1. The Tip of the Iceburg

    Its hard to believe that we have almost finished our thrird week on our first of three 10-week rotations at various hospitals, clinics, skilled nursing facilities, homes, and rehab facilities. During this first internship we are finally getting in past our ankles. By the end of this ten week stint we should  have around a 50% case load of patients.  At OHSU in Portland, OR I am working in the trauma unit which is my first ever acute care experience. And what an experience it has been!!! The diversity in patients is incredible! the age range so far has been from 15 to 99 years old with diagnoses ranging from spinal cord injuries, gunshot wounds, traumatic brain injuries, cervical fractures, multiple system trauma from car/motorcycle/bicycle accidents, and many more. One of the most difficult aspects to working in this unit has been the absence of any predictive value of how the patient will perform at evaluation. I have had patients that have fallen from 25 ft discharge home on the same day, and then treat someone that trips on a curb and is requiring constant vital monitoring and services from speech, OT, and PT. You can never know how a particular injury will present but this difficulty is also why i am really enjoying my time in the trauma unit. It is forcing me to apply clinical reasoning and utilize my knowledge from all of my classes from the first two years. It is truly a place where all of the body’s systems are frequently involved in treatment and need to be addressed and considered in order to deliver optimal care.  I have struggled a little bit with the coordination of care because these patients often have many co-morbidities that require treatment from nearly all professions. Daily events include organizing with nursing to have the patient medicated but alert enough for therapy, co-treating with OT, and Speech, organizing around the patients surgery/dialysis/family visits/x-rays/blood draws/medical consults/bowel care/case management/etc…. And the list goes on and on. It requires a diligence and integrity in ones work, chart review, and documentation to be a successful practitioner and i feel like i am starting to get the hang of it. Still so much to learn still which makes me so happy to have chosen this field of health care.

    Stay calm and PT on!!!  =)

     

  2. "With the new day comes new strength and new thoughts."
    — Eleanor Roosevelt
     

  3. Summer Gone, Internshiop Strong

    The last bit of our summer quarter was quite nice depending on the elective course you decided to take. It seems as though the spinal imaging course and shoulder course were the heaviest in regards to courseload, and in the same respect some of the more enriching course options. For many in the class they opted to do a personal study organized by the professor of their choice. Some of their projects consisted of a cardiac rehab powerpoint detailing the different stages and appropriate interventions, and a presentation on our volunteer experience with Camp No Limits that three of us participated at as physical therapy interns working with children with prosthetics. Ultimately it was a nice and easy closure to our last quarter ever in the classroom.  Unfortunately it was not the end of studying as most of us had already started hitting the notes (literally and figuratively) from the past two years in preparation for the comprehensive exam.

                It has been said that the comprehensive exam is harder than the licensure exam. Well I sure hope so. The majority of the class spent around a month reviewing notes from all of the previous coursework. It seemed as if we were all quite exhausted from hundreds of hours of studying, countless coffees and energy drinks, and more stress than we could manage.  But even with the ominous presence of the looming exam we did manage to come together as a group and take some time away from the books. We BBQ’d in Couer d’ Alene and the beach park, A small group of us went to a Spokane Indians Baseball game,  as well as a group went floating the Spokane river. When the stress runs high (which it often does), it is incredibly important to take time off and regain your bearings. It is too easy to just engulf yourself in studies and go a little crazy creating an environment unsuitable for learning. Making time for fun is a keystone piece for success and sanity in any PT program.  When the time came around for the comp exam everyone was prepared with their bananas and coffee, ready to take on the 3 hour written exam, and 2 hour essay.  Although seemingly daunting, the exam when by faster than most of us imagined. After the scantrons were tallied, and the essays graded, we all emerged with passing grades!! It was such a relief to receive that lovely email allowing us to continue on to our internships. In celebration of  completion of the last school exam of our lives we had an awesome party at the 424 house with drinks, delicious food, corn-hole, games, and music. A proper start to one of our last real summer vacations.

                It seems to be the consensus that the emotions are mixed regarding finishing school. There are feelings of relief and enthusiasm about passing and being able to start on the next leg of our journeys. And there are feelings of sadness and anxiety about when the next time you will see these lovely people that you have come to call your brothers and sisters; the people that have lifted you up in times of need and brought you treats and presents on your birthday. Those friendships that have been cultivated over the past two years on this journey we call PT School. Everyone will be missed but it will make our reconnect that much sweeter when we receive our degrees in just a short years time.

    As we finally make our way to our first of three 10-week internships we say so long summer as the weather begins to turn and our new journey through our clinical education begins.

     

  4. Floating on into Summer!

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    What a rush the past few weeks have been! We have successfully tied up all the loose ends in our classes and completed our last… Final…. EVER!!!! (oh except that comprehensive exam in two months that covers two years’ worth of curriculum). We are all very ecstatic about the completion of our last final and are looking forward to this short summer quarter before our internships.

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    In the past few weeks we finished up our musculoskeletal class with Dr. Kawaguchi lecturing on the hot topic of concussions. As a PT and ATC, Dr. Kawaguchi has seen more than his fair share of concussions. When he was lecturing one of the messages that came across loud and clear is that there are discrepancies in what exactly defines a concussion and how do we properly assess for concussions. Ultimately it is not just one sign or symptom that determines if someone has experienced a concussion, but rather it is a constellation of signs and symptoms that are observed and felt. More importantly there have been way too many inconsistencies in the manner in which we detect concussions that have led to poor outcomes and even death. As PTs we have to be cognizant of some of the signs and symptoms and be able to know when it would be recommended that someone would benefit from further analysis/treatment. Aside from our concussion lecture our last two appearances in class were for aour two finals. Our practical was a case study that contained two diagnoses that we had to figure out from the history and physical exam that was provided. After filling out the entire plan of care we had to explain our diagnoses to our partner and then perform a manual technique or two exercises targeting the area of interest. IT sounds straight forward but there are always difficult questions that are asked by our professors during the practical scenario that challenge us to critically think on our feet.

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    In neuro we completed the quarter with practical study scenarios and our two finals. For the most part the scenarios were with hypothetical patients with brain injury, CVA, and SCI, which are some of the more common diagnose that we will encounter in our acute and rehab settings. Our two finals were difficult in sections mostly because of subtleties that differentiate the treatment and care of these injuries. The incredibly fascinating aspect of neuro injuries is that no matter how much you know about the pathology, the presentation is unique for every patient. Whether it is cognitive, sensory, or motor, each patient will present with an entirely different distribution of strengths and deficits and will require an innovative physical therapist to accommodate their therapeutic interventions.

    In our multiple systems course we finished with the project presentations we had been working on all quarter. Topics that were presented on were chronic illness, cancer, and women’s health. Each of the presentations included a mock case study of a patient with the particular diagnosis. The beauty of these projects is that we have to work through each of the systems that are impacted by the pathology and thus influenced by our interventions. Our final consisted of our two projects completed this year as well as our section on women’s health. Like always there were a few stumpers but everyone passed and we finished strong into summer.

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    On some lighter notes we have been getting out in this lovely weather lately having BBQs and happy hours and birthday celebrations. The other weekend a group of the both the first and second years got together and did a multi-boat raft trip down the Spokane river. Although it was a water battle between the boats most of the way down, we all had a blast without any injuries.  The following weekend was exciting as my classmate Brandi and I share the same birthday. As it landed on the last day of class on a Friday we took to the town and did a tour de Spokane visiting a variety of bars and even Elk fest, one of the sweetest music festivals that takes place once a year in the heart of Brown’s Addition. Another pearl of Spokane that was unexpected at first glance. As you may know the 2014 World Cup has been going on and as an active class we have been getting together for each of the US games through thick and thin and on to the next round!!!

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  5. Professors Love TMJ Week… Cant Ask Questions With A Hand In Your Mouth

    In just the last two weeks in our musculoskeletal class we have covered the craniovertebral junction along with the temporomanibular joint.  These two sections of the body are intimately related and come with plenty of red flags and precautions that have to address prior to treatment, or even a full examination as a matter of fact. Due to the location of the brainstem and the referral patterns of these structures we have learned that it is very important to tread lightly in this area of the body so as to not flare symptoms or misdiagnose a patient that in reality has a potentially deadly pathology or compromised tissue. In the craniovertebral area it seems that less is more. Because of the high rate of dysfunction and the correlation with headaches, neck and facial pain, small grade oscillatory mobilizations and very mild MET treatments tend to be more effective and resolving the tissue of issue while at the same time limiting the reason the patient has come to see you; pain. For our TMJ section Dr. Mary Ellen Anton, our professor’s wife who is equally entertaining and witty came in to help instruct this section. For the lab portion we all gloved up and performed intraoral examination and evaluation of the TMJ and surrounding soft tissues, something that most PT students probably never imagined that we may do as therapists. The caveat that I have to take away from this section is that the TMJ is not only a referral site for a variety of other neighboring soft tissues and structures, but it also may refer to those same areas. This means that as therapists we must be diligent and vigilant when it comes to ruling out TMJ and other local tissue dysfunction in our examinations and evaluations.

    In neuromuscular systems we have been focusing on practical skills and patient interventions. We have been practicing a variety of different transfer techniques for patients with neuro diagnoses like SCI and CVA requiring integration of the patient’s functional presentation and level of dependency. Along with those diagnoses we have also been practicing different intervention techniques that involve new devices like the Rifton and standing frames that allow upright and standing mobility to those that have LE weakness due to neurologic compromise. Our professors decided to take these practical exercises one step further by having us add in vision deficits simulated by modified glasses to mimic disorders like left neglect, retinopathy, glaucoma, and a few others. This exercise helped us recognize some of the speed bumps that may arise with multiple system involvement.

    In our multiple systems course we finished off our section with the pelvic floor muscle examination with diagnostic ultrasound in lab. Dr. Nelson has been doing extensive research on the pelvic floor muscles and has acquired two very expensive ultrasound machines that we were able to use in lab to see real live views of the pelvic floor and transverse abdominis muscle activation to a variety of different cueing strategies. For the pelvic floor the most popular cueing was, “lift urethra up and forward towards pubic bone”. For the transverse abdominis it was split between, “pull your hip bones together” and, “lift up urethra (females) testes (male)”. Regardless it will be important to use a variety of different techniques for your individual patients. More recently we have begun our group presentations on our hypothetical patient cases in which we explore potential exam findings, signs and symptoms, prognoses, and interventions for patients with a specific diagnosis that involve all of the four cardinal systems. This past week the groups presented on cancer and HIV/AIDS, two different diagnoses with surprisingly similar presentation and intervention considerations due to immunocompromised states.

    In our PT administration class we had a guest speaker, Bob Paul, one of the founders of Apex physical therapy, come and speak with us about the plethora of nuances in starting a clinic. The core of a company lies in its PLLC, a document that designates the do’s and don’ts, the manner in which to resolve conflicts/issues, and all of the inner workings of a company. This document must be incredibly thorough and drafted appropriately by a business attorney that really knows his/her stuff. By creating this document, owners and staff will all know their position and roles in the company as well as the distribution of the payment and profits the company makes. The PLLC will allow the company to function much more smoothly without causing unrest with decision making because it will be laid out already and signed by all stakeholders in the company.

    In other news four of us went on a trip to Leavenworth with EPIC, the outdoors program that is associated with the EWU undergraduate campus. There we went rock climbing and whitewater rafting and had some good ole fun camping in such a pristine area of the great northwest.

     
  6. Zach whippin’, and whippin’ it good!!!

     
     

  7. Fun, Sun, and Bloomsday Run

    Over the past two weeks our class has been incredibly busy with activities outside of the classroom. Last weekend was Bloomsday, one of the largest races in the northwest with this years attendance over 48,000 runners, a handful of which were our classmates. This 12 K run is no easy feat, with the last portion being named the ominous “Doomsday Hill”, this race is only for the dedicated. But this races would have been possible without the 5000 plus volunteers, again of which a handful of our classmates assisted with, including the wheelchair time trials the week before. One of the many perks to being part of such an awesome group/family/collective/team of people. Last week a good portion of the class came out to the 424 house for the first official BBQ of the season. Activities included a slackline, beanhole games, yard pong, and good ole relaxation accompanied by hot dogs, burgers, and a delectable assortment of appetizers and beers. Overall it was a success with great ideas for the next one.

    As for class we have been slowly working through more material. In musculoskeletal we have finished up our spinal manipulation section with Steve Allen. It all culminated with our practical exam last week in which we had to perform two the spinal manipulation setups and techniques. Little to say that having such a great guru as a professor we all passed flying colors. The written exam was another story. This exam covered our spinal manipulation, SI joint, and foot and ankle complex sections which made an already difficult exam to study for even more so. Dr Anton makes the majority of the questions very complex reasoning questions that have distractors and require proper analysis before deciding on an answer. Arguably one of the harder exams we have had all year but we were all still breathing the next day so onward we go.

    In neuro we took a visit to the Northern Idaho Advanced Care Hospital (NIACH) to observe Dana work with a patient that had a CVA. The best part of this learning opportunity was getting to see a diversity in the treatments that Dana decided to use to challenge the different systems, including playing catch with a balloon on a foam incline board, obstacle courses, and even Jenga. Her creativity and ingenuity is inspiring and intimidating all at the same time, but we all know that this ability to modify and adapt a treatment to your specific patient is the art of practice and will grow through years of experience. The rest of our neuro classes were spent in the lab practicing wheelchair mobility/recovery and performing the ASIA scale on one another. The ASIA is the standard assessment to determine the neurological level of spinal cord injury that a patient has. This is an important assessment to organize the plan of care of the patient because it will be able to accurate track a patient progress in recovery and help determine the amount of function that is likely to return. Through these practical situations we gain just the slightest insight as to how difficult it is for the recovery of function after a spinal cord injury and the steps in which we must take to track and facilitate their return of function.

    In multiple systems we have moved on to gender health. It was coined as women’s health but as we progress forward as a profession nomenclature is very important and men can also have problems with pelvic floor activation, incontinence and a variety of others similar to those of women. Granted that women occupy the majority of gender health patients, Dr Nelson made it very clear that anybody can have dysfunction, especially in an area as complex and dynamic as the pelvic floor muscle synergy.

    In our geriatrics course we took a field trip to the Riverview Care facility along the centennial trail. This particular facility is a type of Continuing Care Retirement Community that provides a spectrum of care for the aging population. At the facility we had members of the facility come in to be assessed by us to give them an overall idea of their health status. Some of the assessment that we completed were the mini cog, SLUMS, Berg Balance Scale, Tinnetti, 4-square step test, TUG, and some basic information like gross motor function and vitals. This was a lovely experience to be able to be all on our own to engage with patients as the sole providers of care with the ability to choose whichever assessments we deemed necessary, a little preview of what our internships may hold.

     

  8. "Speech apraxia in the elderly: Not applicable to profanity. Those select words are clear as day. =)"
    — Frustrations with communication and speech among patients with degenerative neuro diagnoses are often the most clear and well verbalized.  Some words just never fade…
     

  9. "A patient history is like turning over rocks at the beach; 80% of what’s worth knowing about is found there."
    — Arguably the most important aspect of patient care.
     

  10. "When I do my job well, I get fired."
    — The reality of physical therapists and many of the healthcare team.