musings of a neurogeek

[ilovethebrain-blog]

A Strange Few Days

It's been a strange few days.

Part of the reason I enjoyed hospital work so much was the patients. I still maintain to this day that my favourite area of work was in Transplants, for the reasons because you got to spend a lot of time with people who very much needed you and appreciated that you had the time for them.

Transplant patients are going to die - this is fact. They are on the wait list for a new heart, lung, liver, because without it Death is their new neighbour. While my ball and chain is my wife and child, theirs is the 10L high flow nasal cannula, the constant beeping of the heart rate monitor, the incessant reminder of the ascitic belly spread in front of them like an endless pregnancy. You sit down with them and they have the most positive dark humour, and the most grateful attitude because their last few days are being spent with you. You are privy to their most intimate secrets and feelings because nothing is shy when the end is nigh.

You usually have five or six patients a day, which means eight hours drags. You take your time with chart review, with your patients, with your charting. You go for coffee and talk shop. You spend half an hour on your statistics sheet.

You talk. Your patients tell you about their day, about their days, about future days if they get their organ. They get their organ and spend days in the CVICU. Then they recover, shed their ECMO, lose their drains and the walker they were so accustomed to. They breathe, they walk, they smile.

I miss the talking - I miss the pace where a minute is not a New York one but a Hawaiian one, slow and deliberate. Each moment is sacrosanct - there is no guilt of the appreciation of now. This is care in its truest, distilled, titrated form. Where I work is fast, where therapy is lightning traded for a quick dollar. Talk is efficient, usually spent educating simultaneously between exercises, manipulations.

Imagine my surprise the last few days when time slows for an hour or two and I get deep conversations with clients. My distal clavicle resection shares a keen interest in the classical, so we swap stories of Romantic era composers - my love for Rachmaninoff's fourth piano concerto (oft ignored) and how he loves Chopin. I tell him how Chopin is built for pianists, how the notes fit your hand like a well tailored glove. We swap favourite songs - I write Ballade #1 on the back of a business card and he revels revels about the Nocturnes.

I meet the first eleven I have ever met at our clinic, who is referred for thoracic spine hypomobility from a previous client who owns a fitness company. She is refreshingly sweet and has changed my mindset of the typical meathead bodybuilder - we talk of her first upcoming competition and her inability to pose well like the other girls. She admits half abashed that she recently got a breast augmentation and cannot extend her upper spine well, so we take our time running through foam roll exercises, comparing favourite workouts and stretches. She is polite and thankful, seemingly not knowing that she is beautiful; the best kind. I regretfully tell her to stay away and work on her exercises - while she is therapeutic for me, I am not therapeutic for her.

My young impingement syndrome who works at Williams-Sonoma shares with me an appreciate for knives and I show her my Shun 5 in. santoku and my Wustof paring knife - I explain for her my fascination with the finesse of Asian knives and my respect for the sturdiness of a German one. She mentions a culinary instrument sale at the store and I am sold. We bond over our children while I mobilize her glenohumeral joint and manip her superior AC. We talk weekends and waterparks as I K-Tape for anterior instability, and share being young parents.

I miss the talking. I miss the time spent learning about patients and lives intead of seeing them as their meniscal repair, biceps tendinopathy, lateral epicondylitis. I want more time to spend chatting with them as they exercise, instead of manip'ing their abducted ulna and sending them to the athletic therapist to work out. I know we are physical therapist and not therapist period, but it's hard to separate the human part of me that wants socialization.

I miss being me, and it's taken a strange few days to tell me this.

[ilovethebrain-blog]

Happy

We have a lot of staff leaving us this month. I've lost one of my best friends and coworkers in the clinic to one downtown that caters to NHL/CFL players, which is great for him but not so great for me. We've lost another therapist to part time hospital, and I guarantee by the end of the month she'll drop our clinic altogether. Our athletic therapist has traveled away to the States to begin athletic training, and there's talk that we're going to lose another therapist and our office manager in the coming month.

Turnover is inevitable in the field we are in. PTs are notorious for bouncing from job to job (especially in hospital), picking and choosing whatever they fancy. Clerical and athletic staff are considered transitory by our superiors, and are paid accordingly, unfortunately. We all deserve to be happy, of course, but the climate at work currently is less than chilling. I turn the key and open the door at six in the morning to the air of abandonment, the reek of dissatisfaction, and the sense that the days ahead will be long and frustrating.

I think it's important for every physical therapist and ultimate clinic owner to understand what each and every one of their staff brings to the table. I've worked as both front staff and office manager, now PT and hopefully one day clinic owner. Our clinic is interesting because it brings a strange mix - our owners are a hubby/wife combo of which the day-to-day operations is run by a businessman and the stay-at-home wife is the PT. It means our clinic caters to the bottom line and does not fret over quality of delivery.

This is great to line our pockets with at the end of the day, but I question a lot whether this is good. A PT strives for the good of their client regardless of the situation, and while I understand it's the job of a private clinic to make money because we are in the private tier of health care, I don't understand how to trade my soul for cash. I want to spend time with my patients and make them better, and believe that they deserve quality care regardless of if they are paying their own wallet money or not.

I need to be in a clinic that compensates properly without sacrificing quality care, that treats its staff appropriately and fosters an environment of family, and understands and responds to the needs of their staff. One of the reasons I was so faithful to the clinic at the start was because I believe my boss listened to our needs, but as the years go by I realize this is not so. I don't see him half the time, and when I do bring up concerns via e-mail or in person, they go unanswered.

I am unhappy. This is a bad situation to be in when I have a new house to move into in August, a baby on the way in June, and a family to feed. I know that I want my own clinic and I know what I would do, but I am a rock in a hard place. Transition is hard, but it was have to be endured for the time being.

[ilovethebrain-blog]

failure

Failure is such a funny thing. I've experienced it well academically, from failing physics and zoology, to doing poorly on the MCAT, and eventually on my PT applications getting zero acceptances to any schools the first time I applied. It's an interesting sensation when you are not greeted with success - at first there is the denial á la 5 stages of grief, and then you begin to process it. Why did you fail? Is it because you did not know enough knowledge? Was it because you weren't ready? Or is it because you, yourself, are a failure?

These things are difficult to swallow, and you begin to internalize it. I had the opportunity to write my acupuncture examination recently, something that I have been practicing doing for over a year. I scored impeccably on the written examination, have been using it at length, and partnered with a coworker to practice hard. I was confident - more confident than with any practical examination I've ever taken - that I would destroy this beast.

You can understand my shock when I opened up the letter that said I failed. I failed by one mark, but that one mark was enough to shock my entire career. The self-doubt it casts cuts deep, where you begin to ask yourself if you truly are a good physiotherapist. Are you cut out for this profession?

I strongly understand Kübler-Ross now. Denial (no I couldn't have failed, how is this possible?); anger (this is ridiculous this organization is so stupid my instructors were unfair); bargaining (I'm totally going to appeal this they will see that they were unjust by badgering me with questions); depression (let's call my coworker for beers to drown my sorrows); acceptance.

Acceptance. The final defeat. Or the realization that no, they're right, I was wrong. The ability to look yourself in the mirror, swallow your pride, and recognize that it's not a bad thing to fail because it improves you. I was cocky, I was lackadaisical, and they saw that. They saw that I was blasé with my technique, with my safety, with my disregard for authority. I was careless because I placed my ego above my practice. I placed my pride before my patients.

This is a learning experience, it is not a failure. I can, and will, be better.

[ilovethebrain-blog]

fracture putty

I absolutely adore when sciences mix. I'm a big fan of dialectics - bringing two complementary forces together to strive towards improving the logistics of an area via an unexplored horizon. There's a reason why I enjoy neurotheology, find neuroeconomics so interesting and why I love metacognition. It's examining things through the eyes of a way I never thought to see, and improving and explaining the world around you.

Bioengineering is fascinating. My sister had planned to travel down that field prior to changing her though process and going down energy efficiency and environmental management. What's making all the rage these days in the orthopedic world is the creation of fracture putty. Stem cells have been discussed for a long time, but their real application to orthopedics is all speculation right now.

Bones need a few key components to grow. The first, is the idea of osteoconduction - that you require a scaffold for the bones to grow off of. The second, is osteoinduction - that you need signalling in order to tell the body to create new bone at the site of fracture. The last important component is osteogenesis - the actual growing of the bone at the fracture site. It's fascinating because lots of the time surgeons have spent their efforts devising ways to maximize all three. The general agreement at this point in time is that bone/marrow autografts typically are best - you have proper osteoinduction and osteogenesis because there is no worry about the body having an issue with rejecting its own tissue.

To solve the problem of requiring proper osteoconduction, putty is being created to fill the gaps. This is typically made of a bony scaffold like a calcium matrix which can be supplemented with an autograft in order to maximize take. The ratios according to the literature at usually an autograft to matrix fraction of 1:3, which can be used to coat the fracture ends. Pilot studies have thus far showed increased take with improved healing times, even in individuals with chronic fractures. It can even be coupled with ORIFs to improve surgical healing timelines.

Of course this is all experimental and few studies are currently in the literature, but it does prove promising for an area that is teeming with tons of pathology and few solutions other than "let it heal" or "let's operate on it." It'll be neat to watch how this field progresses as the years go by.

[ilovethebrain-blog]

brains and bruxism

I can't recall a time where I've had this many clients with mental health overlay in to see me at my clinic. When we break down physical therapist there always seems to be the physical aspect that we know and love, but the therapist part is the side of the coin that always makes me slightly uncomfortable. I've developed, over the years, a way to talk to my patients, to encourage them while still being disciplined with their care. I feel the caring side of the equation - the compassionate side - is something that we all take time to master, and that I've broken some pretty good ground with.

The problem is that we are never formally trained to take care of the mental health overlay that exists so commonly. I'm not so sure it's within our job description anyways (kind of out of our scope, really), but really the only exploration that we do of this is in INTER D, our communications course where we learn to socialize with members of other health professions. Even so, this course is a joke where we spend three hours a week stuck in a small group with medical students who already have the holier than thou practicing physician attitude, defensive nurses who think that everyone is out to get them, occupational therapists that spend the majority of the time explaining what exactly it is an occupational therapist is, and the odd dental hygienist or nutritionist that has no idea what they're doing in this course. We were taught the course by - and I kid you not - a registered clown who also happened to have a BSc Nurs, whose motivational techniques included squeezing horns and practicing laughter. You can see what I'm trying to get at here, is that physical therapists are unprepared for dealing with mental health clientele.

We have had the opportunity to take a few masterclasses with the registered psychologist directly underneath our feet in the building, who has discussed a few techniques with us, but almost certainly the answer is "refer out when in doubt". This is a good piece of advice since we are again returning full circle to the fact that this is outside of our scope, but what do we do when the patient is in our clinic and we cannot do this?

I had a client two days ago whom we shall call S., who has a long history of mental health and physical health issues. He is a rapid cycling bipolar and apparently has rage issues, and is on a long list of medications for such. His physical injuries stemmed from slipping in his cousin's mechanic shop and landing on his back, hence why he is in to see me. He is very pain focused and very troubled by his injuries, and he's not a very healthy person to begin with which makes his past medical history somewhat troubled - he has had necrotizing fasciitis on one arm, is at constant risk for random embolisms due to the poor blood flow through that limb, and has had a breast cancer history and has had both "breasts" removed. This is my second round seeing him as a client, and we've been working on the typical soft tissue stuff, but the fact that his case is so multi-faceted is what disturbs me. In addition to the physical:

1. Mental health - He is significantly declining from a mental health standpoint, where he will constantly break down in the clinic and cry and then suddenly get angry. Last day he was in he threatened suicide, but to me this sounded like a plea for attention because he had no formalized plan and was simply spouting when he was upset.

2. Litigation - His cousin is apparently suing him, so he has lawyers involved but this is causing a significant amount of stress. Fortunately, our schooling did put us through a significant health law module, so at least I have some idea of how this area goes. How is it that we receive education on health law and not basic treatment psychology?

3. Behavioural - This has made me uncomfortable a few times, where he has told other members of the team that I have "had a nice body" and to my face last day he mentioned that I "smell good". I haven't gotten to the point where I feel the need to dissociate from this situation (there have been a few times where I've been so uncomfortable that I tell the client I cannot see them anymore), but it certainly takes a lot of time and patience to deflect and shut down this behavior.

I am not adequately prepared for this, and it taxes and vexes me greatly. I attempt to empower my clients by telling them not to focus on the things they cannot change (i.e. injury, associated misfortunes), but to instead try to control the things they can make an impact on. I tell them to take each day as a separate day, moving forward one moment at a time. As I said before, mental health requires a significant amount of patience which is rarely afforded in a private setting, and I am far too underqualified for this task.

I have no good answers for these troubles. When I feel underqualified I usually take a course or something, but I am confused as to where to turn to. The problem right now is that S. is one of many clients I have currently with mental health overlay, and I fear the only reason I am taking these clients on is because of my history and family history myself with this, and the soft obligations that come with the guilt of not being understood when it was me. Is this getting too personal? Or do I just need to be more patient?

[ilovethebrain-blog]

elementary

Memories are funny things. I was initially going to write about the God Complex of physicians, but an event happened recently that makes me think back. I went to elementary at G., and when I was there I had a classmate named C. It's been plastered all over the news locally, but C. got hit by a drunk driver over the weekend and is now being remembered posthumously.

Facebook has been blowing up with kind things to say about C., and a group has been started to create a donations pool for her. I got added to the group the other day and was reading through all these messages, so I looked up C.'s profile and the funny thing is I can't remember her at all. There are all these messages saying that C. was the sweetest little thing who loved to ride horses and was a fantastic mental health therapist, but the truth of the matter is ever since I moved schools in grade 5, I don't know this person at all. I don't remember ever interacting with her other than the fact that there were two C.'s in our class, one with the last name that started with B and the other with P. It was C.P. or C.B., and coincidentally C.B. was the one who added me to the group.

I hate to the be the Debbie Downer and write on a message board full of sweet messages, "Yeah...I never really knew this chick, truthfully I haven't even so much as sent her a message let alone seen her these last 15 years, so like donations are totally cool but I don't have anything sweet to say here" but that's the real truth. Shit becomes real because it's a little closer to home, but I have nothing to say, no feelings to be had over someone that's dead, only an marginal association just because we went to the same elementary school.

Now what was real was the fact that it was my university BIOL 108 lab partner's birthday the other day. I remember us using centrifuges to spin out DNA, meeting on weekends to check on our plant growth, him joking about going to have a pitcher at Duke's once we were done class at 11 AM. Roughly a semester after BIOL 108, he went home on Reading Week and offed himself. J., the funniest most happy go lucky guy I've ever met (honestly), told nobody. He lives on through a Facebook page where people write notes all the time about how they miss him and were thinking about him the other day. It's bizarre.

Death is a weird thing, especially when it comes too quickly. Does it matter how close the association is? The only thing that changes is the perception of death and how much emotionally it affects ME, but at the end of the day it doesn't change the fact that the person is dead - the finality of it all. It's really quite elementary: Death is death.

[ilovethebrain-blog]

don jorge

As I sit here on the couch under the dizzying influences of a recently smoked Don Jorge cigar and a thumb of scotch, I think back to an experience in my episodic memory that sticks out like a sore thumb. We were attending a friend's birthday at The Red Piano, home of famous duelist improvisational pianists, and I recall being vividly angry. Our night was butchered by the fact that the waitress was insanely busy attending to the rowdy bachelorette party next to us who had bottle service, bitchy blonde females, and a penchant for attention. We rarely saw our server the entire night, and when our food came the portions were antonishingly small. I remember eating duck that night and paying $50 for an entree that could've passed as an appetizer for small children; the food was bland, uninspired and minute.

I was angry. After dinner, I left our party in search of a cigar to calm me down. I wrangled up a Montecristo #2 (my favorite by far) and went to the parkade in front of a deserted TNT Supermarket, and lit the sucker up. It didn't disappoint.

Next door, a punk concert was ending and droves of teens dressed like misfits streamed out. As I was puffing away sitting on an overturned shopping cart, a fellow leaving the concert walked up and remarked how it was hilarious to see a random guy in a parking lot smoking a stogie. He introduced himself as Josh and asked if he could join me.

I shared the cigar and we talked, this young whippersnapper and I. We talked about cigars and cigarettes, concerts and cocktails, life and its lessons. I don't recall what we talked about to be exact, but I just remember loving the fact that two people who hardly know each other, myself in blazer and him in mohawk and denim, could connect over something so small as a cancer stick. We laughed and talked about pipe tobacco, something that I still hope to smoke one day, then he excused himself good night and continued on his merry way.

I smoked the rest of the cigar, returned to the party and watched an epic rendition of Queen's Bohemian Rhapsody feeling much like now - dizzy and strangely satisfied. I understand how people can fall into sins like cigar and scotch because it makes the empty feel luxurious.

[ilovethebrain-blog]

the anxious piano

I had the good graces this weekend of being called upon to play music for a friend's wedding. Normally M. will do the honours and I get to turn pages for her or something equally illustrious, but seeing as she was part of the bridal party the task was entirely upon me. I've mentioned previously I do not deal well with stress - I was more nervous writing my most recent exam than I was for my own wedding - so understandably this task was an ordeal.

I've never played for a wedding before, not a venue where if you make a mistake it doesn't matter. This is in front of friends and family, in front of a groom and bride, where you can really fuck something up. I've had the opportunity to play for large crowds, with an orchestra, in fierce competition at the national level without sweating, and yet when it comes to 100 people in a garden, I freak right out. I've never had to manage timing, looking up to see if the bride has started to walk out with her father yet. I've never had to hold down a binder as it starts to blow away in the wind while still continuing to play with one hand to make sure there's no pause in the music. I've never had to manage a keyboard that doesn't have a lower B flat. It's an entirely different experience from which I'm accustomed to.

That being said, the anxiety had sufficient cortisol pumping through my system to give me Cushing's. I haven't had it this bad since school exams, where there were papers everywhere in the living room, dishes were not done and clothes were strewn like litter. I couldn't sleep properly, even with doses of lorazepam. My regular anxiety medication felt like it was a Flinstone's tablet with no noticeable effect except for the bitter taste it leaves at the back of my throat. How M. does this on a regular basis is totally foreign to me.

It makes me sympathize with mental health on days like this, because the way you feel is often out of your control. I had hives all over and just didn't feel right, even though I kept trying to tell myself to calm the fuck down. I understand now my patient who is on antipsychotics and antidepressants, who comes with tattered clothes and dandruff, whose schizotypal personality causes him to look down at the floor when he answers my questions in hushed tones, how he must feel trying to get out of his bubble. He's just trying to fit into a world that seems like a wrong fitting skin, tight and suffocating. None of the medicines or positive thinking can really change that.

[ilovethebrain-blog]

back to the grind

Life is fascinating when you don't have to do shit. Over the last few weeks I've been studying hard in anticipation for my acupuncture written examination. If there's anything that I know about myself, it's that I don't deal with stress well, and the last few weeks I've been more hormonal than a pregnant cooped up wife on a chocolate shortage in her final trimester. Maybe not that bad because I don't have ice cream and pickle cravings, but I'd freak out over the small things. Wife tips over a package of steaks causing leakage of the steak juice? It's like a fucking nuclear bomb went off because I'll be freaking the fuck out. I, who can eat a whole package of samosas, who can make a large pot of potato leek soup and eat it all in the same day, whose 5 lb. pot roast only lasts two days, had no appetite the day before and of the exam. I, who can sleep in until 2 PM on any given day like a sullen, lazy stoner teenager, woke up at 5:30 AM and went to the cafe to study. I'm not sure who I become when anxiety hits me, but it's akin to the Hulk and Bruce Banner.

It's done now, which I love. I'm back to the lifestyle where I can not feel guilty about sitting here and reading through Reddit with my morning coffee, look at pictures of girls on The Chive, browse the links of Caveman Circus. I have no obligations, nothing to hurry me. Last night I watched a documentary about Michelin star chefs and laid on the bed with my wife doing absolutely nothing just because I could. I went to HomeSense on my time off - I don't even like shopping for furniture.

You don't realize how lazy you like to become until you've experienced quite the opposite. I understand how difficult it is for people who are working to return back to academia just because the lifestyle is so different. And yet there are pros and cons to both - you can become lazy the rest of your life and lose all of your curiosity this way, just because it's easy and it feels good. It's dangerous - too much of anything is.

I've always thought about the conversation that I would have with my future students when I end up taking them in a year or two. I imagine myself sitting in a coffee shop with some doe-eyed, ink-still-fresh-on-your-Bachelor's-degree-wet-behind-the-ears schoolboy, asking me with shaking hands what it is I expect from them this placement. If there's one thing I want to instill into my students, or to people in general, I think it would make me set my coffee down, look the student deep in his eyes (that are simultaneously furiously trying to maintain this death stare and at the same time break away out of fear), and say in a low voice, "Be curious."

Curiosity may have killed the cat, but did the cat truly live until he was curious?

[ilovethebrain-blog]

the high school locker room pt. 2

I decided to consult a dream dictionary in order to piece together parts of the recurring dream that I've been having. It's, like, totally going to be perfectly accurate or whatever.

My latest dream adventure started with me heading to high school. This apparently signifies inadequacies or insecurities about my performance or abilities. When I eventually get to school, this is a metaphor for the lessons that I learn in my life, that I am going through a learning process at the moment.

Riding a go-kart means that I am navigating through life's twists and turns, that I have drive and ambition. As I arrive and see a swimming pool, this symbol is supposed to be of relaxation, calm, and ease - that I need to take a break to acknowledge and understand myself and my feelings. I need to cleanse.

As I walk into the locker room and follow the two cool kids, listening or watching someone else talking/having sex refers to my desires to be more adventurous with my own sex life.

Now the locker room in itself suggests that I am trying to overcome some sort of competition and need a chance to cool off. To dream that I am finding a high school locker speaks of hidden feelings, knowledge and attitudes that I must acknowledge, or some physical abilities I have yet to unsheath. Even more so, not being able to find or open a locker shows hesitation or insecurity about where I stand on a particular situation, that I have metaphorically lost a part of myself.

***

I have to say that even though this is purely off the internet, it's fairly accurate. I am about to write an acupuncture exam in the next two days and am definitely insecure about my knowledge and abilities on the subject as anyone would be in an exam situation. I do recognize that I am awful at dealing with stress (good old anxiety disorders) and am conscious of the fact that I need to relax and cool off; this is at war with my need and drive to learn the material and hold onto it. I am in limbo at not knowing whether or not I will pass this exam - Schrodinger's test.

As far as the sex part goes, when I get stressed out sex is often bad or off the table. My equipment has the tendency to shut down when my mind is elsewhere, which is fairly common for anxiety. That's always fun.

[ilovethebrain-blog]

The Recumbent Bike

I have this recurring client, S., who initially came to see me for patellofemoral pain. She had been through several bouts of physical therapy with no success, and was finally referred for a lateral release by her physician. After undergoing her first procedure, she came back with very little pain and a full recovery.

She spent a few months away from me while waiting for her second surgery, and I've had the pleasure of her returning the other week to work on her second. She's the first individual I've ever seen with a plica (I didn't diagnose it, the surgeon found it when he went in) which in itself already makes her a pretty spectacular patient. I really enjoy chatting with her because she's rather pragmatic and reasonable about her approach to rehabilitation, which is nice when clients don't expect us to heal them in one session. Having a bout of physiotherapy for the exact same injury previously really helps to make the second time around a lot easier; it provides perspective on treatment and your own body's healing.

Yesterday we finally started her on some resistance exercises following a few sessions of managing effusion. We put her on leg press and Theraband exercise, and I asked her to ride the bike for a few minutes just to get used to the ranging. I left her alone with the athletic therapist, K., for a few minutes while I went to get her ice/IFC ready.

When she returned to her room I could hear sniffles and so I ran in with a tissue box wondering what was wrong. I was worried she'd be in pain or was having a bad day or something, but she turned and looked at me all bleary eyed and said, "This is the first time since I was 12 that I've been able to ride the bike without pain. These are happy tears."

I know I did nothing for her to make her feel this way, in fact I am contemplating writing to the surgeon to thank him for this miraculous change (modern medicine is incredible) but it's days like this - tears and snot and sweat - where I realize I fucking love my job.

[ilovethebrain-blog]

the high school locker room

I've been having this recurring dream lately. The dream always has a weird way of starting, but I always end up at a high school. I've never seen this high school before but I seem to know where I am going.

Last night I had this dream again. I was driving a go-kart to school which was apparently a really nerdy thing to do because other kids were using slip-'n'-slides to get to school, and the cool kids walked. I get to this intersection and this cool kid is making fun of another kid on a go-kart, so I pick my go-kart up before I get teased and walk the rest of the way which incidentally is across a swimming pool. Once I pass the swimming pool I'm suddenly in the locker room. A cool kid is telling another cool kid how he's going to bang this chick he knows, and then they turn and look at me and they hush up as if it's a secret I don't need to know.

I'm in the locker room and the problem is always the same, that I don't know which locker to go to and I'm not sure what's in my locker. I search around for a long time and eventually I find my locker which is always in the back of the locker room in the last two rows. For some reason every time I have this dream I never initially know where my locker is, but when I go to the back of the locker room I have this sudden recollection that this locker in the very back, on the bottom row second from the left, is unequivocally mine.

I never get to the open the locker but I really want to know what's inside. Usually there's some obstruction that does not allow me to get near the locker - last night there was a large propane tank in front of it and two smaller barbeque-type propane tanks behind.

I want to know what is in that locker.

[ilovethebrain-blog]

best evidence

Sackett described evidence-based practice (EBP) as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." As I sit here and study for my acupuncture examination, I am torn between the realities of EBP in health care and the usage of our physical therapy framework, the C.O.R.E. Model. C.O.R.E. dictates the usage of three main factors into our practice: 1. EBP, 2. Client-centered practice and 3. Personal & environmental contexts (as defined by the World Health Organization's model of health status). Having a wife that took part in the primary teachings of the nurse practitioner program made me realize how closely physicians and nurse practitioners value evidence-based practice, so much so that there are some health philosophers that deem it only worthy to practice using evidence in interventions; only if evidence is not present do you use any other interventions, and really the crux of this finding is to provide the basis for gathering more evidence on the subject rather than treating in the dark.

Part of me understands this, that statistically we should treat because that is the best way to do things according to research. Some (including myself) will argue that there is always that 1% that might not respond statistically - that strange anomaly that seems to be the center of every House, M.D. episode. Regardless, nine times out of ten you are still saving nine people out of ten, rather than one out of ten (my math is erroneous, I realize, but your odds are essentially better if you follow best evidence).

As I study more and more alternative medicines, I run into the difficulties of justifying my practice solely based on philosophy. Physical therapists have the fortune of having a trimodal approach to care, which makes it easier to fall back on client-centered and contextual interventions even though best-evidence is technically best-practice by general consensus. Needless to say, it becomes difficult to promote acupuncture (less so when it is becoming more mainstream with IMS and Groupons promoting the subject) and other hokier practices like magnets, ultrasound. A friend had her dog over the other day and I pointed out a strange tag on his collar, to which she sheepishly grinned, "It's a negative-ion collar" to which I had no response. I said, "I guess it can't hurt," but really if you think about it should we be promoting practices that technically "cant hurt," or should we be advocating for those practices that are scientifically sound?

My approach these days is hesitant. I use acupuncture only after all other modes fail, and perhaps that is because I don't practice GTT or IMS and cannot use it to save my hands. I use magnets only when clients bruise and not for anything else. I never use stick-on plaster needles despite my previous preceptor showing me how to tack on an LI 4. I try to hold on to the EBP side of me as much as I can, feeling guilty every time I apply an ultrasound. And yet part of me thinks of all those people that acupuncture has worked on and has been the only modality that HAS worked and I had wished I had tried it sooner. But by the same coin I talk to my lady who visited the chiropractor and tell her that laser really only has evidence in recalcitrant wound care.

As much as it pains my background to say, the environment I work in promotes the full usage of the C.O.R.E. model in its entirety, and if I look back on my training, I should be valuing this framework in its full extent and not in pieces. Physical therapy is based in client-centered and contextual practice, with only best evidence emerging in recent years. There is great merit to that, because it has been shown that what we do works through evidence only AFTER practice. If we were centered only in best evidence we would largely never exist in the first place. How long did it take for physicians to realize that early mobilization in ICU actually improves patient outcomes? Now we are a blanket referral!

I feel the need to give up a little bit, let loose and relax. This makes me a worse scientist, I feel, but probably a better practitioner. The problem is that there is no metric to grade this on.

[ilovethebrain-blog]

SpIn/SnOut

There are certain inalienable truths about physical therapy, one being the very real possibility for human error exists. I suppose the same can be said about a lot of things in life, but there is no more real situation than the forefront of health care, where everything in your care depends on your ability to perform an accurate physical examination. We oftentimes pride ourselves on our ability to be fantastic orthopedic diagnosticians, that our hands are a direct extension of our brain's power. I absolutely adore when I perform an examination and determine that a patient's radiculopathy stems from the L34 levels or that I believe there is a tear in the supraspinatus, and lo and behold when the MRI arrives it confirms my diagnosis in its entirety. There is nothing more satisfying that being able to use your hands and your brain and know what a machine that peers into the inner cloisters of the human body can see.

That being said, as much as I love that feeling, this is entirely thrown out the window when I don't get the diagnosis right. Sure physios love to fall back on sensitivity and specificity of special testing when the imaging comes back differently, but sometimes it's about admitting that I just suck at certain physical tests. I remember being sat down on my very first placement and having my preceptor run through Lachmann and anterior drawer with me. "Can you feel that?" she says, and I go, "No, not really" and she goes, "Good, that's because there's no ACL there." I think she misunderstood me, because to this day I am awful at detecting ACL pathology. Granted, yes there is a lot that can mimic the ACL and they tell you that when you read through the anterior drawer criteria, but very rarely have I thought that there was a full ACL tear and it came back exactly so. In fact, I've missed a few ACLs, and even just today an MRI came back saying the ACL was fully intact and that my positive testing was entirely due to effusion in the joint mimicking laxity.

I am likewise just as bad at identifying labral tears. I have never seen a labral test not give pain in an impinge-y or frozen shoulder, just by virtue of the stupid positions that you have to put the shoulder in to do them. Any rotator cuff pathology will give you positive labral testing, and I have yet to meet a person with a shoulder that doesn't snap or have some degree of crepitus naturally. Sure there is very little they will do about a SLAP or a Bankart unless it is chronic and extremely debilitating, but it would be nice to know it's there.

I guess that I feel like as the days go by, I should be getting better at this kind of stuff, but it seems that some tests are just shit. I've really learned over the years that sometimes it's the simple things that are the most important; Magee had this slide at the start of his assessment lectures that said "listen to your patient, they are telling you what's wrong". As I go about my business each day, I find that this is the most important part - while the physical examination is the bread and butter of our job, oftentimes it's just the history and the observation that make a therapist's life easier. It felt so trivial chatting with a standardized patient in our OSCEs, but now that I look back in retrospect, I understand why so much emphasis was placed on it. It's the simple stuff that really works.

[ilovethebrain-blog]

Wisdom

is something that becomes of more and more value to me over time. It's one of those things, like youth, where you don't realize how important an experience is until it has gone by; hindsight truly is 20/20. The way that I learn is by far kinematic - I need to do things by myself, with my own bare hands, in order to know what it is. I used to be the type to watch a volleyball game from the sidelines, analyzing their every movements so that I too could hit hard like that, but it wasn't until I started playing league this year that I realized there is no wax on wax off - you learn by doing.

The value of money is similar, something I think about incessantly as I dream of children to come and teaching them the value of currency and hard work. I was watching a Doublelift documentary done by Machinima the other day and he mentioned something that was quite striking to me, that when he moved out with Travis he had no idea how much he was supposed to spend on things. He would go out and not know what an appropriate amount was to drop on dinner, or clothes shopping, or what have you. These are just worldly experiences that happen with time and with interaction, something that could arguably be taught on pen and paper but once you get out there the real value of something sometimes isn't all that tangible and you rely on instincts and experience to get you by.

I remember as a child how valuable a quarter could be when you're going to the Mac's, that you debated what was the better deal getting one 25 cent big candy or five 5 cent smaller candies. I remember stealing loonies from my mom's purse when I was in middle school so that I could purchase a coke from the vending machine or buying a poutine 2 for 1 with my SPC card. University was interesting because all of a sudden my broke ass had money from student loans injected into my account, all of which I had access to and suddenly, with no concept of how much things cost, I would drop $10 on lunch without a second though only to remind myself every day now that I'm paying back what idiocy I had sown years previous. Thoughts then spring back to when I first started dating M., how she had a job through piano teaching and would treat me to KFC, how she bought me that Tristan coat that I saw in my dreams spending her precious savings all because she had the faith that I was the one. That coat I still wear and it still blows my mind; I owe her everything.

So when I see two small children, like the other day, standing in front of TIm's, behind me in line, wondering whether a honey cruller or a Boston creme tastes better, I often want to just buy one of each for them and hopefully their mother doesn't hate me for it or think I'm a pedophile of the worst degree. I just remember running around at the Go Center after a volleyball game, and I found a $20 on the floor. There were two children standing by the vending machine pondering the way children do as to what treasures are held inside. I picked up the $20, wandered over to them and said, "I think you dropped this," knowing full well they didn't but it was their lucky lottery day. 

Money can't buy happiness, I know, but it can sure make two kids have a hell of a fun Wednesday.

[ilovethebrain-blog]

life anew

I see something sad happening lately. After working for over a year in this industry, you start to see repeat offenders coming back in. In this new year, I've had a few patients return back to me following a little bit of time off. They've concluded their WCB or private cases, have tried to return to work, and perhaps are back after their planned surgeries. I worked with them on prehab or rehab.

Don't get me wrong, it's very nice to see them again. I really like to hug old friends, to have them regale me with tales about their return to work/sport and the new developments in their life. I like to have my femur fracture walk in and say, "LOOK WHAT I CAN DO" and then proceed to do a free squat that is rewarded with the highest of fives. I like to have my carpel tunnel lady come back after she has had her beautiful new child, now describing the resolution of her CTS and the introduction of SI joint pain. It's nice to be in the familiar, to see my patient family after some time to see their growth, their change, their stories.

I digress. As I alluded to, there is a disturbing trend that is happening lately. I have a lot of patients returning and returning under sad circumstances. Here my patients must begin lives anew. Their injuries have changed them and now they must put on new masks, new costumes, adorn themselves with a new life. Times change and as you get older sometimes you cannot do the things you previously could do.

I get a call from my lady with an ACL reconstruction + meniscectomy who tells me she is different: She lost her child, her boyfriend has moved back to Europe, she still has a range lag and now has to change jobs. She is back in school to become something different - she cannot perform the career she loves molding materials into magic. My framer who had a truss fall on his leg is back after hardware removal following his ORIF after months on modified, only to find he can't do his job. He's confused as to what he has to do - hopefully we can go through a round of physio and return him back to modified/full, or else he may have to take on a new job.

I wonder how these people can change their lives so much just because of one incident. Sometimes you are forced to adapt, to become something different. We spend hundreds, thousands of dollars on education; we spend hours learning and experiencing and shadowing; we spend our lives making friends and co-workers only to realize that sometimes just one event can reshape our futures. My little cleaning lady with a proximal humerus fracture and subsequent frozen shoulder - you are my little Schrodinger's cat - you exist in a world where we are not sure whether you will go back to cleaning houses or become something new. And yet you smile every time I stretch or muscle energy your arm, you grin through torturous ranging exercises and Mulligan mobilizations, you yell "I AM OKAY!" every time I check on you and are keen to try new techniques be they humeral correction with K-Tape or new acupuncture points that I have learned. In these months on disability, on three times a week rehab, your life is evolving and yet you take it in stride and move forward...despite forward flexion being only 82 degrees with empty end feels.

I am inspired by you all. It takes but one instance, one dosage of you to make me realize that I have a difference. I walk hand-in-hand with you, taking you back to your promised land of pre-morbid functioning, or I usher in a new age of a new you. All it takes is for me to remember my charming little SLAP/Bankart repair lady - endless weeks of stretching and mobilizing and exercising, endless weeks of frightful faces that I would dislocate you, weeks where you came in sniffling due to sickness or sore due to workouts - and yet you kept trucking away. Now you are at 120+ degrees of forward flexion, 85 degrees of abduction, have a great deal of functional scaption and more glorious protraction than Cassius Clay. You can work (well, maybe you just put a lot of stuff on the left hand side so you don't have to reach as far) and most importantly you are back to yoga. Watching you smile as you go through a flow is all I need to continue forward and encourage my patients to keep pushing for all they can push for.

It's hard to think of you all as Phoenixes, as sometimes you will not rise from ash. But as much as I can, I will try to birth you into something beautiful.

[ilovethebrain-blog]

ego; id

I really, really adore metacognition. There is something about the ability that humans have to look beyond the self into this third person eye, to examine the self by the viewpoint of somebody else; theory of mind. I think the thing I value a lot of cognition itself is the idea of perspective, and that the ability to go into the mind's watchglass and see multiple perspectives of the self is truly an astonishing feature of a cerebral being.

That being said, its application to viewing the self can have interesting consequences I have found. Obviously we are biased towards viewing ourselves in a positive light, lest we be the pessimists that dirty humanity. We typically put ourselves up on a pedestal, which makes it so difficult to understand someone else's differing opinion, especially when it conflicts with our personal values and internal states. We feel a lot of the time that we are better, almost (and dare I say it) entitled to feel the way that we do because our way is the best (why else would we think and live that way if it were not?).

The problem obviously arises when somebody else plays our metacognitive devil's advocate and shows us that we are wrong. Something in our schema clicks and our psyche says, "Hmmm...oddly enough I see what you are saying and this feels wrong to me internally and I feel wrong and this is not a good feeling."

I have on two separate occasions received this type of feeling, which has rattled me to the very core of my existence (literally - at least to the degree that it has really changed how I view myself in life). We have a friend who I shall refer to as T., who has this uncanny ability to see right through you. What I mean by this is she can immediately judge who you are and what it is about you that would irritate every other human being. T. turned to me at a Christmas dinner one day and said with scrutinizing eye, "There's something about you where people just don't really know if what you're saying is the truth or not."

I didn't really understand that statement until yesterday, when M. pointed out that I have an excuse for everything. I pride myself sometimes in my gift of gab - that my tongue can sometimes disarm even the most angriest of people. She said, "You always have something to say - you're allergic to parsimmons when really you just don't like to eat fruits or vegetables, you've had a long day and don't want to roll around in the hay when really you're too lazy to have sex, you're too busy when again you're too lazy to the clean the car...why don't you man up and just admit the truth behind why you don't want to do things?" I laughed and kissed her and hugged her and told her she's beautiful when she's angry (which is true, she is). The problem though, is that she is extremely right, that I will sugar coat and wax tongue my way to get to what I want.

I need to stop lying to myself and to others.