Three-In-One BLAB Fest

Hi everyone,

Here is a much delayed release of my 3-in-1 blab session covering acute physical therapy, vitals, and professional ownership. I meant to release this quite a bit earlier, but! Well... life :)

So here they are!

1. Vitals are VITAL (A Follow Up)
2. 5 Ways Acute Care Was My Ultimate Game Changer
3. Physical Therapy Attitude Check: Do you own or do you work?

Thanks for all the inspiration and engagement regarding those Facebook posts. Hope you enjoy these. And, get ready to laugh because it is beyond apparent how exhausted I was recording these. LOL! =P

5 Ways Acute Care Was My Ultimate Game Changer

You either love it or hate. If you're like me, you probably went into PT school thinking about outpatient ortho and/or sports, waiting that magical 5 years until you're good enough, and then opening up your own business.

Well, as life would have it, I would rotate through various settings and some how found the acute care hospital to be my love and passion as it pertains to the raw potential to which PTs can learn -- and -- to which PTs can contribute.

Here Are 5 Ways Acute Care Was My Ultimate Game Changer

1. Best application of knowledge base.
2. Highest level of clinical diversity. Yep, I did plenty of manual, ortho, and even ED.
3. Highest level of clinical complexity. Where else are you going to get someone who has 20 different medical conditions, blood that should be melting out of their body, vital signs that make no sense, but are agreed by all in the medical team to appropriate for home discharge?
4. INTENSITY. With the most intense medical situations & most intense patient care scenarios.
5. Largest political canvas in healthcare. Acute care requires savvy to navigate and typically 10-15 years to move into a significant space of leadership (system level, VP, c-level, etc.), 2-5 years for first promotion. 5-10 years for leadership opportunities.

Some quick commentary. People get scared of the ICU. Well, the ICU is the safest place. You have the quickest response team right there, more monitoring that you could ever ask for. Rarely, does anything "go wrong" in terms of PT in the ICU. In fact and in my experience, all the accidents, strokes, and crazy events occurred on ortho (DVTs), trauma (complexity, despite medical stability), and medical units (because, the guard is down).

Additionally in acute care, you get exposure and opportunities to serve in wound care; be it laser, wound VAC, or MIST... or traditional stuff, sharps, even maggot. You get imaging, coordination with the entire healthcare spectrum of professionals. 

The opportunity in acute care for PT is immense. The ability to leverage nearly the entire spectrum of our clinical training is wonderful. Sure, you're not going to do mobs on everyone. But, really, is doing mobs all that PT is about? Surely not.

Think about acute care. It was the ultimate game changer for me. It remains, to this day, one of the most influential and significant leveraged experiences which affects my clinical practice.

If you're a student, get IN a hospital rotation. If you're a new grad, get some per diem hours... you will never regret it.

Vitals Are VITAL!

So, I shared on the Doctor of Physical Therapy student's Facebook group this insane vitals situation, with a patient I saw this past week. You can find it linked HERE:

Essentially, I had a patient present with absolutely no signs, no distress, no discomfort, no nothing... with a normal'ish blood pressure. But! With a heart rate of 37bpm and O2 saturation of 77%.

Yeah... NOT. NORMAL.

My intent in posting that to the Facebook group was to convey how important it is to take vitals. I know it is still a point of disagreement and contention. Still, I've been told more than once that in any discipline or setting in healthcare, failure to take vitals (when someone goes wrong) is the first place lawyers check in terms of negligence.

Just something to think about. You've been warned.

In any case, I'll get on with this post only to say that it is a PASSIONATE topic for me. If you resonate with me, be on fire with me! If it offends you, I'm sorry it does... it doesn't change the facts. But, I think you'll find that the majority of clinical leaders out there agrees with the position I take.

Here's a quick recap:

Follow Up: Vitals Are VITAL!

To my knowledge, it's a happy ending. Our patient recovered and we can't entirely explain what happened. Personally, I still think referring to ED would've been more prudent -- but, per the policy given & the process followed, she was deemed medically stable enough to stay inpatient. However, the cardiologist involved did suggest "other" avenues of approach given a repeat situation.

My interpretation? I think there was a massively hidden cardiac issue given the "regular" irregular heart rate, history of complaint of chest pain, fatigue, etc. Doesn't that sound like a heart attack to you? Sure, the question: What could we have done? Comes up. Maybe nothing, maybe everything.

The fact is, without taking those vitals, most clinicians would've gone ahead with a full course of treatment for the day. That would've included a lot of exercise, both strength & cardio; exercise that very well may have cause the situation to go from odd into critical.

My follow up, simply stated, is this: Vitals are vital, not just because they are standard of care. Not just because it may implicate negligence when omitted. Not just because it's the right thing to do.

Vitals are vital because they serve as the prerequisite for just about EVERY physical therapy intervention we know. Exercise? It starts with vitals because we are causing a physiological stress response. And... I could go on. But, I just stopped typing this long list because it's exhaustive to even do so. Really, if you can't think of why and how important the cardiorespiratory system -- one QUARTER, mind you -- of physical therapy practice is, in how it interacts and is interdependent with the other three systems we treat... someone, needs to rethink how they practice.

Harsh? Sure. But, vitals are vital. Don't you dare put your patient at risk, ever.

Management Tips: #AcutePT

Alright!!! This post has been a LONG time coming - I've waiting so very long in the gathering of my thoughts to bring these #AcutePT management concepts together. I'm very excited to share and discuss this very exciting, dynamic, challenging, and often "controversial" pattern of physical therapy practice.

Management Tips: #AcutePT

Sucks... It's still a business

One would figure that the hospital environment could and/or should be the one place where science and clinical common sense would reign supreme. In a practice setting where peoples lives are at stake on a second by second basis, shouldn't such values outweigh the bottom line? Unfortunately, they do not. Most Acute PT departments are budgeted through an internal capitated fund; department A gets X amount of dollars no matter how much work they do or do not do. This, of course, leads to the discussion of PRODUCTIVITY!

Keeping Productive

The most generous productivity standards I've seen are held at or above 75%. Unfortunately, most departments measure this level of productivity as units billed per total hours worked. What this allows for employees to do is to spend generous amounts of time (as if one was working with RUG levels in the skilled nursing setting) with less numbers of patients when rmore patients could have been seen in the same amount of time. The reality is that staff members who spend 45-60 minutes with patients who could very easily be completed in 15-20 minutes seem more productive than PT's who are blazing around the hospital, picking up 2 or 3 evaluations per day while only pulling 70% "productivity"... Yeah. There needs to be a better way.

Acute PT is a Supply Chain Problem

Honestly, the best way to operationally view Acute PT is to see it as a business problem requiring a solution. In the end, Acute PT is an ongoing supply chain management task. There are X amount of patients required to be seen on a daily basis. Y amount of patients get referred for consults a day in which most physicians (and nurses) "expect" evaluations to be completed the moment the order set has been confirmed in the computer. Sound familiar? Oh yes, and patients should all be BID if not TID - and - the difficult ones that never seem to want to leave the hospital should be seen 4 or 5 times a day! Right...

Solving the productivity problem will naturally solve the supply chain difficulties. The inherent problem with most productivity standards in Acute PT is that there is no natural system for accountability. As a PT, I could easily see 6 patients for 1 hr treatments in an 8 hour day... taking my sweet time to get my minimal requirements of 75% productivity. While some programs have allowed for PT's to have a booster unit in their productivity calculations for evaluations (ie. 1 extra unit calculated into the 4 unit, 1 hour patient encounter), this typically leads many of the PT's to cultivate an even lazier approach.

"Now that I get FIVE units for one hour evaluations, AND, I only need to get 24 units a day - well then, I only need to see 5 patients instead of six!"

Sound familiar? Yeah. No wonder there are so many dysfunctional Acute PT departments. My suggestion is this: make your staff become stakeholders in their work. Much like many emerging outpatient programs are now giving a lowered base salary combined with a percentage of billed services as a bonus, Acute PT programs need to start thinking in this manner. For the outpatient clinic, if a PT is only 50% productive, the amount of billed services will be lower and their overall pay will reflect this. The unproductive employee will hurt from this behavior; the facility does not hurt as bad. So what's the Acute PT version?

I suggest that a dual productivity scale is necessary in a capitated environment. PT staff should be held to a minimal standard of X amount of billable units a day - AND - be held accountable for the NUMBER of patients seen per day, rewarded if they exceed the average. Why is this? Because it goes back to the supply chain management problem.

Most Acute PT programs are limited in their funds. Managers are only allowed to hire so many rehab staff because they are only given a certain amount of dollars to work with no matter what the census needs are. When complaints occur, it is typically because patients are not seen on a certain day (ie. a weekend day), because an evaluation wasn't completed in 12-24 hours, or, because "special" patients haven't been seen BID or TID. The problem really is a service response, not a clinical one.

If staff is held to the understanding that their contribution of value is the number of services rendered per day vs. the number of units billed for, staff that have made habits of "occupational comfort" will naturally performance themselves up - or out.

I'm also a big believer in rewarding outstanding staff performance. Those who pick up extra evaluations, treatments, or are engaging with nursing staff (an element which is absolutely critical in Acute PT) should be rewarded as such in monetary form (bonus or raise) or via fringe benefits. Oh, the flip side is true; you're a manager, after all - don't be afraid to terminate employees that simply don't make the cut. One weak link will destroy the entire infrastructure you've worked so hard to strengthen.

However, even with solving this productivity-supply-chain issue with a dual accountability scale, the problem isn't completely solved. Supply chain means that when demand is made, supply MUST be delivered and done so quickly. Solution? Expand your service window by working longer hours.

Working Longer Hours

The most successful Acute PT programs I've seen have a mixture of 8 hour and 10 hour per day employees. This allows for late surgery patients to be see on post-op day zero, and, for "STAT" discharge evaluations to be attended to - you know the ones, those "get them out the door" cases that all curiously get "ordered" at 4:30 pm. These longer hours are also highly attractive to the younger generation of employees who relish the opportunity to work four, ten hours days. However, to truly make this successful, staff will inevitably need to rotate in and out of weekend schedules. Also, this is where the dual accountability scale for productivity is so important. Ten hour days in the acute care setting is a great way to physically burn out and begin the process of disengaging, and, getting slack or even lazy. This requires management to keep keen eye on employee engagement (to be discussed later in this post).

Prudent Use of Physical Therapist Assistants

It's odd that lately, only the PT progression has culturally undervalued its support staff. In medicine, physician assistants and nurse practitioners have only become all the more valuable and in demand due to their cost saving skill sets. And, let's be honest - does it REALLY require a DPT to gait train the average, run-in-the-mill patient with pneumonia on the medical floor (with no other significant conditions)? Now the ICU, orthopedic floor, spine floor, cardiac floor, oncology, neuro unit, short stay/observations, emergency department - those are certainly different issues.

Again, Acute PT is still a business, and, the business is supply chain management with a fixed amount of profitable funds. The only way to keep black on the financial ledger is to cut costs. This is where PT Assistants come in. High level, functioning patient populations, uncomplicated orthopedics and other elective surgeries, as well as the generally stable medical patients - these are great candidates to increase utilization of the PTA labor force.

In my humble opinion, the most efficient use of PTAs (at least under California law) is to utilize them by the hour, two at a time, under the supervision of a salaried PT. The best case scenario would lend such that several management tiers of PT's exist in the framework of an Acute PT department. Some hospitals may call this a zoning model.

This would require a supervisor/manager to administrate several lead PT's on salary, a handful of per diem/hourly PT's, and an army of hourly PTA's. Lead PT's would be responsible for managing the PTA's labor and clinical interventions as well administrating evaluations and case managing (hint hint) for their respective units/floors. Per diem PT's would serve as labor overflow for evaluations and treatments.

Why this structure? It runs, once again, back to the issue of supply chain management. The bottom line for most hospital PT departments are most related to discharge and patient safety in house. Business is business; this is a point that NEEDS to be understood for departmental success.

The Future of Acute Care PT Practice - Case Management & Value Development

The bottom line for hospitals for physical therapy departments are these: (1) when can the patient discharge? And, (2) to where (and with what equipment) can they be discharged to? Number (3) is a very difficult to measure value-added presence for fall prevention/safety and a global culture of mobility/health improvement for both patients and staff.

I mean, let's be honest here: how fed up is just about EVERY Acute PT department and their nurse-case manager/social worker compadres by which communication is constantly bounced back and forth between patient, nurse, physician, physical therapist, and case manager/social worker? The best solution is to cut out redundant loops of communication.We all know this: the more people that play the telephone game, the more inaccurate the end message becomes.

The best option is to have the lead physical therapists work along side of (if not as part of) the case management department. Each unit/floor should have a physical therapist, a nurse-case-manager, and a social worker to comprise the discharge planning team. Imagine all the PTA management challenges which would be so easily conquered if a salaried PT were to also act as a designated case manager for a unit/floor/zone, say 25-50% of the time on each unit/floor? Food for thought.

The other future aspect of acute PT practice is value development. Being a very present and active part of physician interaction and nursing practice is the key to a dynamic and valuable PT program. Helping develop a nursing mobility program where nurses are encouraged to screen mobility, develop their own mobility plans, fall prevention programs along side of PT assessments, etc. - these are the future marks of a cutting edge acute PT program. Oh! P.S. - in a hospital, nurses run the show - make the nurses happy, and they will make you happy.

What would really push an Acute PT program into warp drive would be long term outcome trackings for population groupings, diagnosis groups, and treatment segmentation in measurements of bio-markers, overall health recovery, and other non-functional (but critical physiological markers) along with readmission rates/causation and length of stay projection/prediction/adherence. Again, this drives physical therapy practice in the direction of feed-forward case management.

Let's Not Forget The Clinical!

With all this talk about business management, let us not forget about the clinical side of life. After all, physical therapist are clinicians at the practitioner level providing a service in this setting. In the more challenging areas of ICU, neuro, emergency department, etc. - clinical savvy and interpersonal schmoozing is a must! If an employee isn't getting along with patients, family members, nurses, physicians, and other support staff - forget it... You've got a dud in place; reassign that person to another unit/floor. In the same vein, if you have an employee strapping on the gait belt and doing nothing but transfers on the neuro floor... *insert buzzer sound here*.

This all sounds so sad, doesn't it? But why? Well the answer is employee engagement. Acute PT is a setting which is quite easy to burn out of. The patients can be difficult, clinically challenging, and uncooperative. The interdisciplinary climate can be frustrating, interest competing - new ideas mix about as well as oil does with water.

With lack of employee engagement, much of the problems seen such as developing lazy ways to make minimal productivity standards and "seeing" patients for mere transfers/chair exercises becomes increasingly common. With such drab levels of clinical practice, nursing staff will quickly view physical therapists as glorified human walkers and people movers. I can guarantee that if you're hospital nursing staff has even a hint of this view of your department, you have some weak links that need tightening - I bet you already know who they are. If you don't, you better find out quick!

Employee Engagement

Since we mentioned employee engagement, let's flush it out. The biggest threat of employees at risk for burn out, complacency, or resignation is lack of purpose and passion in the workplace. Meaninglessly walking patients down the hall way, performing nothing but Max x2 transfers... these situations put at serious risk, the existential value of what people do for work.

Additionally, physical therapists are PROBLEM SOLVERS. This is the inherent nature of our practice and needs to be fueled for continued passion. When jobs become mechanical, they become boring. What physical therapists need to be considered for is hospital administration and leadership.

Managers need to quickly identity acumen, talent, and influential individuals within their departments. The hospital climate is all about operational philosophy and social power. Popularity is key. The sad thing is, the more popular a physical therapist is with other departments, the more commonly this PT will be the target of intra-departmental angst and jealousy. Management must squash this sentiment and associated behavior as well as protect the talent. When word gets out that one of the PT staff members shines out extra bright, snatch them up and put them in a position of leadership BEFORE their threatened co-workers get the better of them.

Additionally, individuals who wish to rise up above the "director of rehab" level of administration MUST pursue an additional degree. I've mentioned this many times on posts and tweets - health systems consider nurses and physicians the natural choice for leadership at the executive level. Despite physical therapists being educated at a DOCTORATE level, they do not fit the conceptual mold of officer level leadership in healthcare. An additional degree such as an MBA, MPH, or MHA is a requirement to break the mold.

It is also most helpful if a physical therapist demonstrates exceptional performance in driving the marketability of the hospital itself. So often, rehab stories are the stories that marketing departments melt over. A stroke patient who is learning to walk, a trauma patient who stands for the first time with teary eyed family members at bed side. THESE stories are the stories that sell - and - anything that sells, by definition, demonstrates value. The individuals involved with such stories should also be quickly groomed for leadership opportunities. Again, the hospital environment is all about politics. If you are known, that much more power is behind your name. If you are liked, that's even better. Make sure you highlight your employees! And, once again, make sure you protect them for collegial jealousies.

Keep your employees engaged, interested, and passionate about what they do and who they are! We must break the mold and set expectations of the hospital culture. Acute PT's need to be more than "eval machines" and PTA's need to be more than commando treatment gurus. The entire concept of Acute PT need to be re-imagined and revolutionarily administrated. To do this, it requires much grit, thick-skin, and business savvy. To do this, management needs to be supportive all the way up and down the chain of command. Sadly, for many administrations, one must get up there first before the support can be given. Once given, highlight and grow those with talent, demonstrating acumen & performance - be sure to develop the new ideas and the new solutions - these are the sparks that will continue the flames of passionate workplace engagement.

Closing Thoughts

The acute care physical therapy practice will play a very intriguing and important role in the coming days of the healthcare industry. With payer source in question, length of stays to be decreased further, and more work to be done with less funds - the expertise and acumen of physical therapists can certainly be the booster charge hospitals need to reach their true potential of decrease the overall cost of healthcare. Perhaps more importantly, physical therapists in this environment will be best positions to make positive, long term impact on the future life choices of individuals in a health system.

The barriers to this include a stagnant, if not fearful culture to change within PT departments ranks. Lack of physical therapy leaders in the hospital environment who are savvy with business, nursing/physician politics, and stakeholder dynamics for which is the beating heart of almost every hospital based "issue."

As always, to make change, it is easiest to do it in-house rather than to gun for things out-house. Fix those productivity and operational factors first. When the department is up to snuff, then options will open. Many businesses and administrations work with the philosophy of "It pays to be a winner." The more a program is successful, the more funds, technology, support, and toys they get. Once this level of performance is reached, THEN the iron will be hot to strike for grander improvements to the hospital operation at large.


I hope you've enjoyed these management tips for acute care physical therapy practice. There is certainly much to be discussed and flushed out. By no means are these the only tips out there, however, I do find that these tips are quite useful to the majority of acute care PT programs. I hope you will find them helpful in your pursuit of best practice.

Warm Regards,
-Ben Fung

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

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

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.

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.

MORE CASES!

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!

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

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

Case #1: Vertigo... or something more?

With vertigo, what do we typically run to? All your BPPV tools, right? If you ran through all these tests, performed the head thrust, oculomotor assessments, screened out for VBI... all these tests would have given the same result: nystagmus that lasted for minutes at a time, with and without torsional components. And, sure, the patient was complaining of vertigo the entire time as well. What should catch the clinician's eye immediately was the picture I posted in Part 1: Horner's syndrome.

While we're not tapeworms and therefore have given norms for amounts of asymmetry, the clinical eye should widen a bit when a history of CVA is combined with a fall plus vertigo. Now while the patient's Horner's syndrome was not as pronounced as the picture posted, it was definitely present enough for the nurse, the wife, and myself to raise suspicion. Coordination, as would be suspected, was absolutely terrible. Strength was bilaterally strong. Stance, balance, and attempts at ambulation were nothing short of terrifying - the patient simply did not have control over his movements. Did he go home? NO WAY. In fact, I held discharge and insisted on another MRI. In the end, this patient went to the acute rehab unit for several weeks.

Diagnosis: PICA syndrome. What was neat (for me) about this case was that I called out a posterior cerebellar stroke prior to seeing any imaging. What was a bit ironic is that the repeat MRI was practically identical to the admitting MRI. In fact, later in the day (after my evaluation) when the MRI became available, I pointed out the area in question to the nurse who was then quite convinced of my assessment. Oh, yes! Most importantly, the patient even said that all this felt like a stroke - just a "different" type of stroke. Lessons: listen to your patient, always make your own calls, if it smells/feels/looks/acts like a duck - it IS!

Case #2: Acute Low Back Pain with Suspicious Hip Range of Motion

The event: Sign of the buttock. While not following the classical criteria, it should pique some curiosity when anything close to the sign of the buttock presents itself. I made the attending physician aware of the constellation of symptoms and signs that I found, expressing concerns that an x-ray was likely not thorough enough to uncover the physiological root cause of this patients range of complaints. An MRI was ordered. Most unfortunately, the radiologist reported that metastatic cancer had developed throughout the patient's pelvic and lumbar region, quickly spreading into the the thoracic spine. In fact, there were several small compression fractures that had developed due to the cancer. Direct access isn't just about improving the welfare of society by freeing up economic markets; for the healthcare provider, it also means keeping an eye out for the rare but tragic and sinister health events - hopefully, there are times when we can catch it early enough and save lives.

See below for two related publications:

http://www.ncbi.nlm.nih.gov/pubmed/19168712

http://www.ncbi.nlm.nih.gov/pubmed/16294986

Ok. Back to the cases!

3. Physical Therapy Treatment: Total Knee Replacement, Post-Op-Day #2 (POD #2)

A man in his early 70's is on POD#2 of his second knee replacement (on the contralateral side of the first). His first knee replacement was only a couple years ago and was met with sterling success. However, these past few days were met with frustrations of orthostatic hypotension, slightly more swelling at the knee than expected (but within acceptable norms), and a copious amount of pain at the surgical site which was far more threatening to the patient's consciousness than was his first knee replacement. On POD#2, PM treatment, the patient began having difficulty with exertion. In-room-ambulation was fairly easy at supervision with a walker POD#1 PM and POD#2 AM. Although blood pressure was stable, the patient's heart rate was significantly elevated; respiratory rate was also elevated with a slight decrease in oxygen saturation. The nurse and the telemetry technician noted that other than the elevated heart rate, the heart did not seem to be displaying any abnormal signals.

The orthopedic surgeon is now frustrated, concerned, and is asking you - the physical therapist - what do you think is going on. What do you tell him? (Please, don't say, "You're the doctor... you tell me!" That's an automatic FAIL if you rotate with me).

4. Physical Therapy Treatment: Total Hip Replacement, POD#3 AM

A very strong, former high-level-athlete is receiving his first total hip replacement. He is in his early 60's and has been demonstrating the most impressive physical feats post-op. However, he keeps coming across this strange "wall" of fatigue and exhaustion approximately 15 minutes after he completes gait training. His orthostatic vitals demonstrated within normal limits throughout his stay. However, he is becoming increasingly anxious regarding this sudden fatigue that washes over him while he rests in his bedside chair, after he completes his ambulation. In fact, one episode performed with nursing got so bad that the patient was forced to lay back down in bed. He expressed after the episode that he felt like he was going to pass out. When the nurses checked his vitals, there were all normal.

What do you want to check? Do you wish to order any diagnostics if you were the provider? What do you think is going on?

5. Physical Therapy Evaluation: Status-Post-Fall

A severely kyphotic and osteoporotic woman in her late 80's is admitted to the hospital's short stay observation unit due to a possible syncopal episode resulting in a fall. The physicians have ruled out any cardiac factors and are now suspecting a mechanical fall in the patient's bathroom. Per usual practice, a physical therapist was consulted to further evaluate the situation and rule out any neuromusculoskeletal contributive factors. The evaluation revealed nothing out of the ordinary - not even orthostatic hypotention.

However, when cervical range of motion was screened, the patient complained of some neck pain and a small amount of dizziness. Due to the woman's slightly impaired memory, she is unable to give you a definitive history of the fall. She did mention that in the past, she was treated by a physical therapist for vertigo.

What is your most acute concern at this point? How do you confirm this suspicion? What special test/imaging/diagnostic test would you order if you were the provider?

The results of these cases and more cases to come on Part 3 of Acute Care: Preparing Students for Direct Access!

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.

Therapydia PT TV Episode 12: Acute Care, Promoting Best Practice

Hello everyone!

I hope you were able to watch Therapydia's PT TV tonight. In case you weren't able to, Episode 12: Acute Care, Promoting Best Practice is available here:

PT TV was an incredible experience - talking live and discussing the cutting edge concepts and practice patterns with two of the industries most prominent physical therapists was true honor - not to mention a complete pleasure. You should've seen our off the air discussions - we really should do outtakes!

In any case, I wanted to highlight some of the top thought take-aways that I felt were critically important to physical therapy practice.

Top Thoughts (in no particular order):

• Physical therapy schools need to make Acute Care PT a mandatory clinical rotation.
• To truly be ready for direct access, physical therapists MUST be thoroughly trained in the complex setting of an acute hospital.
• Physical therapy professional education and training models need change. Especially in acute care, a  2:1, 3:1, or even more perhaps - needs to be implemented to reduce strain on both students and hospitals. After all, all other disciplines have operated in this manner.
• Clinical independence is insane. Physical therapy has a strange culture of valuing, requiring, guarding, and being emotionally defensive about clinical independence. However, no other profession does this. Most notably in acute care, hospitals & internists constantly consult other disciplines, physician specialists, and order diagnostic tests BECAUSE they are NOT independent - the complex medical involvements seen in the acute care hospital is far too complex for any one practitioner to actually be "independent" - this leads to the unspoken (and politically avoided) question of accountability within the physical therapy profession.
• For lack of a better description, "hardcore" acute care residency and fellowships must pave the way for not just the future of acute care PT, but all settings of PT - particularly in the wake of direct access. If physical therapists are truly to understand medical screening, acute care is not just the best; it is the ONLY place to truly absorb and appreciate the content. Additionally, such post-graduate programs would create a new culture of constructively challenging clinical thought, fostering professional accountability, and developing new business models of physical therapy practice.
• Physical therapists in acute care need to find ways to breach new healthcare roles; case management, healthcare administration, business operations, research BEYOND functional measures - these MUST be championed.
• Early ICU intervention and Emergency Department practice patterns are the new clinical wave in acute care PT.
• Acute care physical therapists bring value to the health system NOT by productivity numbers; physical therapists bring value by adding expert solutions for healthcare professionals, health systems at large... by decreasing readmission rates, decreasing lengths of stay, increasing customer surplus, adding to social welfare, pioneering a triple-thread cord of TRUE continuity of care throughout a health system, and, by improving the medical status of patients via physical therapy interventions - of particular focus,  to positively impact that of non-threatening/non-pathological physiological/pain/movement dysfunctions which are costing healthcare enormous amounts of money as is.

Please feel free to comment here on this blog - and - to tweet myself, Dr. Gorman, & Dr. Ridgeway with any  thoughts, questions, or concerns about acute care!

Sincerely & Respectfully,

-Ben Fung

Therapydia PT TV, March 14th, 2013

Hello everyone,

I'm excited to share that Dr. Sharon Gorman, Dr. Kyle Ridgeway, and myself are going to be on Therapydia's PT TV, Episode 12: Acute Care, Promoting Best Practice!

If you have any specific questions, topics, or aspects of practice you'd like addressed, please:

• Tweet me @DrBenFung
• Leave me a Facebook Post or Message
• Or, leave me a comment here on this blog!

My Best,

-Ben