When historians reflect on the last polio outbreak in the United States, they typically focus on Jonas Salk’s 1955 vaccine that led to near eradication of the crippling disease.
But Johns Hopkins rehabilitation physician April Pruski says we also learned an important lesson from the thousands of patients who contracted polio in the 20th century: the importance of rehabilitation.
“Most people who had polio survived,” says the medical director of The Johns Hopkins Hospital’s rehabilitation consultation service. In 1952, for instance, nearly 55,000 patients who had the disease lived, but many were left debilitated and in need of rehabilitation. “That really raised awareness and sparked a great need for rehab doctors,” she says.
Pruski says 2020’s COVID-19 pandemic has shone a similar light on the field of rehabilitation medicine. The first weeks and months of COVID-19 treatment at The Johns Hopkins Hospital brought hundreds of patients with a sudden need for extensive rehabilitation services.
“We’ve learned that this is much more than just a respiratory or pulmonary disease,” says Pruski.
Patients in post-acute care for COVID-19 can have physical, mental and even cognitive impairments. At The Johns Hopkins Hospital, whenever possible, rehabilitation begins before a patient leaves the COVID-19 intensive care unit. In efforts to prevent patients’ conditions from deteriorating, physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists, neuropsychologists and physiatrists work side by side with acute-care medical teams.
According to a journal article published in the September 2020 issue of the Archives of Physical Medicine and Rehabilitation and co-authored by Pruski and her division colleagues, patients with COVID-19 who need mechanical ventilators for acute respiratory distress syndrome typically spend more time ventilated than the average ventilated patient who does not have COVID-19. They also frequently need mechanical help to fully exhale, which can further injure parts of the lung.
From March 12 to July 22, 2020, nearly 900 patients with COVID-19 were admitted to The Johns Hopkins Hospital, many of whom were transferred from other hospitals when their illnesses worsened. Pruski estimates that from 60% to 70% of those patients required care from the Physical Medicine and Rehabilitation Department — the largest such surge the department has ever experienced.
Meanwhile, Johns Hopkins and other hospitals across the country needed to preserve personal protective equipment and other supplies, adding an extra challenge.
The journal article also reports that patients often required deeper sedation during ventilation in order to better avoid accidental disconnection, which could lead to airborne dissemination of the coronavirus in the intensive care unit. All of these interventions, according to the article, are “associated with worse cognitive outcomes, weakness and decreased physical function.”
The surge in patients with COVID-19 also forced the hospital to convert medical space to rehabilitation space, including separate acute comprehensive inpatient rehabilitation units — one with a negative pressure environment for rehab patients who are still contagious and another for patients who remain sick but are no longer a risk to spread the infection.
All the while, Johns Hopkins rehab physicians and therapists had to remain vigilant to avoid contracting the coronavirus themselves.
In the pandemic’s early stages, Pruski says, that was a source of uncertainty for clinicians.
“There was just so much we didn’t know,” she says. “We’d heard how contagious and dangerous this coronavirus was. And going into a unit full of patients with COVID-19, even with all our personal protective equipment, really required us to put our patients’ needs ahead of our own.”
Today, Pruski says she feels safer in Johns Hopkins’ COVID-19 unit than she does outside the hospital.
“In the hospital, we know where the virus is and how to avoid it,” she says.