OT Settings

OT Settings Series: Occupational Therapy in Acute Care Pediatric Cardiology with Sarah Brady

Did you think that OT Practitioners can only work at hospitals? Think again!

Next up on our #OTSettingsSeries is Sarah Brady, MS, OTR/L. Sarah is a graduate of the University of the Sciences in Philadelphia. Sarah has always had a love for pediatrics and helping others. Over the past few months, Sarah has also realized she has a growing passion for teaching others. In addition to committing to learning on the job both in and out of the hospital, Sarah along with her coworker and friend Katie decided to join the online space (#OTinstagram – see the end of the article for their linked insta) to celebrate and help OT students and new graduates alike whom are navigating their way through their OT journeys! 

Here is a graphic I put together to list out the magical settings that OT practitioners can work in. I know I have missed a few… This graphic has been numerously updated! I am sure it will have to be updated again soon!

MEET SARAH

Name and credentials: Sarah Brady, MS, OTR/L 

Number of years in practice: 1.5 years 

OT setting/s: Acute Care: Pediatric Cardiology 

 Shannen: Hi Sarah, grateful to hear from you. Can you describe the setting you work at and share about any other healthcare practitioners you work with besides fellow OT practitioners?

Sarah: I work at a children’s hospital in Philadelphia, so it is a very urban setting. I can most likely be found on the pediatric cardiology floor! Fortunately, there are many resources available for not only the practitioners, but also the families and patients that are accessible. There are two other children’s hospitals within the city; my hospital offers the most specialized care.

Working with other healthcare practitioners is a MUST. There is constant interdisciplinary communication and collaboration from physicians, residents, physician assistants, nurse practitioners, nurses, social work, case management, child life specialists, respiratory therapists… you name it. There is oftentimes scheduling for cotreat sessions with physical therapy and speech therapy as well. Basically, my phone is constantly ringing off the hook.

Shannen: Very unique setting! Definitely not a setting I have ever done before as a student or as a clinician. Okay so let’s dive in. Who benefits from OT services in your setting? While every person is uniquely their own, can you please describe what a typical presentation of a patient – person – may look like?

Sarah: In the acute care setting at my hospital, there are several floors that specialize in different pediatric populations: oncology, ortho, complex care, cardiac, PICU, pulmonology, and neurology. Fortunately, there are OTs on every floor! I primarily work in the cardiac intensive care unit (CICU).

A typical patient for me can range in age anywhere from 2 days old to about 21 years old. I would say about 60% of the kids I see are post-operative and the other 40% are what we call “developmentals” who are seen at a lower frequency in which we take a more developmental and teaching approach to treatment. I see a lot of rare CHD diagnoses such as hypoplastic left heart syndrome, tetralogy of fallot, aortic valve stenosis, corarctation of aorta, atrial septal defects, ventricular septal defects, patent ductus arteriosus, the list goes on! All of these diagnoses requires surgical intervention. I also treat kids post heart transplant, ECMO cannulation, who may have cardiac arrested, suffered a stroke, and have VAD implantations. 

Shannen: Wow, my heart (pun intended) is happy that occupational therapy is incorporated into those specialized settings. That sounds, however, very difficult to work in this setting with these sweet kids battling those circumstances. Thank you for sharing that and for touching on the value of OT. Speaking of showing our worth, in your opinion what value does OT bring specifically to this setting.

Sarah: OT brings a great deal of value to this setting. Almost all of the kids I see have either strength, endurance, respiratory, or developmental deficits (usually it’s a combination of all!) Because of this, their daily occupations are greatly affected in terms of self-care ADLs, functional mobility, and play participation and acquisition due to a limited availability to interact with the environment from personal factors and medical factors inhibiting them, social and environmental factors, and of course, their lines, drains, and tubes. Those are never ending!

As an OT in this setting, I have learned (and still am learning) how to mask work with play (the most meaningful occupation for a child).

It is very rare (this depends on age of course) that I go into a child’s room and have a session solely focus on the actual task (putting on pants for example). During an assessment period (such as for an evaluation or anticipated discharge), I am inclined to facilitate them to perform straight-forward ADLs; however, overall one of my largest goals is to create a fun space for my kids to play (the most meaningful occupation in this setting) and to regain a sense of choice and control.

We as OTs bring a kind of creativity that I believe no other discipline does which is something that can have a great positive impact on our patients’ performance.

To be honest, in this setting it can be really difficult to look past the sole biomechanical principles needed to progress a patient toward their goals. The days where I am able to integrate social and play exploration, sensory play, fine motor skill training into the therapy mix while being mindful of the remedial and biomechanical skills are the times where I am the happiest as an occupational therapist.

Shannen: That is beautiful. I chose to pursue occupational therapy over physical therapy because I was drawn to the creativity (*** I am not saying that all physical therapy is not creative:) ***). There is beauty in creativity (and doing more than just routine ADLs and biomechanics-focused exercises)! ***jumps off soap box. Anyways, can you describe what the duration and frequency of treatment may look like as well as describe the length of stay and discharge referrals?

Sarah: In my setting, everything is patient dependent (we’ve all heard this a million times!) so it’s all relative. Most of my post-op kids who come in for their procedure and have no other medical needs, can be discharged within 2-5 days. All post-op kids are usually seen either 5-7x per week. In a perfect world, the above would always be true. However, we have had kids who have been with us for 2+ years and others who have never left the hospital since being born.  It really varies. Other kiddos who come in for acute flare-ups who might not be as medically complex, are usually seen somewhere between 1-3x per week.

A really cool thing about acute care is you get to use your clinical judgement to decide on the frequency of a patient. It makes me feel very autonomous! After discharge, patients will usually go home or transfer to inpatient rehab if they still have extensive functional needs. I send almost all of my kiddos home with an outpatient or early intervention referral unless they were independent at baseline and have functionally recovered close to baseline.

Shannen: What theories or frames of reference do you incorporate into treatment planning?

Sarah: Although I’m not particularly aware of what theories I’m using in my treatment sessions (I am working on this), I will say I generally use the biomechanical and rehabilitative approaches the most frequently, while using MOHO and PEO as the broader models. Using motivational principles is ABSOLUTELY NECESSARY when treating children. If you choose an activity that a child is not interested in, you will get nowhere in your sessions. These two approaches are also very important in building trust and rapport with patients and families.

Shannen: What type of outcome measures / assessments do you use?

Sarah: For outcomes measures and assessments (to name a few!), I use WeeFim scores, MMT, ROM/tone screens, quick vision and proprioceptive screens, PDMS-2, BOT, MoCA, GOAL (as time allows), 9-hole peg test, Minnesota Dexterity Test, and the Sensory Profile.

Shannen: I remember vision being such a big part of my occupational therapy sessions as level II fieldwork student in pediatrics – although that was outpatient! Okay, so how do you describe occupational therapy to a kiddo in ways that they and their parents can understand?

Sarah: I almost always preface with pointing out the differences between myself and PT when speaking to parents, caregivers, and patients. We are almost always mixed up in this setting. It usually goes a little something like this “Hi my name is Sarah and I’m your OT! You can expect x ,y , and z to happen during your OT sessions until you go home. When physical therapy comes by, they will usually be working on getting you up and walking around the hallways and up/down the steps. As your OT, we will be practicing all of the things you were doing by yourself at home like putting on your clothes, brushing your teeth, getting in and out of the tub, playing, and making sure you are strong and safe to go home.” 

Shannen: I think that is a great kid-friendly way to describe OT! So can you pinpoint why you like this setting and how it has and is helping you grow as a clinician?

Sarah: I really enjoy the medical complexity and fast-paced atmosphere of this setting.  I am very fortunate to have the learning experiences I have on the CICU especially knowing my privilege in being apart of once-in-a-lifetime cases that likely are not seen elsewhere. I love how prevalent the basics of OT are in this setting such as working on transfers, dressing, and all of the other foundational components that make up ADLs. I can honestly say that seeing even the smallest smile on one of my kids’ faces after a massive cardiac event or surgery, is the most validating experience I could have as an OT. Don’t get me wrong, I have a fair share of times (more than I would like ) where I feel like what I’m doing isn’t helping or I feel like I’m the worst OT in the world especially when one of my patients is decompensating or simply not progressing. But in those times, I still give it everything I have to try and make a difference in my patients’ lives.

By working in this setting, I’ve definitely learned the importance of my voice, my role as an OT, and overall confidence. This floor is not meant for the faint of heart (no pun intended lol). Being flexible, holding myself accountable and advocating for my patients, and learning that I can work really well under pressure are all wonderful things I’ve gained from working in this setting.

Shannen: Beautifully said. It is important to verbalize aloud that nobody has it all together; I thank you for your vulnerability in sharing the bad with the good. What are other things that you either do not like or wish you could change about this setting?

Sarah: If I could change anything about this setting, there would be a big emphasis on having other professionals respect our profession more. As for probably all OTs, the classic PT/OT mix up happens every single day. We often get pushed to the side, and this is likely for all therapies, when other team members interrupt our treatment session. Of course these kiddos are very sick and sometimes they do need to immediate bedside care or instruction, but most times, these can be done at a Iater time. I do wish there was more education to the interdisciplinary teams on the importance of OT and overall a little more respect towards therapies in general. 

Shannen: I don’t think I go more than a week (if that) without having to explain the difference or provide education on the profession to others even in healthcare myself. I hear you, totally. Okay, so let’s switch gears. Tell me how did you “get your foot in the door” to work in this setting?

Sarah: I was a level II fieldwork student at my current workplace but in inpatient rehab. I was fortunate that they offered me a job in acute care once I got licensed. How I got onto the cardiac floor was a little more random. Due to COVID, my team was designated to certain floors so we weren’t intermixing or crossing floors as much. I somehow was designated to the cardiac floor and that’s where I’ve been since. I love it!

Shannen: Where do you see yourself in 5 years? 10 years? How does working in this setting help you reach your personal professional goals?

Sarah: This one is tough and I go back and forth a lot with where I want to be. In 5 years I anticipate being at my current workplace but advancing to be an OT II (my hospital system has a promotion system that ranks professionals based on their research experience, level of mentorship, etc). In 10 years, I’m not sure!  I could probably see myself at my current workplace for that long, but I think by then I would like get into teaching or more of a leadership role. This setting and current workplace is a one-of-a kind facility. The amount of resources, learning opportunities, and mentorship, is unlike anywhere else. There are so many therapists there with so many different backgrounds that I have at my fingertips to pick their brains. I am so fortunate and grateful for my job and my place of work. I also see myself creating planners, merchandise, fieldwork guides, and student guides through my OT instagram page. As I mentioned previously, I love teaching and taking on mentorship roles and would love to be that for students and new grads all over the world!

Shannen: I am happy for you. That is true fortune to be that happy and motivated in your first job out of school. It sounds like a truly one of a kind place. As a unique setting, what specific “special skills” (like things you aren’t prepared from entry level OTA/OT skills) do you feel like you or a new grad would benefit from brushing up on to be successful in your setting?

Sarah: Hard skills are important. Being knowledgeable in OT principles and heart functions are important. But in my opinion, the most “special skills” are the soft skills. In this setting, you have to be flexible and be able to work under high-stress, high-pressure situations. You need to be able to think on your feet, be a self-starter (as in initiate your learning), be prepared for the unexpected, be able to manage a difficult and large caseload, be relatable and use therapeutic use of self in addition to demonstrate leadership, teamwork, and confidence.

No one is going to teach how to process the death of one of your patients while also having to continue on with your day because other patients need you, no one is going to teach you how to speak to the attending physician who asks your opinion on if they a child is ready functionally and strength and endurance wise to have a VAD implanted, and no one is going to teach you how to manage a screaming, vomitting child with unstable vitals who needs to get out of bed because if they don’t, they will decompensate.

In summary: Always have a willingness to learn and always believe in yourself. 

Shannen:  I can imagine you definitely have to be on A game! Okay, so this is real talk here. How do you deal with grief, illness, sadness, loss,… in your setting? (What psychosocial interventions…who do you refer your patients to….how do your prevent burnout and maximize your own self care and occupational balance??)

Sarah: In the CICU, we deal with patient death often. For me, it’s interesting because, when this happens or if I have a particularly devastating case, I don’t really think about it as “sad” in the moment. I think I kind of block that part out most days so I can do my job the rest of the day effectively. It can be really difficult though; it’s especially hard talking about it to people who aren’t in this field. Usually I’ll get the “oh you poor thing” or “what a saint you must be for working with sick kids” which are both answers I’m not looking to get. It’s really important to confide in someone who is able to just listen. I haven’t used any, but I know my workplace has resources to help the employees manage grief.

I don’t think I’ve hit true burnout yet, but I can definitely feel heavy on certain days which is scary a little bit because I’ve only been an OT for 1.5 years. I really try to not bring work home and to keep my weekends filled with things that I like to do. I try very hard to keep both work and home separate which is hard to do sometimes especially because I’m constantly thinking about work. Some things I like to do for myself are spending good, quality time with my husband, walking our dog, visiting family, and going out to eat. Anything that will help me slow down and be present will do the trick!

Shannen: Advice you would give to someone thinking about / wanting to work in your setting? What do you wish you knew about this setting x years ago (before you started)?

Sarah: I wish OT school would have prepared me a little better in acute and rehab settings. And we really didn’t learn anything about OTs and pediatric cardiology. It really wasn’t touched on that much at least when I was in school. At the end of the day, OT is OT, but it would have been sooo helpful to get more line management experience and medically complex conditions (I didn’t even know what a PIV was when I started as an OT in acute care!). If you are interested in working in this setting, I would strongly suggest trying to get a fieldwork or fellowship in either adults or pediatrics. I would also try to get some observation hours or part-time/per diem work at a hospital where OTs work in acute care just to get your feet wet. Always recommend finding a mentor or going to a teacher who has similar experience. 

Want to connect with Sarah?

IG: @theotmethod

Questions? Comments? Feedback!! Please consider posting below!! Follow the hashtag #OTSettingsSeries on Instagram to never miss a post :)!!

Finally, a great thank you to Sarah for sharing a glimpse of her acute pediatric cardiology OT life through her unique lens!

With kindness,

SHANNEN MARIE OT

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