Tales of a Community Occupational Therapist

Take a moment and think of your three favourite activities. Is it cooking? A sport? Reading? Gaming? Now, imagine you wake up tomorrow and your dominant hand no longer functions. Can you still do your favourite activities? Odds are likely that you need two hands to engage in at least one, if not all, of the activities that you listed. A more important question, can you still do your necessary activities with only one hand, like getting dressed, feeding yourself, using the toilet, or showering? How do you think you would feel if you suddenly needed help with all of these activities?

A synonym for the word “activity” is occupation, and occupations are anything that occupy your time. People hear the term occupational therapist and immediately think return to work, but we help with so much more that. An injury or an illness can severely effect someone’s ability to engage in the occupations that they want and need to do to survive and enjoy life. Limitations on what you are able to do can affect your physical health, but it can also change you as a person.

If you’re lucky, over time and with hard work, maybe you can regain the strength and range of motion of your hand in order to engage in those occupations again. That’s rehabilitation. If recovery is not an option, you might have to do the occupation in a different or creative way. That’s adaptation. Maybe you need tools or devices to assist you. That’s compensation. If it is truly is not possible for you to complete the occupation yourself, an occupational therapist may request family or services to assist you. That’s coordination.

I have worked as an occupational therapist for six years. I try to explain to my patients who I am and what I am doing there and they say, “Oh! So, you’re like a physiotherapist!” While the roles of physiotherapists and occupational therapists do compliment each other and our collaboration often yields the best results, our jobs are very different. A physiotherapist will focus on strength, range of motion and balance, which are all important but it does not necessarily equate function. I firmly believe occupational therapists need to brag more about their role in the healthcare system but we are unfortunately a pretty humble group.

I have a lot of pride in my profession but I am also very proud to work in the community. When people think about the healthcare system, they usually think of hospitals and clinics. Most people are unaware that there is a huge health care team of occupational therapists, physiotherapists, nurses, social workers, respiratory therapists, speech language pathologists, care coordinators, personal support workers and doctors that work in the community and provide care in the home. The community is a completely different world.

Every healthcare professional that works in the community will tell you it is not a glamorous job. I have conducted assessments with sweat dripping down my face and back because my patient could not afford air conditioning. I have donned and doffed PPE in the parking lot in the middle of a snow storm. I have chosen to stand during my hour long visit because the home was so unclean, I was worried about bed bugs. I have chosen to leave appointments because my patient and three of his friends were doing drugs when I arrived and I didn’t feel safe. I have stepped in cat feces. I have sat in gum. I have been chased by a parrot. I have had to call 9-1-1 and do ten minutes of chest compressions on a woman who unexpectedly collapsed in front of me because there’s no yelling “code blue!” and having a whole team from down the hall run in with a crash cart. It can be uncomfortable; it can be dirty and it can be unsafe but it’s important. The importance of our role within the healthcare system has never been more evident then during this pandemic.

People were being discharged from hospital, sometimes prematurely, to avoid infection from COVID-19. People could not transition to long term care because the facilities were in outbreak. People were leaving retirement homes because the rules regarding visitors had made it feel like prison. People were choosing not to go to inpatient rehab because they were afraid. Outpatient clinics were closed because they did not have the capacity to provide care while maintaining social distancing. Everyone was stuck in the community and we were overwhelmed. Their needs were more complex than we were used to addressing and we were expected to manage with fewer visits (to reduce exposure), less equipment (companies were refusing to deliver) and less funding (the charities we depended on could not hold their fundraiser events). We somehow made it work. We helped people come home and stay home.

So why do we work in the community when there are other relatively cleaner, safer and more comfortable job options? I cannot speak for everyone, but for myself, I do it because I’m a stubborn, independent and resourceful person who likes a challenge. I like meeting people from all walks of life. Also, people say and do ridiculously hilarious things in the comfort of their own home. I am making a difference and I’ll have good stories to keep me smiling when I retire decades from now.

Occupation Enabled: Toileting

A small change can make a big difference and a few kind words can sustain an individual for a very long time.

Years ago, I received a referral for a man with dementia in his late eighties who was being taken care of by his tiny wife of the same age with her own health problems. The man used to be able to speak English as a second language but had lost the ability as his dementia progressed so most of my questions I directed at his wife and she either answered or translated when appropriate. One of the problems identified during my assessment was that he would try to go to the bathroom by himself but he could not get up from the toilet independently. I suggested a piece of equipment that gave the toilet armrests like a chair so that he could use his arms as well as his legs to push himself into standing. A fairly simple solution to a fairly simple problem.

The recommended equipment was delivered to the home for trial and the enormity of the wife’s gratitude for this simple, inexpensive piece of equipment was overwhelming. Her appreciation resulted in one of the funniest compliments I had ever received when she stated, “It is so nice that young people like you, choose to spend your life helping old people like us, instead of modeling.”

The randomness of her comment as well as her sincerity, made the burst of laughter that escaped me unstoppable. I regained control and responded, “It is so nice that you think modeling was an option for me.”

The extent of her appreciation was still confusing until I realized what had gotten lost in translation. The patient had unfortunately developed aggressive behaviours as his dementia progressed. His wife would often see him struggling with a task and she would want to help him but offering assistance would make him angry and lash out. Toileting had become a major stressor in their lives. The skin of older adults can bruise and tear very easily so I hadn’t been alarmed by the discolouration of her arms when I met her but my heart grieved for her once I fully understood the situation. Her positive attitude surprised me but she explained her husband had been a sweet, gentle man before the disease had altered his personality. My grief expanded to include both of them. The toilet equipment was a temporary solution as he would continue to decline physically and mentally but it had granted them some time and a reprieve.

I think about her hilariously sweet compliment all the time and I was feeling pretty confident for awhile…until about a month later when a different patient asked me if I was pregnant. Do I look like a model or a mom-to-be? Who knows?

Occupation Enabled: Mobility

Any healthcare professional will tell you that it is incredibly frustrating when you make clear recommendations that are ignored by the patient and then the patient seems shocked when there are consequences for their decisions.

I received a referral for an older gentleman who had broken his ankle. I had repeatedly explained his non-weightbearing status several times but I could tell from the angle of his cast that he had walked on his foot repeatedly. I am sure the marijuana smell within the apartment was not helping his retention. Sure enough, I received a notification that the patient had been admitted to hospital and he returned several weeks later with one less foot. I needed to prescribe a wheelchair.

Wheelchairs are far more complex than people anticipate. Changing the height of the wheelchair may enable someone to use their feet (or foot) for propulsion but then it may be too low for them to stand up. Changing the width of the wheelchair may accommodate their hips but make it impossible to get through the bathroom door. A manual wheelchair may be fine to use for short distances but a power wheelchair may be necessary to get to the entrance of an apartment building. We have to consider the person, the environment and what the individual will be doing in order to ensure the prescription will be functionally successful. Every piece of the puzzle must be considered.

The man’s environment was not optimal for a wheelchair. There was boxes and clutter everywhere. I explained to him that if he did not create space before my next appointment, the wheelchair would not fit in the room and he would not be able to try it. I was not surprised when the apartment appeared exactly the same upon my next visit. I went about moving the boxes myself as he needed clear pathways to get around his home and he did his best to help from his bed. While lecturing him about the importance of maintaining clear pathways, I happened to glance at the contents of one of the boxes I was moving. Do not look in other people’s boxes! The boxes were full of old 80’s porn videos. My eyes were assaulted by nakedness, mustaches and bad hair-dos. I became flustered as to where to put the boxes.

Getting to and from the bathroom for toileting and to the kitchen for meal prep are important occupations but watching porn may also be important enough to the individual to risk injuring themselves in order to access the videos. I didn’t want to put the boxes in an inconvenient place that may lead to a fall. Safety and function. Needs and wants. All has to be considered. I put it near the base of the TV.

I have moved and rearranged many pieces of furniture in the name of enabling occupation. Rugs that might trip an individual. Beds so that they are closer to the bathroom. Couches so they don’t block doorways. It doesn’t matter who they are or what decisions they have made, if they are willing to try, then I am too.

Occupation Enabled: Smoking

Enabling is our goal as occupational therapists but that word tends to have negative connotations for the majority of society. There are very rare occasions when I don’t like the occupations I help enable but if the occupation is meaningful to the client, it may not matter what I think or feel.

I, of course, draw the line at enabling my patients to egg houses, rob banks or commit other crimes.

This individual was another amputee waiting for a wheelchair who, in the meantime, was stranded on his couch in his living room. It was very apparent that he was not coping well with the sudden change in his functional status and his wife seemed tense and stressed as well. I did my best to reassure them that the situation would improve with the right equipment and time, but during the course of our conversation, it became apparent that there was suicidal ideation. I had to ask him if he had a plan for ending his life and he reassured me that his thoughts were purely passive but I continued to be worried about his mental health. The boredom and frustration of being stuck on the couch and dependent on someone else was more than understandable. I had helped patients navigate the process of getting a wheelchair, making the home accessible and returning to walking with a prosthetic many times before and could therefore picture his future as an independent, functioning and thriving amputee but he had never experienced this and clearly wasn’t confident that his world would improve.

He summarized his despair when he stated, “All I want is a cigarette on my balcony.” The sliding glass door to his balcony was right beside him but the ledge to step outside was a foot high and there was nothing to hold onto if he tried to hop over. A little bit of freedom was so close, and yet so far away.

The patient had already demonstrated that he could easily stand, pivot and sit on a different surface. I studied the massive ledge separating the balcony from the living room and upon realizing the floors were level, an idea struck me. I remembered seeing a small bench in their entryway so I grabbed it, opened the sliding door and placed the bench over top of the ledge creating a bridge. I then instructed the patient to sit at one end of the bench, slide to the other end, lift his leg over the ledge and once his foot was on the ground, stand up. His mouth gaped but in less than a minute he was standing on his balcony with his arms wide open taking a deep breath of fresh air.

I took it as a good sign that he hadn’t immediately asked for a cigarette but I reviewed how detrimental smoking would be to the healing of his surgical wound and how it could cause set backs in his rehabilitation just in case. He didn’t seem to hear as he leaned against the balcony railing and looked down on his city.

Occupation Enabled: Cuddling

At any given time, approximately 10-25% of my caseload is palliative. That means that it has been estimated that the patient has approximately six months or less to live. It can be very hard meeting a patient for the first time, knowing that you are going to watch them deteriorate. Especially when they are young.

A mother with cancer wanted to stay at home with her kids for as long as possible before eventually transferring to hospice. She had become too weak to walk up and down the stairs to her bedroom so I recommended a main floor set up. I ordered a hospital bed and explained the pros and cons of the different pressure relieving mattresses that could come with it.

“What are the weight capacities of each of these mattresses?” she asked.

I was puzzled by the question as she was clearly not at risk of damaging the equipment. The cancer had fed on her fat leaving her skin and bones which is why I had been worried about bed sores in the first place.

When she saw my frown of confusion she explained, “I want my kids to be able to cuddle in it with me.”

We did the math; we reviewed the weight capacities and we chose the best mattress for protecting her skin while letting her be close to the people she cared about.

Conclusion

I may have made my job sound simple with the stories I have chosen, but believe me, the job is not for the faint hearted. Between the inaccessible homes, client’s physical limitations, client’s lack of motivation, family’s unrealistic expectations, limited funding options, long wait times and the poor communication, something simple, more often than not, becomes a lot of work. I chose these examples and stories to emphasize the importance of the occupations themselves. You don’t realize how much your occupations define you until you cannot do them anymore. So, try to do as many enjoyable occupations as possible. Appreciate the small occupations that you do not normally think about. Try new occupations. And if you are ever seriously injured or ill, be a little comforted that there likely will be a community occupational therapist waiting for you when you get home to help you navigate your next steps.