You walk in to work, you scrub in, gown, mask, shield, gloves, more gloves. You have to be let in to rooms so you aren’t contaminating your gloves. You have to be let out of rooms so you aren’t contaminating your gloves. You work in a negative pressure environment all day, every day. You wear an N95, PAPR, or N100 all day, every day.
Does that sound strange? Does it sound strange that you could possibly spend every day that you treat patients dressed in full PPE for the rest of your career? Does it sound strange that someone would actually choose that? Because that’s exactly what is happening in other countries. Physiotherapists from the UK to India are working their regular full-time days managing and treating patients who have tuberculosis.
Although we don’t see much TB here in the states, in other countries like England or India, or most everywhere else but here, TB isn’t uncommon. In 2018, TB killed 1.45 million people worldwide. That isn’t to say that there are tons of TB (+) people running about the streets, but there are enough to warrant special facilities for their care. It is at these special facilities that PTs and OTs jump in to action.
Patients who experience TB tend to have a long term presentation similar to COVID-19. They are hospitalized for a long time and usually end up very deconditioned. They need rehab to recover from PICS. They need cardiopulmonary PT interventions like using positive pressure devices to induce coughing and exercise to increase their strength. Previously thought to be unsafe, new guidelines are making this possible! They need ADL retraining and energy conservation education to return home safely. And they need to test (-) in order to be discharged home. There are some rehab clinicians who do this work as their full time job. You can read about them here!
Research has even shown that only eight weeks of pulmonary rehab involving all of these interventions makes significant (and large!) improvements in functional outcomes measures like the 6 minute walk test and in questionnaires like the SF36. You can read about that here!
So, what is it like treating a highly infectious airborne pathogen day in and day out? Strenuous. Even though the NIH suggests a certain set of guidelines for care of patients with TB, most facilities implement the highest level of protections. That includes PAPR masks or other respirators, shields, gowns, gloves, more gloves and working negative pressure full isolation environments. Don’t forget anything you might need outside of that room! And the therapists can’t do it all day. They usually work half days in the facilities and half days elsewhere to prevent burnout and decrease viral load and exposure. And what about the physical effects of this work?
There has been some evidence that wearing respirator-type masks (some more than others) cause significant discomfort. We’ve seen pictures of our frontline providers with skin breakdown on their noses and cheeks from goggles and respirators, but that’s just the physical difficulties. There may actually be physiological impacts of wearing respirators long term including significant thermal stress to the skin and airway. This can lead to increased heart rate, dizziness, headaches, difficulty with decision-making… all the things we don’t want to be dealing with when we have major infectious agents to be thinking about. However, like I said, this research is preliminary. And it definitely does not apply to procedural masks or other face coverings which healthcare providers wear constantly.
Does COVID-19 still sound so terrible?
Working in a COVID-19 isolation unit still probably sounds pretty terrible. Working in an isolation environment all day every day is taxing. There is a significant increase in the amount of clinical decision making that has to take place when working in isolation with an airborne agent, especially when providing procedures and interventions that will definitely aerosolize the viral particles. Not to mention, there are treatments for TB that make exposure less of a risk, whereas COVID-19 still has no verified treatment, although it looks like some antivirals are promising. All of this clinical decision-making has to take place under possibly physiologically straining conditions.
However, like TB, COVID-19 knows no age limit, no comorbidity limit, no gender, and can present with neurological symptoms as well as cardiopulmonary symptoms. There are some schools of thought that are concerned that COVID-19 may even be airborne, like TB, due to the many healthcare workers that have contracted it regardless of environmental and PPE precautions in place.
Overall, COVID-19 is not the first time PTs and other rehab clinicians have been faced with treating highly virulent pathogens. It’s not the first time we’ve been asked to don full PPE before walking in to a patient’s room. COVID-19 is not the first time we have been asked to provide care under strenuous conditions. And it will not be the last time that we are asked to do any of these things. New pathogens emerge all the time. Tuberculosis persists. Providing the best rehab we possibly can will persist, too, all around the world.
If you practice in a country other than the US, do you feel any different suiting up to treat COVID-19 than you do when treating any other communicable disease? Let me know in the comments!
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