Jumping back into the “Students in the Field” series, today we have Katelyn sharing about her experiences in the pediatric ICU, particularly with cardiac patients. This interview is so interesting, and Katelyn really dives deep into the highs and lows of pediatric acute care. Working in heavily medically-based settings can be so emotionally charged from every end of the emotional spectrum. I’m so happy that Katelyn shared about her unique experiences here with me and you all! I hope you enjoy this interview!
Hi there, my name is Katelyn and I currently am an OTD student who just completed level 2 fieldwork and will be preparing to start my capstone project next semester prior to graduation and studying for the NBCOT. I am from Baton Rouge, Louisiana and hope to work in pediatrics, acute care in particular. I am particularly interested in neonatal therapy, cardiac rehabilitation and neuro-based therapy
What setting are you sharing about today and can you give a brief description of it? What qualifies a person to receive therapy in this setting?
I am sharing about acute care, particularly ICU (intensive care unit), pediatrics in which I just completed my second Level II fieldwork experience. I was placed in a cardiology rotation where I mostly treated in the cardiac ICU at a children’s hospital. We treated children admitted for a variety of cardiac diagnoses and my age range was 1 day old to 17 years old.
Children are referred for receiving therapy in this setting based on provider discretion, although, the majority of admitted children on these floors are referred due to potential for developmental skill delays secondary to prolonged hospitalizations or post-surgical functional activity within sternal precautions.
What is OT’s role in this setting?
OT’s role in this setting varies depending on the diagnosis and prognosis of the child. A few primary roles include assisting children to maintain or increase functional activity tolerance through play or functional mobility, positioning and developmental support for infants and toddlers, as well as caregiver education. Specifically, children who are in heart failure are engaged in functional activity to maintain function while waiting on palliative care surgeries or transplants. Additionally, children who are of age to participate in ADLs are assisted with learning how to complete them safely following cardiac procedures that require sternal precautions.
Did you feel prepared going into this setting based off of your classes? And how did you prepare before starting?
Yes, I did feel prepared to create patient-centered treatment sessions for the pediatric population based off of classes. My CI sent me resources prior to my arrival to familiarize myself with the increased amounts of lines and tubes present in the cardiac ICU setting, along with additional evidence-based literature findings on cardiac rehabilitation in the pediatric setting. Additionally, I did some preparation with reviewing pediatric developmental milestones and general pediatric coursework (Pediatrics I and II). Lastly, I reviewed pediatric assessments including the Peabody, HELP, AIMS, and IPAT that could be helpful in this setting.
What resources were the most helpful during your time there?
Tools to Grow
Pinterest (general search for specific ideas around holidays or interests of the child), also linked is my board for OT activities that I am always adding to.
The HELP resources were incredibly helpful as well as the AIMS with pediatric developmental
milestones and progression.
CDC Normal Development Checklists
How did you stay organized and manage your time in this setting?
Acute care is very fluid and the schedule changes frequently throughout the day. I utilized a storage clipboard and brought it with me on the floors during treatments. I kept a reference sheet for milestones and lab values handy. I would schedule my patients daily upon arriving to the hospital and coordinate with PT and SLP to make sure we all had appropriate times to attempt patients. I would bring toys or equipment for my session if I knew the patient had to remain in their room or would plan treatment sessions in the hospital’s therapy gym.
Frequently, patients would not be available due to procedures, medical status or parents holding and would have to reassess to find other patients on our caseload to see based on their established frequency per week. I would also document as able during the day to assure I would manage my time as needed to be able to leave on time and complete documentation within 24 hours as required by our facility.
(this clipboard is helpful because it includes lab values which are very important to be aware of in ICU setting, especially cardiac)
What was your schedule like?
I would arrive between 7:15 and 7:30 AM daily, organize who I was planning to see that day based on census and frequency, as well as chart review to see who would be unavailable due to procedures or operations, as well as who was pending discharge. I would then coordinate with PT and SLP to make sure I would attempt patients at times that worked with everyone’s schedule.
I would typically treat on the floors from 9AM-12PM. We would have lunch and documentation time until around 1:15PM, then treat again until 3 or 3:15PM. I would then document as much as possible until 4PM. Occasionally, we would have meetings during lunch or attend rounds with providers at various times during the day that were previously scheduled. This was our schedule Monday through Friday.
What assessments did you use most?
What conditions/diagnoses did you see most often?
I was assigned to the cardiac floors of the hospital so typical patients were infants with congenital heart defects awaiting surgery or post-operative, children 3-17 years old post-surgery or awaiting transplant, or children with congenital defects who are ill from other ailments who are being monitored on the cardiac floors.
Cardiac conditions most frequently seen: HLHS (hypoplastic left heart syndrome), DORV (double ventricles), coarctation of aorta, congenital anomalies, genetic anomalies, TAPVR, VSD/ASD repairs, VAD/BiVAD/LVAD patients, etc.
The majority of patients have increased lines and tubes including but not limited to ETT (endotracheal tube), tracheostomy, chest tubes, PICC lines, G-Tubes, NG tubes/ND tubes, PIVs, and often increased O2 support.
What did a typical session look like?
Sessions often fell into one of three categories:
- Remaining in-room: these patients were critical or had too many lines/tubes to coordinate with nursing to leave the room; these sessions often looked like bed mobility, functional activity tolerance via play in bed or on a playmat, ADL’s (dressing, grooming, teeth brushing, toileting), positioning/handling for infants, tolerating touch for infants, parent education for how to engage with patients when in critical conditions.
- Remaining on-unit: patients were critical but we could assemble enough people to assist with coordinating lines/tubes to walk or wheel around the unit for functional mobility tolerance; often would walk with patients for scavenger hunts in hallways or engage in other play while ambulating to increase tolerance following surgery.
- Able to transport to gym/other areas: these patients were stable enough that providers felt comfortable allowing to leave the floor; depending what medications/lines/tubes the patient had sometimes the RN for the patient would have to accompany us to the gym; these sessions looked more like an inpatient rehabilitation setting would with various toys and equipment at our disposal for treatment areas like bilateral coordination, visual perception, functional mobility/tolerance via gross motor and fine motor coordination, transfers, developmental skills/milestones.
How did you stay client-centered and occupation-based?
During each evaluation, I would inquire with the patient or patient’s family about interests of the patient to engage in during our sessions. I would attempt as often as able to bring toys or activities the patient would be motivated to participate in. There were significant limitations from lines/tubes and critical nature of some patient’s medical status that warranted increased creativity and out-of-box thinking to allow patients to safely engage in occupation-based activity, which for children is often play. Especially for my patients that were admitted long-term, allowing them to increase their independence in terms of ADLs was very important for
them and their families to find a sense of normalcy. Providing activities that allowed patients to engage with the greatest levels of independence was often priority for our treatment sessions. In a similar mindset, allowing children to engage in play and find a sense of control there is often incredibly beneficial when they lack most control in such a heightened medical setting. This time to play and engage in developmentally- appropriate skills was often very joy-filled and meaningful for them.
Did you have to do a project or in-service? Could you share what topic you chose?
I completed a research project and poster presentation via data collection to assess hospital-acquired torticollis development and progression utilizing the Infant Positioning Assessment Tool (IPAT) with my clinical instructor:
Key Words: iatrogenic injury, hospital-acquired torticollis, developmentally supportive positioning
Key Points: Hospitalized infants placed in a prolonged, asymmetrical, or minimally supportive position are at increased risk of developing hospital-acquired torticollis and subsequent developmental delays. This risk increases when lines, tubes, mechanical circulatory support, or use of sedation/paralytics is present. Long-term consequences may include developmental delays and limitations in age-appropriate activities as torticollis impacts multiple functional body systems.
Miles, C. (March, 2020). Torticollis and plagiocephaly: Assessment and treatment of infants and children. Houston, TX
What was your favorite part of this fieldwork experience?
My favorite part of this fieldwork rotation was being privileged to encounter families during a traumatic time in their lives and engage in occupation, particularly play, to recover following surgery or find some sense of normalcy during a prolonged hospitalization. It was incredibly meaningful to be invited into such a difficult time of families lives and create relationships with them, especially being able to encourage them and champion them during growth or setbacks. It was very special to assist patients with their first time walking or participating in play following surgery.
I have a passion for infant and neonatal care so I particularly enjoyed all my cardiac infant patients and their families. Of note, it was very meaningful for families to learn how to engage with their child or learn how to transfer them independently, assist them with self-regulation and soothing, or participate in skin-to-skin. These were very special moments with parents as they learned how to engage with their infants appropriately, often for the first time due to prolonged hospitalizations.
What was your least favorite part of this fieldwork experience?
Being that this was a highly medical setting and in the cardiac floors specifically, patients frequently were palliative in nature due to having congenital abnormalities. Having difficult conversations with families concerning patient’s ability to engage in functional or occupational tasks was something I did not expect to engage in and something I feel was not talked about prior to starting/being placed here. In particular, I lost a few patients during my rotation following tenuous procedures or who did not receive a transplant in time. This was particularly difficult and emotionally draining as I had formed great rapport and relationships with these families over time.
Having to have a conversation with a mother whose son is entering comfort care (in-hospital hospice-like services, withdrawing care) about discontinuing therapy services was one of the more difficult moments I have experienced as a future OT and one I will remember for the rest of my career.
Simply being present and utilizing therapeutic use of self/therapeutic listening felt miniscule but was appreciated from patient families. I feel like this should be talked about more in preparation for more medical-based student rotations on how to have these conversations and how to process these losses.
What is something you learned that you will take with you for the rest of your career?
Similarly to what I mentioned above, I learned more about loss and grief from a therapeutic standpoint than I ever have from the perspective of a future provider. Trauma-informed care is of utmost importance in this setting as these patients and families are experiencing great trauma. On a different note, I learned the great value of engaging in the occupation of play for children, especially for medical settings. Engaging in developmentally-appropriate occupations for children can be very meaningful and provide motivation to continue participation to maintain functional tolerance.
What advice do you have for a student about to start in this setting?
Medical settings often are accompanied by increased amounts of traumatic patient situations, as well as difficult social situations involving CPS. I encourage you to communicate honestly and often with your CI about how you are processing the situations and how you can best engage therapeutically, especially when patients are critical, it can be difficult to motivate patients or plan treatment sessions. In the ICU setting, it can be overwhelming to coordinate all the lines and tubes. Don’t be afraid to ask for help or ask the role of certain lines/tubes during your session, it is always good to learn more about how to best care for your patient.
Lastly, chart reviewing will be so, so important! Take the extra few minutes to get a grasp on the status of your patient and understand the prognosis because this will likely guide your treatment and overall goals. Never forget you are a student as well, you are supposed to be learning during this time so give yourself grace when you feel like you fall short, lean on your CI and ask questions!
Thank you so much Katelyn for your wonderful insight and thoughtfulness in curating your responses to these interview questions. I appreciate it so much!
Feel free to get in touch with Katelyn via her Intagram: @katelynhardin_