Welcome to a chat with a physical therapist who is using their orthopaedic and sports skills outside the typical practice environment. Dr Patricia Weber shares her experience as a senior physical therapist in the shock trauma setting–a world that blends orthopedic, neurologic and multi-trauma in a challenging emotional and psychological environment.
Dr Weber is a senior physical therapist at the University of Maryland Medical Center. She primarily treats within the R. Adams Cowley Shock Trauma center in downtown Baltimore.
[00:00:00] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today.
[00:00:22] Today we have a very special episode for you where we go inside the life of a senior physical therapist working within the shock trauma setting. Dr. Patricia Weber is a senior physical therapist at the University of Maryland Medical Center, downtown campus in Baltimore, Maryland.
[00:00:36] She has residency trained in orthopedics and primarily treats at the R. Adams Cowley Shock Trauma Center within the University of Maryland Medical System where she treats the most critically injured trauma patients, both those suffering from orthopedic, neurological and multi-trauma injuries. My name is Dan Chapman.
[00:00:53] I'm a US-based physical therapist and owner of Summit Physical Therapy and Performance in Baltimore, Maryland. So I am one of the senior physical therapists at the downtown campus currently. I'm actually going on a little over four years of my time at University of Maryland.
[00:01:09] I started my career at Johns Hopkins back in 2016 after I graduated PT school. So I've spent the majority of my professional career working closely with trauma patients. So that includes everything from orthopedics, multi-trauma, neurotrauma patients and
[00:01:28] I have spent some time now with the cardiac surgery population and some pretty advanced trauma populations with BB and VA ECMO. Did a brief stint in outpatient where I did some dry needling certification just to
[00:01:41] kind of keep myself well rounded and keep myself well versed in the populations that I was dealing with. I did my orthopedic residency training back when I spent some time in some outpatient too which has come in pretty handy and working with the trauma patient population overall.
[00:01:57] So just rewinding a quick moment for our friends who have not spent much time working in the hospital or maybe it's been a little bit. Can you remind us what ECMO stands for? So ECMO is an extracorporeal membrane oxygenation and that is pretty much a life sustaining measure.
[00:02:13] Oftentimes you see it as you know reference of the bypass machine so open heart surgeries and things of that nature. Medicine has become pretty advanced over the years and this is actually something that people can spend a fair amount of time on.
[00:02:25] I'm actually sitting in the hospital bed which basically circulates their blood and either bypasses their lungs or bypasses their heart to kind of help offload that in times when they're very ill. So these are some of the sickest patients that you can basically see in the hospital setting.
[00:02:41] So for those who are not familiar with shock trauma and how it's organized, I mean you treat injuries across the board, orthopedic, neuro, multi-trauma injuries. Can you help us understand how your team is made up and then you as a physical therapist
[00:02:55] do you specialize in one of those areas or do you treat all across the board? Particularly within like the shock trauma center which just to give a little background for people who are not familiar, you know the R.A. Kelly Shock Trauma Center
[00:03:09] is a hospital that flies, you know there are hospital beds within the shock trauma center. They also have what's called a trauma resuscitation unit which basically is like a special emergency department for trauma patients. So instead of patients coming through the regular emergency department, if they are
[00:03:27] trauma patients they go through this trauma resuscitation unit. So from there that's basically where the patients are triaged and they then either go to a floor unit or they can discharge from that unit occasionally.
[00:03:39] From a PT perspective we do see patients down in that resuscitation unit if they're ready for discharge. If not, if they make it up to the floor then our therapist pick them up on the floor.
[00:03:52] So when patients then make it up to the floor are they broken down into any kind of different organization via presentation? So is there you know neurodrama versus ortho trauma? Do you treat across both of those or do you have certain teams that specialize in
[00:04:04] one or the other? And like when the patients are actually up on the floor unit we are broken down and you know we have a orthopedic unit, we have a neurotrauma unit, we have a multi-trauma unit.
[00:04:15] So we do kind of cluster those patients together at least to some degree based on the types of injuries that they encounter. You know depending on caseload and how the units are looking certainly we see patients throughout the whole area of the hospital there.
[00:04:28] So I just want to make sure I'm doing your team justice here at the R. Adams Cowley Shock Trauma Center. This is a world renowned hospital and shock trauma here is the only park designated facility for trauma and neurotrauma in the country.
[00:04:40] We have a lot of listeners who may not be too familiar with what this means and how our hospital systems are stratified. So in terms of their ability to treat the most critical patients can you just touch on this for us?
[00:04:52] Essentially in terms of like hospital care you've got your leveling of care for hospital systems you know which go all the way down from level three, level two, level one and then you actually have what's called a park which is considered a primary adult resource center.
[00:05:10] So that's it there's actually even a step above a level one center. So the level three tiers would be your the lowest capability in terms of managing serious patients. So you know the levels are determined by basically what staff is available 24-7.
[00:05:28] So as you go up the ranks in terms of level one trauma center and all the way up to the primary adult resource center and the parks basically in terms of staffing you've got an orthopedic surgeon who is on site on and able to be accessed 24-7.
[00:05:41] You've got a neurotrauma specialist who's available 24-7. So the park designation is a pretty unique criteria to achieve. It has to meet 12 criteria in order to meet that standard and so that's where the Shock Trauma Center lives in that park designation.
[00:05:58] Johns Hopkins is a level one trauma center so they're right up there as well. Yes if you are in the unfortunate situation where you need high level Baltimore is actually a very good place to be.
[00:06:11] We do have a lot of amazing options and amazing teams that provide high level care. Talking about exceptional care let's talk about your day to day experience. I want to know I want to learn you know what is it like to practice as
[00:06:26] a physical therapist in the Shock Trauma Center. Can you walk us through some case examples that kind of give us a good idea of what it is that you deal with on a day to day basis.
[00:06:37] I'll give you kind of an acute care picture a little bit you know you have someone who is in a motor vehicle accident driver head on collision pretty typical injuries that you might see in something like this are
[00:06:49] probably some degree of the head trauma potentially like a posterior hip dislocation from just based on the seated position and things of that nature along with we'll maybe say some blunt trauma to the abdomen or
[00:06:59] the lungs things like that so you know these patients come in they will get triaged down in the trauma resuscitation unit this would probably be someone who is you know maybe not ready for discharge that day who we
[00:07:10] would typically see on the floor either in the ICU or floor level depending on them severity of those injuries but you know for the sake of this particular example we've got someone who's got a head injury who now is confused disoriented maybe a little bit impulsive you've got
[00:07:26] someone who's maybe got some lung injuries they've got a chest tube then they've also got some orthopedic injuries that would limit their weight bearing and limit their hip range of motion in addition to maybe an x-lap procedure to repair any like visceral injuries in the
[00:07:41] abdomen so now you're looking at someone who's got some cardiopulmonary implications with regards to you know that respiratory function they've got a weight bearing restriction that's probably causing some pain and some difficulty mobilizing in general and a head
[00:07:55] injury that's maybe limiting them for even being able to maintain any of those precautions starting simple doing an evaluation every anticipation of sitting this patient up at the edge of the bed which is a
[00:08:05] feat in and of itself depending on the age of the patient and you know their response to that initial mobility at least to the edge of the bed if we're doing our best we're hopefully at least standing and maybe
[00:08:17] putting that patient over to the chair we've got some pretty good resources some overhead lifts so even if we're not able to mobilize these patients you know either via standing or anything like that we are
[00:08:27] usually getting these patients up out of the bed to at least help promote you know bent weaning pulmonary toileting and things of that nature so you've got a lot of things on your plate that you're considering on that
[00:08:38] initial evaluation in addition to a pretty thorough cognitive assessment to kind of see hey what's our trajectory looking like. I'm just sweating right now just just flashbacks to acute care practicals and there's just lines everywhere but this is this is on a
[00:08:53] whole nother level this is just that with steroids these are the most critically injured patients multi-trauma patients that you're dealing with and then on stacking on top of that the emphasis on early mobilization and getting them going and getting them moving that's that's you make it sound easy.
[00:09:13] Let's talk about some more examples because again I know you see a lot of different presentations so I'd love to learn learn more about what you're seeing. Let's say you've got some young kids who are hanging out a bachelorette
[00:09:24] one jumps off the stage breaks both of his ankles but you know theoretically you can have someone who comes in has two orthopedic injuries to lower extremities that are maybe not operatively managed so whether it's a distal tid-fib fracture or a calc fracture something about nature
[00:09:41] basically the trauma team will triage them get their appropriate imaging they decided there is going to be non-operative management and otherwise there's nothing else medical that would keep them there. They will consult us down to essentially this trauma resuscitation unit which we
[00:09:55] refer to as the true to evaluate this patient and deem if they are appropriate to discharge from there or if they have rehab needs then they likely would need to admit this patient and for rehab placement so we
[00:10:06] would go down there and assess their mobility at you know if they're bilateral lowers that are non weight-bearing then we would kind of assess them to see if they've got an appropriate home situation to facilitate you know wheelchair level mobility.
[00:10:18] You know I know over the years there have been like certain studies that come out that kind of make their way onto the front of the APTA journal that's like is early mobility like really all it's like cracked up to be everything you know learn in our careers.
[00:10:29] Certainly I think that you know over time we have gotten better at identifying which patients tend to respond well to early mobility. The number of adverse events that is typically happening as a result of mobilizing patients early is really not all that significant you know
[00:10:46] certain populations like the stroke population for example that within that first 24 hours you're kind of teetering on where the value add is but you know in terms of orthopedic injuries or traumatic injuries where hey the value out of even just simply getting these patients up to
[00:11:01] work on like verticalization I think that there is at minimum very good research that supports that the adverse events are pretty low with early mobility. I said I think we are pretty good at getting in there early
[00:11:14] anecdotally I think that the benefit is certainly been beneficial in terms of decreasing length of stay, bent leaning all those things are like valuable consideration to in terms of you know when we get into that a patient's room.
[00:11:27] So we touched on the orthopedic injuries but you also mentioned that you work with a lot of neurologic trauma as well can you talk to us about that side of your job? Acute neurotrauma patients it's a very unique subset of patients and I
[00:11:42] think early on in my career I as a student even down in South Carolina I did a rotation down there that was very heavy with like management of spinal cord injuries as well and it's really a valuable experience for
[00:11:54] these patients who you know are really experiencing something that's like life changing often these patients are very well aware of everything that's like going on around them and giving them that ability to do things early on that they wouldn't otherwise have the
[00:12:09] ability to do I think there's a very special population to kind of be getting up and moving early on to help with like even just simply verticalization so because their blood pressure management and other things
[00:12:21] are very now are now changed just simply based on their injury so by the time they're over an outpatient I mean the strides between the hospital setting in the outpatient setting I feel like are pretty significant in that patient population.
[00:12:35] So can you touch on the emotional components of your work in this environment I mean it's one thing six months down the line when you're an outpatient orthopedic to treat a patient who has suffered neurotrauma spinal cord injury traumatic brain injury anything in
[00:12:49] that realm it's going to have an emotional component that's not present with typical outpatient orthopedics but the way in which you experience it is totally different I mean you're one of the first if not the first person to even get these people into a
[00:13:05] seated position not to mention start processing you know what is what has happened and what they're going through so I'd love to hear you touch on the emotional aspects of your work. I think that being able to kind of take that on very early is one of
[00:13:22] the most rewarding parts of my job I will agree it's like not necessarily for everyone it definitely can weigh heavily on you because we're all like humans we don't like to see people suffer but I
[00:13:33] think it is truly something to be able to like connect with someone when they're pretty much the lowest of the lows like the most vulnerable they are going to be I've always described my outpatient experience is like you
[00:13:45] know sometimes we give people the choice to like walk in here and they still don't walk in here until like you know go to your sessions and things like that and then you know pretty much everyone prior to you
[00:13:55] meeting them when they come into shock trauma it has no intention of coming to see you as otherwise living a perfectly normal life and this is something that has just like turned the world upside down so you
[00:14:04] know it's just as much of a skill to be able to kind of know what you're doing at the bedside clinically as it is to be able to kind of figure out what's going to make this patient trust you and want to work
[00:14:16] with you and kind of see that like glimmer of hope and most of their hope has probably been thrown out the window so you know I like I feel like I think about my patients you know often I but with like a
[00:14:28] passionate heart and just like wander more so than like a heavy burden per se I've been like fortunate enough to also work for one of our trauma survivor network program which is also very big at shock trauma where you you know do we do support groups we do
[00:14:44] activities it's basically like a band of brothers of trauma patients who you know are in various stages of their emotional recovery along with physical recovery so you know most of the patients their hospital stays like a blur they remember how they're doing and they
[00:14:59] value the progress that they're making an outpatient which makes them like feel human again sometimes but they they all look back with like appreciation for some group of people that like helped them get to where they're at and I think that that is kind of what keeps you
[00:15:13] keeps you going. That sounds incredibly powerful, heavy, challenging and rewarding all at the same time. As we draw to a close here, what do you want our listeners to know about physical therapy in the shock trauma setting that we haven't covered yet?
[00:15:29] Yeah, I'd say one of the greatest challenges and privileges all at the same time is like being able to practice at the shock trauma center is truly challenging yourself to like practice at the top of your license. You know, obviously, we always want to
[00:15:43] practice at the top of our license but you're only as good as your toughest case and your hardest case and so when you throw a lot of components in there whether it's like, you know, clinical considerations or social determinants of health, you know,
[00:15:55] as we kind of transition into this like well-rounded care picture, you know, you have to take everything into consideration because if it's if it's clinically challenging, you certainly now have to consider like what are the implications of a social
[00:16:08] determinant health and like what is your role in that so really being able to kind of lean on on your team around you, you know, take input from the physicians communicate with the positions as well as like your social workers and your case
[00:16:21] managers to like really just at the best level of care that you can out there. So I think that's, you know, the biggest reward of all of us who is just being able to really be like, hey, I'm capable of like doing these things and it
[00:16:34] gets to change lives at the end of the day. Well, I think that's just about a perfect place. Believe it. Dr. Weber, thank you so much for joining us on the podcast and to all of our listeners. Thank you as always for listening to JOSPT Insights.
[00:16:51] Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights on Apple podcasts, Spotify, TuneIn, Stitcher, Google or your favourite podcast app. If
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