ACP Internist Blog

Thursday, October 15, 2020

Sinking in Bed Syndrome has been made worse by COVID-19

There's a condition that I call ”Sinking in Bed Syndrome,” which is one of the biggest epidemics affecting U.S. health care facilities (I am actually going to patent that term). And sadly I have only seen it get worse because of COVID-19 restrictions, both in acute health care facilities (hospitals) and also sub-acute (rehabilitation). Patients are moving around less and sadly becoming more and more deconditioned. If you have a loved one who has suffered because of this, and have a story to tell, please do get in touch with me. Because I feel very strongly that it's such a simple thing that most health care facilities are pretty terrible at. I am reposting this piece I wrote on the ubiquitous syndrome, from a few years ago, and intend to keep doing so every so often until I see some progress.

There's a huge problem we have right now affecting our nations' hospitals. It's not a disease you've ever heard of before, or something that cutting edge research or treatments are going to solve. It's a seemingly simple issue that has been lacking in every single hospital I've ever worked in, whether it be a large academic teaching hospital or a small rural medical center. It's rarely talked about, but endemic nevertheless. I'm hereby going to assign it a name: “Sinking in bed syndrome”

What on earth is it you may ask? Well, the scenario goes something like this. A patient, usually elderly, is admitted to hospital with an acute medical illness. During the first few days of treatment, they are basically lying in bed while receiving all their treatments. They get more and more sunk into their bed, becoming weaker and weaker at the same time (even though their actual illness is improving). As they recover, they find it more difficult to get up out of bed and start walking again. The longer they are in bed, the more difficult it will be. Muscles have become tense and joints are stiffer. Because of this deconditioned state, recovery will be prolonged and patients will spend longer getting back to their baseline state.

All hospital-based doctors see this type of scenario unfold on a weekly basis. Sadly, lots of these patients actually report having quite reasonable and independent function prior to their admission. Of course, they have been unwell, and their illness itself will set them back. But having seen how we leave patients “sinking” in their bed for days at a time, I'm of the firm belief that keeping them in this state really sets them back even more.

In short—we just need to get them up much sooner. Unfortunately, it's not in our systemic culture to do that, and in almost all places I've worked—I sometimes need to plead just to get our patients up out of bed to the chair simply to make sure they are not lying down flat all the time. Sometimes sadly, it's family members who are the ones voicing their concern to me that their loved ones have become weak and need to sit up and walk more. It's a shame too that many health care institutions only think of getting physical therapy involved when discharging from the hospital is imminent—when actually it should be done much sooner.

Only a few decades ago, the culture was to keep patients who were sick in the hospital on complete bed rest for an extraordinarily long amount of time. Patients having heart attacks would be kept in and observed for several weeks. We now know that such a prolonged hospitalization is not only unnecessary, but also very bad for our patients.

So why do we not get our patients up sooner? I believe it's not a question of laziness or lack of resources. Nurses and nurses' aides are the most hardworking people I've ever encountered, and most nurses are aware that it's good to get patients up and moving. However, in the haze and hustle of a hospital admission—with intravenous lines, telemetry monitors, strong medications and constant tests—we lose sight of the simple little things that can make an enormous difference. In my experience, patients even just look so much better sitting up in a chair as opposed to lying in the bed!

So here's what the world of health care should really push for: A National Ambulate the Patient Week. This should involve:
• Education for all health care professionals about the importance of ambulation. Physicians should be encouraged to write “OUT OF BED TO CHAIR AT LEAST THREE TIMES DAILY” as an order for nearly all hospitalized patients as soon as they can, usually from hospital day 2. With that order should be assumption to “ENCOURAGE AMBULATION”, either with or without assistance depending on the circumstance;
• Invest in more physical therapy services and also dedicated PT-aides, also known as “walkers or mobility aides”, to get people up and moving early;
• Administrative oversight from charge nurses and unit supervisors to raise a red flag when they see a patient who potentially has “sinking in bed syndrome”;
• Posters around hospitals encouraging early ambulation and walks around the hospital floor; and
• More comfortable chairs! This may sound rudimentary, but a common complaint I hear everywhere is that hospital chairs are very uncomfortable. However much they are purportedly designed for hospitalized patients, just glancing at them and testing them out myself—I'm very skeptical about how comfortable patients can feel sitting in them. I get the same feedback from relatives who test them out. If healthy people don't feel comfortable in any given place, how on earth do we expect sick people to?

There are certain departments that are actually already very good at mobilizing their patients. One such example is orthopedics, where surgeons are almost obsessive about getting people up as early as possible after hip or knee surgery. If they can do it, so can everyone else.

Richard Asher, the British endocrinologist and forward-thinker from the early part of the 20th Century once said, ”Look at the patient lying long in bed. What a pathetic picture he makes! The blood clotting in his veins, the lime draining from his bones, the scybala stacking up in his colon, the flesh rotting from his seat, the urine leaking from his distended bladder and the spirit evaporating from his soul.”

That quote was from 1947. I will leave it to your imagination to think what scybala is!

Seventy years later, while we are not as bad as we were in the 1930s and 1940s, we can still do a lot better. So let's make it a national priority get all our hospitalized patients up and moving earlier. Starting from today.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.
Thursday, September 24, 2020

Behind the mask assessing risk in COVID-19: playing risk

It's an earnest game, judging what risks are serious, which trivial, and how to balance them through daily life. Over the past decade or two I have changed how I understand risk (and how I discuss it with my patients). COVID-19 makes a correct approach to risk all the more fraught. Correct, however, is not to be determined by a set of axes, but a breadth of view. Follow along.

For a long time I was absorbed by the topic of risk communication. What is your risk of developing a certain sort of cancer during your lifetime? There is the deadly dull (and inaccurate) monologue of the doctor to patient, presenting one number as if it's the Torah from Mount Sinai (you have six months to live goes the joke, and even today, the horrible experience of some people in their provider's office). More accurate is a spectrum of risk, an estimate which encompasses a range of probabilities. Getting people to understand that is not easy, I mean doctors and patients, because difficulty with understanding numeric information is common among both. There are a wealth of strategies, people doing good work in this area.

Neighboring the topic of risk communication comes a consideration of how people process risks, cognitively and emotionally. Yes, presentation matters, but certain risks loom larger than others; errors of omission can be more significant in our eyes than those of commission. Even if you are presented a spectrum of risks in a way which you should understand, your brain might consider them differently than how the presenter intends. “Cognitive bias” is the watchword of behavioral psychologists, and economists, who believe that nudges—incentives—are necessary to guide us towards a less errant view of our own self interests.

There is so much wrong with this approach, to be honest, and I've only come to realize it after a decade of patient care in nested systems which deny patient individuality even as they grindingly reproduce systemic oppression. The idea of “homo economicus,” that perfect rational being who processes risks and benefits, responding just according to the correct market signals, is not just depressing, and indefensible in the ideal, but doesn't conform to empirical reality either. (Even economists recognize this.) Further, people are different. Understanding how each individual undergoes life in a different way is part and parcel of understanding that individual-level risk is also insufficient: we need to understand how systems, cultures, and regimes of control modify the distribution of risk across groups.

I have come to this realization through my disabled patients, and learning from disabled activists (mostly on Twitter). Imagining risks as additive or multiplicative compared to a “normal” baseline ignores that the baseline is malleable, heterogeneous, outside of individual control, and bent by gravitational fields of economic and social priorities.

The social theory of disability (which comes in many flavors) proposes that society needs to be set up for the benefit of people, not the other way around. Similarly, with regard to COVID-19 (and chronic COVID-19), physicians, and all who care for others, need to alter the pattern in which we demand from the chronically ill that they somehow up-titrate their resilience, toggle to less pain, and generally MANAGE BETTER, by decreasing their risk. “Wear masks, wash your hands, stay inside,” unless you can't, or you don't have the water, or you have to work.

How can we alter these patterns? I don't have a fully worked-out theory, but I imagine someone has plumbed the depths of the soil to find where the roots of ableism and of capitalism derive from a single trunk of productivity. Making more for the sake of more underlies many expectations that undermine the chronically ill and those with less. Thinking that those “over there” are somehow more abnormal (or more normal) than we are limits the possibilities of solidarity.

The solution is not to divorce ourselves from the realms of political and social affairs, adopting a moralist quietism that all will be well if we think positive, but to provide sufficient support for all, realizing that individual risk-balancing differs because of how our landscape has been structured over time.

Chronic COVID-19 will cause much chronic disability, and society needs to fit that. We need to realize that before we again adopt a patient-blaming and symptom-minimizing approach.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Thursday, September 10, 2020

Behind the mask: school days

Reopening our schools during the COVID-19 pandemic is on everyone's minds, and the outlines of the conflict are at this point clear to many: not just safety for kids, parents, teachers, and staff, but also for surrounding communities. Decisions may reinforce inequity.

Specific statistical models are available for estimating the risk that a gathering of N people includes at least one person with COVID-19; other models estimate the influence of airflow and other aspects of building design.

The above depend on local factors: who is likely to be infected, and how many; how much contact (or what “mixing,” as epidemiologists call it) is prevalent in a community; what the local schools are like.

But so much isn't known. We lack consistent regimes of testing, tracing, and isolation. Only 14 states make their tracing data public; So many cases (such a basic number!) are not found or included. And those who aren't included are likely to be in the out-of-the-way corners that are too easy to ignore (underpasses, prisons, streets; entire neighborhoods).

Living under uncertainty is its own psychological trauma, but having at the same time to include in all our calculations considerations of who might be forgotten is a tougher job still, whether we are calculating statistics or merely jotting up risks and benefits on our pads or in our heads.

Yet the forgotten are always closer than one thinks.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.
Monday, July 6, 2020

With wellness habits: something is always better than nothing

The philosophy of “something is always better than nothing” is one of the most useful things to remember when it comes to lifestyle medicine and incorporating better habits into our daily routines. I've found that for many people, especially those right at the start of their health and well-being journey, the task ahead may seem very daunting and intimidating. You may eat a load of junk food, have no regular exercise routine, or have a ton of weight you want to lose. Such a big mountain to climb.

A very important thing to remember, is that we don't need to start off with huge changes immediately. There are always little, often tiny, things we can do to keep stepping in the right direction. If you've eaten a fast food meal, why not have an apple or a handful of blueberries afterwards? If you're eating a pizza full of carbs and loaded with cheese (something that you know will be terrible!), why not make an extra effort to put some vegetables on it as well? Do you find yourself sedentary in your desk job for most of the day? Then get up and ascend a few flights of stairs for a few minutes! If you know there's no way you can work out for 30 minutes to an hour because you're so busy—then just have a five-minute workout instead!

These little things add up very fast, soon become normal, and a series of habits that you're regularly engaging in, especially as you start feeling better about yourself in general. “I must eat an apple today,” “I have to have some vegetables with that,” “I need to get up and move around.” I know because this is how I started my wellness journey several years ago. Miniscule changes evolved over time to a regular ingrained pattern that has left me in better shape and feeling more energetic and happier too. I'm not going back!

This doesn't just apply to people initiating lifestyle change for the first time in their lives, it can even apply to seasoned enthusiasts. We all have days of indulging and a lack of exercise. No matter where we are … if we just keep doing those little good things every day … it soon adds up and magnifies.

Suneel Dhand is an internal medicine physician, author and speaker. He is the founder of DocSpeak Communications and co-founder at DocsDox. He blogs at his self-titled site, where this post first appeared.