Toni Talks about PT Today

A Disturbing Trend

Toni Patt — Wed, 14 May 2008 13:21:00 GMT

The old ladies of therapy have been talking again. This time we were discussing a trend we've noticed. We're concerned because what we've seen doesn't bode well for the future of our profession. None of us are excited with the new graduates we've been coming across. They don't impress us. They don't have the same commitment to the profession as those of our generation. They lack skills. Each of us old ladies had an experience of leading a new graduate by the hand through something because the grad didn't know what to do. These are the up and coming therapists who are supposed to lead us toward Vision 2020 and beyond. I expect better.

Now I'm not saying this is true of everyone who has graduated in the last few years. I've met some wonderful new and recent graduates. I've met some who have knowledge and skill beyond their experience. I've also met the opposite. I've lost count of the students who tell me they only want to do orthopedic outpatient. I can't count the times I've heard someone refuse to do something with the excuse of being the therapist. Worse, I've met several recent graduates who look down on us old gals because we do things "the old way." Does it matter how old the technique is as long as it is effective? Robin McKenzie developed his system over 40 years ago. It has proven to be effective over and over again. By that logic we should throw it out because it is an old therapy.

I'm not sure where the problem comes from. I've talked to professors. I'm taking courses. I don't' think the schools are teaching this. The attitude may be an unexpected byproduct of the learning process. I don't' think it is deliberate. Maybe the selection process inadvertently weeds in these individuals. Us old gals think it has something to do with the generation of individuals entering schools. We've noticed an attitude of expectation. Back in the day when I was in school I hoped I would find a job. I hoped I would make a decent salary. I worked as hard as I could so I could keep my scholarships to stay in school.

This last week I came across two prime examples of this behavior. One recent grad boasted how she could handle anything because she worked for 8 months rotating between several units in a hospital. I doubt that. She had trouble keeping her left neglect patient from walking in a circle right before she said that. I know that place she worked. It was good experience but nowhere near all encompassing.

The second example was a therapist who doesn't want to be a therapist. He made it a point to tell me he didn't like being a therapist. His real job was selling a medical product. So, I wanted to ask, why did you waste all that time in PT school? I would have except I had to walk away before I said something really not nice.

What concerns me is the lack of respect for the profession I see in this. Physical therapy doesn't need individuals who settle for mediocre because it is easy to accomplish. We need individuals who are pushing the envelope for every patient. If I take my horse to the vet I want a vet who not only knows what he is doing but is learning more and willing to stay with my horse as long as it takes. Horses are fragile. So are people. I want my loved one to have the best care possible which to me means someone who knows what to do, how to do it and doesn't mind if it isn't easy.

I know lots of experienced therapists who just get by. That isn't age specific. What is age specific is the apparent lack of knowledge and skills. Maybe I'm totally wrong. Maybe what we're seeing is uncertainty or fear of being wrong. As I initially said, it isn't every one. Us old gals were just talking. We're old. We could be confused. I hope we happened to pick up on the outliers rather than the trend.

The Family Issue

Toni Patt — Wed, 07 May 2008 12:46:00 GMT

Last weekend I was reminded of why I hate visiting hours. I went to treat a patient who had family in her room. Usually I let the patient decide if the family can stay. This time the family decided for the patient. Not only did they decide to stay they interfered with what I was trying to do. The patient was an elderly woman with multiple medical problems. This wasn't her first hospitalization. She was admitted with AMS to rule out a CVA. She was very lethargic when I was trying to work with her. She was trying to work with me but couldn't stay awake. She was able to do some exercises but when I stood her up her eyes closed and she slumped to her left. I returned her to bed.

I explained to the family why I wasn't going to attempt gait and why I put the patient back in bed. Now you would think they would be happy that I didn't take any risks and was carefully monitoring what was happening. Wrong. As soon as I sat the patient EOB they berated her for not trying. She was trying. The task was difficult. When I didn't walk with her she was scolded for not working with therapy. One of the daughters told me I was wrong. I should have tried to walk. She proceeded to lecture as to why her mother could walk stressing that they would walk with her later. I had to bite my tongue.

Families are a part of life for a PT. They come in all varieties. Some are good and supportive. Some are absent. Some are difficult. Most of them mean well. Usually I'm glad to have family present. But sometimes families get on my nerves. What aggravates me the most are the ones who fail to see that their loved one isn't progressing the way they expected. They don't see the situation the way a PT does. I don't think they realize that scolding someone for not participating doesn't help the situation. All it does is make the patient feel worse.

I can understand where these people are coming from. They want their loved one to return to normal. Maybe they think they're helping. Last weekend I wanted to set that family straight. Therapists are in a tough place. We can see the probable outcome. Yet, we have to wait for the physician to discuss prognosis with families. We're asked to work with patients who won't be returning to prior functional status. Meanwhile we have families pushing us to get their loved one out of bed, walking, etc. I don't want to practice medicine. I would like to be able to be up front about the therapy prognosis instead of hedging by saying we'll have to wait and see. We don't know what will happen. Once I had a patient who was unresponsive. His functional status was identified as dependent on the communication board. His wife had a fit because I used that word. I found myself caught in the middle of her and administration telling me to change it. The board was left blank because nothing was acceptable to her.

Sometimes I want to tell families to leave the room when I'm working with someone. I've learned to avoid ICUs during visiting hours. I used my clinical judgment when I decided not to walk that patient. My decision was based on safety. I wish the family would have understood that. It's very hard to step back and be objective about someone you love. It's also very hard to accept that a loved one won't be the same again. I wish there was a way to show families that getting in the way with therapy doesn't help.

I'm Confused About Something

Toni Patt — Tue, 29 Apr 2008 12:37:00 GMT

I work as a contract therapist. Using me is expensive. In Houston the rates for contract services keep going up. I think there have been two rate hikes in the last 6 months. Facilities use us to fill vacant positions until someone can be hired. Many facilities around here have openings but can't fill them. Everywhere I go I hear how difficult it is to fill the positions. At the same time I hear how many facilities are trying to cut back on contract therapists because we are too expensive.

What confuses me is why those facilities continue to pay for contract staff when they could easily hire staff if they raised the pay scale. I speak from experience when I say no one in Houston wants to hire someone with experience. Everyone is trying to hire new or recent grads. Why? Because they can pay them less. Meanwhile there may be two or three openings that haven't been filled. It seems to me it would make more sense to raise salaries. Higher salaries will attract and retain employees. My company charges over $60/hour for me. Part of that is my salary, but not all of it.

If an employer was willing to pay what I'm worth they would save money. My salary plus the added cost of benefits still comes out to less than the contract hourly rate. By my calculation that would save at least $10/hour. So why don't employers do that? They can't convince me they're saving money by keeping the salaries low. The cost of contract therapy to fill empty positions is nearly double what they want to pay. One of my PT friends said my problem was I expected administrations to do something that made sense.

Another thing I don't understand is why facilities eliminate all contract therapists when costs get out of control. That happened to me this week. The facility I was at decided to eliminate all contract therapists because we are too expensive. Fine, I will get a different assignment. The thing I don't understand is what they plan to do about treating the patients who were on my caseload? I was cancelled. Unless I'm replaced with someone else they will be short one therapist. I won't be replaced so I wonder who will see those patients. I don't understand why patient care is the first victim to rising costs.

I can tell you what will happen. Patients will begin complaining because they aren't receiving therapy. Doctors will start complaining because patients aren't receiving therapy. If it goes on very long they will lose staff, which they can't hold on to anyway, because working conditions will deteriorate. Then, guess what? Contract therapists will be back. Doesn't it make more sense to skip the whole thing, keep the contracts and look somewhere else for cost saving?

I don't know what administrations are thinking when they make these decisions. I do know that for the most part administrators are business people, not healthcare people. Maybe that makes a difference. In Texas it is pretty easy to see why healthcare costs keep skyrocketing. Instead of trying to address that problem, facilities eliminate positions, charge more and use cheaper products. That hasn't worked yet, but they keep doing it.

As I said I'm confused. I think facilities would have more success with saving money if they started listening to employees. The people actually providing the care are also the ones who know what is going on. I think healthcare is the only industry in this mess. I'd like to see what Exxon-Mobile would do about the problem. I bet they could solve the problems and still make a profit.

Give Me What I Paid For

Toni Patt — Mon, 28 Apr 2008 12:35:00 GMT

My online class is wrapping up this week. I can't say I'm unhappy about that. The class was a big disappointment to me. This was a graduate level class. I paid regular college tuition to be in it. I spent over one hundred dollars on books. I don't think I got my money's worth. I think for what I paid, I should have gotten a lot more class. I spent half of the semester trying to figure out what I was supposed to be doing. The other half was spent getting everything done before the deadline.

I really hate it when you paid for continuing education and walk away feeling like you didn't learn anything. I pay out of pocket for all my continuing education. I don't have a big budget so every course has to count. I'm required to get CEUs to maintain my license so I might as well learn something in the process. The worst class I ever attend was a few years ago. It had good billing and was sponsored by an organization with a good reputation. I can't tell you how disappointing it was when the class consisted of the instructor reading directly from the manual I received as part of my tuition. Even worse, he got confused if he deviated from the topic.

Another thing I hate is when I feel like I know more than the instructor. This becomes a risk as more classes are taken. I've taken "advanced" classes and felt like they should have been introductory. I paid money to learn from the instructor's expertise. If someone is teaching a class, I have the expectation that he or she is knowledgeable in the topic. Now I've had some excellent instructors. One of my favorites was a pharmacology course for PTs. That woman knew her stuff. She was also a good teacher.

Lately I've been using online and home study courses. They aren't as expensive and can be done as my time permits. I've found some very good ones through the APTA. If you're a member they are reasonably priced. Reading a booklet isn't the same as asking questions. Once an instructor looked at me like an armadillo in the headlights and told me he couldn't answer my question nor would he make the effort to research the answer. Hmm, maybe self study isn't so bad. That was another unmemorable learning experience. Lucky for me university courses count for CEUs. I have a few more online courses to take so I'll be set for awhile. Who knows after that? Maybe I'll teach a course.

My Cat Died

Toni Patt — Tue, 15 Apr 2008 17:59:00 GMT

My cat died last night. He was old. He lived a full kitty life. He died last night in my lap and I gently petted him. I could have taken him to the vet but all that would have happened is he would have been put to sleep. I couldn't do that to him. He died at home in familiar surroundings, not in a cold, unfamiliar vet clinic. As soon as I picked him up I felt him curl up and relax. It probably took less than 15 minutes.

That is how my cat died: at home and in peace. It's sad that we don't give our elders the same consideration. Many will die in the hospital either alone or with strangers. It won't always be peaceful. It probably isn't how the person wanted it to happen. Once an elderly person enters the medical system our society doesn't allow for much choice in how one dies. As soon as someone is admitted to the hospital, the focus is on keeping him alive at all costs. Many years ago my grandmother died in a hospital. She had a massive stroke. She went to the hospital. They didn't hook her up to anything. Instead she passed quietly in her bed. That could never happen today.

Living wills aren't a guarantee. If a family member says so, health professionals will ignore it. I've seen this happen several times. Family members have told me their parent didn't want to be kept alive but they can't let go. Even if a patient can voice an opinion on how things should proceed it will be ignored. I can't count the number of times I've gone to see a patient only to be told to go away. These patients have made a decision about their care. They don't want any. They want to be left in peace. I'm not advocating letting people just lay in bed. I am saying that some of those patients have made decisions about how they want things to end.

Being a PT in a SNF is a challenge. The mechanism by which a SNF makes money is based on the amount of care a patient receives. The more care provided to the patient, the greater the amount of money received. Amount of care is measured by the total number of minutes the patient receives care. So a SNF wants everyone to receive as much care as possible.

This weekend I worked in a SNF. I had a patient refuse. I was supposed to see him for 35 minutes. He told me he didn't want to do therapy. He knew he was dying and just wanted to be left alone in bed. I was caught in the middle. On one hand I'm supposed to provide 35 minutes of care but doing so meant encouraging him to do something he didn't want to do. ICUs are another place where this happens. Doctors want their patient s up no matter what. Sometimes it seems the therapy is worse than the disease.

I don't have an answer for this. Sooner or later we will all meet a patient like that gentleman. I have two ICU patients right now that fit that bill. One is a 77 year old new quad from an MVA. Assuming she survives what kind of life will she have? She is A and O X 3. I wonder if anyone has asked her what she would like to have done.

The other one is a 15 year old with severe anoxic brain injury. The chart said he was without oxygen at least 10 minutes. I can work with him. Maybe I can make him a little better. Better is a relative term. Better than what? He is high risk for just about every complication a patient can develop. I'm not sure how much help I'm really providing.

Ultimately these decisions fall to the physicians. When my time comes I want to go quietly surrounded by things I care about. I hope there is someone around to watch over me, like I did for my cat, to make sure it can happen.

Right Where I Want to Be

Toni Patt — Tue, 08 Apr 2008 11:33:00 GMT

I'm back in the ICUs again. These aren't just any ICUs. They are in one of Houston's major hospitals, the place you want to be if anything bad happens to you. This is where I want to be. This is what I think of when I say ICU. These are among my favorite patients. They're critically ill and medically complex. And as soon as I read my first chart I started wondering if I belonged there.

Therapeutically I know what to do with these patients. I know what monitors to watch and what the readings are telling me. I can tell if someone is getting ready to crash. I don't worry about those things. I worry about missing something or not doing enough or doing too much. I worry that I'll inadvertently do something wrong and not realize it. These are thick charts. There's lots of information that isn't always legible. I could miss something. I even worry about pulling out lines. Every ICU therapist has probably done that at least once. I know someone who pulled out a PEG tube. Other than her being shocked, nothing happened. Therapy may not be the most important thing on their agenda but it's a part of the healing process. A chair may be all that separates them from a pneumonia or worse.

Most of them are in the hospital due to circumstances beyond their control like an MVA or brain injury. One minute they were fine. The next minute here they are looking at me through a haze of confusion and pain. Sometimes there is family present. I try to avoid doing treatments during visiting hours but it happens. It's hard to work with someone who is minimally responsive while the family is intently watching. They're looking for hope that things will return to normal. Doctors often have little to say to them because they just don't know. So the families are watching and looking for hope even though they don't understand why I'm doing what I am. I feel bad when the patient isn't doing well and the family is expecting miracles. I tell them the process is just starting. I tell them to be patient. I assure them I saw something. I know what they hear and I what I say aren't the same. This is the hardest part. I sometimes walk out of rooms feeling bad because I got a glimpse of who the patient once was while knowing the prognosis isn't good.

Still I enjoy what I'm doing. I look forward to each day. I pick up as many ICU patients as I can. I accept my concerns and fears. I'd be more upset if I wasn't worried. As long as I'm worried I'm doing my best. I'm not just going through the motions so much as trying to make a difference. That's all I can do. I just hope it is enough.

Loss of Identity

Toni Patt — Tue, 01 Apr 2008 11:11:00 GMT

Last week in the electronic version of ADVANCE Deborah Cox, MSN, CRNP-F tackled the topic of identity loss and the elderly. She explained how entry into a long term care facility such as an SNF causes an individual to lose his or her identity. Instead, the patient becomes the admitting diagnosis. Ms. Cox further shows how the system contributes and promotes this loss that can bring on feelings of depression and isolation. (To read the article from the ADVANCE Website, click here.)

The majority of long term care patients are elderly. It never occurred to me that the very actions being taken to them were actually creating a new set of problems from identity loss. I can see how it can happen. For example, in therapy we tend to refer to our patients by diagnosis. This is more a function of confidentiality protection. We are then able to talk about patients without fear of loss of confidentiality. But, as Ms. Cox points out, we need to remember the patient is more than a body part or diagnosis.

Think of it from the patient's point of view. The entire world has been turned upside down. In a short period of time the patient has been removed from home, lost control of the decision process and instructed to ask for help before doing anything. Going to the bathroom becomes an ordeal. Changing positions or going from bed to chair requires the assistance of someone else and usually happens according to someone else's schedule.

As most SNF rooms are doubles, there is also a loss of privacy. I've heard countless complaints about roommates who have too many visitors, leave the TV on all the time or don't sleep at night. Many patients talk about missing their pets. These pets take on additional significance to an elderly person who has no other companion. Since most SNFs don't allow pets to visit, the patient is cut off from an important part of life before admission. I guess when I'm the patient my request to see my horses will not be well received.

Therapists can either contribute to the problem or address it. I can no more heal someone just by touching them than I can levitate them with my gait belt. But I can help the patient maintain a sense of individuality by asking questions, listening to answers and providing choices about therapy. I let my patients choose whether to walk or exercise first. I bribe them to get out of bed with a promise of a trip to the bathroom. Sometimes therapists are the only ones who will do this so it is an attractive option. I ask patients how they met their spouses, where their children or grandchildren are and where they are from. Not only does it help the patient but I get to hear great stories of times I can only imagine.

Depression is a common co-morbidity of the elderly. It's sad to think that in our well-intentioned efforts to help them, a new problem is being created. I can't imagine how I'd respond if the situation were reversed. I'm healthy and I would have trouble with it. The elderly have additional problems with loss of hearing, poor vision, fear of falling and in many cases difficulty communicating due to aphasia. I've always joked about being the cranky old lady who swings her quad cane if she doesn't get her way. Now I'm starting to wonder if there might not be a grain of truth in that.

Therapists can help. We spend a lot of time with our patients in the long term setting. While working on increasing functional mobility we can also be asking questions and listening to the answers. We refer to our patients by name. We can provide choices. Granted this is a small dent in the overall SNF experience, but every little bit helps.

Who is Responsible?

Toni Patt — Wed, 26 Mar 2008 18:55:00 GMT

Like most therapists, I'm a veteran of interdisciplinary turf battles. Usually the problem is PT and nursing going around over getting a patient out of bed. Sometimes it's about whether out of bed to chair is a PT or a nursing order. This time was a little different. The conflict arose over a VAC. I'm starting to really dislike those things. Night shift had taken the VAC off over night because it wasn't working. I was leery to put it back on because the location made getting a good seal difficult. The patient's nurse was angry at me. She told me she wasn't going to be responsible for the VAC not being on the patient.

I still don't understand why she was upset. At that facility, PT is responsible for all wound care including VACs. If I didn't put the VAC back on, I would write a note and document what I did and why I did it. At the same time, I would have applied an appropriate dressing to promote wound healing. Other than letting me know the VAC was off, nursing had nothing to do with this. The issue here wasn't the VAC. It was the nurse not wanting to be blamed for something that didn't happen. She wasn't concerned that the patient might not have received wound care. She was concerned that she would be blamed. I'm not a nurse, but I don't think that's the best philosophy for patient care.

Responsibility or as in this case, blame avoidance, is an ongoing point of contention. Disciplines are concerned only with their specific area of care. Frequently, the issue isn't that something was or wasn't done. Instead, the issue is who is to blame.

Tunnel vision isn't limited to departments. We do this within the rehab arena. I wonder how many PTs fully assess the arms of a patient who receives both PT and OT because OT "does the arms." I've been guilty at times. One problem with this is using the arms to help with gait and mobility. How can I assess accurate goals if I don't know how much the patient can use his arms? You can't walk on a walker if you can't support yourself with your arms. It's a minor example, because most PTs will figure this out very quickly. On a much larger scale, such as when rehab and nursing are butting heads, the problem is much more significant.

A friend of mine is working on her PhD in nursing. Her area of concentration is process improvement through improved team work. She puts nursing and medical students together and simulates a patient care situation, then observes the results. So far her research has shown better outcomes result when everyone works together. That shouldn't be a surprise. What is less obvious is that individuals are reluctant to accept responsibility for making a mistake. She has had to show the video tapes to individuals to prove her observation. That is a little frightening.

Everyone gets sucked into the blame game. Rehab and nursing will forever argue over whose responsibility it is to get patients out of bed. No one will ever agree on who should be responsible for cleaning a dirty patient. But we must remember the big picture which is taking care of the patient. My VAC patient received appropriate treatment. PT and OT work together to mobilize patients regardless of what body parts are involved. As long as we keep that in mind, we won't sink to the level of these two doctors: Neither one wanted to be the one to pronounce a patient. While the they argued, the expired patient was lying in a room waiting for someone to take responsibility so he could officially be pronounced dead and taken to the morgue.

The Squeaky Patient Gets the Oil

Toni Patt — Thu, 20 Mar 2008 13:58:00 GMT

There's an old saying that says "the squeaky wheel will get the oil." I think a similar saying exists in health care. It says "the patient who complains the loudest gets the most attention." I've never seen it fail. As soon as a patient starts complaining, everyone will bend over backwards to make that complainer happy. It doesn't matter how ridiculous the problem is. It doesn't matter if the resolution comes at the expense of staff. The patient must be happy. The universal rule for health care used to be "do no harm." Now it seems to be "never say no to a patient."

Physical therapy is no different. I had one of those patients today. I needed to change her VAC. I've done this many times without incident. I knew I was in trouble the minute I walked into the room. She wanted to know where "W," the other therapist, was. Nothing I did made her happy including completely removing and reapplying the entire VAC set up. As soon as I left the room, she was on the phone to the rehab manger complaining about me and how she never wanted me in the room again. In an ideal world, the manager would apologize to the patient and stand up for the therapist. In this situation, the manager sent a tech in to switch the VAC once again. Naturally, the patient was happy. I was happy I didn't have to deal with her.

There was no therapeutic reason for that VAC to have been changed so many times. It was functioning properly the first time I put it on. The problem was I didn't put it on like "W." My inclination was to tell her "I'm sorry, W is out. The VAC is working properly. When he gets back tomorrow he can take a look at it." Obviously, that could never happen. Not only would saying that be common sense, it would be telling a patient "no." When did it become wrong to tell a patient "no"?

I don't understand this. Telling someone no to an unreasonable request isn't a bad thing. Patients are always asking to be seen at a specific time. We tell them the best we can do is a.m. or p.m. Any therapist knows it's impossible to follow a tight time schedule. But let administration hear the request and that patient will have treatment scheduled every day at a specific time. It seems like the more difficult the patient, the more effort is devoted to making that individual happy, usually at the expense of other patients. This frustrates staff to no end. When someone is resorting to attention-seeking behavior, the best response is to ignore the behavior. When it doesn't work the behavior will stop.

What's the worst that can happen if a patient is unhappy, assuming all medical and ethical issues are being appropriately addressed? The worst case scenario is the patient leaves the facility. I say let them go. In fact, offer to hold the elevator for them so they can leave that much faster. I don't think anyone will go bankrupt because an unhappy patient decided to leave. The morale boost to the staff is more than worth the action. Too bad administration never sees it that way. When I was a manager I dared to say no. Each time there was a good reason. Each time I was constantly pestered and occasionally badgered to relent and let the patient have whatever was at issue. At times it got ugly. Ask yourself, "What could rehab offer that would make such a difference to someone?" Other than treatment itself, I can't think of anything. I often wonder what those people do when they don't get their way outside of the hospital. It can't be pretty. Until someone comes to their senses, we will have to continue to oil the squeaky patient and bite our tongues.

What if I Won the Lottery?

Toni Patt — Tue, 11 Mar 2008 15:05:00 GMT

Today at lunch we talked about what we would do if we won the lottery. Almost every one said she would continue to work but not at her current job. A couple said they would stay home and be mom. An ST said she would volunteer her time to help uninsured children. Others said they would still work but fewer hours. The difference, we decided, was doing what you want to do instead of what you do to get by. At the same time we wondered why all the good jobs pay less.

I would still be a therapist. That's all I know how to do. My practice would be different. Instead of working with the elderly in hospitals, SNFs and the like, I would like to do hippo therapy. I could combine my love of horses with my profession. For me that would be the best of both worlds. I could spend every day with horses and still provide therapy. The problem is, though the programs are successful and popular, very few exist. Those that do either hire volunteers or pay very little. So, I keep my current job which allows me to have horses.

Making the switch would be a complete change in direction for me. Currently I'm working on a certificate in geriatrics, preparing to take the GCS exam and considering enrolling in a DPT program. Hippo therapy would be something completely different. Geriatrics is pragmatic. I like working with older adults. It is also the fastest growing population requiring services. As more baby boomers reach retirement age, the need for therapists will explode. If I could I would switch without a second thought.

Now, if you had asked me 10 years ago about my dream job I would have said management. I've done that. I could do it again. It just isn't a burning desire. I'm not sure if the change is experience talking or a change in my priorities.

I think everyone has a perfect job they would prefer to do. Some people would go back to school and change careers. Others, like me, would stay in their careers but change what they do. I know some people who've managed to make it happen. I'm jealous. I envy the woman who trains my horses. I would love to do what she does. Meanwhile she talks about wishing she had chosen a different career path. Wouldn't it have been nice to have had this knowledge when choosing a major in college? Or to be able to go back to school to be able to make changes? The problem is everything costs money and there is never enough to go around. Well, at least I have something to think about.

If You Want My Respect, Earn It

Toni Patt — Wed, 05 Mar 2008 13:13:00 GMT

Currently I'm working in a SNF. Every Monday we have our weekly meeting to go over proposed discharged dates. Our census generally runs 125-135 which is a lot of patients to keep track of. Since we're all together in one place we frequently have a department meeting first. We had one today. Once again I sat there and shook my head. My problem isn't the meetings. It's the manager. I don't respect her. I don't think she's doing a good job or really has a clue about what needs to be done. She knows the Medicare regs and ins and outs of how a SNF works. Her people skills are great. She might be an excellent therapist. I don't know. I've only known her as a manager. Her managerial skills need some work.

It's hard to work for someone you don't respect. A level of respect comes with a managerial position. Respect is a funny thing. A job title only goes so far. To have respect you have to earn it. Now no one can know everything. If you're a manager I have an expectation of knowledge and skill that go with the job. I expect a certain ability to recognize problems and implement solutions. I'm not sure she sees the problems. I think she misses the procedures in search of the outcomes. If you don't know the steps you can't fix the problem.

For example we have a problem with lost minutes. If minutes aren't documented they never happened. All SNF reimbursement is based on the amount of time a patient receives skilled services so every minute counts. Her solution is to change the location where we record our minutes. Instead of alphabetical listings, it will be based on assessment periods. Now if I'm forgetting to record minutes I'm going to forget to record them no matter where you want me to write them. This is a great solution if you want to keep track of assessment minutes. But it's not going to help someone remember to write them down in the first place.

Another problem is one way communication. All communication goes through her to the weekly care plan meetings. That's efficient and prevents the therapists from wasting time. The problem is the communication only goes one way. Unless I make a point to ask about a specific patient I never know is said. Telling me someone is going home with family just isn't helpful. It doesn't tell me what I want to know. Will there be adequate supervision? Is the family aware of the patient's limitations? Will the caregiver be able to adequately care for the patient? What kind of environment is home? My patients are frequently confused. They can't tell me these things. Unless I meet a family member or caregiver I don't know. There needs to be a way for the treating therapists to get this information. As far as I can tell our manager doesn't even recognize this as a problem. Our Social Workers aren't much for documentation so there's not much help there.

However today we were told not to discharge a patient for refusals until we try a different therapist. We were also told to put patient who's missed a treatment during the week on the weekend schedule. These things are already happening. I had to sit there and wonder. If your staff is good and knows what to do without being told, does that automatically make you a good manager or just lucky? No one told us what to do. We just do it.

Now I'm not saying I would do any better. Nor do I think I have all the answers. I would certainly address things differently but that's no guarantee of a different outcome. There are lots of great managers out there who work hard. Sometimes a mistake is made. I can think of a few classics from the past I've seen. I think a good manager is someone who knows her department, knows what needs to be done and knows when to ask for help.

Back in the Lab Again

Toni Patt — Wed, 27 Feb 2008 21:28:00 GMT

I spent last weekend in Dallas. I had to go there for a lab for my online class. Three one day labs are required. This was the first. It was also my first venture into onsite graduate education. My first class was 100 percent online. All the lectures were downloaded. I completed assignments and submitted them electronically. I never met anyone fact to face. Even though I was doing school work it didn't feel like school. Working at my computer with my parrot on my shoulder just doesn't feel like school. Being in the classroom and sitting at a desk felt like school.

The most exciting part of the agenda was a visit to the anatomy lab. Since this is a cardiology course we looked at hearts and related structures. The first thing I realized when I looked at those things was how much I've forgotten. The second thing I realized was how much I've learned since I took gross anatomy. I learned more from that hour in the anatomy lab than I would have gotten from hours of lecture and textbooks. There's nothing like seeing to understand. When I looked this time I knew what I was looking at.

My memories of gross anatomy are of struggling to identify structures while memorizing origins, insertions and actions. I might have looked at something else but I wouldn't have remembered it. My entire focus was on learning the anatomy and passing tests. I didn't have time for added significance. This time I knew the anatomy. Instead of focusing on what I considered why and how. I know the aorta carries oxygenated blood. I'd forgotten how large it is. I know what a AAA is. Now I know where it occurs. I had the opportunity to feel calcification in an artery. Now I know the mechanism by which it causes problems.

This got me to thinking. What would happen if I were able to retake PT school? Would I learn all kinds of new things that I missed the first time? I know I would ask different questions. I wonder how much I missed as I struggled to put a whole lot of information into my head in a seemingly short time. Would I be a different therapist now? I'm certainly a better student. Of course one class a semester is a little different than a full course load. Back then I dreaded exams. Now I look forward to them to as a chance to use my mind.

At lunch the four of us sat around talking about school. We all felt the same way. We are in school now because we want the knowledge. We want to do the work. We're all about the same age so that might slant our opinions. That doesn't mean it isn't something to think about. I work with two therapists who have about 4 years experience each. Both have master's degrees. One is adamant about never returning to school. The other expects to in a few years. Compare that to people almost 20 years older having a similar conversation at lunch. It makes me wonder.

Right now I'm enjoying myself. I'm working on a certification in geriatrics which only requires 4 classes almost all of which are 100 percent online. I might feel differently if I was looking at a 30+ hour curriculum or actually had to go to school. I've also been out of school more years than I want to admit. That might make a difference. Right now I'm learning things I can use immediately. That's what is important.

*** Anyone interested in the geriatric certification should go to http://www.twu.edu/. Go to the school of PT and follow the prompts.

We Just Don't Get Along

Toni Patt — Tue, 19 Feb 2008 12:15:00 GMT

What do you do when you have a patient you don't like? I don't mean one you are unsure how to treat or one who drives you crazy. We've all had those. We've all learned to take a deep breath and just do it. I think we all have patient types we prefer to avoid. Mine is whiners followed closely by those who always want something. If I never hear the phrase "I can't" again I won't feel deprived. These patients are a part of life. If you get a group of therapists together everyone will have had at least one patient from hell.

Over the course of a career, a PT will come into contact with many people. Some are patients. Some are family members. Some are co-workers. Mixed in there will be those you don't get along with. Contact can be limited with co-workers and family members. I've worked with people I didn't like. Patients are different. Providing treatment is the reason you come together. I have one of these patients. I don't want to see him or talk to him. I can barely listen to him. He is not a happy man and doesn't have a positive affect on those around him. I think he is depressed. I know he has some confusion. I'll call him Mr. B (not his real last initial).

Mr. B broke his ankle. He is now NWB on that leg. He is overweight and deconditioned. When I look at him I wonder how he got around before he fell. We got off on the wrong foot when he exaggerated his prior functional status. His son corrected that. He ignored me when we first met because he wanted a male therapist. He only comes to therapy when he wants to and complains he didn't do enough. He is a challenging patient without the personality conflict. I like challenging patients, just not this one.

I've tried several different interventions with him: chair exercises, bed exercises, group exercise, the restorator, sliding board transfers and assisting with dressing to work on bed mobility. I've had him a week. We've made no progress. I keep asking myself what else can I attempt? How can I adapt things to a level where he can do them? What else can I try? Meanwhile Mr. B tries my nerves.

I think this is difficult for PTs. It's frustrating to have a patient I can't work with. The obvious solution is to trade patients. I'll have to do that. I'm running out of ideas. Many a different mind will have a better approach. I don't like to trade patients but this isn't working. Did I fail? I tried everything I could think of. Nothing worked. I don't think you fail in therapy if you give it your best effort and rely on clinical judgment. Right now my judgment is telling me to try someone else. I doubt I'll my opinion of Mr. B will change. My obligation is to provide the best therapy possible. It looks like the best way to do that is to let someone else give it a try.

I Wouldn’t Treat a Dog This Way

Toni Patt — Tue, 12 Feb 2008 16:19:00 GMT

My dog, Mckenzie, is getting old. I've been watching him gradually slow down. He's nine which is retirement age in people years. He takes arthritis medicine. He eats a special diet for mature dogs. He's beginning to have trouble transferring sit to stand. As I watch him I find myself making comparisons with my patients and how they are treated. Humans and dogs go through a similar aging process. Bones become brittle. Muscles become weaker. Eye sight and hearing will become impaired. Occasional aches and pains become a daily occurrence. While the processes are the same, the results differ.

My dog doesn't complain. He wouldn't have the arthritis medicine if I hadn't taken him to the vet and been willing to pay the cost. I did that out of concern for him. In many ways he's the same dog he has always been. He refuses to be excluded from anything I do, including yard work. He chases the squirrel that raids the bird feeder, although at a slower speed. He guards his backyard and barks at the neighbor dogs. Other than moving a little slower and stopping a little sooner, he hasn't changed.

Humans, on the other hand, behave differently. Medicines are available to address the many illnesses that can develop. Surgeries are available for humans that few would even consider for a dog. There are medical specialists for nearly every disease process. Buildings are wheelchair accessible. Therapies are readily available and affordable. Communities exist to allow older adults to continue living independently as long as possible. Yet, with all of this I think my dog has it better.

No matter what happens, my dog-and any of my animals-will be taken care of. They'll receive medical care if necessary. I'll make sure they receive any needed medicines, even if it's the cat. They will always have a loving home (or barn) with someone to care for them.

Compare that to my average patient: Some will go home. Some will go home with children, usually fighting and screaming the whole way. A few have siblings or close friends to help with their care. Others require such extensive care that it isn't feasible for them to be at home. The rest aren't so lucky. Their families may not be able to care for them, or may not want to care for them. These patients don't have a home to go to or someone to watch over them. These individuals will receive placement. They will receive whatever care they can afford. This care will be provided by paid caregivers who have no emotional investment in the outcomes. It's sad we live in a world where pets have no worries and our elderly receive only the care they can afford. Sometimes it breaks my heart to see this. To quote a favorite song, "something's wrong in the world today and I don't know what it is." *

*Aerosmith: Living on the Edge

Not All Refusals Are Created Equal

Toni Patt — Fri, 08 Feb 2008 15:18:00 GMT

Last week I heard something that made me stop in my tracks. A PTA was going to treat a CVA patient who was new to her. When the PTA attempted to initiate the treatment the patient refused the standing frame. The PTA sent the patient back to the room, threw up her hands and said she didn't know what else to do with the patient. That really bothered me. I don't know what made me madder, the PTA not knowing what else to do or the PTA not even trying to convince the patient to work with therapy.

Patients refuse. It is a fact of life for a PT. There are many reasons: pain, fatigue, the BR, dislike of a specific treatment, laziness and not wanting to miss "The Price is Right". A confused patient is as likely to refuse as participate. Often a patient can be convinced to participate with therapy after refusing. It is the responsibility of the therapist to try. Not all refusals are a set in stone, no. By asking questions the reason for the refusal can be uncovered. If I know why a patient doesn't want to do therapy, I can do something about it. The reason may be as simple as needing an extra blanket or to go to the restroom. The point is, if you don't ask, you don't know. The PTA I overheard didn't ask. She just gave up and moved on.

Compromise is an important part of therapy. This patient didn't want to use the standing frame. She may have been agreeable to doing exercise or balance activities in sitting. Patients who don't want to walk may still be willing to get up and do therapy, just not walk. As therapists we know the importance of moving patients pushing them. If the choice is between no therapy and a little therapy, I choose a little therapy. I've had patients who won't do anything for me, happily work with someone else and vice versa. Some people are just not morning people and being in the hospital won't change that. You have to at least give it a try.

Sometimes patients refuse because they don't feel well. Not feeling well can run the gamut from mild nausea to a racing heart rate and V-fib. Patients don't always accurately verbalize what they are feeling. Have you ever tried to describe dizziness? It is the responsibility of the therapist to find out if there has been a change in medical status or another reason the patient might be ill. Therapy is supposed to help the patient recover, not send them to the ICU. Of course there are those who just don't want to do anything. I've long given up on arguing with those. If someone refuses to do something, nothing will make them.

When I say refusals I'm not talking about those who will participate with constant cooing and encouragement. I'm also excluding those who are confused and don't know what they're saying. Confused patients will refuse one minute and agree five minutes later. Depressed patients will participate. They might suck the life out of you, but they will work with you. I've had days where if I walked away from everyone who refused, I could be home in two hours. It's our responsibility as therapists to try. I wish the PTA would have made the effort. Her patient would have benefited from some sort of intervention.

Okay, I have the reputation as being mean and I'm proud of it. Refusals don't mean anything to me. I talk them into therapy. There are days when I don't try too hard to convince someone. But I try. At the end of the day I feel good about what I've done or attempted to do. I wonder how that PTA feels.

*My apologies to all PTAs who read this. I'm not picking on you. You have my respect. I would have written the same thing if it were a PT.