I'm Heidi Engel. I'm a physical therapist at UCSF Medical Center in San Francisco, working in the intensive care unit, and I'm here to talk to you about creative approaches for early mobility in patients with COVID-19. Here's what I'm missing from the ICU prior to COVID-19. I'm desperately missing our family members and their ability to interact with and comfort their loved ones, our ability to communicate directly with them, and to make a human connection as part of the mobility experience. It's not just the family that the COVID-19 patients are missing. It is also our ability to communicate easily and reduce their sense of isolation by walking in the hall and walking to the windows and having that sense of broader movement and a perspective on the outside world. In our experience, the severely ill COVID-19 patients require prolonged sedation, sometimes paralytics, prone positioning. It takes us a while before we can actually start to wake them up and mobilize them, and then when we do, they're in a negative pressure room with a noisy engine creating the negative pressure. We are dressed in all this extensive personal protective equipment, and we're shouting through the masks and above the noise of the engine in the room. Meanwhile, the patients require our vigilance because they can be hemodynamically quite labile and surprising and develop neurologic symptoms we weren't necessarily expecting. So how can we get around or work through all of this and still provide the mobility care they really need? More than with any other patient population I've treated in the intensive care unit in the past, COVID-19 patients' resilience is deeply tested in terms of how they are able to recover from the severe critical illness and the prolonged amounts of sedation in ventilation they tend to require. So we still need to look at and examine the amount of physiologic reserve, comorbidities that are brought to the patient in order to know how much we can challenge them in what types of mobility interventions we provide. Currently, I still rely on the A2F bundle to help me understand when to begin mobilizing these patients, and typically we can begin at the same time that they are able to start tolerating a spontaneous awakening trial and a spontaneous breathing trial. So it requires a level of teamwork and coordination across the disciplines for us to come together and realize it's time to begin mobilizing the patient. Thus far, the timing has worked out as well as it ever did, although I'm having to wait longer for the patient to be able to tolerate spontaneous awakening and breathing trials. Once they do, and once we can begin the mobility and having their systems adapt to the upright world, having their systems adapt away from the sorts of things that create ICU-acquired weakness and frailty, which is lying in bed or passively being repositioned as the only intervention for their mobility, as soon as we can allow them to adapt to being on their feet and moving again, they have surprised me and astounded me with how well they can progress back to being on their feet and walking again. So we are meeting the challenge of this difficult disease and the environment it requires us to keep our patients isolated in by having families give us photos to decorate the room for the patient, by asking the patient a lot about who they are as a person, still providing that sense of human touch and humanity when we work with the patient to help get them up out of bed, trying our best to be a consistent provider so that they have a familiar face that they recognize when they come into the room, even though it's just a slit of our eyes through the PPE, treating, of course, their symptoms, their pain, their anxiety, and with sometimes things as simple as a warm blanket or music. We celebrate the milestones, such as the first time they're able to stand up away from the bed, and we often will have a computer screen in the room or an iPad with the family zooming into the mobility session while it is underway. We can still bring humanity into the ICU room with us despite the isolation and the barriers, not even COVID-19 will weigh us down. you

early mobility

COVID-19 patients

ICU

challenges

creative approaches