Lecture delivered at Post-Registration Course at S.A.S.P. National Council Meeting in Port Elizabeth, May, 1968. September, 1968 P H Y S I O T H E R A P Y Page 9 Physiotherapy and the South African Heart Transplant By M A R Y LE N R . I. STERNWEILER, m .c .s .p ., m .s .a .s .p . Senior Ward Physiotherapist, Groote Schuur Hospital, Cape Town Since the 18th Century man has been intrigued with the possibility o f organ transplantation. In ancient times the desire was to join portions o f various beings, not only to counteract disease, but to create such mythical creatures as the Sphinx and the Mermaid. The climax of such dreams was the transplantation of the heart which is so unique an operation that the concept o f even the most basic and routine treatments took on a quite different aspect and perspective. It is because o f this that the Physiotherapeutic aspects o f the Second South African Heart Transplant is presented. P.B. aged 58 was admitted to a Medical Ward o f Groote Schuur Hospital on the 14th December, 1967 with a 12 year history o f heart disease. On admission the patient presented with intractable congestive cardiac failure due to severe ischaemic heart disease. Cardiomegaly, systemic venous hypertension and bilateral basal crepitations were present. He was orthopnoeic and complained o f paroxysmal dyspnoea. The patient was in an extremely poor physical and mental state, appearing drowsy and “dull” . A marked feature was the patient’s inability to open his eyes normally. This appearance reminded one o f a patient suffering from Myasthenia Gravis. For several weeks the patient had been recumbent in a high Fowlers position and was unwilling to turn or be turned on to his side, even for treatment to back and pressure areas. H e could not brush his own teeth, wash his face or blow his nose and after using the bedpan, a recovery period of up to an hour was needed. H e was so weak that he could not hold up a newspaper nor had he the concentration necessary to absorb what he had read. He could not complete a normal average sentence in one breath. Furthermore his general condition was rapidly deteriorating. PRE-OPERATIVE AIMS The pre-operative aims of physiotherapy are identical with those o f any patient awaiting a routine open-heart procedure and include a number o f essential requirements: (1) One must get to know the patient, gain his confidence, and explain in detail the importance and reasons for physiotherapy. The complications that can occur if the treatment is ineffectual should be clearly under­ stood. (2) To clear the lung fields, maintain a good airway and improve ventilation. (3) To teach correct diaphragmatic and localised breathing. (4) To teach effective coughing and how to support the wound when doing so. (5) To prevent circulatory complications. A few days prior to operation the patient is told in great detail how he will find himself on returning from the theatre. This is done in order to allay any fear that might result, which in turn might forfeit his co-operation. The incision and the position o f the chest drains are indicated to him. The fact that he will be nursed flat on his back and in an oxygen tent is explained to him. In the same way the patient is told about: Naso-gastric suction. Intravenous therapy. Urinary catheterization. Indwelling rectal thermometer. A femoral vein cut-down. Electrocardiographic monitor. The response to treatment was exceptionally poor because o f the pateint’s general condition. A mere explanation o f the reasons for physiotherapy was more than he could absorb in one session. H e was only capable o f 5-6 inspiratory and expiratory movements, and became distressed after only 2 Plantar and Dorsiflexion movements o f his feet. As a consequence, physiotherapy lasted the best part o f an hour whereas this should normally have taken 15-20 minutes. Frequent and lengthy rest periods were required and even then, treatment was inadequate. The slightest signs of distress were easily observed by: An increase in the rate o f respiration. A decrease in depth o f inspiration. An increase in pulse rate. A slight tinge o f cyanosis o f the lips. On the 27th December, 1967 a diagnosis o f Pulmonary Embolus was made which was thought to account for the sudden collapse with unrecordable blood pressure on the 23rd December. During this period the patient was drowsy and not quite “with it”, due mainly to heavy sedation. He also expectorated a few plugs o f altered blood, despite there being no evidence o f deep vein thrombosis. There was a further decrease in air entry at the left lung base and an increase in crepitations, with a dull aching pain in the left lower chest anteriorly. There was-no unitiated coughing but decreased air entry persisted at the left lung base. As vigorous a physiotherapy session as the patient could tolerate was productive of some altered blood in the sputum. As could be expected, the patient was extremely distressed after such a session but in view o f the result, the method o f treatment was not altered. X-rays of the chest at this stage revealed an opacity in the left lower lobe with an effusion. It was in this condition that the patient was taken to theatre on the 2nd January, 1968. It is important to describe briefly the suite that the patient was nursed in post-operatively and why this was done. The Theatre Suite in which the patient was treated from the time o f leaving the Operating Theatre until discharge. The arrows indicate the route taken by all members o f the team entering the patient area. Visitors, limited to the patient’s wife and very few others were only permitted into the Buffer area (semi dirty area) and conversed with the patient with the use o f the intercom and viewed him through the “ locked and sealed door” . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 10 P H Y S I O T H E R A P Y September, 1968 Post-operatively, patients with transplanted organs are placed on high doses o f immuno-suppressive drugs to help prevent rejection. A t the same time the drug regime makes the patient far more susceptible to infection because o f suppression o f the normal immune mechanism. The slightest bacterial infection may spread widely and with serious consequences, whereas the same infection in a person not on immuno-suppressive drugs would probably be held in check easily. It is for this reason that the patient is nursed in as bacteria free an environment as possible and must remain so for the entire period o f hospitalization or until the immuno­ suppressive drugs have been reduced to a safer level, when he can then go back to a normal “H om e” environment. It must be remembered that hospitals in general are often reservoirs o f resistant bacteria and therefore the sooner the patient can go home the better. The Transplant Unit in which the patient was nursed, and the way in which he was cared for, was supervised in part by the Bacteriology department o f Groote Schuur Hospital. A little-used theatre suite was made available for the care o f the transplant patient and a routine was laid down to keep the unit as free o f bacteria as possible. Some o f these measures included the follow ing: (1) Careful attention to the number o f nursing personnel required for both day and night duty, for patient care proper and to act as “runner nurses” . (2) The number o f staff attending to the patient was kept to an absolute minimum—only those persons essential to the care o f the patient were allowed into his area. It was for this reason that the “Physiotherapy” carried out in the case o f the first heart transplant, was carried out by the Sisters specialling the patient and not by a physiotherapist. As a result o f the Pneumonia he so regrettably succumbed to, intensive physiotherapy was requested for the second heart transplant and treatment was commenced more than two weeks prior to surgery. It is interesting to record, that all X-rays were taken by the same radiographer and similarly the three physiotherapy sessions in 24 hours were done by one physiotherapist. These physiotherapy sessions were reduced after 23 days to twice daily, then once daily and finally to six times per week to allow the patient as well as the physiotherapist one day o f rest! (3) All staff who attended the patient had swabs taken from the nose, mouth, throat and rectum for bac­ teriological examination to determine if they were carriers o f potential pathogens. These swabs were repeated weekly. The patient had similar swabs taken pre- and post-operatively. If at any stage a member o f staff developed e .g .: Herpes o f the lip, a boil, a cold or a sore throat they were immediately removed from the unit and investigated bacteriologically. Visitors were strictly limited and were only able to view the patient through a glass partition in the buffer zone outside the patient area. (4) All walls and floors in the unit were treated at regular intervals with a suitable phenolic disinfectant, using only autoclaved buckets, mops and paper towelling. Where possible all apparatus used near or on the patient was thoroughly cleaned, autoclaved or boiled before entering the unit and thereafter damp dusted with a disinfectant. (5) A ll linen was autoclaved. The bed linen was changed six hourly, care being taken not to disturb the air excessively. The patient was washed daily with a Hexachlorophene compound, careful attention being given to the perineum and genital areas, which were washed with soap and water and dusted with Hexa­ chlorophene and Mycostatin powder. The hair was ' washed with a mixture o f Cetrimide and Chlorhexidine. (6) The diet kitchen prepared each meal initially in a pressure cooker which entered the unit sealed, the outside having been cleaned with a disinfectant. The outside o f the sealed milk bottles were treated in a similar fashion. (7) All staff entering the unit to attend to the patient left their coats etc., in the passage outside the doctors’ change room. In the change area sterile masks, caps and over shoes were donned. The hands were then scrubbed as for a surgical procedure, sterile gowns and gloves put on and then only after passing through a clean buffer zone did one enter the patient’s room. It will be appreciated that once one had entered the patient area ones steps could not be retraced. If one had already left the patient’s room one could not re-enter without going through the whole scrubbing up process again. For this reason a runner nurse cir­ culated in the gowning area where all the autoclaved equipment, ready to enter the unit, was stored. Her duties entailed amongst other things, receiving the food and keeping the area other than the patient’s actual room scrubbed and cleaned at regular intervals. (8) After any and every form o f attention to the patient, the gloved hands were rinsed in a specially prepared disinfectant. (This was o f great importance to physiotherapists who normally alternate breathing with leg exercises throughout a treatment and therefore o f necessity much time was spent in rinsing the hands.) PO ST OPERATIVE TREATMENT The first and foremost aim in the post-operative physio­ therapy regime was to prevent pulmonary infection. Because o f the risk o f infection strict precautions were taken to keep the patient area as free o f bacteria as possible. For the same reason every possible precaution was taken to avoid pulmonary complications, and as a result, perhaps more physiotherapy was given to this patient than was entirely necessary. Further aims were: To prevent circulatory complications. To increase the exercise tolerance as well as range o f movement and muscle power. As a result o f many weeks in bed with consequent inactivity, there was a marked decrease in the range of movement in the ankles and some limitation o f hip extension. Muscle power, needless to say was very poor through disuse. Post-operative physiotherapy was commenced approxi­ mately 5 hours after the patient had returned from the theatre. A post-operative injection o f Pethedine had been given but, despite this, the patient was fully conscious and alert, so that his first comment on seeing the physiotherapist was “don’t expect me to breathe or cough without giving me something to drink first” . This was so typical o f any post-operative case that it was hard to believe that there was another heart beating in the patient’s chest. It was also noted with interest that for the first time the patient was able to open his eyes normally. Physiotherapy sessions were synchronized with treatment to the back and pressure areas and with the changing of the bed linen, this to minimize any disturbance to the patient. Routine quarter hourly observations initially gave the patient no rest at all, but when these were reduced to hourly and then two hourly intervals, the patient was allowed to sleep. For the first six post-operative days crepitations and a marked decrease in air entry persisted at the left lung base, and in addition bronchial breathing was noted for the first time. (It must be appreciated that on the 23rd December the patient had suffered a Pulmonary Embolus with con­ sequent lung damage so that at the time o f surgery the patient was not a good anaesthetic risk. However, because o f the rapid deterioration in his condition transplantation became the only hope o f survival.) On the 7th post-operative day for the first time the lung bases were free o f crepitations and air entry had improved. From this time on daily X-rays showed a further decrease in the areas o f infarction. A continued improvement in lung function, both clinically and physically, was noted. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) September, 1968 P H Y S I O T H E R A P Y Page 11 X-ray Findings (a) Pre-operative X-ray of 27th December, 1967 reveals an opacity in the Left Lung Base with effusion and congestion of the lung fields. (c) By 29th February, 1968 the lung fields remained perfectly clear with complete resolution of all changes at the left lung base. (b) The picture o f 29th January, 1968 shows resolution of the opacity and effusion at the Left Lung Base and relief o f the congestion. The lung fields are clear. Increase in “ heart size” noted and resulted in aspiration o f 345 ccs. o f fluid from the pericardial sac. Despite relatively vigorous physiotherapy immediately post-operatively, namely, side-lying, vibrations with breathing and coughing, it was found that the bronchial secretions were very viscid and difficult for the patient to expectorate. The patient was fully co-operative but his coughing ability poor and the suggestion was made by the physiotherapist to use the Bird Respirator with a mucolytic agent. The Bird Respirator was used on the 4th post-operative day not with a mucolytic agent but with a specially prepared solution o f 8 cc. o f Mycostatin, (50,000 units per cc.) as a result o f the culture and sensitivity o f the previous days sputum specimen. The Bird was set at a sensitivity o f 5, inspiratory pressure o f 15 and flow rate o f between 7 and 10. The Mycostatin took the best part o f 20 minutes to nebulize which made it a rather tiring session, but the chest cleared within 2 days and the subsequent sputum specimens were negative. The Bird was therefore discontinued for fear of auto-re-infection, but the value o f the Bird, even for this short period, was most convincing. It should be stressed that it is essential that the Bird apparatus or any other respiratory equipment be as completely free o f bacteria as possible. As is routine with any post-operative open heart patient the treatment was started in an oxygen tent and with no hip or knee movements until removal o f the venous line. For the first day the patient was kept supine and on the second day put into partial side-lying and only on the third day was he allowed to turn himself to full side-lying. The chest drains, the urinary catheter, naso-gastric suction, rectal thermometer and venous line were removed on the second and the oxygen tent on the 4th day. The monitor was kept on longer than for a routine open heart procedure. The bed R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 12 P H Y S I O T H E R A P Y September, 1968 was slowly elevated until on the 6th day the patient sat up with his feet over the side o f the bed for the first time. On the 12th day he stood for the first time and took two steps to a chair where he enjoyed his first meal sitting out o f bed. Throughout the post-operative period the patient had an outstandingly good appetite. It might be o f interest here to know that everything excreted and expectorated by the patient was sent to the laboratory for analysis. Swabs were taken from the patient daily and the chest drains and urinary catheter on removal, were sent for culture, as was the dressing when this was removed. These measures were thought necessary to detect any possible infection. A slow but gentle progression o f routine bed exercises, with special emphasis on the legs, and activities o f daily living was instituted as follow s: Each exercise was increased in the number o f times done. New exercises were included. Very gently resistance and/or longer leverage was added where possible. General activities included: From being turned to turning himself. To sitting up with pillows to sitting with legs over the side. To standing and taking two steps to a chair. To increase the distance walked. To putting on his pyjama jacket and dressing gown. To shaving, to brushing his teeth to washing his hands and face. To taking off shoes and at a much later stage, to putting them on. To lifting up a stool and moving it to a desired position. To climbing stairs, bed steps having been specially cleaned and brought into the unit for this purpose. The leg exercises given were chosen to aid the circulation, to increase joint range and were worked against gravity, where possible, to strengthen the muscles at the same time. At one stage post-operatively there was some discussion as to the reason for the weakness o f the legs, complained o f by the patient. A suggestion o f steroid myopathy was made, but from the physiotherapist’s point o f view this weakness could have been due to disuse atrophy. It was at this stage that a pre-operative muscle power chart would have been o f great value. It should, in future, be a routine procedure for any transplant patient to have such an assessment pre-operatively, even if the testing has to be spread out over many days because o f the patient’s general physical condition. As a result o f this discussion the first muscle chart was only started on the 5th February, 1968, and subsequent ones done after his discharge from hospital on the 21st and 28th March, 1968. The results tend to suggest a disuse atrophy rather than a steroid myopathy, as most muscle groups had improved considerably. Residual weakness o f 3 or 34- grading have persisted in only three groups o f muscles: The hip abductors and adductors. The hip extensors. The quadriceps. It is for this reason that the patient still has a “waddling gait” and finds difficulty in managing stairs unaided. There is a persistant flexion contracture o f the hips but up to the time o f discharge the patient had not been put into prone lying. The abductors were difficult to strengthen as a side- lying position was most unstable in bed and the effort to maintain the position, more than was warranted. Apparatus such as slings and springs were not permitted into the unit. The patient himself was a most delightful and co-operative person to treat but his one aim and ambition was to be able to do things for himself, and be independent and it was difficult to insist on his doing more exercises at the expense o f the activities o f daily living that he had for so long not been able to do. Here again one was working in the dark, not knowing what to expect o f a heart transplant patient and how far in fact one could push such a patient. One has also learnt from this patient the necessity to have a form of exercise tolerance test which once again was only started three weeks post-operatively and which in future should be done, as a muscle power chart, pre- operatively. One exercise should be taken, preferably against gravity, such as hip and knee flexion and extension and the pulse, respiration and blood pressure taken before Muscle Charts o f the Upper and Lower Extremities. (a) The upper extremity showed rapid improvement in strength to near normal and no further testing was done. (b) The lower extremity showed marked weakness in several Muscle Groups. Repeated assessments revealed a slow but steady improvement in muscle power. As a result of these findings, concentrated exercise was given to the weakest groups. M U S C L E C H A R T — 5.2.68 U P P E R E X T R E M IT Y L e ft R ig h t P e c to ra ls 3 3 D e lto id 3 + 3 + In te r n a l R o ta to r s S h o u ld e r 3 - 3 - E x te r n a l R o ta to r s S h o u ld e r 3 - 3 - Biceps 3 + 4 T ricep s 3 - 3 + P r o n a to r 3 + 3 + S u p in a to r 3 + 3 + W rist F lex o rs 4 4 W ris t E x te n s o rs 4 4 F le x . D ig . P ro f . a n d S ubl. 4 4 E x t. D ig . P r o f . ........................................................ 3 3 O p p o n e n s a n d In te ro ss e i 3 + 3 + M U S C L E C H A R T L O W E R E X T R E M IT Y L E F T R I G H T 5.2.68 21.3.68 28.3.68 5.2.68 21.3.68 28.3.68 2 - 2 - 2 + G lu te u s M a x im u s 2 ~ 2 3 - 3 - 3 + 4 - H ip F le x o rs 3 - 3 + 4 - 2 + 3 - 3 H ip A b d u c to rs 2 + 3 - 3 - 2 - 2 3 — H ip A b d u c to rs 2 - 3 - 3 - 2 + 3 + 4 In te rn a l R o ta to r s 3 ~ 4 4 2 + 3 + 4 E x te rn a l R o ta to r s 3 - 4 4 3 - 3 + 4 - Q u a d ric e p s 3 - 3 + 4 - 2 + 3 - 3 + H a m s trin g s 3 - 3 + 4 - 3 - 3 4 C a l f 3 + 4 3 4 5 T ib ia lis A n te r io r 3 4 5 3 - 4 4 T ib ia lis P o s te rio r 3 - 4 4 3 + 4 5 P e ro n e i 3 + 4 5 3 + 4 4 + E x te n s o r D ig it. 3 + 4 4 + 3 + 4 4 + F le x o r D ig ito ru m 3 + 4 4 + R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) d after the exercise. This exercise must be done until the tient is exhausted and the number o f times and response nted In this way some idea o f the exercise tolerance can ue a s s e s s e d . It must, however, be remembered that as the natient becomes more active in himself and does more in the way o f activities o f daily living, this can only be an '"dication as to his exercise tolerance. One’s general im- n r e s s i o n o f the capabilities o f the patient day by day will still be the most reliable source o f information. A chart o f joint range could be included in the muscle chart if desired. At one stage a definite period o f decrease in effort tolerance was noted which co-incided with an increase in t e m p e r a t u r e , respiratory rate and pulse rate. There were changes in several biochemical tests, with an increased E S.R. and white blood cell count, and changes in the electrocardiagraphic voltage. It was established that rejection was taking place and immediate treatment was carried out in the form o f increased steroid dosage. This lowered the patient’s resistance to infection and therefore physiotherapy was once again increased to 3 sessions in 24 hours, for a short period. The response to the steroid increase was dramatic and the patient’s general condition slowly improved and continued to improve steadily until the time o f his discharge. A daily exercise tolerance graph was commenced after a marked decrease in effort tolerance preceeding the period of rejection had been noted. It was decided that as all aspects pertaining to rejection had to be considered, this test might have its value. Se p te m b e r, 1968 Q£f ,,|| , fy ^ -:2 : N O S . OF EXCERCISi The patient was discharged on the 16th March, 1968, well enough to walk out o f the hospital to the waiting car. This was a dramatic and emotional day for all, and no one was happier than the team members to see the patient go home to a normal environment. From his home the patient attends the Hospital regularly and is examined by the cardiologist in a room in the out­ patients department where no other patients are seen. Blood is still taken twice weekly for laboratory tests. He is seen by his physiotherapist weekly to assess his progress. Nor­ mally any other patient with such a residual muscle weakness would attend the Physiotherapy out-patient department for further rehabilitation but in the case o f the patient, who is not yet allowed free contact with people, it is hoped that he will continue with his physiotherapy on his own. From time to time new exercises will be given and for example, home made sand bags suggested to help strengthen the quadriceps. Meetings were held at first daily and then twice weekly until the patient was discharged from the hospital and since his discharge once weekly. These meetings are attended by between 20 and 26 people who are all concerned directly or indirectly with the patient. Many o f the doctors at these Page 13 meetings have never seen the patient but are responsible for various biochemical and other tests done. The o n l y people in daily and direct contact with the patient, other than the sisters specialling the patient were: The cardiologist. The surgical registrars. The electrocardiograph technician. The bacteriologist. The radiographer and the physiotherapist. Discussion by the members o f the team o f all the various investigations and treatment pertaining to the patient was very stimulating and indicated very clearly the important and essential role that physiotherapy must play in such a case. Many Biochemical Tests were performed to try and establish a means o f detecting rejection. These are but 2 of the examples. It can be seen that when it was established that rejection was taking place, the dosage of Prednisone was drastically in­ creased for a short period. ACKNOWLEDGEMENTS I am grateful to all members o f the team for their help and co-operation, to the Department o f Surgery, the Cardiac Clinic, Department o f Medicine and the Department ol Bacteriology, University o f Cape Town, for all the help ana guidance. My special thanks to Dr. A. A. Forder lor tne interest, encouragement and ever willing help in preparing this paper and Dr. J. G. Burger, Medical Superintendent ot Groote Schuur Hospital for permission to publish. REFERENCE S. A. M edical Journal, Vol. 1, N o. 48. 3 0 th December, 1967. P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )