Kaitlyn Gibbons Emerson Internship Scholarship

Transcription

1 Kaitlyn Gibbons 2012 Emerson Internship Scholarship This summer I had the immense pleasure of completing an internship at the MedStar Washington Hospital Center Cardiac Rehabilitation and Wellness Program through the School of Health Sciences and Human Performance and the Emerson Scholarship. MedStar Heart Institute is the heart division within MedStar Washington Hospital Center which is ranked as the #1 hospital in the Washington, D.C. region by U.S. News and World Report. With one of the highest volumes of cardiac surgery in the metropolitan Washington D.C. area, MedStar Heart Institute prides itself on experience, team approach, and constant advancement in technique. The surgeons, physicians, and staff work to provide patients with access to the best possible experience, which includes a state-of-the-art Cardiac Rehabilitation and Wellness program. Cardiac Rehabilitation is a personalized exercise and education program overseen in this facility by a physician, physical therapist, exercise physiologist, and two cardiac rehabilitation aides. The medical conditions of the patients at this facility range from myocardial infarctions (heart attacks), bypass surgery (CABG), heart and/or lung transplants, angioplasty, heart valve replacement/repair, to stable angina (chest pain). Once referred by their cardiologist or primary care physician, patients begin the thirty-six visit, Phase II cardiac rehab program, spending an hour, three days per week at the facility. Phase II is the outpatient, structured exercise program to continue the recovery process. The exercise training includes walking, stationary biking, rowing, arm cycling, recumbent biking, recumbent stepping, and resistance training. At MedStar Washington Hospital Center Cardiac Rehab an individualized exercise prescription is provided for the Phase II cardiac rehab patients and they are constantly monitored using electrocardiogram (EKG), heart rate, and blood pressure. Education plays a large part of the process of cardiac rehab at MedStar Washington Hospital Center, lectures are provided on important risk factors and lifestyle changes to help aid in the recovery process. Two days per week the facility has wellness days where patients that have graduated from cardiac rehab exercise. This is an unmonitored program where guidance, if necessary, is provided throughout the exercise session. My internship at MedStar Washington Hospital Center Cardiac Rehab created a multitude of different environments for me to assume numerous different roles. I developed into the role of an exercise physiologist by taking resting and exercise blood pressures, which then nourished

2 my craving to learn as a student. I also helped the patients to make informed decisions through education, and developed long-lasting, comfortable relationships as a friend. Exercise Physiology Intern One of the many things that I loved about my experience at MedStar Washington Hospital Center Cardiac Rehab was that I was immediately given responsibility and held accountable for my actions. After spending some time observing, it did not take long for me to feel like I was part of the team. I felt as though I was truly doing what I will be doing in the real world setting as an Ithaca College graduate. I had the pleasure of being one of the first people with whom the new patients interacted on their first day. When the new patient arrived I took their preliminary measurements. These measurements included resting blood pressure, resting heart rate, resting blood oxygen saturation level, waist and hip circumference, waist to hip ratio, height, and weight. After these measurements the patient would typically meet with the physician. Upon completion of the meeting the patient returned to me for instruction on how to hook up to the heart monitor so we could obtain their EKG on each modality as well as their heart rate. We used a 4 lead heart monitor. I showed the patient the locations on the body where they would hook the leads, showed them how to prepare the skin prior to sticking on the electrodes. The point of the skin prep was to ensure that a clear EKG reading is obtained as well as making certain the electrodes stuck. After the staff confirmed that the EKG was recording on the computer, I took the patient to the indoor track to administer the six-minute walk test. The six-minute walk test was completed at the facility on the first and last day of the program. It is a method of creating a baseline measurement regarding the beginning level of overall exercise capacity. The six-minute walk test completed on the day of graduation from the program is used to measure the patient s progress from Session 1 to Session 36. While the patient was preparing for this test, I took resting measurements first, including heart rate and blood oxygen saturation level. Following that I explained the Rating of Perceived Exertion Scale (RPE Scale) used to measure the intensity of the exercise. The Rating of Perceived Exertion (RPE) Scale is a subjective scale from six to twenty that allows the patient to describe the difficulty of a specific task; taking into consideration factors that are not necessarily measurable by the heart rate and EKG. Modeling after the exercise physiologist I attempted to explain the numbers in ways that the client would understand such as, Six is like you re sitting at home, kicking back, watching television, and twenty is the hardest you can possibly push, there is no more left in you. Next I explained the Dyspnea scale as the ease of breathing scale. This scale went from zero to four and was a method for the patient to explain to the staff the difficulty breathing he/she had while exercising. After getting a resting measurement for the patient on the both the Dyspnea and RPE scale, I then explained the actual walk test. Upon completion of the test, at exactly the six-minute mark, I took the patient s blood pressure, heart rate, blood oxygen saturation level, rating on the Dyspnea scale, and RPE. I also asked if any leg pain, chest pain, or dizziness was experienced. Next, using a surveyor s wheel to obtain the most accurate measurement, I calculated the distance that the patient completed during his/her final lap. Working with patients on this test was rewarding because I was able to get to know new patients, congratulate current patients, take measurements, as well as educate.

3 A large portion of my job in this area was to help the head exercise physiologist create exercise prescriptions. This included taking into account the patient s risk stratification, current/previous medical condition, current fitness level and functional capacity, and goals. Through this process I learned a great deal about the different exercise prescription protocols for various diseases. For example when dealing with a patient with Peripheral Artery Disease it is best to create a walking program. I also learned how to calculate the stopping points for each patient. For example what level blood pressure and blood sugar at which to stop a patient while they are exercising. I was able to sit down with the patients and explain their exercise prescription to them. The patients had access to their exercise prescription every week. On a sheet of paper the prescription explained each modality, duration, frequency, and intensity at which we wanted the patients to exercise. These sheets were updated weekly. It was interesting to take the general knowledge that I had previously obtained about exercise prescription and discover ways to adjust it specifically for each patient. Electrocardiograms are a vital part of any cardiac rehabilitation program as well as at MedStar Washington Hospital Center. The patients in Phase II cardiac rehab were monitored the entire time they were present for their visit. Upon entering the facility they put on a monitor so that we could record any abnormality in heart rhythm and report it immediately to the physician. Luckily, from my studies in the Clinical Exercise Science major, I did have background in EKGs; however my experience as an exercise physiology intern at this hospital required me to learn and recognize irregularities much more quickly and accurately. Some days it was my role to watch the computer to catch any pauses or changes in the patients normal rhythm as each patient s EKG ran across the screen. This was extremely interesting to me because after considerable assistance from the exercise physiologist, I could recognize the typical heart rhythms for each patient. An irregularity may appear on the EKG, but for that person, it could be their normal, which is what I began to understand as I spent more time with the patients and the EKG. After the sessions had been completed each day I spent time sorting through every beat that every heart had contracted while working out that day. It was my job to select the clearest EKG strip with the highest heart rate for every patient on each modality they completed that day. I had to look through every beat to ensure that we had not missed anything troublesome throughout the exercise session. This took me countless hours, but in the end truly benefitted me as an exercise physiology intern. Student As a student I was fortunate enough to observe a great deal of different environments. In the cardiac rehab setting I was able to observe the physician in our facility while she did intakes with the patients. This was extremely beneficial for me because she taught me the key facts to listen for as the patients explained their problems as well as previous procedures. I watched as she administered physical examinations and learned why she looked at particular parts of the body and symptoms for which she was looking. I spent three days observing Phase I cardiac rehabilitation with the physical therapists. Phase I occurs in the hospital, following surgery, for the length of the hospital stay. I also observed a phenomenal exercise physiologist day in and day out. I watched and learned from him as he interacted with patients, answered questions, took measurements, gave educational talks, and helped improve the quality of life of his patients. I was able to watch my clinical supervisor create strong relationships with clients and answer their every question. I was even able to watch and learn as she informed curious

4 patients on the passing of one of their peers. I am extremely grateful to the staff at this facility because they made it their personal duty to ensure that I was able to learn and experience as much as possible during my short time as a summer intern. I spent a full day observing in the Stress Echo Lab at Washington Hospital Center. This lab is in service for both inpatients and outpatients. I saw two patients throughout the day, one exercise test and one using Dobutamine. During the exercise stress test I watched as the nurse prepped the female patient and did a number of EKG readings. After this I watched the Echocardiogram being completed. I had never seen an Echo done before and it was beautiful! I could see so clearly the atria and ventricles contracting as well as hear the heartbeat. I could see both the bicuspid and tricuspid valve at work. The technician took the time to tell me exactly what he was doing so that I could understand why he obtained the views from the angles that he did. After the Echo was completed, they moved the patient to the treadmill and using Bruce Protocol began an exercise test, increasing the grade every three minutes. From the cardiologist I learned that after the exercise test and during the Echo immediately following we should have seen the heart getting smaller and walls thickening. The second woman I saw did not have the functional capacity to do an exercise test, so instead they used the Dobutamine test. The set up was the same, however once it came to the stress part instead of making the patient walk on the treadmill they would inject her with dosages of Dobutamine taking an Echo at every stage. The heart rates that were achieved during these stress tests were the ones that we would use as exercise physiologists in creating the target heart rate ranges in the exercise prescription. I watched the tests and skills that I learned and administered while a student at Ithaca College come to life in front of me and it made me extremely grateful for the knowledge I received at IC. I also was able to spend a day observing in the Nuclear Stress Test lab. This completely opened up a new area to me because I had previously not taken a strong interest in nuclear testing. This lab was extremely fast paced and more focused on inpatients. I spent the day with a physician and a tech in three different rooms watching as both exercise and sedentary tests were used. In sedentary tests, medications like Lexiscan are administered over a twenty second period as to decrease the side effects. One major side effect that a lot of people experience from the Lexiscan is stomach congestion. Because of this problem they give patients ginger ale and graham crackers after the test is completed. The actual main goal of the eating and drinking is so that the food can push the isotope down through the system. This way a clearer picture can be seen during the imaging that follows forty-five minutes after the stress. This food is acceptable because it contains no caffeine. It was explained to me that skinnier people were typically the ones to feel the symptoms. Females also had a greater risk than males. The first patient that we saw had a hip replacement which is why she could not do an exercise test. There was one older woman in her 80 s who did the Lexiscan test and the physician showed me on the EKG where she had a positive ischemic response to the stress. It was interesting to see an abnormality. It was explained to me that these nuclear tests were done primarily to note any ischemia and to what degree. The one exercise test that I did see, the man failed because he didn t reach 85% of his age predicted max heart rate. I was surprised that instead of just counting this exercise test as non-diagnostic and doing the best they could with the heart rate reached, they then went ahead with the Lexiscan, so they did it with medication after a failed exercise. I learned a great deal from this experience because I had never had the hands on approach to nuclear stress testing, and also because it was extremely fast paced. One of the most enlightening experiences I had while as a student at MedStar Washington Hospital Center was observing my supervisor lecturing on the Left Ventricular Assistive Device

5 (LVAD). An LVAD is mechanical pump that takes over the function of the left ventricle to ensure normal blood flow. Throughout her many years as an inpatient physical therapist as well as clinical supervisor in cardiac rehab, my supervisor has worked with an extremely high number of patients with LVADs. I was able to sit in as she lectured on the different types of LVADs, including the Heart Ware and Thoratec Heart Mate II, to the physical therapists that she supervises. She explained everything from their purpose, to how they work, to the controllers, and even the alarms. She followed up the lecture by including a hands-on portion where I actually learned the process of connecting and disconnecting the drive line and batteries for both types of LVADs! I also was taught how to take a Doppler blood pressure because that is the ideal method for obtaining the most accurate blood pressure measurement on a patient with an LVAD. This was all extremely relevant because earlier in my internship we had a man pass away who had an LVAD and attended sessions at our facility. To be able to understand a whole different medical condition than those that I had become accustomed to seeing at cardiac rehab truly benefitted me as a student. Having the opportunity to observe in a myriad of different environments helped me as a student intern to tie everything back to cardiac rehab. Watching the staff every day at my facility helped me to learn what I could expect from the real world. They also taught me information specific and relevant to the cardiac rehab spectrum. Everything that I experienced, just added to the bigger learning process that I experienced throughout my three months at MedStar Washington Hospital Center. Educational Presentation As part of my internship, I prepared and presented an educational talk to both the cardiac rehab and wellness patients. This lecture focused on the benefits of nutrients. My goal was to create positive spin on a subject that usually is presented in a negative way. I wanted to tell them how the nutrients they are also told are bad for you in excess, actually can help their bodies as well in moderation. I named my lecture Learn the Benefits of Eating! to try to catch their attention, as everyone loves to eat! I made five different posters outlining five different nutrients: Water, Fats, Carbohydrates, Proteins, and Vitamins and Minerals. On these posters I outlined what these nutrients do positively for the body, recommendations of how much they should be consuming, and some healthy sources. I also supplied the patients with a four page handout outlining everything discussed in the presentation. The following is an example of one of the visual aids that I used to highlight information:

6 Creating and presenting my lecture was a great experience. I gave two lectures to the cardiac rehab patients; each group consisted of about ten people. They had a great deal of questions and seemed to enjoy the facts I shared with them. I presented my project in both a large lecture setting and a two-on-one setting. During the wellness day I gave the talk to two individuals which was effective because it was more like a conversation.the patients responded very well to it and I was pleased to supply them with new information. I was also educating every day that I worked with a new cardiac rehab or bariatric patient. I sat down with each new cardiac rehabilitation patient individually and went over the importance of exercise as well as the concept of progressive overload, which states that in order for a tissue or organ to improve its function, it must be worked harder than it is normally accustomed and this is what cardiac rehab does to their heart. I also spent a great deal of time going over the ways that we monitor intensity. I explained that we used both the RPE scale and target heart rate and that we wanted the patients working out at a Target Heart Rate Range of 60-85%. I explained how to create an exercise prescription using the form that we use. I addressed mode, frequency, duration, and intensity for a second time. For the bariatric patients on wellness days I addressed very similar topics including exercise prescription, intensity, contraindications to exercise, and resistance training. It was extremely beneficial for me to be an educator during my time at MedStar Washington Hospital Center because it forced me to be able to think on my feet and realize how to customize the facts to suit the needs of each individual patient.

7 Friend One of the most rewarding roles that I played this summer was friend. I was able to form relationships with not only the people that I worked with but also the patients. It has always been my goal to improve another s quality of life. My internship at MedStar Washington Hospital Center Cardiac Rehab fulfilled that goal by allowing me to improve the patients quality of life (I was lucky because in turn the patients improved mine as well!). Every day I looked forward to seeing the patients I worked with! Nothing could replace the joy that I felt as they walked in every morning with a smile on their faces and called me by name. I got to the point where they shared information with me about their lives and I was able to have conversations regarding their personal interests. I was also able to solve the mystery of what motivated these individuals. I knew which people needed me to talk to them to distract them in order to complete their workout and those who needed me to hula dance in front of the treadmill so they could complete their twenty minutes. One of my favorite relationships was one that I had with an older woman who not only had cardiovascular disease but dementia. Every time she came into cardiac rehab she would teach me true life lessons. On some days, though, we would take the lighter route and talk about nail polish. Every week I would surprise her by painting my nails a different color. She looked forward to the change each Monday. It truly hit me on my last two days how big of a role these people had played as my friends as well. Saying goodbye to them was terribly hard. I am currently a pen pal to one of the ladies with whom I worked. These individuals gave me a sense of calm in stressful situations and their faith in me gave me an entirely new confidence for which I will never be able to fully express my gratitude. My time spent at MedStar Washington Hospital Center Cardiac Rehab was the most phenomenally rewarding experience. Each separate role that I played throughout my internship stressed me out, empowered me, and prepared me for life after graduation. I am eternally grateful to the staff and patients at the facility who taught me lessons that I could not have learned in the classroom. My internship at MedStar Washington Hospital Center Cardiac Rehab helped me to grow as both a person and a professional through challenges and triumphs and I will take this experience with me throughout my life as a professional in the Clinical Exercise Science field.