“Just as we rose to the occasion during the polio epidemic, I believe we have another watershed moment at our doorstep to help rehabilitate a world challenged by Covid-19.”
There is no doubt that the entire world has been impacted by the spread of coronavirus, and the subsequent disease Covid-19. This current pandemic is an unprecedented event that has caused widespread suffering, strain on the healthcare system, and financial hardship for the millions out of work. My heart goes out to those who are sick, have lost loved ones, are tirelessly working the front lines, are struggling to care for their families, and those who are dealing with the mental anguish of isolation. The uncertainty of society’s present situation is dwarfed by the uncertainty of the future. When can I see my family? When will I go back to work? When will things return to normal? These are the questions on everyone’s mind, and we share the mindset of anxiety regarding what comes next.
I live and work in northeastern New Jersey, which was considered one of the first “hot spots” since the pandemic reached American soil. Just a month ago, I was a private practice outpatient PT specializing in orthopedics and athletic injuries. Since my clinic is inside a gym, we were forced to close when New Jersey mandated the closure of fitness centers in early March. It was my first time being out of work in my entire career, coupled with my husband being activated by the National Guard in the same week. The life changes were as rapid as they were severe.
In the coming weeks, I started to see people that I know personally become diagnosed and go through the arduous process of battling Covid-19. I felt shame for sitting on the sidelines as other physical therapists continued to help people despite the risk of infection, and seeing everyday the number of cases and deaths on the news increase. My husband’s guard unit was tasked with assembling field hospitals that were meant to absorb overflow from the surrounding hospitals that were already at capacity. When I saw the ad looking for medical personnel for the field hospitals, I found an opportunity to become part of the team.
We all learn about different settings and specialties in PT school. I had rotations in inpatient and acute care. Aside from having to dig out my scrubs, I was ready to go. However, transitioning to an environment where all of the patients are recovering from Covid-19 is a different animal. This is a disease that the medical community has never seen before and the research is just starting. On top of that, many of the patients that require hospitalizations have complicating comorbidities that also need to be considered. In the future, we also will have a demand coming in outpatient to rehabilitate this deconditioned population. Before I dive into my own experiences, let’s start with the basics.
What is Coronavirus?
Coronaviruses are within a category of viruses that can cause illness. The specific coronavirus we face today, severe acute respiratory syndrome-corona virus-2 (SARS-CoV-2), surfaced in late 2019. Therefore, the disease associated with this virus is termed Covid-19. According to the Centers for Disease Control (CDC), the main symptoms of Covid-19 are fever, cough, and shortness of breath. There are other less common symptoms, but these three are used most frequently for differential diagnosis from other conditions such as allergies or flu. Transmission is considered to be mainly droplet spread and/or direct contact with an infected person.
However, particles can remain suspended in the air for up to three hours. It is considered highly contagious, and symptoms typically occur between 2-14 days after exposure. The relatively long period of time a person can remain asymptomatic demonstrates the need for the current CDC recommendations of social distancing, frequent hand washing, and the wearing of face masks when in public. Out of reported cases, approximately 80% are mild to moderate and do not require hospitalization, 15% of cases lead to hospitalization for treatment, and the most severe 5% of cases require a stay in an intensive care unit. The most common complications that lead to hospitalization include pneumonia, acute respiratory distress disorder, and sepsis.
What are current recommendations for physical therapy facilities?
There is a heated debate going in the physical therapy community. Is the risk of coronavirus exposure worth the benefits of physical therapy? Physical therapy offices, including outpatient, for the most part have been considered essential businesses in this process. The APTA recommends that clinicians abide by all CDC guidelines to minimize risk of exposure. This may include limiting the number of patients per hour, supplying personal protective equipment (PPE), and practicing meticulous sanitation protocols. As per the APTA statement on Covid-19, each clinician is expected to use their best judgement on a case by case basis of “when, where, and how” patients should receive physical therapy treatment. Factors in decision making include:
- Age: Older adults are at a higher risk of disease.
- Presence of comorbidities: Patients that have underlying chronic disease, especially respiratory illnesses, are also at a higher risk.
- Type of injury: In some cases, non urgent care can be postponed to a later date.
- Telehealth: Does the patient have access to remote communication?
- Covid Screening: The patient should be asked if he or she has symptoms, if they have traveled to a high risk area, or if there has been known exposure.
We have a responsibility to make these decisions in the best interest of our patients. The advent of telehealth has provided an alternative to traditional physical therapy sessions. Many providers are adopting remote treatment strategies to reduce the risk of exposure for patients. This is an area that is still developing in our industry, but the high demand for online treatment due to social distancing will be a driver to grow this type of service. Physical therapy can still be a significant presence for non-Covid-19 patients during this era thanks to telehealth.
What are guidelines for treating Covid-19 patients?
- Personal Protective Equipment:
- For suspected and confirmed cases of Covid-19, droplet precautions are used. This includes at minimum use of surgical mask, gown, gloves, and goggles or face shield. For cases that have respiratory involvement, airborne precautions are utilized. This would involve additionally wearing an N95 mask. Other items that are considered are hair covers and shoe covers. It is prudent to review procedures for donning and doffing PPE appropriately.
- Physical Therapy Interventions in the Hospital Setting:
- Range of Motion Exercises (Passive, Active Assisted, or Active) to maintain joint integrity
- Therapeutic Exercises for strength and endurance
- Functional Activities such as bed mobility, sit to stand, transfers, ambulation
- Respiratory Interventions: This includes the active cycle of breathing when the patient is able to participate. However, many patients with Covid-19 present with a dry and non productive cough, so some common respiratory interventions such as percussion and vibration may not be indicated. The treating physician should be consulted in this area.
- Often PTs are part of a proning team which is tasked to turn patients to prone positioning to facilitate improved ventilation. This is determined by the physician and 12-16 hours a day is recommended.
What does my day look like now?
Our facility is a temporary pop up hospital that was built by the New Jersey National Guard and is located in the Meadowlands Expo Center. The maximum capacity is 250 beds, and is meant to take overflow Covid-19 patients from surrounding hospitals. These are patients that have already had an extended stay in the hospital, but require more time to recover and wean off of supplementary oxygen before going home. The goals of the treatments are to build pulmonary capacity, and restore functional ability for safe discharge to home to isolate. Another option that is offered after discharge is the use of a hotel for patients that have to quarantine but there is nowhere in the house to isolate from family members.
There is a multidisciplinary team working with this population. There are physicians, nurses, respiratory therapists, physical therapists, and social workers, all working together to plan treatment for each patient. There are also medical professionals from the military offering support and guidance on the daily hustle of intakes and discharges. None of the civilian health care workers that came to this facility knew each other before they got here. Nevertheless, a fully functioning hospital with systems and procedures was produced in a matter of days. The employees of this hospital are people that actively chose to walk into a Covid-19 environment and make a difference
Personal Protective Equipment
When I arrive for a shift, I first find the station for the personal protective equipment. Anyone who enters the patient area is required to wear an N95 mask and a surgical mask, faceshield, gown, gloves, and booties. Next, I’ll find the therapists from the prior shift to get a report on the census of patients. Then, we set to work treating. I’ll be honest. It does take some creativity to practice in what is essentially a warehouse that was not originally designed to be a hospital. That’s when I draw upon thinking about physical therapy school labs and practicals, where we are tasked to come up with treatments without much equipment in a room. There are always ways to modify the environment to provide quality treatments. It doesn’t have to be glamorous. It just has to get the patient well and home.
I keep a pulse oximeter with me at all times, as oxygen saturation is the vital sign that is the most volatile in Covid-19 recovery. Changes in status can happen quickly, and not with that much activity. I’ve seen patients’ oxygen saturation drop to critical levels just from trying to get out of bed independently. They present severely deconditioned and fatigued. There is a line to walk between pushing to do more while at the same time respecting the patient's energy levels and what the pulse oximeter is reading. There also has to be consideration given to the patients’ underlying conditions, and integrating the patient’s medical history with intervention selection. The progress is slow but not worth rushing due to the respiratory compromise. The most common orders from the physicians are for weaning off of the supplemental oxygen to room air, gaining independent mobility, and gait training so they can be discharged safely.
Mental health & Psychological factors
Another aspect of treatment is considering the mental health and psychosocial factors factors. It is important to know if a patient was intubated or in the intensive care unit, so that he or she can be monitored for signs of delirium or cognitive impairment. These patients have been through significant trauma of being in packed emergency rooms and seeing people around them pass away in the chaos. Many of them have family members that are also diagnosed with Covid-19 and are at different phases of the treatment. Some have even lost loved ones. This population must be approached from a position of compassion and understanding that they have been through some of the worst days of their lives just to get to the point in time when they meet us. There could be scenarios where the home situation is not adequate to go back to for recovery and quarantine, so options must be explored with the social worker.
As a physical therapist, we have an opportunity to be a voice of encouragement and finding solutions in a situation that for patients is both complex and daunting to navigate. In this stage of the pandemic, PTs are the facilitators of safe progressions of functional ability, with the end goal of patient independence and proper discharge planning in collaboration with the health care team. It is definitely an unconventional situation, but as PTs we are equipped to handle it.
But, what comes next?
The current focus of the treatment of Covid-19 is treatment of patients with active infection. The next phase for physical therapists will be management of the post Covid-19 population. There will be patients that need ongoing treatment for deconditioning, fatigue, and pulmonary dysfunction. Not only that, but there is going to be a wave of people that postponed their surgery that will pack surgeons’ schedules. There will be plenty of people that will require therapy due to the lifestyle changes of isolation. There will be people that didn’t finish physical therapy before that want to come back. Telehealth is going to be a new facilitator for reaching more patients. The demand is going to be there for the long term, and we have been tasked with adapting to the changing needs of the public.
In the meantime, the fight against the Covid-19 pandemic continues. It is a tragedy unfolding, but we have a skill set that can help. If you are out of work or had your hours reduced, consider looking into if your state or local hospital system is hiring additional medical personnel. If you are able, PTs are needed. If you are already working in a Covid-19 space, I salute you as one of the many health care heroes that are going to get us through this! Your work is integral to getting more people out of the hospital and back to their families where they belong. Stay safe, everyone.
American Physical Therapy Association. (2020, 3 17). APTA Statement on Patient Care and Practice Management During COVID-19 Outbreak. Retrieved 4 15, 2020, from www.apta.org.
American Physical Therapy Association. (2020, 3 20). Letter From President Dunn on COVID-19 Impact . Retrieved 4 15, 2020, from www.apta.org.
Cascella, M., Rajnik, M., Cuomo, A., Dulebohn, S. C., & Napoli., R. D. (2020). Features, Evaluation and Treatment Coronavirus (COVID-19) . Stat Pearls .
Center for Disease Control. (2020, 3). Coronavirus (Covid-19). Retrieved 4 2020, from CDC Website.
Thoma, P., Baldwin, C., Bissett, B., Boden, I., Gosselink, R., Granger, C., et al. (2020, 3). Physiotherapy Management for COVID-19 in the Acute Hospital Setting: Clinical Practice Recommendations. Journal of Physiotherapy .