Episode 1777 - Is acute care the setting for you?

Dr. Julie Brauer // #GeriOnICE // www.ptonice.com

In today's episode of the PT on ICE Daily Show, join Modern Management of the Older Adult lead faculty Julie Brauer discusses the ins & outs of daily life as an acute care physical therapist.

Take a listen to learn how to better serve this population of patients & athletes, or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

JULIE BRAUERWelcome to the PT on ICE Show brought to you by the Institute of Clinical Excellence. My name is Julie. I am a member of the older adult division. Thank you for spending some time on your Wednesday morning with me. Let's dive right in. So one of the most common questions that I receive from students and clinicians is is asking me about acute care. Should I go into acute care? Should I choose home health over acute care? And I'm having a lot of conversations with folks about pros and cons. and sharing my reflections from having been in acute care and home health and inpatient rehab and outpatient and private and home with older adults. So I figured I would do a podcast and bring all these thoughts that I've been having in these individual discussions to all of you. Okay, so what I'm going to do is I'm gonna go through a list of five to seven things that I believe are the most important characteristics of acute care and will help you decide if acute care is the right setting for you and if you are going to thrive in that setting. Okay, so number one, this is what I believe is the most important characteristic that sets acute care apart and will be the biggest factor in helping you determine if you are going to thrive in this setting. All right, number one is that in acute care you have complete autonomy over your day. You have complete autonomy over your schedule. This ended up being The reason why I feel like I thrived the most in acute care is because I wanted full autonomy over how I structured my day. So let me explain what that means. So when I was working in the hospital, I would walk into work, you clock in, and you are more than likely going to be given a list of patients. It is then up to you to decide which of those patients you're going to see. Are they appropriate to be seen? So you're doing some triaging there and you have autonomy to make that choice. And then you get to decide, most importantly, what your day looks like. When do you go see those patients? And this was so key for me. I don't like to be in a box. I don't like to be back to back all day. I like to create my own day. And so I would look at my list and depending on how intense or complex the patients were, depending on my energy levels for the day, I would decide, like, okay, I'm going to knock out a bunch of my patients in the morning. Back to back to back, get it done, and then go eat lunch, and then in the afternoon when my energy stores are down, that's when I do the majority of my documentation. So my afternoon, I wouldn't really have to see any patients, maybe one, and the majority of it was documenting. Or if sitting around and documenting for a long time is something that fatigues you, you can do a system where you go see a patient, then you document. You see a patient, then you document. So if you are someone who really needs that energy reset after pouring into a human, typically one that's very sick and there's lots of complexities and you need a little bit of a break and a breather, you can set your day up so that you get that break after every single patient or perhaps after two patients. So you really have a lot of flexibility there. I remember I was the type of person who I would love to knock everyone out in the morning. I would go find a quiet room or a room that was near some natural light. I would put my music on and I would just sit there and document. So you have full flexibility there. When you look at other settings like inpatient rehab, you are back to back to back to back. It's one of the things that I liked the least about the setting is that I did not feel like I had autonomy over my day. And I realized that that was professionally a big core value of mine. And then if we think about home health, you do have a lot of flexibility. You schedule all of your patients yourself. However, I learned my experience was that that was a big burden for me and I never really knew what I was walking into. I didn't get the choice of who was on my schedule. Scheduling patients was typically fairly time-consuming and frustrating when you're trying to reach out to all these people and they may not be answering and you're trying to very efficiently, Tetris them into your schedule so that you're not driving all around your region. Trying to schedule patients became just this extra task that really stole a lot of my energy. So after having been in multiple settings, I think that was the biggest plus to acute care. And if you are someone who likes to have that flexibility and you feel you can be efficient and effective and productive by making your own schedule, then acute care may be the setting for you over other settings. Okay, that's the biggest one. Number two, When you work in acute care, you learn how to be a master of scale. You have to learn how to come up with unique and creative loading strategies because you are in an environment where you don't have weights. You are in an environment where maybe you are just stationed to the edge of the bed because your patient is, they have tons of lines and tubes attached to them. So you have to figure out how to do a lot with a little. And that skill right there has become, it became my superpower going forward into every other setting. I never encounter a time where I'm with a challenging patient, they're complex, or we are in a less than ideal setting, for example, someone's home, and I have never felt I'm stumped. I don't know how to bring a fitness forward approach to this person. I can't come up with an idea. I don't have weights, and so I just don't know what to do. That has never happened. And the reason for that is because over several years, I learned how to get incredibly creative. So in the acute care setting, that could be as easy. I carry around dumbbells in my backpack. and I'm like rucking through the hospital, I bring my own equipment. We paused, we paused, we're back. That could also look like the, this is my favorite hack, the toiletry buckets that are typically filled with shampoos and soaps. I dump those out, roll up towels, soak them in water, put them in the toiletry bucket, and now that becomes a little bit of load, I would have folks deadlift that toiletry bucket, press it over their head. That was one of my favorites. I would use the tray table for a sled push. I would turn the hospital bed into a total gym and put it at an incline and have them reach at the bar above their head and they're doing pull-ups or I'm having them basically do a leg press with the hospital bed. I just was able to always find a way to bring that fitness forward approach and the acute care setting really forces you to get creative. And that was just such an amazing skill that has carried me through every single setting with every single patient that I've had throughout my career. So that's number two. Okay, number three. You do not, for the most part, have to take any work home with you. Yes. How nice does that sound? So for a lot of you who are in other settings and you typically at night, you get home from work, you maybe go to the gym, you eat your dinner and then you're like, well, here's my glass of wine and I'm going to sit down and I have one to two hours of documentation to do. That is not something that is typically happening when you are in acute care. Now in the very beginning as a new grad, a hundred percent, I was taking documentation home for me. But the vast majority after that learning curve, you know, after I got through that steep learning curve, I was not taking any work home from me. With me. You actually get to leave work at work. The administrative burden is very, very low. The EMR is very easy. It's a very low, low, low documentation burden. Something that I didn't know and I learned when I went into home health is that my god, documentation burden was enough for me to, was a big reason why I quit home health. I truly was so frustrated and cognitively overloaded by how extensive the documentation was that I could not even be present or enjoy the time with my patients. And for me, that was enough to say this setting is absolutely not for me. So if you are someone who you're really trying to create a barrier of when I'm at work, I do my work and I do a fantastic job. And then when I'm out, I'm off, I'm done. You go home and your energy stores go to your partner, they go to your friends, they go to your family. Acute care is definitely a setting where you can more easily create those boundaries. Okay, documentation burden low, that's number three. Number four, you are gonna do a lot of things in acute care that don't look like traditional therapy. Okay, so what I mean by this is that your role beyond improving someone's mobility and getting those sick patients, those, you know, individuals who need to get out of that bed and trying to start to get them stronger. Beyond that, I would say The majority of my time was actually spent being a fierce patient advocate, a fierce patient advocate. That is truly what my role became. And I actually evolved to loving that part of the role even more sometimes than going in and doing the functional mobility strengthening stuff. I thought it was such a beautiful opportunity to be able to advocate hard for my patients. So in MMOA, we call that significance over sexiness. You're not always going to get this patient doing squats or deadlifts or bringing in weights, but what you can do is you can fight to the end so that your patient can get over to inpatient rehab. I will never forget one of my first patients that I experienced working on the trauma floor was an individual who had a spinal cord injury. He fell down the stairs, ended up in the hospital. He did not have insurance. And he worked hard every single day with us. I worked with him for months. But because he didn't have insurance, acute rehab was saying, no, no, no, we're not going to take him. Even though everything else made him the perfect candidate to go to rehab. And we know that his outcomes were going to be so much better if he was able to go over and get that intensive rehab. So me and my colleagues were able to just hammer on that goal and we brought it up to the physicians and we got them to do an appeal and face-to-face peer review and we worked closely with case management and we were able to get him over to rehab because we went after that so hard. and that was more beneficial than probably anything we could have done in a more traditional therapy sense. So you have this awesome ability to really dictate the outcome of these folks and it doesn't look anything like PT. Another example is if you have an interest in working in the ICU you have an amazing role there to advocate. Meaning you're going around with the physicians and case management and the nurse manager and sometimes higher up execs in the hospital and you're looking at these folks who are on sedation and on the vent and you know that you want to get that sedation down so you can get these people up and start that early mobility. and you get to look at their settings and look at what's going on and say, look, can we get this person off Propofol and put them on Propofol? Or sorry, the opposite, take them off Propofol and put them on Procedix so that we can try and decrease the sedation burden that's going on with our patients and get them mobilizing faster. That is so cool. I thought that was amazing. I loved feeling like I was like this mama bear trying to protect all of my patients and get them to the next best. setting and really improve their outcomes. And much of that did not look like teaching them how to do sit to stands or deadlifts. So if that's something that you feel you would love to do, acute care is a really wonderful setting for that. Conversely, if you are an individual who, you know, I talk to a lot of clinicians and students who love the fitness part, like their core values when it comes to their professional career are that They want to be able to work with someone when they are in the stage of being able to load them up. That's what brings them value. They want to work more from a sports performance perspective. And they want them to be at a level where they're able to do all the exercise. Like that's what you love to treat. And so I give them the, you know, I let them know, acute care may not be the setting for you. You really may belong more in outpatient instead. So something to think about just the how dynamic of the role can be in acute care. Okay next you learn how to communicate and you learn how to be on a team. All right you will hear all the time that in acute care you have to have really solid interprofessional communication. 100%, you've heard that word over and over again. But what does interprofessional collaboration actually mean? You learn very quickly that the world does not revolve around you and your therapy plans. These patients are so complex. They have so much going on with them. You are one small piece of the puzzle that actually helps them move on to the next level of care, or helps them get home and be safe. You learn it really quick. You cannot operate in a silo. You start to learn what the nurse's roles are, what the nurse tech's role are, truly what your OT partners and your speech partners can do. And you learn how to work with case management. You learn how to have conversations with physicians. They're all right there, and you have to figure out You have your patient's health and mobility, and you want them to get stronger. That's the forefront of your mind. But you've got to deal with all of these other individuals who have their own priorities when it comes to the patient. the physicians or the surgeons, like I'm trying to keep the lungs and the heart alive, or I'm just trying to keep that brain alive. Like that's what their focus is. You know, the nurses are, Hey, I got to get these meds into my patients and they're overloaded. And you start to learn to have grace for people when maybe they're not fitting the idea of what you think should be done for the patient because you're thinking about your bias of mobilization and strengthening. So you start to understand, how to create allies with individuals who have various priorities when it comes to your patient case. You learn how to argue, you learn how to be direct, but you learn how to respect everyone else's role and everyone else's time. And that can become a really beautiful collaborative effort where you can work together and move people forward. And you just don't get that opportunity in other settings. When I went into home health, I really missed the fact that I could easily collaborate with my OT partners or my speech partners, or I could easily, you know, talk to a physician. In home health, a lot of the time it feels a lot more siloed and My goodness, if I was able to get even just a PA on the phone to tell them about a concern I had with a patient, that was a big win. So if you are someone who values and loves the fact that you're surrounded by a team constantly, acute care may be the setting for you there. Okay, only a few more, I promise. Let's do two more. Okay, next, the emotional toll slash connection is very high in acute care. Now, every single setting you are going to be emotionally connected to your patients, right? You could be in very vulnerable situations with the patient. However, I do believe acute care has the highest amount of emotional connection and along with that emotional toll because you are with folks that are dying, that have been through catastrophic accidents, that are, you know, I will never forget the day where I was working in trauma and a patient came in, terrible car accident. That individual lived, but her spouse died. And you are pouring into this human, they don't even know that their spouse is dead yet. I mean, you are going to face these situations so often, especially if you work more in the ICUs. You are surrounded by death quite frequently, and you're surrounded by a lot of sadness and loss and grief. And that can take a significant toll on you. I think it's beautiful that you are able to be someone who can support your patient, your patient's family during an incredibly tough time. But that can also be something if you are, um, if you are an empathetic person to a fault, sometimes like I am, that you can take on a lot of that grief and that can end up being incredibly heavy for you. So something to consider if you love to be in those vulnerable positions with your patient and you want to help them through dying and sickness and grief and loss, it may be a great setting for you. And that's not to say you don't experience intense joy as well. You can. see folks who were minimally conscious after a stroke or traumatic brain injury, and you can see them, you know, spontaneously start to recover. And that's absolutely incredible as well. But the emotional roller coaster is incredibly high. So if you are prone to taking on a lot of energy and emotion, and that's something that you know is not necessarily a positive for you, then maybe acute care isn't the place for you. Okay, last one here, last one. you do not get to see the sexy outcome. You do not get to see the sexy outcome. In acute care, you truly have to be okay with being the person who sees this person once, you plant a seed and you hope that that grows and that ends up changing this person's trajectory. But you don't get to see that outcome most of the time. And that's really hard for individuals. Many clinicians, they want to build that relationship and go along that journey with someone and see discharge day, see how far they've come from the amount of effort and work and progress that you've been making together. That longer term relationship is so important. This is one of the, um, this is definitely one thing that I didn't like about acute care as much is that I didn't have the ability to see this see this outcome. On the flip side of that, I definitely adopted the perspective that, hey, I've got maybe one or two chances to work with this patient. I'm going to do everything possible to set them down the right path. I'm going to pour into this human 200% to try and make sure that I can hand off the baton to the next person and it's a fitness forward individual and I can continue to keep them in that lane. And I was okay with that. I loved knowing that as a fitness forward professional, when I walked in those doors of my patients' hospital rooms, I knew, I just felt that their outcome was going to be different because I was coming into their room. And I loved being able, I loved being able to have that impact with them, even if it's for a very short amount of time. If that is something that you feel like you can get on board with and you can really learn to value and you can be okay with planting the seed and not seeing the outcome, acute care could be a really wonderful setting for you. If you are someone who knows that they want to go along the journey over a long period of time, they want to see discharge day and know what those efforts look like at the end and what the outcome was, probably not the setting for you. Okay, all, that's my list. It's not an exhaustive list by any means. I would love for you all to add to this list to kind of let more folks know some pros, some cons, some other considerations. Please add to this. Put it in the comments. Send me a message. I'd love to post other thoughts about all the things that go into acute care and whether it is going to be the right setting for you. Okay. So I will end with talking to you all about what we have coming up in the older adult division. So in August we, Oh, first let's talk about July. My goodness. So this coming weekend, we, uh, the whole team is in Littleton, Colorado. And then once we go into August, we are in California, Salt Lake city. in Alaska, as well as our Level 1 online course, that starts August 14th as well. PTINice.com, that's where you can find all of that info. If you're not on the app already, make sure you get on there and get into our community. We're on the app so much more now, so if you have questions or comments, find us in there. All right, team, have a wonderful rest of your Wednesday.

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