PPE is the WORST! (aka Levels of Infection Control)

Did you know that PPE is actually the very last level of infection control??? To be honest, I have to admit that I had NO IDEA. Until COVID-19 became the impetus for my increase in research and writing, I had no idea that people other than healthcare professionals and their governing bodies were making an effort to reduce infection. And, I’m not commenting on everyone washing their hands or our sterilization teams (whom I consider to be in the group of healthcare professionals). I mean there are construction workers, HVAC people, contractors, architects, builders, and entire governing bodies that don’t work in patient care that do 85% of the work of infection control. Let’s call them out!

The infection control process is actually best illustrated as an upside down pyramid. Once you read through it, you will say to yourself, “Well, of course! I knew that!” But you didn’t really think of it until now, did you? There is actually an entire initiative dedicated to Prevention through Design! If you take a look at how this pyramid is constructed, you can see the levels of effectiveness are right alongside the intervention. And guess what? PPE is the LEAST effective method of infection prevention for patients and for healthcare workers. There is a link on the Resources page that will take you to the NIOSH document for infection prevention controls for more details about how some of these things are done.

I’m going to go through each of these steps to explain and give you an example of how this works. I’m going to use the hazard of stairs as my primary example. Obviously not an infection but may of these steps can’t apply to infection, which is why we need so many steps! But, they can all apply to stairs. Then we will go back and talk about infection control.

Elimination. If only it were this easy, right? Let’s just eliminate the hazard and then we don’t have to deal with it anymore. We all know it is never actually that easy. The flu can’t be eliminated so matter what we try. But there are some instances where elimination can work. Eliminate stairs from a hospital and you don’t have to worry about anyone falling down them. Keep everything on one level and no problems from stairs will arise. Obviously this can’t always be done, especially if the building has already been built, and we are trying to reduce the falls down the stairs 10 years later. That’s why there is another step…

Substitution. So instead of stairs, we can have elevators! Of course this isn’t a full substitution because we still have to have stairs in case of power outages, fires, and other emergencies. But if we substitute the major method of traversing floors in a facility to something safer than stairs, we can reduce the hazards that stairs pose. In the therapy world, this isn’t very functional because we know people use stairs at home and in the community. So let’s substitute actual flights of stairs with wooden framed in steps with handle bars on both sides. That will allow patients who need to perform stairs to practice them in a safe environment and reduce the hazard risk.

Engineering Controls. Ok, so let’s go back to the point of the hospital already being built and there are stairs. Can’t get rid of them. No problem. Engineering can come in and add controls. These types of things include hand rails, vertical bars on the turning platforms, gripper tape to the surfaces, yellow striped hazard tape to the edges of the steps, doors to the stairwell, and badge-locks to the doors. All of these things can help prevent the stairs from being as much of a hazard. There are many examples of engineering controls that apply to infection control, too, and we will investigate those later.

Administrative Controls. Policy policy policy. Change the policies, change the hazard risk. If it is policy that no one allows a patient on the stairs without supervision and assistance, odds decrease that the patient will get hurt. You can start to really see by now how these levels becomes less effective as we move down the pyramid.

PPE. For the sake of our stairs example, we are going to call a gait belt PPE. If we are going to use the stairs with someone who is unsafe and be there to provide them support, we can use equipment to decrease the risk of the training we are providing. However, placing the patient actually on the stairs for training is also the behavior that puts them at the highest risk of being injured. But we have to do it, right? So we use the gait belt to give ourselves a hand. It is our personal piece of equipment that helps (a bit) to prevent a hazard.

So how does all of this apply to viruses? Physical hazards are much easier to remove from the situation, but viruses can’t be fully removed. And substituting a different, less dangerous virus isn’t really a better option, nor is it feasible. So we have to come down to environmental controls next. Negative pressure isolation rooms are the most common thing we probably think of when it comes to treating patients who have a contagious condition. They are used for patients who have measles, influenza, and tuberculosis. The negative pressure room keeps all the air breathed in that room away from other rooms. The air is exchanged out individually, not entering the general air supply in the facility.

Speaking of the air supply, again, we are going to get a bit science-y here and talk about some fluid dynamics. Did you know that HVAC systems for hospitals actually have settings that allow for increased or decreased air exchange based on the square footage of the space and the concentration of people in it at any given time? Some can be self-altering based on occupancy, and some are static and have to be manually changed. A recent study was released that measured the air flow necessary to clear certain sized rooms with certain occupancy that would be required to reduce the transmission probability specific to COVID-19. They actually have it measured out how many cubic meters per minute of air they have to move so that no one would have to wait between using the bathroom for the air to be cleared (that’s 10 m3/min or 200 CFM (cubic feet per minute) for a single occupancy bathroom). For shared common spaces, the airflow needs to be 50 m3/min (or 2000 CFM) if the occupancy is fixed. If you are utilizing a public bathroom with several people in and out, the risk of transmission is difficult to control with this tool. Even air circulation patterns alter infection transmission which really comes in to play in oddly shaped spaces. If you are eating in a restaurant tucked away in that romantic corner, you are going to be more likely to transmit and/or receive transmission of infection due to lack of ventilation of aerosolized particles that are delivered to the space via “leaks” from the primary circulation of air in the restaurant.

Photo by cottonbro on Pexels.com

While reading this article, I was thinking to myself, “So what is likely the highest risk thing or place right now based on these factors?” And the article didn’t disappoint. A choir practice in Seattle was studied as an epicenter of outbreak. The airflow in the small church was 20 m3/min and the choir had 60 members present for a 2.5 hour practice. The result of this practice was that 87% of the attendees became infected with COVID-19 from a single source. The authors discussed that choir practice significantly increased the rate of aerosolization with singing (this wasn’t the only choir outbreak) and that other activities such as indoor dance practices and working in a call center would be similar in transmission rate even IF hand hygiene and social distancing were utilized properly.

All of this to really demonstrate that Engineering controls can be put in place to prevent or decrease risk of transmission, but they have to be used properly. And if they are not, other measures put in place like hand washing and social distancing (both environmental controls as they try to remove the contagion) have little effect.

Why am I harping on about engineering controls? Why am I becoming concerned about the amount of air my HVAC system can move? This is why. New findings from this study include

  • 1 min of loud speaking generates at least 1,000 virion-containing droplet nuclei that remain airborne for more than 8 min
  • the smallest droplet nuclei effectively remain airborne indefinitely and have half-lives that are dominated by the ventilation rate, at a saliva viral load of 7 × 106 copies per milliliter
  • Some patients have viral titers that exceed the average titer of Wölfel et al by more than two orders of magnitude thereby increasing the number of virions in the emitted droplets to well over 100,000 per minute of speaking.
  • The droplet nuclei observed in this present study and in previous studies are sufficiently small to reach the lower respiratory tract, which is associated with an increased adverse disease outcome

In essence, talking is sufficient to aerosolize COVID-19 particles and these particles remain in the air for at least 8 minutes. Then pair that with this study with these findings:

  • airborne transmission, particularly via nascent aerosols from human atomization, is highly virulent and represents the dominant route for the transmission of this disease [COVID-19]
  • the importance of airborne transmission has not been considered in establishment of mitigation measures by government authorities 
  • And my personal favorite: It is also important to emphasize that sound science should be effectively communicated to policy makers and should constitute the prime foundation in decision-making amid this pandemic.

All three of these studies referenced recommend personal use of face coverings/masks as the only way to effectively reduce viral transmission and their effectiveness if increased with the addition of other controls such as social distancing and hand hygiene. However, these other controls are not effective without the use of face coverings/masks. For how to make a homemade mask that might actually work, check out this post.

So even though PPE is literally the WORST at controlling infectious transmission, and even though it truly is the last line of defense against transmission, it will end up being the best bet we’ve got. We can’t always control the environment we are in. We can’t substitute a different pathogen that is less virulent. We can implement engineering controls in the facilities we utilize, but not in the community or outdoors. We can add administrative controls to reduce the risk of infections. But ultimately, with COVID-19 and other respiratory pathogens like Measles and Tuberculosis, it’s going to come down to the PPE. Especially in the rehab professions, where close contact and use of different speech techniques are regularly utilized across disciplines, we need to be taking precautions, educating ourselves, and keep each other safe.

Do you work in environmental infection control? How has COVID-19 changed your day-to-day? Tell me in the comments!

More Reads…

Vibration and Percussion

Physical therapists are well known as the people who use their hands to promote healing (and also as the “mean ones who make me exercise”). Using our hands to support optimal respiratory function is just another piece of the manual therapy skillset. If you read my post on airway clearance techniques, you probably saw vibrationContinue reading “Vibration and Percussion”

Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management

In my recent post on COPD management, I mentioned that there are some really important parts of supplemental oxygen management that you need to be aware of and consider in your practice. If you are assisting patients who utilize supplemental oxygen regularly, you need to keep these things in mind. You also may be workingContinue reading “Spilling the Box of Pearls: All the Tips on Supplemental Oxygen Management”

Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)

This is part 2 in a multi-part series on the role of Rehab Providers in the management of chronic disease. Don’t forget to check out Part 1: Heart Failure! Chronic Obstructive Pulmonary Disease is a widely diagnosed disease of the lungs that includes the diagnoses of emphysema and chronic bronchitis. COPD can be caused byContinue reading “Chronic Disease Part 2: Chronic Obstructive Pulmonary Disease (COPD)”


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Evans, M. (2020). Avoiding COVID-19: Aerosol guidelines. Massachusetts Institute of Technology: Department of Physics. Published by medRxiv [ahead of print]. Retrieved from https://doi.org/10.1101/2020/05/21/20108894

NIOSH. (2015). Hierarchy of Controls. Retrieved from https://www.cdc.gov/niosh/topics/hierarchy/default.html

Stadnytskyi, V., Bax, C. E., Bax, A., Anfinrud P. (2020). The airborne lifetime of small speech droplets and their potential importance in SARS-CoV-2 transmission. Proceedings of the National Academy of Sciences. 117 (22) 11875-11877; DOI: 10.1073/pnas.2006874117

Zhang, R., Li, Y., Zhang, A. L., Wang, Y., Molina, M. J. (2020). Identifying airborne transmission as the dominant route for the spread of COVID-19. Proceedings of the National Academy of Sciences. 202009637; DOI: 10.1073/pnas.2009637117

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Out with the Old, In with the New (Dynamic Hyperinflation)

I can’t even begin to tell you guys how much I love teaching people about lung function in the presence of disease (read: HUGE NERD). Teaching patients how to correct for dynamic hyperinflation is one of those things that I really love teaching.

If you remember from a few weeks ago, we talked about how to facilitate hyperinflation for those who suffer from restrictive lung diseases like COVID-19, pulmonary fibrosis, or who were recently extubated. But for people with obstructive disease, hyperflation is actually their biggest issue. Airways get obstructed and CO2 gets trapped in the lung. This takes up space and prevents usable oxygen from reaching the alveoli. So, for people with obstructive diseases like COPD, cystic fibrosis, and emphysema, we actually need to decrease and prevent hyperinflation to improve their function.

Dynamic hyperinflation is hyperinflation that keeps building on itself as they takes breaths. The end result is that the usable space for tidal volume becomes less and less and the patient gets short of breath. Take a look at this video a made for you. It’ll help you understand dynamic hyperinflation as well as a few techniques to correct for it! Enjoy!

(Brockway, K., 2020)

Utilizing these techniques before you get started with exercise is important for a couple reasons. You want the patient to have the most lung volume available for tidal exchange which means getting all the trapped CO2 out that you can. Also, you want to give them some time to practice these techniques. It can be very difficult to breathe this way as oxygen demand increases with activity or exercise so practice is important. In addition to practice, your patient will probably need lots of cueing to keep this up as they become more active.

However, if you can start them off on a good tidal volume, improve their V/Q matching at rest and with activity, and rehabilitate them back to even better than where they were before, you are really doing them the service they need. Make sure to keep monitoring their oxygen saturations with training as they may sink as they learn how to change their breathing. They have spent years trying to figure out how to get air in and you will probably be the first one trying to teach them how to get air out!

What are your favorite methods for getting the old air out and the new air in? Tell me about them in the comments!

More from the Pulmonary Rehab Toolbox…

ABGs (Part II)

So, now that you’ve read all the basics about ABGs in the first post, here is a little more about interpreting lab values and how to determine compensated conditions. This is where it gets fun! First off, let’s take a look at what NORMAL lab values probably look like: pH: 7.35-7.45 Partial pressure of oxygenContinue reading “ABGs (Part II)”

ABGs (Part 1)

This is the first post in a two-part series about understanding and interpreting arterial blood gases! If you want the rest of the post, you’ll have to check back next week! I’m getting real science-y again! So, just a heads up: my undergraduate degree was in chemistry. Kind of by accident, I took a lotContinue reading “ABGs (Part 1)”

Aerosol Generating Procedures

The long awaited clarification on aerosol generating procedures for physical therapists and physical therapist assistants has finally dropped! The APTA just released its professional guidelines for what portions of physical therapist and physical therapist assistant care equates to an aerosol generating procedures, therefore requiring increased PPE for procedure performance to ensure clinician safety. On AprilContinue reading “Aerosol Generating Procedures”


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HFNO stands for High Flow Nasal Oxygen. This is something that was used frequently in patients who were desaturating quickly with symptoms of COVID-19. It has the ability, through the use of several different devices or setups, to deliver very high concentrations of supplemental oxygen to patients with advanced pulmonary diseases or conditions. In the physical therapy world, we don’t see these devices used very often unless we frequently work in ICU or with patients who have chronic disease, so I thought I would give you a run down of devices and what they look like so you can recognize HFNO when you see it and know what that implies for your interventions.

Improving the ventilation of oxygen will hopefully improve the amount of oxygen that gets diffused and perfused. This can be done by positioning, removing obstructions through airway clearance, bronchodilation to increase the space for more oxygen to get into the lungs, or by increasing the overall amount of supplemental oxygen. Given that bronchodilators can be contraindicated and/or have serious side effects and patients need something a bit faster than airway clearance techniques, supplemental oxygen tends to be a first line of treatment. This supplemental oxygen can come in different types:

  • Compressed gas – we typically see these green canisters everywhere, but oxygen delivered from a concentrator also fits this description.
  • Liquid – also called Helio, oxygen is distilled to a liquid for greater storage capacity. Hospitals typically have large storage tanks (called “dewers”) of liquid oxygen which is evaporated on site and then delivered to patient rooms on gas form. Helios can be used in the home setting, as well. The tanks look a bit different, and this is usually only used for high flow needs because compressed gas tanks run out much faster.
  • Compressed gas and liquid can both be run through continuous flow or “on demand” systems.

To understand high flow nasal oxygen, you need to know how much supplemental oxygen is actually being given. That depends on how many liters per minute the patient is receiving. Time to get science-y! Normal atmospheric contents break down looks like this. (See pie chart)

This matters because we have to base our supplemental oxygen calculations on “room air” which is basic inhaled air which is 21% oxygen. Every liter of supplemental oxygen added after that is roughly equal to 3% more oxygen. You can see the math is already done for you in this table.

Source: Pacer Project

You may be thinking, “I don’t know that I’ve ever seen anyone with 6L of oxygen… Doesn’t everyone just get 2 liters? That’s all I usually see…” Yes, 2 liters/min is a VERY common prescription for supplemental oxygen. But, as you can see form the table, that means the patient is only receiving 6% more oxygen than they would on room air (or with no supplemental oxygen). However, in the world of chronic disease, it is incredibly common to see 4 liters, 6 liters, and sometimes 10 liters.

These numbers can be fairly easily achieved with one or two concentrators as the standard concentrator goes up to 5 L/min (some go to 6, it depends on the brand). In the acutely chronically ill or, in the case of COVID-19, just the acutely ill, we sometimes see the need for much higher levels of supplemental oxygen. These levels cannot be achieved with the standard concentrator, so high flow equipment is brought in. Because this high flow is significantly irritating to the human tissues, it also must be heated and moisturized. So these devices must also provide this modification. Moisture can easily be added to a standard concentrator using a humidifier attachment, but this has to be ordered. You may have to request one of these for your patients to increase their oxygen compliance.

A few of the devices you may see…

Some of the appliances and devices you’ve probably seen can be utilized to deliver high flow oxygen if necessary. A standard reservoir mask like this one (aka partial rebreather or nonrebreather depending on the construction) can deliver high concentrations of oxygen (up to 1.0 FiO2 or about equal to 25 L/min) if the flow rate is high enough. You may have seen these in emergency departments or being used by first responders.

Buy Oxymizer Disposable Oxygen Conserver [Oxygen Therapy]

Conserver masks can come in many different types, though, and there are some that are seen only in certain situations to deliver high flow oxygen. These masks collect oxygen in their reservoir and then feed this oxygen back to the patient at the higher collected concentration. Different types are chosen based on patient tolerance and need. These masks can be really great for patients who need to eat with their high flow oxygen because it doesn’t utilize a rebreather style mask that covers the mouth. These can also be utilized in combination with liquid oxygen (instead of with a concentrator). Liquid oxygen (sometimes called Helio) increases the amount of oxygen that can be stored in one place. Hospitals tend to have a liquid oxygen supply that is evaporated and then sent to rooms to provide oxygen to patients. These are some of the most common high flow masks I’ve worked with.

There are also some high flow devices that are a little more standard in their appearance. They look similar to a regular oxygen cannula, but they have a wider inside diameter to allow for increased flow rates.

And remember how I said that this air needs to be heated and humidified so that it’s actually tolerable? Here is the device that provides that! This is the Venturi. This bad boy can deliver anywhere from 20-60 L/min of supplemental oxygen! This oxygen at such a high flow is used to wash out dead air space like with people who have advanced COPD. This also creates a bit of PEEP to improve ventilation, like a CPAP. This is another one of those things that I wish I could have in my trunk!

RT Clinic : Heated High Flow Cannula - YouTube

This heated humid air actually helps the anatomical function of your soft tissues so they can diffuse oxygen better. Without the heat and humidity, large amounts of mucous would develop and actually block airways. This specific device actually allows clinicians to adjust the FiO2 to help prevent oxygen poisoning for those who rely on hypoxic drive. This type of device can also be helpful for your patient on BiPAP who needs to maintain saturation while eating as it utilizes a nasal delivery, so the mouth is not obstructed while the airways remain patent.

So, what does all of that mean for your therapy? Well, if a patient is on high flow oxygen and you aren’t seeing them in the hospital, odds are they have a pretty advanced stage respiratory disease. This can be COPD, cystic fibrosis, pulmonary fibrosis, or any other condition that results in chronic hypoxia. Many of these mask types are portable (with the exception of the last one pictured), but the portable oxygen supply may be short. High flow means they will run out faster. It also means that portable concentrators are probably not an option as most of them are limited at 4 L/min. High flow stationary concentrators are available that go up to 10 L/min, but your clinic would need to have one for the patient to use as they are not portable. Ultimately, this patient either needs to be connected to a wall-mounted oxygen source with a reservoir/conserver mask (this can be done in physician offices, typically), or they need to be seen at home.

If you are seeing them at home or in a sub-acute facility, this means you need to be sure of a couple things:

  • You are monitoring oxygen via pulse oximetry with everything, including rest
  • You are auscultating their lungs at every visit to assess function and/or change in presentation (pneumonia starts quickly when there is a lot of dead space or secretions)
  • You are taking a full set of vitals at least once during the visit
  • You are ensuring titration orders are in place and correct
  • The patient has a back up supply of oxygen somewhere that can last up to 24 hours in case of power outage (Kilo tanks or Helio)
  • You have educated your patient on frequency of cleaning and discarding oxygen equipment to prevent respiratory infections
  • You are still exercising them to an appropriate intensity (60-80% HRmax) for as long as they can tolerate

Yes, I promise, you can still exercise patients who have to utilize HFNO, even up to 85% HRmax. I’ve had patients running 16 L/min alternating squats for strength and amplitude exercises to improve their rib and spine mobility. They will get to their target heart rates pretty quickly and need their activity attenuated to maintain that level without quickly exceeding it.

(Chris Clark | Spectrum Health Beat)

Yea, that’s me doing those exercises. See that nonrebreather reservoir mask? She called it the “bag mask”. See that string hanging from my pocket? That’s my pulse oximeter. As always, she was using her 16 L/min to laugh at me.

Do you see patients who use HFNO? What are the most common diagnoses? Tell me in the comments!

More form the Pulmonary Rehab Toolbox…

The Duet Device

Have you seen an Acapella Duet before? This is another one of those things I wish I could hand out to maybe half of my patients. A Duet device is a special kind of Positive Expiratory Pressure (PEP) that provides resistive oscillatory pressure to exhalation which promotes increased lung volumes due to re-inflation of collapsedContinue reading “The Duet Device”


I spent some really great times as an educator in a heart and lung transplant program at a large hospital system. Specifically, I was a therapy educator. I taught PTs, PTAs, OTs, COTAs, and SLPs what they needed to know to safely provide rehab to patient after heart and lung transplants. I saw so manyContinue reading “FEV1”


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College of Respiratory Therapists of Ontario. (2013). Oxygen therapy clinical best practice guidelines. Retrieved from http://www.crto.on.ca/pdf/PPG/Oxygen_Therapy_CBPG.pdf.

Tepper, S., Wruble, E., Stewart, E. (2020). Anatomy, histophysiology, and pathophysiology of COVID-19. Pacer Project. Retrieved from https://YouTube.be/w7bafww8IWo

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Time to Pump It Up! (aka Ejection Fractions)

I’m starting to push more in to the cardiac side of things. As well as this being the original intent of this blog years ago, it is also because your focus should also be shifting. If you are treating COVID-19 patients, you need to start focusing on their heart. The patients who did a stent in the ICU are likely very deconditioned. We know that deconditioning is not just a skeletal muscle condition, it is also a cardiac muscle condition, and interventions need to target both types of muscle. So it’s time to start building up that aerobic capacity. However, if your patient is deconditioned (whether it be COVID-19 related or just plain old frailty or immobility), you need to be thinking about the effects this has on their cardiac function. Odds are they have a decreased ejection fraction (EF).

What is an Ejection Fraction?

Ejection fraction is the measure of amount of blood ejected from a heart ventricle, typically the Left ventricle is considered when we talk about EF. Questions about ejection fraction show up often on licensing exams because you really have to know the numbers to know what normal is. It’s a fine line with little wiggle room.

55% or more is considered normal
55 – 50% is considered borderline
50% or less is considered reduced

How Is Ejection Fraction Reduced?:

There are so many ways this can happen. We mentioned above about deconditioning which is probably the most common way we see this happen in so many people. But with deconditioning, there is typically an underlying cause. These can include: 

  • Long Term Illness
  • Immobility
  • Left Ventricle Hypertrophy (Cardiomyopathy)
  • Uncontrolled High Blood Pressure
  • Heart Valve Dysfunction       
  • Damage from MI

Do these things sound familiar? They are all associated with heart failure. And ejections fractions are directly associated with heart failure. Like we discussed here, heart failure can come with a reduced or preserved ejection fraction. We will talk more about this in another post.

What impact does that have?

People who have decreased Left Ventricular EFs have increased health care costs! Just look at that list above: hypertension, cardiomyopathy, valve dysfunction, MI. We know those are all associated with large amounts of medical intervention including medications, rehab, and surgeries. The dollar signs amount. BUT, if you thought we just became the “frontline” against cardiopulmonary diseases due to COVID-19, you’d be wrong. Well-prescribed aerobic exercise is the key to success, recovery, and prevention for all of the items on that list. Let’s talk a little more about that.

Can Ejection Fraction be Improved?

Why, Yes. Yes it can.

Sure, there are other ways to improve ejection fraction, like:

  • CABG procedure. Increasing blood flow to the cardiac muscle increases its oxygenation and nutrient supply and therefore its contractile power.
  • Aortic Valve Replacement. If the valve is leaky, blood is flowing out when the muscle isn’t contracting, so when the muscle does contract, there isn’t as much blood left to be ejected. Replacing the valve fixes the leak.
  • β-Blockers (Metoprolol in particular). Stabilizing the heart rhythm improves contractility because all fibers can work together instead of having errant electrical activity interfering with contractility.

But we know these things come with other heavy medical burdens, side effects, and drug interaction risks. So the obvious best choice is going to be an intervention that decreases need for medications, prevents surgical intervention, and has little inherent risk. Enter aerobic exercise! Of course, it isn’t that simple, is it? Or everyone would be doing it on their own. People who have a reduced ejection fraction have reduced oxygenated blood flow from their heart. That means they are in the category of “having a dam built upstream”. Read this post for more on that.

Pre-surgical participation in Cardiac Rehabilitation programs decreased the cost of care for people who underwent surgical intervention. Post-surgical participation in cardiac rehab programs also decreased the cost of care for people who underwent surgical intervention. Can you imagine if we did both??? Utilizing well-prescribed aerobic exercise with appropriate vitals monitoring, functional outcome measures, and patient centered goals is going to get these patients back on track to a normal life. There, of course, are some cases where exercise is not the only answer, but it needs to be used in combination with other interventions. That’s even more reason for PTs and OTs to be involved. Our advanced knowledge of medications, comorbidities, and the effects they have on the body and exercise are what these patients really need.

Patients can’t cardiovert themselves. They can’t bypass themselves. They can’t prescribe for themselves (even though some try!). But they CAN exercise for themselves! With your professional guidance, of course! Empower them to take control.

Who does the cardiac rehabilitation at your facility or system? Tell me below in the comments!

More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19

Isn’t COVID-19 just a respiratory disease? If only that was true. We are good at treating respiratory infections. We have lots of drugs for viral, bacterial, parasitic, and fungal infections of the lungs. Most of them work really well! We also have several back-up treatments, inhaled medications, and adjuvant therapies (like rehab!) that make primaryContinue reading “More Than Just A Respiratory Disease: The Tools You Need to Rehab COVID-19”


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Ades, P. A.,Huang, D., Weaver, S. O. (1992). Cardiac rehabilitation participation predicts lower rehospitalization costs. American Heart Journal. Volume 123(4):916-921. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/000287039290696S.

Engelmeier, R. S., O’Connell, J. B., Walsh, R., Rad, N., Scanlon, P. J., & Gunnar, R. M. (1985). Improvement in symptoms and exercise tolerance by metoprolol in patients with dilated cardiomyopathy: a double-blind, randomized, placebo-controlled trial. Circulation72(3), 536–546. https://doi.org/10.1161/01.cir.72.3.536

Mayo Clinic. (2020). Ejection fraction: what does it measure?. Retrieved from https://www.mayoclinic.org/ejection-fraction/expert-answers/faq-20058286

Roma-Rodrigues C, Fernandes AR. Genetics of hypertrophic cardiomyopathy: advances and pitfalls in molecular diagnosis and therapy. Appl Clin Genet. 2014;7:195-208

Sabbah H. N. (2004). Biologic rationale for the use of beta-blockers in the treatment of heart failure. Heart failure reviews9(2), 91–97. https://doi.org/10.1023/B:HREV.0000046363.59374.23

Tucker, W. J., Beaudry, R. I., Liang, Y., Clark, A. M., Tomczak, C. R., Nelson, M. D., Ellingsen, O., & Haykowsky, M. J. (2019). Meta-analysis of Exercise Training on Left Ventricular Ejection Fraction in Heart Failure with Reduced Ejection Fraction: A 10-year Update. Progress in cardiovascular diseases62(2), 163–171. https://doi.org/10.1016/j.pcad.2018.08.006

Follow @DoctorBthePT on Twitter for regular updates!

Expanding Your Role, Fulfilling Your Scope

So now that you know how I feel about primary care PT, you need to know that this ties very closely with my practice. I have extensive experience in the treatment and management of patients with chronic disease. And when I say the treatment and management, I don’t mean that I went to their house and gave them some exercises, then left the rest to my (very skilled) assistant to handle until discharge. I mean that I saw them for a skilled home evaluation where we discussed the impact of their comorbidities on their life and function, performed evidence-based tests and outcome measures, and then created a care plan that included the patient’s goals as well as lifestyle modifications and education to control their diseases. Let’s be real: our profession is not following a protocol.

That means that there were evaluations where I talked about nothing but going to the bathroom safely and successfully. There were visits where I performed one single intervention for breathing (active cycle of breathing) and it took an hour. There were discharges that became reassessments because the patient started showing changes in their lung auscultation (new onset pneumonia). There were patients I saw for one diagnosis (a clavicle fracture) but treated and referred for another (undiagnosed Parkinson’s Disease). Sometimes I didn’t perform any interventions with the patient at all, but spent an hour with the caregiver trying to work things out. I have even spent an entire evaluation doing diabetic teaching on how to use a glucometer properly.

The chronic diseases I frequently treat include diabetes, congestive heart failure, chronic obstructive pulmonary disease, organ transplant (heart, lung(s), kidney, liver…), incontinence, hypertension, coronary artery disease, frailty, osteoporosis, chronic kidney disease, and end stage renal disease. I do not claim to be a neurological clinical specialist, but I do focus on the cardiovascular impairments associated with neurological conditions including orthostatic hypotension associated with Parkinson’s Disease, the vascular and cardiac impairments that cause cerebrovascular accidents, and the sequelae of falls such as bleeding (internal or external), brain injuries, and vestibular dysfunctions. And after COVID-19, we may even see a whole new subclass of chronic disease that we need to be addressing! Post-COVID syndrome, maybe?

Yes, I see total knee replacements, but I also see the chronic smoking that will delay healing due to intermittent tissue hypoxia and increased risk for infection. Yes, I see shoulder impingement, but I also see the eye aversion and reports of constant fatigue indicating depression and need for referral. Yes, I see low back pain, but I also see the urinary incontinence that so often is copresent and fully treatable.

Photo by Karolina Grabowska on Pexels.com

Did you know that the things you can do as a physical therapist to help manage and treat chronic disease are so small and so easy that you probably have just overlooked them? Let’s talk about those things:

  1. Ask about medications. I don’t mean asking if they take any. Yes, that is important, too, but ask if there have been any recent changes to their medications or if they started or stopped a medication lately. I have treated a patient for falls that happened because she was snowed on psych meds. Once we worked with her doctor to cut her dosage in half, she stopped falling.
    Most importantly, ask if your patient has taken their medications today!!! I cannot even count the number of times I have taken a blood pressure before starting a session to find severe hypertension and when I asked if the patient took their meds today, the answer is always “no, I forgot…” The only thing that tops that is how many times I have found severe hyperglycemia. Medication compliance is terrible generally with chronic disease, but, to be more specific for you:
    1. Patients with type two diabetes are noncompliant with medications up to 81% of the time.
    2. Patients taking medication for hypertension are noncompliant as often as 30% of the time.
  2. Ask about incontinence. Everyone will deny they have it so you need to find another way to ask. “Do you ever have any leakage when you cough or sneeze?” “Do you ever need to use incontinence products?” “Do you ever have to change your clothes mid-day due to leakage?” If you don’t get specific, you won’t get a useful answer. 80% of women and (possibly up to) 60% of men have some type of incontinence at some point in their lives. You may catch them as that point. Stress, urge, functional, and mixed incontinence can be fully treatable if you know they exist. We also know that urinary incontinence and constipation have a strong correlation with low back pain. If you can address either issue or both, back pain has a good chance of improving or being relieved. This is coming from someone who utilizes a fully mechanical approach to back pain like 90% of the time…
  3. Take Vitals. I should really just stop there… but I won’t (Ha! You should know me enough by now…). If you don’t know where you started, you don’t know where you’re at. If you take a blood pressure midway through your session, hey, that’s great! But that number doesn’t carry much weight if you don’t have something to compare it to. In the home care setting, when I have students, I always discuss with them the impact of chronic disease. I ask them, “How can you know if your patient is safe to get up out of their chair, today?” The answer is vitals. Not in the home care setting? Fine. Take them anyway. 90% of the time, you’ll see great numbers and everything will be fine, but that 10% is the part that matters. You may think you are pretty good at identifying people at risk for high blood pressure based on presentation. There is research to show that we are pretty good at figuring out who is really high risk and who is really not, but what about all those people who only have some risk factors (aka most of your patients)? If you need some guidance on those risk factors, the American Heart Association has constructed this table:
image credit
  1. Weigh your patients. This may sound a bit strange, but isn’t exercise one of the best treatments for just about everything including obesity? We know this. This isn’t new. Taking your patient’s weight can also be really helpful to track trends over time. But in the chronic disease management world, taking daily weights is necessary for management of congestive heart failure. (We talk more about that here!) It can also be really helpful when treating patients who undergo renal dialysis as fluid load directly impacts their ability to participate in physical therapy. Teaching your patient how to safely step up on and down from a scale is billable. Teaching your patient the importance of daily weights for preventing exacerbation is billable.
  2. Blood glucose monitoring. Your ability to do this may vary based on your state, but we all know the importance of blood glucose for exercise. If we don’t time our sessions properly, we end up with a patient passing out on us. If we do time them properly, we can actually (over time) decrease or eliminate the need for medication to manage blood glucose. Let’s talk about the logistics of this:
    1. To clear up the risk analysis: If your patient is already diabetic, they already have a physician’s order to check their blood glucose daily. If you ask them to or assist them in doing this prior to your session or during your session, you are in full compliance with this order. If you need to do this for your patient because they are unable, you are still in full compliance with this order. If your patient’s blood glucose is so low that they are fully unable to take their glucose themselves, are you going to sit there wondering if its ok while they fade away? No, of course not. You should probably be calling 911 at that point, but take their blood glucose. (Side note: please wear gloves.) Diabetic teaching is well within our scope of practice. So is diabetic intervention (aka exercise). PTs can even become certified diabetic educators.
    2. You cannot administer insulin if your patient’s blood glucose is too high unless you are trained to use the devices to do so and there is an order in place (if your patient is diabetic, there is an order in place, but you have to know how much, i.e. sliding scales and all that). You should be calling the physician for instruction if your patient cannot self-administer. You can, on the opposite end of the spectrum, give your patient food. You should have fast-acting sugars available in your clinic: juice, candy, applesauce… Even in outpatient clinics, I’ve given juice when I noticed the signs of hypoglycemia.
    3. What are safe parameters for blood glucose? I thought you’d never ask 🙂
      Too low: <50 mg/dL call physician/911 based on symptoms
      Too low for exercise: <70 mg/dL give sugar
      IDEAL RANGE: 100-250 mg/dL
      Too high for exercise: >250 mg/dL call physician, risk of ketoacidosis
      Too high: >350 mg/dL call physician/911 based on symptoms
      ***If doing an exercise class or performing exercise in long bouts (longer than 60 minutes) blood glucose should be checked every 30 minutes to ensure ongoing safety.

Ya’ll, that’s it. Really. All of these things are easy, quick, and well within our scope of practice. If we are claiming to provide primary care (which we definitely claim to do and actually do all the time!), we need to do the things that go along with it. You may be thinking that, even if these things are quick and easy, you can’t afford the extra minutes. When exercising someone with a chronic disease, you can’t afford not to spend the time. It could literally mean life and death in some cases. You may find out some surprising things! Maybe they’ve been struggling with loading needles in to their lancet device, and there’s an opportunity for some education and functional training.

The future of our profession may be providing exercise as an intervention for people with all kinds of chronic diseases like anxiety or depression. We already treat cancer and chronic pain. We need to be treating obesity and hypertension as a primary intervention. It will not be long before we are providing interventions for the prevention of a stroke based on a patient’s risk factors, so you better be good at taking blood pressures. Exercise prescription based on your genetic profile is already on its way where we will be able to predict the risk of a cardiovascular event at different intensities. You may even need to start incorporating a patient’s social determinants of health in to your plan of care if you haven’t already. Are you ready for this?

Well? Are you ready? Tell me how in the comments!

A Public Service Announcement: The Chain of Infection (and How YOU Can Break It!)

This post is written for one and all. If you are not a rehabilitation or medical professional, please read this post. Even if you are, please read this post. I’m going to address some things that need clarification. You can have all the opinions you would like, but there are some things that are justContinue reading “A Public Service Announcement: The Chain of Infection (and How YOU Can Break It!)”

Open Heart, Open Mind

I’m always learning something new. I called the cardiologist after an evaluation to report some severe orthostatic hypotension and the nurse and I got to talking. She was going back through the patient’s history and looking for why this may be happening. I had just finished assessing the patient in their home and they wereContinue reading “Open Heart, Open Mind”

Blood Pressure Basics

Are you taking the blood pressure and heart rate of EVERY patient you see for a new evaluation? How about for every visit? A recent survey of over 1800 Outpatient PTs showed that although 51% of PTs reported that over half their caseload had risk factors for hypertension and cardiovascular disease, only 14% of themContinue reading “Blood Pressure Basics”


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Goff, et al. (2014). ACC/AHA Guideline on the Assessment of
Cardiovascular Risk: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. Circulation. Retrieved from https://www.ahajournals.org/doi/pdf/10.1161/01.cir.0000437741.48606.98

Hedegaard U, MS, Kjeldsen, Lene Juel, MS, PhD, Pottegård, Anton, MS, PhD, et al. Improving medication adherence in patients with hypertension: A randomized trial. Am J Med. 2015;128:1351-1361.

Mayo Clinic. (2020). Diabetes and exercise: when to monitor blood sugar. Retrieved from https://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes-and-exercise/art-20045697#:~:text=You’re%20good%20to%20go,too%20high%20to%20exercise%20safely.

Polonsky W, Henry R. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence.. 2016;10:1299-1307.

Follow @DoctorBthePT on Twitter for regular updates!

Rule of 2’s

So today, we are going to focus on the role PTs and PTAs need to be filling in the treatment and management of congestive heart failure. The first thing you need to address is the rule of twos. Don’t assume someone else had ever educated your patient about this. I cannot tell you how many patients I have seen on their 3rd or 4th exacerbation who have never been educated on fluid restrictions or daily weights (FYI, its all of them).

Obviously there are different stages of heart failure and the patients you are seeing may not be as advanced as some of the patients I am seeing, but that doesn’t mean they don’t need to be managing their condition. The different stages of heart failure all have different needs, no let’s take a look:

Stage A: Pre-Heart Failure. This basically means that the patient is at higher risk of developing heart failure, but they aren’t quite there yet. They probably already have CAD, CKD, DM, HTN or some other set of comorbidities that is leading them down this path. Probably starting some beta blockers and/or ACE inhibitors here. This is the stage we HOPE to see them in because exercise can make a huge different here!

Stage B: Heart Failure. This is the real deal. Cardiac dysfunction is starting to show its ugly face here. Beta blockers and ACE inhibitors continue, and there will likely be a few other medications added like spironolactone or a different kind of diuretic like hydrochlorothiazide (HCTZ). All of these have some nasty side effects. Patients may start showing a reduced ejection fraction if they have HFrEF (reduced ejection fraction). Cardiac valve repairs/replacements and coronary stenting are common here. The disease manifests here as structural changes to the heart. Of note, HIIT style-exercise has shown significant evidence for promoting left ventricular remodeling in an effort to stop or reverse this process! Intensities up in the 90-95% HRmax range are necessary.

Stage C: Heart Failure with active symptoms. These patients tend to show the symptoms regularly, and have now experienced significant changes to their heart morphology. Shortness of breath is common along with fatigue, edema, and nocturia. This is the stage at which we start implementing the Rule of 2s. Pacemakers and/or ICDs make their appearance here if rhythm drugs fail. These are the patients I see often and I still have them doing HIIT programs with great success!

Stage D: End Stage. These are the patients I also see often. If the patient has HFrEF (reduced Ejection Fraction) we are talking about VADs and transplants or continuous milrinone infusion. If they have HFpEF (preserved Ejection Fraction), we have to increase the treatment of all the things that cause heart failure like A-Fib, obesity, diabetes, and hypertension. Even still, exercise can make a huge impact here.

When it comes to End Stage, I tend to see a fair share of VAD patients. Ventricular Assist Devices are mechanical motors installed in the heart (either in the left or right ventricle, or both if you have my patients) to circulate blood. These can be used as a bridge to transplant or as a terminal device and are typically used for patients with a poor ejection fraction (EF). As you could imagine, people with VADs don’t have pulses or blood pressures because they don’t have a pulse… I had the rare opportunity to treat a patient in the home long term who had a Left VAD (EF 21%). It took two years of regular exercise but, you guys, his heart began to recover. The VAD offloaded him enough that his heart began to heal and remodel. By the end of my time with him, I was actually able to take a manual blood pressure and auscultate Korotkoff sounds over the sound of the motor. This is the magic of exercise prescription at work! But I digress…

Photo by Mike on Pexels.com

Overall, general heart failure management is simple:

The Rule of 2
2 Grams of Sodium
2 Liters of Fluid
2 Pounds of Weight Gain

I’ll break that down:

  • Your patient may only have 2000mg of sodium per day in their diet. This is tough for many patients with HF because much of the food they regularly eat (which is part of what lead them to having HF) comes from a box or a deli counter and is, therefore, HIGH in sodium as a preservative. It’s the American way.
  • Your patient may only have 2000mL of fluid intake in a day. This sounds simple, but I promise you that it is not. Four of those single serving water bottles are equal to 2000mL (they are each 500mL). But patients drink more than water. They drink coffee, soup, juice, and tea. They eat ice chips (really, I promise). So, this does actually become tough to measure.
  • They cannot gain more than 2 pounds in a day (or five pounds in a week). This means that they have to weigh themselves at the same time every day and record this weight for further reflection. This is the practical method of watching for the beginnings of fluid overload. This can be treated if it is caught early and we can avoid an exacerbation and hospitalization.

First step: Refer to a dietician! Let’s be real, we aren’t experts at this stuff. And heart failure comes with its own diet plan! So why not get them directly to the person with that info! The dietician will help them with the sodium part particularly.
Second step: Figure out a method of measuring fluid intake that works for the patient. My favorite is to have a 2 liter bottle on the kitchen counter next to the sink. Every time they want a drink, they fill their cup with that amount of water from the sink, dump it into the 2 liter bottle, and then fill their cup with that same amount of whatever they are drinking. That way, they can watch the bottle fill up over the course of the day and know exactly how much they have to go.
Third Step: Safely getting up on to and down from the scale for daily weights. It always amazes me that no one ever thinks to use their walker. Walk the walker right over the scale and step up on it, let go for a second to measure weight, then grab the walker and keep walking right back down off the scale. Done. Keep the weight log right next to the scale with a pen so they always remember to write it down.

Ongoing Step: Monitor symptoms (lower extremity swelling, shortness of breath, crackles with lung auscultation which could lead to oxygen desaturation with activity, abdominal distention) and check vitals. This we should really be doing anyway! You can use this super handy Red/Yellow/Green light handout for your patient (and yourself) so that everyone knows whats the plan is and what to watch out for! I love that the language is super patient friendly.

Source: Heart Failure Zones from the American Association of Heart Failure Nurses

It’s also important to remember that these guidelines are general. A patient may have more specific restrictions like only being allowed 1.5 liters of fluid intake per day or only 1500mg of sodium per day. Those orders come from the physician so if you don’t see it stated, be sure to check. There is also a caveat to the weight gain/loss rule. If you are exercising your patient to a sufficient intensity, you may see weight gain over time due to gain of muscle mass. You may also see significant weight gain if a patient is recovering from a severe exacerbation that left them unable to eat for a time. Still notify the doctor, that’s their call.

And for the final and most important step in the process….. EXERCISE! You can view the BRAND SPANKING NEW Clinical Practice Guidelines for Physical Therapists in the Treatment of Heart Failure for all the information you’ll need on that! You can read about more specifics HERE.

What is your method of teaching patients how to monitor their fluid intake? Tell me about it in the comments!


Research is piling in regarding the neurological effects of COVID-19 and the depth of the research is giving us some really concrete information to help guide treatment, screening, and monitoring strategies. The anecdotal evidence is continuing to build quickly so I’ve significantly updated this post to reflect some of the more recent changes and findings.Continue reading “COVID Brain”

According to the Scientific Community, It’s Time for Change

If you couldn’t tell, I’ve been hinting at this for a while. In several posts over the past few months, there has been discussion amongst the medical community that has created controversy regarding the mode of transmission of COVID-19. Many providers of all disciplines have been very concerned about their contraction rates and that ofContinue reading “According to the Scientific Community, It’s Time for Change”


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Cleveland Clinic. (2020). Heart Failure: Understanding Heart Failure: Management and Treatment. Retrieved from https://my.clevelandclinic.org/health/diseases/17069-heart-failure-understanding-heart-failure/management-and-treatment

Shoemaker, M. J., Dias, K. J., Lefebvre, K. M., Heick, J. D., & Collins, S. M. (2020). Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical therapy100(1), 14–43. https://doi.org/10.1093/ptj/pzz127

American Association of Heart Failure Nurses. (2017). Zone Tool for Heart Failure. Retrieved from https://cdn.ymaws.com/www.aahfn.org/resource/resmgr/docs/patiented/heart_failure_zone_tool_-_en.pdf

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Primary Care PT

During her address to the House of Delegates this year, President Dunn quoted Mary McMillan‘s statements as she travelled back through the history of our profession…

“A physical therapist should keep up with the latest in her profession so that when new things come along she is aware of them, so that she may be of greatest service to her patients. She must believe in herself, for without this, others cannot have faith in her. She must have faith in herself, and that does not mean cocksureness, that all too frequently comes from ignorance. A physical therapist must never let her patients go without hope, and I do not mean false hope either, I mean real hope. Because hope helps to chase away fears. Of course, it’s not always easy. There will be hard knocks. It is the hard knocks that help to bring out the best timber in us. Who wants a soft job, anyway?”

Mary McMillan

Many of you know that I used to work in home health for several years. It was during my time in home health care that I learned the meaning of practicing to the fullest extent of my license. This is my second soap box (vitals are vital being the first), and I want to step up on to it for a minute.

If you’ve worked in home health, you know all too well how this goes. You admit the patient under the hospitalist or the primary care or whatever random doctor the patient names for you. You call them with your plan of care (Yes, this is what home care is required to do. No, it can’t just be in writing.) and they say something along the lines of, “I haven’t seen the patient in 3 years! I’m not signing for this,” or “I’m just the hospitalist/rehab doctor, I’m not signing for home care.” So now you are left to figure this out and hope your medical director will sign for services until the patient can be seen by someone for their face to face visit (another home care requirement). This means you are the only care provider managing this case. This means you are providing primary care in the home setting to some of the sickest patients.

COVID-19 has changed the way we practice. And if you don’t think so, you shouldn’t be practicing. PTs have had to step up and show what we are made of, what we can do, and how much we actually know. All I have to say is: It’s about time!

Photo by Pixabay on Pexels.com

More often than not, when patients return home from a subacute setting to the home setting, they are returning home with one or no caregivers. They may even be returning home with one or no other providers involved in their care (see example above). As physical therapists, practicing to the full scope of our education and license is going to be all the more important. We are now the front line against community spread of COVID-19. This doesn’t just apply to home health, but also to outpatient services. We are also the front line to prevent further health decline and hospital readmission. We are the front line to manage medication and assess health status. We are the front line to differentially diagnose whatever other impairments and conditions may be present. We are the front line to request assessment, tests, and other items that may assist us in patient care. We are the front line in screening for other health factors such as social determinants of health, safety in the home, and hidden health impairments.

So what does that mean for our practice? It means that your job now includes things that it may not have included. For some time, in the home setting, we were screening all patients for Zika, Ebola, and SARS. COVID-19 screening is now going to be common place for every new patient. It is also going to be common place for every patient visit. If you can’t get your nails done without getting your temperature taken, you definitely shouldn’t be in a physical therapy clinic without it. And while you are taking your patient’s temperature (or your aide is), why not also take their heart rate and blood pressure? Let’s screen for hypertension, too. Maybe even catch some early heart failure? That’s what providers do. If you walked in to see a primary care doctor and didn’t have your blood pressure taken, would you even bother going back? I wouldn’t. In the outpatient world, we are providing primary care, so let’s act like it.

It is now our primary job to ensure these patients are receiving screening for the cognitive and mental health effects of their COVID-19 experience and for the cardiovascular impairments they may be experiencing beyond the generalized weakness and difficulty with ADL. We have talked in previous posts about the side effects of ARDS, PICS, mechanical ventilation, ECMO, proning, and so many other interventions these patients may have experienced. The side effects amount and most of them are within our scope of practice to screen, evaluate, and treat. Anxiety and depression already have a bearing on participation in exercise as well as the pain experience, so when is the last time you screened for either? When is the last time you applied exercise as the treatment of either? There is plenty of evidence to back it up.

Photo by Ketut Subiyanto on Pexels.com

We know that the risk for clotting increases significantly (Read more here!) so screening for DVTs and PEs may become something done at every visit. That also means screening and considering the increased risk for strokes. We also need to be establishing a baseline for delirium and other cognitive factors that can change as a result of COVID-19 like we discussed here. Set the baseline and document improvement through skilled assessment over time!

Sure, sure. Taking vitals is not a skilled or billable service. But your interpretation of vitals IS a skilled procedure. This is how you determine your patient’s safety to participate in exercise, or if they might have a PE, or if they are clinically hypertension. I promise you, we are not looking for zebras amongst the horses. We are just looking at the horses. And if you don’t look, you won’t see them until they are stampeding over you.

Beyond screening, we also need to provide interventions for these impairments to the fullest of our abilities. If this care is outside of our scope, we need to be making the referrals necessary to ensure these patients receive the proper interventions from the proper providers within our interdisciplinary team. Education is a huge part of our skillset. I often say that, as instructors in PT programs, we are not just teaching physical therapists, we are educating educators. Education on any of these topics, as well as lifestyle modification interventions, are going to start taking their place front and center in our profession, so be ready.

For some of us, this may not be new. Some of us may have been doing this for some time. Medicare deems physical therapists competent to provide services like medication reconciliation and management, anticoagulation monitoring (PT/INRs) (yes, we do minor blood work), and perform diabetic teaching including the use of blood glucose assessing devices. We need to consider the ability to request labs: UAs to check for urinary tract infections, CBCs to check hemoglobin status, dopplers to check for DVTs, plain film radiographs after a fall, and ABGs when concerned about advanced COPD and oxygen use. (Of course, you better have some good reasons to back up your requests and a good relationship with the physician helps!) If you think about it, all of these things are necessary for us to provide whole-patient care and ensure our patients are safe to perform exercise. Even if Medicare didn’t deem us competent, we were educated to be.

Don’t know how to do this or where to start? Head on over to SRA Lab and take a looksee at their RehabMeasures database. Some of you may remember this as “rehabmeasures.com” but that doesn’t exist anymore. The new site is packed full of screenings and tools that are validated for PT use in any patient population you can think of and for almost any diagnosis. Bonus: most of them are free!

  • Need an assessment of caregiver strain for your patient who has cancer? They’ve got that.
  • Suspect depression your geriatric patient with COPD and diabetes? They’ve got that.
  • Forgot how to quantify tone for your patient who had a stroke after COVID-19? They’ve got that.

President Dunn’s address reminded me of some of the topics in my Podcast with my home health friend Afrin where we looked back in history at how PTs have responded to pandemics and other crises. This is what primary care management looks like. This is the role we need to take on and it’s the role we were educated to fill. Who wants a soft job, anyway?

How do you provide primary care? Tell me more in the comments!

More Reads…


Also known as prior level of function in case you aren’t in to abbreviations. How many times have you written that today? This week? This month? How much thought have you given to what PLOF actually looks like for that patient? Isn’t their PLOF why you are seeing them in the first place? Let’s unpackContinue reading “PLOF”


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If you want to watch all of President Sharon Dunn’s address, check out the link!


Mayer, K., Engel, H., Falvey, J., Ricard, P. (2020). COVID-19: ICU to Home Transitions. [Webinar] Home Health Section of the American Physical Therapy Association. Retrieved from https://aptahhs.memberclicks.net/assets/5-16-20%20ICU%20Webinar%20Recording.pdf

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It sounds like a fuzzy lovable Sesame Street character, but this big boy ain’t no joke. ECMO or Extracorporeal Membrane Oxygenation is basically a lung outside the body. Blood passes through it. CO2 is removed and oxygen is introduced. It sounds simple, but that is the furthest thing from the truth. This is really advanced care and should only be provided by very skilled rehab providers and their teams. I’m going to stay relatively superficial here and focus on information only. These patients are not coming home on ECMO, but there are some factors that may be relevant to your evaluation and treatment of a patient who has recently been on ECMO.

Just like we have patients we can provide external kidney function through hemodialysis and external cardiac function through cardiac bypass, we can provide support for the lungs, also. ECMO also does the pumping of the reoxygenated blood back in to the body, so it functions as a heart, too. You don’t hear much about ECMO in the rehab world, and especially not in the general public and daily conversation. But lately, thanks to COVID-19, that is changing. So, here are the basics of what you need to know about ECMO and what to consider if your patient is coming to you after a stent with the ECMO monster.

My first experience with ECMO was during my time as a heart and lung transplant educator. One of my long time patients had been pre-habbing toward bilateral lung and vasculature transplant due to pulmonary hypertension and COPD. I visited her in the hospital after her transplant was completed and she was on ECMO. The tower next to the bed was breathing for her instead of her own brand spanking new lungs. Large plastic hoses were running out from under the sheets into the machine and then from the machine back in to her. It was a startling sight. Thankfully, the next time I saw her was in her home, and she was sitting up and singing just like she had been before the transplant.

Basically, ECMO is a last-ditch effort, a last resort. If mechanical ventilation isn’t working, even at the highest settings considered safe, ECMO may be brought in. This takes a huge effort, a large team, and round-the-clock monitoring of the machine and the patient. Typically, only very highly skilled teams and facilities are able to provide ECMO. ECMO is by no means a highly successful intervention. A recent study of patients with COVID-19 demonstrated less than 50% of people who were placed on ECMO survived (21 of 58). And let’s not forget that “survival” doesn’t mean they popped up and raced home to their family. ECMO also extends the road to recovery for most patients. However, that could be seen as a percentage of people who survived that would have otherwise died on the ventilator, so we can definitely see the benefit.

So why isn’t every patient failing mechanical ventilation, whether it be due to new onset GBS or succumbing to viral overload, given ECMO? We don’t have the resources. We don’t have the people. Like I said above, utilizing this device takes a team. This team includes twenty-four hour monitoring, usually in the room, by a respiratory therapist or registered nurse who specializes in pulmonary care. A surgeon and surgical team are required to implant the hoses in to the patient’s vasculature (no small feat). Several physicians also must come together to make the decisions on when is the right time, who are the right patients, and who has the best chance of survival. These are just the extras. This is all in addition to the already stretched team of nurses, nursing assistants, hospitalists, social workers, and rehab therapists that are working with the patient. And, prior to COVID-19, we didn’t have hundreds of patients at a single hospital going in to ARDS at one time, so we don’t have that many ECMO machines sitting around.

You can see more about the guidelines for use of ECMO here:

York Hospital's very first COVID-19 patient saved by ECMO treatment
The ECMO machine I’m more used to seeing. (credit)

Now, down to the meat and potatoes. What does rehab look like with ECMO? It depends (of course). Many times, patients are heavily sedated while on ECMO. But, sometimes, they aren’t. Sometimes they are able to be functional and awake and they need you so much at that point in time. Placing and managing ECMO takes a team, but so does rehab during ECMO. I want you to know what it looks like to ambulate a patient on ECMO, so please watch the video at this link.

Things you need to consider when evaluating a patient who has recently had ECMO:

Wounds. Several vascular access sites will still be healing. You may find them in the neck, chest, or upper thighs. Access can be placed in the femoral veins or jugular veins depending on the needs of the patient and the machinery available. These wounds place the patient at an increased risk of sepsis so they need to be carefully monitored for healing and/or signs of infection, dehiscence, or delayed healing. If they were on ECMO, odds are they had several other support devices in place (you saw those pictures and videos), so there will be several other vascular access sites not for ECMO and the same considerations apply. I’ve seen IV sites become infected and cellulitis spread through an arm because of it. Venipuncture sites matter just as much as surgical wounds. More research coming out is showing soft tissue infections as one of the main factors for returning to the hospital after discharge.

Profound Weakness. I’m not talking your average deconditioning. These patients were likely “under water” and/or sedated for several weeks, being completely dependent for all movement. Specifically for patients with COVID-19, the small muscles (intrinsics, muscles of the lower arm and legs) and core musculature seem to be greater challenged than the large musculature. Their diaphragms have done NOTHING for a long time and their cardiac function has been so chemically modified that the muscles don’t even know what to do anymore. Don’t forget about your tools like IMT and PEP to help with this! Supplemental oxygen can typically be run through these devices if needed.These patients need a greater level of reconditioning, a longer timeframe of overall recovery, and they are starting from an even further place than their non-ECMO cohorts with COVID-19. They need coordination training for the muscles of breathing and the cardiac system and they need to take it low and slow. You can find more information about that here.

Delirium. Just mechanical ventilation can cause delirium. Just ARDS can cause delirium. A hypoxic state can cause delirium. So imagine if you have all of those things and then you get put WAY WAY under so that a machine can oxygenate your body. The delirium is going to be there and it’s going to hang on for a while. There are many measurement tools that can be appropriate for establishing level of delirium, but the important thing is that you quantify a baseline so you can show improvement in delirium over time. Keep in mind that there may be little to know carryover or ability to generalize any skills instructed due to the “fog” still present. It has been postulated that these patients present very much like patients after traumatic brain injury and that the Richmond Agitation and Sedation Scale (RASS) used frequently in ICU settings may line up well with the Ranchos Los Amigos Scale/Levels of Cognitive Functional Scale (RLAS/LCFS) used in patients with TBI. It has been noted by several ICU practitioners that these patients really do present as if they have experienced a traumatic brain injury. Based on this, you have to modify your lens through which you view the patient, their participation, your activities, and your therapeutic goals. Those Neuro skills are really going to come in handy!

What was your reaction when you first saw an ECMO machine attached to a patient? Tell me about it in the comments!

More from the Pulmonary Rehab Toolbox…


HFNO stands for High Flow Nasal Oxygen. This is something that was used frequently in patients who were desaturating quickly with symptoms of COVID-19. It has the ability, through the use of several different devices or setups, to deliver very high concentrations of supplemental oxygen to patients with advanced pulmonary diseases or conditions. In theContinue reading “HFNO”


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Boyles, S. (2020). Critically ill COVID-19 patient better after ECMO treatment – experts offer guidance on ECMO use in pandemic setting. MedPage Today. Retrieved from https://www.medpagetoday.com/infectiousdisease/covid19/86003

Lin K, Wroten M. Ranchos Los Amigos. [Updated 2019 May 29]. In: SatPearls. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448151/

Mayer, K., Engel, H., Falvey, J., Ricard, P. (2020). COVID-19: ICU to Home Transitions. [Webinar] Home Health Section of the American Physical Therapy Association. Retrieved from https://aptahhs.memberclicks.net/assets/5-16-20%20ICU%20Webinar%20Recording.pdf

Seethala, R. & Keller, S. P. (2020). ECMO resource planning in the setting of pandemic respiratory illness. ANNALSATS Articles in Press. American Thoracic Society. doi: 10.1513/AnnalsATS.202003-233PS. Retrieved from https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.202003-233PS

The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RKAm J Respir Crit Care Med. 2002 Nov 15; 166(10):1338-44. https://pubmed.ncbi.nlm.nih.gov/12421743/

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The Second Wave

I know you are hearing this phrase a lot lately. We are hearing all the time that, as things open up around our country and around that world, we may experience a second wave resurgence of new COVID-19 cases. But I’m not referring to a second wave of new COVID-19 patients. There is new research coming out regarding patients who had previously experienced COVID-19 being readmitted to the hospital for a second wave of symptoms. These people have gone home. They have been discharged. They have recovered to a functional point. And yet, here they come, back in to the Emergency Department showing symptoms of COVID all over again. Why? What is going on here?

My first thought when I read this article was, “Here we go as a healthcare system, sending people home too soon again, just like we have been pushed so hard to do.” I was making some assumptions based on what I already knew, but what was really going on? Turns out I wasn’t wrong. Those with shorter median length of ICU stay (less than 5 days) were more likely to return for care, however, they were also more likely to not require readmission. They just needed some extra support like NIV/NIPPV, medication, breathing treatments, etc, and then were discharged from emergency back to home. In addition to length of stay, there are some significant factors that can result in patients being at a higher risk of readmission after COVID-19 discharge. Let’s take a look at what those are so you can better inform your practice and keep a closer eye on these folks.

Photo by Daisa TJ on Pexels.com

First off, WHY are these patients returning to the hospital after discharge? The most common reason is a resurgence in respiratory distress. Other reasons included chest pain, falls, soft tissue infections (We will talk more about this in an upcoming post), and altered mental status. Patients tended to return to the hospital within 4-5 days of discharge so this seems to be the high-risk time frame. There were also a few specific conditions and comorbidities that resulted in a higher risk of returning to the hospital after COVID-19.

Not surprisingly, patients who have a comorbidity of COPD had a higher risk of returning to the hospital after COVID-19 discharge (6.8% of returning patients). These patients already have a compromised respiratory system so incurring further damage from viral overload isn’t going to do them any favors. These patents are more likely to require advanced ventilatory support, are more likely to experience severe disease, and are more likely to have a negative overall outcome, so returning to the hospital is not unexpected.

What was a bit surprising is that patients with hypertension were even more likely to return to the hospital than patients with COPD (36% of returning patients)! The mechanism for this continues to remain unknown. However, if you consider the effects of COVID-19 on the circulatory system that we discussed in my post on DVTs, we can infer that the heart and vasculature are struggling for a number of reasons. Down this line of thinking, another factor that placed patients at a higher risk for readmission was whether or not they received anticoagulation therapy… Hmmmmm…

Photo by Gustavo Fring on Pexels.com

Lower BMI at hospital discharge was also associated with higher risk of return to the hospital. It was assumed in the article that the effects of frailty impacted the readmission rates. But, in addition to frailty, which is a defined system of events and presentations, I think we need to consider the effect significant muscle mass loss has on BMI. Because these patients are immobilized for a long period of time, they are more likely to lose significant amounts of muscle mass which then lowers their overall BMI (which is body mass in kg per cm of height). So, if you have a patient who has a large proportion of muscle mass at admission, and a low proportion of muscle mass on discharge, regardless of comorbidities or age, they may be at a higher risk of readmission.

Thankfully less than 4% of people who were discharged from the hospital after COVID-19 returned to the hospital. But for those 4%, more than half required readmission to the ICU, so if they do end up going back, they are probably in dire need of help.

For all of you out there treating patients who have returned home or to a sub-acute facility and are in that 5-ish day window after discharge, you need to be keeping an extra special eye on them if they have COPD, hypertension, low BMI, a shorter ICU stay, or did not receive anticoagulation therapy. Did I just name every home care patient? Maybe…

Have any of your patients gone back to the ED after being discharged for COVID-19? Tell me about it in the comments!

More Reads…

Rule of 2’s

So today, we are going to focus on the role PTs and PTAs need to be filling in the treatment and management of congestive heart failure. The first thing you need to address is the rule of twos. Don’t assume someone else had ever educated your patient about this. I cannot tell you how manyContinue reading “Rule of 2’s”


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Somani, S., Richter, F., Fuster, V., De Freitas, J., Naik, N., Sigel, K., Boettinger, E. P., Levin, M. A., Fayad, Z., Just, A. C., Charney, A., Zhao, S., Glicksberg, B. S., Lala, A., Nadkarni, G. (2020). Characterization of Patients Who Return to Hospital Following Discharge from Hospitalization For COVID-19. MedRxiv [Pre-Print Release]. Retrieved from https://www.medrxiv.org/content/10.1101/2020.05.17.20104604v1.full.pdf+html

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Venous Thromboembolism (VTE) Part 2: PEs

Thanks for tuning in to part 2 of this two-part feature of VTE. The first segment, which focuses on DVTs, can be found here!

So now we are going to focus on the more critical version of a VTE. Yes, DVTs are critical. They are important to assess and treat quickly. But they are less acutely life threatening than a pulmonary embolism. Let’s take a closer look at PEs and how they are relevant to rehab clinicians.

A pulmonary embolism is something (usually a blood clot) that moves through the vasculature and eventually impedes a vessel that supplies a portion of the lung. This sudden blockage is typically a clot, but can potentially be several different things such as fat, bone, soft tissue, air, etc. You may be thinking, “How would any of those things get in to an artery and cause a blockage in the lungs?” Well, through external means. People who undergo surgeries are at an increased risk for PE because the act of cutting through tissue can introduce those elements in to the arterial system. Crush injuries can also introduce tissues in to the vasculature that doesn’t belong there. If these insults are relatively small enough to pass through our peripheral vasculature, they can make it back to the heart, and are then pumped into the pulmonary arterial supply. The emboli are actually pretty large because they are typically formed in the deep leg veins (they start as DVTs) which then dislodge and travel back to the heart through our relatively larger veins. However, vessels in the lungs get very small very quickly (they have to be capillary sized to perform oxygen and CO2 diffusion at the site of alveoli), so blockages are likely to happen here.

Just like with DVTs, PEs have a particular set of symptoms that can be quantified on a couple different scales. Like we talked about in the first post, the Wells’ Criteria has a scale for PE risk assessment. It works pretty much the same as the DVT risk assessment and the criteria are similar. As you can see here, I’ve set the tool for an assessment of a patient with COVID-19 with a typical presentation. However, this score could also be given to a patient after a joint replacement as the assessment would look very similar. The bonus to using the Wells’ Criteria is that it factors in the clinical gestalt. We mentioned this briefly in the last post. Your gestalt has been researched thoroughly and it has actually been shown that clinical gestalt (the feeling that something is amiss) is actually the single most important clinical tool in determining the need for further workup. If all your tools are telling you everything is fine, but you feel something is wrong, something is probably wrong, and there is research to back that up.

Another tool becoming more commonly used is the Revised Geneva Tool (rGeneva). Meta-Analysis outcomes have shown that the rGeneva is actually just as accurate in predicting risk of PE being present as the Wells’ criteria. The difference between the tools is that the rGeneva stratifies risk across three categories (low, medium, and high). The original version of the rGeneva utilized outcomes of ABGs and other assessments that take precious time to order, measure, and interpret, so the tool was revised to be done with only a physical patient assessment. This tool does not weigh clinician gestalt, so it is felt to have less clinical strength than the Wells’ Criteria, however, still very valid and useful.

How to inform your gestalt

There are some clinical factors that should be informing your gestalt when it comes to pulmonary emboli, some physical assessment pieces that should take you down the road of either ruling this out or calling 911. In a patient who has been immobilized or with recent surgery, the most obvious signs would include:

  • Shortness of breath at rest or with minimal exertion
    • (believe it or not, shortness of breath is NOT ALWAYS PRESENT in patients with pulmonary emboli!)
  • Tachycardia and tachypnea
  • Significant decline in functional status
  • Confusion
  • Chest pain with breathing (pleuritic pain) (65% of patients)
  • Hemoptysis (65% of patients)

Other less common clinical factors may include:

If these factors are coming up in your physical exam, patient interview, or functional assessment, you should be very concerned and doing some deeper digging, as well as probably contacting a physician right away to report findings.

So, since I seem to have a patient or two with just about everything, yes, I’ve had several patients where I have identified a new PE. Two were post-surgical (cervical spine fusion and knee replacement), one was severely ill with end-stage COPD, and one was young but immobilized long term due to primary progressive MS. Two of these four died upon reaching the hospital. The patient with the cervical spine fusion had three PEs on his imaging but made it! The one with COPD didn’t return home. All of them were confused, some severely confused, three had a sense of impending doom, all four had abnormal lung auscultation, three had leg swelling. No one had a cough or difficulty breathing.

What happens next?

So we think our patient may have a PE. We’ve called the doctor or sent them to emergency. What happens to them now? They will get some blood work done (a D-dimer and ABGs) and some imaging studies performed. Likely, a CT angiography will be performed. I don’t know if you guys have ever seen an angiogram for a PE, but the images produced are just completely amazing and the clots tend to be pretty obvious. In the image below, image a is a slice of the pulmonary vasculature. The vessel heading off to the right (superior vena cava) is occluded with a large embolism (the shaded tubular shaped area within the white space). And image b is just incredible, but all those tiny dark spots within the white space (the vessels) are subsequent emboli.

Figure 1

This is obviously a large embolus. Emboli that are very large like this one present in the large vasculature can cause major damage as they block such a large vessel which means every other lower-order vessel is now also blocked. These type of emboli tend to emanate from the deep leg veins and are more common in patients who have heart rhythm issues (another reason beta-blockers are so important!). You can see in the assessment tools that there are other factors that increase the risk for developing PEs:

  • Cancer
  • Cardiovascular disease
  • Disorders that affect clotting
  • Pregnancy

That last one is interesting. While living in West Michigan, I regularly encountered patients who had a condition called Factor V. People of European Caucasian decent have an increased risk of carrying a genetic mutation that results in Factor V Leiden, a clotting factor malfunction. This results in an increase in the risk of clotting including DVTs and PEs. There are thousands of clotting disorders out there that increase the risk of clotting.

Preventing PEs

Sometimes there just isn’t much you can do. PEs are one of those things that can pop up over night and have no symptoms until someone is so far gone that you aren’t sure if they are coming back. I’ve had a patient with no symptoms one day, and the next day I had to send him straight to emergency. There are some things we can do to lower the risk, and this list is going to look pretty similar to the list for DVT prevention:

  • Promote mobility programs
  • Promote anticoagulation adherence
  • Promote rhythm drug adherence
  • Graduated compression stockings
  • Frequent position chages
  • Educate patient on signs and symptoms
  • Alternating pressure/compression devices
  • Smoking cessation
  • Weight loss

Does COVID-19 increase the risk for PEs?

As part of DIC (disseminated intravascular coagulopathy), the quick answer is yes. For more on DIC, see the first post in the VTE series. A new study found that 23% of patients in the ICU with COVID-19 had PEs. And I mean several PEs, not just one or two. The presence of PEs was difficult to determine due to the patient’s COVID-19 symptoms so angiography was typically performed much later than usual. The presence of PEs was determined to increase the need for and length of mechanical ventilation.

I wanted to show you some imaging for comparison. You saw the image above of the PEs in otherwise normal lungs. Below you will see what lungs look like when they not only have several PEs, but all the sequelae of COVID-19 including bronchiectasis, ground glass opacities, consolidation, and actual architectural breakdown. This particular set of lungs was thought to have a fluid volume of between 25-50%. You don’t even have to know the specifics of what all of that means to look and this set of images and realize this person is in rough shape.

Figure 2:

Other studies have shown that between 20-30% of all patients with COVID-19 may have PEs whether they are in the ICU or not. In Detroit, doctors diagnosed 51% of the COVID-19-related PEs in the emergency department and 72% of them did not require ICU admission. However, what this can be interpreted as meaning is that even if your patient isn’t critically ill with COVID-19, their risk of having a PE is still very high.

So if you are seeing patients in the outpatient, home, or sub-acute settings, not only does their risk of having a PE or DVT increase simply because they had COVID-19, but the risk stays high and hospitalization for COVID-19 is not a factor is their PE risk. Even in patients who were on prophylactic treatment for clotting, almost a quarter of them still developed PEs. Rehab clinicians need to be watching out for the signs and symptoms of PE and DVT for any and all patients who are being treated after COVID-19 diagnosis or suspected COVID-19.

Have you ever spotted a PE? Tell me about it in the comments!

More Reads…

Primary Care PT

During her address to the House of Delegates this year, President Dunn quoted Mary McMillan‘s statements as she travelled back through the history of our profession… “A physical therapist should keep up with the latest in her profession so that when new things come along she is aware of them, so that she may beContinue reading “Primary Care PT”


It sounds like a fuzzy lovable Sesame Street character, but this big boy ain’t no joke. ECMO or Extracorporeal Membrane Oxygenation is basically a lung outside the body. Blood passes through it. CO2 is removed and oxygen is introduced. It sounds simple, but that is the furthest thing from the truth. This is really advancedContinue reading “ECMO”

The Second Wave

I know you are hearing this phrase a lot lately. We are hearing all the time that, as things open up around our country and around that world, we may experience a second wave resurgence of new COVID-19 cases. But I’m not referring to a second wave of new COVID-19 patients. There is new researchContinue reading “The Second Wave”


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Ceriani, E., Combescure, C., Le Gal, G., Nendaz, M., Perneger, T., Bounameaux, H., Perrier, A., & Righini, M. (2010). Clinical prediction rules for pulmonary embolism: a systematic review and meta-analysis. Journal of thrombosis and haemostasis : JTH8(5), 957–970. https://doi.org/10.1111/j.1538-7836.2010.03801.x

Grillet, F., Behr, J., Calame, P., Aubry, S., Delabrousse, E. (2020). Acute pulmonary embolism associated with COVID-19 pneumonia detected by pulmonary CT angiography. Radiography. ePub online ahead of print. Retrieved from https://doi.org/10.1148/radiol.2020201544

Le Gal, G. (2020). Geneva score (revised) for pulmonary embolism. Retrieved from mdcalc.com/geneva-score-revised-pulmonary-embolism#creator-insights

Penaloza, A., Verschuren, F., Meyer, G., Quentin-Georget, S., Soulie, C., Thys, F., & Roy, P. M. (2013). Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism. Annals of emergency medicine62(2), 117–124.e2. https://doi.org/10.1016/j.annemergmed.2012.11.002

Poyiadji, N., Cormier, P., Patel, P.Y., Hadied, M.O., Bhargava, P., Khanna, K., Nadig, J., Keimig, T., Spizarny, D., Reeser, N., Klochko, C., Peterson, E.L., Song, T. (2020). Acute pulmonary embolism and COVID-19 (a research letter). Radiology. Retrieved from https://pubs.rsna.org/doi/pdf/10.1148/radiol.2020201955

Stein, P. D., Beemath, A., Matta, F., Weg, J. G., Yusen, R. D., Hales, C. A., Hull, R. D., Leeper, K. V., Jr, Sostman, H. D., Tapson, V. F., Buckley, J. D., Gottschalk, A., Goodman, L. R., Wakefied, T. W., & Woodard, P. K. (2007). Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. The American journal of medicine120(10), 871–879. https://doi.org/10.1016/j.amjmed.2007.03.024

Wells, P. (2020). Wells’ criteria for pulmonary embolism. Retrieved from https://www.mdcalc.com/wells-criteria-pulmonary-embolism

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