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PTA Blog Talk

The Health Fringe
by Jason Marketti

Stay active, eat healthy, get plenty of sunshine and take colloidal silver. Okay, so don't take the silver, take something else, like, bitter cola. I think I could produce enough clinical evidence to promote either one though and patients would probably listen to me like I'm an authority on healthy living.

Isn't that part of what we do -- instruct patients on better lifestyle choices? And if I happen to have a fringe mentality on what exactly constitutes lifestyle choices, no one should judge me or my ideas. Would you tell a patient not to use a neti pot even though he has done so culturally for years? Would you have told George Burns not to smoke and drink? Think about it, he lived to be 100 years old.

When treating patients, we don't treat only the part that hurts, because of the interconnectivity of the body. If a patient has a TKA, I won't focus only on her knee but also gait cycle and sequencing, as well as hip strengthening, balance activity and safety with all aspects of transitional mobility. And in some instances, diet, nutrition and fluid intake, which is just as important as exercising and resting.

Healthy lifestyle choices vary in patient populations and we have to respect what some people consider healthy eating habits. Obviously we know potato chips and soda don't make a good breakfast, but cereals can often have high sugar content and some people don't like the consistency of oatmeal or their diet precludes its intake. Grainy bread is good but tell that to your patient who has dentures and the seeds get stuck between his gums and dental work.

For years I was told ice cream is a dessert, however, the high protein and calories can encourage weight gain in some residents. When mixing ice cream and a nutritional shake that tastes like chalk, it's a full meal and kind of good for someone who won't eat meat at meal time because it's hard to chew.

Being realistic with patients, whether it involves using an assistive device and exercises or offering commentary on healthy living, can go a long way. I've heard therapists berate patients when they consume a candy bar, but the therapists forget there are calories in that candy that the patients will need during their exhaustive 75-minute workout.

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Strictly Science-Based
by Jason Marketti
Stem cell research is not a new topic but can be controversial for some. Often it is the embryonic stem cells that get people upset, but there are other stem cells out there that research and biotech companies are looking into for healing and helping people recover from devastating illnesses.

As a purely scientific reading, stem cells are fascinating. You often have to put aside your personal and/or religious beliefs and read the information as if you are researching a topic from school. That, for some, is the hard part. For those who have difficulty with this, remember there were ecclesiastical authorities in the past who made decrees to ban surgery, a practice that's now routine and we actually know enough about to educate patients on. 

Total-joint replacements of hips and knees, titanium cages around the spine that allow people to get up and walk again with less pain and more mobility, it's like an Isaac Asimov sci-fi story. But it's real life and we treat those patients routinely so they can heal and recover from their surgery. Few people make a big deal about putting metal into a human body or electrodes when using a spinal cord stimulator and pacemaker, but mentioning the use of cells that can reproduce into other cells and, well, it becomes a political, moral and religious issue for some.    

Would it be any different if the patients you were treating received stem cells and could now walk or move easier or feel less pain because of the medical treatment? Could you be happy for them and cheer them on with their recovery? Would you still treat the patients even though they received medical treatment you personally or religiously cannot fathom? Remember, you have thoroughly studied the human body inside and out, some have touched a cadaver, and you know the regions of the brain and what part controls where. Wasn't this type of study considered barbaric at one time?

When doing research for any medical advances, we have to look at the information from a different point of view. A clinical mindset and an understanding of scientific data will help. Similarly, when treating patients who have different ideas from our own, we have to put aside those differences and work toward a common goal, to heal people and get them well. 

Some additional reading on human-induced pluripotent stem cells, bone marrow stem cells, and human spinal cord stem cells among others may help you understand what stems cells can do for patients and us, as clinicians, treating them.

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Assessing Physicals
by Jason Marketti

One clinic I worked for provided drug screening and physicals for various employers. I was tasked with a checklist and some basic lifting scenarios to put potential employees through. At the time, the construction business was in full swing so there were a lot of people coming through who wanted employment.

When an older gentleman came through and passed the drug screen, the owner of the clinic (who was also the supervising PT) pulled me aside and told me to make him go through extra scenarios. Who am I but a pawn in the great city of Theratropolis? So my supervising PT gave me instructions on what to do during a screen and asked me to do a little more to ensure the gentleman was capable of performing all the skills necessary in order to gain employment.

I don't know if race had much to do with it at the time; however, the older man spoke very little English and performed well enough on the basic tests of lifting, squatting and moving about. Now I had to test him further than I would test someone else because of his... age? Race? I wasn't really sure why I was providing further testing for a man who passed all the basic skills necessary to do a job. I was never asked to do any other type of testing on anyone else, so why him?

Being a simple-minded PTA, I could have complied, put the man through some extra tasks and been done with it. Instead I talked with him about his family and what type of work he was going to do. It turned out he was trying to make some extra money to put a granddaughter through school. The position he was applying for had nothing to do with lifting or squatting skills. I discussed and reviewed body mechanics with him, signed off on the paperwork and wished him well with the job.

Being able to make a determination on whether to provide services and activity to someone who needs it was part of my position. I assessed the situation, then made a decision based on my questions to the patient as well as the results of the standard lifting and moving tests we provided. The man gained employment, paid taxes, and helped his granddaughter achieve her educational goal without wasting his time performing extra testing.

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Making a Mess
by Jason Marketti

As I opened the gym door early one morning, I was stunned by what I saw. A large polyurethane mug with those beautiful white rings left from the wet bottom of the cup practically glowing on one edge of the mat table. Someone brought their drink into the gym, was treating patients, and left the cup and mess for someone to clean up. Outstanding.

Now it could have been a patient who left the cup, but I know better. I know who it was because this person always brings a drink and proceeds to slurp from it in front of the patients. I once met a psychologist who did the same thing while conducting interviews with new patients. When asked about it, she said she gets thirsty when talking with the patients and didn't see anything wrong with taking a few sips while doing interviews.

Perhaps if I brought in a 72-ounce jug and glugged from it, made that "aaahh" sound while smacking my lips, then maybe people would understand how unprofessional it appears to drink in front of the patients. I wonder if anyone would see anything wrong if I ate several slices of pizza in front of the patients and then left the department looking like a Katy Perry Friday night party. Some therapists probably wouldn't notice a difference.

There's nothing wrong with having water, soda or coffee at work. But why drink in front of the patients? Put the cup in the office and excuse yourself for a moment to take a drink while the patient is resting. Imagine if your surgeon came into the hospital room with a bag of corn chips and a Dr. Pepper, crunching and slurping away while trying to sound professional talking about what type of surgery you are going to have in a few hours.

Or how about a therapist spitting sunflower seeds into a cup while treating patients? Is that any more professional than having a six-pack of soda on ice next to the recumbent stepping machine in case you get thirsty? I would normally say use good judgment when conducting patient care; however, there are some brilliant therapists who refuse to do it.

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Healthcare Economics 101
by Jason Marketti

Would you invest in the company you work for? How about an "Improshare" where the savings between hours worked and production are shared between the company and the worker? Can you "feel" the viability of your company and are they open enough to allow workers to see their bottom line?

It can be difficult when you read that a company you work for has committed fraud, abuse, or is under investigation by the state or federal government. Circumstances like this can put a negative vibe in a working environment. However, just because there's an investigation doesn't mean the company you work for has committed any offense.

There are companies that promote openness and foster a better working relationship between management and therapists. Companies that promote professional development and encourage integrity without risk of punishment are the places to seek out and work for. And if these companies allow you to invest with them, do it, because they will be here for a long time. They understand therapists are vital to their industry and will support decisions made provided they conform to their list of standards to promote individuality.

Investments made early in a career with one company can come to a halt when the company is sold or dissolved. You have to start over and this can be frustrating in the extreme. Mutual fund investments made through an employer are worth it, especially if they match 3-5% of your investment. Start early in your career though, so if you have to take a loss like I did in 2007-2008 you still have something to show for it.

Business and financial courses are often underrated for those in the healthcare field and I don't understand why. Perhaps therapy schools should encourage several courses in the business revenue department or some financial awareness courses for those entering their programs. An understanding of labor, production, and revenue generation allows us to make better decisions about our day professionally as well as personal finance decisions.

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Physical Therapy Prime Requisite
by Jason Marketti

Name: Theraman Walkis

Race: Human

Alignment: Lawful Neutral

Class: Therapist Assistant

HP: 96

Level: 18

Strength: 15

Intelligence: 14

Wisdom: 13

Dexterity: 16

Constitution: 13

Charisma: 17

 

Magic Items

Mordenkainen's Gait Belt of Walking, +2 Fall Prevention

Bigby's Gloves Against Communicable Disease

 

Money/Jewelry

2 Copper Pieces

 

Equipment

Standard Clothing of the Flanaess

 

For those of you who are familiar with the Dungeons & Dragons gaming systems, I most enjoyed the original basic red box set as well as the first edition of the AD&D system. I always tried to increase my prime requisite, that is, the main attribute for the character played. As PTs and PTAs, what do we consider a main attribute for our profession? Is it intelligence, manual dexterity, a therapist's charisma when speaking with family members? Perhaps strength is what we want if a patient were to lose his balance and for all those max assist transfers we do.

For us in therapy, our prime attributes allow us to complete tasks and they may change throughout the day. In the morning, we may need the strength to get patients up and going. In the afternoon, we may have to dig deep into our memory for the intelligence and wisdom of years in the field to answer a patient or family member's question. By the afternoon, maybe it's our charisma that gets people up and motivated to come into the therapy gym. Our dexterity allows us to palpate those bony prominences and our constitution keeps us above the 85% productivity range every day.

To improve one of these requisites takes practice and devotion to the art of therapy, as well as an understanding of patient dynamics and abilities. Sure you can be intelligent, but do you have the charisma to talk to the patients and get them to the gym? Or how about if you have the dexterity to feel the psoas musculature but not the strength to assist a patient from supine to sit? The skills we have must come together and allow us to develop our whole character, not just one area of it. We also have to know when to ask for help if a patient becomes too difficult or we become stagnant in our treatment approaches.

I will always be a happy adventurer in the field of therapy as long as I don't have to go into fellow ADVANCE blogger Toni's Temple of Elemental Evil. And a special thanks to E. Gary Gygax (1938-2008), the original Dungeon Master, for those wonderful and frustrating adventures in Greyhawk.

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Lead PT, Lead
by Jason Marketti

There are some therapists who are born to lead and bring a dynamic quality with them during evals and treatment sessions. Others are hesitant to make decisions and will prefer the "wait and see" method in regard to patient care. I have worked with both types.

Since I don't like to hold a PT's hand when discussing patient care and progression, those who are hesitant to make decisions can be frustrating to work with. I would rather work with a PT who will make a decision based on the most recent data available and then make changes during a reassessment. Those who are hesitant to lead should take leadership courses or improve their clinical decision-making through education. I've often stood by while a PT vacillates between several options. When pressed to make a decision, he doesn't, and I'm treating the patient with no clear goals or objectives from the PT who is my supervisor.

When I have made decisions based on my own clinical judgments and presented these to the PT who doesn't lead, I was met with disdain. Therefore, no hand-holding with the PT when decisions need to be made.

There are a handful of PTs I would follow anywhere because I know they have the patient's best interests in mind during every treatment session. They observe me while I'm treating the patients and will make simple suggestions to improve my outcomes because they know if I do well, they will do better. Like a symbiotic relationship, when one thrives, the department thrives.

Those PTs who are hesitant to lead a PTA to better quality patient care should read up on what it takes to be a leader and direct others. Also, read up on what exactly a PTA can do in your state. PTAs have a lot to offer to improve a department and make a success of every treatment, but since we're not able to make completely independent decisions without the PT's approval, we need skilled guidance to ensure a patient's success.

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Modalities and Treatments
by Jason Marketti

Since I follow the PT's direction in regard to patient care and treatment, I sometimes make suggestions in regard to modalities to facilitate the patient's recovery. Not every PT likes modalities and I respect that; however, if I see the OT providing treatment on a patient we are also seeing, and the OT is using modalities the PT doesn't agree with, what should I do?

I know OTs have different ideas and clinical reasoning behind what they do and why, just like us. But if we take an example of a heat pack and the OT is applying one every day and PT is not, eventually the patient is going to ask why he only gets heat with the OT. The same could be said of cold packs after a vigorous TKA workout. If the PT hasn't indicated an ice modality is okay to use, then I'm not allowed to place ice on a patient's swollen painful knee even though I know it would be beneficial post-treatment.

I understand we shouldn't overlap modalities with patients, but there are times when a patient would benefit from its use. A moist heat pack on the low back prior to activity can do wonders for some of the patients. And if OT provides it in the morning and PT in the afternoon, the patient would probably perform better. When patients ask whether they can have a hot or cold pack, I defer all questions to the PT and allow him to give a clinical reason why PT doesn't provide any modalities but OT does.

Maybe I should just weasel my way into the OT's treatment session for a co-treat because I know the patient will perform better after moist heat. Granted, most PTs will see the benefit and weigh the risks involved and decide ice and heat will allow better patient care and function than none at all. But what about the use of TENS for pain control or ultrasound for tissue adhesions?

If OT decides to treat two days a week and PT is treating for six or seven days a week, there are opportunities to complement what OT is doing in regard to any modality usage. Unless you work in one of those places that clearly divides the patient into different body sections, where only the OTs can work on the upper half and PTs on the lower half. And whenever I come across those places I ask, "Where exactly on the patient is the line?"

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Steps to Conquer
by Jason Marketti

I moved, again. Every time I find a new place to live, there seems to be several steps to negotiate and this can cause some problems with me. There are days my joints do not want to move as fast as I think I can and I wonder how I will be in 20 years. And woe unto me if I break a leg because I'll have a heck of a time going up and down steps just to answer a door.

In hindsight, I should have listened to what so many patients have advised me over the years, "Move into a ranch-style home." The patients who have one-level homes seem to glide across the floor during home assessments, show no hesitation when opening the front door, and walk from room to room with confidence and at times flash and flare.

I've seen patients who live in multilevel homes with stairs to enter become hesitant once they're at the top of the stairs, wondering how they're going to open the front door without falling backward while holding onto an assistive device. After a rest in their favorite recliner chair, they talk about how the laundry is in the basement and their bedroom is upstairs. When the subject of a home helper comes up, there are quite a few who aren't able to afford it because of their fixed income.

I had one patient who was cleared to do a home assessment and she had five steps to enter her home with a sturdy rail. She put one foot up on the step and told me she couldn't do it. When asked how she would get in the home after being discharged, she said, "The fire department comes out and helps me up the steps."

"Every time?"

"Yes. They told me I could call them anytime to get up the steps."

"What if there's a fire and someone needs to be saved and they're busy helping you?"

"They shouldn't have told me to call them anytime to get into my house."

That was the end of the home assessment and it was reported to the PT. The patient went home anyway and probably called the fire department to get into her house. I'm not sure who is at fault, the fire department for encouraging the patient to use their resources or the patient who didn't want to extend herself and work a little harder in therapy to increase her independence.

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A Patient's Norm
by Jason Marketti

No one wanted to treat this patient. He was certainly different and at times difficult to understand. His goals often fluctuated based on his mood and he smelled of cigarette smoke and urine. I treated him though and we got along fairly well. His wife wanted him to be able to walk before taking him home and we achieved that goal with an SPC. It took about two months to get that far, then he hit another patient and was transferred somewhere else. Others told me I wasted time with that patient and he should have been discharged earlier because he was so volatile.

Another patient had flatulence everyday in the middle of the gym and it was often frowned on to bring him into the small area. His goal was to get back home and we almost achieved it but his other medical complications prevented him from discharging. Then there was the patient who had a large wad of chew between his cheek and gums. He was from the 101st Airborne with wounds and stories you wouldn't believe. Those who despised tobacco hated to see him with his cup of tobacco juice sitting on a table while he performed his exercises faithfully in the gym. I never mentioned the effects tobacco has on his body. I'm sure he would have told me where to go if I ever did. And who am I to dictate this patient's norms when I don't have a medal and never parachuted into a hostile territory?

We cannot expect patients to conform to our schedules, mandates and social order of things in a healthcare setting. The situation is foreign to them and they may not understand all the nuances involved in healthcare. Yet, we often expect patient to act and react in certain ways. The homeless patients I worked with have a different outlook than the very wealthy residents and each has a different perspective about their health provider. Our personal standards should be shelved as soon as we walk into a room and interact with a new patient. We cannot let our own personal values and social order dictate whether a patient has the ability to succeed or fail.

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Safety First
by Jason Marketti

Patients expect health providers to keep them from falling, injuring themselves and free from harm. This is not a new expectation but one we should be mindful of. There are patients who have been convicted of crimes and require our assistance to improve functional mobility and activity.

I've worked on a patient in a hospital on the surgical floor who had on the striped prison uniform and an armed guard very close by. I've also been in a locked unit with various prisoners, ensuring they were performing their various exercises to improve functional mobility so they could return to prison as soon as possible. Since several of them were handcuffed to their beds, there was little in bed mobility I could accomplish with them.

In an outpatient setting, I've worked on ex-cons who have done their time and are trying to improve their lives after several years behind bars. I never discussed details of their crime and conviction because it was none of my business and it didn't interfere with their functional progress in therapy. But in a SNF environment, there are patients who live in close quarters, dine together, share stories of their favorite therapist (me), and complain together about medication, food, and me.

The expectation is that these patients are safe and free from worry while in a SNF. They have so much to worry about as far as recovery and getting back to their prior level of function, they shouldn't have to be concerned about their own personal safety.

This government website can give patients and health professionals that extra security to be sure they are safe from harm. A facility should have already done the checking for all admissions and new hires but just in case we could also do a search. As health providers, we have a responsibility to ensure our patients are well taken care of and in a safe environment while recovering from an injury or illness.

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Bringing It Home
by Jason Marketti
Last week I wasn't feeling well. Between patients, family members and other employees, there's a lot that can be passed between people in a facility. Although I use the alcohol gel and wash my hands, there are instances where a virus will find its way to me and I cannot avoid it. I didn't have a fever or any of the "normal sickness" symptoms, I just didn't feel good and wanted to sleep to get better. 

A few days later, my daughter became sick with a high temperature and vomiting. She was better after several days, then it was passed to my son. Soon the rest of the family will become ill and the cycle will have completed itself. So, did I bring home a virus from work that caused my family to become ill? Maybe.

I look back and work is not the only place I went to. I went to several different stores and used a shopping cart, I handled paper money and coins that others have as well, and I used an ATM machine. Since I didn't have access to those handy alcohol wipes that kill 99% of every known virus, I wasn't able to wipe off the handle of the shopping cart or the ATM keypad. I could have picked up a virus almost anywhere -- the gas station, opening a door, touching a handrail while going up stairs etc. There is no escaping contact with those pesky viruses.

I could easily blame any sickness on other healthcare workers who come to work sick and spread it among everyone else. I could also blame all those family members who come in and cough and sneeze in the therapy department, then leave. Maybe I'll emulate Steve Martin and not shake hands with people so I don't spread a virus to anyone else and I won't have to risk picking up one from someone either. When I met new people, I could do the forearm bump like he did when he met President Obama. I could also wash my hands more frequently with soap and water and make sure I thoroughly dry them off before doing another task.

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Works Well With Others
by Jason Marketti

Looking over my yearly employment reviews of the past, I often came across standard phrases that could describe any person. I was surprised no supervisor wrote, "Jason is a patient advocate and will question decisions he deems not in the best interest of the patient."

I suppose if someone actually wrote this, I would not be seen as a team player and therefore labeled a troublemaker who threatens the authority and integrity of a cohesive department. Would it be better to go along with the group decision and not make waves that could disharmonize a therapy structure? How about when I was sent to jury duty? When everyone else voted guilty, guess who questioned the validity of the witnesses. Did I do the right thing by questioning certain information and documents? In my position as a health provider, I do the same thing and can be criticized for it.

Overall my yearly reviews of the past have been positive. Of course, there's always room for improvement and I would be shocked if there wasn't. We should always improve ourselves professionally. Often that can mean taking an unpopular stand and being a devil's advocate for the betterment of the patient. Perhaps there are some who would like me to be more complacent and would love to have a totalitarian rule when it comes to patient care and interaction with other health providers. As long as I continue to provide therapy services for a community, patients will have an advocate by their side who can question decisions but will try to work well with others.

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Assistance Levels
by Jason Marketti

When we are documenting patient care and tracking progression of goals, we'll typically chart assistance levels and whether the patient required verbal cues as well as manual cues to complete a task. What if the assistance levels were eliminated from our documentation? Insurance companies would no longer be able to deny services because the patient wasn't meeting their goals based on our own documentation.

I wrote about how one PT eliminated goals for gait because certain insurance companies were discharging patients based on distances walked and not on function. If assistance levels are not documented, patients could no longer be denied services for lack of progress during therapy. The argument for this may seem illogical but with creative goal-writing, it's possible to keep patients on therapy who need the skilled services but would normally be denied by their insurance carrier because of a perceived lack of progress by a reviewer.

This may open up some departments to a fraud alert, however, there has to be an objective measurement that can be reached by the health providers during therapy. A standardized balance test could be used to justify services or strength testing could be used to track progress objectively. I'm not sure how this will play out in some departments since it seems like a new method to keep patients on therapy for a longer period of time. But so far I haven't heard of any therapists being called before a panel and questioned about its practice in patient care.

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Time Off Work
by Jason Marketti

A recent study of surgeons who had a couple days off work showed an increase in patient mortality rates when they came back to the hospital and performed CABG surgery. This increase may have been from scheduling the sickest patients first, who would not have survived regardless of when the surgery was performed, or from a lack of attention to detail and being out of practice with the surgery team. There was also a noticeable decrease in costs when a surgeon came back to work, which may be attributable to surgeons not ordering tests they normally would after a surgery.

So what would happen after a week or two off in the therapy field? Would we forget details, hand placements, basic exercises? Would we be able to properly educate patients on hip and back precautions or are we so skilled in performing our art that information stays with us forever? After I took a couple of months off in 2004, I struggled with my first few patients. After a week, I was back in full swing like I never left. I did forget some information but that was quickly recovered with a home review of details on the patient's limitations.

I would suspect that time in the field has a lot to do with how we perform after being away for a while. The longer we do an activity, the more innate it would become. Like throwing a baseball or hitting a golf ball. The more we practice and perfect what we do in the chosen profession, the easier it is to remember exactly how to do it and how to respond when we need to adjust and adapt to changes.

When I had surgery and took a three-month leave, I actually did more research into what we do than I had ever done before. I looked at evidence, patient responses to what we do, muscle actions, almost anything that dealt with our profession so I could better understand patient perspectives and what they look for in a therapist. The time off was well spent for me and I didn't miss a beat when I came back to work.

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About this Blog


    Jason J. Marketti
    Occupation: Physical Therapist Assistant
    Setting: San Jacinto, CA
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