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Occupational and Physical Therapists save lives in the ICU with their unique and complementary expertise. Bryan Lohse, DPT, CCS and Paul Arnold, OTR/L, CLT share with us how their Awake and Walking CVICU has developed their therapy teams. They address the question of PT & OT cotreatments in the ICU.

Episode Transcription

Kali Dayton 0:02
Brian and Paul, I’m so excited to have you guys on the podcast. Can you introduce yourself? Let’s start with Brian.

Bryan Lohse, DPT, CCS 0:08
I am Brian. Brian Lohse, I work at we work at the University of Utah Hospital in Salt Lake City on cardiovascular ICU. I have been on the cardiovascular ICU for the last nine years. And I recently got my CCS certification in the last couple of years.

Kali Dayton 0:30
Congratulations. And for everyone, what is the CCS certification?

Bryan Lohse, DPT, CCS 0:33
Oh, I’m a board certified cardiovascular and pulmonary specialists now.

Kali Dayton 0:39
Awesome. And it shows. Paul, what’s up?

Paul Arnold, OTR/L, CLT 0:43
Yeah. And I’m Paul Arnold. I’m an Occupational Therapist at the University of Utah. Also working in the cardiovascular ICU. Initially, in my career thought I would pursue working in inpatient rehab, working with patients after TBI and stroke and stumbled upon the wild wild west. That is the ICU. So I’ve been having a lot of fun learning and growing in the cardiovascular ICU here at the University of Utah.

Kali Dayton 1:12
And I’m so excited to have you guys on because I have admired your unit for a long time. I think the first time I realized what you guys were up to was when I had a patient, I’m gonna say back in 2017, no, maybe 2018 Or so he had severe ARDS, septic shock. We had a walking on a peep of 18 and 100% and a couple of days oppressors, but he did get to the point in which he had to be prone and paralyzed. And I think for the first time ever, we can have them cannulated there, and then flown just a few miles your way to the University of Utah. And we’d worked so hard to pre-habilitate him.

And we were just had a fingers crossed that he would do well come to find out we kept in contact with the family during that time. Once he got to your unit, and was obviously stabilized that he could finally oxygenate on ECMO. He was up and walking again. And I didn’t know much about ECMO at the time, I was like, Okay, people do that. And I was like, I don’t know how many people do that.

But the University of Utah CVICU has their patients awake and walking. And then I had a classmate from there. We talked more about it during my grad program, and then I did rotations during my residency at the cvicu there and I was really impressed. And I’ve just followed some of what you guys do. And I, you are obviously an Awake and Walking CVICU.

And I define that and awake and walk in ICU is an ICU that only studies patients if there’s an indication for sedation, allows patients to have the highest level of mobility unless there’s a contraindication to mobility, would you consider yourself an Awake and Walking ICU?

Bryan Lohse, DPT, CCS 2:56
Definitely, at least we do our best to be. And mobile mobility is definitely talked about every day in rounds. It is it is a standard of care on our ICU. If at all possible. These patients are supposed to get up and move. And we do our darndest to do that as a team.

Kali Dayton 3:21
And there are you know, there are exceptions which it’s not the right time for the patient. Not possible. But tell me about how you guys got to this point of having this the standard of care for every patient that it is possible with.

Bryan Lohse, DPT, CCS 3:36
So we’ve always had nursing leadership and physician leadership be pro mobility. But we just were never quite sure how to fully execute that. And when shortly after I started on ICU. Our staffing ratios, just didn’t allow for a whole lot of therapy supporting the mobility. We just weren’t well staffed enough.

Kali Dayton 4:06
And this is nine years ago, right? Yeah, yeah. So physical therapy in the ICU was still kind of a back end thing, right. Kind of visiting the ICU not not what it is now.

Bryan Lohse, DPT, CCS 4:17
Yeah, we were very much a consultative service. And we sent somebody to the ICU to do what they could. Every day. There wasn’t it wasn’t a standard person, it was often a floating rotation situation. And so you could be on the ICU one day, and then the next three days you’re on the floor. It just kind of went the way it went. Yeah. And

Kali Dayton 4:46
probably not a lot of training or expertise in all things. I see you.

Bryan Lohse, DPT, CCS 4:50
Yeah, very much not. Yeah. Um, and then we had a physician start, who was very promo Quality and, and healing dealt with us very quickly. And together, we are able to approach our management and then hospital management about doing a quality improvement project where we made therapy a priority on their ICU. And we wanted to start with just doubling our staffing. And just see what happens. We didn’t set parameters for date, days of the week or times, we just wanted to let the clinician make the best choice that they could for the patients. And we had some really good results.

Kali Dayton 5:39
And now I’m sure listeners are ripping their hair out saying How did you get pull that off to get doubled staffing? How did you get by and for that? I mean, I imagine this is before at the Johns Hopkins evidence or research showing that it’s a return on investment, right?

Bryan Lohse, DPT, CCS 5:55
Yeah, I mean, we did we, um, it was an era too. So we had planned growth in the facility, there is new floors and new building going up. And so there was planned hiring to take place for that. And our we pitched it initially as well, let’s take these new FTE and just put them on ICU. And then let’s see what the results are. And if we don’t like the results, we can just move them into the new area. Okay.

And so the timing worked for that. And, and what we found was, we had improved functional outcomes, we had decreases in length of stay, we had, we had improved continuity of care, because this this group was dedicated to the ICU. And we had improved teamwork across the board therapy and nurses working together therapy, and the physicians interacting daily, it really set a new standard of care.

Kali Dayton 7:07
And how did you see increased presence of PT and ICU impact sedation practices on the nursing side?

Bryan Lohse, DPT, CCS 7:15
Um, there was more therapists saying, “Hey, can we work with this patient?” our goal, our mandate for the project was to give all appropriate patients all the therapy time that they could handle and that we could provide.

And what we found when we delve deeper into the results, and the data was that actually our most critically ill patients benefited the most from this. So the ones that would typically be more sedated the ones that typically got less therapy, because we didn’t have the know how or the time to figure out how to work with those patients. We the project gave us the opportunity to figure that out.

And we found that all of our most critically ill those with ECMO or mechanic temporary mechanical circulatory support, continuous renal replacement therapy, and mechanical ventilation for greater than 24 hours or some combination of the three. For those patients, we could decrease our ICU length of stay by two and a half days with the increased therapy they were getting. And their overall hospitals they decreased by almost five days, it was about four and a half.

Kali Dayton 8:41
Wow, did you measure discharge to this position where they went after their hospitalization?

Bryan Lohse, DPT, CCS 8:47
We did. Um, and one of the things that’s hard with us is we our cardiac ICU, has a partnership with the VA health system in Salt Lake. And so once they go to the VA, we kind of lose a little bit of that, that ability to track and so we weren’t able to dive as deep into the discharge planning.

Kali Dayton 9:12
Yeah, that makes sense. This is so validating. I have to share that just yesterday I was in on a meeting and with a healthcare system and talking about all these things- collaboration moving forward. And one of the physicians expressed on behalf of the physician group, that they were worried that their patients “weren’t appropriate because they were on vasopressors and stuff like that.”

Meaning that it was really nice, but we were talking about but their patients are sick, therefore they have to be sedated. And it’s really hard for me to find the right words at the moment. So I somebody even asked the question, “Well, where’s the validation for sedation in that moment? You’re asking for validation for to move them to get them off sedation, but where’s validation, even start sedation, if they’re on vasopressors?”

Why is that culturally, you know, why are sedating per acuity? Why are we immobilized per acuity? Again, there are exceptions that they cannot oxygenate this movement, if they become completely unstable, obviously, that’s a threshold.

But what you’re saying it validates my experience is that the patients that are sicker are the most benefited, they’re going to have the longest course. And when you do it early in right away, you set them up to survive and thrive. So that’s extremely validating, I wish I could have had you in on that call at that moment to approach that.

That’s a very common mentality. That’s not to knock anyone at that healthcare system, or even the person that mentioned that. It is a shared mentality. But you are a mythbuster. You pro proved through your data through your work, that the sicker patients benefited the most, from your interventions.

Bryan Lohse, DPT, CCS 10:47
Yes, very much so. And the opportunity to do the therapy with the sicker patients, has really changed the paradigm, even among our rehab team, that in how we prioritize our patients. I mean, we use objective measures every day. But bottom line, you know, to very much simplify who’s ever worst is to go first, as long as it’s medically safe.

Kali Dayton 11:18
And how did this impact your skill set? I guess I’m gonna hear from Brian as well. Or Paul, how did how did you develop this skill set? You know, you were fairly new in your, your field. Occupational therapist, probably the same as physical therapists, don’t get exclusive intensive ICU training to be prepared for this. So how did increasing on this process of care standardizing this, this approach to medicine, improve your skillset, and then give you the confidence to be this aggressive?

Paul Arnold, OTR/L, CLT 11:50
Yeah, so I think it goes back to thinking about the kind of the old school model of rehab in the acute care setting is, maybe one therapist is dedicated to two floors, every day, half of my patients might be neuro half my patients might be on a trauma unit. By increasing our staffing, what that’s allowed me to do is to stop worrying about a breadth of knowledge and start focusing on some very specific pieces of knowledge.

Rather than worrying about being efficient at are actually kind of just okay, at 510 different things. It’s allowed me to say I’m going to be good at two things. And I’m going to dive really deep in on this. And so that’s done a couple things. For me, that’s improved my competency by being able to just take a deep dive on cardiovascular bathos pathophysiology and treatments.

And then it’s also allowed me to engage and be more involved with the interdisciplinary team, the benefits of having higher staffing on a floor is not only does it improve the PT and the OTS competence, but now we become a familiar face with our physicians, we’re familiar face with our RNs, who we rely so much upon.

And because we’re these faces, these experts in just this one area, now we’re collaborating more and more across not just therapists, but across with the interdisciplinary team. And when that happens, when you start to line up, and everybody gets that same vision, it really opens up the gates of what you’re able to do. If you want to try something new, and you’re a trusted face, and you’ve done your homework, you have a little bit more leeway to do those kinds of things.

Now, if I was floating to a neuro floor, and then sometimes on the cvicu, and I have this idea, even if it’s based in the most contemporary research, I might approach an intensivist and say, Hey, let’s try this new delirium prevention protocol. They might say, who are you? And and that would be a bummer if we ran into that conversation. But that’s not the case here. We’re able to have this very frank conversations with our RNs, our fellow therapists, and everybody on the floor to dive in a little bit deeper.

Kali Dayton 14:12
And sounds like you had a good culture starting out with but Brian, I mean, nine years ago, did you have this level of interdisciplinary collaboration?

Bryan Lohse, DPT, CCS 14:23
No, very much not. We had we had fantastic leadership that knew that mobility was important and promoted it but did not know the IDEO sequences to doing it. And they are floor leadership very much demanded to our therapy department. Like hey, we need dedicated staffing here. We can’t have people floating and this is a this is not uncommon argument in health systems, you know, people are advocating for themselves and in their patients.

But I was I was lucky enough to be in a position where I had done my clinical internship when I was at school on that floor. So I was familiar with all of the equipments. I was familiar with, with the staff. And so very early in my career, the my leadership or therapy leadership made the decision like, Hey, if you’re okay with this, we’re just gonna have you stay here. And I was absolutely okay with that.

Kali Dayton 15:42
Anything about from coming from a nursing perspective myself. Nurses generally don’t like to float amongst all the different specialties, right, if an ICU nurse gets flooded to the floor, they’re not excited about it. If a floor nurse is expected to flow into the ICU, everyone gets alarmed because that’s unsafe. But we’re expecting that of PTs and OTs!

Bryan Lohse, DPT, CCS 16:05
Yeah.

Kali Dayton 16:06
And we’re not providing training that can nurse gets onboard into the ICU with intensive programs and training, which I think still have gaps. But we don’t do that for PTs and OTs. They just say, “Here’s your assignment, get up there, go go Do you know your your therapy thing, whatever that is.”

So there’s obviously so much merit in having a very dedicated place to build relationships, repore, history with them, have your expertise honed in on that exact patient population and those needs and then to know each other and work collaboratively towards overall goals and, and quality improvement projects like what you’re describing

Bryan Lohse, DPT, CCS 16:45
100% And I really have to give our boss credit because I think he envisioned this years before it was actually able to happen. This was a process long in the making. And shortly after, I became dedicated on the ICU with one of my colleagues, our staffing as a whole transition to teams like therapy team. So we have a critical care team which our ICU, our team fell into, into the group with so we’re we’re a part of a bigger team that is responsible for multiple ICUs. And we have a neuro team that just takes care of the neuro patients and we have internal medicine and ortho and apprenti.

Kali Dayton 17:34
I like to use the word even therapy, not just rehabilitation therapy, I want to go on a tangent. I know that rehabilitation is a bad word. But I feel like the context in which we use it implies that we’re going to do this only on the back end to fix the cleanup the damage. But to me to hear you say therapy is a therapy team, not just a rehabilitation therapy team means that the timing can be whatever. And you guys do it on the front end. So you’re more for most patients probably pre habilitative– preventing the problems. You’re not just the rehabilitation team that comes in on the back end. But you’re there on the frontlines with everyone else right away.

Bryan Lohse, DPT, CCS 18:14
Oh, yeah.

Paul Arnold, OTR/L, CLT 18:15
I think that’s the shift that we’re starting to see at least we’ve seen it here at the university, but as a culture in the therapy world as a whole is moving away from at least into the same degree moving away from the consultative service saying, “Hey, I’m therapy, I’m recommending you go to skilled nursing, you go to inpatient rehab,”.

We’re moving more towards starting that therapy process right away, increasing the minutes and the interactions that we have with the patients to prevent and reduce the impact of this hospitalization altogether. So our boss has this catchphrase. I don’t know where he came up with it. But he says “Acute care is the new rehab, start treating patients as if they’re inpatient rehab”.

Patients in the ICU on the step down units. How much further along are we going to have our patients by the time they do get to a skilled nursing facility? By the time they do get to inpatient rehab? Will they need inpatient rehab, by the time they’re done with their hospital stay if we’ve already treated them, you know, 30 times between PT and OT?

Kali Dayton 19:23
Oh, I love it. And we’ll get into that. divvying up the doses right between PT and OT. But I think what happens in some of the older models of care is that patients stay sedated until they’re trained and paid. And then they’re sent to L tech. And suddenly, they’re appropriate to mobilize, even though nothing about their status has changed.

And maybe they sat there for a few days in the ICU waiting to transfer but they weren’t mobilized because they were in the ICU. They were “too sick”. They were sedated because they’re just there. But the idea of treating it like in a rehab center during the critical Illness is a really good approach. You just captured what we’re working towards on this podcast!

And you guys are sitting side by side, both talk to me about this project that you’ve worked on together. I think sometimes we perceive OT and PT as interchangeable. But you’re really not. I know you’re both a little bit triggered by that, right?

And I’m sure many listeners are too! And I bring that up because it is a hot topic, right? It really gets people going. Not the nurses, not the doctors, not the RTs. It gets the OTs and PTs going right?

So explain to the rest of us the difference in your roles, and how you guys work together, because I see as I’m working with teams, especially when patients are deeply sedated, and then they’re trying to rehabilitate them. PTs and OTs are working together. And I think there’s such a better way to do it. And you guys have this mastered. So tell me about how you guys work together but not together?

Paul Arnold, OTR/L, CLT 20:52
Yeah, the way I looked at this, the analogy I give is occupational and physical therapy, we are sibling services, we so siblings are going to have similar characteristics may have learned some similar things, or we’re going to have our distinct personality. I as an occupational therapist in the ICU.

While I am a rehabilitative service, I’m going to focus on early activity with my patients. I’m trying to reintegrate that patient’s role and identity and help them to maintain that sense of activity participation while in the ICU. The benefits of doing that have returning them to their normal applied daily activities is ideally to help reduce the incidences and duration of delirium that take place. It hopefully is in place to help reduce the effects of learned helplessness that happens to a lot of our patients in the ICU.

And it ideally is going to help reduce the risk of ADL dependence on other individuals, if patients are not able to do their ADLs. By the time they leave the hospital, they are at a higher risk of coming back to us in the following 12 months. So I’m trying to make sure they can do those safe activities safely and independently. By the time they leave the hospital. That’s where I’m I’m envisioning my role as in our ICU.

Kali Dayton 22:24
And that preventing readmissions, one of the ways in which fairly recent study showed that OT is one of the only services that have a direct impact on health care costs, in terms of readmission for very specific diagnoses, right.

Paul Arnold, OTR/L, CLT 22:40
Yeah, that was specifically for patients with myocardial infarction and heart failure, I believe, and pneumonia are the three diagnosis found that O T was an underutilized service for patients with those diagnoses.

Kali Dayton 22:57
So increasing your staffing, even just for OT’s isn’t obvious return on investment. Tried and

Paul Arnold, OTR/L, CLT 23:03
Yep!

Bryan Lohse, DPT, CCS 23:06
Then PT, you know, we’re a little bit more known in healthcare, we’re the mobilizers. Our job is to get people up, get them moving, get them out of their room, and, and do the big exercises, the big, the big movements that patients need to do to have the strength and endurance and ability to be able to discharge safely.

We we can start this very early on as little as post op Day Zero sometimes. And do this in a safe in an educated way. Collectively, I think PT and OT, are the, for lack of a better term, the tour guides for patients functional recoveries. And we help do this through education and chances that we give people the opportunity to do these activities, and we figure out where they’re struggling and help them to overcome that.

Kali Dayton 24:27
And why don’t you treat together?

Paul Arnold, OTR/L, CLT 24:29
Oh, yeah. The problem with seeing both services as one PT OT as just one independent service is it’s going to decrease how specialized we can in specific we can be with the patients. It’s also going to reduce how frequently those patients are going to be seen.

And there’s been a handful of studies one by schweickert and Pullman one by Evelyn Alvarez. They’ve shown that increased frequency of treatment with patients is going to benefit them more than than fewer treatment, it seems like a simple thought.

But if we’re just treating it as one unit PT OT, then that patient might only be seen one time during the PT or OT, it’s the inner if we’re seeing it as interchangeable, versus if PT and OT have their own unique identities. Now, Pts working on some very specialized, they are the experts of mobility and getting patients up.

Now they’re going to get a second session with OT, focusing on early activities and ADLs and getting them independent. So now we’re both getting them up and active and increasing that frequency and volume of treatment with our patients.

Kali Dayton 25:43
And each time each session, the body and the brain and the patients I want to soul, everything’s engaged, versus laying in bed for 23 hours a day not interacting. I see you guys leaving assignments, homework, tools, you’re engaging the family, you’re telling the family what to do. And so each time that happens, that’s reinforced.

And the patient and the family have more things to do when you’re not in the room. So I think you’re the impacts that you leave lasts far beyond when you walk out the doors. And the more that’s reinforced, the more people that hear it from and actually engage with, the better it is. And I again, from a nurses perspective, I’m not worried about my patient, when ot isn’t there, right?

Someone’s watching them, I know that they’re going to be worn out, they’re going to sleep after that session, they’re going to be calm, their needs are going to be met, they’re going to someone else’s helping communicate with them, like all those things are making my job easier, which I don’t think nurses really appreciate. But sounds like your nurses, they probably run to you and I have delirious patient, right?

Paul Arnold, OTR/L, CLT 26:52
Yeah, we’re pretty lucky we actually on our unit, we spend a whole day during the nurses orientation, where they we spend time mentoring them on, what’s the purpose of PT? What’s the purpose of OT? Why are we even going into seemingly provoke your patients to begin with. And so we go over a few articles as to why this is beneficial.

We spend about 20% of the day just talking about that, and that kind of a didactic kind of format. And then we bring them along and do a little ride along, they see, you know, three to four PT sessions, they see two or three ot sessions, and then they get to follow speech along and watch some modified barium swallows and some swallow interventions, those those kinds of things.

And that that point in time during their orientation is a little ways in where they’re a little bit more familiar with the floor. And they’ve seen who are these random people coming in my room. Okay, now I get to see why they’re doing what they’re doing.

And so I think that’s an important point during our nurses training that’s helped with us to be a little bit more collaborative with our nurses. As a result of doing that over the last like five years that we’ve done that now is our nurses do come to us and they’ll have conversation saying, “You know what, I’ve got this patient when I turned down their propofol, they’re becoming quite agitated, do you want to come in and see if you can direct them along and see if we could get the see if we can get the restlessness out of them?”

And it’s, it’s pretty magical to take a patient from a point where they don’t know where to burn this energy to reorient them in and guide them through and become familiar with their situation again, and to afterwards see them or their nurses say, you know, I think we can titrate this down a little bit. We’re in a, we’re in a better spot now. So it’s pretty cool to see.

Kali Dayton 28:41
Thank you guys for the big guns that need to be there during awakening trials. And it baffles me that nurses are not informed of what their resources are or how to utilize them. But yet, they’re the ones that are left with a huge task of turning sedation down or off. It just it obviously, is not working.

Unless you have this kind of culture in which they know their why they know why these things are happening, why patients are agitated, they’re not wanting to continue deep sedation because they know why.

But they also they know you! I love the idea of you guys being the ones to be training them on this as part of their introduction to the ICU instead of one one trainee nurse saying call OT and PT whoever they are, or whoever’s on that day, but you’re there being like, hey, we get it. We are the delirium experts. We are the mobility experts, and here’s how we want to help you. You’re right off the bat, building up that rapport with them, those relationships, that trust that obviously plays into what happens at the bedside. It’s magical.

Bryan Lohse, DPT, CCS 29:44
They’re very much though and I mean, during the therapy day, it’s not just them observing us. They’re participating in therapy. Yeah. And we at some point during the day, have a hands on scenario discussion where we just go into an empty room. We use the hoyer we, we familiarize them with all the equipment that’s available.

And and we kind of classify, you know, what? What is a? What is a patient that should probably have PT or OT doing the majority of the mobility? And very much so what it is a patient that anybody can help mobilize?

Paul Arnold, OTR/L, CLT 30:22
Yeah.

Bryan Lohse, DPT, CCS 30:23
And so when we do have these patients wake up, they get isolated postoperatively, maybe it’s overnight. If, if they’re safe to get up our nursing staff, just get them up. And yep. And if they’re not, we, when we walk in, in the morning, before we even sit down, we usually hear from the night Nurse like, “Hey, Make room 22 or priority, they’re ready to go whenever you are.”

Paul Arnold, OTR/L, CLT 30:46
Yeah.

Kali Dayton 30:48
I’m sure other PTs and OTs that are listening to this are weeping. That is that is the dream, like that’s what we want to happen in our teams. And I get frustrated when I see efforts and projects being rolled out for early mobility and they say “We just can’t get our nurses to do it.”

Oh, that that for me, that’s a trigger! You can’t get your nurses to do it? Have you actually taught them how to do it? Have you provided the support have you brought in all the resources in the collaboration that they need to make that happen?

Because a lot of times what I’m seeing is that nurses, especially those that have come in during COVID, which are a lot of our nurses now, they didn’t receive any formalized training. Yet, because it’s part of the job description or scope of practice, they’re expected to just know how to get these patients up.

When really all they’ve been trained to do is sedate them and turn them. So we have to be providing the education. So I really appreciate that. That’s part of it. I think a lot of nursing onboarding programs and ICU, go over our titration, a lot of monitoring, management, things like that, but not mobility and not delirium. For the most part.

Bryan Lohse, DPT, CCS 31:48
I mean, one of the things that we’re lucky to have also is being a cvicu, there is a lot of other equipment. There’s ECMO is temporary devices, ventilators continue, oh, that’s all that, you know. And you know, so for I mean, any temporary device.

It’s just our policy that nursing is there during therapy to monitor the device. We understand the devices were educated on the devices, we go to all the same welcome with ICU basic ICU classes that our nurses do. But we, we they very much help us with monitoring and managing the devices during mobility.

So they’re there. And so they’re getting exposure to mobility during therapy also, and we work together with them now understanding that our nurses are quite busy, they have their own jobs to do they have all the things that they need to do on the day. But because our floor leadership makes mobility such a priority, we work together to find appropriate times for each patient to do therapy.

Paul Arnold, OTR/L, CLT 33:04
Yeah.

Kali Dayton 33:05
And I think that’s probably one of the keys in to not co treating with PTs and OTs is that you have nursing engagement, and the skills and the perspective and the culture all of that. I had to look back into why was I as a nurse, so comfortable walking patients on ventilators at night with no PT?

Because people say “We don’t have PT at night or on the weekends.” And I’m like, well, that never really stopped me as a nurse. I had to look back into my experience and like No, it’s because I’m day shifts. I you know, PT was there. I was coaching with them. I was helping with that.

So I developed that skill set. And so I think that ICU could still have more formal training, especially for onboarding nurses. Poor travel nurses or new nurses that come in are like, “Hi, this is what we do welcome!” And just assume that they’ll jump in like the other nurses.

I’ve realized now that that’s not really fair. But that is what happened to me. That’s what we just do there. But participating with a PTs and OTs gives our RNs an opportunity to develop that skill set. And it makes it a lot quicker I’m seeing with teams that I work with initially. All of this is so tedious. It takes so much attention and brainpower just like with pruning to look through every little process, even for the therapists, right, that don’t have all the experience that you have now for mobilizing patients, all these lines for years.

Everyone has to really be cautious. I mean, you’re always cautious, but they had to think through every little thing. But that speeds up. Did you experience that as far as cuz I’m thinking your your nurses are really busy, but they’re there. They’re in on those sessions. But how do they do that? Could it be that you guys have that skill set that makes this a much quicker and streamlined process?

Paul Arnold, OTR/L, CLT 34:48
I think it part of it is we have the culture already in place. And so there’s an expectation already. When you’re starting out to to move forward with these kinds of things, there’s initial resistance or hesitation, I should say, to actually get involved in doing these things. But when you’ve done it so many times, and it becomes an expectation, when new nurses and different individuals start coming in, they just jump in, because that’s the expectation of what of what you do. I think that’s what we have going on right now. What do you think the initial process was, like, nine years ago? Starting that up, though?

Bryan Lohse, DPT, CCS 35:30
I think there is. I think it helps to have top down support. Yeah. Like we had an attending that very much that therapists are the experts that moving patients, we need therapists here. And, and, but once, once you kind of get everybody on board, and and do those first couple big scary sessions, and see that things are fine, and see that things are okay.

Paul Arnold, OTR/L, CLT 36:03
Yeah,

Bryan Lohse, DPT, CCS 36:04
People start to say, “hmm, maybe we can do this!” and they start to look to do it. You know, we recently as much as we mobilized, we recently mobilized our first femoral balloon pump. And we stood him up on the tail table, dropped him down the floor and walked off the table. And a lot of people were like, ah, and, and but everybody that saw that, you know, the next 30 Balloon pumps that came through the door, they’re like, “Can we do it with this one? Can we do it with this one?”

And once once you see that it’s okay. And you take all the safety measures that you can take absolutely creates buy in. And in we all love see our patients get better. It’s, it’s really easy to get burnt out when your patients aren’t moving in there are less than stellar outcomes associated with that when people move, there are better outcomes. And in mobility is an easy improvement to see. Even just sitting in the hall at a computer charting if you see a patient making progress. It’s like huh, “okay, this is what we do here. And increase buy-in.

Paul Arnold, OTR/L, CLT 37:27
Yhere’s some that Bryan does that I noticed when I started here, back like five or six years ago. Bryan, you can’t tell on the screen here. But Bryan’s a pretty tall, intimidating looking guys, six, six, he’s got deep voice, he’s very charismatic. But I noticed he’d bring patients out into the hallway. And he’d set up shop right in front of nurse’s stations.

And so he would have these, you’d have these built in like cheerleaders for patients. I think that was you do this all the time. And I think that’s so beneficial, not only for the patient, to have somebody like saying you can do this, but it’s so exciting for the nurses to see, “Hey, there’s this patient up in the hall with an RVAD right now. And they’re, they’re crushing it, they’re doing really well.”

And so everybody together gets into this just exciting kind of moment. And I think that propels things forward, as much as we want to be. Like, humble about our job and things, right, just get in, do the work, do a good job, the social aspect is really beneficial. Let everybody know about the winds that your patients are having. And people get excited. My some of my favorite conversations to have after at towards the end of the day when things are winding down is when an RN comes over and says, Hey, we had an awesome session today, that was pretty cool. And you can tell they were pumped up about that therapy session too. And it gets to be contagious.

Bryan Lohse, DPT, CCS 39:00
It even it creates buy in for the patient to, for the patients to hear. And when it’s not just the same therapists coming and saying, “Oh, you’re doing so well.” But when 20 Different people are telling them the same thing, then they start to believe it. And then the patient’s self motivation is is huge in their own recovery.

And those patients that we can develop that those patients that have grit, you know, that make it easy to fight for them, but those patients that we can develop the grip, yeah. Those are some of the most enjoyable turnarounds that we can see. And with what we do, and Paul is very nice, but I am definitely a big believer in doing therapy out of the room and and off the floor, if appropriate.

And it’s just there’s something that switches mentally for patients, when they see different people in it. different set of walls. Yeah. And it’s so important to do. And it’s, I am very much not an edge-of-bed therapist. I know there’s a lot of there’s a lot of training sessions that can be happen, there’s a lot of good things you can do sending a patient on the edge of that. But I think to really create buy in for mobility people, patients need to see other people and people need to see patients moving.

Kali Dayton 40:28
Absolutely, I think I’ve been just dissecting my experiences, realizing the impact that it has on other patients that are in their beds are in the chair, right. And they’re maybe on the ventilator as well or getting close to it. They’re watching other patients go around the unit. And it just normalizes the whole thing. Like ” I am in the ICU, I am sick, but I’m not dying in bed right now. And neither are they and they look like they’re doing okay, I can do this too.”

Especially for the patients that don’t have that innate grit or a lot of reservoir of emotional or physical capacity it’s really motivating. I love it when therapists play music in the halls with the patients that are walking. Just the tone that it sets, because yeah, you can have a really hard event in the morning. And everyone can be feeling the impacts of that. And then you have another patient that’s in their own little world, right? Listening to Michael Jackson, cruising the halls, and and it just, it brings you back into “Let’s move forward to the next patients, they still have a chance.”

Paul Arnold, OTR/L, CLT 41:26
Yeah, there’s this great poem by Galway Canal called St. Francis and the SAO. And kind of the thesis of that poem is, sometimes it is necessary to reteach a thing, its loveliness. And I think some of my favorite sessions are when I have a patient who maybe doesn’t believe in themselves in that moment, to get them up in the hallway to do something that’s maybe stressful, maybe difficult.

And then have them sit back down, get get comfortable on a chair back in bed and to just see a big grin on their face and to see them like feeling that having having had that reminder, like, Oh, I’m a pretty a pretty hard working individual I can I can do this. I can I can work my way through this. It’s pretty powerful stuff.

Kali Dayton 42:13
I think I’ve felt like the best clinician when I am really pushing a patient to do the right thing for themselves. And keeping them focused on the big picture of walking out of the ICU and going home. And sometimes Yeah, they’re not excited about it. And it is a hard thing. I just remember.

I think I told the story in previous podcast episodes, but I had a patient that at baseline, she’s a motorized scooter. But we were afraid while she was on the ventilator for for some severe pneumonia, that she was going to end up with a tracheostomy because she was so weak. So we basically rehabilitated her during her time on the ventilator. And she was just dead on shake, not just because she was weak, but because she was scared.

She was so scared. She was pretty emotionally fragile, too. And I pushed pushed, pushed her anyways, years later, she found me in the cafeteria of another hospital and said, “Hey, I know you, you’re my nurse in the ICU, I thought I hated you. You were so mean, you made me walk when I was scared and tired.”

And I was like, “Oh, this awkward. And then she had me this huge bear hug and said, but I’ve loved you ever since you saved my life.” And I was like that, and this is before like the podcast before understanding the big picture stuff, I just realized that these things that I was doing, work really paid off, and they recognize it in the moment.

So having that perspective in that moment, made me feel the most powerful and more powerful than bagging someone or titrating vasopressors. Like that is true power right there is to get them to fight for their own lives.

And Bryan, I knew about your work way before I ever met you or became in contact with you or knew your name. ESPN posted video one of your patients years ago, who was on ECMO shooting baskets outside? Tell me about how that happened. And what other crazy stuff do you do there?

Bryan Lohse, DPT, CCS 43:57
Um, I mean, that was that was a fun session. Um, what’s really interesting is that ESPN posted that and that was like four years after we actually did that. So that made its way to the internet, very, very late. But we were very much around the time we did that QI project. We we had this idea that our system came up with this idea called Imagine perfect care.

And we we came up with this idea, you know, like instead of instead of saying, “No, we can’t do this, no, we can do this.” When people propose things we say “Well, let’s figure out if we can make this happen.”

You know, there’s obviously some hard lines in the sand that we can just can’t do but taking an ECMO patient outside who was a very high functioning individual prior to getting sick um to challenge them in a different way, like going and shooting some hoops was was very much within the realm of doing appropriate therapy.

Some people thought I was crazy, but to my credit, their cannula was on the was on the right. He was left handed. So the ball was always away from the from the ACMA. Um, but the what? A little note aside, um, oh, I don’t know, what was the question again?

Kali Dayton 45:33
Just how did that happen? Oh, um, how did you get buy in from your team?

Bryan Lohse, DPT, CCS 45:39
Um, they, they said, “What do you want to do?” And I said, “Let’s go outside.” And they said, “Let’s do it,” though. It was his nurse was a just an amazing individual.

Kali Dayton 45:52
And visionary.

Bryan Lohse, DPT, CCS 45:53
Yes, visionary. She are our nurses. We have a nurse led a nurse driven ECMO program. And so our nurses manage our devices, we are not perfusionists on the floor, managing our devices, it’s our nurses. And so, which is great. They get the whole picture. They do they get the whole picture, they understand that patients need to move, they understand how to help patients move.

And so there’s one last person to create buy in with and without having to go through a perfusionist on the floor. You know, so it’s in our attendings are like, just keep them alive. And I’m like, great, we can do that. And we, in our goal is to do as much therapy as possible. So we, we walked over to that basketball court. And so that basketball court was outside of our old rehab hospital, which was probably 2500 feet from the ICU. And in so it was a very solid therapy session. He wanted to go outside and I said “Let’s go outside!”

Kali Dayton 47:10
What did it do for his morale?

Bryan Lohse, DPT, CCS 47:13
Oh, it was great doing doing he was an individual that did sports at baseline. So being able to, to do something sports related, even in his situation was was great for him.

Kali Dayton 47:28
I’m hoping to do a podcast episode with him. So I won’t give away his uh, his final outcomes, but he is doing well and will end up following your footsteps in a lot of ways. Let’s just put it that way. This is amazing the impact that you made in that moment? What else what other similar stories?

Paul Arnold, OTR/L, CLT 47:48
You know, I had a, I had a patient, maybe not as like, flashy of a situation but something pretty magical as maybe maybe could I share two short stories that are added in. So we had a patient that was quite young, and we don’t, we don’t typically get the younger patients. And we were working pretty hard with this younger person.

And they were on a device and everything. And everybody was rootin for this patient, and we’re doing everything we can as therapists, nurses, whoever. And after a couple months of being here with us, that that patient ended up actually passing away over over a weekend and it it hit me pretty hard.

I actually called into work did not come in for a couple of days, because I was a little cut up about the whole situation wondering, “Is the ICU even a place to work as a human being? This is this is emotionally devastating.”

Not long after that I had a patient that was quite delirious, could not get him to wean off sedation without fighting with the ventilator. And the nurse came over and said, “Hey, this guy has had a lung transplant, we need to get him vertical. Can we see if we can figure this out?”

Went in and worked with that patient ended up helping to wean down their sedation a little bit. Our whole treatment session was just standing edge of bed and getting him to give his son and give his wife a hug. That was our that was our session. And it was pretty special in that moment for that that mother and son to have that with their dad continued to treat him and he ended up being with us for a little while.

And so you start feeling like “Oh no, this is going to be a repeat of some other things that have happened.” He ends up doing well as we progress with him and work through that process. Well, I ended up kind of forgetting about him because he did so well.

And I was at a soccer game a few months. Slater for my son’s six year old son. And if you’ve never been to a little league soccer game that are adorable, they just hang out in a little pod together and chase the ball. And so I took off the morning from work had kind of the sun in my eyes, I was watching this and a gentleman in a baseball cap, and a hoodie comes over and says, “Hey, can I shake your hand?”

I had no idea who this individual was. And it was that patient who had had the lung transplant, he said, “You were my OT when I was in the ICU. And I’m so glad I ran into you today.” And I just gave him a hug. And we just talked about golf for the rest of the time.

And it was pretty magical to see the contrast, you know, you see so many hard things every single day, and that can weigh on you. But just being able to see the outcome of this guy, it was his first time actually going out in public afterwards. And we happen to run into each other he was at his grandson’s soccer game, and I was at my son’s and to that, that reaffirmed to me that the process, the struggle that you go through as a therapist, as a nurse is whoever it is worth it.

And there are these really beautiful things that happen for folks afterwards. And that’s only going to happen if we do the right if we create the opportunities for that to happen to begin with. If we would have said, You know what, this, we can’t win this guy’s sedation, just wait and see, it might have been a different outcome for this guy. But instead, we worked together and said, let’s give it a try. We’re going to trust the evidence and create this opportunity going forward. And it worked out in that situation, which is pretty cool.

Kali Dayton 51:42
And that’s what this is all about. That just captures what all of this work you’ve done for so many years, all the pushing all the changes all the revolutionising that you’ve been doing, you create those opportunities for patients to thrive and the impact that you make is immeasurable.

Right? I just think about those moments, those little decisions that the little things are not so little while, you know, I think we always think, why not wait another day for sedation, right. But that’s, I looked like to a doctor because she said in a couple episodes ago, every drop matters, every drop is toxic, every drop makes an impact.

And there’s a recent study showing that early mobility changes cognitive outcomes immensely. But it’s you guys that are bringing in this focus and expertise and really lean your your team to optimize everyone’s role for this overall outcome. I’m so grateful for all that you do in this example that you set for the rest of the community, anything else that you would share with the ICU community.

Bryan Lohse, DPT, CCS 52:47
Um, I think we’re really lucky to work on a floor that tries to help everybody work at the top of their license and in give some some breath for some individual autonomy and decision making, within the scope of medicine as a whole.

But it definitely has taken a few there’s a few key innovators that have been a part of this process that have really pushed for it and, and their their efforts have taken a while for us to get to allow us to get to where we are today. And I think for those out there that are are trying to be the innovators keep keep doing it.

The it’s the critical care medicine is kind of like a big ol giant cruise ship, it takes a long time to turn a cruise ship. And so change can happen and in, in culture shifts can happen. And I think we all just need to continue to promote doing the right thing and following the evidence.

Kali Dayton 54:06
Patient by patient person by person. Yes, absolutely. And any victories of victory. Some people get inside of there first. But once you get that taste of the sport for this patient, it’s hard to watch it not happen for all the patients every shift from then on out.

So I think that’s one of the big trials of being a revolutionist is high that patients maintain that perspective and that hope so thank you for that validation. Thank you for everything that you’re doing. And I’ll post that video on Instagram of your your friend, city baskets on ECMO. And we’ll I’ll tag you guys in it so they I’m sending off the wolves everyone can come contact you. I think you guys are obviously experts in this and should be utilized as such. So thank you so much.

Bryan Lohse, DPT, CCS 54:52
We are open to help him wherever we can.

Paul Arnold, OTR/L, CLT 54:56
Yeah, we love talking about this stuff. Thanks for having us. We appreciate it.

Kali Dayton 55:00
Thanks for being willing to share what you’re doing appreciate it

Transcribed by https://otter.ai

References

Improvement in outcomes from early mobility in the CVICU:
https://pubmed.ncbi.nlm.nih.gov/30172645/

Benefits of Occupational and physical therapy in the ICU:
https://pubmed.ncbi.nlm.nih.gov/28385485/
https://pubmed.ncbi.nlm.nih.gov/19446324/

St. Francis and the Sow Poem:
https://www.poetryfoundation.org/poems/42683/saint-francis-and-the-sow

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