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The trauma ICU has unique risks to agitation, delirium, and long-term impairments. How does occupational therapy help the trauma ICU team avoid sedation, maximize mobility, and radically transform patient outcomes? Phillip Gonzalez, OTR, MOT, shares with us his expertise and success as an occupational therapist in the trauma ICU and traumatic brain injuries.
Episode Transcription
Kali Dayton 0:00
Throughout the past two episodes, we have discussed the various conditions in the trauma ICU, such as traumatic brain injury, pain, delirium, and so on. That can contribute to agitation, increase the risks of inappropriate sedation practices, and set patients up for long term impairments and disability. Elizabeth, a trauma ICU nurse and podcast listener shares with us her success stories with practicing the ABCDEF bundle in her trauma ICU
Elizabeth 1:07
Kali, thank you again for including me in your project. Here’s some stories about some trauma patients that taking care of this last two years, my first trauma patient I’ll never forget. older lady in her 50’s. She had a history of hypertension was in a car accident with broken ribs. She was intubated when I was taking care of her and physical therapy, hatters sitting at the edge of the bed. And before that, I turn off sedation see what she did. My preceptee and I, she was a new nursing grad, had the idea of having a write to us on a whiteboard.
And so she’s writing to pointing to things this woman had full of energy, physical therapy had her our patient walk in at the edge of the bed. And I asked the intensivist if we could do SBT or try to activate the patient. We did an ABG after her breathing trial and her co2 was little highest thing was in the 50s. So the intensivist said, “No,” we had to wait a couple more days. So we weren’t able to extubate her. Over the days taking care of her in the next week. I noticed that our patient not only wasn’t extubated, but she was on a rota prone bed because she developed pneumonia, most likely from the pulmonary contusion she had. And this woman died.
Our next patient that I can remember, he’s a young man who everyone said he was neuro strong and he had a pretty severe brain injury from a rollover rib fractures, of course. And this young man was heavily sedated. He’s very strong. So the nurses needed to manage and like had max on first said fennel and purple fall when I took care of he was getting the doctor say teed up to go to LTACH So he was getting a trach placed. And the next morning I took off sedation see what he did. He was moving everything to commands but was super weak.
I got with my physical therapist. We had an off sedation and sitting in a chair that morning. What I hypothesized was that these neuro storms are actually him developing pneumonia. A nurse had told me that this patient had fevers that weren’t controlled by Tylenol. And only after begging the physicians to start antibiotics did they finally clear up. So anyways, a couple days later, he was sent home and decannulated.
So not only did this young man may not have needed the trach but go through that procedure, the costs involved with the procedure. At least you got to go home.
Other two stories I’ve taken care of a young man or an older man, he’s in his 50s who shot himself through his chin and there’s a bunch of buckshot that was left in his sinuses, but his airway was intact. All the scan said that he was negative and that they were going or likely anticipating some edema. Or intensivist was explaining how sometimes the endotracheal tube how it’s pressing on the tongue and the venous return, it can cause even more swelling of his tongue to have the ET tube in.
So thankfully, he supported my idea of waking up the patient. So, turn him off sedation in the morning, give him a whiteboard set with him and talk to him. He used the call bell, he was watching TV. And my nurse buddy looked at me and said I had the biggest balls in the entire unit. And we’re letting somebody be intubated and not be restrained. Then I took care of a so he was extubated and did fine. Then I took care of this man who developed tremendous GI bleed he had or esophageal bleed from esophageal cancer complications.
So unfortunately, we did have to leave the endotracheal tube in. But he had it, his he needed a procedure. And after the procedure, we extubated and the next day, but when I took care of him, I gave him a whiteboard, took the sedation off. And he wrote the amazing, most amazing stories to me, he told me that he played for a famous band, a very famous band from the 70s. And that we needed to call his wife. So he would, she would bring his guitar. He also told me that he did not want to be tied up, because it reminded him of when he was restrained during the Vietnam War, and that he has PTSD from it. And I think that was the real message I sent home.
He even nominated me for a DAISY Award. And he filled out the whole thing with a sharpie, still intubated. He played a song for us on the guitar, and I wasn’t there the next day, but when I gave a report to the on off going nurse, she was a color grouchy been a nurse for a very long time, very smart, but doesn’t want to change your ways. And when she saw that I had a patient unrestrained writing, not sedated, she nearly had a heart attack. And I showed them all the messages that she had, he had written to us that he doesn’t want to be restrained, that he experienced all these terrible things. He told us that he was scared about his bleeding in his throat. But he went home even sent me a text. So sweet. Play the guitar. So those are some stories that last one though that gentleman he wasn’t a trauma patient. He was a medical he was managed by our medical intensivist team. And that team is more willing to emulate their patients, their patients don’t have broken bones. And then when it goes to neuro. The neurologists actually don’t want their patients to be sedated because it makes their assessment harder they to collect.
Kali Dayton 9:02
When we truly practice the ABCDEF bundle, we will turn to a toolbox of other treatments before ever considering the use of sedation. This is why occupational therapists are so vital in the ICU and especially the trauma ICU. Phillip Gonzalez joins us now to share why occupational therapists are vital players in the trauma ICU team, and how they support their teams and radically change patient outcomes. Phillip, thank you so much for coming on the podcast. Can you introduce yourself to us?
Phillip Gonzalez, OTR, MOT 9:37
Hi everybody. My name is Phillip Gonzales. I’m an occupational therapist. I have been a practicing ot for about seven and a half years now. I graduated from Texas Tech University Health Science Center in Lubbock or Red Raiders. My primary area of practice is acute care hospital based occupational therapy with an emphasis on ICU rehab. So that includes early mobilization and delirium management. And a lot of the critically complex patients that we follow down in the ICU out of the seven and a half years that I’ve been practicing six of it has primarily been in trauma, ICU, neuro related ICUs really working on getting those patients to start the rehab process so that we can mitigate some of those long term disabilities early on.
One of the reasons I fell in love with hospital based OT was specifically because of the ICU population and giving patients and family a sense of empowerment of where to even start and the rehab process. I think, when we think of ICU, it can be very daunting of our patients being very fragile. And I wanted to give something back to those individuals of how to be able to actually even where to begin, because that’s one of the biggest questions is how are we even going to do therapy with all the different equipment, all the different complexities of the diagnosis, all the different impairments are involved all of the amount of metal, life sustaining medications that are required to support this patient? And how does rehab fit in to the picture at that time.
Kali Dayton 11:20
And as an occupational therapist, I just have so appreciate that you guys come in to this critical, complex situation with this perspective of the their future. When the rest the team is so focused on what’s happening in that moment, and taking care of some really important life threatening conditions. You’re also looking at this functional future and quality of life, and especially working with neuro and trauma patients. You already have diagnoses that are very tenuous as far as being life threatening, but also having altered functional futures.
Phillip Gonzalez, OTR, MOT 11:57
Yeah, trauma can be very impactful at any stage of injury or any severity of injury. And I think really delving into what the immediate impairments are is very important, but also looking beyond just the hospital stay in what are the possible future impairments, and how’s that going to impact overall level of function, independence and, most importantly, quality of life.
Kali Dayton 12:21
And throughout this podcast, we’re talking about, you know, changing some sedation mobility practices that can further impair that functional future, but also prolong or hold us back from certain rehabilitation? And how have how has that impacted your role as an occupational therapist, and kind of what has been the environment and the work dynamic that you’ve experienced throughout your career?
Phillip Gonzalez, OTR, MOT 12:45
Yeah, so early on in my career, when I was first starting out, even for myself, as well as for most clinicians, I would say the ICU can be very daunting and just having an education, the education needed to know what OTs can do at that level is so important when my first year of practicing if a nurse or physician or a family member gave pushback of participating in therapy, because of the patient, not necessarily being what they deemed an appropriate arousal state, or requiring certain medications to minimize agitation levels, they were quickly written off.
And as my experience developed, and as years went by, and as I better educated myself, I realized, well, no, we’re doing more of a detriment to these patients. There’s always something that you know, the patient can do or the family can do or the hospital staff can do to really help continue to progress these patients ways, other than needing sedating medicines to keep them in a calm state. There’s other things that we can do to really facilitate that recovery for any diagnosis, whether it be related to organ transplants, traumatic injuries, or pneumonias, ARDS that requires sedation to help rise to the vent a little bit, that there’s still things that we can do this outside of sedation to help keep them in a relaxed state, but also promote that recovery so that the body itself doesn’t become debilitated.
Kali Dayton 14:24
And this is one of the main reasons I have you on today because of your power to help treat things like agitation, confusion, delirium in the setting of those agitation, confusion, right and delirium, especially for traumatic brain injuries. That’s been a big question. We talked about preventing delirium and a lot of different kinds of ICU patients, but traumatic brain injuries, you don’t get to prevent all of that. So how can occupational therapy, in your experience play a vital role in helping minimize sedation
Phillip Gonzalez, OTR, MOT 14:57
so with the The traumatic brain injury population, I think it’s important to really examine what constitutes a TBI. TBI is can be your typical what you would think that just a simple bump on the head that results in a minor concussion. All the way to motor vehicle accidents, gunshot wounds, assaults are results in severe trauma to the head with multifocal points of injury. One thing that we as OTS do in the TBI population is really assess where patients fall as far as the severity along with the physicians and medical team, the nurses meaning what severity of TBI this patient may have.
And then from a rehab standpoint, looking at how that type of severity of TBI correlates to what impairments they may have, whether it be physical, whether it be cognitive, whether it be behavioral, one of the common things that the rehabilitation world, one of the common assessments that the rehabilitation world uses as far as determining whether a patient falls on a level of COC cognition is a Rancho Los Amigos scale scale you’ve developed in Rancho Los Amigos, California, that kind of dictates the sequential recovery phase of where patients fall from onset of TBI as well as through the entirety of their recovery. And patients can make it through that entire scale, or they can stop at any specific level.
And one of the good things about the scale that really dictates or I wouldn’t say dictates it really explains what type of deficits someone may experience, but also what kind of functions they would typically be able to perform at that stage of recovery. With that scale itself. The one that we take, the ones that we typically see most in the ICU would be levels, 1,2,3,4, and 5. So it’s a 10 point scale, with the first three levels, being a comatose patient, patients that aren’t really participatory patients that aren’t really responding to stimulation patients that aren’t really engaging from an external stimuli. Now, once a patient wakes up, their brain goes into a almost a hyperactive state.
And that’s where we kind of start to look at them and classify them as a Rancho Los Amigos level four, and the title of that stage is very much appropriate. It’s called confused and agitated. So because of that hyperactive state, resulted from the trauma, the brain itself isn’t able to modulate any internal or external stimulation that it’s feeling. So the response to that stimulation results in outward expressions of agitation riving, non purposeful, spontaneous, reaching or pulling that objects or items around that patients have no awareness to what’s going on.
Patients may cry or scream disproportionate to the stimulation being provided, they’ll have very labile moods from varying from being kind of maybe hypoactive states to being up completely hostile to being euphoric the next second. So really where ot falls in those patients is helping them to progress to that next phase, where we’re able to really start to not control behaviors, but facilitate the brain’s ability to modulate the stimulation to better manage those behaviors. And I think that correlates really well into the podcast that you’re doing, which I think is phenomenal by the way of how sedating medicines fit into this patient population.
Because early on in my career, if I came up to a patient that was classified as a Rancho level four, nobody really knows what to do with them. The nurses like oh, no, they need sedation to keep them calm. Well, can we win the sedation back a little bit and really see what they’re able to engage in? Because studies show that patients that are deprived of their environment, they’re deprived of their external or that external stimulation really slows the recovery through the traumatic brain injury phases and doesn’t allow the brain to engage in that neuroplasticity? That is the remoulding and the relearning and improving and overall function.
Kali Dayton 19:33
Wow, it’s a lot to unpack there. I know it’s so it’s so much but it’s really fascinating that such a pivotal point in the recovery. And we talked about all these other diagnosis different kinds of patients that what we’re doing in the ICU is going to determine the rest of their lives in so many ways. And it sounds like that is especially applicable to TBI patients that they’re at this point where it’s actually now split salvage function. later or continue with our routines to date them. But I mean, it’s it’s absolutely understandable why needed, right? Because you have to keep them safe keep lines and keep them in bed all those things. So what do you bring to the table to help make it feasible for the staff to have them less or no sedation? How do you help the team navigate that?
Phillip Gonzalez, OTR, MOT 20:23
Yeah. So I think one of the important things to pinpoint which where I think staff across the spectrum in the country is as required getting a little bit more education is knowing that when a patient moves from that comatose state from a TBI to that hyperactive state, it’s expected. I think what tends to happen more often than not, is it’s an unexpected change. Because these stages life can last anywhere from hours to days to even longer. So when those patients actually wake up, who is going to be the healthcare provider managing that stage, and a lot of the times the physician or the nurses are at the forefront of it, where I think ot rehab in general is specifically ot really has a niche applicability in that area.
Because we look to the future, we look to that what we want the patients to get to to these next stages, what behaviors we need them to demonstrate, to really help that progression of recovery. A lot of the same things that we do with a TBI patients is the same things and same skills and same tools that we use to manage delirium. These patients are almost in a forced to delirious state because of the injury.
And so utilizing those same strategies that we use for delirium really helps to help the patient navigate through this process. So what I mean by the strategies to manage delirium, helping to regulate the sleep wake cycle a little bit better setting these patients up on a schedule where they’re being engaged with staff at the same time, every day, medicines are being delivered at the same time every day, family members are visiting at the same time every day, they’re sitting up in bed at the same time every day.
Therapies participate in at the same time every day, you’re having the same people engage with the patient. You’re allowing for daily rest breaks to allow for periods of the stimulation. I think one thing that I’ve learned and experience and even continue to experience in my career is there’s a big emphasis on really trying to keep patients awake during the day so that they sleep at night so that you don’t have to use a sedating medicines at night to help them sleep because as we’ve learned, sedating medicines doesn’t actually equate to sleep all the time.
But one thing I think that we as healthcare providers can be more educated on as well is in the traumatic brain injury population. Periods of destimulation during the day are pivotal for that neuroplasticity to really take effect. You wouldn’t sit there and work out for six hours out of a day without giving your body a rest break. So why would you at that level of recovery? Force your brain to work out for six to eight hours at one time without giving it a rest?
That hyperactive state at the ranch level four level, like we talked about is exhausting for the patient. And so you’re gonna see that agitation being a result of one factor or another. So being able to identify those causes helps as well. And that’s one thing that ot can do is really identify certain, either staff patient or family members behaviors that may increase agitation, what behaviors can we modify or change? What environmental factors can we change, to help to modify that agitation or reduce that agitation.
And then really, one of the biggest factors of OT is the early mobilization component and ICU and routine establishment in relation to ADLs. And how we can start to introduce that to really get the patient to engage in things that are familiar to them. I mean, we take for granted as people in general that we get up in the morning, we typically go to the restroom, wash our face, brush our teeth, do anything we need to do, they’re at a pretty consistent time. Every day. Those things are familiar to us, those things are almost ingrained in our body. And when you’re in the hospital, those routines are completely changed. They’re at the mercy of all the health care providers around you.
And as OTS we can really start to implement these routines back to the patient and these tasks of back to the patient in a controlled environment and a non distracted environment, an environment that’s really going to help the patient to engage or begin to engage in the recovery process. A lot of the times with the traumatic brain injury population, it’s not just the brain that that’s affected. It’s you have these polytraumatic injuries that really dictate what you’re able to do. And so as therapy, as we’re assessing the cognitive aspect of it, we’re also assessing what other impairments they may have, and what other cautions they may have resulting from surgery that are going to affect their recovery, that can also be causing that agitation.
Kali Dayton 25:37
And can you see a difference in when it’s just a TBI or when there’s there are elements of delirium? I mean, can patients with TBI, develop delirium? And how do you? Is there any way to pick through the two? Do you ever see them? Over time, get cognitively worse in question whether or not Stellarium.
Phillip Gonzalez, OTR, MOT 25:57
Yeah, absolutely. So with the with the TBI population, you’re gonna see a little bit of a roller coaster of recovery, where you’ll have periods of improvement and periods of a little bit of regression and followed by periods of improvement. So looking at the consistency of improvement, you always want to see it moving in the right direction. Now, where delirium comes into play typically results from when patients transfer units or interchange, or they even transfer out of the hospital, where that familiar environment that was established, completely changes.
So with TBI is one of the biggest things that impacted is your ability to process information, your ability to retain information, and your ability to or things. So if we’ve established a routine and a specific unit in a specific room for the patient, some something that they’re familiar with that they can start to get a grasp on, and we change that environment, then you’ve completely changed a patient’s routine, you’ve completely change something that’s familiar to them to move them to an unfamiliar situation.
And then that alone can cause an agitation, an increase in agitation, or more agitated behaviors, because they don’t have the cognitive processing at that stage to understand what’s going on. So from a therapy standpoint, we can help to identify continue to identify those barriers, and how can we modulate or modify them a little bit so that it doesn’t have such a profound effect on the patient during this phase.
Kali Dayton 27:44
But I absolutely see why it’s easier to patients in the ICU. Because it’s, I mean, it’s a lot, it’s a lot and it’s you know, I talked about treating patients with severe delirium in the ICU, things like mobility, family sleep, those are effective for TBI patients as well. It’s a much quicker recovery when it’s just delirium. But you’re really dedicated to the long haul. And the more severe they are, I’m just imagining really agitated patients.
Phillip Gonzalez, OTR, MOT 28:14
How there’s a little bit of a, I wouldn’t say a joke, but patients at that stage, if they’re going to participate in therapy, it’s you have to really be ready for physical outburst. You have to really be ready for complete expressions of the body and any movement pattern at a very surprising force for what a patient may have injury wise outside of just a TBI. There have been times where I’ve been working with patients and mobilizing them, and I’ve had to pretty much bear hug them to hold them in a position that I needed them in to provide sensory stimulation to provide that change in position for them, while another therapist was trying to get them to engage in something you really need additional personnel.
and I think clinically trained personnel to help to mitigate some of the possible adverse events with patients at that stage. So we talked about early on in my career, those patients very often scared me because I didn’t know what to do with them. And now there’s some of the most exciting patients to work with, because you don’t know what they’re gonna do. And you can really be very dynamic in your intervention strategies to really be able to find what works for them.
Kali Dayton 29:34
And it sounds like it’s so different for each patient.
Phillip Gonzalez, OTR, MOT 29:38
It is, yeah.
Kali Dayton 29:39
When you find those interventions, those approaches or techniques that work for patients, how do you disseminate that information to the rest of the staff or help kind of guide the staff in applying those things when you’re not there?
Phillip Gonzalez, OTR, MOT 29:52
So one of the stories that immediately comes to mind is a patient that I was working… hn probably I would say maybe working with I should say… about four years into my career. A young young teenager was struck by a vehicle auto versus pedestrian, it was a hit and run type of event, severe severe traumatic brain injury with also orthopedic injuries as well. Pelvic fractures, leg fractures, broken ribs, broken back, just a variety of very severe traumas.
This individual will love theater, and was a part of their high school theater club. And they were when therapy was implemented. Luckily, we had an ICU that was very progressive, that really wanted therapy involved. And we had trauma physicians that supported therapy and what we asked from them as well as getting us even with patients that weren’t aroused to participate to help them move through those early stages.
As we talked about, this patient was at that Rancho level for the confused and agitated, agitated, so non purposeful activities non purposeful vocalizations couldn’t express his wants or needs. And this is a patient that I was talking about that I had to bear hug at the edge of the bed because of his orthopedic injuries, because I didn’t want to break in surgical precautions, while my other therapists, my physical therapist was with me, was helping to engage. And one of the things that profoundly stuck was when his mom told us that he loved the theater, favorite musical was Hamilton.
I was like, “Well, let’s play some music. Let’s let’s start using those things that are familiar to him, things that are ingrained into us that are typical routines.” And so we turned on the soundtrack to Hamilton. And he went from this completely whole body riving movements back and forth, and side to side, he just melted like butter. And immediately a sense of calm, completely washed over him. And he was just able to sit there. And so from there, we were able to do gentle rocking. And different planes really work on the stimulus stimulation really work on just proprioceptive stimulation and sensory input.
So that we could help the brain modulate that external stimuli, as well as modulate its own internal pain that it’s feeling from all the orthopedic injuries, but also provide a sense of calm for the patient a sense of familiarity, a sense of safety, because these patients don’t know what’s going on. They don’t have the information processing to problem solve, to reason what’s happening to them. But it was eye opening to see that the music that he was familiar with, really had a profound calming effect, that was able to allow us to engage more purposefully for therapy. And so we took that information and any time he would start to become agitated with nursing, they would turn on his music. They would turn on Hamilton, they would turn on other Broadway shows that he liked.
And it would reduce the need for sedation for sedating medicines that he needed, and allowed nurses and doctors to wean him off of that, while still allowing him to more actively participate in therapy and move past the agitation phase. Now, it doesn’t mean the agitation phase immediately stops once they move to the next one. There’s going to be exacerbating factors, frustrations that are demonstrated that are agitation that can be caused as a result of something, but the unexplained agitation started to dwindle. And this patient was able to start to move to more purposeful activity with therapy with staff with physicians and really progress towards the next phase of recovery.
Kali Dayton 33:52
Wow, that’s that is an amazing story. I just from my perspective, I see that moment as a fork in the road.
Phillip Gonzalez, OTR, MOT 34:01
Yeah, absolutely. It was. I mean, it was the nurse was with us when it happened. And she was like, what do you do? Like we just played the music for him. And I said, continue to try this and just that routine establishment changed the progression of his recovery.
Kali Dayton 34:20
And as a nurse practitioner, that probably wouldn’t have been my first thought.
Phillip Gonzalez, OTR, MOT 34:25
That’s right, but and that’s where we come in where the entire interdisciplinary model is so pivotal, because as an OT, I look at a patient’s occupations. I look at things that they do prior to or that they’re expected to do past the hospital stage to really make sure that what they’re doing is purposeful to them. And so finding that thing that was so meaningful and purposeful and powerful to him, really was an asset to are tough for us to use in his recovery and ended up being safer and more feasible for the staff.
Kali Dayton 34:59
Even when you’re not there… it changed his outcomes. What recommendations? Or what would you teach? Especially nurses that are there at the bedside all the time, they’re the ones weaning down sedation, even before you get there, what would you teach them about? When why it’s important to start that weaning process? Why it’s important to try to get them back to this world?
Phillip Gonzalez, OTR, MOT 35:25
Yeah, that’s a good way to put it.
Kali Dayton 35:26
…and what and what tools they can even use during that process, and how to work more collaboratively with rehab services?
Phillip Gonzalez, OTR, MOT 35:34
So I think one thing I would help to educate nurses on is finding truly what the patient’s baseline is, and utilizing what assessment and scales that rehab services can provide to really assess where the patient is, cognitively. Are they in a comatose state? Are they in a comatose state because of sedation? Or are they in a coma comatose state because of the injury itself. The other thing I would educate nurses on is, as they move through the recovery phases, there’s going to be unexpected phase and agitation. And that expected phase of agitation shouldn’t result in an immediate need for sedating medicine medications, unless obviously, if it was life threatening, but what other interventions can we provide? Can it can physical restraints be an okay, alternative? I’m not an advocate for physical restraints by any means. But with this populations, I understand that they are absolutely necessary…
Kali Dayton 36:40
But what if sedation is more restraints?
Phillip Gonzalez, OTR, MOT 36:43
Right? Do they have limbic injuries that are going to cause damage from restraints, or vice versa? Or is the sedation going to be more harmful to the body? For a whole global debilitation standpoint? What’s going to be the fine balance of what to use at that phase of agitation that we talked about was expected? And then what other interventions can we provide? When do we get therapy involved? Very early on in my career, I would get that pushback from nurses saying no, they’re confused, they’re agitated, they’re not participating. You can’t do anything with them. It was almost like a broken record. And finally, after educating myself, which what I think was the first step, I said, No, we’re going to do something with my expertise.
And I’m perfectly comfortable and capable to do this. And let’s see what we can do. And I think, as I change as I helped to change the culture at that hospital that I was at, at the time, nurses saw the profound effect rehab had at that stage, to really help the patients. And so we started getting less pushback, it’d be no different with patients that were just dealing with delirium, and were confused, maybe a little agitated from delirium, then with a traumatic brain injury population. And so I would have nurses come and find me and say, “Hey, when are you going to come see this patient? I want to wean his sedation down. And I know that he rests really well after therapy.”
Kali Dayton 38:12
Oh, that’s so key.
Phillip Gonzalez, OTR, MOT 38:14
Yes, we jokingly wear them out so that they can get restful sleep in a D stimulated environment, without sedation, so that the brain can start to remould itself. And that’s the key to moving through these phases of recovery is allowing for purposeful rest, purposeful activity engagement, and using those two things to get the brain to reteach what it needs to do for the body and for the person.
Kali Dayton 38:48
And so you saw culture change over time? And reinforced obviously, by the outcomes that they were seeing. Yep, seen as believing and your expertise brought ease and burden for the rest of the team, which who doesn’t want that?
Phillip Gonzalez, OTR, MOT 39:06
Right? Absolutely. And I think even as therapy in the ICU, there’s such a, I would say discrepancy in skill sets from therapist to therapist. Not from like an inability to do certain things, but or a foundational knowledge but just the experiences itself. So my experience has really been cultivated from having had so many years in trauma hospitals, whereas I wouldn’t expect someone who was in a county hospital that helped manage trauma patients to really have that experience and know what to do with these patients. And same thing for nursing staff as well. Is your almost like your, you know, what you have to do from a foundational knowledge standpoint, but actually applying it to practice it’s a very different thing.
Kali Dayton 39:57
And if the culture is already set to where they’re going to We need this data for prolonged periods of time. How can you bring in these interventions? As occupational therapists? How can they advocate for a decrease, sedation vacations, weaning process? Or to avoid sedation? How can they even get their foot in the door if the culture is set? What do you recommend?
Phillip Gonzalez, OTR, MOT 40:21
So I think I am a huge advocate for interdisciplinary rounds, every hospital that helped manage trauma patients had an interdisciplinary rounding team where therapy was highly involved, whether it be just the physical therapist, or just the occupational therapist, or even the speech therapist. And as if it was just one rehab discipline, making sure that you advocated for the other disciplines as well, building that communication bridge with the physicians of showing the value of our skill sets at that stage.
Because all of us as healthcare providers are very focused on our scope of practice, we’re really able to look at what we need to do we do it well in our scope. And the next step is branching out, okay, what other disciplines can I involve to help manage this patient, I’ve done what I can for my scope. Now I need other disciplines to help. So really learning what the other disciplines can do is huge. I think that culture change really started when therapy was involved in rounds with the trauma physician saying, Hey, we have this comatose patient. And they would turn back and say, “No, they’re not appropriate for therapy, they’re not awake.” And we pushed back and said, “No, we’ll let us get in there early on, we want to help them move through that comatose stage, we know that there’s going to be a stage of agitation, we can still be involved at that phase too.”
And having us involved early on, helps to mitigate some moves will help to move patients through these stages of recovery faster, as well as mitigate some long term damage, a patient who remains in a coma for an extended period of time is going to present with physical impairments, outside of just any other injuries they may have. I mean, I think the general rule of thumb is anytime someone who is bed bound and immobile, you lose about 4% of muscle strength every day. And that’s outside of any other medical complexities they may have. If they require mechanical ventilation, if they are restrained to the bed, if they have electrolyte imbalances, kidney dysfunction that’s going to cause are caused by Rhabdo, things like that, that can impact their body from a physiological standpoint, you’re also causing a disability from keeping them in bed, just from that alone.
So it builds up pretty quickly. And so allowing us to be involved at that stage and teaching nurses and physicians and family members that, yes, we can do this, we can do this safely, we can help to move them through these phases, really is the start of their rehab phase is the rehab process. And it’s really eye opening when it works. It’s really groundbreaking when it works because then nurses and physicians and family starts to see the value. And they asked for us. And when they start asking for therapy, when is there becoming that means that we’ve done our job means that there’s been some form of education, there has been something that worked there, they’ve seen the improvement, that they’ve seen the value and what we bring to the table not only for maybe this one patient, but for all the patients.
Kali Dayton 43:34
And it sounds like this is as you’ve used the word progressive, likely with the rest of the ICU community, not every trauma ICU has such a occupational therapy presence. Correct? How do you recommend that nurses or any part of the team advocate for greater presence, more employment of occupational therapists as as well as some more integrated role? I just feel like trauma sometimes can have a very tough culture where we’ve always done it this way. We’re just going to take and pagan you know, so how, how would you recommend we break through that?
Phillip Gonzalez, OTR, MOT 44:08
I really think having a strong OT, they pushes the boundaries of what we can do as a profession in the ICU is imperative to changing the culture. Having colleagues from the other rehab disciplines that really understand what you bring to the table can help to advocate for a greater OT presence. Like I said, as healthcare providers, we are fantastic at knowing what our scope of practices, but I think sometimes we can be so focused on what our scope of practice is, we tend to forget what our other disciplines can bring to the table.
So personally over the years that I’ve practiced, I’m guilty of that myself where I really focused on what I wanted to do as an OT, and didn’t look at what PT needed to do, or even more so what speech therapy needed to do. And so as I gained that experience, I became a huge advocate for all of my colleagues, PT and speech therapy alike of when we needed to bring those patients in, or these rehab services in to help with a patient’s deficits or things that are, I call them red flags for me that I know I’m not the expert. And so I would advocate for my colleagues who aren’t the expert at ADL management, or routine establishment or identifying the patient’s occupations to advocate for, “okay, let’s bring the OT and because they look at things from a different lens than I look at, they look at things or they look at things from the physical therapy lens, or they look at things from the nursing lens, or they look at things from the physician lens.”
But a lot of the times you don’t look at things from an occupation, lens, where what are the occupations, and I don’t mean work, I mean, what are the daily activities, these patients, one have to engage in, to want to engage in and three are purposeful. And introducing that at the ICU stage can be hugely impactful in their recovery.
Kali Dayton 46:11
And that may be a shift in perspective for a lot of clinicians to think I just feel like especially maybe for trauma, you have so many other things going on that the rehab side that is for Eltech. That’s for rehabilitation side. But I appreciate your expertise and your perspective on how much that perspective that can impact patients outcome. What kind of resources can you provide for us as far as what will be included on the blog? What’s the homework?
Phillip Gonzalez, OTR, MOT 46:39
So I think the homework that I would have for any listeners right now is really understanding what the Rancho Los Amigos scale is in relation to traumatic brain injuries, and kind of starting to look and see where someone might fall in that stage of recovery, and then also understand what the expected behaviors are and what they can and can’t do what they can and can’t reason through.
The other thing that I would recommend looking at is center for Neuro skills in the Brain Injury Association of America have a vast amount of resources for both acquired brain injury or any type of brain injury, but with a huge emphasis on drum Matic brain injuries as well. And then a OTA and the American Journal of Occupational Therapy, constantly put out research and publications, case studies. As far as OTS role in the traumatic brain injury, population intervention, assessment and intervention strategies that therapists can use that other health care providers can learn at what OTS brings to the table, what the value of our profession is for these populations. I think those are probably my three big ones.
And then if you need just more experience, there’s always continuing education and asking colleagues who may have that experience of what more can we do? I think, as healthcare providers, once we establish routine of what works for us, we tend to miss the question of what more can we do? And I think what makes a great health care provider is someone who constantly asks, What more can I do? And the more doesn’t necessarily mean, what more can you do specifically, it just means what more can you provide to the patient if it’d be another professional, if it be a resource, if it be a support group, knowing what else is out there for these patients and for these family members, because trauma itself doesn’t just impact the patient.
A traumatic brain injury doesn’t just impact a patient, it impacts their support circle, it impacts their family, it impacts the rest of their lives. So we’re not going to stop at just the hospital phase of recovery. This is something that goes on for a long time. But if we can introduce this material early, it helps to it helps with mental loss for words right now, but it helps with the overall one acceptance of what happened, but also provide resources for support groups because caregivers face the emotional trauma of these diagnoses as well. And I think that’s something that we can recognize as healthcare providers to is it isn’t just about the patient, we also are inadvertently treating the family as well.
Kali Dayton 49:39
And I think when we have patients that are responding interactive, we see more of the human side of it, we see more of the the dynamics within the families and that’s gonna be more Nate to try to provide them with the tools for success in the future. And it will include all of that on the blog. Phillip, thank you so much. Is there anything else you would include?
Phillip Gonzalez, OTR, MOT 50:00
No, I’m very happy to be a part of this. It’s been a pleasure meeting you speaking with you. Thank you for you allowing me to be on this podcast. I think like I said, what you do with this podcast is phenomenal. I am a huge advocate for all of my ICU colleagues to listen to a nursing rehab, just anybody that works in ICU, I think you are pivotal in changing a culture. And I want to thank you for that.
Kali Dayton 50:28
Although there would be nothing to talk about if you weren’t doing what you’re doing and proving that this is possible and essential and drastically changes our community. So thank you so much for what you’re doing good luck with your future endeavors and just know that you’re making an impact not just in new patients lives but in the ICU community in general. So thank you so much.
Transcribed by https://otter.ai
References
https://www.cdc.gov/traumaticbraininjury/moderate-severe/potential-effects.htmlhttps://www.neuroskills.com/education-and-resources/rancho-los-amigos-revised/
René Padilla, Anna Domina; Effectiveness of Sensory Stimulation to Improve Arousal and Alertness of People in a Coma or Persistent Vegetative State After Traumatic Brain Injury: A Systematic Review. Am J Occup Ther May/June 2016, Vol. 70(3), 7003180030p1–7003180030p8. doi: https://doi.org/10.5014/ajot.2016.021022
Pei-Fen J. Chang, Mary Frances Baxter, Jenna Rissky; Effectiveness of Interventions Within the Scope of Occupational Therapy Practice to Improve Motor Function of People With Traumatic Brain Injury: A Systematic Review. Am J Occup Ther May/June 2016, Vol. 70(3), 7003180020p1–7003180020p5. doi: https://doi.org/10.5014/ajot.2016.020867
Gordon Muir Giles; Demonstrating the Effectiveness of Occupational Therapy After Severe Brain Trauma. Am J Occup Ther September 1989, Vol. 43(9), 613–615. doi: https://doi.org/10.5014/ajot.43.9.613
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