SNF Side Hustle

I've been working my way through Eric Cressey's older blog articles (as well as a collaboration he did with Mike Reinold called Optimal Shoulder Performance) and came across this post written in 2005 in which he debunks weightlifting myths.  In the post Eric recalls: "Dr. Jeff Anderson, Director of Sports Medicine at the University of Connecticut, said to me once: 'If you live your life the right way, you'll likely find yourself in an orthopedist's office at some point. If you live it the wrong way, you'll likely end up in cardiologist's office instead.'"  "Doc A" unfortunately passed away last year, but he was a great physician and all-around nice guy.  Reading his quote reminded me of my experience observing this in real life.


When I first graduated from PT School, alongside my job in outpatient orthopedics, I also worked as a per diem PT in a skilled nursing facility (SNF).  (#sidehustle). I was mostly scheduled to evaluate patients who arrived to the facility on a Friday and, because of insurance mandates, needed a weekend evaluation for admission. I regularly observed Dr. Anderson's statement, but it is only now, reading the quote, that it seems so much more simplified and realistic.  A day at the SNF would have a patient schedule of about six patients, an hour to 90 minutes for each one, often looking like this: 

1) Frail lady with osteoporosis, 82 years old, who fell and broke her hip.  Many of these patients would also present with a urinary tract infection and confusion. (primarily orthopedics)
2) Type II diabetic, obese, sedentary man in his 60's who just had a total knee replacement (orthopedics with cardiology risk factors/co-morbidities).
3) Man, 76 years old, life-long smoker, worked a manual labor job for his whole life, who recently had a stroke or a heart attack. (cardiology or neurology)
4) Younger woman, early 20's, detoxing from drug overdose. (could fall under several categories - I'm not exaggerating, here.  I really did see a lot of patients who were either detoxing or recovering from an overdose or had an accident that involved drugs or alcohol.  The first time I saw track marks left an impression.)
5) Overweight woman, 55, using supplemental oxygen with debilitating back pain and depression. (orthopedics with cardiology and psychological co-morbidities)
6) Homeless person who is malnourished and recovering from pneumonia. (also a variety of categories)

If the patient had been newly admitted to the facility, they may not have been out of bed for several days.  This 2007 paper outlines the effects of bed rest on the cardiovascular system, the muscular system, and the skeletal system but a basic summary is that everything gets worse when you stay in bed for too long.  What the paper doesn't explore is how self aware people are when they have been on bed rest.  These patients had frequently walked themselves into a hospital or were brought via ambulance within the past two weeks.  They sometimes have lost a little bit of sense of time, but they were able to walk not too long ago, so of course they can stand and walk.  I'd estimate about 25% ultimately weren't able to hold up their weight requiring me to hold them up when they got lightheaded from orthostatic hypotension or when their knees buckled from disuse of their quads.  Want to know another awesome benefit of standing and getting out of bed for the first time in several days?  The gravitational effect on your gastrointestinal tract! That's right, many of these patients would stand for the first time in several days and take a few steps and would need to be at the commode in under 14 seconds.  I was pooped on 1 out of every 2 shifts I worked. 

I would finish my day, exhausted from lifting people to help them transfer in and out of bed and onto the commode.  More than physical exhaustion, I would be a wreck from the intense emotional drain of trying to motivate people suffering from pain and limited endurance to go for walks and exercise.   This type of work really got to me.  The gains were small from day to day and I was only there once or twice a month so I never got to see the patients improve.  I had only worked there for a few months when I found myself finishing my day, sitting in my car, unable to get going because I was too busy wondering what the end of my life could possibly look like. 

According to the CDC, heart disease was the #1 cause of death in the USA in 2015 accounting for 23.4% of deaths that year.  When broken down by age, unintentional injuries/accidents was the most common cause of death in people younger than age 45.  This includes a fall as a cause of injury in addition to numerous non-orthopedic accidents such as drowning or smoke inhalation.  I don't think Doc A was referring to death in his conversation to Eric, but that's how my brain got here, and I like the idea that if you use your body so much that you develop orthopedic issues, you could be preventing some of the co-morbidities associated with cardiovascular pathology. 

The world really isn't so black-and-white and these outcomes aren't so dichotomous.  There are very active people running on a regular basis, who die unexpectedly from a cardiac event.  Can you lead a lifestyle that decreases your risk of cardiovascular pathology?  Yes, and it doesn't inherently mean a future of orthopedic issues is coming your way.  Can you take good care of your body with exercise and prevent arthritis/bodily breakdown?  Yes and it doesn't dictate you're going to have a stroke.  What does this mean?  It means try to eat a healthy diet and exercise regularly because in the end, we only get one life to live and one body to use, so we should make the best of it!