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What roles do physical and occupational play in helping COVID19 patients survive and thrive? How have they changed their approaches during the challenges of COVID19? Why should we never remove their therapies from ICU care?

Episode Transcription

Kali Dayton 0:28
When COVID-19 came our way with concerns about isolation, patient load, and PPE immediately physical and occupational therapies were dismissed from ICUs all around the country and world. In the beginning of March, I shared my concerns about the impact to patient outcomes such as survival, discharge disposition, and quality of life as a result of removing such vital therapies.

Last episode, we heard Dr. Kenneth Hurwitz, talk about his triumphant return home. This partially answers some of the questions we have received about how the awakened walking ICU has been treating COVID-19, yet there is more to share.

Today, I have Erica Beach, one of our physical therapists, here to talk about the huge role physical therapy plays in helping a COVID-19 patients survive and thrive. Erica, our physical therapist extraordinare, tell us about what you’ve been doing these COVID patients, what are some of the challenges you faced? And what are you guys doing to keep people awake and moving?

Erica 1:12
I think one of the challenges that we face is the ability to keep them moving to an extent that’s going to help improve them being within the confines of the room. So we’ve bought arm leg, stationary bicycles, that both occupational therapy and physical therapy can use to work on aerobic endurance, because I think that’s one of the things that we lose not being able to walk long distances. So that allows us to work in sitting position to allow them to be safe. It also allows us to work on something that we can challenge them more on during our exercise sessions in the room, and then also have them do homework of it. So it’s safe for them to do and we’re not in the room.

Kali Dayton 2:19
So there’s no chairs during the day, for the most part, right? And they are doing the arm bikes by themselves?

Erica 2:27
Yep, so we often will do it during the sessions to either progress or regress or teach them a little bit more about what things we want them watching to make sure that they’re staying within a safe range with it. But it allows them to break up the activity a little bit more so that we don’t always have to be doing everything exercise wise, during our 30 minutes that we spent with them, it allows them to break that up into smaller chunks, which is something that we see allows them to tolerate more activity altogether in a bit, it can break it up a little bit more.

Kali Dayton 2:52
And then you brought in stools?

Erica 2:57
Like little step stools? So for patients that are going home, and we are able to walk out to a normal staircase with them, being able to work on the balance and the hip, and the thigh strength that it takes to be able to ascend stairs and be able to safely at least get into their home. As well as just have a slightly more challenging strength exercise for them in the room will act like Richard Simmons, get in there, but it’s gonna go up and down.

Um, you know, being able to step forwards, on and off that stair, sideways on and off that stair, work just even on tapping their toes back and forth onto the stairs to work on balance. Um, and then just kind of what we would do before but maybe focusing a little bit more on just standing strengthening exercises, having them use their body weight to be able to do things and challenge their lungs in that way. Because as we know and ease your muscles you burn oxygen and so even just that sometimes it’s a challenge for them.

Kali Dayton 3:53
Yeah, and I’ve seen you doing squats with people.

Erica 3:57
Yep, doing squats doing marching in place. I was just marching in place to John Philip Sousa for the last 10 minutes. Um, so yeah, just doing different exercises using their body weight, I’m showing them ways that they can take those exercises that we do with them in the room that are maybe a little bit more challenging for their heart, their lungs, or their balance to a level that they can do also when we’re not in the room.

So just like the biking we do the squats or the marching in place or the walking that we don’t want them doing when we’re not there just kind of pacing in the room and teach them seated exercise. So having them march in the chair having them do kicks in the chair having them do thigh squeezes and butt squeezes and leg raises and things like that so that they can continue to work those muscles in a safe pace in a safe level for them to do and we’re not in the room. Again, breaking it into smaller chunks.

Kali Dayton 4:52
Okay, that makes more sense because I’m not in the room with you guys. Usually I see you guys walking the halls now. I don’t see you walking the halls. Yeah, I’m seeing these patients eventually walk out of the rooms when they are testing negative.

Erica 5:05
Yeah, so before it was usually that the getting out of bed, the standing up onto your feet, the walking chain from the toilet or the walking in the hallway was what we started with. You know, you start with that it gives you a gauge of okay, what muscles are weak? What muscles do I need to do extra supplemental exercises with in order to make sure that they are able to do that either more independently or more safely?- and that so that was our kind of our gauge.

And then you say, “Okay, well, they’re having to use a walker, because they don’t have the strength to stand up tall on their own, or they have trouble standing up, their hips are weak, okay, as they can tolerate it, we’re gonna keep getting him out of bed standing up and walking him, but then we’re gonna as we can tossing exercises for him strengthen hip muscle endurance.”

Now it’s more, we can’t see you walk that far. So we don’t really get that good gauge of where you’re at. But we know that by not walking, those muscles are getting weaker. And so in some cases, they’re able to do three sets of 10 for strength. And, you know, it’s not that we’re bringing weights into the room or anything like that. But, um, or just more proactively doing those exercises so that when they are to the point where they walk those community distances, those muscles are A- strong enough to do it, but B- have the endurance to be able to hold on and help them do it so that they’re not fighting their lungs and their muscles at that point.

Kali Dayton 6:25
Oh, that’s a good point. Yeah, you’ve already got weaken lungs, and you don’t want their bodies to get weaker.

Erica 6:32
Because we know that this, this virus can cause catabolism of those muscles. And we know that. And so if we can do our best to front load these patients with that exercise, now you might come in, and you might have been a marathon runner, manual labor, and you’ve got that strength. But if you don’t use it, you lose it, they’ll know that. So we’re kind of getting them on these exercise regimens to keep that strength so that when that may be inevitable muscle catabolism happens, then they’re starting off in a better place that hole that they dig themselves as hard to climb out of.

And then, you know, we’re preventing some of those, you know, we’ve got these different types of muscle twitch fibers, we’re preventing those muscles from converting themselves when you don’t use them for certain exercises or types of functional activities, you’re switching those exercises, or sorry, those muscles to using different fiber types. So you know, we want this slow oxidative muscle fiber type in those big large muscle groups to be able to do that aerobic exercise instead of switching to more anaerobic muscle fibers where they’re building up that lactic acid and having that muscle soreness. So we’re just kind of in training those muscles to continue to be able to do exercise in that aerobic sense and be able to hold on for that long period of time, those big postural muscles,

Kali Dayton 7:51
And you’re being so creative. I mean, how are you facilitating walking?

Erica 7:55
Honestly, I just kind of go out with the patients can do, you know? Like, if they want to walk to the toilet, sometimes that’s the only walking they’ll do. Usually, we just do a lot of rearranging of the room like a feng shui, I go all the way to the side, the far side as much as we can. And we make sure we position the ventilators so that the ventilators on the side of the bed where the toilet is. So if they aren’t mobile enough, it’s not just the fact that they’re tied down that ventilator that they can’t get there. Because those ventilators have wheels and they can allow them to get around the room a little bit. So yeah, we just kind of set up the room for success. Push the bed give us a big of a runway as we can and they just pace.

Kali Dayton 8:37
You’re just kind of doing back to back circles in the room. I’ve seen you go to the door.

Erica 8:41
Yep.

Kali Dayton 8:42
And back and door and back.

Erica 8:43
Yeah.

Kali Dayton 8:44
Amazing. I saw you walk into a patient’s room with a golf set… a little “play golf set”, what was that?

Erica 8:51
I think it was a bed pan and a cane? But yeah, I mean, just with anything that you’re gonna do, you got to be able to tap into what’s gonna make that person want to do it. Of course, I can come in with all the sunshine I want. And I can ask the patient to exercise but let’s it’s meaningful for them. They’re not gonna buy in and they’re just gonna grimace and get through it.

But if you can make it relatable on its, you know, something we always do as PTs, we’re trying to make it patient-driven. So if we can do anything to kind of brighten their day, I mean, they’re stuck inside four walls, sometimes not even looking at a window that has anything but a view of a concrete wall. So you know, bring a little bit of them into it. So I we try to do a good job between therapists and just not just saying, hey, they’re on this ledge oxygen, and they’re walking this fire, they need this level of assist for saying, “Hey, this guy used to be working at you know, Crown burger, and he needs to do this and this is what really makes him tick likes to go fishing…” and then then that person knows you’re not just seeing their numbers, you’re seeing who they are, and then they’re gonna want to do it more. I dunno, it makes them laugh.

Kali Dayton 9:55
And you see their life as a whole. Yeah, and trying to fit them back into their lives. which is so…. I don’t want to say “novel”, but it kind of is novel for the critical care world, right? We see an acute illness, we see how critically ill they are. And a lot of times, especially if they’re sedated, and now there’s no family with us. We forget who…. we’re not just forget…. we don’t get to know who these people are.

Erica 10:19
Yeah, that is a hard credit for like not having the family here. You know, when they’re intubated? Normally, it’s yes, no head nodding, maybe a little bit of this versus that, as far as indicating when I’m asking questions, but the family is what jumps in and says, “Oh, yeah, he can, he goes downstairs, um, does puzzles every day, and he’s constantly out leading in the garden and this and that…”- it gives you an idea of what you’re trying to get that person back to.

And I feel like sometimes when they don’t have family around, to be able to speak to that for him or herself, that you’re striving for them. You end up just kind of going through the motions if you don’t and, and I don’t mean to say it’s, it’s all for them. I think maybe sometimes it’s a little bit for us as a therapist, just kind of helping these patients to have us be in a better mindset so that we’re not just going through the motions. You know, we get to know them better, and the more you know a patient, the more you’re gonna fight for him. So when they’re having that hard day, you’re not gonna, because they’re having a hard day, just say, “alright, that’s okay, that’s fine. You don’t have to.”- you’re gonna give them maybe that extra five minutes to rest, and you’re gonna spend more of your time in that room and have productive and understanding way for them.

Kali Dayton 11:30
Ooo… I like that because I have marveled at physical therapists. Sometimes people, especially these COVID patients, they just seem depressed, despondent, anxious. Yet you come in, you’re like, I know, you’re exhausted….But we’re gonna get up and party! Yeah. And I’m like, “How do you do that day in and day out?” But that’s so insightful that you see them as, as people. I know, it sounds mundane, but you see them for who they really are. And you appreciate that. And that’s what drives you to keep pushing them. And how different is COVID compared to other illnesses that we’ve treated? Because a lot of times, in general, our patients are awake, totally clear, communicating. And these COVID patients seem different. How does that impact? What are you seeing? And how does that impact your therapies?

Erica 12:21
Well, I mean, I do think a big part of it is, but they don’t have their families around. You know, we know delirium can be brought on by a lot of things biologically, and just environmentally. And that’s, I think one of the biggest environmental things right now. And ICU is that versus somebody else that had, you know, ARDS before and will come in, but they had their families around, they have that grounding source, you know, so we’re having trouble being that grounding for them.

Unknown Speaker 12:48
So I guess I think, in a way, maybe I tried to insert myself a little bit into people’s, you know, that I let them know, like, I’m here, I’m your support crew, I try to get to, like, get to know them so that they know when I’m going to have some data, they know what I’m going to ask them to do. But they also, you know, know that I’m knowledgeable enough to do it in a safe way. I try to teach them about what they’re going through both leading up to it, you know, a guy that we’ve got right now who was on the medical floor, and he didn’t want to come down here because he was afraid of the ventilator. Basically, he didn’t want to be intubated. He was just so it made him so anxious, so nervous, and he came down here, he wasn’t on it right away. But he knew it was possibility.

Unknown Speaker 13:27
And that’s why he knew they’re transferring down here, because he was kind of trending that direction. And I just had a really open honest conversation with him about, you know, before we could maybe speak to more, we see this all the time, and this is what’s gonna happen, and you just have to stick with it. Now we’re having those same conversations that we’re saying, you know, in my experience over the last couple months, this is what we know, this is what you could expect. So I kind of just tried to lay it out for them, what what bad could happen, what good could happen, but that we’re in the now, instead of, you know, being afraid of this breathing machine. Let’s do it.

Unknown Speaker 14:06
We know we can do now that’s productive and positive. And I think having those conversations with them and letting them know that yeah, we’re going to do hard things, but it’s going to make either how bad this gets the less bad or it’s going to give you something to divert your attention to, it’s going to give you something that feels kind of normal. No, we’re going to get challenged, then we’re going to help the white girl but you know, we’re not gonna put you back into bed, we’re not going to lift your legs out of bed, we’re gonna ask you to do as much as you can. And I think if they feel empowered by you that they can do what they can do and you’re going to help pick up the slack with a you’re always going to ask them to try, um, then they feel empowered that okay, I know that if I’m feeling this way, but you’re telling me it’s okay.

Unknown Speaker 14:50
And you’re gonna let me rest, you know, they start to trust that and I think that’s the hard thing is we do a lot of “I don’t know right now”. Yeah, I don’t know how long you’re gonna be able to spend later. I don’t know if it’s gonna get worse before it gets better. And I think we have an element of that before all this, but you’re hearing it from a stranger now versus me saying it and the family member being there to reassure you of it.

Kali Dayton 15:12
Right.

Erica 15:13
So I guess, you know, in that sense, it’s different. But same, we just don’t have that family element to kind of corroborate our story and kind of be there as a grounding force for them. So we pick up a phone and we FaceTime them. And you know, we haven’t be there.

Kali Dayton 15:28
So you still use family and your therapy?

Erica 15:30
Yeah. Yeah. I mean, if I’m getting up, and they’re doing something that makes the family’s experience from afar, humanized as well, they can see, oh, he’s sitting up, he’s not just thinking about or, yeah, he’s got that breathing tube in and he, the nurse has been telling me he’s been able to write, they get an idea what that is, it’s not just writing one word. You know, it’s, maybe they’re writing sentences, and they’re able to joke and they’re able to say things to have them realize that they’re still aware of, you know, say hi to so and so forth.

Make sure you update so and so for me those things. So it gives them that chance to interact with them when they’re being their most human self, you know, they’re they’re getting up, they’re doing things for themselves, they can kind of see that glimpse of just them being their, their selves that they knew before they drop them off at our door. Yeah.

Kali Dayton 16:27
And I have always seen physical therapists, that’s a huge part of humanizing our care in the ICU, you, you keep them human, you keep them functional, you keep them strong, you keep them moving and able to do things. But it’s so good to hear that you, you’re part of keeping them vocal, even on the ventilator, you’re giving them a voice and connected to them to their families, I was oblivious to that aspect of it. And that is so great.

When you tell people, like for example, some of the people that come down, now we’re doing oximizers, high flow, and then intubating, if it comes to that, when you tell them and try to assuage their fears about being intubated that you will be there, even when they are on the ventilator, they will still be awake, and still be moving, and you’ll be there with them. What does that do for them? Do they accept that?

Erica 17:15
Well, it depends on the person, right? I mean, if you go into it with the perspective that you trust, the people that are taking care of you, and you are still, you know, like you’re going to be a part of your carrier, then it helps them and helps them to know what to expect, right? They’re not just a passive participant in this being taken care of they know, okay, I know I’m gonna have therapy twice today. And I know that even if things get worse, she’s still gonna walk in the door, I’m still gonna do what I can.

And then I think I think that’s the biggest thing is that, I always tell patients, like, “I’m not, like, I don’t expect you to do the same you did yesterday, I expect you to do it, your body can within reason, until, uh, let you both you and I feed into what that is, right. You might feel like you can’t, but everything about your vital signs, everything about how much help I’m giving you everything about what I know about your past and your history and who we’re trying to get back to says, yes, you can, then we’re gonna push into it a little bit, we’re gonna try things that are hard, you’re gonna you’re gonna rely on me.”

And then there’s moments where I just have to tell people to the patients a little bit, they have to tell me when they need rest breaks more, there’s a lot you can’t see about this virus, because sometimes we’re seeing either those numbers be fine. And the patient is, you know, breathing like crazy. Or they feel fine. And the numbers are ticking, you know. So I think it what it does for them is it just lets you know that you’re not just willy nilly saying, like, you have to do it, you’ve got to get out of bed, you’ve got to walk, it’s just a part of what you do. It’s okay, by, you know, by no note expected, I know it’s gonna be safe if we get to that point. So if you tell them, hey, we don’t know where this is gonna go, but we are gonna keep seeing it. We’re gonna help you get back to you.

Kali Dayton 19:10
And that’s such a good point. There’s a lot of fear at COVID. And reasonably so it is a scary virus. It does crazy things. It’s unpredictable. Lungs are severely severely inflamed, damaged. And I think sometimes people imagine that we’re whipping people army crawling on the ground blue. Right, but you make a good point that we’re doing whatever they can to their capacity. It’s all personalized, and it’s, it’s safe. Yeah. And there have, there’s been a lot of discussion since COVID started about the role of physical and occupational therapy, because recently, so there are a lot of concerns about PPE. And so it sounds like in a lot of places, physical and occupational therapy had been removed from the ICU. Any thoughts about that?

Erica 19:57
Well, I think it depends on if you’re looking at the now or if you’re looking at the future. As doctors and nurses, and this is the reason I didn’t necessarily choose that profession, you’re in charge of their life now and in the future. But my perspective, is a default more to: What is your eventual quality of life after this? Do you get back to your former self? How long does it take you to get there? What’s going to happen when a bunch of people that were allowed to live through this virus then need to get back to who they were? Right?

So if, if we’re looking at the here, and the now, you know, maybe there’s some rhyme or reason to in certain situations, and, you know, depending on where certain city is, or certain facility is, maybe there’s some rhyme or reason to, okay, this person can’t do much. You know, we’ve got a great nursing staff here, I can rely on you guys in certain situations to help patients do some of the basics, just basic mobility, right?

But if we’re talking about a facility that’s extremely strapped, and they aren’t having that mobility happen at all, if we’re not in the room, then I think it’s highly important if you’re talking about their eventual quality of life, and who they’re going to get back to. So I think it just depends on what what is the situation you’re in, I’m in a great situation where I have people I can rely on that I know are gonna move that patient to the extent that they feel like they can, outside of my sessions. And I don’t have to be on the pronning team where all I’m able to do is just make sure we’re preventing things. As far as pressure sores and helping to safely move and position patients, I can rely on my coworkers for that, you know. And so in that sense, you know, yeah, I’m using PPE. But I think we’re being smart about it. I think we’re we’re looking at not just what we’re in, we’re when we’re in the thick of it, we’re looking at where we’re going to be. And if we have all these folks that are then falling on rehab services outside of the inpatient setting, what did we do them a disservice. Right?

Kali Dayton 22:20
Did we harm and damage, yep. And the PPE I don’t have any numbers on one of my speculations is, when we remove these services, we prolong the time in the hospital. And I feel that uses more PPE in the long run because their hair longer. I mean, we’ve sent people home that were nasal cannula that had been able to go home and continue to recover there and weaned off the nasal cannula.

But if they were still in the hospital, we’d still be taking precautions against them yet they went back to their families because their families were were infected as well. So I don’t know how we would even trace trace that but I speculate that PPE use is equal if not less when we get patients better, faster and get them home.

Erica 23:05
I agree.

Kali Dayton 23:06
Well, thank you so much for all that you do and sharing your expertise and for being so creative in this COVID pandemic and for sticking it out with us. We need you. Thanks.
Transcribed by https://otter.ai

 

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