Doubling Down on Non-Surgical Conservative Care

In recent years I have gone out of my way to educate clients, colleagues, and others on the success of non-operative, conservative care for a variety of conditions. The #GetPT1st campaign has been a big motivator for me and is a great resource for PTs wanting to educate those around them on the potential to avoid surgery for a variety of conditions through PT. In my own clinical practice, in a ski town, I have become somewhat obsessed with the idea that the majority of clients with ACL tears should be put through a mandatory 6 week waiting period before electing surgery. Here, the tendency is for skiers to elect immediate surgical reconstruction for their ACL-deficient knees. The thought is “surgery will add stability and decrease the likelihood of premature arthritis,” “skiing is different than other sports, you need an ACL,” and “our population is just different here, everyone is extremely active.” I have been fighting these misconceptions for a couple years now, but change is slow – some of my PT colleagues still don’t buy that there is a percentage of people who can live an active, fruitful, physically elite life without an ACL (if you guys are reading this, I will get you eventually… you’ll see). I think the idea of the active non-surgical ACL is gaining some traction – if not yet with the medical community in town, at least more patients are starting to self-select a waiting period before surgery. Just to be clear, evidence tells us that there is a significant percentage of the population that can return to full function without an ACL – this percentage includes division I athletes and downhill skiers. Studies have specifically been done on ACL deficient elite athletes, there is a significant percentage who return to sport without an ACL – in fact, for those with a well informed sports medicine team, the non-surgical option can be a quicker way back to competition. Repairing your ACL does not decrease your chance of early arthritis – the life of a knee without arthritis following ACL reconstruction is about 15 years according to the literature. So there. People just don’t want to be patient and do 6 weeks of strengthening for a less than 50% shot at avoiding surgery – hey, if that’s the choice they want to make, I don’t really blame them…. But I feel strongly that they should be accurately informed.

We’ve had a couple injuries in the Spencer household lately and we’ve had to choose conservative care over surgical intervention.

Here I am pressing my thumb into the counter to keep it extended while I work to re-tape the splint for support. The morning ritual takes longer than you’d think and has evolved to my using 10 separate pieces of tape each time.

I had an unfortunate water polo accident (said no one else ever). Goofing around between actual play, I had a shot blocked and my thumb went tip first into a swatting palm. I immediately knew something wasn’t right – I instinctively grabbed my thumb. There wasn’t much pain at all, but I had heard a small pop and my thumb would no longer actively extend – I could easily push it straight with the other hand, but could not hold it there without assistance. I don’t do a lot of hand therapy (I’m spoiled by having some great hand therapists around me), but I knew enough to know immediately that some sort of tendon no longer existed. The next day, I got bootleg-assessments from one of our talented OTs and a trusted Orthopaedic Surgeon next door – the good doctor diagnosed mallet thumb. Mallet thumb? “Yes, it’s mallet finger but in your thumb,” he said frankly. This is not common. The extensor pollicis longus tendon is broad, thick, and fibrous – it doesn’t usually rip. Because it’s relatively rare, there’s not a whole lot of research on mallet thumb – but I did find some case studies. It seems I could surgically have a pin put down the length of my thumb bones for 8 weeks and have a return of most of my thumb extension pretty much guaranteed …or… I could wear a splint on my thumb for 8 weeks – no bending the thumb, ever. I can take the splint off to clean the thumb with the tip pressed against a counter-top for extension, but if the thumb bends, the 8 weeks starts over. Most people do well with the conservative treatment, but full return is not as guaranteed as with surgery. I figure with a small army of OTs, PTs, and Orthopaedists at my disposal, I should do well – we’ll find out in about 3 more weeks. The idea with both the surgical and conservative treatments is that the tendon will scar down to the bone wherever it is – hopefully it scars down somewhere useful. I’m just happy that I’m able to keep working, and, more importantly, continue skiing.

But my little thumb injury has been put to shame by Kate who went out and tore her ACL. I need to pause here and quickly explain that Kate is pregnant and we are excited to be adding a baby girl to our gypsy caravan in April! So, needless to say, many exciting changes ahead. I’ll do a separate blog soon about how this will affect our traveling life – for now, let’s stick to the current topic.

Kate had been skiing cautiously and picking her ski-days judiciously. She was simply coming to meet me for breakfast on the mountain and for one ski run. She was skiing on a wide open run 5 minutes after the mountain opened when she was clipped by another skier. The fall wasn’t bad, but it was enough to tear Kate’s ACL (no other injuries to momma or baby). After struggling through our planned breakfast, we called ski patrol, and Kate got a ride down the mountain.

What we have here is a situation where we have no choice, Kate won’t be having surgery (at least not until after the baby is born) – we must try our luck at conservative management of Kate’s knee. Although, I did receive a call at work this week from another pregnant woman in town who had torn her ACL. She had tried skiing on it again already, but “it didn’t feel right” so she stopped. Her OB, suggested that she should have the ACL repaired soon, so she would avoid crutches while super-pregnant or while caring for a tiny baby. I guess it just goes to show the persistence of the myth that an ACL is absolutely necessary.

Anyways, Kate’s knee swelled up pretty big and there was some visible bruising. Kate did get an X-ray just to make sure there is no fracture. As we have progressed only a few weeks from the injury, Kate has started formal PT with one of our coworkers and she is already hiking lightly without a brace. So, she’s doing all she can do and hopefully when this summer comes, more vigorous hiking is not a problem. Perhaps next winter, she will ski comfortably without an ACL – her early success at walking without a brace seems encouraging.

Onward we both go. We’re doubling down – no surgery here unless we absolutely need it. Surgery is, and should always be, a last resort.

#Camperlife

Watching football on the camper's big screen.

Watching football on the camper’s big screen.

Kate and I had wanted to live in a camper for a while. We had this old, awesome RV in Alaska a few years back and had always talked about living in one for a full summer. When we accepted our assignments on Martha’s Vineyard this summer, we started looking at apartment rents and quickly realized living in a camper was our cheap way out.

The funny thing is, 5 months of camper living have passed and I barely even recognize that it happened. I had all these grandiose intentions of sharing all kinds of tidbits about “#CamperLife”, blogging about the great advantages of living in a camper and having some great take-away message after almost half a year living in 150 sqft. I posted less during the time living in the camper than I intended. When I did post, it was mostly pictures of campfires. Now that it’s over, I have no revelation, I have no great take-away message, I have no feeling of great accomplishment from living a minimalist life. It just feels… I don’t know, it’s like I’ve simply lived in a small apartment that I really liked.

Our main kitchen for the summer. Cooking indoors will never be the same. The kitchen sink was a garden hose.

Our main kitchen for the summer. Cooking indoors will never be the same. The kitchen sink was a garden hose.

There are a few appreciable improvements on life that are worth mentioning. I spent the vast majority of this summer outdoors. We had a great screen room and deck that was where we spent all our home time – 3 months went by where I didn’t cook a single meal inside. Meal prep happened on our outdoor stove top, grill, and fire pit. All this outdoor cooking and campfiring left me wondering about whether my carbon footprint was really improved by living in a camper. Originally I had thoughts of buying solar powered generators to be really minimalist in energy usage, but our very shaded campsite put the kibosh on that very early on. Our entire electric usage for the summer was about 750 kilowatt hours, my understanding is that for 5 months, that’s a relatively small amount of electricity. I figure with all the campfires we had, that we broke about even on our carbon production – sorry, Earth. I did find myself a little more in-tune with nature through all of our outdoors time. Most days, I could tell you the sunset time within 15 minutes, could tell you whether the moon was waning or waxing, and could describe any recent changes in the flora and fauna surrounding our campsite… so that was pretty cool.

People have been asking, “How’s living in a camper?” It’s fine, it really hasn’t been much of a change from how I like to live. It’s cool that I’ve lived minimally and mildly increased my connection with nature, after all, these are two things I have been looking to enhance in my life. So, if you’re wondering if living in a camper is for you, go for it. Hopefully you’ll have a very pleasant and unsensational experience like mine. Although, now that I think about it, maybe my blasé experience says less about the experience of living in a camper than it does about me. Maybe it didn’t affect me because I’m built for this. Me and a camper fit together so seamlessly that I barely noticed it. Let’s latch home onto the back of the car and keep moving – maybe I could be a traveler forever.

See you on the road.

Camper Life

The cold has finally broken me. I just went out to the trunk of the car, where our ski gear is stowed, opened up the bag, and grabbed my wool cap. Back inside the camper that we have been living in for almost three weeks, the oven door is open after dinner to help get whatever residual heat we can from it while the propane heater kicks on and off. When I thought of living in a camper on an island for a summer assignment, I tricked myself into thinking it was already summer in New England – just a couple more weeks and maybe it will be.

It feels like I’ve been waiting forever to write anything of substance about the camper we’re living in. I guess, in reality, we’ve only been living in this camper for less than three weeks. I’d like to wait a few more weeks to write anything so that I have some firm conclusions on what life in a camper is really like, but it’s going to be a long process of adjustment. There’s another 5 months ahead to share all the other things that come up, so why wait… this is the first installation of a series of posts on camper life that I will be putting out this summer and into the fall.

Kate and I have lived in close quarters before. On my very first travel assignment, before we were married, I had a studio in Boston that is still the smallest place I have ever seen – at less than 6 feet in width, you could not lay down on the floor cross-ways without bending your knees. The length of the room wasn’t much longer. Just a twin bed, a shelf, and a very, very small attached bathroom. Later, we would live together in far Northern Maine on a travel assignment in a small one-room cabin. I think this was the first time we became aware of “tiny-living” through some blogs like tinyhousetalk.com. The tiny living movement has really caught since then and shows about tiny living appear nightly on HGTV, DIY Network, and the like – or so I’ve heard, since we’re living without TV.

The cabin we rented in Presque Isle, Maine. Fun fact, "presque isle" means "near an island." Presque Isle, Maine is land-locked and near no islands.

The small cabin we rented in Presque Isle, Maine. Fun fact, “presque isle” means “near an island.” Presque Isle, Maine is land-locked and near no islands.

Let’s address the no TV thing. I love it, I just absolutely love not having a TV. Last summer in Hawaii was the first time we went without TV, or at least without cable. The only thing I truly missed was sports. Last summer/fall we would go out for football games or sometimes miss them if the Pats weren’t being televised. For now, since we’re in New England, we’re able to catch our precious Red Sox on the radio nightly, and if we’re out some where, it’s always on TV. Last summer, without TV, completely ruined us for our return to Colorado during winter where we rent an apartment pre-supplied with cable. At first, TV was hard to watch. Having to tolerate multiple minutes of advertisements between brief segments of the actual show was infuriating, but, with passing weeks, the time the TV was on during the day began to grow and my tolerance for ads returned. I don’t think I ever fully got back to my pre-Hawaii TV routine, which I’m proud of, but I did continue to watch far more than I needed to. I’m really glad to be back to no TV. I’m getting more done in my life, relaxing with a book more often, and the radio is usually all that’s needed for a little entertainment, although the Sox need to pick up some slack if that’s going to continue to be the preferred programming. Occasionally, once or twice a week, we’ll treat ourselves to a movie or show on Netflix – a sensible amount of mindless TV.

That assignment in Hawaii last summer plays another interesting role in getting us into the camper this year. The Hawaiian Island of Moloka’i, where we were without the TV, was a very rural and uncomplicated place with a very straight forward life. After work, there was little that “needed” to be done. Life was simplified to working, getting some exercise, and relaxing. Relaxing usually came in the forms of going to the beach, reading a book, or watching the sun sink into the Pacific ocean from a lounge chair on the driveway. I think last summer was the first time I came to truly appreciate a more simplified life, with less going on, and more relaxation – this is the first thing I most appreciate about living in a camper at a campground. We frequently have camp fires and once the day’s work is done, nights can be pretty lazy, or least I expect them to become more lazy once we have settled in and have finished more of the projects that need to be done around the camper.

For now, I’m going to leave the camper talk at that. I realize I really haven’t said much about how living in a camper is going so far, but that will develop over the next couple weeks. As far a life in a camper to this point? I’m having flashbacks to episodes of Tiny House Nation and people talking about consolidating their belongings, coming up with inventive storage solutions, becoming more conscious of their water and electric usage, and having to be more organized on a regular basis to prevent living in total squalor. That’s all you get for now, but I’ll post more soon.

Today, I’ll leave you with the first video I have ever done for this site – a tour of our camper. Enjoy!

 

At Least It Wasn’t In Boston

Hang with me. I’m amped, I motivated, I’m psyched, I’m downright manic – and I only have a short time before this feeling fades to make as much progress as I can, including pumping this blog out to you.

Actually the weather when we left Denver, but Indy was very similar upon our arrival. The weather bothered a lot of people, me too actually, but at least I was used to and prepared for it.

Actually the weather when we left Denver, but Indy was very similar upon our arrival. The weather bothered a lot of people, me too actually, but at least I was used to and prepared for it.

I just got back from CSM (APTA’s Combined Section Meeting) and I have the same feeling I always do after one of these conferences – I need to make an impact, and I need to do it now. For those of you who may not be familiar with CSM, it is a 4 day conference held annually that brings together over 10,000 PTs, PTAs, and students for some high level education. Well, education is the pre-text, I find myself more drawn to the social… excuse me, “networking” events. The reunions with old classmates, professors, colleagues, and friends are totally priceless. These people, automatically by being at the conference, are also all jacked up about PT and what we need to be doing to make it even better. So, while I indulge heavily in the social “networking opportunities,” I look forward to the conversations all year: Conversations about the research friends are engaged in, different practices in different clinics around the country, and what every individual therapist is doing to improve PT and all of healthcare in their communities and nationally. Don’t get me wrong, I found the actual, formal programming fascinating too and have several clinical-pearls to bring back to the clinic an implement immediately, but I just love getting together with everyone.

Lots of education, meetings, and receptions at CSM. Luckily many of the meetings come with ample networking and a cash bar.

Lots of education, meetings, and receptions at CSM. Luckily many of the meetings come with ample networking and a cash bar.

CSM is an ultra-boost, one of the highest forms of motivation, but not everyone can or needs to go to CSM. BUT! Everyone should do something to get a similar charge. As travelers we can exist very isolated in our individual silos unless we make a concerted effort to expand our horizons and take in some new information. There’s a certain stereotype of the traveler out there that just simply doesn’t apply to the vast majority of travelers – let’s give this stereotype a name, how about “Clint” – definitely just a random name, yeah, random. Clint is a lazy slob. Clint hasn’t had a meaningful continuing ed experience in 4 years. Clint is at work to survive the day and definitely not to excel. The thing about Clint is, I’ve never met a traveler like him. Travelers are generally insanely fascinating people who have the motivation, gall, and cajones to drop convention and get out on the road. A seasoned traveler can be dropped into a clinic on Monday and be completely indiscernible from the permanent staff by Wednesday – a true chameleon. In PT these days, autonomous is a hot word. If there’s anything more autonomous than loaning your services out for 3 months at a time to the flavor-of-the-month employer, I haven’t seen it. A traveler is truly autonomous, highly resistant to the negative influences that colleagues, bosses, and referral sources can build over time. The hyper-autonomy of the traveler’s life, moving from place to place and determining your own path, can be isolating. We must seek out education and motivation if we don’t want to end up like Clint. There are tons of great options out there: Courses offered locally during contracts, courses offered at a distance on a road trip between assignments, state meetings of your professional association, and more long-term certificate and specialization courses. We must make sure we get out there and get supremely jazzed-up by interacting with other professionals and finding out what else is happening beyond our small sample of personal experiences. There’s nothing worse than seeing a new traveler show up to a job with all the confidence in the world that they know everything there is to know. A traveler will learn over several assignments that while there are great things about the way they have been taught to treat already, there is much, MUCH more to learn. Let me be clear, mastery of treatment and skills does not come from one clinic or one model of treatment, it comes from exposure to a great expanse of different treatments and styles over years (another advantage of travel).

Sunrise in the Indy airport after the last night of CSM. As you can see, the weather did get better, it was actually pretty nice by the end of the conference.

Sunrise in the Indy airport after the last night of CSM. As you can see, the weather did get better, it was actually pretty nice by the end of the conference.

So, go find your own CSM. Whatever gets you excited about your PT, OT, or SLP career, explore it in more detail, get exposed to all the different tangents that surround it. Put yourself in groups of other therapists and talk about what you do – more importantly, listen to what others do. I’m psyched, I’ve got video gait analysis techniques to implement, new post RTC repair techniques to use, emails to send to old friends to tell them how nice it was to see them, and emails to new friends to ask them to tell me more about their projects and passions. While out exploring the country, get invigorated, don’t get isolated in your own silo, don’t justify the stereotype of Clint.

Jack of All Trades

On my very first travel assignment, almost 8 years ago, I quickly started appreciating parts of PT that I never thought I would be working in or ever need to recall from the most doodled-on pages of my college notes. But, there I was, 6 months into my career – that I had originally intended to be as a professional sports PT – and I was standing by a whirl pool doing debridement on a homeless guy. Alex, an experienced PTA with a crazy amount of passion for Physical Therapy, had recently taught me the ins-and-outs of the simple wound care we were performing and why we were doing what we were doing. On this first travel assignment, I was also baptized into the world of prosthetics. Alex taught me about shrinking the stump and different techniques for wrapping and making simple adjustments to the prosthesis itself. Alex was a neat guy who took a “non-traditional” path to being a PTA and was one of my best early mentors. Along with Alex, there was a handful of PTs with varying degrees of experience who were all willing to help me through my first travel assignment. Me, Non-Traditional PTA Alex, and a few other PTs were conquering all the issues of the good blue collar people of Lowell, Massachusetts – and were definitely not doing professional sports PT. The funny thing is, I enjoyed it. Prosthetics was a cool field. Wound care wasn’t anything I cared for, but it was different and new. I even got some early ER experience and found some excitement in the mayhem I would find every time I walked through those doors – cops, crooks, drunks, and broken parts of all kinds. I ended up spending 10 months in Lowell getting some quality mentoring and all kinds of experience in a wide spectrum of PT. This was the first place I experienced the kind of place where you treat “whatever walks in the door” (or rolls in the door), it certainly would not be the last. After a few contract extensions, I triumphantly left that assignment, nearing a year and a half of PT experience under my belt – I knew it all, nothing could surprise me now!

[Just something to listen to while you read – enjoy! About Kaunakakai, where we currently live.]

I’m somewhere around 20 travel assignments now – I’ve worked in about 30 clinics. It amazes me that I have learned something significant and useful on every single assignment. My new knowledge on each assignment comes from both the things my bosses and co-workers are doing well and the things that could be done better. Much of the time, I’m learning something positive directly from colleagues who have become specialists in their own unique mixture of whatever walks in their door. Often my education is purely experiential in working with a new population, a new culture, or in a new setting – home care, inpatient rehab, private practice, acute care, hospital outpatient, ER. There is just so much variety of what you can do with PT and how you can deliver it. At the end of every assignment I make a note of what I may have learned and confidently think, “Now I’ve seen it all, I can’t possibly see something at my next assignment that I haven’t seen before.” I’m being a little sarcastic here, but seriously, after a while, there can’t be too many surprises left… right!?

I knew on this current assignment I would have to be a true generalist and pull from many different parts of my skill-set. On this island, there’s no OTs, no SLPs, no nothing other than one other PT working at a community health center up the road. To really up the anti, there’s just absolutely no where else to find any specialists, there is open ocean between us and anybody else – referring out to someone more equipped for a particular job isn’t an option. We are essentially the only option for whatever ailment you can dream up. I took a phone call last week from a case manager in the large hospital system we are a part of. The main hub of this system is over in Honolulu, and there are many smaller community hospitals throughout the islands that are a part of this health system – although, I can’t imagine any one of these small community hospitals being any smaller or more isolated than Molokai General Hospital (MGH). Anyways, this case manager in Honolulu was wanting to send a Molokai resident back home but wanted to make sure we had both PT and OT for her referral. I explained to her that we do not have an OT here at the hospital and there are absolutely no OTs on the entire island, but that we are used to filling many roles and can handle the patient. The case-manager seemed unimpressed with a reply of, “OK. Thank you,” and hung up. After the call, I realized that in a way, I am fulfilling a very Molokai role. Nobody expects to have every resource available on Molokai, but many people fill multiple roles and help the community as best they can by wearing many hats. Many employees in the hospital have their main role, but then serve an adjunct role as the as infectious disease coordinator, or employee health director, or any other job title you can picture being a full-time position in most hospitals. A funny sidenote: I was talking with someone who was one of 3 employees of the local paper, a transplant to Molokai. She described how word got out that she was decent with computers, and people (mostly older people) started showing up with their computer issues at the newspaper office for her to help. People here don’t expect to have every amenity or service, but they help each other out however they can.

Kate and I have enough years experience behind us in enough different settings that we are able to confidently carry out the vast majority of our responsibilities. At MGH we cover inpatient, outpatient, ER, and SNF (14 beds in the hospital – 7 rooms). We are serving as hand therapists, neuro PTs, the Ortho Specialists that we actually are, and essentially work in the role of rehab specialist on every condition from the age of 1 to 100 with only modest resources. We have a surprisingly great clinic, gym, and staff, but are routinely having patients order equipment they need online – there is a local pharmacy, but it’s pretty limited in the DME department. Kate has taken on the wound care, and while I appreciate having learned some about wound care in the ol’ days with Alex, I’ll pass, thank you. My learning experience on this assignment was revealed to me early on when I realized all the additional roles I would be filling:

Social worker – Kate and I both worked our butts off last week to get 2 SNF patients discharged. We called family members, called outside services, and essentially fully arranged and negotiated these patients’ discharges. Kate even went to her patient’s house to help her transfer out of her car and into her home. Not what you would call billable hours, but good work that achieved great results.We are also a part of a team that is charged with delivering a decision on whether or not to admit SNF patients. The list of variables to consider is huge, since to even get here as a SNF patient, you are typically flying commercial on a puddle jumper. Also, you have to be thinking discharge ahead of admission – there’s no home therapy services, there’s no long-term nursing home, there’s no assisted living. If a person can’t ride a commercial flight with a nurse or be expected to discharge home – they shouldn’t be admitted in the first place.

There are no surgeons. When someone cannot or will not go off island for an Orthopaedic or other surgical consult, we are the next best thing. The PCPs, many of whom we have gotten to know well in a short time, are quick to refer anybody with an ache, pain, or movement dysfunction to us for more specific diagnosis and treatment. We are determining weight bearing status for acute fractures, managing follow-up appointments, and suggesting when someone might need additional imaging. It’s a unique experience to be working with a patient that you know should have surgery, but that off-island surgery is just not a realistic option in his world. I could write another entire blog about performing PT in reality – treating within people’s financial limits, having realistic/sustainable goals for patients, knowing when someone has reached their own individual ceiling of health. When a guy shows up needing a metal plate in his ankle, but that metal plate is a plane ride away that he’s not going to take, that’s when some real-world PT is needed and when we need to decide what the best conservative treatment option is for the patient.

I do feel well equipped for this assignment that requires a wide range of skills and a certain depth of knowledge. I would not recommend this assignment for anyone without a few years experience across a few settings. It’s nice to be in an environment where we get to use a full range of our skills as PTs. Most of the time PTs will work in a setting that sees only a very small slice of the full scope of practice. Sports and ortho is still my bread-and-butter, but I have gained a lot of skills and knowledge in other areas over the years. When I am back in Colorado in the winters, I work for a hospital that practices orthopaedics at a very high level. The patients with various sprains, strains, and fractures are handed down from a team of Orthopods and ER docs that absolutely nail their diagnoses. It’s a nice luxury, but to be honest, my diagnostic skills atrophy severely in the winter from disuse. As I’m bending and straightening joints all day, patients ask , “You had to go to school for 7 years for this?” I defensively explain how making their knee bend is only a very small part of what I learned in school and that PTs are trained across a large variety of diseases and dysfunctions. But, back here, I’m using every last bit of those diagnostic skills and every ounce of my education across a very broad spectrum of pathologies. The health community here may not have specialists or surgeons, but to be as comprehensive as possible, everyone else must work their role to its limits. It’s fun, challenging at times, and definitely a new learning experience.

Friends in Places

Recently, I’ve done really well at getting a blog out to you almost every other week (::sound of me patting myself on back::). The winters in Colorado are just too much damn fun to be sitting around writing on my silly website. That leaves the 7 months when ski lifts are closed to be productive and get some marginally decent writing done. The past several weeks, this blog has been quiet…. A clear sign I’ve been having too much fun outside of ski season.

Our first glimpses of Waikiki on our puddle jumper over from Molokai. In the group of tall building by the shore (Waikiki), the building we living in during 2010 is the furthest to the left.

Our first glimpses of Waikiki on our puddle jumper over from Molokai. The building we lived in during 2010 is center of the picture, but the furthest to the left and small in the group of tall buildings near the shore.

It all started when we moved to Molokai 4 weeks ago. After one weekend on Molokai, Kate and I could see the lights of Waikiki calling from across 26 miles of open ocean. 4 years ago, we had a 6 month home care assignment over there and lived in an apartment 3 blocks from Waikiki Beach. The job on that assignment was one of the worst travel assignments I have ever had. A quick review of my blogs over recent months and years will reveal several passing mentions of that job and my rehab-oblivious boss. But, the combination of my Craigslist-surfboard and the 5 minute walk to the waves of Waikiki made the assignment easily bearable. Early on in the assignment we made friends with a few other travel PTs. We spent all of our non-work hours kayaking to small offshore islands, hiking, singing karaoke, and eating at a delicious underground sushi bar. It was pretty awesome. Over a few months, we added one friend’s significant other and some new travelers joined the group. We reached peak form in month 5 and had – as the kids say, “a frickin’ blast.” Somewhere along the line, we discovered Honolulu’s best deal ever: a catamaran called the Na Hoku II – they would let you on for a local’s price of $25 and sail for 2 hours around the shores off Waikiki, with a free open bar. Our Saturday habit quickly became beach/surf, then booze cruise on the Na Hoku II, then sushi, then if still upright we would sing karaoke (and eat more sushi). Every week was a countdown to Saturday. We got to know the characters on our weekly routine – to start the afternoon, Captain Crash would drive the boat out of harbor while playing The Booty Song, to end the night at karaoke, an old local man named Uncle Ron would sing Smoke Gets in Your Eyes. During the hours between The Booty Song and Smoke Gets in Your Eyes, we would have a blast. That was the summer of 2010, We. Had. So. Much. Fun!

Diamond Head keeps a watchful eye over Waikiki. As seen from the blurry eye of the Na Hoku II.

Diamond Head keeps a watchful eye over Waikiki. As seen from the blurry eye of the Na Hoku II.

3 weeks ago, we somehow got the whole group back together in Waikiki. I can’t think of another group of friends that could all get back together in one place without somebody missing. Traveling PTs from the summer of 2010 came from the Pacific Northwest, Texas, Molokai, and Waikiki to be together for 48 hours of AWESOME. We hit all the old haunts: we had our afternoon on the Na Hoku II (minus Captain Crash) and made it to late night sushi/karaoke – complete with Uncle Ron still singing Smoke Gets In Your Eyes. We started mornings with killer brunches and finished our nights sharing memories of our old times together. Kate and I eventually made it back to our 9-seat puddle jumper headed back to Molokai for work on Monday morning.

We only had a short time back on Molokai, because just ten days later we had a trip planned to Colorado for a really great friend’s wedding. I grew up with the groom as my best bud. Eventually, when he and another close friend said they were moving to Aspen, Kate and I said, “We’re coming too!” The wedding in Breckinridge was beautiful. The weather was perfect. The foliage was at its peak for the 10,000 ft ceremony. But, that is NOT what I found myself talking about during my return to work earlier this week. Because of my friendship with the groom during our move cross country together, we shared many friends throughout different phases of life. At the wedding, I saw friends from growing up in the suburbs of Boston and also from my new, seasonal life in Colorado. Kate and I got to swing by our winter-time job to catch up with some fantastic friends, and had a bonus night out on town. We bumped into people we didn’t expect, but were happy to see them and had… a frickin’ blast. Having fun with a bunch of friends is what I remembered and was sharing with patients at work this week. What a great time with old and new friends! I apologize in advance for the abundance of ski videos the HoboHealth Facebook page will be posting this fall as a result of my one weekend in Colorado.

We got the band back together. Here's the whole 2010 group together enjoying a brunch in 2014. A great time.

We got the band back together. Here’s the whole 2010 group together enjoying a brunch in 2014. A great time.

So, what’s the point? This post is not long excuse for why I haven’t written in a few weeks. Sure, I’ve had fun this month and haven’t been able to write as often, but this post is meant as an example of the life I’ve chosen to live as a traveler. I sometimes think of the sacrifices I make to enjoy the places I get to live. It turns out that some of those sacrifices are made up in my own head and I’m getting the best of both worlds.

I sometimes get an uneasy feeling when I go back to hangout with friends from the “good-old-days.” I inevitably come to meet the NEW friend who is a neighbor of my friends, or a coworker, or a CrossFit gym-mate, or whatever. I guess the feeling I get is jealousy, but there’s also a feeling that I’m missing something by being away traveling; that me and this new guy could be really good pals if I were around more often. But, it’s really fun times like the last few weeks that I realize I’m not missing out. I’m off building relationships that are just as strong. These relationships are built on the traveling experience and only exist because of the Na Hoku II, knowing who Uncle Ron is, powder days in Colorado, and dozens of fun things between. Someday, I’ll get my chance to make a lifelong friend across the picket fence (or at least in the next RV parking spot over). For now I feel really good traveling and I’m having a really good time making great friends in unconventional places. I hope on this assignment that I’ll meet some good people who I can stay in touch with.

I’ll try to write more often. After all, it’s not going to get any easier to write with all the fun with friends coming this winter.

Travel safe!   …but not too safe… what’s the fun in that? 🙂

Enter Island

A hike in the Haleakala National Park on Maui. Insanely beautiful bamboo forests.

A hike in the Haleakala National Park on Maui. Insanely beautiful bamboo forests.

As I write this, the sun has recently set and I’m sitting in the house Kate and I rented today. Our landlord will soon return to Seattle, but for now, he’s our quazi-roommate staying in the separate studio attached to the house. He’ll be finishing up a few house work tasks before eventually returning to Seattle. Nice guy, interesting guy. Apparently he’s a lawyer by trade, but has spent some time working in Denali National Park. At some point, he bought this house out here on the most remote of the publicly accessible Hawaiian Islands and clearly enjoys all the great nature activities here. He has two large lockers of camping and snorkeling gear in the garage collecting dust that he has encouraged us to use, so that’s a real bonus with this short-term rental. There’s also a mountain bike thrown into the deal that he spent part of yesterday afternoon fixing-up, JACKPOT! I’m sure we’ll get some more stories out of him before this is all over. Before getting on island here yesterday morning, we spent 5 days hiking, camping, and relaxing on Maui. My visits to Maui in the past have always been short, usually over a long-weekend from Honolulu, and usually packed with as much activity on as much of the island as possible. This time around, we concentrated the trip on two main areas of the island with a few days at each place, and we were really able to soak it in and relax. In coming from the Big Island, Maui was actually an increase in pace. More cars, more traffic, more busy, more tourists – my disdain for tourists is really quite impressive considering my living the vast majority of each year as a tourist in various tourist towns. I fear for my reintroduction to the mainland in 3 months – if Maui’s pace is too fast for me, I can only imagine the shock a city or metropolitan airport would bring.

Man, I hate tourists. We camped wright by the beach, it was really peaceful in the morning and evening hours.

Man, I hate tourists. We camped right by the beach, it was really peaceful in the morning and evening hours.

I’ve grown used to the small 9-seater planes we have been taking between islands. This trip to Maui was the 4th time flying by small plane in the last several months. To sweeten the deal on Mokulele Airlines, legs between islands are $50 flat rate and free from TSA searches and waiting in a line of any kind. It’s definitely flying with all the airport hassle removed. Yesterday, however, we did not fly, we took a ferry boat over to Molokai from Maui early in the morning. We rushed off to look at the house and then were able to quickly and truly settle back into relaxation-mode. Maui is slower paced than Oahu, the Big Island is slower than Maui, and Molokai is the slowest by far. The past 36 hours here have already been an experience. Afternoons have been filled with empty beaches and sleepy, small-town diners and bars. The land here is dramatic and beautiful. This afternoon, we took a walk up a small dirt path from the beach we were on. We knew the dusty red path would lead us to some secluded beaches down the shoreline that are inaccessible by car. During a short walk down the path, we saw wild turkeys and a bunch of deer. The deer here are cool to see, but are not-native and highly damaging to the vegetation. The damage to vegetation ultimately leads to a whole other chain of erosion events and has big negative affect on water quality and sea-life. Luckily, these deer are tasty, so local hunters are able to put a significant dent in their population. Our beach-stroll turned nature-walk got really interesting when it opened up to an abandoned beach formerly occupied by a resort company that used to run this part of the island. As Kate and I strolled down the beach looking at the decaying buildings set a ways back from the water, incredible views in every direction, and crystal clear water breaking over shallow jet-black lava rocks, we somehow both failed to see the 500 lbs monk seal sleeping in the sun that we were literally about to trip over (when I say “literally,” I mean it). Kate was about 3 feet from the huge monk seal and his partner when in an instant we and the seals all realized the others were there. The huge seals rolled over and Kate and I did a super-speed reflexive sprint about 10 yards up the beach. I’m not sure about the true ferociousness of a monk seal, but I know they can move faster than you’d think and can pack a wallop with their teeth or tusks or whatever it is they have. As we cautiously circled to the other side of the seals at a distance, we watched the seals, they watched us, and it seemed like everyone understood that all four parties involved were equally surprised. There’s only about 1,100 of this species left, and here we are just running into two of them on a day at the beach… crazy. We continued a short distance down the beach and saw some fish and an eel swimming in a tide pool – nearby, there was a “lahge lobstah” shell dried out on the beach. This beach, departed only a short distance from humans was just totally saturated with life. Kate and I had been in the sun long enough, and headed back to the car. As we passed the seals, the huge one let out a bark at us, I think just to see how fast we could move again.

Taken as we approached Molokai on the Molokai Princess Ferry. A dramatic island.

Taken as we approached Molokai on the Molokai Princess Ferry. A dramatic island.

I can’t believe we haven’t been here two days yet. We’ve experienced a lot in our short time here. It will be a wild 13 weeks for sure. Work starts tomorrow morning! But for now the night is pretty quiet except for the roosters I can hear clucking around the neighborhood. More updates and pictures to come soon – I can’t believe I didn’t bring a camera on that walk today. Oh well, next time.

The Downside

I have written many uncompleted drafts of this post over the years. For about 4 years, it sat uncompleted in my drafts folder titled “Trouble in Paradise.” I deleted everything I had written and started over – like a waste bin full of crumpled papers by a typewriter. I have a hard time expressing the cons of traveling PT because I do really enjoy it and can’t even seriously consider how different my life would be working the last decade in one place, doing the 9 to 5 grind. Uhg, the thought disgusts me. 🙂

But here it is, my attempt at talking frankly about the downside to travel PT. I’d also like to hear from other travelers about what they think the downside is. Here we go, back to rainbows and unicorns next week.

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There’s not much to gripe about with traveling physical therapy. After almost 8 years of travel, I’m beginning to think that the nightmare-assignment barely exists. In about 20 assignments, there is only one I’ve had to terminate the contract on early. If I had asked the right questions during the interview, I don’t know that I ever would have worked that assignment. Over time, I realized my boss was a unlicensed foreign chiropractor. I also realized that I was a PT giving massages, not a PT doing PT. After a couple agonizing weeks and all of the full-time staff quit, I managed to get that contract terminated. From that experience, I believe two things about bad assignments: 1. Awful assignments are pretty rare; 2. If you perform your due diligence in researching your assignments, you can easily avoid disaster;

Therapists that repeatedly finds themselves in difficult situations or putting out fires with their bosses needs to take a deep look internally and know their roll. As a traveler, you are frequently not treated as a full team-member; you are a temp filling a spot and may be a bit of an outsider from the other staff.  Even with facilities that are very welcoming, you may find yourself the work-horse while other overworked staff gets their long-needed rests. If you eventually accept more permanent employment from a facility, then, your role may change, but until that time, do not tell your boss how you think the facility could improve. I did this on assignment back in 2010 at a home care company – I was told, “We welcome your feedback, we want to know what could be done better.” Even if you are begged for feedback, you are a temp, do not tell your boss how the facility could improve. I have learned this lesson, don’t repeat my mistakes. The last day of that assignment came with one of the most unfriendly goodbyes I have ever experienced. That home care company has since closed their doors. OK, so maybe 2 assignments out of 20 didn’t go as smoothly as they could have for me. That’s a 90% success rate, I still believe really bad assignments are a rarity.

The only thing in travel PT that gets me riled up on a regular basis is the licensure juggling act. I think I have ranted about licensure in the past. After a period of time, Kate and I had let all our unused licenses lapse. We found ourselves in a jam last spring and started re-upping many of our licenses. We decided at that time that we would maintain all our current licenses as long as we traveled, because it’s too much of a pain to renew a license you have let expire. That strategy went to junk last week.

All Alaska PT licenses expired on June 30th. Can you imagine what this month is like in the Alaska licensure office!? Holy Cow, just hope you don’t have to contact them to get anything done in the next couple weeks. Anyways, Kate and I set into filling out the paperwork for licensure renewal which included a 20 question juris prudence exam heavily focused on the new continuing education regulations – also, you had to write down the statute number that contained the answer to each question. Over the last two years, I’ve attended several multi-day national meetings to discuss PT issues and practices, but this is not considered continuing education by Alaska. So, I set off on the internet to find a cheap courses that would provide the CEU’s I needed. Two hours into this process, we had the applications in the envelope (no email or faxing allowed), $240 checks written each for renewal, and I was about to order a lousy $300 online course for my CEU’s when we finally decided to pull the plug on staying licensed in Alaska. Kate and I may renew in the future, but the prospect of shelling out $800 to keep a license we might not use seems a bit ridiculous. I did end up ordering a much higher quality, online course from APTA that I’ve been wanting to take, so the 2 hours spent not-renewing wasn’t a total loss.

The licensure process stinks, it’s an antiquated process that bears no real function in the modern world, other than to satisfy the outdated rule books. I will soon write ANOTHER letter to FSBPT expressing my displeasure, but in the meantime, I just take it as the way things have to be done to continue traveling.

Licensure is the thing that bothers me most about traveling, but it’s a relatively small inconvenience. I think people’s primary fear about traveling is getting stuck in a nightmare assignment. As I’ve expressed, the really bad assignments are rare. If you find yourself in a bad assignment it will only last 13 weeks, and it will probably take you half of the 13 weeks to even realize you have accepted a bad assignment.  If it’s exceptionally bad, there are ways out, and a good staffing agency will have your back. Other than what I’ve already talked about, there is very little downside traveling physical therapy. The frequent moving can get a little old at times, but that process streamlines itself with practice. Who am I kidding, packing and cleaning will always be the worst – just awful.

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Stay tuned, lots of excitement happening in the initial stages of searching for an autumn assignment. I’ll keep you posted. And please do share your gripes about traveling PT… a one time chance. I will not write another negative blog for a long time.

Home is Where

“Where do you live?” It’s a simple question that is likely to be asked at the start of a conversation with any stranger. It’s a question that is easy for most people and that the asker expects a quick answer to.

For any traveling healthcare worker who has been at this for a while, it’s a loaded question. My mind races over a series of responses, “I have an apartment in Maine, but I’m rarely ever there.” “Well, the IRS says I live in…” “I live part of the year in Colorado and keep going back there.” I usually settle on the most simple response, secretly hoping the conversation will change topics, “I live here right now, but I move a lot for work.”

But, NO! They can’t drop the inquisition, it always continues on, “You move a lot? Well where’s your home base? Where are you from? When are you going to settle down? What does your wife do?”

I, again, try to keep the answer simple. Again, hoping the conversation can move along from this complicated topic, “Well my wife is a therapist too, so we move from contract-to-contract together. We’re both from New England, but we’ve been doing this a while now, so we have some fairly scattered roots at this point.” Meanwhile, I’m thinking, “This poor guy was expecting an easy answer. There isn’t one.” Traveling PTs don’t fit most people’s pre-determined mold of what a life, home,and job should look like.

There’s a whole host of issues, social and logistical, that complicate the home question both extrinsically and intrinsically. First is the IRS, travelers live by their rules and we do the best we can to try to maintain a life that fits their rules. Unfortunately, certain states have laws that complicate the picture by having loose standards for what a fulltime resident is and taxing people based on that status. I’m looking at you, Maine! I am certain that there is a traveler out there somewhere who has the perfectly wrong combination of living situations and who is taxed as a permanent resident by multiple states.

Don’t get me going on the system for forwarding mail by the post office. OK, do get me going. Every 3 to 6 months I head to the USPS website and submit my change of address forms. To their credit, the post office usually gets me my mail, but sometimes that mail makes a few stops along the way to reach me. I have attended weddings and received the invitation afterwards. Gad zooks!

The years since starting travel have started to really add up for me. I used to be able to intuitively know how many years ago I was in Hawaii, or how many winters I had spent in Colorado. When I showed up back here 3 weeks ago, I went around telling people it was either my 4th or 5th year coming back, I wasn’t really sure… WRONG! After some counting by figuring out what years I was in which apartment, I have come to the realization that this is winter number 6 (out of the last 7) that I am living out here in Colorado. How can we tell people where we live if we don’t even know!?

On the return, Saturday, 3 weeks ago, Kate and I quickly moved into the same employee apartment building that we have lived 3 years prior. On Sunday, we drove 1.5 hours to the local Costco and stopped by our storage area on the way back. It turns out that in our storage area, with all of our skis, 7 pairs between the two of us, was a ton of stuff that we have accumulated. Kitchen supplies, wedding pictures, snow tires for the car I sold this year, a painting I picked out of the trash at work 4 years ago, a bag of clothes to take to the local consignment store, beer brewing kit, computer printer, and our beloved 18 inch Christmas tree. I hesitate to say we keep a lot of junk here, because most of it has a purpose, but we do have a lot of “stuff” here. By Monday morning at 10, we had our ski passes and we were on the mountain where, by chance, we ran into a group of friends and skied with them all day. On Tuesday, Kate and I returned to work where we were greeted with hugs, a one-hour orientation, and quickly slipped into a seamless afternoon full of patients. Yeah, this is familiar, good friends, the old apartment, great job, and all my… “stuff.” Since the first year here, unlike many other places I’ve lived, people are willing to quickly include me in the small group they call “locals.” It’s tempting to call this “home” or to at least be less committal and admit that I live here, because I do have an established life here.

Back on the ski lift, a familiar conversation ensues, “Where do you live?”

“Here.” “… in the winter. This is my 6th season.”

The quick response, “Where do you go the rest of the time?”

Here we go again. Why doesn’t this conversation get any easier? 🙂

I used the word “inquisition” above, so this video seems pertinent. Until next time, travel safe!