Friday, April 26, 2013

Acute Care: Preparing Students for Direct Access (Part 3)

Continued from Acute Care: Preparing Students for Direct Access (Part 2)

Case #3

While POD#2 for a total knee replacement is still just a tad early for considering a DVT/PE, NEVER rule it out. In fact, there was suspicion in 2010 regarding the Wells Criteria in that the application of the criteria was not as predictive for inpatient populations. Why? Well, they aren't as ambulatory or normally functioning as outpatient populations would comparatively be. The tell-tale-signs in this case was the elevated heart rate & elevated respiratory rate. Whenever the lungs are slacking, the heart must work harder to push more oxygenated blood around the body. Similarly, whenever the heart is slacking, the lungs must work harder to better enrich the circulatory system with hopeful oxygen to get around. This combined with the swelling in the knee and difficulty with exertion would prime the mind to suspect a cardiopulmonary factor. Interestingly enough, the subsequent Doppler demonstrated the DVT while the CT did not show PE's.

This is where I jump on my soap box regarding too much reliance on diagnostic imaging. In the end, ANY imaging analysis is only as good as three factors: (1) the technology (resolution, focus, contrast, etc); (2) the view of the image (angle, perspective, etc); and, (3) the viewer of the image itself (human error). I tell nearly all my patients who are fixated on imaging that, in the end, it is no different than photography: if I were to hide my hand behind a book, the image would tell you my hand is a book. Diagnostic imaging should help our physical examinations, not determine them. Ultimately, the patient is the rule - not the picture.

Case #4
This is one of my very favorite acute care cases (in fact, I once again came across this same set of symptoms just recently). When dealing with exertional limitations in the absence of suspicious vital signs, IMMEDIATELY back up to your basics: anatomy, physiology, fake. Now, let me first say that the bridge between the "physiology" and "fake" category are the complex links of biopsychosocial factors.

So let's work through it. Anatomy: Is there anything wrong with this patient's anatomy? Other than the hip surgery, not at all. He is as healthy as a horse with no truly interesting medical history. We could request imaging, but, imaging of what? Besides, using imaging as a knee-jerk-response to problems is bad practice (see above soap box).

Okay, so now, we must shift our thinking to consider physiological factors. What are physiological factors of exertion? Heart, lungs, neuromuscular control, musculoskeletal integrity. Was he physically weak? Did he lose control? No and no. So lets investigate the heart and lungs. First line of defense: bust out that stethoscope!

If you performed auscultation of the heart, what you would have heard was a distinct and blatant S3 heart sound - indicative of early heart failure - one of the first classic signs, in fact. To make for a sanity check, you could have had the patient perform inspiratory and expiratory holds to make sure you weren't hearing a physiological split-S2. This patient eventually was found to be in acute renal failure. The sudden exertional fatigue was heart failure kicking in after the exercise was complete which is why the delay was present, free from any type of orthostatic hypotensive event. Fortunately, the PT in this case was able to catch this event early enough that a quick round of diuretics prevented anything permanent or serious from occurring.

Case #5
The safest thing to do when dealing with dizziness, vertigo, falls, etc. is to screen out that VBI component. Now, some individuals don't have the spinal range of motion to "officially" assess the situation. Nevertheless, you can always get creative. In the end, VBI is the inability to sufficiently circulate superiorly - so - just challenge that physiology and you will unveil at least something. For this patient, VBI screening was actually doable and positive; with reproduction of symptoms and even a scary moment of slight non-responsiveness, I decided just to do a few quick tests to discern vestibular components: nothing. An MRA was performed confirming the suspicion of VBI. While the VBI screening test isn't the most reliable test in the world, it is still one of the only tools we have in this area. What should probably speak louder than the VBI screen itself is the patient's history, age, and posture.


6. Physical Therapy Re-Evaluation: Intensive Care Unit - To Move or Not To Move
My observations have served to say that there exists a definite cultural stigma in the healthcare industry surrounding the ICU - "the unit." - as if patients are so fragile that simply touching, breathing on, or looking at them would cause something to go terribly wrong. Behind the scenes of Therapydia's PT TV Episode 12,  we brought this up and universally agreed that the attitude should NOT be of "what might go wrong if the patient gets mobilized out of bed". The attitude that would better serve the patient would be "give me a reason why I shouldn't get the patient up" - and - "what might go wrong if the patient DOESN'T get mobilized out of bed."

That said, here is the case of a male in his late 60's with a long history of COPD, A-Fib, chronic kidney disease, and valvular insufficiency. This is a great time to point out to my #DPTstudents that this trifecta almost always exists in some form (whether detectable by modern medicine or not): HEART + LUNGS + KIDNEYS (much like ears/nose/throat) - when one chain in this trifecta is broken or bent, the entire chain will become affected and will weaken. This unfortunate man was admitted to the ICU for a COPD exacerbation and had very little inspiratory reserve left to fight with. The RCP placed the patient on 10 L of oxygen with an oxymizer and was very nervous about the possibility of a physical therapist causing the patient to exert and desaturate any further than he already had. He was hanging on at this supplemental flow rate in the high 80's and low 90's in percent saturation of oxygen.

So! Do you move this patient? Will you get this patient out of bed? Is the risk worth it? What if this patient desaturates into the 70's??? What would your discussion with the RCP and the RN look like?

7. Physical Therapy Evaluation: Intensive Care Unit - Ventilated Trauma Patient
A 20 year old male suffered a terrible motorcycle accident and was fortunate enough only to sustain minor rib fractures and some minor trauma to the left shoulder (no fractures) from an orthopedic standpoint. Curiously, the patient was found in respiratory distress at the scene, and as a result, ended up ventilated with a tracheotomy. When you arrive at the room, the patient is awake, alert, following commands, and purposefully moving his extremities to reposition himself in bed. However, the RN is nervous about mobilizing the patient further than a dangle - sitting at the edge of the bed.

Do you still want to move this patient? What questions do you have for the nurse and yourself before you get inside the room? What would your discussion with the RN look like?

8. Physical Therapy Evaluation: Short Stay/Observation - Acute Low Back Pain
An electrician in his late 40's presents to the emergency department with acute low back pain and inability to ambulate without excruciating pain. He receives all the usual tests and measures with an MRI displaying a greater than 5 millimeter central disc protrusion (slightly left of midline, less than 10mm). The internist is convinced this patient will need a diskectomy and consults a spine surgeon. The nurse reiterates that the patient will likely need surgery and requests that the physical therapy evaluation be held off.

What would your discussion with the RN look like? Do you still want to treat the patient? If so, what would your treatment approach look like? Is the prognosis good? bad? ugly? indeterminante?

9. Physical Therapy Evaluation: Trauma - ATV Crash
A 40 year old male was driving an ATV and suffered a crash. He was admitted with a clean fracture of the left humerus, just distal to the surgical neck. Outside of some minor rib fractures, he was given clearance by the internist and orthopedist for home return pending a physical therapy evaluation. The fracture was deemed as reducible and thus not requiring open reduction; the orthopedist had the arm splinted citing that the majority of cases involving these types of clean fractures will heal without the need for surgery.

All systems checked out within normal limits except for the fact that the patient kept complaining that his arm felt like it was in two separate pieces. He's rather frightened about returning home tomorrow morning and is seeking your advice regarding these sensations. Also, functionally, he qualifies for home return with spouse.

What do you wish to further investigate? Do you suspect the splinting has failed? Or, is this just sensory noise from the trauma and inflammation? Should you recommend this patient to be sent home?

The results of these cases and more cases to come on Part 4 of Acute Care: Preparing Students for Direct Access!

1 comment:

  1. Dr, Fung, where are the answers to your new cases? There isn't a link for Part 4. I enjoyed reading these!