Rise to the Challenge with Difficult Clients

By Jacqueline Thrash, OTR

Having worked as an OT for 20 years, I have had the opportunity and satisfaction to see many, many clients progress. I have tried to do at least one really great thing with each client, and part of the fun of being a clinician is figuring out what that one thing might be. Not everyone has the same challenges and goals.

I especially like the difficult clients. They keep me on my toes, and the satisfaction is even sweeter when I am successful. I have a handful of patients who stick in my memory. One of them is Ray, who gave me permission to tell his story.

Ray came to our SNF rehab around May 1. He was involved in a bad car accident in early February and spent three months recovering from a fractured pelvis, a closed head injury and the removal of his spleen and one kidney. He had received rehab at another SNF in Tarzana, CA, but he didn't progress as they hoped, so he was sent to our SNF.

Ray had recently married his long-time partner, and she came every evening after work like clockwork.

When he came to us, Ray had a lot of challenges. He was bed-bound and required max assist with everything. He had a J-tube and decreased PROM in his shoulders, elbows and hands as well as his lower body. He couldn't pick up anything and couldn't turn over in bed. He exhibited many behavioral problems symptomatic of his head injury.

We were given a few weeks to see what we could do with him.

I could hear Ray shouting when I walked down the hall to his room. "Help me! Help me!" He was loud and desperate. Luckily, I have worked in neuro/head injury rehab, both at Good Samaritan in Phoenix and at Kentfield Rehab in California, so I was familiar with brain-injured clients.

When I tried to do range of motion, Ray hollered so loud it made me cringe. We tried to help him work through the pain with reassurance, deep pressure and tough love, but it sounded like we were torturing him, and I had to stop. (Plus, he yelled, "Stop, Stop!")

He knew who he was, who his wife was, and that he used to be a mechanic. He was alert, and tried to be cooperative, but the head injury left him with decreased ability to reason and understand why we were giving him "pain therapy," as he called it.

I was able to teach him to wash his face and brush his teeth, and he was able to tolerate time in a geri-chair. Because he didn't progress much, we had to give him to the restorative nurse assistant for ROM, and see if he could become more appropriate for skilled therapy. I stopped in every day to see him, touch him softly on his shoulder and see how he and his wife were doing. He was able to get up in the geri-chair every day; later I found a tilt-back wheelchair (we call it the "Cadillac") and taught the CNAs how to transfer him to it. He was able to sit up for several hours, and even started propelling the tilt-back wheelchair around the halls.

We invited Ray down to the rehab room for "activities." Whenever a client has been on our caseload, we invite him to drop in, and we give him things to do. We believe the rehab room is a place of possibility and hope—even if the client has plateaued, we want him to be encouraged by the rehab team and other clients.

Ray was agreeable to practice with the colored pegs, the clothespins, and he even wanted to be able to write. His mind started clearing up, and he was able to ask good questions and follow directions better. He wanted to work with PT on standing. We decided to let PT have a go at him, and then, after he progressed, I would pick him up again.

He was able to progress from the Cadillac to a regular wheelchair. We taught him to do "wheelchair walking"—propelling his wheelchair with his legs while seated. He would happily do laps around the building and built up his leg strength.

With PT, Ray was able to stand in the standing frame, then progressed to the parallel bars and to the walker with contact guard. He was discharged from PT back to restorative nursing, where he walked every day. Speech therapy was next, and the SLP was able to get him back to eating regular food for all his nutritional needs. Bravo!

I picked him up again, for three times a week for a month. My goals were supervised dressing, toileting, transfers to and from bed, wheelchair, commode and toilet, and supervised after set-up for making a tuna sandwich. I wanted to increase his range of motion, but wasn't sure he'd let me.

Last week was the end of my month with Ray. With my guidance and Ray's hard work, he is independent with toileting, toilet and bed transfers, independent with upper-body dressing and independent following set-up with lower-body dressing with assisted equipment (reacher, sock aid, etc). He can even tie his own shoes. He made a tuna sandwich for his wife, and still comes down for "pain therapy" on the overhead pulleys.

He is scheduled to go home on an overnight pass in the next two weeks to try it and see how it goes.

When we were doing our therapy debriefing, I asked him what he thought was the most memorable part of our work together. He said, "I liked that you kept coming to see me, and build up a rapport. When I first saw you coming back, I thought, 'oh no, pain therapy.' But you also made therapy fun." We laughed together.

With tears in my eyes, I told him that people like him are the reason I do this job—to work with challenging clients and help them become independent again. It's my joy.

Jacqueline Thrash, OTR, has nearly 20 years of clinical experience in California and Arizona, in acute care and outpatient rehab, SNF, adult day treatment, and home health. Reach her online at www.livingskillstherapy.com or by email at thrash@pinkiemae.com.