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Is it save to mobilize patients with trans-formal devices such as balloon pumps, impellas, and ECMO? Who was the first person to dare to ask, “Why can’t we mobilize patients with trans-femoral balloon pumps?” Stephen Ramsey, PT, DPT, CCS shares with us his journey to developing the Ramsey protocol and revolutionizing mobility in the CVICU.

Episode Transcription

Kali Dayton 0:05
I was recently visiting a small city ICU to see how they were doing and to do a gap analysis prior to an intensive training with them. They were so excited to show me a patient that was sitting up in a chair on a room air looking great. They then showed me a picture of him intubated and clearly very deconditioned. They said that he had a femoral balloon pump and was completely flat for about a week and was then struggling to wean off of the ventilator.

The intensivist was preparing to do a tracheostomy and the patient when the physical therapist and the nurses rally together and convinced him to hold off a while, while they focused on mobilizing him, they were able to successfully excavate him without having to do tracheostomy the effort, teamwork and skill required to mobilize this man that barely had any head control was rooted in such deep compassion and vision from this team. This was an absolute success in ICU rehabilitation, I honor and celebrate them at the same time.

Looking at these pictures of the group and equipment working so hard to sit him up and fight I saw quite a weakness. I couldn’t help but ask Could this ice acquired a weakness have been prevented? Obviously with a femoral balloon pump there is concern and precaution needed to avoid bending at the hip yet was laying completely flat without any movement totally necessary. Could they have pre habilitated him with intervention such as standing on a verticalization bed could have walked off of such a bed without bending at the hip and therefore maintained his ability to walk this episode. I’m thrilled to have the creator of the Ramsey scale.

Stephen Ramsey here with us to talk about his pioneering work and mobilizing patients with high acuity, these life sustaining devices and even a variety of femoral access. These Steven Ramsay is finally on the podcast I have been collecting interviews with different pioneers and revolutionists throughout this podcast and I really felt incomplete with having these Steven Ramsay on. Steven, can you introduce yourself to our listeners?

Stephen Ramsey, PT, DPT, CCS 2:43
Sure, Yeah. Thank you so much for having me. I am Stephen Ramsey. I don’t know about the Stephen Ramsey, but practicing in Atlanta, Georgia, in cardiovascular ICU at a big facility here in Atlanta, been doing that for about eight years. And in the midst of that also did a residency and then mentored into residency and runner residency. And currently teaching a little bit on the side as well. So yeah, most of my research experience, and certainly all of my clinical experience has been in the cvicu, with patients on mechanical support. So just happy to be here and and talking with you about this stuff. Absolutely.

Kali Dayton 3:18
I hear your name all the time come up, especially when people ask questions about mobilizing with femoral cannulation, and ECMO and all these things. They always refer to the Ramsey protocols. I know that you mentored Jenna Hightower, who I think is an excellent resource and expert. And so tell us more about what was it like when you entered the field? And at the beginning of your career? What were the standard practices? And what inspired you to push the envelope? What What led you to ask? Why not?

Stephen Ramsey, PT, DPT, CCS 3:49
What is? Yeah, that’s a great question. I think I think I was a bit naive when I first started. And the simple question was, I don’t understand why these patients can’t get up and move. I think that that was my big kind of curiosity was what’s the limitation here? What are the barriers? And, you know, at that time that the question was primarily about these patients that have femoral balloon pumps that were, you know, in the ICU awaiting sort of a Plavix washout awaiting CT surgery, and they were just kind of there for five, six days kind of late.

And so I thought, initially started with exercise with these patients. And once I learned more about the balloon pump, I thought, if I can limit the hip flexion, which seems to be the biggest barrier for these patients, could I in fact, get them standing? And if I can get them standing, and knowing what I know, just biomechanically about ambulation? Could I keep them? Can I get them walking without exceeding 30 degrees of hip flexion?

So that’s where the question started. And I think I was really lucky because I posed that question to our ICU director, who was former CT surgeon, you know, boarded in many different things that has tons of experience and he was like, yeah, well Just do it. And then the scary part was, then I was like, Oh, crap, I have to do it. Now, you know, this has all been theoretical. And I think that that first time was really nerve racking. So I had the whole idea planned, I was gonna get a tilt table, I was gonna get them up and standing and and limit hip flexion, and then have them step off and walk.

And I think again, luckily for me, the first few sessions that we did went well, I think that was huge, that there wasn’t any sort of intolerance to upright, the balloon pump function perfectly. Their blood pressure was stable, these patients tolerated well, and actually voiced how much they enjoyed doing that, because they had been laying there. And so at that point, then we started to collect some of that data to say, alright, well, the first one went, well, what’s the true need here in our hospital and potentially other hospitals, how many patients are actually laying here kind of waiting on surgery?

And is this worth the risk, or the theoretical risk to do this? So we collected some data, I did some background digging, and as you imagine, we called a lot of places and everybody said, Don’t do it. And so began, luckily, that did not deter us, we call them the reps for the balloon pumps, recalled other facilities, and got a lot of your crazy don’t do that kind of stuff. Meanwhile, this was all like, while I was in, you know, residency at the time, so I was like, this is a great research opportunity for me as a resident, you know, new to the field, new to the ICU.

But you know, sort of get back to the point here, I did all of this, because I was a little bit naive. And luckily, it went really well. So we did a little bit of work on the back end of that first session to kind of make this a protocol and make sure that we are collecting the appropriate data, and then disseminating that information out to people.

Kali Dayton 6:48
I know I said many times that there’s, there’s so much value in a new and fresh perspective. I don’t know if I would have a question all the things or being able to be such a revolutionist that I hadn’t started and an awakened walk in ICU, where it was normalized. So I have so much respect for people that come in, and are adaptable to the cultural norms, and the protocols that are implemented, but also have a bigger perspective of saying, “Is there a reason for this? Why why not? What if?” but being new, I think does make you more malleable, does make you say, well ask questions, because you’re asking questions, anyways, you’re learning and you’re there to learn.

So saying, “Why aren’t we doing this? Why aren’t we mobilizing our patients?” And as a physical therapist, you are there to mobilize patients. So you really shouldn’t know why there is a reason not to and you didn’t sound like sounds like you didn’t even accept the reason why not to, which was amazing.

Stephen Ramsey, PT, DPT, CCS 7:45
yeah, absolutely. It didn’t make sense to me. I mean, it does not make sense that, okay, they can’t flex past 30. Well, there’s tons of ways we can get patients up without bending the hips. So what is what is another reason and then you get all of the well, the the aorta is going to rupture? The balloon is going to rupture, you know, they’re gonna dissect, they’re gonna die and all this stuff.

And, and, again, I had this, in my mind, that seems so simple. Well, let’s stand. If that goes, well, we’ll march in place. If that goes, well, we’ll step off. If that goes. Well, we’ll walk. And I think that was the whole the whole premise behind that. And so at that time, I certainly did not understand that I was that this was a big barrier for a lot of facilities. But I was doing anything that was out of the norm. I was just trying to, like you said, find a way to move a patient that needed to be moved.

Kali Dayton 8:31
And you were sounds like you were really trying to do it soon before they lost the ability to move. 100%. Yeah. And as a physical therapist, that should be one of your primary focuses. But if, I mean, if you work in the rest of the ICU community, you can see that that’s just accepted that patients are going to lose the ability to walk. Yeah. But that to them is an was unacceptable. Yeah.

Stephen Ramsey, PT, DPT, CCS 8:59
And that’s been that’s been my feeling about this since I started in the ICU. And I tell this story all the time, to people that I’m working with, or training or mentoring, that when I first started, I mean, it’s literally like, you can probably speak to this too. It’s literally banging your head against the wall. You’re pushing against concrete of resistance from your colleagues, and all these coworkers that respect you and you respect and that’s just like, hey, this is the way it is you can’t do these things. And I think it just takes a little bit of somebody that doesn’t like to hear no. I don’t know if you’re familiar with the color profile. I’m a blue, which means I’m a people pleaser.

And I had to become an orange. I had to become a rule breaker a little bit because I was like, I cannot accept that. We’re not going to do it just because that’s the way it’s always been done. And so at our facility, we weren’t super aggressive with our own ability. It really started in when, if you’re seeing a femoral balloon pump, walk around So why are we not walking patients that are just on ventilators? Why are we keeping them sedated? Why are we not pushing the envelope with ECMO and things like that. So that was a big, open door for us to be aggressive with the rest of the population.

And I actually think that that’s a great strategy for people is if you’re mobilizing patients that are theoretically the sickest? What’s the excuse for the rest of the patients in your ICU, don’t let that be a barrier that they’re sedated or that the staff is uncomfortable or that there’s no culture for early mobility, it takes somebody that’s willing to create that and push against the environment.

Kali Dayton 10:34
And now you’re speaking to an audience of primarily ICU revolutionists that are that know that cement wall? All too well. Some people that are listening to the podcast have been pushing for this for years, and they feel so discouraged and frustrated. And absolutely not every personality is going to be wanting to push the envelope I’m, I’m half red, half blue. And so the side of me is just constantly panicked about what I’m doing the red side is me is going crazy over pushing the envelope.

So I have a constant inner battle. So I really feel for people that are blue that want to please people that don’t want to ruffle feathers that don’t want to offend people. We had a couple episodes ago or leaving last episode, a pharmacist, I would say in rounds, we are killing people. And it didn’t go over well with her colleagues. But, but it’s really hard to navigate, being honest about the harm that’s happening. And a lot of these changes are well founded your changes you were founding. So I think that’s even braver to be that kind of visionary.

I mean, you were collecting data, you were looking at it statistically to make sure that this was a reliable pattern of being safe and feasible. And I want to talk about some of the things that you do to make it safe because I’ve had questions about this. But now, we like you’re saying we walk them the most critical high acuity complex patients with tenuous devices. And yet another ICUs even sometimes in the same hospital, their patients on mechanical ventilation for one organ failure, usually acute respiratory failure. Right. They’re deeply sedated, and now they’re acquiring all the other complications. Why do you think that is?

Stephen Ramsey, PT, DPT, CCS 12:16
Yeah, I think it’s this, it’s still kind of spawns from this idea that we have to keep patients comfortable and calm. And I think that it doesn’t recognize to your point that bedrest is active harm, right, that this actually is a short term solution that’s creating a long term problem. And in my experience in places that do early mobility, well, if you’re, if you’re just getting anecdotal information from the patient’s, they really want to be awake, and they really want to be communicative.

And they really want to be mobile. It’s an I think, a lot of us as healthcare professionals, if we’re really truly about what’s best for the patient, and their comfort. And I think that early mobility is the answer for that. And I think the only caveat to that is the way that we communicate that the way that we approach it the way that we consent the patient, it requires one competence, because in my in my belief, competence drives competence. And if you’re competent, and confident, and your patients feel that, and they know that and then your family members see it. And so then they start to buy into the benefits as well.

Because I’ve had people that say, Hey, the staffs on board, but some of the families and patients are actually the ones that are not and and my question to them is always is this? How are you selling it? What are you saying about this? How confident are you in your ability to move this patient safely? And I think that that, you know, a lot of times that conversation helps break that barrier down because I think patients go as the healthcare providers go a little bit.

Kali Dayton 13:54
Absolutely, if you walk in, you’re like, “Hey, Mrs. Brown… today, we’re gonna get you up. And it’s, it’s gonna be I know, you’re really scared.” And you’re like, showing that you’re really as a clinician, that you’re really scared. And then we’re anywhere fumbling and we’re trembling, and they can feel that. And even when you are confident, they’re gonna probably have some concerns.

They know what their lifeline that’s down their throat, they know a lot of equipment, they know they’re sick. But when you as a clinician walk in and say, this is as routine and optional, as an antibiotic, this is to save your life. We do this with our patients. This is how you’re going to walk out of here, you’re going to be okay, we’ve done this We’re experienced there. It’s really hard to say no to that. But then how do you develop that kind of competency and confidence?

If you’re one of the only revolutionists on your team, if you’ve never really done it before, how do you get there and that’s why as, as a consultant as my consulting team, we do simulation training, and I think it’s really important to do that routinely, so that everyone can practice in a safe environment, when it’s not a real patient. But you have your real equipment or figuring out your process.

Obviously, you don’t want to fake competency. But we also do have to trust the research that shows that if we do this systematically, and with the right patients, there’s a point 6%, adverse event rate, and very few of those are actually serious events. So we have to have a shift in perspective, but also the opportunity for our clinicians to become that competent.

Stephen Ramsey, PT, DPT, CCS 15:24
Yeah, I 100% agree with that. I think that’s mentorship is the key to this, if you’re at a facility that you don’t have, maybe you don’t have the reps because the team is not on board, or maybe you’re at a facility that doesn’t have a robust ICU, in general, and you’re trying to get into that I think the mentorship piece is invaluable for that. And I think you’re right, I think there’s no replacement for live patients real, real touches. And, but you have to start with what is the procedural steps here.

And I need to get reps to drive that competence. When I was early in my career, I hated protocols, I hated them. Because it is that same mindset of, I want to like, we are truly, you know, in the PT profession, we’re trying to push for sort of autonomy, quote, unquote, right to be independent practitioners making decisions. And I just hated this idea that somebody else would tell me how to do it.

But I do think that there’s value in having protocols and procedures when you’re starting. And I think that that helps you get some framework around, what does it supposed to look like. And then I think once you get some touches, and riffs, and I think you start to use your creativity, to know how to maybe go off script, you go off protocol or off procedure, to try to optimize mobilization of the patient.

Kali Dayton 16:43
Yeah, and different ways as far as what equipment to use, how to navigate the IV pump and the ventilator. Some people like to walk backwards as AR T, some people like to walk forwards. I mean, that is a personal preference. Some of that depends on the patient. I mean, there’s just so much that, I think, is really overwhelming to consider adjusting. But once you get it’s very general scaffolding to the protocol, everyone understands and understands their process. It becomes streamlined and adaptable.

I think about like, proning, patients, I use that example all the time, because initially, it took so many people so much time, it was really scary. You tried to get a really rough protocol, and now get streamlined, we understand what we’re doing and how to get there. And so I see with teams that are starting, they’ll report back and say we just got someone to the chair, it took 30 minutes, we cannot take 30 minutes to get someone to the chair every time.

And I said absolutely, of course you can’t. And it’s not gonna take that much time, the next time and the next time and it’s just gonna get quicker. But teams need enough support, enough staffing, to allow that kind of luxury of spending that kind of time trying to navigate everything, when it’s so you have to think through every little step at the very beginning of an early mobility program. Yeah,

Stephen Ramsey, PT, DPT, CCS 18:00
I agree with that. I think that’s, that’s how it started with us. It took me when we first emulated demurral, va, ECMO, and 2015. There was three perfusionist, two physicians, physician assistants, there was three nurses, there’s two pts. I mean, like, you should have seen this parade that was happening for honestly, a patient that was pretty functional, pretty strong. And it was just this huge thing. And then all of a sudden, you look around now and it’s 2024. And that’s, you know, me and the nurse, or maybe and the nurse and a perfusionist.

And I think it does, it just takes it takes a lot of support on the front end to get it off the ground. It takes diligence and preventing significant complications. And to your point, there’s really not a ton of risk of moving these patients what we’re finding out. I think once once people start to see success, then I think that that starts to breed more excitement about early mobilization and rehabilitation. Absolutely.

Kali Dayton 18:56
And it feels like so much work upfront. Yeah. And then what I’m seeing with these teams is once they get more comfortable with it, they don’t even talk about the workload. I had an AR T and a team that with RTS were some of the biggest barriers. And this is I mean, in 2021 I think that I was training them and they were just so hesitant saying, “We’re already underwater, we’re so maxed out, we don’t have time for anything else.” Very valid concerns right?

Later this RT, like about a year later, she goes, “Mobility doesn’t take that long.” And I was like, hold on. That’s not the song you were singing a year ago. Right? So as you know, now I use her to train other teams Her name is Emily. She’s she’s amazing because she really understands their perspective. But I had to remind her of her initial perspective because it had become so instinctive for her and her tire team, right. When when you have new people come onto your team, maybe PTS from other facilities, RNs from other facilities, how do you help them understand that this is the norm and develop that They’ll set as well.

Stephen Ramsey, PT, DPT, CCS 20:01
Yeah, I think that now that you’re in, like you’re at a place where it’s established, I think it’s so much easier to get people to buy in because they can look around and watch it happening. So I think that there’s less, less concern when you’re seeing it happen in real time. And you’re like, I didn’t think this was possible, I think that people buy in a lot quicker, I will say, from, especially if people have experienced, I think there’s, there’s part of that where it’s breaking down, not habits, but just old ways of thinking and old approaches to patient care and trying to get them to see that all these barriers that maybe they were told to you at one point, or maybe you’ve built up these barriers in your minds and mobilizing the patient, they really don’t exist.

And let me prove it to you by that patient on ECMO with a balloon pump that’s on to Lynette troops and three pressors and intubated. That person just got out. Okay, so now look at your patient that’s on 15 likes of propofol know, and they’re kind of groggy, and the nurse doesn’t want to do it. Like we you know, you have really no excuses at that point. So that’s what helps us is, if we’re mobilizing the sickest again, and I think it’s there’s really no excuse to not mobilize the rest of the patients in the ICU.

And I do think though, that staffing has been really challenging to that point. So not only staffing to do the early mobilization, staffing to train the new people, right, to make sure that they’re getting good habits, and they’re exposed to quality care, on both sides, the nursing side and the rehab side. And that I think is probably a challenge everywhere. And you could probably speak to that that’s a challenge in many facilities across the country across the world.

Kali Dayton 21:37
Because so much of what makes the safe is the experience, the expertise, the knowledge, and how you approach it, you guys make it look so easy. But now that I’m on this back end of trying to teach it, I’ve come to really appreciate that it’s, it isn’t as easy like when when I now I put myself in the position of those that have never done it before.

I’m trying to explain, you know, I try to think, okay, when you go to teach a brand new nursing students how to hang an IV, it’s not that easy to explain it, because now it’s something that you just do it just instinctive, it’s almost like muscle memory, you’re critically thinking about realizing that you’re critically thinking. And so it takes, it takes a teacher to be able to teach that. So to find the right staff that’s able to be a mentor, able to have the time to really teach the next generation to make sure that they are safe to be doing this.

It it doesn’t make sense for any other procedure that we would just throw them into it, expect them to do it. Right. Like if you would never, as an as practitioner, I didn’t just like graduated, just start doing chest tubes and intubations without training and following protocols. Yet, when it comes to early mobility, it feels like so often, maybe hospital administrators, clinical leadership is saying this is good. This is a great thing. We should be doing it now. Clinicians go do it. Yeah. Exactly. Without any training, and then to expect the next generation that’s coming in to just pick it up and do it. That’s not safe or fair.

Stephen Ramsey, PT, DPT, CCS 23:07
Yeah, I think that actually sets us up for failure. When we’re having non competent and competent people doing it, then I think that’s when you run it, there’s some risk and some complications and some oversights. And then all of a sudden, the administrators are like, wait a second, I thought this is supposed to be great. And it’s not. Some things are happening that we don’t love, like let’s just shut this program down. And I think that’s where we, if we don’t approach it in the right way with the right, administrative support, and staffing support, I think when you’re starting a new program, I think you’re at risk. And it’s not just they do it over there. So let’s do it here. I think it does take again, that mentorship piece, commitment to doing it the right way. And there is a right way. And there’s a wrong way to starting a program like that when you’re trying to be really aggressive.

Kali Dayton 23:53
It was your team, right? That put out a study just recently showing the some of the financial benefits of it, the impact the length of stay for every 10 additional minutes of early mobility.

Stephen Ramsey, PT, DPT, CCS 25:08
That wasn’t our group. But I saw that article. And that’s exactly my point, right? That’s the, that’s the benefit, right? We know that there’s benefits to this. And that’s the, that’s the paper that you drop on the desk of the administrator. And you say, it can work. But we need this, this and this, we can’t just start it, you know, we have to have the support.

Kali Dayton 25:27
I tell administrators, when I’m doing a financial pitch that if you if they just turn around and tell the clinicians turn off sedation and get them walking, without providing real support in terms of staffing, equipment training, they’re gonna have a mutiny on their hands. This could either totally trigger up the trauma from the from COVID, or it could help heal it. And so they’re really at a crossroads with how they approached this.

That study, by the way, I’ll put the link in the transcript showed over one day decrease in length of stay for every 10 additional minutes early mobility, which is I mean, just case closed, but it’s amazing how they’re always looking for ways to decrease costs, decrease the hospital acquired complications, decrease length of stay, and boom, boom, boom, early mobility hits at all. And yeah, it seems like that’s the last thing to ever be approached, or attempted or supported.

Stephen Ramsey, PT, DPT, CCS 26:19
Right? I agree. And that’s, that’s what we see. Even even at our facility, like when we’re thinking we’re being really aggressive. There’s still these barriers, and it’s like, Hey, guys, at we’ve not only can read the data, we’ve seen the benefit for the patient. Why are we going back on this? And I do think it’s, I just don’t know that it’s a, I think it’s the making decisions that are short term that have long term impacts, and not really still sticking to what we know is true long term, which is move the patient’s not only is it safe, it’s also beneficial.

I think that’s even even after the team team trial came out, I think that a lot, you see a lot of clinicians that have come out and said, Hey, look, you know, we can talk about the specifics of the article. And I think you’ve done a great job with that already. So we won’t, but I will say, the clinicians on the ground are like, whoa, whoa, whoa, like, this is still the right thing to do for the patient, this is still best practice, it’s still active harm to not move the patient. And so I think that I think we just have to keep that at the forefront, that this is better for the patients. This is not just a cost savings.

It’s not just a decreased risk of pressure ulcer and ventilator acquired pneumonia and all these things. It’s also better for them from a psychological, mental, spiritual, emotional standpoint. I think that’s so often missed in in healthcare, I don’t want to filibuster. But that that’s sort of the patient first idea. I think that that’s the missing piece here. And early mobility checks that box too.

Kali Dayton 27:48
Yeah, that that study put out all these fears about there being increased risk and harm for early mobility, but not taking into account incredible risk and harm. And I think in the future, some legal and financial liability, you’re not mobilizing patients. So that whole narrative needs needs to change. One question that I received from physical therapists and the CVICU, she said that she’s, she considers herself pretty aggressive, and wants to find ways that make early mobility accessible for more patients.

And so she was worried about how to mobilize patients with aortic balloon pumps. And how to have a worst case scenario. backup plan in case something goes wrong, especially if they’re in the hall. So how do you guys do it? Tell me talk to me about the logistics?

Stephen Ramsey, PT, DPT, CCS 28:34
Yeah, so I’ll tell you the sort of the progression when we first started, you know, we had a tilt table. And our tilt table, like I think was, you know, manufactured in the 70s. You know, when we first started this, we were, we had to take the face of the controller often touch two wires together to get it to go up and down. Like, that’s where we started, which I didn’t love that at all. Like it would get stuck up and standing instead, it was crazy.

So luckily, we advanced to maybe a newer version of the tilt table. And then ultimately, we got some vital go tilt beds, but which made our process a lot easier. But we would follow the patient, we would at least put the tilt table out in the hallway in case something happened. And that was always our our concern is patient safety. So what do we do when we’re 100 feet 200 feet away in the room, and the patient has some sort of complication, whether that’s arhythmia or hypotension or, you know, worse than that, right?

So I will say that, that when I talked about this with our groups, we never had that complication and knock on whatever’s around you, Kali, we’re just not going all the way around us. We still haven’t. And we’ve done, I think in the initial article, or publish maybe around 70 patients, but we’re, you know, up north of 600 700 800 patients at this point and still have not had a major complication and what goes with that is a really robust screening process to start a good chart review.

Understanding when it’s the right time to say, No, we’re not going to move this patient, I think that speaks to the competency piece. And then having a structured approach to getting him to standing, progressing from standing to marching, marching to stepping off, stepping off to walk in, usually the patients are in standing for three to five minutes before we start running down the hall.

And if they’re going to be orthostatic, we’re already we will have known that, if they’re going to have some exertional hypotension or tech cardio that we’re concerned about, we would know that when we’re marching in place at the bedside, so that doesn’t preclude any complication from happening. As you you will appreciate this. Things happen to really sick patients, and you can do everything you can do to control that. And that’s just the way it is.

A complication does not mean it was the wrong decision. A complication is the realization that these patients are really sick. So as long as you’re kind of doing all of those things leading up, we haven’t had any significant complications. But to answer the question, I think what people want to know is, what would you do? So, and we’ve, we’ve, we’ve done, sim labs kind of thought through this a little bit, because you obviously don’t want to sit the patient down with a criminal record.

But that’s sort of the point of getting a tilt table and standing up, don’t sit them down. But you would get behind them and, and lie them down and sort of lower them to the ground that there’s an emergency. And I think that’s our approach to when that happens. Not if because it’s going to happen at some point. And we’re, you know, nine, this is year nine of doing this. So, you know, it’s going to happen at some point. But that’s, that’s the approach. And I wish I had a better answer. But I’m glad I don’t. Because if I had a better answer, it would be because we’ve experienced it. And we have.

Kali Dayton 31:48
Which is amazing, and probably shocks people with over 600 Mobility sessions with patients with aortic balloon pumps, you’ve never had an adverse event, and yet, you’re always preparing for it, which I think is really key.

Stephen Ramsey, PT, DPT, CCS 32:01
Yeah, yeah. So never had a so we categorize them in the minor and major. So we’ve never had a major complication that would be categorized as significant bleeding, or arrest or arrhythmia, or CVA. Now, we’ve certainly had some minor complications, you know, sort of the the minor bleeding at the site, we’ve had some minor migration, we’ve had some infection and things like that. But yeah, the catastrophic things, the major complications have not occurred.

And even with talking with other facilities that are in the infancy of their femoral balloon pump mobilization, they’re seeing some complications, but it’s not the major type where they’ve dissected and aorta and a patient’s died, right, it’s the this patient is orthostatic, or this patient just complained of discomfort from they felt this balloon pump, and it made them kind of feel funny, like that’s sort of the major things that we’re seeing those kinds of complications.

Kali Dayton 32:54
I really liked Sabrina Eggmann’s, recent article in The Lancet, and I’ll link that as well talking about how we really need to be better classifying these adverse events, because there’s a difference between serious adverse events, and minor adverse events, and they still should be reported, but we need to classify them. And I think that was one of the things in discussing the team study is not having a good classification of those adverse events. And that really provoked a lot of unwarranted fear.

Stephen Ramsey, PT, DPT, CCS 33:21
Yeah, yeah. It wasn’t just for us as clinicians, a lot of questions, right. A lot of questions after that. What does that mean? How do we look for these these complications? If we don’t have a list, sort of a robust list of its defining

Kali Dayton 33:36
That’s right, I think, I think that’s important, too, is to be able to track adverse events. Because if something happens, it’s important to do a root cause analysis and say, What was that preventable? What can we do better next time? And to make sure that we’re doing this as safely as possible? Yeah, I agree. There’s just so much to pick your brain about, but I think what we love to hear are case studies. Do you have any just off the top of your mind? I didn’t prepare you for that. But what can you tell us? I know it’s normal to you now?

Stephen Ramsey, PT, DPT, CCS 34:05
Well, no, I think it’s the cool stories are still the ones that stick out. So there’s a couple that we’re in process of writing up and trying to get out there. So I think one thing I’ve transitioned to a little bit of my career, and anybody that knows me and listens to this is going to like be laughing right now. But I use a lot of diagnostic ultrasound in practice now. So looking at the heart, looking at the aorta, looking at the IVC kind of stuff like that, similar to what the medical team would be doing when they’re rolling in rolling out, you know, something in the ICU.

So trying to incorporate that into practice led to us we’re seeing a patient that was on ECMO, he had post infarct DSD, so heart attack, septal wall, between the ventricles had a massive hole like a two centimeter hole, not a small hole. In fact, his shunt fraction so the amount of blood going the wrong direction, was like 2.7 times the amount of blood going through his pulmonary outflow tract compared to his LV outflow tract, which is a concern. This patient also had a balloon pump from a balloon pump. And so this is the type of guy that we’re like, let’s just, you know, let’s stand up.

Like, let’s see what happens when we get them in vertical. And more than that, not just look at what happens from a physiology standpoint, you know, hemodynamic standpoint, but let’s actually put a probe on his chest, get a sharp traction, get some RV systolic measures in supine, and standing with marching, and then see how that changes. And the interesting thing And granted, this is an of one.

But the interesting thing when we, when we did that, when we got an echo and supine and standing and with marching in place, we actually saw a shunt fraction reverse. So his QP q s dropped almost one to one, which is normal, we have normal amount of blood flow on the right side, left side, his RV systolic function improved. He reported no symptoms and hemodynamically stable. But that was so interesting, because the biggest fear is, as I increase sympathetic input to the heart, I’m just making that shot worse.

The LV is just kicking all that blood over to the right side. And that wasn’t the case, in fact, that are the RV sort of responded. Well, in that scenario, even going from supine to standing, you know, and so I had all these fears in mind of what could have happened based on the fact that this guy had an infarct, you know, that we’re taking away some of this pre loaded by standing up that we’re increasing exertion level on a heart that just was damaged. That’s not fixed yet. But you know, all that stuff was put to rest because we had real time objective assessment, right? We were using ultrasound.

Kali Dayton 36:48
You use a veticalization, bed right?

Stephen Ramsey, PT, DPT, CCS 36:52
So we used a really controlled environment.. Yeah. And I think too, and this is, I’m spoiled because in my mind, ECMO and balloon pumps, and swans actually give us more data. And so they scare me less than the patient that has to peripheral IVs. That’s, you know, just in the ICU, I have any amount of information that I want I’ve got at my fingertips. So that’s where I feel at home. And it was weird to say, but that’s just kind of where I’m at with that.

So that was a cool case study and that person was able to progress towards ambulation, even on ECMO with a balloon pump, multiple sessions of ambulation prior to getting his infarct, or the VSD repaired which, you know, post infarct VSTS. You really don’t want to touch those for about two weeks after the infarct. So, that was cool case to keep him mobile for several weeks before he actually went to surgery. And ultimately, you know, survived went home. So

Kali Dayton 37:41
yeah, so you were able to prehabilitation him knowing that he was going to have a period of unavoidable bedrest.

Stephen Ramsey, PT, DPT, CCS 37:47
Yeah. And I still believe like in probably 99.9% of facilities that goes on bedrest, that guy is not moving. Yeah. And so and that was nice. And now again, I always say this, bad things that happen to sick patients is doesn’t mean it’s the wrong decision. And just because that went well doesn’t mean every patient in that scenario meets criteria to move.

So I think it is patient specific, you know, considering all of the things and making a decision, as part of the medical team, and I’m speaking specifically of PTS, we have to come to the table with some real objective kind of thoughts about the patient, not just is it okay, if we start moving them? Are you guys cool with it? What should I look for, we have to actually be a part of that discussion, but to speak the language.

Kali Dayton 38:37
There should be no single discipline that really shuts that down or is the gatekeeper of that right? If you were to go just to the RN to say can immobilize your patient open and absolutely no way. Yeah, yeah. But that should aren’t shouldn’t be the only one to make that decision. Or the final say, in that, which I think is happening a lot of ICU. So I’m just I’m definitely do another victory dance right here, because I think that’s a really important point. But when PTS come with serious data, they’re critically thinking they had they can support their ideas and their proposals, and really do a risk versus benefit analysis and the entire team that said, we have true collaboration, not just asking for permission,

Stephen Ramsey, PT, DPT, CCS 39:20
Right? 100 satisfied. So all the pieces that I mentor or students that I teach, you have to speak the language, you cannot be a part of the discussion if you don’t speak the language. And so that speaks to the competency part. And in PT school, we just quite frankly don’t get the training that you need to have the conversations in the ICU, so it does require postgraduate, whether it’s residency or however you get the access to information. It’s postgraduate mentorship is really what you need the ICU and you can’t rely on other disciplines to drive it for you as the therapist. That’s I 100% agree with that.

Kali Dayton 39:55
I love that. What other stories do you have? I know people are going to eat this up

Stephen Ramsey, PT, DPT, CCS 39:59
Oh gosh, let me think of some other good ones well, like all that come to mind are ultrasound related stories. But now we have many, many sick patients on ECMO suite. Well, I’ll say this, this is trying not to give a ton of detail. But you know, there’s different types of cannulas that we would use for ECMO. And I think in our facility, we’re super creative to try to support the patient the best way we can. So we do a lot of transseptal cannulation.

So draining the left side of the heart, in order to decompress the left side, which a lot of facilities would use like an impeller to do that, we usually use an ECMO cannula to do that for us, or in that case, that’s a patient that, you know, the retrograde flow to the LV is too much. And so yes, they need it for perfusion, but their LV is starting to balloon out and they need a transseptal.

We’ve even used dual lumen single catheters, like the Protect depot or something like that, and put that up the apex of the lb to work as an LVAD. So those are some cool stories. And the cool part of that is the novelty of the use of the equipment from the medical standpoint. But then what’s required from us is then how do we move that patient? Like, how do we monitor that patient and move that patient safely? So?

Kali Dayton 41:16
Yeah, kind of discussions as to what kind of device to use and where to place it in regards to how will that impact mobility? Or are you just able to accommodate now, because of all of your technology and expertise?

Stephen Ramsey, PT, DPT, CCS 41:30
Yeah, so I love having the conversation, but I tell them all the time, whatever you put in, we’ll figure out a way to do it. And so I think that frees the medical team up whether they listen to me or not, I don’t know, you know, I can’t tell. But most of the time, we’ve been successful moving the patient. So don’t worry about the mobility, let me worry about that part, and do what you need to do to support the patient. And we’ll figure out a way to move that patient. So I think that’s been our approach there.

Kali Dayton 41:56
Now, I think that’s going to hurt the brain of a lot of clinicians, because I, you’re in a very unique unit, you have to appreciate that, right? So there’s been many teams, ECMO is seen as a barrier, or femoral devices at all, in general is still seen as a barrier. And so things like that. So it’s really, that’s a big statement. That’s really powerful to say, we’ll find a way we’ll figure it out. But again, that’s not from a novice that’s just like, well just throw him out of bed. This is from expertise and an entire team that can support that process.

Stephen Ramsey, PT, DPT, CCS 42:29
Yeah, and to that point, we just did some talks here at CSM, our combined section meeting for PT, which is great, but I’m still kind of shocked to hear that the barriers are what they are like a femoral basket, right femoral Swan ganz catheter, we’re still demurral A lines, like we’re still talking about things that I thought in my mind, because of how unique the experience I have. I thought that was all things of the past. And that’s not to say that that’s minimizing that barrier. That’s a real barrier for people inside I like a firm that, that that is really where people are. But the reality is, as PTS it feels like, we don’t feel like we have the freedom to drive the conversation.

And what I want to instill in people where you do one, there’s data, which is helps the conversation but to Europe, PT said drive the conversation and say I can do it, we can make this safe, and we can do it effectively. And that’s driven us to now want to do maybe a complex cases, kind of discussion at CSM, appreciating that not every facility can relate to the specific patients, but hopefully they can relate to the conversations, which is this patient traditionally should not move, let’s figure out a way to make it safe and effective. And we’ll drive that in the PT side.

Kali Dayton 43:37
I tell people all the time of PTs and OTs and I get their masters and doctorate degrees to do passive range of motion, nor to only be rehabilitating on the very back end of critical illness. Yeah, it’s exhausting. And it’s not the most productive.

Stephen Ramsey, PT, DPT, CCS 43:52
No, and I probably have not responded with much grace when I’m told to do that, right? Because I think there’s a time in place, right? If we’re trying to increase ventilation, just moving the joint can increase ventilation, right? That’s helpful. There’s things we can do from a cardiovascular pulmonary standpoint by just moving the limb. But that doesn’t need to be me doing it. And I think I’ve ruffled some feathers by saying like, “I’m just not going to do that, you know, I’m going to figure out other ways.”

And I think that people the lesson for people maybe use more tact and more pace. But also realize that there’s more that we can offer than just moving the patient’s limbs. So that’s, that’s my lesson there. I think there’s a place for it, but it does not replace other things. Right? It does not replace moving the patient in terms of getting them up out of bed, standing walking. And

Kali Dayton 44:40
it probably shouldn’t even fall in the same category as early mobility, especially in our research. No, it does not mess up our data. Yes,

Stephen Ramsey, PT, DPT, CCS 44:47
That’s in that’s the biggest thing I’d see in early mobility data is what does that actually mean? And so if we’re using these mobility scales, right, and zero is bedrest in one is range of motion and that’s considered really moving Only then I think we have to redefine that a little bit. That’s probably not really mobility, but not probably it’s definitely not early mobility.

Kali Dayton 45:07
Anyone that looks at that data needs to scour look to the methodology, look at the definition and the timing of mobility, the level of mobility. Absolutely. Tell me as we wrap up about your Ramsey protocol. Well,

Stephen Ramsey, PT, DPT, CCS 45:19
I, I hate the name, I’ll say that. I struggle with it. You know, as a, I don’t, I did not name it that there was a physician that I was working with on that paper that was like, you have to do that. That’s just part of it. I’m glad I did in some ways, but I hate the name. That’s where I’ll start. So but yeah, just the protocol was developed after several sessions of moving the patient, because in my opinion, you have to trial and error before you design a good protocol. And we’re actually at the place with that protocol. But it’s outdated, right?

Like, there’s things that are different that we do now, that needs to be published and need to be put out there and other facilities have adapted the Ramsey protocol as you should, you should take it and make it make sense for you. But the whole point of the protocol is an approach to evaluating an appropriate patient, once they’re appropriate for mobility, which is, I don’t want to gloss over that, right. That’s an important step, you have to be able to assess their ability to participate, the safety of participating, once you determine that they’re a candidate, then this is just the protocol to move them safely. So we get them from supine, up to full standing, stopping about every 30 degrees to assess vital signs, tolerance, balloon pump site, do all of those things, ultimately getting them into standing progression and marching and then getting them off the tilt table or tilt bed and ambulating.

And then the reverse of that is pretty self explanatory, get back to the bed, tilt back into supine, again, reassessing their tolerance to that change of position as well. That’s actually where I’ve seen most people have symptoms is going from standing to supine after they’ve just walked 2000 feet around the unit. And I think there’s something to be said there of kind of ramping down the sympathetic nervous system in a really sick patient. And not just going from activity to to rest, and then just putting them straight in supine, especially for our heart failure. Patients with dilated cardiomyopathy is we should not be slamming them from from standing to supine. And that’s where I’ve actually seen some some one of the complications, but some symptoms that patients may experience. It

Kali Dayton 47:27
Sounds like verticalization beds should be standardized, and every CVICU.

Stephen Ramsey, PT, DPT, CCS 47:31
I believe that I, we there’s they’re not without their challenges, right. I think everybody that’s used to beds, they are perfect for what they are made to do, which is get the patient in standing, the movement of the bed, like physically pushing the bed and things like that, when they’re on multiple mechanical devices. Those things are, I think, being updated and changed.

There’s companies that are working on designing these beds, you know, to be more similar to like the Stryker ICU beds and things like that from a drive function and some of the features of the mattress. But yeah, I, I 100% believe that every hospital should have access to a tilt bed. And if not a tilt bed, at least a tilt table that they’re using in the ICU, like go steal it from the outpatient clinic and take it to your ICU, that would be my recommendation. And

Kali Dayton 48:14
It’s good, because you shouldn’t have to run around with everything you have to do. You shouldn’t have to hunt down equipment.

Stephen Ramsey, PT, DPT, CCS 48:20
The best of us early mobility, you know, advocates are ones that steal equipment, in my opinion, steal equipment, and hide equipment and use it.

Kali Dayton 48:28
So that equipment isn’t even being used anyways. I mean, I just seen so much equipment, the hospitals that are collecting dust. A lot of times where his teams, we’re not even really having to, like invest in new equipment. It’s just how do you utilize equipment you need? Or where can you find equipment that you’re going to use? Other people aren’t? Right? I agree with that. Anything else who would leave but the ICU community?

Stephen Ramsey, PT, DPT, CCS 48:53
No, I’m super appreciative to be on this platform, and certainly am open to any any PTs, OTs or nurses that want to reach out and talk through whether that’s the Ramsey Protocol, or mobilizing ECMO or any early mobility sort of topics. And I know you’re a great resource for that, as well. So I’m just I’m always open and happy to help in any way I can. And then I would say learn from my my failures as much as the successes. So I’ve got plenty of those too.

Kali Dayton 49:21
I’m just shooting from the hip here, but I think it’d be great if listeners submitted case studies. Questions. Yeah. And have you gone and we could walk through even if it’s, you know, a patient that you’ve had that you wonder could things have gone different? I would love to hear Stephens thoughts on this. I think it’s really powerful to do case studies of here’s what went right, here’s where it could have gone wrong, or here’s what went wrong. Here’s where it could have gone right so that your your ideas and let’s have Stephen back on the podcast.

Stephen Ramsey, PT, DPT, CCS 49:47
Thank you so much for that. I’d love to be back.

Kali Dayton 49:50
Thank you so much.

Transcribed by https://otter.ai

 

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