they're hard. and useful. and infinitely complicated. the NYT summarized it better than I in the story they tell of Dr. Abraham Verghese:
http://www.nytimes.com/2010/10/12/health/12profile.html
Wednesday, October 27, 2010
Monday, June 28, 2010
The nurse's role
One of the most interesting things about my program is learning that nurses understand themselves and their role, and position themselves professionally in a way very different than, I think, most non-nurses, or at least non-medical professionals, understand. There's a whole lot more to it than "patient care." Or maybe I mean that "patient care" is a phrase that should be understood very broadly. I'd had no idea. I'd had vague notions that nursing was more about process and prevention, and possibly education, than medicine. But there's a lot more to it.
The absolute hierarchy we'd had given to us as NACs involved us being at the bottom of the totem pole (of course), and the stipulation that under no circumstances were we to ever take direction from a physician. We are nursing assistants, after all. But there is more to it than that. Especially in a hospital, nurses just don't work for doctors. Nurses work for the hospital, and doctors are independently contracted, which is why hospital visits that include doctors always involve at least two sets of bills: facility and equipment and possibly procedures (depending on who did them), and the doctor's charges. Nurses don't really take orders from doctors. They are _not_ assistants to doctors. They work with physicians in different settings and are often below them in a hierarchy in particular situations, but this is not on-going. They also carry out physician-prescribed patient care, but there's often a lot of leeway in how and when it happens.
One of the most important ways in which nurses and physicians interact, and which I didn't really get at all before school, is around medications. Nurses are the patient's last line of defense against medication errors. One of our instructors, Evelyn, told us never to "administer a drug if you don't understand the reason for its use." Nurses are responsible for knowing what any medication they are administering to a patient does and how, knowing why it's being administered to _this_ patient, who it shouldn't be given to and for what reasons, knowing whether and how it might interact with the other drugs the patient is taking, knowing correct dosages, dosage schedules, and all the various methods of administering drugs, and knowing what side effects are possible and monitoring for them and dealing with them when/if they appear. Evelyn has said, "if you don't defend your license, no one else will."
One of our [many] textbooks says that "nurses play a major role in promoting and maintainng client health by encouraging clients who need medications to be proactive consumers" (_Fundamentals of Nursing_, Craven & Hirnle, p. 495). We teach patients about how the meds they are taking might affect their lives, tell them what side effects to watch for, In fact, a lot of what nurses [should] do is patient education (which often includes educating their families) and advocacy (which often involves educating clients and helping them make decisions around the benefits and risks of different treatment options). We also engage in assessment and management.
So this brings me to a weird thing I have encountered, and did not expect to find, in nursing: the Nursing Diagnosis. Notes I've taken from my various textbooks lead me to explain a nursing diagnosis thus: a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provides a basis for selection of nursing interventions to achieve outcomes for which nurse is accountable. Ideally the cause of the ND is something that can be treated by a nurse. This is weird, subtle animal, and clearly I'm not yet "thinking like a nurse"*, because I don't come up with the same diagnoses when given the same set of objective and subjective assessment data as others do.
*(This is a phrase often bandied about, occasionally, and frustratingly, in lieu of an actual explanation as to why a given test answer is not as good as the "right" answer.)
Among the unexpected aspects of nursing diagnoses is that they cannot share language with medical diagnoses, even though they are occasionally discussing exactly the same issue. For example, a nurse cannot diagnose a patient with dehydration, but can diagnose that patient with "fluid volume deficit." This is odd to me. There are lots of diagnoses that are "at risk" diagnoses: "at risk for falls" is a big one. I'm wondering how, when, and where nurses in hospitals, say, have time to come up with diagnoses and apply them--are they paid for that? is it part of their job description? The professionalization of nursing requires standardization, so there is a governing body, NANDA (formerly the North American Nursing Diagnosis Association), which "defines the knowledge of nursing" by publishing journals and references with standardized diagnoses, their typical signs, symptoms, and concomitant care plans and outcomes. I have a NANDA guide, and currently find the language somewhat mystifying, and occasionally impenetrable. There is definitely a nursespeak, and I'm frequently reminded of how far from fluent I am.
Finally, another cool thing about nurses is that, at least with all the instructors I've encountered so far, there's a lot of respect afforded, and credit given to, people just starting nursing school. Our instructors, while individually teaching a group of us, will say "we" in reference to nurses. We are encouraged to identify with being nurses already, even though we're far from done with our training. This is motivating, and actually has some parallels to letting beginning language-learners attempt to communicate with more adept speakers and each other: mistakes are okay, it's assumed you'll get there eventually, and you can only get there if you're working hard and trying stuff way outside your skill level. But you're not motivated to put in the time if the "experts" don't welcome you to join them and learn from them.
Throughout my time in academia, I never felt included by my instructors. It was always made clear to me that I was below them on some hierarchy that mattered to them, and that obviously they thought should matter to me, as well. I like this a whole lot better.
The absolute hierarchy we'd had given to us as NACs involved us being at the bottom of the totem pole (of course), and the stipulation that under no circumstances were we to ever take direction from a physician. We are nursing assistants, after all. But there is more to it than that. Especially in a hospital, nurses just don't work for doctors. Nurses work for the hospital, and doctors are independently contracted, which is why hospital visits that include doctors always involve at least two sets of bills: facility and equipment and possibly procedures (depending on who did them), and the doctor's charges. Nurses don't really take orders from doctors. They are _not_ assistants to doctors. They work with physicians in different settings and are often below them in a hierarchy in particular situations, but this is not on-going. They also carry out physician-prescribed patient care, but there's often a lot of leeway in how and when it happens.
One of the most important ways in which nurses and physicians interact, and which I didn't really get at all before school, is around medications. Nurses are the patient's last line of defense against medication errors. One of our instructors, Evelyn, told us never to "administer a drug if you don't understand the reason for its use." Nurses are responsible for knowing what any medication they are administering to a patient does and how, knowing why it's being administered to _this_ patient, who it shouldn't be given to and for what reasons, knowing whether and how it might interact with the other drugs the patient is taking, knowing correct dosages, dosage schedules, and all the various methods of administering drugs, and knowing what side effects are possible and monitoring for them and dealing with them when/if they appear. Evelyn has said, "if you don't defend your license, no one else will."
One of our [many] textbooks says that "nurses play a major role in promoting and maintainng client health by encouraging clients who need medications to be proactive consumers" (_Fundamentals of Nursing_, Craven & Hirnle, p. 495). We teach patients about how the meds they are taking might affect their lives, tell them what side effects to watch for, In fact, a lot of what nurses [should] do is patient education (which often includes educating their families) and advocacy (which often involves educating clients and helping them make decisions around the benefits and risks of different treatment options). We also engage in assessment and management.
So this brings me to a weird thing I have encountered, and did not expect to find, in nursing: the Nursing Diagnosis. Notes I've taken from my various textbooks lead me to explain a nursing diagnosis thus: a clinical judgment about individual, family or community responses to actual or potential health problems or life processes, which provides a basis for selection of nursing interventions to achieve outcomes for which nurse is accountable. Ideally the cause of the ND is something that can be treated by a nurse. This is weird, subtle animal, and clearly I'm not yet "thinking like a nurse"*, because I don't come up with the same diagnoses when given the same set of objective and subjective assessment data as others do.
*(This is a phrase often bandied about, occasionally, and frustratingly, in lieu of an actual explanation as to why a given test answer is not as good as the "right" answer.)
Among the unexpected aspects of nursing diagnoses is that they cannot share language with medical diagnoses, even though they are occasionally discussing exactly the same issue. For example, a nurse cannot diagnose a patient with dehydration, but can diagnose that patient with "fluid volume deficit." This is odd to me. There are lots of diagnoses that are "at risk" diagnoses: "at risk for falls" is a big one. I'm wondering how, when, and where nurses in hospitals, say, have time to come up with diagnoses and apply them--are they paid for that? is it part of their job description? The professionalization of nursing requires standardization, so there is a governing body, NANDA (formerly the North American Nursing Diagnosis Association), which "defines the knowledge of nursing" by publishing journals and references with standardized diagnoses, their typical signs, symptoms, and concomitant care plans and outcomes. I have a NANDA guide, and currently find the language somewhat mystifying, and occasionally impenetrable. There is definitely a nursespeak, and I'm frequently reminded of how far from fluent I am.
Finally, another cool thing about nurses is that, at least with all the instructors I've encountered so far, there's a lot of respect afforded, and credit given to, people just starting nursing school. Our instructors, while individually teaching a group of us, will say "we" in reference to nurses. We are encouraged to identify with being nurses already, even though we're far from done with our training. This is motivating, and actually has some parallels to letting beginning language-learners attempt to communicate with more adept speakers and each other: mistakes are okay, it's assumed you'll get there eventually, and you can only get there if you're working hard and trying stuff way outside your skill level. But you're not motivated to put in the time if the "experts" don't welcome you to join them and learn from them.
Throughout my time in academia, I never felt included by my instructors. It was always made clear to me that I was below them on some hierarchy that mattered to them, and that obviously they thought should matter to me, as well. I like this a whole lot better.
Wednesday, June 23, 2010
Nursing school is fun
It's been a week and a day, and I'm really enjoying myself. Just sayin'. This despite the fact that I have to get up early (I know, woe is me) and be at class early.
I'm taking 3 courses this quarter: pharmacology, pathophysiology, and "fundamentals of nursing." The first two are straight-up lecture-and-exam format (with lectures on one topic or the other for about 5.5 of our 8 hours in class on Mondays and Fridays), the third occurs in lecture, lab, and after the end of week two (this week), clinic. I'll devote a separate post to the awesomeness of my pharmacology textbook. There are information, concepts, and skills we're trying to learn and absorb coming at us from many directions, so there's a lot of straight-up homework as well as studying.
I've been mildly surprised and totally pleased that my textbooks from my prerequisite courses (Anatomy and Physiology and Microbiology), as well as my books from taking my nursing assistant certification (NAC) courses, have been helpful; I've referred to them lots while completing assignments and going over stuff that doesn't make sense from class notes. All of this stuff actually connects! :)
Last week we had our first 3 lab sessions, 4 hours each, 3-4 "classes" per session. We worked on blood pressure, temperature, bed baths, bed-making (for unoccupied and occupied beds), oral care ... really, mostly on things that NACs, not nurses, do in normal settings. I found my NAC training super useful for this, and realized the nurses instructing us haven't had to perform several of these skills in a long time, and as a result, hadn't thought through the chain of transmission (of pathogens)--at what point in these processes do you have to wash your hands and doff and don gloves again? It was, however, a much less scarily exact set of procedures than it was for my NAC training (aspiring NACs can fail their exam if they do crucial or trivial things in the wrong order), and I guess this is because nurses are allowed to think, and NACs aren't supposed to. Nonetheless, reading through the same procedures in my NAC books after re-learning this stuff was great, because I had a better idea of the do-what-when rationale underlying them. Better still, an actual order that someone thought through at some point, thoroughly enough to be worth including in a book for NACs, includes necessary materials and lots of picky details...since NACs should memorize, not think. :/ This isn't quite fair of me to say, however; at least one of my instructors said multiple times that in such-and-such a situation, she would ask her "nurses' aides," because they have a better idea about whatever it is.
We currently have many nursing instructors for lab because we're divided into our 6 clinical site groups (about 8 people per group), and for each lab, an instructor will teach one set of skills repeatedly, so we rotate through. I've noticed some funny linguistic usages and habits that most of our nursing instructors have. I'm no better at not asking questions in lab or lecture than I've ever been at any point in my life. In response, a few of the instructors will give a hand-wavey answer whether or not they have a real one, and follow that up with, "Does that make sense?" It's like they all learned that they're supposed to verbally check comprehension, but the question comes across more as a termination of inquiry than a genuine solicitation of admissions of confusion. They say "Does that make sense?" I hear, "It should make sense. If it doesn't add up to you, that's your problem, not a conflict in the various sources of information you've been given."
This is especially odd given that we're supposed to be developing "critical thinking skills." This is another buzzword we've heard several times. Rather than, "think about it," or explaining that critical thinking actually means analyzing new information in light of what you've previously understood, attempting to reconcile the two, and questioning discrepancies, we're told, "use your critical thinking skills." But in actuality, if our "critical thinking skills" lead us to ask questions at an inconvenient time, the response isn't ideal. (I am grateful that this seems to be more of a lab than a lecture issue.)
For example, one of the instructors was leading a practice on temperature taken at several different locations with several different instruments (did you know that a temporal temperature takes an average of temperatures across your forehead!?) and height and weight, and the metric to standard conversions that go along with those. I had to weigh my partner, so before I did so, I attempted to zero the scale. The weight that I would think should slide back and forth so the scale _would_ zero just didn't move. I looked all around the scale, was still at a loss, and finally asked the instructor. She tried to do the same thing I had, and when she got the same non-results, she said, "Weight is something you want to know as a baseline, so you can compare gains and losses over time, or know if there's sudden gain, which would be indicative of edema. In infants, small differences in weight matter, especially if you're administering meds, but in adults, a pound or two doesn't matter. Use your critical thinking skills! [Repeats all of the foregoing in a different order, then half of it again.] Does that make sense?"
While all of this did make sense, she had effectively denied that it was problematic that this scale seemingly could not be zeroed. She tried it, gave up, moved on, then gave me a spiel that indicated I shouldn't have tried to zero it (I guess). I'm hoping I'll get better at predicting which questions will stump/irritate the instructors, who will be our clinical supervisors, and just avoid those. Maybe at clinic there will be other people I can ask things of without causing frustration?
During our third lab session, after learning about "SBAR" (Situation-Background-Assessment-Recommendation), a communication protocol in medicine aimed at preventing medication errors through general improvement of communication, we did a simulation on one of these:
https://my.smccme.edu/ics/Institute_for_MFTE/Simulation_Lab/Meet_the_mannequins.jnz
(that's a random google hit)
Our Vital Sims mannequin is named Stu-the-Dude, and his compatriot Alex is currently across the country getting repaired, so we have a stand-in (lie-in?) named Miguel. In our lab, there's a "hospital room" with two beds, one for Stu, one for Miguel. They are hooked up to computers so that a person behind the 1-way glass wall of the lab can control their blood pressure, pulse and respiration rates, thus allowing students to be tested on taking the correct measurements of all these vital signs. The person at the controls can even talk into a microphone the speaker of which is in the Sims's mouth. After our introduction to Stu and Miguel, we were given 10 minutes or so to practice taking vitals on them, then our instructor Joanne (primary instructor of Fundamentals of Nursing, and head of the entire summer program, which is an absurd amount of coordination to do, bless her) told us we were going to do a simulation.
"As y'all are walking to clinic in the morning you see Stu riding his skateboard down the hill, lose control, and run into a stop sign. He's bleeding profusely from his femoral artery. You 4, leave the room. You 4 are on the scene. What do you do?"
Ack!
Four of us went into the lab to stand behind Julianne, our other F.O.N. instructor, as she tried to talk into the microphone like a skateboarder between moans in her unusually high-pitched, girly voice, while changing Stu's vitals. We watched through the one-way glass. The first team was given about 10 minutes, instructed to decide whether to tell 911 they needed an ambulance (A-car, I think it's called?) or paramedics. Then it was our turn, and we were supposedly there while the paramedics arrived, and had to make the transition, giving them necessary information.
Turns out Joanne was mostly interested in our ability to work as a team and get a job done, and we briefly discussed how that works. She said normally decisions happen because (1) there's an established hierarchy or (2) someone was first on the scene or (3) the person with the most confidence starts delegating. This was a little weird, though, since we're all new to each other and the program, and no one, I think, wants to be, or be perceived as, bossy or center-of-attention-ish, because one might run the risk of being disliked. Not useful in a program where one's cohort is so essential to one's survival.
After that brief discussion, Joanne had us do it again, reversing roles, and deciding ahead of time who would be in charge. Both groups performed better--of course, we knew what the situation would be ahead of time and had practice, as well.
This whole exercise was stressful and really, really fun. It reminded me of competing theories of language learning. Some instructors only want to give you problems that you have every tool to solve. Others want you to put things together, and attempt to reach beyond your level, and learn that way. I was in the latter camp, and I am excited that my instructors, and this program's philosophy, seem to (mostly) be in that camp, too.
I'm taking 3 courses this quarter: pharmacology, pathophysiology, and "fundamentals of nursing." The first two are straight-up lecture-and-exam format (with lectures on one topic or the other for about 5.5 of our 8 hours in class on Mondays and Fridays), the third occurs in lecture, lab, and after the end of week two (this week), clinic. I'll devote a separate post to the awesomeness of my pharmacology textbook. There are information, concepts, and skills we're trying to learn and absorb coming at us from many directions, so there's a lot of straight-up homework as well as studying.
I've been mildly surprised and totally pleased that my textbooks from my prerequisite courses (Anatomy and Physiology and Microbiology), as well as my books from taking my nursing assistant certification (NAC) courses, have been helpful; I've referred to them lots while completing assignments and going over stuff that doesn't make sense from class notes. All of this stuff actually connects! :)
Last week we had our first 3 lab sessions, 4 hours each, 3-4 "classes" per session. We worked on blood pressure, temperature, bed baths, bed-making (for unoccupied and occupied beds), oral care ... really, mostly on things that NACs, not nurses, do in normal settings. I found my NAC training super useful for this, and realized the nurses instructing us haven't had to perform several of these skills in a long time, and as a result, hadn't thought through the chain of transmission (of pathogens)--at what point in these processes do you have to wash your hands and doff and don gloves again? It was, however, a much less scarily exact set of procedures than it was for my NAC training (aspiring NACs can fail their exam if they do crucial or trivial things in the wrong order), and I guess this is because nurses are allowed to think, and NACs aren't supposed to. Nonetheless, reading through the same procedures in my NAC books after re-learning this stuff was great, because I had a better idea of the do-what-when rationale underlying them. Better still, an actual order that someone thought through at some point, thoroughly enough to be worth including in a book for NACs, includes necessary materials and lots of picky details...since NACs should memorize, not think. :/ This isn't quite fair of me to say, however; at least one of my instructors said multiple times that in such-and-such a situation, she would ask her "nurses' aides," because they have a better idea about whatever it is.
We currently have many nursing instructors for lab because we're divided into our 6 clinical site groups (about 8 people per group), and for each lab, an instructor will teach one set of skills repeatedly, so we rotate through. I've noticed some funny linguistic usages and habits that most of our nursing instructors have. I'm no better at not asking questions in lab or lecture than I've ever been at any point in my life. In response, a few of the instructors will give a hand-wavey answer whether or not they have a real one, and follow that up with, "Does that make sense?" It's like they all learned that they're supposed to verbally check comprehension, but the question comes across more as a termination of inquiry than a genuine solicitation of admissions of confusion. They say "Does that make sense?" I hear, "It should make sense. If it doesn't add up to you, that's your problem, not a conflict in the various sources of information you've been given."
This is especially odd given that we're supposed to be developing "critical thinking skills." This is another buzzword we've heard several times. Rather than, "think about it," or explaining that critical thinking actually means analyzing new information in light of what you've previously understood, attempting to reconcile the two, and questioning discrepancies, we're told, "use your critical thinking skills." But in actuality, if our "critical thinking skills" lead us to ask questions at an inconvenient time, the response isn't ideal. (I am grateful that this seems to be more of a lab than a lecture issue.)
For example, one of the instructors was leading a practice on temperature taken at several different locations with several different instruments (did you know that a temporal temperature takes an average of temperatures across your forehead!?) and height and weight, and the metric to standard conversions that go along with those. I had to weigh my partner, so before I did so, I attempted to zero the scale. The weight that I would think should slide back and forth so the scale _would_ zero just didn't move. I looked all around the scale, was still at a loss, and finally asked the instructor. She tried to do the same thing I had, and when she got the same non-results, she said, "Weight is something you want to know as a baseline, so you can compare gains and losses over time, or know if there's sudden gain, which would be indicative of edema. In infants, small differences in weight matter, especially if you're administering meds, but in adults, a pound or two doesn't matter. Use your critical thinking skills! [Repeats all of the foregoing in a different order, then half of it again.] Does that make sense?"
While all of this did make sense, she had effectively denied that it was problematic that this scale seemingly could not be zeroed. She tried it, gave up, moved on, then gave me a spiel that indicated I shouldn't have tried to zero it (I guess). I'm hoping I'll get better at predicting which questions will stump/irritate the instructors, who will be our clinical supervisors, and just avoid those. Maybe at clinic there will be other people I can ask things of without causing frustration?
During our third lab session, after learning about "SBAR" (Situation-Background-Assessment-Recommendation), a communication protocol in medicine aimed at preventing medication errors through general improvement of communication, we did a simulation on one of these:
https://my.smccme.edu/ics/Institute_for_MFTE/Simulation_Lab/Meet_the_mannequins.jnz
(that's a random google hit)
Our Vital Sims mannequin is named Stu-the-Dude, and his compatriot Alex is currently across the country getting repaired, so we have a stand-in (lie-in?) named Miguel. In our lab, there's a "hospital room" with two beds, one for Stu, one for Miguel. They are hooked up to computers so that a person behind the 1-way glass wall of the lab can control their blood pressure, pulse and respiration rates, thus allowing students to be tested on taking the correct measurements of all these vital signs. The person at the controls can even talk into a microphone the speaker of which is in the Sims's mouth. After our introduction to Stu and Miguel, we were given 10 minutes or so to practice taking vitals on them, then our instructor Joanne (primary instructor of Fundamentals of Nursing, and head of the entire summer program, which is an absurd amount of coordination to do, bless her) told us we were going to do a simulation.
"As y'all are walking to clinic in the morning you see Stu riding his skateboard down the hill, lose control, and run into a stop sign. He's bleeding profusely from his femoral artery. You 4, leave the room. You 4 are on the scene. What do you do?"
Ack!
Four of us went into the lab to stand behind Julianne, our other F.O.N. instructor, as she tried to talk into the microphone like a skateboarder between moans in her unusually high-pitched, girly voice, while changing Stu's vitals. We watched through the one-way glass. The first team was given about 10 minutes, instructed to decide whether to tell 911 they needed an ambulance (A-car, I think it's called?) or paramedics. Then it was our turn, and we were supposedly there while the paramedics arrived, and had to make the transition, giving them necessary information.
Turns out Joanne was mostly interested in our ability to work as a team and get a job done, and we briefly discussed how that works. She said normally decisions happen because (1) there's an established hierarchy or (2) someone was first on the scene or (3) the person with the most confidence starts delegating. This was a little weird, though, since we're all new to each other and the program, and no one, I think, wants to be, or be perceived as, bossy or center-of-attention-ish, because one might run the risk of being disliked. Not useful in a program where one's cohort is so essential to one's survival.
After that brief discussion, Joanne had us do it again, reversing roles, and deciding ahead of time who would be in charge. Both groups performed better--of course, we knew what the situation would be ahead of time and had practice, as well.
This whole exercise was stressful and really, really fun. It reminded me of competing theories of language learning. Some instructors only want to give you problems that you have every tool to solve. Others want you to put things together, and attempt to reach beyond your level, and learn that way. I was in the latter camp, and I am excited that my instructors, and this program's philosophy, seem to (mostly) be in that camp, too.
Wednesday, May 12, 2010
Nutrition and Willpower
Have been taking a nutrition course this quarter, with the instructor I had from my first quarter of Anatomy & Physiology. He's excellent. The class isn't actually a prerequisite for my program, but I thought it necessary before beginning my RN/MSN program in Community and Public Health nursing, since there's not nutrition course per se as part of my program.
The course is great, and everything I've been seeing in the news lately has made me think this was a wise decision, especially this article from the May Atlantic, which I've posted in several places:
http://www.theatlantic.com/magazine/archive/2010/04/beating-obesity/8017/
Most important in this article, I think, is the way it reframes obesity from being an issue of lack of willpower, to being one of a cultural ill, yet another result of capitalism's excesses.
Important to note, from another useful article on the topic
http://www.huffingtonpost.com/lisa-bennett/should-anti-obesity-campa_b_569921.html
Ugh.
I was speaking recently with a friend of mine who's battling an alcohol problem, and we were discussing one of the [many] pernicious cycles in substance abuse: each time a person trying to cease a bad habit 'fails,' he or she feels bad about him or herself for what was clearly caused by a lack of willpower, and therefore commonly viewed as a character failing. This self-loathing leads to more abuse as an escape.
The other problem is that we misconstrue how powerful willpower actually can be. Some people have the idea that they should be able to work themselves into a state in which they are devoid of desire, and in which being surrounded by temptations of whatever sort would simply not affect them. This is silly. Willpower is, on some level, finite, and except for in the case of the most unnaturally austere people, if one is surrounded continually by temptation, physiology and biology will win out. I know that in certain contexts, when I am around cigarettes, I still want to smoke. So I avoid being around them, and it's not a problem. This is a self-hack, and it's necessary to keep me from smoking. Many, many former smokers I've spoken with have said that the most helpful factor in their attempt to quit smoking was the indoor smoking bans that have passed in various states of the U.S. only relatively recently.
In a way, this conceit of equating infinite willpower with good character supports the crappy-food industry. Of course three Oreos are not a problem if I'm a good person, so I can buy them, have them in my home, and if I eat the whole package, that's not the advertiser's and manufacturer's fault, that's my own moral failing.
In the Atlantic article I linked to above, Marc Ambinder states this in a different way:
That is, deciding not to eat a sugary, fatty food is doing something my body and brain did not evolve to have me do; it is the imposition of culture on top of somewhat of a physiological imperative. So my hack is to not watch TV, not see these ads, not bring this crap into my house, because I know that if it is there, I will consume it.
I think having this different perspective on weight problems is good for me, because if I am doing community health nursing with marginalized or underprivileged populations, I will encounter many many obese people, and I need to get over the idea that their obesity represents a moral failing. Taken to its logical extreme, that is a racist idea. Since I would see more black and Hispanic people with these weight problems, I would have to conclude these are peoples more prone to moral failings. Awesome.
The course is great, and everything I've been seeing in the news lately has made me think this was a wise decision, especially this article from the May Atlantic, which I've posted in several places:
http://www.theatlantic.com/magazine/archive/2010/04/beating-obesity/8017/
Most important in this article, I think, is the way it reframes obesity from being an issue of lack of willpower, to being one of a cultural ill, yet another result of capitalism's excesses.
Important to note, from another useful article on the topic
http://www.huffingtonpost.com/lisa-bennett/should-anti-obesity-campa_b_569921.html
[...]we also recognize that the influence of the media, advertising in particular, is daunting--and cannot be ignored. In 2004, the Kaiser Foundation reported that the majority of research shows that children who spend the most time with media are most likely to be overweight. Contrary to popular opinion, this is not because they are not getting out and exercising. The more likely factor, the study concluded, was the influence of billions of dollars spent on advertising and marketing of unhealthy foods.
Ugh.
I was speaking recently with a friend of mine who's battling an alcohol problem, and we were discussing one of the [many] pernicious cycles in substance abuse: each time a person trying to cease a bad habit 'fails,' he or she feels bad about him or herself for what was clearly caused by a lack of willpower, and therefore commonly viewed as a character failing. This self-loathing leads to more abuse as an escape.
The other problem is that we misconstrue how powerful willpower actually can be. Some people have the idea that they should be able to work themselves into a state in which they are devoid of desire, and in which being surrounded by temptations of whatever sort would simply not affect them. This is silly. Willpower is, on some level, finite, and except for in the case of the most unnaturally austere people, if one is surrounded continually by temptation, physiology and biology will win out. I know that in certain contexts, when I am around cigarettes, I still want to smoke. So I avoid being around them, and it's not a problem. This is a self-hack, and it's necessary to keep me from smoking. Many, many former smokers I've spoken with have said that the most helpful factor in their attempt to quit smoking was the indoor smoking bans that have passed in various states of the U.S. only relatively recently.
In a way, this conceit of equating infinite willpower with good character supports the crappy-food industry. Of course three Oreos are not a problem if I'm a good person, so I can buy them, have them in my home, and if I eat the whole package, that's not the advertiser's and manufacturer's fault, that's my own moral failing.
In the Atlantic article I linked to above, Marc Ambinder states this in a different way:
The only way to cure obesity is to radically rewire the relationship between the stomach and the brain. Diet and exercise can’t do that as quickly or as well.
That is, deciding not to eat a sugary, fatty food is doing something my body and brain did not evolve to have me do; it is the imposition of culture on top of somewhat of a physiological imperative. So my hack is to not watch TV, not see these ads, not bring this crap into my house, because I know that if it is there, I will consume it.
I think having this different perspective on weight problems is good for me, because if I am doing community health nursing with marginalized or underprivileged populations, I will encounter many many obese people, and I need to get over the idea that their obesity represents a moral failing. Taken to its logical extreme, that is a racist idea. Since I would see more black and Hispanic people with these weight problems, I would have to conclude these are peoples more prone to moral failings. Awesome.
Friday, March 12, 2010
Opportunity costs
Home sick today. I feel nauseated, have felt this way all day. Tried to nap, but there was nothing to distract me from how my stomach felt. Mental activity has proved most helpful, as it helps me escape my body, which is not a very pleasant place to be right now. There are people who live with pain on a permanent basis; they must crave distraction more than anything. Nausea doesn't seem to be a longterm problem in general; a quick Google search yielded little other than random personal blog hits of people undergoing cancer treatments. I've read about burn patients playing virtual-reality video games set on ice planets while undergoing their extremely painful therapies, and that they report experiencing less pain.
It's been an illness-filled week. Lots of our friends' children have fallen ill, our daughter did, too, and I stayed home with her all day a few days ago. Today I have whatever-it-is.
I made the decision a while ago to cut my working hours back from 5 days a week to only 4. I had found myself resenting the last hour or so I spent at work every day, thinking of the things I wanted to accomplish outside of work that I wasn't able to do. A friend pointed out that the fact that my hours have a dollar amount attached to them now (a meagre $11) means that I am able to concretely weigh how much different opportunities are worth to me. Would I rather forego the $11 and spend that time going to the grocery store, running other errands, doing schoolwork and housework? Often, the answer was yes.
It doesn't help that my position at work is weird. I'm working at a position for which I am only required to be a highschool graduate certified in CPR. Everyone I work with outranks me, and so can tell me where I should be and what I should be doing at any given time. Right before I started work there, I got my food handler's permit, which, coupled with the fact that I'm currently taking microbiology, meant that I have been hyper-aware of contamination, cleanliness, etc., and especially concerned with the kitchen. The program I work with is headquartered in public housing, so rodents are, and should be, a concern. There was a long time that whenever I went to work in the kitchen--to do all the dishes, at the beginning of our move back, before we had someone come to do dishes; to get it organized, get things labeled, get systems in place; one of my many bosses would shoo me back to spend time with the clients. I'm happy to work with the clients when I can tell my presence is needed and not redundant, but that wasn't always the case. At some point, I snapped at my coworker, Joey, when he came to shoo me out of the kitchen, then finally talked to my principle supervisor, Jody, about it.
I brought up the fact that I am paid so very little. I know it's a nonprofit, I know what's in my job description, and... I have been trained to do most of the things that my two coworker/bosses do, and I also take initiative, improve systems, and use my time efficiently. I told her it also distressed me that the one work-study student there, Jeremy, does none of those things. He congenially does whatever is explicitly asked of him, but he doesn't look for work to do, and isn't really qualified to substitute Jody and Joey in leading group activities. This distresses me because I know he is paid $1/hour less than I. This is government-subsidized, of course, so Geriabulous isn't shelling out nearly as much for him as they are for me. The money isn't why I'm there, obviously, although it's nice to have any sort of income after 6 months of none. The difference bothers me because it feels like I am not valued. So Jody wisely listened to me rant and seems to have mostly changed the things she could: I'm still paid my crap wages, but when I asked my uber-supervisor if I could work one day fewer per week, Jody chimed in her support and suggested a day that would work for all of us. She & Joey have also gotten off my back about going in the kitchen whenever I find spare moments.
And it's actually better for me to not be working the 5 days, because that would've averaged out to over 22 hours/week, which would make me fulltime and eligible for benefits. I am much better off with my husband's and the extra fees we have to pay for me to be covered by them. This is a Bummer: my joblet in healthcare, which for many people in the organization is their primary soure of income, comes with not very fabulous healthcare benefits.
The fact that I don't have benefits means that I don't have paid sick leave, and I therefore don't feel guilty about not going in for work when I don't feel well. Of course, I shouldn't feel that way at all, even if I had paid sick leave, because everyone is better off if a sick person stays away. I do hate leaving Jody & Joey in the lurch, though; I know how busy Fridays are. :(
It's been an illness-filled week. Lots of our friends' children have fallen ill, our daughter did, too, and I stayed home with her all day a few days ago. Today I have whatever-it-is.
I made the decision a while ago to cut my working hours back from 5 days a week to only 4. I had found myself resenting the last hour or so I spent at work every day, thinking of the things I wanted to accomplish outside of work that I wasn't able to do. A friend pointed out that the fact that my hours have a dollar amount attached to them now (a meagre $11) means that I am able to concretely weigh how much different opportunities are worth to me. Would I rather forego the $11 and spend that time going to the grocery store, running other errands, doing schoolwork and housework? Often, the answer was yes.
It doesn't help that my position at work is weird. I'm working at a position for which I am only required to be a highschool graduate certified in CPR. Everyone I work with outranks me, and so can tell me where I should be and what I should be doing at any given time. Right before I started work there, I got my food handler's permit, which, coupled with the fact that I'm currently taking microbiology, meant that I have been hyper-aware of contamination, cleanliness, etc., and especially concerned with the kitchen. The program I work with is headquartered in public housing, so rodents are, and should be, a concern. There was a long time that whenever I went to work in the kitchen--to do all the dishes, at the beginning of our move back, before we had someone come to do dishes; to get it organized, get things labeled, get systems in place; one of my many bosses would shoo me back to spend time with the clients. I'm happy to work with the clients when I can tell my presence is needed and not redundant, but that wasn't always the case. At some point, I snapped at my coworker, Joey, when he came to shoo me out of the kitchen, then finally talked to my principle supervisor, Jody, about it.
I brought up the fact that I am paid so very little. I know it's a nonprofit, I know what's in my job description, and... I have been trained to do most of the things that my two coworker/bosses do, and I also take initiative, improve systems, and use my time efficiently. I told her it also distressed me that the one work-study student there, Jeremy, does none of those things. He congenially does whatever is explicitly asked of him, but he doesn't look for work to do, and isn't really qualified to substitute Jody and Joey in leading group activities. This distresses me because I know he is paid $1/hour less than I. This is government-subsidized, of course, so Geriabulous isn't shelling out nearly as much for him as they are for me. The money isn't why I'm there, obviously, although it's nice to have any sort of income after 6 months of none. The difference bothers me because it feels like I am not valued. So Jody wisely listened to me rant and seems to have mostly changed the things she could: I'm still paid my crap wages, but when I asked my uber-supervisor if I could work one day fewer per week, Jody chimed in her support and suggested a day that would work for all of us. She & Joey have also gotten off my back about going in the kitchen whenever I find spare moments.
And it's actually better for me to not be working the 5 days, because that would've averaged out to over 22 hours/week, which would make me fulltime and eligible for benefits. I am much better off with my husband's and the extra fees we have to pay for me to be covered by them. This is a Bummer: my joblet in healthcare, which for many people in the organization is their primary soure of income, comes with not very fabulous healthcare benefits.
The fact that I don't have benefits means that I don't have paid sick leave, and I therefore don't feel guilty about not going in for work when I don't feel well. Of course, I shouldn't feel that way at all, even if I had paid sick leave, because everyone is better off if a sick person stays away. I do hate leaving Jody & Joey in the lurch, though; I know how busy Fridays are. :(
Like Flynn!
Or something. I got the letter in the actual snail-mail two weeks ago indicating that my crush is reciprocated: my dream program wants me. This makes me very relieved and happy, and means I've been able to start planning my life somewhat around the program's timeline. I'll start classes the fourth week of June.
Sunday, February 21, 2010
Incontinence
is no fun. And I'm coming to see my own ability to "toilet" myself as a rather long blip on the screen. I've changed many an infant diaper by now, and have worked hard at potty-training my toddler. Now at work I help adults in various stages of losing, or, in the best case, attempting to regain, their abilities to (1) recognize when they need to use the bathroom, (2) get themselves there, (3) get themselves safely onto and off of the toilet, (4) get themselves cleaned and dressed afterward, and (5) wash their hands. Some just need supervision and reminding because they have epically short memories. Some, since they're hemiplegic, need help getting onto the toilet, or maybe just pulling their pants up. You try getting re-dressed sometime with just one arm. :/
It's a weird position to be in with adults, with whom I have normal conversations about normal things when we're not in the bathroom. It's infantilizing, and how I do my job can mitigate or exacerbate this dignity-robbing effect. The advice I was given back in NAC training was to be professional and matter-of-fact, and non-judgmental. This I have done, and it was good advice.
One hemiplegic client last week was on his way to the toilet, but the process of getting out of his too-big-to-fit-in-the-bathroom wheelchair and getting set up to use his cane to walk in took longer than it usually does, so he didn't make it. I spent a good 30 minutes getting him cleaned up and changed. He was mortified and apologized profusely. I was totally okay with it, in part because of the number of infant diapers I've changed, but that's not a comparison that would have made him felt better. Another client, who takes himself to the toilet without reminding or assistance, has now twice pooped--once on the floor, once on a chair--in the middle of group activities. He is the absolute _last_ client I would have predicted such of--no one else has done anything like this. It seems a little crazy. The second time he left the room without mentioning that it had happened, and someone had to point it out to me. I cannot imagine how incredibly embarrassing this must be for him.
A lot of our clients wear Attends or whatever other brand of disposable adult undergarment. This was the case in the nursing home where I did clinic. Unlike that home, however, we do not merely rely on changing these undergarments, bypassing the bathroom altogether. They still use the restroom. This seems so very important to me. Babies and toddlers don't go to the toilet by themselves, and to not encourage and assist adults' bathroom use communicates to them that they are children.
It's a weird position to be in with adults, with whom I have normal conversations about normal things when we're not in the bathroom. It's infantilizing, and how I do my job can mitigate or exacerbate this dignity-robbing effect. The advice I was given back in NAC training was to be professional and matter-of-fact, and non-judgmental. This I have done, and it was good advice.
One hemiplegic client last week was on his way to the toilet, but the process of getting out of his too-big-to-fit-in-the-bathroom wheelchair and getting set up to use his cane to walk in took longer than it usually does, so he didn't make it. I spent a good 30 minutes getting him cleaned up and changed. He was mortified and apologized profusely. I was totally okay with it, in part because of the number of infant diapers I've changed, but that's not a comparison that would have made him felt better. Another client, who takes himself to the toilet without reminding or assistance, has now twice pooped--once on the floor, once on a chair--in the middle of group activities. He is the absolute _last_ client I would have predicted such of--no one else has done anything like this. It seems a little crazy. The second time he left the room without mentioning that it had happened, and someone had to point it out to me. I cannot imagine how incredibly embarrassing this must be for him.
A lot of our clients wear Attends or whatever other brand of disposable adult undergarment. This was the case in the nursing home where I did clinic. Unlike that home, however, we do not merely rely on changing these undergarments, bypassing the bathroom altogether. They still use the restroom. This seems so very important to me. Babies and toddlers don't go to the toilet by themselves, and to not encourage and assist adults' bathroom use communicates to them that they are children.
Sunday, January 24, 2010
Personality is sorta chimerical
A few days ago, our planned physical activity of the day was indoor basketball with a 5' tall plastic basket. Steve, my co-worker, who's a case manager with several of the TBI clients I work with, ran the show. He decided that to even things out, he'd split our group such that the two clients with motorized wheelchairs were on opposite teams, another usually wheelchair-bound client was on one of their teams with her non-motorized chair, then he pulled 3 extra chairs out of the equipment closet. Two clients who normally walk on their own took the first 2, and I evened out the teams by taking the 3rd chair.* I don't think I'd ever sat in a wheelchair. It was fun, and I'm glad I don't have to ride in a wheelchair normally.
I've still not read any clients' files, so I'm still creating my own ideas about what they're "like," what's illness, what's part of their former personality. I'm sure it's a relief for them to be somewhere that people _don't_ continually compare their pre- and post-incident selves. There are some general characteristics one finds such as speech problems (softer than normal and/or inarticulate and/or disconnected and/or nonsensical speech) or loss of certain inhibitions (quicker to anger, tendency to make inappropriate remarks of a sexual or non-tactful nature). But then I think that if I'd had an accident that robbed me of, say, the use of a side of my body, and made me talk funny, and meant I wasn't as smart anymore so my spouse no longer found me attractive enough to be intimate with me, I'd probably be grumpy and quicker to anger than normal, too. And maybe have lowered inhibitions because I quit caring about social consequences because my deference to them didn't seem to help me be accepted by the world at large, anyway, now that I was disabled and looked down on or pitied or ignored.
One client seems to have vocabulary straight out of a John Hughes script. Her response to most things said to her is to grin widely, wave her hand, and say "I'm so sure! I'm so sure!" Did she talk like this before whatever-it-was injured part of her brain? Was she always such a cheerful person? Did her grumpy wires get disconnected altogether? Or the client who makes continual inappropriate flirtatious comments to me--maybe he's always objectified women in this way? Is that just his injury talking? My boss leads group discussions about once a month on communication skills and uses that phrase with the clients, telling them that what they said wasn't their best self, it was their injury talking. It's great they're learning explicitly to use other parts of their brain to inhibit certain behaviors. And this reminds me what a fragile construct self and personality are.
What if I had to ride around in a wheelchair as my only means of locomotion, and couldn't think or talk as fast? That would sort of be someone else, except they would have my not-as-functional body and some percentage of my memories.
*If you did the math, you realized that's not many clients. On any given day we have between 14 & 21 clients present. After the lunch that takes up the first hour, they're split into two groups, red & blue. One does the cognitive game/activity while the other does the physical, then they switch, then everyone goes through free-weights/sitting/arm/leg/standing exercises at the same time in the two groups in two different rooms. That day, the client who should've been in the wheelchair I took was still eating her lunch. She typically takes about an hour to eat the meal that most people consume in 10 to 15 minutes.
I've still not read any clients' files, so I'm still creating my own ideas about what they're "like," what's illness, what's part of their former personality. I'm sure it's a relief for them to be somewhere that people _don't_ continually compare their pre- and post-incident selves. There are some general characteristics one finds such as speech problems (softer than normal and/or inarticulate and/or disconnected and/or nonsensical speech) or loss of certain inhibitions (quicker to anger, tendency to make inappropriate remarks of a sexual or non-tactful nature). But then I think that if I'd had an accident that robbed me of, say, the use of a side of my body, and made me talk funny, and meant I wasn't as smart anymore so my spouse no longer found me attractive enough to be intimate with me, I'd probably be grumpy and quicker to anger than normal, too. And maybe have lowered inhibitions because I quit caring about social consequences because my deference to them didn't seem to help me be accepted by the world at large, anyway, now that I was disabled and looked down on or pitied or ignored.
One client seems to have vocabulary straight out of a John Hughes script. Her response to most things said to her is to grin widely, wave her hand, and say "I'm so sure! I'm so sure!" Did she talk like this before whatever-it-was injured part of her brain? Was she always such a cheerful person? Did her grumpy wires get disconnected altogether? Or the client who makes continual inappropriate flirtatious comments to me--maybe he's always objectified women in this way? Is that just his injury talking? My boss leads group discussions about once a month on communication skills and uses that phrase with the clients, telling them that what they said wasn't their best self, it was their injury talking. It's great they're learning explicitly to use other parts of their brain to inhibit certain behaviors. And this reminds me what a fragile construct self and personality are.
What if I had to ride around in a wheelchair as my only means of locomotion, and couldn't think or talk as fast? That would sort of be someone else, except they would have my not-as-functional body and some percentage of my memories.
*If you did the math, you realized that's not many clients. On any given day we have between 14 & 21 clients present. After the lunch that takes up the first hour, they're split into two groups, red & blue. One does the cognitive game/activity while the other does the physical, then they switch, then everyone goes through free-weights/sitting/arm/leg/standing exercises at the same time in the two groups in two different rooms. That day, the client who should've been in the wheelchair I took was still eating her lunch. She typically takes about an hour to eat the meal that most people consume in 10 to 15 minutes.
Sunday, January 3, 2010
Getting Paid
My volunteer gig has turned into a paid job. The whole thing feels quite serendipitous. The TBI (traumatic brain injury) group had its program moved back to a former location, and its director asked that I move with them, and talked to the right people so that I got hired. The new/former location is quite close to my house, only a 12-minute bike ride or so, as opposed to the original volunteer location which entailed a 30-to-45-minute bike ride south. The move also meant they could switch back to their former hours, as well, which means that my workday fits very neatly into the time between when the Microbiology class I'm taking this quarter ends and when the kids' daycare ends. I can easily pick them up on my way home, in fact. I am still a little shocked that I found a job in my field that fits inside daycare hours and allows me to take the last prerequisite required for my dream program. (I submitted that application on 12/1, won't hear whether I got in until 3/1.)
The first few days of my job I spent washing dishes and barely talking to clients. We aren't running our own kitchen fully. Instead, we're having food brought up daily from the south branch, and having to do our own dishes. I got my food handler's permit the first week, and other than that spent that week getting the kitchen back in order, which felt somewhat like moving into a vacation cabin. The stuff was unused for so long, it all got dusty, it's all needed cleaning, reorganizing. I've thrown away a bunch of random stuff that was either in terrible shape, unidentifiable, or a crappy duplicate. As for the rest of the tasks I was ostensibly hired for, I'm slowly being trained in the why's and how's-of-the-why's: bathroom assists, leading exercises, helping certain mostly wheelchair-bound clients do their particular occupational-therapist-devised standing exercise regime. Each day involves lots of different kinds of tasks, and this makes me really happy and makes the time go by quickly.
I've especially enjoyed the one-on-one time I get with clients when I help them with the standing exercises. I've found my experience with Iyengar yoga and its emphasis on alignment and physical adjustments really helpful in this endeavor. We go to a bar facing a window, I fasten what's called a gait belt around their waists, and help them to do things like stand up with both feet facing forward and parallel to each other, or to put weight in their heels (one client would constantly be on his toes otherwise). My help consists of reminding them of the exercise routine and staying by their weak side, holding the gait belt, in case of falls. They're bearing most of their weight themselves. Because of the yoga stuff, I've been able to brace a heel, or support a calf, so that a client can move the other half of their body more freely, or with more control.
TBIs--and maybe their aftermath, like life in a wheelchair for some? I need to research this--lead to common muscular conditions, one of which is called "high tone," which occurs especially in the lower extremities. Their quads are always contracting, meaning it's hard for them to bend their knees much. Many TBIs involve only one side of the brain or the other, so clients have no control over one side of their body. But both sides, the side with and the side without control, have this "high tone" problem. One client always asks us to tuck (force) his left foot back onto the footplate of his wheelchair. If we don't, his whole lower left leg springs into the air and stays there. With his right leg, he can do the forcing himself.
During standing I end up chatting with the clients. I've found out that the Beatles fan in the wheelchair isn't quiet at all, and that when he's standing up he's about 6-foot 1. His TBI was from a car accident when he was 16 years old. He says he was in heaven 2 to 4 years after the accident, that God sent him back, and that he doesn't really remember the time he was in heaven. This does not come across as delusional rambling in the least. He's incredibly polite, and quick-witted, except that his perfectly articulated, soft speech is produced at about 1/6 of the speed of average speech. One day I called him a "rockstar" because of his hard work; I know from what my boss tells me that he's improved his mobility a great deal, and that this is due to his determination. He replied, immediately, carefully, and slowly: "I prefer to call myself a stud. That's what I was called in high school. I was a wrestler and played soccer." He's 29. He managed to finish high school over the course of several years after the accident, and thinks he survived for a reason. This has something to do with the time he spent in heaven. He wasn't driving the car.
The first few days of my job I spent washing dishes and barely talking to clients. We aren't running our own kitchen fully. Instead, we're having food brought up daily from the south branch, and having to do our own dishes. I got my food handler's permit the first week, and other than that spent that week getting the kitchen back in order, which felt somewhat like moving into a vacation cabin. The stuff was unused for so long, it all got dusty, it's all needed cleaning, reorganizing. I've thrown away a bunch of random stuff that was either in terrible shape, unidentifiable, or a crappy duplicate. As for the rest of the tasks I was ostensibly hired for, I'm slowly being trained in the why's and how's-of-the-why's: bathroom assists, leading exercises, helping certain mostly wheelchair-bound clients do their particular occupational-therapist-devised standing exercise regime. Each day involves lots of different kinds of tasks, and this makes me really happy and makes the time go by quickly.
I've especially enjoyed the one-on-one time I get with clients when I help them with the standing exercises. I've found my experience with Iyengar yoga and its emphasis on alignment and physical adjustments really helpful in this endeavor. We go to a bar facing a window, I fasten what's called a gait belt around their waists, and help them to do things like stand up with both feet facing forward and parallel to each other, or to put weight in their heels (one client would constantly be on his toes otherwise). My help consists of reminding them of the exercise routine and staying by their weak side, holding the gait belt, in case of falls. They're bearing most of their weight themselves. Because of the yoga stuff, I've been able to brace a heel, or support a calf, so that a client can move the other half of their body more freely, or with more control.
TBIs--and maybe their aftermath, like life in a wheelchair for some? I need to research this--lead to common muscular conditions, one of which is called "high tone," which occurs especially in the lower extremities. Their quads are always contracting, meaning it's hard for them to bend their knees much. Many TBIs involve only one side of the brain or the other, so clients have no control over one side of their body. But both sides, the side with and the side without control, have this "high tone" problem. One client always asks us to tuck (force) his left foot back onto the footplate of his wheelchair. If we don't, his whole lower left leg springs into the air and stays there. With his right leg, he can do the forcing himself.
During standing I end up chatting with the clients. I've found out that the Beatles fan in the wheelchair isn't quiet at all, and that when he's standing up he's about 6-foot 1. His TBI was from a car accident when he was 16 years old. He says he was in heaven 2 to 4 years after the accident, that God sent him back, and that he doesn't really remember the time he was in heaven. This does not come across as delusional rambling in the least. He's incredibly polite, and quick-witted, except that his perfectly articulated, soft speech is produced at about 1/6 of the speed of average speech. One day I called him a "rockstar" because of his hard work; I know from what my boss tells me that he's improved his mobility a great deal, and that this is due to his determination. He replied, immediately, carefully, and slowly: "I prefer to call myself a stud. That's what I was called in high school. I was a wrestler and played soccer." He's 29. He managed to finish high school over the course of several years after the accident, and thinks he survived for a reason. This has something to do with the time he spent in heaven. He wasn't driving the car.
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