Rehabilitation of Critically Ill COVID-19 Survivors

Prakash Chandran (Host): This advanced podcast was recorded on April 15, 2021. Advancing health. Personalizing care. At Memorial Hermann, this is our mission.

This podcast shares the science and stories behind those efforts. Today, we're interviewing Dr. Gerard Francisco. He's the Professor and Chair of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth Houston and Chief Medical Officer at TIRR Memorial Hermann in Houston. We'll be discussing how TIRR Memorial Hermann, a national leader in medical rehabilitation and research, is caring for patients post-COVID-19. This is Advance, the podcast series from Memorial Hermann. My name is Prakash Chandran. So, first of all, Dr. Francisco, it's great to have you here today. I'd love to get started by understanding a little bit more around the types of challenges patients are experiencing post- COVID-19.

Gerard Francisco, MD (Guest): Well, Prakash, thank you so much for having me here. And for speaking to me about this rapidly emerging topic of the long-term effects of COVID-19. Keep in mind, I think it's important for the purpose of context, that it's only been a little over a year since the word COVID entered our lexicon. So, what we are going to discuss today are things that we know so far. And everyone should keep in mind that they really have to be aware that in due time, we will gain new knowledge about the long-term effects of COVID. So, what we know so far, is that many people who had that infection, no matter how mild the COVID infection is, may be at risk of developing long-term complications in practically every organ system in the body.

I think what has been established with COVID, is that it's not only the infection from the virus itself, but also the body's response. And, I should say the entire body's response in the form of inflammation to this COVID infection, as such, practically every organ system can be affected. And that is why people who have the long-term effects of COVID may complain of different symptoms. Some may have only a few, others may have an entire constellation of symptoms. It also appears that the two most common symptoms, as far as we know, are fatigue and difficulty breathing. Now there is a subset of people who have complained of loss of memory and thinking.

So, the term brain fog has been used quite popularly. And I think that it's a very descriptive term of what the person experiences. These are people who may not be thinking clearly. And they are aware that they're thinking quite differently from the way they did before they had the COVID infection. In addition to that, they can have problems with sleep, and if you're not going to get enough sleep, you're not going to be functioning well the following day. So, whatever memory loss or fatigue that you already have as part of the long COVID, which by the way, has a new term now which I will go through in a little bit. The problems with sleep may even aggravate those existing symptoms secondary to the COVID infection.

Host: Yeah. I think that people are aware of the common symptoms people go through when they have COVID, like the shortness of breath, the loss of taste and smell. But there's this cohort of people, as you're mentioning, that have these ongoing symptoms afterwards. What do you call this group of people that's affected?

Dr. Francisco: There is now a new term for this condition. It's called the Post-Acute COVID-19 Syndrome or PACS, P-A-C-S. It's a very generic and general term. However, I think this is a fair, label of this syndrome because the presentation, or the presentations, of different people vary widely. And there are so many symptoms that are obviously because of prior COVID infections, such as difficulty breathing, persistence of the loss of smell and loss of taste. But there are others that were not expected. So for example, about a fifth of people with this condition PACS, or previously known as long COVID or long-haul COVID, can complain of hair loss, significant hair loss, or attention disorder. These are things that you never even thought would be associated with an infection which is transmitted through their respiratory system.

Host: Wow. Yeah. So, I was just going to ask what the difference between PACS and a long hauler is, but you're saying PACS is the new term for it. Is that correct?

Dr. Francisco: It is a new term. I personally, I like the term because it sounds more medical than long COVID. And I'm hoping that a more medical-sounding syndrome or terminology, will call more attention to this constellation of symptoms. Hopefully, it will grab the attention of clinician scientists so that they can do more research as to how this happens. So, that in the future, we might be able to find ways how to prevent that from happening when someone gets COVID. And for the general public, I hope that it will be taken more seriously when it's actually called the syndrome. It's more medical than just saying long-haul COVID.

Host: So, let's talk a little bit about how TIRR Memorial Hermann is addressing the needs of these patients.

Dr. Francisco: Sure. So, when the pandemic started last year, many of our colleagues around the country were pulled to work in acute care hospitals. So, they're rehabilitation physicians and clinicians who now have to work in the ICUs. And we got a lot of information from them because they noticed that some of the patients, as they recover, were displaying symptoms that we have seen in other rehabilitation populations. In particular, those who've had a stroke or a traumatic brain injury. It seems like some of the complaints that they have regarding brain fog is quite similar to the symptoms that have been reported by people with brain injury, especially those with mild brain injuries, which is persistent loss of memory, difficulty with decision-making and with thinking.

And if you recall early on, there were reports about a unexpectedly high incidence of stroke in previously healthy people who were infected with COVID, even those who had mild COVID infections. So, it got us to thinking that perhaps rehab has a role. We are the ones with the expertise in managing many of the long-term complications of stroke and brain injury. So, we can generalize the knowledge and skills that we have developed in our field over the last several decades into helping people experiencing the same symptoms, albeit from a different cause this time around. It is COVID.

I also mentioned that fatigue is one of the most common symptoms in PACS or in Post-Acute COVID Syndrome. And we do have a lot of patients that we admit who are de-conditioned, who have difficulty with endurance. Many of us also have experience in dealing with rehabilitation patients with difficulty breathing, those with respiratory symptoms. So, we take all that knowledge together when we try to rehabilitate someone who's recovering from COVID with symptoms similar to those that we have seen in our prior patient populations.

Host: So, maybe talk a little bit about how you were able to create the program so quickly and the makeup of the team. And, I know you alluded to this, but the makeup of the team in place to provide the care.

Dr. Francisco: Well, I think the rehabilitation team composition did not really change. Everyone has a role depending on the type of symptoms or problems that the patient presents with. So, it really did not take a lot of time and a lot of energy. It's just a matter of reframing our treatment, knowing that the person we're treating, does not to have a diagnosis or what I would call a common rehab diagnosis, such as a stroke, spinal cord injury or traumatic brain injury. However, the clinical treatment of those symptoms are really no different from what we had done before. So, it wasn't, it was a seamless transition from treating the traditional rehabilitation population to that of treating a sub-specialized population specifically, those who've had COVID.

Host: Understood. So, who exactly would be a candidate for this program and how would you be admitted?

Dr. Francisco: Sure. So, the patients that we admit run the range of those who were in the ICU for a very long time. There is a condition called Post-ICU Syndrome or critical illness polyneuropathy, that is characterized by weakness and poor endurance, severe loss of muscles or what we call muscle atrophy. These patients also were more likely to have been on a respirator or a ventilator for quite a period of time. So, even the lungs and the respiratory muscles are weak. Some of them had involvement of the heart. So, we tailor the program to the specific needs of a person. There's really not one treatment paradigm for anyone with a diagnosis of Post-COVID Syndrome.

We tailor our treatment based on what the person needs. So, some of the post-COVID patients get admitted to our inpatient unit. And we have a team of rehabilitation physicians called physiatrists, different kinds of therapists, including physical therapists, occupational therapists, and speech and language pathologists. Even neurologic music therapists are involved in taking care of these patients. And of course, let's not forget our nurses and pharmacists and case managers and social workers who help us with the other issues that we deal with, so that we can better transition a person from the ICU to the rehabilitation hospital, back to home and the community.

Host: Yeah, it is amazing that you have such a multidisciplinary team working together to make sure that patients are getting the best and most seamless care possible. So, I'd like to shift topics here. When most of us think about who is impacted by COVID-19, we're probably not thinking about people with disabilities. So, can you talk a little bit about how this demographic has been impacted?

Dr. Francisco: That is an excellent question. I think it's been like a double or triple whammy for people with disabilities. Number one, many of them have chronic medical conditions that can predispose to severe COVID infections. Number two, many people with disabilities, are, to a certain extent, isolated from society either because of their physical inability to be more active in the community, or sometimes it's a problem with cognition, thinking or behavior, and this pandemic even magnified that isolation. A very concrete example is that when the vaccination programs were rolled out, some of these patients were not able to easily access those services. Some of them have issues with transportation.

Some of them had, because of their underlying cognitive problems, did not even know how to go through the process of making an appointment for the vaccination. So, we were anticipating that based on our experience in dealing with people with different disabilities. So, when we finally got many doses of the vaccine and the hospital decided that we should extend this to our patients, we did not wait for them to call, we actually called them. We started with our patients and, some of them the caregivers who are also at risk of getting the severe infection, were considered for vaccination. And the thinking behind that, is that if you have a person who has many disabilities being taken care of by just one other person, it doesn't seem productive if we will vaccinate the person with disabilities, but not the caregiver. Because if that caregiver gets ill, who will take care of our patients, who will take care of those persons with severe disabilities and impairments? Going to an institution such as a nursing home is out of the question because no one would want to be brought to a nursing home last year because of the high incidence of COVID.

So we thought that through this clearly and this is totally in line with how we approach the problem or problems in rehabilitation. We not only have one person, i.e. our patient, but also the people around that person to make sure that they will be well taken care of, given the limitations of resources once someone is at home. In the hospital, we can provide practically all the help that they need. But once they're at home, there may be only one or two people taking care of them.

Host: Just staying on the topic of people that might be adversely impacted by COVID. Let's talk about your background or experience with patients with neurological injuries.

Dr. Francisco: My background is in stroke and brain injury rehabilitation. Following my training in physical medicine and rehabilitation, I sub-specialized in brain injury or brain diseases. So, over the last 25 years, I have been treating people who've had stroke and traumatic brain injury, especially those of the severe varieties. And it is very clear that many of the problems that were challenging to us in this patient population are pretty much the same as what we're seeing in some people who have survived COVID.

Host: So, before we close today, are you able to overview advocacy highlights for us?

Dr. Francisco: So, TIRR Memorial Hermann has been in the community for almost 60 years now. And ever since, it has been one of the strongest advocates for the needs of people with disabilities. We were part of the development of the Americans with Disabilities Act. Lex Frieden, who is still with us here at TIRR Memorial Hermann was one of the people who were influential in the passing of that law. So, we do have the rich history of advocating for people with disabilities. And we have learned a lot during this COVID pandemic. We are used to helping them during hurricanes and other natural disasters that have happened here in Houston. But this time around, this is a new learning experience for us. Fortunately our past experience has helped us continue to advocate for our patients with different kinds of disabilities. We were able to make accommodations. We're able to assist them in getting the services that they need, even during the peak of the pandemic.

And with all this learning, I'm pretty sure there will be new things that we will be developing, so that should another pandemic happen in the future, or should another challenging situation happen, we will be proactive in making sure that the needs of the persons with disabilities will not be interrupted by this conditions. For instance, when we had a recent weather disturbance in Houston, many people lost power. I think there were. It wasn't much of a concern for many of our former patients because they have received some information from us about how to handle situations when there will be a loss of power for a few days.

So, for instance, we advise them on making sure that they have a spare battery that they need for their wheelchairs. For some, it's the battery that they will need for their ventilators at home. So, we were able to give them advice proactively and whatever new knowledge that we have gained during this recent pandemic, I'm pretty sure that that will be rolled into the future versions of this information, and educational materials that we provide our patients.

Host: That really is wonderful Dr. Francisco. The final thing I wanted to ask you today is how has COVID-19 impacted how patients see providers?

Dr. Francisco: So, at the height of the pandemic, we remained open and we were seeing some patients, but I was concerned that there were some patients who are due for a follow-up or certain treatments, who opted not to come to the hospital for fear of contracting COVID during transit or from the hospital itself. There were reports that some people with medical conditions did not call the ambulance or did not want to go through emergency rooms, once again for the reason of or the fear of contracting COVID if they leave the house. Those are valid concerns. So, we had to be creative. We activated our Telehealth plan so that we were able to remain connected with our patients virtually either through the phone or through video visits. I think we have to explore that further. Learning from this past pandemic, medical schools in particular should include Telehealth as part of their curriculum. So, that if these future doctors will encounter and, hopefully they will not have to, but in the event that they encounter another pandemic or another challenging situation, they will be adept in how to continue providing high-quality care to their patients, not in person, but through virtual means.

Host: Well, Dr. Francisco, this has been an extremely insightful conversation. Thank you so much for your time. Do you have any final thoughts you'd like to leave with our audience?

Dr. Francisco: My final thoughts are continue to be safe. The pandemic in some parts of the country is still raging; in other parts of the country, it's improving. But let us not let our guards down. Let's continue to listen to our health officials as to how we can help. How, by working together and then through cooperation, we will be able to finally put a stop to this pandemic.

Host: Very well said, Dr. Francisco, thank you so much for your time today. That's Dr. Gerard Francisco, Professor and Chair of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth Houston and Chief Medical Officer at TIRR Memorial Hermann in Houston. To learn more about rehabilitation for COVID-19 patients, please call 1-800-44rehab or visit If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks for checking out this episode of Advance. My name is Prakash Chandran and we'll talk next time.