Physical therapy in the emergency department is a relatively novel practice; however, over the past decade it has started to become more common, with 23 major medical systems across the U.S. reporting the use of emergency department PTs as of 2014.1
Naveed Shan, DPT, is a physical therapist in Phoenix who works in the emergency department at Banner University Medical Center. He has been practicing in the ED since January 2018, where he continues to learn and grow as a clinician.
What does a day in the life of an ED PT look like?
NS: So, for me personally, I’ve shadowed one or two other ED PTs, but I can only speak on my own account. I typically get in and look over the board and see what patients are in, and then talk to the NPPs (Non-Physician Practitioner) or the physicians about whether I can help their patients. Or I just wait for them to refer patients to me. On a slow day, I’ll see 6-8 patients, but it varies a lot. I think the most I’ve seen in one day was 20. I would say 6-15 would be a good average.
What do you do for your patients in the emergency setting?
NS: It depends on what their needs are, but my main focus is trying to reduce pain and get them moving so that they can be discharged home. Most of the patients I see are very non-urgent. They are usually the patients that most NPPs and Physicians aren’t super excited about, like the guy who comes in and he’s had knee pain for two or three weeks. That’s where I come in - because I’m actually excited about the knee pain that they’ve had for 3 weeks. I can also help with patients who come in with dizziness or vertiginous symptoms. I can work with the NPPs and Physicians in deciphering a few things: between peripheral or central causes of vertigo and whether I can treat them in the ED or if they need to be referred out. I also do disposition evaluations. For the patients with failure to thrive, or those who aren’t sick enough to be admitted but may need skilled nursing facility placement, I can help determine if they’re safe to go home from the mobility standpoint.
What’s your relationship like with the other staff: the physicians, the residents, the nurses?
NS: It’s great. But it took a long time for everyone to be comfortable referring to me. Like, for the first six months I was there I hardly saw anybody because the docs weren’t comfortable just letting this random PT just show up and come see their patients. I remember asking a practitioner, “Hey can I see your patient with back pain?” And she said, “Not before I see her, I don’t want you to kill this patient.” She had no idea what I did. So it took a lot to gain the trust of the physicians, NPPs, and nurses. The biggest thing is making sure everyone is comfortable with me working with their patients. I’d like to think I have great relationships with all of them now; we discuss cases and break down different things and I learn from them every day. I hope that I’ve taught them a thing or two.
What benefits do departments that have physical therapists see versus those that don’t?
NS: It varies based on how they’re utilized. We’re still very early on in PT in the ED in the U.S., but we’ve found that there is reduced imaging utilization, reduced opioid prescriptions, reduced length of stay, improved patient satisfaction, and overall reduced cost, in part because of better referrals to outpatient PT and orthopedics and sports med. Especially in patients who needed home health or SNFs (Skilled Nursing Facilities), PTs helped reduce the number of visits and cost in the long run.2
What kind of things would you like to see ED docs do more in their work with you?
NS: I think it varies from physician to physician. Ideally I would like every Physician to utilize us appropriately and realize what our knowledge base is. Really I wish they understood our scope of practice better. I don’t expect every ED Physician to know what physical therapists do; we’re a young profession. PT has only been around for 100 years and really only started in the ED in 2000, with Mike Lebec. It’s still a very novel approach. And not every system has access. If I went to a town of 10,000 people, ED physical therapy would be unheard of. But I hope that with time the ED physicians will understand the role of physical therapy and how it can be utilized.
So what about when you’re working with NPPs, physicians, and residents that you wish they would do less, or maybe not at all?
Naveed: There’s one thing they do, and sometimes it’s appropriate and sometimes it’s not, but they’ll tell me, “I want you to wait until the medication kicks in.” Like they just need to take the edge off, but I would rather see the patient at their worst to determine what I can do, and to get to the root cause of the dysfunction if I can at that moment. Waiting until the meds kick in can make my physical therapy management a little more difficult. But that’s also a case-by-case basis. One thing about PT that is mismanaged in the ED setting is the wait time. From the time the patient comes in to the time they’re seen, I think it just makes for a better patient experience. I still come in as an afterthought and I wish I was consulted earlier on patients. Like if they had called me earlier, this guy with back pain could have been gone an hour ago.
References
- Guy R, Kesteloot L, Lebec MT. Physical therapists in the emergency department: a national survey. Poster presentation at the combined sections meeting of the American Physical Therapy Association. Las Vegas, NV. 2014.
- Jogodka C, Lebec M. 236: Physical Therapist Consultation in the Emergency Department for the Treatment of Whiplash: An Analysis of Effectiveness. Ann Emerg Med. 2008;51(4):542-543.
- Kim HS, Strickland KJ, Mullen KA, Lebec MT. Physical therapy in the emergency department: A new opportunity for collaborative care. Am J Emerg Med. 2018;36(8):1492-1496.