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Kali Dayton 0:22
For anyone that works in medicine, you know that culture and habits are hard to change. So what was it like for a seasoned an expert, intensivist and leader, Dr. Peter Murphy, to suddenly hear this new concept of awake and walking ICUs. I’m excited to have him tell you all about it.Hi, Dr. Murphy, thank you so much for coming on the podcast. Can you introduce yourself to our listeners?

Dr. Peter Murphy 1:14
Thank you, Kali. It’s my pleasure. I am Peter Murphy. I’m an intensivist. Approaching now 50 years in practice. I’m old. I’m Assistant Dean and chief and professor of medicine at California northstate University College of Medicine.

Kali Dayton 1:34
Well, I’m honored to have you on the podcast. You have so much to offer the critical care community, almost 50 years of experience that is unfathomable. So you are definitely an expert in the field. And tell us what has as far as delirium, sedation mobility, what has been your career up until recently, in regards to those practices?

Dr. Peter Murphy 1:58
Well, Kaylee, I’ll tell you, I am absolutely burdened. When I look back at my career, because at least 30 to 35 years of that practice, I practice exactly like everyone else in the field. And sadly, like the majority of people are practicing today. And by that, I mean, I basically had a patient come in to the ICU, we had this idea that we had to absolutely keep them comfortable. And that involved absolute sedation. And it’s kind of a if they were fighting the ventilator are sort of were moving. That was sort of our indication that we had not given them enough sedation, and the immediate knee jerk response was to more sedation.

Now, I’ll tell you, for the first sort of 35 years of my life back professional life, that seemed to me, like it was working very well. And in fact, when I saw a patient, leaving my ICU on a gurney, rather than a body bag, I thought, well, this is a real success. I’ve saved someone’s life. And I essentially had no follow up, or essentially no feedback from the majority of patients are for that matter, caregivers later on. And the was new mechanism, essentially, for ICU doctors to get any kind of feedback. And particularly with the work of Dr. Wes Ely, and others, I became, you know, familiar with this post ICU syndrome.

And as I began to read the literature, noting that, you know, 60 to 80% of my successes like the ICU survivors, we’re having an extraordinarily challenging life with anxiety, depression, PTSD, cognitive impairment, physical deconditioning (1). And, in fact, far from a successful outcome. I was actually shocked by really what we were doing. And I began to ask myself, a is there a better way of doing this? And I was sort of slowly beginning to feel that there is a better way, but I hadn’t sort of crystallized that in my mind. And I think as I’ve told you, I’m pretty active cyclist and I listen to podcasts a lot. And you will know the exact time but your first appearance on the ACCRACpodcast (2), and I love Jed Wolpaw who is the presenter there. He’s just fabulous.

And I listen to you. And I’m first of all, initially thinking, “this lady is crazy, because I mean, she’s talking about, you know, having ICU patients in the ICU and not sedated up walking.” But it was exactly kind of the stimulus that I needed to get as I’m listening to you, I could actually understand that you can run an ICU like this, and that, in fact, you’re talking about nurses having a lot less work to do, because they’re now mobilizing patients in their first 24 hours, not after they’ve gained, you know, 12 liters of fluid under two weeks lying around in bed.

So that was as sort of a shocking, eye opening to me. And that was really my stimulus that you know, not alone, can we do a better job, but we missed we must do a better job. And at the same time, I was sort of becoming aware of sort of outcome data for American medicine in the British Medical Journal in May of 2016. Martin Makary, who is one of the docs from Johns Hopkins and a colleague, at publish, that the third leading cause of death is actually medical errors (3).

And that was actually sort of shocking to me. And then on top of that, A, he put a figure to this, which is basically, we’re losing about 250,000 patients a year from medical errors. That’s the equivalent of sort of two large airliners crashing a day. And frankly, there is almost no awareness. And I’ve gotten some surveys kind of in preparation for our little discussion here with many of my colleagues, and almost no one is aware of that. And because of that lack of awareness, no one is doing anything about it. And, you know, we have two major problems as I see it in medicine. One is we are very slow to access kind of new data.

And, you know, I always go back to my friend Dr. Semmelweis in Budapest in the 1840s, when he dramatically showed that hand washing would dramatically cut death in women with peripheral fever. He was immediately booted out of Budapest to Vienna because he was crazy. And in fact, Koch of Koch’s postulates, who was one of our absolute heroes in TB, and also thought he was crazy, and in fact, Dr. Semmelweis ended up his days in a mental asylum being essentially a tie down and guide of cellulitis age 47(4).

And you think well, we can take what that that’s the old days, well, Barry Marshall in in a Australia in the early 80s. He was convinced that in fact, peptic ulcer disease was due to a bacterial infection. And of course, all the smart doctors like myself, knew it was actually due to acid and stress. And in fact, when I was an intern in a large university hospital, we do five or six five big otomies in pyeloplasty every week to cut the acid and gun and prevent ulcers. He got so much pushback that he drank a beaker of H. Pylori, and himself gastro scoped four times show that he got an announcer and in 2006, he got the Nobel Prize (5).

But frankly, I mean, all he got was pushback, and, you know, and out of hesitancy and Foresman in the, like, early 30’s in Germany. He put a catheter into his vein in the arm showed it could go into the heart, and immediately people found out about this, they kicked them out of cardiovascular disease he had to go and become your urologist. And then in about 1980, he won the Nobel Prize for cardiac catheterization(6).

In the early 30s, 1930s, there was actually some equipoise, about whether paralytics cause analgesia. In fact, it was relatively common in the 1930s, to do surgery with paralytics alone. Now, I don’t even want to contemplate what that was like. But this, Dr. Smith out of Utah decided, you know, we better confirm this, that this really is true. And so he had three of his colleagues, give him increasing doses of kewra. And after about 32 minutes, and I’m shocked at 30… 32 minutes, but after 32 minutes, they were able to notice that this guy is not breathing, they intubated him. And then it took four hours before they could extubate. He published an article in anesthesiology in January 1947, saying, “You know, curarine has no analgesic effects. And he pretty much stopped that practice there.(7)

And then, but when all these things that he showed you is that there is an incredible sort of resistance to a, you know, changing the status quo. And if we’re dealing with the kind of numbers that I talked about earlier, deaths, and injuries are even dramatically more profound, we may have up to, you know, four and a half to 5 million people, according to up to date, who survived the ICU experience. And we probably have a 60 to 70% of those who are having anxiety, depression, PTSD, cognitive impairment, physical deconditioning. And that is almost getting zero attention. So to me, and that requires us to say, “Guys, you knew we’re not doing the job that I think all of us as physicians and clinicians think we’re doing. And certainly we’re not doing the job that we shouldn’t be doing.”

Kali Dayton 12:27
The study that you refer to with the medical errors, this harm, even the death from inappropriate sedation practices, were not included in that. That’s not considered “medical error”, so we’re not clearly measuring this.

Dr. Peter Murphy 12:42
Yeah, in fact, if you look at up to date, they actually would suggest that that the debts may actually be twice to 50. Sidney Wolfe, about 25 years ago, maybe 20. And the Institute of Medicine said at that time, that we were causing 100,000 deaths(8). He got incredible pushback, but you knew no one ever disproved any of the things he said, and I suspect that up to date, is actually much more likely to be correct. And in fact, we may be resulting in a half a million deaths.

Now, the other thing that is out there is that there is an incredible lack of sort of utilization of using the best practices we know today for optimizing outcome. In fact, in critical care medicine in October 2008, they went to eight University Hospitals in Germany. I love it with Germany, because we think of the Germans, you know, as being kind of compliant and obsessive compulsive and like, as an Irish man, I can say I went to Ireland, “hey, they don’t follow anything.”

But anyway, they went to the States intensivists, “How often are you wouldn’t call a using or employing all the good practices we know?”- And they essentially said, “Oh, we do that most of the time, like 95, you know, pretty much all the time.” Well, sadly, it was less than 30%. So you knew even back then, and we’re talking about head of bed and lung volume ventilation and DVT prophylaxis, all of the things that we know today would make a difference.

Now, let me tell you, that’s not just the Germans that are doing that. And we have known for probably now goes to 20 years, maybe longer, that lung protective ventilation is dramatically effective in ARDS, probably 16 to 20% mortality benefit. We have known that proning from the proceeds of study in 2013 is also incredibly effective. You know, this is absolutely, if you were to go to any conference that wouldn’t even be discussion on do these things work, right?

The problem is that, first of all, and there’s two nice studies looking at this, that one was in JAMA 2016, volume 315 (10). And another was in chest 2021, volume 160(11), where they look at practices in the US. And what they’re basically found is that only about 60% of the patients who have actually ARDS by the Berlin definition, are actually diagnosed at that, given that title. And then of that 60%, only, only about half of those are actually given lung protective ventilation.

So if you were to live with a big figure, you’re seeing almost half are not recognized, and a little more than half are giving the treatment. So if you look at all the ARDS patients, probably only about 40% are getting treatment that we know today is life saving, and the figures are even even worse. For pruning. I mean, proning is looked on now as being a very difficult very challenging, obviously, with COVID. A lot more places did prone.

But I work in electronic ICU, where I monitor about 60 and 80, in hospitals, and most of those smaller hospitals don’t do proning. So you knew, even today, where we know, these incredible, life saving interventions are out there. You know, we were just not not incorporating those practice.

Now, you started off with with delirium. And delirium is incredibly important, you know, both in the acute management of the patient, and I’ll talk a little later about the dramatic, long term outcomes. But you knew, we know when, in fact, from Wes Ely and others and many of your podcasts, we know exactly what to do to reduce and prevent delirium. But it’s almost universally and not being done. I think I told you, when I became a kind of a disciple of yours, I want to just see, you know, a is there. Is this a week and walking ICU? Like, is this a myth? Or is this really something that’s out there?

Kali Dayton 17:52
Right away? And you said, “Hi, I just heard your podcast, I have my bags packed. Where are you?” Yes, ready to jump on a plane the next day. It was amazing how receptive you were to that information, even though it defied everything you’d ever experienced, or mostly believed?

Dr. Peter Murphy 18:09
Well, that is absolutely true. But you know, my mind true, Dr. Ely and others had been absolutely kind of changed that, you know, at best, I could say we were doing a fair job. And I didn’t actually realize how bad a job we were doing when it came to, uh, you know, at the anxiety, depression, the cognitive impairment. And I was just shocked by that. And I realized that, you know, I had some kind of payback to do here for relatively all the damage that I had done in the prior 20 years, 30 years.

And I needed to become a little bit of a disciple here to really change things. And we actually have done that significantly with our 30 to 40 MD, critical care group, and we’ve certainly done it around the hospitals. And with the introduction of your program, the awaken and walking program, we have seen a 30% reduction in delirium, dramatic improvement.

I mean, we used to have pictures in the past, of people walking on a ventilator, we put that right beside the picture of the unicorn, because we almost never saw it. I mean, now, you know, it’s a much more common event, and very much more doable. And when you look at the impact, and we talk a little bit, a few minutes about the impact of delirium on long term mortality and all Oh, I mean, this is drastic, this this, this is incredible. We had data from our hospital that said our length of stay in the ICU was 5.7 days. And we said, this is crazy, this visit doesn’t reflect our patients. So we just couldn’t get, you know, good data.

Kali Dayton 20:24
You had cardiovascular patients mixed in there, right? Post op hearts?

Dr. Peter Murphy 20:28
We had some we had occasional trauma and some others. But we said guys, we’re going to look at 100 patients. And we’re not going to include, say, cardiovascular surgery patients because they really have their own way of doing things. And we’re not going to include some thoracic surgery because they, you know, have again their own way. So we picked the routine and med surg patients to post op the sets as the drug overdose. So it’s a pneumonia, you name it.

And in the process of collecting 100 patients, I actually collected 108 patients, this was prospectively. And you know, we couldn’t publish this because this was, you know, this was this was not random. This was obviously we’re not going to put into cardio vascular pages. So we decided, okay, these are 100 native our routine patients, the basic length of ICU stay in was supposed to be 5.7 days, if we included one of those 100 needs that stayed 24 days, our length of stay was 1.6 days, if we excluded that patient, it was 1.4 or five days.

So you know, a dramatic reduction. But we did all the things I mean, the minute the patient would come up from the emergency room, to our ICU door, and immediately was first of all stopped the propofol. I mean, I had a gentleman last night I just admitted before I finished work at seven o’clock. He’s been chased by our men in blue, he had a fistful of pills in his hand. He swallowed them all. Got him up to the ICU, he was intubated. For agitation, I was leaving at seven. But from about 4:30 to seven, I stopped everything and I’m trying to extubate him, but he wasn’t really awake enough.

But this morning, I come in totally awake. He’s transferred out of the ICU this morning. I had a gentleman two days ago who came in cardiac arrest in his in his in his, in the gym, where he’s working out, he came in and of course, he got an hypothermia and a sedated and I’m talking to the family and said, guys, you know, we’re going to dramatically cut down sedation. He’s in about 24 hours, he’s not completed hypothermia yet. But we were only going to 36. So I was worried about the temperature being uncomfortable. By mid afternoon, he’s awake and talking to be by 10 to seven last night he was excavated. Now in a previous life, we would kind of have left that guy intubated to rest. And just because that was practices, so this is how we were able to get these dramatic reductions.

Kali Dayton 23:21
Incredible, incredible work. And I didn’t even go on site with your team. This is through webinars. Yeah, how? Well first of all, you had your bags packed. You went to LDS hospital to that awaken walk in ICU? What was your experience? You just heard about this on the podcast, you were hopeful. And you went and what was your what were your immediate impressions?

Dr. Peter Murphy 23:46
Well, I assumed that you were talking like I think about Ireland, when I was a kid. I think of like those long, warm summers and the great times and I’m thinking, “Well, you’re describing, you know, maybe 10% of your patients that possibly could do this.” And I wasn’t totally convinced.

The first thing that surprised me is that the people there were kind of almost like, “What’s my problem? Why am I not believing that this is possible? And this is what we’ve been doing all the time, I think for the last 15 or 20 years. So we this is the only way we know how to do business.”

And then I go up to the ICU. And I see no sedative infusions going I see guys either walking are on ventilators with their ipads. And I mean it was simply shocking, but at the same time, magnificently encouraging because I could see that listen. “Oh, what am I doing here? This guy can be done anywhere. This is not magic. This is actually, you know, and I absolutely know that walking a patient, you know, in the first or second day is a hell of a lot easier than as we’ve talked about, you know, the deconditioning. And the muscle wasting of sepsis, pneumonia, weakened the ventilator, I mean, that is disabling.”

And so to see these patients, you know, who are often walking and not needing an army of people maybe needing a therapist on one side and a nurse on the other side. And that’s pretty much it. It was, I mean, it was actually shocking, because I really, you know, I really wasn’t sure this could be done, but

Kali Dayton 25:47
Maybe had to see it to believe it. Yes, thank goodness, you’re open minded. That’s not always the case. I will remember being really humbled, because you’re reaching out to me with over 45 years of experience, to me as a nurse practitioner, who was just hiding in her closet with a microphone to say, “Teach me, show me”.

Dr. Peter Murphy 26:08
Let me just tell you why I think that it is so important. We look at it as an article from Jama in 2010 by wuntch, who’s basically talks about 60 to 80% of the people in the ICU being delirious(12). There’s an article in Lancet 2011 by latronnik, ASCO, 2011, volume 10, where he says 60 to 80% of the people are physically impaired , and 50 to 70% of the people are neurologically impaired (13). I mean, this is profound injury.

We look at an article from Herridge in New England journal (14) and Needham in critical care medicine(15), saying that, you know, muscle weakness almost occurs in everyone in the ICU. But the disturbing thing is that 60% have significant weakness. A year out. I mean, this is this is incredible. We have an article in The Lancet by Schweikert, in 2009, noting that, in he looked at a group of patients who were in kind of a mobility intervention group and the control control group 59% of the mobility group were functional post discharge 35%. And the control group, that’s almost double. I mean, that that is absolutely shocking (16).

Kali Dayton 27:47
Scheikert still used= a lower dose of mobility than what you saw on the Awake and Walking ICU.

Dr. Peter Murphy 27:51
Oh, yes.

Kali Dayton 27:52
More sedation, less mobility? Yes, the timing of the mobility was, was later. So even, even solving a difference is dramatically different.

Dr. Peter Murphy 28:04
And then we look at an article from Wes Ely in JAMA in April 2004(17), and Pandharipande in the American Journal, and they’re basically saying and data delirium is a predictor of mortality with a three fold increase in mortality at six months, and every day of delirium is associated with a 10% increase in mortality. I mean, that is a that is fantastic.

Then there’s an article in the New England Journal in 2013. Looking at cognitive impairment, 25% of patients discharged from the ICU at 12 months, had mild Alzheimer’s equivalent 33% had moderate. So guys, we’re talking here, over 50% of the patients have long term impairment (18).

Now, I was really happy that I was saving a life when the patients are leaving on a gurney. But my real question is, was I saving a life that was, you know, worthy of being lived? And you and I have talked about, Wes Ely’s last book, and I think it should be required reading for everyone who is going to go into critical care, because a puts a face on the damage that we’re doing. And I remember so many of the cases in that book (19).

But the one that I remember specifically is he had a nuclear scientist who was all upset about how poorly she was doing and knowing where as a he was going to go in and make our fields so good at that. In fact, it did her IQ and she had an IQ of something like under 135 or 140. And she was devastated. It used to be 162 You know, and so I think that he puts a face on the damage that we are doing.

And the real problem is, the damage that we’re doing is almost absolutely unnecessary, I would say unnecessary, probably at the 80 or 90% level. Now, maybe higher than that. I mean, frankly, it should be a miniscule fraction of these patients that shouldn’t be getting sedated.

And in fact, as a result of your training, so yesterday morning, or at this time, yesterday, when my gentleman from the gym with a cardiac arrest, is waking up, I had his wife and his two kids there. And I said, “Every five minutes, you tell him, he collapsed in the gym, he’s in the ICU, he got a tube down his throat.” You know, I mean, if I was to wake up in the ICU, and a tube down my throat, and not know what the hell is going on, there aren’t restraints strong enough to keep me that.

Kali Dayton 31:08
Yeah.

Dr. Peter Murphy 31:09
And so literally, all this guy needed was constant. And in fact, when I was leaving last night, I said to his son, you know, I had a daughter, I said, “I would like one of you to sit by his bed all night, you know, this, perfect, you know, so, I mean, and this way, you know, Doc, who’s not familiar, it’s not going to call and say, Mr. So and so is agitated when you start the propofol.” And, of course, you know, he ended up getting extubated in the evening anyway. But you know, we can change these practices.

And I think, you know, we have this incredible privilege of doing what we do. And I always tell my students, you know, you could be, you know, selling cars, selling houses ,are you will identify with this spelling as selling expensive, Jimmy choose on the shoes. And, you know, I’ve said, there are 100 places to buy a car, buy a house, buy a purse, but I said, when you are dealing with someone’s spouse, someone’s kid, you get 110% of their attention.

And you get the privilege of being in the center of Bash arena. And if you’re not able to appreciate how privileged that is, I always say it’s like buying a bottle of very good wine and put it on your chin and drinking it. Well, yes, you did drink it, but you missed about 98% of the experience. And I think if you’re doing ICU care, and not understanding the privilege that we have to be participating, and this is exactly I mean, people ask me, you know, I should be retired 10 years ago, why I’m doing this, and I say, “I love it. You know, I get so much satisfaction.”

And now you have imposed this burden on me to try and correct all the damage that I did for the first 30 years to make sure that anyone who will listen to me knows about this.

Kali Dayton 33:28
Yeah, you said that right away. You said, “I’m nearing retirement– whenever that’s going to be–but you said this is a legacy I have to leave. I have to change this before I leave.” And I thought that was incredibly inspiring.

That sense of calling like these podcasts listeners, everyone can relate to that. I think anyone that’s heard this and had this awakening can feel a sense of responsibility to do something about it throughout all of this delirium research, we’ve always talked about the problem. It’s been very evident. But we don’t give enough tribute not enough attention to the solution.

So here you are…. going to this Awake and Walkubg ICU, seeing it in action. You’re understanding the literature, and it’s coming to life. You are so motivated, inspired, and you came back to your system and you were ready to just turn it all around? How was your enthusiasm received?

Dr. Peter Murphy 34:18
Well, I’ll tell you, not with a universal acceptance by any stretch of the imagination. But you knew, I think, I mean, I look back at my dear friend, Mr. Semmelweis. Dr. Semmelweis and Dr. Marshall are not listening, when you are essentially telling people that there’s a dramatically better way of doing what they’re doing.

And particularly if they have been doing that, like me, for the last, you know, 10,20, 30,40 years, and there’s a little bit of an indictment going on. And I think you’re initial reaction is going to be you know what, “I am a superb doctor. And I’ve done great work. And I’m not so sure about this new approach here.”

But, you know, you have to talk about what we’re doing. And you have to realistically talk about, you know, 70% of the patients that we’re sending out of our ICU, are permanently injured. I mean, they are permanently injured with anxiety, depression, you know, PTSD, cognitive impairment, then you have had 100 of them on your podcast. awareness has talked to them in his book. I mean, this is this is undeniable.

And, you know, I think it’s like most things in life, I think, if you’re dealing with a sort of a thoughtful, reflective person, they’re probably going to leave that conversation and maybe think a little bit about, hey, is there something about Dr. Murphy is saying, and why are we actually doing this? You know, you would never think of a sedating a patient with a tracheostomy. I mean, why do we sedate a patient with an endotracheal tube? I mean…

Kali Dayton 36:17
It’s a cultural myth that it’s “safer, more comfortable, or that we do trach so that we can take off sedation”. Never found it in the literature. Whoever started that that trend…. I don’t think they realize how lethal that line of thinking would be for our patients.

Dr. Peter Murphy 36:34
What do you see, Kali, that is the problem, because like me, for, you know, 30 years, most of the clinicians have little or no feedback, and they do not understand. And I mean, you have had people on your podcast, who said they were so scared of the ICU, they couldn’t even bring themselves back to come and tell the nurses how bad the experience was. So you knew, we have very little mechanism to get the feedback.

But you knew, you put me in touch with Alan Pearce writing his book, and I was critical somewhat of the SCCM, the Society of Critical Care Medicine, who I did take a real leadership role in defining delirium, but really, I think, held back step in forcing, you know, a process to how we deal with this. But I was actually delighted about a month ago, they came out with about five or six recommendations, which are all essentially, a watered down recommendation of what I or you would really want.

They say, you know, consider “decreasing sedation”. My recommendation would be stop all sedation on everyone, unless the occasion one or two patients or three or four that you have to get. I mean, I would say like everyone should be up walking, except the people who actually are hemodynamically unstable, and the people who actually had.

Kali Dayton 38:14
And right away! Not just this… “sedate them and then deal with it later, at some subjective ambiguous time. “—That’s what really, that’s how ICU liberation has been. And I understand that every patient is different. You have to have guidelines that are adaptable, but you have to have the tools to critically think through each patient and understand what the norm should be, so that you can identify the exceptions and deal with them. But right now, as our guidelines have been, they’ve been very ambiguous, which has just seemed to continue this culture.

Dr. Peter Murphy 38:46
And, you know, perhaps I can understand the SCCM saying that you knew what they’re fighting is so pervasive. I mean, the practice of ICU medicine today is to sedate, keep them in bed, and essentially, you know, do all of the wrong things. And so, I think the SCCM is trying to get the thin end of the wedge in there.

The problem, though, that I see is that while they’re getting that in end of the wedge in there, we may lose another half a million or a million people and we may permanently injure another several million people and you knew that is not acceptable to me.

And I’ve talked to you earlier about, I mean, I did a bronchoscopy this morning, and I talked to the patient, about the one in 5,000 risk of dying in every ICU essentially in this country except an occasional one like we’ve talked about. People are routine really getting a treatment plan, which if they survive, will guarantee then 60 to 70% of the survivors will have permanent injury. And no one talks to them at all.

And says, you know, how are you with that are, you know, we actually have a treatment plan that where we can dramatically reduce all those risks. And in fact, the people who have been exposed to that treatment plan, when given a choice, want no sedation, instead of sedation, the majority of the time, but

Kali Dayton 40:37
….and those that have had it both way want to be awake.

Dr. Peter Murphy 40:41
Yes. Yeah, exactly. Exactly. And I think I think if you and I were in the hospital, I would absolutely unequivocally want to be given the chance to see watch this like, and then maybe giving a little push or fentanyl now and then it kind of getting tough, but not not me. I agree. propofol are benzodiazepines are whatever. And I mean, that is the major challenge that we have to do.

I am hopeful that with the introduction of sort of artificial intelligence and the electronic medical record, we will be able to identify, you know, practice patterns that give us the best and short term, better outcomes. And maybe, maybe that’s what’s going to drive us. I mean, if I were to go to an insurance company and say, “Listen, I can get most of your patients out of the ICU in under two days, versus five to six days.”—– I suspect they’d be extraordinarily interested in having me come in and have a chat.

Kali Dayton 41:53
The financial picture of that is just undeniable. But it’s unknown to those financial decision makers.

Dr. Peter Murphy 42:01
Yes, it Yes, it is. And, but you know, I am encouraged with the, with the SCCM. Coming to where they are. And, you know, I am seeing a bit more of the reduced sedation in our E-ICU where we handle, you know, 14 hospitals, maybe we’re seeing probably some less use, but it’s about what

Kali Dayton 42:33
You’ve had more success with your personal ICU that you’ve physically been at. What has helped to bring that change? How have you gotten buy in from the rest of the team, especially the nurses and respiratory therapists?

Dr. Peter Murphy 42:46
Well, I think it’s like you and Wes Ely has said, you know, a picture in this case is worth about 10,000 words, because when you were saying this thing on the podcast on ACCRAC, I said, “Ehhh…., and maybe that’s possible, but not really likely. When you go and see it. I think you absolutely say that, you know, “Absolutely. This is possible, why not do it?”

And I think it’s the same now with with the nurses seeing, you know, where patients walking? I mean, the initial responses, if you were on a ventilator, you had have a one or two sedative infusions going, we don’t even get that question anymore. And in one of our hospitals out in Roseville, a bunch of the nurses have said, we don’t use sedation infusions here. And that’s the hospital where they have seen a 30% reduction in delirium. Amazing, you know, and so it becomes, it becomes difficult to argue against this. And all of the bad things that you kind of anticipated happening that haven’t really happened.

Kali Dayton 44:07
Such as unplanned extubations?

Dr. Peter Murphy 44:09
Well, everyone everyone talks about a you know, well, that could extubate themselves—- like as if this was the end of the world. Well, I’m going to tell you and probably be other doctors listening and nurses and nurse practitioners:

that I don’t think we have very good mechanisms for identifying who is ready for extubation enough, you know, we’ve Martin Tobin’s RSPA, and a million other things. But I’ll tell you, when I look back at my career, I have seen hundreds of patients extubate themselves. When I either was thinking about it, I wasn’t sure or whatever, and only a miniscule fraction of those required to be intubated did.

In fact, Wes Ely in 2007 had essentially the same experience in a, you know, a published study where you said yes, they had more extubations, but that they did not have more reintubations. So I think what we’re seeing is, there are a number of patients who are probably ready to be extubated. To be honest, I have no perception at all about our incidence of extubation has gone up at all.

But I mean, that’s the thing that most people think about. I’ve never heard anyone post-extubation say, “Gee, that having the tube in there was terrible,” you know that. It’s just I’ve heard no different from the way you used to practice five years ago. So I don’t think that there really is much different. I think there is the assumption that it’s going to be chaotic, and it’s going to be World War Three in every other patients room. But in fact, it isn’t.

And the biggest thing that I think people need to do is keep family involved. I mean, I was there yesterday when this guy was making up after his cardiac arrest, and he was barely able to flicker his eyes, and I’m telling him, “Hey, you collapsed in the gym, we had to put a tube in, you’re doing really well to go to get the tube out. And someone has to be settled, telling him that every five minutes.”— And the other choice is you snow them with propofol. But we know what that does.

Kali Dayton 46:30
And I’m really concerned about the visitation restrictions that have persisted even after COVID. We have not healed from that. And we’re not practicing the A2F bundle. And therefore not practicing evidence based medicine if we are kicking family members out there, they’re a part of the ICU team. We don’t kick out RT’s after seven o’clock at night. Why are we kicking out family?

So thank you for telling families asking families to stay at the bedside. And then allowing them to most families want to most families are going to be an invaluable tool and make everything easier. But we have had a culture shift so far away from that. So you’re absolutely right. And stay tuned for some episodes are very, very focused on the family involvement in the ICU, because we need to hit that hard.

Dr. Peter Murphy 47:17
You know what is so important and you get this from patient from families that is, you know, that little weirdness and kinks that we have or that occasions like this, “I like this music, I like such and such.” And you know, those are the things that are going to make the difference and make them feel secure. So I have found these are absolutely essential. And I think the more we use them, the less we’ll have to use pharmacology.

Kali Dayton 47:44
But all this has come because you’re going away from deep sedation, you’re trying to re humanize the ICU or humanize wherever you’ve been from your culture before. But when you do that, it makes sense to have families there.

Dr. Peter Murphy 47:59
Absolutely. And you know, Dr. Ely has made the comment that sort of humanity is the antidote to burnout. And I think as you get involved with a patient and their families, you get to know them a little better, you get to know kind of a little quirks and idiosyncrasies, and you feel more connected to that family? And you know, I think that with that question, the COVID family, the COVID, everything was horrible. But, you know, we have to get over that. And we can absolutely correct the work we’re doing.

And the my challenge right now is that I think we have the information that can dramatically improve outcomes. But as with lung volume, ventilation and proning, getting clinicians to have that the absolute, you know, modus operandi, the thing they do every day is the real challenge.

And I’m going through right now, our corporate guidelines in the ICU for management about patients with the local administration, the corporate guidelines are absolutely excellent. But we’re not, you know, applying those as vigorously as I would like, and we are doing a lot better than most hospitals.

So, you know, but I do think that if we were able to look at kind of every orchestration of the costs, and for example, if you could cut your ICU length of stay by two days, you could dramatically improve physical therapists, respiratory capacity, you know, their supply, so I think we could end up with substantial savings, because you know, the length of stay would be dramatically less.

Kali Dayton 50:06
Absolutely. And there is evidence to support that. And within that evidence, when we show the 30% reduction in health care costs from the ABCDEF bundle, we have to remember that that was on a spectrum. That was not the full awakened walking approach. But we know that the less space we use, the more we mobilized patients, the more families involved. All the outcomes get better. And when the outcomes get better, the cost decreased. Yes, but some of you out there advocating for that. And thank goodness, it’s you.

Dr. Peter Murphy 50:36
And I’ve gotten a little pushback from the, you know, the New England Journal Article Six months ago, on the TEAMS study. And of course, Wes Ely has done an excellent on your podcast (20). Yeah. Yes. Okay. And you might get a reference that, but the big difference is the control group in that group, we’re getting eight minutes of exercise?

Well, I’ll tell you, that is eight minutes of exercise more than most ICU patients are getting each day in this country. And then the other big thing is they didn’t change sedation at all, the sedation administration was essentially the same in both arms. And to be honest, I don’t see people walking very much on benzos are propofol IV.

So you know, but people who haven’t looked at the article in some detail, and in fact, I think the article was actually referenced in up to date. And I was very discouraged that they actually, you know, without having a discussion on it, but, you know, look, I can always get you an article that will support or disagree with anything you want.

We’re not talking about one article, we’re looking at the weight of evidence. And when we look at such a poor job, as we’re relatively doing in ICU, and I say this criticizing myself 100%, we have a requirement and an obligation to do much better. Now we can influence much of what we did yesterday, that’s kind of in the rearview mirror, but we can work on today, I’m going to dramatically work on tomorrow.

And given that the average American has about nine and a half hospitalizations during the lifetime, almost all of us and our families are going to end up in the ICU at some time. And when you look at the cognitive impairment, that results from a significant state, forget about it, all the rest of the stuff, which is terrible, but just look, if you’re a doctor, an engineer, and a lawyer and accountant day, you know, whatever you are, the odds are you may well not be coming back to work after that.

And if our treatment, our practice is going to make that difference. I think we have an absolute obligation. And I think we also have an obligation to discuss this with patients and families. You know, you can they can say, well, the last time they were in the ICU, they were “asleep” for a month. Well, yeah, that that is an option. But let me tell you about all the downsides of that.

And so I think we, you know, I think and I mean, I hate to say it, but I think this is an area, you know, potential litigation in the future, as you know, as patients come out, like if I’m, you know, 30 year old doctor who gets septic, and you know, “My mind is destroyed, I’m going to be wanting to look somewhere for something.”

You know, that should not be the driving force, like shouldn’t be and I think what is the driving forces, we all want to do the best job and I am absolutely certain that every clinician who comes to work every morning, wants to do the best job possible. But you know, as part of doing the best job possible, you have to make sure you’re aware off the best practices, you know, it’s not just a like a, you know, I would like to, you know, run a three hour marathon.

Well, I’m going to do that I need to start training and you start dieting, I can’t be that I just like to run it. So you have to make yourself aware. And I think, you know, listening to podcasts like yours, which people can do driving back and forth to work and there’s lots of other excellent podcasts out there. I mean, this will if this doesn’t start to disturb your comfort zone. You know, it’s it’s a little surprising, because you will find there, the way we’re doing business today is unequivocally not the best way.

Kali Dayton 55:14
How can we claim that we are practicing evidence-based medicine if what we’re doing goes against the evidence? And so that’s been a really uncomfortable irony to hear things, people talking about the “evidence” when we’re just we’ve we’re practicing fear-based medicine, we’re practicing normal medicine.

Dr. Peter Murphy 55:35
The problem though, Kali, is very simple in my mind. First of all, there is incredible complacency. You know, I mean, we are just, you know, we’re convincing ourselves every day, we’re really doing a good job. And we are doing some things magnificently. We’re slipping in, like aortic valves to your femoral vessels in your home that night. And we are now taking clots out of your brain, or we’re doing some things magnificently.

But we’re certainly not doing everything magnificently. The other problem is that there’s almost no discussion among medical students among the university. Faculty, there’s almost no awareness of this. So basically, you know, students are coming out, they’re essentially practicing ICU medicine the way we did one, two and three generations earlier. And this is a problem. And then as I stated earlier, even when we know, fantastic life saving interventions like proning and protective ventilation, it’s an operation less than 50% of the time.

Now, how could you honestly a day, have a patient die in your ICU from ARDS and not have offered lung protective ventilation or proning? I mean, you know, you really haven’t done everything that’s available to you. And I don’t know, you know, of any particular reason why you could say, “well, gee, I didn’t do this, because, and I can guarantee you that.”

I mean, I was just listening to a podcast recently from the University of San Diego, there was a professor of infectious disease got sick down there. And they hardly septic. And they gave him some kind of a genetically modified bacteria that the defense forces were using down in San Diego. Well, realistically, what do you think the chances of a guy walking in from the street and getting that would be?

And I think it’s a little bit the same with clinicians. I think, if your spouse had ARDS, I pretty much guarantee you, that spouse would be getting prone the lung protective ventilation. And I think that we have to have the same ownership for all of these patients.

I will briefly end up with my sister’s experience. And so about 15 years ago, I had diagnosed her breast cancer by examining her shoulder shoulder, we were going to play golf. The next morning, she had a lymph node under her shoulder, so the golf had to be canceled. And I was my head on University Hospital at two o’clock that afternoon in Dublin. And they she got treated and did okay. And then about three years later, she’s seen two golf balls, and I told her hit the big one. And she turned out to have a cerebral metastases. And I with her right across the table from the top neurosurgeon in Ireland.

And he didn’t use these words, but he essentially told her, “You know, to go home and die,” and he didn’t use those words. I mean, he was saying, “you know, this really terminal.” It turns out that her son was a very successful supporter of Cromwell Hospital in London. She went over there, was hospitalized for two days, had a met removed and lived another five years when she saw her third son married and two more grandkids born.

And every day, she said every day she woke up was an incredibly special day, because she was in extra innings. And in fact, when she was dying, and sitting by her bed, she was in hospice and holding her hand and we’re kind of reminiscing, and then she was telling me about the best doctor that she had ever seen. And I was kind of eagerly awaiting this. And she says, “Well, he was the Nigerian hospice doctor who was just treating”

— and I didn’t have the courage to ask her, “Well, you know, what’s the like the newer surgeon who removed your brain met? Are are myself were we on the list?” But the bottom line is that, you know, here’s the impact that a you sort of think like just your routine Dr. A is having on people. And that’s the incredible privilege that I was talking about earlier. And I think if we view everyone, you know, as being special, and kind of put ourselves a little bit in their shoes, and advocate for them. I saw a patient about a month ago, and he had horrible lung disease, and he was 61. And I said, you might think he didn’t give us a lung transplant. And these are “no, no, we won’t do that.”

We all impact people in different ways. And you know, you don’t have to be doing a brain transplant or someone to make all the difference, it can be something very simple. And you know, in the ICU, we see the horrific damage that is being done. And you know, we don’t have to do everything absolutely perfectly.

But I think, you know, I would see right now as the top three things would be essentially almost no sedation for anyone and get some levels of mobility going, you know, literally in the first 24 hours and as much as possible, and then have the family together, you know, the family could be there, pushing the IV trap, or whatever. And so I really think if we did those, that would be a great start.

And it would probably, you know, eliminate maybe 50% of the damage that we’re doing. And if you believe, like the up to date data, that we have 4.8 million survivors leaving the ICU every year. I mean, that is a horrific number of people that we are injury. So you know, by doing relatively small things in our ICU, we could make a dramatic difference. And I think that I would sort of challenge every clinician, particularly anyone who’s listening to this, first of all, listen to more of your podcasts because it will absolutely, you know, affirm and consolidate, you know that this is really incredibly important.

But when you’re going to write a proper full order or propofol or a benzodiazepine, I mean, ask yourself, do you understand the impact that this is going to have on this patient? And, you know, yes, maybe the first week or two, you’d have a little struggle with with the nurses or with someone, but you knew it’s going to become routine, much better care.

And, you know, I think that, like I said earlier, you know, we were talking about, you know, which movie are we going to see, you know, which Hawaiian island, are we going to, you know, not a big deal. But I mean, we’re talking about someone’s life. We’re talking about how they’re going to live maybe for next 10,20, 30 years. I mean, this is critical. And we need to understand, and the data out there is absolutely compelling.

I mean, whether we like it or not, we are not doing a good job. We’re not doing the kind of job that I think most of us would ask ourselves when we get up in the morning, you know, “Hey, do I want to go in And, and it was so-so job” I think all of us think that we’re like, we always think we’re really super we do we think we’re great. We think we do great work.

And you know, sometimes we do, but the data would suggest that we’re not probably as good as we think. And I’ll tell you, I was at the top of that list for the first 30 years of my life, I’m sending patients out of the ICU, you know, on a gurney thinking, you know, “I’m really a great doc.” And I wasn’t saying that anyone, I was just saying it to myself. But then as I realized, you know, “no, I’m actually not that great.”

I mean, these patients are going out, some of them to live a horrific life. And when you read, you know, Wes Ely’s book, and when you listen to your podcasts.If these don’t, you know, give you a little pause to think, you know, “am I doing the best I can do?”

And you have to realize that, you know, the odds are that you may well end up as a patient in the ICU, your family or your your parents, your grandparents. I mean, you knew this is a real problem. There’s none of us getting out of here, sort of probably then without spending a lot of time in the ICU. And the question is, “How do you want to be after you leave the ICU?”

And, you know, I think everyone has answered that question for themselves. But you also, I mean, have to avail yourself of the educational experiences of Dr. Ely has a fabulous repository, www.icudelirium.org (21) , you can actually check that that’s the address, but I think it is, and everything you ever wanted to know about better ICU care is in there.

And I know you have been incredibly helpful in bringing our nurses up to speed with your way your webinars and your lectures. And, you know, the nurses, as you well know, but not all doctors would necessarily admit the nurses are really, the people doing the work in the ICU. They are dealing with all the challenges, they’re dealing with a family issues.

You know. if you don’t have them, you know, totally buying into this program, it’s going to be more difficult. And the easiest way to get them to buy in, is to actually do it on a couple of patients, let them see that this works. And then a couple more. And suddenly, you you’re like our ICU nurses in Roseville who say, you know, we don’t sedate patients here. And to me that is you have arrived.

Kali Dayton 1:07:51
I love that you came back from that Awaken and Walking ICU, and you just started doing it with your patients.

Dr. Peter Murphy 1:07:56
Yes.

Kali Dayton 1:07:57
You started ringing the bells trying to bring in systematic change. But you focus on that one shift and those patients that you could impact during that shift. And that set off this domino effect. And I just came in and brought the tools, more information, tried to make it a decision to disseminate it throughout the entire team.

But having a leader that believed in it, and then just doing it just starting just taking that step of faith to not even start sedation. And then seeing what happens. It’s amazing listening to podcast listeners who haven’t even brought their teams in for consulting or done any of this they are alone a one lone nurse, one lone RT, making these little choices. Little steps, applying the evidence and whatever power they can.

They are saving lives, they are making a difference. And it’s easy to get overwhelmed by the magnitude of change that needs to happen. But it’s the boots on the ground, those daily choices, each shift with each patient that is making the biggest difference.

Dr. Peter Murphy 1:08:58
And you know, I think the biggest thing to look at is that you are probably not going to change world practice. Well you actually make sure your podcast but I’m not going to change world practice in you know, a in the next week or two or anything else. But I am going to make an incredible difference for those patients that I’m working with.

And you know, to be honest, that’s really all we’re asking for most clinicians is for you to do the best job with the patients that you have the privilege of working with, you know, I can’t cure hunger in Africa, and I can’t do a million Bill Gates as taking care of malaria and others… but I can make a dramatic difference in the patients I work with. So can essentially most other you know clinicians and you knew you go to some of you know, where’s the lies, you know, educational process there. You know that this is this is something we can do and must do. And the privilege of doing what we do requires us to do it better.

Kali Dayton 1:10:11
Dr. Murphy, you are a true ICU revolutionist. Thank you so much for everything that you’ve done and are doing. Thank you for supporting this movement and leading it where you’re at, we have a lot more to learn from you keep us posted on any data, you come up with all the tips and tricks of bringing this change, congratulations on your success. And we’ll be in touch.

Dr. Peter Murphy 1:10:32
And you know, I would want to say that I’m working with great physician colleagues and fantastic nurse colleagues, who all they need a is a little direction and a little understanding. And you know, they’re great soldiers. So thank you.

Kali Dayton 1:10:51
That’s what I’ve experienced, too. I’ve had years ago, medical director said, “Well, you, we can’t get our nurses to do that.”– But what I am experiencing is that you really can they deserve the education, support, guidance, collaboration to make it happen.

But you give them those tools. And they’re the ones that fly with it. And I’ve met your nurses that I’ve heard how excited they are about this and how well they’re doing. And it’s been an honor and privilege to be involved in that process. And I believe in nurses, I believe in our clinicians, I think you’re spot on, that we want to do the best job and that we are willing to do it. So thank you so much.

Dr. Peter Murphy 1:11:30
Thanks again for everything. And you know, we’re going we’re going to succeed here, it’s going to take a little time, I think I really think that in five years, and this is going to be the way ICU care is delivered. I really because you knew the problem we’re doing right now is so far from where I think most people would really want to be. And you know, if you start exposing people to better ways that they take on integrity, not everyone but the majority. That’s all we want the majority beautiful.

Kali Dayton 1:12:06
Spoiler alert— but stay tuned. SCCM is coming out with new guidelines coming up. That’s all I can say right now.

Dr. Peter Murphy 1:12:13
Thank you. Thank you again.

Transcribed by https://otter.ai

 

References

1. https://www.uptodate.com/contents/post-intensive-care-syndrome-pics
2. http://accrac.com/episode-179-ambulating-while-intubated-with-kali-dayton/
3. https://www.bmj.com/content/353/bmj.i2139
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240806/
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661189/
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1767093/
7. https://pubmed.ncbi.nlm.nih.gov/20281549/
8. https://curiousclinicians.com/2022/03/30/episode-46-the-man-who-purposefully-paralyzed-himself/
9. https://www.latimes.com/archives/la-xpm-1998-apr-15-mn-39509-story.html
10. https://erj.ersjournals.com/content/20/4/1017
11. https://pubmed.ncbi.nlm.nih.gov/26903337/
12. https://pubmed.ncbi.nlm.nih.gov/34089739/
13. Delirium is critically important and severely under-recognized. JAMA 2010 volume 303 page 849.
14. Cognitive impairment, Lancet, neurology, 2011.  V10. P931
15. https://pubmed.ncbi.nlm.nih.gov/21470008/
16. https://pubmed.ncbi.nlm.nih.gov/18596631/
17. https://pubmed.ncbi.nlm.nih.gov/19446324/
18. https://pubmed.ncbi.nlm.nih.gov/15082703/
19. https://pubmed.ncbi.nlm.nih.gov/24088092/
20. https://www.icudelirium.org/every-deep-drawn-breath
21. https://daytonicuconsulting.com/walking-home-from-the-icu-podcast/walking-home-from-the-icu-episode-117-diving-deep-into-the-teams-study/
22. www.icudelirium.org

 

 

 

 

 

 

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