Diary of a Physical Therapist – Episode 1
17th March, 2022
It was just another day in IRCU. I had the usual I-am-not-in-the-mood feeling before I stepped into the ICU. I had this daily because of the lack of sleep that had become a constant in my life. Anyway. It had been a while since a challenge and working had been quite mundane.
I collected the gloves from the locker near the entrance and took a round of the ICU wearing them – looking for familiar and unfamiliar faces. I noticed the patient on bed number two, he seemed to be conscious and oriented today – an occurrence after almost a month. I expected to receive his call. As I reached the other end of the ICU, one of the chest medicine residents caught hold of me and specified that I had to mobilize Deep, the said patient, on priority.
As I walked towards him two more residents urged to do the same one by one unaware that I had already been told by their teammates. Now, I really wanted to see what the hype was about. Maybe the challenge that I was looking for was finally here.
I walked over to his bedside. Picking up his file I asked him how he was. He just moved his eyes in response. Registering his every response, taking in his demeanor, having one eye on the lines and tubes he was attached to, my other eye was on the file. I had already seen his file before – when he was not eligible for physical therapy. He had contracted tetanus and had a ventilator stay of almost a month. I made some quick mental notes looking at his recent charts.
After a rough assessment, I narrowed his major impairments to two major things. First, the mucous production in his chest in view of the tracheostomy tube (the tube that was inserted directly in his wind pipe and connected the ventilator) and second, the overall deconditioning his body systems had been subjected to in the due course of being bedbound and fighting the illness. Of course, a few remnants of the illness persisted but they were taken care of by the medical management. However, full recovery without getting some exercise was impossible.
This was a seemingly easy case, especially compared to my other critically ill patients who have severe respiratory conditions. My patient had the baseline strength and range to carry out all the necessary movements. The hindrances although existed were not very profound. I just had to give direction to his recovery. After all, isn’t that what rehab is all about?
Only if that was the case!
Despite having the ability – he didn’t even move a muscle!
I realized that I didn’t have to treat his body. I had to treat his mind. One of the biggest challenges in our practice is dealing with the psychological aspect. It is a huge challenge because our curriculum doesn’t train us for that. Neither it is our domain. In fact, we are time bound. We are supposed to bring a physical change in the limited session time that we have. However, physical change is impossible to occur without the approval from the mind.
From here on begins the story of dealing with his mind. When he stared blankly at me as I asked him to move his limbs, I tried to understand – why? I called his father inside – something that is seldom allowed in an ICU. However, I knew I needed moral support for this patient. He was barely 22, at the prime of his youth, working in another city, very much independent. A woman slightly older than him, who was smaller in frame and probably wasn’t as strong as his healthy self, was giving orders to him and teaching him how to move. It was a little bruising on the ego. But more so, he looked scared. He was attached to all these tubes and he hadn’t eaten solid food in days.
I asked him, “Are you scared?”
He barely nodded. Not that he could speak properly anyway with the tracheostomy tube. He was still on Oxygen supply.
“All these tubes are going to come off eventually. You need not worry. You will be able to walk again. Just try. You can do it.”
I could see from his face that at first, he didn’t really believe in all the things that I said. I slowly asked him to lift his pelvis in air after placing his legs and arms in the bridge position. With as much support and motivation from me, his father and the intern who was with me; he lifted his pelvis a few inches. That gave him some confidence.
After a few repetitions, we took his legs on the edge of the bed, rolled him with some active effort from his side and helped him upright. He sat for the first time in 34 days! This is what makes me love my profession. I could be a part of the reason he could use his abilities. And it is not just me – all the superphysios out there are here in this profession for these little triumphs. Our day is full of these little feelings!
Now that he was sitting, he became the centre of attention of the entire ICU. All the residents, nurses, ward boys – all of them started looking at him and appreciating him. I knew I was pushing my boundaries when I asked him to stand. It was barely his first time sitting. But my clinical judgement told me that he could stand.
“Did you feel good sitting after so long?” I asked.
He nodded. His lip slightly twitching into a smile.
“Let’s stand?” I asked tentatively. “I won’t make you walk today!”
Agreeing on the bargain, he agreed on standing.
As he stood up, a fellow resident came in to motivate him further. And misogyny turned to be helpful here as he even took a few steps after the male intervention. After 3-4 steps near the bed, we helped him lie down. I was happy that day. Feeling fulfilled after making a small difference.
When I entered the ICU the next day, I had already planned to make him walk with a walker. His Oxygen supply had been turned off making it even easier to take him away from his bed.
He refused to walk.
I was at a loss here.
Standing and taking a few steps should have boosted his confidence. He should have been excited to do more. His fear was something that had been dealt with. Then why did he refuse?
At first, I tried to convince him. He literally shooed me off with a certain amount of ego and a lot of anger. He made me feel like I was doing something horrible to him. That some-how I was making his life miserable. That I wasn’t understanding his plight. I called his father again. He tried to calm him down. I asked him what was bothering him. From fear to his urinary catheter giving him pain and burning sensation. He refused each one of the reasons.
His father too was asking him very gently. Cooing, brushing his hair, asking what was wrong? Telling him that he needed to pass this test to survive! None of this seemed to work. He seemed to be angry at me. One reason was his male ego. His face screamed — who is she to order me? But there was something more too. This was what he showed. But there was something deep down that he wasn’t telling.
Time was running low. I had to manage the entire ICU. I told him I would wait on his bedside for 5 minutes if he didn’t walk it would be his loss. I told him he was old enough to understand what was good and bad for him and if he didn’t walk in the face of all the odds – the fear, the fatigue, the weakness, the pain – he would not survive. And I just stood near his bed – waiting.
I could have forced him. But that would’ve just made him bitter. It would’ve hurt his ego further and he would’ve probably given up midway anyway because he hadn’t consented to do this. Who was I to question his autonomy? He didn’t agree. So, I didn’t treat him.
Although one day before, he was happy that he could stand, he felt devastated seeing how much effort standing took and how drained he felt after this little bit of activity. However, I had no idea he had been feeling this way.
Next day, when I walked up to him. I found it prudent to involve a few residents with me. I told his treating doctor that he hadn’t been co-operating and he told him that he wasn’t going to discharge him unless he walked. I also spoke to his father. He told me that Deep felt he couldn’t walk until he started eating.
I took charge. I told him how he had been getting his nutrition from the RT and how the tube directly went from his nose to his stomach. I told him that the energy he thinks he isn’t having would come back with a combination of diet and exercise. And then I asked him if he was ready to walk.
This time, he agreed.
Not only did he agree, we were walking through half of the ICU with a walker in no time. I was elated. But – the challenge was not over.
Half way through, he suddenly lost his balance and began to free fall….
Obviously, I had made his father walk right behind him while I covered the front end. His hands were already positioned in a way to catch him – only he wasn’t touching his son. It is a common precaution we physical therapists always take. Non-maleficence – doing no harm – is a bigger ethic than benevolence.
However, patients hardly fell. My first thought as he was falling was – ohh God why him?!! He really needed this session to go well!
Anyway. I had to deal with this.
I gave him a chair. He was almost about to cry. I could see. He wasn’t looking at anyone.
I gave him a few moments.
“Deep, look here!”
He looked at me with eyes that said “I told you so!”
“Deep. Nothing has happened? Why do you think Papa was behind you? He was there because it is expected that you could fall. You are walking after 36 days! You have been on ventilator. With all those tubes. You are naturally going to be weak. And that may cause you to fall! That is okay. This is why so many of us are around you while you walk! Come on now, lets go back to our bed. Okay?”
He looked at me with those eyes that wanted to believe what I said for the first time. He nodded. A warm ball of triumph burst into my chest!
He safely walked back to his bed.
Next day, I was again a little skeptical. But as I entered the ICU, he was sitting and well…. Smiling!!
“I already walked!!!” He spoke with an enthusiasm that was contagious. I noticed the metal in place of his tracheostomy opening which aided in his loud voice.
I like to believe that physical therapy played a part in his cheerful behaviour. And it makes my heart so full and all the effort worthwhile!!! I know that he would recover now because he himself has started walking on the road to recovery!