STEPs® 2-3: Neuro/Spine Step-Down Unit

Hi friends! Today I’m back with another STEPs recap! If you are new around here: 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. Check out my post all about my first STEP on a cardiothoracic step-down unit!

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 actually 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. Transfers and manual muscle testing (MMT) were the skills for our 2nd STEP (1-week experience). Range of motion (ROM), ambulation, and strength training were the skills for our 3rd STEP (2-week experience). For the past two STEPs, I was on a Neuro/Spine 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 Neuro/Spine 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 spinal surgery. This is not a long-term situation, and most patients are here for about a week max. On my floor, the patient population could range from young adult to geriatric. The types of things I saw on this floor included but are not limited to:

• Multiple Sclerosis (MS)
• Guillain-Barré Syndrome
• CVA (stroke)
• Spinal fusions, laminectomies, etc.
• Myasthenia Gravis
• Huntington’s Disease
• Intramedullary lipoma
• Seizures
• Spondylolisthesis
• Spondylithesis
• Laminectomies
• Laminoplasties
• Spinal fusions
• Sjögren’s Syndrome
• Brain lesions
• Radiculopathy
• Creutzfeldt-Jakob Disease (vCJD)
• Von Willebrand Disease
• Asthma/Bronchitis

My Daily Schedule

My STEPs experiences started on a Monday and ended on Friday. My schedule varied a bit day to day, but this is roughly what went on:

8:30-10:00am: Arrive at the hospital and meet my CI (clinical instructor) and teammates in the PT/OT gym. Our CI would assign us a patient for the day, or she would give us the list and we would assign ourselves. We would then 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. Our CI required us to fill out specific information regarding each patient:

I always kept a little notebook on me with notes and information about each patient, so that I could have it handy during our treatment sessions. Sifting through charts quickly takes a lot of practice, but by our 3rd STEP we were pros (okay maybe not pros but we were decent haha). Some days we would also attend rounds, and this took place around 8:45.

10:00 am-12:00 pm: See our patients (we saw 3-4 patients each day which was perfect, because there were 4 students on my STEPs team). We tried to knock them all our during this time, but that didn’t always happen.

12:00-1:00 pm: LUNCH! Our CI required us to fill out SOAP notes for each patient, so we would work on these during lunch as well.

1:00-1:15 pm: Share our SOAP notes with our CI and each other for feedback.

1:15-2:30/3:30pm: See more patients (if we didn’t get to them all before lunch) and discuss their SOAP notes. Go home and knock out for 2-3 hours because ya girl was tired as ever!

Things I got to do

• Assist in transfers
• Perform manual muscle testing (MMT)
• Create mini exercises programs
• Palpate muscle contractions
• Ambulate patients and analyze gait
• Read patient charts
• Take vital signs (BP, HR, SpO2)
• Assist in plan of care
• Lead treatment sessions
• Observe a spinal fusion surgery
• Attend morning rounds
• Perform a full patient evaluation (interview, history, etc.)

Reflections

• Outcome measures are important (thanks Dr. Clewley)!
• As some of you may know, my granddad (one of the most important men in my life) has been in the hospital for the past 4/5 months. This was my first time being on the “other side”. My first time not having the answers. I had to wait for rounds to see how a surgery went. I couldn’t just look in the chart to see what notes were left. I couldn’t just page a provider to ask a question. I had to have patience…understanding…faith. Waiting is hard. Not knowing what comes next is hard. At one point, he had a 5/10 chance of survival. I had to mentally prepare myself for that loss…that very scary, but real possibility. I am so grateful that my granddad is doing better, and on the road to recovery. I am grateful for the surgical team, the nurses, the respiratory therapist, the hospitality staff, and everyone else at that hospital that treated (and is still treating) my family so well: for letting us pray before prepping my granddad for his 3rd surgery, for always keeping us updated, for letting more than 2 people in the room at a time, for laughing at my jokes, and so much more. This experience has reminded me how important it is to keep the humanity in healthcare. To remember that every patient is someone’s grandfather, or mother, or brother. That every patient deserves to be treated like a human, no matter their age, race, religion, or socioeconomic status. That every patient matters, and is a real person.
• If the 3rd years can do it, so can I (we saw a lot of the new 3rd years during our 3rd STEP, and it gave me a lot of hope)!
• I got the opportunity to observe a neurosurgery during the STEP. A few days later, I actually got to treat the patient from that neurosurgery. This was such a cool experience, and it was beneficial to see what our patients go through before we see them for therapy. This particular patient had an extensive spinal surgery, so when we saw them for physical therapy they were in a great deal of pain (9/10). Not that I didn’t “believe” patients when they said they were in pain before observing this surgery, but I could better understand the pain that this patient was experiencing after having seen what they endured during surgery. This experience really reminded me of how much our patients go through, and how important it is to trust and listen to them no matter what. They are always the experts on themselves, and I will keep this in mind moving forward in my education and practice.
• The real OR is nothing like the ORs on Grey’s Anatomy lol.
• Teamwork makes the dreamwork! It is okay to fall back on your teammates, they are there to help you!
• Stay hydrated, wear compression socks, and MOVE! During one patient encounter, I started feeling lightheaded and hot. We were wearing gowns—gotta love that PPE—and the patient’s room was pretty warm. I knew immediately that I needed to leave the room (shoutout to my CI for being super understanding). I took a little walk, got some water, stretched/did some leg exercises, and then sat down for a few minutes to try to feel better. I have never fainted and I rarely feel lightheaded, so this was a pretty weird feeling. I have to remember to drink water and move around.
• Be nice to the nurses!!! They run the floor.
• Don’t forget about that darn IV pole! Keeping it in front of the patient is best (that goes for all lines and leads).
• Our CI really wanted us to take the time to get our environment ready before moving a patient. This means untangling lines and leads, getting the chair set-up if needed, making sure the walker is close, lowering the hospital bed, etc. Doing these things take time, but are necessary for the safety of you and your patient.
• It’s okay to be wrong, that’s how you learn. You’ll get it right next time!
• I actually know a lot, I just need to have confidence in myself.
• I learned that my CI really values the people around her (other PTs, OTs, MDs, etc.). Mentorship is so important! When she is stuck or has a question, she feels comfortable going to other people and asking for help, and this has been crucial to her clinical reasoning development. She also really values CEUs, attending grand rounds monthly, the literature, and “in-services” that are done during lunch. She emphasized that developing sound clinical reasoning is a process. It doesn’t just happen overnight; it takes time and practice. She stressed to us the importance of not feeling the “pressure” to clear patients or to do what other providers want us to do, and learning to recognize patterns in patient cases.
• Body mechanics are important. Lift with your legs. Raise that bed when you are assisting with exercises. Trust me, your back will thank you.
• Ask as many questions as possible and soak up all the knowledge you can!

I hope you enjoyed reading about my 2nd and 3rd STEPs experiences. My next STEP will be in the fall, and I’ll be in an Outpatient Orthopedic setting. I can’t wait to continue sharing my experiences with y’all!