Good afternoon. Welcome to our first inpatient consultations community session. Thank you all for joining us today. We will spend the next hour and a half discussing our role in challenging cases, guided by the expertise of our excellent panel of specialists. And we hope that this will be the beginning of an active and collaborative group. This session will be followed by a networking session, which will not be structured, rather it will be open forum to meet one another and share our experience. So the session will be moderated by us. This is Dr. Adriana Valbuena. She is the chair of this inpatient consultation community and she is a medical director of the PM&R consultations at Jackson Memorial and the University of Miami Health System. She has been an integral part of the development and growth of our PM&R consults here. She is also dual certified in general PM&R and in brain injury medicine. I have the pleasure to be here with Dr. Jocelyn Gober, dual certified in adults and pediatric rehabilitation. She's the medical director of pediatric rehabilitation and heavily involved in both adult and pediatric consults here at Jackson Memorial, University of Miami Health System. We are lucky to have these expert panelists with us today, including Dr. David Gater, Dr. Jose Vives, who are experts in the spinal cord injury field. Then we're going to have Dr. Monica Ortuzco Gutierrez, who is an expert in the brain injury medicine. This is followed by Dr. Lisa Pasqual, who is an expert on orthopedics and trauma rehab. And finally, Dr. James Salerno, who is an expert in management of medically complex conditions. So today's objective is to provide recommendations for patients with different diagnoses, including spinal cord injuries, brain injuries, multi-trauma, and medically complex conditions in an acute hospital. Now, all these cases have been real challenges that have been presented within various hospital settings during PM&R consults. Please keep in mind that there's not just one right answer to any of these cases. Our main goal is to present different perspectives as management. The format of this session will be as follows. There'll be approximately 15 minutes per speaker to talk about two different cases and answer some associated questions. And then there'll be followed by five additional minutes for questions from the audience. Now, if we don't get through all of those questions, we will have additional time at the very end of the presentation for the rest of the questions. And then any questions that you do have should be submitted to the chat feature and we will relay them to the faculty to answer. And again, like you said, this presentation will be followed by a networking session and we welcome everybody to join. We don't have anything to disclose pertaining to this session. So let's start with to get to know the audience and we'll have our quick polls. Are you involved in inpatient PM&R consults at your facility? So we're getting the answers. OK, can we show our results? So everybody is so everybody. So let's move to the second question. In what setting do you practice academic, private, community or multiple settings? Can we share our answers? So the majority are academic and a few have multiple. OK. Okay, so first we're going to have Dr. David Gater for our spinal cord injury cases. Unfortunately, he's unable to be here today, but he has graciously taken the time to pre-record his responses for us, and he'll introduce himself in the video. Can we play the video now, please? Hi, my name is David Gater. I am the Chair and Spinal Cord Injury Fellowship Director at University of Miami Miller School of Medicine and Chief Medical Officer for the Christine E. Lynn Rehabilitation Center for the Miami Project to Cure Paralysis. I'm sorry I'm not able to be there in person with you today, but I wanted to thank Drs. Valbuena and Gober for allowing me to participate in this community session on inpatient consultations. I'm going to speak today specifically about spinal cord injury consultations, and hopefully when I finish, you will be able to review somatic autonomic spinal cord injury disruption, talk about key components of the inpatient consult, and review spinal cord injury and its likely comorbidities as well. We're going to be talking about two specific cases and questions that Drs. Valbuena and Gober have put together for me. So as a starting point, I just wanted to remind you that spinal cord injury includes both somatic as well as autonomic nervous system disruption. The somatic nervous system we talk about by level of injury and completeness of injury, but as well we have to keep in mind that the autonomic nervous system is often interrupted as well because the sympathetic nervous system actually originates within the thoracolumbar regions of the cord. So as we put together our spinal cord injury consult, you all know that you take your history and put together your review of systems as I have on this slide. The physical examination is going to be especially pertinent for the international standardization for the neurological classification of spinal cord injury. So typically what we call the Asia examination actually to list out the level of spinal cord injury as well as the completeness of injury. And as we do our consult, recognize that a person with a new spinal cord injury likely also has at least a half a dozen and sometimes more than 20 new comorbidities that were never noticed prior to this new injury. As we finish out the consultation, as with all consultations, we need to attest to the medical necessity of the person participating in inpatient rehabilitation. And so I want to highlight aspects of case one. So this is a 31-year-old male individual, no significant past medical history, was in a motor vehicle collision and was unrestrained. I don't know about his consciousness level at the time of the injury. We do know, however, that he had significant cervical spine damage and cord damage. He underwent C5 through 7 anterior cervical decompression infusion. His course was complicated by pneumonia, neurogenic bowel and bladder, and neurogenic orthostatic hypotension. His in-ski examination demonstrates C5 Asian impairment scale A, that is complete tetraplasia. Vitals are stable, but with low blood pressures that gets worse as they elevate the head of the bed. He has intermittent complaints of dizziness and sweating. He is already fitted with TED hose and an abdominal binder. He's on both Midodrine and Florinef at max doses. He's very motivated to participate in therapies, but has been unable to tolerate sessions more than 30 minutes out of bed because of the neurogenic hypotension. So the acute care team is asking about admission to acute rehabilitation. And they report that the patient is medically stable from their perspective. So as a reminder, neurogenic orthostatic hypotension occurs because of the sympathetic blunting associated with higher levels of spinal cord injury. So we don't have the sympathetic drive to promote vasoconstriction in the arterial system, nor venoconstriction on the venous side of things. So the person has a neurogenic orthostatic hypotension that is uncompensated by heart rate, again, because of sympathetic blunting. So the first question to me, what would your recommendation be for this individual? And I would recommend that they go to acute rehabilitation for greater than three hours a day, five days or six days a week of physical therapy, occupational therapy, speech language therapy, and psychosocial vocational rehabilitation services. Would you transfer the patient now and work on his neurogenic orthostatic hypotension in the acute rehab facility? Yes. So first off, TED-HOS, that's thromboembolic deterrent HOS, great marketing, but they don't have sufficient compression to improve significantly neurogenic orthostatic hypotension. And so I would recommend changing to thigh-high graduated compression stockings, either medical grade class one or class two, with at least 20 to 30 millimeters of compression pressure. And that should be trialed along with the abdominal binder. Physical therapy and occupational therapy can work on mobility tasks and activities of the day to day living, progressively increasing his tilt on a tilt table and using a tilt wheelchair. We can, although the Midodrine and Florenef seem to be at max doses, you could additionally add Droxedopa up to 600 milligrams three times a day, adding that to the medical regimen in titrating to effect. So what is the acceptable level of the head of the bed in order for the patient to participate in acute rehab? Again, this is really not applicable in this situation. I would anticipate being able to optimize his compression with the compression garments, the lower extremities, the abdominal binder, and then optimizing his medical regimen. Using tilt table and tilt wheelchair, we should be able to meet goals in the acute rehab setting. So the second question, or part B of the first question, how would you treat neurogenic bladder taking into consideration the patient is receiving bolus IV fluids to help manage the symptomatic hypotension? So I would consider an indwelling urethral catheter until his 24-hour urine output is less than two and a half liters per day, and then changing to intermittent catheterization. Every four to six hours, maintaining bladder volumes less than 450 cc's. Patient probably is not going to be able to do this independently, and so family training will be needed. And then once he's out, about three months after the original spinal cord injury, obtain baseline urodynamic studies and a renal ultrasound to assess the integrity of the upper urinary tracts. Second question, so what if they also have a stage IV pressure injury with sitting restrictions of one hour per session? So in the face of the orthostatic hypotension that he's experiencing, a grade IV pressure injury would put me at thinking about sepsis. And so this type of a situation does warrant a sepsis workup. Now, assuming that he doesn't have sepsis, then it depends on the location of the pressure injury whether or not he'll be able to participate in acute rehabilitation. If the wound is a sacral wound, then you could use an appropriate cutout cushion, and our therapists could still participate with him three hours a day. I would run this by our wound care team as well and emphasize frequent pressure relief. However, if this was an ischial pressure injury, you know, the one-hour sitting time would prohibit meeting his acute rehab goals, and he would benefit from a long-term acute care stay, optimizing nutrition and pressure relief until the wound is healed. I would also ask that they have completed a progressive sitting protocol that's usually over seven days, getting him to the point where he could sit consistently two hours a day. Because of the marked muscular atrophy associated with paralysis, his protein reserve is going to be markedly diminished as well. So we're going to need to supplement nutrition with a high-protein but low-calorie supplement to increase his prealbumin greater than 18 milligrams per cent, and that's considered necessary in order to heal these wounds. Now, the caveat is if his C-reactive protein is greater than 15 milligrams per cent, then the prealbumin levels that we get from the lab are not really interpretable, and so you have to go in with a high index of suspicion of osteomyelitis and have the medicine team work with you to manage the osteomyelitis. So question three, you have advice on how to approach the patient and family when they ask you if he'll be able to walk again. So the reality is most individuals with complete tetraplasia will recover one, maybe two levels of motor function over the course of the year. At one month post-injury, any muscles that are greater than one out of five manual muscle testing strength will predict functional, that is, greater than the anti-gravity strength motor recovery at one year. But a lower extremity motor recovery is unlikely if the person still has complete spinal cord injury one month post-injury. As far as breaking the news, Steve Kirschblum's group out of Kessler wrote a great paper in 2016, essentially saying hope for the best but prepare for the worst. The paper recommends that an experienced clinician should lead the conversation, use a trained health interpreter if a language barrier is present, sit at eye level and close to the patient, speak simply, slowly, deliberately, clearly and honestly, using eye contact and body language to express warmth, sympathy and concern, discuss treatment options, avoiding negativity and then provide more information about support services. And then question four, any recommendations you'd like to highlight for this case? Other than saying an early PM&R consult is always essential for a person with spinal cord injury. For him, I would also want to rule out the possibility of a brain injury and so neuropsych testing would be appropriate and to clearly establish the C-spine range of motion and orthotic precautions and the duration of those precautions. Allowing good communication with patient and family. This includes adjustment to disability and peer mentoring and then preparing the patient and family for needs at home that are going to be significantly different than he had before. Helping the acute care team to be aware of what may be unsuspected comorbidities that I listed earlier and then reducing the likelihood of preventable comorbidities including hospital acquired pressure injuries, clots, infections, falls and ultimately obesity and then obviously improving transition from acute care to acute rehabilitation. So the next case is a 59-year-old gentleman with past medical history of hypertension, diabetes and hyperlipidemia who has a progressive new onset of lower extremity paraplegia associated with bowel and bladder incontinence. He was found to have a lytic destructive vertebral lesion with a pathological compression fracture causing significant pain and compression of the cauda equina. Neurosurgery performed a biopsy that showed plasmocytoma but it's not clear that they recommended any stabilization. He's now completed radiation therapy and steroids for treatment of multiple myeloma. His pain is only partially controlled with oxycodone and gabapentin. He's highly motivated but his therapy sessions have been limited by bowel incontinence and we'll say diarrhea. And the team is asking can we take him to rehab. So this is the Bristol stool scale. And essentially it allows us to talk about, you know, what his fecal matter looks like. We would be concerned if we see things on this end of the scale about the diarrhea. Recognizing that diarrhea, the most likely cause of diarrhea in somebody with spinal cord injury is constipation. And there can be a number of reasons for that. It could be that he has obstructive constipation that is just pouring fluid around the obstruction. This is sometimes called obstipation. And warrants an appropriate workup. So question one, what would be your recommendation? I would consider tapering off the opioids, considering a new opioid receptor antagonist to try to dissipate any opioid induced constipation that is now leading to diarrhea. For the compression fracture pain, I would, again, stop the opioids and consider using just a calcitonin one spray that's 200 units a day. There's evidence that demonstrates this is significantly helpful for healing, but as well for treating the acute pain associated with these vertebral compression fractures. I need more information to know what to do with regard to his bowels. In particular, I want to know if he has an upper motor neuron or lower motor neuron bowel. And so checking for global cavernous reflex is going to be critical. The difference between the two bowel care programs is that if he has an upper motor neuron bowel, he will also benefit from chemical and mechanical stimulation, including a magic bullet digital stimulation. If he has a lower motor neuron, and he likely does because the level of his injury, then I still want to optimize the positioning upright on a commode 30 minutes after a meal. And then he's probably going to require manual evacuation. And we're going to try to maintain his stool consistencies as firm so that he's not as likely to leak out through a flaccid sphincter. Checking labs for infections using a KUB if necessary. If he's full of stool, but no blockage, consider from above, moving things through with mag citrate, lactulose or polyethylene glycol. And from below, using an enema or a smog enema, which is including that is saline, mineral oil and glycerin in a one liter preparation. Potentially in this scenario, if you think that he has blockage or an alias, surgical consult is appropriate. I would hold his admission until the diarrhea resolves, unless the acute care team is simply unable to perform and document about care outlined as above. What recommendations would you provide regarding his neurogenic bladder? As before, once his urine output has stabilized to less than two and a half liters per day, consider discontinuing the Foley catheter and providing intermittent catheterization. If he senses a full bladder and would like to try to void, then we can use a timed voiding trial approximately every 46 hours, offering him a urinal and then still checking post-void residuals. Intermittent cath for post-void residuals greater than 100 CCs. And then I like to have at least three PVRs less than 50 CCs before I clear him to be able to void on his own. If you have three PVRs that are over 100 CCs, then you should continue intermittent catheterization or resume it and then recognize that you're going to have to provide him training to do intermittent catheterization at home. And as before, baseline neurodynamic studies and renal ultrasound are going to be necessary afterwards. What recommendations would you provide regarding pain management? In addition to the calcitonin already described, if he's got neuropathic pain, then acutely consider a lidocaine patch and gabapentin. If this continues, you might want to add in a tricyclic antidepressant. Amitriptyline is great if he's also having problems with sleep. If he's sleepy during the day, I would consider adding nortriptyline instead. And then in the long run, you might want to, if you've maxed out both of those, move on to pregabalin up to 600 milligrams a day. Non-pharmacological interventions could include TENS, acupuncture, and a dorsal column stimulator. And really, the recommendations that I would highlight, again, reflect a very early consult, PM&R consult, for anybody with spinal cord injury. So as I finish up, why get a PM&R consult for spinal cord injury? As my children were young and we would go out in public, we would have codes to keep them from arguing with us or throwing a tantrum out in a public space. And our code was Nike Quaker Oats. Nike, just do it. And Quaker Oats, as Wilford Brimley used to say, it's the right thing to do. Not much time left, but if there are questions, my colleague, Dr. Vivas Alvarado, is available. I hope that this was helpful to you, and I wish you a great conference. All right, so in Dr. Gator's absence, we are fortunate to have Dr. Jose Vivas join us in his place, as he is also a spinal cord injury specialist himself, and he recently joined us at Blue Rose Miami. So thanks for taking the time to be here with us, Dr. Vivas. Any questions from the audience? Wait for a little bit. All right, we got lucky, Dr. Vivas. Okay, so now we move to Dr. Monica Bertusto Gutierrez. She's a professor and chair of the Rehabilitation Medicine Department at UT Health San Antonio. She's also the Medical Director of Critical Illness Recovery and Notor Rehabilitation at Warm Springs Rehabilitation Hospital in San Antonio. Thank you, Dr. Gutierrez, for being here today. We'll present the case for you. Thank you. Okay, so you have a 37-year-old male who worked as a radiologist and has a past-level history of anxiety, but presented to the ED with seizures after a fall. Imaging revealed a large left epidural hematoma. He underwent a left craniotomy and evacuation. His hospital course was complicated by respiratory failure on a ventilator and paroxysmal sympathetic hyperactivity manifested by fevers, tachycardia, and diaphoresis, and he's on Cressavix. On examination, he was responsive only to painful stimuli without posturing. His pupils were responsive but sluggish. He did not have increased total spasticity, but was noted to have sustained ankle clumps bilaterally. No active movements were noted on initial evaluation. At that time, Kim and I was consulted for recommendations for brain injury management. Dr. Gutierrez, what would be your initial recommendations for PSH? Okay, thanks again for having me, and I did not type up everything and put it in there. So, I'm just going to talk a little bit about PSH. So, not knowing for sure everyone that's in the audience, I'll start with a little, you know, what is PSH? I always, when I did consults as one of my primary jobs, I always had, most of the time, had trainees with me, and so I always take it as, I'm taking it almost as, let's see a patient and let's talk through and discuss it that way. And so, you know, there's paroxysmal sympathetic hyperactivity, and there's multiple other words that have been used throughout the history of brain injury medicine. They used to first call it mesencephalic seizures, and of course they're not real seizures at all. We know neurostorming, brainstorming, PAID, which is paroxysmal autonomic instability with or without dystonia. And I think, finally, they had more consensus statements that came back and said, okay, PSH is going to be the word that we're going to use for, you know, autonomic storms and sympathetic storms and all these other things that we used to say. And so, this is, of course, related to excessive sympathetic nervous system activity after a brain injury, usually a traumatic brain injury, just like in this patient. About 80% of the time it's in traumatic brain injury. And what are they going to have? They're going to have paroxysmal tachycardia, hypertension, tachypnea, sweating, fevers, and posturing as well. And then, of course, this is usually precipitated by some type of afferent stimulation. So, the first thing I always say about PSH is, for everyone, it's heterogeneous. And you need to find what is the main pathophysiology. Like, what's the dominant one that this patient's having? Are they having sweats? Are they having fevers? Are they having posturing? Or are they having tachycardia or tachypnea? And then, what is responsible for that clinical picture? And that kind of guides us in how we're going to treat it. But before even going to treatment, the first main, I guess, the main three things of treatment that I think are, avoid the triggers that are provoking. Remember, I said this is due to some type of afferent stimulation. So, first and foremost, I'm always like, don't just say, oh, it's only storming. But you have to rule out and make sure, if it's a fever presentation, that there isn't an infection that they have that's underlying. And so, that's something, I said, always please rule out everything else before just trying to, you know, put Tylenol on them and say, like, stop the fever. So, what are the triggers that are provoking it? Is it touching? Is it a line? Is it a Foley? Is, you know, something that is making them worse? Do they need a low stimulation environment? The next thing is, you know, mitigate any kind of excessive sympathetic outflow that they have. And then, also, you have to address the effects and the impact on other organ systems. So, if a patient is getting tachypneic and it gets so bad and it's happening so frequently, do they need to stay intubated for a longer period of time until it's better controlled? So, first, we have to just prevent and abort any type of, you know, causes that could be underlying. And the same thing for this patient. So, you know, look, what are the medications he's on? Is, you know, where he had his surgery, does that look fine? Is there a urinary tract infection? Is there, you know, so many patients get tracheitis if they have a tracheostomy at that time. And the other thing is, for medications that we use for storming, we don't have any randomized controlled trials for PSH. So, we have to say, what can we use? And it's usually, again, going on the phenotype of the type of storming they're having. And we're going to use probably a combination of multiple agents. So, also, which agent do we have that has the best data on it? The best data is probably on intrathecal baclofen therapy. But we're not going to give that to every patient, especially ones who are just having acute storming a few days after they've had a severe brain injury. The other thing I noticed, what is this patient on? They said he was on dexmedetomidine. I don't know. We always call it Presidex or just call it Dex when they're in the ICU and they're on Dex. And actually, it's a really, really great way to treat storming. And it's clonidine-like in that it works on alpha-2 receptor antagonists, but it doesn't act on a GABA receptor. And so, this is something that can help calm. But the patient usually, it's going to sedate them pretty much. And so, it's someone that is usually still have some kind of breathing and they're very, very agitated on top of their PSH. Please be careful if the ICU team wants to be like, well, let's just put them on propofol. Propofol is something that has to be really limited in the ICU setting. Especially, you can't do it more than 48 hours because there is something that's called propofol-related infusion syndrome that can be deadly. And it's especially something that happens a lot in Hispanic persons, which we have here and in Miami as well. So, then we look at, okay, what are the other meds that we have in our toolkit that we like to use? So, in the presentation, we heard that the patient had tachycardia. So, what's great for that? A non-selective beta blocker. So, what do we have in our toolkit for that is propranolol. So, propranolol, again, is great. It's lipophilic, so it's going to be the one to best cross the blood-brain barrier of all the beta blockers that we have. So, that is usually one of the top recommendations. There's also data that shows that patients who get beta blockers after severe brain injury actually have better outcomes as well. So, it's good for kind of calming down that part of the storm that they have. So, that's probably what I would say if, you know, they're going to be taking them off the Presidex, is propranolol, if we can do it for him. Other medications on the list, of course, opioids. So, opioids we can use to suppress some of the allogeneic response. Usually, it's used something like morphine, sometimes PRN, sometimes scheduled. Occasionally, we've done fentanyl patches and put something so they have this continuous amount of opioid. But very, very cautious and very, very slowly with fentanyl, please. Sedatives as well, like midazolam, something that can be used. Alpha-2 adrenergic agents, we'd already talked about. Presidex, but also clonidine can be used. Of course, you have to be careful when that's stopped that they don't get rebound hypertension. Gabapentin, of course. We know gabapentin is going to work at presynaptic voltage-gated calcium channels that are in the spinal cord. And so, that can help also. Bromocryptine, which is a dopaminergic D2 agonist. And this is going to be especially if someone has more of the temperature and the sweating changes. And then, of course, Baclofen. I talked about intrathecal Baclofen, but of course, we have enterobaclofen as well, which is GABA-B agonist. And it works at inhibitory inner neurons in our spinal cord dorsal columns. And then, dantrolene as well can be used, and especially if there's a big posturing component to it. So, again, it would be based on his presentation and his exam, and also what he's currently on. So, that would probably be my initial. And then, remember, look at reversible causes, and if anything is causing it. Okay. You did say propranolol first, right? Propranolol first is what I said. Question two. Four days after the initial evaluation, the team contacts you because the patient did not tolerate propranolol due to hypotension. The patient continued to have difficulties with alertness, so the MRI brain was obtained, and it showed, one, no integral changes of the subjacent extra axial hematoma and left residual subarachnoid hemorrhage, and two, diffusion restriction in hyper-intense flare and T2 signal within the splenium of the corpus callosum, the genia of the left internal capsule, and the coronaradiata of the left parietal temporal lobe. These findings are, in keeping with cytotoxic edema, likely related to acute or subacute ischemia, secondary to prior compression or mass effect. What would be your recommendations now? Okay. So, also doing this. You went all over the medications part. Right, I did, right. The other thing is, I read these questions, I'm like, what am, you know, when attendings, you go to attendings already, you're like, what are they thinking? You know, it's like, am I supposed to be reading into the MRI here? Propranolol is one of the most common views, and then they get challenged when they say, okay, it's not tolerating propranolol, it's not, it's impressed, and it's still storming. So, you know, what are the other options? But you went over all the medications and indications, and that was it. Yeah, you got to answer that question too. Yeah. So, I think, you know, probably either an opioid or gabapentin. I also like non-opioid type of medications. And just, again, it goes with, what is their presentation? Is it with the storming? And then we talked about the different classes of medications that could be used. Or could even like baby propranolol be used? In this case, I think what we used was Bromo. Was Bromo. Yes, and then I was going to say that too. And looking at this thing, like, well, I think. Not so much the temperature part, but the alertness. Right, exactly. That Bromo, because it works dopaminergic and D2, that it can help with arousal. So, I definitely like to use it early on as well. What's interesting, the ICU starts using it, and they start it real, real high. And I'm still very cautious. Exactly the same here. How I use it. Exactly the same here, yes. Same. All right. Two weeks later, he is now working with therapies who are recommending a skilled nursing facility. I don't know how often that happens in your hospital, but this is a challenge that we get here with these patients. He's awake and alert with significant emotional mobility. He's demonstrating dense right side hemiplegia, requiring total assistance with all mobilities and ADLs. He exhibited severe cognitive and linguistic deficits, aphasia, suspected apraxia, and oropharyngeal dysphagia with an AD2 in place. Family approached you and stating that they're not interested in a skilled nursing facility. What will be your response? And this is more about how to approach the therapist that tells you he's not a candidate, he's too low level, he hardly can work with you. How can we make this a patient that as for therapies is a skilled nursing facility to an acute rehab? Part of the education process of the whole team. Right. So first, one thing that also caught me was that, you know, the family approached and said they're not interested in SNF. So first, I think it's really interesting that the family even knows about these different levels of care. So I think one of our roles is to try to educate the family as much as possible. So that way that they're also advocates. Of course, we're saying like this is a person, they're young, they're 37-year-old, they're a professional, they're at the, you know, peak of their life. And so it kind of behooves us to make sure that they get the best kind of rehabilitation that's possible. And that type of rehabilitation is going to be best done in an inpatient rehabilitation setting. So I think if we can, you know, talk to the team about that, talk to the family about that and say, okay, well, skilled nursing facility, you have to be more stable. Doesn't seem like this patient is still completely stable. And they have an NG tube in place. So there's no skilled nursing facilities that take NG tubes, at least where I am. Because that's just too much of nursing care. So they still, and there's some rehabs that take NG tubes for these patients. And then talk to the therapist. And, again, plead the case of, okay, let's get him, let's, what's limiting him from working with you to be able to participate in more therapy? Do we need to give him a stimulant at that time? Do we need to take off medications that might be making him sleepy when he works in therapy? Are you just trying to do passive range of motion and run off to the next room? And say, you know, this is, again, advocating. Young person needs a chance. The best place is going to be at inpatient rehabilitation. And that also this is still only two weeks and four days. That it's too, we can't, based on DOC guidelines, I know he's kind of awake now. He's not DOC. But we shouldn't be prognosticating so early. And he needs a specialized brain injury program. So, you know, just always try to, when I was in the, doing a lot more acute rehab, I'd really partner a lot with the therapist. I think that's the key point in this. You know, in general, to just not go by this recommendation of one discipline. It's just getting the whole team together and evaluating what are the issues that they're having with therapy. And see how can we make that better so we can engage better with therapy. That's the educating part of this question. Like, try to make it better. And I try to, again, empower the families. Because a lot of the families don't understand all the levels of care. Especially if there's low health literacy in their family. And also we know that you're in Miami. I'm in San Antonio. That Latinos are also less likely to get inpatient rehab for brain injury. Sometimes, you know, 30, 50% less likely. And so we really have to be advocates for them. The next question is, any other recommendations you would like to highlight in this case as a PM&R consultant? You don't have to. I know, I've talked about a lot of stuff. I think just continue to follow the patient. Continue to advocate them. Look at them holistically. There's also data. We know data showing early PM&R consults helps with outcome. We know that now there's even more data that came out of UTMC where they said early brain injury consults helped with patients long-term, including ones that they did better in rehab. They're more likely to wake up from disorders of consciousness and be able to go home and have less, like, a discharge back to the acute hospital once they're inpatient rehab. So, you know, do work with your colleagues in the ICU seeing brain injury patients. All right. Case 2. Here you have a 45-year-old male from Columbia with no past medical history who was found down at home by his wife, uptended. There was a GCS of 3 on arrival with fixed dilated pupils. CT head showed a large right cerebellar ICH for which he underwent midline suboccipital craniotomy, pre-heatoma evacuation, and resection of the tumor of vascular malformation. Pathology came back as a poorly differentiated malignant eoplasm suggestive of medulloblastoma, WHO grade four. MRI of the complete spine was negative for evidence of metastatic disease. He was treated using cranial spinal radiation for a total of 31 treatments delivered over a period of six to seven weeks using photon radiation therapy. His hospital course was complicated by respiratory failure of stethospose trach on FAO2 of 40% and dysphagia of stethospose peg. His physical exam was significant for ataxia in the right upper and lower extremities, weakness of hypotonia in the left upper and lower extremities, hypophonia, and urinary retention. A repeat brain MRI demonstrated stethospose right suboccipital craniectomy for resection of a mass within the right cerebellar hemisphere and broadly similar appearing left cerebellar hemorrhagic lesion with surrounding vasogenic edema. He was very motivated with therapy, alert and oriented types two and following one to two step commands. All ADLs and mobility are performed with total assistance. He is sitting edge of bed with total assistance with loss of balance to the left and posteriorly. The team invites you to an interdisciplinary family meeting to help educate on realistic functional goals that could be achieved in acute inpatient rehab before returning to Columbia. What would be your recommendations? All right, so I think at first, I think the cases have been great so far. And I think I would go to the meeting and talk about, I always start at these family meetings and I love to take pictures or take, you know, to show them because I think some people learn in different ways and some people are not auditory learners and some may be better at visual learners. So I always like to at least open a screen, show a brain. It's unfortunate when I see people in outpatient clinic and it's the first time they've ever seen how their brain's affected. So I will, you know, sometimes say, okay, this is the area. You can see there's, this is swelling, this is blood. This is where they removed the tumor. And this is a part of the brain. And then explain what it is that controls movement and controls your balance and coordination. And that's what we're seeing, you know, this part, they took out the tumor. That's why that part of the body is weaker. And that's why he needs a lot of assistance. So kind of give them a baseline and then see if they have questions related to that. And then say, okay, we want to work with him because he's otherwise, the rest part of his brain is good. The part where he can think, act, or, you know, at least try to act, but communicate, you know, he's happy. He's following one or two step commands. And so we want to bring him into acute inpatient rehabilitation. What would be the goals? And then talk about severity. You know, this is something that's more severe. So the goals would not be for him to go back to be completely independent, but this is someone where we would want to be able to make sure that he'd be safe to do transfers and to teach the family how to care for him. The other things other than the mobility, you know, make sure he has the right equipment to return home, make sure that family are trained in things like transfers, and then also ensure that he's able to eat in a safe way, whether that be by swallowing, which is also often affected by cerebellar lesions or through a feeding tube, and also deal with any secretions that he may have from having to, that we see a lot. And also to tell patients, family, that this is, you know, inpatient rehab's short-term, and then long-term he'll need to continue to work on exercise. And of course, rehabilitation care is different in other countries. And so they will have to see what kind of resources there are there. Now, oncology was concerned about posterior fossil syndrome and wanted your opinion. As this is more common in the pediatric population, what is your experience with adults? Are there management options? And what is the timeframe you usually see for improvement of this? Okay, so I was like, posterior fossil syndrome. Well, the first case I was like, cerebellar tumor, sis a kid's case, which we usually don't see there. And the same thing was like, posterior fossil syndrome. Yes, it actually was a kid's case. Everything that happens, it happens. I was involved in a disciplinary meeting. Yeah, so for those that don't know, posterior fossil syndrome is also, you know, obviously mostly happens in kids. If you look at some of the literature, it's a lot more reported in kids and also called cerebellar mutism in, I don't know, before always known in the adult world as cerebellar cognitive affective syndrome. And so that's definitely something that we've seen, which is a combination of a kinetic mutism, but also some prefrontal like behavior. And so this is what, it's definitely more common in the pediatric patients than the adult patients. But this is also something that I had learned recently in the last year that actually, you know, our cerebellum is part of our brain, only weighs about 10% of what our brain weighs, but our cerebellum has 50 to 60% of all our neurons. And those neurons have projections to other parts of the brain. And so in children, children are more vulnerable because they're still creating all these links in their brains, and they have this uncompleted maturation of their brain versus someone who's a 45 year old adult. So they're more vulnerable to this, a kinetic mutism. Time course for it. Oh, the other thing that I also learned was that usually when they have this, it's at the vermis. So in like 80%, the lesions at the vermis. Time course, it's usually on relatively soonish and can last about four or five weeks. It just kind of depends on patients. And in adults, we see it more as, and people are kind of, maybe it isn't always the mutism, but just other frontal, you know, like their personality changes or they have pathological laughing and crying, or they're just different people or they become depressed. And so this is something that is, you know, interesting. And how do we treat it? There's, sometimes it depends. Again, I always like look at the patient. Are they kind of more depressed? Do we need to give them something serotonergic? Do we need to give them dopaminergic like modafinil? Is it something where we give them a denepazil because there's a cognitive component to it, or sometimes even trying something like a benzo trial to see if that kind of breaks them from their mutism. So that is what is my experience with it. Thank you very much. It was actually, for me it was, what? But I had my colleague here for pediatrics and she helped me with the management. And when I seen it before, it was usually by the time they had already transitioned to the inpatient rehab. And then we'd notice that like the speech therapist would tell us, or the neuropsychologist would kind of give us that feedback about their behavior changing. So, yeah. Last question is anything you want to add on these cases? This is your last slide. Again, just look out for it, educate your patients. And I know I'm running out of time. So thank you for these good cases. Thank you. Thank you for joining us. All right. We'll probably move on and do questions at the end since we're running a little bit later. So now moving on to our orthopedic and trauma rehab cases. We have Dr. Lisa Pasquale, who has extensive experience in these conditions as she is the Chief of Rehabilitation Services at Zuckerberg San Francisco General Hospital and Trauma Center, and the Gunahonda Hospital and Rehabilitation Center. And she's also a clinical professor and Chief of Criminology at UCSF. Thanks for joining us. Okie dokes. Your first case. Okay. Here you have a 35-year-old male, status post-mortem motor vehicle collision sustained a pelvic fracture and a rectal tear with extravasation of fecal contents into the surrounding tissue. He required multiple debridement resulting in a huge soft tissue defect at the pelvis and hips to the point where one could see the posterior aspect of the acetabulum, articulation of the hip and the sciatic nerve. Kim and I was consulted to participate in interdisciplinary rounds with a trauma surgeon, an orthopedic surgeon, and a plastic surgeon to discuss limb salvage versus amputation. So here we are. The upper left pic is before debridement. If you have to turn it, I accidentally inverted the photo so we can turn it the other way. I think that's technically, I can't remember which cheek that is. But anyway, we have to match it up. The orientation is all different. So anyways, you can see here when they actually debrided down, you're gonna be seeing all this soft tissue and muscle. And actually that drain is actually tagging his sciatic nerve. So his sciatic nerve is really kind of blown in the breeze there. And by the time I saw him, all of that necrotic tissue in his gluteal region was already debrided and I could see the backside of his acetabulum. And then towards his hip joint, if you moved his leg, you could actually see articulation of the hip joint because it was that much exposed and debrided. The good news here is that they actually asked for an interdisciplinary team meeting between trauma surgery, orthopedic surgery, and the plastic surgeon as to kind of what to do next. Go ahead and go on to the next slide. So I can just- The question would be, as a physiatrist, what are the topics that you discuss when considering lymph salvage versus amputation? Yeah, so this is very interesting. One of the, the trauma surgeon had just come back from Afghanistan and was, you know, there it's really, it's really damage control orthopedic surgery. So you're probably going straight to amputation. The orthopedic surgeon, because we did have the quote luxury of time to try to figure this out, was wondering given his pelvic fracture, could we make that fracture stable? And then could we do limb salvage on that limb? And what type and could we avoid the possibility of an amputation? The challenge though, the plastic surgeon was kind of like a little bit bug-eyed, like, hey, that's going to be like the biggest flap that I'm going to have to do ever because not only was the size of the defect large, it was really, really deep at that point. So wherever you were going to get tissue would have to fill in that area. So I was kind of the last one to put an input. And I basically said, in this particular case, the most important thing for me is not necessarily for him to walk at this point, but he needs to be able to sit. And the reason is, is because whatever we're going to be doing, and I'll show you some pics later about skin integrity, it's going to have to be really good when we do something about that soft tissue defect. So things that we consider just in general for limb salvage versus amputation is we always have to look at pre-morbid functional status, how it may relate to the person's life in general, how it may relate to their vocation. Was it somebody who was sedentary? Was it somebody who was wheelchair bound already? We have to look at all those kinds of different aspects, we also have to look at obviously viability of the limb if we're going to think about salvaging it. Is there nerve compromise associated with this? Most likely yes, because that sciatic nerve is tagged. Skin compromise, absolutely. There's skin issues that are going to be important to take into consideration, because what we don't want to do is put on a flap that's going to preclude any kind of weight bearing surface from actually functioning. Also, if we're talking about limb salvage, the question would be, is it going to be many stages? Can the patient tolerate that many stages of limb salvage? Is there going to be real functional viability to the salvage limb? Are they going to have as much function in that limb that they might or might not have if they had an amputation? So all of these questions, of course there's no right answer with all of this. And of course we take into account when the patient is able to contribute to the discussion, their wishes and goals as well. In this case, this gentleman was intubated and sedated. So let's see, for him, one of the most important things that we had to think about was skin integrity at the site. Either skin integrity related to a prosthesis or skin integrity related to any type of orthotic device. We had to consider if he had a nerve injury, what kind of orthotic device that would be. And we can't obviously do manual muscle testing when he's intubated and sedated. So that's something to consider as well. Then we have to think about energy expenditure and function. What's the energy expenditure of using orthotic, which is the energy expenditure of, if this was an AK, if this was a hip dysartic, if this had to be a hemipelvic to me, all of those kinds of things. And trying to look at this, what we did was we tried to get an idea of a nerve damage that he had. So we did do an EMG. Of course, in the ICU, it's difficult to do and he couldn't cooperate. So it was basically seeing what was hot on EMG. And not only was his sciatic nerve innervated muscles hot, also were his femoral nerve muscles as well. So the degree of weakness would be considerable. And of course we couldn't tell the difference between axonamnesis and neuramnesis given the setting where we were testing the patient. So we knew that it was going to be, if it's an orthotic, you're just going to be using, it's going to be at least a KFO. Then energy expenditure, for going up as high as a hemipelvic to me, walking is akin to jogging when you're looking at mats. So that's something to consider, especially if the patient may have been sedentary or was not somebody who walked a lot, or maybe was somebody who walked a lot and was an athlete. So these are the kinds of things you have to take into consideration. Patient ultimately underwent left hemipilectomy. Will the precautions after the surgery, sample seating restriction on the breast side, limit the patient's ability to participate in the acute inpatient rehab? Yeah, so if we can just go back to those initial pictures real quick, and just note how, and especially in the picture on the left bottom, how sort of healthy, robust, and lovely that tissue is right there. And that is basically what they rotated up into the soft tissue defect to give him a really good coverage of, not only coverage of the room, but it was really, really well cushioned. So just FYI, let me go back forward to where we were before. Okay, so in terms of acute rehab, so things that we'd have to consider is what his weight bearing limitations would be on the graph site to determine whether or not he could even do sitting activities in acute rehab. As it turned out for him, he was nearly practically healed by the time we got him. He had no disposition at that point, and he was already doing some standing activities. And unlike, I guess what it sounds like, in some other places, one of the rehab centers I have has, has an acute rehab component, but also a skilled nursing component that we call SNF Rehab. It's run by a physiatrist, and it's sort of a acute rehab light. And for him- I'm sad. I'm sad. That makes things easier. I know, man. It's sort of, it's a real luxury that we have here. It's sort of a double-edged sword. We can talk about that whole thing. We can talk about that whole thing at another time, but it's really great for people who just can't make the cut for acute rehab, or they're too good. As we all know, sometimes that occurs for acute rehab. But it's really good for people who have unilateral amputations and are already starting to do standing. And now it's just a matter of having to wait for a prosthesis. So in this case, he went to SNF Rehab. He was already mobilizing by the time we got him and that he was cleared to start to mobilize. And he was already starting to do single-limb stance activities. And of course, had no dyspo. So that's always something that we always have to think about as well. So that was that with the acute rehab program. Any other recommendations to highlight in this case? Yeah. Yeah, so I have some pics here. Oh, the pictures. Yeah, I think I put it on there. When I was talking about the importance of having really good soft tissue integrity, whereas the surgeons were mostly looking at like, are we gonna be able to get this guy standing? Really, the first thing that we have to consider is, do we have good soft tissue so that we can either have somebody have a KFO where their weight bearing on his buttocks, which is right where that soft tissue defect was, or in this case, that's actually his prosthesis where he's going to be sitting on. And I have pictures of the fabrication where it's really clear that you need, you really need good soft tissue coverage. And then because of energy expenditure for somebody who has a hemi-pelvectomy, it is not infrequent that they're going to be primary wheelchair user for functional activities. So it's important that they have a good buttocks for sitting on if that's what they're going to be doing most of the time. So whether they're sitting in a wheelchair or standing in their prosthesis, or if we did limb salvage, a KFO, then it would be important to have right where that second arrow is on the right, some really good soft tissue right in his ischial area. And that's what they did. They just kind of basically rolled up that really nice tissue of his thigh up into that soft tissue defect. Okay. And then let's see. Other thing I wanted to mention, there is something in the orthopedic literature, there are two studies, the LEAP study, which the orthopedic traumatologists are really familiar with, and the METAL study. The LEAP study looked at high grade injuries below the femur and tried to decide whether they should go limb salvage or whether they should go amputation. They didn't like assign people to one or the other. They just kind of looked at the outcomes. And one of the interesting things was that cost was supposedly less if you went limb salvage, which we all kind of go, hmm, because you have so many more hospitalizations, but I guess over lifetime, that might be the case. There is some question as to the validity of that in that people were saying that it was kind of a retrospective look back on costs, and it may not have accounted for pharmacy costs, residential adaptation and institutional care. And then there's something called the METAL study, which was actually done in the military setting that looked at a population similar to the LEAP study, which looked at lower extremity limb salvage versus amputation. And one thing that it had in common with the LEAP study is both groups, both in the civilian population and the military population, they both had high levels of disability, whether they had limb salvage or amputation. And the rates of depression were approximately the same. But the interesting thing was those patients who were in the METAL study seemed to do well, do better functionally than those who were in the LEAP study. And the question was why was that the case? And there's a bunch of different factors that might be the case. And one is that in the military setting, there might not have been a choice as to, oh, am I going to go limb salvage or am I going to go amputation? Because in the military setting, the leg, for example, might be nearly all the way off, and then you're just going to do an amputation. There's not going to be much more discussion about it. So those who had the very severe injuries went on to amputation. Maybe that was a difference. And the other difference was, is for the peer support in the military population, if they get sent to a rehabilitation center where there are a lot of other military personnel who are undergoing rehabilitation for amputation, and getting that kind of support and peer support may have really helped as well. Versus if you were limb salvage, you were basically in bed waiting for something to happen, waiting to heal, waiting for that X fix or that limb lengthening procedure to take hold. So everything is all delayed versus you're going to see your peers who already have their prostheses and are starting to move around. It's a very interesting look between the civilian and the military population in terms of outcome. So there's that one. All right. Case two. So here you have a 44-year-old male who was the victim of a drive-by shooting, resulting in a gunshot wound to his right back. He sustained injuries to the spleen, small bowel, and transverse colon. During admission, he had several complications and procedures, including hemorrhagic shock, transfusion-related acute lung injury requiring ECMO, and pressure-induced necrosis of limbs, which ultimately led to bilateral trans-tibial amputations, as well as a trans-radial amputation of the left upper extremity. He has been hospitalized for six months and all the surgical wounds have now healed. PM&R was consulted for a prosthesis evaluation. During your evaluation, you noted a painful bony prominence of the left residual limb located at one of the pressure point areas. It was ultimately found to have heterotopic ossification. Okay. So I guess this is a real case that you guys have, but it's sort of a real case in terms of HO in an amputee that I had just a couple of months ago. And you can see the heterotopic ossification at the distal tib, at the distal tib. And actually the patient presented saying, you know, I've got kind of this knobby thing and it hurts now when I'm wearing my prosthesis. And sure enough, that's what it was right there. So it is at a painful pressure area. And what we did for him in his case is we did some socket modifications. And there are different kinds you can do. You can either just dig out areas of the socket, but it depends on where in the socket it is because he had a pin suspension socket. So you can't really quote, dig out so much in that socket area near the pin, but you can potentially put gel foam, cups, pads, or discs in that area to help as well. The other area that's sometimes problematic is over at the, at the distal, just as in terms of a pressure area, not necessarily with respect to heterotopic ossification is at the distal fibula or at the fibular head. I had a guy who came in who, whose fibular head basically were all the way through his skin. And we actually had to do a cutout there. And then we ended up having to do an excision of his, of his fibula. For heterotopic ossification, it's really interesting. It was just at a, an orthotrauma course. And, and they, they were talking about a case where somebody had multiple trauma and had heterotopic ossification. And a lot, a lot of things in our world, we think of things like use of bisphosphonates and things like that, really that's used in the neurogenic heterotopic ossification world, but what the heck, you could potentially use the same thing in a traumatic case, but really in orthopedic literature, when you're looking at that, and actually, if you do a search on the literature in general for traumatic heterotopic ossification, as opposed to neurogenic heterotopic ossification, bisphosphonates really don't kind of figure in the, in the literature much. Really, they're looking, they talk about non-steroidals. Do you do, and they talk about non-steroidals, especially indescent in terms of prophylaxis. But by that time, you know, when we're seeing that it's already kind of too late, right? So, so you, so you end up using the NSAIDs for, for symptomatic means and pain control. And then the question, the big question was also, do you do passive range of motion? Do you do active range of motion to joints that have heterotopic ossification? Not in this particular gentleman's case, which is at the distal amputation site, but even physical therapists, there, there's really no one way to do it. Do you get aggressive at the joint as somebody might be losing range of motion, or do you just range through their available range? And I don't think there's any, there's any literature that says one way or another is necessarily better. So for management, it's the, the, what I was noting was symptom, basically symptomatic management. And, and for this particular case, pressure relief over the, over the involved area. So I mentioned this already, do you use? I'll move on to the next question. You mentioned the pain management, but I will, I would like you to mention this case, the team contact me, if, if they can take the patient to surgery to remove the HO. So any, any comments about when it's the mature, when you tell the surgeon, yes, it's okay to, to have it resected surgery? Sure. So I think in this, he's six months out, correct? Yes. Six months. So, okay. I'm going to date myself, but old school wise, we used to be, we used to be told, Hey, you know, it might be a good idea to wait till the bone scan is negative before you take your HO out. But a, there's not a lot of places that do bone scans. We don't have access to bone scans where I'm at to just do this, like to do that. And then B so B in the orthopedic trauma world, they don't do bone scans to figure out if something's cold or not. They wait for things to be mature. And I asked my colleagues, like, what do you mean by mature? Oh, I think what did come out was about six months. Okay. That was sort of the consensus six months. So I think for him, if they want, if they, if you cannot manage it by padding or pressure relief or socket modification, and it's, and it's disrupting his ability to ambulate, you just can't figure out another way to do it. It is a potential, a possibility. The question is of course, you know, will it come back after you resect it? That's always the big question. And in some of the, in some, in the literature, some say that if you really do an excellent resection, that, that the risk of a recurrence is low. So six months out, excellent resection, hopefully get it all out. And it's not a benign surgery as far as I I've heard it heard as well. So if you get everything out, you might you, it might, he, he might benefit from that. I would try conservative means first, if at all possible. What did you guys end up doing? Oh, well, we, then he contacted me and I look in the literature. I was not really clear. What's the timeframe? And what I thought I found was it was a year, 12 months, bone scan. And I was like, I'm not sure I don't have much experience in this area. This is, you know, Esho is one of the challenges that I get in many different pathologies involved with TBI. And then you cannot use NSAIDs and significantly limited patient's ability to, to work with the therapies out of bed. In this case, he has three links with amputation and this one was really almost out of the skin was breaking. So they were asking me, should we take this to surgery? I was like, I'm not sure. In the ortho trauma world, they probably would have taken it, especially if it's compromising his skin. I think they would have taken them because I think six months I, from what I was talking to my colleagues about, and of course there's really nothing in the literature about what's right or wrong or whatever. And really in the ortho world, they are not getting bone scans. And for that matter, I don't know if they're really get like, people are getting bone scans really routinely either now. So I think if skin, if there's skin compromise, it would be reasonable to consider resection. Well, I think you made a very comprehensive recommendation. Thank you very much, Dr. Pascal. You're welcome. We do have one question, but I think we'll leave it at the end because it could actually go with everybody. So we'll move on. Okay. So last but not least, we have Dr. James Salerno speaking about medical cases. He's the chief and medical director of the MNR department at the Memorial Health System. Thank you, Dr. Salerno for being with us today. We'll read the case for you. Okay. All right. So you have a 43-year-old male with a history of alcohol-associated cirrhosis complicated by non-bleeding esophageal varices, hepatic encephalopathy, and ascites. He underwent a liver transplant. And follow-up liver ultrasound shows pain, hepatic vasculature with normal direction of flow, and elevated peaks of solid philosophy, and the portal venous system. His hospital course was complicated with post-op pain in the surgical site, ileus, altermentation, and agitation. His labs were significant for thrombocytopenia and stable anemia. And he was on 80 milligrams of IV Lasix BID, steroids, and immunosuppressants. He has inconsistent participation with therapies due to his ultramental status, but during his last participation one day ago, he was able to do bed mobility, sit to stand, AVL mobility to the restroom, and toilet transfer with moderate assistance with verbal cues for increased safety awareness. The patient is resistant to therapist's hands-out assistance, demonstrating poor insight into deficits and impulsivity. The therapists are recommending a skilled nursing facility. However, in your evaluation, you feel that you will benefit from the acute inpatient rehabilitation program. So the recommendations for the therapist, I mean, personally, when I, you know, engage in these kind of conversations with them, I like to have a conversation. So I start by asking them questions. I know it said here in the last therapy session the day before, you know, that he participated better, but I'd like to see the overall arc. Do they think he's, you know, slowly improving? And, you know, begin to discuss with them how it's different with this population. You know, the hepatic encephalopathies after liver transplant, I've found they clear as fast as they came up. So if someone blew out a liver for some medical toxicity or something like that over a period of, you know, a handful of days and was lucky enough to get a liver transplant, those patients usually clear pretty quickly. However, patient like this, hepatic encephalopathy from alcohol uses probably came on over, you know, period of years. So they don't clear up overnight. It really helps to address not just with the therapist, but the rest of the team that that's kind of expected. But again, I'd really try to focus on the overall arc of the therapy. Are they progressing in terms of, you know, going from total to this moderate assistance? I'd also ask the therapist, you know, have they tried engaging other people from the team, whether it be psychology or the family members, other participants in the therapy progress? Because sometimes the patients really do do better with those kinds of influences. And I also want to just know about the general disposition of the patient. You know, typically a transplant, you don't have to worry about that. They've already been screened for things like supportive systems. So you have usually a bench of people to help, either some family member, medical services, good insurance, something. But I also think, you know, it's good to get in that discussion. But basically, what ended up being a little bit longer than I intended, the short answer is just try to discuss with them to see, you know, if there is some overall arc. And if there is, then I, you know, strongly, you know, stress that, you know, this is a patient likely to participate well in an inpatient rehabilitation program. So the potential complications and factors, again, the hepatic encephalopathy, which I just said, you know, the time course for resolution is pretty significant. But with transplant patients, obviously, they've got a whole new host of medications that are going to affect them. Obviously, high dose steroids can cause myopathies over a period of time, as well as cognitive deficits. Prograf is well known to cause neurologic disorders, whether it be, you know, just that benign tremor that most of the time goes away over a period of months, or it can even cause cognitive disorder, complicating the picture further. Sometimes you have to work closer with the transplant teams, remain in communication with them to get away from something like tacrolimus and try other agents like sirolimus, even cyclosporine in certain groups of the population who don't respond well or tolerate well, better said, the side effects of prograf or tacrolimus. Obviously, you know, as a rehab patient, like we always do, you got to do some of your basics here, the prior functional level, how functional was this patient in the community before they went in for their transplant. Again, transplant patients tend to lean towards having been more fit. That's not always the case. So it's always good to do that. And again, investigate the social support and the general medical stability. You know, from the data you put there on the patient example you gave me, I mean, that's a pretty stable liver transplant patient. As far as I'm concerned, you know, the platelets not really worried about that level, as long as it's stable. And then anemia is pretty solid. And whatever other parameters, I mean, if they were, as long as they were just, you know, tachycardic from deconditioning, things like that. You always have to have a close eye on their medical status for making sure they do not get infections. It's something like, I like to teach the residents when they're coming through on these rotations for transplant patients. There's six meds you have to think about whenever you're seeing a transplant patient. Six classifications of medications. You got, for your anti-microbial agents, you need to have your antibacterial, you know, for PCP, you need to have your antifungal and your antiviral, as well as, you know, worry about the immunosuppressants with Celsep, Prednisone, and Atacralemus, or what other agent the transplant team has chosen. So I try to always focus on those things when going through these cases at admission with them. So making sure they don't lose their organ and make sure they don't get sicker. Short answer on two. Three, the therapists understand and agree with your assessment, changing the recommendation. However, you get the fun peer-to-peer. So this is becoming an increasing problem. I don't know if it's just in our market here in South Florida, but they don't even talk to rehab doctors anymore here about that. I really want to hear input in here, because this is such a pain. It considered me a very bad biased source, you know, which is weird because you're the expert on the topic, but so we're having to utilize here the primary doctors or the hospitalists to have these conversations, which is an interesting thing. So we're educating them on the peer-to-peer. So on the peer-to-peer process, you know, I feel like the crux of the conversation really comes down to two things. Definitely showing that the patient's going to participate and be able to benefit from the inpatient rehab program. You know, the inpatient evaluations by the acute therapist really play into that a lot. And that's why having those kinds of conversations with your acute therapy team and really getting them tuned in, especially the transplant ones. We've gone out to our surrounding transplant facilities to help educate the therapist on the proper terminology and way to look at it from a, you know, just not your granular picture, but really the big picture of what's going on with the patient in terms of a therapy progress. So I think those educations help out a lot. But the other thing is really, and, you know, I feel like the transplants make that an easy case is the medical complexity and the need for daily physician oversight of the care. I mean, you have your close monitoring of your medications, your immunosuppressants. You have, in this patient's a great example, a lot of labs that most people would get a little bit nervous about, but really is, you know, par for the course here. So you need to be watching those closely. You know, you can have all sorts of issues with the blood pressure management, watching out for a Paterino syndrome. I mean, these liver and kidneys are not, you know, synchronized yet, and you can see a lot of complications just come out of nowhere with minor fluid changes from a patient not being totally compliant with a good diet and hydration. In, you know, the other part then is just breaking it down for them about what the PMNR doctor does and does best, you know, with close monitoring, neurologic status, proper use of orthotics, and other measures to make sure that they are able to really fly in the inpatient rehab program. And, you know, as a consultant, again, you know, I kind of was saying how I do it with a therapist, you know, about the 10,000 foot level glimpse, and then, you know, also being able to fine-tune and pick out for the case of the particulars that really you need to be paying attention for. It's the easiest way to justify these cases for the insurance company, as well as to, you know, for the family and the patients. But I think the general psychiatrists, we need to get together and revise those CMF13 rules. Transplants should be part of those diagnosis, very complex cases that are not part of the CMF13. So that's what the insurance kept telling us. They do, I mean, okay, so a little bit, I'm a reformed internist. I was an internal medicine doctor before I became a rehab doctor. I, you know, I have, which helps out a lot with the explanation of these things, but really the, I feel like the relationship between the medically complex physiatry attending and the transplant team is what seals that deal. And that's because that transplant team gets into the loop with the conversation with the insurance company and explains that there's nowhere else we're gonna send this patient. You can either keep paying for inpatient and they're getting therapy for half an hour or an hour a day in the inpatient, or you can send them to inpatient rehab. Because your success with keeping that line of communication open and doing well with these patients is your biggest selling point. It's not something a SNF can replicate. And most for-profit centers can't do. They just, they don't have the same level of dedication of a staff. So I think, you know, it really does come down to communication and relationship building with your transplant team. And let them be your biggest advocate to the insurance company, because they will. And they do listen to them. I mean, they've already invested tons of money into the transplant. True. All right, case two. You have a 63-year-old male with a history of asthma who was admitted to the ICU with acute respiratory failure due to COVID pneumonia. He was intubated and required a tracheostomy. He completed courses of remdesivir and dexamethasone. His hospital course was significant for bacteremia, dysphagia, and alias without surgical intervention. At the time of PM&R evaluation, the COVID-19 precautions are already discontinued. The vitals were significant for tachycardia and tachypnea. He's on a T-piece with FiO2 30% tolerating the oposthomere valve. And physical exam revealed generalized atrophy, and turned gravity of all limbs except bilateral foot drop and right wrist drop. He's very motivated and participates in therapy. However, his participation is extremely limited by fatigue and palpitations. He's requiring Max A in all the mobility activities and total assistance with transfers using Oral-X. PM&R is consulted for recommendations. So, you know, I mean, here it's some of the basics like maximizing nutrition, but, you know, it really does come down to just making sure there's no other manageable causes of the tachycardia, anemia, or something else going on with an arrhythmia. If that's not really going on, it's really just aggressive therapy. I've taken care of a fair amount of these type of patients at this point, and they do have a much higher baseline heart rate than your typical like critical myopathy or polyneuropathy patient you see out of an ICU stay. It's probably related to the amount of hypoxia they've undergone and the amount of stress on the system. But this amount of tachycardia, I think you said it was a heart rate of like 110, 120. That's kind of typical. Even after I have them walking independently at the hospital, they're still running about that. So, you know, I mean, then you can try to help control it if the blood pressure is up a bit, you know, doing some beta blockade, some basic medicine treatment, I think is a really great idea and trying just to mitigate the blood pressure to a certain degree. But the biggest thing is gonna be aggressive therapy. You know, a lot of pulmonary rehab. It's gonna be a good pulmonary management with a respiratory therapist. I'm sure you guys at this point have all seen what the CT scan and chest X-rays look like on these patients. If they're that sick to go like what this particular patient did, they have severe lung damage and that just doesn't recover overnight. So it's really aggressive therapy and good nutrition more than anything else, but doing whatever medical management needs to be. So, you know, treating other things like the anemias and things like that. And then other potential complications and factors that can affect the rehab patient. Obviously you gotta be watching out for D-cubes. A lot of them do come with D-cubes from pressure wounds, having laid in beds. I know all the teams in critical care have done a great job in trying to prevent that, but it just, you know, it's difficult. Managing and trying to avoid further hospital acquired infections. The amount of time these patients stay in the hospital with everything going on, they've pretty much had it at least one hospital acquired infection with a multi-resistant bug. But, you know, you have to be careful with that, especially if they've had Foley's and other things go on. Making sure no contractures develop. The pulmonary management's quite key. We've been very successful in weaning down the oxygen, but it's not even a daily thing. It's something we do all day long with our patients is trying to minimize the oxygen that they're getting to try to eventually wean them off. And it just has to be a big team effort. It's not just RT or the docs. It's really a buy-in from the therapist doing it, the nurse is doing it, and that makes a big difference. And then, you know, it kind of rolls into, and then preventing any permanent debilities from all those things. And then, you know, rolling into your question number three, really is, you know, neuropathies and myopathies. So these patients got high-dose steroids, well-known to cause myopathies. The patients have been in the ICU a long time, well-known to cause myopathies, probably from the same, you know, not the glucose just not being able to be managed acutely as well as you would like due to the stress on the system, the person's body. And in this case, the patient, you know, also the polyneuropathies. I know it didn't say in the exam if they had numbness or not, but, you know, the general rule I find is that, you know, you have proximal greater than distal weakness in the myopathies and the polyneuropathies, you know, it's really distal affected more than proximal. This patient sounds more like a critical illness polyneuropathy to me, but obviously there's probably myopathic components as well going on, given the events in the person's case. This is an interesting combination that I have seen specifically with patients with COVID, that it has a very drastic polyneuropathy, like this case, it has bilateral foot drop and wrist drop, but also has significant myopathy with trunk control problems, which I, you know, have seen other ICU patients being long time and not seeing this like distribution of both at the same time. I wholeheartedly agree with you. And then there's been weird cases where we've had one limb affected more than the others or other evidence of direct neurologic injury during a COVID case. So, you know, I know the kidney issues have been well-documented, obviously pulmonary, but I think when things are really ferreted out and there's much more research done, we're actually gonna see a direct nerve pathology from COVID that exceeds just the regular critical illness myopathies and polyneuropathies. So the other recommendations I really would just highlight in this case is family involvement. You know, my facility, we're very fortunate to have a very pro-family environment. COVID obviously has made that wildly complicated, but we try to do our best, you know, whether it'd been through iPad virtual ones or when we can get them in, to get them in. I think that makes a huge difference in bridging that gap. And we've seen that in our other populations as well, who are very sick, you know, traumatic brain injury and whatnot. You know, and I wanna go back just to highlight the max heart rate here and therapy awareness. That's been something that, you know, I've had to educate the therapists on. You know, they'll get a patient in their fifties and they're like, oh, they're tacking at 120. Do we have to hold therapy? I'm like, absolutely not. You know, and it's then education about max heart rate, what the patient can realistically tolerate and trying to get to that threshold, backing off, letting the heart rate drift down is kind of like interval training. Then, you know, bringing the heart rate back up and then letting the heart rate drift back down and doing that during a therapy session rather than just either getting to it once and then holding it or even worse, just not even trying. So that's been a big part of what we've had to do. You know, the multidisciplinary involvement, we have a lot of great support in our particular facility with pulmonology, ENT, so managing the traits and getting all those things out as well as other specialties to really make a big difference in the rehabilitation and successful bridging at home. And then, you know, again, early and aggressive rehab. Firm believer in it in all cases, but especially this population. Thank you. Thank you very much. Actually, we'll just do questions for anybody now. Everybody can come back on so we can see your pictures, but we did get an interesting question that I think kind of applies to all of you. States, our inpatient rehab facility has increasingly sought reciprocal agreements with the acute care for patients with poor disposition plans under which we accept a patient, but if we can't get them to a community setting within a reasonable period of time, they take the patient back to acute care. I wonder if any of the panelists are seeing such agreements at their facilities where they perform their consults. And if so, what are your opinions of those arrangements? I don't know if Dr. Pasquale is still with us. So two things. She mentioned about these problems in her facility. Yeah, so two things. One is that there are times when, if we have a spinal cord injured patient who needs to kind of, who's taking a, we're having a hard time getting off the vent, sometimes we'll transfer them to another facility. They're not, if at the time the vent is off and they're not appropriate for acute rehab, we will take them back to our facility. It's very rare when that occurs. The other, we have the luxury, as I was saying, we have a 780 bed skilled nursing facility here. So if we have somebody who is not appropriate for acute rehab, either too good to, or not kind of, not going to tolerate or can't tolerate, we can take them to SNF rehab. And if needed, we can bump them up from there. Same team, same therapist, same physiatrist. We have similar kind of setup as what Dr. Pasquale's describing. We have a SNF within our system that we can use for patients. But what we really try to do is everything under the sun to get them home. And that's included even the system picking up the cost of home therapy or things like that, that's gonna bridge the gap for a couple of weeks to successfully discharge them to home. The system will do that. It's obviously not preferred. It's obviously not something we publicize. We do the reciprocal agreements. I feel like we do that more just to keep people from trying to send wrong patients. It's more of an education thing from the referring teams. But we rarely send them back. In fact, during this COVID crisis with the bed crunch, we've taken patients they couldn't disposition over to our hospital and were able to get them home. Yeah, we currently use that system here. It was not started just maybe six months just to try to some of the patients that really benefit because we have a skilled nursing facility but outside the system. So patients are a little bit resistant to be sent to a different facility. So we'll bring it and we'll try to discharge but if there is some issues, we have a backup plan. Any other questions? I think we answered all questions. You guys did a great job. Great presentation. Thank you very much all the panelists for so comprehensive explanation of the cases. Trying to put a lot of information. There was too much information for just one slide. Thank you guys for helping to coordinate it. It was really great to be a part of it. I think part of the more challenging, as I just said, is becoming the peer to peers. And when you do a consult, they expect you to do it because they don't have time to do it. They have to do an exercise transplant, all these fractures. And in general, it's getting more and more denials of patients that are very appropriate and despite stuck in with the physiatrist and given that not the physiatrist, the director of the insurance, it seems frustrating that we are the one evaluating the patient face-to-face. Therapists are recommending acute rehab and they're reviewing a documentation and still denying the case. So that's the part that is really frustrating as I feel that it's evaluating the patient in person and you're an expert on the field and they're still denying the admission. So I don't know how frequent is becoming this in your facility, but it's getting more and more. I know- It depends a little bit on the insurance. I know some of the ones who deny every single time the doc's names that you still do the peer-to-peer, but it's really futile. I've never heard of them approving a case other than relatives of the administrators of the insurance company, which is cute. That's correct, exactly correct. Well, yeah, we are now on the networking session. So everyone feel free to open your shot on videos or meet yourselves. It's a free word.

craniotomy

cerebellar hemorrhage

medulloblastoma

complications

radiation

dysphagia

weakness

urinary retention

rehabilitation

mobility

transfers

eating methods

posterior fossa syndrome