December 2013, Week 3: Caught red-handed

The incident I wish to reflect on in this entry happened last December 16, 2013 Monday.. For that day, there were not patients scheduled for treatment and so the interns were to do administrative duties (or admin duties for short), which I understood simply as clinic-related tasks. However, what I did instead of doing these was that I watched a movie, which is against the clinic rules.

Although I had initially no plans of watching a movie before I entered the clinic, what I did was my fault because no one forced me to do it. I do not blame anyone for having a movie on his or her laptop or for not reminding me that I was breaking a rule because I know the rules and the decision to watch was mine alone. My action reflects my  lack of ability to set my priorities straight. I know that this is my weakness and I am trying to improve.

I am somehow grateful that a clinical supervisor had caught me in the act so that the lesson of “first things first” will be deeply ingrained into my mind. (I had to admit though that I find myself severely unfortunate to be caught red-handed, considering that most of the time, I religiously observe the rules, including the most easily evaded ones.)

Now if I were to go back to that day, what would have I accomplished if I was not reprimanded for watching? I may have added a movie or two on my list of “Already Watched Movies”.  But now, I think it is more fulfilling to share that I had already done the 2014 attendance sheet of the patients decked to me, finished encoding the demographics for their endorsement notes and  got to know my patients better by reading their previous notes.

Not that big accomplishments, but because I take a good amount of time to finish paper works, the things I did feel like a great head start to finishing my backlogs for my pediatric rotation.

December 2013, Week 2

The session during the second week of December 2013 that I wished to reflect on in this entry was with patient LD, a 9 year-old male with the medical diagnosis of visual and hearing impairment. The father's chief complaint about the child is his inability to feed by himself, manifested by non-grasping of utensils.

The child basically demonstrated impaired hand function due to his behavior of throwing everything he would hold with either hand. The case was novel because the causes of impaired hand function I encountered so far were spasticity, loss of motion or muscle weakness. LD did not have any of those at the time of assessment. He could grasp the ball, for instance, but then I could definitely see the deliberate throwing motion after approximately 15 seconds of holding, evidenced by finger extension.

This session was the first time I meet the patient after he called to cancel during my first week in the clinic. Upon gross assessment, he demonstrated poor visual tracking, auditory localization and tracking and inabilityfor visual localization. Most likely because of these impairments, he was rarely, if not never, facilitated with toys.

Upon assessment, I came up with two goals for the patient: (1) to walk without assistance on level surfaces for at least 2 meters and; (2) to improve hand function, congruent with the father's chief complaint. My hypothesis was that his balance deficits and associated apprehension for falls prevent attainment of Goal 1 while his sensory issues and associated developed habit prevent attainment of Goal 2.

Let me discuss the problems I had encountered during the session:
First was the lack of visual and auditory localization and tracking. These caused difficulty in facilitating the child during the session because he was not attracted to toys. In which case, I learned to maximize myself, or what the other paramedical professionals perhaps call as the "Therapeutic Use of Self". During session, I switched between what I understood as "Active Friendliness" and "Kind firmness".

Second was the presence of sensory integration issues, namely tactile, vestibular and proprioceptive hypersensitivity, as endorsed by his previous OT intern. During these times, the importance of notes became evident. I addressed this issues based on the home program attached on the child's chart. I was reminded that other disciplines such as OTs are as needed as PTs and no one is a genuine "Jack of All Trades", even the OTs. I appreciated the importance of interdisciplinary approach in treating patients.

During my session with LD, I learned to be patient; that is, I should not be frustrated when I do not see any improvements during the session. I also learned that I should be confident with what I do. During the session, I was unsure if I was doing the right management. After the session, I consulted my clinical supervisor and was told that I was on the right track.

December 2013, Week 1: To crawl or not to crawl

The session I wish to reflect on in this entry was with patient JF, a 4 year-old female with the medical diagnosis of CPSQ. The patient’s primary means of mobility was wriggling her pelvis while in ring or long sitting position. She has no other means of independent mobility, such as creeping, crawling or cruising. This current means of mobility was obviously not typical (in the sense that it is not included on the long list of motor milestones) so the first goal I came up with after seeing her in person was for her to learn how to crawl (quadruped mobility). I did not immediately deem cruising as a goal, being a more advanced skill than crawling, which she was unable to do. At the back of my mind, however, I felt that something was amiss with my goal: the patient is a 4 year-old female and a child of her age is already expected of walking. After a quarter of the session's hour had elapsed, the patient still was not showing the slightest hints of improving in crawling despite manual guidance. Maybe, if I were to train mobility, I might as well train her to walk. The impairment, however, that kept me from choosing walking as the goal for that session was the severe lower extremity extensor spasticity of the patient. When assisted to walk, she presented with hyper-extended knees and plantar flexed ankles, which only went to neutral after short duration of rest (<30 seconds). I thought that by training how the patient to crawl, I was training her to move out of this extensor spasticity. I might have, but the carry-over of reduced spasticity would probably limited to activity of crawling. Again, I should remember that spasticity will never be completely resolved so I might as well just work with it with the skill I want her to develop. The lesson now is that first, I should try to be more specific with the activity. From then on, I can apply Motor Relearning principles (now appropriately called motor learning principles for the pediatric setting). In JF’s case, it is probably impractical to religiously subscribe to the neurodevelopmental approach of training motor milestones because doing which would perhaps prevent me from progressing my goals. What I can think of right now is to incorporate training of these "earlier" motor milestones on training walking alone. For instance, maintenance of quadruped position for JF would be used to promote weight-bearing on his lower extremities.