Going Mobile

This weekend has been busy and I have not had my computer, so that definitely provides a challenge when it comes to blogging. I have had to use my phone and it does not allow me to really incorporate much.

Nothing much prosthetic related today...just school work. The upcoming week is our last week in transtibial. Crazy how after 6 weeks of doing this, we are going to move on to new challenges!! This last project for TT starts with our patient castings tomorrow and ends so quickly - we present and critique on Thursday!! I will be casting tomorrow and expected to fit and have my patient walking by Wednesday. I foresee a couple of long days in my future...

In other news (and against my prosthetic topic only blog rules), I just had to share my view from the beach this morning. I think it is important that if I am going to spend 50 hours a week deep in the world of prosthetics, I take a few hours on the weekend to look at what is right outside my window. Thank you prosthetic school for bringing me to this beautiful place :)

Tune in Thursdays

If you are an avid watcher of Grey's Anatomy and have yet to watch this week's season premiere...spoiler alert!!! One of the main characters, Arizona Robbins, became an amputee as a result of a plane crash that ended the last season. I do not know if it is one of those situations where I am noticing things more because I am aware of them, or it just happens to be a thing where amputees and prosthetics are breaking into being a mainstream topic lately.

I think it is so neat to see something that is very near and dear to me, and really unknown to most people, become a storyline of one of the most popular shows on TV. I know the writers and producers of Grey's Anatomy are working with amputees and the amputee community to do the best they can to accurately portray all of the struggles and emotions that go into living with an amputation.

This is the clip from the show on Thursday night when Arizona reveals that she had her leg removed...

http://youtu.be/sTzszKNZIgQ

I think it is such a true portrayal of how anyone would feel in that situation, much less a very successful doctor who's own partner was the one who amputated her leg in surgery.

I am really interested to see where this storyline goes and how it is all going to play out this season. I want to know when she will start walking, how they will show her therapy and rehab. I want to know what kind of leg she is going to end up wearing. I just really hope they give the matter a good amount if attention and the millions of people who watch the show can gain a new perspective on this world and see not only the struggles, but the triumphs and the endurance and perseverance as well.

Thursday night will definitely be appointment television watching for me this season!

Silicone...Silly Putty for Adults

Not much to report from school today...a short day to end a long week.  We learned more about pathological gait and watch loads of videos on gait deviations to try and learn how to spot them when we see a person walking on a prosthetic leg.  I am finally feeling as though I am getting a decent grasp on these things and am relieved that I am able to notice, detect and diagnose an issue with a person's gait.  Then, of course, you have to list to potential causes for the deviation - those can range from problems with the prosthesis you have made or problems with the amputee and their own style of walking.  All things that can, and must, be changed in order to get someone walking with normal pathological gait.  

Then we watched videos on making liners and other inserts out of silicone.  We also got to spend a good portion of the morning playing with all of the different types of silicone.  This is the stuff that you can paint onto people to make masks of their face, you can put it into different molds and create fun things and you can also use it for actual useful things like making custom liners for a prosthesis.  Apparently we are all going to get a chance throughout the semester to make a little silicone bowl of our very own that we can use in the future for holding or mixing plaster.  I am thinking pink with gold glitter...

All in all, a short and easy day.  A good bit of school work to get done over the weekend, but I am taking the rest of the day off to have fun and I will try and get back to biomechanics and Syme's take-home tests tomorrow or Sunday.  

I Think I Can, I Think I Can

I must keep repeating this to myself in order to make it through till the end of the day tomorrow.  After a long week of feeling pressed for time and rundown with so much schoolwork in the evenings, we had another 10 hour day at school and this time, 9 of it was sitting through lectures and demonstrations.  It is really just too tough to do a full day of that.  I think everyone benefits more from a mixed day - half of hands on things and half lecture.  It is very stressful and exhausting to have a full day of hands on work (although it goes by MUCH faster), but it is way too mentally taxing to have a full day of lectures.  It is obvious to everyone that by about 2:00, the instructors have completely lost their audience and we are all pacing the back of the room just to stay awake!!

Today we watched a professor modify the Syme's cast that he made yesterday.  You think that staring at your own plaster mold and trying to take plaster away and add it on is tough...imagine staring at someone else doing that...for 3 hours!!  It is not that exciting when your own hands are dirty, it is quite literally watching plaster dry when someone else is doing it.  As I mentioned yesterday, it is just tough to watch someone perform these demonstrations because I will not have a Syme's patient again until they are my own and I can almost 100% guarantee you that when that time comes, in at least a year from now, I will not be able to recreate what I "watched" for 4 hours one time in prosthetic school.  After the modification viewing, we went to watch another professor show us how we are casting our patients for our sockets next week.  This was informative and interesting (and only lasted an hour), so much more bearable.  In this picture, Mark (the instructor) is pulling on the pin hole at the end of the liner to show how much these liners can move when locked down with a pin in the end of a socket.  Next week we are creating pin and lock liners.  This is where the liner has a hole in the bottom (as pictured above) and through that hole what looks like a giant screw goes through and into a hole that is laminated into the bottom of the socket.  Instead of just having the socket suspended with silicone or the sleeve suspension that we have been using, it gives them a really secure way to know they are completely locked into the socket.  Without hitting the release pin on the side, their leg is not coming off :)

Another added bonus to this casting today (or it might end up working against me), was that Mark casted the guy who is going to be my patient next week!  So I got a little preview and some inside tips into what liners to put on him and what the best way is to cast him...I think that will be really helpful, but like I said, could work against me in the way that my professors also have casted him so they know what to be looking for in my socket.  I am looking forward to trying a new technique and the pin and lock system next week - we also get another chance to laminate (where we added the skin color last time) and I think they are going to let us pick fun fabrics to put on the socket!  It is the little things like that that keep you going through these long weeks...

It must be said...the end of the day was a little bit miserable.  We listened to a 2 hour lecture on thigh joints and lacers - a technique that has been around since the end of the first World War (the last time it was really considered revolutionary) and was used as a suspension system to hold a prosthesis onto a leg.  Our instructor said (repeatedly) that this was something we were probably never going to see in our career and probably never make.  Nonetheless, we apparently needed to spend a really long time learning about them anyway.  And then spend another hour and a half learning how to make the pattern for what would become a thigh lacer...and THEN yet another hour, making these patterns ourselves on our classmates.  As you can tell, I was not crazy about this activity.  I have no problem learning things, staying for long days and well past 5:00, I just have a problem doing so when I am being told over and over that it is basically pointless.  At least try and sell me on it and tell me that this is something really important that I must know how to do!!  I mean, looking at this picture, it is obvious we have come a long way in creating suspension systems for prosthetics and I like learning the history, it was just a lot of history and spending a lot of time on a project that seemed to not have a lot of practical value in it.  In the end, I obviously survived and I think once I have a weekend break from school, I will be in a better place mentally.  We have had work to do at home every night this week (I am about to take a quiz online right now) and I think I am just a little bit worn out from it all.

In regards to the feedback from my professors, I received an email back saying all really positive and encouraging things, but like I had suspected, he suggested that I do indeed take advantage of all of the free materials at school and do a couple of other projects just for practice.  So Monday when I pour my mold for the patient, he said to pour two and use one for the grade and critique next week and use one in my spare time for learning and practice.  I think if I do this on the next few projects it will really help me become much more adept and confident in my hand skills.  Granted, it seems as though I will be spending much more time in the lab than I had bargained for, but I know it will pay off in the long run. Tomorrow is a short day and I am very thankful.  Just have to make it though four hours of lecture and then free for the weekend.  I think I can, I think I can...

Critiquing and Casting

Today we were back in the treatment room, between the infamous parallel bars, for patient critiques.  This is what it looks like when we do these critiques.  Two sets of parallel bars in the middle of the room and students sitting on either side of the room to watch the patients walk back and forth.  The professors are all sitting at the end of the bars at a table with their critique sheets out, taking notes on the good, the bad, and the ugly.  My patient critique went really well today, but I always think that they could go better.  Buddy showed up this morning and I am not sure what happened between yesterday and today, but his swollen limb from yesterday was back down to normal size today.  So, of course, this meant that my socket fit him a little big.  This was slightly frustrating, but to be expected and not something I was going to be docked for in critique.  I can only do so much to account for the fluctuation in volume of the residual limb.  And it is much easier to add a sock or two to give you back some volume then to have a limb that will not even slide down into the socket.  I felt like I did a really nice job presenting and we have already been given our grades and I did well and got some great feedback from my instructors.

One of the things that I think is the most unfulfilling aspects about school is that we put our heart and soul and time and sweat into these sockets and legs and after standing and presenting them to the class for 20 minutes, we are instructed to break them down and toss them out.  Here I am with my socket after pulling off the pylon and foot...I mean, I guess I have to start throwing them away at some point - there is only so much room under my desk for stashing sockets :)  In the feedback comments I got on my grade sheet today, I was told that I have excellent patient communication and interaction skills and that I portray a lot of confidence when I am in front of a room or with a patient...and that both of these things will go a long way in getting patients and referrals in my future.  The negative part of the comments and feedback was that my "hand skills need work."  I am actually still digesting how to take this because I know this is true.  I am not offended by the mention of needing to work on my hand skills (modification and fabrication), I believe this is only my third or fourth thing to ever make, but it still gets me down a little bit to hear this.  I almost feel as though it does not even need to be said.  I actually believe that this is a comment that could easily be made to me 10 years from now - these are skills that I am going to constantly be improving throughout the rest of my career in prosthetics and orthotics.  Like I said, I am not taking offense to the honest feedback (it is nice to get any feedback), but I have just been feeling like I have been improving vastly in that area and then to have my professors say I still need to really work on that feels like maybe I am the only one thinking I have improved!!  It has also been a super long day and a very busy week so I might just be a little over-sensitive at the moment...

Of course it would not be enough to just have us do patient visits and critique for the day at school, we cannot let our brains rest for even a little bit!!  So this afternoon we spent the four hours talking about Syme's Amputations.  These are amputations that are essentially at ankle level and just involve losing some or all of your foot.  Although we do have some Syme's patients among our patient population at the VA, we will not be seeing them or casting them so we watched Scott perform a demonstration on how to do a casting.  I was a little disappointed that this was at the end of a long day because it was hard to stay focused and really pay attention and this level of amputation is really common so it is definitely something I am going to be encountering in the future and will need to know how to treat.  Because of the shape of the residual limb (with the bulb/ball shape at the end) these can be really tricky in manufacturing a socket and figuring out how to get it securely on the limb.  We learned all of the techniques and options today and tomorrow they will be showing us how to modify this cast and to actually make the socket.  It is always much tougher to learn from just observing so I am not sure that I will get as much out of it as if I was actually doing it myself, but it is interesting to see and I am sure I am retaining more than I think.

Next week, we finish up transtibial and then quickly begin transfemoral (above the knee amputations).  I emailed my professor to further discuss my feedback and to get clarification on a few things and just to ask what I could be doing to further improve my hand skills.  I have a feeling this will mean that I am signing myself up to do some "for fun" projects in whatever free time I have at school, but ultimately (and as exhausting as it sounds at the moment), I think that is what I need to do.  I know I am getting better with practice so I think I just need the chance to really practice more.  They say practice makes perfect...I am not setting unrealistic expectations on myself to be perfect, but I want the next feedback I receive to make note of a noticeable difference in my amazing hand skills!

If at First You Don't Succeed...

Try try again.  This was my mantra of the day.  Today was the initial fitting of the check socket that I made for Buddy last week.  Let me remind you that I was super confident and feeling really good about this leg that I had made.  Buddy came in this morning, sprightly as ever and ready to get going.  I had to be at school an hour earlier than usual so I was not as cheery, but seeing him perked me up!  I was ready to get this leg on and admire him walking in it!  I got Buddy all situated, I put on his liner and then I attempted to put on his leg.  The key work here being, attempted.  As in, the leg would not go on.  No amount of Buddy cramming or standing and stamping would make his residual limb slide down into that socket.  I was silently pleading, but it was not working.  Alas, the socket was too tight.  I just kept staring in disbelief, I knew I had measured everything correctly, I knew I had made a really good cast and pulled a really nice socket - how on earth was this not even going to go on his limb!?  Panicked, but not down and out, I took off the leg (well, the half that was crammed on him) and sat down on my stool.  I was looking at Buddy and contemplating what could have gone wrong when I looked down at my progress notes and measurement sheet from our first visit.  Something had to have gone awry in the last 5 days!!  My instructor (probably sensing my confusion from across the room), came over and told me to remeasure him today to see if the measurements were different than what I had gotten last week.  Aha!!  A genius idea!!  Not his first time seeing this problem...

I re-did all of Buddy's measurements only to find out that he was measuring .5-1 centimeter over everything that I took last week.  If you take that into consideration and remember that we modified the casts down to about 1/2 inch less than the measurements to make it fit tight, I am sitting here with a cast that is about 5/8 inches smaller than what his limb is measuring.  Big sigh of relief from me...for a second.  I was happy to know that it was not me that had completely screwed this up, but that still did not give me a magic solution to get a "too-big" limb into a "too-small" socket.  Buddy informed me that he did not wear a liner all weekend and had spent most of the weekend sitting around watching TV.  Therefore, this meant his limb had a little more fluid in it today than it had last week.  No one told me to account for fluctuating limb volume when taking so much off the mold last week!!  This is a very common issue in amputees so I am glad I had the chance to experience it because it is something that is going to absolutely happen to me in the future.  (Okay, let me be honest, I am only saying I was glad to experience it after the fact, in the middle, I was unable to find the gladness in my heart.)

My instructor told me I could put the liner on Buddy and wrap his limb in an Ace bandage and elevate it for a little while to see if that distributed or reduced some of the fluid.  So, I set about doing that.  While Buddy was elevating his leg and thinking shrinking thoughts, I went ahead and modified my socket a little bit by heating it up with a heat gun and pulling out the little shelf in the back to give him more room.  I did not want to completely count on him shrinking in half an hour enough to fit down into the socket, a little heat flaring out never hurt anyone.  Thirty minutes later, we are back to trying on the prosthesis and seeing if we have any more luck.  This time, Buddy manages to get about 1/3 farther down than he had the first time, but we were still a good 2-3 inches from him being completely settled into the entire socket.  Stop and repeat.  Re-wrap, re-elevate, re-heat and re-flare.  Imagine me doing these steps another two times and then you will be 3 hours into the fitting and caught up with me to the point where Buddy actually managed to get his entire limb into the socket and achieve total contact.

Hallelujah.  We put a little silicone ball (sort of like silly putty) into the bottom of the socket so when the patient puts their limb in the socket, we can see if it flattens out like a pancake...thus, meaning they have gotten total contact into the socket.  I was so happy to finally see a flattened pancake shaped piece of silicone that I am almost broke into song and dance in the treatment room!  At this point, most every one else had their patients doing multiple walks up and down in the parallel bars.  The stress immediately left my body after finally getting Buddy down into the socket.  Alignment may not be my strong suit yet and it definitely makes me nervous, but I was far more concerned that I was not even going to have a chance to even try and align him.

Once the leg was on, I still had a lot of work to do.  The alignment was crazy off and I had to spend a good amount of time tweaking it to get Buddy walking with a decent gait.  He kept encouraging me by commenting on how comfortable the socket felt, so although I was on the ground and unscrewing and re-tightening the screws on the socket over and over again, I kept thinking to myself...hey, one out of two ain't bad.  A really comfortable socket seemed like an impossible goal a few hours before so I was thrilled with that news.  After many back and forth strolls, I managed to get Buddy walking really nicely and feeling really great in my leg.  Buddy only walks about half an hour a day total and today I had him walking for at least that amount of time just trying to get all of the alignment in the right place, so I think that was a definite success on my part.  We had to rotate his foot and slide things around and move the pylon back and forth, but by the end of the morning, we were in a good place.  Buddy was ready to take a smoke break and I was ready for my bologna sandwich so we both were ready to call it a day.  I accomplished what I went into the day wanting to accomplish...my patient felt comfortable, he was safe, and he was walking successfully and with no pain.  What started out looking very dismal at 9:00am ended up being very promising by noon.  I put my leg away and I feel like critique is going to go really well tomorrow.  I feel confident in the changes I made to get Buddy into the socket and now that I have been through one critique, I am not nearly as worried about the second one.  I know that regardless of if it is perfect or right on, it is safe and functioning properly and that is enough of a start where I can talk my way through the rest :)

So, a long day, a learning experience and a chance to feel triumphant at the end of it all.  I am excited to see Buddy walk again tomorrow and it makes me proud to know that he is going to tell my professors how comfortable the socket feels.  He is fairly particular about his socket fit so this a rare achievement!!  A socket being too small was not the only lesson I learned today...I learned a little lesson (and consequently a little class lecture) in sexual harassment!!  When I walked Buddy out to his car (which is a requirement at the end of a patient visit), he said to me, "Can I tell you something?  And don't take this as inappropriate, it is meant as a compliment...you havd a great butt."  Ummm, I did not really have a response for that.  I awkwardly stood silently or maybe gave a crooked smile and then was like, okay Buddy, drive safe and I will see you tomorrow.  Then I kind of wanted to walk backwards up the ramp for fear that he was watching me walk away!!  It did not offend me, I was not upset by it - I did not really think it was a compliment and I am sure it was more inappropriate than appropriate, but he is a 60 year old man and I have learned it is silly to be personally offended by a comment like that.  I mean, I would like to have a good butt so I do not think that is a bad thing, I just don't think it should be information being told to me by a patient.  And neither did my professors - someone else in the parking lot heard the comment and then there was a talk after lunch about appropriate language and sexual harassment and what to do if our patients were engaging in those things.  Needless to say, I know it was a harmless comment and after tomorrow, I will not have interactions with Buddy again so I am going to choose to take it as a compliment...and make sure that I wear those black pants next time I go on a dinner date ;)

Easily Bought

Swag.  People will do anything, like anyone, listen to a four hour lecture, answer questions when asked...all in the name of getting free stuff.  This was the main lesson I learned at school today :)  Swag and free lunch...that is all it takes to buy the affection and loyalty of 20 graduate students.  I need to remember this for the future...

Today we had a four hour guest lecturer come in from Ossur to teach us (and essentially sell to our future selves) about their amazing liners and feet.  We learned the entire history of every single liner Ossur makes and why they make them the way they do and what makes them the best and most amazing and most comfortable.  The most important thing she did was start off the day by giving us all free Ossur goodies.  I mean, if you would have told me 3 months ago that I would be jazzed about receiving a free shoe horn, I would have told you that I have never even used a shoe horn before.  Now, whenever I am prying these dynamic feet out of their foot molds, I will look down lovingly at my Ossur shoe horn smile knowing that it is all mine (I already wrote my name on it, I am not messing around).  Not to mention my cool wrenches and screwdrivers and lanyards and tape measures.  I admit it, the way into my heart is with presents so I was sold before the presentation even started.  Not to mention that I am already slightly partial to Ossur anyway...

After an hour or so of just talk of liners, we moved on to all of the different kinds of feet that Ossur makes.  They have recently become most famous for making the 'Cheetah' - the legs used by Oscar Pistorius in the Olympics, but they make some of the best and most popular feet on the market.  It was interesting to see them all out on the table to and to learn about their components and why they are made in a certain shape or with certain materials.  I, of course, loved looking at the pediatric foot and the tiny baby little liners.  I have never seen liners that small!  We then had two patient models come in and were able to try on three of four different feet with them and get their feedback.  It was a really fun experiment to see which feet they immediately liked and did not like and what their reasoning behind each response was.  Like all things in prosthetics, it becomes a period of trial and error.  Clearly I do not know exactly what these feet feel like on, I can only run down their list of features and components.  It is going to be a decision based on my knowledge, but ultimately what the patient feels most comfortable walking in and what really works for their every day lifestyle.

After the foot experiment, the Ossur speaker made her next best decision...she ordered pizza for everyone.  A four hour lecture immediately became something that I did not think was that unbearable when I looked down at my bag full of swag and was happily munching on my free pizza and Coke.  I admit to being easily bought.  The same woman is coming back to speak to us in a couple of weeks...I hope that she realizes that she has now set the standards and has raised our expectations to be standing in the lecture room waiting with our palms up for our presents and then looking forward to our free lunch  Hmmm, maybe that is unfair to expect of her every time.  Fine, I can eat my bologna sandwich that I had already brought, but I will not be happy if I do not leave each guest lecture series without at least one Ossur marked product!!

Well, we did not do any work on our legs today, we literally were in the same lecture room (in the same horrible uncomfortable chairs) for the entire duration of the day...but because I lost the picture on Friday, I wanted to share my finished leg!!  Is that not a beautiful sight??  The luster has not worn off yet, I saw it this morning on my workbench and felt a surge of pride.  I dusted off the foot and stared at it for a few minutes.  I cannot wait to try it on Buddy in the morning and I am just hoping that he thinks it is comfortable and I have him up and walking successfully without a lot of complications.  I know it is not perfect, but I am definitely getting better with every attempt!!  Because I used an Ossur foot and liner, I learned a lot about both elements today and will be able to repeat that information when I have to stand up for critique on Wednesday.  Tomorrow is a long day, we have an early start and a late lunch so I need to be well rested and bring plenty of snacks - it would not be fair to Buddy to have a grouchy practitioner because I am sleepy or hungry...both of which tend to put me on a downward spiral to unhappiness.  This week is already proving itself to be even longer than last week, but I think that means it will probably go by that much faster.

As for me now, I am going to go put on my Ossur t-shirt, surround myself with my new Ossur products, and eat the leftover Ossur pizza that I brought home from school.  Today was all about Ossur, tomorrow is all about Buddy.

iLimb iLearn

Welcome to my Saturday seminar from Touch Bionics about their awesome iLimb upper extremity prosthetics.  Granted, sitting in a 4 hour lecture on a Saturday morning was probably not my first choice in ways to spend my weekend - I get enough lectures and not enough sleep during the week, but I was invited to attend this training and information seminar and I thought it would be pretty interesting.  And luckily, it was!  I have only been learning lower extremity prosthetics thus far in school - upper extremities are the last thing we do before graduation...so I am still probably 9 weeks away from even starting that part of the program.  Which essentially means, I have very very little knowledge about anything to do with upper extremities, besides what I have seen in clinics or at camp.  Getting these arms and hands (mainly the hand motions) right and even comparable to an able-bodied person is really really tough.  This is why the technology for upper extremities is more advanced than what is being done for legs. The technology for both has come a long way, but people can live a very active and normal life with a foot that does nothing but stay flat and provide balance.  Thousands of amputees walk on these basic feet everyday.  A hand that does nothing is only beneficial from an aesthetic point of view.  There are plenty of people who have upper limb amputations who truly only want something cosmetic and do not really desire or need a fully functioning hand, but there are plenty of other people who do.  This is where the iLimb hand shines above and beyond all other hands on the market.  This hand is UNREAL!!  It can be programmed to make 14 different motions or gestures...including the 'hook em horns' sign :)  It can grasp money, pinch and pick up tiny things like pills, hold groceries, help you button your shirt...it was pretty amazing.  It is definitely futuristic looking and makes the noise of a machine - this turns some people off, but as far as functionality, it is the closest thing to the real thing that you can get.  I also was able to help cast a patient who came in to try out the arm/hand and who is currently being fitted for the device.

I was tired and it is always hard to give up half a free day when all I want to do is lay in bed, but I am so glad I went.  I was able to see something not a lot of people get to see and I think it will put me a little ahead of the game when it comes time to do upper extremities in class.  I learned a lot and am interested in learning more...prosthetics is more than just legs...although, not in my world just yet!

An Observer's Point of View

I am lucky enough to have a professor who is very into photography as one of his hobbies.  He has fancy vintage cameras and on his free periods, comes into see what we are doing and takes somewhat candid shots of us.  These are the shots from throughout the last week - lots of leg making going on :)  I always think it is fun to look at his pictures and so I thought I would post some of them!

Johnny, Erin, and me hard at work on modifying our molds.

Clearly focused on getting my measurements just on...or maybe staring blankly at the mold hoping it will modify and measure itself :)

Me and Sean discussion all things prosthetic I am sure.

Fitting Mr. R's leg on for the first time.

Erin, Chad and me looking absolutely enthralled in the lecture we are watching.

Michelle, Sarah, Dan, Joe and me trying our best to decipher a patient's gait and all things possibly wrong with it.

Focused and confused.

Making sure to point out my monogrammed lab coat - it makes me more official :)

See, I really really like casting!!

Okay, so not the most candid shot ever....

Me and Shawn taking a little break from the grueling day of casting patients.

Fighting the plaster. 

I told him he had to take a picture of me where I looked happy when I was working on something, not so serious!!

Take the Bad With the Good

Okay, the only bad thing about today is that I downloaded the new iphone software and in doing so, lost all of my pictures.  It is super super sad.  I am trying my best to not think about these things and still trying to recover them.  I backed my phone up last night so I should be okay, but I took photos of my finished leg today and I think they are lost forever.  Sad :(

But of course the amazing part of that sentence was that I finished my leg today!!  Yea!!  Hurrah!!  A huge relief and a great way to end a long week!  We had a 3 hour research lecture this morning - exhausting.  I feel as though research is bad enough on its own, but to then talk about how to do it for 3 hours is just that much more painful.  I think it is fairly obvious that I am not interested in the research aspect of this field - alas, I have to do a whole big research problem anyway.  Something to be put off for another day...

I started working on finishing my leg immediately after lecture.  I was able to draw my trim-lines and cut it out of the plastic.  I had to break my cast out of the plastic socket (picture a hammer and a chisel and me beating away at the big plaster mold), it is the least fun way to have to free a socket.  I believe that was one of the worst things I had to endure today.  I managed to grind my check socket down to smoothness rather quickly - quickly for me, anyway.  I could not stop running my fingers along the smooth edges and admiring my own handiwork!  I think I was just relieved after the fiasco earlier in the week and having to present a terribly rough piece of plastic.  I think Buddy will be really pleased that I had enough time to get this one patient friendly.

After the grinding and smoothing, I was feeling really excited about my progress.  I skipped lunch to make sure I was going to finish before the end of the day and it was only 1:30 at this point and I had almost convinced myself I had time to go eat.  I decide to go ahead and do the gunking and fiberglass reinforcement before taking any breaks because I just wanted to make sure and get it done before I ran out of time.  I have a new enemy at school - its name is "bench alignment."  This is when we place our legs in a jig (I had taken a picture of it to help out my explanation, but it is gone...) and place the socket in the correct position to attach the components of the pylon and the foot.  It means flexing it a certain amount of degrees and tilting it and moving it all around to fit the patient's needs.  I got mine in the position we were instructed to place it in and just went ahead and used the gunk and put on my pylon.  My instructor asked me if I would like him to check my bench alignment before making it permanent, but I declined.  I decided that I have to learn how to do this on my own - and it took me over an hour to get it right (hence why it is my new nemesis) and if it was not right, it was my mistake to learn.  I know it is safe and I followed all of the instructions so I am just going to have to see how it works on Buddy when I see him on Tuesday.  It might be a huge "failing forward" moment for me, but I am feeling pretty good about it.  I then attached my foot (another Ossur branded product, of course) and I was done.  I capture this moment on film...a triumphant me holding up my beautiful second leg....again, sad.  I will just have to take a new picture next week.  At some point, the pictures of my legs will all run together and probably not be that exciting, but I feel like a second leg is still a pretty big deal so it is definitely photo worthy.

I am thankful it is Friday and this long week of school is over.  I cannot believe I am down to only 13 weeks until I am finished with Prosthetics.  I am planning on doing as little school work as possible over the weekend and resting my brain to get geared up for what is looking to be an even longer week next week.

I just realized that both of the legs I have made have been left legs...I have yet to even make a correct set!  Hopefully I will get a right leg on the third try :)

The (Almost Perfect) Storm

I really only used 'storm' for the title of this post because yesterday I called it the calm before the storm. It only then seemed appropriate to refer to today as the storm.  It was a whirlwind, more tornado like than anything else, but I guess a tornado can be a storm if you do not want to get to technical about it all.  I digress....

New patient today!!  How very exciting!!  I love my new patient, I will refer to him as Buddy in the blog (for some reason that name suits him in my opinion).  I was ready to go bright and early this morning, standing eagerly by the door of the school, ready to greet Buddy at 8:00am.  Every other student's patient came through the doors (I greeted each one in anticipation) and Buddy did not show.  The panic set in...I thought maybe I was cursed and something about me caused my patients to be no-shows.  Luckily, Buddy was just running behind and came to school around 8:30 profusely apologizing.  I think I can count on him to show up for all his scheduled appointments.  Buddy is a super nice guy - he is very interesting, very chatty and has been a student volunteer for many years...so frankly, the man knows more than I do when it comes to these sessions.  He was even giving me tips on how to fool the professors into thinking my cast was perfect even if it happened to not be!  He said he would walk and just not grimace even if he did not like the socket.  I am glad that I charmed Buddy, but little does he know I am a perfectionist and extremely determined - if my professors say it is not good enough, I am going to do it over again.  Sorry, Buddy.

The first thing we were looking for in this visit was finding the right silicone or gel liner for our patient.  We were all instructed to try three or four on each patient to see which one they liked best.  I, of course, chose an Ossur liner for my patient (let me be honest, I tried on three or four different liners - they just all happened to be Ossur branded).  I think if I chose another brand, it would be like going against my religion...it might actually cost me friendships :)  I am nothing if not brand loyal!  It actually worked out really well, Buddy, who is typically very opposed to these fancy liners, said he felt really comfortable in this one and really liked it.  Buddy is going to be a tough patient because he sits in his wheelchair most of the day and says at this point he is only walking about half an hour a day.  This means almost any leg I put on him is probably not going to be that comfortable or easy for him to walk in, not because of the design (although, if the design and fit are off that certainly will be a factor), but mainly because he does not ever use his body to walk in any leg.  When walking is not something you do regularly, you lose the muscles it takes to do so without pain and you lose the ease and regularity of it.  He really wants to be a regular walker, he just has yet to have a socket or leg made for him that he feels comfortable enough in to be able to walk for long periods of time.  Maybe my leg will be the one that makes getting out of his chair worthwhile!!

We were supposed to make two casts on our patients today.  I found the right liner and took all of Buddy's measurements and set about casting him.  As you can see in the top picture, I was clearly focused and working very hard.  And as you can see in this picture, I was also laughing and having a pretty good time.  This alone is a big step for me - feeling comfortable enough to laugh and have a conversation while casting means I have come a long way.  I used to feel like no one could talk to me or distract me or I was going to ruin what I was working on.  Today, I felt like I knew what I was doing and was really comfortable working with the plaster.  Buddy was also making the experience much more relaxed because he was very patient and very helpful.  A willing and accommodating patient definitely makes a big difference.  I took my first cast to show my instructor and he said my casting technique had come a long way and he could really see a big difference and made a point to comment on how far I had come...yea for me!!  And, in other amazing news - my first cast passed all of the measurements and looked so great that I did not have to do a second one!  I would not have minded doing a second one for the practice and the fact that I was not so stressed out about it, but I had a lot of work to get done (and Buddy was dying for a smoke break), so having a short casting session really worked out well for the both of this morning :)

The next step was filling the cast with plaster and making one of those molds I am always talking about.  I was able to get this done before lunch and take my lunch break while the plaster was setting and hardening in my cast.  I came back from lunch and pulled my mold out and was left with this beautiful looking residual limb.  If you have read any of my other posts, you know what comes next.  Modification!!  Supposedly this was an easy modification and in the future (when we are official and have been at this for more than 4 weeks), we will be able to do this one in about 15 minutes.  For those of us who have only modified a couple of times, it was more like 2 hours.  That is okay though because I think I made a really really good cast and a nice mold and was able to modify it in a way that made me happy and feeling confident that it is going to become a great check socket.  I got approved and checked off to go pull my plastic for my check socket about an hour before the end of the day.  I was feeling a bit of a time crunch, but made the decision early this morning to not let the time constraints stress me out today and to know that I would rather have a better socket than to be done an hour earlier.

So, I was able to go and pull my plastic for my check socket and this is where I ended the day.  This is why it was an almost perfect day.  I would have liked to have gotten a little further - this was where we were told to be by the end of day, but of course you can always go beyond that.  I would have liked to have gotten to make my trim lines and cut it out and have even worked on grinding a little bit, but I think I will be able to get it all done tomorrow.  Every time I make one of these I learn a few new tricks that help me do better the next time so I am hoping to use some of that knowledge tomorrow and knock it out in a few hours.  I have lecture the entire morning and then we have three hours in the afternoon to get from the point I am now to attaching the pylon and the foot.  Tomorrow will be grinding and gunking and aligning to get this ready to try on Buddy next week.  It was a great day and so wonderful to not feel the stress and to have more confidence in what I am doing - at least in order to be more relaxed and to really enjoy the process.  I am feeling really really good about where I am and what I have gotten done and I am excited to post a picture of my second completed leg tomorrow!!  

The Calm Before the Storm

This is what an empty training room, set up for casting looks like.  Gentle, clean and no chaos.  Tomorrow at 8am, this room will be the complete opposite state.  It will be full of 10 patients, 20 students and 4 instructors...and about 100 rolls of plaster.  Buckets of water everywhere, tools being tossed about, and lots and lots of cups of coffee.  Measuring tape and scissors, progress notes and casting socks.  Tomorrow we are casting our (new) patients for a transtibial prosthesis.  Remember the 3-stage casting technique we learned the other day?  Well, tomorrow are going to be applying casts using two of the three stages that we used a couple of days ago on our classmates.  Per usual, I am not really sure of the reason for using or not using the third stage, but I figure, it is one less stage to have to worry about and thus, I am very happy with just my two stages.  I am really looking forward to meeting my new patient tomorrow and to have another chance to expand my casting skills.  Again, we will make two casts for the patient, regardless of how well the first cast turns out.  I really like that we do this because I need all the practice I can get.  Plus, it makes the casting session feel a little less like a do or die situation.

Today was a day full of lectures and demonstrations.  Truth be told, these usually make for long days that are often hard to stay focused and awake during, but after yesterday, I was perfectly content staying relatively still all day.  The morning was spent talking about why we cast in certain ways and all of the different types of liners (what goes on a patient's leg before their socket) are on the market and the pros and cons to each different type.  Like all of the other aspects of this industry, it is unbelievable to see all of the countless options for liners out there.  It is just another area of preference and trial and error to see which one works best for your patient.  I have a feeling I could easily spend hours just trying on liners with someone!  In our casts tomorrow, we will be casting the patients with a gel liner on.  This will help make our patients more comfortable in the sockets we make.  Gel liners are a wonderful invention because it takes a lot of the pressure off the bony areas in a residual limb and just provides general, overall total contact and comfort for the amputee.  The downside is that they are tough to cast on because it makes the limb into more of a cylindrical shape (my professor says the "coffee can") as opposed to being able to distinguish all of the bones and landmarks like you can when the skin is bare.  Apparently this means you just have to squeeze down much harder when casting to try and feel these landmarks through the gel liner.  I am really interested to see what the difference feels like tomorrow when I am working with my patient.

This is what the chalkboard looked like today in reference to what we are trying to capture when we are casting tomorrow.  We have these drawings done for us multiple times a week - I can only imagine how many lower limbs and different socket drawings my professors have done over the years.  They are very proficient at it :)

And this gives you a good idea of what about 4 hours of my day looked like...I think it makes it look more inviting if I write in pink :)  Note taking is my strong suit, I can memorize these things all day long.  A day full of this definitely does not have me rushing home mentally and physically exhausted.  So, as sleep-inducing as they may be at the time, they are a nice mental break from all of the modifying and grinding.  It is also nice to leave school in clean clothes.

Big day tomorrow - we are expected to have wrapped two casts, fill the best of the two and do all of our modifications AND pull the plastic over the molds by the end of the day.  No more three weeks to get these things done, we are down to a mere few hours from start to finish.  Cross your fingers that in tomorrow's post you see a completed project because we are supposed to be attaching the pylon and foot by Friday.  My patient is supposed to be walking on this leg next Tuesday.  Nothing like the deadline of giving someone the option to walk or not to get you motivated to move faster!!

3-Stage Stress

Today was a 10 hour day so I am having to really get motivated to get this blog done tonight.  I had to rush home and take a midterm online and all I can think about is how desperately I want to go to bed!!  Alas, I have made a promise to myself (and the few of you who might be reading) to update this on a daily basis, so here goes with what definitely feels like the longest day of school thus far...

The day started out with a 2 hour demonstration on how to modify the 3-stage cast that we performed on each other yesterday.  I understand the reason for the demonstration, but they get tough to sit through when you are staring at the clock, knowing you are approaching a deadline in which you have to be finished with your project, and feeling like you have seen the same thing shown three or four times.  I have just learned that I do so much better and get so much more out of the experience when I get my hands on the cast or mold myself and really try perform the tasks they are teaching us.  I am struggling to understand how to make all of the modifications just by listening to them said aloud and watching someone else do them.  After removing my plaster cast, this mold was what I spent most of my morning working on.  I added all of my markings and drew in my places for circumference measurements and begin to work on smoothing the entire thing out.  This was a really quick project for us - meaning, it was supposed to be completed quickly.  Not that it actually was quick.  We were given two hours to do the casting yesterday and then about three hours today to go from cast to mold, to modified to plastic pulling, to trimming and cutting out, to grinding and smoothing.  Not to mention that we then had to present it to the class and the instructors for a critique at the end of the day.  Needless to say, it was high stress level from the moment I walked through the doors this morning.

Ahhh, the look of innocence...of someone who does not yet know the time constraints that will be placed on her in a mere matter of minutes :)  This was me while I was waiting for my plastic sheet to heat up so I could make this into a hard socket.  At this point in the day, things were going smoothly and everything seemed doable...

This picture makes me laugh because I always have a look that is slightly terrified and also excited when I have to reach into this giant oven to pick up my melted plastic.  There are all of the nerves of trying not to get burned and the intense hopefulness that you get it right on the first try and do not end up with a giant mess of plastic and have to start it all over.  It is a very big moment - most people in the program have gotten over this moment and grab their plastic and move on.  I still like to take a few seconds to appreciate the powerfulness of the pizza oven :)

And then things got serious.  There is a very small window to wrap the plastic around my mold and then go to work creating the perfect seam down the back.  I know that this can be a one person job, but I am still at the point where I like to have someone else there to talk it through with me as it is happening.  I managed to convince Chad to help me out today - another Orthotics veteran so his experienced hand was much appreciated.  I will be honest, I think my favorite part of the whole plastic pulling thing is getting to wear those ridiculous oven mitts.  How do they expect anyone to have any amount of dexterity at all in those things!?

As you can tell, I might have the nervous smile on my face before grabbing the plastic, but it is all business when it comes to actually having to handle it and get it in the right place before turning on the vacuum.

And that is how it is done!!  One beautifully formed plastic socket ready to be made into a knee brace for my classmate.  Mind you, this all happened before 11:00am this morning.  I was trucking along thinking I was going to enjoy my lunch and have the afternoon to get this sorted out and smoothed up before presenting it for critique.

And in walks trouble...and by trouble, I mean Mr. R.

Literally, walked into the door unannounced and unexpected.  Apparently school has become a walk-in clinic and my sweet patient just thought he could come back for his leg fitting whenever he so pleased.  Let us begin with the first stage of stress.  I was informed that I would not be having the next couple of hours to work on my current project, I would need to get my prosthesis ready and fit it on Mr. R and present it to my instructors for a critique.  My time to work on my knee brace just got cut down to half an hour.  I need more than half an hour just to grind this thing to a point where it is not going to cut my patient!  I have to be honest, having Mr. R walk in really threw me for a loop.  I struggle with the time constraints we are given at school as it is, and to have my time cut short when I typically need more time than most people sent me into a bit of a panic mode.

I managed to inhale my sandwich and trim out my socket before having to run to my car for a change of clothes.  Did I mention that a surprise critique still require professional attire!?  Thus begins the second stage in the stressing.  I am dressed and ready to go and it is time to get my patient up and see if he can still successfully walk on my leg.  Just a reminder...the first leg I have ever made...this is a big deal.  The quick and short version of the story is that Mr. R walked comfortably and safely in my leg and I gave a presentation that my professor deemed great and told me I had a really wonderful way of engaging the audience.  I think that stage two of the stress was just counteracted by the positive critique and affirmation I got in doing a job well done.  I will be honest, despite it being a success, I really hope my next patient shows up on the day he is scheduled to be there!

The third stage of stress was immediately after finishing my critique with Mr. R and then having to rush around like a chicken with my head cut off to try and catch up with the rest of the class in my knee brace/socket.  I felt like everyone else had their projects completed and ready to be critiqued and mine looked like it had been gnawed off the mold by a bunch of beavers.  At seeing my frantic running around (I went to the grinder, realized I had forgotten my safety glasses, ran back, realized I needed a different tool...), one of the grinding pros in the class - Nate - came to my rescue.  Nathan gets the award for being my life preserver today.  His project was done so he stood patiently by and helped me get mine to as much of a finishing point as time allowed.  Nate was already well into his Orthotic residency before coming to school this semester for Prosthetics so he can grind these plastics down with his eyes closed.  It is amazing how fast he moves - we all know that I am still leery when it comes to those spinning wheels on the Trautman machine.

So, thankfully (and because of Nate), I was able to get a decent knee socket created.  But I was still disappointed and frustrated because I did not get to finish.  It certainly is not something I would ever give to a patient and I had to present it in critique anyway because of the time limit of school today.  The edges were not perfectly rounded, there were plenty of parts that still needed to be smooth and straightened out and the fit was not exactly right.  I am still learning and I know that I will get faster and better at this stuff, it is just because of my personality (one that likes to be in control and have things done fully and correctly), that I was not 100% happy turning in something that I felt like I could have done much better on if I had had more time.

I am still on a crazy high from seeing my leg in action today - that is an indescribable feeling for another post.  As long as I do not let the lack of time and the rules of school get me down, I know that I am going to be very successful and very fulfilled in the future.  It is funny, I am exhausted and cannot believe that I spent 10 hours at school today - most of it working really hard, but I would not hesitate to go back for an extra hour if I knew that I could get my project completely finished.  Once again, just taking another turn on the learning curve...time constraints are a real life issue and things come up - people are late to appointments, people do not show up, and sometimes people come early.  I am learning to roll with the punches, I would just prefer to only have one stressor per day.  Is that too much to ask??

A Little Dirty Work Never Hurt Anyone

Just when I think I have mastered the art of plaster casting...they introduce what is called a 3-stage cast!!  That is two more stages than I would prefer!  And of course, I had not actually mastered any sort of casting, but at least I was feeling like I had a decent grasp on the whole concept.  I should have known better, I should have been waiting to be thrown for a loop today.  A 3-stage cast is exactly what it sounds like - casting a person's leg three different times.  It is three different plaster applications on the same casting.  That is three times to make sure to put pressure in the right places.  Three different "magic 90 seconds" to get it all right before it becomes a piece of hard plaster and the window closes for any alterations.  Essentially, three times the stress level.  I went from a panicking time frame of 90 seconds to 270 seconds to really worry that I was getting it all right.  The good news is, the 3-stage first time experiment was performed on a classmate...no patient was harmed during today's session.  Although, I definitely got plaster in a lot of leg hairs on Shaun (my partner) and apparently, as a male, that really hurts when it gets ripped off.  Oops.  Better him than a paying customer :)

Scott took the morning to show us how to perform this 3-stage casting.  It involves making a front plate to capture the bony areas in the anterior portion of the leg, then wrapping the entire leg (so you will have a stronger and more reinforced part over your shin) and then creating a second plate that covers the top half of your knee and around your thigh.  We left the back open because we usually end up trimming that part off when modifying the cast so the patient can bend their knee.  I thought that they were eliminating this so it would be less modifying and trimming down, but then when we have to add a flap on the empty part to fill the cast with plaster to make it a mold.  So, I am still not quite sure as to the reasoning for creating the front half of a cast and not wrapping the entire quad portion of the leg...but I can almost promise you that I will learn it by the end of the day tomorrow!  It is definitely a little different to do the cast on an able-bodied person and a full limb than on a residual limb (which was how Scott showed us), but we will be casting our patients later on in the week with this same 3-stage cast so I appreciated getting the practice in any way I could.

This is Joe casting Nate (they were my buddies next to me...which means I watched everything they were doing and then tried to copy it)!  Both of them have been through the Orthotics program so they have much more casting experience then me.  And this is Shaun making the markings to cast my leg.  If I have to hear one more comment about how knobby my knees are....

Here I am in all of my professional casting glory!!  In between stages 2 and 3 of the casting, you have to apply Vaseline to the top 1-inch of the cast in order to remove the part of the cast that you wrap around the thigh.  It is amazing that just a little Vaseline can cause that plaster to not stick together.  I am just learning all sorts of crazy uses for these every day items!  

After all three stages have been applied, and before the third stage "goes off" (this whole magic 90 seconds concept...before it sets and gets hard), the most important step of this type of casting (which is a SCSP type of cast for those wondering) happens.  I believe Scott called this the "vulcan death grip."  I also believe this is not the official name for it :)  You literally press your four fingers as hard into the cast as you can, right above the person's adductor tubercle.  This is basically pressing into the fleshy part on the inside of your thigh, right above where it dips in at the kneecap.  This is what causes suspension in the cast and keeps it from slipping off a person's leg.  It is ironic because those 90 seconds seem SO short when you are trying to get all of the things in the right place on the cast, but when you are attempting to hold your hand like this and press your fingers down as hard as possible into the cast, it seemed like the 90 seconds was never going to end.  Good news...it ended and I successfully made 4 little finger indentions into the cast.  Bad news...after showing my cast to Scott, he told me my hands were probably too small to be able to get the whole death grip thing just right and he should have showed me a different technique.  Too little too late, I will work with what I have.  He said it was no big deal, it would just mean I would have more to do in the modification phase tomorrow.  What a relief, you know how much I love the modification phase!!  I just bought myself more plaster and more grinding?  Excellent!!  Hey, I guess this is what the learning curve is all about, right?

And then finally, the end result of what a day of being casted looks like!  This is my leg that actually was used in the casting, but sadly enough, my other leg had almost the same amount of plaster on it.  I might be getting better at getting the actual plaster casts made, but I have yet to come very far when it comes to not getting it all over the place.  All in due time.