He has agreed to host all of these videos on their website, at least through the end of 2020. So if you have been unable, if your colleagues have been unable, or you're aware of programs that have been so overburdened with the COVID-19 outbreak, or if this is just a bad time of day for you, these will be available for your review, at least through the end of this calendar year. So with that, we will move on. We have gone through some of the goals. As always, we're gonna keep everyone video and audio muted. If you have any questions, my name is Sterling Herring. I'm a PGY-3. I should be at the top of your list or near the top of your list. You can double-click my name under the participants button and send me any messages for content-relevant questions that may come up during the course of the lecture, and I can present them to our lecturer at appropriate times. And of course, general questions can go to Candice there at her email address there on the screen, or you can find us on Twitter. So without further ado, we're excited to have Dr. Haig with us. Thank you for joining us, sir. Hi, everybody. Hope you can hear me. I just finished up lunch. Wanted to have a safe drink before I started this lecture. Gonna get out to my slides, and I hope that works. So here we go. Yes, continue. Please let me look at my desktop. I'm viewing Sterling's screen. Sterling, I want to view my screen. Let's see. All right, should be able to. Oh, here we go. Yeah, we're coming. I just got to get to my slides, which are these. Here we go. Give me a thumbs up or a screen if things aren't working out. So most of you are either in the middle of the panic or the beginning of the panic or the end of the panic, and it's a crazy time for everybody, and we're in the same place. So I want to introduce myself, talk about what we've been doing, and hopefully give you some tools to use for this, and have you get involved in the kind of stuff we're doing. Dr. Hague, I'm not sure that we're seeing, I'm not seeing your screen. I see my screen. Let me just back up a minute. I'm gonna escape. Should be a button that says share my screen or something along those lines. Yeah, but hold on a second. Stop video share. I got to shrink this down and find you again. So share screen, I'm trying it again. You stop the other, continue. What are you seeing, Sterling? I'm just seeing my slide. I think you have to turn yours off because when I go share screen, it says this will stop the other screen sharing. Do you want to continue? I say continue, and it's obviously not cooperating. Oh, so I stopped my sharing and now I see your face. Oh, that's, I'm so sorry. But let me get to my screen share then. Hold on a second. Back now, now I should be doing a screen share and it should share my screen. And are you seeing my screen with a bunch of words on it, basically? I am. Okay, let me get to the slideshow then. Okay, guys, here we go. So first, my entire life story, right? Which goes, let me get rid of this thing here. I live in Vermont right now, but I, where are we going? Come on, slides. Started in Wisconsin, went to RIC. My first job was here at UVM. They have a total of four rehab doctors. And check this out, in all of New England, outside of Boston, there are 10 medical schools, not a single doctor training in our field. So New England needs help. As a result of that, I skipped out and went back to Wisconsin, worked up north, then spent most of my career at University of Michigan. And with family and other fun things to go, decided, okay, I can retire as soon as possible, and came back here to the mountains where either we're cross-country skiing or biking or paddling, depending on the weather, or sitting in the rain. So there's Bridget and I. My, come on, slides. My son, William, is with us now. He had been skiing, and he's what brought us here a little bit earlier than we planned, but we always plan on retiring here. And a person worth knowing about as we do this is my brother, Tom, who, after I became a spine expert, had a spinal cord injury. And Tom is my co-leader of this group called the International Rehab Forum. And when I'm talking to primary care docs, I talk about people being in pain and having disability and saying they don't match, but that's the point. Yeah, yeah, okay, right. So the IRF, that's our website, and you're gonna come back to that over the lectures. We're a not-for-profit consortium supported by universities and individuals. I use the word supportive with a small s, like our total budget is about $1,000 a year, but this is a group that has a lot of influence, as we'll talk about. Our mission is to build medical rehab where it's needed. Our vision is to fill the gaps, which means we kind of, we're a disruptive innovator sometimes. We're a lot of times a leader where others haven't led. And often, we can move faster than the powerful organizations that should be leading, and then our job isn't to beat them up. Our job is to hand it off to them and help them, and I'll show examples of that. I started with the IRF after I'd done a whole bunch of NIH research and other stuff on spine and work disability and got adopted by this world-class leadership guru in our business school. And he's like, you know what? Quit doing the technical crap. You gotta go lead people. And it kind of inspired me that we need to do something to help others get strong in rehab. So this is kind of what I've been focusing on the last decade. While I've been doing EMGs and back pain and stuff like that. So disruptive innovator. Anybody wanna interpret this slide? Number of physiatrists per 10 million people, Africa, Antarctica. When we submitted this to the journal, they said, you know, you forgot the data. And I said, no, actually we didn't. Here's the second slide. Above Adelaide Penguin in Antarctica, below Homo sapiens in Africa. Both have a statistically similar chance of interacting with a physiatrist. Note that the penguins all have legs, right? So this is a paper we wrote. It was called the white book on physical medicine and rehabilitation in Africa and Antarctica. And it was kind of a joke based on the white book on rehab medicine in Europe, which is an international standard for rehab medicine. And it was a big, funny, funny joke, ha ha ha. But guess what? Only article in the history of medicine that got published in five international journals simultaneously saying, what the heck, man? There's only seven rehab doctors in all of Africa. What the heck? The International Society of Rehab Medicine, which is the WHO liaison officially, had no Sub-Saharan Africans in the group. So nobody represented them. And me, a white guy from Wisconsin was the Africa representative when I started raising trouble. But what happened is when journals saw this, they were in shock. And when the WHO saw our stuff, they were embarrassed into changing their policy. Before this, the WHO policy for poor countries was community-based rehab, getting the grandmother to take care of the kid with cerebral palsy. And so in this article, we advocated community-based brain surgery, teaching grandmas how to do craniotomies. And it didn't go over well. It kind of embarrassed the WHO to the point where now the World Report on Disability and WHO Rehab 2030 cite this article over and over again, saying that governments have an obligation to train people in rehab medicine, not just to train grandmas how to do the work of a doctor who's in the middle of a four-year residency. Leading where others haven't led. So now what? You know, we started holding world congresses with all 40 of us or all 60 or all 80 of us, right? So like in Bangladesh, we held one of our world congresses. Bangladesh is a tough place to go to visit, right? And we had enough international folks come. But what really happened is, and we knew it, and we did it in the middle of an Islamic riot. So it was the only meeting I ever got smuggled to in the back of an ambulance through the riots, right? But the minister of health had to come and cut the ribbon, give a speech, and his speech was, and as a result, our national hospital will open up a 40-bed rehab unit, and all my Bangladesh friends were slapping five, and we all felt that road trip was well worth doing, right? Well, now we got Sub-Saharan Africa. We called out the problem. We did make people look foolish. What are we gonna do? Well, we started the very first English-speaking fellowship in Ghana and Ethiopia where there are no rehab docs. So how do you train fellows without rehab docs? Like this. So up there is my buddy Sisay in Ethiopia, and Tesfi in Tilihun is in the corner, and Abina in Ghana, and Una, who's at Mary Free Bed as a resident, is coordinating this, and there's me. And at 7.30 in the morning Eastern time, or seven o'clock in the morning Eastern time, every Tuesday and Wednesday, we had these lectures. And in addition, we had visitors and skill sets and other people. And January, right before COVID, I flew out to Africa to kind of hold graduation ceremonies, more or less, for my Ghanaian and Ethiopian friends, and just barely made it back home before everything crashed. But they are now fully-fledged, legitimate, trained rehab medicine doctors for their countries, and they now can become the faculty. All of you can help us next year when the damn COVID thing is over, because we need teachers and volunteers and travelers online and in person. But we actually did it, and we not only caused problems, but we tried to solve the problems. Moving faster than powerful groups should be, should, who should be responsible? Like disaster rehab. So this is in Pakistan. Take a look at that river. Now take a look. See all the white? That's what it was. That's what it was a few hours later. This is what it really looked like, right? This is an earthquake, and there's people looking for their missing family. This thing disappeared on me. There we go. Looking for missing family members, people buried in the stuff, and then this kind of thing happening, right? This is a scene we've seen too much, right? What if that woman on the right has a spinal cord injury? She now has a complete spinal cord injury. It's kind of cool. Okay. What if they got transferred by helicopter instead of by stretcher? Oh man, it costs so much money, right? So this guy, Farouk, oh, he keeps skipping forward. I'm sorry. This guy is Farouk Rathore. He was a resident at the only training program in Pakistan, and he and his buddies commandeered a women hospital, and one day they had a bunch of admissions, like 200 admissions of spinal cord injury, right? And these residents and their faculty, but honestly, Farouk and the residents get all the credit. They basically took charge. They did functional assessments. They did ultrasound for DVTs. They did everything you do when you have four admissions one day on a Friday night and you're pissed off. They did it on 200 people, looked at functional outcomes. Total answer is nobody died, two new babies, right? When people were admitted to other hospitals, there were deaths. Nobody came in who was quadriplegic because everybody's quadriplegic died on the streets. And the people who got helicoptered in had less nerve damage than the people who didn't get helicoptered. Bunch of residents doing this, right? They are my heroes. So I emailed this guy and said, who the hell are you? What's going on? And Farouk went on to really work with us to start founding the field of disaster rehabilitation. Jianyun Li in China is a senior guy there and he'd been doing some work in their earthquakes and they actually had a, not a randomized, but a controlled trial of one city where they had rehab acutely and one city where they didn't. And less deaths, less disability, et cetera, et cetera. Now in China, whenever there's a disability, an earthquake or a disaster, they have a ready rehab team that needs to respond. So we held this meeting in Turkey, pulling together people who had been involved in disasters. It was the first meeting ever on disaster rehabilitation medicine. What do we have to do? Pretty quickly afterwards, is that on my slide? Yeah, Haiti happened and I broke my arm and I couldn't respond. And I was doing this. I was calling up the US Navy saying, you guys, you built that, you put a hospital ship there, but if you don't have crutches, they aren't going home. Hey people, I know who's been doing stuff in Haiti, Colleen O'Connor and Jeff Randall have been in Haiti for decades. They know the language and the culture in rehab. Hey, pay attention to the experts, to which nobody listened. And then about a week later, you saw the New York Times article. Nobody's leaving the tent hospitals because they don't have legs, right? So we kept on screaming, you need rehab from day one. And they kept on going, but we're good at this. We're emergency medicine doctors. And as a result, they had people living in their tent hospitals for a long, long time because they didn't have crutches. They didn't have family members ready. Nobody prepared them. Nobody taught them. Pay attention, pay attention. We got a disaster in the US, right? So anyhow, so we then had a couple other meetings and eventually handed this off because our job isn't to run the whole fricking world. Our job is to lead and get things going to the International Society of Rehab Medicine, which you all can join as AAP members. You have free membership, put it on your CV. Just talk to the AAP about this. It's a great advantage of being an AAP member is you're automatically for free a member of the International Society of Rehab Medicine, ISBRM. So we handed it off to them. It's now the biggest, most popular committee there. And they answer up to the WHO and deal with disasters, okay? So there, that's what we wanna do. Put together a training modules, et cetera. Let's get to COVID. They get sick. They get restrictive lung disease. There are neurologic consequences, which are kind of, we're learning about them, right? Some of them get major brain disease. Like their brains really get like an encephalitis kind of thing. Some of them get peripheral nerve diseases. I've seen case reports of Guillain-Barre and this is all starting out. And then there's the subtle stuff. You know, it's just really rude to hold your breath for hours at a time. And hypoxic brain damage and other CNS disease that makes it so that they're not doing so well, right? But they already were sick. And this is the lesson of things like the floods in New Orleans, right? The assumption that the average person is average is really, really stupid. There's a breadth and scope of functioning and abilities in a population. I always talk about the chairs you're sitting in. If they're not adjustable, those chairs were designed for a five foot, 10 inch dead white criminal in Cleveland, Ohio. Because the beginnings of ergonomics had to do with an assumption that means and standard deviations describe the population. They took a bunch of bones from dead white criminals in Cleveland, measured them, came up with means and standard deviation and say, on the average, this chair will fit a five foot, 10 inch dead white male criminal. And then made all the chairs, right? And we know that that's not true. Ergonomics has moved forward, but emergency medicine has only recently begun to realize the breadth and scope of people they are dealing with. And as many of you may know, in New Orleans, they failed to evacuate people with disabilities. They turned off ventilators and killed them. People got pressure sores, people got amputations because they came in with stuff. So what do we have here? This population is at risk because they have diabetes, obesity, heart disease, they're older, right? Then you add COVID, and then you get stiffness because their arthritis is getting worse because they're lying in bed for a month, right? You get strokes because they aren't doing so well. Peripheral vascular disease for the same reasons. Bed sores, other, you know, foot sores, other things like this. So they got wounds to heal. And then you guys know this, this is like, like, is this the first lecture you had in residency? You know, what happens when you take some young marine, marines that were conscientious objectors in the Korean War and lie them down in bed for two weeks, right? Basic science of rehab medicine, deconditioning syndrome. They're weak, they're orthostatic, their cognitive function declines, their emotional function declines. And of course these people get PTSD because they're lying on a ventilator thinking they'll never see their family again. And they begin to develop a catabolic state where they're eating up stuff instead of healing stuff, right? And then you take a look at other aspects of rehab, like who are they plugging into? And what you see is, you know, the usual stuff, you do this every time you do a consult. Is there family support? Are there stairs going upstairs? Do you have a walker at home, a toilet seat? You know, do you have the social support you need outside for money and food and heat and stuff like that? Except now what you have is they can infect their family. Their family themselves may be sick. Their finances are in ruins. And the outpatient resources like that home health agency or that PT place they're gonna go to are really, really limited. So we have a huge challenge related to COVID-19. So the usual way is, you know, I'm an acute medicine doctor, I'll call rehab medicine maybe, or wait around till they're stable and then we'll call social work and we'll send them home, send them to a nursing home or to a rehab unit. But any delay, a one day delay occupies a precious bed on an acute hospital ward. And your acute hospitals are filled up with these people, right? Getting them out one day earlier isn't just a thing that helps get Medicare money. It's a life and death thing to get people off their vents and out of the ICU. And so anything we can do to help these acute doctors is a really big deal. But the acute doctors don't know it. They take you guys for granted, okay? Waiting worsens their outcome for the patients, right? So we've started this campaign called Rehab for the Day of Admission. And what it involves is determining pre-morbid disability issues, making sure the patients stay active, putting together psychosocial evaluation and supporting them, and beginning the plan at the very beginning with the patient and the families. You know, if we're gonna win the game, we gotta win the game, right? Let's talk about how you do this, okay? It's kind of funny with COVID what we're doing. And if you ever decide that you're gonna go help in a low-resource country or volunteer in the inner city or something like this, what you need to realize is that your role, unless you're planning on living there, your role is that a catalyst to help something that the local people want, okay? We're not selling ice cubes to Eskimos, Inuit, please. You gotta make sure it's something they want and need unless you're gonna stay there and ram it down their throats, okay? So first thing we have to do in Africa, in Haiti, in Asia, is come up with what they really, really need at that stage and then get behind the leaders and help them, right? We're a catalyst, we're not adding energy, we're decreasing the energy of engagement, right? So what does it mean? First of all, we have to help them realize that there is an opportunity to do better, okay? How do you get the word out to people all over the world who are not rehab medicine doctors? Then they're gonna wanna do something, like, right, wow, this is good. But they may not act because they don't know what to do and they won't have time to plan and decide. Talk to your hospital president sometime. Well, you won't be able to because they're too busy running from crisis to crisis and keeping staff from quitting, right? So a catalyst is to lower the barriers to action. So here's what we did. The African team and the Americans, actually, just, I think it's three weeks ago, we're at our weekly conference and the African doc said, oh my goodness, you know what, our hospitals are so clueless. You know, you Americans have rehab doctors, we're the only doctors in our health system and our hospitals are just gonna send them home to die. And I said, well, actually, my local hospital here in Vermont is no better. So we started saying, what are the issues? How do we solve the problem? So much credit to Avina Tanner in Ghana and Ghana and Sise Gisa in Tesfai Berhi and Telehundesta in Ethiopia because they're driving the question here, right? We decided we had to design some tools for the administration of hospitals. How do you lead? For the acute care nurses, how do you take the place of a rehab doctor when you are running around with masks on? And more than ever to engage the patients and family in doing rehab problem-solving. Some patients and family are incapable of this, but if they have any capacity to do something, let's get them to do it instead, right? And then to raise awareness. So Facebook, Instagram, etc, etc. Yeah, Facebook. Yeah, okay, you know, never mind. I don't want to say that because I feel bad as a boomer, right? But press releases, we're fortunate. My sister Barb is a former talking head for a TV station and she consults on media relationships. She knows how to do this. And we spammed every national and international organization we could think of in rehab, in disaster response, saying, hey, we got these tools, right? So I think, I'm gonna keep, I'm gonna switch over now to our website stuff. So here's our International Rehab Forum website, right? And it's rehabforum.org and you get to tools.html and you get, you know, these different news things. There's a really tacky TV show I'll show you if we have time. It's really tacky because I was exhausted when I did it. But then tools for administrators, tools for medical staff, tools for patients, and of course finding other resources. So walking through this a little bit, here's an administrative strategy. It's a bunch of bullet points because they don't have time, right? But let's take a look here. And you can just pull these down too, right? So, you know, they have to realize getting home after rehab, we give them reasons, hospital bed scarcity, the resources are out there, the lungs and things like this. We've walked through that kind of stuff. We acknowledge there are limited resources and the fact that rehab medicine doctors are just really scarce around the world, that the therapy professionals aren't available because they're overused, they're sick. At a local hospital, one of these, a lot of therapists aren't showing up for work, right? And this is what's expected when there's a medical disaster like Ebola, right? And then we say, okay, so on admission the patient family fill out some of the patient success tool and they get the getting home handout, which I'll show you. This poster we put together is everywhere for patients. There's a secret thing about when you put up patient posters. We've done this for back pain programs as well. The nurses read them, okay? So these are designed for patients, but they're actually something that the medical staff in the hospital begin to walk past every day and they get bored, right? And these exercise videos, U of Michigan is supposed to pull one together for us pretty soon, but we made a really tacky little one, which you can see a little bit of in a minute. And then weekly, the nurses and patients don't have to do paperwork, they don't need more paperwork, but they just look at the form and say, hey, how are we doing? And on hospital wards, they have to figure out if they have to educate the patient about some things. On the week of discharge, they have this discharge planning tool, okay? You guys know how to do this, but we got to teach the acute hospitals that this is what to do. I suppose even if you quizzed an ICU nurse, they'd say, yeah, we know about that, but doing it is something, right? And then for the patients, these bedside sitting strategies, okay? Sitting in a chair is exercise, you know that, right? Getting orthostatic is a good thing, right? Simple weights are like rubber bands and cans of soup. The patient getting on their cell phone to connect to some of these things, they don't use transfer belts and sliding boards because they always have 12 nurses, right? But now this is a place where they're understaffed, so they need that kind of tool. And then, you know, these resources, the virtual consultation with you guys, right? I'm going to ask when we're done if anybody's doing virtual consults in the intensive care unit or not. So you can pipe in with notes about that. Virtual in-person therapy, speech, PTOT, rapid team triage, which I may have time to get to, and making sure they actually have a supply of these things. They think about face masks, they think about walkers, you know, they're going to be a bunch of them for people, right? And then, did the hospital really make a contact with the acute rehab hospital? Imagine, of course, your hospital may be associated with a major university hospital, but imagine the community hospital here in Vermont, which thinks they're going to admit people to the four-doctor rehab unit at the University of Vermont. Well, have they ever talked to them about whether the hospital is able to accept them? The post-acute rehab facilities, on the news they sound like deathtraps, don't they? Right? Another nursing home with everybody dying, right? What's the rule there? How are we going to get people to post-acute, or will they not accept anybody? Or can we, as the expert team, develop a 20-bed ward in the post-acute facility that deals with our patients, right? Home health agencies and outpatient therapists, you know, the universities often have this monopoly of, like, send them to our therapists. Well, they're a little bit overwhelmed, and the private therapists are, like, holding up their tent, you know, just doing online stuff, maybe. If you need those therapists, can you organize those outpatient therapy groups to be active, to help out, to bail out your therapists? Again, politically, for major university systems, that's the competition, right? Get over it. These are the people that help your therapists, and places like hospice, unfortunately, right? And then the assessment of the patient. What can they really handle, right? What telemedicine when they're an outpatient? How can admission and discharge processes be done? And then, actually, we put this together, because you can come up with the greatest theory of whatever in the world, and if you don't have a feedback loop, it dies, okay? We were doing a research project on spine patients at Michigan, and our faculty, I ran the spine program there for a long time, and the faculty were really kind of inspired to look, find every person with spinal stenosis. It flopped, because we didn't get feedback that says, you know, hey, Tony Chiodo, you missed one, you know? Hey, Matt Smoot, you know, you look at all last week, you never sent those in, but, oh, shoot, I gotta, and we eventually had to change the process, instead of changing, instead of yelling at doctors, right? So, whenever you put together a program, you gotta get quality assurance it doesn't happen. So, we're spoon-feeding the administration, getting quality assurance assigned to a non-clinician. This doesn't require a clinical role. Having a local leader, they can contact me, I'm putting my face out there for them if they need it. Percent of people that got the screening tool filled out, percent who had a tentative date of discharge from the day of admission posted on their bed, right? How many got that poster? How many got the discharge checklist before they left? You know, gathering data weekly, analyzing weekly for the first month, then backing off a little bit, and we're hoping they share the information with us, so that we can get some, some cumulative data. And then, if they have time, looking at mortality, readmission, institutionalization, Barthol index, which we'll talk about, satisfaction, caregiver satisfaction, etc., etc., right? So, this is a machine that people are using that's going to teach them how to, you know, be efficient with this. By the way, if you pull this off with your hospital, it's a really great research paper you can publish and become famous. That's my whole thing. Let me back up here a little bit. For the medical staff, we have a couple of things here. Sean Smith, before I left Michigan, ran all kinds of things, and one of them was the cancer rehab program, and my young punk protégé was Sean Smith, who's just become a fantastic leader. And together, Sean and I were looking at cancer patients and saying, wow, so how do you, how do oncologists identify who needs rehab? You know, you need rehab because you're gonna die, and sometimes you need rehab because we saved your life, and sometimes you need rehab six months later because the radiation therapies caused the problem. It's not as easy as a stroke or a spinal cord injury. So, we came up with the cancer rehab screening tool, which is a tool that's asked the question, and I all of a sudden went, wow, we need that for COVID, and I switched it over, put it online, and within an hour, Sean texted me and said, hey, Andy, do you mind if we use the cancer rehab screening tool as a COVID rehab screening tool? So, this survey on admission helps patients to understand where they're at, right? So, pain, function, how before the illness, and then right now, this is the Barthel index, which doesn't deal with cognition and speech. It's got weaknesses, but it's simple, right? And going home, can you get in and out of the house? Can you get in and out of the bathroom? Do you have food, water, heat, and somebody's gonna be there? The week of discharge, have assistive devices, medicines, family support. I've been connected to rehab. When I get home, I feel I'll be safe. I think I might fall. I might fall apart emotionally. I think my caregivers will fall apart emotionally. I got enough money to survive the next month in an open. Do you have any other things, right? The next tool, if it looks like they're not gonna make it home, then Sean's modification looks like this, and this is kind of neat if you guys want to use this for other stuff, too. By the way, all these are copyrighted either by University, this is one University of Michigan, all the others by the International Rehab Forum, with explicitly statement that you can use it for academic and clinical purposes. They just can't have somebody steal it from us, change it around, and make money off of it. So, these are copyrighted so that you can use them, right? So, you know, are they using oxygen? What's their cognition? How many steps to get in the house? Some of the same questions here, what can they do right now? And you add it all together, and Sean's got a nice score that hospital staff can use that says, whoa, they're not quite ready to go, okay? The next document here is the discharge planner, which is very, very simple. Got the equipment, bandages, supplies, etc., etc. And then Hannah from Spalding, new faculty member who's going to be a leader in global health someday, has this really neat COVID clinical guide, right? What to do, what's going on. It's worth reading for you guys, really kind of well done. When you get down to the medical, sorry, to the patients, my daughter Molly's a graphic designer, and thanks to Molly, we have this poster that goes in the clinic, right? And the point of a poster, again, is there's lots of stuff here, but the themes need to teach staff. Get psyched, get your head together, don't do it alone. If you're overwhelmed, talk to your clinician. Get strong, do something that makes you breathe hard and get tired for a half an hour every day. Do light squats at your bedside or lift your legs up and down. Get organized, all the things we talked about for discharge. Get prepared, make sure you can eat well, pooping is important, we like that. If you have other disabling problems, deal with it and get flexible, do some stretching, right? So this poster, you can just print it out, use it, and it tends to help the patients and staff to understand what they need to do. And then the patient handout, which is less fancy, but it's the same kind of stuff, right? So the hope would be that this gets handed, oh, we got second page of blankness. This can be handed to family, like, hi, your family is in the hospital, you can't visit them, but here's what you got to do, right? You don't have to invent this, is the whole point. And then Preet Rana, I got, so Preet Rana is the global health librarian at the University of Michigan. Ain't many of them in the world. Preet is my buddy, and she knows so much about resources. She also is recovering from COVID, and in the middle of her being pretty sick and recovering, she started giving us all kinds of other resources, and we'll flesh that out in some great detail. So I'm gonna end up the formal part of this talk by putting us back onto the slides for just a minute to give you the website. Here we go, rehabforum.org. So here's the deal about rehabforum.org. For a few years, as I left the university and other projects were going, the organization has really not focused on getting you all involved, but we are back at it. As of the last AAP meeting, we actually planned on holding an American meeting and a global meeting in Ghana. Those are both on hold until we get something going, but I encourage you to join us on Facebook right now, which is really hacky. I know, I know, you know, boomer the whole bit, but that gets you into the list of what's going on. This tells who we are. Hi, I'm Jane, or I'm Fred from the residency, and I kind of want to, whatever. And then we're gonna regroup and kind of get a much more formal list of people that are really, really involved. I mean, you know, my cousin joined us on Facebook, and she doesn't care. She just cares about us, right? If you have any questions, or if I can help, andyhaag at umich.edu still works. If you put at med.umich, it crashes because that's inside the system. I'm going to get back to putting my face up here and popping up to answer questions, I hope. Hang on a second. Stop share, and excuse me. Am I on video? I hope so. I'm looking at chat, and let's see. I'll be glad to answer other questions if people have them up on chat. Yes, sometimes they'll send them over to me. So there was someone that asked, you were talking about non-physician, the roles of non-physician providers are momentarily, and there was a question about your thoughts regarding the CMS proposed rule a couple of weeks ago for non-physician extenders instead of rehab docs in inpatient rehab facilities to kind of fill all of the roles or responsibilities that were, that have traditionally been attributed to or assigned to physicians. Any thoughts on that, and how is your group approaching that? Right, it's a mixed bag, and that's a really, really good and complex question. At some basic level, CMS is saying, any port in a storm, let's rock and roll, you know, let's go get help. And in primary care, that works pretty well, you know, freeing up nurse practitioners and PAs to do things that are part of what they really are well trained at. In rehab medicine, it also may be very necessary. So I don't think I want to have a strong opinion that it's bad or good for now, but I want to point out the good and the bad. The good is, okay, we have lots of friends out there who've been sitting in team meetings forever and kind of know what we're doing, right? It's like, I kind of know what a physical therapist does, and I can go be a PT, but frankly, I think my PT friends are smarter at what they do, right? The challenge is borne out both in my experience in the United States and especially in my experience in Africa. Over in Africa, with only seven rehab doctors all in South Africa, I kept on trying to build rehab by recruiting my friends in physical therapy to do it. And they're smart, they're smarter than us. What was interesting is, by and large, they couldn't do it. In fact, my friends at University of Ghana were committed enough that somebody came over and spent months with me, and their conclusion is, nah, we can't quite do what you're doing. So when this occurs, there are some true weaknesses that are something than nothing. And it goes like this. PAs and nurse practitioners, unless they've been in rehab, really don't get it. They really don't get discharge from day of admission. Team meetings need to run like this. How do I make a dumb speech pathologist into a smart speech pathologist? How do I really organize and keep a team going over a lifetime? Even as residents, you may not quite appreciate that because you get skipped from service to service to service. But someday you're going to own that team. And leading that team towards greatness in the long term is a different thing from showing up and having a nice meeting with your friends, okay? So this doesn't happen well from the rank and file. And especially PAs or NPs who are trained in general medicine struggle with it unless they've spent a lot of long time in rehab medicine. Physical therapies, occupational therapists, speech language pathologists, but especially PTs, because they're our biggest allies here in many ways, often don't really quite understand the sophistication of what we do. Like when do you add a spasticity drug? Why would you inject steroids into a joint now instead of having a PT work on it for a month when they've got bigger things to work on? What do we do for the mental health problems? Do we use a drug? Do we get the counselor to work harder? There are these medical decisions that they kind of take for granted, just like our acute care doctors take all the rehab for granted. Many of our colleagues in a single allied health profession, boy, they're smart. And I'm just trying to draw a contrast so that we're aware of the strengths and weaknesses. So, you know, this is no critique. But you may find that that social worker doesn't get the medical sophistication or that the PT doesn't quite know where the speech pathologist fits in, just hopes that they do. And so the coordination may fall apart a little bit when you get an allied health professional leading the team. The ideal in Africa, the ideal in a crisis here, is what my colleagues in Cuba, in Malaysia, Indonesia, and other third world or low-resource countries do, which is do you have the hub and spokes and spokes? You've got a really great, functioning, world-class rehab team. People who don't need that sophistication have something that's pretty darn sophisticated, but there's an automatic process where you call up the experts, right? Maybe a simple stroke doesn't go to the university hospital anymore for a while, right? But if it's a stroke and all of a sudden something weird is happening, their legs getting amputated, you know, maybe they go up there, right? And then beyond that, you've got the community hospital level, right? So as leaders of this, as the people that really are experts, you rehab docs need to look around and not say I'm doing my job and those PTs at that hospital are running things. It's more like you need to say, hey, let's develop some processes where automatically I do what I have to do and you do everything else. So the triage process from hub to spokes to smaller spokes is something that the rehab doctors have to lead so that these allied health professionals can do the very best they can. Long answer. Yeah, no, that was helpful. I think you put it into a greater systemic perspective, so thank you for that. Not seeing any further questions. Do you have contact information that we can share in case any questions do come up? Yeah, a couple different ways. So first of all, AndyHague at umich.edu. That's A-N-D-Y-H-A-I-G. There we go, at umich.edu. Thank you very much. Don't hesitate to bug me, okay? I encourage you to pop on to the Rehab Forums website and I encourage you to Facebook us. It's so old school, but we are really kind of redesigning and rebuilding things and soon we will ask everybody on Facebook to send us real information so that we can collect us all and get newsletters out and do a much more organized way of capturing all of you experts. If you have any interest in the longer term of getting involved in global health, this is my, I'm spinning off because I have another minute here, right? Please be in contact with us. We're looking at building the careers of people in rehab medicine who want to be involved in global rehab. There is, you know, there are grants to be had, there are careers to be built, and even if all you want to do is get online and help teach and organize, there's so much that we're starting now and as COVID fades away we're going to be doing later. The fellowship, you know, knock on cement, is going to start up in October with a whole new group of fellows and a couple of real faculty there. So jump in with global health and ask us for help and ask our team for help if you have questions about the COVID thing. Excellent. Thank you so much, I appreciate it. So people can reach out to you directly there at that email address, they can track you down on Facebook, and again if anybody knows someone that wasn't able to watch this lecture who they think might be interested, they can go on to that website, physiatry.org slash webinars, and the links to all of these videos are posted there. Any questions about this, obviously reach out to Dr. Haig directly or to me or AAP there on Twitter. Thank you again, Dr. Haig, for joining us. Yeah, thanks. You guys are my heroes because you're actually in the trenches and I'm sitting up here in Vermont. So keep going you guys, good work, thank you. Thank you.

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