Beyond Standard Practice: Advanced Roles in Trauma Physiotherapy with Melissa Webb

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Hi there, fellow physiotherapists.
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I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care.
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So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you.
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Today, my guest is Melissa Webb.
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Melissa is a senior physiotherapist in trauma care at the Alfred Hospital in Melbourne, australia, and also does part-time work as lead of the trauma team at this hospital, and she's joining me today for a conversation about advanced roles of physiotherapists in trauma care in Melbourne.
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Melissa, welcome to the discussion today.
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Thank you, Helene.
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It's really exciting to be here.
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Thank you, Helene.
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It's really exciting to be here.
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Thank you, Melissa.
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As we start, would you mind just telling our listeners how you ended up working in trauma care and what excites you about work in this field as a physiotherapist?
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Yes, of course.
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So I have a very long clinical background in trauma care.
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I've actually been working in trauma care for about 30 years, which feels like a very long time.
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I started my graduate physiotherapy work at the Alfred Hospital and I was one of those typical enthusiastic grade one staff or junior staff who, every rotation I went through, I felt like I loved it and I wanted to be there.
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And that was orthopedics, that was intensive care.
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I did a burns rotation at the Alfred and I felt like every single clinical space that I went into I really wanted to work there.
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I was super enthusiastic and super excited.
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And then I landed a couple of trauma patients within my intensive care rotation and I just felt really it's a very overwhelming thing dealing with a multi-trauma patient one who's severely injured in ICU when you're a junior staff member.
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But I just felt really excited and enthusiastic about the variety of different injuries I was managing.
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I was managing the orthopedic things as well as the chest trauma as well as the subtle brain injuries, and I really felt like this had brought all of my enthusiasm from those other rotations into one patient profile and I just fell in love with it and I went out and did further rotations on our trauma ward and again really really fell in love with it.
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And I went out and did further rotations on our trauma ward and again really really fell in love with the work and, I think, the contribution that physio has really made in the space.
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We are so diversely skilled in terms of our cardiorespiratory work, our orthopedic and musculoskeletal work as well as our neurological work, and I just felt like there was something that physio could really offer every single patient and it's very motivating.
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Within a trauma service there are a large majority of young patients who are, you know, generally very motivated and generally, do you know, you can really see a progression in their actual function and physical state with the intervention you provide.
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So it just felt really rewarding.
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So, yeah, that's how I landed in trauma care and honestly, I've never left.
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I got a senior role within the trauma service and then a further grade three role, another senior clinician role.
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So I really worked my way up through the ladder in our trauma service and developed really close links with our medical staff and our trauma unit and that's some of the work that's really led on to these advanced practice roles.
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So, yeah, that's how I've landed where I am.
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That's great and I must say your enthusiasm shines through your voice.
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Before we delve into the discussion of today, I was wondering whether you could just paint the picture of what standard physiotherapy in trauma care at your hospital would consist of, before we talk about advanced roles.
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Okay, I'll set the background a little bit because the Alfred Hospital is one of the major trauma services within Victoria.
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So Victoria is the state I reside in.
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We have two major trauma services, both at all the Royal Melbourne Hospital and the Alfred Hospital, both situated in Melbourne.
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So the majority of major trauma patients are triaged to our organisation.
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So we see a really high volume of multi-trauma patient.
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But then we also get the minor trauma that comes in from within our catchment as well.
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Victoria also has a paediatric centre.
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So within the state of Victoria we have a very small number of major trauma services, level one trauma services.
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So within the Alfred we have a dedicated intensive care unit for trauma patients.
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We have a dedicated trauma ward for trauma patients and there is often, like a lot of different areas, a little bit of overspill into outlying wards.
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But the vast majority of major trauma injuries, patients with major trauma, are managed on our dedicated trauma ward.
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So within that ward we run what's called an early and intensive allied health model of care and that's part of my team leader role.
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So that is very recent within the last five years but very evidence-based early and intensive therapy to cohorts of the trauma population to try and improve their function and reduce complications and improve their chances of being discharged home rather than to another acute care facility.
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So our allied health model of care is very early.
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Every single discipline rounds on every single patient every day, talking through what the issues are, what the injuries are, who needs to be involved now, who needs to be involved later.
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But everyone has a really good overview of the patient and, as I said, we round once a day thoroughly on every patient and then again as a multidisciplinary team with the medical staff again later in the day.
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So part of my work as a team leader is really to try and identify very early the disciplines that need to be involved and make sure they are seeing the patients and reviewing the patients early to try and reduce their complications.
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We have a very big allied health team which consists of all the usual players physios, ot, social work, nutrition but we also have psychology and neuropsychology as well as in-house orthotics for all of our braces and orthotic devices and we also have a group of allied health assistants that work on our trauma ward, dedicated to us, that support the therapy team in providing additional therapy to try and really increase that intensity that they're receiving.
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So yeah, yeah, so a really great holistic approach to patient care with having so many professionals involved in the trauma team, so that's amazing.
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I just wanted to touch a little bit on what you said earlier about providing intense care for the patients.
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So would that mean that each patient is seen once a day or more times a day by the physiotherapist, or is it based on patient need?
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To a certain extent it is based on patient need and there are certain cohorts of patients that we have specifically targeted during with our intensive model and that is patients that we know we can really make a difference in terms of that intensity of therapy.
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So chest trauma patients are one group.
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The other group is patients who are two or more limbs non-weight bearing, so patients who essentially we understand or deem to be needing a wheelchair for their mobility.
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Now that's obviously fairly labour intensive in terms of what's required to develop their independence, to get them into wheelchair transfers and that's generally something that would happen in a rehab facility.
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But we're really trying to front load that and bring that into the acute care hospital.
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So their recovery mindset is really switched on really early.
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So the chest trauma, the two limbs, non-weight bearing trauma, and there's also the other group that we deal with which is the severely injured abdominal trauma patients, also the intensive care discharge patients.
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So anyone who's come from intensive care as a trauma patient.
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We would target them as well as needing intensive therapy that would be essentially minimum of once a day, usually twice a day, but that's supported by the allied health assistance and also some therapy groups that we run.
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So it's usually a dedicated one-on-one therapy session with the physio, and then it's taken a little bit more broadly and the allied health assistance can provide a second treatment.
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The physios can do the second treatment or the patient can attend a gym group, depending on what their level of need is.
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Yeah, that's great and I like that as part of standard physiotherapy service delivery, have this fast track into rehabilitation that starts in the acute care setting and doesn't wait for later on in the patient's journey to recovery.
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So that's excellent.
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So, having described what standard physiotherapy is, what would advanced roles for physiotherapists in trauma care entail?
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We've had a little bit of success in our organisation because, as I said, we've had senior physio staff who have really been dedicated to the trauma unit for quite a long time, and that means you really develop a good understanding of trauma care, you develop a rapport with your senior medical staff and you can start to push your scope a little bit in terms of what you're providing to the trauma patient.
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Now, as I said, one of my notional roles is a trauma allied health team leader and when we talk about advanced practice or advanced scope or extended scope that those terms are a little bit interchangeable and different people will talk about those things, meaning different things.
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But certainly, as a trauma allied health team leader, leading a group of allied health clinicians, we're really acting in a sort of high-level consultant role with our trauma team and we're interacting with our trauma medical team on a consultant-consultant level.
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We are attending consultant meetings.
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We're doing things that generally the clinical staff on the floor would not do.
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So in one way, that trauma team leader role really does have some advanced levels of not necessarily practice but leadership and stewardship within it.
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So that's one of the things we're doing in terms of pushing the scope a little bit out.
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My team leader role doesn't necessarily involve a lot of clinical care but it does certainly involve problem solving with the physiotherapy staff on the ward about complex patients and using that clinical experience that we've got.
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The other role that we're doing which is considered a little bit more advanced scope, is the physio-led trauma tertiary survey.
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So for those people who are familiar with trauma care, the concept of a tertiary survey is another thorough, full assessment of the trauma patient, usually one to two days after they've been admitted, when most of their surgical interventions have happened, when most of their investigations have happened, and it's a really thorough look at the trauma patient, again from top to toe, with a good physical exam, looking at all of the imaging results, looking at all of the surgical results and reassessing the patient, having a conversation with the patient if that's possible, and really trying to identify if there's any injuries that have been missed.
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It's not a great word, but certainly not identified in those early days because, as you can appreciate, those early days are very hustle and bustle.
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There's a lot of activity in the emergency department, there's often a lot of activity in the ICU and injuries unfortunately can get overlooked, and that's a reality of trauma care when we're focused on big life-threatening things we tend to skip over things that really don't demand our attention in those early days.
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So the tertiary survey is really utilised to try and identify anything that's been missed in those first couple of days.
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So we ran a project, a 12-month project, to upskill physios to perform that task, so literally to take over that assessment from the medical staff Now based on our numbers of patients.
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We couldn't do them all, so we did job share the role with the medical staff and they did some tertiary surveys and we did some tertiary surveys but that's really helped to try and manage the demand and the volume of tertiary surveys that are required.
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So I would say that sits a little bit more in the sort of really advanced scope area, particularly because tertiary surveys are traditionally a medical role.
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I do appreciate that nursing staff often do them in different trauma centres, but certainly within our organisation they are a medical assessment and we had to undergo quite a lot of training and upskilling in areas that really are not within our usual scope to be able to perform some parts of the assessment.
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And then we had to go forward and think about some of the radiology and imaging and do a little bit more upskilling in that.
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So yeah, we've not taken over that role.
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Obviously because of the burden of workload we can't do it all, but we do share that role with the medical staff.
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So that probably sits a little bit more within the advanced scope work.
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So they're the two main advanced sort of roles we're doing.
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We do have a couple of others that we're trialling out and using.
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I guess test piloting is a good way to put it and that's certainly within the ICU space, trying to work together within the team leader role for the ICU bundle of care, as well as a role involving a physiotherapist looking at being a non-weight-bearing case coordinator essentially.
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So look at patients who within that sort of orthopaedic trauma space and trying to problem solve and expedite management plans and inpatient decision making and outpatient progress.
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So that's a little bit more musk sort of advanced scope work.
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So they're the areas that we're really trying to expand into within the trauma space.
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We obviously have a lot of work going on in the emergency department with primary practice, physios, contact for patients down there, which isn't necessarily within the trauma sphere but certainly that's a really accepted and well-known kind of area of advanced practice and extended scope where the physios identify and triage minor injured patients to their caseload in ED and manage that caseload together with the emergency department consultants.
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Okay, yeah, so in essence it is being a communicator at a higher level and being an advocate for the patient, with the discussions that you're having with your consultants, and also that main role that you play in the tertiary assessment of patients on the ward after they've come from the ICU or from theatre a few days later.
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So we know that as physiotherapists, we tend to spend a lot more time with the patients at their bedsides doing rehabilitation than what the medical team may have time for.
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Are there any challenges in communication between the physiotherapy team and the patients on the trauma ward, or do you find that that communication happens freely, without any inhibition from the patients?
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Yeah, as you said, we are often clinicians that are involved with these patients for a long period of time and we often have a lot of input.
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So we often do spend a lot of time with the patients, more so, maybe, than the medical staff who round pretty quickly.
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So we find that our rapport with the patients is really quite good and I think that's something that's really been very obvious within the tertiary survey role.
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We're very used to talking to trauma patients.
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We're very used to picking up on little, you know, just small comments, sometimes that they make around weird symptoms and weird signs that might lead us down a path, maybe that the medical staff have really skipped over or the patient hasn't felt they've had enough time to report things to the medical staff.
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So, yeah, I think we're very, very good at that and because of our consistency on the trauma ward, we are there.
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You know most of us have been there for a very long period of time, so we're there fairly consistently.
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We do get to know the senior medical staff and we can escalate things to them pretty quickly, as it would be the same world over.
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Our junior medical staff rotate fairly frequently and it just feels like you get a bunch of new people or new doctors who you've got to know.
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They've got to know trauma.
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They kind of know the systems and the processes and then they're moving on and that's really, you know, sometimes a bit frustrating.
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So I think, within certainly the tertiary survey role, but as well as the allied health team leader role, I think that consistency across new medical staff coming in and out is really helpful and I think the medical staff really appreciate it and I think the patients really appreciate it too and they see you chatting to the medical staff on a ward round.
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They'll see you coming in to do your tertiary survey, so they do feel quite comfortable with you and they do develop a really good rapport with you.
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I totally agree about the frustration with the junior doctors that tend to rotate so quickly through the trauma team, you know, onto other fields where they need to specialize.
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So, and just the fact that you have to continue to re-educate you know as the new staff come onto the board, so I can empathize with that.
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Yeah, it's like a never-ending process.
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Exactly, melissa.
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I know that you've been involved in some research over the years in the field of trauma and I came across a paper that you were involved with where you describe a trauma booklet.
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I think it was that you developed to educate patients about what happened to them and to just give them a little bit more insight into what symptoms they should expect to have and when they should ask questions of the multidisciplinary team.
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Can you maybe just expand on that a little bit more?
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Yeah, absolutely.
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And look, this is one of the things that I think really makes a big difference with trauma patients, particularly, as I said, our early and intensive model of care started in 2020 and it involved a couple of things.
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One thing it involved was a new trauma ward, which is lovely, and, you know, it gave us access to some therapy spaces, which is wonderful to be able to provide that intense therapy.
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It gave us more allied health staff, which is terrific, because resourcing is always really important.
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But the other thing it did provide was this information booklet for the patients and that I feel like, in the excitement of a new ward and a new, you know, whole team of allied health people, that piece of information got lost.
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But I think that's a really important piece for the patients and I think particularly trauma patients get quite overwhelmed in terms of the volume of information they have to receive.
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They're seeing multiple different care teams.
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They're seeing the orthopaedic team, the plastics team, the trauma team, you know, the OT, the physio, the social worker, the neuropsychologist.
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They're seeing so many different people and they often have really complex injuries that probably, to be fair, aren't well explained to them consistently.
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So we really utilize this booklet as essentially a bit of a one-stop shop for the patient in terms of their information.
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It's got a lot of information about being in hospital as a trauma patient.
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It's got a body chart that we were responsible for writing their injuries on and talking them through that with x-rays and information if they needed that.
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It's got a space for each of the individual disciplines to write in.
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It's got a space for each of the individual disciplines to write in.
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It's got a space about and some conversations about being in hospital.
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You know, bring your pyjamas, have some slippers, your you know, your family can ask questions really simple stuff that we sometimes think that trauma patients because they stay in for a long period of time have heard about already but they don't take that information in.
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So the patients really loved the booklet.
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We found a little bit of trouble in terms of who was accountable for it and who was responsible for it and, like a lot of things, when everyone's responsible, no one does it.
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So we needed to really be clear about whose job it was to fill in the majority of that booklet and we did target the booklet for major trauma patients.
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So if the patient came in and they had a couple of fractured ribs in isolation or a broken T-fib in isolation.
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We probably didn't use that booklet because it was really around communicating quite complex care team plan and injuries.
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So, yeah, I think that booklet's been something and, look to be fair, we're not the first people who invented that.
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There's quite a number of places over in the US who have got booklets, and booklets like this are used throughout other areas, cardiac surgery in particular.
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But I think for trauma patients, the bringing together of a lot of information is really important and it's something that we don't tend to focus attention on and we don't tend to do well.
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So I think the booklet has helped us and it's helped our patients to have a little bit more understanding and we've really encouraged them to write questions in it, to write their recovery journey in it, to use it as a little bit of a, you know, maybe a bit of journaling or mindfulness, just to write down some things during a really stressful and difficult time for them.
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So, yeah, we're really, really proud of that booklet and we do tend to use it and I think it's something that the patients have really got a lot of value out of.
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Yeah, I know, and I was so impressed when I read that paper because I think this booklet is, even though you're not the ones that developed it initially, the fact that you are introducing it and taking what others have done in America and using it in your local setting I think is a wonderful idea.
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And with them taking the booklet home, I think it also helps them to work through the psychological recovery after this traumatic incident happened, to just recall all the things that happened and to understand why they may be having certain types of dreams or strange thoughts.
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You know that come back to them months after discharge from the hospital.
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So I think in the sense it could help to curb that post-traumatic stress disorder on seats, you know.
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Yeah, absolutely agree with that.
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And I think the other thing we found is there is a lot of patients who aren't in the space to use that.
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But families have found it really helpful.
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So it does go to the patient.
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But equally, if the patient's not in a space that they're ready to deal with a lot of that thing which often in those really acute days they're not we provide that information to the family and we go through it with the family in a similar way to what we would the patient and then we try and transition to the patient when they're ready, and particularly some of the brain injured patients, some of them won't be ready for a long time to look at that and discuss or talk about that information.
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But the families really need that as well.
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I think yes, yeah, just that we are so much more aware of the psychological impact and particularly when, within our intensive and early model, we're really trying to set up a recovery mindset for these patients and potentially push them a little bit harder than what they're physically and emotionally ready for, because we know that that early intervention does reduce complications and it does make a difference to their eventual outcome.
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But we've got psychologists and neuropsychologists who help us with that sort of wraparound, psychosocial support as well, because I don't think some of these patients you can push really early without care.
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syndrome for patients but also for the families in the months and up to two to five years after discharge from the institution.
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And it's so relevant in the trauma population as well.
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So it's great to hear that you've got psychologists involved in patients management from the start.
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Melissa, as we wrap up our discussion today, are there any sort of words of wisdom or tips that you want to share with junior physios who are rotating into trauma and may not feel so comfortable in the setting that you are at this stage of your career?
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What would you say to them?
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Oh, that's a great question.
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That's a great question and I love dealing with junior staff, junior physios who come onto my ward because, as I said, I love my job and I love what I do every day and I think there's a really important role for physios with trauma patients.
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I would encourage junior physios to embrace it because it often is quite confronting.
00:27:54.883 --> 00:28:06.061
Firstly, I think there's a lot of patients who are in a lot of distress around the circumstances of their injuries, around the circumstances of what happened and brought them into hospital.
00:28:06.061 --> 00:28:08.554
So it can be very overwhelming.
00:28:08.554 --> 00:28:15.043
I'd encourage them to speak up if that's the case, but I would also encourage them to you know, just sit with those.
00:28:15.043 --> 00:28:18.974
You know really uncomfortable ways of that.
00:28:19.034 --> 00:28:32.773
Sometimes just the world works like the world is a difficult place sometimes and I think taking some time for yourself, but also taking some time with the patient, and sometimes it's as much about what we're laying our hands on and doing as what we're not doing.
00:28:32.773 --> 00:28:38.211
You know, don't be afraid to do nothing and stand by a patient just when they're really struggling.
00:28:38.211 --> 00:28:56.225
I think sometimes just being that person for the patient in that moment is really important and that will enable you to develop some rapport and you'll actually see some really moments of tough moments but also moments of real clarity where a patient can deal with that and then move through it and deal with you on a better level.
00:28:56.225 --> 00:29:06.525
So certainly, embrace it, be really in terms of very logical, practical, sensible information, be really thorough with what you're doing and be really systematic.
00:29:06.606 --> 00:29:12.890
These patients often have a lot of injuries that are very difficult to conceptualize and process in your brain.
00:29:12.890 --> 00:29:25.412
You know, we spent a long time working up an assessment form for our junior staff to fill in every single body chart and every single operation and as they get more experience they kind of let that go a little bit.
00:29:25.412 --> 00:29:33.600
But I think it's a really good way to start working with trauma patients and trying to, you know, really integrate some of that complex knowledge with them.
00:29:33.600 --> 00:29:53.193
And you know, not everyone's going to love trauma care and that's OK, but certainly I think it's a very interesting space to be in, to see the role that physio actually has, because I think it's a massive role and I think our medical staff appreciate what we do, I think our colleagues appreciate what we do and I think the patients really appreciate what we do as well.
00:29:53.193 --> 00:29:56.562
So, yeah, that's probably my little sum up.
00:29:58.050 --> 00:30:11.714
Thank you so much, melissa, and thank you for giving us a glimpse into physiotherapy involvement in trauma care at the Alfred Hospital and for sharing so freely of your experiences.
00:30:11.714 --> 00:30:17.533
I've really enjoyed our discussion and I appreciate you making the time to be here with me today.
00:30:17.533 --> 00:30:18.856
Thank you so much.
00:30:19.838 --> 00:30:20.559
Absolute pleasure.
00:30:20.559 --> 00:30:21.702
Thanks, Helene, for having me.
00:30:21.702 --> 00:30:22.263
It's been lovely.