Week 7: Dismantling the Box

Week 7: 21-24 April...

Over the last 7 weeks of fieldwork, the same realisation has been reiterated: when it comes to OT, no amount of theory can equal the hands-on experience of being on prac. In  a profession that is so inherently client-centred, theory can only serve as guideline that must be added to and adapted to suit the needs of each client.

During our theory lectures, clients seem like neatly boxed entities that fit all the diagnostic criteria and follow a pre-determined rehabilitation progression from admission to discharge. It becomes easy for us to believe that we can simply pick an intervention session out of the set programme and apply it to our client. However, humans are complicated creatures, a feature that is only multiplied with injury or disease.

Pain, personality & context make each client unique, limiting our ability to rely purely on theory to achieve successful rehabilitation of the client.

 

 

With my current burns client, the first I've had, there were many things that theory could not prepare me for.

Although we had discussed it during theory lectures, the sight and smell of burn wounds was something I had underestimated and had to get used to quite quickly, given the close proximity we have to our patients. 

 

Implementing theory was slightly difficult with this client, because there were aspects, such as the language barrier and the client's severe pain, that cast a spanner in the works.

I know from theory that maintaining range of motion becomes one of the most important aspects to focus on during acute burns treatment. However, it's one thing to know that the activity must be structured around mobilising the affected limb, and quite another trying to convince a woman in excrutiating pain to use her badly burnt right arm for the activity instead of her functional left arm. 

I got around this dilemma by starting with a simple, familiar task of washing her face, using a scented cream and plenty of encouragement as motivation to participate. Whereas she was previously reluctant flex her shoulder & extend her elbow, she managed to achieve these motions by reaching for the items placed nearby.

 

To achieve reach, structuring becomes an important aspect to consider. In a hospital setting, there is not always furniture of the right height to achieve the desired degree of reach or facilitate specific movements. Hence, improvisation , using things like cushions , boxes and chairs becomes an important skill to develop, something that only comes with practical experience.

 

 

 

On Friday, we ran a paediatric stimulation group. Not having covered the theory of paediatric therapy in much detail, we read up on the sort of principles that would be applied. However, with children in particular, once again, there was only so much that could be learnt from reading. With the sort of spontaneity and short attention span of children, experience is the best teacher. Having these opportunities to try what we have learnt in the real therapy environment has been a challenging, but amazing and valuable gift.  

Throughout fieldwork, I have realised that theory is just a framework for us to be able to orientate ourselves once we begin treatment. The real learning comes in through our attempts to apply this theory to each of our patients.

Applying what I've learnt is difficult, and there are still times when I only join the dots and reach a 'Eureka' moment a few hours after I've left the hospital.

However, I know that as I make errors, learn from them, and begin to understand more than our lectures and textbooks can possibly include, I have begun the long transition from student to therapist.

Week 6: Pushing for Progress

Week 6: 14-17 April...

Arriving back at campus after a day at hospital, conversation with my classmates inevitably turns to fieldwork. After the initial bout of complaining about our varying levels of impending insanity, the positive stories start to emerge.
A patient with no previous active movement has just started getting finger flexion back. A woman who could barely sit up in bed due to fatigue can now engage in a 15 minute activity. A child with a learning disability has just learnt to distinguish shapes from each other.

These stories renew our commitment towards OT and remind us why we chose this course. However, none of these stories are mine.

Working in an acute setting, I have yet to report significant progress in any of my clients, simply because out of the eleven patients I've had so far, only two of them remained in hospital long enough to be seen more than twice before transfer or discharge. While this has been extremely beneficial in pushing me to develop rapid assessment and treatment skills, it leaves me with many questions about the effectiveness of my therapy. Without being able to see the end result of my work, I find it difficult to gauge whether the little therapy I have done and the home programmes and assistive devices I've given where possible have actually been useful.

Many students at more chronic physical facilities seem to have the opposite problem: their clients remain within the facility for so long that the students have trouble coming up with enough sessions to address performance component deficits. Often, the clients have already plateaued, leaving little room for progress during the students' time with them.
Although we sometimes become frustrated when there isn't a lot we can do for our clients, it's important for us to remember that an OT role sometimes is limited to maintaining existing function, or where this cannot be achieved due to severe illness or progressive conditions, simply ensuring the best quality of life for the client as possible.

To ensure progress of the client, the session must be therapeutic. To ensure the session is therapeutic, the session must be pitched at the correct level for how the client presents on that particular day. As a result, grading of the activity becomes critical.

Of the two clients I was able to work with for slightly longer, both presented differently from the first therapy session to the second or third, prompting a change in the actual session. On-the spot grading then became an essential part of my treatment plan, as it determined whether my treatment was actually therapeutic, or whether I was simply entertaining the client.
I found this difficult, as I had not anticipated the degree to which these clients' performance skills would differ from my initial encounter with them. The most recent example would be the CP child I had worked with. From the first treatment session, in which she was starting to show response to auditory stimuli, to the second session, her chest infection had worsened, resulting in her being distressed and on a nebuliser.

The NDT positioning and sensory stimulation session was therefore pitched too high for her. I attempted to apply some of the tone inhibiting principles of elongation and asymmetrical to symmetrical movements, using the rattle as a stimulus, but because she was unable to be brought into sitting, the important weight-bearing aspects were absent. She was also too distressed to respond appropriately, diminishing the therapeutic value of the session.  
This has served to build my experience, but also highlights the importance of a thorough understanding of the diagnosis, and the many complications and co-morbidities associated with it, to be able to draw up appropriate grading principles.


The same can be said for clients who improve from one session to the next. My current CVA client was unable to raise her affected arm beyond 26 degrees upon initial assessment, which was likely due to fatigue following an intensive physiotherapy session. A few days later, during a upper body dressing session, she was able to increase this range to 45 degrees, thus being able to complete the dressing exercise quicker than expected, with only minimal assistance required for the buttons. Hence, I was able to upgrade by incorporating other aspects into the session, such as balance and preparation for lower limb dressing.

I hope that as the next 4 weeks of fieldwork unfold, and as I push for progress with each of my clients, I begin to see the improvement I'm waiting for. Until then, I'll continue doing the best I can in the time I have with each person that comes into my care.

Week 5: Back to Prac

Week 5: 7-10 April 2015...

 

After a welcome week of midterm break, Tuesday morning saw us delve straight back into fieldwork.
Having gone straight from midterm demo's & case presentations into the holiday, we'd had plenty of time to think through our first month of fieldwork over the break.

 

Being assessed for midterms had been quite an experience: not only had my body chosen that particular week to succumb to food poisoning , but my only remaining client had been transferred to another hospital just before my treatment demo was to take place. Luckily, one of my fellow student colleagues was able to stand in for my client so that we could simulate the treatment session I had planned: a grooming activity involving the tying of a traditional African doek.

 

Apart from enabling the client to perform her own self-care tasks independently and thus improving her sense of autonomy and self esteem, the task also focused on many of the performance components that had been affected by the injury. Having to reach upwards holding the comb and doek ensured that full range of motion and muscle strength of the unaffected arm was being maintained. This made sure that prolonged hospitalisation would not prevent the client from performing home management and self-care activities once she returned home. The repetitive above head motions also required a significant amount of energy and concentration, ensuring that physical and mental endurance was maintained.

 

Although we bandaged the student's arm in the same way as the client's to simulate the same diagnosis, and used similar structuring, the student's response to the activity was different to the imagined response I'd had for my client. To me, this highlighted why such importance is placed on the client's context over and above their diagnosis.

The student was younger, fitter and, as a white female, had soft, straight hair and had never tied a doek before. This meant that the activity was completed in a much shorter time as it would have with the actual client, because the good physical endurance of the student meant that there was no need for rest breaks, and that movements in general were faster. Because the student had soft hair, it was faster to brush, but more difficult for her to tie the doek one-handed without it slipping off her head. As she was unfamiliar with doek-tying given her cultural context, the end product was not as neat as I'd expected my client's to have been, and she was not as motivated to ensure a perfect end product.  There were aspects, such as posture, that I would have had to correct for my client, but that were irrelevant for the student.

It was eye-opening to see how the same session, performed on someone with the same 'diagnosis' could yield such different interpretations and results when applied to someone with a different context and value set.

 

 

Following the treatment demo's came the case presentations: presenting our entire plan for our client based on their background within 20 minutes. Prioritising what to include in the presentation proved to be a challenge, ensuring that while a comprehensive picture of the client was presented, sufficient time was given to the treatment plan. My presentation ran two slides over time, indicating that I would benefit from doing a quick timed run-through before my final case presentation to ensure timing is optimally utilised.

 

 

 

With the new term came a new challenge: my first paediatric client. Diagnosed with cerebral palsy secondary to TB meningitis she contracted at the age of one, the little 6-year old weighed just 9kg and had no active movement. She did not respond to visual stimuli , and only responded to auditory stimuli during the second session by a flicker of her eyelids.

 

My first treatment session consisted of basic positioning and sensory stimulation, which were all done passively as the child had no active movement. As the child was drowsy, possibly due to medication, it was not surprising that there was no response apart from the flickering of her eyelids. It will be a good idea to see the child at different times of the day to determine whether the lack of response is a permanent factor, or whether it is only present after medication.

   

With her lack of responsiveness, it will be important for me to consider all the necessary downgrades that will be needed when applying the relevant NDT principles. I know that for my treatment to be successful, a great deal of research will need to be done on this client's condition and presentation so that therapy is pitched at the correct level for her.

 

For the first time, I also have two other clients to look forward to next week: a client with a dual CVA and below-knee amputation and a rheumatoid arthritis client.

The variety of conditions, comorbid factors and aspects of client context that need to be taken into consideration means that I have a great deal to consider and research over the weekend so that, come Tuesday, I can tumble into prac feet first.