Sunday, January 20, 2013


I spent the entirety of last week as an occupational therapy elective student in the acute care unit of the CMC hospital. I was in A Block. A Block is the area of the hospital that provides healthcare for the patient population that can afford to pay, thus the hospital rooms and staff to patient ratio is a little more pleasant than the general ward. I thoroughly enjoyed my time there. I was working with two other occupational therapists, Paul and Elizabeth. You have met them before (if you have been following along with this blog).

The patient population varies, but during my week-long experience I saw spinal cord injuries, claw hand deformities, viral encephalitis, traumatic brain injuries, and stroke. The majority of the patients I worked with were spinal cord injuries.

Healthcare in the hospital is very different than what I am used to. Let me give you a few comparisons. In the US, closed-toed shoes are mandatory; here shoes are optional (for patients and family) and open-toed shoes are the norm. In the US, you “gel in, gel out” before and after seeing every patient; here you just make sure you wash your hands before lunch break. In the US, medications are scanned electronically and delivered orally (or through IV if swallowing is an issue); here medications are kept in a drawer in the patients room and to deliver the medications a nurse comes in with a stack of 3x5 cards and flips through them until she finds the right patient then scrounges through the drawer until the medications are found. Once found, she crushes them with a mortar and pestle, dissolves them in water, and delivers them using gravity feed through an NG tube. In the US, therapy items used for patient treatment (such as theraband, cones, etc.) are sterilized between usage (or thrown out); here they are simply placed back where they came from and used again. In the US, every patient is given their own wheelchair to use during their stay (if necessary); here the floor shares three chairs. Those are just a few of the differences I noted in my first week.
This is looking into the OT gym. If a patient is able to get out of his/her room, they come here for treatment. There is often four to five patients and their family members plus their therapists in this room. It becomes very small, very quick.
Another shot of the OT space.
Yet again another shot.
This is looking from the back corner of the OT gym towards the doorway. The ladies you see in the far background are the nursing staff. They were white saris and are called "sisters."
This is the complete theraband supply. These fragments of theraband are reused again and again and again. The most common way to use them it to wrap the loose end around the extremity a number of times to secure it, then have the patient move again the resistance-- and hope and pray they have good skin integrity. 
That is a little bit of the “background information” for my description of A2 therapy services. Perhaps a walk through my typical day would be a good way to describe occupational therapy here.

I wake in time to catch the college bus from the college canteen at 7:30am every day. The 7 km bus ride usually gets me to the hospital campus by 8 am. My first stop is the OT outpatient clinic. There I participate in a few blessed minutes of praise and prayer. Together as a staff we sing a hymn of praise, read a daily devotional, and the end with a word of prayer. It is a 100% totally foreign concept for me to engage in such a wonderful activity with an entire team of hospital staff. All the hospital departments start their day in this manner. It is not mandatory, and if you are uncomfortable with it, you are welcome to arrive around 8:15 or so to begin the day. I personally find it refreshing and encouraging; in fact, it is nearly my favorite part of the day. I will miss it when I return home.

After prayer, I head over to A block to place my belongings away and tidy up the therapy room for the day’s work ahead. Elizabeth and I have been running down to the A Block canteen for a quick breakfast, and I hope to be able to meet her there again this next week. It is my second favorite part of my morning ritual. By this time it is near 8:45am, and I am getting antsy to begin treatments. The therapy staff, on the other hand are relaxed and moving at a lackadaisical pace. This is their routine. There are no set patient schedules. There are no “appointment” times. There is only a list of patient’s names on a white board in the therapy room. By the end of the day, each patient should have a tick mark by their name indicating that one of the OT’s has seen them for 45 minutes to an hour. There are no productivity demands, no insurance companies to reconcile with; it is a relaxed pace of life. For this young and inexperienced OT it was a very slow pace of life that I had to adjust to.

When the team was ready, we would go around to the floor to see what patients were ready for treatment. When a patient was found that was finished with breakfast, not engaged in physical therapy, and ready for the day, we would begin treatment.

On my second day there, Elizabeth turned to me and said, “What patient would you feel comfortable seeing today?” Uhhhh…. Come again? This is where I quickly donned my big girl pants and called out some of the only patient names I could pronounce. I then became their therapist for the week. I loved it. I had a number of patients whose treatment I looked after; three in particular have wiggled their way into my heart.

My first patient had sustained an incomplete spinal cord injury at the C6 level. He was still on neck/back precautions as the injury had happened only four weeks prior. This meant that he was lying supine without the ability to move or even turn his neck. Our treatment goals were to maintain and improve his remaining biceps/triceps strength, shoulder abduction, and work on functional tenodesis grasp and release. As he worked on his exercises, I worked on my Tamil (counting to ten). He was a might bit groggy my first few days with him, and he tested my patience to a new degree as we (his daughter-in-law and I) would wake him between each couple of repetitions. The last two days he was doing so well with his level of alertness that I was able to progress him to the last level of theraband, and increased his finger flexion to the next level. SO exciting to see progress even in a short week!

 I like to think we bonded a little. We taught each other many lessons in a short week. We practiced saying (correctly pronouncing) each other’s names. Upon entering his room one morning, I asked him to recall my name (to assess alertness, memory recall, etc) his response was “Your name is in my heart, but I cannot bring it to my lips.” And then I melted. He did not speak much English, but his daughter-in-law faithfully stood by his side and translated all our interactions. He was eventually able to recall my name.

One of my other patients sustained a complete spinal cord injury at the C4 level. He is twenty years old. He is able to shrug his shoulders. And smile. His smile is amazing. He has a trache in, so his voice is soft and it takes a lot of energy for him to speak. If the trache hole is covered, his voice is loud and clear; however I felt like I was killing him whenever I did that so I did my best to make out his labored whispers. Our goal for treatment was to increase his sitting tolerance. When I first arrive on the unit he was able to sit for about 30 minutes a day, but the time I left he was sitting for two hours a day, an hour at a time. Progress. Therapy for us was me keeping him company as we strolled around the floor and looked out every window. I quickly found that I don’t have much in common with a twenty year old Indian boy. Between the lack of similar interests and his difficulty speaking, the hours became VERY long-- I think for the both of us. Then I had a thought. Why don’t I go get my computer and find some online strategy games we could play together? (I had found out that he liked to play computer games that featured strategic challenges.) So that is what we did. I found a game in which posed this scenario to us: we had been locked in a car, mafia style. Our goal was to search the car for tools to make an escape. My savvy patient told me what to do, and together we escaped through the trunk. We escaped from the car, and from a very long hour of staring at one another. We enough fun to draw the PT and OT staff around to watch over our shoulders as we planned our escape. Sitting tolerance was increased to well over an hour that day.

Yet another patient I saw had a degenerative condition that caused severe claw hand deformity. I was never able to quiet understand her diagnosis or prognosis, but the goal of therapy was to maintain range of motion and strength while using adaptive equipment and splinting to regain function in the upper extremities. There was a routine to her therapy. She would come to the gym and work on gross grasp with large blocks. The she would work on lateral pinch, and “tip-to-tip” pinch with placing small objects into specific places. I found her activities to be rote and, although beneficial, somewhat dull. I think she may have shared my opinion. On Friday I determined to mix it up. The supplies and resources are very limited here, so my creativity had to be turned up a notch. I was thankful that the OT staff was comfortable with my coming up with various treatment ideas for patients. In the back corner of one of the four supply cupboards I found some slightly dried Play-Doh. It would work just fine. I mixed a little water in to soften it up and then set my mind to work. The wheels in my head spun a bit and came to a screeching halt as I realized that our language barrier was going to be a problem. How could I make this activity beneficial? How could I make it fun? Tic-Tac-Toe was my answer. I quickly found a piece of blank paper (much harder to find than you might expect) and drew out a game grid. I gave my patient the ball of play-doh and grabbed some small dice for myself. She was play-doh, I was dice. Her job was to break off small pieces of the play-doh and make little balls in order to play. If she won, she was allowed to play a round with the dice (only using her right, and more affected, hand). Winning! Well, actually she won the overall Tic-Tac-Toe war, but together we fought off boredom and accomplished our mission for therapy.
Elizabeth working on gross grasp using a splint with the patient mentioned above. Note: all photographs of patients have been taken only after permission was granted by the patient.
A close-up of the splint. The palmar portion of this splint prevented adequate function of gross grasp, so an alternate splint will be made when the splint expert has the time. I desperately wanted to try my hand at fabricating a splint for her, but I am not proficient enough with splinting to be able to get it right on the first try, and I didn't want to put a hurting on their limited splinting supplies. My one regret.
Playing tic-tac-toe with an OT student, Riya,
Working hard to form her playing pieces.  The position you see her hand in is the relaxed position.
At half past twelve, we would take our lunch break. I would grab lunch at the A Block canteen and “parcel it,” meaning get it to go. I would then meet up with the other OT staff in the back classroom of the out-patient clinic and we would share lunches while enjoying conversation. I mostly nodded and smiled because I could only understand two-thirds of the conversation, nevertheless enjoying myself.

This is a patient I did not mention in the blog. He sustained an incomplete C6 spinal cord injury fourteen months ago. He was discharged to the CMC Rehabilitation Institute so I will likely see him during my posting there. He is from Sri Lanka and speaks very good English. I worked with him for a day or two and he also taught me much; more about life, Indian food and culture, and some about occupational therapy. Our goals for him were to increase his independent tall sitting tolerance, increase upper extremity strength for functional mobility tasks such as supine to sit and pressure relief, increase independence in bed mobility, increase independence in functional tenodesis grasp/release patterns. I very much enjoyed working with him.
After lunch we would see the patients that had not yet been seen. By four-thirty, and by some miraculous measure, all the patients would have a tick mark by their name and I would set off to catch the student bus back to the college campus. All in a day’s work. All in a lovely day’s work.

Yes, the pace was slower than what I am used to. Yes, the resources are far from what I am used to. Yes, the patient population is not what I am used to. Yes, there is a noticeable lack of patient documentation (I have yet to write a note, or seen a note be written, though I am told they are written weekly.) Yes, I loved my week at A2. The therapy staff welcomed me and my funny ideas. They answered my questions patiently, and corrected my mistakes quickly. The patients I was responsible for treating have all stolen little pieces of my heart, and in return have taught me lessons I couldn’t learn anywhere else. I will miss them, but I look forward to my next week in Q3 where the patient population is the same; however, the conditions of medical care are not as high-class.

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