[JUDITH MEER, HOST] I'm excited to speak today with Dr. Phillip Mirian, a Board Certified Cardiovascular and Pulmonary physical therapist at a major New York City Hospital. Phil, thank you so much for taking the time to join us today, I really appreciate it.
[PHILLIP MIRIAN] Thanks for having me.
[MEER] So I'm hopeful that you can shed some light for patients and their loved ones as people are returning home from the hospitals. You yourself, first of all -- thank you so much for doing the hard work you do. Every single day right now you are treating COVID-19 patients in New York City, which is the epicenter of this pandemic, and we owe you a huge debt of gratitude for your service. Can you can you speak a little bit about what your experience as a hospital based physical therapist has been, and under under what must be some pretty challenging conditions right now.
[MIRIAN] It has been a very unique experience. Our hospital is New York's - it seems to be considered - New York's COVID hospital. The reason I say that is because we've had our entire units, all of our wards, have become COVID except for one we have some clean units. Because people get sick, as usual, so we need to be able to take care of those, but we've really taken on new COVID patients who have gotten COVID-19. And we have mobilized every one of our physical therapists in an effort to take care of these patients. We've also mobilized in ways to help out other parts of the hospital as well, including proning, so since we're not doing elective surgeries, we are helping the orthopedist residents and we're working on proning patients, which means to take them from a laying on their back position, to a laying on their stomach position for the patients who we have on a breathing machine. And we've also helped to transport, and mobilized many different ways to help out in every way we can in the hospital.
[MEER] So let's say that someone has thankfully survived their hospital COVID-19 experience, and they're now hoping to return home, but instead they are sent to sub acute or acute rehabilitation. Could you explain a little bit about what those options are, who decides why someone might go to one option or the other instead of going home, or is the preference right now to send everybody home? What what is it like as the boots on the ground?
[MIRIAN] The major personnel who are responsible for creating this decision are the physical therapists. That's actually one of the biggest roles we have in the hospital, is trying to get patients out sooner and keep them healthier, and then also making sure that they go to the most appropriate place, the safest place that they need to go. So we are trying to mobilize as many patients and getting them home, as much as we can. There are, though, a lot of people who we're sending out to what we call subacute rehab. This is basically like a nursing home that has a rehab facility within it. And so, these people will go 45 minutes to an hour daily to get some physical therapy rehabilitation and a very few subset of people right now are going to an acute rehab. This is a rehabilitation that has three hours of therapy a day. They get it from any kind of rehab service: speech rehab, occupational rehab and physical rehab. But we're, I don't think that we're sending most of our patients there right now, except for maybe those who get some strokes, because there are some kind of clotting issues that are happening. So there are some strokes happening, we'll send them to the place where they need to get the best care.
[MEER] So, that's a really good point Phil, I, I've heard a bit about patients being put on blood thinners while they're in the hospital to avoid the risk of blood clots. Can you, can you explain why that is? What is it about COVID-19 that, that means that might want to be putting people on blood thinners, and what that means for folks when they get home when they start getting back to their life as they knew it?
[MIRIAN] That's, that's one of the interesting things that's happening with this disease process. These patients are undergoing this kind of clotting cascade. And we can pick up on that in their blood tests. So, our hospitals done a really good job at identifying this very quickly, and sometimes even if these tests come back negative, because there is a false positive, excuse me, a false negative rate, for these testings that we're doing, we can kind of pick up: does the patient maybe have COVID because of the clotting cascade. And so hospital's done a great job at making sure patients are on the appropriate blood thinners. And when appropriate, we're mobilizing these patients as much as we can to prevent it. So by the time that people are going home, they may still be on blood thinners, but if they're up and they're mobilizing and they're stable, you want to take just about any risk that you'd -- you don't want to bump into things, you don't want to fall, the things that you don't want to do anyway. But there is a slight increased chance of bleeding if these things happen. So just be careful not to bump yourself or fall.
[MEER] That's really, that's really helpful to know, Phil. I'm, I'm also curious in learning from you, as a specialist in cardiovascular and pulmonary physical therapy, we're seeing that in addition to these blood clotting issues, there may also be some residual damage in the lungs, or the heart. Can you talk a little bit about what that might feel like for someone who has now gone home, or what sort of damage are we are we really talking about here?
[MIRIAN] So this virus, it attaches to a certain protein that we actually have all over our body. So, there might be a perception that it really kind of targets these areas, but that perception comes from the idea that we have these proteins most predominantly on lungs and our intestines, so that's why we're seeing a lot of these respiratory and diarrhea type issues. And so, when patients are going home they might still have a bit of shortness of breath that they're going to experience. And in fact you're sending some of these patients home on oxygen, just because we need to try to make space for the most acute patients. So if patients are safe to go home, they're doing well, we send them home like that. And so, when you're going home, you might also feel quite a bit of fatigue, just because you're getting over this virus. And just like any kind of flu, for example, you're feeling overall fatigue, your body is spending a lot of energy to try and fight this. So that's going to contribute to more shortness of breath, and sometimes some of the patients who are in the hospital for a week or more, they're mostly in the bed. And that's going to create some deconditioning, which further contributes to this shortness of breath, this fatigue, and this difficulty moving around.
[MEER] You bring up a really interesting point there, Phil, about how someone might have this fatigue and shortness of breath, and that could be a little bit scary in terms of getting back to staying active, but they're also - it's also really important, we as physical therapists know, to stay active for our own health and well being. Is there a way that, as someone who is recovering from COVID-19, I should think about monitoring myself? Let's say maybe I'm working with the physical therapist at home or maybe I don't have that option and I am trying to get back into some sort of physical activity. How do I know if I'm pushing myself too hard, what are the best ways that I could monitor myself to make sure that I'm not doing too much, I'm not over exerting myself, but also know that I'm still getting the benefit of physical activity, instead of getting a little bit scared because things just don't feel like, like they used to.
[MIRIAN] This is actually a very scary thing. Especially the patients I'm seeing in intensive care units, once they are ready to start mobilizing. It is very very scary. And part of that is because you know you feel weak, I think, but also because of the breathing. And the COPD patients are a great example to look at this, where you almost feel like you're suffocating sometimes. And it's a very scary, abnormal feeling. So one way to measure that is to know that a little bit of effort is not a bad thing.
When we were kids, we were running around huffing and puffing. For some reason, back then, it was a pretty okay thing, but now we're huffing and puffing it's kind of a scary, strenuous thing. And so a little bit is good, though, because our bodies, respond to stress. But the appropriate amount of stress. So let's say you get up out of bed. You're sitting at the edge of the bed and try to stand up and with that alone you start feeling like that's a big effort. And that you're a little bit short of breath. That's okay. Just a little bit. But if you start walking and you're really saying to yourself, this doesn't feel right, then your body's telling you something probably pretty accurate. So if you were to, for example, put yourself on a scale from one to 10. And you think yourself, you know, if I were to grade this breathing right now, I would grade the amount of effort that I'm putting in. And I'd say, it's like a seven out of 10, then you're on the verge of really pushing yourself kind of too much, just because we don't have that reserve yet get as we get over the virus.
But, if there's a little bit, and you're walking and you're a little bit out of breath, a little bit of effort that you're not used to, it, it's okay to push yourself in that way. And that's how, one way you're gonna get better, as a matter of fact. Another good way to measure is with a pulse oximeter. This is gonna measure how much oxygen is in your body, and sometimes shortness of breath isn't the indicator that we're not getting enough oxygen, but in this case, it's much more likely given the pathology of the virus. And so if you can get one of those $20 device from CVS or get it from Amazon, you want to make sure that if you're up and you're walking around, you really want this number to be 92 or above if you can, but absolutely no lower than the number 88.
[MEER] I think that guidance is going to be extremely helpful both for physical therapists who may need a little bit of a refresher on how to work with folks who are having that shortness of breath, and personal trainers as well and definitely for people as they get home and might not want to get out of bed, if it feels a little bit scary, so I really appreciate those insights. Phil, I know you have to run and get back to the hospital. Do you have anything else to add, any thoughts that might be helpful for everyone back home?
[MIRIAN] Um, the only other thing I want to mention is something called PICS: post intensive care syndrome. We might start seeing maybe a bit of a bump in patients who might have this. And this is associated with anybody who's been in the ICU, and intubated or have the breathing tube, for upwards of seven days or more. And it's really marked by cognitive, behavioral and physical impairment that can be seen for many years to come. Cognitive impairments can be instances of memory loss or difficulty maintaining your job sometimes. Behavioral issues can be depression or these type of issues, and physical is just more coordination, strength and endurance. These deficits become very very profound in the intensive care unit because everything that these patients have to go through. And I just want to make sure that families, and any healthcare provider, physical therapist, anybody who has access to the people who've undergone this really kind of looks out for this, and can identify to take care of these patients well.
[MEER] That was really helpful to know as well. So that was PICS: post intensive care syndrome. We'll be sure to include some resources about that on the, on the website. Dr. Philip Mirian, Thank you, thank you so much for joining us. Thank you for being out there in the field working with our COVID-19 patients, our friends, our loved ones, our relatives. We owe you a huge debt of gratitude, as I said, and I really appreciate you taking the time today to speak with me and to get some good information out there for, for patients, for families, for clinicians who may start treating these patients pretty soon so thank you so much, Phil, really, really appreciate you taking the time.
[MIRIAN] I hope it helps. You take care.
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