Defining Moment Defining Moment: Vulnerability and Courage For PTs and PTAs, the two never have been more closely intertwined. By Carrie Hall, PT, MHS | June 2020 This Defining Moment column is being made available in advance of the rest of the June 2020 issue of PT in Motion magazine. Enjoy this published-ahead-of-print article now, and look for the entire June issue around the first of June 2020. For a different perspective on responding to the COVID-19 pandemic, also read this APTA blog post from a Washington-state PT who closed the outpatient department of a critical-access hospital and shifted her resources to meet critical needs elsewhere in the hospital. Listen to an updated version of this print column, voiced by the author. Think of this piece as both a portrait of a moment in time and a commentary on the timeless value that physical therapists and physical therapist assistants offer to society. I'm writing this in early April. It's about why my outpatient physical therapy practice remains open in the midst of a pandemic, and how I've been making that work. These are extraordinary times, with circumstances and directives changing by the hour. There's no way I can predict what work conditions and patient and staff safety issues will look like — here in Seattle or anywhere — when this essay is published in June. What I can say with confidence, however, is that nothing will change my love for my profession or my pride in what physical therapists and physical therapist assistants do. Safeguarding an Essential Service I own an outpatient physical therapy company with three practice locations. Long before COVID-19 became a household term and omnipresent source of fear, the quote describing my philosophy of life in the short biography on our website was "You cannot have courage without vulnerability." Those words were put to a test I never would have imagined when I recently weighed the difficult decision whether to keep our doors open as the pandemic hit our area hard — making us the first epicenter of the COVID-19 crisis in the United States. I had to consider an array of health and safety factors for both patients and staff. What I kept coming back to is the fact that physical therapy is an essential health care service. People still are getting injured, still are in pain, still are managing chronic neuromusculoskeletal conditions, and still need our assistance to optimize their movement, remain healthy, and live their fullest life. I determined that, provided I take every possible precaution to protect the health and safety of our patients and staff, I would remain open to serve those in need. Among those precautions — implemented with full appreciation that there is evidence of asymptomatic and presymptomatic spread of the virus — are: We are constantly receiving and adopting safety updates for outpatient clinical settings from the University of Washington, where I am a member of the clinical faculty. Via a highly visible flyer posted on our door, email communications to our patients, social media blasts, and a banner on our website — we state very clearly that if you have a fever, cough, or difficulty breathing, you must consult your physician and reschedule or cancel your appointment. In addition, we ask screening questions of all patients before we begin treatment, such as "Do you have a fever?" and "Any signs of illness?" We have infrared thermometers for use at each of our locations if anyone is in doubt. None of our team members come to work if they're feeling ill for any reason. They are asked to monitor their temperature daily before leaving home. If they are sneezing or coughing, we require a physician's approval for them to return to work. Patients and the provider wash their hands before and after each treatment session. We have automatic soap dispensers and single-use paper towel dispensers to minimize hand contact. Providers wear masks and practice physical distancing to the greatest extent possible. It's very easy in our clinics because the model of care that we use is one-to-one with the physical therapist. We don't use a third person. We have built physical distancing into our treatment areas, with private rooms and tables that are 10 to 15 feet apart. Obviously, the PT can't necessarily employ full physical distancing through the entire treatment. The mask helps protect the patient during closer contact. Patients are instructed and reminded via text to wear a cloth mask, and are issued a mask if they lack one. We've removed chairs in our waiting area to maintain physical distancing of 6 feet. Tape on the floor enforces proper social distance from our receptionist. We've taken everything off our counters except tissues and hand sanitizer. We no longer use the credit card reader; we are manually inputting credit card numbers. We have sanitizer and tissues at every workstation. All surfaces and equipment are sanitized with Centers for Disease Control and Prevention-approved solutions for the appropriate length of time after each treatment session. I have been consulting with a friend who is an epidemiologist and a science writer. He recently wrote an op-ed piece regarding the use of public restrooms. The virus has been found in feces. When you flush the commode, you aerosolize what's in it, so that's a potential method of virus transmission. In an abundance of caution, we have closed our restrooms to public use. Gloves are available to protect therapists when they're doing manual work or are in close contact with patients during transfers. All patients receive a full explanation of our treatment options (in-person, telehealth, postpone), the risks and benefits of each, and the myriad safety measures we are taking. They are required to sign an informed consent before they can receive in-person services. This is documented in their chart for each date of service of an in-person visit. Looking at the needs of patients on a case-by-case basis, we are advising some individuals — particularly older patients and those with underlying health conditions that increase their risk of serious health consequences should they contract the virus — to stay home and move to telehealth if appropriate. In selected cases of high-risk patients who are not appropriate for telehealth, we offer an in-home visit — for example, if a patient has had a total hip replacement, is at high risk of falling, and needs in-person care. In such instances, we follow strict personal protective equipment and disinfecting procedures to best ensure patient health and safety. What was going to be a gradual telehealth rollout this year for full implementation in 2021 became a one-week full-court press to get these important services up and running. Given our governor's "Stay Home, Stay Healthy" order, we felt that time was of the essence. By the end of those seven days, all needed internal and external policies and procedures — including informed consent, advanced beneficiary notice, HIPAA-compliant platforms, billing, and marketing — had been implemented. The addition of telehealth services has been a silver lining in this period of crisis. We have heard nothing but praise from patients who have converted to telehealth and tell us how helpful they are finding the cuing and direction in their home environment. We conduct a risk-benefit analysis to determine the best care-delivery option for each patient at that point in time. Often, telehealth is the optimal choice. Even with all these precautions, I'm always weighing and revaluating my decision to remain open for in-person visits — even when I'm trying to sleep at night. It's a huge responsibility. Again, our PTs see patients in-person only after careful analysis — and mutual determination that the benefits outweigh the risks. Naturally, our caseloads have dropped considerably, as many times the best decision for the patient is simply to wait things out. We are not generating the same rates of new patient visits due to the stay-at-home order and suspension of elective surgeries. In Washington state, employees can go on partial unemployment and receive "gap" pay without having to look for other work. A Sliver of Light The patients who choose to come in are extraordinarily grateful we're here. They call it their "health visit." They're so thankful we remain open to help them stay physically healthy — which in turn, they say, boosts their emotional wellbeing. The other day I treated a patient who couldn't get an injection for her severe pain from multiple-level disc herniations because of current rules postponing elective medical procedures. I provided her with manual therapy, we gave her a trial brace that helped her tremendously, and we sent her home with a list of exercises for maintenance. She left the building walking far more comfortably, feeling optimistic about her recovery, and literally breathing much easier. She said she did not know what she would have done had we not been open. Her biggest fear had been having to go to a hospital emergency department for help, where COVID-19 patients might be present. She felt far less at risk coming to us, especially given all the safety procedures we've implemented. Yes, I'm feeling overwhelmed. But I'm reassured by the fact that we have policies and procedures in place that are proving effective. I'm constantly monitoring every situation, mindful of adaptations that may be needed to better ensure safe and effective practice. It's a fluid situation. It promises to continue to be so for a quite some time. I must go with this flow and be prepared to manage ever-changing conditions. I do understand and appreciate that not all PTs feel the way I do. Some have weighed the same set of factors that I've described and have come down on the side of closing their doors. There's validity to that viewpoint. I respect it. I understand, too, that despite all of the precautions we've taken, and regardless of the benefits that come from keeping our doors open — including potentially reducing the demand on our hospitals — I can't completely eliminate the possibility that I, my staff, or my patients could become infected at our clinics. Zero risk cannot be guaranteed in any aspect of life. But again, it's my professional judgment that physical therapy is an essential service — in fact, it has been identified as such in national and local guidelines that include health care among the exceptions for stay-at-home orders. I feel responsible to provide essential and medically necessary care as long as I feel I can do so as safely as possible in this challenging environment. As I see it, there's a sliver of light in the current dark cloud, at least where our profession is concerned. This is the perfect moment in history for PTs who have unfettered direct access to patients and clients — as is the case here in Washington state — to inform and reassure people that they can come to us directly if they feel they would benefit from our services. As frightening and devastating as the COVID-19 pandemic is, and as long-lasting as its effects are certain to be, we ultimately will get on the other side of this crisis. We then will be able to reflect back and see how much we learned. We will appreciate the fact that we rose to the challenge, as trusted health care professionals who weigh all the risks and benefits, then do what is best for each patient at a given moment in time. By navigating this crisis with determination, prudence, and a spirit that honors the service of our forebears, we are solidifying physical therapy's standing as the profession that helps keep people healthy in body, mind, and spirit not only in the best of times, but also in the very worst — with vulnerability and courage. Carrie Hall, PT, MHS, is the president and founder of Movement Systems Physical Therapy, with locations in Seattle, Gig Harbor, and Mercer Island, Washington.