Ep 3: The Crystal Ball 

Welcome to Talking All Things Cardio Home. I am your host, Dr. Rachele Burriesci, physical therapist and board certified Cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions. Research, current trends, expert opinions, and patient experiences.

The goal is to learn, inspire, and bring cardio palm to the forefront of conversation. Thanks for joining me today, and let's get after it.

Hello, hello and welcome to episode three of Talking All Things Cardiopulm. Today we are going to talk about the magical crystal ball. This is a concept that I often talk to my students about because I think this is something that develops over time, and I'd like to just kind of put out there what I mean by this magical crystal ball.

This ability to predict the future that you have the answers literally in the palm of your hands, just like if you were holding a crystal ball. Now, in real life, we know there is no crystal ball, but I like to use this analogy because I think this is part of our clinical reasoning and clinical decision making, and I think honestly, with experience and.

Things that occur within your career, you start to develop this crystal ball and really all that it is, is it, it's not magic, it's clinical reasoning, predicting outcomes, and um, truly looking at the whole picture to basically anticipate. Four steps ahead or the next step, or whatever it might be. I think as a pt, or maybe this is just a me thing, it's always about thinking 2, 3, 4, 5 steps ahead so that you're always prepared for the next step and that you're anticipating what that next step might be.

And I don't think it's, um, a prediction. I think it's understanding. Aerobic capacity, vital sign, response symptom, symptomotology, and just being able to look at the whole picture and say, oh yeah, this is about to happen. And then do what you have to do to prevent set event from happening. Um, I'll go back to my New York days.

When I was in, um, orthopedic acute care unit, I again was never. on an acute care unit before that first experience, so I was very under prepared for the amount of patients that were gonna pass out on me. The number of Syncable episodes that had happened in this orthopedic hospital was. Quite significant and it, it wasn't always my patient.

I just always happened to be around when it was either about to happen or just happened and I'm like passing the room and I'm summing someone's saving grace. You know who you are cuz we've all been there and you just hope that the right person is passing by as it's about to happen. And it became, there became a point where I could predict it.

I knew it was gonna happen, I could prevent it from happening. And so I joked about having this crystal ball, and it's not a crystal ball. It's experience. It's looking at the picture, following the trends, understanding the physiologic response that's about to happen, and then making good decisions. And I think this is really important.

Part of it is recognizing and part of it is making a decision. And when you're in the acute care setting or just PT in general, you are constantly making. What are you doing next? What are you doing next? How are you progressing next? There is always a decision that has to be made. Do you stay? Do you plateau?

Do you progress? It's a constant decision making game and you can have decision fatigue, right? Like I know for myself that after, um, creating plan of cares of plan of cares all day when I come. . Creating my own exercise routine is like, Ugh, I just wish someone could do this for me. And honestly, I do that now because it's just one less thing for me to have to think about.

But you're constantly making decisions and you're constantly making decisions based on what you're seeing. These decisions can become more acute depending on what type of setting you're in. If you're in the ICU and your patient's hooked up. Maybe two pressors or other high level meds, those decisions become a little bit more strategic and cautious.

Versus I'm an outpatient cardiac rehab. Do I increase my intensity, my percentage, what have you? But I'm gonna stick to the Syncable episode because I think it's a really great way to basically describe this crystal ball experience matters being. In a position where you see something happen matters. I saw literally on my first day at the acute care unit, um, my supervisor was taking me around.

I was observing him and he got, he transferred someone to the bedside chair, and I kid you not within seconds, patients passed out. Um, I had to notify my supervisor that this happened. And of course, like there's this immediate thing that happens to. . So I started to see these trends and one of the biggest trends related to Syncable episodes hap happened to be related to the type anesthesia that was being used.

And a very common denominator for syncope was epidurals. We had a very high hed epidural rate at this hospital, especially early on. It's, you know, everything has trends and things are in style. Epidurals were definitely in style for quite some time, and lots of people passed out. So if the patient had epidural crystal ball, point number one is, well, now I'm gonna take this slow.

I'm gonna gradually incline. I'm gonna raise the head of the bed. I'm gonna take my time when I get to the edge of the bed. And of course, I'm assessing vitals and it's so important that you assess vitals before you start anything. And I, I really wanna like make this such a big point because if you don't have a base value and something happens, that next number means nothing.

I can't tell you how many times I've had patients who were hypertensive and if you. Didn't have that base number and you took the second number, say edge of bed or standing, and they're like one 20 over 80. Your initial response is, oh, that's a great blood pressure. You wouldn't think twice about the next step.

But if we switched the script or give you another piece of information and say that patient's blood pressure was one 70 over 89 in the supine position, and then edge of bed was one 20 over 80. Mm, I feel differently about the response. So vital signs is a huge piece. That blood pressure response on initial supine to sit, sit to stand is paramount, especially if it's first time out bad.

I bed. That is a huge part of your crystal ball. Now, let's play this out, right, because the whole point of the crystal ball is that you have the awareness that something is gonna happen because of X, Y, Z. So I already told you patient's blood pressure was one 70 over 80 in supine. You sat them up. They're one 20 over 80.

Now that's a 50 point drop Systo. Likely that patient's going to be symptomatic. If they're not symptomatic, I'm still gonna wait it out because that is an inappropriate response to position change, period. We'll talk about all the things that you should be doing in this point, but if I ignore that one 50 or that 50 point trap, I ignore it because I don't have my crystal ball yet.

I might might, I might make the decision to stand and ambulate. For instance, I was running post-up day zero initiative. That was the goal to ambulate on post-up day zero. So if I ignore my vital sign response and just barrel ahead, well, I wish I would've had that crystal ball because that patient's gonna pass out and it might not happen immediately.

It's probably gonna happen when you're 20 feet away from the bed. So it's important to pay attention to the simple. Vital sign response, and it is so important to have a base value, blood pressure, heart rate, SPO two minimum. You should also, if you have access to the ecg, peep that ecg. What does it look like at base?

Are they in AFib? Is that their base? That's very different than being in normal sinus rhythm because if your patient switches rhythm, During your activity, that is an inappropriate response. Are they throwing PVCs? Are they not? Those are all pieces of information that build your case to proceed or back off that is your crystal ball or part of it.

So part one, we said we know what type of anesthesias we have. We can expect a certain outcome. Patient has an epidural. I'm already. Thinking, this patient's gonna pass out. This patient's gonna pass out until you prove me wrong. And when you don't, great. We're gonna keep going, but I'm gonna tread lightly and make sure 1000% that we're in the clear before we leave that bed.

buy yourself time. Look at the whole picture. So knowing your anesthesia is definitely one, and that could be substituted with other things. What type of medications are they on? Are they on any potent IVs that could potentially dramatically drop their blood pressure? A big one in my mind right now is a diuretic, a loop diuretic.

I. Version of a loop diuretic can be a potent or cause potent hypotension, so pay attention, right? All these things that you learn, you need to be observing and then adding them up as you're going, right? These are pieces of information that are just building your puzzle about how it's gonna go. It's creating your crystal ball.

It's helping you to make a prediction about what may or may not. . Another piece of the puzzle is simply looking. Look at your patient. Look at what they're attached to. Look at their coloring. Look at their demeanor. Are they chatty? Are they not chatty? These are all pieces that are important to know before you start, because if there's a change, pay attention.

Um, decreasing color to the face, power to the face, specifically the lips. If your patient loses color, pay attention regardless of what's happening with that blood pressure or heart rate, or ecg. If your patient loses color, pay attention. Sometimes the lips go white before the blood pressure responds. If your patient becomes sweaty, all of a sudden, You just see beads of sweat coming off their forehead.

Pay attention. If your patient is really chatty and they're, you know, long winded or talking quite a bit during your session, and you get to the edge of the bed and they just get really quiet or they just stop, you know, given their 2 cents on whatever you're talking about. Check in with. That is a very key sign that you will not find in a textbook if your patient gets quiet on you or their demeanor changes, like their personality changes.

Tap in, see how they're doing. Maybe rest if they're like, oh, I think I'm okay. You get both sides of it, right? You get the patient that's gonna be, um, Pushing and like trying to maximize everything they do. And then you have the patient that might be a little bit more scared or requires encouragement either side of that spectrum.

You have to play into it. Either you have to pull them back or you have to push them and you know which one you have to do because you have this beautiful crystal ball. Your experience, your clinical knowledge, your ability to reason, dissect, synthesize, and put the pieces together in real world, real time action.

So, You've done a good chart review on this patient so you know what meds they're on. You know their background, you know, if they've had a certain type of anesthesia. If this is an orthopedic patient, a red flag. When you have those epidurals, um, you are checking vitals before, during, and after you're looking at your patient.

You're assessing their color. Does it change? Is it the same? Does it mean anything? You're listening to your patient. What is your patient telling you? Is your patient literally saying, I don't feel well? Pay attention. Do not ignore, do not just push and be, um, you know, the cowboy all in, trying to get the most out of every second.

Sometimes you have to back off because if you push too hard, you can push too. . So pay attention to what your patient has to say. If they get quiet on you, that's a red flag for me. That's a pay attention. Check in with your patient. Ask them the questions, how they feeling. Just do a little check in point.

And then if they're overtly telling you that they have symptoms, that they're dizzy or lightheaded or nauseous, or that they feel cold and clam. Do not ignore. Those are important telltale signs that something isn't right, and if you haven't checked vitals at this point and your patient becomes symptomatic, or the symptoms are changing or worsening in intensity, stop and assess.

There is no award at the end of this, right? Like. You're not gonna get a medal at the end of the day for pushing your patient the hardest, the furthest, the fastest, whatever you need to constantly be thinking what is best for my patient? How do I keep my patient safe? How do I progress them appropriately, and how do I pay attention to the things that are right in front of me?

We don't have a crystal ball. It is not magic. It is about looking at the whole picture, the whole story, the background information, and what is literally in front of you in that very moment so that you can make the next step, the next decision, the next progression safely. This is the same type of, um, Rationale that you have when you're helping predict discharge location.

There is no crystal ball. It is not magic. You don't see a person one time and know exactly how they're gonna progress in that very moment and where they have to go based on just walking into the room. Absolutely not. It is looking at the whole picture. It's doing a thorough chart review. It's understanding the background, their home setup, their social history, their capacity, their independence level prior to this event.

It is about looking at the whole story, synthesizing the information, and making an appropriate decision that is safe for your patient based on your clinical reasoning, your experiences, what you've seen in the past. And then revisiting it to the now and looking at this specific patient. Nothing is cookie cutter.

People surprise you all the time, but you build this layering of information and you have to rely on your experience of what you've seen in the past to help you predict the future. That's it. The crystal ball is basically understanding. That your experience in the clinic in life is going to help you make good decisions in patient care.

It's not magic, it's time, it's effort. It's staying on top of your reading. It's doing the little things and. It's paying attention to your patient. It's super important that when we're with our patients, that we are paying attention to them. We're listening, we're looking, we're using our senses. And I'm gonna throw one more thing into this crystal ball.

If you have a gut feeling, good or bad, do not ignore your own gut feeling. Sometimes your instincts kick in before. The objective numbers do so pay attention to your person, your own feelings, and be present in the moment. And I promise you with time that crystal ball is gonna get a little bit more precise, a little bit more predictive, a little bit more, shall we say, magical.

All right. Thank you so much for, uh, being here, for listening. Hopefully this was helpful for you. Um, If anything resonated with you or if you have any questions, um, please reach out. I'd love to hear from you. Hit me up in the dms on the Instagrams, or shoot me a text at 9 1 3 3 0 8 4 4 9 4. I'd love to hear from you.

I'd love to hear your background, your experience, and what you have to say. So I hope you have a wonderful day and whatever you have to do, get.