Physical Therapy during COVID-19: reflections from Regis DPT Faculty

Regis DPT faculty Alicia Lovato, Amy Rich, and Jenny Logan share their experiences practicing during COVID-19 in both home health and inpatient settings.

Thank you so much for your tremendous service, your mentorship, and your vulnerability in sharing your experiences. We miss seeing you in person so much and are so proud to call you our faculty and mentors.

~Alicia Lovato, DPT, North Rehab Lead, SCL Home Health~

This Pandemic… Has established fierce leaders

  • Has brought valid fear and anxiety.
  • Has demonstrated the strength and resilience of our team.
  • Has excelled our Telehealth innovations.
  • Has promoted critical thinking on how to keep our Home Health clinicians and patients safe (have to get creative when you don’t have that lovely PPE bin set up for you in the hospital hallway). 
  • Has increased my knowledge and awareness of how to treat patients diagnosed with COVID.
  • Has taken its toll emotionally and taken me outside of my comfort zone.
  • Has made me so grateful for my health and ability to work.
  • Has amplified my fierceness for this profession.
  • Has reminded me to have compassion for myself and others.

I miss seeing all of your faces at Regis. I can’t imagine the feelings and emotions that this has brought up in your education and personal life. Like good ole Dolly Parton said, “Storms make trees take deeper roots.”  Hopefully by the end of this we will be like Wild Fig Trees (per Google search these tree roots can dig down 400ft!). 

 

Working as an inpatient acute care physical therapist during COVID-19: A perspective

~Amy J. Rich, PT, DPT, NCS, Senior PT, University of Colorado Health~

*this opinion reflects the perspective of the individual and not necessarily that of the organization*

It’s 11:15am and I’m getting ready to call into my daily COVID-19 phone call from the rehabilitation team leadership in order to get updated on daily changes and progress, personal protective equipment updates and the number of patients in house who have tested positive for COVID-19.  While I await to virtually connect into our meeting, I reflect on 5 words that seem to define my experience of watching COVID-19 flip all perspectives within my healthcare institution upside-down:  Anxiety, Grief, Compassion, Empathy and Innovation. Never in my 20 years of practicing in the hospital and ICU setting have I seen such circumstances as I have now due to COVID-19.  One vivid memory I will recall is working the Sunday after our Governor instituted a “stay at home” policy due to the Coronavirus.  It was such an odd sensation to be driving TO work in an environment where patients were positively infected with COVID-19 while the rest of the community stayed home.  I entered the hospital donning my newly mandated mask, keeping my head down, noting that the hallways were eerily silent.  Just a few days before, the hospital had mandated a “no visitor” policy in an effort to protect the safety of our patients.  This invisible virus, over the span of a few weeks, progressively took away our outpatient clinic visits, our non-emergent surgical procedures, our visitors, our administrative assistants and our cafeteria workers among others.  The hospital went from a bustling “city” of people and procedures and socialization to a quiet empty space where essential healthcare workers, with masks on at all times, prepared for the surge.  The surge of the virus bringing the sickest of the sick to our doorstep. 

During this time, my perspective was of an environment filled with anxiety and fear of the unknown mixed with a strength and courage to combat the COVID-19 virus.  It is difficult to feel calm when everyone around you is wiping all surfaces with cavi-wipes, keeping a 6-10 foot distance from one another and wearing masks at all times.  It is an odd feeling to practice social distancing with your peers, but then walk into a patient’s room to perform a max assist transfer with them to enable them to get out of bed to a chair.

As the days progressed and the rules for social distancing tightened, I felt a bit of grief surround our hospital community. Grief over losing our “normal,” grief over watching family members have to say their goodbyes and stay at home instead of by their loved one’s bedside, grief over watching our bustling hospital community slowly become quieter as we prepared for the surge.

But in the midst of this extreme fatigue and anxiety and grief, I also saw signs of hope.  Leadership gave constant reminders to show compassion for our patients and advocate on their behalf to their family members and compassion for ourselves during this time.  One such memory is facilitating ambulation for the first time with a patient who had a severe traumatic brain injury.  His wife had been at his bedside every day up until the moment she was asked to stay home due to COVID-19.  She needed to be a part of this milestone of walking.  As I prepared the patient for ambulation, the nurse was able to facetime his wife via iPad.  While this patient would not look up and out from under his helmet for myself or the nurse, he was able to stand upright, attend to task, and take steps under the encouragement of his wife from the iPad shown in front of him.  Another bright spot of hope is the unimaginable outpouring of support from within our organization and from our community.  We have had offers for home-made masks and food, free access to meditation smart phone applications and even free coffee!  Peers are offering to donate vacation pay and individuals without work can apply to be placed in a resource management pool in order to earn a paycheck during this stressful time. 

From an inpatient rehabilitation perspective, I feel this COVID-19 virus has bound my rehabilitation team in a way I could never have anticipated.  As the COVID-19 surge preparation began, our rehabilitation team leadership asked for volunteers to be on the COVID-19 “A” team.  These are the physical therapists, occupational therapists and speech language pathologists that have volunteered to step INTO the rooms to provide essential health care for patients with COVID-19. These therapists are working with these patients providing essential rehabilitation in order to maximize functional outcomes while also reducing the risk of their colleagues being exposed to this virus.  This self-less act has put me in awe of my team members.

The innovation seen during these times is also amazing.  For example, I was able to provide PT intervention for a patient intubated via endotrach to a BiPAP machine!  This innovation brought forth by an interprofessional team of physicians, nurses and respiratory therapists allowed for appropriate ventilation for the patient while saving a mechanical ventilator for those that have no other option.

Through the leadership of our Inpatient Rehabilitation Educator and fellow Regis graduate, Jennifer Gunlikson, the rehabilitation staff received constant and pertinent information along with a platform to be innovative.  Her efforts in combination with our entire organization’s leadership has kept us informed, safe and calm.  One of the greatest pieces of education was for all patient care employees to understand how and which personal protective equipment should be used with patients who have COVID-19 and for patients who need to be protected from the virus.  As information brought forth by the CDC was ever-changing, so was our education.  Detailed information frequently and in various platforms was provided so that use of PPE was safe, effective, and efficient.

As a rehabilitation team, we banded together to make innovative discharge plans and identify key needs for ongoing education surrounding the COVID-19 virus.  We came together as a team to facilitate quick and safe discharge plans for patients who were not positive with COVID-19 in order to get them out of the hospital.  We increased treatment times and frequencies, we increased family training (including virtual training over iPad and smart phones) in order to maximize function and facilitate a safe discharge out of the hospital.  We also came together to share our individual expertise to the rehabilitation team, providing increased mentoring of therapists for practice in the ICU and increased training on mechanical ventilators and respiratory equipment.  With collaboration from our community Doctor of Physical Therapy programs at Regis University and the University of Colorado, we were able to develop a training video on respiratory pathology and common interventions to maximize ventilation and mobilize secretions.

The battle to contain COVID-19 and care for our patients is not yet complete, and the future is still uncertain.   We will continue to feel anxiety, grief, compassion, empathy and innovation as we navigate these unexpected times.  But in the meantime, we hope we have flattened the curve, we are prepared, we are strong and we will overcome.

 

A Day in the Life of a PT Treating Patients with COVID-19: true stories from the front lines

~Jenny Logan, PT, DPT, NCS, Senior PT, University of Colorado Hospital~

I park my car in the parking lot of the University of Colorado Hospital and begin my walk into the hospital. I pass night shifters leaving the hospital still wearing a mask. I momentarily feel exposed and naked without a mask. I head to the small office that the COVID therapy team has been relegated to in order to decrease exposure. I grab my surgical mask and begin to chart review.

Patient A (55 y/o male, no past medical history, anesthesiologist), day 29 of hospital stay, 21 days in ICU, mechanically ventilated x 18 days. Per chart, patient is medically ready to discharge when cleared by PT.

Patient B (26 y/o male, no past medical history) 34 days in the ICU, 31 days on mechanical ventilation, decannulated from ECMO 6 days ago, extubated yesterday

Patient C (37 y/o female, history of HTN, DM, obesity, Spanish speaking, undocumented, no insurance), 27 days in ICU, trach placed five days ago, still mechanically ventilated. Decannulated from ECMO 10 days ago.

Patient D (65 y/o female, no past medical history, Spanish speaking, undocumented, no insurance), 18 days in the ICU, still mechanically ventilated x 15 days.

Patient E (39 y/o male, no past medical history), hospital stay x 32 days, mechanical ventilation x 28 days, trach placed 7 days ago.

Patient F (53 year old male, no past medical history, Spanish speaking, undocumented, no insurance). 37 days in ICU, trach placed 4 days ago. PEA arrest x 3.

 Patient G (45 y/o female, history of HTN and obesity), 18 days in ICU, 12 days on mechanical ventilation.

I grab my N-95 mask that was reprocessed yesterday using UV light. Is it really still effective? I can’t think about this too much. I have work to do.

I head to see my first patient, Patient A. I don my N-95 mask, yellow gown, gloves and face shield. Immediately my nose begins to itch. Why does this always happen the moment I put on my mask?

The patient is sitting in bed, chatting on his phone but immediately hangs up when he realizes that I am from PT. I assist him to ambulate in the room without a walker. He is very unsteady on his feet and but he only loses his balance twice which is an improvement from yesterday. He can only tolerate 30’ to the door and back twice before needing a rest break. Despite his shortness of breath, his SpO2 remains above 90% on room air. I ask if we can call his wife to discuss discharge planning. Once she is on the phone, I explain that her husband is ready to discharge home today. She begins to cry tears of joy. It has been 29 days since they have seen each other. I explain that he will need to quarantine himself at home for 14 days to avoid exposure to his family. This means that we will need to send him home with a walker because he cannot walk safely or independently without it. Neither seems bothered by this despite the fact that he was working as an anesthesiologist prior to contracting COVID and was an avid cyclist and skier. I also explain that she will need to assist with his medications at home. This is for a man who managed medications for a living but now has cognitive impairments that will prevent him from doing this safely on his own. I review the home exercise program that I have created for him and provide a few TheraBands. He will likely be unable to receive home health PT as he has yet to test negative for COVID. I exit and wish him well at home. “Thank you for everything you have done for me,” he says.

I head to the Neuro ICU, which has been transformed into a COVID ICU. I catch a nurse as she heads from one room to the next.

“How is Patient B doing this morning? Stable after extubation? Can I work with him?” I say. Yes, please, says the nurse as she rushes into her next room where the patient is crashing.

The patient is drowsy but wakes easily when I say his name. I introduce myself and explain that I am here to help him get moving. His eyes widen and he whispers, barely audible, “ok.” His voice is very weak likely due to the amount of time spent on a ventilator. I administer a CAM-ICU, which is positive for ICU delirium. He does not know why he is in the hospital and he thinks that the date is in April. He was admitted in April but it is now May. He looks shocked when I tell him the date and that he is in the hospital for coronavirus. I explain that he has been very sick in the ICU for weeks and on many medications that have made him lose track of time and forget everything that has happened to him. I ask him to raise his arms and he can barely lift them past 30 degrees of shoulder flexion. He cannot lift his legs off the bed in a straight leg raise. I help him move to the edge of the bed with maximal assist. He feels very dizzy. His blood pressure drops initially but stabilizes quickly. He seems to have forgotten how to use his arms to help support him while sitting on the edge of bed. After several minutes, he finds his equilibrium and can sit up with only a minimal amount of assist. He whispers, “This is so cool.”

Periodically someone knocks on the glass door and gives a thumbs up. It is a question. Am I doing ok in the room? Do I need anything? Usually the answer is no. I’ve got this. This is what I do – working in an ICU to help patients regain function. But it’s nice to know that I am part of a team that has my back and is working to help each other.

I move on to the next patient, Patient C, who I have been working with for a few weeks. “Do you want to try standing today?” She vigorously nods her head. She can’t talk because she has a tracheostomy but she can write. She writes that she has been waiting for me all day because she can’t stand being in the bed any longer. She also writes that she feels sad today. She misses her family and really wants to talk to them, especially her sister. I tell her that her sister went to rehab today (her sister also has COVID and our rehab has been to converted to a COVID only rehab) so maybe we can try to arrange a Face Time session later. She needs less help to sit up at the edge of the bed today. With help from me and the nurse, she stands but can only stand for ~ 30 seconds. She sits back down and looks frustrated. “Why can’t I walk?” she writes. I try to explain that she has been in the hospital and very sick for weeks. It has made her muscles very weak and her lungs unable to provide enough oxygen to her body. She will have to re-learn how to do just about everything.

As I walk down the hall to take a short break (ie remove my mask, breath some fresh air, scratch the itch I’ve had on my nose for hours), a physician assistant stops me. “We would really like for you to work with this patient because we think she is too weak to wean off the ventilator.” Roger that. Mask back on, no time to rest. This patient, Patient D, is on spontaneous settings on the ventilator, meaning that she is doing all of the work to breath on her own. Her respiratory rate is high so I cue her to breathe deeply and slowly. I show her the numbers on the telemetry monitor as visual feedback and she is able to slow her respiratory rate. I assist her to the edge of bed just as her medical team walks by. They wave at her through the glass and she waves back. After the session as I leave the room, the respiratory therapist tells me that the team was so impressed with how she did while mobilizing that they are going to extubate her today. “Yesssssss!” I think to myself.

I meet up with my OT colleague to see our next patient together, Patient E. He is too deconditioned to tolerate two separate sessions. He is awake but fidgety. I walk in and remind him who I am. He says, “Hey, how are you?” He has a speaking valve over his trach and I am hearing his voice for the first time in a week. “It’s so good to hear your voice,” I say. “Can I have a diet coke?” he asks. I explain that he has not yet been cleared to swallow by the speech therapist because his muscles for swallowing are weak just like the rest of his body. Once sitting at the edge of the bed, he asks again “Can I have a diet coke?” I explain again why this is not yet possible. OT and I assist him to stand and pivot onto the bedside commode. After he catches his breath, “Can I have a diet coke?” We stand and pivot into a chair. “Can I have a diet coke? Please let me have a diet coke. Can I talk to the diet coke boss?” I assure him that I will speak to the diet coke boss (ie SLP) when we are finished. Outside of the room, I say to OT, “He really presents like someone with an anoxic brain injury – so perseverative and unable to remember from one minute to the next.”  “Yeah, that’s tough. He’s so young,” she says.

As I gear up to head into my next patient’s room, someone walking by yells that the neighbor is disconnected from the ventilator. I already have on PPE so I go in. The patient has self-extubated and I suddenly find myself alone in a code-like situation. I scramble for the ambu bag and begin giving breaths to the patient manually. It takes a few minutes for nurses and doctors to get all of their PPE on. Once in the room, they take charge. The patient’s oxygen saturation is dropping quickly so I help to restrain the patient while the physicians quickly and expertly re-intubate him.

After my tachycardia subsides, I decide it is time for a break. I grab food that someone has donated to the hospital. Once back in the office, my OT colleague on rehab tells me “Remember that patient you worked with that had a brachial plexus injury from poor positioning in prone? She is getting some return in her arm and is now walking.”  “What?!? That’s awesome!” I say. “ I’m so happy she is making such good progress. She was a hot mess when I evaluated her in the ICU.”

I check in with the nurse for my next patient, Patient F. “I don’t know,” she says. “He has been really agitated and tried to pull out his trach a little while ago. But I guess you can try.” As I walk in, the patient is restless and attempting to get out of bed. I calmly begin speaking to him in Spanish, reminding him where he is and why he’s here. His body begins to relax a bit. His sheets still have bloodstains from when he tried to pull out his trach earlier today. I help him move to the edge of the bed and he is suddenly very calm. I notice photos of his family in the room so I bring them over and we talk about his family. I don’t recognize the patient from the photos as he has lost at least 50lbs from his time in the hospital. Like so many others, he has been in the ICU for weeks, most of that time on a ventilator with a trickle of nutrition going into his stomach from a tube in his nose. Today he takes his first steps. He is like a newborn learning to walk again, feet too narrow and then too wide, hands holding him up on either side. After the session the patient is calm in bed, his agitation having ceased. The nurse is amazed and grateful.

My final patient of the day, Patient G, is a nurse who works at a rehab facility. She has a gentle southern drawl and a great sense of humor. Her arms are so weak that she cannot bring her hand to scratch her face or feed herself or hold her phone to talk to her family. Her sister calls while I’m in the room and I hold the phone to her ear so she can talk to her. She is able to stand for the first time today with the Sara Stedy. She does a little shimmy while standing because she is so excited. We laugh. It feels good to laugh.

At the end of the day, back in my car, I breathe a sigh of relief. It’s been another good day of work but I’m exhausted. As I drive away, I see signs saying “Thank you healthcare workers.” I feel grateful to have chosen a career that allows me to fight this pandemic from the front lines, giving the gift of function back to my patients.

 

 

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