10 Things Your PT Books Didn't Tell You (Part 1 of 2)

It's been quite awhile since I've written a PT blog entry.  I have received several messages through Facebook "encouraging" me to start another entry for PTs to read.  So to those who message me on FB, thank you so much for appreciating my write-ups and I will try to fill up the void.  I guess reading a PT blog entry is sometimes a welcome relief from the mundane exercise of going to your PT class, PT review and PT job.

Let me start off by saying that everything I am listing down here is completely unscientific.  There is no research to prove anything that I am about to say--- and I don't read researches anyway like duh!  Thus, you cannot quote anything here without justification.  And you cannot debate with the contents here in a well-Kisner-said-this-and-that manner.  All of what I have written here are purely based on observation and experience.  Now, all of us will have them differently but I'm sure at least one way or the other you can relate to the errrr "truths" (misinformed or otherwise) that I am going to share.

It is also very important to discern that if you are preparing for the US licensure exams and some of the contents confuse you, ALWAYS pick the other source, not this blog entry.  Remember, this is NOT scientific.  However, I would also like to point out that the things that I will discuss are completely relatable especially if you are or will be assigned in a skilled nursing facility or a nursing home.

Now as I went on writing this piece, I realized it was getting way too long so I decided to make it in two parts for easy reading and less information overload.

As always, reactions, corrections and intellectual discussion are highly encouraged.  Feel free, in any civil manner, to express your opinion on the subjects presented.  Now with everything in place, let us start the countdown.

1.)  Be wary of giving water to patients during exercise.

Yes, I know that the Bible tells us to give water to the thirsty.  And yes, all health magazines highly recommend drinking fluids before, during and after workouts to maintain steady electrolytes and prevent dehydration.  So why, you ask, should we be wary of giving water to patients during exercise?  Here's why:

Remember that the patients that we see in skilled nursing facilities and nursing homes are mostly elderly.  Many of these patients have many medical complexities including history of stroke, Parkinsonism, dementia or a combination of everything.  Many of these medical complexities have direct or indirect effects on swallowing muscle control.  Hence, the importance of you not giving water freely especially when you have no idea if the patient is at risk for aspiration pneumonia.  The best thing that you should do is, of course, consult your speech therapist.

Now, in the Philippines, I believe most PTs have not been exposed to speech therapists (ST), aka speech-language pathologists (SLP).  As their title implies, of course they are involved in evaluation and management of speech impediments arising from neuromuscular conditions.  Aside from that, they are also specialists in cognitive therapy such as memory enhancement, pill management and implementing safety strategies for patients.  The most important aspect of their job, for me, though, is their evaluation and management of the pt's ability to swallow bolus.  It is, therefore, the ST's job to determine if Lolo can still safely eat the steak he loves so much.  It is their job to assess if Lolo is at risk of having his half-chewed steak down into his lungs instead of his gut.  Well, you all know that if it goes to Lolo's gut then it turns into poop, normal, old boring poop.  However, if it goes to Lolo's lung, with his age, Lolo could easily succumb to aspiration pneumonia sending poor old Lolo into the great big steakhouse in the skies.

Question 1:  If we have no ST at the moment, how would you determine that Lolo is choking on his food or his water?  First of all, you look into the obvious signs: Upon drinking, Lolo starts coughing, or clearing his throat, or grunting, or a wet voice, or coughs again.  That is a very overt sign that Lolo is aspirating.  However, there is also such a thing as silent aspiration wherein Lolo doesn't show obvious signs of choking but food or water may still be going towards the lungs.  Some of the signs would be: watery eyes, runny nose, and change in voice quality after ingesting fluids.

Question 2: What happens then if you determine that Lolo possibly might be aspirating on food/fluids? You automatically refer the patient to your ST for evaluation if they are still not under caseload.  If the ST determines that the patient is indeed aspirating, he/she might be able to downgrade the patient's diet.  For food, if the patient is not aspirating then he is given "regular food", meaning he can eat anything he wants at any consistency.  The downgrade would be "mechanical soft" which has softer sides and chopped meats (also given to patients who lack dentures and can't chew meat very well).  The next downgrade is puree in which everything is put into a blender.  If the patient is still aspirating on pureed food then a gastric tube might be recommended.

The texture of the food though doesn't really affect us PTs because we are mostly uninvolved with feeding unlike STs and OTs.  However, we are very involved with the fluid intake of patients.  When we exercise patients, of course they would feel tired and thirsty and would sometimes ask for water.  When a patient is not aspirating, he is given "thin liquids" or basically just regular drinks.  A downgrade would be "nectar-thick consistency fluids" and further down is "honey-thick consistency fluids".  The further the downgrade the thicker the consistency is. Remember: Never ever give patients any water unless you know the consistency that the patient should be on less you risk the patient developing pneumonia.

Also, remember to check the chart or ask the nurse if the patient is on fluid restrictions.  This is usually the case with patients with CHF or/and using diuretics.  Ask the nurse how much water you can give the patient during exercise.  The patient is only sometimes allowed a certain amount of water throughout the day and thus, we cannot just freely give water to the patient even when the patient asks for it.

2.)  Watch out for skin tears in patients on blood thinners.

We learned from Goodman/Snyder that bruising if typically observed on patients on blood thinners.  What the book didn't inform you is that bruising is not the primary concern of PTs as the patient can bruise even without trauma.  Our primary concern is to decrease the patient's risk of having his skin torn.

Remember that as PTs we are involved in training patients in ambulation and transfers and unless the patient is high-level, we usually are in close contact with the patient during transfers and ambulation.  Our close contact relationship with the patient, plus equipments that we use (e.g. walkers, rolling walkers, gait belts, parallel bars) increase the chances that a patient may accidentally rub his skin on the area and tear it in the process.

A patient in chronic use of blood thinners literally give new meaning to the expression "balat-sibuyas".  Their skin is sometimes so thin that they tear even while asleep.  I can only assume that they probably rub it in the creases of the pillow or blanket.  

Question 1:  Your patient has a skin tear during exercise, what should you do first?  My first action is to make sure I am not in contact with the blood (don gloves whenever possible).  I will ask the patient if he is alright and then I will call the nurse.  I won't do first aid or put pressure on the artery above the tear (wow, manual arterial pressure ka pa ha? panalo) or attempt to stop the bleeding.  Remember, this is just a skin tear, this is not a medical emergency, so calm the f--- down.  The nurses will come in, assess, measure the size and clean the wound and they would usually tape the skin back into place so it doesn't flap around.  You would also probably be asked to write an incident report on the matter.

Do not be terrified of writing an incident report.  It will not ruin you or your career.  Just write everything in detail and that same incident report which you dread so much will protect you in the future.  If a patient has a skin tear, it is most likely not due to your negligence, it is just a side effect of prolonged blood thinner use.

3.)  A patient with chronic hepatitis may no longer manifest with jaundice

Jaundice as a review is caused by the inability of the body to complete the breakdown of old dead red blood cells in the body. The heme in hemoglobin will be turned into bilirubin which the liver will process to turn into bile which will assist in digestion of fats (note: it's been too long since I have read anything about hepatitis so this may not be accurate; correct me if I'm wrong).  With hepatitis, the liver becomes inflamed and swollen, it no longer is able to process bilirubin and bilirubin floods your bloodstream in a condition called hyperbilirubinemia (tama ba?).  The yellowish hyperpigmentation will manifest first in the sclerae and then the skin including other mucus membranes. 

Now the history of my patient who had chronic hepatitis was vague but basing it from what his mom said, it is alcohol related.  What was curious was that despite not turning SpongeBob-color, he did have manifestations of chronic liver disease.  Since his liver can no longer detoxify very well, the toxins in the body try to escape via his skin, so his skin appears to have many eruptions and vesicles.  It didn't appear flaky like dandruff but it was rough and his hands were always itchy.

 He also manifested with hepatic encepalopathy.  I reported this observation with his nurse who informed his doctor.  He was a high level patient but he needed O2 supplement prn.  The hepatic encepalopathy developed within three days wherein I noticed at first that his attention span became shorter.  That was followed by lethargy, then complete confusion and total decline in function.  He was one who was walking around the facility pushing his wheelchair and now he can barely stand up.  They did lab work and found out that his bilirubin was off the roof.  He got back to his old self after a few days of medical management.

I never got to find out what happened to him after that since I moved to a different facility.  Also, I never got to find out if he had clay-colored stool as what Goodman/Snyder said. Haha

4.)  You can survive without kidneys

One of the most interesting cases I've ever encountered is that of an extraordinary woman without kidneys.  She lost both kidneys, 10 years apart, from kidney cancer.  She is in dialysis three times a week where she stays for about 4-5 hours each time. 

I already know that a person can survive sans one kidney.  What happens is that the remaining kidney usually enlarges to almost twice its original size to compensate for the missing kidney.   Remember that the kidney is also an endocrine organ which produces the hormone erythropoeitin, which triggers the production of erythrocytes.  Without the kidneys, red blood cell production is severely limited and causes erythropoeitin-deficiency anemia.  So aside from the fact that the patient undergoes dialysis which makes him very tired already, he also suffers from anemia, the patient would most likely be able to participate in only very light activities.

Beware/ Warning:  During dialysis days, treatment time for a patient is usually reduced and the day after the dialysis, treatment time is increased mainly because of patient's activity tolerance.  A reasonable rehab director should be able to identify this.  However, there are facilities and companies which always put all patients in the ultra-high RUG level.  Ibig sabihin, the patient should and must be seen at the highest possible minutes that you can, irregardless kung me dialysis siya or what.  If you belong to a facility/company that forces you to treat a dialysis patient who appears very weak for 70-90 minutes for that day, or even forcing you to treat a patient for the entire assigned minutes who appears dying (dying na! malapit nang matigok!) make sure you develop an exit strategy from that company! When your gut feel tells you that the patient is not able to tolerate anything but you still force him to do stuff just because you are being told to do so and you know that what you are doing is unethical or simply alam mo na it's not right, you should be firm and stand your ground to justify why you are not getting his entire minutes.  Then, get out of that company as soon as you are able.  You are risking your hard earned license and your future!  That is borderline fraud, and believe me many companies do that.  I am just lucky that both my rehab directors are reasonable people.  Not all therapists are that lucky.  

On a lighter note, the patient I had (who also became a very dear friend) who lost both kidneys, is no longer able to PEE! Paano ka pa iihi eh wla ka nang kidney? Haha. She told me that the fluids get flushed through her bowels.  And we would always joke around that "she would laugh so hard she would pee herself".   And then we'd laugh again.  I just learned yesterday that that wonderful patient passed away just a month and a half ago.  I surely would miss her and her vibrant spirit. 

5.)   Depression largely goes undiagnosed with the elderly

A lot of elderly residents in my facility are diagnosed with depression.  However, I don't think that the extent of their depression are accurately determined by the psychologists and psychiatrists.  Based on my experience, depression is high among the elderly but even I cannot be certain and am certainly not the best professional to make a judgment if the resident is merely sad and homesick or has fallen into real clinical depression. 

Clinical depression is a persistent unhappiness and feeling of emptiness that affects activities of daily living for weeks or months.  Sometimes, I feel like it is so subtle you can barely notice it.  It is very important that we, as therapists, although we are not clinical specialists for depression, should be sensitive to this anyway as in the long run, we might just happen to save a life.

I personally think that undiagnosed or underdiagnosed depression may cause adult failure to thrive.  I don't perfectly comprehend what what they call "failure to thrive" is, I know that it is a reason for residents to be picked up by hospice.  But my understanding is that failure to thrive is that a person is showing signs of decline (e.g. losing weight, poor appetite, weakness etc) without apparent cause.  Lab results would be normal or very close to normal, no signs of infection whatsoever, but for no apparent reason the patient is just going downhill.  I still think that depression is closely linked with this phenomenon.  

I work in a wonderful nursing home with completely diverse staff from all over the world.  The facility is Medicaid-supported, shared by three counties and has two assisted-living buildings on its wings.  It has constantly ranked highly and has had a five-star rating for a long time.  It has consistently been included in the top 50 best nursing homes in the entire US.  There are more than 16000 nursing homes in the US and to be counted in the top 50 means that you are giving the best care there is that a nursing home can offer.  Now, if you ask if the nursing home is grand with exceptional amenities, the answer is no.  It is Medicaid-funded so you won't expect that it will have swimming pools or spas or bowling alleys.  But it does have a great kitchen staff, exceptional nursing care and all.  

Add to that, the activities department of this facility is wonderful.  They have a lot of programs and activities for the residents all the time to keep the residents entertained.  They have games, movies, pet therapy, parties, parades, trivia and many more that keeps the residents entertained and busy all day long.  Compared to my old facility whose only activity is bingo, everyday bingo, this new facility is actually way above its class.  

You would think that all of these parties, karaoke, therapy dogs that are too cute and sweet, musicians, art classes etc will keep the residents happy.  Sometimes, they do.  But there are times that these poor elderly just feel...sad.  These elderly people sometimes talk about suicide.  Suicide for God's sake! 

Question:  What do you do if a patient tells you he wants to kill himself?  First, try to empathize with the resident.  Ask him what is bothering him and how you can help.  Try to talk to the patient and comfort him.  Whether you think the patient is serious about his suicidal ideations or not, you have to let the nurse know.  Any desire of a patient to harm or kill himself is urgent, you have to let the nurse know.  Alarm the nurse.  They will assess the patient, and would do necessary measures to ensure that the patient does not harm himself.  I had one patient who told me he wanted to kill himself.  I knew he had a history of deep depression and I immediately reported it to the unit manager.  They took off everything that he might use to hang himself like belts, nurses bells and blankets and they set a 24 hour watch on him with a standby CNA.  

On one of the assisted living units though, during the early part of this year, a resident committed suicide.  She called a cab to pick her up (they are allowed in ALFs to use public transport), then she had herself dropped near a train station, walked towards the rails and leapt to her death towards an oncoming train.  If I were to guess how she felt before she decided to end her life, I would say she felt depressed.  Why else would you end your life?

Which leads me to a very important point.  You may not think of yourself as important.  But know that as a therapist, you have a close relationship with a patient.  And sometimes we take for granted that we might be the only person, the whole day, that the patient can really talk to.  Yes, nurses talk to patients and so do CNAs.  But casual talk is not real talk.  We therapists talk to our patients while we exercise them and it sometimes our silly conversations with our patients help them make it through another day in a nursing home, where they are resigned to live a mundane life until their Maker takes them.  

My friends, let me end the first part of this blog entry for now.  I hope you learned something that might be of use to you in the future.  Once again, commentaries are very appreciated.  God bless us all, God bless Filipinas!

side-by-side

side by side, we sat
    the tension there once was
        has faded like
            the sounds of our laughter

the look in our eyes is of
     nothingness

we are the strangers we
didn't know we could become

strangers, we have become
    and still we cannot tell
        the difference
          between holding hands
and
    hand-holding.

side by side, we sit

strangers
there is nothing here
      nothing
and the hand I am holding,
   the hand that remains,

is my own.

6/15/2013 3:03 pm

Visiting Lexington

It's been quite awhile from since I wrote my last entry for this blog.  Let's just say I've gotten preoccupied with pretty much a lot of useless stuff completely unrelated to fruitful living.  I've been hooked on the same computer game with a few new serious player friends I met online.  Also,  I've been trying to work out.  Yes, me, the botod, is trying to get fit.  Nope, I am not giving up pork or beer or smoking completely.  But I have started running on the treadmill and lifting weights.  So far so good.  I haven't bulked up yet and I see no guns on my arms but I noted that they are not as flabby or as lard-soft as they were before.  I have also noticed that my endurance for running on the treadmill has improved.  Whereas when I started I can only manage probably a maximum of five minutes before my thighs start burning prompting me to slow down and catch my breath, I ran for forty straight minutes without slowing down just yesterday.  That is a feat for super sedentary me.  I have lost several pounds and gained a couple back during the past weekend when I went over to Teffy's place for another whine and wine experience.

Now, Teffy is my former colleague and boss at the College of PT at St Paul University where we also both went to PT school at before becoming instructors there.  She lives about a three hour drive away from me at Lexington, VA.  Lexington is a quaint picturesque historical small town famous for its significance in the American Civil War.  This is also the burial site of the famous Civil War general Stonewall Jackson and the location of his house now turned into a museum.  I just love how this small town thrives and bustles with life, a strange blending of the old and the new, literally and figuratively speaking.  

Lexington houses two well-known universities: the VMI, Virginia Military Institute and W&L, Washington and Lee, which is a very reputable law school.  Lexington, however, is also considered a retirement community where mostly middle-aged to senior couples find solace in the peace, beauty and laid-back atmosphere of this town. I find it refreshing how the burning red energy of youth can blend in well together with the calming blue aura of wisdom in this lovely town.  True, occasionally, they would clash with mostly the elderly complaining about the college people's noise but generally, the town is peaceful as it's meant to be.  

One thing that draws me towards this town is that the school system here is doing really well and is highly ranked within the state.  If you would want to raise a family, you would want to have your kids go to a decent school and Lexington offers them such.  Teffy was trying to sell me the idea of moving over the area once my wife comes over.  I still have my reservations but yes, that place looks promising for me.  

However, unlike where I am now, that small town is less diverse than what I am used to.  I have seen only a handful of Asians there, a few Blacks and almost no Hispanics which is weird as Hispanics can be found almost everywhere.  I don't know if discrimination exists there but it would be hard to expound and build other friendships when the town is overwhelmingly white.  I don't know though, because to be honest  so far I have not experienced discrimination in the strict sense of the word, maybe because I am quite lucky to be more educated than most.  

Anyway,  I am just letting you into what I have been up to for the past couple months: starting a book I never got to finish, starting my exercise regime (holding up for almost a month now), and driving up and down Lexington twice.  I already have an idea of what my next entry would be for this blog.  The only problem is when will I ever get to writing it.  Till then, stay tuned. 

TOEFL-ibt and You... A Love Story

The bane of many therapists since its conception, this dreaded exam has broken many hearts comparable only to its equally, if not more, challenging big brother we shall nickname NPTE.  This exam is a lingering wraith on your back, a heavy shadow on your future, a dragon you need to kill to get through the first phase of your American dream.  Yes, I am talking about the TOEFL-ibt, frequently mentioned with colorful adjectives preceding it such as: P. I.ng TOEFL yan! or lintek na TOEFL yan!  The popularity, or lack thereof, of this particular exam continues to grow. More often than not, it invokes a strong sense of dread and hatred but at the same time of intimidation and respect.  For some, it has grown into a sort of urban legend, fed by the many stories of failures, to which quite a few have balked to take it.

A lot therapists do complain that the requirements for TOEFL is quite steep, most of them up in arms with the speaking cut off score of 26/30.  It doesn't matter if your other scores are good, a failing score in speaking is a failing score overall and a headache for the examinee.  Now he has to take the exam again or to risk having it rescored which can go either way.  The more painful part is that most therapists who fail TOEFL fail the speaking part by a mere point or two.  So, if you ask me, would it be better if the speaking requirement of  TOEFL be decreased to 24/30? That way everyone is happy. My answer might surprise you.  I will say no. 

Now before you bitterly spew out the words: Wow pare ang yabang naman! Feeling! Let me explain why I don't think they should lower the requirement. First of all, you want to come here to the US to work.  You do understand, though, that for every PT job given to a foreigner, like you and me, it is one less potential job for a US citizen, irregardless if they can fill that position or not.  Therefore, that foreigner has to prove that he deserves the job.  One way to prove it is having a good command of their native tongue.  Being able to communicate well in English is a must in our profession.  We will be interacting with many patients, nurses, doctors, social workers, nursing aides, etc.  Sometimes, it just isn't enough that you understand English.  It is necessary that you KNOW how to communicate in English and communicate well at that.  

As a therapist, you will have to go to care plan meetings every now and then.  A care plan meeting is a convention of the patient/family of the patient and everyone else involved in the patient's care: therapy, nursing (floor nurse, nursing aides, Medicare nurse, wound care nurse etc), dietary, activities and social workers.  At care plan meetings, the team will be discussing the patient's current status, the family's concerns if there are any, the goals, the outcomes, the discharge plans and a lot more.  It may take a long time especially if the patient has a lot of medical complexities.  However, as a therapist, you would only be able to attend for a short period of time.  During that short period of time, you have to discuss the patient's functional progress with the family and with the rest of the medical team.  The family might ask you questions and you have to be prepared to answer them.  Will my mom be able to walk again?  My dad is speaking, why does he still have speech therapy?  Would my mom always need a walker?  Will Dad be able to climb up steps to get into the house? A lot of different questions can arise during care plans and your main goal there is to get in and out as fast possible while giving clear and satisfactory answers to the family's queries.  Why the hurry?  Well you have other patients to see and care plans (if the patient is not present) is considered non-billable time which means that therapy is losing money the longer you stay there and not treat patients.  Therefore, your responses have to be straight to the point and yet should not lead to confusion.  Ergo,  you need to speak fluent English and not waste time with your "uhms" at every word.  "Uhm... Mrs Smith, uhm... would probably use the, uhm, walker to, uhm, get around the house to uhm, go to the bathroom, but, uhm... she would need somebody to...uhm...assist her".  This just doesn't cut it.  It will make you sound like you don't know what you're doing.  And yes, those who are generous with their "uhms" usually fail the speaking part of TOEFL.  Or am I wrong in that assumption?

Also, the subjective parts of TOEFL include the dreaded speaking part and the writing part.  The writing part of TOEFL can be trained for, mostly in review centers.  The speaking part errr... not so much.  They can give you all the advice in the world but at the test center, you're on your own.  Now, in review centers they would probably advice you to write in a basic format: a heading (the intro), a body and a tail, which would be a brief summary of the intro and the body.  It would really help if you train yourself to think in English rather than think in Filipino first and translate it to English.

 The need for you to think in English and transform your thoughts into sensible sentences would eventually benefit you when you are working in the rehab setting in the US.  Tandaan: Each workplace have their own productivity expectations for their therapists.  What is productivity?  Productivity is the amount of time you spend treating a patient over the total time you spend at the facility.  My company has 82% productivity expectation per therapist.  This means that at least 82% of the time you are treating patients and making money for the facility.  You have 18% of your 8 hours (if your patient load allows you) to do everything: write notes, print papers, send emails, write orders in the chart, fetch patients, take patients back etc.  That is about an hour and a half each day to do stuff not directly related to billable patient care.  Lahat yan, technically, is counted against that hour and a half: washing hands, going to the toilet, asking aides to get patients up or cleaned up, chatting with co-workers etc.  It is hard to keep up with productivity expectations especially if you have a ton of notes to write.  It certainly wouldn't help you if you would spend (read:waste) time translating your thoughts into English when writing your notes.  It is important that you know how to express your observations in a clear and concise manner when writing your notes.  You won't be able to do that when you don't have good command of English.  Hence, the need NOT to lower TOEFL requirements but rather, us, Pinoy PTs, should step up to the challenge of this test which has delayed many a therapist's American dream.  Some even gave up totally dahil hindi mapasapasa ang lintek na TOEFL na yan. So pano nga ba ipasa ang TOEFL?

How to pass TOEFL ibt:

I'm sure you all have received a lot of advice from fellow PTs and from review centers on how to pass the exam.  Probably, the few tips that I might share may not even influence your opinion on how to approach the test.  But I'll try anyway, who knows I might be able to help someone out here.  

I took my TOEFL-ibt test five years ago and passed it on my first try.  I hope I don't sound like a douchebag but I got a really high score.  I don't mean to brag but I got a score of 117/120.  I got 30 for reading, 29 for listening, 28 for speaking and 30 for writing.  Now, before you make the assumption na ako'y nagmamayabang, let me explain this first.  All of us were given extraordinary gifts by the Lord, some are talented musicians, others mathematicians, others are gifted athletes, others are gifted with charisma, others with beauty etc.  I was gifted with the gift of linguistics, I have a knack for language, meaning I always have excelled in English class, literature class, Pilipino class, anything that has anything to do with words, writing, vocabulary, pronunciation and language itself.  Although I believe in humility as a virtue, I also strongly believe that failure to acknowledge the Lord's gift by shying away from compliments like saying "Hindi, chamba lang yan" or "Sinuwerte lang" is in a way a form of rejection of His love.  But that's just me, I don't want to impose my beliefs on anyone at all.  

Anyway, let me give you some unsolicited advice on how to improve your TOEFL scores.  First, start reading real reading materials in English.  This does not include beauty magazines, Harry Potter books or Shades of Grey.  Instead read opinion sections of newspapers, essays by Patricia Evangelista, Fr Joaquin Bernas or Conrado de Quiros, books by Jessica Zafra or National Artist Nick Joaquin.  Read something that will enrich you while improving your vocabulary.  Your vocabulary will grow without you having to try very hard when you constantly bombard yourself with these kinds of reading materials.  Difficult words, when encountered in sentences often, will eventually reveal their meaning to you.  You don't have to look  up  the dictionary all the time, sometimes just by how they are used in sentences you get their meanings.  By following this advice, you have hit two birds with one stone: you'll have better reading comprehension while improving your vocabulary to use in your writing.  

Second, with listening, there is nothing much really I can do to help you with this part.  No one can train you in how to understand what you hear.  So probably the best thing to do is to take down important notes while listening to the conversation.  Remember: I said take down important notes not everything they said.  Some people rush to scribble everything said that they eventually don't understand what the conversation was all about.  By doing that, they won't be able to answer the questions for the speaking part of TOEFL.

Finally, the speaking part.  Here is the advice no one has told you before:  SPEAK YOUR LOUDEST during the speaking part.  Speak loud short of screaming.  I did that when I took my test.  I didn't care that there were other people beside me taking the test.  I didn't care that they can hear my answer.  I didn't care if I intimidated them or I sounded stupid to them.  I didn't care if I am distracting them.  All I know is that I just wanted that even if the Internet connection is not perfect or the recording machine is f*ked up, the person on the other end will still HEAR me.  So I spoke as loud as I could without shouting.  That way my answers were clear.  Of course, I had my uhms and of course, I was nervous, but the hell with all of that.  I need to pass this exam and I don't care what the other test takers would think of me afterwards.  So there you go: this is one good secret for the speaking part.  

As I conclude this rather lengthy blog entry, let me remind you that the TOEFL exam, does not and will never define you as a therapist.  Just because I passed my test on the first try and you passed yours on your seventh, doesn't mean I am a better therapist than you.  Physical therapy is a profession, a culture, a passion, a devotion and a calling.  It rises waaay above an objectified and potentially flawed language test called TOEFL.  So treat TOEFL like it should always have been, a worthy opponent but a roadblock not worthy enough to stop you from success and your American dream. 

Dyud and the Zombie Apocalypse

Just when the world has gotten pretty much over with the 80's and 90's alien invasion as the would be cause of humanity's demise, the new millennium ushered in speculations that zombies would eventually overtake the world.  The new zombies are still flesh-eaters and are seen overrunning cities and metropolises in their slow never ending limp to eat human flesh, blood trickling down their half-opened mouths, uttering guttural sounds. Blockbuster movies like Zombieland and I Am Legend, and widely popular series The Walking Dead and even social activities like Zombie Runs have highlighted the world's fascination for the dead who don't want to stay dead.

In deep thought, yours truly had an epiphany.  If, God forbid, we indeed would have a zombie apocalypse in the future, distant or near, yours truly would not be the crusading hero, (in ascending volume) blowing zombie heads off, scouring and eventually finding the remaining survivors of the human race ready to make one last stand for the sake of the future of the human race and of the world. Whew! Like, yeah right, like that is soooo gonna happen.

The epiphany I had was the complete opposite.  I realized I will not be able to survive the zombie apocalypse.  In fact, knowing me, I would be the first to be converted to a zombie.  Now how did I reach that conclusion?  Here, let me show you a picture:

 

That is me, about three weeks ago, in Pennsylvania.  That is me, posing, like the poser that I am, pretending that I know how to ski.  I sucked at it.  I even took group classes for beginners so that I could at least get to learn how to do basic skiing.  And yes, I sucked so bad at it, the instructor eventually gave up on me. (For the record, though, the instructor wasn't even remotely good. He just showed us once and expected us to do it right the first time and moved on to the next task).  Anyhow, my balance was bad and I spent all the precious little energy that my poor deconditioned body can muster getting up from the snow cause I fell...again...and again. What broke my heart though, was not merely that I was falling every time, unable to  maintain even just a little bit of stability, and ski peacefully in the soft almost flat out horizontal beginner's slope.  It was the fact that each time I struggle to get up, there are a couple three or four year old kids running circles around me in the skis or snowboards, making it look so easy for them but not for me.  You have to fight the urge to whisper: Your parents don't love you, you are adopted just so they feel as bad as you do.  It shakes your belief that all men were truly created equal.  And yes, there goes your dignity.  So there I was, defeated and cold, waiting for my friends to finish up so we can go home.  

During the summer, we went to my roommate's friends lake house in North Carolina.  The owners of the lake house are the the most humble secret millionaires I have known (errr well I don't really know a whole lot to begin with).  Anyhow, they own a speed boat, a couple jet-skies, a couple kayaks for water sports.  Of course, the amazing muah decided to try wakeboarding for a change.  My roommate went first and did it seemingly without any difficulty.  I tried it next and viola! Before I knew it I was struggling with life and death, gurgling lake water and using up whatever questionable amount of energy I had splashing around to get back into the boat.  That, despite having a life vest on me.  In fact, I was so weak, the boat had to circle down several times so they can get me from the water.  Ah, the shame.  

My weak body and my weak spirit, ultimately, will be my undoing.  I can never be a soldier or a warrior.  I can barely do ten decent push ups, can barely run a mile without stopping to breathe and walk.  And I am not even fat fat. I can't tie ropes very well, can't fix a car, know nothing about electronics, know nothing about computers except the addresses of free porn sites.  I can never survive on my own, in the wild.  I can never be a warrior, a fighter, a soldier.  Hell, I don't think I can defend myself if my life defended on it. 

What I do think though is I would have made a good propagandist in wartime.  I would be one of those instigators, rallying the crowd to the cause and slipping back into the shadows as chaos ensues.  I have always known how to inspire and to provoke.  I would never, ever want to be in the frontline.  I revel in shrewd, calculated cowardice.  For me that is an art form.  I learned in psychiatry class that I am passive-aggressive and I will probably play that part come the zombie apocalypse.  

I won't be able to run far, so chances are 1.) I would be eaten first or 2.) I will hide.  I would probably be the last to pack up provisions and when people would start the exodus to go away and hide, my dissenting opinion would be to hide where I am, praying desperately that the zombies don't get me.  Hide in the shadows and wait for the opportune time to escape or the perfect time to be eaten and converted.  

If I turn zombie, I would probably be a picky eater.  Like I won't eat the hairy ones, the fat ones and definitely not the ugly ones, especially the fugly ones.  And I would probably prefer to eat a vital organ, heart, liver or brain.  Intestines would be out of the menu, same for hair and sex organs, ewww.  Oh and if I turn zombie, I probably won't do the zombie walk: slow, lumbering eternal steps.  Lazy as I would ever be,  I would be one to drag my leg on the floor, or hide in fresh loam and stick my hand up like this: 

That is probably how I would get my prey assuming anyone even dares to come near it.  At the end of the day, it doesn't matter if I survive the zombie apocalypse or not.  I found a wonderful meme to summarize everything I have bitterly typed here today:  

 

Have a great zombielific day ahead! 

Cultural Competency: A Therapist Trying to Understand America

This is a crash course in cultural competency from a wanna-be know-it-all trying-hard physical therapist trying to make his mark in the world.  Now, whatever I am gonna say would purely be based on my observation and may not entirely reflect the truth.  While it is impossible to paint a complete picture of what is America and what makes America America, especially one who is not really into the science of sociology and more into the informal art of people-watching, it does not hurt to at least try as seen through the eyes of a full-blooded Filipino. 

Let me give you a little background about myself then so you can pass judgment on my judgment.  I haven't been here very long in the US, and there are still a lot of things I am trying to get around to.  I am based in the State of Virginia, first from Chester, somewhere south of Richmond and then I moved up to the northern part of VA near Washington, D.C. when my former facility decided to go in-house.  My experience is limited to skilled nursing and long-term care rehabilitation, at least for now.  I am now working in a wonderful nursing home with a racially diverse staff and residents.  In the rehab department (speech, OT and PT), we have four Indians, two Filipinos, three Caucasians and one Hispanic. Interesting to note, too, that the four Indians have different religions: Islam, Hinduism, Sikhism and Roman Catholicism.  In the entire nursing home, we have a healthy mix of races from Asians to Africans to Latinos to Middle Easterns to Europeans for the staff.  The cultural diversity in this facility opens up your mind more to different cultures and beliefs that encourage acceptance and tolerance. I hope that what I will be sharing will give you a little bit of insight about the most culturally-diverse country in the world.  

Hablo español. Americans, of course, speak English but Spanish is gaining a strong ground all over the US as Hispanics are the fastest growing minority here.  At first, when I think of Hispanic, I only think of Mexicans.  I was wrong.  I found out that everything south of the US, from Mexico all the way down to the tip of South America, they all speak Spanish.  Except for Brazil, which speaks Portuguese.  So although, speaking Spanish is not a pre-requisite, it can give you an advantage in dealing with Spanish-speaking patients.  The good thing is, as some Filipino words are the same or close to Spanish, we can understand a little bit here and there about that particular language. Also, if you affectionately address your patient as dad/father in Spanish, don't use papa as it can be mistaken for potato (also patata in Spanish).  Use papi instead.

Weather.  I found it odd at first that people talk about the weather quite frequently around here.  Initially, I thought it was just some ploy for small talk.  But, no, people take the weather seriously around here.  In the Philippines, people don't talk about the weather very much, not unless a very dangerous storm is coming.  Back home, when you wake up in the morning and see that it's bright outside, chances are it will be sunny the whole day.  If it's gloomy, it will probably rain the whole day.  It's simple as that.  Maybe now with global warming, Mother Nature can't decide very well what to do with herself, the weather gets a little unpredictable back home but I would still bet on either a sunny day or a rainy day, period. Here, it is quite different.  It may be gloomy when you wake up, sunny at around 10 am, cloudy by 3pm and thunderstormy by 5pm and back to humid by 9pm.  It matters to know what the weather is because it affects safety on the road during commutes and rush hours.  However, you can lay off blaming Pag-asa all the time about inaccuracies in its reporting.  Even here in the US, they can't predict weather patterns perfectly all the time, so give the Pag-asa guys some slack.

Umbrellas.  Since I started talking about the weather first, let me go to the next topic at hand.  People here do NOT use umbrellas unless it rains.  We, Asians, are used to carrying our folding umbrellas to combat the scorching heat of the sun and avoid getting soaked in a down pour.  Here, umbrellas are only used during rainy days.  They do not use an umbrella for shade even during the summer when temperatures can reach a hundred degrees Fahrenheit (that's about 38 degrees C). The umbrella is solely for rain and sleet.

Rice.  Americans are actually in bewilderment in how Filipinos can consume so much rice everyday.  It is not that they do not eat rice, they do, but only once in a while.  Even my Indian co-workers, themselves having rice as a staple, are amazed by how much we actually consume.  Indians don't usually eat their rice plain, like us Pinoys.  They usually have something mixed in it like some curry dish.  So they are surprised that Filipinos actually eat rice for breakfast, lunch and dinner, plain rice at that, too.  I explain to them that Filipino dishes are designed to be very flavorful, hence bland plain rice is needed to temper the strong, delicious flavors.  

Traffic.  For us living in large Asian cities, we grew up in traffic and noise with senseless beeping and honking all around us.  Eventually, we have gotten immuned to it as it becomes part of our daily lives.  Here, traffic is the pet peeve of Americans even though I noticed that they almost never have bumper-to-bumper traffic like what we have back home.  If a regular ten-minute commute turns to a twenty-minute commute due to "traffic", they go ballistic.  Also, honking is considered rude around here.  You don't honk unless it is absolutely necessary.  You could trigger road rage by using your horns inappropriately.  Having said this, as the general population here drives, a big majority of them are pretty responsible drivers.  They really do follow the traffic signs and have a good grasp of road courtesy towards other drivers.  Not unlike back home when every driver feels like he is king of the road and you have to get through traffic with jeepneys, and pedicabs, and tricycles weaving in and out of traffic the whole time.

Handsoap.  Americans pour soap into their hands first before wetting them unlike us who wet our hands first before applying soap.  I found it odd at first not to wet your hands before applying soap but this is how they do it here.  Americans are also very particular with toilet hygiene.  That may be arguably limited to toilet hygiene, not hygiene in its entirety.  They want their toilets flushed after use and people to wash their hands after using the toilet to do number one or number two.  They would be repulsed if they found out we wash our bottoms with our hand and soap and water.  You could always argue that soap and water beats tissue paper for proper cleansing purposes but it just grosses them out.  They would also be grossed out if they found out our men pee anywhere, not wash their hands, sit back on the table to continue drinking with other men sharing a single shot glass for everyone.  Yes, I know you like to "strike anywhere" just like I do but hey, in here, you don't want to pee on that tree if you don't want to be called out for indecent exposure.  

Handshake.  The American handshake is firm and not too brief nor too long.  It is firm to signify truth and sincerity.  Not too brief because that would indicate disinterest and not too long because that is errr... creepy.  Now, we are accustomed to the Filipino handshake, which is relaxed and soft.  The Filipino handshake is soft for goodness sake!  I don't think it is because we are not sincere when we shake hands with other people but rather we associate soft hands with being elite.  Those who give firm handshakes are ruffians with rough dirty hands that are associated with having menial jobs.  Giving a soft handshake with soft hands indicate that you are educated and didn't really do a lot of housework for yourself.  Alas, not here though.  So when someone introduces their name to you and reaches out for a handshake, give him/her a firm and not too brief not too long grip.

Weekend activities.  Americans work the whole week.  Yes, you might say, well I work the whole week too.  Not really.  Filipinos work AND play the whole week.  It is not uncommon to grab a beer or two with friends after work, or maybe catch a movie with your girlfriend after work, or maybe go shopping with your friends after work, or maybe just hangout.  Bottomline is, a Filipino's workday doesn't end with you just going home, unless you are a really really busy mom or dad (which even then every once in a while you get a break).  In the US, they work M-F and seldom do stuff after that.  They work for the whole week and almost always have plans for the weekend.  They would ask one another about what are their plans for the weekend or what happened during the weekend.  I don't know about you guys but personally, I don't really like to plan weekends.  I'm good with having a very busy weekend or a very lazy one.  But as everyone here, again, wants to take the pressure off from working hard during the week, I understand why they want something less drab to do during the weekend.  Just a tip, you usually have to drive to get to bars and you gotta be careful if you drink or drive around here, you get yourself into some serious legal mess.  Also, you can't get too drunk and decide to go home by foot so as not to be caught drunk driving.  That would still land you in legal trouble for public intoxication.  So if you plan on getting buzzed and wasted during the weekend, your option is to have a non-drinking friend be the designated driver or to stay at home altogether and get wasted there instead. 

Eating shrimp.  Americans cannot eat anything that has a head and a face staring back at them.  They cannot eat shrimp or squid with their heads on.  Heck, some can't even eat anything with bones on them like chicken (boneless chicken like nuggets are okay for them).  Squid, if it's too small, is not food for them, it is bait. Shrimp, they can only eat if it's headless.  Few of them will try dinuguan unless they are ignorant of what it's really made of and fewer still will brave eating the notorious balut.  On the brighter side though,  almost all Americans I know who have tasted the world-famous Philippine Adobo  have all praises for the dish.  And they mention it just out of the blue.  Like I have a patient who when she found out I was from the Philippines said: "Well, my grandson just married a woman from Philippine and oooooh that woman from Philippine is so sweet and she makes this wonderful dish..what, it's called..what, it's called...oh! adobow!"  Sometimes, I think that adobo will bring the Philippines recognition faster than our now growing economy and our wonderful beaches.

Freedom.  Americans value freedom more than anything else and that is why the American president is considered the leader of the free world.  Having said that, respecting personal space is something they all exercise here to the limit.  That means my business ain't yours and your business ain't mine.  Unless I do something illegal, you have no right to interfere with my life, my home, my backyard or whatsoever. It is inappropriate for you to give me advice unless I ask for it, tell me how to do my job unless you are my superior, tell me how to raise my children etc. Back home,  if it's someone's birthday, you do your videoke, disturbing the peace of the neighborhood, until midnight or something like that, and the neighbors seldom complain or send the police over as long as it is not too much, knowing that you will give them the same consideration if they will celebrate their birthdays with a bang like you are doing now.  Here, you have to take that ruckus down or else the police will be knocking on your door.  Though it is true that you have the right to do what you want as long as it is not criminal, your neighbors also have a right to peace and not be disturbed by the uber-energetic party animal that you want to be.  

My friends, this is all that I have for now, I'm sure as I discover their culture more I can share more with you.  I am very open to corrections and if other people would like to share their experiences and observation, I would welcome it, too.  Again, my insight is far from perfect and I tried to generalize everything.  In the end, we are all unique and not one quality can define us all.  For those of you who are not here yet, I hope this helps you understand the country you want to work in even just for a little bit.  For now I bid you all, adieu!

Coping With Medicare Changes

Some of you may have read my previous blog post and worried yourself sick over the future of PTs in the US.  Some of you are students, some are professionals on the path to achieving their US license and some are already PTs in diaspora scattered throughout the US.  Now, after reading my last blog entry, a little hope might have died on you or you may have lost a little faith in yourself and in your future as a therapist in this country.  This blog entry I am now writing, is intended to restore whatever was lost in you and make you dream big again.  

Once more, I am no expert in Medicare as well as in the many different practices of healthcare in general and physical therapy in particular.  Therefore, I would very much welcome all statements and comments from other US PTs in our community to help clarify the real goings-on in our practice.  

The thing I want all of you to engrave in all of your being is that there is a need for PTs in the US.  There is a need because the baby boomer population is getting older and they would need therapy eventually.  There is a need because PT programs here reach a staggering seven-year curriculum to get a DPT.  Education is very expensive in the US.  Unlike in the Philippines where it is considered the parents' responsibility to send their kids through university, here people work to get themselves an education.  A whole seven years to spend schooling is seven years of maintaining high grade point averages while working at least one job on the side.  Most people would have a hard time coping with such a schedule.  Thus, fewer Americans are taking up physical therapy as a career and as older American PTs go to eventual retirement, they would need replacements and even more PTs to keep up with the demand from baby boomers.  Most likely, they would hire Indian and Filipino PTs because of our good command of English and very close resemblance of our PT school programs to theirs.  

Now I did mention of Medicare going bankrupt and the Manual Medicare Review being a pain in the ass in my last entry.  It is largely out of frustration that I blurted that one out.  Though the fact remains that Medicare may run out of money if drastic reform is not undertaken to curtail unnecessary expense and fraud, I am hopeful that the reforms they will apply are reasonable and can be worked with.  The Manual Medicare Review (MMR) will eventually become more organized and efficient and will be streamlined with private insurance company procedures.  Now, private insurance companies may be stingy with the amount of treatment they would be paying for the patient (like allowing only 10 treatment days instead of the fifteen days you would request to work with a patient) and are also very demanding with paperwork, private insurance companies are efficient in their delivery of benefits.  It is like you contact them regarding a patient under their insurance policy, send them the necessary paperworks including your prognosis and expected outcomes for the patient, you would usually receive a reply from them within the next two days.  MMR, on the other hand, would take a month to process everything and send out a reply to you.  However, once the MMR system becomes more organized, delivery of services and reimbursements will be faster and more efficient.  

I would also like to clarify that the mess that MMR has gotten us into, so far has no effect on Medicare A patients.  Medicare A covers hospital care and that means PTs working in acute care rehab (hospital in-patient) and skilled nursing facilities (sub-acute care) are not affected.  MMR affects outpatient services under Medicare B which includes homehealth therapy, outpatient rehab and long-term care such as nursing facilities.  (Take note that a skilled nursing facility is different from a nursing facility. A nursing facility is basically a nursing home, a retirement home for the elderly  where the patients are usually long-term whereas a skilled nursing facility is more of sub-acute care.  Patients in SNFs are usually short-term; they are those that don't really require very close medical monitoring but are not yet healthy enough to go back home.  It is not unusual that a nursing facility may have several skilled bed units or a skilled nursing facility have some long term care residents).  The new Medicare changes will have the MMR process continued for this year, so hopefully those running the system start getting the hang of it and get things done faster.  To cap it all, life goes on easy for PTs working in SNFs and hospitals but PTs working in nursing homes, home health and outpatient facilities will have to make necessary adjustments. 

Another point I would like to stress out is that the demand for PTs continue to be really high in many parts of the US.  We probably never hear of them because almost all of our peers are concentrated on the Eastern and Western seaboards.  Almost everyone is in NY, NJ, California, Florida, Illinois, Maryland, Washington and Texas.  These become supersaturated with PTs that it seems you won't be able to find another place to work at if you move.  However, if you think about many other mid-Western states and other states without the very large metropolises, this is where PTs are needed most.  Think New Mexico, Arizona, Alabama, North Dakota, Oklahoma, South Dakota, Ohio, Oregon, Missouri, Iowa, North Carolina, Tennessee, South Carolina, Louisiana and Mississippi.  In these places where it is less flashy and more quiet, you can get the most out of your money.  I live in Northern Virginia, about thirty minutes from Washington DC, and I pay fourteen hundred for a two-bedroom apartment.  My friend in New Mexico pays five hundred for a three bedroom house with a fenced yard.  I get paid slightly higher than her but with the cost of living here, she gets a whoooole lot more for her money.  Try living in New York and your wallet would hurt more. True, you probably would have to drive at least two hours (or maybe five) to get to something exciting over there in New Mexico.  And true, Washington DC is but a half-hour drive for me.  But the fact remains: How many times do you really need to see the White House and get your picture taken before you're satisfied?  Even in a big city like New York, you won't even be able to enjoy exploring it if you are working hard five times a week.  At the end of the day, it is best to pick a place where you have a good work-life balance.  And another tip, if it is possible, don't pick a state where there are a lot of Filipinos.  You'd be free from all the drama and pataasan-ng-ihi events.  It is best to pick a state where Filipinos are afew and therefore are a much tightly-knit and closer community.  You'd thank me later. 

Finally, my friends, our best defense against evolving Medicare regulations is to hone our ability to perform a very necessary but seldom emphasized skill in the clinic: documentation.  In the Philippines, we take for granted writing notes because 1.) we directly communicate with a patient's family and his doctor regarding his progress and 2.) we copy/paste our notes for almost all our patients involved (e.g. PT Note dated today:  Pt was seen with the same management as so-and-so date.  Pt tolerated tx without untoward incidents.)  We write this PT note for all our patients sa Pinas.  This is way different how we do things here.  Our notes  are more detailed and functional progress (or regress) should be stated clearly and in a meaningful, complete but concise detail.  In order for you to be able to do that, first of all you should be keen in your observation and evaluation of your patients.  I mean, how can you write a good, accurate and scientific PT document, if you don't even know what to observe in a patient in the first place, or what questions to ask the patient in an interview or if what a patient is explaining to you may even be relevant in your note-writing?

Your clinical decision-making skill will be called upon if you want to keep a steady caseload.  It is very important to know how to screen patients who are appropriate to be picked up by physical therapy.  Take note that I used the term "appropriate" instead of "need".  Not all patients who need therapy are appropriate to be picked up by physical therapy.  It is you who make a clinical determination of that.  Remember that the appropriateness of giving skilled physical therapy services is among the factors that will ultimately determine denial or approval  of MMR.  Modesty aside, since October to early December 2012, from among the fifteen or twenty patients that I have sent out for MMR, I only had one denial.  That denial was based on technicality (wrong Medicare number or something) so that isn't my fault.  The reason for my success with the MMR process is simple: proper and complete documentation.  I am not saying my notes are perfect, but they are definitely suffice to the standards set by Medicare.

As I conclude this blog entry,  let me leave you with some advice.  1.) Don't worry about the future of PTs in the US; we have a good future here.  We are skilled professionals.  People will get old, people will have fractures, people will get sick.  There will always be a need for us.  Worry ka ng worry sa future mo hindi mo nga mapasa-pasa yang lintek na TOEFL na yan.  Focus on the present first and later on decide to cross the bridge when you get there.  2.)  Despite the rumors (or urban legend :-D ) that documentation is really hard, the truth is, it is only hard in the beginning.  Once you get the hang of it, it will just flow more easily from you. 3.)  Learn to drive.  Unless you want to live in NYC where you can get anywhere with trains, anywhere else you would need to be able to drive around.  So before you leave the Philippines, take some driving lessons (with an automatic transmission car); it will make your life way easier and acculturation way faster. 4.)  If your main goal of going to the US is just to earn money, you will never be happy here.  Better stay in the Philippines with your loved ones than come here and hate your job and situation.  To be satisfied with your lot in life as an expat PT, come here to LEARN first, and to EARN second.  Money is not the end-all and be-all of your life as a PT.  Happy New Year to all and I hope nabuhayan ng kahit konti ang mga pangarap ninyo.

P.S.  I would very much appreciate comments and additional information that you guys would like to add to paint a more complete picture of our experiences here.  Let us work hand in hand to ensure that more PTs will discover their true calling as extensions of God's healing hands. 

P.P.S  For the grammar Nazis, my apologies.  Tao lang po.