By Caity Heath
I swipe my ID badge, and the double doors swing open with a click. I’m greeted by the familiar beeps of various monitors, and the background hiss of oxygen being pumped through ventilators and *Optiflow machines. As I make my way through the medical surgical intensive care unit (MSICU), registered nurses discuss care plans at their bedside tables, carefully reviewing flow sheets and updating interdisciplinary team members on the status of their patients. The open concept unit is buzzing with activity as everyone prepares for another busy day of patient care, rounds, and readying themselves for the unexpected. I carry my notebook with me to the nursing station, where I meet with the physiotherapists to establish my case load for the day.
This short walk through the unit has been my routine for the past eight months. My journey coincides with the Provincial Early Rehabilitation in Critical Care (PERCC) project at St. Michael’s Hospital, beginning in October 2018. Before PERCC, the MSICU didn’t have a physiotherapist assistant working on the unit. As you can imagine, this was a very exciting opportunity for me; not only was I going to experience a whole new dimension of acute care, but I was going to contribute to important data that could shape the future of mobility in critical care.
I have been fortunate to experience a variety of clinical practice areas since starting my career over three years ago. Having developed a passion for acute care as a student, I was beyond excited to start part-time in the Inpatient Mobility unit (a fast-paced, high volume orthopedics and neurology floor) as an entry-level clinician. This unit had a well-established team of occupational therapists, physiotherapists, and dually trained OTA/PTAs, so one of the main transitions I needed to overcome was practicing independently. As time went on, and the more I became comfortable in my role, I developed a passion for education and promoting the role of OTA/PTA. I was able to implement this passion as I transitioned into several different acute care areas over the next three years, including palliative care, respirology, oncology, general surgery and gastroenterology, and cardiovascular surgery. I found myself presented with numerous opportunities to clarify the differences between an OTA/PTA and a therapist, while highlighting the skills and benefits that OTA/PTAs bring to the team.
Walking onto a unit that has an established culture of mobility can be exciting and challenging, especially one that has not staffed a physiotherapist assistant before. I was ready to take on this new patient population, to learn, and to appreciate the skill level of the interdisciplinary team; I knew I needed to embrace that most of the clinicians I encountered did not know my scope of practice. Since starting in October, I have had many conversations about the practices I can and can’t implement. Part of the challenge when having these conversations is to remind yourself to respond from a place of positivity and patience; you can’t expect that everyone will embrace change optimistically. With this in mind I muster my enthusiasm for my position and do my best to describe the uniqueness of OTA/PTA clinicians.
Let me give you an example. I received an assignment to complete range of motion exercises and to mechanically lift a patient to a Broda chair, and at the time I had a student with me on her intermediate fieldwork placement at Humber College. As we were finishing up with the exercises, the patient’s oxygen saturation was beginning to dip down to the low 90’s. This patient had a tracheostomy and was on a trach mask at the time. I knew the patient needed to be suctioned, but I couldn’t do this for him; tracheal suctioning is a controlled act with the College of Physiotherapists of Ontario. As I was fairly new, some of the staff were still working out who I was; at the least they knew I was involved in physiotherapy, and in most cases they assumed I was a physiotherapist. I called over to the respiratory therapist (RT), who very nicely, albeit mildly confused, obliged me and suctioned the patient. I explained that I wasn’t able to suction the patient because I am an assistant, and I am not able to perform controlled acts. Later on the physiotherapist shared that the RT had said he didn’t understand why I couldn’t suction the patient (despite my hurried explanation in asking him to help me); the PT explained again that there are specific acts as an assistant I cannot perform as they are controlled and require training that does not fall within my scope.
You might see this as a potentially negative encounter, but I think it’s just the opposite; the reality is there are some aspects of the PTA scope of practice that are limited in an ICU environment, but it doesn’t diminish my role or make my being there any less important. A PTA brings the knowledge and appreciation for various conditions that require skilled hands for positioning and facilitation, not to mention feeling comfortable with the equipment needed to promote mobility. The OTA/PTA scope of practice really enables clinicians to contribute to patient experiences in ways therapists are sometimes unable to due to other requirements of their role (i.e. completing assessment forms, rehabilitation applications, etc.). We can establish rapport with patients easily as we are usually in regular contact with them to implement daily plans of care, such as applying various mobility techniques, teaching, and utilization of functional equipment to promote a patient’s independence. These aspects I’ve mentioned are all ways that demonstrate the positive impact of having a PTA (or OTA/PTA) in the ICU. Lastly, having these conversations about the role are part of the process of facilitating open dialogue and ongoing learning, and finding common ground with other clinicians while cultivating good teamwork that focuses on quality patient care.
There are days when some people still don’t know my role entirely and still ask what service I’m from. There are days when some people still mistake me for a physiotherapy student or a physiotherapist. There are days when I have great interactions with other staff and I feel fulfilled with having helped someone during one of the most significant health events of their life. These ebbs and flows between understanding and questioning are what have made my experience in the MSICU exciting and challenging so far. Ground has been broken and paved for highlighting the value of a PTA in the ICU, and this continues as the PERCC project has incorporated a part-time occupational therapist (OT) into the unit. As a result, I am now going to be able extend these scope of practice conversations further with the implementation of my dually trained skills. I am looking forward to continuing to innovate and advocate for the OTA/PTA role, not just at the level of an ICU setting but to the broader OT, PT, and OTA/PTA community. I have learned so much these past several months, and I continue to reflect on the beauty of working in this field; if you are open to experiences and engaging in the ongoing conversation, the possibilities for positive change are boundless.
*Optiflow: non-invasive device which warms and humidifies high flow nasal cannula air/oxygen blends which are delivered to the patient.