Friday, April 19, 2013

Acute Care: Preparing Students for Direct Access (Part 1)

In Therapydia's PT TV Episode 12: Acute Care, Promoting Best Practice, there was some discussion about how to prepare students for unrestricted direct access. In this discussion, it was keenly identified that an acute care rotation is absolutely essential to garnish the exposure of medical complications, the diagnostic skill sets, and the mental toughness of high pressure second-by-second thinking in a truly unstable medical environment - all crucial parts of bringing the #DPTstudent to the next level.

For this blog post, I'd like to cover the conceptual basis for this as well as a couple case studies for which I will follow up with posts covering the results of each case.

A Pinnacle of Medical Screening and Diagnostic Training for the Student Physical Therapist:
Much of physical therapy practice is taught from the perspective of the outpatient clinician. From a didactic perspective, students tend to filter patient complaints from a far more cautious and defensive posture. Of course, this is better than being careless when it comes to medical screening. Nevertheless, when such a mind enters the environment of the acute care hospital, especially in the intensive care unit or oncology unit where lab values are almost always critical and everyone is a breath away from rapid response or code-blue,  some of those red flags become a moot point since not treating the patient will ultimately be far more detrimental than treating the patient with physical therapy interventions.

The acute care physical therapy setting allows for clinicians to observe, learn, and participate in live play-by-play diagnosis with physicians, nurse practitioners, physician's assistants, and registered nurses. Additionally, it is really only in this environment where physical therapists can have combined access to hour-by-hour lab values, day-by-day imaging changes, and second-by-second cardiopulmonary responses to exertion. I humbly suggest that it is exclusively in this amorphously intense environment that a student physical therapist is best served when it comes time to learn about acute illness, injury, trauma, and complex pathological medical conditions - in situations that can change within seconds, with patients who are very likely altered in mentation/judgement, with frightened family members scared for the lives of loved ones hanging in the balance, where a day's schedule can mean nothing, in a practice setting where politics and power structures can make or break your efficiency as a clinician and effectiveness in your own scope of practice.

For these reasons and MANY more... I highly advocate for physical therapy programs to explore making an acute care rotation a mandatory part of the didactic experience. This would only strengthen the future of the physical therapy profession and healthcare at large. Logistically, creating a new clinical education model of a 1:2, or 1:3, or even a 1:4 clinician to student ratio would permit facilities to be better enabled to attend to their own operational needs while serving education of students. This model could also allow for a controlled, graded exposure to the intensity found in acute care physical therapy practice. Students can group together to problem solve, think aloud, conduct case conferences, and ultimately perpetuate a collaborative culture of accountability and best practice.

So with that, here are some interesting cases I've recalled for your enjoyment (some of these were discussed in a #solvePT tweet chat):

1. Inpatient Vestibular Physical Therapy Evaluation and Treatment: Chief complaint - Vertigo.
A man in his mid-60's is admitted after a fall outside of a hotel while vacationing from out of town. He is sent to the emergency department to rule out a stroke. The MRI revealed negative for CVA except for some evidence of a past CVA which was known to this man's medical history. Other than the usual contributory heart disease, high blood pressure, and pre-diabetic (DM2) - there is no further evidence in the mind of the neurologist, emergency physician, and internist to keep this patient in the hospital except for a vexing case of vertigo. Despite the fact that throughout this hospitalization process, no one had yet attempted to ambulate with the patient, the attending physician had concluded that the patient was medically stable for discharge and required only that a physical therapist complete an evaluation and recommend outpatient vestibular rehab if appropriate.

Oh. His eyes looked like this example (but nobody seemed to care until I saw it & notified the nurse):

What special tests would you have done? What results would you have expected? What do you think this man's mobility looked like? Do you think this patient was discharged this same day?

2. Physical Therapy Evaluation: Acute Low Back Pain.
A woman in her 50's was admitted to the emergency department after being unable to walk effectively at home for several days. She had been displaying classic sciatic type pain with some minor hip pain which caused the ED physician to order an x-ray, just to confirm nothing orthopedically sinister was present. Due to the massive amount of pain and need for narcotics, the emergency physician requested that a hospitalist admit the patient into the short stay observation unit where a physical therapy consult would be conducted.

The physical therapy evaluation demonstrated a constellation of findings. However, one very important finding was revealed. The patient had a positive straight leg raise. However, when screening supine hip range of motion, the patient complained of pain reproduction during hip flexion (with knee flexed).

Can you name this event? What additional special tests/imaging/diagnostics would you have ordered if you were the provider? What do you expect to find?

Let me know your thoughts via Facebook, Twitter, or the comments section below! I will post the conclusions of each case in my next blog post in this series regarding #AcutePT - and - many more exciting case studies to follow! Stay tuned!

Here's the follow up post on PART 2 of Acute Care: Preparing Students for Direct Access.

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