Trauma @ The Alfred:
Coming from a hospital with a regional trauma unit, wher I have also worked, I was very keen to see the trauma unit at The Alfred.
The Alfred’s trauma unit is known for being one of the best trauma centres in Australia, their service (http://www.alfredhealth.org.au/traumaservice/) covers all of Victoria, along with the RMH and the RMCH. It is also known for having one of the best hospital layouts for trauma admissions and triage in the world. The fact that their helipad is situated at the end of the ICU trauma bay, with 2 ED set up beds, is testament to that.
This opportunity also gave me an better insight to the ICU management at The Alfred, and the physio’s role within it. (as did my work with the transplant team on the Friday).
All of these areas are exposed to tracheostomy patients and therefore great to see how they are managed away from the formalised neuro team.
The Alfred’s ICU has 45 beds split into 3 pods, within these 45 beds they have level 2 HDU patients.
Due to such a large ICU area, this has impacted on the physiotherapy management on ICU. Rather than having lots of ICU physio staff to cover all the beds, each speciality see’s there own patients on ICU. There are still ICU physio’s who assist as well as seeing the patients who do not fall under a specific team.
This allows each speciality to give continuity of care to their patients from admission to discharge. This also allows inpatient teams to continue with there ICU skills and experience. Normally it is the senior and specialist staff from each department that will see the patients on ICU, however they will get support and assistance from their junior staff as required. This then allows for the junior staff rotating to have a bigger opportunity / exposure for learning with ICU patients. As they will assist on their through multiple rotations, rather than having one rotation and then not seeing that patient group again for months or years.
This is particularly important in places like The Alfred where they do not have an on call service for physio. I also believe their weekend service is structured for all departments, so there is less opportunity there for the junior physio’s on ICU at the weekend.
As you can imagine the trauma service is very busy and therefore so are their therapists. From a tracheostomy perspective, the physio’s take the role of airway treatment and work alongside speech and language to manage the weaning of the tracheostomy as able.
As stated previously, this process is supported by the ICU liaison team which rounds every morning at 09:30.
The therapists on trauma do feel that their opinion regarding the patients progression is listened to, and are happy to have a role within trache care. Feeling this role is the treatment of a patients chest and assistance with weaning, exercise tolerance is also key in this patient group, as not all of these patients will be able to mobilise. Therefore physio has a big role in optimising patients posture and positioning.
The team did also say that they are actually seeing less of their trauma patients getting traches, but were unsure of the reasoning.
Much the same a NUH, the trauma patients have a lower % of patients that end up with a trache compared to other areas such as core neuro, ENT, transplant service, but of those who require one they have a greater % that are decanulated quickly prior to the ward.
Their overall trauma care is very similar to what I have experienced at NUH, one of the big differences however is the lack of physio assistance. At NUH we are very lucky to have great physiotherapy and OT assistance on most of our wards and in all departments. The Alfred has very few and therefore is always under time pressures and needing to find extra staff to assist with treatments.
At the Alfred the trauma therapists are very keen to see how other trauma centres run, and so maybe there is room for a few international links here!
(Prevent Alcohol & Risk-related Trauma in Youth)
For a few hours on one of my days I got to observe and assist with the PARTY programme which is run at The Alfred.
This programme is run for a variety of youth clients e.g. schools, juvenile detention centres etc. With the aim to improve their understanding and prevent trauma.
This is a day programme with many different parts to the day:
• Lectures in the morning
• Visit’s to wards and ICU (seeing clinical practice, imaging etc where able)
• Time with PT, OT, Orthotics (understanding roles + how difficult life could be post injury)
The sessions try to be as interactive as possible to give them the greatest understanding.
There does seem to be a large element of ‘scare tactics’, but a greater role for educating them to stop and think before making potentially dangerous decisions.
I also thought it was a great way to introduce them to many care carrier choices, and some did show interest in working in the health care setting in the future.
Please look at the website for more information, or feel free to contact Janet McLeod, the programme co-ordinator @ firstname.lastname@example.org
The Transplant team:
My final day was spent with Ben, a physio on the transplant team.
This team has recently seen a lot more tracheostomy patients ? the reasons for this.
This day was a great new experience for me as I have never worked with acute transplant patients, and my knowledge is very limited in this area. We saw mainly double lung transplant patients all day.
General (text book) progression at the Alfred is for their patients to stay on ICU for 3 days then move down to the wards. Within 4-6 days these patients will be walking a good distance independently or with minimal assistance (50-100m).
After this time they will be given further exercise programmes as they progress, e.g. static bike, hand weights. As well as a great education and chest management regime.
They then move onto a strict outpatient programme to continue their rehab and progression. At the end of this time (depending on what the patients were like pre-morbidly) they hope for the patient to have met or exceeded all their goals. For example one of their patients had just started running again.
Physio obviously has a very large role with these patients from both a respiratory and mobility point of view.
Therefore if one of these patients has to have a tracheostomy they are often consulted. I was told however that the onus is very much on the ICU intensivists.
We discussed the role of a physio with traches here as the emphasis is still on chest treatment, but there is also a great emphasis on the need to improve exercise tolerance quickly and the trade off between a poorly timed decanulation that may impact on exercise tolerance for the next few days. E.g. is the patient having to work harder once decanulated or requiring a small amount of oxygen?
Would have keeping the trache a few extra days to give the ability to work on mobility and exercise tolerance given a smoother transition?
Therefore the physio has a role here to inform the MDT on how the patient is progressing.
Whist with the team I saw lots of physio respiratory sessions and mobility sessions, both on and off of ICU. I was also fortunate enough to see a routine day 1 post op bronchoscopy of a bilateral lung transplant patient. Even though it was not all trache talk, it was a great learning opportunity for me, which is what these fellowship things are all about!
Thank you again Alfred hospital. And correct me if I’ve got anything wrong.