This month we provide an inside look at a healthcare case manager, the choices she made on the road to success, and the challenges ahead.

Victoria Powell, RN, CCM, LNCC, CNLCP, CLCP, MSCC, CEAS II, Founder and President of VP Medical Consulting, LLC.
HIN: What was your first job out of college and how did you get into case management?

Victoria Powell: My first nursing job was working in a med-surg unit at a local hospital. I had worked at the facility as a nurse’s aide while I was attending nursing school and had been afforded some great educational opportunities. I did not know or understand anything about case management at the time. We had one nurse who worked in utilization review and I did not understand until many years later that this position was within the umbrella of this fabulous thing we call case management.

My first experience with case management was in 1999. I was working as the office administrator for a large orthopaedic group. Many orthopaedic issues are the result of injuries and I was introduced to various nurses who would come to our clinic and attend appointments along with employees who had been hurt at work. Even then I thought all case managers worked in workers’ compensation. I left this role to pursue another job, but made a contact at this time that eventually led to my case management career. One of the physicians’ wives was working as a case manager for a national case management company. They had an opening and she insisted (very strongly) that I consider joining the corporation. I was not interested, but she continued to call and email me about it regularly. I finally decided I would call the company to quiet her requests, but ended up being hired over the phone on that very first phone call!

Has there been a defining moment in your career? Perhaps when you knew you were on the right road.

My father was diagnosed with cancer six years ago. I was at the point in my career when I felt burned out and was looking to do something different. His diagnosis put my plans on hold and I began to manage his care through the spectrum of testing, specialists, surgery, rehabilitation, and so on. The services I provided were no different than I would have given to any other patient. The tasks were not difficult, but this time they were personal.

Somewhere about a month into his diagnosis and treatment, my parents thanked me profusely for my assistance. They explained they did not feel they could navigate the health system without me. With tears in her eyes, my mother stated she was in such a state of shock at his diagnosis that she could not think clearly for herself, much less for him. She described me as a life preserver. I tried to explain that I did not do anything; I just made some calls, collected some records, scheduled some appointments. I thought it was something any daughter would do, but they helped me to understand that their daughter just happened to navigate the healthcare system for a living. It was my training, education, and experience that made these “simple tasks” to me, but I found out just how much of a difference they could make in the lives of others.

Today I remain in case management because of my father’s diagnosis. I found a purpose and now I realize that my entire career has groomed me for the position I now hold.

In brief, describe your organization.

We are a nurse consultant organization providing a variety of nurse-related education and services. We began strictly by providing case management services to workers’ compensation patients, and later expanded into multiple areas including life care planning, Medicare Set Aside allocations, ergonomics and more. We are located in central Arkansas and have a new office opening soon in northwest Arkansas, but provide case management service to Arkansas and the contiguous states. We provide life care planning services nationwide and even abroad.

What are two or three important concepts or rules that you follow in case management?

Patient advocacy is always first! Advocacy is the basis of not only case management, but nursing in general. A huge part of patient advocacy involves education. A patient cannot realistically expect to know what he or she wants to do unless they fully understand their options. Once the information is understood, the patient is allowed to make a decision on the direction of their medical care.

That does not mean however, that the carrier with which one contracts is responsible for the payment of those services. This is the most difficult thing for our nurses to understand. They are required by their nursing license to advocate for the patient, but at the same time they are responsible for understanding that just because a service is needed does not mean that our client is responsible for providing that service. This is why I prefer to hire nurses with excellent critical thinking skills who are comfortable ‘outside the box.’

Another rule in our company is that we are always working to establish rapport with our patients. Since we work in a highly litigated area (workers’ compensation) establishing rapport is essential in the reduction of litigation expenses. Many times cases are brought into the courtroom because the patient does not understand the process or feels forgotten. Allowing him or her to have a sounding board helps as does having a case manager to help them to understand complex processes or issues. We educate our patients on medically related issues as well as their rights and responsibilities under the state workers’ compensation system. This is just another way that our legal background and training helps to minimize expenses of the cases for which we manage.

What is the single most successful thing that your organization is doing now?

The one thing VP Medical Consulting does better than most other case management firms has to do with the way in which we approach each case. We have experience in the legal system both within and outside of workers’ compensation. The experience gleaned from working in the legal system means a new way of managing claims. Rather than focusing just on the situation as it stands before us, we are also looking toward the future. It is like a game of chess. Each case decision made now may result in a different outcome and open up new issues which need to be addressed in the future.

In our current state of medical care, the healthcare providers have limited time to talk with the patients face-to-face. The training and experience of our nurses means that in preparing for an appointment, we have fully assessed the situation and have documented the issues in an outline complete with the history of the complaint or condition, the dates and locations of all treatment, and have listed the questions which need to be addressed by the provider at the time of the next face to face meeting. This results in confidence from those we care for and allows the physician to get to the heart of the matter quickly so that all face-to-face time is spent focused on the issues and questions at hand. By reviewing the medical reports following the face-to-face meetings, we also point out discrepancies and have them corrected in a timely fashion rather than allowing misinformation to invade the medical record.

What is the most satisfying thing about being a case manager?

I love being a case manager! Education is such a fun part of my job and I get to meet people of all walks of life with all sorts of issues. I am always learning, whether it be about a disease or condition, a new treatment option, a new resource for information or even traveling to conferences and networking with colleagues all over the United States. Meeting new patients from all walks of life and discovering what makes them special and unique is also satisfying to me.

Where did you grow up?

I grew up right here in central Arkansas in the same neighborhood where I now reside. In fact, my parents built a home in 1976 in what used to be considered ‘the country.’ I graduated high school while living in that home and despite every plan to leave, I never did. I have lived on the same street for 36 years, just moving from one home to the next as our family grew. The neighborhood has grown by leaps and bounds and we are certainly not in the country anymore!

What college did you attend? Is there a moment from that time that stands out?

I began my education at Baptist School of Nursing in Little Rock. It continues today as a diploma program and is one of the best in our state. When I left school to begin work the adage was that a Baptist grad would always get the job before one of the candidates from one of our many other schools. It worked for me. I was so glad to finally be out of school, but as soon as I entered the workforce I suddenly wanted to return to school and listen to my professors once again. I felt like I missed so much and now that I had begun work, the light bulbs were turning on and things like pathophysiology suddenly made sense. I just wanted to return and scoop up the things that slipped passed me the first go around (just without all the exam anxiety).

Are you married? Do you have children?
I am married and we have four adult children; two boys and two girls. Our youngest boy is attending college to become a mechanical or bio-mechanical engineer. The youngest daughter has returned to school and is in a BSN program. Three of our children still reside in Arkansas while our oldest daughter and her family are in Virginia. We are currently expecting our ninth grandchild! Considering neither of the boys are married yet, there could be many more grandchildren in years to come.

What is your favorite hobby and how did it develop in your life?

I have so many hobbies, but rarely have time to pursue them. Currently some friends and I host a monthly “Pinterest Party” where we get together and craft something we saw pinned on Pinterest.com. My husband and I like to travel and we try to get away to a new locale at least once a year. I also love movies, photography, reading, and of course playing with the grandchildren.

Is there a book you recently read or movie you saw that you would recommend?

I usually read nonfiction, but new movie releases got me started on a few fiction pieces recently. I completed the Hunger Games series by Suzanne Collins and also The Help by Kathryn Stockett. As for my non-fiction I have just finished Dave Ramsey’s EntreLeadership. All were excellent and I give them 5 stars each.

This entry was posted on Friday, March 16th, 2012 at 11:20 am and is filed under Behavioral Health, Case Management, Case Manager Profile, Disease Management, Uncategorized. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

As seen in Healthcare Intelligence Network News

“Every day after lunch, I lie down on the sofa in my office,” he recounted. “I hold my car keys in my right hand and let my hand hang toward the floor. When the car keys fall out of my hand, I know I’m done.” (Evidently, the famous artist Salvador Dali had a similar practice.)

Napping Celebrities

Then I discovered many other successful people who were nappers:

• Leonardo da Vinci took multiple naps a day and slept less at night.
• The French Emperor Napoleon was not shy about taking naps. He indulged daily.
• Though Thomas Edison was embarrassed about his napping habit, he also practiced his ritual daily.
• Eleanor Roosevelt, the wife of President Franklin D. Roosevelt, used to boost her energy by napping before speaking engagements.
• Gene Autry, “the Singing Cowboy,” routinely took naps in his dressing room between performances.
• President John F. Kennedy ate his lunch in bed and then settled in for a nap—every day!
• Oil industrialist and philanthropist John D. Rockefeller napped every afternoon in his office.
• Winston Churchill’s afternoon nap was a non-negotiable. He believed it helped him get twice as much done each day.
• President Lyndon B. Johnson took a nap every afternoon at 3:30 p.m. in order to break his day up into “two shifts.”
• Though criticized for it, President Ronald Reagan famously took naps as well.

Could these successful leaders know something you don’t?

Napping Benefits

I suggest you seriously consider taking a daily nap for the following five reasons:

1. A nap restores alertness. The National Sleep Foundation recommends a short nap of 20–30 minutes “for improved alertness and performance without leaving you feeling groggy or interfering with nighttime sleep.”
2. A nap prevents burnout. In our always-on culture, we go, go, go. However, we were not meant to race without rest. Doing so leads to stress, frustration, and burnout. Taking a nap is like a system reboot. It relieves stress and gives you a fresh start.
3. A nap heightens sensory perception. According to Dr. Sandra C. Mednick, author of Take a Nap, Change Your Life, napping can restore the sensitivity of sight, hearing, and taste. Napping also improves your creativity by relaxing your mind and allowing new associations to form in it.
4. Reduces the risk of heart disease. Did you know those who take a midday siesta at least three times a week are 37 percent less likely to die of heart disease? Working men are 64 percent less likely! It’s true, according to a 2007 study published in the Archives of Internal Medicine. Dimitrios Trichopoulos, of the Harvard School of Public Health in Boston, who led the study said, “Taking a nap could turn out to be an important weapon in the fight against coronary mortality.”
5. Makes you more productive. Numerous medical studies have shown workers becoming increasingly unproductive as the day wears on. But a 2002 Harvard University study demonstrated a 30-minute nap boosted the performance of workers, returning their productivity to beginning-of-the-day levels.

Napping Tips

I typically take a 20-minute right after lunch. If I can’t do it then, I try to squeeze it in before 4:00 p.m.

While working in a motor shop in college, I would eat lunch in my car and then lie down in the back seat. When I was CEO at Thomas Nelson, I napped in a “zero gravity chair” that reclined to a horizontal position. Since I now work from my home, I retreat to my bedroom and lie down in my bed.

Here are a few practices I have found helpful.

1. Be consistent. Try to nap at the same time every day. This helps stabilize your circadian rhythms and maximize the benefits.
2. Keep it short. Avoid “sleep inertia,” that feeling of grogginess and disorientation that can come from awakening from a deep sleep. Long naps can also negatively impact nighttime sleep. I recommend 20–30 minutes. Set an alarm on your phone to avoid oversleeping.
3. Turn off the lights. Light acts as a cue for our bodies. Darkness communicates it is time to shut down—or go into standby mode. If you can’t turn off the lights, use a simple eye mask. I bought mine at Walgreens. Turn the lights back up to full brightness when you wake up.
4. Use a blanket. When you sleep, your metabolism falls, your breathing rate slows, and your body temperature drops slightly. Though not imperative, you will usually be more comfortable if you use a light blanket when you nap.
5. Be discreet. Getting caught napping at your desk is not a good way to earn respect. In some old-school environments, it might even get you fired! But most people get an hour for lunch. Eat in half that time and then go snooze in your car, an unused conference room, or even a closet.

Finally, shift your own thinking about naps. People who take them are not lazy. They might just be the smartest, most productive people you know.

I love this article by Michael Hyatt. I so want to be a napper. My grandfather was a machinist and would eat his lunch then lie on the lunch table bench for 15-20 minutes each day. He continued this routine into his retirement until the day he died.

Most days I don't even take a lunch break. I certainly don't have a regular schedule, so how do I get started? Any ideas?

Ellecia Small received a kidney transplant at the University of Mississippi Medical Center in November 2009.

Less than three months later, Small, 31, of Canton was dead.

Kinyata Johnson, of Alabama, who received the same donor's other kidney, is partially blind and needs constant care, said Jackson attorney Joe Tatum.

"He thought it would help him, but he was better off before the kidney," Tatum said.

Small's family and Johnson now have separate lawsuits seeking an unspecified amount of damages against Mississippi Organ Recovery Agency and UMC, with Tatum as their attorney.

The kidney transplanted into Small came from a donor who had been diagnosed with encephalitis, according to her lawsuit in Hinds County Circuit Court.

"Both defendants were aware that the kidney donor was infected with encephalitis before the subject kidney was transplanted into Ellecia Smith. And as a result, Ellecia Small, developed severe encephalitis, neurological damage and died," the lawsuit says.

But MORA and UMC are denying the lawsuit's accusations and further say in court papers that Small's death was attributed to her previous medical conditions.

"While we're sympathetic to the patients, their families and the health care professionals involved in this tragic incident, we're unable to comment on pending litigation," UMC spokesman Jack Mazurak said.

The Clarion-Ledger was unable to get a comment from MORA.

Small and Johnson were among four people who received organs from the infected donor.

In 2010, when the situation became public, UMC said the parasite was identified after the fact by the Centers for Disease Control and Prevention in Atlanta as Balamuthia mandrillaris, a free-living soil amoeba that causes encephalitis, or inflammation of the brain. No commercially available test exists for the parasite, UMC officials said then.

They also said then that the parasite had never been identified in an organ donor before and never been transmitted in an organ transplant previously.

Nor had any case of the parasite previously been diagnosed in Mississippi.

Very sad for the recipients, but there was no test for the parasite. I was once involved in a case of Mad Cow Disease (Creutzfeldt-Jacob) diagnosed in a lady that received a cornea transplant. Some of these recipients have been waiting a long time and some never get a transplant. If we have to begin testing for all these off the wall illnesses, the organs will never be used. More on the waiting list will die waiting.

How to Exercise

Exercise and keeping your body active is important even if you have endured the amputation of a limb. Amputations of a part of the leg or foot may be necessary due to peripheral vascular disease and diabetes, which hinders blood flow to the lower limbs, causing part of the tissue to die or become necrotic. Other reasons for an amputation include an accident or injury that severely damages the leg. You will require physiotherapy after your surgery to learn how to exercise the affected leg and become mobile again with the help of a prosthetic limb or wheelchair. Even if you cannot walk, it is important to exercise your sound leg to maintain healthy circulation and prevent blood clots. Your doctor will advise how soon after surgery you can begin an exercises. Once you have been given the go-ahead, try these exercises.

Range of Motion

Step 1

Lie flat on your back on an exercise mat with your arms at your sides. Keep your hands palms down on the mat for support. Use a pillow to support your amputated leg if that is more comfortable.

Step 2

Slowly lift your unaffected leg off the mat as high as possible. Keep your amputated limb motionless. Hold your leg in the air for a count of three to five, while keeping your toes pointing straight ahead and stretching your leg as much as possible.

Step 3

Move your leg in a circular motion in the air. Bring your leg back down on the mat and relax. Raise your leg again and move it from side to side five to 10 times.

Step 4

Return to the starting position and rest before repeating the entire exercise, completing 10 to 12 repetitions. This exercise helps to relieve leg cramping that may occur from sitting or being in a wheelchair for long periods of time. It also improves circulation and leg flexibility.

Muscle Tone

Step 1

Sit up straight in your wheelchair or a sturdy chair. Loop the elastic exercise band around your toe and grip the handles tightly in each hand.

Step 2

Raise your leg so that it is extended straight out in front of you. Bend your leg at the knee to bring it as close to you as possible. Pull back on the exercise band handles by bending your elbows and bringing your hands close to your chest. You may need to lean back slightly.

Step 3

Remain in this position and extend your leg out straight again. The resistance from the exercise band should make this difficult and work out the muscles in your leg. Hold this position for a count of three to five. Relax, lower your leg and continue the exercise 10 to 15 times.

Balance

Step 1

Stand up straight and hold the back of a heavy chair or a table with both hands for support. If you wear a prosthetic leg, remove it so that the weight of your body rests on your sound leg.

Step 2

Let go of the table or chair and spread your arms out to balance the weight of your body on your leg. Maintain this position for a count of 10 or more.

Step 3

Hold the table or chair again and relax before doing the exercise five to 10 more times. You can also hold a broomstick straight in front of you in both hands to help you balance.

One limb becomes much more important when you are missing the other. For good orthopedic health it is important to maintain strength and flexibility of the sound leg in order to maintain long term mobility. The exercises also improve muscle tone needed to help with return circulation.

The US winner of the James Dyson Awards has been announced. Cadence, by Art Center College of Design student Seth Astle, is a prosthetic limb and pedal system that makes cycling more accessible for below-the-knee amputees. It offers a full range of motion, and better efficiency than traditional prosthetic limbs. The Cadence prosthetic “has an elastomeric band that collects energy while riding, giving the cyclist added muscle strength.  As the foot rotates, kinetic energy snaps the foot and leg back up and around to the top.  By combining the pedal and prosthetic, the cyclists can clip into the pedal, allowing more control and ease of use.”

The split toe design allows the rider to see where he or she need to clip into the pedal, and the special pedal design allows the rider to unclip with a back pedal motion.  Without the muscles in the lower leg, a traditional pivot release pedal system is very difficult for amputees.

As the US winner Seth will receive $1,400 and move on to the international final, announced in November. His design will also be featured in a display at the London Olympics next summer.

For more information about cycling with a prosthetic leg, check out Amputee in Action (based here in Greenville, SC). The site points out that, according to the Amputee Coalition of America, “there are approximately 1.7 million people living with limb loss” and “one out of every 200 people in the U.S. has had an amputation.” If a product like Seth’s can help a percentage of those people to experience the joy of cycling, it is certainly worthwhile.

I find it interesting that the pedal was combined with the prosthesis for cycling. I am excited to see this design and hope it does well in the international final in November.

Check out all the cool stuff to help around the home. These technology helps aren't just for seniors. My catastrophic injured patients need these home modifications and aids for independent living too.

Thursday, April 7, 2011

Neuros Medical's Electrical Nerve Block Showing Significant Amputation Pain Reduction in Early Study

Filed under: Neurological Surgery , Neurology , Orthopedic Surgery , Rehab , Vascular Surgery

Neuros Medical of Cleveland, Ohio has developed patented Electrical Nerve Block technology for modulating peripheral nerves. The technology, which consists of a pacemaker-like device and leads stretching to the target nerve, was tested in a study involving five people with chronic amputation pain. Four of the participants reported significant, and even complete, reduction of their pain.

From the announcement:

Study participant Darren W. said, “My pain was gone, something I have not experienced since my amputation. I was able to sleep completely through the night, my first pain-free sleep in several years.” Participant Claude G., also experienced considerable pain relief, and said “the reduction of my pain was amazing, provided a feeling of freedom, and allowed me to work in my woodworking shop for hours.” The study was led by Dr. Amol Soin of the Kettering Health Network Innovation Center and the Ohio Pain Clinic. “Providing such significant pain relief for the patients is outstanding,” said Dr. Soin. “A complete reduction is often unheard of, however the high frequency electrical nerve block technology showed the ability to do so, safely and consistently, and the strong potential it holds for patients suffering from chronic pain is very encouraging,” he added.

Press release: Neuros Medical Announces Successful Feasibility Study...

Neuros Medical...

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A Boston surgeon who performed the wrong procedure on the hand of an elderly woman has disclosed the excruciating details of his error in one of the nation's most prominent medical journals.

Dr. David C. Ring, a hand and arm surgeon at Massachusetts General Hospital, described in the latest issue of the New England Journal of Medicine how a series of personal and system-wide mistakes led him to operate incorrectly on the hand of a 65-year-old woman with a painful “trigger finger.”

“Just imagine the worst thing that’s ever happened to you and that’s how it feels,” said Ring, 42, of the surgery mistake that occurred about two years ago. "I don't want anybody to make the same mistake I made."

Ring’s public admission is rare in a field that typically cloaks doctors’ errors in anonymity, if not secrecy. Patient safety advocates praised Ring’s seven-page mea culpa as a necessary step to reversing rising numbers of wrong-site surgeries and other errors.

“My immediate reaction was ‘Bravo!’” said Dr. Helen Burstin, senior vice president for performance measures at the National Quality Forum, a safety coalition famous for pioneering a list of what were once called “never events,” medical mistakes that should never occur.

“I thought it was exceptionally brave,” she added.

1. Health highlights
   1. 

      Surgery error leads doc to public mea culpa

      Dr. David C. Ring, a Boston surgeon, described in the latest issue of the New England Journal of Medicine how a series of personal and systemic mistakes led him to conducting the wrong surgical proceedure on the hand of a 65-year-old woman.

In 2008, the most recent year with complete records, 116 wrong-site surgeries, up from 93 in 2007, were recorded by the Joint Commission, a national hospital accrediting agency. Preliminary reports logged 137 wrong-site surgeries from March 2009 through June 2010. That’s despite more than a decade of attention to the issue following the landmark 1999 Institute of Medicine report titled “To Err is Human.”

Series of mistakes led to error
Ring, along with colleagues at Massachusetts General and Harvard Medical School, detailed the series of missteps that led to the wrong operation in the patient whose ring finger on her left hand was stiff, painful and sometimes got stuck in a flexed position, a condition known as "trigger finger."

The patient, a Caribbean native who spoke only Spanish, was the last operation on a day that included three major surgeries and three minor surgeries, Ring wrote. No interpreter was available, so Ring, who speaks Spanish, was asked to translate for her.

Stress was high because several other surgeons were behind schedule. As a result, the patient was moved to a different operating room at the last minute, with different staff, including the nurse who had performed the pre-operative assessment.

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Ring spoke to her in Spanish, which was mistakenly interpreted by a nurse in the room as a “time out,” the safety pause for the medical staff aimed at double-checking surgical sites, but no formal check occurred. In addition, there was a change in nursing staff in the middle of the procedure and a bank of clinical computers that diverted nurses’ gazes away from the patient.

Ring performed a carpal-tunnel-release operation, instead of a trigger-finger-release procedure. 

“About 15 minutes later, while I was in my office dictating the report of the operation, I realized I had performed the wrong procedure,” Ring wrote.

Ring quickly notified the staff, the patient and the hospital’s safety team and asked the patient if she wanted him to perform the correct surgery, which she did.

‘Blame and shame culture’
Although he apologized to the patient, waived her fees and successfully performed the correct surgery, Ring said nothing could undo the mistake. But by writing and talking about it publicly, he hoped to break the silence that still surrounds doctors’ errors — and prevent them in the future.

“We’re transitioning from the blame-and-shame culture,” Ring said. “This is not something you sweep under the rug.”

Disclosing the details of the mistake will help others learn from Ring’s experience, said Dr. Peter Pronovost, a surgeon and medical director of the Center for Innovation in Quality Patient Care at the Johns Hopkins University School of Medicine.

“It’s only by understanding this richness that we will be able to defend against this,” said Pronovost, a renowned patient safety expert. “He should really be applauded for his courage.”

Ring acknowledged that he’s risking his reputation among colleagues and, more importantly, among patients.”

“They will say, ‘I’m glad he didn’t do the wrong surgery on me,” he said.

Massachusetts General Hospital officials reviewed the error, reemphasized safety protocols and coached Ring and others involved in ways to avoid specific mistakes in the future.

“I hope that none of you ever have to go through what my patient and I went through,” Ring wrote to his medical colleagues. “I no longer see these protocols as a burden. That is the lesson.”

As for Ring’s patient? Hospital officials offered her a settlement within weeks of the event. However, her son told Ring she’d “lost faith” in the doctor and that she’d seek future care somewhere else.

© 2010 msnbc.com Reprints

I have been meaning to write a blog post on this ever since I read about this earlier last month. I am so pleased to see this Boston surgeon go public in what is typically swept under the rug. I work with a medical malpractice attorney who tells me of a surgeon who routinely made mistakes, but was always quick to apologize and miraculously was never sued. In this case, the patient sought treatment elsewhere, but the important lesson is his public confession and steps to prevent this in the future. As we see from the description from the article, things are not always black and white. We are human and sometimes errors occur.

For the life care planner, note this lady's statments about how her life in the wheelchair forced her to look up all the time, to miss out on being outdoors with the wind in her face, and not being able to hug another heart-to-heart.

That is why technology like this is so essential. From Berkley Bionics, the eLegs are expected to be in select rehabilitation centers around the nation by the middle to end of 2011. The hope is to eventually refine the product for home use by the end user.

There are many standing wheelchairs out there and this is one concept. The chair is designed for the young, active paraplegic.

The standing chair is used for both physical health; maintaining bone health, relieving pressure points, etc., but also for mental health. It allows the user to stand at eye level with others rather than being looked down upon to converse.

As a life care planner, I often include standing wheelchairs for my spinal cord injured patients. It allows more freedom of movement. The user can reach cabinets and things that were out of reach before.

To designer, Tim Leeding, keep up the good work!