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
Balancing Risk And Recovery In Neurotrauma Care with Andrea Christmas and Tatum Michael
We walk through the physiotherapy approach to traumatic brain injury in ICU, from neuroprotection and ICP thresholds to respiratory care, tracheostomy weaning, and safe early mobility. A real case shows how curiosity, teamwork, and measured risk move recovery forward. If this helped sharpen your neurotrauma instincts, follow the show, share it with a colleague, and leave a review with the one strategy you’ll try this week. 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. Welcome to our listeners. Today's episode of Physiotherapy Trauma Talks deals with the management of patients with traumatic brain injury. And with me are two returning guests, Tatum Michael and Andrea Christmas from the Mole Park Hospital Trauma Intensive Care Unit. Andrea and Tatum, thank you for joining me for this discussion today.
SPEAKER_00:Thanks for having us again, prof. Thanks, Prof.
SPEAKER_02:So we know that traumatic brain injuries are commonly encountered in the trauma ICU as a result of road traffic accidents. But are there any other causes of traumatic brain injury that you also see in your unit?
SPEAKER_01:Most commonly we see blunt force trauma to the head, and the mostly caused by your motor vehicle crashes, your pedestrian vehicle crashes, motorbike crashes, as well as rock falls in the mine. Some falls from heights, so your industrial accidents, such as those patients that are working on a construction site, so falling from quite a high height of three to ten meters high. And then your assaults, also blunt force trauma, and then the older population who tend to fall either on the same level or just a few stairs down.
SPEAKER_02:And what type of brain injuries do they present with? Is it mostly subdural hematoma or do you see other types as well?
SPEAKER_00:We basically see both open and closed injuries, prof, also focal injuries, which result in epidural hemorrhages, subarachnoid as well as subdural hemorrhages. And then we also see diffuse injuries resulting in diffuse axonal injuries. And these are normally more severe and generally have poorer outcomes in prognosis.
SPEAKER_02:Okay. So quite a variety of uh severity of traumatic brain injury that you see then. We know that there's often discussion about primary injury and secondary injury after trauma to the brain. And the primary injury refers mostly to the direct mechanical damage that's caused to the brain at the time of the accident or assault, with secondary injury being the delayed non-mechanical damage to the brain that develops over hours or days after the primary injury. And in this context, people always talk about trying to control the intracranial pressure to ensure that there's optimal blood supply to the brain during this acute period after injury. What is the management strategies in your unit to try and curb the secondary injuries as a result of hypoxia, for instance, that could develop over the hours or days after the primary injury?
SPEAKER_01:In our unit, we usually follow a neuroprotective protocol or ICP management protocol, and that includes keeping the head of the bed elevated at 30 degrees with the patient fully sedated. We would also follow low pressure ventilation called neuroprotective ventilation, where we would ensure that the PAO2, your partial pressure of oxygen, is kept between 80 to 100 milligrams of mercury. And then your PCO2 would be between 35 and 45. Then we would also ensure that the ICP stays less than 20, as well as your cerebral perfusion pressure, no greater than 60. But then that will also be determined by your map, which would we would like to keep between 80 to 85 millimeters of mercury. There's also use of manitol, which is your hypoosmolotherapy to manage your cerebral edema, which also aids in lowering your ICP. And normally they prescribe it as 100 moles every six hours. And then should the blood pressure drop, then they would stop the manitol. And then the other thing is also keeping the patient within a normal temperature, which would also be below 37.4. And they may use paracetamol to help with a temperature that may be rising. And they would also ensure normal glandcemia.
SPEAKER_02:Okay. I just want to come back to the point that you made about the positioning of the patient. So you said trying to maintain the head of the bed up to 30 degrees. Is there any rule regarding having to keep the head in the midline or is positioning into side flexion of the neck permitted?
SPEAKER_01:Definitely we would keep the head in neutral. So obviously, with nursing staff, we would also educate them about maintaining a neutral spine, making sure that there's no flexion or extension or lateral flexion, because we know that that also affects blood flow to the brain. So sometimes we do have an accompaniment of a C-spine injury, and those patients are managed in a Miami J collar. So making sure that the collar is applied correctly, not causing any pressure in the neck, but then also that it is fitted correctly so that the head is in neutral, the chin is positioned well, also just to prevent later on your complications of pressure sores and that. But definitely keeping the head in neutral and the head of bed up at 30 degrees.
SPEAKER_02:Yes. And I suppose it would also then be very important when you turn the patient into sideline that that neutral head position is maintained in the sideline position as well.
SPEAKER_01:Yes, prof. Definitely keeping head in midline. So we would probably put a towel next to the ear just to maintain that midline with rolling for patient care or for treatment.
SPEAKER_02:Okay. And then I take it from the values that you shared with us earlier that ICP monitoring is done in your unit. What devices, what monitoring devices is used for that?
SPEAKER_00:So, prof, we generally use the ICP, the ICP monitor, and the ICP monitor will measure your ICP level as well as your CPP. And it's inserted by the neurosurgeon once they have diagnosed or seen on the scan that there is an increase in intercranial pressure. And like Andrea said, ideally we want the ICP less than 20 and your CPP between 60 to 80.
SPEAKER_02:Okay. Thank you for that. During this acute phase of the patient's admission into the ICU, where the focus is really on trying to control the ICP, what is your physiotherapy policy regarding treatment of these patients that have a higher ICP?
SPEAKER_00:So, Prof. Patients with a high ICP, you know, we need to really monitor very carefully. We would start off by checking their ICP and their value. And should it be higher than 20, we don't touch the patient. Generally, the patients are on quite a high dose of sedation and also on inotropic support to keep the blood pressure and obviously the cerebral perfusion pressure maintained. So we would then check the ICP and together with the ICP, the vitals. If the ICP is lowered by a bolus of sedation and the patient reacts well to the sedation, then we would ask the nurse to give a bolus of sedation prior to treatment. We would then assess at the bedside what happens to the ICP. And should it lower and be maintained below 20, then we will initiate the treatment. We obviously will check pupils as well initially, during the treatment, after the initial suction, and then after post the treatment. So it's a very step-by-step and slow process because obviously these patients are very dynamic. It's changing all the time. So, you know, we we need to do we just with a touch or handling or even auscultation, the ICP can rise. So it's very touch and go. And, you know, sometimes we'll do one suction and the ICP will shoot up and it will stay elevated. So therefore, this the treatment will cease. Sometimes it shoots up and it almost immediately drops back down below 20. We will assess the patient, assess pupils again, assess vitals, and continue like that whilst keeping the head of bed and all the precautions that Andrea had mentioned earlier, still keeping those intact and following those precautions.
SPEAKER_02:Okay, no, that's wonderful. And I suppose from a physiotherapy point of view, our role in that acute phase is really to assess and see what happens with the ICP, as you mentioned, but also to try and identify patients who have an increase in ICP as a result of pulmonary complications, such as, for instance, someone that aspirated at the time of the accident and now presents with an ammonia and becomes productive with secretions, and also those that may have aspirated and developed lung volume loss because of the vomit that has obstructed some of the airways. And it's important to understand how those pulmonary complications may impact on the ICP, and that in those cases it is really important that we step in and try and clear the obstructions from the airways, together with all these precautionary measures that you've mentioned to try and then clear the secretions or the vomit from the airways to see if it has an impact on lowering the ICP. So I think in this acute phase, definitely the first 72 hours or maybe a day or so longer than that, it's really important to weigh the benefits of physiotherapy intervention to address the respiratory system with the risks associated with sustained increases in the ICP. So, yeah, I thank you for that explanation that you offered, Tatum. So, in which cases would surgery be indicated for patients with traumatic brain injury in your unit?
SPEAKER_01:Initially, when our patients come in, they all go for a PAN scan, a CT pan scan, which is a full-body scan, just to see where all the injuries are. And if there's a suspicion for trauma to the head, a CT brain is performed to accurately diagnose the extent of the head injury, as well as to plan the management thereof, which is then performed by the neurosurgeon. And then if it is a severe head injury and they need to release the pressure or decompress, they would do an emergency craniotomy, which would just be to cut open into the skull, or they would do a decompression craniectomy, where they would remove a segment of the skull. So this may be needed to be performed to alleviate the pressure in the brain and then allow for swelling to reduce. And then at a later stage, once a patient is much more stable and hopefully off-ventilation and in a rehab phase, a cranioplasty may be performed where the bone is replaced, or they may make one for the patient out of biochemical material, this will be suitable. But most of the time the bone is kept in theater. I have seen a patient who's actually had a bone kept within their body in their pelvic region, just to maintain perfusion in that of the bone.
SPEAKER_02:Wow, that's fascinating. So in the case of the decompression craniectomy, when those patients come from theatre back into ICU, what would your precautions be regarding positioning of the patient, especially with a part of the skull having been removed?
SPEAKER_01:So usually they do put a sticker or a soft cloth dressing over the area just to say no bone, and that's replaced every day to remind all the staff that that area is quite sensitive and it shouldn't be touched at all. So also just to remind our nursing staff with turning, as much as bed, bathing, and cleaning is a priority, we need to make sure that there isn't any pressure over the area where there's no bone. Um so just to also remind the nurses to turn on to the opposite side to avoid to avoid any pressure on that area. But there is normally a sticker that says in capital letters no bone.
SPEAKER_02:Yeah, and I suppose it's very important not to have any pressure on that area at all. So it's great that it's labeled clearly so that everyone involved with patient care knows. Um so we touched a little bit earlier on the respiratory system management of patients with traumatic brain injury when we talked about that very acute phase after admission into ICU? If we now think of the patient who has now become a little bit more stable with regard to their ICP, and you've got more leeway to intervene to try and prevent complications in the pulmonary system. What is your approach to management? Um, what type of interventions do you find work well?
SPEAKER_00:So, Prof, as mentioned, um, you know, initially when they first come in, we would abide by the neuroprotective measures. And obviously, as I said before, handling is quite minimal, maintaining the head of the bed at 30 degrees during the treatment session for at least those first 48 to 72 hours, performing secretion clearance techniques such as manual chest physio, suction, and MHI, provided they're stable, the vents tectins are stable and they don't have an ICP monitor in situ. And obviously, then also maintenance and restoring of passive ROM of all limbs, and then initiation of early mobility programs. Obviously, this would be then when the patient is stable. Now the ICP monitor is potentially removed. The repeat and control CTBs are clear, or there's improvement and only a residual bleed or there's resolve bleed of the initial bleed on admission. And the patient is then extubated or has a tracheostomy, and we would start sitting over the edge of the bed, standing, mobilizing as the patient presents. But obviously, remembering now that we're dealing with a traumatic brain injury patient. So we would need to take into consideration the different areas of the brain that were injured and how these patients would then present, which would then give us a bit more, you know, we would need to be a bit more cautious, take into consideration the precautions a little bit more when we are mobilizing them away from the bed in terms of safety.
SPEAKER_02:So the precautions that you mentioned just now, would that be related to their cognitive function? So whether they can understand instructions and things like that, or did you have anything else in mind as well?
SPEAKER_00:Yes, definitely. I would say cognition. Um, and a lot of them can be quite temperamental. And uh, if you say sit over the edge of the bed and they are they following that command and do they follow it in the first instance, and then do they change and you know automatically stand up on their own or lay back down on their own and they still have a tracheostomy still connected to the ventilator, you know, you need to, with all patients, obviously, precautions and safety is is paramount and important. But because we're dealing with the brain and different areas of the brain presenting differently, we need to take into account that and and be a little bit more careful, you know.
SPEAKER_02:Yeah, so I suppose initially it would be really important to have someone someone else there with you when you're starting to do all the transfer activities out of bed and starting to mobilize for these reasons that you've mentioned. Yeah.
SPEAKER_00:Yes, definitely. We're lucky to have a very good working relationship with our nurses. So we do help them with pressure care and help them to turn patients. As Andrea mentioned earlier, uh, we also give education about turning and pressure care, et cetera. And then they help us with mobilization. But when it's the early phases and when a patient is still when we would sit them for the first time, for example, or stand them or try and mobilize them for the first time, we would generally do it with the nurse as well as with another physio. And the nurse would generally push the oxygen or just be there at the back, and then the two physios would be more hands-on. And um, yeah, it definitely helps. And then as the patient progresses and improves, then we obviously give less assistance and then we can do things more with the nursing staff, and they really appreciate it as well because they learn and they learn handling techniques from us as well. So it's a very nice interprofessional approach to treating the patient. Yeah, that's wonderful.
SPEAKER_02:And um, do you have occupational therapists that work in your unit uh with these type of patients?
SPEAKER_01:Yes, probably. Yes. Yes, we do have OTs as well. Um, they focus a lot on the cognition as well as upper motor um upper limb function. Um so we do have a variety of MDT input with regards to these patients, um, as well as your speech therapists, um, your social workers, your psychologists. So we have a broad variety of MDT input into this patient's recovery.
SPEAKER_02:That's that's great. Taitum, you mentioned earlier that many of these patients end up having a tracheostomy. What is the policy in your unit regarding tracheostomy care in the sense of who is involved and what would their roles be?
SPEAKER_00:Yes, prof. Um together with the nurses, we ensure that trache is done daily to prevent any infections at the site of the stoma. So we would clean it daily with saline and gauze, and if needed, a sponge-type dressing, like an aloe vein or something, maybe used around cut um appropriately or into the correct shape and size, and inserted just around the trachea and around the stoma. And we do notice also with head injuries that they do have, as you also mentioned earlier, prof, that they do have increased secretions and they sticky, they thick, and the stoma does tend to, sometimes the stoma may be a little bit bigger and they can leak out of the stoma. So the trachecare is very important. And obviously it doesn't stop there, you know, even when they fenestrate it and they have a fenestrated trachee in, then obviously the trache is probably even more important then because we sometimes spigot them with a cap, and um, it's very important to clean that inner tube out so as to prevent the tube blocking and just maintaining a patent airway.
SPEAKER_02:Okay, so the trachecare happens on a daily basis. And um in cases where patients have very thick and sticky secretions, uh, do you use nebulization um to try and loosen the secretions?
SPEAKER_00:Yes, we would use nebulization. We would use a saline neb or otherwise a um salbutamol or a butoneb kind of thing. And then if we are really struggling with the secretions and we do need a little bit of a pharmacological input, then we can speak to the trauma surgeon or physician attending and just ask them to prescribe a mucolytic type of agent such as ACC200.
SPEAKER_02:Okay. Um, Andrea, you mentioned um a little while ago that the speech and language therapists also deliver service to your trauma ICU. What is their role in management of a patient with a tracheostomy?
SPEAKER_01:So the speech therapists in our unit are quite involved with aiding, weaning from the ventilation and as well as swallowing and language therapy, obviously. Um, they frequently do cuff deflation trials once the patient's ventilation has been weaned. They would deflate them for 10 to 20 minutes, depending on how the patient is coping, and then assessing their swallow to assess if they are at risk of aspiration. And as of late, we've been using tracheostomies that have a suction aid, so it's just a suction mechanism that's above the cuff, and then depending on how much secretions you are able to get from the syringe via that device or that um pathway, it will tell you if this patient is at risk of aspiration. So if you get quite a lot, then we know that they're not able to manage their secretions well. And then if they do blue dye testing as well, so should we be able should we be getting blue um stained secretions, we know that this patient is at risk of aspiration. And sometimes it doesn't happen immediately, it may be 20, 30 minutes later after the speech therapist has been, and then the nurse would notice also we may have already seen the patient in the morning, and then the following day we get a bit of blue tinged secretions, and we know that this patient is at risk of aspiration. We know that they have a lot more secretion load. Um, they do struggle sometimes if they have cranial nerve input to swallow or manage the load with um swallowing secretions as well as whatever they've been given. Either it's they would normally start with a thickened fluid, either a yogurt, a blue-stained yogurt. Um, and then once the patient's a bit stronger in that regard, then they move on to fluid and see if they manage to drink water or sparkling water or whatnot. And then they would also give us an indication about the strength of their swallowing technique, and then from our side, depending on secretion load from the chest, we'll be able to determine if this patient is suitable for fenestration, if their cough is strong enough, um, and obviously if they're able to follow command in that with coughing and clearing their secretions well enough. So to aid um swallowing, and then obviously if they had language difficulties, they would be intervening regarding language and communication.
SPEAKER_02:Okay. And um, just to maybe clarify to our listeners, what do you mean with fenestrated tracheostomy? And what would the benefit of that be over a normal tracheostomy tube with a cuff?
SPEAKER_01:So a normal cuff tube is one that's used for ventilation. So you have a sealed outer lumen of the trachea. Um, and obviously for long-term ventilation, they choose to do tracheostomies for these patients. Once they are suitable and they're able to be weaned on a lower ventilation setting, i.e., your wall CPAP, then a fenestrated trachea would be used. And the difference between the two is that the fenestration has fenestrations, i.e., holes in the outer lumen, as well as an inner lumen tube that you would place in that also has fenestrations. You can also get a cuffed fenestrated trachee. And sometimes the speech therapist suggests that if the patient is at risk of aspiration, so at least then if we needed to place the patient back on ventilation, we could inflate the cuff and place a sealed inner tube into the outer lumen that has the fenestrations, and then that would basically seal that trachee for ventilation purposes. And so once the patient is weanable, they're able to maintain their airway. We would then fenestrate them, place them on nasal cannular oxygen, and then spigot the trachea. So then they are able to manage their upper airway, breathe via the upper airway, cough and clear via their mouth. We would still have access to the trachee in case we needed to suction them. Um, if they were at risk of occluding that airway, we would have access to that inner tube to monitor what's happening on that inner tube if they are at risk of occlusion. So you get a fenestrated cuffed trachee, and you also just get a normal fenestrated trache. It is also downsized. So initially, when the tracheostomy is placed in, they would choose a size nine, depending on the size of the patient, and that would be a cuff tube. And then once we do the fenestration, we would downsize them to a size seven. And if it's a very small person, maybe a size six, the only risk is that the size six is quite small, the inner lumen is quite small, so more at risk of occlusion. But on average, we use a size seven, and we prefer the the Portex brand, and so that's what we normally use in our unit.
SPEAKER_02:Okay, thank you for that lovely explanation. So, at what point would you decide with the other members of the trauma team that it's safe to decannulate the patient? So to take the tracheostomy out completely?
SPEAKER_00:Generally, we look at a few factors for this. So if the patient is fully awake, they are following commands, they are coughing up the secretions on their own and clearing the secretions independently. That when we do do an assessment suction, there are minimal to no secretions and they don't require frequent suctioning because the load of secretions has obviously gotten much better, because we are now hoping at this stage that the patient is mobilizing a lot more. And obviously, we know with mobility improves our respiratory system and our secretion load. Generally, also sometimes the doctors or the surgeons, if the patient still needs to go into theater, they prefer to keep the trachee in. If theater is finished and the doctors are happy as well, then as a team, together with the speech therapists, the doctors as and us, if we are all happy, then we decannulate the patient. We dress it with gauze and soft cloth, and that stoma just uh slowly closes over a few days, and eventually you don't need to dress it anymore.
SPEAKER_02:Okay. Yeah, I know that all makes uh very good sense. I'm sure the listeners have realized that patients with traumatic brain injury often have a longer stay in the intensive care unit and on the hospital wards as a result of the severity of the injury. So, from your perspective, do you follow the patients after discharge or do they tend to go to a rehabilitation facility directly from your hospital?
SPEAKER_01:So usually patients get stepped down to the high care part of the ICU. Unlikely that they would be moved into the general ward at the acute phase. But all our patients then get transferred to the rehab, which is news, usually net care rehab. Depends on their funder as well and where they live. But majority of them, if they are Joe Burg, they go to net care rehab. And then they would at least be closer to their home if they went to a rehab closer to their home. Their family would be able to visit them. So in our regard, we would then write a referral document to give to the patient on discharge, and then we would state the mechanism of injury, the injury sustained, any surgical or medical management that happened at the hospital, and then obviously the current physical state from a respiratory and a musculoskeletal aspect. Um, just so they have a baseline to work from and to continue the rehab at the rehab facility.
SPEAKER_02:Okay, great. So, Andrea, I know that you've mentioned to me before the recording started that there's a success story of one of your patients that you'd like to share with our listeners. Um, please go ahead and tell them what you'd like to share.
SPEAKER_01:Thanks, Prof. Uh, yes, we had a very interesting case which gave us a few gray hairs. She presented quite interestingly because of her hemodynamics that we weren't really used to in a head injury patient. Um, she was a foreign national from Italy. She was in South Africa, I think Lumpopo, on a program where she was doing her postgraduate studies, I think in animal studies. And she was a backseat passenger in a backseat of a bucky, so backseat passenger, but in essence, she was at the back of a bucky where she was involved in an MVC and uh was under strained, obviously, and then on scene her GCS was 10. So she was flown to us by Heli and she was then intubated because of her low GCS. Um, she sustained a subarachnoid hemorrhage, cerebral edema with a raised ICP. She had an abrasion on her left eyelid, she also had a C-spine injuries as well as rib fractures and her right fibular fracture. So initially her ICP was well managed, definitely below 20, and she had that in for about a week and a half. Subsequently, after her ICP removal, she started having elevated heart rates. So her heart rate would range between 130 to 170 at rest. So obviously, as a physio, you do know that you probably shouldn't be touching this person, but you need to figure out why her heart rate is so elevated. So is it because she's restless? Is she in pain? Um, thankfully, she didn't understand English, but she was very restless in bed, um, despite the sedation that she was given. So we obviously discussed it with the neurosurgeon. They had repeated scans and they had found that she had pontine edema that apparently was the cause for her having this persistent tachycardia. He said, Yeah, it was very interesting because your heart rate's also beating very fast, and you're thinking, no, I shouldn't actually be touching you at all. Um so her ICP was well managed, we managed to get the ICP out. She eventually had a tracheostomy, her fibula was also fixed, and then it was just this persistent heart rate. So once she eventually settled, we would work with heart rates between 130 to 140 and slowly start mobilizing her from that point. So working on her balance, which was quite, she was quite all over the place. She did end up with a pressure sore on the back of her head and on her right ankle because of the moon booth that was kept on. Um, so that was removed, that was also deprived. So that's actually what kept her in hospital longer than she needed because of the wound management later on when she was mobile. And then towards the end of her stay, she obviously got repatriated back to Italy. She remembered everything. She remembered what she was here for. She remembered she was here with her fiance at the time. Um but she was able to have good memory recall from prior to the accident. She ended up walking with a walking frame. Um, quite an anxious person, but she was determined to get better. So I think her anxiety also just added to the heart rate eventually, but successfully discharged about two, yeah, just less than two months that she was working. Us, yeah, eventually left walking with one crutch. Sorry, apologies, one crutch and a moon boot. That's our story, but it was a very rewarding time with her.
SPEAKER_02:I'm sure. What I like about your story is the fact that you didn't hesitate to investigate further uh what was happening with her heart rate, what were the causes of this high resting heart rate level, and to very gradually introduce physiotherapy rehabilitation within her abnormal heart rate range to see that that was safe in the end, where I think people who are new to the field may feel quite intimidated by how she presented and may not have been as active in finding a solution and discussing with the team what would be safe and what not. And I think it's really important that that discussion with the team happens so that everybody knows what the goals of rehabilitation are and how it can safely be achieved. So thank you so much for sharing that. As we come to the end of our discussion, I would just like to give you some opportunity to share some last thoughts, maybe, if you have, especially with our junior listeners who may not be so familiar with managing patients with traumatic brain injury.
SPEAKER_01:I think from my side, Prof, I think working with head injuries are, initially when they are in the acute phase and they are quite touch and go, it's important to be patient. As much as we have come in with our plan that we're going to do chest physician, we're going to suction, we're going to turn. You will learn very quickly that you cannot go in with your own agendas, should I say. But also that the journey is very long. You need to be patient, but also it's a journey of hope. You definitely are able to see patients that recover very well. I think if you're younger, you do have age on your side and you see that they recover much quicker. But it is something that you need to just go back to the basics of knowing what your normals are and what you're aiming to achieve for your session or have goal setting. And also just to find someone that you're able to trust and bounce ideas off to be like, what do you think about this? Am I doing this? Am I thinking in the right um line of thought? But it does take time and we aren't God, and only God knows what the long-term recovery is for these patients. It may look a bit daunting initially that they may not recover. But we have many a story where patients do walk out of ICU and it's very rewarding. So just to stay the course and persevere. Thank you, Andrea.
SPEAKER_02:Any last thoughts from you, Tatum?
SPEAKER_00:Yes, agree fully with what Andrea said, prof. And like we mentioned earlier, you know, it's about weighing up the benefit versus the risk, and sometimes less is more, especially initially with them, because they are generally quite unstable. And you will see your progress and you will see the patient's progress, and you will have the time to do what you want to do. But it does, it takes time and it's a step-by-step process, and they're not as scary. Well, the monitors and the ICP is not as scary as it looks. But yes, we have seen some very high ICPs, and you know, you need to just you need to investigate and and see what is causing the high ICP. And if it is because of secretions, then you need to treat it, but also you need to be careful and you need to trust your gut and you need to respect the patient and respect what the patient is presenting as clinically. And yes, it will all come together and clinical reasoning and experience, it will all come with experience.
SPEAKER_02:Thank you so much. Um, I think the message that we can take away from what both of you have shared today is that the physiotherapy involvement with these patients is a journey of hope. Initially, less can be more if we are thinking about protection of the intracranial pressure. It's a step-by-step journey, it doesn't happen quickly. And ultimately, we are not God, and we also need to realize that we should just do our best in managing these patients, but the ultimate outcome is decided by someone else. So thank you so much to both of you for your very valuable um contribution to this discussion. I truly appreciate your time.
SPEAKER_00:Thanks, Prof. Thank you, Prof. Thanks for having us.
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