a week -- phew!), observing courtroom sessions to prepare to be a Guardian, taking one daughter to a specialist in the middle of my day (driving across town to pick her up, and back again toward the physician's office), attending a concert mid-week, getting in three tennis games, and I wish I could remember the rest. But quite frankly, with all this going on, my memory is failing. Thank goodness for reminders on my cell phone!

Instead of balance, I consider life to be a blend of personal time and work, dynamic and yet chaotic. Pleasantly chaotic. Except for maybe this week, but I got this handled. With two weeks left for my first submission of the abstract for my case report, I'm getting a little nervous that perhaps I may not be ready to submit, being that my preference is to turn things in at least a week in advance. This will be my biggest challenge and will have to wait for the weekend.

Right now, I'm off to the courthouse to observe a permanency hearing for a child who was taken from her parents due to poor choices by them. As I wait, however, my textbook of writing case reports is in one hand, while with the other I write down my questions about the process of being a Guardian. Blended lifestyle, with a growing responsibility to the community, surrounded by wonderful friends, family and co-workers, I will survive.

I believe I felt the same way during "Evidence-Based Clinical Practice," which seems like a lifetime ago. Interestingly enough, what was learned last year has prepared me for this most daunting task of creating a case report that will add to the body of knowledge of physical therapy. It wasn't until a month ago that I opened my book of statistics again, to review some of the most difficult material I've ever come across. This time, however, I'll apply this to my own patient and approach my final semester with (fingers crossed) a strong finish.

As work becomes busier, and I put together a team to walk for the American Heart Association this weekend, I also begin training for the Guardian Ad Litem program of Broward County. Days have easily become lengthier and more productive in every aspect. Strength and endurance are generated by helping as many people as possible, in combination with getting enough sleep, keeping a positive mindset and producing meaningful, quality work and projects. There may not be enough time for play these days, but the time is well spent on family, school, work and community.

The abstract is revisited several times a day, with constant revision and review. In the very near future, it will be submitted for first review and be returned with recommendations to adjust, revise or start over. Soon enough I'll let it out of my hands to be critiqued, so that I may be able to move on with the production of the final project, my case report.