Latest / The STA Clinician Podcast / Ep.302 'Sepsis: Critical Care Journey & Post Intensive Care Syndrome (PICS)' with Alanna Forrester

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Ep.302 'Sepsis: Critical Care Journey & Post Intensive Care Syndrome (PICS)' with Alanna Forrester · The STA Clinician Podcast

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You're listening to the STA Clinician Podcast, connecting clinicians across healthcare.
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Association podcast, formerly known as the Sports Therapy Association podcast.
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Geez, my voice is not normally this hunky. It's just got man flu again.
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And this episode is being recorded live on the Sports Therapy Association YouTube
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channel and Facebook page at eight o'clock UK time on a Tuesday.
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So very shortly in this episode entitled Sepsis, the critical care journey and
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post-intensive care syndrome picks, I will shortly be joined by special guest
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Alana Forrester, who is clinical nurse lead for critical care outreach.
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Alana is going to be discussing the physical and psychological impact survivors
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face following critical illness,
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including muscle wasting, severe fatigue, and deconditioning,
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and how you, the listener, soft tissue therapists and movement professionals
1:03
can play a part in supporting long recovery.
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Before that, as always, I'd like to give a big thank you to my guest from last
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week's episode, Understanding Stomas, A Guide for Soft Tissue Therapists,
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in which I was joined by special guest Jenny Jones, a community stoma nurse based in Norfolk.
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In this episode, we look at what a stoma is, the three main types of stomas
1:27
and the impacts stoma surgery can have on a patient's overall quality of life.
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That's episode 301 of the STA Clinician Podcast available as always on all popular
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podcast apps and the Sports Therapy Association YouTube channel.
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If you have joined us live, then thank you very much. As always,
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you are able to ask questions to our guests directly. And if you do ask a question,
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I can bring it up on the screen.
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People are coming through already. Brian, how are you doing?
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Nice to see you. Thanks for joining us.
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Gary Benson, founder of the STA is in the house as well. Hi,
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Gary, and everybody else. And if you listen to the podcast, then thank you very much.
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It means you're listening to the recording. If you do have a question.
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Then you're free to go to YouTube and put it down there.
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And we do track the YouTube comments so we can get back to our guests and ask
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them questions. So don't feel the conversation is over. That'd be ridiculous.
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With 300 episodes, no way we have more than a week's shelf life.
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Do use YouTube if you have a question.
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Cecily Hislop has just joined us as well. Says, evening all,
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too busy recovering from bird flu for sympathy. Bird flu.
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Okay. But take care though. Thanks, Cecily. I think there's sympathy there somewhere.
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And Steve Kirby is back with us as well. And thanks to Steve Kirby for putting
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these episodes together as this month is sepsis month.
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And Steve, who has lived experience of that has helped put last week's and this
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episode together so hi Steve thank you very much and thank you for sharing your experience,
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right then let's start tonight's episode sepsis the critical care journey and
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post-intensive care syndrome with my special guest Alana Forrester.
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Hey, Alana, how are you doing? Hello, I'm very well. Thank you. Lovely to be here.
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I appreciate it very much, sir. And there's Steve Kirby, you're still on the
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window there. Steve is who brought us together. And Jenny, you know Jenny as
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well, don't you? Have you worked with Jenny?
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Yes, I worked with Jenny for years, so it was nice to see her face on last week's episode.
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Thanks, fantastic. I do appreciate both of you giving up your time to join us.
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And it's a topic, the feedback we've had so far has just been great,
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because it's something which isn't.
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Is one of those conditions that isn't just talked about enough on shows like this.
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It's always kind of Achilles and patellofemoral pain syndrome and ITP syndrome.
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And we forget about the huge amount of population who come in affected by something
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which, you know, we're not trained in. So I really appreciate you giving up your time.
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Absolutely, no problem at all. I suppose if we jump straight into it,
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maybe if you could start by giving our listeners a little bit about your role
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as clinical nurse lead for critical care outreach and how that links maybe to
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tonight's topic of sepsis.
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Lovely so yes so critical care outreach is a kind of service that is available
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in most hospitals these days through throughout the uk we are a group of specialist nurses usually,
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many have a background in intensive care nursing but we take nurses from other
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kind of acute backgrounds so my
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team some of them worked in the emergency department or in acute medicine,
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we work in a role where we cover all wards throughout the hospital.
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So we'll take referrals from nurses, doctors, anybody out in the ward who has
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got a patient that they're looking after
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and they think this patient looks like they're deteriorating and that might
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be that they've noticed something in their observations or they just kind of
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have got a bit of a not good feeling about them.
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They'll give us a call and say, can you come and have a look at this patient?
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And we support kind of clinically to optimise them, try and prevent them being
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admitted to critical care.
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But where they do need to be admitted to critical care, we do a lot of the transfers
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up there. And my background is in intensive care nursing.
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And another really key part of my role that is particularly relevant tonight
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is that we also support all the patients who are stepped down from critical care,
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to the ward because they are a very vulnerable group of patients who need a
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lot of additional support,
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and are also at risk of deteriorating again.
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So we follow up every patient at our hospital who goes from critical care to
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the ward and trying to make sure that we assess them holistically and make sure
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that they've got the right support.
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I'm not an expert in the kind of longer term rehabilitation after critical care,
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but obviously my experience of working with this patient group kind of gives me an insight of,
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the journey that they've been through because I've witnessed that with following
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a lot of patients through critical
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care and how that can kind of impact on things further down the line.
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And also, specifically in relation
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to sepsis, we obviously do a lot of managing sepsis out on the wards.
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And we also provide a lot of education around sepsis and look at how it's managed
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in the hospital and optimizing it. Amazing. Thank you very much for that.
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I suppose really as well, we should, not everybody probably understands what
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sepsis is. So could you give us a definition of that?
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Yeah, absolutely. So yes, sepsis is, I think it can almost be used quite broadly.
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So it is useful to kind of nail it down to exactly what it is.
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So if I give you the fancy definition and then I'll kind of break it down a little bit.
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So it's characterized as a life-threatening organ dysfunction due to a dysregulated
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host response to infection.
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So what does that mean in reality so sepsis can occur in anybody who's got an
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infection so not everybody who has an infection is septic or will go on to become septic,
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so most people will develop an infection and they might just.
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Fight that off themselves naturally or they might need a few days of antibiotics
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from their GP and they'll fight that off but in a small group of patients and
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some are higher risk than others, though it's not completely understood as to
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why some people will develop sepsis.
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That infection goes on to cause sepsis and you get a kind of overwhelming immune
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and inflammatory response throughout the whole body and you get this kind of dysregulation.
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So normally if I've got an infection or an injury, you get an inflammatory response to that area.
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In sepsis, that inflammatory response is kind of out of control and throughout the whole body.
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And that starts to cause a whole kind of cascade of problems.
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So you get widespread inflammation, your blood vessels become very leaky and
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more permeable. You'll start to drop your blood pressure. And that then.
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Can go on to cause septic shock, which can start to then damage your organs at the other end of that.
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So pretty serious stuff then we're talking about. Yes. I mean,
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it's, you know, I don't want to, you get kind of different levels.
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So some people will have, be developing a kind of what looks like a septic response
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and we'll give them some antibiotics and they'll respond really well to that
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and get better quite rapidly.
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Other people will develop sepsis and become overwhelmingly very unwell very, very rapidly.
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And it's not particularly well understood as to why some people will get that,
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overwhelming response.
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I can think of a patient I saw once many years ago who had just got a strep
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A throat infection. And most people will get a strep A throat infection.
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They'll fight it off. They might not even need any antibiotics.
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They'll have a bit of sore throat for a few days, get better.
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And then you'll get somebody who gets the same infection from the same bacteria
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and they just become overwhelmingly septic and become very very unwell and there's
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there's a lot of ongoing research to kind of understand that,
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you know there are potentially some genetic factors that make you more at risk
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things like if you're on immunosuppressant drugs or.
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For example chemotherapy or something that suppresses your immune system you're
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more at risk pregnant women are more at risk very young children,
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but it's yeah it's not entirely understood as to why some people become so unwell
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and not everybody who develops sepsis will go on to be very very unwell but
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a small kind of subgroup will.
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So if we don't really know, thank you for that. So if we don't really know what
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causes it or why some people are prone to it and others, then what sort of precautions,
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because you mentioned like you're in education, what precautions do hospitals
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take to try to avoid it from happening?
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Yes. So what we try to do is we kind of, the Sepsis Trust have done a lot of
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work promoting kind of think sepsis. So every patient who is in a hospital,
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we regularly monitor all their vital signs.
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So anytime that those vital signs kind of fluctuate outside of what we would
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expect as normal, we encourage and we teach people to think sepsis and they
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should be what we call screened for sepsis.
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So sepsis screening just involves a clinician taking the time to think, could this be sepsis?
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And anytime that you answer to that question, yes, this could be sepsis,
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then that then triggers some more interventions, a review from the medical team
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and a more kind of comprehensive of look at could this,
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you know, do we need to start on antibiotics?
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And in those subgroup of patients, which we call red flag sepsis,
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when they're showing really clear signs.
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Will then kind of triggers a set of actions, the main one of which is getting
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antibiotics into them within an hour,
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which is our key target for those kind of red flag patients,
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because that's been shown significantly improve the mortality from sepsis.
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Okay. Is this something that has been improved over the years then?
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Was there a time when people didn't really look for it as much and now it's
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something which is much more?
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Yes, certainly in my own experience. I mean, I think I've been nursing nearly
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20 years. I know I don't look that old. Impossible.
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I know, everybody's shocked. And I think it has really grown in,
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And I think the Sepsis Trust have done a lot of work to kind of promote this
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and put it at the forefront of people's minds and just make sure that we are taking the time.
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To think about it and considering it just because it is so important to get
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those treatments in in a timely manner excellent we'll look at some of the,
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signs for it which you mentioned already but give us an idea before we do that
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what sort of instance are we talking about how many people in the uk,
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will get sepsis so i think the sepsis trust says around 226 000 cases that's
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very specific i definitely haven't got that written down in front of me.
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But that compares to around kind of a hundred thousand admissions from a heart
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attack per year so we're talking,
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you know a quite quite a significant number of people and then it accounts for
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about five percent of emergency admissions to hospital,
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and they say it's about five deaths an hour claimed by sepsis so this it's a
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significant problem that um,
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and that's you know partly why i'm here today to kind of raise awareness around it.
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That is, yeah, quite scary. That's quite a lot, isn't it? And out of those cases,
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how many does that mean out of those 226, I think you said 1,000,
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how many of those do cause death?
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So if you look on the sepsis shrubs website, it reports as around 20%.
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However, I think they're subdividing that into the most severely septic patients.
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So we're talking about when patients have developed,
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septic shock and are becoming very severely unwell and it's hard to kind of
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stratify it beyond that and give a very clear figure of everybody because as
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with many disease processes you really get a kind of,
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not everybody is going to fit into that most severe category of sepsis many
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patients will show that kind of response will treat them they'll respond really
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well to the treatment and so it's very variable and it's difficult to put an exact number on.
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Oh, that makes sense. That makes sense. Right. We're going to bring some,
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we've got some screenshots taken from sepsistrust.org, which is a great website
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that on the show notes, it gives you loads of information.
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If you are a therapist or practitioner, you want to read up on it,
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then I suggest you go to sepsistrust.org. But we're going to put some on because
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we're live on YouTube and Facebook. We'll put some up on the screen as well now.
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For those of you who like the visuals, again, obviously, sepsistrust is trying
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to raise awareness of this. And it's not kind of scaremongering,
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it's just fact. And it's got a screenshot here saying 48,000 people died of
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sepsis last year in the UK.
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Together we can change this.
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How does that compare to kind of, I mean, you said, did you say that 5% of emergency
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admissions are because of this?
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Yeah, so it's a significant proportion of emergency admissions to hospital.
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And if you compare that to something like lung cancer, bowel cancer,
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which obviously gets a lot of coverage, rightly so, that it's more than all those combined.
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I think it is important to caveat that because we're not I'm not a massive fan of,
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pitting kind of one disease off against the other because actually some of the
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people who die of sepsis will be people who are suffering from,
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a cancer who are then having treatment that suppresses their immune system and
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they may go on actually to die of sepsis unfortunately So I don't want to go
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too heavily down the kind of,
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you know, these disease processes are often very complex and we're trying to
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balance lots of different needs for patients. But it does just work.
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Emphasise that this is a significant problem. And not all of those deaths will
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be preventable because they will be people who are already unwell with other
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illness. And unfortunately, it then becomes very difficult to treat sepsis.
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But there are a good proportion of those where actually, by making sure that
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we're managing it properly, we can make sure that as many people as possible survive.
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And that kind of leads importantly onto the next slide, which is recognising
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potential signs that you should either go to a or contact your doctor which
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you're going to bring up on the screen now because i'm guessing that
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as with many of these systemic issues catch it earlier and you're more likely
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to be able to deal with it properly and safely,
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absolutely getting antibiotics in early is really really important however i
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do have to emphasize at the same time Not everybody who's got an infection will
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go on to develop sepsis and we can't, I don't want to,
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kind of make people too scared that I need to take antibiotics immediately for every infection.
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Most people will have a mild infection, their body will respond to that,
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they may need some antibiotics to treat it and they'll get better.
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So not every patient who has an infection will go on to be septic.
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So the idea of these particular signs are to help you identify when actually...
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We're moving beyond just having an infection and actually this is looking like
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this patient's septic and in those instances you do need very urgent medical attention.
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So it's trying to find those real kind of red flag signs.
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So slurred speech or confusion can be a really sensitive marker of sepsis.
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So if you see, if I have a patient, particularly a young patient who's normally
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very cognitively with it and they are developing a new confusion,
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even if all their other parameters at the moment okay that's a really worrying
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sign so that's something to look out for extreme shivering or muscle pain can be an indicator,
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passing no urine in a day or i'd probably say just passing very low amounts
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of urine in a day could be an indicator of developing sepsis because what happens
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is you're then not perfusing your kidneys very well and they're not producing
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the normal amount of urine.
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So anybody who's got that symptom, I would say, you know, you need to be presenting
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to ED immediately. Severe breathlessness.
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And then it feels like you're going to die. So what patients report is,
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I've never felt this unwell. I feel really unwell. I've got this kind of sense of impending doom.
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And, you know, that can be, should be taken very, very seriously.
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And skin being mottled or discoloured can be an indicator.
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And it's really important to just emphasise and think about people with darker
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skin tones, that that might be a slightly harder sign to pick up.
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So you can look for changes in the skin, particularly in the palms of the hands
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or the kind of forearms. It might be a little bit easier to see in people with the darker skin tones.
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So where you think you've got an infection, you can seek support through the
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NHS 111 service or your GP.
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But when actually you're showing these signs and you're concerned specifically
18:31
about sepsis, then that's where you should.
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In really severe cases, calling 999, you know, may be appropriate if you're
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showing a number of these signs.
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And I actually recently had a little girl who I looked after when she was two
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who had meningitis and was septic from that.
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And actually, they'd called 999 and she'd been given antibiotics by the paramedic
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crew because they can give it for where it's clear sepsis.
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And that was probably the reason that she survived is because she'd got that
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urgence. So where somebody is rapidly deteriorating...
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Get really urgent attention or present an ED and say, look, I'm concerned this could be sepsis.
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While I'm talking about that, it's important just to talk about children as
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well, because they might present slightly differently.
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So what the sepsis is just about, talk about for that is breathing very fast,
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any fits or convulsions, looking mottled, bluish or pale, which is similar.
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And once again, the same considerations around people with darker skin tones.
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And they emphasise a rash that doesn't fade when you press it.
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So they talk about the glass test, which is the easiest way to see it.
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So if actually you've got a, it'll look like a kind of purpley rash and when
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you roll a glass on it, it doesn't blanch or go away. It remains purple underneath
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the pressure is a real sign.
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And just check your children all over for that. I remember, I can't remember
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his name now, a very famous author who wrote, we're going on a bear hunt,
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I forget his name, but his son, unfortunately, died of sepsis.
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And he said that it presented kind of with a rash under the arms.
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So just check your children all over if you're really worried about them for
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this rash and it can develop. And it's a horrible thing to see.
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Feeling very lethargic or difficult to wake for children and feeling kind of
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abnormally cold to touch. And then in very young children, it's kind of additional
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signs where they're not feeding, repeated vomiting or that low urine output.
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I see Steve's just added in the chat that he can remember about the breathlessness
20:38
and that feeling that he was going to die and that things moved very quickly.
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So for us as clinicians and for anybody listening to our patients and about
20:47
how they're feeling and that they're.
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Telling us that they're feeling very unwell and we should be responding to that
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and taking it very seriously.
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I guess that there's, I'm looking through those symptoms and there's a crossover
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with other potential kind of systemic issues going on as well.
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But even if it's something else, it's still, there was a solution that would be A&E important now.
21:10
You know, if it was a stroke or something or if it's meningitis,
21:12
the same kind of stuff, you're still going to end up, act now, get to A&E.
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Yeah, exactly. Like any of these, you know, We don't want to overrun any departments,
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but they are there for a reason. And actually, any of these signs would be significantly
21:27
worrying and warrant presenting at ED.
21:30
So, you know, I don't, in terms of these specific symptoms, if you've got any
21:35
of those, they will then consider whether it's sepsis. But as you say,
21:38
there could be other things going on that need urgent attention.
21:43
Amazing. Really good. And, and there's a, there's a, I was getting confused
21:48
in mnemonic and acronym.
21:49
I think it's a, I don't know, but sepsis is broken down into those different
21:54
identifiers. And there's a nice way of remembering that if you go to,
21:58
again, the website, sepsistrust.org, it's something you may want to print out
22:02
or just familiarize yourself with.
22:04
And I'm listening to this and I'm thinking, obviously as a soft tissue therapist
22:08
or sports therapist, whatever, you're very unlikely to have somebody coming into your clinic.
22:13
I mean, it could happen, but these are things which I think,
22:17
especially in the private care industry where you're spending maybe an hour
22:21
with clients, massage therapists, you're talking so much and you share so much information.
22:26
And we said it's time and time before, this is where you can help educate the
22:29
public so much. You're not diagnosing, you're not going outside your scope of
22:32
practice, but the same way as you talk about the signs for possible stroke or something.
22:37
And that could be someone's father, mother, daughter, child,
22:39
cousin, whatever, boss, somebody at work.
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So I think there's so much we can do as therapists if we just educate ourselves
22:48
a little bit with this because people will listen to us because they trust us. Yeah, absolutely.
22:53
Absolutely. Anything that can kind of raise that awareness and get people thinking
22:56
about it is really, really important.
22:59
Great. And again, Steve, yeah, thank you for sharing your experience there.
23:04
And it shows as well the importance of listening to the people in front of you.
23:07
We hear it a lot, don't we, for heart attack, I think, that impending sense of doom.
23:11
And we've talked a lot about it on first day courses and that.
23:15
But unless you actually talk and listen to your client and watch out for diagnostic
23:20
overshadowing, I think they're just overreacting because they're always like
23:22
this. You've got to listen and take it seriously.
23:25
Really important. And Cecily has got a question here for later.
23:28
We don't wait for later, Cecily, when it's a question from you.
23:31
Can patients suffer from a long sepsis, similarly to how people have long COVID? many things.
23:37
That's a really good question, Cecily.
23:41
I'd say in many ways, yes, though I wouldn't think you'd necessarily particularly call it that.
23:49
But we're going to go on to talk a little bit about post-intensive care syndrome
23:54
and the long-term impact.
23:57
So long COVID has some very specific symptoms related to the COVID itself.
24:04
For example, the impact on the lungs and the breathing and the long-term breathing problems.
24:10
But actually, a big part of long COVID is also about the impact of being very,
24:17
very unwell and in critical care and being very unwell.
24:21
And that will be very similar to somebody who has experienced sepsis and been
24:27
very, very and well and had a,
24:30
prolonged admission to critical care will have a really, it will take them a
24:35
very long time to recover and we'll be able to perhaps give a little bit more
24:38
insight into that as we talk about kind of post-intensive care syndrome.
24:42
Great question, Cecily. Thank you for that. I was thinking of that earlier on,
24:46
the links between there and monitoring people. But yeah, great question,
24:49
Cecily. As always, thank you very much.
24:52
We mentioned in the advert Martha's Rule, which I think is, yeah,
24:57
could you expand on that?
24:59
Yeah. And this links in really nicely, actually, because Martha's Rule is about listening to patients
25:04
and recognising that they have a really unique insight into how well they are
25:11
and the symptoms that they might be experiencing.
25:15
So Martha's Rule has three components. So the first component is that,
25:21
we as clinicians in the hospital should be asking patients at least once a day
25:27
how they are feeling, how that compares to how they felt yesterday.
25:32
And so what that is really recognising, as I said, is patients and their loved
25:37
ones or anybody who knows them it might be a carer.
25:42
And knows them really well and knows what is normal for them so me walking in
25:46
as a nurse I don't know what they're like normally and it might be harder for
25:49
me to judge if something's going wrong,
25:52
whereas a relative who knows them really well might say this really isn't normal
25:57
for them this isn't right at all and they can be really sensitive to picking
26:00
things up so what it's promoting and what we're introducing is regular check-ins.
26:05
So every shift, how are you feeling? How does that compare to yesterday?
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And if they're saying, well, actually, I feel worse, taking that really seriously
26:13
and saying, okay, is something not right here? Do we need to escalate their
26:17
care? So that's part of Martha's rule.
26:20
And then the other part of Martha's rule is a telephone service.
26:23
So what that does is that allows patients themselves, relatives,
26:29
any visitor, any staff member, anybody in the hospital to look at a patient
26:35
and say, I think this patient is acutely deteriorating, something is not right.
26:41
And we encourage people to escalate that within the teams themselves.
26:44
So hopefully they go and speak to the nurse looking after them and that gets
26:47
escalated through the normal channels.
26:49
But where they've done that and they've said they're not right and they're still
26:52
not getting the appropriate response, Martha's Rule gives them access to a dedicated
26:56
phone line where they can call and say, I feel like my relative is deteriorating.
27:02
Nobody's listening to me. Can you come and help?
27:05
And what that comes through to, that comes through to us as a critical care
27:09
outreach team. And that's how it's run in a majority of hospitals.
27:12
It's critical. You will get a critical care outreach nurse.
27:15
And that is an important distinction to make because unfortunately some of the.
27:20
Some of the advertising has been around a second opinion. It doesn't provide
27:23
you a medical second opinion. So we can't kind of come and say,
27:27
no, actually your diagnosis is wrong and kind of solve that problem.
27:32
There are different routes to which you can do that in a hospital.
27:35
This is about identifying acute deterioration and listening to patients and
27:40
saying, something is not right.
27:43
I'm coming in as an independent person.
27:46
There's no impact of hierarchy, I'm a fresh pair of eyes.
27:50
Is this patient acutely deteriorating? And if they are, and this comes off the
27:55
case of a really sad case of Martha Mills, who was a young girl who fell off
28:00
her bike and ruptured her pancreas.
28:03
And she was in hospital for about nine days and was becoming increasingly unwell.
28:09
And her parents, who are very articulate, very educated,
28:14
people, who you would think would be able to get the help that they needed could
28:17
see that she was becoming more unwell
28:19
but nobody was listening to them and unfortunately she went on to die,
28:23
of sepsis and what they found was that their opportunities were missed and if
28:28
she'd been escalated earlier she likely would have survived so it's about giving
28:33
patients themselves or relatives the opportunity to say,
28:36
something isn't right something's been missed here can you come in as a kind of fresh pair of eyes.
28:42
And in my hospital, you'll get one of my lovely team turn up as a fresh pair
28:46
of eyes and kind of say, is there any sign that this patient's acutely deteriorating,
28:51
and listening to those concerns?
28:55
That's so amazing. That's so tragic. But yeah, I think the key word there was,
28:59
yeah, it's the phone line of no one's listening to me.
29:01
That's so vital, isn't it? Is there any more information without kind of naming
29:05
and blaming, but just to learn from it, why that kind of diagnostic overshadowing
29:09
happened in the case of Martha Mills and her parents? What went wrong?
29:14
So there are several. I think if you just search Martha's rules,
29:18
there's lots of articles out there there is an absolutely devastating interview that,
29:24
with her mother talking about what happened while they're in there so that's
29:27
a really you know it's a really hard listen but worth listening to,
29:32
a lot of the findings were around the impact of hierarchy was a big and that
29:37
kind of confirmation bias or
29:40
so one person has said there's okay they're okay so and actually if that is
29:44
a senior person which i think in this particular case it was somebody very senior,
29:49
and the medical team is saying they're okay then that kind of feeds down and
29:53
actually then when they spoke to junior doctors nurses afterwards they're like
29:57
well I was a bit worried about her but they couldn't you know the consultant
29:59
said they were okay so that kind of reassured me.
30:03
So yeah hierarchy did play a part and sometimes and that's about that's what
30:06
Martha's rule is about just kind of completely breaking that down and getting
30:09
somebody completely fresh in who's kind of not not part of that hierarchy and
30:14
saying right let's just take a fresh look at this,
30:16
something's not right and usually to be fair to those clinicians usually,
30:23
so most of the time these calls we find that actually everything is being done
30:27
as it should quite often it's just a communication issue well I say just a communication
30:31
issue communication is obviously very important but you know everything is being
30:35
done it just hasn't been communicated well and.
30:38
But occasionally we do pick up something where something could be improved.
30:42
And where we do that, usually we take that back to that medical team and look,
30:46
you need to take another look at this patient. And generally people will go,
30:50
OK, you know, let's have a fresh look at this and we work together.
30:53
So, yeah. Very interesting.
30:57
And there may well be other lines to do it, but could you mention like members
31:01
of staff feeling pressure or kind of appeal to authority in that?
31:05
But I mean, would a member of staff be able to use this phone line as well? I mean, absolutely.
31:11
Yeah, it's completely designed. So actually, that's what the master's rule says.
31:15
It says this should be available for all staff and patients and families.
31:19
So that could be that might be, you know, another health professional who is visiting the patient.
31:26
So it might be an occupational therapist or somebody who's could be anybody
31:31
who comes in to see that patient says, I'm worried. I don't,
31:34
for whatever reason, feel like I'm able to raise it through the normal channels.
31:38
We can kind of get a completely fresh set of eyes. And so, yeah,
31:41
it's there for everybody.
31:43
Okay, I'm going to force myself to go on. I'm just always fascinated and traumatized
31:48
by diagnostic overshadowing. We've had lots of people on, you know,
31:52
the show talking about various different ways.
31:55
And yeah, unfortunately, it's not always, for example, sometimes it might be
31:59
neurodivergent. Sometimes it might be something like a learning disability,
32:02
like Down syndrome. but also it can happen with older people,
32:04
with women, with children.
32:07
And it's not always done like with bad intention. It's just human nature,
32:12
isn't it? You think, oh...
32:14
I mean, I can't offend a male person who says she's just been a woman,
32:17
but I'm just trying to think of an example where it's not always done out of
32:22
bad intention. It's just human bias,
32:24
isn't it? People come from different experiences, but it's frustrating.
32:27
Yeah, it's very hard to kind of pull those apart and kind of question your own
32:32
bias and keep that in check all the time.
32:34
So okay right right well i'm gonna pull pull myself away right okay so let's
32:39
move on we mentioned as well thank you for the questions people if you've got
32:42
more questions then do feel free to,
32:44
put them in the comments yeah we mentioned picks before post-intensive care
32:47
syndrome so yeah could you expand on that yeah absolutely so i'll just mention
32:52
a little bit just give you a little bit of a.
32:56
A thought of what the experience is like being a patient in intensive care.
33:00
And I think that then feeds through to understanding what then happens afterwards.
33:04
So, obviously, patients who come into intensive care with a very broad variety
33:10
of presentations. So, it might be sepsis, they might have had a cardiac arrest,
33:14
you know, all sorts of different presentations.
33:17
And what we often, obviously, it depends on what's going,
33:20
on, but let's use a septic patient as an example so we might have had to put
33:25
them on a ventilatory support so we put a breathing tube down the throat we,
33:31
sedate them quite heavily,
33:33
obviously in order to tolerate that and we kind of take over their breathing
33:37
for them to overcome their respiratory problems,
33:40
and we might have to give them quite hefty drugs to keep their blood pressure
33:45
up so once again in a septic patient talked about your blood vessels being very
33:48
leaky we give them some really what we call well there's some kind of inotropic
33:52
drugs or vasoactive drugs that.
33:55
Might help constrict the blood vessels or encourage the heart to pump more forcefully.
34:01
So they're quite, but they can be quite damaging to kind of your peripheral
34:05
circulation and things, but it's necessary at the time.
34:08
They might develop kidney failure and we have to put them on.
34:11
It's a bit like a long-term dialysis machine, but it's a bit gentler.
34:15
We're using critical care to kind of do the work of their kidneys for them.
34:20
So we kind of take over everything. We sedate them very heavily and they are very well in itself.
34:27
And what that can lead to is your experience as a critical care patient.
34:32
And I'll encourage Steve to chip in with anything that I've missed because obviously
34:36
that real life experience.
34:39
But it can lead to patients having big blocks of missing memories where they've been heavily sedated.
34:45
And actually that can be really traumatic for people. they can have really vivid
34:49
hallucinations that they really firmly at the time believe are happening people
34:54
talk about all sorts of things where they've you know.
35:00
They think they're being held hostage or they're lots of people seem to think
35:04
they're on a boat I'm not sure I don't know whether that's to do with air beds,
35:07
lots you know they have to have really vivid dreams and nightmares,
35:12
they're obviously really can if they're aware enough they're very scared that
35:15
they're going to die so there's there's a massive,
35:20
physiological and psychological impact of critical care and I will just mention
35:24
while I'm on the talk about how tracheostomies are used in critical care because
35:28
I think that might be interesting to to some of your practitioners so,
35:33
where a patient is on ventilatory support we put a breathing tube down and take
35:38
over the breathing and sometimes they'll get well enough quick enough that we
35:41
can take that breathing tube out and they can breathe on their own themselves.
35:44
But where they've been that unwell from a respiratory perspective,
35:48
sometimes we'll use a tracheostomy. And what that allows us to do is to wake the patient up.
35:53
Because you can't wake someone up while they've got a tube stuck through their
35:57
mouth, but they can have the tracheostomy and they'll be awake with the tracheostomy
35:59
and they can still be on the ventilator.
36:01
And that allows us to very slowly wean down that respiratory support as they
36:06
gradually build up their strength again.
36:09
So that is something that critical care patients might go through.
36:12
So that's just a little bit of the flavour. I mean, you could talk for hours on end just about that.
36:19
So then we talk about post-intensive care syndrome. So what impact does that
36:24
have? So I'll make it very clear, I'm not an expert in rehabilitation after
36:28
critical care, certainly and particularly not in the long term.
36:33
My focus is more around that transition from critical care to the ward and that
36:37
kind of immediate impact.
36:39
But I can hopefully give you some kind of general insights. So physically,
36:43
muscle weakness is a really big issue that will be really relevant to your clinicians.
36:48
So we call it ITU acquired weakness.
36:51
And I always think when I explain to it, people, if you've ever,
36:54
which I'm sure you have, because this is a profession you're in,
36:57
when you see somebody who's broken their leg and they've had a plaster cast
36:59
on, no, we don't use plaster cast as much as we used to.
37:03
These days, but they've had a plaster cast on and you take it off and then you
37:05
compare one leg to the other leg and you can visually see that significant muscle wasting.
37:12
Well, if you imagine a patient who's been in ITU in bed for a significant period
37:16
of time, but we do try and get them mobilising as much as we can to kind of
37:19
keep, preserve that muscle.
37:21
But despite our best efforts, they might have had a significant period where
37:25
they're not using their muscles at all.
37:27
So you've got that same muscle wasting across the whole body and that's the
37:31
muscles that you can see and it's also the muscles that you can't see.
37:34
So for example, where we've taken over their breathing and they've been on a
37:38
ventilator, they've gone from using their respiratory muscles to breathe to
37:42
being on a ventilator and we are pushing the air or the oxygen in
37:46
and actually get wasting of their respiratory muscles.
37:49
And you can't see that in a patient. But so if you think about that widespread
37:53
muscle wastage and we do a lot of things in ITU to prevent that.
37:57
For example, when somebody's got a trachea and we're weaning them off that support,
38:00
we'll start getting them out
38:02
of bed and and doing things to to preserve that as much as possible but,
38:06
um even with that so that's a really big thing that can then they can have really
38:11
severe fatigue so even just the most basic thing can make them absolutely exhausted.
38:17
And we do a lot of education for nurses on the ward trying to help people understand
38:21
this because they might sit there in the bed when they've gone to a general
38:23
ward looking fine but actually just the motion of having to pick up their own cup and
38:29
get themselves a drink is really, really hard for them because of that muscle
38:33
weakness and just the tiredness.
38:35
And they might experience chronic pain, either generally related to their kind
38:39
of critical care condition.
38:41
Interventions, or it might be specific to the disease process that they've had.
38:46
Sleep disturbances, so that links between the kind of physical and the psychological,
38:51
are really, really common. So, difficult to see when they lose their normal
38:55
circadian rhythm because, you know, they've been sedated for a long while.
38:58
We don't have a lot of windows in ITU. I don't think most ITUs do.
39:02
So, they get completely out of rhythm with that.
39:04
And then cognitive problems. So, post-intensive care syndrome is split into
39:08
physical, cognitive, and psychological.
39:10
So, cognitive can be issues with memory, issues with attention span,
39:15
concentration, and any kind of executive functions like organising,
39:20
planning can be really, really difficult and then feed into that fatigue.
39:24
And it takes a lot of work to kind of do basic tasks.
39:28
And then the psychological impact can be absolutely massive.
39:32
So anxiety, depression can be really significant after critical care.
39:38
Some people can go on to develop post-traumatic stress syndrome disorder after
39:44
critical care admission.
39:45
And that's not all patients. And I don't say that because we have got a clinical
39:50
psychologist who works in our intensive care unit and they do a lot of work
39:54
to obviously prevent that and hopefully by talking about things,
39:57
working through things.
39:58
But some groups of people will go on to develop that.
40:02
Sleep disturbances, panic attacks can, can happen after because actually people.
40:10
There's many different things that can impact that.
40:14
So directly, that experience of critical care is very, very traumatic.
40:19
Then also they can be adjusting to, you know, they might have been a perfectly fit and well,
40:25
person before, you know, thinking about your kind of perhaps some of your key
40:29
clients, you know, they might have been a really fit sports person who is used
40:33
to being really independent and really strong.
40:35
And suddenly now that's all been kind of stripped away from them and they might
40:40
have you know physical disabilities or deficits after that
40:43
and that is a massive kind of life change for them so psychologically that can
40:48
be enormously difficult,
40:51
and then there can be kind of so that's the kind of general overarching post-intensive
40:55
care syndrome and then there can be things that are specific to what they've
40:59
come in with so if they've come in with a respiratory infection that they might,
41:04
have longer-term damage to their lungs from the inflammation.
41:08
There might be a patient who's had a cardiac arrest and now they've got really
41:12
big problems with their memory, which can go on to last for years or be a permanent change. So,
41:19
It's a massive, you know, it's a massive life change for those patients,
41:22
but it's very individual to the specific patient and their journey.
41:29
That's fascinating. And it's such a massive insight into how it's not just all
41:35
the physical. I mean, it's amazing.
41:39
You explained it so well with the idea of a leg and a cast or something like
41:43
a thigh and you can see the atrophy.
41:45
And but when it's talking about the muscles internal muscles and that then you
41:49
can't see it so that just and and there's a tendency to think oh again they're
41:53
not making an effort what's going on but it's not just the physical but then
41:57
you went on and talked about the cognitive as well and the psychological which is,
42:00
again we talk about so much on on the show especially with kind of like moving
42:05
away from structure to the biopsychosocial and all that sort of stuff so fits in so well,
42:09
and i guess all of these areas although this is when so the pics is when symptoms
42:15
are getting worse and there's like a relapse and and,
42:18
but I guess all of these symptoms can persist maybe not to such a big degree
42:23
just with somebody who's been through this and lived experience of sepsis and
42:26
they're still going to have maybe
42:28
that difference in cognitive processing and and depending on their everyday
42:32
life and I suppose it can go up and down it's not going to be just,
42:35
you know it could be depending on other factors that are going on in their lives.
42:38
Yeah I think it I think it's really variable so some patients will come out
42:43
by to you and look like they're really struggling and but have quite a rapid
42:47
improvement other people will will,
42:50
stay at the same level for a you know extended period of time and and really
42:54
struggle and other people kind of go up and down it's really,
42:58
very individual to the patient and it's really about just listening to them
43:02
and what their story is and their journey and actually.
43:07
I think there's a lot to be said for people having the opportunity to talk about
43:12
it and just listening to them. And actually that in itself, particularly in
43:15
terms of some of the psychological impacts, can really help.
43:20
For example people who are able to reason through and talk about the strange
43:26
dreams that they had and the hallucinations actually,
43:29
the ones who are able to reason that through and say no actually I can recognize
43:33
now that that was a hallucination that didn't really happen psychologically
43:38
will do better than the ones who get really stuck in that,
43:44
thought process that that really happened and really struggle to kind of reason
43:49
out that actually that you know that probably didn't really happen so actually,
43:54
just giving people a lot of opportunity to talk and that's a lot of what my team do so,
43:59
when the patients arrive in the world we see everybody the day after they're
44:02
discharged regardless of how long they've been in critical care,
44:05
and part of that is physically checking up on them because they you know sometimes they can be
44:11
they're vulnerable if you've got if you've got muscle weakness you're going
44:14
to be more vulnerable to picking up another infection getting ill again so we're
44:18
physically checking up on them but obviously giving them that opportunity to
44:21
talk through their experience,
44:24
is really really important.
44:25
And that can persist for a long
44:27
time I think it's also important to emphasize the impact on the family,
44:33
and their journey can be extremely traumatic as well they've obviously watched
44:39
their loved one often nearly die they They can be very traumatized and their
44:44
experience can be different.
44:47
And sometimes I think the experience of the patient and the family,
44:54
it can be difficult for them to connect with one another sometimes over that.
44:57
Because actually the, you know, I'm genuinely saying perhaps the family are
45:03
massively thankful. Oh, you've survived. I thought you were going to die and
45:07
you survived. are so scared, and now you're getting well again.
45:13
Whereas that survivor themselves is maybe only able to, they might not be feeling
45:20
thankful because they've survived.
45:23
They're thinking, oh my goodness, you know, my whole life has changed.
45:27
I can't do things, you know, I feel scared, I feel traumatized.
45:30
So actually there can be, I think it is important to recognize the impact on the family as well.
45:37
That sometimes they're not always in the same place as one another and it can
45:42
be difficult to kind of bring those things together.
45:45
Yeah, that's really interesting. Yeah, a total mismatch between what they're
45:49
feeling and, yeah, the secret to poor communication then and things getting desperate.
45:56
Yeah, amazing. Thank you, Alan. That's incredible. Steve, talking of lived experience,
45:58
Steve has come back and said, every day is a school day.
46:02
A professor said to me, I believe that passionately as a therapist,
46:05
and that is one thing I saw in the ITU.
46:08
Somehow I spent 18 days in the ITU, yet I had some very strange dreams.
46:13
And he goes on to say, pain, MSK pain being shattered very quickly and sleep issues.
46:19
Alan is so right from being very fit, sepsis major surgery this can destroy
46:23
all the folks do a fantastic job in the hospital one nurse said life gets better
46:26
every day when you open your eyes if,
46:30
yeah and it's just that like yeah that very slow,
46:35
gradual recovery and those and i think that's probably maybe what's useful for
46:40
for you know the practitioners listening to this,
46:44
podcast it's that setting those little goals once again i'm not i'm not an expert
46:48
in rehabilitation many of your listeners know a lot more about that than me,
46:53
but what i've kind of learned from listening to patients is it's it's focusing
46:56
on those little goals like one little thing at a time and gradually,
47:01
building it up because and that goal might be something,
47:05
very very simple,
47:08
so some of the things we do in hospital like the first goal might just be sitting
47:10
on the edge of the bed and just holding your weight up on the edge of the bed
47:15
for a period of your time might be one of the first things that you do or you
47:19
know it might just be as simple as feeding yourself and getting you.
47:23
You know getting your muscles moving a little bit so those little goals and
47:26
then gradually building up and then sometimes accepting that then then will
47:30
be a little bit of setback and gradually so that I think for your,
47:35
your listeners if they come across this in practice will be what's really important
47:39
so listening to where that patient is now and what are a kind of realistic small
47:44
small goals that we can look for.
47:46
And I guess thinking of our listeners who hopefully now with the information,
47:52
you've given, I've got more confidence if someone does come in and they see
47:56
that they are recovering from this kind of experience, they can help them.
48:00
I mean, starting off with the physical, I guess it's classic kind of loading really.
48:04
You're looking at that Goldilocks zone where it's not too little, not too much.
48:07
But with this knowledge then, you
48:09
can help guide the patient who might be trying to do too much too soon.
48:13
I guess there's some people like that and other people who've got a little bit
48:15
of kind of kinesophobia or just phobia of damaging themselves even more.
48:19
So it's just working out who's in front of you and guiding absolutely and that'll
48:23
be as you say that's spot on it'll be very individual to the patients so some
48:28
patients will really struggle,
48:31
and want to be doing everything because you know they want to get back to their
48:33
normal life they want to push things forward but actually,
48:36
by pushing themselves too hard they make more a risk of kind of getting very
48:40
fatigued and causing setbacks so it's about helping them to kind of set the
48:47
smaller goals that can then help them achieve those big goals.
48:50
And I can, you know, as a kind of keen sports person myself.
48:56
I can imagine that frustration from going from being able to do everything and
49:00
suddenly not be able to do everything.
49:02
But then there will be other people who are absolutely terrified of doing anything.
49:06
So the ones that come to mind for me are might be the ones who've had a very
49:12
sudden, you know, they might have collapsed.
49:15
You know we've had people collapse at the gym and have a cardiac arrest and
49:18
yes they have been fortunate enough to survive but now they are absolutely terrified
49:26
to do anything because you know,
49:29
because of what's happened to them so it's very much about listening to where your patient,
49:35
is perhaps just bearing in mind what could be going on under the surface because
49:40
I guess it depends some people will you know,
49:44
talk quite openly about things whereas other people for a variety of reasons
49:48
will be more reluctant to talk about things.
49:53
But listening to them and, you know, helping them to set those goals that are appropriate for them.
50:02
I think it's always interesting with, because we talk about loading with strength
50:05
and conditioning coaches and that, but I think part of loading can be communication
50:09
and listening to somebody is starting off on that rehab ladder of loading where
50:13
you're giving them confidence, allowing them to
50:15
hear themselves, you know, because they might not have had a chance.
50:18
People can talk to themselves and I do it all the time. It doesn't really help
50:20
that much. Sometimes it does, but when you've got someone else in the room and
50:24
they're listening to you not giving advice but they're just there and they might
50:27
be doing I mean if you're trained in it or if you had a,
50:30
maybe if you've done a great communication course check my website then you
50:33
might know just now and again to do a few summaries or just reflective listening
50:37
just to show you are engaged but not giving advice,
50:40
and that person could walk away after an hour massage and just have sorted out
50:44
so much stuff just from having a chance to hear their own thoughts,
50:48
coming out of their mouth you know and they might not have had that before because
50:51
they might not have wanted to tell anybody before we're so big on the show of of trying to,
50:56
empower massage therapists in particular,
50:59
of the power you have not power is the wrong word of how much you can help someone
51:03
but just make them feel relaxed during a massage and let them talk let them
51:07
speak their mind and stuff it's it's a gift isn't it if you have that yeah yeah
51:11
i completely agree that can actually be.
51:15
Yeah be completely life-changing and especially when people have been through
51:19
these really traumatic experiences just having that that time,
51:24
i wanted to check i think it's important as well because if they if if,
51:28
as well as doing that and they're not soft skills people don't don't call them
51:32
soft skills anymore so it's probably one of the most missed parts of rehab is
51:35
that is the communication and helping someone find the motivation and the reason
51:38
to do it rather than just telling them,
51:40
but when people do move on to the actual physical loading what we should mention
51:44
Are there any particular red flags where maybe you are doing too much?
51:49
Yeah, so there's a few things you could look out for kind of physically,
51:53
I guess, if they're really significantly
51:56
breathless and they're really struggling to kind of get there.
51:59
I would, you know, I would certainly suggest that they go and get that checked
52:03
out with their GP if there's any kind of oxygen desaturations.
52:07
Saturations but i don't know whether that would always be something that some
52:11
people might have access to,
52:12
but that would link in with severe breathlessness anyway so that might be what's
52:16
happening even if you can't see the oxygen saturations if they're feeling really
52:20
breathless that could be what's going on in the background any kind of what's called syncope so any,
52:24
episodes where they're they're kind of fainting or losing consciousness,
52:29
sorry to butt in but could that happen is that something you should be aware
52:32
of they're training for the kind
52:34
of first time and maybe if they've wanted to do a little bit too much?
52:39
I wouldn't say that's a normal finding, which I guess is why you'd think of
52:43
it as a red flag. You wouldn't expect to see that and it could indicate that
52:46
something else is going on.
52:48
As I said, it's not really my area of expertise specifically related to this,
52:52
but I think you'd always want to get that checked out. You wouldn't be expecting
52:56
to find that. So they should be getting that checked out by a medic.
53:00
Kind of worsening fatigue where things are getting kind of worse over time.
53:05
And I think the really important thing to emphasise is any kind of psychological distress.
53:12
And that's as big a part of it as the physical. So where people don't.
53:19
Aren't able to talk or process things that can be a really big concern,
53:26
and just making sure that you know unfortunately services for people to support
53:32
people after critical care are variable we as a hospital run a follow-up clinic
53:36
so they'll get invited back and,
53:39
they'll do an in-person walk around the unit which can be really helpful for
53:42
them for them to process those memories and and things so there are services
53:48
out there so it might be that they can get in contact with the critical care
53:51
unit where they were a patient,
53:54
or obviously through their gp they can access support,
53:58
or there is if one of our listeners is working and they're thanks to you they're
54:02
thinking i can help this person i'm going to worry about and i'm going to just
54:05
collapse in front of me if i just make them do one thing but i suppose again
54:09
it's worth reaching out getting in contact with their GP.
54:13
Although it's not it wouldn't be like a contraindication but it'd be good practice
54:16
to get in touch with them just say this is what I want to do can you help me
54:19
can we work together sort of thing yeah I mean I'm a massive fan of that kind
54:23
of multidisciplinary working and you know everybody,
54:27
has got different insights and different things to to kind of so actually by pulling that,
54:34
different kind of knowledge base together then actually that can lead to really
54:38
good holistic care so yeah absolutely kind of seeking what's appropriate what
54:43
can help or for example somebody who's had something like,
54:48
a cardiac event that's led to their critical care admission they,
54:52
most hospitals or i might hopefully it's all hospitals have like a cardiac rehab
54:56
program where they will bring them in for a little bit supervised exercise on
55:00
a treadmill where they can monitor
55:01
things like their oxygen saturations so that kind of link in to help
55:05
be that bridge between moving them on from that that could be a really useful
55:10
kind of way that you could link through as well so,
55:14
yeah putting that all together is really good to.
55:17
Great stuff. Look at that. 8.59. That's been amazing, Lannis.
55:21
Thank you so much for sharing your experience. Yeah.
55:24
I feel empowered. I'm not even a clinical practitioner anymore.
55:28
It's always funny. Gary, Gary's probably sitting there after shows like this,
55:31
Gary, the founder of the STS thinking, I really want to open up clinic again.
55:34
I really want to help these people, but that's the way it should be because
55:37
we're empowered by people like you sharing, you know, how we can help and the
55:41
positivity and that and the need for it. So Yeah, amazing. Thank you so much.
55:46
We mentioned sepsistrust.org. So that's a great place for information,
55:50
I guess. Is there any other sources of info if people are interested in?
55:53
So there's a charity called ICU Steps. So if you search for that,
55:57
you should be able to find it.
55:58
And that's a real source of information for patients, their families,
56:02
but also for any clinicians to find out a bit more about critical care.
56:06
So that's somewhere that you yourselves could get information from,
56:10
but also a place to signpost patients or relatives to, to, to get information,
56:17
that can kind of support them because it's,
56:20
Most people who are in this situation are searching for that information and
56:26
navigating their way through a complex journey. So they are there to support.
56:30
We'll make sure the most of those go into the show notes. Are you,
56:34
you probably haven't got time, you're too busy helping people,
56:36
but do you blog or anything or put anything online? Are you involved in sharing information?
56:41
Not, no, not particularly related to, you know, my clinical work.
56:46
Sounds like there's something else going on. You've got a running blog, haven't you?
56:50
I i i have got an etsy store where i sell crocheted things so we'll make sure
56:54
that alanna forest's etsy store goes a few calisthenics videos online but really okay,
57:03
yeah so yeah best places then are um yeah sepsis trust or good i see step store
57:07
unless you're after any um is that not on the high street as well or just etsy
57:11
no just etsy i've only just i've only got two things yeah i've only just restarted that because,
57:15
young children and all that i used to have a lot more time but.
57:20
Gary benson has jumped in here i didn't see this comment before gary benson
57:23
founder of the sta says such an interesting chat this evening gives us an understanding
57:26
of what goes on in emergency medicine when someone is having a bad time with
57:29
their health yeah this is makes you want to go back and cleaning doesn't it
57:31
gary i know that's what's going through your head,
57:33
don't do it you're enough going on all those people you have to talk to every
57:36
day but anyway right brilliant time is escaping us thank you everybody who joined
57:41
us live thank you again steve for sharing your experience and helping put this
57:44
together i mean It's such a great example of people coming together and Steve's an STA member.
57:48
Obviously, Steve's a great point of contact if you are an STA member to reach out.
57:52
But also, yeah, you've got those websites. If people want to...
57:58
Know more about you and what you do is linkedin are you on linkedin or anything
58:01
like that or linkedin i'm not i don't think healthcare you haven't got time
58:05
have you well i think i think working in a big big hospital like i do we don't,
58:11
necessarily tend to use those resources like that because,
58:14
i you know i've kind of worked here for my whole career and worked through that
58:19
so i don't you're very much in education there isn't that's part of your role
58:23
as well yeah but it's very much which I guess it's kind of.
58:26
Quite inward facing.
58:28
I've got the whole hospital to educate. So I don't do that much.
58:31
But maybe this has inspired me this evening because I was very nervous about
58:34
doing it, but I've actually really enjoyed it. Hopefully, wouldn't it?
58:36
That'd be great. That'd be cool.
58:37
Well, thank you so much for your time. You never know. Amazing.
58:39
Really, really, really amazing.
58:41
Cecily as well, the great questioner, as always, has said another cracking episode.
58:45
Has been a cracking episode.
58:47
So thank you, yes, Alana Forrester. And everyone who joined us live,
58:50
thank you very much for listening.
58:51
We always do these live because we always get the feedback that although we
58:54
download the podcast, we love the fact it's live and it just makes a difference.
58:58
So we will continue doing it.
59:00
I don't know whether it'll be for another 302 shows. Who knows?
59:02
We're all getting older, but we'll try.
59:05
Next week on the show, we are going to begin our countdown to Therapy Show 2026,
59:11
formerly known as Therapy Expo, which is happening once again at the NEC Birmingham
59:15
on the November 25th and 26th.
59:17
And it's only eight weeks away. So we're going to start that countdown.
59:20
I'm going to be joined by the marvellous Mike James, who a lot of you know as the endurance physio.
59:23
He's going to be coming on the show to share information on what he's presenting
59:26
this year at Therapy Show, as well as what he is looking forward to.
59:29
So that will be a live recording as always next tuesday october the 8th uk time,
59:34
on the sports soviet association youtube channel or facebook page but until
59:40
then just thank you once again alana forrester for your time thank you much appreciated,
59:45
and yeah thanks everyone who joined us thank you to the listener if you listen
59:48
to the podcast and you've enjoyed the show a couple of things before i leave
59:51
you one just share it with somebody don't keep it yourself come on now let's
59:54
help the good of the whole industry and two
59:57
a great way of sharing it indirectly is just leaving a rating or review It will
1:00:01
literally just appear high in Google searches when someone puts sepsis in.
1:00:05
And that's how we just get the good word of our guests like Alana out there.
1:00:08
So leave a rating or review. Take the time. I know eight seconds is like everything
1:00:12
these days, but that's all it'll take, especially if you're on iPhone.
1:00:15
Leave a little rating and review there.
1:00:17
Brilliant. Thanks, people. Hopefully speak again soon. Until the next time,
1:00:20
take care of yourselves and each other.