Monday, May 6, 2013

Acute Care: Preparing Students for Direct Access (Part 4)

Alright! We're at the conclusion to this blog series on Acute Care! Here are the results of the last three case studies:

Case #6: To Move or Not To Move...
As mentioned many times, there is a definitive culture of stigma - fear - uncertainty - and/or anxiety in regards to intensive care. BUT! I always ask, "what bad may come if I do NOT see the patient?" In this case, my answers are these:

  • Yes. I move the patient.
  • Yes. I will attempt to mobilize this patient out of bed per his response to exertion.
  • Yes. The risk is worth it. The hazard of this patient further declining in musculoskeletal function with a decreased lung capacity is far worse than should this patient (once again) de-saturate to critical levels of oxygen.
  • And, what IF this patient crashes into the 70's? We've already been here. Worst case scenario is that the medical team must now pursue more aggressive oxygenation; the same place they just came from. Albert Einstein is famed for saying that "Insanity is doing the same thing over and over again and expecting different results." If we wish for the patient to return to health, he needs interventions other than bed rest and supplemental oxygen.
  • The discussion with the RCP & RN should include mentioning the risks and concerns of prolonged best rest. It should also include the above mentioned expectations of status quo versus active intervention. This discussion would also benefit from assurance that should the patient respond poorly to exertion, that such discovered limits would be expected & respected. Much of the time fear of change drives decision making more than goal of outcomes; every discussion with the above in mind for this setting has always lead to agreeability on all sides for mobilizing patients in the unit.
Ultimately for this patient, he was muscularly quite strong given two weeks of bed rest. He was able to transfer to a chair at moderate hand-held-assistance and was also able to participate in airway clearance, diaphragmatic breath, breath sequencing, and some gentle therapeutic exercise of the UE, LE, and trunk control. His saturation (surprise surprise) moved from the high 80's/low 90's clear into the mid-90's after 10 minutes. We were even able to wean off from 10L to 6L without any decline in oxygen saturation.

My vote on this one: TO MOVE!

Case #7: ICU, Ventilated trauma patient
Similar to the above case, the rationale I saw for this patient was fairly straight forward: if the patient doesn't maintain his physical capacity, he will lose it. At this point, the "only" barrier to function is really the physiological function of the lungs due to the trauma sustained. The patient was following commands and appropriate in mentation - I saw no danger and could gather no valid reason NOT to mobilize this patient. While the nurse expressed her nervousness regarding moving a ventilated patient, she respected my expertise and had confidence that I would not cause harm to the patient after a detailed explanation of my evaluation plan. I requested that she be present in the room as a second pair of eyes & hands to manage lines - and - off we went. The patient was able to stand, step, transfer, work on balance strategies for UE, LE, and trunk. He wrote on a piece of paper how thankful he was to be out of bed. Imagine the disservice of NOT having this patient be active during this state when all other systems are perfectly functional and safe!

I think there needs to be a cultural re-working of the ICU. In my opinion, the ICU is literally the SAFEST place a patient can be while staying in a hospital. Compared to other units, there is far more frequent and closer attention by the medical team than in any other unit - this includes the technological monitoring of patient status. Anecdotally, I can attest that the majority of the unanticipated events that befall rehab staff  during patient care tends to occur in their encounters outside of the ICU, where the monitoring is not as detailed.

I feel that the lesson of these first two cases in the ICU is that there must be a legitimate reason NOT to engage the patient in physical activity for physical therapists to defer evaluation and treatment. Otherwise, we are simply practicing Einsteinian insanity.

Case #8: Lumbar Disc Protrusion > 5mm; SURGERY?!
For this patient, I had a quick conversation with the nurse regarding MDT and the evidence behind early intervention for low back pain by physical therapists. About two minutes later, I was in the room introducing myself to the patient. I spent significant time educating the patient regarding the biomechanics of the spine, pain science, and expectations of the evaluation should the patient choose to proceed.

The patient expressed that he really did not want to have surgery. I explained that it is quite possible for us to avoid it should we be successful in reducing pain and restoring function. I started this patient with extension in lying on pillows then eventually moved onto full extensions while prone. Copious education and ice was to follow; the nurses were EXTREMELY helpful in reminding the patient not to position in spinal flexion as well as to encourage icing during the overnight short stay.

The next morning, a colleague of mine followed up with extensions in standing and the patient was able to ambulate pain free (minus a mild central soreness) as well as perform two flights of stairs. Surgery PREVENTED (at least for the moment) - the burden for a health system then would be to make sure this patient followed up with an outpatient physical therapist. Nevertheless, the lesson here is that even if imaging highly suggests the need for surgery, imaging is still imaging - the patient's response is what guides the direction of care.

Case #9: ATV Crash, Arm in two pieces?
Before we get anywhere: ALWAYS be your patient's #1 advocate! When patients start to complain that something doesn't quite feel right and you've screened out secondary gain, start looking deeper! Further investigation of the shoulder complex would have revealed that the patient was able to rotate the proximal humerus INDEPENDENT of the rest of his upper extremities.

Do NOT recommend this patient to be sent home. A closed reduction needs to REDUCE the fracture into one more-or-less "functional" piece; this patient felt like his arm was hanging out by itself - apart from his shoulder joint. If you feel the rotator cuff muscles shorten AND feel the greater tuberosity of the humerus move AND appreciated ZERO movement distal from the fracture site... the fracture was NOT reduced.

The orthopedic surgeon was paged and informed. He expressed much gratitude and after surgery, stated that this fracture site was SO clean that it was as if a laser cut the bone in two - reduction was impossible. The humerus was openly reduced and pinned. After the surgery, the patient was exuberantly thankful that someone intervened on his behalf. At first, the physician, nurse practitioner, and floor nurse were all trying to pass off the closed reduction as stable and good for home. The job of the physical therapist isn't necessarily to go with the flow - the job is to advocate for the patient's best interest.

Some closing thoughts:
I hope this blog series demonstrates the intensity, the breadth of scope, the situational awareness, and some of the political/communicative savvy required to be a consummate clinician in the acute care setting. These case studies were but a snapshot of some of my experiences and some of my colleagues experiences which is a DAILY part of acute care physical therapy.

Dr. Kyle Ridgeway expressed his concerns that should the profession truly move into an unrestricted direct access environment, the only realistic way for graduates to be able to recognize such complex and intense medical situations is through the exposure and training gleaned from the acute hospital environment. How else would one recognize a hypertensive crisis? How else can a graduate gather a sufficient auditory sample of auscultations to identify an S3 heart sound? I think its fairly clear that an acute care rotation should be a mandatory part of the #DPTstudent academic experience. Surely, we need to change the model of education for the acute care setting, both for the student and for the clinical instructor. I feel that acute care, with the medical complexities and instabilities involved, requires a graded exposure. I mentioned in PT TV Episode 12 that it should be much like a martial arts experience in training. Students start out as a white belt and are exposed to the simpler and less unstable situations. The content is then made more complex and intense over time. Also, much like martial arts, there is typically one teacher with several students. This is a prudent model for the acute care setting as schools can logistically operate for greater numbers of students per site, and, it would allow students to develop collaborative skill sets. Besides, so many other healthcare professions are ALREADY operating in this manner and have demonstrated much success. We should move forward as well.

In closing, I hope that this series has inspired some students to request and seek out acute care rotations. I can tell you from my personal experience, the acute care internship was the iron that sharpened the blade of my clinical judgment to its finest point as a new graduate.

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