We’re beginning a new monthly series called, “The IHP Interview,” a Q&A with a member of the IHP community.
With March being Brain Injury Awareness month, we caught up with Pauline Fiorello, a 37-year occupational therapist, certified brain injury specialist, and clinical and lab instructor of occupational therapy who works with clients in the Sanders IMPACT Practice Center and patients at Spaulding Rehabilitation Hospital.
Much of the rehabilitation at the centers within the IPC involves working with patients who have brain injuries. Whether it’s a traumatic brain injury after a fall or an acquired brain injury after a stroke, physical therapy, occupational therapy, and speech, language, and literacy therapy are offered at the Julie Atwood Speech, Language, and Literacy Center, the Marjorie K. Ionta PT Center for Clinical Education and Health Promotion, the Tabor/Connor Family Occupational Therapy Center for Leaning, Participation, and Rehabilitation, and the Ruth Sleeper Nursing Center for Clinical Education and Wellness.
The conversation between Pauline Fiorello, OTR/L, CBIS and OSC’s Sean Hennessey has been edited for brevity and clarity.
Why is a month like Brain Injury Awareness Month so important?
To do exactly what’s it’s saying – awareness. We want to prevent brain injuries. That's why there's so much in the news now about concussions and sports and protecting our children because we don't want them to sustain brain injuries.
Our opioid crisis - that's leading to brain injuries. People overdose - they can end up with an anoxic brain injury – no oxygen to the brain. Kids wearing helmets, fall prevention; these are all things that we want. I know, especially as an OT, we want to get out there to prevent brain injuries from happening
There's a difference between traumatic brain injury, or TBI, and an acquired brain injury. Talk about the misconceptions people have.
A traumatic brain injury occurs when there’s an external traumatic force. In that category, you’re talking about falls, assaults, motor vehicle accidents, sports related injuries, gunshot wounds, domestic violence, in the military blast injuries.
An acquired brain injury could be a stroke, meningitis, encephalitis, a tumor, an overdose, or a cardiac arrest that could lead to a complete lack of oxygen to the brain.
During your work at the IPC and at Spaulding, how do you go about treating these brain injuries?
We start with an assessment. The severity of the injury is going to guide how we’re going to develop our goals and treatment plan. If it’s a moderate to severe brain injury, then oftentimes we’re going to see limitations in limb movement. In all brain injuries, it’s going to be cognition - attention, memory, problem solving, time awareness, time management, judgement, self-awareness, and executive functions, language, and motor planning – being able to do something that you normally did before without a problem. Often times we're working as a team with a speech therapist and a physical therapist as some of what we do often overlaps because we're treating the whole person.
While people may suffer the same type of brain injury, every person’s case is different. What approach do you take to treat people?
It's particularly important to us as occupational therapists to have a patient-centered approach. Who was this person before? What do they want to achieve? And what are their goals going to be according to the person that they were before this devastating injury?
For instance, if it's someone who wants to go back to work, part of occupational therapy might be looking at pre-vocational skills. What was their job? What were the requirements of their job? Do they have the skills to be able to do that?
If they are a busy mother managing three school children - how do you do all that scheduling? How do you make sure they're getting out the door on time? Can you shuffle the permission slips and the forms that need to be completed at the beginning of the school year?
Going back to the patient centered approach - you're looking at physical, cognitive, visual, emotional, along with what their support systems are because their support systems have an enormous impact on patient outcomes.
It must be gratifying when someone walks out of the IPC or Spaulding in much better shape than they were when they walked in. On the flip side, there must be frustration when clients aren’t progressing in a way you hoped, and they hoped they would.
You bring up a good point, and this is definitely something we see with brain injuries. There can be what we call impaired or limited insight for self-awareness. Those are the folks that we have the most challenges with because they have difficulty or are unable to recognize their challenges. So, it's like denial but for some of these people, it’s not conscious that they're denying it. It's that the brain injury does not allow them to have that self-awareness for that insight.
I had a woman who had an aneurysm. She had been a nurse, and she was trying to be independent, and we were talking about meal prep, and she said she was so frustrated. She had ordered one of those adapted can openers but said it doesn't work.
I said, “Bring it in.” I found some expired canned goods and brought them in. I asked her to demonstrate how she was using the can opener and I saw she wasn’t putting it on correctly. Once she put that can opener on correctly, she could open up a can. She laughed for 10 minutes, and was saying, “Oh my Goodness! Opening up cans is going to help me so much with my meal preparation.” So, it's those moments that you walk away, and you say, ‘Wow I just really made a difference in this person's life.’ I know that sounds hokey, but it's true.
That answers the next question of why you do what you do.
It’s because I enjoy doing it. But there are days when you go home and think, ‘How can I do this again?’ because when you can't help someone do or achieve their goals, it can be really disappointing. But you know that you're making an impact in some way, shape, or form. If it's not for that person you're treating, maybe it's for a family member because we always have to remember that we’re helping caregivers at the same time. So, helping them to be aware of how they're going to help family members be able to accept the differences in this person and how they're going to continue living their lives together.
You’ve been at the IPC since 2015. Talk about educating the next generation of healthcare workers.
I love sharing my years of experience with students, and I'm always giving them examples because I'm living it. I'm still carrying a caseload of patients at Spaulding and I can say, ‘The other day, this is what we did, and this is what worked. This is what didn't work.’ It makes it real to them.
Students get to work with clients in all different years of their experiences here at the IHP. First, they might come in just observing, but then they might decide to take the OT CLiPR elective and actually carry a case load of clients themselves. It’s hands on learning. You can't just read how to do something in a book. You have to experience it. That's the best way to learn.
The real-world examples you bring to students must be invaluable.
Last week, I did a two-hour lecture on brain injury and community re-entry to help students understand what the necessary cognitive skills are for a person who's had a brain injury to be able to get back out into the community. I’m a lab instructor this semester in the Physical Dysfunction course and I sometimes will ask one of the OT CLiPR clients to come in and be part of some of these labs so that the students can see what it's like to assess someone's arm that has hypertonicity (muscle tightness making body part movement difficult). If they’re part of a cognition class, the students might come in and do a cognitive assessment with one of our clients. So, I help facilitate those assessment skills with the students to support the OT faculty teachings that I work with.
Any concluding thoughts?
It takes a lot of patience, a lot of energy, you have to have the same enthusiasm when you walk through that door, and you know you've got a list of patients that you're going to see. Sometimes those sessions might even include some crying and some tissues. On the other hand, some clients might have me dancing because I'm just so excited about them being able to do something, you know?
I'm passionate about what I do. I'm passionate to be an advocate for OT because this profession is not always well understood. People know what PT does. They know what speech does. They know what nurses do. But they often don't understand what OT does, and I firmly believe we're a huge contributing factor in healing for people with brain injuries or any other diagnosis.
Brain Facts (according to the International Brain Injury Association)
- Of all types of injury, those to the brain are among the most likely to result in death or permanent disability
- Motor Vehicle Crashes account for 50% of all Traumatic Brain Injuries (TBIs); this includes autos, trucks, motorcycles, bicycles, and pedestrians hit by vehicles
- Brain injury is the leading cause of death and disability worldwide
- Falls are the leading cause of TBI among persons aged 65 years and older
Do you have a suggestion for The IHP Interview? If so, email ihposc [at] mghihp.edu.