I got the H1N1 flu shot today at work, but many of my coworkers are declining to have a flu shot.  Mostly, they haven't gotten the flu in previous seasons and don't feel any increased risk with the H1N1.  Some are afraid of needles.  Several cannot take the nasal mist version of the vaccine because they work with transplant patients.

I thought we were taking every precaution to isolate patients who may be carriers of this flu strain and protecting other patients from possible contamination.  We wear masks, eyewear, gloves and a gown with every isolated patient. 

However, a family friend of mine was admitted to a hospital in Canada.  At that hospital, every patient is allowed only one visitor, and that visitor must document their temperature upon arrival and departure from the hospital and must also demonstrate hand sterilization before entering the hospital premises.  These rules were established to protect everyone from possible H1N1. 

What do you think?  Is the H1N1 flu a media frenzy?  Should we be more conservative with patient visitors? Are you getting a H1N1 flu shot?

However, this therapist I tend to talk with has been interpreting my question-asking as incompetence.  He doubted my capability to work with difficult patients and wondered if I was able to make clinical decisions on my own.  I'm sure he questioned if my patients were appropriate for therapy, or if I just walked aimlessly into hospital rooms. 

It's interesting to think that students in school who ask questions, who stand out, who do exceptional work- are all honored and respected by their professors and classmates.  On the other hand, therapists who ask questions, who stand out - are misfits. 

There's nothing worse than feeling like I'm doing a bad job.  Well, worse would be me feeling like I'm doing a bad job and other people thinking I'm doing a bad job.  I'm hoping this is one of those things that just fades with time. 

The problem occurs when I look at the chart and see a glucose of 345, or a hemoglobin/hematocrit reading of 7.1/23 percent.  Prothrombin time of 45 seconds. 

There is a fine line of discussing these cases respectfully with nurses or other health care providers without subtracting from their role as caregivers.  When I explain the patient is not appropriate for PT, many will respond with "If I can walk him to the bathroom, you can work with him from therapy."  Many nurses believe it is their responsibility to determine what impact lab values have on other treatments and have a difficult time accepting our opposing clinical judgment. 

It's always a compromise to say "I don't feel comfortable treating a patient with this current status.  Let me have my supervisor speak with you if you have any further questions." 

Educating our co-caregivers on risks of activity and importance of recovering from medical complications before strenuous activity is an important part of our job.   Have you ever dealt with this?  Where do you draw the line of acceptable lab values for a pt to work with therapy? 

During our ambulation trial, I nudged this patient laterally to see if she could recover independently.  With a history of falling and a request to be discharged from PT, I wanted to verify this woman was not a fall risk if she would be bumped in the hallway.  I did not warn her that my perturbations were coming.

The patient became very upset.  The perturbations had scared her and she and stated "If I had fallen, you wouldn't have been able to catch me".  She was hungry, uncomfortable, and I had literally pushed her past her mental/emotional limits.  She did, however, recover independently and didn't demonstrate any unsteadiness or safety concerns. 

She then talked with our patient care manager, who paged my supervisor, to inform them of this complaint. 

My stomach sank.  I think I do a fairly decent job of reading my patients and knowing what is/is not appropriate for them.  It is difficult for me to think I was helping someone, when it was actually hurtful.  Furthermore, I never want my coworkers to think of me as a bad therapist. 

Luckily, my supervisor was more than understanding.  She explained that we all need reminders to slow down and take our time with each patient rather than rushing through an evaluation just to get them discharged.  She also understands my "style" of treating patients, and knows I had the best of intentions but need to forewarn my patients if a treatment includes something to challenge their balance. 

All-in-all it was a good learning experience.  I should have warned the patient that I was going to challenge her during our walk.  Even though it was a very bad day, it turned out to be a good situation.

Add to this mix: mandatory lunch meetings.  The policy at work is that these meetings are built into the 25 percent of unproductive (non-billable) time at work. 

I don't think this would bother me as much if I felt as though these meetings were a good use of my time.  I usually walk away from 30 minutes of lecture thinking "I could have read that in a 5-minute email".  I suppose for manager reasons, meetings must be held so each employee is accountable for knowing the information and therefore, cannot plead ignorance on new policies or changes. 

One positive note: Our department usually only has 1 or 2 meetings per month.  At one of my clinicals we spent at least 3, if not 4, days per WEEK in meetings.  Outrageous! 

On my schedule today I had three patients admitted for alcohol withdrawal, one of which was accompanied by a police escort for his hospitalization.  It is obvious these patients are not safe with mobility. Withdrawal tremors, unsteadiness, and significant balance deficits make these patients fall risks.  I have no problem with treating these patients, even considering they will likely be readmitted in the near future with a similar diagnosis. 

However, with the temperatures dropping and warnings for frost on the weather, we are seeing more and more of these patients.  Many are homeless, and many realize that being admitted to the hospital means a warm place to stay and food to eat. 

What's the right way to help these patients?  How can you participate in discharge planning for a patient with no home?  With such limited resources, it's hard not to feel helpless. 

Several weeks ago I was at our daily OFT (Outcome Facilitation Team) meeting when we heard over the speaker system, "Code 4. 5^th floor. Room 12."  A Spanish-speaking patient had passed out and became unresponsive, and a code was called for the Stat team to her room for resuscitation.  As the nurse would later describe, she was attempting to fix the patient's IV as the patient sat at the edge of the bed.  The patient said a few words (in Spanish), and proceeded to fall backward onto the bed.

It was like a scene out of a TV show. 

There were probably 30 people crammed into this small hospital room, so I stood at the doorframe and just watched to see what was happening.  I had never witnessed such teamwork, such decisiveness like that.    MDs and pharmacists were working together, RNs watching the EKG for any heart function, lab technicians were taking draws for blood gases, respiratory was providing rescue breaths while another health care provider continued with CPR.  Every few minutes the whole room would go silent, someone would start the AED, and then an MD would yell "Resume CPR", and the room would return to it's level of cooperation.  Every once in a while someone would yell out for a piece of equipment, or to watch for family members to arrive. 

I really had no medical purpose to be near the room. But, I was so drawn to watch it and couldn't pull myself away.  I hadn't ever imagined being involved in, or even seeing, something so heart wrenching.   Many times in the hospital we put up barriers in our jobs, saying things like "That's a job for a nursing assistant, not me".  Or, if a doctor interrupts our treatment session, many therapists will walk away and re-attempt the patient at a later time.  We divide our territory into segmented pieces, many times for good reason.  However, in situations to revive an unresponsive patient, we work together as a seamless machine.  Titles no longer make a difference.  Every person plays a vital role. 

I saw a Hispanic-looking woman step off of the elevator and burst into tears, and knew immediately it was the patient's daughter.  One of the MDs and the chaplain took the daughter into the family lounge to discuss the chain of events and options available.  The patient eventually went into V-tach and was transferred to the Neuro ICU. 

For the sake of completion, I will tell you the patient did not make it.  And even more unfortunately, no one understood her last words. 

1. I have lots of fresh ideas. Having recently graduated, I had many assignments that involved researching new treatment techniques and was able to investigate effective interventions. While experienced therapists know what works, many also don't have the luxury of unlimited time to read up on these new trends. Also, having worked at 4 different facilities with my clinicals at school, I was able to see different approaches to health care and PT from an administrative/organizational level. I have been exposed to many different facilities and can propose ideas to make the PM&R department more efficient.

2. No enemies at work. Being a new hire is a fresh slate. An open canvas, as they say. I am building bridges and making new connections.

3. I have energy. I'm not burned out. Being a new grad, I am so excited to spend my time with patients all day instead of face-down in my notes, studying. I love working, and I love getting paid.

4. I am eager to learn and develop myself as a professional. This goes along with point #3. I have a drive to push myself. I want to learn how to treat in ICU settings, to learn different diagnoses. I am not stuck in a rut with my career.

5. I have fun at work. It has taken me a lot of hard work to achieve this career goal, and now is when the fun begins. I have a fresh attitude and truly enjoy my time at work. Many of my coworkers have been at this job for years upon years. They have seen different managers, different policies, gone through short-staffing periods and have recently suffered through pay freezes of the recession. Many of my coworkers are simply going through the motions.

Hopefully I can continue these ideas throughout my career.  I'll try to remember my mindset now, and carry it with me through the years as a PT.

However, there are some instances when it really, really sucks being a new hire.  

1. There is no reason why my vacation requests are less important that yours. I suppose that it must come down to something, so seniority is the judge.

2. I don't enjoy being spoken to as if I was incompetent of higher-level thinking. An RN belittled me in front of a patient and family members when I asked how to clamp an NG tube. I'm not an idiot, I just haven't done this before.

3. Learning the "unwritten rules" of the therapy department- what topics are/are not appropriate for lunch, which people get along and who doesn't...what does all the non-verbal language from my supervisor really mean?

4. Hierarchy. Isn't health care about teamwork?

5. There are some subjects I know a lot about because it's fresh in my mind- (ultrasound parameters, contraindications to e-stim) that some of my coworkers don't remember. It's not a bad thing, in acute care the focus isn't on using ultrasound for pain relief, but it does come up. In these situations I have to remind myself that I, too, will forget all these details with time, and it doesn't mean my coworkers are less skilled than I. In fact, many of my coworkers are much more experienced than I and are able to teach me a lot about working in this acute care setting.

6. Time. My productivity is often lower than my coworkers because it takes me more time to find supplies and equipment, or RNs or charts. I am still learning the physical location of these things, and some of my time is wasted trying to gather everything I need before a treatment session.

Next week I will be writing about all of the reasons it is GREAT to be a new hire!  Stay tuned.

A patient came into our Emergency Department last week with chest pain, shortness of breath and a generally malaise-type feeling.  The patient couldn't point to any specific cause, and had a significant family history of heart disease.  The patient was classified as "obese" by her BMI and was a smoker.  The patient was hooked to a 12-lead EKG and admitted for observation on our cardiac floor.

I left out a vital piece of information in that introduction.  This was the 24^th ER visit from this patient since February.  24 times in 7 months means approximately one visit every 10 days.  Words like "multiple hospitalization" don't even cover the spectrum of resources this patient wastes. By the time the patient is admitted, blood tests taken, and the protocol for cardiac patients is started, literally thousands of dollars have been spent.

It is unclear if the patient is driven to seek attention, trying to receive pain medication, or if the symptoms are truly legitimate.  There are many factors pointing to the former.  While I enter every treatment center with an open mind and good intentions to provide the best therapy I can, part of these treatment sessions are hard for me to get through.

While you hate to blame patients for abusing the health care system, 24 visits in 7 months seem outrageous.  Yet, no health care plan will be able to adjust for these expenses.  Part of the problem with our health care system involves the innate American culture. 

During a co-treatment with OT, we were able to mobilize this patient to the edge of the bed and place a bariatric recliner in front of her.  The back of the recliner had two metal bars to act as a transfer bar, and the chair itself was a wonderful method of providing anterior knee block support.  In two trials, the patient attempted to stand and demonstrated significant trunk elongation and good use of upper extremity support, but did not actually clear her buttock from the bed.

Since the chair was blocking her knees, we were unable to move the chair or the patient would have fallen off the bed.  Instead, we asked a nurse and nursing assistant to help us mobilize the patient back to supine.  Count them: 4 people in total.

The point here is: This woman needs skilled therapy to increase mobility, and she requires a minimum of two people, and in this example, four people to safely attempt any transfer.  How realistic is it to assume we will be staffed well enough to meet these needs?  What are the other options?

In all reality, this patient should have taken whatever additional time was needed to find a hospital specifically for bariatric patients.  

On average, I ascend between 17-25 flights of stairs every day.  I run between several floors to treat patients, and it is more convenient and much faster to take the stairs.  Likewise, I am also on my feet all day.  I sit during my documentation time, but otherwise I spend my day doing a fair amount of manual work.  When I ask a patient to perform therex, I sit by their side and perform it with them.  I have several total assist patients on my caseload each day- an exhausting task in itself. 

In addition, I TRY to run 2-3x/week, usually between 2-3 miles each time.  I really have to push myself to do this, because I am exhausted at the end of my day.  Every time I run I think of my patients who can't run, and it motivates me to push myself farther. 

While I blabber on and on to my patients about exercise and healthy lifestyles, in the back of my mind I know it's a difficult commitment to make.  The American day is short- we are busy people with thousands of tasks to complete once the work day ends.  However, it would be difficult for anyone to take advice from an inactive therapist, which is why I do my best to stay in shape.

For a given patient in contact isolation, I gather all possible materials I may need; clean sheets, gown, slideboard, walker, and place it outside the room.  I poke my head into the patient's room to verify they are willing to work with therapy, because the process of sanitizing is time-consuming, and not an efficient use of time for a patient who may likely refuse therapy.  Then I glove, gown, and enter the room.  (I won't get into the basal temperature changes my body experiences with all this PPE.) 

The most laborious aspect of patients in isolation is the lengthy process of obtaining permission from infection control for the patient to ambulate in the halls.  First, I must talk with the RN to see if the patient is actively stooling, or if a wound is draining, etc.  Then, I call infection control and relay the current status from the RN and ask for any restrictions the patient has regarding community ambulation.  This information is then documented in three places- the current PT note, the "sticky note" on the computer documentation for other health care providers, and the paper chart. 

It's easy to see why many therapists avoid this lengthy process and simply ambulate patients in their hospital rooms.  In addition to all the other tedious parts of PT, isolation precautions add even more time to patient care. 

What is your hospital's policy for infection control?  What do you normally do? 

I think a big part of it is motivation.  If I asked my friends to come to a tour of religious and architectural influences in modern day Madrid (which exist, by the way), I'm sure they would be total assists as well, on that day.  But ask them to come with me for a day of shopping and sushi, and they would probably reach their max heart rate racing to the car. 

I guess it's one of those things you learn to love about physical therapy, how every day can bring something new.   It's just difficult, not knowing what to expect, how to prepare for a day of treatments when I'm not sure what my patients will need.  But then again, life is the same way.  You have to expect the unexpected. 

While I think it is good to work with other disciplines and have another set of hands, this co-treatment business has been hard for me to adjust to.  First, the treatment styles of the OT and PT must be compatible.  Second, there seems to be more wasted time with this method... OT obviously needs to assess things that aren't necessarily important from a PT perspective. I guess I haven't gotten into a real rhythm yet. 

Even more than co-treating with OT, I also have a plethora of nurses, doctors and social workers in this hospital setting, which is very different from an OP PT clinic or a privately owned clinic; where mainly PTs rule the road. 

What do you think?  What's the best way to handle co-treatments, or working with other disciplines?