Thursday, October 25, 2018

Occupational Lessons About Head Injury

Once upon a time, in a suburban acute care hospital, there was a client walking and talking within the four walls of their hospital room. Their supportive family sitting all around the client's bed; awaiting the rehab team to come evaluate their loved one.  Their beloved family member sustained what appeared to be a "very mild" brain injury.  

The OT arrived to assess and provide treatment intervention.  The OT thought the client was doing well (based on observation and by what the client self reported).  The OT believed the client could go home; that conclusion was so wrong.  That OT, once upon a time, was me.

At the time of this encounter, I rationalized that the client was "just tired."  

I remember the speech language pathologist (SLP) asking me to watch their treatment session with the client. I wasn't sure why it would be necessary; I had already shared with the SLP that I thought the client could go home because of how well they had been doing. 
I gave it the time and watched the next few minutes go down.  

It was in those few minutes my perspective and OT practice shifted forever.  

It was that moment that took me from what I thought 5 years of OT experience looked like, back to feeling like I had ZERO years of skilled experience and then back to what 5 years of experience is supposed to feel like.

It was embarrassing; to admit to myself I was acting more like a bystander; seeing the client from a superficial lens.  What I thought I was doing was being compassionate and respectful of the client's experience in the hospital.  I was not using my clinical or skilled eye to make a lifelong impact for my client.

So how do you shift from bystander observation to skilled OT practice assessment? 

If you see your client agitated and irritated and "tired" you want to leave them alone out of respect right? The thing is, we aren't doing them any favors by letting them rest.  We are actually creating the barrier to the meaningful occupations they are expected and desired to return back to in the home and community. 

After the SLP elicited the client's true deficits, a lightbulb went on for me. 

Witnessing the client's rationale showed me it was apparent they would not be able to safely take care of their young children...or manage multiple errands in the community...or tolerate conversation in social gatherings...or have a meaningful relationship with their spouse.

Although the client was physically able to do ADLs, including demonstration of getting on their knees (of the hospital floor) to simulate pulling out a broiler drawer of an oven (they used it often to cook for their family); independence with this dynamic activity was not enough for daily activity success.  

To get a perfect score on a MOCA screen does not mean they are safe from the real-life struggle ahead of them (and ahead of their family).

While I felt drenched in humility, the situation convinced me that the client should go to acute rehab (ARF) before returning home.

Then, I came across my next battle:

Convincing the Physical Therapist out of their recommendation "independent; home." 

The PT said: "_____ should be able to go home to recover; you shouldn't want them to be stuck in an acute rehab!  They walk fine; let them go home to spend time with their family."

After multiple discussions we were able to get the PT on board to recommend acute rehab, begrudgingly.  Encouraging them to use other assessments that were going to challenge the client at a higher level was a strip from their ego.  To ask them to observe the client's reactions, comments and behaviors when participating in the assessment was an easier feat.  After this advocacy, the client did get into acute rehab (whew). 

Skipping forward two years (2018):

One of the things about working in acute care hospital is we do not see (or always hear) about the outcome of the client's rehab recovery at the next setting they go to.

When we do not see the benefit of our work because of lack of closure, we may convince ourselves that what we do must not work or be of that much benefit.

Truth is, we get to be first on the scene of their life changing event.  We get to start our clients on the right track of recovery and cross our fingers what we did or recommended to them worked or made a difference in their lives. 

I got my closure recently on this particular case.  

Two years from the time I saw this client and their family, the client's spouse and I run into each other unexpectedly at a local coffee shop…at an ungodly hour of the morning by the way (I never wake up this early but, I wanted to get a head start on my department’s next competency project before the rush of colleagues came flooding into the office…that’s for another story).  Standing in street clothes, grabbing a straw for my coffee, the client’s spouse remembered my name and what therapy discipline I was. They said to me "Alexis, what you did for ___ and my family made a huge difference in our lives.  We will never forget it. The only trouble they have now is ___.  I have my ____ back again. Thank you."

Two things came to me in that moment:

1. I asked "What did I do?" I shifted attention to thanking the profession of Occupational Therapy for reminding me of the meaningful components that impact our life.

2. I picked myself up off of the floor after knocking myself down. This client's restoration, return to meaningful daily activity and family wholeness could not have reminded me more of why the challenges we face in our day to day practice are worth battling.  

Have you ever had a time where you were able to be facilitate your client's access to meaningful occupation after their traumatic event because of your advocacy efforts?

Have you ever had a situation where you experienced a lesson you will never forget in practice? 

I want to hear from you and your story; you are not alone. 

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