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In Part 2 with Stephen Ramsey, physical therapist and ICU mobility expert, the discussion dives into a complex cardiothoracic ICU case Stephen presented at APTA’s CSM conference.

Using the MENTOR framework, Stephen walks through how rehab clinicians should approach critically ill patients — from chart review to interdisciplinary communication to real-time clinical decision-making.

Episode Transcription

[00:00:00] This is the Walking Home from the ICU podcast. I’m Kali Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we’ll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive.

Welcome to the ICU revolution.

Okay, we are back with the Steven Ramsey. If you don’t know what’s going on or who he is, listen to the last episode. But it’s part two of Steven’s show. [00:01:00] Hi, Steven. Hi. Thanks for having me back after part one. This is exciting. Yeah. Yeah, this is great. So tell us what you’re envisioning and what we’re gonna do this episode.

We teased this in episode one, but basically I think wanting to use this platform as an opportunity to provide some amount of education and thinking through ICU cases, obviously from the rehab team perspective, but we’ll have your perspective as well. And so today I thought it would be good to go through a fairly complex case and talk about some frameworks that I use to think about complex cases, some of the framework I use to have a discussion with the medical team and just, yeah, have a discussion about that.

And then that will lead into maybe more specific touch points back to some education opportunities later on in other episodes. So I can introduce the case. Just know for the audience that’s listening, just know that this is not all of the information. It would take a long time to go through the entire case.

So I’m just gonna give snapshots of it [00:02:00] and just an overview and then, then jump in. Is that cool? You presented this case at APTA’s CS. I said CS. Yeah, that’s right. Um, and really framed for teaching physical therapists. Right. And I am really excited to have this perspective ’cause I want all the other disciplines to listen to this and also be critically thinking in the same way, but to be learning about how physical therapists can, should, or do think and function, the role they should play.

I might interject with some yeah, buts or hesitations from the provider perspective or other disciplines to kind of balance what real-life barriers physical therapists face at the bedside right now in many ICUs when it comes to practicing in the way that Steven’s gonna going to be painting the PT role Great.

Yeah, I– there’s some connection stuff, so if it, if I drop out, let me know. Okay. But, [00:03:00] so yeah, so I, and I, and I did wanna just mention I was fortunate enough to, to present this case with a couple of colleagues. So Paul Ricard from Johns Hopkins talked through the history of, of the recent history of ICU mobility from a data standpoint.

And then we had my colleague at Piedmont, Ben Purrington, who talked through just the, a mental framework around mentorship and menteeship. So, and that, that’s actually I think a really great point that you’ve alluded to on your podcast, is that it’s not always on the mentor to make the mentor-mentee relationship, that it does…

There’s a big onus on the mentee to be open and accepting of feedback, to be self-critical, kind of self-analyze. So, he did that and then y- Megan Gessurst, who’s in Chicago, did a great job talking about, yeah, just discussing with the medical team how to have difficult conversations, which as PTs, if we were self-reflective and critical, sometimes that’s what we struggle with, so…

And then I brought it home with a [00:04:00] case. So that’s what I’ll do now So, well, I’ll introduce a 63-year-old male with a past medical history of CAD. Also has a heart failure with preserved ejection fraction, paroxysmal AFib, hypertension, hyperlipidemia, diabetes, some remote alcohol use and/or abuse in the past.

Over a year ago, had a STEMI and discovered a 99% occluded distal LAD and diag- first diagonal, 90% occluded first diagonal. Got three drug-eluting stents at that time, and all was well. The only complication post-PCI was that there was some ectopy, and then ultimately in follow-up with cardiology was started on amiodarone at home.

Over the course of the next several weeks to months, the patient reported dyspnea, was k- more fatigue. Just thought it was like post-MI fatigue, trying to get back into exercise. In a planned echo as follow-up in June, so that was all in February. Then in June, [00:05:00] found a small six-millimeter ASD with a left-to-right shunt, and already saw signs of right atrial enlargement.

So when we’re thinking about structure and function changes, we’re already seeing evidence that there’s right-sided volume overload and right atrial dilatation. And there was a mild reduction in RV function, so they decided to just follow that. They echoed again in October. That ASD has grown from six millimeters to 1.6 centimeters, and at that time it was a moderate shunt, severe RV dysfunction, severe pulmonary hypertension, severe TR.

Not a great picture, but yet still preserved systolic function on the left side. So the whole plan was, we’re gonna have to do something with this. This is growing rapidly. There’s symptoms associated, so we’re gonna probably do an ASD closure, plus or minus tricuspid valve clip maybe, and then that probably would need to be protected with an Impella RP flex or some sort of right-sided support.

That was the history. Before even getting to the surgical planning phase, the patient suffered [00:06:00] a kind of a syncopal episode at home, fell into the table, hit his chest, fractured some ribs, showed up to the hospital. That post-syncopal phase, hypotensive, had some chest pain. CT revealed– Chest X-ray and CT revealed this big effusion that had collected on the right side where he had actually fell and hit his ribs, which is suspicious Now, we’ll fast-forward.

About five days later, the structural heart team takes him for ASD closure, given the fact that it had been a symptomatic ASD, wanted to go ahead and get on top of it. Patched it as part of that procedure. Obviously, sh- the plan is to give a bunch of, of heparin. They admit him back to the floor and, you know, basically are like, “PT/OT, go do your thing.

Get him out of here.” Unfortunately, later that evening, the patient suffered an arrest, got ROSC really, really quickly, but was intubated on pressors. The first CT showed a big right hemothorax with active extravasation. So just to quell that, they put a, just a 14 French [00:07:00] pigtail in with the plan to always to upgrade that to a larger bore chest tube.

Again, jumping ahead, so he’s in the ICU, goes to IR, gets some coil embolization of four intercostal vessels. But there was still this active extravasation, although they had diminished some of that active bleeding. They did upgrade that 14 French to a 28 French, and we’re hoping we’re out of the woods at this point.

So the patient unfortunately did look SIRS-y at that point, but is that post-arrest, multiple interventions, all that stuff. They did blood cultures and found MSSA bacteremia. So the next 48 hours was a struggle. High-dose pressors, inotropes, even started nitric oxide for the RV dysfunction. Index was 1.7. So in this mixed shock picture now is this distributive shock with cardiogenic shock with still maybe some lingering hypovolemic shock.

I don’t know. But end organ functioning was [00:08:00] worsening on CRRT with an AKI. Thoracic was consulted for all this stuff, and ultimately the plan was, “Hey, this guy’s gonna need a VATS,” but he’s not really stable and ready to go for a VATS. He was on 100% FiO2, a high PEEP, so the patient was really sick.

Fortunately, about four or five days after this, started to be able to tolerate coming down on pressors, actually weaning some sedation, weaning FiO2. But at this point, now that the patient looks like they’re stabilizing and we’re trying to make a decision on is this patient appropriate for mobilization and rehabilitation, now we have to assess the systems.

So still kind of- Febrile. So they get, uh, Dopplers of the upper extremity, lower extremities, which they found upper and lower extremity DVT. Still on relatively high FiO2. So on the day of potential PT eval, blood pressure’s stable, 105 over 72. Heart rate’s 96, still in AFib. He’s oxygenating and ventilating [00:09:00] well on 70% FiO2 and 10 of PEEP.

CVP’s four. PA pressures have come way down from where they were when he was admitted after we passed the ASD. At this point, it’s obviously the patient’s very sick, but we need to make a decision on if this person’s appropriate. So what I presented at CSM was actually using a structured framework called the MENTOR framework.

Basically, we just map the story, so that’s M. Map the story, and then we get into exposing the unknowns. What about this case do we have questions about? Do we need clarification about? After that, then we get into, we just basically narrate our reasoning. So whether that’s you with a mentor or a colleague or the medical team, here’s what I’m thinking.

Does this make sense? I’ve answered these questions. I’ve discussed the case, so I’m narrating my reasoning. And then once you make a decision, you test your theory, so that’s the T portion. I think we should reframe how we view PT and OT from an intervention to more of an assessment. So when we talk about treating this [00:10:00] person, we’re really saying we’re gonna assess their physiologic response and then make recommendations to the team.

So we’re gonna test the theory. The theory is the patient’s gonna be tolerant and benefit from mobilization, and let’s go test it. When we do that, the O is observe for signals. So what are they showing us in the room in real time? Did they in fact tolerate it? Did they not? And then why? And then finally, the R is review with the team.

So take all that information that you’ve gained through your thorough chart review, your exposing, kind of your unknowns, discussing with the team, and then testing your theory, and then go back and provide some feedback to the medical team. So I know that was a lot, but that’s the case, and I’m gonna prompt us with several of the potential unknowns.

And I get the benefit of hindsight is 20/20, so I get to sit here in this chair and act like I know all, everything. But if you’re listening to this, you could probably come up with some questions that you would have for the medical team. With that, and I do want your opinion here, Kali, ’cause this is something [00:11:00] that I, speaking from the, a PT perspective, I think there’s a right and a wrong way to approach the medical team.

That’s just my feeling on that, and I don’t think it should ever be a can I or should I or would you when we’re talking about potentially risky interventions and assessments And so I usually think about when I’m trying to encourage mentees to approach the medical team, it’s usually using some sort of structure.

So I’ve interpreted something, I’ve done a risk assessment, so what do I think is the actual risk, and then I make a request or recommendation. But from your perspective, how do you feel like you from the medical team approach those two things differently? One, can I or should I go see this patient versus, hey, I’ve looked at everything.

Here’s the risks, here’s the benefits, here’s my plan When you ask a nurse, “Can I? Should I?” [00:12:00] You establish a hierarchy. Yeah. You… And if I had been asked, “Can I see this patient?” It would make me wonder whether or not you were confident, competent, capable, safe. And so I’ve heard some nurses have the perception that PTs don’t even know how to read vital signs, and they’re terrified of let- letting them touch their patients.

And so that’s my perspective as a nurse. As a provider, I might appreciate that collaboration, but also it puts the burden on me to do all the critical thinking. And if I don’t have experience with mobility, if I don’t have… If I don’t come from an awake and walking ICU, I don’t have much experience with this kind of critical thinking, and I have- I’m very risk-averse, and I’m very afraid of mobility or anything in the unknown, I will say no.

And especially saying, asking, “Can I?” [00:13:00] makes me automatically suspect or assume that you don’t know whether or not you should, and therefore you probably shouldn’t. So that would be my initial gut response as a nurse, also as an NP. Yeah. Which that’s been my experience as well. I think I don’t wanna put someone else’s license on the line for a decision that I’m gonna ultimately make and then an intervention or assessment that I’m gonna carry out.

Now, with that being said, I think we have to acknowledge that there’s, like, as a PT, that you have to then be at that place to feel comfortable having the conversation, which is a big part of what our CSM talk was about. So when I first started, it looked a lot different. It’s more like, “Hey, I wanna learn about this.

Here’s all the information I’ve gathered, and I’m…” It’s more back into get that kind of E, expose the unknowns. Can you help me reason through the physiology? And then it becomes collaborative in a way that’s not like, “Hey, I’m… Can I go do it?” It’s more like, “Let’s make a decision [00:14:00] together.” So I wanna, you know, at least provide some amount of insight into it j- it shouldn’t, year one, year two, year three even, look like, hey, I’ve looked at the echo, I’ve looked at their imaging, I’ve made these decisions independently and I’m gonna go do it.

Get out of my way. M- maybe it should never be that, but it should definitely not be that early days, right? It should more be a collaboration. Do you… Does that s- feel right to you as well? Oh, yeah, and we say this about nursing and probably any discipline. If you’re not asking questions, especially early on, you’re a hazard.

I remember, I, I just, I was… Even though I had my associates, I had zero experience. I was such a hazard in that environment. It was the right environment to learn because they welcomed questions. And I would ask questions that I knew were probably really obvious, and it was embarrassing to ask those questions.

But they would always say, “If you’re asking questions, that helps us trust you, that you know where you’re at.” So I think that’s part of building a relationship is to ask for [00:15:00] education, mentorship, not just from other PTs, but other disciplines. And if they say, “No, they’re not appropriate,” even leaning in to say, “Help me understand why not.”

Not just can I or can I get your permission, even just asking, “What are your thoughts about mobilizing this patient?” Especially early on, to have that collaboration and to learn from the perspectives and the hesitations of, or the encouragement of the other, uh, clinicians, but also recognizing that they may not be mobility-ologists.

So even in this- Mm-hmm … case, I think in many ICUs, if you approach a provider and say- I’m planning on mobilizing this patient,” they might have some hangups. They might say, “Well, they’re on thero- epinephrine. They’re on dobutamine. They’re on 70% FiO2. They’re at a PEEP of 10.” I mean, some ICUs, you can’t mobilize patients if they are above a PEEP of eight and a FiO2 of 60%, [00:16:00] or if they’re on vasopressors, let alone an inotrope on top of that.

There’s still hesitation about mobilizing patients with DVTs. There’s a lot of myths about dislodgement or risks with exacerbating those DVTs. The irony is, I think we all recognize, but those might be some hesitations. So I think a PT approaching a provider probably should have some awareness of where the providers are at.

If you’re approaching a provider that’s 60-plus years old, just understanding that they come from a different generation and it behooves you even more to be prepared to support your plan Right. And I think let’s be practical about it. If the question is, “Can I?” And the answer is no, now all of a sudden, even if you have a great argument to why you should, you’ve already– it’s already been a no.

And I think then you’re in a hole already that you’re trying to get out of, as opposed to, “Here’s the interpretation of all the information. Here’s the risk, here’s the benefit, [00:17:00] here’s the plan.” And I think that’s just a different approach. So I did– I put together a couple of questions, and there’s a lot of questions in this case.

And many listeners may be like, “I have a lot of questions. I need more information.” But which is fair. But I put together three common questions that we might come up with. Why is the patient on two inotropes in the context of having a normal ejection fraction? So he’s on dobutamine and epi, and yet his EF is 55 to 60%.

That’s one question that we would maybe need to get answered or at least think through physiologically. Why is the patient still on 70% FiO2? Keep in mind, you still have this active kind of slow extravasation into the pleural space. He does have a chest tube that’s frequently being clotted. I didn’t really mention that.

So they kept having to do TPA and dornase to clear this chest tube to keep it patent and flowing. But that’s a question, right? So this– why are we still requiring so much FiO2? And then lastly, and you mentioned this, should we proceed if now we’ve discovered an upper extremity and lower extremity DVT?

Which I think is an important question and important discussion. [00:18:00] So when we’re approaching those questions, and we’ll answer those through some information. So why is the patient on dobutamine and epi? Let’s look at their most updated echo. And I love echoes, and I’ll try to be brief. But what we confirmed on this echo, still normal LV systolic function.

So EF at this time was 65%, but keep in mind we’re on two inotropes. But the important thing is we have grade three diastolic dysfunction. So we’re still– Our stroke volume is still 49 ccs, and so we’re still maybe demonstrating a reduction in stroke volume and cardiac output even though we have a normal systolic function.

So that’s something that we need to reason through and come back to. Their left atrium is still severely dilated. Left atrial volume is actually 82 mLs, so their volume index is 40, 42.7, which is really high. So when we’re thinking about this, think about what’s gonna lead to pulmonary edema on the chest X-ray.

Well, if your left atrial volume is really high, [00:19:00] then obviously you, you’ve created some sort of back pressure from the left side of the heart, whether that’s a valve or the ventricle. And in this case, we have grade three diastolic dysfunction, which is a restricted filling-type pattern. So we’re not able to get volume in the ventricle hypertrophied small cavity, and so we’re backing up all this volume into the left atrium and then ultimately to the pulmonary veins and into the lungs.

So that could explain two things. That explains maybe that’s why our chest X-ray looks the way it does, and maybe that’s why we’re still on high FO2 in combination to this hemothorax with atelectasis on the right side. That doesn’t explain the inotropes. But then when we go to the right side, moderately dilated, moderately reduced systolic function, some of their echo measures of systolic function like TAPSE or free wall S prime or VTI, which I plan future episodes to dive into echo, but those are below normal.

So when we’re talking about inotropes, that’s likely contribute- or likely on board to actually assist the right side with RV forward flow. So think about this guy’s physiology, right? We have ASD [00:20:00] that has led to RV volume pressure overload, pulmonary hypertension. Now we’ve fixed the ASD, but that doesn’t just lead to a single day remodeling.

So we still have to support the right ventricle and hope that over time, as we decrease RV volume, that we get our Frank-Starling jive back on and we can have improved systolic function. But so that’s probably why our inotropes are on board So we get into the pulmonary system, like I mentioned, ABG was good, so 739/37/72, 21.6 base excess of negative 2.7.

But pulmonary edema pattern, atelectasis on the right. So and we discussed that. And then here we get into the discussion for the DVTs. So I’m gonna role- well, let’s role play this because I actually, in the presentation, had two different approaches and maybe the f- first way we’ll call it maybe the not optimal way, and the second way may- maybe the more optimal way.

So this is the role play of PT maybe doing the wrong approach. Should I see Mr. Blank before you [00:21:00] start anticoagulation? All right, now it’s, it’s to you as the nurse practitioner. Should I see him before we start anticoagulation? No, you know, we really can’t risk a clot dislodgement. The last thing this guy needs is a stroke or PE.

Just not worth the risk. Right. Yeah. And by the way, you get answers to the questions you ask, okay? So the PT did the right thing in asking a question, maybe the wrong approach, but got the answer of no. And so now, I always use this analogy, we walk away with our tail tucked and we’re like, “Okay, we can’t do it.”

But I think there’s better approaches to this, so I will do a little bit more of a framework that is hopefully a little bit more thorough. So interpretation. So yes, I know the ultrasound showed Mr. Blank has acute upper extremity and a below knee lower extremity DVT. The risk assessment, he needs to move.

I know he’s not on anticoagulation, but given this hemothorax and given the location of the thrombus, we’re likely not planning to start anticoagulation. And so then the request and recommendation [00:22:00] is if he’s not an anticoagulation candidate, then there’s really no reason for us to hold mobility. In fact, we would say, potentially argue that immobility is a bigger risk from a thrombus formation and propagation standpoint than mobilization, especially for below knee DVTs and upper extremity DVTs.

So now that conversation with the medical team led to, yeah, we agree. We’re thinking we’d probably start sub-Q heparin tomorrow and see how that goes, and maybe escalate to low intensity, then maybe ultimately to high intensity. And so when you have this conversation and understand the trajectory of anticoagulation that’s not gonna start today, maybe is gonna start tomorrow, it’s gonna take days to ramp up and be therapeutic, then we now understand the risk-benefit le- lends itself towards maybe mobilizing today.

So that’s the interdisciplinary discussion on DVT Good. Yeah And yeah, they would, I mean, a provider would be like, “Oh, yeah, I guess, I guess they probably couldn’t tolerate more clot [00:23:00] burden, and I guess this is the only intervention we have to really minimize that.” But also posing it in a way of, “Do you think they could tolerate more clot burden?

Do you think this would be helpful to prevent clots?” There’s some psychology behind that as far as this is your idea, right? You endorse this, right? Yeah. I love it. There’s always different iterations in hierarchy, but making it as much their idea as possible I think is helpful. Yeah. So I think what’s funny, and I’ll share a personal note.

My wife is a PA, so she’s much smarter and prettier than I am. But she worked in CVICU for several years, and I, I learned a lot from her in that exact thing. So because from a PA standpoint, a lot of times it’s convincing a surgeon that your idea is actually their idea, and then ultimately doing the right thing for the patient becomes the, yeah, you’ve convinced them that they’re saving a life.

She talked a lot about this idea of using words to convince somebody that it’s actually their idea. “Don’t you think it’d be [00:24:00] better if we mobilize this person now as opposed to waiting four days for their therapeutic on anticoagulation and risk all these other things?” And then provider’s like, “Oh, yeah.

Makes a lot of sense.” If you enter a certain environment and you actually know a lot more about evidence-based mobility practices and you have a better critical thinking when it comes to this stuff than the providers, which is not a far cry, it might make some people feel threatened and shut down. And so- Right

establishing these relationships in a very open, safe way that you can teach them it might require kind of eating it a little bit and playing that game, unfortunately The best part was, and the funny part of the story is that she knew my, like, soapbox on, like, PTs coming to ask her if it’s okay. Like, “Hey, Kristen, is it okay if I mo- move this patient?”

And Ben, when he was a resident, this is some years ago, went to ask her, “Hey, can I go see bed three?” And, and her [00:25:00] response is, “I don’t know. Can you?” And I always loved that because she’s just like, “Is it right? But, hey, this is your thing, man. You’re, you’re the expert. Like, can you? Should you? I don’t know.” And, and we should own it, right?

If you’ve been listening to this podcast, you’re likely convinced that sedation and mobility practices in the ICU need to change. The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team.

Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task. How does this transformation start? It can begin with a consultation with me to discuss your team’s current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU.

I help teams master the ABCDEF bundle through [00:26:00] education, consulting, simulation training, and bedside support. Let’s work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

mobility standpoint, if we are the experts in mobility, we should own that. And so the decision-making does fall on us, and the risk therefore falls on us. So our understanding of the case is a big deal, and that wasn’t because he didn’t understand. That just is because he, I think, wanted to have that collaboration, maybe just approached it in a way that she was like, “I ain’t doing that for you, dude.”

But, you know, so back to the FiO2, we’re still on 70% FiO2, there’s PEEP of 10. I’m gonna again compare two approaches to this. At the time, my mentee, the approach was, well, they’re awake on the vent. They’re at least waking up [00:27:00] on the vent. We haven’t seen them yet, despite there being a PT, OT order since basically the ASD closure.

And so we could probably be helpful in preventing some secondary kind of complications associated. Which is all true, but I think it’s so much more than that. And I think when we’re trying to make a case to get into a room that maybe there’s some perceived risk, right? 70% FiO2, 10 of PEEP, hemothorax with this kind of atelectasis.

Knowing that thoracic surgery in this case is like, we need to VATS this guy, but I really don’t know that we’re quite ready to go travel and do a VATS and all that stuff. So maybe a better approach, FiO2 hemodynamics are precluding the VATS, okay? There’s an ongoing intrapleural hematoma, hemothorax, active bleeding situation.

Sitting up may actually improve oxygenation. It could increase level of alertness, decrease FiO2 requirements, and then even get us off pressors, right? When we start to activate the sympathetic nervous system and all of a sudden we’re off levo and we’re off vaso, and then all of a sudden now their, the risk from thoracic [00:28:00] surgery is not the same.

They’re down on FiO2, they’re off pressors, they’re more awake, and so that’s a huge piece. So we actually could lead to earlier intervention, which would potentially make days to weeks of a difference in length of stay if we go ahead and address this issue as early as possible. And that’s not even to mention like, hey, could upright actually, from a gravitational standpoint, actually drain this collection in their pleural space?

And so that would be huge. So we talk about direct improvement in ventilation and oxygenation and aeration and cognition. So I think that there’s so much more and it’s not wrong to say they’re awake, we have an order, and we can prevent other things from happening. We can be a lot more specific than that, which was the case in this guy’s case, which led us ultimately to get into the room This is something that could’ve been done even before that point.

This is how many days after- Yeah … surgery and the rest that you’re really getting into the room. Is there anything that could’ve been done to give some kind of intervention [00:29:00] to help get him at a better spot now that he’s at the point of being able to actually work with you guys? 100%. I actually think that we could’ve been actively sitting up arguing for sedation liberation earlier in this case.

And again, it’s easy to Monday morning quarterback this, right? When you’re coming onto the case later on, it’s easy to say, “Hey, we should’ve done something earlier.” But even if that’s not reasonable or feasible, let’s say we try to wake him up and he’s hemodynamically intolerant, his FiO2 kind of goes up and he’s hypoxic and he’s in pain and all that stuff, and you’re like, “Man, I don’t know that sitting up’s gonna be a thing.”

I think at our facility, we utilize the tilt bed so much in our cardiac ICUs and now in med/surg and neuro that this would’ve been a perfect candidate for a tilt bed, right? For a bunch of the reasons I just mentioned. Improved oxygenation, improved diaphragm function, improved clearance of this hematoma hemothorax.

I think it would’ve been big for him. And that’s not even to mention the axial loading and some of the musculoskeletal benefits. So, [00:30:00] that should’ve been probably, h- honestly, even early on, on point four of levo and vaso and epi and dobutamine, I think maybe just get through the instability of lifting over to the bed and just be there and be ready as soon as that patient looks appropriate, so.

And go gradually- Yeah, that’s a great point … just see what he can tolerate and do whatever he can tolerate s- and, and- Yeah … increase every day as he can tolerate. But this is where I love that those beds being nursing-led. Yes, absolutely. So that’s just another safety net to make sure that every patient is getting gravity as soon as possible.

And so they should’ve immediately been thinking, “Oh, he can’t stand and bear weight. Is he a candidate for the bed?” And sometimes you don’t know until you try. But at least he’s on the bed ready to go, and if he can’t tolerate it today, odds are he’s going to especially need it tomorrow, the next day, or whenever he can actually tolerate.

So it’s not a loss if you start to verticalize him and he can’t tolerate it. It just, you already have it, he’s already [00:31:00] transferred onto it, he’s ready to go, and we continue to try every single day. But I don’t think that’s just on, on the pro- the NPs, PAs, doctors, nurses to not be thinking about how do we get this guy gravity right away since he’s not a candidate to be up and walking around.

Yeah. It’s so funny to me, in a place that we’re, we’re so aggressive with early mobilization of our patients on mechanical support. Literally, you put this guy on ECMO with the exact same hemodynamics and he’s sitting up day one. Right? And yes, we are protected from a circulatory standpoint theoretically.

But it’s so funny once you like, “Hey, we don’t have a device,” and it’s all of a sudden we’re like, “What are we doing? Why is it like week two and we haven’t mobilized the patient?” So I do think there’s, there was tons of opportunities in this case to approach it differently for sure. I can’t control that. A lot of PTs are walking in and they can’t rewind the clock, so here we are.

Oops. You’re right. Yep. Here we are, and I think making the right decisions from now is a good plan. So we’ve narrated the [00:32:00] reasoning, right? We’re still in that mentor kind of framework. We discussed the plans with the interdisciplinary team. And I think when we’re getting into testing our theory, so, “Hey, I think this person’s appropriate.”

We’ve had the discussions around the DVTs or whatever anticoagulation. We’ve had the discussion around why their FI02 requirements are high and how we maybe could help. Then it’s getting into what do we actually expect when we sit up. So what do I expect the hemodynamics to do based on their physiology, based on their echo, based on how long they’ve been in bed?

What do I expect their oxygenation, ventilation to do when we sit up? So having a working theory I think is really helpful. It’s really hard to go into a room without at least an expectation of what you would see. And we do this a lot when we’re mentoring, whether it’s residents or people just new to the unit, is if the patient was to decompensate, what do you think would be the driver of that?

Was th- would this be cardiovascular? Would this be pulmonary from a respiratory standpoint? Would this be something else? [00:33:00] Because if you have a working theory of if they don’t look good, here’s what I think would be the cause, then you already have a treatment for that. So if you can name it. So in this case, right, the, we’re on, at this point, low dose pressors.

We’re on some inotropes. We have a swan and central line, A line, intubated, CRRT. We have all this stuff and we have all the information we’d need and we would probably say, “We’ve been in bed for almost two weeks. My anticipation is that we’d be hypotensive.” Right? So maybe there’d be some orthostatic responses to upright ’cause he hasn’t really utilized any of this muscle pump and he’s probably vasoplegic.

He’s had this MSSA, dreamia, and all this other stuff. Well, if that’s the case, we already have pressors in line and we could already have a discussion before we sit up, right? And that would be huge to, to can soften the blow on the nurses because there’s perceived risk. Hey, in the case that Mr. X is hypotensive, we already have vaso in line and we can go up.

We can drop our PFR on CRRT so we’re not taking all this volume [00:34:00] off of him actively while we’re sitting up. We can do something, we can gradually progress to upright so we can try to mitigate some of these things before they even happen. So I think that would be huge. So having the anticipation of what would happen and then what’s the plan to fix it.

And I think that fits into from a medical team standpoint, right, too. That could be baked into your discussion with the team. “Hey, if you’re worried about hypoxemia or hypotension, here’s the plan. We’ve already got a plan for this.” And that way maybe it puts you at ease, too, if you were nervous as a provider.

Absolutely. Yeah. That helps me trust a clinician more to know that they’re not going in naive or blind. They’ve really done a risk versus benefit analysis, and they’ve got a plan if things do go south, that they could even… It’s one thing to just start CPR on someone. Mm-hmm. It’s another thing to know- Yeah

already the H and H. Or at least have some primary options or thoughts anticipating that. That provides clinicians a whole another level of trust who are also educating [00:35:00] nurses. They may not be critically thinking through that, and it helps us think. Historically, we’ve been afraid of vasopressors and mobility, but you’re also saying, “Well, maybe we can increase the vasopressors, the inotropes, to make mobility safer.”

That brings a whole another level of competency, and you need the entire team to be thinking the same way, so you’re helping create a safer environment. Right. But it’s physiologic. Like we all know, even if you wouldn’t say, “Hey, I wanna start a presser during mobility,” you all know the pathophysiology of orthostasis in the ICU after prolonged bedrest.

And if some of that is a peripheral maladaptation, and so we think that they’re not gonna be very quick to respond to the changes in volume shifting, then let’s help them by increasing SVR and vasoconstricting. That just makes sense physiologically. So to me, it’s a no-brainer. Hey, we’re gonna probably have to go up on presser.

We’re gonna have to probably decrease PVR. So I use the RUSH protocol or EFAST, [00:36:00] the pump, the tank, and the pipe. So like if their CVP is four and we think that they’re just hypovolemic and we’ve been pretty aggressive on CRT, then hey, not even just presser, but maybe we actually give something, a crystalloid or a colloid for this patient, and actually treat pre-upright to prevent that big hypotensive response.

And so we’ll do that all the time. Hey, let’s give 250 of 5% or let’s give 50 of 25%, something that’s gonna help kind of pull some of this into the vasculature and have a better response, so. But every PT and OT in the, in my opinion, in the country could speak to why the patient was hypotensive. And because you can do that, then you understand then what the treatment would be.

It’s just about having the conversation with the team. A- and it’s probably a newer role than most people are used to have PTs and OTs be so involved in medical management But that’s oftentimes a gap. We’re not optimizing patients to facilitate mobility. We see them with where they’re [00:37:00] at, and we’re quick to exclude mobility instead of looking at why they’re not appropriate, why they’re not tolerant, and exploring what we can do to combat that in order to mobilize them.

So I think PTs and OTs are well-posed, but maybe- Yes … that’s gonna be a new role for them as well as the rest of the team to have those proposals coming in from that department. I mentioned Megan earlier, and her group up at, in Chicago at Advocate Christ actually took a critical care ultrasound course with me for this very reason.

Because, yes, the first step is understanding the physiology and then what the ask is, but the second step, and I think this is where we’re going as a profession, probably still years down the road, but actually doing a bedside assessment that includes a physical exam and an ultrasound-based exam. Because your feeling of their volume status is not as good as a direct measure of their volume status.

And so in this case, yeah, looking at the IVC, seeing if there’s hepatic vein [00:38:00] reversibility of flow, like they’re congested or are they hypovolemic. And that has really been a big game changer for me clinically, is being able to say, “Hey, there’s objective data here. Their IVC is one centimeter. It’s collapsing.

I think they could benefit from some fluid,” is better than just saying, “Hey, I’m worried that they’re gonna be hypotensive. What should we do?” And then, and the team up there in Chicago reiterated that same thing. Day one after taking the course, they were like, “Hey, we have these VADs that we thought might have these LV suction events because their PI is low and they’re- we’ve been drying them out and they’ve been peeing a ton.

And we ultrasounded them and we actually anticipated that they would suck down and be hypotensive, so we actually gave them volume and they tolerated the session great the first day.” And that’s- so we’re talking about changing practice here. And so, and they’ve latched onto that, and I think it’s a big deal for our profession to go that direction.

In those kind of situations, it could’ve been easy to be like, “Well, they were stable in bed. We thought they were appropriate for mobility. We mobilized them. They became hypotensive. We discontinued. We’ll try again tomorrow.” But then it [00:39:00] also passes through the nurses of, they got hypotensive. They got syncopal.

Mm-hmm. Yeah. It’s unsafe. And then it makes everyone a lot more hesitant the next day. So you might delay their progression substantially with what happened that day by not knowing the why, anticipating it, and again, changing medical management in response. Yeah, it’s a huge detriment. And so anytime we do something risky as a profession, if we don’t have the anticipated responses and then the treatment plan, then I think we risk derailing our progress with some of the mo- more risky things.

So that’s why it’s huge. And I’ll get into the habit of this. It doesn’t matter what the, who the patient is, “Hey, i- if we’re hypotensive, here’s the plan. If we’re hypoxic, here’s the plan. If we’re tachycardic or have a rate and rhythm change, here’s the plan.” And I think verbalizing it ahead of time, then God forbid it does happen, nobody’s surprised, everybody has an action that we’re gonna take, and then the narrative is different.

It’s not like, “Hey, they did terribly with [00:40:00] PT, and so they’re not ready.” It’s more like, “Hey, we had this. We thought it might be a case, we thought it might be a risk, and they proved us right in that, and so here’s how we treated it. Here’s the plan for next time to mitigate that going forward.” So I think it does make a huge difference, especially for those nurses that are new or the providers that are new that are like, “Hey, I’m concerned about this.”

We can provide some amount of comfort for them. Absolutely. Well, I say we wrap up the case we have. We t- testing the theory and then observing for signals is the O portion of this. So we decide to go in the room, and in this case we did. So we went in and then what did they show us? How did they actually demonstrate their tolerance or intolerance?

And so in this case, yeah, the patient was, uh, heart rate was 112 on arrival ’cause they were waking up a little bit. If you remember earlier, I said their baseline kind of on some sedation, blood pressure was 105 over 73. Their heart rate was 96. Now they’re AFib 112. Blood pressure’s 98 over [00:41:00] 70. We sit them up, their blood pressure’s now 83 over 50, MAP’s 59, but they’re oxygenating well.

Their CVP is zero to one, and so ultimately day one was limited by hypotension. Now, in this case, based on what was going on, the discussion wasn’t really robust enough to talk about giving volume ahead of time or the response, and so that’s a great example of how this could have gone differently if we had that discussion.

So in real time, the PFR was decreased from 150 to zero, and so that’s on CRT. But that’s gonna take some time to accumulate that additional volume in the circulation. So what we probably should have or could have done is given volume or maybe gone up on our vaso. We were on .01 of vaso at the time. So again, hindsight is 20/20.

I’m operating somewhat as a mentor in the case, so it’s like I’m gonna take my hands off of driving here. But there’s, I think, opportunities there to make that first session more successful. [00:42:00] So it gets to review with the team, and so I just teased that and gave away the response as, “Hey, from an oxygenation standpoint, they did well.

We’ve been doing a really good job drying them out, and so unforeseeably they were hypotensive when we sat up.” And so now we can treat that. We can go forward with that. But the review with the team is so important Whether it goes great or it goes terribly, it is our responsibility to go and have that discussion.

And so I always say, if it goes great, I, I think in the CSM presentation, I don’t know who the… I’m not good in pop culture, but it’s some R&B star that was like a GIF that says, this is gonna sound so lame on a podcast, “When that grind pay off, baby, we show off,” right? So we did all this work and it went great.

I don’t, I’m, so I feel like this is terrible. I’m gonna have to put a p- a picture so somebody tells me who it is. But if we did all this work and had all this discussion, and we were really mindful of taking care of the patient and optimizing safety and mobility, and it goes great, let’s go shout it from the rooftop.

Because we’re trying to change a culture, and you [00:43:00] don’t change a culture by being quiet about the things that go well. I think we have to have that conversation with the team. And then similarly, if it doesn’t go well, having the sort of group discussion of, “Hey, I think this is what we need to do differently next time.

We anticipated it, but we didn’t respond maybe the right way day one, and we can treat it.” So last thing I’ll say about this before I want your opinion on these things, but we get so trained to let the outcome of an assessment dictate whether it was the right decision or not, which is, it’s wrong. That’s wrong medicine.

So a good process does not always equal a good outcome. We could do everything right, and it doesn’t mean it’s gonna go well. And similarly, a good outcome did not make it a good decision to go in the room. If nothing went wrong, it’s not because it was the right decision to be in there. There’s, you might have just sidestepped a grenade, right?

You might have gotten lucky. And so I think that’s all, it still goes back to the mobility experts in discussion with the [00:44:00] medical team of having a really good process and not letting the outcome dictate if it was the right decision. But there’s, the re- the patients are sick on a lot of support, and things could happen, and you could have every conversation, every preparation, and it still might not go well.

And so I wanna hear your, from the medical standpoint, in this context, how do you view that? Um, I love the idea of celebrating successes. I feel like there’s no success too small to celebrate, especially when you’re starting an early mobility program. It’s really hard when you have those kind of scenarios in a vulnerable program that’s early on, because that kind of scenario where a patient got hypotensive, again, will spread like wildfire.

So I think it’s important to also utilize those moments and scenarios as an opportunity to debrief, to make a case study out of it. When I’m visiting teams, I’m looking around and, of course, I’m there with a different lens than if I’m actually taking on these 24 patients myself, but I see these opportunities [00:45:00] for so much education.

And so I, I pull out all these case studies and I’m like, “Ooh, you need to send out emails and write up these case studies about these patients, because there’s so much your team can learn from your own patients.” And maybe we’re not thinking of it that way, but there’s also so much going on that I think PTs are in a good position to do that as well, to say, “We had this situation.

Send out this email to the entire team,” or collaborate with the nurse educator, the providers, to send out things, again, to celebrate and also to learn from what happened. And you can really help control the narrative on that. Otherwise, if it’s just gossip running around, we play the telephone game, and it’s also being spewed by people that don’t have a very high level of critical thinking or objectivity.

And then that helps also the providers learn that PTs and OTs are safe. If you then go back and you say, “Here’s why I think the patient was hypovolemic or was hypotensive,” in that moment, [00:46:00] those providers are like, “Yeah. Okay. I, I’m glad that you were critically thinking through.” They’re gonna have more trust in the next scenario, even though it wasn’t a huge slam dunk success.

But if you then lead the team to debrief it, it just establishes you as a mobility leader and not the person that came in and caused the patient to be destabilized I think, so if we play this out, this is the outcome, right? Hypotension. And we frame it in two ways, what’s the cause and what’s the response?

So what are the various causes? Is this sepsis vasodilatory kind of picture? Is this hypovolemia? Is this orthostasis? And some of these can be like yes and. Is this a lack of inotropic support, RV forward flow problem? Or is this a chronotropic problem? They’re hypotensive, they’re in AFib, their rate goes up when they sit up.

Is this a chronotropic problem? ‘Cause then the response is gonna be dictated by what you think the cause is. So if it’s sepsis vasodilatory, well, we should’ve gone up on vaso. If it’s [00:47:00] hypovolemia, decrease the PFR to zero, give some volume. If it’s orthostasis, probably a combination of those, right? Give some volume, decrease PFR.

If it’s inotropic, increase the dobutamine. If it’s a chronotropic problem, so let’s say– And why would it be that, right? They’re in AFib, which already you have your atrial kick at the end of diastole is impaired, so you’re already reducing your cardiac output by 15%. But let’s put it in the context of severe grade III diastolic dysfunction.

Now we have a filling problem with now a filling problem with now a filling problem. So you have AFib without atrial kick. You have a small and hypertrophied ventricle, and now you sit up and you reduce their preload. So all of that is a problem. And so one thing that we actually talked about in this case in retrospect was should we have tried to control the rate a little bit more?

If we slow the rate down and increase filling time, could we have gotten away with a little bit more activity day one? And so the reason why that was a conversation is because the hypotension, again, I’m remembering details from this case. The hypotension was actually [00:48:00] delayed a little bit, so it wasn’t just an immediate response, and that’s huge, too.

Physiologically, if we’re the experts in physiology, then we have to be able to say they were hypotensive at this point, which means this, versus- Mm-hmm … it was delayed, which likely means this. The conversation with the medical team was, “Hey, they demonstrated a drop in MAP, but it was delayed.” It was really when their heart rate got above 130 at that time.

PFR was– We dropped the PFR. They seemed comfortable and awake even though they had this hypotensi- hypotension. CVP was one. Ultimately may do better if we try to rate control them a little bit more. And so what you find out in these scenarios when you start to think about these things is the team had actually already stopped his, the amio, and they’re like, “Hey, maybe we should restart our amio.

Maybe we should… I don’t know that we have the ability now on inotropes to do like a beta blockade for management of AFib, but we can do something, and so maybe rate control them and see if they tolerate it better.” So that’s an example of what could have happened that we could have had a discussion about.

So- Do you include in your notes what drips [00:49:00] patients are on? You’re nodding your head yes Definitely Because I noticed at least the last time I trained that that was not the standard, and so I was trying to understand their critical thinking, what happened, why it happened, and then I’m having to go through the MR at the same timestamp as where I think their mobility happened per when their order, their note was written.

It was concerning. I mean, one scenario, they sat a patient up, and they described the patient as barely able to open the eye- their eyes and look at the husband while they were sitting at the edge of bed. And when I dug into it, it looked like they were still on 15 mics of propofol. And then, but then I’m thinking, did they know that?

Were they looking at that? Because I don’t see any notation of anything related to that in their note. And so when you’re giving this kind of feedback and wanting to know if PTs and OTs are critically thinking through or what was going on in the moment, what was actually running when you had that kind of response, I think, at least for me as a provider looking back at these notes, it’s really important to include what [00:50:00] drips they were on.

You also don’t wanna leave any question that you know what those drips are which I think is some, in some environments, I’m hearing from PTs and OTs that they’re not sure that their colleagues know what those drips are, that they know what amiodarone is, or if they care if it’s on or not, and that’s really important.

So I would… I know your notes are already so loquacious, so thorough and extensive, but even if it can auto-populate or just some sort of notation, that would be really helpful Yeah. I think that’s a great point, and we talk about that, and it’s such a, it’s such a touchy subject in the rehab community because it gets a little bit into, like, our didactic knowledge, right?

Our understanding of the baseline medicine drives these conversations, and so it’s impossible to jump to Z when you haven’t learned ABC first. And I do see that, right? [00:51:00] So yeah, when is epi an inotrope versus a presser? So what is amio? What are the kind of ramifications or side effects to some of these medications, right?

So I think that these things are really important. We’re in a really tough spot as a profession in some ways because there’s not a limit to what we could know that would help us in our jobs. You could learn, you could go dive into pharmacology or diagnostic imaging and it’ll make you a better therapist.

There’s just not a lot of professions that have to know such a wide breadth of information at a depth that’s actually fairly deep. I say this to a lot of PTs and OTs I talk about, I don’t envy us for that, but it’s also really exciting. And to know that the work you put in to understand the medicine is actually gonna, to lead to better outcomes for your patients for the very reasons we talked about.

The conversations can preempt the intolerance, and you can have a plan going into the room instead of being responsive or reactionary to what you see physiologically. [00:52:00] So I don’t ever like to be surprised by what I see in the room when we sit up. I like to have a plan for A, B, C, D, and so on. So I, I totally agree with that.

But we have to look in the mirror. Like for me, I had to understand, h- I don’t know this stuff and I’m gonna hurt somebody. And that’s why I did a residency, right? Back to my story. That’s a year into work, I was like, “Dude, I’m gonna hurt somebody. Uh, I need to go learn a lot, um, because these patients are really sick, and I want to provide high-level care to patients that are in the most need.”

That was my, like, philosophy. Just from an emotional, psychological standpoint, we can be such a help for the patients, so but we can’t do that if we don’t go in the room, so we need to do that. Thank you so much, Steven. I’m so excited for your upcoming case studies as well. If you guys have requests or ideas, things that you wanna pick Steven’s brain about, please DM me, email me, let me know.

He’s a wealth of knowledge, so don’t hesitate to put in your requests. He’s like a jukebox. [00:53:00] Yeah, no. No, but I think it’s fun. If somebody has cases to discuss, I’d love to talk to them. I think that’d be really cool to do on these podcasts. So yeah, please send cases in or questions in. That would be great.

Great idea. Thank you so much, Steven. All right. Thank you.

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