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Toni Talks about PT Today

What to Do When They Bring It on Themselves
by Toni Patt

People who work in healthcare are familiar with the term "frequent flyer." It refers to patients admitted over and over to the same facility in a short period of time. We have our share where I work. Most of them have chronic medical problems that are difficult to manage. I've watched these individuals deteriorate over multiple visits.

But there is another group. These people are admitted, recover and go home to do exactly the same things that brought them to the hospital in the first place. I have two of them right now. Both have chronic respiratory problems. Both are oxygen-dependent. Both have continued to smoke. One is on his third or fourth trach. The other complains about not being able to walk to the bathroom without becoming short of breath.

It is almost ridiculous. They come to therapy but only do what they want to do. Nonetheless they improve enough to return home. Two months later they are back. They admit they smoke and state they will continue as soon as they're discharged. Neither of them follow their recommended diets. It's no wonder they keep coming back.

I've asked our doctors. They say there's nothing they can do. Once the patients are discharged, it isn't their responsibility. The docs say even if they say something, the patients ignore them. They provide education. We provide education. Everyone provides education. Nothing changes.

I can't help but wonder what would happen if these individuals would make even a few small changes. I suspect the periods between hospitalizations would be longer.

It is frustrating for us. We provide the best care we can. We get them well enough to go home. And still, back they come. I'm sure this isn't a unique situation. It's happened at every facility I've worked at. The only difference is now the patients are sicker.

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An Instructor's Perspective on a CEU Course
by Toni Patt

While I was teaching last week, it dawned on me that I have a unique perspective on continuing education courses. I've been on both sides of the projector. When I teach, I'm not listening. I'm trying to remember to say everything I want to on a topic. I have set examples I use every time but no two courses are the same. If I get distracted, I sometimes forget what I meant to say next.

I can see everyone in the room when I'm up there. I see who is listening, and who is doing a crossword, reading the newspaper or sleeping. I don't mind the sleeping. I get paid whether or not you learn. I prefer you learn but that's your choice. I also prefer the sleepers to stay in the back. It throws me off when you're in the front row.

Once I had a woman spend the first hour solving a crossword. Later she wanted to debate me on something I had said. I didn't give her much opportunity. If you want to correct me or object, at least be paying attention and I'll be much more willing to hear the differing opinion.

Even though I spend the day looking at the class, I remember nothing about the people in it when I finish. With rare exceptions, I couldn't tell you if you were paying attention or not. I try to look toward everyone but I never focus on any one person, so I don't store anything in memory.

Room size makes a difference. The larger the rooms, no matter how many are in attendance, the less I perceive about the class. Larger and very small classes are harder to connect with. I try to look around the room while I'm talking. It helps me gauge how I'm doing, if people are listening, etc. I know no one cares about everything I say.

I have evidence to support what I'm saying. You may not agree, but I can support my opinion. This means I have to introduce the evidence into the course. I know going over specific articles is boring. But sometimes I have to do it to bring in the evidence.

I try to learn from other courses I've attended. The worst one so far was the stroke course prior to CSM last year. They read from the slides. They offered no examples. It was biased toward individual interests rather than providing all viewpoints. I spent most of the time sitting on my hands to keep from causing trouble. Worse, one of the main speakers talked more about herself than the material. If I ever fall into any of those ruts, I hope someone slaps some sense into me immediately.

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The Criteria for Our Priority List
by Toni Patt

Last weekend I was at a horse show, which means I was off on Friday. One of the things I do is manage our list for who gets out of bed over the weekend. We start the list on Monday, adding names as the week progresses. We have a tech who works the weekend, getting patients out of bed. Sometimes he gets to everyone and sometimes he doesn't.

This morning when I started this week's list, I noticed some patients were marked as priority for last weekend. We normally don't do this. I was somewhat shocked when I read the list. None of the patients I would have made priority were on the list. Instead there were two patients with difficult families. The rest had out-of-bed orders, which are standard admission orders for one of our physical medicine docs. Everyone gets that order whether it's appropriate or not.

Yes, out of bed is important. It would be great if everyone could get up. But when only a limited number of patients can get up, I prioritize those who will either lose ground or need to practice transferring. Just because a family is difficult doesn't mean the patient will get the most benefit from being out of bed. The same is true of standard out-of-bed orders. Some people will benefit more than others.

Maybe this is an old school, new school thing. I'm frequently told I'm very old school. When I teach, I can easily divide my classes into old school and new school. I base my decisions on what I believe are best for my patients and nothing else. New school people take other things into consideration.

The person who made the list bases everything on what is best for her and avoids conflict. I'm not sure when avoiding conflict became a criteria for necessity of therapy, but I guess now it is.

This isn't something major. Someone made bad decisions. It worries me because if you do something like that once, you can do it again. If you keep up the practice it becomes the norm. I can see that happening very easily here. I don't have any more shows for a few months so I don't have to worry.

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Things You Hear at Work
by Toni Patt

Many years ago there was a television show called "Kids Say the Darndest Things." I think the same could be true of our patients and families. Over the last few weeks I've heard many things that make me want to shake my head.

I was trying to help a man stand in the parallel bars. He was rather large and non-weight bearing on one leg. After several attempts he informed me he could do it just fine at home. He has one of those rocker recliners. He parks and locks his four-wheel walker in front of it, rocks and back forth until he gets up some steam. Then he can pull himself up.

A few days ago I was evaluating a woman who'd been on hospice at home but was now in the hospital. Her daughter was concerned about the hospice agency. Her mother was getting sicker and sicker and they weren't doing anything about it. Finally she took her mother to the emergency room because no one at the hospice agency would do anything.

This morning I assessed a 90-ish woman who was not arousable. My plan was to get her into a neuro chair to work on arousal and provide stimulation. Her daughter requested we wait until after lunch to get her mother out of bed. She said her mother liked to sleep late and she didn't want us to disturb her.

The list could go on. I'm not even considering all of those family members who have unrealistic expectations of therapy, overestimate the patient's ability to participate or expect me to singlehandedly lift someone who weighs at least twice as much as I do and is dead weight. I wish I had a tactful way to explain to obese people that obesity is the problem, not the diagnosis that admitted them.

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Making a Successful Case
by Toni Patt

A few weeks ago, I expressed my frustration with our capital budget process. While I was gone, my coworkers submitted a request for, among others things, a stand lift transfer device. To say I was shocked was an understatement.

Since that time I've campaigned against the thing. It doesn't promote functional transfers. It doesn't allow patients to practice transfers. There are so many things we need more, like gel cushions for our wheelchairs. In the literature it's touted as a time saver that prevents back injuries. Every article I read started out by describing the transfers as non-functional. But no argument that I made worked until today.

I pointed out that it would be used for a month or two. Then it would be pushed aside because it will create more work than it saves. We will have spent several thousand dollars on something gathering dust and getting in the way. Last year our manager bought us two electric, bariatric neuro chairs. They've been used twice since they arrived and now are in the way and gather dust.

So it turns out the strongest argument I could offer wasn't promoting functional mobility. It wasn't promoting independence. It wasn't quality of care. It wasn't even the cost. The strongest argument I had was pointing out the same mistake had been made the previous year and it didn't need to be repeated.

Granted there are many things wrong with the whole situation. I wasn't saying anything they didn't already know. I guess they just didn't want to hear it. Maybe it was easier to refute my argument by ignoring it. Then again, I convinced them by citing cost versus usage, not quality of care or any of the other things that are supposed to matter.

I keep asking for wheelchairs and cushions, which we would use on a regular basis. Still haven't gotten any more of those. Oh well. Score one for the good guys.

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I'm Not Going to CSM Next Year
by Toni Patt

For the past few weeks, I've been receiving email reminders that early registration for the 2015 APTA Combined Sections Meeting (CSM) is underway. Separate emails inform me of how to reserve housing. Another batch tries to entice me with the various topics. Naturally I go immediately to the neurological section and see how many courses will address stroke.

Heading into CSM last February, I was very excited. This time I'm toning down the enthusiasm as I'm not going. I made the decision months ago. Part of it stems from the location. It's in Indianapolis, which will be cold in February. I don't do cold. One reason I stay in Texas is we don't really get winter. I don't care how many sky bridges and underground tunnels there are. It will still be cold.

The bigger reason I chose not to go is disappointment from the last CSM. The pre-conference stroke class was such a letdown that it ruined the rest of the conference for me. I hope they seriously retooled it before taking it on the road. Plus it seemed like every lecture I wanted to attend was scheduled at the same as another I wanted to attend. Although there were several things I wanted to go to, they were all at the same times. I spent most of the conference trying to figure out what else would be interesting.

Of course that's not the fault of the planners or organizers. With something that big there are bound to be conflicts. Topic choices aside, the conference was very smoothly managed. I can't complain about Vegas. I got to go to the famous pawn shop. Yes, it looks just like on TV. I never had to leave my hotel for entertainment.

Budget figured into this decision as well. I had a choice to make: CSM or take two horses to regionals in the spring. I guess we know what I chose. I'm torn between being excited about regionals and disappointed about CSM. Going there is really the only time I feel like I'm living up to my professional potential. Plus I take notes on topics. One of my bucket list goals is to present there. Yes, I'm strange. But then we all knew that.

So this spring, instead of having broadened my horizons in February, my mare Allie will take her first major steps toward a national championship. My gelding Flame will represent our barn in the growing arena of sport horse. Should Allie live up to her potential, I won't be attending CSM until it comes to San Antonio in 2017 if I'm lucky.

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Only TPTA Members Can Contribute
by Toni Patt

While attending the Texas Physical Therapy Association (TPTA) annual conference last week, I got to chat with the chapter director for a few minutes. We were standing next to the election table and PAC table waiting for people to either vote, donate or both. Eventually fundraising came up. He told me something I really didn't know.

Only members of the APTA and therefore of the TPTA can donate to our PAC. This comes straight from those who oversee those activities. Donations from a PT or PTA who isn't a member could result in an ethics investigation.

This also means our patients can't donate either. The only thing a patient can do is call a legislator. The same is true of our friends and relatives. They can call legislators. Now this is an important function. Our lawmakers need to hear from us and understand we are a force to be reckoned with.

But we also need money. And there's a finite number of people who can donate to our PAC. The more I become involved with TPTA activities, the more I realize how important legislative protection has become to our profession. We need legislation to protect our reimbursement. We need legislation to protect our scope of practice.

Until this conversation, I thought anyone could donate. I didn't understand what all the fuss was about. Now I do. If you want to talk to a lawmaker, you need money to get in the door. If you want to talk seriously with a lawmaker, you need serious money.

Yes, I donated some money while I was there. I'm more inclined to give to the TPTA than the APTA since that has a more direct effect on me. At least I'm giving. That's what's important.

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A Bridge from PTA to PT
by Toni Patt

Last weekend I volunteered at the Texas Physical Therapy Association annual conference. I sat at the election table and verified membership numbers during the day. Later I helped count ballots. During the slow times, I spoke with one of the professors at a local PT school. She is in the process of developing a bridge program for PTAs to become PTs. How cool is that?

The first class will begin next fall. It is a two-year online program. Admission criteria include two years of work experience, an undergraduate degree and completion of the same prerequisites as for a DPT program. There will be some weekend classes each semester. I forgot to ask if the program was designed for full-time students or like a tDPT program where students continue to work.

This is something that has been lacking for a long time. Before we went to the DPT, several programs offered bridge alternatives for PTAs. Others took a PTA degree into consideration for admission. Once the DPT came into being, options for PTAs became fewer.

The professor said even though they've been keeping things low-key, interest is increasing. The first class will be 20 students. They anticipate successive classes to be larger. They are also talking with other universities.

Oddly, not everyone is happy with this development. The school has received hate mail from PTs who are angry that the university thought it could teach PTAs to become PTs with an online program. According to one letter, the PTAs need the clinical experience. To me, requiring two years of work experience should address that.

I hope the program succeeds beyond their expectations. There are many PTAs out there who would benefit from this program.

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I Am a Doctor of Physical Therapy
by Toni Patt

When I earned my DPT, I also earned the right to be called doctor. I must include the clarification that I'm a doctor of physical therapy. The same is true for doctors of pharmacology. I continue to find this amusing because most of my patients can't remember their names. They certainly aren't going to remember the difference.

Whether or not I use the title, I'm entitled to it. This is not true of PAs. In many ways they function as physicians but their degree is a master's. They are not doctors. However they do wear white coats. To many people, anyone in a white coat is a doctor so it's up to them to make the correction. I wouldn't be surprised if they aren't instructed to do so while in school.

Nonetheless some patients refer to their PA as doctor. Usually it's an elderly person who calls anyone in a white coat "doctor." That doesn't bother me. What bothers me is the two PAs at my facility who never correct anyone. I've heard the kitchen staff call them both doctor. I've heard our maintenance staff call both doctor. Never have I heard either one correct the speaker.

One of them works for a pulmonary group. In many ways he functions as a doctor. The other one works for one of our PM and R docs. He is as useless as his physician. I understand why patients do it. I sort of understand why a family member does it. I don't understand why neither of them correct the speaker.

Maybe I should start demanding that I be called doctor. Granted I would never answer when called. Nor would I recognize my name. As much as we joke about new grads being called doctor, we've earned the title. Whether or not I function as a doctor, I can use the title. I guess these two doctor wannabes never got the message.

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Sometimes You Say the Right Thing
by Toni Patt

Last week I wrote about my latest conflict at work. The others want to use capital budget to purchase a mechanical lift. I am opposed because mechanical lift transfers aren't functional. The patient is a passive participant.

Last Saturday I was teaching a course in Florida. During the section on transfers I talk about mechanical lifts. I make the same point. While sometimes necessary, mechanical lift transfers don't facilitate functional transfers. Patients never get to practice transferring if a mechanical lift is used the only time they get up.

During the break following that section, one of the attendees came up to me. Her facility was having a similar problem. In that case the lift had already been purchased. The rehab supervisor was trying to make using it a requirement. She and three of her coworkers were thrilled that I covered it thoroughly. They were especially thrilled because the very supervisor who was trying to force the lift on them was sitting in the front row of the seminar.

She wanted to apologize to me because they were laughing while I was speaking. Once they told me, I had a good laugh as well. I hope I helped them.

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Promoting Functional Transfers
by Toni Patt

My facility is looking at capital budget for next year. We've all been asked to submit requests for equipment. The process is pretty simple. We submit a list of items we desperately need. Later we're told we can have one or two of them sometime during the next year. Usually I limit my requests to more wheelchairs and wheelchair cushions.

This year we have a conflict. Some of the other therapists are requesting a mechanical lift that brings the patients into standing during transfers. I haven't seen a picture but am told the belt goes under their arms. They hold onto the hand grips and the feet remain on the floor. It helps the patients stand up and improves their ability to transfer.

I'm against the thing. I've used something similar in other facilities. I could be completely passive and still be transferred in the standing position. It did make transfers easier, particularly when it came to putting patients on the toilet, but none of those transfers were functional. If we never make the patient do the transfer, the patient never learns how to transfer.

It doesn't matter how the thing is designed. If it's doing the work, the patient won't. This lesson is clearly demonstrated by robotic walkers. There's an entire area of research devoted to getting patients to work while in the machines.

We have patients that aren't able to transfer themselves. If this thing makes transfers easier, then nursing needs to buy it. Maybe then they'd be more proactive about getting patients out of bed. We're therapy. We teach patients how to transfer. If they can't, we get a mechanical lift.

Our department needs so many other things. We should be spending what little money we're allocated on something that will promote function and independence. Nursing can buy the mechanical lifts.

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The Burden of Caregiving
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I've been watching a familiar scenario play out over the past few weeks. The wife of one of my seriously ill patients has been living a dual life. She simultaneously stays at the hospital all day to care for her husband while racing home to raise three children. Every time I see her she looks more exhausted.

Trying to be Wonder Woman isn't new among caregivers. Over the years I've seen many women, and some men, run themselves into the ground trying to care for an impaired loved one. The circumstances are always different except for one common theme. There is one woman caring for her family and her loved one, while not taking care of herself.

I read a paper a few years ago that described the various diagnoses that go untreated in female caregivers. The usual reason given for lack of medical attention was not having enough time. Number two was being unable to leave the loved one unattended while seeking the medical attention.

Those with hospitalized loved ones have an advantage over those at home. While they might be present 24/7, they aren't providing the care. They can leave the room for periods of time. Homebound caregivers may not have that luxury. Often there isn't anyone to assist or the assist is only available at certain times. Respite care seems to have become a thing of the past.

Even those who don't live at the hospital are burdened. Doctors' schedules are unpredictable, resulting in frustrated family members who want to talk to them. There are always questions being asked and decisions that need to be made. Making arrangements to bring home the loved one can be an ordeal in itself. Once the loved one comes home, caregiving becomes a 24/7 obligation.

You can tell who the caregivers are in any facility. They are the ones who look exhausted.

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Making the Right Rehab Choice
by Toni Patt

I've previously mentioned my disappointing stroke patient. First he had a stroke. Then he had almost every possible complication. Finally he's doing better and getting ready to go to rehab. Everyone agrees he needs to go to rehab. Now there's disagreement about which one.

In Houston there are several inpatient rehab centers. One specializes in brain injuries. His therapy team, wife, and PM and R doc want him to go there. From day one that has been our goal. Today I learned that probably won't happen.

His attending physician at my facility prefers to keep her patients local. Neither she nor the other doctors who've been following him go to the brain injury facility. It's too far away. The attending physician wants him to go to a local place. It doesn't have a good reputation. None of the patients I've worked with who've been there want to go back.

Insurance is not a problem in this case. It will pay for rehab wherever he goes, but he'll be lucky to get more than a few weeks covered. Although he will get 3 hours of therapy at both places, one will certainly be more bang for the buck.

As far as I know, no one is addressing this. The attending doctor is known for temper tantrums and yelling at people. She also brings the most admissions to the facility. I'm so far out of the loop that I would be scolded by my department head for even attempting to speak to the doctor. Although the doctor seems to care about the patients, all decisions are based on what's best for her.

My department head said she will try to talk to the doctor. What happened to making decisions based on what is best for the patient? This is worse than insurance companies practicing medicine. Where this patient goes for rehab will determine his quality of life for as long as he lives. I don't think a friendly chat with this doctor is going to fix the situation.

I really don't know what to do. I'm going to try to think of some way to bring more attention to the problem. Maybe if there's enough attention on it, the doctor will do the right thing to look good. I can hope anyway.

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Working in a Wheelchair
by Toni Patt

No, I'm not the one using a wheelchair. One of my fellow therapists is. She has chronic knee and ankle problems. It started out as wearing a walking boot, then progressed to a knee brace and either a walker or a wheelchair to get around. She chose the wheelchair.

The rest of us don't know what to think about this. She says her problem is walking across the facility. The distances are so great that walking them makes the pain unbearable. I think part of the appeal is she travels faster via chair than walking. Using the chair has also brought her much attention. At least once a day, I overhear her giving someone an update.

Here's the problem. Walking is part of her job. So is standing and transferring patients. If weight-bearing is so painful that she can't walk on the leg, is she doing her job? This is not a person who did much standing before this happened. Like clockwork all of her patients do the same activities with her sitting next to them.

Here's a bigger question. She is relieving the pain by staying off the leg. What if the pain never subsides? Is she going to continue using the chair indefinitely? Maybe since the constant walking and standing is causing her these problems, she needs to rethink where she's working. There are other settings that require much less walking and standing or where patients are brought to you.

None of the rest of us believes we would be allowed the same luxury. I limped around for 3 days on a sprained ankle, hiding from administration so I wouldn't be sent home. It never occurred to me to grab a wheelchair. I should mention we're entering our second week of wheelchair-based therapy.

I don't know about anyone else, but if I were in the hospital and my therapist came to treat me via wheelchair I'm not sure I would take that person seriously. That person might be an excellent therapist but perceptions matter. Someone rolling around in a wheelchair isn't giving me a good impression.

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Coordinating Our PT Requests to Congress
by Toni Patt

I'm now participating in monthly conference calls for advocacy for physical therapy. Participating might be too strong a word. I listen. Others report. As a result, I've learned that much effort is being put into eliminating the therapy cap and other reimbursement issues.

At the end of the call, the facilitator encouraged everyone to keep talking to their elected officials. We were told our big ask this month involves the therapy cap. Please ask Congress to support the latest bill under discussion.

That made me wonder how many things we're asking for and who is doing the asking. The APTA has paid lobbyists. This probably happens on the state level as well. Their job is to push legislation we want. I'm not sure how the process works, but it seems to me we'd have a bigger impact if everyone was pushing a united message.

In Texas there seems to be three key areas we focus on: direct access, preservation of scope of practice, and reimbursement issues. I don't know if the same people work on all of them or if separate groups focus on each one. I do know the TPTA PAC is constantly asking for donations to push our agenda. I wonder if we would be more effective if we picked one area, say reimbursement as that affects almost everyone, and put all our efforts and funding into that legislation.

The average therapist is more worried about having a job, a decent salary and getting time off than many of the items I heard discussed. It almost sounds as if our legislative group is out of touch with the majority of practicing therapists. Of all the practicing therapists I interact with on a regular basis, only one would put direct access at the top of a list for legislation.

I'm not saying all those things aren't important. It just seems to me there's a better way to accomplish our goals with the resources we have.

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