Women Leaders in Medicine, Ep. 7

Mobilization of the Critically Ill Patient

05/03/2023

This podcast series aims to highlight the women leaders in medicine across the United States. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.

 

Episode 7: Moderator Jaspal Singh, MD, MHA, MHS, interviews Christiane Perme, PT, CCS, FCCM, and Ellen Hillegass, PT, EdD, CCS, FAPTA, about providing physical therapy for patients in an ICU setting and the challenges and rewards of mobilizing critically ill patients.  

Additional Resources:

Christiane Perme, PT

Christiane Perme, PT, CCS, FCCM, is a board-certified cardiovascular and pulmonary clinical specialist by the American Physical Therapy Board of Specialties, a rehab education specialist at Houston Methodist Hospital, and the owner and president of Perme ICU Rehab Seminars in Houston, Texas. 

Ellen Hillegass

Ellen Hillegass, PT, EdD, CCS, FAPTA, is a board-certified cardiovascular and pulmonary clinical specialist by the American Physical Therapy Board of Specialties, an associate professor at Mercer University in Atlanta, Georgia, and the president and CEO of PT Cardiopulmonary Specialists, Inc. 

Jaspal Singh, MD

Jaspal Singh, MD, MHA, MHS, is medical director of pulmonary oncology and critical care education, as well as a professor of medicine, at Atrium Health in Charlotte, North Carolina.

 

    TRANSCRIPTION:

    Moderator: Hello everyone. Welcome to "Women Leaders in Medicine," a special podcast series, led by our section editor on Pulmonary and Critical Care Medicine, Dr Jaspal Singh. The views of the speakers are their own and do not reflect the views of their respective institutions.

    Dr Jaspal Singh: Hi, everybody. I'm Jaspal Singh. Welcome again to Women Leaders in Medicine, a podcast series on Consultant360. On behalf of Consultant360, I'd like to welcome our listeners. Today we have another great pair of esteemed guests. With me today are Ellen Hillegass and Chris Perme. Ladies, want to introduce yourselves? Ellen.

    Ellen Hillegass: Sure. I am an American Physical Therapy Association board‑certified clinical specialist in cardiopulmonary. I'm also an adjunct professor at Mercer University in Atlanta. I'm the president and CEO of PT Cardiopulmonary Educators, which is a web‑based education company.

    Jaspal: Fantastic. Chris.

    Christiane Perme: My name is Christiane Perme. I am a physical therapist from Houston, Texas. I am currently a Rehab Education Specialist at Houston Methodist Hospital. I'm also the owner and president of Perme ICU Rehab Seminars, which is a company which presents lectures and seminars on the topic of early mobility in ICU.

    Jaspal: Fantastic. First of all, I just wanted to say, I'm a huge fan of both of your work. I think Ellen, you and I met through the American Thoracic Society.

    Chris, you and I met at the Society of Critical Care Medicine. Both of you have inspired a lot of people I know, including the physical therapists I worked with who are such experts probably because of both of you. Tell us why you are so passionate about the mobilization of the ICU patient?

    Ellen: I learned early on in my career, the horrible side effects of bed rest, and how it impacted my patients, their return to function, their return to their leisure activities, and their all‑around quality of life, and I said, "There's got to be something better."

    We had always been doing early mobility, way back when I started, and that was before we had restraints. When all of this sedation era came through, I started to see these people who were so impaired. That's my passion, is that I know you don't have to be that impaired mentally and physically. I know that it can be done. That's why I've been passionate about it. How about you, Chris?

    Christiane: Ever since I was in physical therapy school, I was always drawn to the acute care side of medicine, and also to the really complex issues that some diseases presented.

    When I started working at Houston Methodist, I started doing chest PT in the late 1980s, and after that, I started working a little bit in the ICU. At that time, there were two physicians that were very passionate about early mobility and they kept telling me that if I just got those patients out of bed, and I walked them that they would not die.

    I just could not really understand the relationship between my job as a physical therapist and patients not dying at all. I didn't really want to do a whole lot of that just because I never had the training.

    That's not something that I learned in school, I never had a professor or a teacher or a course that would teach me how to mobilize those patients in ICU, so I was extremely frightened.

    The ICU environment was overwhelming, but luckily, those two physicians, they were there to help me because they were just so into getting his patients mobilized that for the most time they would just be there with me, because I told them, if they're not there, I wouldn't do it.

    The whole thing is that the more I did it, and I saw the results, the more fascinated I became and finally, by the early 1990s, I decided that's the only thing I wanted to do as a physical therapist and my entire career.

    Jaspal: Amazing. Both of you connected to your patients, to others, and you both have inspired others. I was going to ask you, prior to COVID‑19, we've struggled a lot with mobilization as a country as a profession and internationally. This is nothing intuitive. Chris, you talked about that a little bit, but the aspect of what are other barriers?

    You mentioned training, Chris, are there other barriers that you think needed to be overcome to limit this part of the mainstream culture?

    Christiane: In my opinion, number one barriers to mobilizing patients in critical care is the knowledge deficits of professionals that they're totally unaware of the terrible side effects of bed rest, and immobilization, because I honestly, believe that anybody who reads about bed rest and mobilization and what that causes to the human body, even in healthy subjects, they would be a lot more interested in mobilizing those patients.

    That is, I think the number one barrier is the knowledge deficit. In addition to that, of course, the sedation. It's not a barrier because you can have the best physical therapist, the best nurses, everybody, but the culture of the ICU is like a third sedation. There's not much we can do for those patients.

    Another barrier, I believe, is the lack of resources. These resources would be as far as the staff or even the equipment because, for example, if you send me, a physical therapist, to mobilize a Critical U patient on mechanical ventilation and CRT in the ICU, I'm not going to go very far by myself.

    In the same way that if the patient is profoundly weak and I do not have the technology or some of the equipment to help me, I wouldn't be able to do it. Basically, I like to think of those barriers not necessarily as barriers, but I also like to say that these are potential barriers, that if we really want to we can overcome that.

    Jaspal: Ellen, anything to add?

    Ellen: Yes. I think one of the things is just that there is also a lack of understanding between the disciplines. We really need interdisciplinary care of the patient but we're not trained that way, many aren't.

    Nurses are trained to care for the patient and take care of things and make sure they're comfortable. Physical therapists are also called physical torturers. We're taught to get them up, get them moving no matter what, it's better for them. We're hitting heads because we're going against our basic beliefs.

    Our belief is not to keep them comfortable, but to keep them moving because we know that's better. Nurses want to make sure the lines and tubes don't come out, and I don't blame them. They also want to make sure the patient's comfortable and not in pain. and so we butt heads there.

    Then we all can understand the role of the physician but maybe not the respiratory therapist. We just need to know each others' roles, we need to work together and not compete. We need to work together. I think that's the barrier, it's when you don't have a team and you don't work together.

    That's a challenge but I think it's a communication challenge. You can teach each other and you can communicate with each other and I think that can be overcome. I totally agree with Chris that sedation is huge and understanding the effects of sedation on breathing and mobility. I also agree with her about the training, because I don't think walking into an ICU is entry‑level physical therapy.

    They don't have the training in their own physical worlds, and a lot of other disciplines don't have that so I think training is also key.

    Jaspal: Training and knowledge. The culture of sedation. The idea of resources, equipment, staff, personnel. The idea of interdisciplinary care and communication at a high level. I think what you're getting at, Ellen, is also a culture of a shared goal. I think the idea of mobilization is part of a shared goal for the patient to go for liberation, which is something that we've all been working and talking around, the idea of getting patients out of the ICU back to a reasonable quality of life.

    I have to say I learned a lot from both of you as well as the rest of the whole discipline actually, and I include occupational therapists in this discussion as well. This is all stuff we've been working on as a society, multiple societies, young professional societies.

    We're kind of making some headway I think as a society about trying to go more towards liberation including interdisciplinary team care, including the idea of mobilization, including occupational rehabilitation as well.

    Then along comes COVID‑19. This pandemic comes and pretty much turns all the progress that we did sort of on its head. Explain to me, someone very simple like myself, how did you approach this? How did you overcome some of the challenges? What are some of the challenges with COVID‑19 for our audience? Ellen?

    Ellen: One issue was, we didn't have enough equipment, PPE equipment, to be treating the patient going in and out when we wanted. We had to overcome that barrier. What we did is, we learned how to communicate through glass to the nurses who were in there who had to go in and out a lot.

    We communicated the things that we wanted to see done and we also helped educate them and work with them to try and, "Tell me what you hear in the lungs," and get them sitting up and stuff. Because one of the things is that they would be left alone if we weren't going in.

    We had to go into the units and get them to mobilize the patients through the wall and maybe watching the monitor. We'd be communicating back and forth. We kind of taught people how to do some of our skills because of this situation.

    We were also pushing to get the patients up early. We understood that they were sick and all that kind of stuff and people were short‑staffed. We were really pushing for the mobility part, because if you listen to some of the places where they didn't have enough staff, such as in New York, and they were overwhelmed with patients.

    They were sedating them, sedating them, sedating them because they couldn't get into the units if they pulled something out. There was nobody working with the patients but the nurses, and so they sedated them heavily. Mobilization was delayed in those places, so we tried not to do that. I'm going to tell you one really interesting thing that happened in COVID at our facility.

    We built a brand‑new building, and it wasn't supposed to open up for during COVID. It was all glass, from floor to ceiling glass, in the ICU units. They moved all the COVID patients out there, and do you know what? They had less problems with mental cognitive issues because they were looking around at life. They weren't looking at a teeny window out to the courtyard. They were looking at life.

    We noticed a huge difference in their cognitive and their personality. They were more responsive. It was amazing to see the change just in the environment of the glass where they could see life versus seeing an ICU unit. We saw huge changes in our COVID patients. I'm going to tell you, that environment was interesting to watch.

    Jaspal: Chris, what did you notice?

    Christiane: I truly believe that COVID really changed the landscape in critical care, and definitely changed the landscape for critical care physical therapy not only in the US, but throughout to the entire world in a very positive way. I think now, physical therapy in ICU is a lot more recognized than it was before COVID.

    Yes, we did tons of challenges in order to care for those patients. I agree with Ellen that one of the most important things was just resources as far as PPEs that we could not be using, so it was limiting us going to the rooms. In addition to that, we had to be concerned about the risk of transmitting the disease to other patients, or even our staff, getting that.

    There was always that fear associated with caring for the patients, particularly in the beginning. The equipment that we would generally use to care for those patients, we were not allowed to bring them in the room because if we brought into the room, it had to stay there. We were limited on things that we could offer to patients.

    Another thing that we felt the difference was families not being present. We generally really engaged the families, and we teach them the exercises. We want them to be part of the patient's recovery. The patient's family not being there, it was very difficult for us.

    We also noticed the difficulties with some cognitive issues that we identified in some patients. We had to learn, as physical therapists, to identify those in our care for the patients in our evaluations and also let the doctors know about it. Also, refer to speech therapy and cognitive training, and things like that.

    Another huge challenge that we found was the lack of available placement in post‑acute settings. For us, that became a challenge because we had to send those patients home, and we had to really make sure that we did whatever we could to help those patients recover so we could send them home.

    Jaspal: Interesting. I think both of you highlighted what is a nice segue to what some are calling, for lack of a better term, long COVID. The idea of what results in prolonged critical illness type of physiology. The effects of this virus, not just the virus but the effects of sedation, lack of family, the idea of unable to get them to really see.

    I think, Ellen, you said it very nicely, the light made a big difference. Just seeing life around you, the stimulation without family, sort of barriers you might say to improvement, we saw a huge change in how we think. It might have an effect on what we call long COVID exactly, which you're kind of getting at. That's interesting.

    I think, Chris, you brought up something interesting, you said almost like a silver lining was people recognized we were doing all these things. Now you take it away, and now you realize how much it was missed. I think we all felt it. We felt the sudden...Our hearts sank that we couldn't get them the physical therapy, the occupational therapy, the mobilization going.

    We needed to walk them, or they weren't ready to go home yet. We had to, out of necessity and placement, send people to places that may not have been ideal, or quite ready for their ideal recovery just given the resources. Is that pretty accurate? Anything else to add?

    Christiane: I think that covers it. [laughs]

    Ellen: Chris had a lot of points that we had the same problem with. We realized that we had to do a lot more rehab of our patients before sending them on. I think now there's actually been two studies that have come out talking about pro‑rehab. The more you push, the more minutes of rehab, the better the outcome. I think COVID helped with that too.

    Jaspal: You mentioned these interdisciplinary relationships. Have those changed since COVID?

    Ellen: In our facility, we had a great comradery. Our biggest problem is when we don't have regular staff. When we have travelers, it makes a difference because they don't know the culture. They don't know the team spirit. I think that's a huge thing, is we're seeing so many travelers. That's really unfortunate for our environment, because they don't know how to be part of the team.

    Jaspal: Interesting how much you guys have helped shape what this mobilization looks like. Lots of society is working in this space. Can you tell us a little bit, for those of us...I'm in pulmonary and critical care, and I only know my own little fiefdom, you might say, of disciplines and societies.

    This is a much broader movement nationally, internationally. Give me some highlights as to what's happening around the globe and around the United States, if you don't mind, that excites you in this field.

    Ellen: I'll jump in. We found with COVID, that ECMO did save a lot more lives. We're seeing a lot of ECMO. We were doing a lot of ECMO. We're seeing places doing a lot more ECMO, and more people are contacting us trying to learn how to do mobility with ECMO.

    We're seeing people where they backed away from some of this more mechanical circuitry, and mobilizing patients with mechanical circuits. They are now doing more mobility. I think that's really good. As far as other places, unfortunately when you have change of staff, you're seeing change in the mobility program.

    I hate to say it, but we know places that had a really good, strong mobility program, when staff changes, the mobility program decreased. I can't emphasize enough how important having a nurse champion is on a mobility team, and having more and more nurse champions because that's what keeps mobility going.

    Jaspal: Chris, what have you noticed?

    Christiane: First of all, I just want to say something before I forget that goes along with what Ellen was saying, is that what we have to really understand and never really forget is that mobility of patients in ICU, it's everybody's job. We really have to let it go, this idea that, "Oh, we're just waiting for PT to come here to get the patient out of bed."

    Mobility, it's everybody's job. I don't think that there's any one discipline that is part of that critical care team that is not responsible for mobility. I'm going to be honest with you. I'm very vocal about this. I remember once in a meeting a physician looking at me and saying, "Well, does that mean you want me to do your job now?" I said, "No, I really don't. That's not what I mean."

    What I want everybody to know is...For example, physicians. They completely underestimate the power that they have as educators. If every physician came to the bedside and asked the patient, "Have you been out of bed? Are you getting out of bed for your meals? Have you been lifting your legs? Let me see if you lift your arms?"

    Just that. You don't have to get anybody out of the bed, but your words towards encouraging the patient and the nurses. Making sure that you pass it onto the nurses how important you believe as a physician that kind of activity is for your patient.

    I'm going to be honest with you, I believe that if the mobility of patients and ICU was a pill, physicians would be giving this pill [laughs] all day long, without even thinking about it.

    I think that's one of the most important ideas that I want people to remember is that don't ever think about, "Oh, let's wait for physical therapy," because that way that we do may impact somebody's life. It may cost someone...The fact that there will never be able to walk again, and I have seen that in my career.

    Jaspal: That's very interesting, is well said. I think what you're saying is mobilizations, a team sport, is a team sport that has significant consequences if not done well.

    Ellen, I think you piggybacked on that and saying, not only is a necessity, but now we're seeing it actually being done in newer venues, and then a bus scale that we haven't seen before with advanced mechanical circulatory support, and other devices, as we advanced our critical care frontier, we cannot forget that mobilization is still a premier goal.

    You don't need to be an expert in it. You just need to encourage it, work along with the team, but that everybody in the teams involved from the pharmacists adjusting medications to the respiratory therapist and adjusting there's ventilator strategy, respiratory strategies to the speech and swallow pathologists.

    Everybody's involved in how to get these patients feeling. Is that pretty accurate?

    Christiane: Yeah, the way I think is like, just imagine, that's my dream. Imagine like if the nurses came to check the vital signs and instead of doing a blood pressure of the patient laying in the bed, if they set the patient on the side of the bed, "Let me check their blood pressure and set them on the side of the bed."

    If you do that two or three times during the day...but unfortunately that's not a priority. I fully understand nurses are completely overworked but I don't know that anybody really gives the true importance, how that little bit that is done throughout the day can make an incredible impact on the recovery of these patients.

    Jaspal: Well said. Ellen, you want to say something?

    Ellen: Yeah, I have a residency program and I tell my residents as part of their training, ask questions like, "Why can't we get them up? When you get pushback, if the whole team would say that, "Why can't we get them up?" They say, "Well, they've been on this IV med." How long have they been on that IV med, are they stable?

    Those kinds of things, clinical reasoning is very key with these patients, which is what we teach, but asking why? When I have these fresh new therapists coming into ICUs, and they're afraid to do things I say, "Learn from others. Ask why, or ask RT to show you things on the ventilator."

    If we would teach each other instead of having these silos, and teach each other about what we do. It's not like we're going to take over for respiratory therapists and manage the ventilators, we're not going to do that, but we do have a lot of knowledge about ventilators, so what is it about this ventilator setting that you don't want me to get the patient up?

    Is there a different setting we could put them on, so that we could get them up. You try and come to a mutual agreement so that your goal is mobility. Sometimes we just don't understand each other because of our background and our training, but if we would just ask the question why can't we, and Chris is pill [laughs] , the doctor goes around.

    But why can't we, what is limiting them? Then try and figure out a way. We've had patients, yeah, they can't sit over the side of the bed. They have no muscle control, so we started using standing beds.

    When we started to use the standing beds, we actually could ween Guillain‑BarrÈ patients off of the ventilator, even though they couldn't sit over the side of the bed, because we could get them more upright, so you ask the question, why can't we get them up? Then you all work towards figuring out a way to get them up.

    Jaspal: That's a great way of doing it, not saying how do we get them up, but why are we not? That is the goal. That is the true north essentially, is getting people to a functional status.

    I think Chris said it very well, if it was a pill, I would almost challenge our listeners to think it's not just that you wouldn't be getting it. It'd almost be unethical not to give it, because it's such an important part of the recovery process.

    With that, I'm going to change gears a little bit, talk about the pandemic has had a lot of effects, all of society, including our physical therapy and the in colleagues. How are you doing? How are the people in your profession doing, your teammates doing? Give us a little insight about what's the culture like today?

    Ellen: Oh, I have to tell you there's a lot of burnout out there. There's a lot of burnout out there. First off, we all feel safe. That was once we got our vaccine. We had this whole different approach to life, but then there's this whole burnout.

    There's this fear of this coming back again, fear of having another increase. I don't think people are out of the burnout enough to tolerate a big increase.

    The second thing is, part of it is, is like you get this big increase after you open up and people don't do the right things. You're stuck taking care of this patients that didn't do the right thing.

    Part of that is, gets you a little angry and frustrated that people aren't doing the right thing. Why didn't you get your vaccine, and these because people can get vaccines now? People will say, "Oh, if I'd known it was this bad, I would've gotten the vaccine," and you're sitting there going, "Really?"

    Jaspal: Too late for a due over.

    Ellen: Yeah.There is greater comfort with the vaccine. I think it's wonderful, but there's frustration out there. There's some burnout and there's really a need for many, many more trained staff. I think Christiane will say the same thing about that and we just need to ramp up the training on some of these people.

    Jaspal: That's well said. Chris.

    Christiane: I completely agree. Particularly our physical therapist that had to work the COVID units, they were burned out, completely exhausted, and working nonstop. Again, another issue that we're having right now is like all of those patients who did not seek medical care because of COVID last year.

    Now they're coming back to, I don't know, other hospitals and our hospitals sicker than ever. It's really interesting to see that these patients are not only sicker, but they're also somehow weaker and they have a lot of other issues. I totally agree with Ellen that the burnout it's a big issue.

    We are really trying to hire more staff, but everybody's really working very hard just to be able to see those patients and then make sure that they're being discharged to the appropriate level of care, and also if they go home, that they're safe going home.

    Jaspal: That's well said, and hopefully we can keep you guys from burning out. I want to thank you first of all for all you're doing. It's amazing. But not only are you guys teaching, working at the bedside, doing all this stuff, inspiring others. You both started your own companies.

    You both are extremely successful and well‑respected in your fields. I think it's amazing. A lot of our audience today are women clinicians. Can you give us some advice, as women leaders in the field, that you want to share with them, Chris?

    Christiane: What I would just say is that, find something that you're passionate about it and just go for it. Just put your heart into it. If you do that, everything else is going to come naturally. That's all I can think. Just really follow your heart, follow your passion.

    Particularly, when you talk about patient care, if there's an area that you are passionate about it, just do that and then everything else is just going to just come naturally.

    Ellen: You have to realize that as women and as physical therapists, we're caregivers and we don't take care of ourselves. I'm guilty. [laughs] I really think it's so important to take care of ourselves.

    You need to find time to have coffee with somebody, to zoom with someone at night, have a glass of wine on zoom with someone. If you can't meet with them, because you've got to stay there because your kids are little or you're taking care of your parents. I did both.

    I had kids and parents that I was taking care of, and we're really bad at not taking care of ourselves. Schedule a date to go get a mani‑pedi, whatever it is, but you really have to.

    I, personally, just started back, taking up tennis. I gave it up the whole time during my career and with my family and I had been really active playing tennis, and I am having a blast playing tennis and it's like, wow, there is life out there. You have to do those things.

    Jaspal: I think we're out of time, but I want to say to both of you, thank you for all you do for everybody and not just for recording today's podcast and spending the time with us with our audience, but also for the heavy lifting everyday, pun intended.

    On behalf of Consultant360, we thank our guests, Ellen Hillegass and Christine Perme, for being wonderful and inspirational role models for everybody. Thank you everybody, have a wonderful rest of the day

    Ellen: Thanks for having us.

    Christine: Thanks for having me.