Tuesday, September 3, 2013

Don't Stop Living Just Because You Think You're Getting Old!

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I was sitting at Rustin Way on the waterfront eating lunch with a friend on Saturday. It was in the 80's with bright sunshine, the kind of weather which prompts Washingtonians to spend their days outside. Jim and I were talking up a storm, people watching and telling stories.

the view from where I was sitting...
Three quarters of the way through our lunch, we noticed an elderly couple walking down the dock to the water of Puget Sound. She, a petite little gal, led with a determined walk, and he followed slowly with a slight festinating gait, stabilizing himself with his single point cane.

"Ohhhh, nooooo," I said to Jim, "I am afraid he is going to fall!" 

Twice I winced, sure he was going down, ready to get up and run over there if he did.

He made it to the boat somehow, and followed her (I winced again at the danger of it) as they boarded a boat that offered parasailing over Puget Sound.

getting set up for the ride....


I have to admit with a bit of guilt that when I saw them, I thought, "How in the world can they go parasailing? They must be in their mid-80's!"

We watched as the staff on the boat instructed them on the process, set up their riggings and took off.

taking off...

My doubt turned to inspiration when I saw the red balloon begin to pull in the wind, lifting them off the boat.

WOW. This couple was determined to KEEP LIVING LIFE.

Maybe this was on their bucket list. And who cares that they were in their 80's and had trouble getting in and out of the boat?

They spent a good 40 minutes in the air.

yes, they were dangling up there, and the tiny little boat was in the right 2/3 of the photo....

Jim and I left the restaurant and watched them from the pier.

This was a simple lesson about being open to living life fully every day.
No matter what!
No excuses!
Let's all GO LIVE LIFE.

Good Bye, Travel World....

Back to my blog home page: http://travelingotr.blogspot.com

I made a very difficult but timely decision last week.
I ended my travel career.

I accidentally traversed into a place that shocked and surprised me...I realized this is a place where I'd like to put down some roots, bloom a little and create a network of friends. It has the cozy "small-city-feel" of my hometown of Kansas City, but it offers the additional wonders of water, mountains and temperate weather all in one place.

The hardest part about this decision was saying goodbye to the BEST recruiter in the world, Tony Leber, and Med Travelers. The guy is - hands down - the best recruiter any traveler could ask for. He has given 100% for me, and I am really going to miss him!

My feisty recruiter, Tony

So, today, my final blog for the travel healthcare world is simply to thank Med Travelers and Tony Leber. Thank you for the great assignments, the opportunity to explore some beautiful areas of the country and the chance to meet some kindred spirits/great friends along the way.

Thank you for three great years.

Tuesday, August 20, 2013

State Supervision Requirements for Occupational Therapists and OT Assistants

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The occupational therapy field in the United States has an amazing certification organization called the NBCOT - National Board for Certification in Occupational Therapy. I was on their website today because they are having a slogan contest, and I wanted to see if they had posted info on it there. While I was surfing their site, I came across some really great info I want to share with you. It will come in very handy if you have questions about supervision of OT assistants, especially in remote areas.

NBCOT has provided a one-stop reference to all the state practice acts regarding supervision, which is titled,

An Overview of State Regulatory Supervision Requirements for Occupational Therapy Assistants

It is available through the following link:


How helpful! Thank you, NBCOT!

PS - I copied today's  email about the slogan contest in case you did not receive it:

OTR/COTA Pride Slogan Contest Announcement:

Occupational therapists across the nation tell us how much they value their NBCOT certification and the value it creates for the profession.  We want to capture that value in a new slogan and invite you, our OTRs and COTAs, to share your ideas.  

The Contest
Submitting one or more slogan entries that capture the pride and value of being OTR/COTA certified by NBCOT in seven words or less! 

The Prizes
Grand Prize: A new Apple iPad 2 - 16 GB Wi-Fi model 
Second Prize: iPod Touch - 16 GB model 
Third & Forth Prize: iPod Shuffle

NBCOT will accept entries until September 6, 2013.  Winners will be announced October 30, 2013.  

How to Enter
Go to https://www.surveymonkey.com/s/OTRCOTAslogan to submit your slogan entry(s). 

Official Rules
All entries will become the property of the National Board for Certification in Occupational Therapy.  No purchase is necessary to participate.  Contestants must be 18 or older.  The contest runs between August 20, 2013 and September 6, 2013. Winning entries will be selected by a panel of judges and winners will be notified by email.  Winners will be required to sign a release and affidavit of eligibility.  Odds are determined by the number of entries.  The approximate retail price of the prizes does not exceed $5,000.  Void where prohibited by law

Saturday, August 17, 2013

Medical Care Hermano Pedro Hospital Style

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I need to update you on my activities!

For the first time in my travel career, I left an assignment early.

I wrote a separate blog about it, but I want to reiterate to you if you feel a sick knot in your gut about what you see in a building, call your recruiter and your clinical liaison immediately and tell him or her what you see. It is vital to start the process of communication between the two companies. My recruiter told me, "Tre, you have never complained in the years we have been working together, so I know something is not right."  Within a week or so, the travel PT and I were released on the same day. Until then, I dotted every "i" and crossed every "t."

Thank God!

Within a week of leaving this job, I was on a plane headed to Antigua, Guatemala. These transitions can be blessings in disguise!

Plaza Mayor, Antigua, Guatemala
I had the good fortune to complete two weeks of Spanish as a Second Language training and medical Spanish at Christian Spanish Academy  (CSA), which I highly recommend! My studies, which concluded yesterday, included five hours of 1:1 instruction with my teacher daily and about two hours of homework each night. I developed a list of many questions/cues I use during evaluations and treatment, got them translated (look for these on another blog article soon) and learned the parts of the body. I would actually recommend four hours of training a day because the fifth hour is really fatiguing!
Me and mi maestra, Cristina

Last week, I had the wonderful opportunity to tour Hermano Pedro Hospital as an extracurricular activity through  CSA. It is located at 6a Calle Oriente #20, between 3a and 4a Avenida Sur in Antigua.
I was so touched by what I saw that I immediately asked about volunteering. By the way, there are a few requirements to volunteer at Hermano Pedro, just so you know.


1) Take the tour, which is offered Tuesday/Thursday afternoon at 3pm
2) Provide two passport size photos of yourself for your ID
3) Complete an application to volunteer

Beautiful inside and out
4) If you are a licensed medical professional, you must submit a copy of your license.

Hermano Pedro Hospital houses almost 250 people from babies to ancianos (older people), most of whom have been abandoned, have severe physical or cognitive disabilities or who have outlived their relatives. The hospital has separate living areas for male and female adults and children.

What was amazing me to was the amount of great patient-specific equipment there due to donations from different groups in the US, especially the Knights of Columbia Wheelchair Foundation. Bravo, Knights! The wheelchairs below were donated by the K of C. I didn't get a chance to take a photo of the real specialty wheelchairs - the ones you fit during a seating clinic. There were more than I could count.

The wheelchairs I saw at this hospital that is run solely on donations were on average better than the wheelchairs I see in for-profit facilities in the United States.
 What does this say
about our for-profit skilled nursing facilities?

Just a thought.

I spent most of my time with the adults because that is what I do in the States. The women were housed in long dorm rooms with about 14 beds per room. Their beds were positioned so that each woman was just out of reach of being able to touch another. Their clothing was neatly folded on tall open shelves at the end of the room.

As I spoke with each of these women, I found that every one of them had one thing in common. They had no family. They were SOLA. My heart went out to each of them. In fact, I saw this picture on facebook yesterday, and it made me think of them:

So. I knew that the way of the Guatemalan therapists would be
different than the US. I wanted to integrate into their system. I was not there to teach them all I know. I wanted it to be the opposite. I was assigned to the PT gym for the adults. I never met the three OTs. I was told they did fine motor coordination activities and that they mostly worked with the kids. (I did meet a group of six OT/PT/ST students from University of Texas-El Paso on the street on my way to school and later in the pediatric area working on specialty wheelchairs.)

Let's strip away everything we know about the US rehab system:
  • efficiency
  • documentation/paperwork/charts
  • Medicare guidelines.
Hmmmm. What a change.

They weren't watching the clocks nonstop. They weren't pecking out documentation on a computer or writing in a soft chart. They weren't coding billing. They simply focused on treating patients.

They didn't have a standard mat to do matwork. They treated people on plinth tables. They didn't use gait belts to get them up on the tables, either. They hoisted them up onto the plinths.

Most of the ancianos I saw did not have knee contractures. They had pain and stiffness, but not contractures. "Why?", you may ask...
 ...I have to believe it is because of the way they begin every session. They begin every session with a 15 minute footrub.

LOVE it. It completely confirms what I learned in a reflexology CEU that the body can respond beautifully to treatment in other areas than where we normally see the symptoms.

The PT, Amanda, really surprised me when she had her 80+ year-old patients roll from supine to prone on the plinth and then do modified push ups for arm strengthening. Wow.

They did not have a plethora of therapy equipment other than their hands to do their treatments. If we want to get down to basics, let's acknowledge that the best tools we have are our hands and minds that can critically and clinically reason.

They do not have restorative aides to do range of motion (ROM) on their residents (which is especially needed for their adolescents with cerebral palsy). I spent one afternoon with Amanda in the adolescent unit doing Neuromuscular Re-education and passive range of motion (PROM), which was an entirely different world than the older ladies. These young ladies are mostly bedbound, nonverbal and locked in their own worlds. They need daily work, but there is just not enough staff to provide it.

The therapists had a lovely connection with their patients. They were respectful, playful and caring. By the time I left, I felt as if I was saying goodbye to a family.

My week at Hermano Pedro is simply a drop in the bucket of what I would know about the place if I stayed longer. I'm sure I'll learn more when I return next year. If any of you have visited or volunteered there, please drop me a line and tell me about your experience. It's an amazing place with a grand mission of service.

A tip:  If you are in Antigua and you wish to volunteer your OT or PT services, ask to work with the adolescents. They are the ones with severe contracture formation and appear to be a semi-forgotten population.

A request: if you work in a building that has a bunch of old Neuroflex-style splints laying in the closet or in storage under the mats, would you do me a favor? Ask your manager if you might donate a few of them to Hermano Pedro. Email me and I can get them sent to Amanda. They really need splints!

Tuesday, August 13, 2013

How to Manage A Toxic Assignment

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It's been a smooth ride since my first travel assignment in August 2009. I'm happy to reminisce on great work environments, coworkers who have become dear friends since then, and interesting places I've been...it's been so very life changing!

Last month, I moved from California to Washington. I absolutely love Washington, and I know I would like to stay for a while to explore such a diverse place. It provides a perfect landscape for my love of hiking, biking and living near water and mountains.

My first Washington assignment, though, was less than stellar.

I was in a building that looked beautiful, had the largest and most well stocked rehab gym I've been in for years, and happened to be

SNFs (skilled nursing facilities) are not always what they look like. I've been in some that look shabby but that provide the finest care around.

This SNF was in stop placement.

That means they were not allowed to admit any new patients,
which happens when a building is in trouble with the state.

In my first six work days at the new place, I was tested on abuse/neglect, attended an in-service on abuse/neglect, and an employee from a sister facility went around the building quizzing employees how to answer state surveyor questions about....

you got it...

abuse and neglect.

What the heck happened there?
I never sat down and read the results of their latest survey. Within two days, I was working with my recruiter and clinical liaison to get out of the contract. It was difficult to find more than a handful of people who had worked here longer than a month or two. Really, in 17 years, I had never seen anything like it.
This was one of those times I was glad that I was not a new grad traveler, which would be absolutely frightening. I can't go into further details except to say that this was one of those places in which I was seeing situations that make me uneasy...I didn't see abuse or neglect, but I just wasn't seeing the level of commitment to caring for others that I have experienced in past assignments.  In addition, the rehab director was not only absent, she was...clueless. I hate to say it, but again....I have never seen anything like it.
Today's blog is about recommendations for how to handle a toxic assignment. This is not how I function on a daily basis. Usually, it is so very easy to provide great therapy and to communicate with a healthy, proactive nursing and social work team. This advice is for dysfunctional buildings.
 Rule #1: CYA
Hyper-vigilance is sometimes called for. Be aware of every word you say.
Do not offer any information other than what is asked of you. Cross every "t" and dot every "i." Document everything you notice about your patient, especially any new bruising, behaviors, or conditions. For example, I found the same patient soaking wet every mid-morning for several days. Unsurprisingly, she also had a UTI - and so did several others on her hallway.
Rule #2: Explain
Explain what you plan to do with every patient/resident prior to treating. In some cases, you may need to explain to someone else, like a family member or a state surveyor who is watching or questioning you.
Educate other staff members, nurse aides or nurses and document your education sessions. (You should be doing this anyway!)
Rule #3: Know "best practice"
If you are asked to evaluate a patient and there is no skilled documented in the chart to justify the referral, educate the nursing staff about what documentation you need. Communicate with the Director of Rehab that the referral lacks clinical justification. A screen from rehab does not justify treatment. It looks simply like a self referral. The DOR in this troubled building actually stated to me that "a screen form from the PT justifies evaluation" with no other documentation in the chart to support the referral. The poor PT was new to practice in the United States and was unaware of best practices.
Rule #4:  Identify a support system
If your manager is not physically there to support you and your team, seek support with the members of the team and identify the strong players on the team or people who know the history of the building, the staff and the residents.  
Rule #5: Communicate with team members
If there is no rehab department leadership or regular rehab meeting to coordinate patient discussion between the therapies, initiate a time with the other therapists to do proper discharge planning.   
Rule #6: Know what you're dealing with in the building
Get a copy of the HCFA 802 from the MDS coordinator
so you can see who the building has identified with which Quality Indicators, which may include pain, pressure sores, UTIs, falls, behaviors, declines in ADLs or ROM, swallow, or weight loss.
HCFA 802 (example to the right)

Rule #7: Follow your gut
 If you have a queasy feeling in your stomach about working in the building, start making a list about the things that make you uneasy. Call your recruiter - and talk with the clinical liaison from your company. Don't cry wolf over small things. Make sure your concerns are founded on valid concerns.

In my case, the travel PT and I called the clinical liaison together. We also left the contract on the same day, which happened to occur the day the state walked into the building.

We are all mandated reporters. The state was aware of our issues. They were already addressing them.

Rule #8: Don't be afraid or embarrassed to leave an assignment early if you know it's the right thing to do.

It should rarely happen. I am still surprised it happened after such a lovely flow of assignments. I am, however, relieved and ecstatic to be away from such a negative place.
I hope that you don't have this experience as a traveler.
If you do, don't hesitate to contact me.
Maybe I can help you through it.

Wednesday, July 31, 2013

Goal Writing and Step by Step Instructions for Management of Joint Contractures and Splinting in SNFs

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Back to my blog home page: http://travelingotr.blogspot.com

I received an email from John who wrote,

"Can you provide me with some specific goals for contractures that are functional, measurable and objective that you've used?"



Thanks, John, for the nudge...

Allow me to sound off from my soapbox about contractures. We can really write good functional goals if we catch the contractures before they become moderate to severe.

Do not wait until a patient or resident cannot stand up or transfer due to 45 degree knee flexion contractures! Catch them when they are just starting to bend at the knee as they stand. Do not wait until the hand is so tight that the fingernails have broken the skin on the palm.

You can screen everyone in the dining room

at one sitting

by asking the residents 

to open and close their fingers

or straighten their legs or elbows. 

It's really that simple.

You get the idea...

OK. Goal writing, along with step-by-step instructions for splinting Tre-style...

 Caveat: This is not a complete listing of goals. Think about your residents/clients and what functional tasks are important to them. This information may or may not jive with your ideas about splinting and documentation. I have never experienced denials on my documentation or the review process through CMS/intermediaries, and I have been involved in reviewing documentation/managing ADRs as a DOR and an RVP.



When documenting treatment of contractures with orthotics, you want to document two things:

1) the progression through the splinting process, and

2) the functional response to the application of orthotics.


You've already determined the person has a joint contracture.

You can't just write one goal for splinting. The process sequences in the following order:    

A) Pick the splint. Measure for it. Order it.
Splinting is complex!
If you have questions about how to choose a splint,
email me at treccad@gmail.com
GOAL: Client/resident will participate in identification, measurement and ordering of appropriate orthotic to address joint integrity deficits of (contracted joint) by (date).  (written at evaluation)

B) Splint arrives. Fit it. Modify it.

GOAL: Client/resident will participate in fitting and modifications of (ordered orthotic) to (contracted joint) by (date) to increase (contracted joint) AA/PROM for promotion of functional independence or reduction of CG assistance. (written at the first progress note)

...be patient...function is next...

By the way...at fitting and donning, check fit to ensure that two of your fingers fit under the straps; otherwise, you're going to find strap marks on the person when you go to doff the splint.


C) Start wear time at 15 minutes on day one. Increase 15 minutes daily until your long-term goal of 3-6 hours.  Stay with the patient through the whole wear period the first three treatments of wear.

Don't slap a splint on for 2 or 3 hours on day 1!

You'll lose any hope of compliance if you do

because your patient/client/resident will be

in pain.

Note: not every resident is capable of tolerating 6 hours of daily splint wear. Over the years, I have seen 2-3 hours/daily work just fine if the orthotics are applied consistently. The key is staff education and consistency.

GOAL: Patient will increase wear time of (orthotic) to (time daily, i.e. 3 hours) for promotion of low-load passive stretch to (affected joint).


As you increase wear time and improve joint integrity/AA/PROM, you will progress toward development of more functional goals. I have also used photography of the affected joints with resident and family approval to provide a visual aid to document improvement in joint integrity.

...and now, function:

GOAL: Patient will:  (pick your functional activities below)..

Functional Gain 
(LOA = level of assistance)
Area of Improvement
  • Improve grasp of utensils at meals
  • Improve grasp on toothbrush or brush
  •  Increase ability to straighten fingers (go to 3rd column)
  •   To feed self with (LOA

  • To groom  self with (LOA)  
  • To prevent  fingernails from digging into palm for promotion of optimal skin integrity. Document presence of fingernail marks or photograph hand.
  • To promote accelerated healing of wound in palm. Make sure wound  info is documented. Photograph.
  • Straighten arm (to degrees)
  • Straighten arm (to degrees) (go to 3rd column)
  • To brush hair with (LOA)
  • To dress UE with (LOA)
  • To reduce CG burden when dressing UE from () to ()
  • To promote optimal skin integrity and (%) reduction in size of wound of elbow crease (for severe contractures and wounds in elbow crease)
  • Lift arm (to degrees)
  • Lift arm (to degrees) (go to 3rd column)
  • To dress UE with (LOA) 
  • To reach overhead into kitchen cabinets
  • To reach for car door when transferring to/from car
  • To lift items from shelves into cart at grocery store
  • To reduce CG burden when dressing UE 
  • To reduce CG burden to provide hygiene under arms during bathing
(contracture goals can also be written for hips, though you obviously won’t splint hips)
  • Straighten legs to (degrees)   

  • Promote improved standing posture and WB through B LE’s (go to 3rd column)
  • To promote increased standing tolerance and stability during LB clothing management
  • To promote improved posture and standing tolerance to (# of min) while standing at sink to groom.
  • To reduce CG burden during toilet transfers from () to ()
  • To promote optimal stability during sit to stand for reduced risk of falls from wheelchair  (or bed or toilet) – this is for people with documented fall histories – make sure to analyze surfaces from which they have fallen - in addition to other factors...
4) Always assess the skin integrity and document the skin condition in daily note after orthotic wear.
DAILY TX NOTE(Client) wore B Flex Knee orthotics for 45 minutes while supine in bed  to provide passive low-load stretch for optimal knee extension and positioning of LEs during naptime. Skin was assessed following doffing of splints; reactive hyperemia (redness) was observed over patella areas and blanchable erythema resolved within (time frame, i.e. 30 seconds).
About reactive hyperemia:  (this is normal during splinting)
Usually, reactive hyperemia is the first visible sign of ischemia. When the pressure causing ischemia is released, skin flushes red as blood rushes back into the tissue. This reddening is called reactive hyperemia, and it's due to a protective mechanism in the body that dilates vessels in the effected area to increase blood flow and speed oxygen to starved tissues. Reactive hyperemia first appears as a bright flush that lasts about one-half or three-quarters as long as the ischemic period. If the applied pressure is too high for too long, reactive hyperemia fails to meet the demand for blood and tissue damage occurs.
About blanchable erythema: (you want the skin to blanche. If it stays completely red, you have a Stage I pressure sore developing, and you need to contact the nurse.)
Blanchable erythema can signal imminent tissue damage. Erythema results from capillary dilation near the skin's surface. In the patient with pressure ulcers, the redness results from the release of ischemia-causing pressure. Blanchable erythema is red when it blanches, turns white when pressed with a fingertip, and then immediately turns red again when pressure is removed. Tissue exhibiting blanchable erythema usually resumes its normal color within 24 hours and suffers no long-term damage. However, the longer it takes for tissue to recover from finger pressure, the higher the patient's risk for developing pressure ulcers.

My favorite company, ACP, who provides modalities in SNFs, used to handle orthotics. They now provide orthotics through Orthopedic Rehab Products, a Hangar company. They can send you a DVD of all their order forms, which include criteria for the specific conditions indicated for each splint, as well as other administrative forms necessary for ordering splints. (Good info for another post...)

anyway, call Monica or Miranda at ORP at 800.652.1136. They'll be happy to send you a DVD catalog/order forms. (hours: 8-4;30 MST)...

I am in the process of packing for a 2-week excursion to Guatemala to practice medical Spanish, so I have to close! I do hope this post helps you with splinting and goal writing. Drop me a line if you have questions or you want more goal ideas.

Hasta luego,