This is part two of a series on how COVID-19 is affecting physical therapy. Part one addresses outpatient physical therapy. This article is about hospital-based physical therapy.
Dr. Karl Arabian, PT, DPT
In fact, Dr. Karl Arabian, PT, DPT, a Staff Physical Therapist at Long Island Jewish Medical Center in New Hyde Park, NY, said at the beginning of April he had not worked with a COVID-negative patient in three weeks. His hospital is located on the border of Queens and Nassau county in Long Island, in the heart of the epidemic on Long Island.
Before the virus hit, he primarily worked on general medicine units or in the Intensive Care Unit (ICU), where he has been a therapist for less than a year. At the moment, he is working overnight in the makeshift ICU units that are “understaffed and overfilled with patients. My primary duties [are] to lead team members proning patients, performing chest PT when indicated, and turning and positioning patients.”
Although he admits that at first, “going into these airborne/contact rooms was nerve-wracking mostly due to the lack of knowledge,” he now says, I “proudly walk into these rooms to make a difference in someone’s life, hopefully save some lives as well, and allow these people to return home to their loved ones.”
Part of this mindset shift came from replacing thoughts of “they have the virus” with “they have been in bed for several days,” something that allows him to realize “as physical therapists, we are most equipped to help these people.”
He notes there is a wide range in how COVID-positive patients present: “Some are able to stand and ambulate with supervision for safety and oxygenate on room air symptom-free. Others are so deconditioned that transferring supine to sit is challenging, and to compound that, they will desaturate and need to return to supine within a matter of minutes.”
In general, he says physical therapists do a lot of positioning, ambulating, and exercise: “COVID-patients need to get up and off their back to allow their posterior lung fields to oxygenate and improve their body’s tolerance to an upright position. Furthermore, due to remaining in bed for several days, there is gross muscle deconditioning. Ambulating, as well as basic therapeutic exercise, is crucial for them to regain enough function and strength to safely return home.”
Besides the precautions, “Our treatment sessions are longer with these patients because they need increased time to recover, and often will take longer to complete basic transfers.”
Unfortunately, he is one of thousands of healthcare workers facing shortages of personal protective equipment (PPE): “Northwell has done a sufficient job aiding the physical therapy department with the necessary equipment to work with these patients, however, we have to rewear our N-95 masks for five days or more. Supply of these masks appear to be low.”
Although few people were prepared to deal with a global pandemic of this measure, many physical therapists say their schooling and experience working in acute care settings have helped make the transition easier.
Dr. Mariel P Castro, PT DPT
Dr. Mariel P Castro, PT DPT, has worked in a Level II Trauma hospital in the northeast for about two years. Although she typically works in a neurology unit, her caseload has changed recently due to a lack of elective surgeries and other hospitalizations due to an increase in people being told to stay at home, and influx of COVID-positive patients. She said working in acute care has helped her feel prepared to treat these patients.
She also acknowledged being scared of treating patients with the highly contagious virus at first: “But you can’t think like that as a healthcare professional. You have to treat everyone as if they are your own family.”
Treatment is a little more complicated during this time.
She notes, “The patients appropriate for PT at this time are medically stable, and have been extubated. They might be on high flow or nasal cannula.”
She said it takes an additional five minutes at the beginning and end of each session to don and doff PPE and clean equipment. Because of all the gear, she noted it can feel like being in a sauna during treatments: “It feels like you can’t even breathe, and by the end, you’re sweating because you’re wearing an N-95, a surgical mask with a shield over the N-95, a hair cap, and they have us wear two blue contact gowns, one in front and one in back, plus booties with two gloves.”
As for the physical therapy she said, “It is a very similar treatment as [it] would [be] for a medical patient with pneumonia, asthma or respiratory failure. Patients with COVID-19 typically have poor endurance and are limited by shortness of breath, fatigue, and weakness, so it’s very important to monitor vitals – especially O2 saturation. I typically focus on strengthening and endurance training during my bedside treatments, though being on airborne precautions is quite limiting in the hospital’s small rooms, so you have to get creative with your endurance activities. Our goal in acute care is functional independence and addressing the limitations preventing the patient from achieving that goal.”
Since these patients are not allowed into the hallways, space is limited, and therapists are forced to be inventive with their treatments.
As is often the case even before the virus, she deals with a scenario common to many physical therapists: other healthcare professionals who are unsure of what physical therapists can do.
“I have found that not many of our nursing colleagues understand what our role is during this pandemic. It is understandable that many of the COVID patients are not medically stable to move or participate in therapy, however, many of these patients who have been extubated and have been downgraded to a nasal cannula or high flow, and whose vitals are stable, are appropriate to participate in therapy. We have to advocate for our profession and educate our colleagues [on] how important our role is in the full recovery of these patients.”
Dr. Molly Smith, PT, DPT
Dr. Molly Smith, PT, DPT, another new graduate physical therapist, has had similar experiences. She has worked at a hospital in Seattle, Washington for a little less than a year as an acute care physical therapist floating between the neurologic telemetry floor, cardiac telemetry floors, and the Neuro/Cardiac ICU.
She recalled a nurse asking for a mechanical lift for a COVID-positive patient. The patient was no longer intubated, and hadn’t yet received PT. Dr. Smith told the nurse that rather than a lift, the man needed to start moving: “He needs to start physical therapy – it is vital in his functional mobility recovery.”
She began working with him and anticipates he will be able to return home soon. The man, a physician who treated COVID-positive patients himself, went from being intubated, sedated and placed on ECMO for nine days to walking with a walker. During his stay, therapists such as Dr. Smith, worked with him to help him sit and stand – tasks that often required the assistance of two people. At one point when he practiced standing on his birthday, he FaceTimed his wife since she was unable to visit during his hospital stay.
While working with another patient who had already been in the hospital with a neurological condition before acquiring COVID-19, Dr. Smith made use of a translational tool since the woman did not speak English and could not have family members visit to help translate. After walking the farthest she had walked in three weeks – 10 feet in her room, five times, the woman began to cry.
Dr. Smith waited for the translation to come through.
When it finally did, she heard, “These are happy tears. I am finally seeing a light at the end of the tunnel as I begin to walk more. Thank you for your help, thank you so much.”
The APTA has set up a website for physical therapists looking to volunteer with COVID-19 patients.