Week 4 done

I think I've been so wrapped up in working that I haven't been doing much updating.

Life has gotten into a much better flow at CC for me. I'm now seeing 4 patients a day - and responsible for all of their documentation. I'm even seeing some of the patients alone, while the rest I see with the physical therapist. My supervisor is really letting me get out there and see how things go for me on my own. She told me she thinks I have good clinical judgment and base knowledge so she is comfortable with me seeing patients on my own. I've also started to be responsible for making discharge recommendations for any patients when I complete the evaluation. This is probably the most difficult thing for me - at least it was this week.

I had quite a few patients who wanted to go a different place than I thought was the right place for them. It's interesting to see which patients will put their foot down and head to where they want to go even if we recommend something else. It's even more interesting to see what patients qualify for skilled nursing (read nursing home) care placements,and which patients qualify for acute (read at least 3 hours of therapy a day) rehab. Some patients are so set on going home they will fight tooth and nail to avoid both situations. If they are lucky enough to have good family support at home, typically we can make it work for them.

The only really difficult thing is when patients don't have any (or much) assistance at home and are unsafe. Hip replacements are very complicated when it comes to after surgery precautions. Patients that are unable to  remember or apply the precautions should not go home unless they have someone there to really help them remember and stay safe.

I also had a patient this week that selected not to follow the walker safety precautions at all - he joked about how far to move his walker (tossing it in front of him about 5 feet, standing up without it, etc) and he just didn't seem to care. It was really difficult for me to do - but I discharged him from OT since he didn't care to listen to anything I had to say. I felt that there were lots of things I could have helped him out with, but he just didn't care - so there's no real point in taking services from someone who wants to learn and be safe to give them to someone who does what he wants to do anyway.

I also learned about what some MDs think of therapists - the hard way. We had a patient in the ICU because her blood levels dropped exceptionally low (they should be around 13, she was at 4) and had to have blood transfusions. She had orders to be on bed rest, so we canceled her session for the day. Physical therapy & OT both canceled after the PT talked with the floor and we reviewed the chart (general surgery MD was concerned that there might be internal bleeding) and saw the bed rest order. The following day there was an order from the surgeon (the original surgeon) with a snide comment about how it would be nice if PT & OT wouldn't choose to ignore patients in the ICU. Instead of realizing that we did a thorough chart review and made a decision using our clinical reasoning skills he immediately just assumed that we were just ignoring a patient because it was easy to do. I learned that that MD, along with some of the others think that therapists should just do exactly what they say without thinking for ourselves. It was very eye opening about how important it is to make a clinical judgment - and have information to back it up. As the PT said "I obviously went to school for 7 years so I could follow blindly!"

Overall, the staff is really great with us. The nurses are generally great at following our recommendations and ask us for help when they aren't sure what is best for the patient. The PCNA (nurse's aides) are also great - we work together to help the patients all the time. When we know a patient may only be able to get up once, we go in and let the PCNA know so they can come in and change the bed while we're working. It's great for the patient to get the best service possible. Many of the MD's are great too - when they return our questions/pages and are willing to talk to us in person when we see them. Overall, I'm still very happy with the staff and placement in Cleveland!