Jenny Logan pulls a wispy yellow gown over her scrubs, snaps on blue-rubber gloves, and shrouds her head with a powered air-purifying respirator (PAPR) that provides filtered air via a ribbed tube connected to a pump strapped above her tailbone. She slides open the glass door to the fishbowl of an ICU room, closes it again behind her, and approaches the bed of someone with by far the most common diagnosis among UCHealth ICU patients over the past year.
Logan is neither a doctor nor a nurse. She’s a physical therapist. The COVID-19 patient she greets has been sedated and on a ventilator here at UCHealth University of Colorado Hospital on the Anschutz Medical Campus (UCH) for 11 days. To the uninitiated, physical therapy might seem premature. But Logan and others on a team that includes PTs like herself, occupational therapists (OTs), and speech-language pathologists (SLPs) have been working with severely ill COVID-19 patients since the beginning of the pandemic, and they have quietly made a big difference for hundreds of them.
Technically, the ICU therapy team is an ancillary service. That’s understandable given that the primary work of an ICU is to keep patients alive. Critical care medicine specialists, cardiologists, pulmonologists, infectious-disease specialists, nurses, and others focus day in and day out on such involuntary functions like respiration, circulation, and immune response.
Logan and colleagues, on the other hand, concentrate on the voluntary: cognition, communication, and movement. Without those, one can be alive without living. Research has shown that starting PT, OT, and SLP therapies in the ICU makes a big difference. UCH ramped up physical therapy for ICU patients in a pilot project that launched in April 2015. The results of that project backed up those of a smattering of studies from around the world: that patients who receive therapy while still in the ICU show improved physical function and muscle strength, and that early therapy helps patients get back to a higher quality of life. Doing so also shortens ICU as well as hospital stays and reduces the time patients spend on ventilators. Never has that been more important than during the coronavirus pandemic.
Needing Spanish-speaking therapists in the ICU
Logan joined the team a few weeks into the spring 2020 coronavirus-patient surge. She typically works with patients who have suffered brain injuries and strokes, but she’s a fluent Spanish speaker, and many UCH coronavirus patients are Spanish-only speakers.
“They’re so isolated, they can’t have family with them, and they don’t know if they’re going to survive,” Logan said. “I thought, ‘If there’s some way I can help, I want to do it.’”
The patient at hand is, like many of the coronavirus patients Logan sees, a Spanish speaker. On this day in February, there are a half dozen patients lie in this COVID-19-dedicated ICU. That’s down by about a factor of 10 from the spring 2020 peak, a function of some combination of improved medical care; social distancing, mask-wearing, and other so-called “nonpharmaceutical interventions” among the general public; and vaccination among those most vulnerable to severe infection. But there are still enough patients in UCH’s COVID-19 ICU – and in the inpatient acute rehabilitation unit to which patients transition for a week or two after the ICU – that Logan is always busy with Spanish speakers.
‘Is it August?’
Logan and her critical-care therapist colleagues don’t step in until the medical team’s work has stabilized a patient’s blood pressure, breathing, and other factors. The patient must also be awake enough to follow simple commands. This particular patient appears to have gotten to that point. Eleven days on a ventilator isn’t long by COVID-19 ICU standards, but it’s about double the average for ICU patients in general and more than enough time for serious deconditioning to set in. When the human body goes unused, it has a ruthless penchant for throwing itself away. Therapists are seeing much more, and much more serious, ICU-acquired weakness among COVID-19 patients than among typical ICU patients.
Logan speaks to the patient in loud, simple Spanish. She holds his hand and asks him to squeeze “yes” to yes-and-no questions including “Is it August?” “Is it February?” “Are you in a house?” and “Are you in a hospital?” He doesn’t know what month it is; he knows he’s in a hospital. The hand-holding is about more than providing a means of communication, Logan explains later.
“For so many of these ICU patients, the touch they’re receiving is negative. It’s being stuck with needles and lines and tubes,” she said. “Usually family provides that positive touch, but they can’t be here. So that’s what I try to do, whether it’s holding a hand or putting a hand on their shoulder.”
Therapy in the ICU step one: Sit up
Katie Freeman, a UCHealth occupational therapist, soon suits up and joins Logan. PTs, OTs, and SLPs tend to visit patients in teams of two, if possible, helping each other out as they note different aspects associated with similar activities. As the patient lifts and lightly kicks his legs out at Logan’s request, Logan observes the physical motion as Freeman notes the patient’s lucidity in following commands. Same story when the patient opens and closes his hands and then pumps his fists. Freeman’s help often extends to heavy lifting: this therapy session’s main goal is to help sit the patent up with his feet dangling off the side of his bed. COVID-19 ICU patients are so weak that it takes two helpers to move them into position.
For most of us, sitting up on the edge of a bed does not, unfortunately, qualify as a therapeutic act. For an ICU patient, it certainly is. For one thing, sitting up forces the heart to pump blood against the force of gravity, something it hasn’t had to do for many days. But there’s more.
“It improves their strength and core muscles they need to be able to breathe, to cough, to clear secretions,” Logan said. “It helps their mental status. It helps wake them up. Those are all reasons people have trouble getting off a ventilator.”
The patient’s blood pressure isn’t cooperating. It’s too low, and the leg and arm movements aren’t bringing it back up. Sitting him up wouldn’t be safe, Logan and Freeman conclude.
The patient can’t speak because of the breathing tube, but the therapists see that he wants to communicate. They try having him write; between IV lines and his physical state, it’s not legible. While the team has whiteboards prefilled with an alphabet and a few Spanish phrases, Logan and Freeman didn’t expect to need it, and infection-control measures make going in and out COVID-19-patient room a bad idea. Freeman improvises by inking an alphabet on the back of a laminated sheet. The patient points to a few letters. Between that and the handwriting, it’s clear that he’s self-diagnosing: his blood pressure is low, he believes, because he’s been in bed for so long. This plus his ability to follow commands and the relative ease with which he moves his arms and legs give Logan and Freeman hope that, tomorrow, he’ll be able to sit up, and, within a couple of days, be able to stand and soon move on from the ICU.
Occupational therapists focus on two main aspects of recovery – first, what are called activities for daily living, or ADLs. This is, as Freeman’s OT colleague Allie Fen explains it, the ability to do basic self-care tasks.
“Bathing, going to the bathroom, grooming and hygiene, oral care, self-feeding – we’re assessing someone’s ability to do those things,” Fen said. “We’re assessing someone’s ability to do those things, and they involve physical and cognitive aspects.”
Therapy in the ICU focuses on body and brain
OTs as well as speech-language pathologists are particularly keyed into the patient’s mental status. Perhaps because of the extended period on the sedatives necessary to keep coronavirus patients comfortably intubated, UCHealth ICUs have seen much more delirium than usual among ICU patients.
Even as COVID-19 has brought more delirium, the nature of the pandemic has made delirium harder to treat. Letting in natural light through windows and enabling normal nighttime sleep cycles has been shown to help, Fen said, but during surges, ICU patients ended up in rooms without external windows, and patients who are prone to boost oxygen uptake must be awakened and moved every couple of hours. Furthermore, the protective masks, PAPRs, gowns and other PPE that providers must wear can slow patients’ ability to orient themselves once conscious. Also, Fen added, family members who typically help ground ICU patients can’t be in the room at all.
PPE presents a special challenge to speech-language pathologists, the third pillar of the ICU therapy team.
“Speech,” as the specialty is also known, is about much more than speech. SLP encompasses spoken and written language processing, expression and, by extension, the assessment of a patient’s cognitive status and degree of delirium. Speech-language pathologists are also experts in the mechanics of swallowing and the interplay between swallowing and breathing. COVID-19 ICU patients often have cognitive as well as swallowing issues and, later, face challenges in using their voices again. As with PTs at OTs, the work of SLPs starts before patients are off ventilators – that is, before they can actually speak.
COVID-19 has challenged SLPs in a couple of big ways, said UCHealth Speech-Language Pathologist Jocelyn Mellen. For one thing, the PPE that providers must wear makes it harder for SLPs to connect with patients.
“Communication is about so much more than talking,” Mellen said. “It’s about reading facial expressions or, for the hard of hearing, reading lips. A breakdown of communication can really impact somebody who’s going through such a scary experience.”
For another, SLPs for months weren’t able to use a standard diagnostic tool to assess swallowing – a fiber-optic camera attached to a thin catheter, called a FEES – for fear of spreading infectious aerosols.
To recover from COVID-19, a patient has to be able to swallow on his own. If swallowing seems a trivial concern for a coronavirus patient, consider that it prevents saliva and other fluids from entering the lungs where they can cause infection. With sufficient PPE supplies and vaccinated providers, FEES is back in play, Mellen said, and the tool has been important in helping understand the origins of swallowing problems – be it muscle weakness or nerve problems from having a breathing tube in for days or weeks.
Logan and Freeman finish up with the patient in about 25 minutes, a bit more than half of what they had expected assuming sitting him up at bedside had worked out. Tomorrow, they’ll again. The aim, as ever, is to help the patient rebuild strength, coordination, cognition, and communications – and, post-ICU, provide him and his family with the education – he will need to go home and get on with his life.
For many, that won’t be easy, and that’s all the more reason for the rest of us to take the pandemic seriously, mask up, socially distance, and embrace vaccination until COVID-19 ICU patients are a rarity rather than a regularity, Logan said.
“I’ve seen so many people whose lives are going to be ruined because of this,” she said. “It’s devastating not just to lungs, but to lives, and it’s going to affect a lot of people forever.”