Sunday, January 27, 2013


Last week I finished my posting in the Q3 Ward of the hospital. The patient population is similar to that of A2 (primarily spinal cord injuries, and traumatic brain injuries) only this is the general ward, meaning that patients don’t have the resources to pay for health care. The services they receive on Q3 are the same as A2, only in a more… economical fashion. There are four to seven beds per “room” and all the beds share one bathroom. The spaces are smaller and medical supplies used are less fancy, though they get the job done.

I enjoyed having the opportunity to work on this unit; however I didn’t get as much patient interaction as I did in A2 (more only disappointment). I did, however, have a wonderful occupational therapist to follow around. She made sure I learned (or re-learned) the ASIA scale for spinal cord injury, She taught me India’s way of using FIM scoring for measuring independence. She educated me on the Rancho Los Amigos scale for coma assessment and how they use it here in India. She introduced me to the Addenbrooke’s Cognitive Examination-Revised (for the Indian population) for assessing cognitive function in patients with traumatic brain injuries. She also oriented me to the SMART—(Sensory Modality Assessment and Rehabilitation Technique) Sensory Assessment Response Monitoring Form which they use for their patients with traumatic brain injuries. She also reviewed Upper Motor Neuron lesions vs. Lower Motor Neuron lesions and showed me patients with both so I could see the differences. Ah, and I can’t forget the brief run-though she gave me on assessing myotome and dermatome patterns for spinal cord injuries to find out the level of injury. Needless to say, I was given a lot of information to review and process. It was all information I have had in my academic courses, but I was able to see it in action now, which has somehow helped the lesson sink deeper.
This is the Occupational Therapy gym in Q3 ward. It is not uncommon to have 20+ people in here for therapy (patients + family members.) 
A corner area of the OT gym in Q3.
Another shot of the OT gym.
I was able to sneak a few photos of some of the empty beds on the ward just to give you an idea of the conditions of the rooms. A little bare, but the staff makes it work well.
Another shot of a general ward bed.
Another bed in a different bay of the general ward.
The main difference I saw was not in the injury or assessment of injury, but in the treatment of the injury. The end goal of therapy here is different for a number of cultural and financial reasons. The largest influence on treatment goals is the family. Have you heard this before? It is true. The family bathes, toilets, dresses, and feeds the patient if they cannot do it themselves. It is a cultural thing. Families come together to provide for the patient. Independence then becomes a matter of the family unit, not just the patient.

Financial means also impact the treatment goals, especially for those of lower socio-economic status. Family income is often reduced when someone becomes injured. This is often not just a reduction of one income, but also of the family members that now care for the patient rather than work. With a shortage in finances, the means to purchase equipment is also not there. Wheelchairs and adaptive devices are difficult to afford, thus treatment and discharge planning is done without relying on such things.

Literacy also impacts treatment plans and goals. Many of the patients in Q3 ward were being treated for grade three and four pressure sores. It seems like it is a challenge to get patients and families to understand the importance of skin care and pressure relief for patients with spinal cord injuries. Some of the therapists I worked with mentioned literacy when I asked about the high prevalence of pressure sores.

Treatment for patients with spinal cord injuries in the Q3 ward follows this general pattern. They are taught upper extremity exercises to promote the ability to engage in pressure relief at least once every twenty minutes. The patient and family are taught positional changes in bed to prevent pressure sores; changes are to be made every two hours. Patients and families are taught to rub Neem Oil over the patients insensate limbs to prevent rats and bugs from compromising skin integrity when they are lying on their mats on the mud floors of their homes. (Neem Oil is bitter oil that prevents unwanted guests from biting the skin.) Education is provided on skin care. Positional tolerances are also part of treatment for spinal cord patients, depending on whether or not they have healing pressure sores.

Due to sacral pressure sores, this patient received bedside therapy to maintain upper extremity strength and range of motion to increase independence in functional mobility. He has a low level thoracic spinal cord injury sustained eight years ago by falling seventy feet from a tree. He is from Kolkata.
While this patient was spending time in a standing frame for physical therapy, the occupational therapist was working on bilateral arm function. After lying prone for so long (due to pressure sores) he has lost some range of motion in his shoulders.
This patient was engaging in push-ups to maintain upper extremity strength to increase independence in functional mobility upon discharge.  
One of the occupational therapy students is working with a patient who sustained a traumatic brain injury resulting is tremors. She is working on intentional movement (grasp and release) with him.

** Note: Written consent was received from each patient to tell their story and/or share their photos. 
Treatment for patients with brain injuries also follows a little bit of a pattern. In Q3 they use functional coma stimulation and traditional coma stimulation. Traditional coma stimulation is using the five sense to evoke a response, and as the patients becomes more alert the responses become more appropriate. Functional coma stimulation is using objects and passive range of motion to increase awareness and alertness and stimulate the ability to follow commands.

In Q3, the number one goal of patient care is to get them medically stable. Therapy is administered to prevent decline (contractures, decreased muscle strength, etc.) and maintain function. If gains are made, all the better. Once the patients are stable, they are generally transferred to the rehabilitation institute where therapy becomes the focus.

I learned a lot during the last week. The differences and similarities in occupational therapy services continue to intrigue me. I am looking forward to working in the rehabilitation institute towards the end of my posting at CMC. I will then get to see many of the same patients I saw in A2 and Q3, only with more focus on rehabilitation. 

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