Call in a Consult

If you know me or if you’ve ever worked with me, you will know that I am a huge fan of multi-disciplinary care. I am always trying to look for underlying issues that can be addressed by my colleagues and teammates that can improve outcomes for my patient beyond what I can provide them. COVID-19 is no different.

There are many side effects of not only the pulmonary condition itself, but the resulting conditions of acute respiratory distress syndrome and post intensive care syndrome that not only warrant, but mandate a multidisciplinary approach.

I’m feeling a bit salty today, so I’m going to be implementing some memes
for my own entertainment.

I don’t know if you’ve ever been intubated, but I have. For a procedure that would take longer to write out than the 45 minutes the procedure actually lasted, I was intubated. I needed an upper airway reconstruction of sorts because I had been diagnosed with obstructive sleep apnea when I was 21 years old. Turns out I was pretty anatomically dysfunctional, and my airways were just not performing the way they should have. So, after eight months on a CPAP which I completely failed, we decided to go forward with the surgery.

I’m betting you’ve had at least one patient who uses CPAP. Do they tell you that it’s extremely uncomfortable and they don’t like wearing it? They are 100% correct! CPAPs are incredibly uncomfortable and difficult to wear if it’s something you’re not used to. I’ve talked with many people who use them religiously and could never sleep without them, but in my personal experience, it was some of the most uncomfortable nights I’ve ever had. It was hard to breathe at all with that pressure blowing back in my face. I utilized a nose-mouth mask, but quickly had issues with claustrophobia, so switched to a nasal mask only. I attempted to use nasal pillows, but couldn’t keep those on any better than I could the regular nasal mask.

I cannot tell you how many consultations I had with my respiratory therapist, Holly, who is one of the most amazing people I’ve ever met. Holly did absolutely everything she could and gave me every mask she could find to figure out one that worked for me. She was in constant contact with my ENT to adjust pressure settings to improve my comfort and tolerance while still maintaining patent airways. Eventually, Holly and I decided that, given my age and my intolerance to the device, it was time to move to surgery. And she was right! The surgery was successful and I’ve never had a problem sense.

I bring this up because, even though I had seen a respiratory therapist for my initial mask fitting, I had always gone back to my ENT to address my intolerance of the device. I was still in graduate school at the time, and had not had a large amount of exposure to respiratory therapy other than my own personal experience. Had I known that consulting my RT was the way to go from the start, I could’ve save myself a lot of discomfort and time and gotten much better sleep. Inter-disciplinary consults work the same way for COVID-19.

Thankfully, respiratory therapists are already integrally involved in the treatment of COVID-19, so they will likely be the ones consulting us, not the other way around. But there are some other disciplines we may want to consider. Like I said, I’ve been intubated in the past, but only for 45 minutes! And even after that very short amount of time, I still experienced some problems. My ENT had warned me that I would be a challenging intubation because I have very small airways, and a shorter neck (in his words…) Can you imagine how patients with COVID-19 feel after days worth of intubation??? Not great, I’m betting…

So, after I came out of surgery, my neck was killing me. Two days later I saw physical therapist for some cervical spine work and one visit was enough to correct the issues and I had no further problems. Although we may initially think of physical therapy being utilized for COVID-19 to treat post-intensive care syndrome and impairments to airway clearance and diffusion, our orthopedic skills can still be just as important.

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I’ve had many patients that were intubated for heart and lung transplants. Some of these surgeries last 14 hours and the patient is intubated for the entirety of the procedure. Afterwards, their swallows is so impaired that they end up on tube feedings. Their vocal cords can be damaged creating vocal and volume impairments. They can also have severe throat soreness. All of these are things that can be addressed by consults to our wonderful friends the speech therapists.

If you have a patient in any setting who is been discharged from the hospital for any reason and is experiencing any of these symptoms after being intubated, they need a consult from the speech therapist. The symptoms can be short-lived, but they can also be very persistent. Most of my patients did end up getting off of the feeding tube after transplant, but some did not. If you read my posting about acute respiratory distress syndrome and the other posting about post intensive care syndrome, you will have learned that there are significant cognitive and mental health side effects of both of these conditions. Possible delirium and cognitive impairment are things that need to be evaluated for baseline function and measured for return to normal by our speech therapist associates. And there’s that possibility of a feeding tube after being intubated, so the SLP is so crucial in returning the swallowing capabilities of our patients!

After patients leave the hospital, they may be coming home on a BiPAP, a CPAP, or possibly even home ventilation. If this is the case, there’s a lot of education that physical, occupational, and speech therapist can provide, but if you have access to a home care-based or outpatient respiratory therapist to help with management of all of these new devices, this patient will need direct support.

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And then there’s our close colleagues the occupational therapists! Many of these respiratory devices come with masks that are difficult to manage and take a significant amount of strength to don and doff. The range of motion required to get a mask overhead is sometimes more than a patient is able to muster, especially after experiencing post intensive care syndrome. We’ve learned more recently that COVID-19 affects the smaller muscles of the body, so we can expect that the hands, arms, wrists, and fingers will be affected significantly. Velcro closures are challenging enough to figure out what goes where on these masks, but trying to manage them when you have no strength it’s going to be so much more difficult.

And that’s just the pulmonary device aspect of coming home! These patients will still need significant education on energy conservation, probably to the point of rearranging large portions of their home, so that they can still continue to function in their own environment without exhausting themselves. I once had to teach my mother how to put on deodorant with one arm after she had a wrist surgery. She had no idea that this was possible! Most people don’t. But our occupational therapists can come in and teach our patients how they can do more things with less.

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If you have access to dietary services, a dietician is going to be an integral part of your team for patients after COVID-19. We typically think of modifying our diet to promote wound healing, but the wounds that COVID-19 patients experience are all on the inside. Their lungs have experienced a lot of damage and it’s going to take a change in their caloric intake to support healing from this damage. They also need to be taking in enough calories to support their activity levels which are going to be significantly increasing now that they’ve gone from being bedbound on a ventilator to having several therapies every day. And do you remember that feeding tube thing I mentioned earlier from being intubated for a while? Our dietitian friends can help with this, too! We also know that many of the patients who have had COVID-19 and need our care will also have several comorbidities that need to be addressed.

Many of these comorbidities have dietary restrictions such as sodium limitations, fluid intake restrictions, and different food group exceptions. Did you know a renal diet needs to be very low and beans? And since we know that 30% of patients who have COVID-19 in the ICU end up with renal failure and on a hemodialysis program, this information is important for their recovery. Many of them also have diabetes and need to maintain very strong blood glucose control to promote healing in their body. Our dietitian friends can help with all of these things.

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And because most of them are going to be coming home at a level that’s probably not what we would consider ideal, they’re going to need access to as many community resources and services as we can fine for them. Because of the emotional and mental health inferences of these experiences, they may also need access to support groups and counseling. This is a perfect opportunity for our social work colleagues to step in and play a role. The social worker can work directly with the case manager at the physicians office, or with friends and family of the patient that they may not be able to contact due to continued isolation after returning home. They can figure out how to navigate some of the financial burdens many people are now experiencing and what assistance may be available, financially, emotionally, and physically. It may also be the case that these patients are returning home on hospice care. A social worker needs to be involved to ensure end of life measures have been properly established within the patient’s wishes.

And this is all assuming our nurse friends are already involved in managing all of the new medications, changes in medications, new medical diagnoses, and all the inter-related system presentations that we are all going to be struggling through to get our patient back to optimal health. Like I said in another post: Teamwork makes the dream work! 🙂

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Do you have a favorite story working with an interprofessional team? What disciplines were represented? Let me know int he comments!

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