Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Acute Spinal Cord Injury with Andrea Christmas and Tatum Michael
In today's episode on acute spinal cord injury, experienced trauma physiotherapists Andrea Christmas and Tatum Michael unpack what effective physiotherapy care looks like under pressure: how to protect a vulnerable spinal cord, keep the lungs open, and set realistic goals that carry patients from ventilation to rehabilitation.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com/2431934/episodes
Book: Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Elien van Aswerchen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. In this episode, we are going to take a closer look at patients with acute spinal cord injuries and how physiotherapists intervene to help these patients during their hospital stay towards recovery. Joining me for the conversation this afternoon are two experienced trauma physiotherapists from Johannesburg, Andrea Christmas and Tatum Michael. Welcome to you both. Thank you. So Tatum, before we get into a deep discussion about the topic, won't you just share with the listeners what brought you to the trauma environment and what stimulates you to continue working in the trauma setting?
SPEAKER_02:Sure. Trauma is something that I think once you're in it, you can't get out of it. Although I do think there's a specific place for a trauma physio. I was actually a student at Mill Park with Moira Wilson, and I applied after my community service, and I got accepted, and I've been there ever since. And you're just constantly learning. It's you can never know enough, you never know at all. You see different patients every single day, and these patients present differently with the same injuries, and you're just constantly learning. It is so um, it's so encouraging because it's not a boring environment at all. And there's kind of like a thirst for knowledge. You just want to know more, you want to do more. And obviously, it's so rewarding because they come in presenting with multiple injuries, and you know, you get them from being ventilated to walking again. So it is just such a rewarding environment, and yeah, I love it. A lot of people think we're mad, and how can we deal with that on a daily basis? But yeah, it's definitely my passion and I love it. That's wonderful, and Andrea?
SPEAKER_01:Hi, Prof. I've been with for the Moira Wilson team since probably since post-HomServe. I located there in 2010. So I've been there at that hospital since then. So the past 15 years have been definitely challenging but rewarding. Um, like Technology said, it takes a specific type of physio to work in an ICU of that environment. It's very high-paced, and I think it's also overstimulatory because it's all your senses that are working, but it's also important for you to remember to, you know, stay grounded in yourself and be calm in a very stressful situation. So I think I do enjoy that adrenaline, um, as much as people think we're crazy for wanting or like the thirst for more. Um, but it's definitely rewarding to see your patients very critical and the day-to-day change that you see that they go, they get better, there's highs, there's lows. But when they come back from rehab and they come back walking and have gained a bit of weight, and they may not remember you fully, or they remember your scrub top, your color, they may not remember your name. But to see them again and you think, sure, you're almost at death's door. And the fact that we work in a multidisciplinary team where there's multiple factors that play a part in making sure that that patient has the best outcome. It's very rewarding to see that you contributed to somebody getting back to society, being back with their family. They may or may not be able to go back to their work specifically, but just to be a functioning human being in society again and just to have that second chance again. It's something that, you know, you just you can give yourself a soft pat on the back to say, sure, I was part of that, and I'm grateful for the fact that I'm able to contribute to so many patients' life on the daily. So yeah, as much as it's we call it the circus every now and then, but we enjoy being at the circus, and I absolutely love trauma because it keeps you on your toes, you never know too much, and we're always learning from each other. So it's we have a good team that we're that we work with, and no matter the the years of experience, we're always learning from the younger staff and and vice versa. So it's definitely stimulatory, it's rewarding, and yeah, we're very grateful to be able to be in this environment and to provide the care that we are able to.
SPEAKER_00:That's really lovely to hear. We know from evidence that exists in South Africa that people with spinal cord injuries uh tend to be younger around the ages of 22 through to 35, 36 years old, and that males tend to be a lot more involved in accidents or sporting injuries that lead to acute spinal cord injury. If you had to think about the population of patients that you see at your hospital, would you say that your demographics fit in with what we know from research that's been published through South African physiotherapists, or is your experience slightly differently regarding patient demographics?
SPEAKER_01:Prof, with regards to your question, I definitely think that it matches the demographic that is currently being published. We definitely see more young males injured with spinal cord injuries. Um we see maybe one in ten, I think, females that get injured with a spinal cord injury, but definitely predominantly male. But yes, definitely matches the demographics of the published data.
SPEAKER_00:And um, the causes of injury is that mostly road traffic accidents, or what other type of causes for acute spinal cord injury do you see, Titan?
SPEAKER_02:Um so because we are level one trauma unit, we do get a wide variety of mechanisms of injuries. And also um, because we see patients who have been injured on duty, specifically sometimes underground in mines due to rock falls. So we see a lot of patients that have been injured because of rock falls on some part of the body, as well as fall from hearts, gunshot wounds, and uh as well as motor vehicle crashes. So it really can range from every from anything, and obviously your low velocity to high velocity impact trauma. So we really do see quite a wide range of injuries from different mechanisms.
SPEAKER_00:Okay, no, thank you for that. Andrea, would you say that you see predominantly cervical spinal cord injuries, or do you see a mix of cervical, thoracic, and lumbar injuries?
SPEAKER_01:I do think the majority of our patient demographic is cervical. Commonly the cervical area, which is your C4, C5, or C5, C6. And we do get your thoracic spinal cord injuries as well as your lumbar spine, but those will be a bit lower down and are often associated with a fractured pelvis or a lower lump fracture. I would say the T12, L1 lesions are not as common as the C spine and T-spine. However, we do see them, they are generally more stable and they do then progress to reactor much earlier than the higher lesions.
SPEAKER_00:Thank you. And also, do you see associated thoracic injuries with the, you know, chest wall injuries, sternal fractures, um, that sort of thing with the thoracic spine injuries?
SPEAKER_01:I would say yes, we do get a lot of them with multiple rib fractures, um, which may or may not have a flail segment, but they are then associated rib fractures with the hemoneothorax. Not as common do we get the sternum fracture, but definitely rib fractures or any lung trauma associated with your thoracic spine injury.
SPEAKER_00:Yeah, and if we think a little bit about complications that occur, we know that at the time of the injury, that instability that occurs at the spinal cord is there due to the mechanism of the injury, but that there's also a risk for developing secondary complications after the spinal cord injury, particularly spinal edema, spinal cord edema, um, and that that can cause the swelling within the spinal cord to rise up to two levels above where the initial injury was, and therefore can compromise the patient's cardiovascular function and their ability to breathe on their own. Um so I was just wondering in your unit, is there a particular protocol that is followed when patients come in with acute spinal cord injury to ensure that whatever you do in the ICU doesn't promote more swelling within the spinal cord? Tatum, if you want to answer that one.
SPEAKER_02:Thanks, Prof. Um, yeah, so there's definitely uh a set protocol that we try and follow, you know, definitely from a medical point of view and obviously also from a physiotherapy point of view. And generally when patients come in, they are either still in head blocks or they are if it's a cervical spinal cord injury or suspect it's cervical spinal cord injury, or they have been immobilized in a in a Miami J collar and they are in a reverse Trendellenberg position and they are still, they could still be awaiting a neurosurgical consult. If the neurosurgeon has consulted and they have assessed that the patient will require surgery, the patient will obviously stay in this reverse Trendellenberg position and they would be for log rolling, for pressure care, etc., if absolutely necessary. Um, a lot of the time, you know, we like you said before, there are other injuries that are that are accompanied with the with the spinal cord injury. So as physios as well as nursing staff and doctors, they need to take all of those into consideration before the neurosurgeon can say, okay, we're going to take this patient into have their spine fused. Obviously, if they are hemodynamically unstable or if there's too much swelling around the area, the neurosurgeons will then opt to wait a little bit for that swelling to subside and obviously for them to become more hemodynamically stable. You know, talking about whether the patients are on inotropes, whether they are ventilating well, if they are ventilated, whether they are stable. And the trauma surgeon will definitely then give the direction or the go-ahead whether the neurosurgeon can then take the patient in for surgery or not. So while we're treating those patients as physios, we'll obviously abide and adhere to whatever they are presenting with, whether they are stable in terms of their vitals, and obviously then to not do anything that will be contraindicated, such as changing their position in bed or putting the head of the bed up, etc. So we need to be aware of all of those things before we can just go ahead and say, okay, the patient needs physio, let's treat the patient.
SPEAKER_00:Okay. And then just to clarify for listeners who may not be aware of the term reverse John Dellenberg position, uh, could you maybe just explain what that means?
SPEAKER_02:Yeah, sure. So basically the the bed is flat, so the patient would be in a in a supine position, but the top of the bed would be tilted upwards. So we're not changing the alignment of the spine, we're just changing the alignment or the tilt of the bed by still keeping the patient in a neutral alignment and that the spine is not malaligned, so to say.
SPEAKER_00:Okay, so that means the patient's head is higher than their feet. Yes, prof. Okay, no, that's that's good. Um so I I suppose one would be interested to see what respiratory complications develop in these patients, and that has a lot to do with the innervation of the nerves that run through the spinal cord. So in patients with complete spinal cord injury and a definite level of injury, one can work out which respiratory muscles are still innovated and which ones are not. And in that way, uh, how much assistance the patient needs with the breathing exercises and their ventilation in the ICU versus someone with an incomplete spinal cord injury that may regain some of the respiratory muscle function. Just from your daily clinical practice, how do you manage patients' respiratory systems and try and prevent any complications from developing? Andrea, would you like to speak to that?
SPEAKER_01:I would say, like you mentioned, with regards to depending on where the injury is. So we do know then obviously your C-spine injuries are likely to have their diaphragm affected, so your C345, your phrenic nerve. Um so those patients usually do struggle with expiratory or expiration function and ability to cough and clear their secretions. So obviously, if they are awaiting spinal fusion or they are bedbound and immobile, they are more likely to accumulate a lot more secretions and struggle with clearing secretion. So daily we would assess their chest with an auscultation, assisting them to cough if need be, so providing a manual assisted cough over the abdomen. Um and then your inspiratory and expiratory techniques, so your ACBT, your active cycle of breathing, your incentive spirometer we use. If they do have secretions within the chest, then we would do your manual chest therapy of percussions via shaking. Obviously, if it's not contraindicated, if they didn't have any associated rib fractures or if there was any contraindication with regarding manual techniques, but more of making sure that that patient's chests are maintained to be clear, improving their lung volumes. Um, and if it's a lower-down injury, obviously the abdominal muscles are also affected. So the expiratory muscle function isn't great with regards to their respiratory system. So improving or preventing lung volume loss, but also aiding secretion retention, so assisting with the secretion retention for the patients with the highest C-spine injury. Then obviously changing of position, provided that it's not contraindicated, so alternate sideline and treating them in sideline as necessary. And then we always aim to mobilize our patients as soon as they are hydrodynamically stable, and it allows for us to do that. So getting them to start sitting on the edge of the bed, mobilizing them to the chair, and doing these exercises in an upright position to allow for bits of insulation. We do find that patients that are mechanically ventilated, specifically the ones with quadrategia, become very productive with an increased secretion retention. And this is because of their neurology, the weakness in the paralysis of their muscles of inspiration and forced expiration. This often leads to generation of insufficient inspiratory volumes and then a poor peak expiratory flow rate, which then results in the poor cough effort or no cough reflex at all. So therefore, they become a bit more challenging to clear. So then we will provide them with um bid daily physiotherapy to assist in improving their lung volumes and helping them with their cough secretion retention.
SPEAKER_00:Wonderful. And um, I'm glad that you mentioned the body position changes into sideline. And I assume this will be done through log rolling during the time that the spine is still unstable, and the importance of treating the posterior lung segments and trying to clear secretions from those posterior segments, because they tend to accumulate there a lot when the patient is in supine and then lead to things like atelectasis and pneumonia, which we know from clinical experience, but also evidence that has been published that increases the patient's risk of prolonged hospital stay and indeed worsening of their condition. So I'm very glad that you mentioned the position change. I was just wondering whether the use of ambu bagging is something that you would consider for your patients who are intubated and ventilated to help clear secretions and to improve uh lung compliance and improve lung volumes.
SPEAKER_01:Yes, prof, definitely we do use manual hyperinflation quite often, provided that the ventilator settings allow and they're obviously dynamically stable. Um, and we do find it it does give better results. We do do it in combination with our percussions, vibes, and shaking, alternate sideline. And so we do normally tag between two physios um where we do it together, and then we would obviously suction our patient afterwards and then reposition them. But we do often use manual hyperinflation with good effect.
SPEAKER_00:Okay, that's wonderful. Sometimes patients develop bronchospasm, even if they don't have a history of asthma, just because of the level of the lesion, and this is often in patients with a lesion above the level of T6, because that sympathetic control is lost. And therefore, the tone in the patient's airways changes and can often lead to bronchospasm, which has an impact on the patient's ability to clear the secretions from their airways effectively. Um, I was just wondering whether the use of nebulization therapy with bronchodilator agents is part of your protocol in managing such patients?
SPEAKER_02:Yes, Proc. So we would use um bronchodilators. Um, they may not necessarily be prescribed, but if the physio does pick up that there is a problem and we are struggling with secretion retention due to the bronchospasm, we will ask the trauma surgeons or the physicians to um prescribe a bronchodilator, generally like a cell butamol or phenotyol, and then as well as that we, if they are ventilated, the HME device also assists us with that. And then obviously, we will then work on breathing techniques as well as your standard chest physio protocols to try and clear those secretions.
SPEAKER_00:Yeah, and we also know that sometimes patients with acute spinal cord injury in the initial few days after the injury may present with pulmonary edema. Is this a complication that you see often and how would that impact on your physiotherapy management?
SPEAKER_02:Yes, we do see this. It's not very often, but obviously we need to take more of a conservative approach when there is a when there is pulmonary edema present, and we allow then for the medical management to resolve it, obviously by using diuretics and for them to correct the fluid balance. We will then ensure optimal positioning to assist with oxygenation. But then again, whether the spine has been fused or not, and again taking into consideration what's indicated, what's not indicated, and what's going to be contraindicated in the positioning of this patient. Should they be fused yet or not? So we've got to remember all of these things before we try and take an approach, even if it is a conservative approach.
SPEAKER_00:Thank you for that clarification. So if we look at these patients a few weeks after the injury, um, where they're more stable, particularly the patients with spinal cord injury that is a permanent lesion. Do you find that these patients struggle to breathe when you change their body position from a supine to a sitting or a standing position in bed? And how do you deal with that? This would be more appropriate for patients with a cervical complete lesion.
SPEAKER_01:I think, prof, um, we need to look at several factors uh with regards to this when remembering the changes in body position and how that affects your lung volume and your lung capacity. So when a person with outer spinal cord injury moves from a seated to a supine position, their vital capacity then decreases and their inspiratory capacity increases. However, in a quadrupedic patient, movement into a supine position then leads to an increase in their vital capacity and inspiratory capacity, not only because of the increased interthoracic volume, but also due to the effect of gravity on the abdominal context. This is why we find that patients with quadrupedia report less breathlessness and a greater ability to cough in a supine position compared to when they seated. And then, due to the immobility or the lack of mobility, positioning is very important for several reasons. So, firstly, to optimize the VQ matching, then also to prevent secondary complications like pressure ulcers. Quite often, because of the nature of the trauma of the patients, there are other injuries, as mentioned earlier, for example, your fractured ribs with an associated hemorrhothorax. So, not always, but often, do we see that the lungs are being compromised even six weeks post-injury, and they still face challenges with full lung expansion and maintaining these lung volumes. So we try to optimize their positioning by alternating sideline from su spine to sideline with the head of the bed elevated. We try to optimize sitting upright in a chair. Obviously, if they are, if their C-spine is stabilized, we then mobilize them to sit on the edge of the bed. We put them in the chair for one to two hours, we then put them back in bed. But also just to educate the nursing staff as to what is the optimal position for these patients for optimal ventilation and for other reasons for their joint mobility, um, hemodynamic stability, um, just in general, why positioning is a good thing for these kind of patients, um, not only from a respiratory point of view. But it's also then important to remember that an upright sitting position may cause the paradoxical breathing pattern, and this is due to their weak diaphragm and their intercostals. So this is depending on the level of the injury. But if it's a thoracic lumbar spine injury, these patients can generally assist with pressure relief themselves once in the chair. But for a C-spine injury, we need to be cognizant of this patient holistically and their inability to do pressure relief in an upright sitting position and also how this impacts their respiratory function.
SPEAKER_00:Yeah, no, indeed. I was just wondering whether you ever use something like an abdominal binder because of the loss of abdominal tone with these high cervical cord injuries that cause the organs to sort of rest forward in these patients when they're in sitting or standing and then lead to the reduced vital capacity. Would an abdominal binder be a good suggestion for these patients just to try and control the amount of forward protrusion of the organs in the abdominal compartment to assist with breathing?
SPEAKER_02:Yes, prof. So we don't order an abdominal binder routinely. Once we start mobilizing the patients over the edge of the bed and two chair, we see how they react hemodynamically. Generally, we do see, especially when they are the higher cord lesions, such as cervical cord lesions, even thoracic, we see them drop blood pressure, they become bradycardic, so dropping heart rate. And obviously, then they become a little bit unresponsive because they are having that orthostatic hypertension. So ways in which we combat that initially, we try and keep flow tons connected just for blood flow, and we try and um elevate the legs. So if they're on a lazy boy and we see that dropping position, that drop in blood pressure or heart rate once they are seated, we try and elevate the legs and see if that makes a difference. And then also sometimes they may still be on anotropic support. Um, obviously, we keep the anotropes connected depending on the dose and obviously how many anotropes they are on and when was the anotrope started. So obviously, if they had been on for a while, it's a low dose inotrope, it's only one and they are stable on it, we leave it connected for the entire duration of the MOBE. So while we are mobilizing them over the edge of the bed or while we are mobilizing them to the chair. And if that still doesn't help with the blood pressure and with the hemodynamics, and time and time again, so we we do it once, we do it twice. Okay, the patient's not responding to these interventions, then we will order the abdominal binder or the corset. And we really do see a difference in that. It helps the tone, it helps with that reinforcement, and then we do see an improvement in the heart rate and blood pressures, and then they may need it for a while, or they they may get used to sitting over the edge of the bed and um and in a chair for longer periods of time. And as time progresses, they may not need it, or they may need it for a while or the way till they are until they are discharged to rehab. Um, so we do have that option, but we don't pull it in initially. We will get it if our other interventions haven't proven to be successful.
SPEAKER_00:Okay, yeah, so based on individualized patient need.
SPEAKER_02:Yes, definitely, because like we said, you know, I mean, one patient can have the exact injuries as the other, and it really just depends how they present. And you know, you can't say, okay, this is a recipe treatment, it's a C4, C5 complete cervical injury, um, they're gonna need this, they're gonna need this. It really just depends. And it depends on so much, you know, it depends on their premorbid presentation as well as their other injuries that they obtained, you know, whether there was a pelvic fracture or lower limb fractures in addition to the spinal cord injury. We really need to tailor it to each patient and see how each patient presents.
SPEAKER_00:Yeah, no, for sure. Next, I would like to ask about uh pain. Is pain a common complaint of patients with acute spinal cord injuries in your setting, Andrea?
SPEAKER_01:Yes, uh Prof. We do see a lot of those patients complaining specifically a lot about their shoulders, um, and that could just be due to the overactivation of the upper trap muscle for the higher lesions in this V spine injury patient, or from sublaxations due to their glenohumeral joint and the flaccidity of the upper limb, or just poor handling from the nursing staff when turning or shifting the patient up in bed where the shoulder may not be supported adequately. And so those contributing factors are also other contributing factors also tone, um, whether the limb is flaccid or not. But these patients are more prone to these shoulder subfluxations, it also causes further pain. We would then speak to the trauma surgeon about optimizing analgesia, but we also use um techniques like K-TAPE or rigid tape to assist with pain and stability management of the shoulder, as well as education and in-service training to our nursing staff as well as our physio teams for correct handling and turning patients and shifting them. Other complaints that patients may have is from the spasms that they may experience. We do find it quite common in this cohort of patients, and they have been described as very uncomfortable and painful. So generally they are prescribed lyrica, which helps with the neuropathic pain, but also if there's increased tone in their lungs, in their arms or legs, then these patients are more at risk of contractures. So we do then also advocate for Botox at a later stage, should it be indicated, and this will obviously assist with the long-term management of the patient and their rehabilitation.
SPEAKER_00:Okay, that's excellent. So to summarize, it seems like you've got a very uh holistic approach to pain management from pharmacological interventions through to uh typing that you use, as well as education of the nursing staff about how to handle the patient when they move them in and out of bed. Um, so yeah, that sounds like a really holistic and good thought-through process to reduce the patient's discomfort. We mentioned earlier in the discussion that some patients may be at risk of developing uh pressure sores. Um, is there a protocol in your unit, uh, Tatum, to try and prevent the onset of ulcers? Because again, that can prolong the patient's stay in the unit and cause various complications that may impact on their outcome.
SPEAKER_02:Yes, definitely. You know, common complications related to the skin and spinal cord, um, as previously touched on, are the pressure ulcers. And we've we specifically see them over the sacrum, over your greater trichanta, um, the occiput, and even around the areas where the Miami J may be, um, if not checked daily or if the actual collar is not positioned correctly or fitted correctly. So in our unit, we actually obviously turning is very important, and the nurses, you know, we have a very good relationship with our nurses. So we often will do our physiotherapy treatment, we'll turn the patients for pressure relief in the session, um and in turn the nurses will help us with our mobilization of the patients. Also, in our unit specifically, we have two dedicated days where pressure saw or pressure ulcer team, so to say, um, will then go to every single bed in the unit. They will turn the patients and check the patients for these pressure sores. Bi-weekly, so to say, and just make sure that nothing is developing. And should there be something that develops, you know, immediate action is taken. And obviously, then we positioning and is very important. So, for example, the patients will be kept in sideline. We generally put these kind of patients on a ripple mattress from the beginning because of the immobility. And just general, this is where nursing care is very important, but also for us as physios to educate and to give in-service training on this is also very important, you know. And even when we put our patients in the chair and mobilize our patients to the chair, it's important to remember that some of these patients cannot perform pressure relieving techniques, whereas some of them can. So obviously, then education to the patients that can perform it, whether it's a thoracic, a lower-down thoracic, and they still have good upper limb function and they can do pressure relief on themselves. Or if it's a higher up cervical cord injury where they cannot, then obviously we need to be cognizant of the time that the patient is left in the chair. And it should not exceed two hours because we need to remember that a change in position should be happening within every two hours.
SPEAKER_00:Yeah, sure. That is a really comprehensive approach to try to prevent ulcer formation, but also to manage it when it does occur. So I think you've got a wonderful system in place in the hospital that you work in. And it becomes clear through the discussion today that you have got very good communication in your trauma team with the doctors and the nurses and the pressure ulcer team that also visits twice a week? Which other members of the health care team do you often interact with, particularly with continued rehabilitation of the patients on the ward? And when it comes to discharge planning, which other team members are important in these instances to consult?
SPEAKER_01:Hi Prof. We are definitely very lucky or fortunate to work with numerous subspecial specialities in the MDT. So, namely the OT occupational therapists who then assist with edema management of the hands, upper limb function, providing the patient with a universal cuff to use to perform ADLs, and then teaching patients how to get back to those ADLs, the simple techniques of feeding themselves, brushing their hair, brushing their teeth, applying Roland, applying cream. Also cognitive training that they do. So patients that may have an associated head injury, but also the long-term staying patients who have episodes of delirium or discontusion or disorientation, they assist with that. We also have speech therapy. So they also then assist with swallow assessments specifically for your C spine, spinal cord injuries after fusion. So the spelling that had results post-that injury. Also, if they were a long-term patient that had a tracheostomy, then they would be assessing their swallow to see if they're safe for swallowing to start their oral intake, and then also giving us guidance as to when we can fenestrate our patients to remove their and take them off the ventilator, obviously, if once they've been weaned enough and they have a safe enough swallow so they'll be able to manage their secretions well once we've fenestrated the trachea. We also have a team of psychologists and trauma counsellors, and they are involved from the beginning with the patient's family as well as the patient. Obviously, with the family, if the patient is quite sedated and ventilated, but once the patient is then off sedation, awake, and following commands and able to respond, then they would interact with the patient and then provide some psychological support for the patient. And then they would also assist with processing this patient's new normal. So then the social worker would be playing a role with regards to if the patient was involved at the injury at work, addressing their emotional, social, and practical needs to assist the patient and facilitate them to a smooth transition back to work if possible. And this may be in a different role, but within their organization. They also assist the patient with their work payouts and applications for temporary or permanent disability. So we are very fortunate to work in a collaborative team. That's a collaborative effort from all members of the MDT to assist in decreasing the patient's length of stay, improving patient outcomes as well as their long-term rehabilitation once they leave the ICU.
SPEAKER_00:That's really fantastic to hear the comprehensive care that patients receive after such a traumatic event within your hospital. So, from a physiotherapy point of view, how do you prepare your patients for discharge? Which things are considered and what type of education do you provide to them?
SPEAKER_02:So we start the rehab process as they are able to while still in the acute care unit. Almost all of our spinal cord injury patients are discharged to a rehab facility once they are medically stable and generally on REMAIN. It is here where they continue their rehabilitation process with the MDT. A wheelchair is normally issued to them, specifically measured for them and issued. They generally have home visits for the team to assess how the patient will be able to function at home with this new diagnosis. If by any chance they don't go to rehab due to funding issues, for example, then we will assist with the family. We give them education, caregiver input, as well as assist with organizing a wheelchair from the family's preferred supplier based on our recommendations. We would teach them wheelchair transfers, pressure relief techniques, correct lifting and ergonomics for the family or the caregiver. And where relevant, we'll obviously refer on to a community focus or support group, as well as a physio that can do home visits. So, yeah, basically from day one, rehab starts and we try and do the rehab from the very beginning as much as we can, as much as it is indicated and safe to do so. And then, yes, they are most likely discharged to a rehab facility.
SPEAKER_00:Titan, thank you so much for that. And I want to thank both of you for sharing your experience with our listeners today. It is very clear to me that you are part of a trauma team that cares very much about the patients that you see in the hospital and that you really endeavor to provide individualized patient-based rehabilitation for these patients and in that way try to ensure that they make the best possible recovery. Lastly, I would like to give you the opportunity to share some words of wisdom with junior physiotherapists who may not be so experienced in working with patients with spinal cord injury, just as a form of encouragement. And can I ask Andrea to start?
SPEAKER_01:Like you mentioned, Prof, that it is quite a daunting experience to treat these patients. I think it's when you're treating them not only from a neurological perspective. When you're working in a trauma ICU, you've seen patients with multiple injuries, your polytraumas that have multiple factors that play a role in how you are going to start your rehair process. I think it's important to start small, find the main goal of your treatment of what you want to achieve daily, make small changes daily, and then obviously you need to think of the long-term goal. So it is a long journey that you're going to walk with your patient. It's important for you to always remember that we will live in a society where the patients come from different backgrounds, they have different beliefs. So what information you give them, how you encourage them, how you make yourself relatable to them is also important so that they can trust you because trust is a very big thing. And we always say to our patients, trust me, trust me, I'll only fall. But it's very different when you're on the other side and receiving end where you've never been in a situation like this where you're trusting someone with your life basically. Um so important to develop a relationship with your patient, making sure that they trust that you have the best interest at heart for them, providing something as simple to simple changes every day. Obviously, you're going to be assessing them and treating them holistically, but providing that small changes every day. And as much as it can be quite a daunting experience, it's a long journey that you and your patient will travel together. But there'll be good days, there'll be bad days. But all in all, once the patient leaves and comes back and says thank you very much for what you've done for them, just they'll remember the small things that you did for them as well. So it's important just to remember to persevere, remind yourself that ultimately your goal with the patient is to get them back home to their loved ones and into society. So not to be too hard on yourself, to take it in your stride, do the basics right and all work out. And yes, just to also make sure that you make find a relationship with your patient, make sure to make sure that they trust you and trust yourself that you know the basics and you're going to do the basics right and provide the best care for that patient. But yes, it is a rewarding journey that you will go on with your patient.
SPEAKER_00:Very wise words. Thank you, Andrea. Um, Tatum, any last thoughts from you?
SPEAKER_02:Yes, I think Andrea um summarized that very well. But yes, as she said, it's a daunting experience, but it is very rewarding. And you've got to take every patient as they present. And you need patient buy-in, and you need you need therapist buy-in, and you need to the little the little successes and the the little progression that you see every day, and once they see that, your patient buy-in is much better. And I think if you start off by knowing your basics and you being safe in your treatment, the rest will all follow. And it comes with experience and it comes with patient treatment and seeing different kinds of injuries, and it will all follow after that. And I think the biggest thing, you know, neurological rehab is very rewarding, but it's also very rewarding to take these patients from being ventilated on a very high ventilation setting all the way to free breathing, fenestrated, and then assisting with transfers, sitting in a wheelchair and getting discharged to rehab. So it's a wonderful process. And yeah, I mean, it's difficult at times, and the patient will have difficult days, and so will you. But at the end of the day, it's very rewarding and all worth it.
SPEAKER_00:Thank you so much, Tatum. And yes, I agree with both of you that building that relationship of trust with your patient is very important, and also knowing what is safe to do and what not, and to continue to learn as you walk the journey with the patient. So I want to thank you both for this lovely discussion this afternoon. I appreciate your time and look forward to inviting you to the podcast again in the future. Thank you both. Thanks, Prof. Thank you very much.
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