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PT on the Run

The Finish Line
by Michael Kelley

Whenever I stand at the starting line of a race, I always think about one thing: the uncrossed finish line waiting for me at the end. And as with any race I have competed in, this blog too has reached its finish line.

In my very first ADVANCE blog post I wrote, "My hope is that this blog serves not just as a place for me to express my thoughts on the world of PT, the healthcare system and life outside the workplace, but as a forum that spawns discussion online as well as around your own clinics, lunch tables and water coolers." I have done my best to write about intriguing, relevant topics from my workplace, in our field and the healthcare system in general, and it is my solemn hope that those writings have spurned discussions in your workplaces as well.

There is no doubt that physical therapy is a fast-evolving field. It seems every time I talk to another PT, I'm hearing about some new treatment technique, insurance guideline, or specialty we have worked our way into. Yet with all the expansion we have done so far, it seems as though we're still in the infancy of our profession, and that to me is truly exciting. Where will we go next? How will our services and skills be utilized as new healthcare legislation is enacted? What role will we play in the ever-changing healthcare field as new technology and advanced treatments arise?

I want to thank those who have taken the time to read this blog over the past year. I want to thank those who have commented and shared their own ideas and opinions. Your insights have always been welcome and I think have made this blog as successful as it was. But, as with all things, it must come to an end.

The past year writing for ADVANCE has been a challenging, yet exciting exploration into my own perceptions of the varying aspects of our field as well as others' perceptions and opinions of it. The time has come, though, for me to move on and discover what other "uncrossed finish lines" lay before me. It is my sincere hope that you all have enjoyed reading this blog as much as I have enjoyed writing it. I wish each of you the best in all your endeavors in both our PT world and in life.

Thanks for reading,


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Political Confusion
by Michael Kelley

I think in previous posts when I've discussed politics, I've disclosed that as a lifelong Chicagoan, I've been brought up with a pretty liberal mindset when it comes to politics. That being said, I've also always felt that despite my liberal leanings, I've always been willing to listen to and discuss with those who disagree with me or have differing ideas. But this week, the Republican-controlled House of Representatives did something that really just has me baffled. Let me try to explain...

In 2009, the then Democrat-controlled Congress passed the Affordable Care Act (better known as Obamacare). After many long drawn-out court battles and even several stints in the Supreme Court, the law remains largely intact today, and various parts of it have gradually been implemented over the past 5 years. Now obviously today's congressional Republicans aren't the biggest fans of the Affordable Care Act, and they've voiced their opinion to the tune of nearly 50 votes to repeal or replace the Affordable Care Act (not a single one of those votes amounted to anything).

But this week, Republicans voted to give the House of Representatives the authority to file a lawsuit against the President for his lack of enforcement of the law. Over the past few years, President Obama has delayed the implementation of several parts of the law, notably the requirement for small businesses to provide healthcare coverage to their employees or pay a fine. Congressional Republicans now seem to be saying that by delaying the full implementation of law, the President is overstepping his constitutional authority, in which he is charged with enforcing the laws that the congress passes. Congressional Republicans say they are doing this to preserve the Constitution, the separation of powers, and their own congressional authority. Democrats say it's a political stunt.

Here's my take... I can't imagine Congressional Republicans are suing the President just to enforce a law they absolutely despise. If they hated the law so much, shouldn't they be rejoicing at the President's willingness to delay implementing part of it? If they are really suing the President in an effort to uphold the Constitution, well, I would certainly salute their patriotism, but I doubt their motives are quite so sincere (I have no proof of this, just my gut feeling).

So we are left with the "why?" Why sue the President of the United States to get him to enforce a law you hate? Are they trying to force the President to enforce the full law in hopes that people are hurt by it somehow (financially or otherwise), so Republicans can then use that as some sort of political leverage? If that's the case, that to me is a pretty huge risk! It's just got me so confused. What's the end game here?

What do you think about all this? What do you think is the motive behind Congressional Republican's actions this week? Do you agree with them? What would you do if you were a Congressional Republican or Democrat for that matter?

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Role Reversal
by Michael Kelley

So this week, my dad had to have a GI surgery (I'll spare you the gory details) and he is currently in the hospital where he will stay for a few nights while he recovers. Due to his insurance, he had the surgery at one of my hospital system's biggest competitors, so while visiting him, I must admit I'm doing a bit of spying to see how things run there!

I should start off by saying all the staff I met at this hospital were professional, courteous and are taking great care of my dad. And remarkably, it seems that their workflow is pretty similar to ours. I haven't had a chance to see how their therapy staff operates, but from the nursing standpoint, it doesn't seem like there's a big difference compared to my hospital system in terms of their post-surgical care. (I suppose this is good considering I really like the way the nursing staff at my hospital handles post-surgical patients!)

It's also been interesting to see how my family has been reacting. I've had to tell my mom a few times, "Nobody likes the overbearing family member!" My family is obviously concerned about my dad, and they seem to look to me when they have questions. As a healthcare professional, I do my best to assuage their concerns, but I don't know everything, especially in a different hospital system. I think this is a little frustrating for my family because I can't answer all their questions. Needless to say, it's been interesting playing the family member as opposed to the healthcare professional.

And then there's the inherent awkwardness when the staff there learns that I'm a physical therapist. I don't want them to think I'm judging them or the care they are providing, even if I am a little bit. I actually had to tell my family not to tell them I'm a PT. I'd rather them focus on my dad than worry about impressing me, or wonder what I'm thinking about their performance.

Have you ever been on the receiving end of the healthcare system as either a patient or family member? Are you open about your profession?

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Scheduling Conflict
by Michael Kelley

I've got a bone to pick with you outpatient therapists! When I first started working at the hospital, our inpatient office was right next door to the front office of our outpatient department. It was pretty easy to listen to some of the phone calls come in, and one of the most frequent things I'd hear that always bothered me was a conversation that went something like this:

Patient: "I need to come in for physical therapy for balance."

Office Staff: "Well we only have two ‘balance therapists' and they are booked out for the next three weeks."

First of all, why are we labeling therapists as "balance" or "neuro" or "ortho?" I can appreciate that specific therapists have areas they like working in or maybe are more proficient at than others, but I've always had a problem with therapists restricting themselves to one diagnosis or problem area. (This is probably one of the reasons I work in inpatient... I get to see a little of everything!)

Secondly, three weeks to get an appointment? Are you kidding me? And sadly, this is common practice, not just at our outpatient facility, but at many throughout the area. It hit me again today as I was trying to assist a patient who had been admitted for BPPV. Typically we like them to follow up with an outpatient therapist within 48 hours, but the first appointment available within our hospital system was almost two weeks out! I ended up having to set him up with a rival company just because they had the availability in their schedule!

Now, I can certainly appreciate that outpatient physical therapy is where the money is at (when compared to inpatient physical therapy at least), so having a full schedule for your therapists is obviously preferred. But what kind of message does it send when you have to tell new patients that they have to wait two or three weeks to get in? And then finding treatment sessions after that, well good luck!

Surely there has to be a better business model than this. One that maximizes therapist efficiency and productivity, while still maintaining a flexible enough schedule to accommodate new patients coming in within a reasonable timeframe!

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Student and Patient Communication
by Michael Kelley

So I had a student start a couple weeks ago. You may recall I wanted to have a "student summit" this summer, but unfortunately it got bogged down in some administrative red tape. Needless to say it's been tentatively scheduled for this fall after my student's rotation is done.

Anyway, my student has been doing well. This is his third clinical of five, and will last for eight weeks. So he's picked up the documentation pretty quickly and his treatment planning is decent. The problem is, and I know it's only been a week-and-a-half, but I'm having trouble getting an idea of what his personality is like. He told me that he has only worked in outpatient orthopedics before so his inpatient experience has been limited. So I'm not sure if he is just nervous or what, but he seems a little uneasy with inpatients -- almost awkwardly so.

I've tried to offer advice on how to talk to patients with more difficult diagnoses, especially when it comes to patients with altered mental statuses (Alzheimer's, dementia etc.) for example, but it doesn't seem to be getting through.

I'm not saying everyone should talk and act like me (we can't all be perfect -- ha ha), but I think there's a way to talk to members of the geriatric population that's different from other, younger populations. Maybe it just takes more practice?

Any thoughts? Any ideas on how to calm a student's nerves to let him better communicate with patients?

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New Beginnings
by Michael Kelley

For many in this country, the beginning of July is marked by celebrations of America's independence. Parades, BBQs, fireworks... it's all part of the annual celebration of this land we call home. But for those of us in the healthcare field, the beginning of July also signifies something else: new residents.

That's right folks, around the country, thousands of young, bright-eyed, newly christened "doctors" are venturing out into their first year of residency. While, no doubt, the road they've traveled to reach this point has been arduous at best, leaving the safety and security of the classroom can be unnerving for anyone.

Even we as PTs had to go through this, as we left the confines of our lecture halls and supervision of our clinical instructors and started really earning our paychecks. And while I don't know what the sentiment is everywhere else in the country, at our hospital there's always a guarded approach to dealing with these new residents.

Our hospital system does a fairly good job of orienting new residents. They have some pretty serious training on pretty much all aspects of how the hospital functions, but there still seems to be a rather slow learning curve when it comes to rehab services. It seems it always takes some time to bring these residents up to speed on when to order, when not to order, what services are provided, what services aren't provided etc.

When I was in PT school, I remember our professors telling us that medical students get very little education on rehab services. I never thought this was true until I talked to a friend a couple of weeks ago who's in medical school and she confirmed my worst fears! How is it that the physicians who are in charge of ordering our services or referring patients to our services, don't have a thorough education on what our service actually does? It's mind-boggling, I know.

Needless to say, over the course of the next few months, we have staff who will be attending monthly multidisciplinary meetings with these young doctors to try to further educate them on all we can and will do. It may be a long road, but we've got a few years here to get it down pat before these young residents turn into attendings!

On a quick aside, I wish everyone a happy 4th of July. To all those who serve our country, their families, and those who serve our men and women in uniform and their families, I offer you from the bottom of my heart a great big "thank you" -- can't say it enough.

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Into Thin Air
by Michael Kelley

I had the pleasure of spending this past weekend out in the beautiful Colorado Rockies. A good friend of mine attempted to run a 50-mile ultra marathon in the mountains (sadly, he had to drop out... the 12,000-plus feet of altitude got to him pretty early in the race). But regardless of his performance, we were able to get in some great hiking and ate a ton of great food (some of the restaurants in these small mountain towns have outrageously good food!). It was one of those trips that was only 4 days long, but felt like 2 weeks. I have to say, being back at work is pretty depressing knowing where I came from this weekend!

Anyway, in honor of my "Rocky Mountain High" this week, I thought I'd discuss a little about the effects of altitude on the human body and how that might relate to PT.

I've been up in the mountains now a half dozen times or so. Usually it doesn't affect me too much, maybe a little headache or something, but that's about it. This trip, however, I really felt the lack of oxygen. On one particular hike we went on, we were up near 12,500 feet and man-oh-man was it tough. My respiratory rate increased dramatically. My heart rate skyrocketed to compensate for the lack of oxygen. My muscles were burning much sooner than they should have been. And for the first time at altitude, I got really dizzy (like can't see or walk straight dizzy).

We weren't moving very fast on this hike and we were taking rest breaks pretty frequently, but the lack of oxygen still really got to me. (Fear not, however, I made it back down the mountain and lived to hike another day... the next day in fact when I was back up a mountain at 12,000 feet!).

So all this has me wondering now, what do PTs at altitude have to do to adjust to the decreased oxygen? Do patients whose pulmonary systems are already compromised need supplemental oxygen more than those at sea level? Are patients at altitude fairly well acclimated so they don't even feel the effects of it? Should we be shipping all of our patients down to sea level so they have increased oxygen levels to breathe in during their rehab? What do you think? Any "alpine" PTs out there have any thoughts?

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Are You Competent?
by Michael Kelley

Every year, our department completes a series of competencies designed to ensure our compliance with and understanding of basic hospital policies and procedures as well as more departmental-specific things. It is apparently a Joint Commission requirement (those guys are such a drag!) that we complete three competencies every year. And so, our corporate rehab department has created a number of competencies to help cover pretty much every aspect of our jobs. The problem is I think many of these competencies are downright silly. Yes, you heard me, silly.

Now some of the competencies we have are okay. For instance, we have a competency on how to use our telemetry computers in patients' rooms. This isn't the kind of equipment you would necessarily learn how to use in PT school and the equipment used is going to be different wherever you work, so it's important to know how this equipment works for the safety and well-being of your patient.

But then there are the dumb competencies. For instance, we have a transfer competency. Now I'm going to be critical of this, and I want everyone to know I made up this competency, and I still think it's dumb. You see, I made this competency a while ago when we were hiring a bunch of new aides. It was designed to ensure they knew proper body mechanics and techniques while transferring patients.

Unfortunately, it was decided this competency would be used for all new employees. So we just hired a new OT this past week and, sure enough, I had to make sure she passed her transfer competency. This girl, who just spent the past few years in OT school learning and practicing transfers among her other skills, now had to prove that her school taught her well. My question is this, do we really think a school (PT or any other discipline) would give a student a diploma if she couldn't do a basic transfer? I felt embarrassed making this new OT go through this ridiculous exercise.

I apologize for this being more of a rant this week, but it has been on my mind for a while, so I thought I'd put it on here. Do you have to go through annual competencies? We have competencies for seemingly everything (telemetry, transfers, wound care, edema management, orthopedics, neuro, diabetes management, TENS usage etc.). Are all these really necessary? Shouldn't we put a little more faith in our PT and OT schools?

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Parkinson's Problems
by Michael Kelley

According to the National Parkinson's Foundation, nearly 1 million people in the US are currently living with Parkinson's Disease, with an estimated 50,000-60,00 new diagnoses each year. Here in the US, the CDC has identified it as the 14th-leading cause of death and worldwide, nearly 6 million people are believed to be affected by this debilitating disease. As with all-too-many neurodegenerative disorders, there is no cure, but research is ongoing.

Over the last month, I've treated two patients with Parkinson's Disease. I didn't treat them for their Parkinson's, however, but rather for fractures they had suffered following falls. While presenting an interesting case, both patients were difficult to manage from an orthopedic standpoint as a direct result of manifestations from their Parkinson's.

In the first case, the patient took Parkinson's medications every hour, on the hour, for 17 hours a day (not at night). Obviously for his surgery he needed to be off his medications for the 5 or 6 hours before, during and after surgery. Needless to say, when he woke up, he had some significant dyskinesia. He didn't have tremor and any bradykinsia wasn't too apparent, but the extraneous movements of his entire trunk, head, neck, arms, even eyes were very pronounced. All this movement did not lend well to ambulation, as you might guess. Over his 3 or 4 days in the hospital, the dyskinesia improved, but he never did make it back to his baseline (which was not having any dyskinesia at all). 

The second case was a patient who also did not have any dyskinesia or tremor or any extraneous movement prior to her fall. In fact, she fell getting up from playing the piano at home. The same situation occurred where she was off her medications for surgery and woke up with significant dyskinesia. Her movement wasn't as bad as the previous case, but still ambulation was difficult to perform for her.

In both cases, the medical team seemed to focus more on her acute orthopedic needs rather than her more chronic neurological needs. The only problem with this approach is while on the surface they may seem separate issues, each directly impacted the other.

Because Parkinson's is more of a chronic issue, it's not something that we see a whole lot of in the acute setting. Certainly our outpatient department sees a lot of patients with Parkinson's; we even have a therapist who has written a couple books about the treatment and management of patients with Parkinson's. They have been challenging patients to treat, but I think good overall exposure to a diagnosis and world of movement disorders we don't typically get to see.

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Professionalism vs. Personality
by Michael Kelley

So a while back, I was working with a patient who just had a total knee replacement. She was mobilizing well, but kept looking down at her feet while she walked. So I stood next to her and looked down at the ground where she was looking and said, "I have a question for you." She said, "What's that?" I said, "Is there something interesting down there you keep looking at?" She picked up her head, looked directly at me and said, "F*** you!" We both started laughing. We had a pretty good rapport, but thankfully there wasn't anyone else around to hear!

Needless to say, it got me wondering, at what point do we sacrifice some professionalism and let our personality shine through. I am a pretty lighthearted person. I like to joke and can be extremely sarcastic. I also like to think I'm pretty good at reading people, so I know what I can and can't get away with when talking to patients or family members. Personally, I feel like all this "professionalism" stuff can impede our ability to form relationships with our patients. I think providing good customer service is a good and necessary part of any practice but not at the cost of eradicating my personality.

And honestly I think that patients appreciate my being honest with them. I have a bit of a reputation for telling it how it is and I have found that patients and families both really tend to respond well to it. The patients who are doing well find it amusing, and the patients who aren't doing so well find it motivating. Our rehab supervisor, as well as some of the nursing supervisors who are on the floor, are all about the good customer service and maintaining a professional persona at all times. I'm not sure that works all the time though.

Certainly in tough situations it's necessary, but in the day-to-day dealings with patients, I have found that being real and being myself can really go a lot farther than putting on a fake smile and being overly (and dare I say "awkwardly") polite. I think it's important for patients and families to see that yes we are healthcare professionals who are here to provide a service to you, but we're also human beings. We have feelings and emotions and they help express who we really are.

What do you think? Where is the line between professional behavior and our true personalities drawn? Have you ever had an instance where your personality conflicted with the professional expectations of coworkers or supervisors?

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Patient or Victim?
by Michael Kelley

This past weekend most of us in the US enjoyed a nice three-day weekend in honor of Memorial Day. I had the opportunity to catch up on some news and came across an article online about a soldier who had lost all four limbs after a bomb exploded under his truck in Afghanistan. This happened a few years back and he now has four prosthetic limbs. The article wasn't long and it pretty much revolved around one central idea this soldier had: the notion that he was not a "wounded warrior."

I'm paraphrasing here, but he goes so far as to say, "I was a wounded warrior. But I'm not wounded anymore." Pretty powerful words coming from someone many might view as helpless or severely disabled. (For the record, the article went on to say the soldier is married, has a child, is an avid snowboarder, and runs a foundation to help other "wounded" vets).

Anyway, this article got me wondering, do I view my patients as "wounded" or as "victims?" Do I have the right to view them this way? Isn't that their choice? Certainly we've all had patients who play the helpless victim and some are deserving of the title, but do I get to label them as such? I wonder what patients would say if I asked them how they felt about themselves in their current condition and station in life.

I suppose it's all a matter of perspective. I can envision a 50-year-old stroke patient asking how something so terrible could happen to him. And at the same time I could see a 95-year-old with the same stroke reminiscing about what a good life he's lived. Do we treat patients as victims of their condition? If so, should we? What do you think?

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The Joint Commission is Coming!
by Michael Kelley

Well, it's that time again. Our hospital system is up for reaccreditation from the Joint Commission. This will be the fourth accreditation I have gone through now (we've had two for when we became a certified stroke center and one general accreditation prior).

As usual, everyone is on edge and hospital administrators and management are constantly reminding staff to pretty much do their jobs the way we always have. In the past we've never been marked down for anything major; in fact, we've been recognized on a number of occasions for having "best practice" models already in place.

This time around, our hospital system has decided to set up some "dry runs" to help ease everyone into when the actual surveyors might come. Essentially, managers from every department are assigned a different department that they have to "survey."

For PT, this means someone from nursing or the lab might follow a therapist around for an hour or so and observe that person treating patients or maybe just ask him questions. I can't decide if it's a good thing that we're practicing so we can be all prepared when the actual surveyors arrive, or if it's just a colossal waste of time.

I had a manager from the nursing department sit down with me for 10 minutes and run through her list of questions. Pretty much I told her, "Yes, I wash my hands before and after every patient." And, "Yes, I ask the patients to verify their name and birthday." And, "Of course, I wear my name badge every day." It all seemed a little trivial to me.

What do your clinics do to prepare for the Joint Commission surveyors? Do you practice what they might ask you? Do you just wing it?

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Job Prospects
by Michael Kelley

Over the course of the past couple of weeks, we've had a few new grads interviewing for positions within the corporation. It got me wondering, what is the PT job market like these days?

Back in 2009 (happy five years since graduation for me!), I remember our professors and CIs would tell us pretty much that the world was our oyster. Jobs were plentiful in every area of PT and we should apply for whatever job we wanted.

Today though, it seems like things have changed. I have a family friend who graduated from PT school last year and couldn't find a job for almost six months after graduation. Even then, it wasn't in the setting or location she wanted. I've also heard that students are being told the job market isn't what it used to be. Have we really saturated the market? I can't imagine that PTs aren't needed en masse anymore.

And what about prospective PT students? We have an aide at our hospital who as far as I can tell is an ideal candidate for a PT program. This person is smart (better grades than I had) and motivated, with several years of experience working as a rehab aide, yet applied to several schools and didn't get into any of them. I've heard similar stories from other PTs in the area as well. Has PT school really become that competitive to get into?

What are you seeing in your area? Are we headed into a softening of the job market that was seen in the late 1990s? Any thoughts?

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Turnover and Guilt
by Michael Kelley

When I first interviewed for my current position, my supervisor told me up front that the average turnover rate for new therapists was six years. At the time, as a new grad, I was kind of surprised this potential employer was so up front about this type of statistic, but alas, it's been something I've never forgotten. I've been at the hospital now for four-and-a-half years and over the past year or so, I've thought pretty seriously about moving on to a new job. But then, the guilt sets in.

At first I felt guilty to even think about leaving because there were therapists at the hospital who had a year or two of seniority on me, and I felt they should be able to move on in their careers and I should wait my turn. Well now, I'm third in line in terms of seniority, and the two ahead of me aren't going anywhere anytime soon. Then more guilt set in because I had only been at the hospital a few years. I'm involved in a whole host of projects and committees and not to sound self-absorbed, but my leaving would leave gaps in a number of different areas.

Last winter I thought pretty seriously about looking for a new job. I did some pretty thorough searches online for different positions in and around Chicago. However, after some close examination of my schedule, I realized I had already planned a number of trips that required pretty much all the vacation time I had banked at my current job. So starting a new job would cause me to lose all of that time and prevent me from taking those trips. Alas, I'm still at the hospital. I still enjoy where I work, so I haven't reached the "burnout" phase just yet. But I'm getting close, perhaps a little sooner than the average "six years." Hey, when your heart's not in it anymore, it's time to move on.

When do you think it's time to move on to a new job? Do you ever have guilt about leaving and if so, how do you deal with it?

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Locked-In and Speaking Up
by Michael Kelley

Colleen Shaw, a 20-something aspiring filmmaker living and working in New York. Patrick Stein, a 20-something man living with Locked-In Syndrome. Two lives that couldn't be more different but have come together to tell a remarkable story in a very remarkable way.

Every few months I get a copy of Marquette Magazine, the quarterly publication from my alma mater. This past week, I received the most recent issue. In it I found the story of these two individuals and was completely fascinated. Shaw is a Marquette alum who has taken it upon herself to tell Stein's story, or rather, help him tell his own story.

We all know Locked-In Syndrome can be a life-altering condition, and when one's only way of communicating with the outside world is through eye movements, time can pass at what some might consider an unbearably slow pace. But since suffering a brain aneurysm four years ago that left him paralyzed, Stein and his family have marched on and Shaw is now helping give Stein his voice back.

As the article explains, Stein has "written" a number of journal entries through the use of a letter board and Shaw is using some pretty awesome technology to allow him to "read" these entries out loud through the use of a computer-generated voice. I first read the article a week ago, and I still can't help getting chills when I think of how awesome this is. While I can't imagine what Stein and his family have gone through over these past years, I also can't help but believe that finally getting his voice back must serve as at least some small victory.

My kudos to Shaw on shedding light on Locked-In Syndrome and helping another human being in such an inspiring and meaningful way. Here's a link to the article from Marquette Magazine. There are several YouTube videos as well as the official trailer for the documentary. The documentary itself is still in production, and I for one can't wait to see the finished product.

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