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Toni Talks about PT Today

My Disappointing Stroke Patient
by Toni Patt

Everyone who knows me knows how neuro-focused I am. It's easy to imagine me getting excited when a relatively fresh ICH patient was admitted to our facility. I felt like someone gave me a present. He'd had some complications postoperatively so he came to us prior to rehab.

As soon as I read the chart, I was already thinking of what I wanted to do. Not only was he awake, he was following commands. I teach this stuff on a regular basis. Now I could actually do what I tell others to do as well as test two of my pet theories. The patient would benefit because if anything, he'd get more therapy. This is definitely a win-win situation.

I've worked with him for three days. And to paraphrase a movie, Houston we have a problem. This guy is lazy. He doesn't want to work. He doesn't try. If it is the least bit challenging, he won't do it. My tech and I have gotten him up each day. We no more than leave the room and his wife is coming down the hall saying he's tired. He needs to go back to bed. Of course he's tired. I just wore him out.

The wife is another problem. I've never seen a family member so disinterested in therapy. She spends most of the sessions shopping on her phone. The nurses have told me she quit her job so she can stay in the room with her husband. Twice she has asked if her husband can have medical marijuana. He asks for cocaine.

I already had the nice come-to-Jesus talk. I explained what it takes to recover after a stroke. I explained how important it was for him to work with therapy and build up his endurance. I explained the criteria for inpatient rehab, which is where someone 40-something years old should go. I also explained the alternatives. I might as well have been speaking to a brick wall. No, at least the wall would have absorbed the words.

I almost want to cry. Here is someone with so much potential. This is why I do what I do. I could get him walking. Instead he wants to lie around in bed and get high. I'm going to keep trying. Maybe the light will eventually go on and he'll realize it's up to him. My tech has already told me I'm fighting a losing battle and to let it go. There is nothing I can do for someone who won't take responsibility for getting better.

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I'm Always the Bad Guy
by Toni Patt

I'm noticing a disturbing trend. I'm always the one pointing out the bad news. I admit I do better with realistic than cheerfully optimistic, but it seems like it's always me pointing out the flaw with a plan. If I'm not pointing out the obvious, I'm explaining why the obvious isn't going to happen. It feels like everyone else is focusing on happily ever after and I'm saying not during this admission.

This is particularly true with our PM & R crew. I've complained about them before. For some reason they ignore what the patient is currently doing in favor of what the patient wants to be able to do. I've heard one of the PAs make promises to patients that aren't realistic. Giving patients hope is one thing. Setting them up for failure is another.

When I confront them, the response is always, "Well it could happen." Sometimes I feel like I'm teaching basic rehab science to an empty room. I almost like it better when they don't interact with the patients. That tends to keep the expectations more realistic.

Most of the patients in my facility are very sick. Rehab usually isn't their biggest need. They need to get well enough to do rehab somewhere else. We're not a rehab facility. We get people ready for rehab. I'm tired of constantly explaining this to people who should know better.

Oddly I have no problems with the case managers. They all seem to get that these patients aren't going home when they leave us. They work to make the transition as easy as possible.

I don't want to be negative. I just know from experience what is possible, what is not possible and how long it takes.

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The PTA Student Who Only Wants to Do Orthopedics
by Toni Patt
Last month we had a PTA student at my facility. The other PT was his CI because while schedule facilitates time at the barn, no one else wants to start work at 6 in the morning. From the beginning, the student made it clear he planned to work in an outpatient orthopedic clinic. I believe he had already lined up a job.

I didn't think much about it until a doctor wanted a functional assessment of an incomplete SCI patient. Because I'm the neuro person, the student asked me. I tried to explain the ASIS scale to him. He didn't know what it was, which didn't surprise me. What surprised me was his attitude. He didn't want to know. He said he was going to treat orthopedic patients so it wasn't that important.

My response was pointing out there will be an ASIA question somewhere on the exam. He will need to know it to pass his neurological course. I guess he plans on memorizing for the exam and then forgetting like everything else neurological.

It seems like all students want to either do orthopedics or pediatrics. But this is the first time I've heard anyone be so dismissive of neurological principles. The sad fact is, as much as I wouldn't want to, if a total joint patient rolled into the gym I could treat the patient. I wouldn't enjoy it but I could do it. If a stroke patient ends up at an ortho clinic, they are clueless. Unless it's someone with minimal impairment, they don't know what to do.

I didn't bother to give this guy an attitude adjustment. Sometimes you just have to let nature take its course. It's bad enough that wherever I go, I hear the DPT graduates aren't prepared for anything but to be called doctor. Now I've met this guy who seems to think a good part of physical therapy education isn't necessary.

Is the problem us? Is it the programs? Did he just not say anything to anyone previously? Had he been my student, I would have called the program. All of the previous students I've encountered have been told to keep biases to themselves and concentrate on the current setting. I hope this one was the exception to the rule.

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My Little Old Man With the Brain Injury
by Toni Patt

Currently I have an elderly gentleman with a traumatic brain injury from a fall. One version says he tripped over his dogs. Another says he had a seizure. Either way he hit his head on the way down, developed a bleed and had a craniotomy. The man was clearly ambulatory and functional prior to his injury.

I'm not getting anywhere with him. It took a while for him to wake up. It took a little longer for his aphasia to improve. Lying peacefully in bed, he can speak in complete sentences most of the time. In fact he is pretty well behaved until I try to move him.

He has perceptual deficits and possibly a right visual field cut. He's a little weaker on the left compared to the right. Those are all things I can deal with. The problem is the premorbid alcoholism. According to his chart, he averaged a bottle of vodka a day. Add that to some dementia. As soon as I try to move him, he fights me.

About every third day he is relatively clear. He sits EOB with SBA. He follows commands. He even stands with assist. I could have him walking if not for the confusion and combativeness. His sitting balance is good enough for a w/c but I can't put him in one. Someone would get hurt in the process. Every day I stand in his door and try to figure out what to do.

He will discharge to a SNF, where if his behavior continues he will become bed bound. Everything I could want in an ICH patient is there except for the cognition. How many times is it the other way around? Usually I have patients who can participate but lack motor activation.

My tech is a real sport about this. He gets the brunt of the resistance. Yet he still smiles and says okay if I want to try sitting this guy up. We can't do this much longer. We're getting beaten up. Pretty soon I'm going to have to accept there is nothing I can do about this.

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How Can This Be a Safe Discharge?
by Toni Patt

This morning I was working on discharge planning with one of our case managers. A doctor was ready to discharge a patient and she had asked me for recommendations. I immediately said SNF. He wasn't able to safely transfer out of bed. I had yet to see him walk due to complaints of back pain. And he lacks insight into his limitations. The case manager agreed with me but said the patient was refusing to go anywhere but home.

Believe me, this is not someone who needs to go home. He can't make it to the bathroom without assist. I don't know how he would function if he were home alone. On top of that he has a 10-step entry into his home. Finally the case manager called the man's wife. After some hemming and hawing, she stated the patient's brother had recently moved in and would be able to assist her with assisting him.

Both the case manager and I know that isn't going to work. His family isn't going to be able to manage him. The case manager informed me his insurance won't pay our facility if we say he needs to go to a SNF and he goes home. The only way we'll be reimbursed is if he follows whatever discharge plan we establish.

I get that is a problem. What I don't understand is when did we stop billing these people? Who decided and when that patients are no longer responsible for medical bills? Maybe the question is when did people stop caring whether medical bills were paid? Once again, we have decisions being made based on reimbursement that aren't in the best interest of the patient.

Both the case manager and I documented our concerns. She added a statement that his wife states she and his brother will be able to adequately care for him 24/7. Both of us know that isn't correct but there's nothing we can do about it. It'll only be a matter of time until he is readmitted, probably worse than he already is. How is this good patient care? How is this good discharge planning?

The saddest part of this is that it's not an isolated case. It goes on every day where I work and in facilities throughout the country. These people are in and out of the same facilities over and over again. Eventually the insurance companies will refuse to pay us because of multiple admissions for the same problem.

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Strategic Meeting
by Toni Patt

As part of my leadership program, I attended the Texas Physical Therapy Association (TPTA) strategic planning meeting last weekend. The idea was to get newer and upcoming leaders to meet and mingle with people in leadership positions. We also got insight into how decisions are made and what is on tap for us in the future.

I loved it. I chose to participate in the professional development subcommittee. I think I have found a new niche. Right away I realized things I've been thinking and saying were parallel with what was going on. I was able to make some suggestions that were added as steps to the overall strategic plan. I want to do more of that.

There's one problem. All of the people involved beside a few leadership fellows hold elected positions. In order to attend further meetings, I need to be elected as either a district chair or to a state-level office. I'm on the nominating committee but am not chair so that doesn't help. I don't think I'd be turned down if I wanted to attend again, but I need to ask in such a way that it's obvious I will be a contributor.

It's been a while since I've done something I've actually enjoyed doing. Other than teaching and keeping up with the stroke literature, there hasn't been much. My eyes have been opened to a new avenue to pursue: leadership. I'm not sure what's out there but I need to investigate.

As a leadership fellow, I'm expected to complete a service project for the TPTA by October of next year. I have until October of this year to select what it will be. I'll be working with a mentor to complete the project. The purpose of the mentor is to problem-solve and keep me from reinventing the wheel. I brought the materials home to study. Ideally I would like to dovetail my project onto this meeting.

I also discovered that a horse show is an acceptable excuse for missing some meetings. Several others mentioned they wouldn't have been there if "blank" was going on. I can't describe how relieved I felt. It was worth it. Allie and I got three firsts but I felt I was missing an obligation. In order to run for higher office I must serve as a delegate. That requires some travel. I'm not sure how that will work out in the future but planning is everything.

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We're Not Going to Pay for That Brace
by Toni Patt

A few weeks ago, a woman was admitted to our facility with a knee injury. She appeared to have ligamentous damage on top of arthritic deformities. She came to us for medical management and antibiotics prior to surgery. Before she was admitted, her orthopedist ordered a KAFO for the involved leg.

I'm not a big believer in KAFOs. In my experience they are bulky and uncomfortable. In this case the woman weighed more than 300 pounds with chronic lower-leg edema, although her skin was intact. This meant the brace required extra reinforcement to be able to support her.

When the brace was finally completed, it cost $2,500. My facility refused to pay for it because that money would come out of their reimbursement. Management stated the brace was ordered before she was admitted and therefore wasn't our responsibility. Furthermore, the brace wouldn't be used until after the surgery, when she would transition to a SNF, so the SNF should pay for it. Naturally the brace company wouldn't release the brace to her without reimbursement.

I wish I could say this was an isolated incident. Maybe the cost is a little more than usual, but it happens all the time. No facility wants to pay for any sort of brace or orthotic. If something off the shelf can't be used, the patient must wait until transferring to the next facility or using Medicare part B if discharged home. Stroke patients do much better with hinged AFOs but they are almost impossible to get.

It almost seems like facilities and insurance companies are practicing medicine. The need is identified. The physician writes the order. Then either the insurance refuses to pay for it or the facility does. Insurances simply say the device wasn't covered. Facilities say the patient can get it at the next level of care, which also won't pay for it. The end result is something deemed medically necessary with a physician's order isn't purchased for the patient.

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My Latest Continuing Education Course
by Toni Patt

Last month I went to an onsite CEU course. Back in the day, I was a CEU junkie. I'd go not just for CEUs but if the topic sounded interesting. More recently I've had to cut back and limit myself to CSM. This year I got burned by the stroke course at CSM. Needless to say, I was a little nervous about this one.

The topic was motor learning. It was taught by someone I'd heard speak previously. He was interesting a few years ago. More importantly I was positive he knew more about the topic than I did. I was correct. It wasn't so much that I learned new information. I learned better application of what I knew and gained some insight into why I see some of what I do.

It was nice to sit in the class for a change. I didn't have to watch the clock. I didn't have to be on for 6 straight hours. I could go to the bathroom whenever I wanted. People attending a class don't realize this. They can get up and run to the bathroom whenever they want. The instructor can only go on the breaks.

I realize the more I know about a topic, the less there is for others to teach me. I'm trying to pick things that are newer or unfamiliar. Having written course descriptions and the like, I'm getting better at reading between the lines.

It was a nice experience to sit back and listen to someone else for a change. Not once did I have to sit on my hands to keep from correcting him. Nor did I have the urge to cite literature contradicting what was being said. More importantly, I actually received useful treatment suggestions for application in the clinical setting. I didn't agree with everything he said, but he supported what he said with research so I understood how he drew those conclusions.

When I attend courses, I try to be considerate. I keep quiet if I disagree or have evidence otherwise. If I want to discuss something, I wait until the break. It was nice to actually get more than my money's worth this time.

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The Change Cup
by Toni Patt

The facility I work in isn't very large. We have a cafeteria that's only open a few hours at time. For lunch we have two entrees, soup or the grill. Just like everywhere else I've worked, we all complain how expensive it is. When you check out, there's a small cup for pennies. The cup rarely holds just pennies. There are usually a few dimes, nickels and even a quarter. It's never empty.

At first I would drop in the pennies I got in change. Then I started adding more. I'm afraid I'll be short one day when buying lunch. I put more in so I won't feel guilty if I have to rely on it to make up the difference. Now I probably put in anywhere from 50 cents to a dollar each week.

A few days ago I was behind someone who was 20 cents short. The woman was going to run back to her purse and get the difference. The cashier grabbed the difference from the change cup and told her not to worry. When I checked out a few minutes later, I added the difference to the cup from my change and told her not to worry.

Since that time, I've seen the same thing happen three times. Now I know why the change cup is always full. We're all putting in extra change to cover everyone else.

Wouldn't it be nice if we could do that on a larger scale?

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The Nominating Committee
by Toni Patt

Last year, I was elected to the Texas Physical Therapy Association (TPTA) nominating committee. The role of the committee is, as the name suggests, finding individuals to run for the various open seats in the TPTA. This is the first state-level position I have held and take it very seriously.

Imagine my surprise when I received an interest-in-running form from someone I know doesn't care about the profession. A few years ago, he was my supervisor. He told me my tDPT was worthless. He made fun of my involvement in the TPTA at the time. Later I filed ethics complaints about him within the company and the TPTA for other reasons.

When I worked for him, he didn't care about being a PT. He cared about being a manager. I don't think I ever saw him treat a patient. At that time, his primary interest was in being promoted and how much money he would make.

This is not someone we want representing us in any way. My suspicion is he's running so he can put it on his resume. Maybe it became a job requirement for a pay increase. He is too far removed from everyday therapy to have a clear understanding of what's important to the profession. Yes, we need more people involved, but we need people who are involved in the profession. Sitting in an office crunching numbers doesn't foster that knowledge.

Not being one to keep quiet, I sent a group email saying I didn't think he would be a good candidate. Unfortunately I think someone else on the committee encouraged him to run. That's another problem. I feel strongly enough about this to have sent an email to our chairperson saying I'll resign my position if he is slated.

I don't know how this will play out. I will be off the committee in 2 years. If he is serious about running he can always try then. Or, I'll be off the committee within the next month as our slate is due by the 1st of August. Wish me luck.

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Sometimes It's Hard to Feel Sorry for Patients
by Toni Patt

Last weekend I was describing a difficult patient I had worked with earlier in the month. It was someone with several chronic and out-of-control problems, obesity and medical noncompliance. I summarized my statement with, "I don't feel sorry for him. He created his situation."

I was immediately taken to task by someone who overheard some of what I said. I was told I shouldn't be working at that facility, much less in the profession if I don't feel sorry for my patients. This was someone who never works directly with patient care. She also only eavesdropped on part of the conversation because the statement made more sense in its entirety.

My eavesdropper apparently has equated good, quality care with feeling sorry for a patient. I don't feel very sorry for people who bring it upon themselves by neglecting diets, skipping medicines and becoming obese. That doesn't mean I won't provide the best care I can for them. Nor does it mean I don't want them to improve. I don't have to feel sorry for you to treat you to the best of my ability.

The sad truth is much of what we do involves working with people who don't want to do therapy. Or who don't want to get better. Or who don't want to take responsibility for anything. They would rather have a PT lay hands on and heal them. Once they leave the facility, it's only a matter time before they return with exactly the same diagnosis and deficits.

One such patient was an obese gentleman who came to us with an infection and chronic back pain. He didn't want to walk because it was painful. He couldn't move enough to make exercises effective. The only thing that was going to significantly help his pain was weight loss. He didn't think weight loss would work because he'd always been big-boned. That was not someone who was easy to help.

People don't always make the best choices. Just because I don't feel sorry for you for making bad choices doesn't mean I won't help you try to get better.

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Gerichairs Are Not Recliners
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This is something I've never experienced. The facility I work for uses therapy gerichairs as recliners for patient family members. For some reason, the facility has yet to invest in recliners that can be put in patients' rooms.  When a family member or patient requests a recliner, someone is dispatched to the rehab department to retrieve a chair.

This creates many problems. Once the chair goes into a room, I'm not allowed to remove it. This decreases my already limited supply of chairs for patients. I'm not allowed to remove the chair to keep the patient or family happy. Currently I know of two chairs being used as recliners in rooms where the patient isn't on caseload.

If I point out I need the chairs for patient comfort, I'm told to make do with what I have, but make sure the patient is happy. Usually this means rotating the chairs between several patients so everyone gets out of bed but for a limited time. 

To make matters worse, whenever a chair is commandeered it's always one of the newest ones. Family members sit in the newer chairs. Patients sit in the older, less comfortable ones. I'm already forever searching for wheelchairs that have been commandeered to transport family members, then left in the room so the visitors have some place to sit. Now I have this.

When I brought the problem to administration, everyone agreed it was a problem. Everyone agreed the patients needed the chairs. Currently there is no money in the budget to buy recliners, or any other chair for visitors. It wasn't budgeted for. That's interesting. This problem has existed for years and no one has thought to budget for even one chair.

This is another one of those battles I cannot win. More chairs are not the answer. I got more chairs this year. I can't keep them in the department.

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New Grad Readiness Survey
by Toni Patt

Last week I completed an electronic survey asking if new graduate DPTs were ready to enter the clinic. Then it asked about specific areas of education and characteristics of new graduates and how they related to the first answer. It's about time someone looked at this. In my experience, no new graduate is completely ready to be thrust into a caseload but recent graduates seem less prepared than in previous years.

Every new graduate faces an adjustment period from student to clinician. Some transition easily, others take time. In previous years, the students had a fundamental understanding of what to do and why to do it. I'm not seeing that now. This is a common lunch topic when I teach. Many other therapists are saying the same thing.

The schools try to address things such as professionalism, punctuality, readiness to learn and patient-centered therapy. They don't seem to be spending as much time on fundamental knowledge. Or, maybe it isn't soaking in as much as it used to. Students vary in ability and knowledge but I hear this across the nation. We can't all be getting weaker students.

I don't think teaching methodology has changed that much. The problem lies elsewhere. I've had more than one person tell me new grads don't know anything but how to be called doctor. Obviously something is missing in the education because they should know many things.

Not that long ago I worked with a new grad who thought he knew everything. The material he knew, he knew well. He either didn't know there was more knowledge out there or didn't think it was necessary. As a result, all of his patients did the same things all of the time. There was no telling him anything because he didn't listen.

I hope this survey helps someone quantify what the rest of us are describing.

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Let's All Be on the Same Page
by Toni Patt

Last week as I was preparing to do an evaluation, I overheard one of our case managers talking to a family member of one of my patients. Nearly everything the case manager said started with, "Rehab will take care of that." They were discussing gait training and preparing the patient for discharge home. That would have been wonderful except for one small problem.

The patient's chart was talking about end-of-life issues. The patient was not expected to survive long enough to be discharged and if she did, it would be to another care facility due to vent dependence and dialysis. There was a palliative care consult in the chart. Everything I read implied the patient wasn't going home.

Now, I can understand the family asking those questions. Patients and families always believe they will be the one out of a million who gets better. What I don't understand is why the case manager, who should have also read the chart, wasn't redirecting the conversation somewhere else. At least she could have prefaced her responses with, "If the patient improves" or "If the patient goes home." Give them hope but try to be realistic.

Now I, meaning therapy, will be the bad guy here. I'm not going to be doing what the family expects because the patient won't tolerate it. Someone with a resting heart rate over 120 isn't going to jump out of bed and walk to the bathroom. She didn't even tolerate transitioning to sitting.

It isn't that I don't want to progress the patient. Walking to the bathroom would be great. It just isn't going to happen any time soon, if at all. However, since the case manager talked about therapy walking the patient to the bathroom, the family probably thinks it is possible. Sooner or later, I'm going to be explaining why I'm not doing something with a patient who couldn't do it in the first place, because someone thinks it should be done.

I wish the case manager would have limited what she said to, "If that happens" or included a timeline to keep the expectations in line with reality.

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HIPAA Violations Can Be Overheard Too
by Toni Patt

The other day, I was sitting at a nursing station and overheard a conversation between a patient and a physician. I wasn't trying to eavesdrop. The patient was very hard of hearing and the doctor had to yell to be heard. The patient was yelling back. I realized I was overhearing a major HIPAA violation. Between the two of them, they were broadcasting protected information down the hall.

First of all, the doctor should have closed the door. I still might have been able to hear but wouldn't have understood what was being said. A nurse walking by did almost immediately after the conversation started.

With the onset of electronic charting, facilities have been stressing precautions to protect the data. I think everyone knows to limit exposure to printed information and throw it in the shred box when finished. Passwords must be changed every few months. We go out of our way to not say patient names in hallways, elevators and the like.

What about the patients who can't hear us unless we yell? I can talk loud enough that even those with the poorest hearing can understand me. I have to remember to close doors and have conversations is relative privacy. It just dawned on me how much protected information I've been given at full volume.

Doctors seem to be the worst. They have conversations in the hall. They see people in the rehab gym doing therapy. One had a conversation with a patient in the bathroom. I know this because I was in the bathroom with the patient. That was seriously wrong. He should have asked the patient's permission for me to be present. It wasn't anything I didn't already know, but that isn't the point.

Patients forget this a lot. Many of them yell information into the phone. Either they speak loudly, the other person can't hear or both. I've noticed there is no privacy during phone conversations. They'll share everything.

There isn't too much we can do about patients with loud voices but we can be aware of what we're doing. We can also close the door when the doctor forgets.

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