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Kali talks with Angels, DPT about how physical therapists in the awake and walking ICU save lives and enable patients to have their lives back after discharge. They talk about what is it like for physical therapists that get to do more than a passive range of motion with patients on ventilators.
Episode Transcription
Kali Dayton
Welcome to restoring life in the ICU. Today, I have Angela Hallstrom. With me, she’s a physical therapist in an ICU in Salt Lake City, Utah. She is a shining star in the ICU with mobilizing patients in critical condition. And she’s going to share with us some of her insights and her experiences. Welcome to the show, Angela.
Angela
Thank you.
Kali Dayton
So, Angela, from your perspective, why is activity during critical illness important?
Angela
Well, first of all, we’ll say the obvious. Studies have shown that one week of bed rest increases the loss of strength by 10%. And that’s in a healthy individual. Bed rest also increases the weakening of the diaphragm so it causes further respiratory issues. We have increased length of stay increased intubation time without activity.
There’s also evidence that shows decrease in cognitive functions. There is a decrease in the serotonin level. So there’s decreased cognition from that and also decrease appetite which we already struggle with in our critically ill patients. There is sleep deprivation, from bedrest. There’s sensory deprivation. There is a loss of self esteem, a of loss of individual functioning, which affects people’s outlook.
And another part that we don’t want to neglect is the intestinal system. We have decreased mobility of the intestinal system, which causes patients to be constipated. And we also get abdominal distension from that. Also, we have the incidence of DVTs, that increase with bedrest. And we increase the incidence of skin breakdown with prolonged bed rest.
Kali Dayton
So when patients come in, and they’re, you know, there’s septic shock, or they’re, you know, their, their life threatening condition with so many ailments. Why, why is it so important? Why is that suddenly a priority to get them up and mobilized? We know that all of those adverse effects that you’re describing…
where is the balance? I guess, there’s always concern, especially with some of our bedside staff, that there’s a fear of falling, there’s, you know, there are all these risks involved in mobilizing people. But it sounds like from what you’re saying, is that we’re risking more when we leave patients in bed. So how does mobility become such a priority, even during critical illness?
Angela
Well, there are risks of mobilization. And luckily, in our hospital, I work with a very good team, and we collaborate with physicians, respiratory therapists, physical therapists, nursing staff, to make sure that the patient is kept safe. It goes in increments, a patient might be critically ill, and they might not be able to get up and walk. But maybe they can get up and sit at the edge of the bed or stand at the edge of the bed until they are safe to do more.
And it’s a team approach, and we monitor their vitals. And the risk, I think of getting them up is you know, the risk that the decrease of risk from not getting him up is definitely outweighed. So we have more to benefit from getting them up and letting him lay in bed. And we do monitor them to make sure that we have it successful. Because if it is successful, then the patient is more apt to do it again.
Kali Dayton
Oh, I like. “That the patient is more apt to doing it again.” So why is it early implementation? Why is early mobility so important? Why not, you know, let them be sedated for a few days. And then when some of this critical illness is more resolved, then try to get them up?
Angela
Well, because like we said earlier, there’s 10% loss of strength per week. Their lungs are going to get worse. And the patients sometimes get complacent with laying in bed, because they that’s their safe zone and they don’t know what it’s like to get up and move and how they’re going to feel if they do it. So there’s a fear factor involved. And then we’re fighting, or the battle with the respiratory status decreasing, their cognition decreasing. Possible sleep deprivation, anxiety increases. So there’s other factors that we need to consider when we’re just letting the patient lay in bed because we’re losing time to get them better.
Kali Dayton
Perfect. And how do you determine who is safe or able to do what activity? I see you work and I think you’re Houdini, you are a magician. How do you determine who can get up?
Angela
Well, again, I, I correlate getting them up with the medical staff. And we assess the patient in bed, we check their strength, can they move their legs against gravity? Do they have sitting balance? There’s a lot that goes into account.
Sometimes we just have them stand for a minute at the edge of the bed and take some sidesteps. But usually, if they can hold their trunk up at the edge of the bed and they can move their legs against gravity- they are good to go. They’re good to try. Even if we have to take the ventilator there, they’re usually successful at it.
Kali Dayton
I’ve seen people that come in and can barely walk to the bathroom, barely walk to the kitchen, they usually use a jazzier or scooter to get around. And then you have them walking 200 plus feet around the unit with a ventilator in tow. How do you do that?
Angela
I think a lot of the problem is patients will do what they feel they’re expected to do. And if they haven’t been pushed or encouraged to walk before, they’re scared. We get a lot of patients doing more when they leave here than they did coming in. Because we build that confidence in them.
I tell them, I believe in them. And I, you know, if we don’t believe they can do it, if we as a team don’t believe they can do it, they’re not going to be motivated to do it. We need to instill that confidence in the patient that they can do it. And then once they, they do it, they feel better. I’ve had people tell me before that they never tried it because nobody believed that they could do it. And, you know, I just always tell patients, I think you can do it. It’s a team approach. And we, you know, take a little bit at a time, but people like to be independent. So they, you know, they just need encouragement, they need us to show them that we believe in them.
Kali Dayton
I like that. “People like to be independent”. Sometimes will come in and they’re already dependent. But you allow them to still take a role in their journey.
Angela
Yep, that’s what they know. They they know, independence. But they, they’ve been secluded, they haven’t been forced to try it. And I shouldn’t say force- they haven’t been encouraged to try to do more. Because people don’t believe that they can do but they are surrounded by people who believe in them. It’s amazing what people can do.
Kali Dayton
I’m going to kind of take a sidestep for a second. You’ve seen patients that have come from outside hospitals that have already been in the ICU for sometimes up to weeks, that have been sedated and been immobile…. And now they’re with us- following this protocol. So what is it like for you in comparison to patients that are mobilized and walking early to those that have been sedated and immobile? What difference does that make to you?
Angela
You know, again, we talk about why is it important, early intervention important? Because the longer we wait, the more times lost and the harder it is to recover. They are recoverable. But it’s hard. And they kind of lose that sense of “I can do it” and they feel they can’t do it at that point. You know, like I said, I’ve had people tell me, “You are the only one who believed I could do it. And that’s why I’m doing what I’m doing because somebody finally believed in me.”
Kali Dayton
And what are some of the motivating techniques that you’ve used?
Angela
Um, part of it is I help people envision themselves doing more, and encourage them by what they can do, whether it’s, you know, holding a child or being able to go to dinner with family, and I am their cheerleader, I It’s equally as important for me to get patients up and moving and see their success. And it’s like a journey for both of us. If they get better. I feel better if they’re moving, I feel better. And so it’s kind of a process that we go through together and when they make every gain that they make is it’s a pat on the back to them and I feel better. And I let them know that how much how much? How much I feel? That’s why I do what I do. Because if they get better, I feel better.
Kali Dayton
How do you respond to families that expressed concerns about the patient getting up on a ventilator?
Angela
You know, people are concerned, because they, it’s the unknown. But we educate family first, and we try to tell them why we’re doing it. And once they see their loved one doing it and see them doing better, you know, families will start videoing, um, and they, they’re always on board, once they see that we can do it in a safe manner. And they’re seeing the smiles on their family’s faces that they’re actually up and moving. It does make the patient feel better.
Kali Dayton
Yeah, there’s a huge instilled sense of hope and progress. When patients are up and the family sees it and they interact with them, and they help push the wheelchair and whatever they can do,
Angela
Right. And we try to get families involved. We give families exercises to practice with the patients, we kind of make it a journey for everybody. A journey for family, journey for patients, the health care workers. You know, people always look better up in a chair than laying in the bed. And they, for the most part, feel better. Yes, they do. Once they start doing it, they start requesting to be up. You know, and like I said, initially, it’s scary for them. They don’t have trust in themselves. But once they can trust us, and trust themselves, that they can get up and it’s going to be safe. They start requesting to have us come.
Kali Dayton
We just recently had a patient on a ventilator. I think she’s on like a peep of 16 and 70%. I mean, high ventilator requirements. At every morning that I go in and talk with her. She writes on the board, her communication board, “When is physical therapy coming? I need to walk, I need to get in the chair.” She is waiting for you to come because she’s not comfortable in the bed hospital. Hospitl beds are not comfortable.
Angela
right? She’s sitting up in the chair all the time. She’s always requesting therapy. We play music, and she does her little jig and dance. And it’s it’s cute. It’s just, that’s when I see your smile. Yeah, that’s the same one that was dancing to Michael Jackson. Yeah. All right, yep. And everybody in the hall, the nurses are encouraging her. It’s just it’s a good environment, a healing environment instead of a sick environment.
Kali Dayton
And I think she’s walking more here than she was even at home.
Angela
Absolutely, she is she’s doing much more now. And she’s on a ventilator than she was doing at home. That’s amazing. But she trusts herself. And, you know, we, you know, we do it in steps. So with every step, we can get the patient to trust us and trust themselves. And it’s amazing when, you know, we said a lot of people leave our ICU doing more being sick than they did when they were presumably well when they were at home.
Kali Dayton
And what’s that process? Because some people you know, some people are able to just get up and start walking on their own. Others are barely weight bearing. You follow them with the wheelchair, and then what kind of what’s the process of how do you balance pushing them to do more and yet, reading signs of fatigue or instability.
Angela
It’s constant monitoring, it’s, once you work with a patient, you get to know them, and you get to feel when things aren’t right. A lot of times they, I feel it when I walk in the room, you know, things are different. If they’re struggling, we allow them to sit, we allow them to rest. They trust us and we try to trust them. And we don’t want to push so hard that they don’t trust us anymore. Either. We got to listen to their signs and symptoms and back off when we need to and speed up when we can.
Kali Dayton
Wonderful. Trying to think … while I have you here? I have seen you be a wonderful resource for assessment, prevention and treatment of delirium. Can you tell me kind of your perspective on ICU delirium?
Angela
Yes, I mean, it’s a real thing. And part of it, I believe that really helps is having patients sleep better at night, and be awake during the daytime. And that’s part of what activity helps we try to get them up. We try to have them sit up in the chair, be awake during the day and sleep better at night, which activity really helps them get better sleep. And I think that that is a one way that we can ward off delirium in ICU. Yeah, thank you.
Kali Dayton
Um, how would you see your role in the grand scheme of impacting patient outcomes?
Angela
Well, I tell patients that their mobility as is as important as taking their medication, and I thoroughly believe in that, if, you know we can, as we stated, first of all, all the benefits of activity. I think that it is equally as important as anything else that we do for the patients. And it’s a way that they can help themselves get better instead of, you know, we give them medication we do, you know, we do all we can medically to get them better, but they need to participate in their own wellness. And this is one way that they can thank you.
Kali Dayton
And any Lazarus moments you want to share with us?
Angela
Well, one patient, I will tell you that had told me he had been very sick, and he had been in our hospital and he left and he went to an LTACH. Then from an LTACH, he’d gone to a skilled nursing facility. And then he came back to us. And when I initially evaluated him and asked him what he was doing, he had not been out of bed, he was using a lift to get to the chair. And he was depressed, he was severely depressed and feeling hopeless and scared, really scared.
And when he left us, and it was just probably like three weeks down the road, he was walking 200 feet with just me with a walker, getting out of bed with minimal assist. And he told me, the reason I got better was because you believed in me, he said, Nobody believed in me before you believed in me. And it allowed me to believe in myself. And so I think that that’s the important part. If we believe we can do something, we find the means to do it. And if it’s not expected them, you know, if we don’t, if we don’t expect it of our patients, and we don’t believe that the patients can recover, they’re not going to feel that they can recover. So I think we need to be optimistic and share that optimism with the people that we treat.
Kali Dayton
Thank you. I tell patients if you stay in bed, that’s way where you will say
Angela
yeah. So true is a body in motion stays in motion, a body at rest stays at rest.
Kali Dayton
When I heard our, our statistics that 98% of our survivors go directly home, I immediately thought of physical therapy, as well as our nurses that push so hard to get patients up out of bed even and especially on ventilators and moving. I think one of the main reasons our patients in the critical care world require care after the ICU is because of deconditioning. So thank you for working so hard for a patient and doing all the right things that preserve their independence and their function and their complete lives.
Angela
I feel fortunate that I work in a environment where everybody is on board, and the nurses are on board, the respiratory therapist on board, we all have a common theme that we want our patients moving as much as possible and to leave our ICU with a better quality of life not just surviving, but having a good quality of life when they leave our ICU. And the reason it works was close. We have a great team of health professionals and we all have the same vision in mind.
Kali Dayton
Yeah, thank you for keeping the big long term pictures beyond our ICU doors in mind. Thank you. Thanks, Angela.
Transcribed by https://otter.ai
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