how to assess without the script
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[00:00:42] Like I'm, I'm having to break a lot of, not just your habits, but your thinking around it. Right? So I'm not diagnosing like you, I'm not diagnosing like a doctor diagnosis and sends it to whatever, whatever, to get an MRI, to get a what, you know, But I have to get to the root cause of the problem. All right.
[00:01:05] A diagnosis is essentially the root cause of the problem. A diagnosis to us is a little bit of a different diagnosis for the doctor, right? Mm-hmm so, yeah, in OT school, we are taught like, oh, only so and so can diagnose and we're supposed to just follow. Their order, but this is [00:01:30] why OTF no specialty, like you have lost all power in terms of what you can and cannot do.
[00:01:39] Like you've essentially, they teach you to give all your power away because if you don't know what the fuck is going on, how do you fix that? How do you fix that? If you are given a script so vague, right. From a doctor that doesn't give two shit to talk to you because you supposedly don't know his protocol.
[00:02:05] How the fuck are you supposed to know his protocol? If he won't fucking talk to you? Right? So that, that, like, that's a shit that pisses me off. I'm not pissed off at you. Right. I'm pissed off at the institution. That's taught you this bullshit, right? I'm kind of mad at you for keeping it after all the years that you've known me and all the shit that I talk about.
[00:02:35] Like, there's a certain amount of autonomy that you want. Don't you. Yes. So it's not so much the word diagnose. I will tell you what is wrong with you. but if you have risk pain, we are critical thinkers, problem solvers and decision makers. Someone comes to you with [00:03:00] wrist pain. What happened? I should be able to rule in and rule out.
[00:03:05] A certain type of problem, right? I'm supposed to know how to do certain tests to rule in it out. Like what works, you know, what's irritated, what's noted. I'm supposed to be able to rule in and out the different exercises and activities. That irritate me or don't irritate me. Like you're doing a great job with her.
[00:03:25] She's happy with you. Like that's amazing. Right? That's really good. Why are you still not happy? Cause you don't know what the fuck is wrong. right here we are frustration 1 0 1 again. Right here we are. I don't know. Something's working we have got to get to the root cause we have to get to a diagnosis, right.
[00:03:51] Patients come to us because they wanna know what's wrong. Elena, tell me what's wrong. Well, you know, your elbow. That shit's coming from somewhere. Let's, let's work it out and find out where it's coming from. It can become from your hand, come from your elbow can come from your nerves, which activities is irritating, the shit out of it.
[00:04:16] Well, let's find out it's cuz you're sitting too long. It's cuz you're reaching it's cuz you're gripping. That is the diagnosis. That we have to come to that conclusion of what [00:04:30] is wrong. Right. A diagnosis is what is wrong.
[00:04:37] OTs can diagnose, I don't wanna make a blog on that right here. Right? OTs can not in the like licensing way or the board way, but in our way, and our way is to find out what the fuck happened. Right. You can take that to skilled nursing facility, acute care. Pediatrics. If you cannot see if our job that differentiates us from everyone else is to be able to observe and find out what is wrong.
[00:05:08] Right. So we can then fix it. Right. If we can't do that, what fuck are we done? So you can diagnose, you can find. It's wrong. Right? That's our, our, like our motto. We find out, we're gonna get clear with you on what's wrong. And then we're gonna get you the right help. We might not be the right help. Right.
[00:05:33] I've turned patients away when they have atrophy. Once you have atrophy, you, you know, You're gonna need to go and have surgery. Now I've talked to some therapists that you don't need surgery. Well, listen, if the nerve reduction tells me, it's like severe and you have atrophy, like, dude, let's go have surgery, get that fixed so we can work on it.
[00:05:56] Right. I mean, we've seen people. Who have it. [00:06:00] If, if someone comes to us and they have their attendance fixed and we've been working and it does not get better, I've diagnosed a problem that shit stuck like Chuck and we've been working out with, this is what we're doing. And we know, we know because we've been doing it.
[00:06:19] We've splinted, we've scar massaged. It we've stretched the shit out of it. And it's still not moving two months later. What would you like to do? Would you like to keep doing the same thing we've been doing? Not getting any progress or could we potentially talk about a surgery called lysis? Right. We have talked to your doctor about that.
[00:06:38] I've had a doctor tell me that it's not my job. to make the recommendations or somebody told me it wasn't my job. It is my job. Let me correct you where you are incorrect. It is my job to make recommendations for that, that that patient to go back to his surgeon, to speak to them about what's the next possible solution.
[00:07:00] Because nothing is moving. That's my job. Right. My job would not be done if I sat there and pretend like, I didn't know what was wrong, that I didn't know that that tendon was stuck and that, that they need to go back to see the doctor. I wouldn't be doing my job. I just sat, kept there and saying like, oh no, let's, let's pretend nothing's wrong.
[00:07:22] Let's keep going. And, and act like someday one day by, by some miracle, it was just like flip, [00:07:30] like loosen up by itself. yeah, they called me and I was like no, I, it is my job doctor turned out the doctor wasn't mad at me. It was whoever didn't understand what my job was. Right. Let me explain to you what my job is, what my role here.
[00:07:48] My role is to find out what's wrong. My role is here to fix it. And if I'm not the one to fix it, let me refer to the person who can, right. That is my job.
[00:08:02] Okay. So Daisy tri control fracture. What do we know about fractures? They take time to heal. How whoa, how much. Four to six weeks. Okay. And then I would've said no moving for some time. Okay. And then this whole time, she's she, I told you she was like washing her daughter's hair. Her daughter has curly hair.
[00:08:23] And then she's like, and I was doodling dishes. And then she's like, and after that she puts on the brace and she's like, Nope. But I went on, on and on about my day. And I was like, you wash your daughter's hair. She's like, yeah, she's coming hair. And I was going like this. And I was like, all right, no pain, no pain.
[00:08:36] I am great. And I was. okay. So when she said that, I was like, then it can't be the ligament thing because ligament was only this and we've been doing this. And then after you told me you did this and all the dishes you did, I don't think that you, I think by now you would've had extreme pain. If this was your only movement you were allowed.
[00:08:54] So then I was like, okay. So then I would wait. You know, her fingers are fine. [00:09:00] Her, her elbow is fine. Ation pronation is fine. Even radio D D she's fine. Yeah. So, and I think I'm also kind of a bit scared. No, but however, when I do do retrograde, it's not retrograde massage, but when I do, yeah, cause she doesn't really have swelling, but when I do, I should be like, oh, right there.
[00:09:20] And then who, and then she'll be fine. She'll be fine. I'll squeeze. And I, and I've done like the whole, like where's your scaffold? Push it down. Then I'll I'll like go little side. No, no, your scout board is there. That's not your scaffold. No, my time. Where's your scout board right here. Okay. So. Where's closer to say, oh, okay.
[00:09:49] It's very radio. Your scar's very radio. Your triquetral is a little bit more middle central to middle to owner sided. Okay. But it's a fracture, right. But if they didn't have surgery and usually your fractures to that bone is a mild. okay. Right. So non-displaced right. They're very mild. And so they're immobilized for a period of time and then you start gentle, active motion.
[00:10:21] And if they can tolerate really well, then you start going into like more past arrange motion to get the, you know, and then by six to eight weeks, you, she would start little [00:10:30] gentle, gentle. Right. And then is until 12 weeks. So you can be more weight bearing and you can be more preceptive right now. We didn't say that she was a ligament injury.
[00:10:42] I just said that you had to potentially rule out ligament problems. Mm-hmm and oh, it was the paper, the. She brought from like MD. Now that she's like, it's the only thing I have on me right now. That's fine. And it said, yeah, it said the ligament. So that's when I was like, oh, a potion of something of the Trone.
[00:10:58] So you went from ligament strain sprain to, oh my God. Complete tear with. Rotational no, no, no. I, she was like, I, when I asked her how she fell, well, she fell at work and then she's like, oh no, I tripped over the broom. And then I went, I landed like this. Yeah. Mm-hmm and then I thought I was like, oh, cool fracture.
[00:11:20] And then, and then she's like, no, no, no, like it's not a fracture. And I was like, And then I just went about it. And then when I was to, and I spoke to you about it, you're like fraction. I was like, no, that fracture's 10. You're like, it's not 10. And you're like ligament. And I was like, there's only those many things.
[00:11:34] And I was like, crap, it could have been a ligament. And then that's when you were like, oh, this is the only motion. And I was like, oh crap. But then you did say like, keep it in mind. Like, oh, if she comes back with pain, then you know, you know, like take back, take him back. Yeah. Right. Then it's a little bit more of a ligament, but if she didn't come with.
[00:11:49] Ligament ligament problems. If she was washing dishes, if she was doing her hair, she would've felt more pain after the activities. She won't feel the [00:12:00] pain during the activities. No. Yeah. She'll feel the pain after activities, usually fractures are stiff, so they might feel the stiffness or pain during the activity, but if it loosens them up, then they won't feel the pain afterwards.
[00:12:12] It's a very generalized statement. Which can be true, like, let's say 80% of the time. Right? Okay. But this is where it's so important for you to be like on the first day, you might not be able to rule in rule out everything cuz they come in, they have maybe too much pain, they haven't moved or whatever.
[00:12:30] You're doing a very generalized thing to kind of get some more motion. But then the second day you can really kind of rule in and relax off based on what her symptoms or her Complaints when she comes back. Right. But the whole dart throwing position was if she came back and she was gonna have more pain mm-hmm so get real specific with, you know, what people are coming in with.
[00:12:56] Okay. Use that framework. Is it a bone problem, right? Is it a bone problem? Meaning is it, is it a fracture? Is it a joint issue? Is it a joint incongruity issue? Is it, you know, that kind of stuff? Yeah. It's a bone problem. It's a joint problem. Is it a ligament? Usually wrist ligaments they're meant to be very strong.
[00:13:12] So just falling straightforward on it might not tear Lu. I mean, I'm not saying that nine, like a hundred percent of it won't happen, but majority of the time ligaments are torn when they're twisted, you know, or they're torn when they're You know, when something heavy falls on them [00:13:30] and then it jolts the bones out of place.
[00:13:34] Right. Mm-hmm so, that kind of stuff. But she came back and she's like, I'm in no van I'm in shoot, but she wears the braces. She's like, I do wear it cause I'm scared something gonna happen. And I was like, yeah, like she's scared to fall again or whatever. And what can you tell her about the protocol that, you know, Yeah, by not wearing it who wouldn't?
[00:13:53] No, I would be like, keep wearing it because keep, wait until your doctor tells you to take it off until two more weeks. Because in my head you're not fully healed yet. You. well, there's clinical healing and then there's full healing in terms of like, where if you fall again on that, it won't break again.
[00:14:14] Right? So there's, there's clinical healing. Once there's a certain amount of clinical healing, that means that you're allowed to start weaning out of it. Right. So if you're, if you're just in your house, take it off, you're already taking it off and doing all this shit. Right. And then. You know, just slowly but surely start weeding out of it by like six weeks.
[00:14:32] You don't have to have it anymore. You're doing great. Okay.
[00:14:42] So, but then her other question is. And she wears to sleep cuz she does wear it to sleep. She's like that's the one time she's like, I can't take it off. Well, she's, she's terrified to like take it off. Well, first of all, don't be terrified, right? Cuz we know that you have some healing going on. You're already doing a ton of stuff.
[00:14:59] You don't have pain. [00:15:00] where do you think her fear is coming from? So you sort of have to know what they're fearful. Like you need to predict, you need to almost like read their minds right. Of what they're fearful of that way. You can address it before they even tell you. And then you're an expert because how did you know what I was thinking before I even said it her fear is coming from.
[00:15:27] I know she imagines her bone popping out and she's like, oh, and then she won't be able to do anything in her life again. Right. That is her biggest fear. Well, listen, I know you might be afraid, you know, if it's going outside or the sleeping, listen, you're okay to sleep with it as long as you're comfortable.
[00:15:46] However, let me just assure you. Your bones are healed. Your ligaments are fine. Like you have to find your way of saying it. Like the bones heal by like X number of time. It all really looks good. You. You know, the fact that you didn't have surgery told me that your fractures a little bit on the small side and usually fractures to that bone are really not that terrible.
[00:16:06] Like they're not gonna just pop out right. As soon as I gotta rebreak on its own. Right. That's all they wanna know. And not gotta rebreak on its own people with scars. It's not gonna just re by itself, you know, all by it lonesome in the middle of that night when you're sleeping. people are afraid that they're going to do something in the middle of the night.
[00:16:24] That's gonna cause them pain. Mm-hmm that they didn't, that they weren't aware of. Right. I [00:16:30] don't wanna be falling asleep and then grabbing my blanket and pulling it. And then all of a sudden I fracture my wrist again, or I have this extreme pain that I can't fall back asleep. That's what they're. . And so, because you know that they're afraid of that.
[00:16:46] You tell them, Hey, listen, you can wear it for another two weeks to go to sleep or whatever. Just know that it won't get hurt. Just know that the bone's not gonna pop out. Just know that there's nothing you're gonna do. That's gonna like make a break again. Right. You're getting better. You're doing X, Y, and Z, and just know.
[00:17:08] That even when you do stuff in the moment, it will probably won't hurt as much as you think it's gonna be, because you're already doing this, this and this and this and those things are pretty heavy. Right. And you're not, do you have pain? I don't have any pain. Well, man, you know, now she might have pain pushing down like that.
[00:17:25] I believe she will. There is. I don't wanna get up and accidently push like that. I don't want to get up and do something like that where it's gonna hurt me. So great. Protect yourself for another two weeks or so. And then we'll talk about it again and we'll just make sure once you get comfortable, but part of it is like you're teaching them to be comfortable with themselves again, right?
[00:17:48] Your words of encouragement, your words of assurance, because you know what you're talking about.
[00:17:58] Be [00:18:00] specific, but be specific in a way that helps them understand. We don't need to be talking about like a specific, well, the tri pretrial sits next to the loony and the like, none of that's gonna fall apart. Like they don't give shit, they just need to know that for their condition. They're gonna be right.
[00:18:21] One day they're gonna be normal again. Likehonestly that's all they wanna know. Every person that comes here wants to know, will they ever be normal again? Mm-hmm right. Even the people who are quote unquote normal, you know, will I ever feel good again? Because I don't wanna feel like this in my forties.
[00:18:41] You know what I'm saying? Like, I just want to know. Yeah.
[00:18:45]
[00:18:45] Hey, thanks for listening to Wong's world podcast. If you are brand new to the hand therapy world, head over to my website, www . Hand therapy secrets.com, where you can get started with some of our free guides and paid programs for both OTs and PTs diving into the world of hand therapy. Or if you've been listening for a while watching on our YouTube channel and you think you could benefit from developing and moving your career further along in hand therapy, reach out to me and my team at info @ Hand therapy.secrets.com and tell us exactly what you're looking for, By the way, if you know someone who could benefit from today's show, please share.
[00:19:22] Thanks. See you on the next episode.
