University of Illinois at Chicago
This week we spent time in Physical Medicine and Rehabilitation (PMnR). PMnR is truly a collaboration of physicians, nurses, and physical and occupational therapists. I walked through the doors to Occupational Therapy (OT) and suddenly I was standing in an apartment — well, sort of. OT’s role is to assist patients with activities of daily living (ADLs). In order to help patients learn how to perform ADLs, they need a bed, sofa, kitchen, laundry machines, etc., all of which are in the OT room.
In addition to the contents of the room, OT’s provide specialized tools to assist patients. These range from special utensils for individuals with tremors to walkers to splints. While many of these are pre-made, they sometimes require modifications to make them user-friendly to the individual patient. For example, the OT often bends the pole of the long sponge to allow patients with limited shoulder flexion to wash their backs. Some of the devices, such as a hand strengthener apparatus, appear cheaply made and often break, yet they cost thousands of dollars. For that price, it’s hard to think that there is no better device on the market, but the better option is more than twice as expensive. Patients that use walkers are limited to clunky accessories, such as tray tables and baskets that don’t fit properly. Improvements would not only help patients with walkers but could also help them feel more comfortable with them. Overall, I was impressed by the number of tools available to assist patients with ADLs but disappointed in their quality and the limited variety.
Ventriculoperitoneal shunts, aka VP shunts, are surgically placed in patients with hydrocephalus, a condition in which there is excess cerebrospinal fluid (CSF) in the brain’s ventricles. Throughout the course of treatment and after recovery, a patient may require different amounts of drainage or none at all. There are two main categories of shunts: non-programmable and programmable. The former come in various sizes, which is selected upon placement. The latter and newer model can be programmed to accommodate various amounts of drainage. It must be programmed at the hospital, and just like a pacemaker, must be reset after MRI.
Although the programmable VP shunt is adjustable, it truly is still static once it is set to a given size. I was surprised to learn there is no dynamic valve that adjusts drainage based on the conditions and has the capacity to determine the optimal size. Both over-draining, which can happen when patients stand up, and under-draining could be harmful to patients but no mechanism exists in VP shunts to prevent this in the dynamic conditions of the body. But “shunt” it? (i.e. Shouldn’t it?)
EEGs, electroencephalograms, are routinely performed on patients with seizures. Sometimes recordings last 20 minutes, other times they last 24 hours. Reading them is tedious. The doctor not only looks for seizures themselves, but also epileptiform activity that is present in patients with epilepsy. These occur sparsely and are not evident to the untrained eye. Watching a couple doctors read through several recordings, I was impressed by how quickly they scrolled through the recording, occasionally stopping if they suspected an abnormal waveform. I couldn’t help but also question whether some were glanced over and missed. Other than adjusting the gain and a few other settings to clean up the waveforms, the program didn’t do much. It didn’t point out where abnormal waves could be. According to the attending, software does exist for that purpose but doesn’t work well due to the variability in shape and waveforms and great amount of noise in the recordings. However, apparently for a given patient, epileptiform waves are usually rather consistent. I can’t help but wonder how to create a more accurate software to increase the sensitivity and speed of reading EEGs.
Probably the most surprising part of Pulmonary and Critical Care was the loss of communication of patients on ventilators. I discussed this and provided some ideas on how to improve communication in a previous blog post. What I didn’t expect was to see the same exact issue on my next rotation, Neurology. The past week, I rotated with the stroke team. Depending on the location of the stroke, patients lost different abilities — perhaps they couldn’t comprehend language, find the right words to say, move parts of their body, or a combination of many deficits. In some cases, there aren’t necessarily tools to assist patients with strokes with communication. However, in cases of expressive aphasia, which is due to damage to Broca’s area, I wonder if providing some tools like those I discussed in my Pulmonary post would be useful. Perhaps a printout of commonly asked questions by patients would help the patient feel less helpless — or maybe they would not be able to use the tool due to the stroke. I witnessed the frustration of patients with expressive aphasia as they tried to speak but couldn’t say the words. They opened their mouths but couldn’t form the words they were thinking of and all I could think of was if there was a way to help the patient communicate.
Although I’ve switched from the lungs to the brain, I am still spending a lot of time in the ICU. Beyond the difficulties in communication between patient and doctor, many of my observations still apply as many of the technologies in the ICU are the same, such as IV pumps. I am excited to see what other similarities and differences I notice in the next couple weeks.
Oftentimes, we ignore the little problems in life — those that seem unequivocal. Some have existing solutions, but we are so used to dealing with them that we don’t even consider using them. But when you add up all those little things that interfere with the flow of the workday, they add up and can cumulatively have a big impact.
The past several weeks, a some “little problems” jumped out at me. First, patients in the clinic were struggling to sit on the exam chair. Although adjustable, even at its lowest height, the chair was too high for many patients. Even I had to hop on and off. As a result, many patients were examined in the chair they were sat in during the medical history. Let’s say the doctor needed to examine the patient lying down, the standard chair would not allow for that. Fortunately, this dilemma could be solved by placing a step-stool in the exam room. Another issue I observed was during the allergy clinic. After applying the allergen extracts on the patient’s arm, the nurse placed the applicator in the Sharps container. Each time was a struggle. The applicator was too large to fit comfortably in the container. An easy solution for this problem exists as well — replace the existing Sharps containers with larger ones in the allergy clinic.
A third problem I observed does not have an existing solution that I am aware of but could be improved from an engineering and design standpoint. The armrests for the beds in the bronchoscopy suite are difficult to attach. Every time we observed procedures and the armrests attempted to be attached, it required several people and time to accomplish the task. Once the mechanism was explained to me, I noticed that it was pretty simple to attach but there were some exposed parts on the arm that made it confusing to a user when looking at the piece. While all three of the problems mentioned seem minor, they all interfere with the flow of the patient’s visit and could be tackled relatively easily.
In most cases, communication between physician and patient is largely through speech. So, when a patient is intubated, is all communication lost? Based on my observations in Pulmonary Critical Care the past several weeks, my answer is almost certainly yes. Sure, the physician can still examine the patient, use vital signs as indicators, and talk to the patient and ask questions, but the patient is almost powerless in responding. Although some patients on ventilators are unresponsive, many are responsive. Over and over, I heard healthcare providers ask patients to nod their heads yes or no to answer, and while some were able to, others could not and tried to communicate with their hands, seemingly unsuccessfully at getting their point across.
This brought me to the question – why aren’t we providing tools to help intubated patients communicate? As one patient tried using small movements of her finger to signal yes or no instead of nodding her head, the medical team kept repeating the same question, unable to understand the answer. I asked a resident if they ever write “Yes” and “No” on a piece of paper and have the patients point to the answer. He said they could try it, and everyone proceeded to exit the room with no answer to “Are you having any pain?” and “Are you breathing comfortably?”
Although this summer program is focused on observations and not on solutions, I can’t help but think of simple ways we could empower patients to be able to communicate. For example, have a board with “Yes” and “No” written that the patient can point to, provide a diagram of a human and ask the patient to point to the area they have pain, provide a printed list of commonly asked questions the patient may like to ask the medical team that the patient could point to. Seemingly simple tools may significantly improve communication and provide the patient with some sense of control instead of what I imagine would be frustration.
Image from https://americannursetoday.com/post-intensive-care-syndrome-what-it-is-and-how-to-help-prevent-it/
I put on the mouthpiece, tried taking a breath, and it immediately felt different — breathing was exhausting. Taking a breath required work. After about a minute of testing different settings, I was tired and my airway felt irritated. My eyes were on the verge of watering.
Walking through the ICU, you see many patients on ventilators. What you don’t see is how exhausting it is to use one. I always thought that breathing with a ventilator would feel natural, almost passive, but I was mistaken. I was told by the respiratory therapist that it would feel like breathing through a regulator when Scuba diving, but as an experienced diver, I can confidently tell you that I disagree. Unlike normal breathing or even breathing through a regulator, ventilators use positive pressure. To put it simply, when we normally breath, the diaphragms contract, causing in a negative pressure in the chest. As a result, air passively flows into the lungs. However, ventilators pump air into your lungs, which causes a positive pressure in the chest that forces it to expand. In summary, airflow into the lungs is no longer a passive process.
The positive pressure created by ventilators can have negative consequences for patients, yet no modern ventilator uses negative pressure, which seems to be a desirable improvement by physicians and technicians. Ironically, the first ventilator, the iron lung, did. First designed for patients with polio, the iron lung was a large chamber the patient’s body, but not the head, was placed inside of. The pressure of the chamber decreased, causing the chest to expand and a negative pressure in the lungs relative to the atmosphere surrounding the head, resulting in air flowing passively into the lungs. Since then, ventilators have become much more compact and portable, but as mentioned, they now use positive pressure.The general principles are simple but the technology is impressive. There are numerous settings and data from any ventilator in the hospital can be downloaded easily into the EMR system. Inhalers, other than those that are dry powder, and nebulizers can easily be attached to the tubing, and a heat and moisture exchanger ensures the airway and lungs do not dry out. Although many changes have been made since the iron lung first appeared, many medical professionals expressed some frustration with the slow progress with the technology since the positive pressure ventilator hit the market. Since this equipment is integral to so many patients’ survival, it does seem as though attention should focus on improving comfort and reducing negative effects.
Suddenly, everyone in the room becomes silent. Over the lout-speaker, “Code 1, room xyz” is repeated. All the residents and fellows rush over to help. A patient may be in cardiac arrest or have a compromised airway requiring emergency assistance. Fortunately, several minutes later, they return with calm faces and no bad news.
On the way to room xyz, I imagine someone picked up the red cart in the hallway. This crash cart contains common medications and supplies needed in case of code 1 emergencies. Contents include a defibrillator, airway kits for adults and peds, and medications such as Epinephrine and Atropine. If it is critical to have access to the contents as rapidly as possible, then why aren’t they in each hospital room? After all, hospital rooms contain a seemingly large supplies of spare materials. Each room in the Medical Surgical Intensive Care Unit (MSICU) contains a half-empty (at the least the one I looked through) cart with the basics, such as syringes, gauze, IV tubing, and blood drawing kits. It could easily fit an airway kit and some other supplies. I understand that for safety reasons medications cannot be kept in the room, but why not some of the other supplies, like the airway kit? Perhaps it’s due to the cost of the supplies. I am curious to learn over the next couple weeks about why certain supplies are and are not in every room or hallway and how it is decided.
Breathing comes naturally. We take our first breath of air after birth, but long before that, at around 9 weeks gestation, the fetus makes breathing-like motions. Most of us don’t think about it on a day-t0-day basis unless we’re doing strenuous activity, but for many patients with pulmonary issues, breathing is constantly on their minds.
For many patients with issues such COPD or asthma, inhalers offer great improvement throughout the day or relief from attacks. However, patients often misuse inhalers due to several reasons. There are a variety of drugs and applicators of inhalers, making it confusing for the patient especially when taking multiple types of inhalers daily. For example, some inhalers use a propellant to expel the drug, while others are breath-activated. Some recommend spacers, other shouldn’t be used with spacers. One medication comes in the form of a tablet which the patient must place into an inhaler each time he needs a dose. This can be especially confusing to patients as some may not understand why they cannot simply swallow the tablet. New drugs and methods to administer them are constantly being released, and insurance companies change which medications they cover. As a result, inhalers are often misused and the drug may be incorrectly be determined not to be effective in that patient or require a higher dose.
Standardization of applicators across inhalers is unlikely, although it would be helpful to patients. Some companies provide the clinic with placebo samples for staff to educate patients on how to properly use the prescribed inhalers. However, oftentimes there is only one sample so the patient cannot actually test the inhaler in the clinic with the specialist observing and correcting technique. Because proper use of inhalers is critical to the health of patients using them, more resources should be put into educating them.