A More Humanistic Lens

A few weeks ago, you purchased a digital single lens reflex (dSLR) camera for the first time. You were excited about all the pictures you were going to take – they were going to be way better than those pics you were taking with your cell phone.

Of course, there was a bit of a learning curve with all the buttons, settings, and adjustments, but after exercising your Google-fu and practicing a bit on your own, you learned quite a bit in a relatively short time and you are a bit proud of yourself. You aren’t a master photographer quite yet, but you have quickly learned that there is a relationship between a camera’s:

  • focal length: the ‘35’ in a 35mm camera; the larger the number, the greater the zoom, and the greater the distance between the image sensor (‘film’) and the aperture
  • aperture: a measure of how big the hole in the lens is, the hole allows light to pass into the camera. Measured in a fraction of the focal length (e.g. f/3.5), the larger the aperture number, the smaller the hole that the light passes through
  • shutter speed: the amount of time the camera lens allows light to enter the camera, usually measured in fractions of a second
  • ‘film speed’: perhaps you remember going to the store to pick up 200 ISO or 400 ISO film for everyday use, before the advent of digital photography…the larger the number, the more light sensitive the film (the values are standardized by the International Standards Organisation, thus ISO)
Fig 1. The cat in the foreground is overexposed.

Fig 1. The cat in the foreground is overexposed.

You have been tinkering with the dSLR for a few weeks now, and you have a pretty good feel for things. You have come to realize that there is an ideal amount of light that needs to strike the image sensor (virtual ‘film’) to create a good picture. If too much light strikes the sensor, the picture will be over-exposed and will appear too bright (Fig 1). If too little light strikes the sensor, the picture will be under-exposed and will appear too dark (Fig 2). You now appreciate that the lighting in your environment dictates the ISO you choose (200-400 for daylight, 1000+ for low light conditions – but be careful, the more sensitive the ISO, the worse the noise). You realize that if your subject is moving, you need a faster shutter speed so that the picture isn’t blurred. You understand that a faster shutter results in less light hitting the sensor, so (in that instance) you would need to compensate by increasing the aperture size (ironically adjusting the value smaller, because it is the denominator of a fraction, whose value you wish to increase).

Fig 2. The building is underexposed.

Fig 2. The building is underexposed.

Now imagine for a moment that you just purchased a new lens for your dSLR camera. The lens that you received with the camera (often referred to as your ‘kit lens’) quickly proved to be inadequate (you think) and you needed to upgrade so that you could take pictures with more flexibility than was afforded you by the simple 18-55mm f/3.5-5.6 lens you have been using. Some folks will go to a reasonably priced prime lens as their first lens purchase, but many (like yourself) decide to go with a bigger ‘zoom’, so they obtain what is termed a ‘telephoto lens’. In this instance, you have selected a lens that should work in most instances under typical lighting conditions: an 18-300mm f/3.5-5.6 lens.

If you are not a photographer, perhaps it would instead be easier (at this point) to imagine that you have just graduated from PT school and you realize all too quickly that – while you are now licensed to practice – your skills seem inadequate; you are not helping as many people as you may like, so you elect to go to a continuing education course. The course is designed to hone in on a certain aspect of your care and improve your expertise in that specific area. In doing so, you are improving your ability to ‘zoom in’ on a subject/patient. In other words, you have the basic know-how to operate the camera, but increasing from 55mm of available focal length to 300mm feels like completing the first 4 courses of a certification program – only (for $800 USD) the lens is considerably cheaper and is likely to bring you greater pleasure.

In many instances, though, while the telephoto lens helps you take pictures of things in the distance (i.e. birds or your kid playing a soccer game), you will quickly discover that the telephoto lens has limited utility. The farther you zoom in, the darker the picture becomes – the mechanics of the lens dictate that the aperture can move no larger than f/5.6. To compensate, you need to increase the ISO, which adds more noise to the picture. You could avoid adding noise by reducing your shutter speed, but now there is likely going to be increased motion blur in your picture. And then there is the issue with perspective…

What about perspective?

If you take a picture from the same angle each time, how can the perspective possibly change if it is taken with one focal length versus another?

Compressed

Fig 3. Compressed Skyscrapers

Firstly, the picture taken with a telephoto lens will appear compressed or flattened. Look, for instance, at Figure 3, a photograph of skyscrapers which appear as though they have been built atop one another when photographed with a 300mm focal length. It is a neat effect in the photo, but the loss of depth is undeniable and often undesirable.

Secondly, the background of the subject photographed with a 300mm focal length from a distance is narrow; it is physically incapable of capturing the surrounding environment (see Fig 4).

Meanwhile, if you wish to photograph a subject in their environment, capturing context, you need to use a smaller focal length. You need to move closer to the subject, much closer. With a shorter focal length, the larger (f/3.5) aperture is now available so more light can come through the lens. With more light available, you can adjust down the ISO, reducing the noise in your picture as well. The closer you get to your subject (with your wide-angled, 18mm focal length), the brighter and clearer your picture can become and the greater your field of view.

Fig 4. The left photo on the left is taken with a telephoto lens from a distance, the photo on the right was taken with a wide angle lens from close up

Fig 4. The photo on the left is taken with a telephoto lens from a greater distance, the photo on the right was taken with a wide angle lens from close up

Of course, then you realize that your kit lens could shoot at 18mm too. Sure, every once in awhile, you may find a use for the 200mm or 300mm focal lengths, but (for the most part) you could have saved $800 and mastered the kit lens, instead. There are occasions when the extra focal length may be helpful, but you will not rely on it every day.

.   .   .   .

In a competitive marketplace where every continuing education purveyor is trying to get you to buy their special telephoto lens – each with its own special features – consider honing your skills with the kit lens first and foremost. The small focal length on the kit lens is what encourages you to stand closer to your patient and develop a relationship. Moving closer to your patient helps clarify the picture you are trying to capture; it reduces the noise. The different/closer perspective affords you the opportunity to see more variables that surround, stress, and influence a patient embodied in their unique environment with its particular circumstances.

Fig 5. A telephoto view of the patient

The telephoto lens encourages you to zoom in on one area, only to zoom out and back in on another. The telephoto lens directs us to look at the parts, in isolation. It is the telephoto lens that separates the biological from the psychological from the sociological. The telephoto lens has fractured and fragmented our patients. The world is filled with clinicians with 300mm lenses – far fewer have mastered 18mm.

My only question: can you be a wide-angle PT?

Fig 6. A wide-angle view of the patient

Fig 6. A wide-angle view of the patient

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Adventures In Home Care

1540 – [I close my car door and prepare to start the engine] “Huh – still on schedule.”

1537 – [as I clean my stethoscope, with disinfectant wipes] “I am sorry that I couldn’t have been more help”

1534 – [I move the stethoscope for the final, fourth time. I wait 10 seconds. I hear nothing. He isn’t moving] “If only I hadn’t had this stupid operation, I could have been out there…this would have never happened,” Mr. Crenshaw said

1531 – [She continues to gently rub his torso, his neck and his head] “Come on, little guy,” she says, “Stay with me. You’re gonna be okay.”

1530 – [5 minutes have passed. I am holding a hair dryer over the kid, trying to warm him as she continues to rub, stroke and stimulate the infant that is resting on her lap, wrapped with an electric heating pad. There has been no apparent change in his condition] “I felt him move, I think,” she says.

1524 – [I can hear it – it is faint] “He’s alive. It is very slow, less than one per second, but it is there. He is so cold. Do you have an electric blanket?”

1523 – [His wife is holding the newborn goat in her lap, trying to stroke some life into it’s limp body] “Is it alive?” Mr Crenshaw asks her. “I don’t know,” she replies. [I walk to my bag and grab my stethoscope]

1522 – [His eldest son – aged 26 years – walks in the door, holding something in a dirty towel] “Fuck, Dad. This one is still alive. The other one is dead.”

1521 – “I am just going to get your ‘John Hancock’ on a few more papers, then I will take my leave.”

1520 – “Alright…and I have written my cell phone number here [pointing to my number on a folder], so if you have any questions or concerns before I return tomorrow, please don’t hesitate to call. If I didn’t want you to call me, I wouldn’t give you my number, right?

1358 – [I knock on Mr Crenshaw’s door] “Okay – this should go smoothly. Young, few meds, an anterior approach. Piece of cake.”

0845 – “Okay, hon, I am leaving. I should be home around 3:45. I have 4 revisits on the hour in the morning, then an admission at 2:00, but it is just down the road. I’ll call you if I am going to be much later.”

So Smart

She had spent 3 weeks in short-term rehabilitation after a stroke. She was one of the lucky ones: the medics arrived to her home quickly, and she arrived at the hospital in time to receive appropriate/beneficial therapies. She now presents without noticeable residual deficits. I evaluated her yesterday, 2 days after returning home from rehab.

Gertrude and her son (who lives in the same home with her) informed me that she is walking around the home well, but she is having difficulty with moving to standing. Otherwise, she is reportedly at her baseline with regards to her mobility in the home.

“Are there any ailments, aches or pains that I should be aware of before we get started with the formal assessment?” I asked.

“Just this left ankle, sweetie. It has been bothering me since October, but there isn’t anything that they can do about it.”

“Who is ‘they’?”

“The doctors. First I went to the Dr. Jones, because I had seen him before for another problem in my other leg. He did an x-ray and it didn’t show a thing. Then he did an MRI; that didn’t show a thing. Then he referred me the ‘ankle-guy’ in the group; he thought he saw something on the first x-ray that Dr Jones missed, so he gave me an injection in my ankle. He thinks I have tendinitis.”

“Did it [the shot] help?”

“Maybe a little, but not for long.”

“Okay, I will take a look at the left ankle in a couple of minutes, but first, I would like to – and forgive me; I am usually not so forward on the first date – but could I walk with you to your bedroom?”

She chuckled and agreed. After walking approximately 10 feet (with bilateral foot drop and a rolling walker), her left lateral ankle pain was provoked (per subjective report) but there was no significant change in her gait. The pain reportedly persisted until she was able to unload the ankle, sitting at the edge of her bed. While looking around her room, I noticed that her CPAP machine was at her recliner a few feet away, not at her bedside.

“Are you sleeping in bed, or in your recliner?” I inquired.

“Since I came home a couple of days ago, I have been sleeping in the recliner, because I don’t want to have to deal with the tendinitis.”

“What position are you in when you are lying in bed?”

“On my back…but I can’t stay there for long.”

“Are you having any pain now, while you are sitting here at the edge of the bed?”

“No.”

“What if you place your hands on the back of your hips like this [I demonstrate] and lean backwards.”

[she moves into seated lumbar extension]

“It hurts a little.”

“Your back?”

“No, my ankle”

“What happens if you separate your knees and reach down, with your hands, toward your feet?”

[she reaches toward the floor, moving into seated flexion]

“It goes away.”

After 5 repeated extensions, her symptoms were significantly worsened. With a single repetition of seated lumbar flexion, her symptoms were again abolished. She raised her eyebrows and her eyes widened.

“You are so smart. How did you know it was my back? I have been to two doctors since October and just spent the last 3 weeks complaining to PTs in rehab and none of them could figure this out.”

I didn’t have the heart to tell her that I learned how to complete a lower quarter screen in my first semester of PT-school.

“Perhaps I was the first person who paid attention.”

#alwayslearningPT

Learning From Experience, Pt. 7

 

I read the above tweet when it was posted and nodded my head in agreement. 6 weeks later still, I was laying in bed ill and apathetic to my family, my patients, and myself. I just wanted to lay in bed. I didn’t want to move. I didn’t want to read. I didn’t want to write. It wasn’t that I didn’t care if I existed – I didn’t care how I existed…and this was Monday, less than 48 hours since the onset of my illness. I thought to myself:

That was Monday. Four days after beginning antibiotic treatment, I was just beginning to motivate myself to type some thoughts that I had jotted down 48 hours earlier on a grocery receipt. I had my first meal with the family only the night before. Considering how the immune system had rendered a typically motivated and devoted father/husband into a useless and listless blob, I have a new appreciation for my need to more strongly reconsider how I approach some of my patients following a hospital stay after illness.

Each therapist brings their own biases into the patient’s home. My biases include:

  • many patients don’t want me there – they oblige my evaluation only because it was a condition of their discharge from the hospital
  • patients often get better on their own
  • to over-medicalize a patient’s condition removes their locus of control
  • patients deserve respect and autonomy, not paternalism
  • other therapists who don’t appreciate items 2-4 likely overburden patients and our medical system while “helping” their patients

In my estimation, one of the challenging aspects of determining “need” of skilled services is trying to guess (someone else would say “assess”, but they are full of shit) if the patient is likely to have a spontaneous recovery from the hospital stay or if they will require home care PT to return their baseline.

Of 35 therapists on my agency’s staff, my therapy utilization is the lowest (or so I have been told). Why? Fueled by my biases, I understand that patients who are already able to get around their home safely will move around more as they feel better, so they will get stronger, so they will move around more….well, you get the idea. Traditionally, I have felt comfortable evaluating such patients for safety and independence alone, discharging them the same date. Nursing is typically involved for about 3 weeks, and they know they can re-refer me at anytime if the patient isn’t progressing as expected. Management has informed me that most therapists work with similar patients for about 2 weeks (3-4 visits) to help them out along the way.

After this entire immune-response that I have experienced I am reconsidering my assessment of patients who aren’t quite back to full strength yet after just coming home from hospitalization. How would I best assess their motivation? Every patient SAYS they want to get better – I would say the same – but I would also be content to just lay in bed too.

So how does that change my assessment? What I will NOT do is begin to see people with greater frequency arbitrarily. That would be ridiculous. What I am going to try to do, instead, is plan to arrange for a phone call with the patient 3-4 days after their evaluation, then discharge (if still appropriate) after a follow-up ‘teleconference’ (No, I am not billing a visit). In spending 5 minutes of time on the phone with the patient, we can discuss the findings of their initial visit and compare them to the abilities at the time of the call. Maybe I guessed wrong and their recovery is not as “spontaneous” as I would have otherwise anticipated, maybe not. Either way, it provides me with another opportunity to get things right.

End of an Era

Learning From Experience, Pt. 6

I was able to sleep for 4 hours on Tuesday night, which was the most rest I had received in the better part of 72 hours, ‘stuff’ was already breaking apart in my throat and my fever did not spike overnight. The antibiotics were already beginning to have their effect.

Despite feeling marginally better, I would not be taking my son to his dentist’s visit this Wednesday morning, but my wife would go in my place. I was disappointed that I couldn’t be there because he looks to me for strength during times of stress, when he would be undergoing dental work that would require nitrous and a local anesthetic, but circumstances were beyond my control and – besides – he was just as happy to have Mommy there, I am sure.

While he was in a dental chair a few miles down the road, I considered the events of the day before, including my interaction with Dr Kors, and I recalled his initial hesitancy to prescribe antibiotics, our mocking of physicians who dispense antibiotics too readily, and my improving symptoms after antibiotic administration. Then I thought of my son and I became angry.

I often lament for the lives that my children may live in the future. There are solutions to many of the problems that their generation will face, but I still find their prospects sobering as citizens of a country with increasingly polarized political parties and decreasing liberties in a world with a changing climate and 14th-century minds playing with 21st-century weapons threatening enlightened thinking throughout the world. These issues, of course, play out on our media daily, feeding the fears of the insecure and ill-informed electorate (which is ironic considering its apathy).

And while Ebola garners wave after wave of crisis and headline coverage – a far greater threat receives little to no coverage whatsoever: “We’ve Reached “The End of Antibiotics.

In this linked piece by PBS’s Frontline, Dr Arjun Srinivasan says:

These drugs are miracle drugs, these antibiotics that we have, but we haven’t taken good care of them over the 50 years that we’ve had them…We also know that we’ve greatly overused antibiotics and in overusing these antibiotics, we have set ourselves up for the scenario that we find ourselves in now, where we’re running out of antibiotics.

We are quickly running out of therapies to treat some of these infections that previously had been eminently treatable. There are bacteria that we encounter, particularly in health-care settings, that are resistant to nearly all — or, in some cases, all — the antibiotics that we have available to us, and we are thus entering an era that people have talked about for a long time.

For a long time, there have been newspaper stories and covers of magazines that talked about “The end of antibiotics, question mark?” Well, now I would say you can change the title to “The end of antibiotics, period.”

…We’re here. We’re in the post-antibiotic era.

So…by the time my children are my age, a similar infection that allowed me to be treated conservatively at home today may require hospitalization and far greater suffering for them at a later date. That is no less scary than Ebola or ISIS…but the coverage?

I suppose there is not a large-enough ‘antibiotic voting block’.

(crickets chirping)

Ritual

Learning From Experience, Pt. 5

[there was a knock outside the door]

Me: Come in.

[Dr Kors enters the exam room. It is now Tuesday morning. He puts my charting on the counter and rolls his stool in front me, sitting down to face me as I am seated comfortably in a chair. He has been my physician since 2010.]

Kors: I am sorry to have see you under these circumstances, Ronnie [the nurse who took my history and assessed my vitals] shared with me how challenging the last fews days have been for you. So, what do you think is going on?

“Well, initially I thought it was a 24-hour-thing, but it has persisted now for 3 days. Every morning I feel better with the fever at about 99-100 degrees, but by mid-day it is at 102 and every evening spikes over 103. I am shaking violently, getting little sleep and have night sweats. So, to answer your question, on Sunday I started to have concerns about leukemia – [I pause for laughter] and I appreciate you not smiling or laughing while you are in the room…you know that I know better. Besides, yesterday morning I developed a pretty significant cough that has progressively worsened. So, you would think that would dispel any notions of leukemia – but, then again, it is me.”

Any panic attacks?

“No, sir. An elevated heart rate, but that has been present since the fever started and that could be related as much to my immune response as anxiety. I did take a klonopin 2 hours before this visit, but have otherwise kept things under control. So, it is in the back of my mind – and I know better – but I know that the most reasonable thing to expect is that this is just a bitch of a virus. But how long can something go on this intensely?”

Five days or more.

“Ugh, I guess I have been lucky never to have anything like this before.”

Yes, you have been. Are you having any difficulty breathing? Any additional respiratory symptoms aside from the cough?

“No, just the cough and it all seems like it is in my upper throat.”

Any congestion?

“No, sir.”

And you told Ronnie that your fever responds well to ibuprofen?

“Indeed, 2 tabs every 4-6 keeps me comfortable…until the evenings decide to kick my ass.”

Okay, it sounds like you are probably spot on by thinking that it is viral, but let’s go through the exam.

[Dr Kors commences his exam….and later concludes it]

So…here is what I recommend; you let me know what your thoughts are. First, your lungs sound clear and your throat and ears don’t appear infected, so I don’t want to use an antibiotic that is just going to give you some other side-effect symptom to worry about a couple of days from now – besides if you were shopping for antibiotic you would have gone shopping at Urgent Care, right? [we both have a chuckle at Urgent Care’s expense]. Continue to use the ibuprofen as you are for comfort; it is working. Don’t use any cough syrups, but you can use cough drops for comfort if the coughing begins to irritate your throat. I still want to take chest x-rays because there is a chance it could be bacterial pneumonia and maybe I just can’t hear it; if so, I will call in an antibiotic to your pharmacy at that time as it would then be considered appropriate. And lastly, before you leave, we will do a quick blood draw and check your WBC to make sure that nothing too nefarious is going on – then you can sleep better at night. What do you think?

“It all sounds appropriate, but do you think the blood-work is necessary? If I had not mentioned it, would leukemia be something you would consider or are you simply appeasing me?”

If you didn’t have this cough, and your fever was high this morning, and had been for 3 days straight, I would get the blood work done. But, Keith – I think you’ve got it wrong. You call it ‘appeasing’, I call it ‘working with my patient.’ You have symptoms that indicate that blood work is appropriate, so we are going to do blood work. Tomorrow morning, you will get the results. If I am correct and this is viral, you may have symptoms for the next 2-3 days and the blood work may save you a trip to the emergency department, don’t you think?

“Well, I appreciate that, and your willingness to work with me, sir.”

And I appreciate all the care you provide to my patients. Please continue the great work. You are an asset to your company and the community…Ronnie will be back in a couple of minutes to draw your blood and I will call you this afternoon with the results of the chest x-ray, okay?

“Yes, sir. And thank you again.”

You’re welcome.

.     .     .     .

At 1530, I received a call on my cell phone from Dr Kors. “Well, Keith. I was wrong. I couldn’t hear it, but you have pneumonia. So that accounts for all of your symptoms and it is now most appropriate to consider an antibiotic….”

.     .     .     .

Ronnie called me the next morning after we exchanged stories of anxiety and fictitious maladies while she drew blood the day before. “You are fine, but you knew that already, right?

“Yes,” I replied, “but I appreciate your calling. Thank you.”

Unreasonable

Learning From Experience, Pt. 4

I woke up Sunday after only 3 hours sleep, but my fever had dropped to 99.3/37.3; the chills were gone and the pains were greatly reduced, which I was thankful for as AJ was going to celebrate a belated birthday with his friends at the bowling alley. I planned to hang out in the background, snapping some photos while watching him enjoy himself.

By the time I was snapping pictures, it was back. I didn’t need a thermometer. I could just tell – all the symptoms were the same. The aches, the sensitivities, the chills…they were all back and I excused myself early from the party.

This wasn’t like me at all – I am a ‘one-night-fever” kinda guy. I am like Tigger – I just bounce back. “What the hell? What could it be?” I asked myself.

I didn’t have a sore throat, so strep was unlikely.

I didn’t have a cough or any difficulty breathing, so a respiratory ailment seemed unlikely.

Granted, my appetite was reduced, but I didn’t have any nausea/vomiting or diarrhea, so the flu seemed unlikely (and it should be – I received my vaccination)

I didn’t have neck pain, so meningitis is no where near the top of the list.

It is November, so I ruled out EEE and West Nile.

I did have night sweats the night before…maybe leukemia?

Yep – the chink in my armor of reason this week was going to be leukemia. I went to the medicine cabinet, just to check…yep! I had some clonazepam just in case. Next? I started to consider likelihoods and my lack of other symptoms – no fatigue, no muscle pains, no weight loss. But maybe this was the first sign? “No, you smeg-head, it is just a virus – lay your ass in bed for a while. Put on some more Red Dwarf.