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Therapy Dogma
436 Plays5 months ago
Josh and Miranda talk about the the critics in hand therapy and how to handle situations when others prefer to do it a different way.
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Transcript
Introduction to Hand Therapy Academy
00:00:05
Speaker
Hi, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. Let's cover a little bit of a delicate subject today. Let's go over something that we could get ourselves in a little bit of trouble with.
Dogma in Therapy: Clinical Experiences
00:00:18
Speaker
Let's talk about dogma in the therapy world.
00:00:22
Speaker
Yeah, so I think Josh and I talk about this sometimes because I think we share a lot of like clinical stories that we have with other providers or you know, we looked for each other to support when something happens. So we were talking about this as a topic and I know that everyone has probably experienced it, been on the receiving or the giving end, right? Like I think sometimes we can be a little bit nitpicky about, I don't know if I will say nitpicky, but more particular about stuff.
00:00:47
Speaker
that matters to us. So I thought we could share some of our clinical experiences and how we can handle these in maybe a different way or in a way that better serves our patients. Because at the end of the day, it's really the patient that probably is on the receiving end of it or the one that's going to have the problems associated with it, not us as therapists or the other person that was doing the recommendations.
00:01:14
Speaker
Yeah.
Complex Hand Injury Case Study
00:01:15
Speaker
So, although first my experience recently was with a wound care nurse who was doing home health with a patient. This patient had a mangling hand injury with amputation on site of the injury of small finger and index finger. Later was not salvageable and necrotic. He ended up with a large graft from his forearm.
00:01:35
Speaker
To the owner side of the hand because of that injury a lot of adipose tissue was padded heavily and the distal edge of it i mean it was proud of the base of the hand by probably an inch and a quarter i'm probably four inches in the longitudinal length so it's very bulbous and the distal end of it was black and necrotic.
00:01:55
Speaker
First time I saw him, I was the second of our therapists to see him
Simplifying Wound Care: Facing Opposition
00:01:59
Speaker
in our clinic. First time I saw him, I take off this giant elbow to fingertip curlex dressing and I'm expecting when he comes in to see this disastrous forearm and hand and I start unwrapping and there's nothing on the forearm that's wrong except zero form everywhere.
00:02:17
Speaker
even on the graft donor site that is now in the remodeling stage of healing, he has xeriform. He has xeriform on the dorsum of the hand on the radial side with no injuries. He has xeriform on the palm of the hand that has scar that is now mature and contracting but not open. And he has xeriform all over this now nearly fully macerated ulnar graft.
00:02:42
Speaker
And I said, listen, we got to change this entirely. I said, how much of the zero form do you have? Oh, I have a home health nurse. She comes in and does wound care. And so I said, let's progress this. You don't need this anymore. That may have been necessary initially, but your wound has progressed. We need to progress our protocol with this.
00:02:58
Speaker
So I did one, one by eight inch piece of zero form that was around the interface between the graft and his native skin. And it kind of traveled around Palmer, the distal aspect and back down the dorsal aspect and was plenty in one piece. And then I gauze wrapped him. I didn't use any other zero form or anything and he was moving great. He was free. I used the stretch rolled gauze, not curlic, so it wasn't as bulky.
00:03:22
Speaker
And I got a call maybe an hour and a half later because the wound care nurse had showed up to his house to do the normal wound
Resolving Conflict with Wound Care Nurse
00:03:28
Speaker
care. And I was on a three-way with the case manager, the wound care, and myself. And the wound care nurse was ticked off. She was like, why didn't you put all this stuff on him? Why did you tell him not to do this anymore? The doctor asked for wet wound dressings with zero form and all this stuff. And I said, when did the doctor ask for that? Oh, that was back at his first post-op. I said, that was four weeks ago.
00:03:49
Speaker
He's progressed. He doesn't need it on. And I listed all the services. She's like, yes. But that eschar on the distal end, she says, that needs to be softened with xeriform. I said, it's not eschar. It's necrotic. She's like, well, then she started throwing credentials at me. I said, OK, if we wanted, and I was trying to be as diplomatic as I could because I knew the case manager was on the fault. Call with us. And so it just became this trying to find a happy medium. And I said, all right, let's put xeriform on the distal end on the eschar.
00:04:19
Speaker
let's put a little bit on that scene, but he doesn't need it on all these other surfaces. Yeah. And so what was the, was the nurse happy with that resolution or?
00:04:28
Speaker
I'd say she was content. Although the next visit he came back, he was wrapped all up in zero form again.
Breaking Away from Rigid Protocols
00:04:36
Speaker
And so the dogma side of this that we're talking about, and that can be a very negative connotation, is that sometimes we all get stuck in a pathway, like a rut and saying like, these are the products I'm supposed to use. This is what the doctor asked for. I'm doing that until he says something different.
00:04:53
Speaker
But if I put him in the same dressings for four weeks between follow-up visits, I'm not letting that wound mature and progress and develop in a way that it should. I should adapt my treatment style, my wound care dressings, all of that as the patient progresses to help them advance before that next doctor's visit.
Three-Way Call and Home Health Discharge
00:05:11
Speaker
Yeah. And then now looking back since you got that phone call, would you do anything different?
00:05:17
Speaker
That's a good question. I think, like I knew going into the decision when I told the patient, wound care nurse is going to show up. She's going to put everything back on you. I said, don't let her do it. Cause look how, how wet this is. So I knew walking into this exactly what I was doing. Yeah.
00:05:32
Speaker
Yeah, I was stepping into the ring for it. I didn't expect the three-way call, but honestly, I'm okay with it because then the nurse case manager got to hear the back and forth of, you know, this decision-making process. So I don't know that I would have done anything different. Honestly, I kind of did it again when I told a follow-up therapist, just put Adaptic, no more zero form, stop putting zero form on him, hand him five packs of Adaptic, tell him to use little pieces as needed. And so we advanced him on.
00:05:58
Speaker
And then the nurse case manager discharged the home health wound care. She's like, I don't think he needs any more. He could have been doing that all by himself all along. I think that was enabling him to be passive about
Miranda's Experience with Therapy Dogma
00:06:07
Speaker
it. Yeah, that's probably true. I had a similar situation with a similar
00:06:12
Speaker
nurse in a nurse case manager, it was a patient that had his trans metacarpal amputation. So he lost his index index through small finger. And I called the nurse probably like three or four times and she never called me back. I was trying to be proactive and say, ask more of a question like, Hey, what do you think about us changing this and doing it a little bit differently than what you did? But they never got back to me and I changed it. And there were no, you know, ramifications from that. I guess I got lucky online, but
00:06:40
Speaker
My response was going to be, well, I tried to call you to talk about it, but you didn't answer. I think in these situations, I have a similar situation with a patient from the burn unit. We were having to use hand sanitizer to get the prosthetic on.
00:06:54
Speaker
there was no other way for the patient to get it on other than us changing or the prosthetist changing to like a pair, you know, like they put the parachute on to don the prosthetic. Yeah. Um, which wasn't really an option at that point in time. And the hand sanitizer was drawing out the, the burn, right? So then they were upset that, uh, you know, that I was like saying we had to put a hand sanitizer to get on.
00:07:17
Speaker
um and they're like well we don't want that and but there was really the option was spending you know however many more thousands of dollars to switch the way that we don the prosthetic and that ended up happening but i was thinking is that really worth it could we get like some a moisturizing
00:07:33
Speaker
hand sanitizer or something like that to use instead. Yeah. Yeah. And I think there are like, there's, I've had one prosthetist give a patient this like $800 little squeeze bottle of a silicone lubricant that's intended for that. But the guy's like, I don't want to use this stuff because it's ridiculously expensive. He says, I'm just using hand sanitizer. He wasn't a burn patient and had old, old mature wounds. So it wasn't a big deal. But yeah, sometimes getting,
00:08:00
Speaker
whether it's someone in a different discipline or maybe even other hand therapists you work with to say like, hey, there's other ways to work around this
Multiple Solutions in Therapy
00:08:08
Speaker
issue. We like to say in hand therapy academy, there's lots of right answers to the same question sometimes. So lots of, usually clinically, not anatomy necessarily, but lots of ways to solve a problem that can all be good options.
00:08:20
Speaker
Yeah. And I think communication is key, right? Like a lot of times we don't know what they're going to be unhappy about, right? I think, you know, we've learned over the years, what things might set certain providers off. So we kind of know those things, but also just communicating with them. And I always try to phrase when I'm not fully agreeing with what the plan of care is, I try to call the physician and identify what I think the problem might be, and then ask them for suggestions as well. And then I offer mine. So it doesn't seem like I'm telling them
The Role of Communication in Therapy
00:08:47
Speaker
what to do. And they're telling me what to do. It's more of a team approach.
00:08:50
Speaker
Yeah. And maybe I should have reached out to that nurse, that wound care nurse proactively, but in the moment I figured, eh, just let's do this now. So maybe that was, maybe that would have been a more diplomatic approach for me to have taken, but yeah. Yeah. I don't know. We are who we are though, right? Yeah. Yeah.
00:09:06
Speaker
Yeah. All right. Well, I'm sure you've experienced something like that. Maybe you are on the receiving end, maybe on the giving end of some of that therapy dogma that we were talking about. So if you have those kinds of things, definitely share them below in the comments, reach out to us. If you have any questions, our social media handles hand therapy academy or our email info at hand therapy academy.com. Yeah. We'd love to hear about yours.