After a near-fatal cardiac event and emergency heart transplant surgery, a 58-year-old woman experienced a series of severe complications that kept her in the hospital for 13 months. Preparing her to go home required a prolonged, coordinated effort by a multidisciplinary team of rehabilitation experts.
A Cascade of Morbidities
The patient was transferred to NYU Langone Health from NYC Health + Hospitals/Bellevue on October 1, 2019, after suffering cardiogenic shock due to unexplained infiltrative cardiomyopathy. She was treated with extracorporeal membrane oxygenation (ECMO) while awaiting a heart transplant, which she received eight days later.
By mid-December, the woman’s condition had stabilized sufficiently for her to be transferred to inpatient care at Rusk Rehabilitation. However, her persistently fragile medical condition—with repeated episodes of nausea and vomiting—precluded significant improvement. In January 2020, diagnosed with a gastrointestinal bleed, she was moved back to acute care.
Over the following months, the patient experienced a cascade of morbidities. In February she pulled out her percutaneous endoscopic jejunostomy (PEJ) tube, leading to peritonitis and kidney failure; she was subsequently placed on hemodialysis. In March she developed a right chest seroma, pneumonia, and neutropenic sepsis. She underwent washout and debridement of the seroma, as well as a subclavian graft replacement. As the year wore on, she developed wound dehiscence in the right shoulder and hemothorax in the right chest, complicated by fevers, hypotension, a deep vein thrombosis in the left lower extremity, a mild stroke, spinal compression fractures, and recurring pneumonia. She underwent a tracheostomy and chest tube placement.
Having survived this succession of traumas under the exceptional care of NYU Langone’s clinicians and support staff, the woman was transferred back to the inpatient unit at Rusk Rehabilitation on October 29, 2020.
“This was one of the most complicated patients I’ve ever seen,” says Jeffrey M. Cohen, MD, clinical professor of rehabilitation medicine at NYU Grossman School of Medicine and medical director of Rusk Rehabilitation’s Medically Complex Rehabilitation Service. “She had been through so much, and she was profoundly deconditioned. Our mission was to help her get her life back to the greatest extent possible.”
A Multipronged Approach to Complex Rehabilitation
When the woman arrived at Rusk Rehabilitation, she was barely able to roll over in bed. She required maximum assistance to go from supine to sitting and to transfer from her bed to a chair. Although she was able to eat orally, she needed nocturnal tube feedings to maintain adequate nutrition. Due to the tracheostomy and other factors, her speech was both hypophonic and dysphonic.
Physical therapy, led by Rusk Rehabilitation expert Jacklyn Ward, PT, began with a focus on bed mobility and transfers from sitting to standing. From there, the patient progressed to ambulating with a rolling walker; initially she could go no farther than 25 feet and needed contact guarding to prevent injury, but her distance and agility steadily improved. She underwent wheelchair mobility exercises to build her upper-extremity strength and endurance, and step-up exercises to enable her to negotiate stairs and curbs.
Occupational therapy, led by Brittany Cuthbert, OT, emphasized self-care. “We worked on grooming while standing at a sink,” Dr. Cohen explains. “We also practiced toilet transfers and upper- and lower-body dressing skills, such as putting on a T-shirt, underwear, and pants.” The patient was trained on adaptive equipment to help with shoes and socks.
The speech-and-swallow team performed a clinical bedside swallowing evaluation, which determined that she was able to tolerate regular solids and thin liquids. She was taught safe-feeding strategies and aspiration precautions, such as alternating small sips with small bites, and sitting upright for all meals out of bed.
The team also worked to improve the patient’s ability to communicate her needs and wants. She was fitted with a Passy Muir valve, which is designed to enhance voice and speech production, and therapists trained her in speech compensatory strategies. “We worked on coordinating subsystems of voice production, including respiration, phonation, and articulation,” says Dr. Cohen. “The training incorporated video and audio feedback to enhance her awareness of her own speech quality.”
The patient was followed closely by psychologist Catherine Atkins, PhD, supervisor of psychology for inpatient acute rehabilitation, to monitor for depression or other mood problems and to reinforce her ongoing emotional resilience.
A Carefully Arranged Homecoming
After a month at Rusk Rehabilitation, the patient showed striking gains in strength, balance, endurance, and respiratory function. She no longer needed supplemental oxygen. She could walk 125 steps using a rollator, at 0.46 meters per second—nearly double her initial speed. She could climb as many as 7 steps. She could comb her hair, brush her teeth, and dress herself. Her speech was nearly normal, and with her dysphagia almost gone, she was able to maintain an adequate diet orally.
Still, she needed supervision for all these tasks and minimal to moderate assistance with most of them—including such basic activities as entering and exiting a shower. She would require round-the-clock care indefinitely, and fortunately, the patient’s adult daughter and son were willing and able to provide it. During her time in rehabilitation, they participated in extensive education regarding functional mobility, fall prevention, wheelchair management, exercise protocols, goal-setting strategies, and other skills. They were also trained to set up and position assistive equipment around the patient’s home.
Once these preparations were completed, the patient was referred to the Visiting Nurse Service of New York for nursing, physical and occupational therapy, and home health aide evaluations. Outpatient hemodialysis services were arranged. And on November 30, she was discharged to her family.
“It’s remarkable how far this individual has come,” says Dr. Cohen. “At many points along the way, people who treated her didn’t think she was going to make it. Now, after more than a year in the hospital, we were able to safely send her home. I consider it a huge success story.”