January 27, 2016

Saved by the 80% Rule

Ironing aprons after the Spring Sale at my church reminded me of a pleasant childhood memory.  Remember when your mom taught you to iron by having you iron handkerchiefs?  This was a simple task I did successfully the very first time.  I had forgotten how soothing it is to iron flat fabric that does not have darts or gathered curves that accommodate breasts and shoulders.  However, it is easier to get every wrinkle out of a dish towel than a canvas apron.  This got me to thinking about the 80% rule.  These aprons do not have to be ironed perfectly.  They are going in to be stacked in a box until next year and will come out a little wrinkled anyway. 

Business managers use the 80% rule to keep down costs.  Some tasks that are 80% correct will not affect the bottom line while others have to be closer to perfect.  For example, when I walk I need to be very close to vertical.  The rule says you need to think about striving for perfection because the last 20% takes nearly as many resources as the first 80%.  Business managers are paid to decide when a company should spend the extra resources to approach perfection.  I wish I had known about the 80% rule when I was married.  When my husband did not smooth out the bedspread perfectly I would have known that this is an acceptable business practice. 

I do not know where I got the idea that ALL work has to be done perfectly ALL the time.  I used to be a perfectionist, but now I think perfection should be a conscious decision rather than a habit.  When I am tired I don't pull the stroke card.  I live alone so I cannot cop out when I am an exhausted caregiver.  I use the 80% rule.

January 13, 2016

Toilet Training is a Disaster

When I was in a rehab hospital I learned how toileting training is done.  OTs evaluate how clients get on and off the toilet, but NOT how clients handle clothing in the bathroom. Aides are the ones who deal with dressing and undressing during toileting.  Unfortunately aides have large caseloads so they get everyone to therapy on time by doing everything for their clients.  Stroke survivors need training to be safe when toileting.

One challenge is handling clothing.  It took me three weeks for my standing balance to improve enough for me to feel safe when I pulled my pants up over my hemiplegic (paralyzed) hip.  I had to twist my trunk to let my sound reach the front and back of my hemiplegic hip.  Small weight shifts while rotating my trunk were enough to throw me off balance.  When my skin was damp after a shower or a vigorous therapy session it took repeated tries to get my pants all the way up.

Toileting is also a balance challenge because it requires repeated turning in small spaces while  attention is divided.  When I went home I learned that managing a cane, the door, and the toilet interfers with my ability to monitor if I am vertical.  After I walk into the bathroom I have to turn 180 degrees to close the door.  I want privacy when I use bathrooms in the community (e.g. doctor's office, friend's house, restaurant).  I am facing the door I just closed so I have to turn 180 degrees to walk to the toilet.  When I get to the toilet I have to turn 180 degrees so I can sit down.  I turn again after I stand up to flush the toilet.  The last 10 seconds of this video shows why I do not want to be sitting when I flush the toilet.

PTs walk clients in large unobstructed paths in the gym where clients are required to think only about controlling their body.  OTs know about divided attention, but they do not evaluate gait or standing balance in the bathroom because ambulation is PT's domain.  Requiring 24 hour assistance with toileting often leads to a nursing home.  This is a severe consequence.  Different disciplines need to stop worrying about stepping on each others toes.  Therapists need to stop worrying about embarrassing clients by asking them to uncover a private area of the body.

January 1, 2016

The FAST Campaign Is Not Working

The American Stroke Association (ASA) and National Stroke Association (NSA) publicize their FAST campaign to get people who are having a stroke to the emergency room quickly.  FAST stands for Face (sagging on one side), Arm (weakness in one arm), Speech (impaired), and Time lost is brain lost.  However, these are warning signs for strokes that affect the front of the brain.

The ASA estimates that 25% of strokes cut off the blood supply to the back of the brain that produces different symptoms.  One type of stroke that affects the back of the brain is a lacunar stroke.  A lacunar stroke is caused by cholesterol clogging small blood vessels in the brainstem which connects the brain to the spinal cord.  A second type of stroke that affects the back of the brain is stenosis of the vertebral artery.  This artery runs up the inside of the neck vertebrae and sends blood to the brainstem.  Stenosis narrows the vertebral artery which permanently restricts the amount of blood going to the brainstem.  Loss of blood flow to the brainstem can damage the bridge to the cerebellum (pons) which controls balance and coordination.

The scary part about poor balance and coordination is that medical personnel ignore them as signs of a stroke.  I immediately went to the emergency room with a sudden onset of impaired balance but a neurologist was not called for two hours.  Two years later I again had a second sudden onset of poor balance.  A neurologist said this was probably caused by an ear infection.  He finally agreed that I had another stroke when I told him I lost the ability to distinguish between hot and cold in my hemiplegic leg and acquired double vision that was confirmed by an optometrist.

Both stroke associations should promote the Five Sudden, Severe Symptoms outlined by the stroke program at Cedars-Sinai Medical Center in Los Angeles.  The five symptoms are:
1) sudden severe dizziness, loss of balance, difficulty walking, or incoordination, 2) sudden trouble seeing on one side, 3) sudden severe headache with no known cause, 4) sudden numbness or weakness of the face, arm, or leg on one side of the body, and 5) sudden confusion, trouble speaking, or trouble understanding.  What makes these warning signs of a stroke is that they are sudden or severe or both.  ASA and NSA need to step up and serve the entire stroke community.