All right, well, welcome, everybody. I'm Sam Mayer. I'm from Johns Hopkins, and I'm also the medical director for the Medical Student Summer Clinical Experience Program. So those of you that are in that program have already met me briefly. And just to announce about that, we'll be having a meeting of you all immediately following this meeting. It's in a different Zoom account, so you'll have to log off of this one and log into the new one immediately after this meeting. But anyway, today we're going to talk about medical complications in inpatient rehab and go through some of the common ones and discuss them, and then we'll have plenty of time for questions. So we can do that. But before I get started, I want to get a little bit of an idea of who all you are. So if I could have you guys a second here, I could have you all, as I call out, raise your hand and then put your hand down afterwards, but I want to find out how many M1s there are. Right? A good portion of you. And then you can put your hands down and then how many of you are M2s, finishing up your M2 year? Okay. Okay. And M3s? Okay. And do we have folks that have just graduated? M3s can put down their hands. Those two. Good. All right. So we got a pretty widespread. So I think this talk will probably be good for everybody, but it may be a little bit oversimple for the M4s and a little bit more than you're familiar with for the M1s. But, you know, at the end of this, we can go through it and people can ask questions and hopefully get familiar with this. So this is obviously a very important topic when you're a resident and then if you wind up being attending an inpatient rehab or in a subacute facility, which is very common amongst us, you'll see these things all the time. So we're going to talk about common medical complications in rehab, describe how we prevent them, how we diagnose them, and then how we treat them. So we'll go through all that with each of these. So first of all, what's the role of the physiatrist? So we're really responsible for the medical and rehab care of the patient while they're on the rehab unit and coordinate both the therapy and also the medical consultants and manage all those issues. We write for any precautions when they need certain precautions, we need to be able to write for them. So whether that's cardiac precautions, isolation precautions, weight-bearing precautions, we need to be familiar with all that. And then we have to do some prevention. So we need to prevent all these complications. We need to diagnose and manage the complications, determine if the patient needs to return to acute care. So in some circumstances, if it's a severe complication we can't handle on the rehab unit, then we need to move them elsewhere. So we play a really big role and use a lot of our medical school skills in managing patients on the rehab unit. So I'm going to start off with the number one cause of preventable deaths in hospitals, which is venous thromboembolism. So this is blood clots that form in the lower limbs, primarily, sometimes in the upper limbs, and they can percolate into the lungs causing a pulmonary embolism. And the scary part is that a pulmonary embolism can be fatal. So risk factors are immobility, any prolonged period of bed rest. If you've had lower limb surgery or fracture, if you've had stroke or a brain injury, if you've had a spinal cord injury, cancer, there's a number of other ones. But basically, if you look at the list, it's virtually every patient that's on the inpatient rehab service. And so almost all of our patients are at high risk. So we need to think about preventing things because of them. So there's guidelines that are set by the American College of Chest Physicians, and they're revised every two to three years. And we did a study in our own institution, our own rehab unit, I did a study a number of years ago, we looked at following the guidelines versus what we did before there were guidelines. And we reduced the incidence of thromboembolism by fivefold. So it went from like 5% to 0.9% just by following the guidelines. And before it wasn't like we were doing nothing, we were giving them, many of them heparin or Ted Ho's or other things, but we weren't following the guidelines in a rigid way. And just doing that, making sure everybody was on prophylaxis made a huge difference. So the scary part about VTE is that death can be the presenting symptom. So you know, the patient just literally collapses immediately and dies right in front of you. It hadn't happened to me, it's very scary and terrible. And I hope none of you ever have to experience that, but it's a scary part of DVTs and PEs. And that's why we have to be really on top of it in terms of preventing it, and then diagnosing it as quickly as we can. So in terms of symptoms for deep venous thrombosis, it's usually calf tenderness, swallowing in one leg is a big red flag. So if you all of a sudden have one leg that gets swollen, it should be a big red flag to everybody. And then for chest pain, shortness of breath, tachycardia. So you know, sudden change in their vital signs, they get hypoxic, and even a small degree of hypoxia can be a sign. So if there's change, so they get, you know, they've been 99 all along and they get down to 91 or 92 all of a sudden, you should be worried. So tests that we need to get done right away are for a DVT, it's a DOP or ultrasound that we get. And then for PE, it's a chest CT with contrast are the two main things. For PEs and patients that have contraindications to contrast, you can do a VQ scan. They're a little less sensitive, specific, but sometimes you have to rely on those. But those are the mainstay of what we use in the hospital to diagnose. Treatment in most cases, we can treat both DVT and PE with Noxaparin, which is an IM injection and direct oral anticoagulant. There's a number of them on the market now, probably familiar with them, but that's usually the standard of care for most patients. There are some exceptions if they have renal problems or other things going on. And most of the time, you can treat certainly almost all the DVTs and most of the small PEs and keep the patient on the rehab unit and keep them, you know, you just hold their therapy for a day until their anticoagulation is therapeutic and they can resume therapies. If they have a large PE, we get them to the ICU. They may be thrombolysis or open thrombectomy, which is pretty rare, but there are situations where we won't need that. So next up is aspiration pneumonia. So another lung problem, and it arises from swallowing problems, which are common in our patients with CNS lesions, which are obviously a significant portion of our patients, I believe. So patients with stroke or traumatic brain injury or other types of brain injuries or brain tumors. So we need to screen folks for dysphagia. So anybody with a brain lesion, we should be screening these with a bedside swallow and possibly a modified barium swallow or a video fluoroscopy or there's a fees test, which is a more direct way of looking down the throat. Anyway, there's several ways to do that. And we also have to make sure that patients who have dysphagia keep good oral hygiene. It's really critical. So brushing their teeth three times a day actually does a huge amount in preventing PE. So it's a very simple thing. Cardiac arrhythmias are also pretty common in our population. Atrial fibrillation, hopefully not ventricular arrhythmias, but those happen too. Those are more urgent depending on the neurosymbiotic language that aren't so urgent, but we don't have time to get into all that. They're associated with strokes. So first of all, many of our stroke patients have atrial fibrillation, but also people who maybe for other reasons would worry about them going into atrial fibrillation than having a stroke. So if it's a more chronic case of atrial fibrillation, they usually need anticoagulation. There's certain guidelines about that. So the neurologist or the cardiologist about whether they fit the criteria, but almost everybody fits the criteria for that. And then in new AFib, we have to control the tachycardia right away. So you usually get a beta blocker to slow them down and to convert them up for the motor. Next up, delirium. So delirium is very common after any kind of major surgery, anesthesia, and also ICU states, especially in the older population. And in older folks over the age of 65, the incidence is something like 25%. We also see it a lot in patients who have brain injuries of various types in younger patients. There's a strong association when you have delirium with a longer hospital stay and with increased mortality as well. So delirium comes in two varieties that can either be agitated or they can be sedated. The agitated ones are kind of easy to diagnose because the nurses will immediately tell you that patients climbing out of bed or punching staff or screaming, yelling, they get a lot of attention. The more sedated ones don't get as much attention, but you have to watch out for them more because they actually have a higher mortality rate. But if somebody's sleeping all day, really isn't able to participate, it's a big deal too. So basics of treating this, we want to start off with some non-medication interventions. So particularly keeping them reoriented at all times. So keeping a calendar in the room, keeping a clock in the room, reminding them where to find that. You know, asking them several times a day, what time it is, what day it is. It's really helpful. And then a big problem in the hospital is the sleep-wake cycle. So very frequently, particularly in the ICU, their sleep-wake cycle is fully driven out of kilter. And so they're sleeping all day and up all night. And so we have to get them back into that pattern that may involve some sleeping medicines as well as keeping them awake during the day, giving them appropriate rest breaks for naps during the day, but not coming to nap all day and getting them up and on schedule. Just being on the rehab unit where there's a pretty rigid schedule helps a lot with that. And then we want to look at their med list. So the first thing I do when I get a delirious patient is I look at their med list and see what's going on. And we want to eliminate any drugs that have CNS side effects. So common ones are any pain medications, benzodiazepines are a big one, anything that's anticholinergic, we want to get rid of. So we want to minimize that. Management. We want to avoid restraints when possible. So in acute care, this is more difficult because they have a lot of tubes and monitors and so forth that they have to have while they're in acute care. But when they come to rehab, we should try to eliminate all that unnecessary stuff. So if we can get rid of IV, if we can get rid of a catheter or NG tubes, we can switch them over to a PEG tube and that can be covered so that we can protect it. We can wrap up IV ourselves so they don't pull them out. And then we avoid putting them in mitts and restraints because the main reason we put them in mitts and restraints is to prevent them from pulling things out. And so that helps a lot because putting somebody in mitts will make them even more agitated. If you can imagine, you don't know where you are, hands are tied up and, you know, tied to your bed, you know, makes things even more scary and worse for the patient. Also, in terms of fall prevention, actually, restraints cause more injuries, in fact, in many cases, the patient's been strangled by restraints and so forth. So we really want to avoid that if we can. Sometimes we have to use meds if the patient's very agitated, getting out at staff or causing harm to themselves. So sometimes we have to use meds. The two preferable meds to use are Heloperidol and Quetapine, Aldol, and Seroprel, the trade names. We want to avoid benzodiazepines as much as possible, so don't give them value for additives for this, it makes it worse in many cases. You want to avoid those meds. And many of the other antipsychotics are associated with increased death rate, particularly in the elderly, so we want to be careful about using those as well. So, hopefully, get them calmed down. They're very agitated, too, in a brain injury case. There's also evidence for using beta-blockers. There's also evidence for using beta-blockers. It gets a little bit beyond this talk, but it's a way to manage agitation in brain injury patients. Hypertensive urgency. So, again, many of our patients have a history of hypertension. Often it wasn't well controlled, and that's the reason they had their stroke, for example, or, you know, their amputation. And, obviously, if it gets too high, there's a risk of having another stroke or myocardial infarction. It's an urgent issue if there's associated chest pain, headache, or visual changes, or of course, any signs of stroke. There's a number of NA hypertensives that can be used acutely to bring the blood pressure down. It's very dependent on the patient. It's kind of a complicated topic, but sometimes we use nitro paste acutely because it's nice because it can wipe it off once the pressure's come down so we don't bottom it out in the other direction. So that's one little hint that we sometimes use. In general, we can have patients participate in therapy with high blood pressures. Exercise doesn't usually dramatically increase blood pressure. In fact, getting them out of bed may help decrease it. But we do usually hold therapy for systolic blood pressures, over 200 diastolic, so over one. That's very dependent on the patient. Then there's urinary tract infections, which is another thing we commonly see. And a lot of our patients are at high risk because they either have post-op urinary retention, so that's very common after many surgeries, especially spine surgeries. They often develop flaccid bladder post-op and deal with that. Or in patients with CNS lesions, especially spinal cord lesions, they can develop neurogenic bladder. So in terms of preventing it, hand hygiene is the best way to prevent all infections in the hospitals. And hopefully they've drilled that into you early on in medical school and will continue to drill into you when you're a resident in most hospitals, do observations, make sure you're doing hand hygiene, and monitor that very closely. So if you want to look at infection rates versus percentage of compliance with hand hygiene, so it almost makes an X in terms of the rates do. We want to avoid indwelling FOI catheters whenever we can. And in cases where they're still retaining urine, go to intermittent cath, where they place the catheter in their bladder and then remove it once it's empty, has a lower risk of infection, but it's really only lower if the patient can do it themselves. So when you have another caregiver or nurse doing it, it doesn't make a huge difference versus a FOI. So really, if we're going to be doing that, we need to be working towards having the patient learn how to do that themselves. And that can reduce their risk of infection over time. So most spinal cord patients, for example, who have good hand function, if they're quadriplegic, can cath themselves and manage that for the rest of their lives. And then there are various medications to reduce urinary tension which can help prevent urinary tract infections. That's a pretty complicated topic, so we won't go into that today, but that could be an hour-long lecture on bladder management. So when we look at diagnosis of UTIs, a common mistake that's made is that people look at an infection as greater than 100,000 organisms, and it's really not the way you diagnose it. You have to put it together with your analysis, and you also have to put it together, most importantly, with symptoms. So just having colonization or an asymptomatic bacteria is not a reason to treat them. And most patients who have chronic FOIs or mid-cath will have colonization all the time, and you don't want to be putting them on antibiotics that leads to resistant bugs and harder to treat when you get sick when you get them. So we don't want to treat asymptomatic complications. Another misnomer that's commonly done is people think that if they're delirious, it's because of a urine infection. And it's true that if they're septic from a urine infection, they have a systemic urine tract infection, they have a fever, they certainly can get delirious. But just having a cystitis does not cause a delirium. So you shouldn't treat that either. Commonly, the nurses will come to you and tell you somebody has cloudy or foul-smelling urine, can they get a UA? And really, if that's the only symptom, don't get a UA because you're not going to treat it because they're just that. So a lot of cloudy urine and smelly urine is because of colonization. It's often mostly because of fungal colonization, which we treat. So you don't treat that. But if they do have dysuria, if they have painful urination, burning, new incontinence or frequency, those are all reasons to treat people. In spinal cord patients, another common symptom is increased spasticity. That's they don't have sensation in their bladders and they don't get dysuria, they will get increased spasticity. So here are some recommendations in terms of medications for it. You have to consider whether they're uncomplicated or they're complicated. So uncomplicated is basically a patient who doesn't have a neurogenic bladder who's in an outpatient setting who gets a urinary infection. So that's not really our patients for the most part. Our patients are usually complicated. And the first and second lines of these are going to depend on your institution, what their sensitivities look like in their urine infections. So your infectious disease people probably will have guidelines in terms of what to use. Ours at Hopkins, for example, are different than these. So actually they recommend nitroferanto as a first line of treatment, not supraflaxacin. But it varies again from institution to institution based on their sensitivities. So speaking of unnecessary antibiotics, one of the biggest complications from unnecessary antibiotics is clostridium difficile infection, C. diff, which is a big cause of morbidity and mortality in hospitals and in nursing facilities. So there's over 500,000 infections per year. It's a pretty common thing. And at least 29,000 deaths, so it's not a benign thing. And it comes from overgrowth of the bad bacteria, the C. diff, when you kill the good bacteria in the gut from antibiotics, primarily, although you can get it without antibiotics as well is very contagious. So prevention, hand hygiene is absolutely critical again. For patients who do have C. diff, you have to isolate things. And then when they transfer out of their room, they're discharged, their room has to be thoroughly cleaned. On our rehab unit, for example, and this goes to the importance of all staff on the rehab unit are really critical. We had our lead environmental service woman went on a two-week vacation. We hadn't had a C. diff infection on the unit in over a year or a year and a half. In the two weeks she was gone, we got three infections because the rooms weren't adequately clean. And obviously that was a big learning issue for us. We would be reaching about how they're cleaning it. Usually people follow the instructions and use the proper chemicals to clean, et cetera. So big issue. Also, you should know that hand sanitizer is not effective against C. diff. It's one of the few things that's not effective. So usually hand sanitizer is fine for most all patients, but if they have C. diff, we have to wash themselves with water. You want to avoid unnecessary antibiotics. There's some mixed data in terms of using probiotics when they're on antibiotics. And so that's still a work in progress. There's some data that it's helpful and some other data that it's not. I usually advise my patients to at least eat some yogurt or some kombucha while they're on the antibiotics. It's probably a good idea and pretty harmless. So first-line treatment for C. diff is metronidazole, Fagil, and then oral vancomycin, et cetera, on treatment. So pain is another big issue in the inpatient rehab service and is really, should be considered a medical urgency as well. You need to treat pain seriously. Many patients who come to the inpatient rehab unit have very complex pain problems. Very often it's acute, chronic pain. For example, most patients from spine surgery. So they went into surgery because they had pain. Often were on opiates before they came to surgery and then they have surgery and then they have to manage their pain afterwards. Pain is also a very common problem with spinal cord patients and with amputees. Of course, we get phantom limb pain as another big issue. So pain management in any setting really requires interdisciplinary management is really using all the tools of a rehab team together. And not just jumping to writing a prescription. These prescriptions can help, but they rarely cure pain. You wanna, when you're admitting a patient that has pain, you wanna really get a good history of how they've been treated in the past. Know what medicines they were on before they came to the hospital. Know what other treatments they've had, what's worked, what hasn't worked. Whenever possible, we wanna manage pain in the rehab unit with oral medications because we wanna get them ready to get home. Going to IV medications is kind of going backwards. Not really a great idea in the rehab unit. Also, IV medications are very short acting. So they don't give you a long lasting relief. So usually they only last a couple of hours at best. So, kind of feeding into the cycle, escalating doses. So often patients will need a short-term opiates post-op due to contraindications of other medicines. So, after a major surgery, most patients can't take non-steroidals either because they're just completing stomach problems or renal problems. So many of our patients have contraindications for that. There may be contraindications to other medications because of their mixing, other things are on. So there's like duloxetine, which are great to use in the outpatient setting, inpatient setting, issues with drug interactions that you have to be careful about. Some of those medications that are adjuvant medications those will take a while to kick in before they work. So that rate in the hospital setting where the patient has some immediate pain that you have to treat acutely. So unfortunately we do wind up using a lot of opioids in our post-op patients, but we need to make sure that we minimize their use after they go home. So if it's a fairly straightforward, operative case where they weren't on opioids before surgery, you don't want to make them on chronically on opioids. We really want to limit, but opioids we send them home on. So typically we always send them home with a week's worth and then we have them follow up if they're new to narcotics and make sure they're following up with some meds in outpatient pretty soon after going home. So even the surgeon, we have a post-op pain clinic. Fortunately we have in our institution where we'll be anesthesiologists we'll see patients a week after they go home and man's tapering them off their opioids when at least having them follow up with their primary care physician. Primary care physician is going to do that. In some cases we may have to follow up with them ourselves. So I want to drive home the point that really we're in PM&R, we are life savers. People often think, oh, when they come to the rehab unit they're perfectly stable and nothing happens, but really we truly every day are doing things to prevent the complications and then to manage them and really save people's lives. So, we're of course also great at improving quality of life. So we have that as our major focus, but in order for this to improve quality of life we have to make sure that they're medically stable that they can participate in our rehab program. So for all of you going into the field, one good message is that you really have to get a good general medicine knowledge base. So it's good for you to really use your fourth year electives to expand your knowledge in some of these areas. It's a good idea to do an ICU rotation. It's a good idea to spend some time with a pulmonologist or infectious disease doctors, others, cardiology are all important rotations for you. So make sure you pay attention to those and not just think that PMR is all about neurology and musculoskeletal issues. Our patients have multi-system problems even if their primary problem is a stroke or a spinal cord injury, they have all these other problems associated with. All right, with that, I'll open it up to questions. Dr. Merrill, while we wait for a few questions, maybe you can tell us how you got started into PMNR and what attracted you to the specialty? Yeah, so I went to school with very strong PMNR programs. I was lucky about that. I went to Northwestern, but I particularly, what Gell did for me was my father had a stroke while I was a medical student and he was in rehab at the Institute of Chicago, so I'm sure Ryan was taking it fabulously well and made a wonderful recovery as a family physician. He went back to work eventually. And so that's what really got me hooked on the field was seeing this recovery. But I think it's just a great field. It's a fun field to work in because we all work together as a team. I love the team dynamics. I love the focus on patients' quality of life and not on their goals. It's that we're always, first question to patients, what are your goals, as opposed to spending time fixing lab values for x-rays or other things that other doctors spend their focus on. So not that those things aren't important, but I think we really get into the core of what the patient wants out of their medical care. Questions? I have a question for you, Dr. Meyer. Yes. Thank you for that presentation. I just wanted to ask about when you're working with these complex patients, I was able to do inpatient, outpatient, have a couple experiences in PMNR. It seemed like with a physiatrist that the process was a lot more of a collaborative effort when dealing with these conditions than I had seen in other settings. I'll give some examples to explain what I mean. For example, a patient was still having pain. The physician was working with the patient and really asking them, okay, would you like some more pain medication? Kind of here are the options. Would you like more? Would you like less? As opposed to just prescribing it, writing the order and being out of the room or even with things like consultation, asking the patient, okay, would you like more of this laxative or not? Or kind of where are you at? And so it seemed like this was a space where it was much more collaborative than other spaces. Have you also noticed that? Oh, yeah, definitely. So, yeah, I think you always need to involve the patient in decision making. And I think our primary role as physicians, which we don't often think about, is we're mainly teachers. And we're really there to teach the patient how to manage themselves. So, you know, so getting them involved with these decisions, talking to them about why we're doing, you know, various prevention things. For example, why are they getting the heparin shots and the DVT and having them understand that. Instead of just poking them, don't know why, and then they're angry at getting poked every day. You know, so it's really important to have those discussions. And, you know, also using your whole team and collaborating with your whole team. I think this is a great asset that we have, too. So, you know, having your nurses be the first eyes on the patient, listening to them when they say something's wrong. It usually is. Paying attention to the patient, too, when they point to something's wrong. Yeah, absolutely. Thank you. Anybody else? I put this question, or I messaged it to you separately, but I was wondering about the use of Haloperidol. So I think we had a speaker a few days ago who kind of said that, you know, she tries to avoid its use. So I wanted to know if you could talk about when the benefits of using it kind of outweigh the risks. Yeah. So, first of all, I very much agree that we should avoid using all these medications as much as possible. But there are situations where you have to use something. At least there's some data that the two antipsychotics that are the least harmful, and that's a big, you know, a low bar because they're all okay, are Haloperidol. So those two meds are the safest of the antipsychotics to use. But I would agree that you shouldn't be using them knowing by any means. There's a question in the chat about asking how can we be more rehab minded in hospital medicine when thinking of referrals and better using PT and OT. How we can be more rehab minded in acute care setting? I'm not sure who asked the question. It was Andrew. Hey, absolutely. Sure. How can we do a better job to keep rehab in mind and better utilize the field of physiatry when we're on inpatient medicine and thinking about rehabilitation issues and including them in the patient's plan? Well, we have a very active consult service in our hospital. So we're very involved from day one. We see all stroke patients from, you know, they get to, we get consults from the same spinal cord and trauma patients and ICU patients. So we, we, we start seeing patients right away in acute care and we're an integral part of the team. So I think that helps a lot. And there's, there's, sorry. So there's different tools that can be used in the hospitals to kind of flag patients that are at risk of mobility problems, and then getting received by therapies early on. So we have some protocols that we put in place. We've also put in place what we call our AMP program, activity and mobility program, where we try to get the nurses up and moving the patients in the acute care setting so that they're not languishing in bed. So that's another way we get involved. But I think that it's critical that we view rehab as a whole continuum of care. So it begins from the onset of an acute illness and continues on through rehab, whether they're in the inpatient rehab setting or subacute setting. And then through when they go home and outpatient rehab. You know, traditionally rehab has kind of taken place in freestanding rehab hospitals away from the main hospital, and there wasn't a whole lot of involvement in our acute care. And I think that's a mistake. I think we really need to be on the front lines and really that view rehab as a piece of the medical system but rather as a continuum throughout the medical system. We're not some add on service. Any other questions? These are great questions, by the way. There's another question in the chat box, asking in terms of emergencies in PM&R. It says, I couldn't think of many besides something like a pump dysfunction or a thalmic storm. What is the most common type of emergency in PM&R, or generally a patient with pain, whether acute or chronic? So, pain is obviously one of the most common ones. Like I said, DVTs and PEs are still fairly common even though we do a lot to prevent them. Infections, aspiration, and UTIs, CBF all happen on the rehab units, so those are common. Cardiac problems. And talk about orthostatic hypotension, but that's another big one that comes up quite frequently. So, there are a lot of medical problems to manage on the rehab unit, a real wide variety, and that's why you have to really use all your medical skills. So, don't sleep through those lectures in medical school or during your internship because they're really important. Other questions? I don't see any others in the chat box. I don't know if maybe someone sent them directly to you. Okay. All right. Well, thank you all. For those of you that are MSSCE students, what we'll do is have you sign off, take a little bathroom break, and we'll reconvene at 2 o'clock and just check in with you. All right. Take care, everybody. Pleasure talking to you all. Thanks, Dr. Mayer, for everything. Thanks, everybody, for being here today. Tomorrow we'll be doing cancer rehabilitation with Dr. Lisa Rupert, and I look forward to seeing you all then. Have a great rest of the day, everybody. Bye-bye.

venous thromboembolism

blood clots

prevention

complications

anticoagulants

patient involvement

medical students

general medicine