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In this episode, Kali talks with Merrill, MOT, to find out how occupational therapy is utilized when patients are awake and walking on the ventilator, what role occupational therapy plays in preserving physical and cognitive function during critical illness, and how this enhanced role has impacted Merrill’s his career.

 

Episode Transcription

Kali Dayton

I’m here today with Merrill Nearman. He is an occupational therapist and a medical surgical ICU in Salt Lake City, Utah. And he is willing to share with us his role and getting patients straight home from the hospital after an ICU stay. Merrill thanks for joining us.

Merrill

My pleasure. Thank you for having me.

Kali Dayton

Can you tell us a little about your role in the ICU?

Merrill

So as an occupational therapist, we get the orders when the patients come in to do the evaluation. And then based on what the patient’s able to do with the time and work with them to get them to the maximal functional level. We do everything from simple range of motion, to getting them up, walking them down to the shower room, having take their own shower, getting dressed, standing, and do the grooming, brushing teeth, washing hands, washing face, we do the whole thing.

Kali Dayton

But this is an ICU right? So a lot of people are really sick. So what is it like? Um, like you said, you do according to what they can do. How does that vary? I mean, even when they’re on mechanical ventilation, some of them on breathing machines. How do you work with him then?

Merrill

So we work very closely with physical therapy and respiratory therapy. We make sure all the lines are set, all the tubes are where they’re supposed to be. And we get them up. And if they can tolerate standing, we’ll do the first day we’ll see what they can do. If they can stand for 30 seconds while they wash their hands, fantastic. That’s a start. Next day we push for 45. Sometimes they go for a minute, two minutes, we’ll see what they can do and kind of go from there.

Some people can’t do that. So we’ll start doing something simple like brushing their hair while they’re sitting up in the chair or on the side of the bed. Just trying to get them to do whatever they can do, besides just laying in bed and staring out the window or at the ceiling. Trying to get them functional, get their brains moving, as well as their extremities moving.

Kali Dayton

And when someone comes into the ICU, obviously, if they’re in critical position, they’re at death’s door. Why are these things important? During that moment, why not wait until things have cooled down, they’re feeling better, they’re more stable? Why not wait?

Merrill

Because as they lay there with the tubes, and endotracheal tube, and everything, everything kind of goes downhill. The muscles atrophy, the brain kind of goes downhill, there’s no stimulation. They’re not doing the things we’re supposed to do everyday. We’re supposed to get up, we’re supposed to get dressed, we’re supposed to brush our teeth, brush our hair, put our shoes and socks on.

And as they’re laying in bed that’s taking away from their independence and their function. And from what I’ve seen in my 20 plus years of experience, is that people want to get up. They want to move, they don’t want to lay in bed they want to do, even if it’s something as simple as putting on socks, or brushing their hair or whatever, that’s something they want to do. And there’s a sense of accomplishment.

So they have this, “Oh, I sat up at the edge of bed and I brushed my hair today!” Where there might not be a big deal for some people, for them it is and they want to do more, they want to brush their hair, and they want to shampoo, they want to do something else put a shirt on- even with all the wires and tubes, we can still work around that with a gown and have them practice putting their arms and sleeves. It’s just the fine motor coordination, the connection between the brain and the hands and the arms. It’s fantastic to get people up and moving. Even on a breathing machine, even on the breathing machine absolutely helps stimulate lungs, increases cardiovascular, and it gets them moving. And it gets people off of the vent faster.

Kali Dayton

So true. And I’ve seen I’ve seen patients …and there was an iPad, you were doing cognitive therapy with them. What is that for? And what’s that, like?

Merrill

So we’re working closely with speech therapy on cognition and with the iPad when people are vented. Obviously, they can’t speak. So we have different applications on the iPad, or if they’re not comfortable using iPads, they have their own iPhones or Android. And there’s many apps that they can communicate with like one of my favorites is text to speech where they text and then they hit a play button and it speaks for them and it stores what they’ve typed. So if there’s something they want to say over and over and over again, they just hit the phrase and in the play button and it speaks for them. That works on fine motor coordination, cognition ,to you know for sentences, I’m hitting the right play button to say what they want to say picking the right phrase. And that’s a lot easier for some people than writing.

Because writing once the page is full, it’s usually thrown away. So they have to write the same thing over and over again. On one hand, that’s okay. But with the with the tablet or the phone, it’s just much easier to type it out and hit play, and it speaks for them. And a lot of people like that actual speaking and having that sound. Other things we have on the tablet, our cognition apps, that allow people to play games to work on their brain function. A lot of them are called, you know, brain teasers or IQ work or things like that, where they can download them for free on their phone, if they want to, or use our tablet, and work on cognition while they’re just sitting there in the chair or laying there in the bed.

You know, TV is great, but it’s just on, there’s no real interaction. With the tablet, there’s, again, fine motor, eye hand coordination, cognition, and it helps them stay stimulated, which helps encourage patients to do more, because you’re not just laying there like a lump. And it’s really helpful we found.

Kali Dayton

What have you seen personally, what have you seen with these critically ill patients that… sometimes we don’t expect them to be able to engage much… but what do you see over time, by the time they leave?

Merrill

from the time, you know, certain patients get here to the time they leave they we’ve seen such improvement, not just with, you know, the physical of you know, walking or getting the vent taken out, just the cognition of not falling back. Of not losing ground of at least staying where they were and then increasing. And then when they leave, there’s so much gratitude, like, you know, “I didn’t just lay there, I was able to play a game on the tablet, I was able to talk with someone even though I had the the vent, and it was, it’s so much better for me.” And they’re very grateful, and usually pretty happy.

Kali Dayton

And what does it mean for long term outcomes?

Merrill

So there are some studies out there that say that the more engaged a patient is, while they’re in the ICU, the less the long term effects are,  like the PTSD, or decline in cognition, or decline in physicality. By having engaging them and doing all the activities, PT, speech, OT, they’re able to gain faster, advance faster, and get out faster.

Kali Dayton

Yeah that’s so true. An ECMO survivor that was awake and mobile, was given occupational therapy during his ICU stay. And he talks about how he thought it was just ridiculous that they were trying to play dominoes with him, he just didn’t understand why. And now he looks back, because he didn’t realize how long he was going to be there, what it’s going to be like, how crazy it was going to make him to look at the same four walls. And so now he is so grateful.

And his experience just sounds so different than some of the other survivors that when they only had the back of their eyelids to look at. And that just turned into hallucinations and terrible experiences and PTSD. And your survivors get to remember those small victories that progress and actually working towards their own discharge home.

Merrill

Yeah, and they do remember that they feel better for it. And it’s, you know, our bodies are meant to move, we’re supposed to do things and when you’re just laying there against your will, and not being able to do anything, it’s really takes a lot out of you. And even something as simple as playing Candy Crush for 10 minutes during therapy, um, being able to keep the tablet and being able to do a brain game that’s so stimulating and helpful, that you know, people you don’t see it on, you know, on a such a small level. But as it gains and grows, they’re able to do more and more than they come off of the vent and they’re able to do so much more. It’s so, so helpful.

Kali Dayton

And what does it mean to you as an occupational therapist, to work in an environment and a culture that allows your patients to participate in occupational therapy throughout out their ICU stay?

Merrill

It’s so so nice. When I first started…. when I did acute care in another state and another hospital, obviously… ICU evals were basically just “Do the eval,” and then if they were vented, “Just do range of motion”. There wasn’t a lot of stimulation has come in, move their arms, so they don’t get contractures in their arms. PT would do the legs. Sometimes we try to set them up but they were a little more awake.

So going from there to here where, you know, we’re fully engaged, we go in, and we’re just, we’re in it with them and we’re pushing. And even if they don’t want to be pushed, then they know deep down that it’s going to help. And sometimes we have to tell them that, but it’s so helpful and they gained so much from that in the ICU stays are way shorter now than when I first started.

They’d be there for such a long time. Because while we’re doing with just the simple stuff, it wasn’t until they were able to participate that we started doing things, and it just didn’t work out so well, because it wasn’t a lot of engagement. And people just kind of went downhill with depression, and everything. It just didn’t work out well. So being here, it’s so nice that when I first started coming down the ICU, and I saw what was going on, I was thrilled. I’m like, “This is great! This is what OT is about! Getting people engaged doing functional activities, to get them to their maximal level.”

Kali Dayton

And you can only do that with people that are awake, that have fairly clear brains and are calm.

Merrill

Mm hmm.

Kali Dayton

That’s amazing. And what does that mean to you in the satisfaction of your career?

Merrill

So, I did spinal cords for a long time before I came here and there was some satisfaction there. But here you see it so much more because the spinal cord injured patients, it was such long term, a long time. Here you see people get better in just you know, a couple of weeks. A patient comes in and they’re intubated, and they’re a little confused, but you see them gain something.

And if it’s not everyday, it’s every couple of days, and then the endotracheal tube comes out. And they’re able to communicate a little bit better. They can talk and they actually say, “I really appreciate the tablet or, you know, just brushing my hair, you know, trying to put a sock on, because that was something I did every day.”  And as most people say, you don’t realize what you had until you lost it. So they get this sense of “Oh, yeah, I really want to work so much harder now.”

And it’s so nice to hear that from the patients themselves, just how appreciative they are. And that certainly makes us feel much better.

Kali Dayton

Yeah, that I forgot about that part. They have hope.

Merrill

Yeah,

Kali Dayton

These are other survivors that wake up after weeks of deep sedation and immobility can’t even lift a finger off the bed. And they’re demoralized. I mean, there’s there are studies that show just the sense of self is so lost, when they realize where they are, what their life is like now, how far they have to go to get anywhere close to where they were.

Yeah there is such a contrast because they’ve been working towards these goals the whole time. They haven’t lost that much ground, and they get to move forward. Thank you so much for all your good work in preserving function. You bring such an important insight and expertise into our team and you help people go back to their lives and actually function. So thank you, Merrill for sharing your expertise and wisdom.

Merrill

My pleasure. Thank you for having me.

 

 

Transcribed by https://otter.ai

 

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