The Dangers of Providing Necessary Care

We know the doctors, nurses, respiratory therapists, anesthetists, and all those other incredible people caring for patients in the ICU and ED are risking their lives every moment. But there is another side of this pandemic: the side that stays home.

Patients that stay home or are sent home still require care. Many may have comorbidities that require higher level skills (like pulmonary hygiene interventions or medication management) that can’t be performed virtually. So someone HAS to go to them instead.

The definition of “home bound” has completely changed. This is a term home health care providers are extremely familiar with. It is often a reason we have to deny services or discharge services: a patient has recovered to a point where they are no longer home bound. And most payers will NOT reimburse care provided in the home for those who are not home bound. However, due to the recent implementation of “shelter-in-place” orders across the country, EVERYONE IS HOME BOUND.

This means that the utilization of home health care based services will exponentially grow in accordance with the growth of COVID-19 cases. It is understandable. If you can’t go out because you are at high risk or you risk infecting others, then health care has to come to you. But what does that mean for the providers who go from house to house?

The number of health care workers who are infected climbs every day. Some are recovering, some are not. This isn’t meant to spread fear, it’s just the truth. We, as health care workers, are carriers just like everyone else if we have somehow been exposed.

Home care providers are at very high risk for infection due to the inability to maintain social distances from their patients, the manual interventions that require close contact, and the inability to ensure a clean and sanitary environment in which to practice. And that’s only the risk to us!

We also pose a significant risk to our patients! We go from house to house and are out in the world risking exposure and bringing it in with us. In to the homes of the MOST fragile, the homes of the very sick, and even group homes where we could infect many people at once.

But Physical Therapy is STILL a necessary service that many patients will require, not just to recover from COVID-19 or keep them of of ventilators, but to keep them out of the hospital for other conditions like vertigo, back pain, and injuries due to a fall.

If you are a home health care worker and you are feeling the strain of this, you are not alone. Many home health care therapists and other providers are sharing their concerns:

Home health workers fear spreading COVID-19

The APTA has given some guidance on this:

“….our profession plays a crucial role in the health of our society, and there are people in our communities whose health will be significantly impacted by disruptions to care.

[Physical Therapists should] use their professional judgment in the best interests of their patients and clients and their local communities – including rescheduling non urgent care if that is the best approach, or making other adjustments when the risk of exposure to COVID-19 outweighs the benefits of immediate treatment.”

-APTA representative (link)

So the question comes down to this: What care is truly necessary to be performed face-to-face? Are you implementing any virtual visit platforms to complete care that doesn’t have to be done face-to-face? How are you prioritizing your patient care?


If you are a home health care therapist, let me know what you think in the comments! Or share your tips with others!

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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Airway Clearance Techniques

Thanks for checking out the first blog post in this series about respiratory interventions for Rehab Clinicians!

Airway Clearance Techniques (ACTs) are best practice for patients who are in acute exacerbation, sub-acute exacerbation, or are stable with obstructive lung conditions.
Long-term management of obstructive lung disorders including cystic fibrosis, COPD, bronchiectasis, and chronic bronchitis, and those with impaired cough including ALS, SCI, and post lung transplant should include instruction in ACTs.

Pulmonary Hygiene takes a team – reinforce regular performance of ACTs!

I have a special treat for you!

I created this a while back. All you MDTs out there will love it. This is a force progression (backed with evidence!) for applying, combining, and progressing airway clearance techniques. It starts out with the patient providing their own forces from the inside and outside, then adds the external forces you can apply as a part of your airway clearance techniques.

Brockway, K. (2017) Pulmonary hygiene toolbox – force progression tips
(Original content)

Tips for airway clearance techniques:

  • These are considered AGPs (Aerosol generating procedures)! Therefore, they require full PPE and an N95 mask per the CDC guidelines when performing with a patient with known or suspected COVID-19 (or any other viral infection of the lungs).
  • Always consider changing positions to utilize postural drainage positions to encourage increased secretion mobility.
  • When implementing oscillatory devices, keep in mind that not all oscillatory devices can be inverted or turned sideways and continue to function (such as the Aerobika). However, some can do this easily (like the Acapella).
  • Have tissues ready! My friends in ICU tend to use a cup. Secretion color and consistency matter and can tell you really important things!

Don’t forget about other tools in your toolbox!

  • Increase water intake: This thins secretions so they are more mobile.
  • Increase overall mobility: increasing mobility means increased respiratory rate and depth which natural mobilizes secretions.
  • Change positions frequently: utilizing postural drainage positions or just changing positions frequently throughout the day reduces consolidation.
  • Utilize Mucolytics: for very thick secretions and/or patients who are not mobile to improve secretion consistency for better mobilization and expulsion.

So that’s just the intro! Come back often to find all kinds of great techniques and information to update your skills and get you ready to practice in the cardiopulmonary setting!

More from the Pulmonary Rehab Toolbox…

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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We’ve never had a better reason…

…to brush up on our respiratory intervention skills. These are my bread and butter. In the six years that I practiced in home healthcare, I learned to love these skills I never thought I’d need. And the more I grew to love them, the more I loved using them. But that means seeing the patients that are the most medically complex.

This brought me to heart and lung transplant care. That may seem scary for some people: providing aerobic exercise and respiratory interventions for patients who have just had their organs removed and replaced with someone else’s. But it is my passion. And that passion led me to get involved with the heart and lung transplant education team at my hospital system. I started providing the education courses for other PTs, OTs, and SLPs, so they could also provide these interventions and care for these patients with confident competence.

I can promise you, the patients being treated before or after transplant are just as scared as the ones being treated for COVID-19. No one knows what their outcomes will be. In lung transplant, we say “50% will live 5 years”. That may not sound like much, but many of these people are literally DAYS away from suffocating to death. It’s a chance they are willing to take.

With COVID-19, I imagine the feelings are the same. We don’t even know how long 50% of the hospitalized patients will live. We hope they return to the majority that recover, but not everyone will. Some will fall into that percentage that require extended hospitalization. The others will get the red tag.

I have taken a patient through YEARS of pulmonary pre-hab for a double lung transplant and many months of rehab after. She was on her way to visit family to say her final good-bye, trucking along her 10 L/min supply, when she got her phone call. The lungs were available. She knew what that meant, but she also knew she had to accept that reality quickly and get to the hospital. Thankfully, the family she was visiting lived nearby.

She had some rough road after her transplant, but it turned out to be successful. She had a beautiful two years of life after transplant. She returned to gardening, spending time outside, and welcomed a new grand-niece in to the world. So what kept her going?

SO. MUCH. PT.

Seriously, years of PT.

Obviously, you can’t do that in every setting. But, we spent our time strengthening her diaphragm using a Threshold IMT for progressive resistive exercise, diaphragmatic breathing activities with PNF-based manual inputs, practicing breathing with activity, PEP for airway clearance, active cycle of breathing, huffing, postural drainage, percussion, and even METs for rib mobility. She was in desperate need of cough efficiency planning because she had so little reserve.

I utilized auscultation and active pulse oximetry prior to and after interventions to demonstrate progress and instructed her in high-intensity interval training. Yes, even someone with advanced COPD, pulmonary hypertension, and an indwelling pulmonary catheter on 10 L/min of oxygen can do high-intensity interval training.

You can read more about this story here and see some beautiful pictures of respiratory interventions taking place. But more importantly, you can see the happiness that beams from her, even though she can hardly breathe.

If you’ve checked out the World Confederation of Physical Therapy’s Guidelines for PT Treatment of COVID-19 in Acute Care, you’ve seen these types of interventions listed. Patients who have COVID-19 need respiratory interventions from a skilled PT before they end up on a ventilator, during their ventilated time, and after they are removed from the ventilator. Active interventions should always be given priority over passive ones (aka EXERCISE!) but you do what you can. And don’t forget about contraindications for some interventions.

To perform these interventions properly for patients with COVID-19, the WCPT recommends that PTs who are already skilled and experienced in providing them be the ones to do so. However, that doesn’t mean you won’t see these patients outside of acute care. It’s time to brush up. It’s time to take back this part of our practice. We are the most skilled in providing physical interventions to improve cardiopulmonary function. If you haven’t done this stuff in a while, you can find online courses everywhere (or here!). We need more people providing these interventions because the demand is going to be high.

Image credit: Chris Clark, 2016

Do you think it’s time to brush up on your CV/P skills? Let me know what you feel like you need to most brushing up on 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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The Why

Hey everyone,

I continue to receive numerous texts, emails, phone calls, and messages asking how the heck PTs are supposed to keep practicing amidst the trials of COVID-19. The laws are changing constantly, states are laying down practice restrictions, and payers are opening up and expanding, but amidst all that, many of us feel lost.

I’ve held leadership roles in our profession, but I definitely am no COVID-19 expert. What I can tell you is that Physical Therapists are incredibly strong, smart, undaunted, and resourceful. We have jumped at the chance to respond to pretty much every epidemic, pandemic, and natural disaster around the world since the inception of our profession. COVID-19 shouldn’t and won’t be any different.

Our sense of altruism is too strong. That’s why most of us are TERRIBLE at marketing ourselves. Our values are deeply engrained. That’s why we keep wondering how we can help.

I had the idea to start this site years ago, but the inundation of communication I’ve received related specifically to the current situation pushed me to open this up sooner than I had planned. I never imagined that I would be launching this site in response to a pandemic that has left my colleagues providing chauffeur services for other healthcare providers, or being a greeter at the front door of an urgent care, or applying to work at Costco. Yes, these are all things our fellow PTs are currently doing. And It’s killing me.

I, like Liam Neeson, have a very particular set of skills. I am a physical therapist who specializes in the management of advanced chronic disease. I do that by providing skilled interventions targeted at the cardiovascular, pulmonary, and neurological systems in the geriatric population. I spend most of my days treating end stage COPD, ESRD, or CHF, and I love it. As a PT, I want to see more people in our profession utilizing these types of skillsets. We all have them to some extent. We all learned this stuff somewhere along the way. I just kept learning it and never looked back. My goal is to help all of you relearn it, too. I want you to feel comfortable with the skillsets you will need to treat patients with advanced heart and lung diseases, like COVID-19. I want to teach what interventions you’ll need in your toolbox. Most of all, I want you to be able to keep doing your job because you are valuable and I want you to be able to prove it.

If you are an outpatient orthopedics therapist who doesn’t really remember much from cardiopulmonary class, this is for you. If you are a new grad who just wants to know everything you don’t know, this is for you. If you have been practicing in skilled nursing for 25 years and want an update, this is for you. If you don’t care at all about cardiopulmonary physical therapy services, but you know you need them right now, this is for you (but we should talk more later).

I want you all to feel confident in the competence you have in these skills. I want you to know that someone else is out there fighting for you and with you through all this crazy. I want you to know that there is somewhere you can go to brush up on all this stuff quickly and without cost so you can go right back to work tomorrow and DO these things. I want you to feel valuable and give value to your patients.

I hope you can find some help here. And once this passes, if it passes, I hope to re-focus on other practice issues.

Stay safe and stay healthy, because we can’t stay home.

Doctor B

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More Reads…

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)”

COVID Brain

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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Coronavirus Is Our Future | Alanna Shaikh | TEDxSMU

Check out this TEDx video from Alanna Shaikh, a global health expert.

What do you think about Alanna’s perspective? Let me know in the comments!

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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The Best We Can Do (So Far)…

We finally have enough research and enough answers and enough patients and enough confirmed cases that have received care. We can start making some recommendations and have at least a minimal amount of evidence for some guidelines on treatment.

The World Confederation of Physical Therapy has published acute care guidelines for care of patients with COVID-19 specific to PTs. There are plenty of guidelines for physicians and nurses right now, most with a fiar amount of evidence, but not PT. We haven’t gotten much to guide us.

My favorite part of these guidelines is that it makes recommendations for who should and should NOT be seen for PT in a critical care setting. I feel like these recommendations for service triage will be modified for application to other settings. So many therapists are reaching out right now because they are struggling with the lack of definition of “essential” and this could be the answer. Some states (like Michigan) have taken it upon themselves to define “essential” as life-saving or life-sustaining care.

How do you feel your employers are doing with utilizing the term “essential” when it comes to patient triage? Take a look at these guidelines for triage and treatment.

Guidelines

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What are you doing for patients who have COVID-19? Let me know in the comments.

PLOF

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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Your Mission, Should You Choose to Accept It…

Depending on your setting and expertise, you may or may not be asked to take on a special role during this time. There are some resources to assist you from the World Confederation of Physical Therapy. But don’t feel like you have to do everything. We have such a varied skill set as a profession that we fall all across the board when it comes to crisis response. Here are some thoughts on roles you can play.

The big one that most people think of is trauma triage.

Most people think of a physical therapist as someone they see after a broken leg or an ankle sprain or a surgery.

So the natural next step would be to triage injuries so that doctors and nurses can provide medical treatment for very serious life-threatening injuries, and then PTs can take over for the non-life-threatening injuries that just need training, education, or exercise.

PTs can easily provide medical screenings of patients and nonpatients.
And we don’t have to be limited to virus screenings, either. PTs can screen visitors and other providers for symptoms and provide education on quarantine guidelines. We can also screen people for secondary issues that will determine their course of care, like fall risk, and pneumonia risk. PTs can also check and monitor vitals to ensure people stay safe.

Something people probably don’t see PTs do often is chronic condition management, but there are some PT’s who provide this type of care everyday.
Like care for COPD, CHF, Diabetes, Gout, RA, and anything else that sticks with you for the long term. In times of crisis, PTs can assess these patients for acute and non-acute needs and provide basic and advanced interventions as part of their normal scope of practice. Of course this would include taking medical histories and determining the needs of each patient which most of us do pretty much every day, anyway.
This would also include wound care. At the very minimum, PTs can provide basic first aid and treat minor to moderate wounds, but some PTs actually specialize in wound treatment and can treat advanced, complicated, and chronic wounds easily.

PTs can also play a natural role in Accessibility Consultation. Sometimes, people have to be relocated because of a disaster affecting their home. PTs can help search out, extract, and move people whether they are injured or not.  And once we get them out, we can assess what accessibility needs they will have at the new location. PTs can determine if they will need medical equipment like walkers or crutches and teach people how to use them. And if there aren’t enough PTs to do the people moving, we can train others how to safely move people so they don’t get hurt in the process.

PTs can also take on administrative roles to reduce the burden on others. This can include simple tasks like inventorying, stocking, recommending, and moving supplies and coordinating other services like dieticians, social workers, and nonclinical help. PTs are also prime coordinators when it comes to people management. Our expertise is human movement, so when it comes to moving large masses, we can take control and do this safely.

For people who are already under medical care, PTs can provide assessment of rehabilitation potential during field (on site) or facility triage phases and facilitation of discharge by assisting patients to functionally recover enough to return home or to another level of care like a rehab unit.

Outpatient therapists are currently working on seeing patients virtually as much as possible. However, the overarching goal of outpatient therapists will likely soon transition to offloading primary care physicians, emergency departments, and urgent cares from orthopedic injuries and pain management concerns. Some Outpatient Orthopedic clinics have already transitioned to urgent orthopedic care centers utilizing direct access rights!

And, of course, PTs are all trained in minimum emergency response, or what we call Basic Life Support. This means we can participate in Code Teams and provide CPR/AED support. Some PTs are trained in Advanced Cardiac Life Support and are able to provide even further care in these situations.

Looking at this list, I’m betting lots of people don’t know we do all of these things!

People like the general public or your hospital administrators. Even people like your community emergency response team (CERT). And they will never know unless you tell them.
We are SO much more than greeters or chauffeurs (yes, that is how PTs are being utilized right now), but we HAVE to educate others.

Join the international team of PTs responding to COVID-19!


Are you taking on an unexpected role due to COVID-19? Let me know in the comments!

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”

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”

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