Author: Kari DiVito, PT, DPT
As you can see, the face of an acute care PT has changed over the last year. I’ve been riding this COVID-19 wave since March 2020 and I am proud to announce that as of the end of May, I FINALLY no longer have a single infectious patient with COVID-19! I was reluctant to volunteer to be a PT covering these acutely ill patients with COVID, but as an aspiring Cardiovascular and Pulmonary Specialist (Exam results still TBD) I knew this was my time to step up and put my knowledge and skills into action.
Starting in April 2020, my caseload switched from cardiothoracic patients to being exclusively infectious COVID-19 patients and remained that way until roughly January 2021. Most of my caseload were those requiring ICU care, but not just any ICU care, my patients were requiring ECMO support. At one time, I had 11 ECMO COVID patients and I cannot describe to you the mental and physical exhaustion of working with such a complex group for my entire work day each and every day. ECMO is relatively new for treating adult patients, so if you haven’t heard of it, I over-simplify it to my non-medical friends by saying: the patient’s blood is circulating outside the body, is oxygenated by a machine, and then returned to the body through large tubes. If you aren’t afraid of seeing blood, I highly recommend searching ECMO online.
These patients could be anyone. COVID-19 doesn’t discriminate. I had all types of patients including the young teenager whose family brought it home from working in an essential retail store, the folks who didn’t take any precautions because they believed that COVID wasn’t real, the 100-year-old who was staying home and taking precautions, but got it from the person delivering her groceries, and a number of hospital workers exposed just doing their jobs in an unprecedented time. These hospital employees were probably what scared me most. I was constantly worrying I would be next. Was I going to bring this home to my husband? Would one of us accidentally expose our parents by my work at the hospital? I remember the high level of anxiety I felt the night before I was going to see my first COVID positive patient because at that time it felt like we didn’t know anything about what we were battling.
COVID-19 isn’t just affecting PT in the acute care setting, but COVID isn’t necessarily going to require donning of air purifying helmets and respirators in all the other settings, and the patients might even be coming to you mask-free at this point! These patients might look like your typical outpatient candidate at first glance, but it’s up to you to be aware of what COVID-19 really is and recognize this diagnosis in the history as a yellow flag. They may be more functionally impaired than your typical patient due to skipping a step in their recovery as many rehab centers weren’t accepting patients with this diagnosis for quite a long time. Other individuals I worked with would decline rehab placement at discharge out of fear of becoming re-infected considering at first we really weren’t sure what could happen following the battle with this deadly disease. I would have patients tearfully look at me and say things like, “I have to go home and stay there. I can’t risk going through this again.” After seeing someone on the brink of death, I couldn’t blame anyone for feeling that way.
COVID-19 is so much more than a dry cough, feeling short of breath, loss of taste, and loss of the sense of smell. Are you prepared to ride the rehab wave that’s coming? Here are some things to think about when this wave hits your clinic.
COVID-19 is an endothelial disease. Think of all the locations of endothelium in the body! Therefore, you can’t think of this virus as just damaging a person’s lungs. When endothelium is damaged, a number of things happen including moving into a pro-coagulant state, releasing inflammatory cells, and vasoconstriction. This immune reaction then leads to increased vascular permeability at the lungs and these infiltrates cause ground glass opacities on chest x-rays. The increased permeability causes retention of fluid in the interstitial space, therefore increasing the distance for gas exchange to occur, which decreases the efficiency of gas exchange and hypoxemia ensues. On the surface, the person may not demonstrate dyspnea and SpO2 may not be immediately dropping, and this might give you the impression that it’s okay to keep pushing your patient to do more activity, or more challenging tasks, however, recall that the brain regulates breathing based on our pCO2, not our pO2 levels, and there might be a delayed sensation of shortness of breath.
I would strongly recommend frequent vital sign monitoring of these patients in your clinic even if they report only having a mild case that they were able to manage at home, because again, COVID-19 doesn’t discriminate and some scary and dangerous changes can occur to the inside of the body even when the person looks fine on the surface. Monitor SpO2 continuously if possible in your clinic to be sure your patient is tolerating your interventions well. If someone was severely sick and hospitalized, they may have developed issues that lead to fluid on the lungs and the dry cough may have become a wet cough. You may want to dust off your stethoscope and listen to those lungs to be sure you don’t need to incorporate airway clearance into your treatment plan. After all, it only takes a minute to auscultate the lungs.
Hypoxemia is going to alter cardiac function as well because it will be the heart that is trying to compensate for the lung’s deficiencies. Therefore, you may note tachycardia when SpO2 drops because the heart is working harder to supply the oxygen that is getting to the blood to the other parts of the body. Not only this, but cardiac output is increasing to try to pump more blood to the lungs themselves in order to compensate for the decreased gas exchange. This increased workload on the heart can then lead to a number of cardiac issues including Cor Pulmonale.
The cytokine storm associated with the immune response puts these individuals at increased risk for MI as well. The cytokines enter the myocardium and can cause direct damage with an existing atherosclerotic plaque to destabilize, break off, and cause an artery blockage. Additionally the myocardium isn’t being supplied with enough oxygen, due to the supply-demand mismatch, and infarct may occur for this reason alone. The inflammation can also lead to myocarditis, especially in the young patient. If a young, active individual is exercising with a mild case of COVID while still symptomatic, this can actually INCREASE viral replication, and myocarditis is accountable for up to 20% of sudden cardiac death cases in young athletes. Monitoring your young patients who had mild cases closely is still important! Again, break out the stethoscope and listen for abnormal heart sounds to be on the safe side.
Because the body is trying to heal the damage to the endothelium caused by cytokines, the body is constantly in a healing cascade, and more so if they had to undergo invasive treatments in the hospital. If the patient was on bedrest for a prolonged period, they not only experience the long list of issues associated with bedrest, but vascular stasis plays a role in the state of being hyper-coagulable. If the person is chronically hypoxic, the body will secrete more red blood cells in an attempt to provide more carriers for oxygen, increasing the thickness of the blood, which can cause more clotting issues. This hyper-coagulable state increases our patient’s risk for stroke, heart attack, pulmonary emboli, and venous thromboembolism.
It is becoming terrifyingly more common for an otherwise healthy person who had gotten COVID to return to the hospital due to complications from this disease. These folks may be coming to your clinic or rehab facility next. Recognize the increased risk for and signs of MI and stroke. Screen for VTE and recognize the signs of a pulmonary embolism. Those also returning to the hospital following COVID include those who now require lower limb bypass surgeries or worse: amputations, because of the vascular issues COVID has caused them. Encourage mobility of ALL those who had COVID regardless of the severity of their case as movement has a lysis effect. Monitor for cool or dusky toes and feet and monitor pulses in the lower extremities and refer the person out if needed.
This is certainly not an exhaustive list of issues that we may see as we start seeing the aftermath of COVID-19 in the outpatient world. Continue to listen closely to your patient’s history, be observant, and stay diligent and we will keep riding this COVID-19 rehab wave together. Good luck!
as a coworker who wasn’t on the COVID 19 Team i applaud your work with your patients and your efforts to educate us all!