STEPs® 1: Cardiothoracic Step-Down Unit

What the heck is STEPs?

So I keep talking about STEPs, and many of you are probably wondering what STEPs even is. If you missed my Instagram post from Sunday (or haven’t seen any of my posts from the past week), then you’re probably out of the loop (get it together! Jk jk). During the first and second years of my program, we have 1-2 week clinical experiences every semester called STEPs. We will have 5 total, with half in an inpatient setting and half in an outpatient setting (1 setting per year). STEPs stands for “Student Team Experience in Practice”. We are randomly assigned to a STEPs team (3-4 students per team), and this team is different than our Team-Based Learning (TBL) teams.

Participating in STEPs gives us a chance to practice the skills we are learning in the classroom on real patients, prior to our terminal clinical experiences during our third year (p.s. this was one of the reasons I chose Duke’s PT program!). It is also an opportunity for us to work with a different group of classmates. For each STEP, we have a set of skills that we are responsible for demonstrating. Vital signs (blood pressure, heart rate, SPO2) and palpation were the skills for this STEP. For this STEP, I was in a Cardiothoracic Step-Down Unit (acute inpatient at the hospital). I had never observed in this setting, so this was completely new to me!

What goes on in a Cardiothoracic Step-Down Unit?

Step-Down Units are floors that provide an intermediate level of care between the Intensive Care Units and the general medical-surgical floors. They are basically transition units for patients after they have undergone any type of cardiothoracic surgery. This is not a long-term situation, and most patients are here for about 2-3 weeks. On my floor, most of the patients were from a geriatric population. The types of things I saw on this floor included but are not limited to:

• Lung transplants
• Valve replacements/repairs
• Aortic dissections
• Heart transplants
• Coronary Artery Bypass Grafting (CABG)
• Lung cancer
• Esophageal cancer
• Strokes
• Heart attacks
• Lobectomies
• Pneumonectomies
• Pacemakers
• Ventricular Assist Devices (VADs)

My Daily Schedule

My STEPs experiences started on Sunday (11/4) and ended on Thursday (11/8). My schedule varied a bit day to day, but this is roughly what went on:

7:00 am: Arrive at the hospital and meet my CI (clinical instructor) and teammates in the PT/OT gym. We would chart review, which consisted of looking up our new patients, and discussing any changes in our current patients. We would look through lab values, history, and notes from other healthcare providers. We had to try to create a “picture” of our patient. I always kept a sheet of paper on me with information about each patient, so that I could have it handy during our treatment sessions. Sifting through charts quickly takes a lot of practice, so our CI directed us to the most important information.

8:00 am-12:30 pm: See our patients (with a few snack breaks here and there of course). We saw 3-4 patients each day.

12:30-1:30 pm: LUNCH!

1:30-2:30/3:00 pm: Talk about the patients we saw, and come up with our treatment plan for the next day. My CI always made sure to ask our opinions, and let us decide what we wanted to do with the patient.

2:30/3:00 pm: Go home and CRASH for like 3 hours due to exhaustion lol. Sitting in a classroom for 8 hours and being on your feet for 8 hours are two totally different things (shoutout to those 31,667 steps I accumulated throughout the week though!). I slept for almost 12 hours Thursday night (after my last day).

Things I got to do

• Assist in transfers
• Take vital signs (blood pressure, heart rate, SpO2)
• Palpate muscle contractions
• Ambulate patients
• Read patient charts
• Assist in plan of care

Reflections

• Three words: lines and leads. They were everywhere. Each patient had at least 2-3 lines, and that was something I wasn’t used to. I had to learn about each line/lead, and make sure to protect them during our therapy sessions. I can’t tell you how many times the BP and SpO2 cords were tangled. Think laptop charger, headphones, and phone charger all tangled up in a ball in your bookbag.
• One of my favorite parts of STEPs was interacting with the other healthcare professionals (nurses, OTs, SLPs, PAs, physicians, etc.) while in the hospital. We even co-treated a few patients with an OT, and it was cool to observe the session dynamic, and really understand and appreciate the OT’s role. Healthcare is a team, and I witnessed that firsthand.
• Going from shadowing as a pre-PT to actually participating in care as a SPT was a big transition. I was so used to watching quietly, and not really being a part of the patient’s care. I was pretty nervous as well. After the first day or 2 though, I felt more comfortable, and was ready to get in there. I grew so much over the past week. At the beginning of the week, my teammates and I felt pretty useless. We have only been in PT school for a few months, so we didn’t feel like we really knew enough to make a difference. As the week went on though, we began to make those connections. Everything began to click, and we had those “aha” moments. Things we learned in physiology, movement science, anatomy, etc. were showing up in/on real patients. I could participate in a maximum assist transfer. I could interpret an EKG. I could properly ambulate a patient. I knew what to do when my patient’s systolic BP decreased. A patient has an IV line, a tracheal tube, a chest tube, and a rectal tube? No problem! I went from being afraid to even touch patients to being able to assist in transfers and take vital signs like a pro.
• Bodily fluids…lots of bodily fluids.
• I owe a lot of my success and growth this week to my CI (if I can be at least half the PT she is in the future, then I’m set lol). She’s honestly the best, and really helped me build my confidence and ease my nerves. She is so knowledgable, and I tried to soak up as much as I could. She made the environment very safe, and was always so encouraging. I felt very well prepared/guided for each patient encounter. We could be as hands-on or hands-off as we wanted, we could mess up, and we could get things wrong without fear of being ridiculed. The week was really about us and our learning, and she made sure that we knew that. My input mattered. My thoughts mattered. What I wanted for the patient mattered.
• The hospital is so much more than what I’ve seen on Grey’s Anatomy and Instagram!!!
• My CI talked a lot about therapy being therapeutic/functional. For example, if we were standing a patient, we had to decide if it was actually functional for the patient, or if all we did was “muscle move” them. We were constantly asking ourselves if our sessions were therapeutic for the patient. I think that this is something that is very important to consider/think about!
• I really enjoyed the team dynamic of STEPs. It was nice to have 3 other people to fall back on when I didn’t know the answer. They were always willing to help, and it was nice to collaborate when coming up with treatment plans. My teammates were so freaking smart too! One of them has a Masters in physiology, so that really came in handy for this setting. Another is a licensed PT in Taiwan, so he is super knowledgable and has lots of experience. My other teammate was a caregiver, and has lots of patient care experience. I will work 1-on-1 with a CI during my terminal clinical experiences in my third year, so it is nice to get this team experience in beforehand.
• After sitting in a classroom all day for about 3 months, this week was a breath of fresh air. It gave me perspective, and helped me remember why I spend my whole life studying. It’s not to get a 100 on an exam (and I mean that would be great, but that’s not the point). It’s all for the patients. So that I can be the best physical therapist that I can be. So when I start to feel like my studying is pointless, or that I’m not getting anywhere, I’ll just think back to this STEPs experience and remember my purpose.

I hope you enjoyed reading about my STEPs experience. My next STEP will be in the spring. I’ll be in the hospital still, but on a spine floor (I also have not observed in this setting). I can’t wait to share that experience with you guys!

P.s. if you are interested in the second-year version of this post, Yusra over at The DPT Diaries has you covered! Check out her post to hear about her experience in this exact setting/location (same CI and everything)!