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We know that critical illness, sedation, delirium, etc., can leave patients with deep psychological trauma. How can we help them recover? What resources are available to treat post-ICU PTSD? Dr. Brian Peach shares with us his exciting developments and research.
Episode Transcription
Kali Dayton 0:00
This week I flew out to meet with the executive leadership team of a hospital. This means that Chief Executive Officer, Chief Financial Officer, Chief Nursing Officer, Chief Medical Officer, and so on. invited to the meeting were also the clinical leaders and even intensivist of the five ICUs of this hospital. The objective of the meeting and my presentation was to focus on the financial benefits of an awake and walking ICU.
My mission was to help the financial stakeholders understand the financial and legal liabilities and costs of sedation and immobility to inspire them to invest 1000s To save millions. This would mean bringing in text potentially more nurses, PTs, etc. Whatever the teams needed to successfully become awake and walking ICOs, and they would see a huge and instant return on investment.
Though my main focus was the numbers, I did briefly share some short clips from survivors about how they have suffered from sedation and immobility. But the rest of the 45 minute presentation was focused on how to save money through best evidence based sedation and mobility practices. At the end, and intensivists raised his hand and said, quote,
“I have seen numerous horror film films that were graphic, gory, and harrowing, yet they are nothing compared to this presentation. I am traumatized by what I have just heard. I had no idea that this is what I’ve been doing to my patients my 30 plus year career, we have to fix this so I never have to sit through this agonizing presentation ever again.”
I was shocked to have such a response. I realized that as I was showing in the numbers, how preventable these infections, pressure, injuries, delirium, deaths, prolonged length of stay, re-admissions, tricky, ostomies, etc, were and that best practices could drastically turn it around. This intensivist was having flashbacks in his mind to the innumerable instances in which he had seen that damage in action.
I think the numbers became real people, real patients real suffering. His colleagues all shook their heads and agreed. They didn’t know they didn’t want this to be happening and they were desperate to change it. It reaffirmed to me that though the financial benefits are profound. Even that discussion comes back down to humanity and compassion. No one wants to traumatize enter or even cause the demise of our patients.
Just recently, I had a friend from my past posts online a few weeks ago, that her husband was intubated for influenza and being flown to a large and leading hospital. I instantly called her it was an overwhelming situation, to say the least. I tried to tell and warn her of what was to come. Yet it was a leading hospital. So she understandably trusted them. She did ask the questions I encouraged her to ask but was immediately shut down by the team.
They would say he’s intubated, he can’t walk or he’s sleeping, he’s more comfortable this way, etc. Fortunately, he was excavated five days later. He’s been a total of 11 days in the ICU and florid delirium. He’s now home and finally emerging from the delirium and started to talk about his side of what he experienced in the ICU. Sexual abuse. past traumas were replayed in neglect isolation terrors, outside of what critical illness could have done to him. He is traumatized and broken. He was a professional golfer in his 40s and father of six kids. His family needs him to be the full, functional and best him.
So now what, how can we help survivors recover from the trauma ICU and especially ICU delirium? Dr. Brian peach joins us now to share his exciting work and post ICU PTSD
Brian Peach, PhD, RN 0:08
Absolutely. Well, thank you for the opportunity to come on. I love what you’re doing with your podcast. So my name is Dr. Brian peach. I’m an assistant professor at the University of Central Florida, where I do research with critical illness survivors, and also teach critical care courses and acute care, adult health courses.
Kali Dayton 0:31
And how did you get into this interest that you have in ICU survivorship?
Brian Peach, PhD, RN 0:37
You know, it’s, it’s kind of become a passion project. I’ve been a nurse for over 18 years, most of the time has been in critical care. And, you know, I started reading about some of the outcomes of critical illness survivors, and some of the challenges they had in terms of anxiety, depression, PTSD.
And I found that very troubling, the idea that we would pour so much into saving survivors lives only for them to have a terrible quality of life afterward. So it really just became kind of a passion thing. And I thought, okay, what can we do? What can we learn from them? And what can we do to try to help them? And so really, that’s the impetus behind my research.
Kali Dayton 1:26
And as you’ve been researching, what have you learned that you wish that 15 years ago, bedside-Brian understood?
Brian Peach, PhD, RN 1:34
Sure, absolutely. Well, number one, I think many of the issues that ICU survivors develop, actually start in the ICU. So they start with delirium, we know that people who develop delirium in the ICU are much more likely to have long term mental health issues after they leave. And it’s not just mental health issues, you know, it’s cognitive issues, and it’s physical issues as well.
So, you know, I think, number one, had I known years ago, things that I can do to try to prevent those issues. And had I know that these were even issues, I probably would have been a lot more proactive in terms of mobilizing patients, in terms of being very careful with my sedation selection. So there’s a number of things that I think I would have done differently.
Also, it’s another thing to hear from ICU survivors directly, as opposed to just reading about their outcomes. And so they really had an impact on me. You know, I’ve learned that many of them have PTSD that resembles sort of what soldiers experience, or what first responders experience or mass casualty event survivors, they have triggers.
They have things that they see things that they hear things that they smell, the trigger PTSD, and, you know, it isn’t just for, let’s say, a week or a couple of weeks after their ICU admission, goes on for months, sometimes years. It impacts their quality of life. And I’ve kind of always had this mantra that, you know, when patients come in for one problem, they shouldn’t leave with three to four new ones. And so really, that’s that’s driven my interest.
Kali Dayton 3:30
I think that’s been one of my big “aha” is as well. The fact that someone can come in for pneumonia. Yeah, really, with a neuromuscular condition. Like post ICU, dementia, PTSD. I mean, their lungs can heal, but then that’s the least of their problems.
Brian Peach, PhD, RN 3:48
Right? Absolutely.
Kali Dayton 3:50
And maybe when I had that thought of the concept of post ICU PTSD before, I would think, okay, if they smell saline, or things that are directly related to the ICU, yes, it’ll remind them of the ICU. But talking to survivors, it sounds like and correct me if I’m wrong as far as the majority, but Right, oftentimes, these triggers are not medical.
Yes, I ever said that. She believed that she was in a coffin, or she was in the morgue, and the instrumental music that the nurses were playing in the background played into this scenario. Yes, when she gets in an elevator and an Instrumental music plays or the grocery store, it’s a trigger, and she’s lost back into that morgue. Trying to tell them don’t bury me alive. Yes. So what kind of triggers are have you heard that have been related to post ICU PTSD?
Brian Peach, PhD, RN 4:43
Yeah, sure. So we actually we have a research study where we’ve been collecting data on what are the triggers for people and so common things are things like seeing medical professionals. Driving by hospitals we’ve heard from a number of our participants are be searched that they have to look away or they have to drive a different way when, you know going out somewhere because they don’t want to drive by the hospital, seeing medical equipment, so things like walkers and wheelchairs and oxygen tanks for many people to trigger them.
I have a participant who was at Disney World, and she saw somebody being wheeled out on a stretcher. And it took her right back to her own emergencies. So some of them are things like that, things that they see on TV, or on social media are oftentimes triggers. Sounds can be triggers, any kind of beeping sounds, doesn’t even necessarily have to be beeping, like the IV pumps or, or the alarms, the ventilator.
But really any kind of loud, repetitive noise can trigger PTSD, and, you know, take them back to either memories of the hospital. Some of them don’t actually remember their time in the hospital. But they’re still sort of triggered, and they can’t figure out why. You know, sometimes it takes them back, as you said, two very painful dreams that they had in the hospital. And you know, they didn’t realize they were in the hospital at the time, but you know, they would have these very wild, crazy vivid “dreams”.
Smells are big ones. So the smell of Bleach Wipes, the smell of you know, other cleaning supplies. Sounds like helicopter sounds are oftentimes a trigger. And what was interesting is we had one person who was not life flighted. Many of the people that had helicopters, trigger them were life flighted, but this particular person wasn’t, but their room was right next to a landing pad. Okay, so they would hear that helicopter constantly coming and going. One of the most interesting things that we’ve learned…
Kali Dayton 6:59
Did they know that it was a helicopter?
Brian Peach, PhD, RN 7:05
You know, that’s a good question. And I don’t know that I asked that question. You know, if they knew that’s what it was, because oftentimes, people under the effects of sedation, they hear things, but you know, they, they’re living in a very different reality than you and I are living in.
Kali Dayton 7:20
Right, like they, they’re…. it reminds them of that delirium where they live in delirium. It’s not that they’re afraid of helicopters, because I would suspect that patients that understand what’s going on, they know to helicopter. I mean, it might, it might make them shatter, like, “Oh, yeah. When I was in the ICU, I heard a lot helicopters?” But it’s different than, “I was being shot by helicopters in the war.”
Brian Peach, PhD, RN 7:45
Yes, yeah.
Kali Dayton 7:46
So yeah, how does delirium change that? Or why is there such a strong correlation between delirium and PTSD?
Brian Peach, PhD, RN 7:54
Yeah, no, that’s a good question. You know, it’s hard to say, I mean, I think, again, they’re living in a very different reality, they’re under the effects of very strong, you know, medications, their, their filtering organs are impacted their liver, their kidneys. And so, you know, their, their reality is all screwed up. And so sometimes, you know, they remember that things from the hospital.
And we actually, as part of this study, we do collect information on what people remember. So sometimes they remember having the breathing tube put into their throat or having it removed. And sometimes they have no recollection whatsoever of things. But, you know, again, they’re still triggered. And then for many of them, they have these dreams, or these experiences that reflect what were going on around them.
So for example, we had a very, you know, strong gym teacher, have lived a very healthy life prior to coming into the ICU. And he remembers wearing a string bikini and ripping off that string blue bikini. And it was actually the telemetry leads, you know, he and his family later, sort of figured out as they talked to like what it was, we had another actually, the same person felt like he had monkeys wrapped around his legs.
And in fact, it was the SCDs that we put on patients to keep blood flow in their legs. So, you know, there’s all these sorts of weird things. And so I think, you know, that cognitive impairment really sort of develops in the ICU, and then, you know, it unfortunately goes home with them. And I don’t know that we are always as proactive as we should be in addressing the delirium or sometimes even recognizing the delirium. And so, you know, we may see signs that maybe they’re a little off but we don’t really fully address them in a way that we should. And so then they go home with, you know those sorts of things.
Kali Dayton 10:05
And I learned from one ICU survivor, I mentioned this in an earlier episode, Episode 20 or so, I had a survivor that I had a patient, and she was having these pseudo seizures. And I went in to tell her the EEG showed that they weren’t real seizures. And she said, I know I’ve been having these and rewind, she was there because of attended suicide.
Brian Peach, PhD, RN 10:29
Okay.
Kali Dayton 10:31
And so we got started talking, and she’d come from Puerto Rico, and she had life full of trauma, hurricanes, kidnappings, rapes, terrible life, but she was working as a school teacher, managing her PTSD, living her life.
She came to the States, I think visit her son, I live with her son. She had a pseudo seizures on a train. And she ended up in taking the ED intubated, and then the ICU. Wow. But she was sedated for probably a week or so. And even though these were pseudo seizures, so she said, “I never did have a seizure but I stayed on the ventilator. I don’t know why.”
Now, it makes sense with awakening trials, you turn on sedation, they come out thrashing you translation back on. So she was probably today because she was intubated and intubated, because she was sedated. So there she rides in delirium. And she relived all those events, rapidly, vividly. And she had to really learn how to sit, stand, walk, swallow, and that was hard. But once she went back to her son’s home, with a clock, she couldn’t balance her checkbook. She couldn’t function. She depended on her son for everything.
Brian Peach, PhD, RN 11:36
Yeah, yeah.
Kali Dayton 11:37
And that baseline, PTSD was right in her face. But what she described was, essentially, that her cognitive impairments made it so she could not use her other her baseline coping mechanisms,
Brian Peach, PhD, RN 11:48
right
Kali Dayton 11:48
to deal with the PTSD, the old PTSD now the new PTSD, but she couldn’t…. she knew what she probably should do. But she couldn’t anymore, that training was gone because her brain is broken, in my mind about how cognitive function is essential for dealing and healing from PTSD. But we break both of those- psycholgically and cognitively.
And then we don’t even tell survivors or the families what they’ve experienced. And we set them on the way and we’re like you, your heart’s beating, we’ve done our job, go live your life. So what is available to them? How do they recover from this?
Brian Peach, PhD, RN 12:23
Yeah, that’s a great question. Man, there’s a lot to unpack in what you said there. And I’ve heard this over and over again, from survivors is, you know, the cognitive piece how much they are impacted. And you know, there’s a number of different types of therapy out there. Some of which, you know, have mixed success.
There is a type of therapy called EMDR. You know, that’s been used a little bit. And it’s, I think it’s, you know, about retraining the brain a little bit. A lot of ICU diary programs. You know, there are support groups that are available on social media, for people to kind of talk through more, maybe the mental health issues around anxiety. You know, there’s different treatments like that, you know, we’re trialing a treatment right now for PTSD.
Not really that cognitive piece, but for PTSD. And it’s what’s known as compressed exposure therapy. So the idea is that we are desensitizing people, retraining their brains so that they no longer react to these, you know, stimuli that they encounter. Okay, so the idea is that with repeated exposures over a two week period, that people become desensitized. And so when they do see, you know, a helicopter or hear a helicopter or see medical equipment, that they don’t have this strong emotional reaction. And this is not a new therapy.
This is actually a pretty well established therapy. We have a clinic at our campus in Orlando. And they’ve been doing this work for years with first responders and active and retired military members and survivors, mass casualty events and people who are sexually assaulted. And this therapy has been shown to be very effective in terms of reducing PTSD.
But we’re trying late with critical illness survivors. So we’ve had some great initial preliminary results with those who have completed therapy. You know, I was gonna mention earlier, going off a question that you asked about non medical things triggering people that two of the people who have completed our therapy said that their PTSD was triggered by lawn mowers and weed whackers. And I thought, how does that tie to the ICU?
And they said that the sound that those make sounds like the bed inflating and deflating. Okay, and the one set like, I don’t know how often the bed inflated and deflated in the ICU, but it felt like every 15 minutes, and she was there for at least two weeks, maybe three weeks. So every 15 minutes that she was there, she kept hearing the sound, you know, going back and forth, back and forth. So there are a lot of sort of non hospital.
I mean, it was hospital related, I guess, but the sound that she hears outside of the hospital is, you know, just a similar sound that comes from a different piece of equipment. So, we’ve had great response in terms of PTSD, also in terms of depression. And we’ve seen increased resiliency and physical activity and improve sleep with this therapy. So we’re very excited about, you know, the pilot that we’re doing.
Kali Dayton 15:50
Wow, and what kind of data do you have?
Brian Peach, PhD, RN 15:53
Yeah, so we are screening people for PTSD and depression and physical activity, resiliency and sleep issues. Right before they complete therapy, and then two weeks out. So two weeks after therapy to see if they had any kind of response. And then three months after that, to see if that response is sustained. And I can tell you that I’ll just share scoring from one of the participants who completed therapy.
So on a zero to 63 scale for PTSD score drops from 51 to two. Her depression score on a zero to 60 scale dropped from 40 to 10. Hey, her resiliency went way up, her physical activity went way up. But you know, more than just scores. This is somebody who has dealt with crippling anxiety for the last few years. And she said, You know, I couldn’t go to restaurants because restaurants, you know, are really loud.
So people with PTSD have a hard time with loud noises. So, you know, dishes, and, you know, people talking all around them, they have a hard time in general going to places with crowds. She said, you know, two weeks after her therapy, she said, I’ve gone to two restaurants this week, my husband and I are planning a trip to Paris. Okay, this is somebody who’s largely been a shut in, in many ways, the last few years. You know, so I have somebody else who wasn’t able to work. And that’s a common thing that we hear from Coronas survivors is because of those cognitive issues because of those mental health issues. They’re unable to return to work.
This person is back working now. She had major sleep issues where it would take her hours to fall asleep each night, she would actually check her Apple Watch multiple times a night because she was afraid she would miss signs of being septic again, we’re getting really sick. So you know, she would look at her heart rate. And now she falls asleep within 30 minutes and sleep seven hours a night. So so we’ve got data to support, you know, some preliminary data is for the effectiveness of this intervention. But really, it’s the stories that impact me and like the improvement in their quality of life.
Kali Dayton 18:14
Well, I’m thinking of so many survivors that I know that still struggle with this. Yes, yeah. Is this still this is obviously still study. Yes, more participants? When and how will this be standardized? And more accessible?
Brian Peach, PhD, RN 18:29
Sure. Yeah. So we are taking participants. It is a active study that we’re enrolling people into. I have flyers that I’m happy to send people. My email address is Brian br IA n dot peach, p ach@ucf.edu. And, you know, we’d love to help people. And you don’t necessarily have to live in Orlando, although you would have to travel to Orlando to participate. But we are recruiting adult ICU survivors who are on a ventilator, and are experiencing symptoms of PTSD. And we actually screen them for PTSD. Before we can I enroll them in the study.
Kali Dayton 19:15
That is amazing. That is so exciting. And are you still at the bedside?
Brian Peach, PhD, RN 19:20
Yes. Yeah.
Kali Dayton 19:24
How has this impacted your approach to the bedside now having these experiences?
Brian Peach, PhD, RN 19:29
It’s huge. Yeah. No, I still practice as a multi system, ICU nurse and, you know, part of me sometimes, you know, I struggle with that a little bit because knowing what I know now, I think, “do I still want to be an ICU nurse?” And it turns out, I do because I love what I do. And we do have some good outcomes as well.
But I’ll tell you, you know, it’s, I’m a lot more communicative, communicative. Excuse me with my patients. Now. I used to think that, oh, there’s a day that they don’t hear anything that I say, Well, just because they’re sedated doesn’t mean their ears don’t work. And, you know, sometimes we’re talking with our co workers and, and so I really try to be a lot more present and engaged with my patients.
As I am weaning them off of sedation, I tried to, you know, communicate everything that we’re doing, I communicate where they are, you know, I try to fight through that disorientation that they are feeling about where they are. And then certainly, and this has really been something I’ve worked on for a long time. I tried to get them off the drugs, you know, try to get them up and moving.
You know, I’ve known for a long time. Just, you know, from what I’ve read, and what I’ve experienced that, you know, when we load people up with fentanyl for pain and and Versa, verse that in particular, or anatomy, or these benzodiazepine drugs, absolutely.
Kali Dayton 21:02
Versed is only second to lorazepam.
Brian Peach, PhD, RN 21:05
yeah, you know, drugs in that class? Yep. Drugs in that class are called benzodiazepines, you know, I’ve known for a long time that those drugs should be avoided. And so I’ve really kind of used what I’ve learned over the years to try to educate my co workers. At times, they don’t want to hear me, but it’s it, you know, it just like you, Kali, it’s something that I’m very passionate about.
And, you know, sometimes I think we make it really hard on ourselves, because we hit people with all this sedation, and then they’re super confused, coming off the ventilator, and they’re agitated, and they’re impulsive. And, you know, I’ve seen nurses, they get really angry, and they’re, they’re frustrated, and they’re saying, “Stop pulling it, that stop calling it that.”
And, and again, I’ve learned from the research that I’ve done that they, you know, they’re experiencing something very differently than we are. You know, there was somebody, actually a couple of people who have reported that when they were having when they were being cleaned up around their urinary catheter, that they thought they were being sexually assaulted.
You know, that’s horrifying to think about. So I think the more we can communicate with our patients, the better that is for them. I think the quicker we can get them off sedatives, the better that is for them.
I think a lot of people go for unnecessary head CTS, because we completely knocked them out. And then we wonder why they’re not waking up. And we think, oh, there must be having a stroke. And sometimes they’re just way over medicated. You know, I had a patient years ago, I walked into his room, and I think he was in his late 80s, early 90s.
And, you know, he was on I think, 15 or 20 milligrams, a Versed at an hour and huge amounts of fentanyl. And, you know, as you get older and Kali, I know, you know, this, like as you get older, you’re those filtering organs, the liver, the kidneys, you know, that filter out a lot of our meds out of our system, they don’t work as well. And so, you know, that was just kind of horrifying. And I’ve never forgotten that one.
Kali Dayton 23:12
And the beers criteria for geriatric geriatric still applies in the ICU.
Brian Peach, PhD, RN 23:18
Yes.
Kali Dayton 23:18
And probably more especially applies, right? Because you’re taking frail vulnerable people and putting them into a very vulnerable environment, and then you’re plowing them with toxic drugs? It’s a loss for everybody.
Brian Peach, PhD, RN 23:33
Yeah. Yeah. Such a good word. And, yeah, you know, I have a 96 year old grade art right now. And, you know, I think to myself, she has lived such a amazing life. I would hate for her final days to be delirious. And, you know, dealing with PTSD, and, you know, it’s just, that’s not how an older adult should experience the final stages of their life. And so, you know, it’s very troubling in that way.
So I get, I understand why clinicians, you know, they think, oh, let’s update them. So they don’t have to live this experience. But they don’t think about what happens after they leave the ICU. And I think they don’t know, I think many people legitimately have no idea what happens.
Kali Dayton 24:26
It’s not part of our education. It’s not part of our nurse education is not part of the medical education, respiratory therapy at no one location, I assume, in their undergraduate studies or their graduate studies. Nothing was mentioned about this and my acute care nurse, doctorate in nursing practice.
Brian Peach, PhD, RN 24:43
Yep.
Kali Dayton 24:44
program that was very centered on ICU care. Nothing about this. So I, if I hadn’t met survivors and do my own research, I would still be totally in the dark. There’s no way for us to know. And so then if we don’t know how do we prepare Have you change our practices in that moment? And to? How do we prepare families and our patients for what lies ahead when I have suffered delirium, right?
What do you how has this changed how you discharge patients or transfer them? Or even within your teams? Is there a way that we can improve? Preparing them and given access to resources? Like the one that you’re developing?
Brian Peach, PhD, RN 25:24
Yeah, that’s a great question. And, you know, one of the things I’ve heard from patients and families is, you know, “When I was in the ICU, I had all this care, you know, I had people coming in every hour.”– oftentimes multiple times an hour, sometimes that’s a good thing, sometimes it’s a bad thing when they’re trying to sleep, you know, they need sleep. So they don’t need you in there every 10 minutes.
And we know that, you know, sleep is really important for, you know, brain health and healing, brain injuries, so. But what I hear is that, you know, we’re in there all the time, and then they go to the medical surgical floor, and maybe the nurses come in every, you know, 2,3,4 hours, and then they go home, and they have no one, you know, or they only have each other, you know, maybe they have their family members to help.
But you’re right, the, the family members do not feel equipped. And I know that there’s a lot of great research going on into, you know, what the family members are experiencing. And it turns out that many times they experience what the patients do. So, you know, they report some degree of PTSD, you know, keeping in mind that they weren’t on sedatives, and so they were sort of living the experience of their loved one being intubated.
And, and, you know, they oftentimes report depression and anxiety. And so I think that when they are being discharged, or certainly when they’re leaving the ICU, we need to prepare them with the knowledge of, “Hey, just so you know, when people are coming off sedation, they’re oftentimes very confused. But some of that confusion can can continue after they leave the hospital. So, you know, this is something to talk with your primary care provider about, you know, make them aware that you’re having these issues.”
And really, for the primary care providers out there, one of the things that I hear a lot from our participants, is that the primary care providers don’t believe them. They don’t believe that they have PTSD, or that any of this is ICU related. They think, oh, no, this person’s just anxious a baseline. And while it is true, that some people are anxious a baseline and that this only kind of exacerbates things, there are many people that were had no mental health issues before they went into the hospital, and they leave with a trove of mental health issues.
So you know, I think the primary care providers out there, you know, in the pulmonologist who are seeing people after they’ve left the ICU and other specialists, they need to be aware that this is an issue, and that they can screen for it, that there are tools out there to screen for these sorts of things, so that we can get people to help the, you know, they need.
Kali Dayton 28:19
Absolutely. My brain is already going through, how do we get your episode out to the primary care side and bring more awareness on that side, because there is such a need. And I’ve heard that as well from survivors. They’re on an island. And then they bring this list of symptoms to their providers. And they’re met with absolute disbelief, for a little validation, and absolutely no help.
Brian Peach, PhD, RN 28:40
Yeah. And I this is something that I’ve been having conversations with other researchers about. And, you know, I just went to a couple different conferences, one out in San Francisco in January, one in Philadelphia in May, I know you’re familiar with these conferences, you know, critical care focused. And for years now, I’ve attended these conferences, and I’ve heard all about, you know, the experiences of the ICU survivor, we oftentimes use this term post intensive care syndrome.
So I’ve been hearing presentations on post intensive care syndrome for a long time now. And so I know that in critical care settings, we know this is a thing. But what I don’t think is happening is this message isn’t getting to the primary care providers conferences and to their publications. And so really, I’ve been thinking a lot about this about, you know, even though I love going to critical care conferences and publishing in those journals. I don’t know that that’s necessarily where the greatest need is at this point. So I’ve been thinking about how can we publish more in those types of journals and get that message out?
Kali Dayton 29:46
Absolutely. We have to hit it from all sides.
Brian Peach, PhD, RN 29:49
Yeah.
Kali Dayton 29:49
And we have a lot of data. We have a lot of evidence and you’re developing more on the ICU side. I think there’s enough to influence change in practices. Now we just have to take what’s been developed, really get it to the bedside, right, to prevent a lot of this harm, but we’re not going to prevent it. 100%. So we do need to start focusing on the back end of critical post ICU side, and making sure that we screen for them that we catch the survivors, because that will also save their lives.
Brian Peach, PhD, RN 30:19
Yes, 100% agree. Yeah. And, you know, it’s, it’s, I mean, who wants somebody to live like this, you know, who wants somebody, I mean, I hear this all the time, the, the fact that people are just shut in, because of their mental health issues, or that they can’t work, you know, that their cognition is so impacted, that things that were so basic, you know, one of the things I hear a lot is, “I can’t really cook, because, you know, I need a recipe. And sometimes these recipes have, you know, 20 steps, but sometimes they just have three or four, and they still have a hard time with concentration,”
and, you know, so, so things that we do in our everyday lives that are so easy to us, and maybe were easy for these people before they went into the hospital, suddenly, you know, it’s a very different experience for them, you know, reading a book, you know, things that we just take for granted. These ICU survivors really, really struggle with.
And so yeah, I agree, you know, that we really need to address the delirium piece in the hospital. And, and we, as clinicians, have it have the power to do that. It’s, and one thing I’ll just add is that, you know, sometimes I think that people get sedated heavily for our own comfort.
You know, it’s, what can we do to make our shift easier, you know, and I think we always have to have the mindset of, we’re working towards getting this person out of the ICU, we’re working on getting this person out of the hospital, if we just sit there, and we go, and we talk in the nursing station, and you know, we’re not in our patient’s room working on weaning their sedation, and working on weaning their other meds. You know, it’s great for us, but it’s not for them. And, and I think we have to own that.
Kali Dayton 32:10
Like our goal should always be having them walk home from the ICU. Yes, absolutely. And that focus on that discussion? It’s the start day one.
Brian Peach, PhD, RN 32:19
Yes.
Kali Dayton 32:20
Not on day 13.
Brian Peach, PhD, RN 32:21
Yes,
Kali Dayton 32:22
It’s day one.
Brian Peach, PhD, RN 32:24
Yeah.
Kali Dayton 32:24
Like you said, you said, we make it harder on ourselves as nurses because we start taking medications. We plow them with it, and then we as a nurses get to clean it up on the back end.
Brian Peach, PhD, RN 32:33
Yes.
Kali Dayton 32:33
And that’s the last thing nurses need right now. And so I really try to be careful when I share this information at conferences and such, because it is hard to hear.
Brian Peach, PhD, RN 32:43
Yes.
Kali Dayton 32:44
That what you’ve been taught and trained to do and what you’ve done diligently. That’s come a great effort. It’s not that easy to sedate someone it is, in a sense for that moment.
Brian Peach, PhD, RN 32:53
Yeah.
Kali Dayton 32:54
But you look at it, you’re still running at least two sedatives controlled substances that need double checking, you have to waste them. A lot of times you have to sort of vasopressor to compensate for that proper fall, then you have to give a central line for that base oppressor. Turn that every two you have days to weeks extra on the ventilator? It is a lot of work.
Brian Peach, PhD, RN 33:13
Yes. Abosolutely.
Kali Dayton 33:14
Which is worse a skill that that work. We’re used to it. To think that we do all this work for these outcomes for our patients.
Brian Peach, PhD, RN 33:23
Yeah,
Kali Dayton 33:23
It’s hard. But I always follow up with it doesn’t have to be this way.
Brian Peach, PhD, RN 33:28
Yes.
Kali Dayton 33:29
That scenario, these outcomes, these can be the minority. We know how to fix it. I think we’re really good in critical care about talking about the problem.
Brian Peach, PhD, RN 33:36
Yeah.
Kali Dayton 33:37
Over and over again, the problem, the problem- great, cool. We know the problem. We also know the solution, and it deserves probably even more attention.
Brian Peach, PhD, RN 33:45
Yes.
Kali Dayton 33:46
And the solution is to avoid sedation, optimize mobility, get family in there with liberal visitation, and prepare our patients and families with tools to be supported and to be healed after the ICU.
Brian Peach, PhD, RN 34:01
Yep. Yeah. And one other thing I’ll just add to is, you know, I think a lot of nurses don’t think about the synergistic effects that you’re pumping all these different medications and they impact each other. You know, somebody taught me this years ago, I was it was actually my PhD program where they were talking about cigarette smoke and how there’s over 7000 chemicals in cigarette smoke, and we don’t know all the synergistic effects between all these chemicals.
And so we’re, we’re pumping so many different medications into our participants, and, sorry, into our patients are there and, you know, we’re just not thinking about how they’re all interacting together, and how that can cloud someone’s mental status and cognition.
And so, you know, I’m realistic. I know, they’re probably people, maybe nurses that are listening. They’re like, “Oh, you know, no sedation, no sedation, and, you know, you just want those people to sit there with a tube in their throat.” no I mean, like, I recognize that, you know, patients are uncomfortable, they’ve got a big tube down their throat, all I’m advocating for is using good clinical judgment, to try to get these people off as soon as possible.
You know, they always need to be on the minimum minimum that they need to be that we don’t need to, you know, turn up the propofol or the first said, and fentanyl to the max that they can go to the ketamine to the max it can go. And and I’ve seen that too often, I’ve seen patients, you know, move in bed, and nurses are like, Oh, I better go give them a verse embolus. There, they’re moving. I don’t know about you, I want my patients to start crying like, I don’t want them just stuck in bed. So you know, it’s one thing to where you’re trying to keep them safe. It’s another way you’re going way over the top to try to knock them out. Because they moved to their fingers a little bit or something like that.
Kali Dayton 36:04
Absolutely. And I think that psychomotor activity is perceived as automatically related to discomfort and we make the movement stop. We’ve made the comfort to stop this comfort stop, which is obviously inaccurate. But that is the cultural training perception that we’ve received. And no one’s saying, “You know what, I think I’m going to give a couple of extra grams to increase mortality, delirium and post ICU, PTSD because I feel like it.”
Brian Peach, PhD, RN 36:28
Yes,
Kali Dayton 36:29
That’s not…. that’s not the cognitive process happening in our clinicians. But until we understand the reality of that decision in the moment, yeah, you continue to this exacerbate these practices. And so I hope that moving forward, we give our clinicians, handouts, information to pass on to our patients and survivors to say, you have suffered delirium, here’s what that is, you may have these long lasting effects.
But there are resources, there is therapy, for the cognition and for the PTSD, I’m excited to see your approach become standardized that becomes mainstream that primary care providers, post ICU clinics are saying, you’re home from the ICU. Let’s work on this. I believe it’s real, but there is hope.
Brian Peach, PhD, RN 37:17
Yeah, and, you know, we’re trying to make our therapy, very scalable. You know, that’s, that’s ultimately I think the goal is, what can we do to make it so that this can be delivered and many different places. And the other idea is, you know, it’s a two week therapy, as opposed to months and months, or sometimes years of therapy. So, you know, that’s why we’re really excited about it is we’ve seen great response in a very short period of time. And to those who have been delivering this therapy for years now.
They’re not surprised, because they’ve seen, you know, the soldiers that have responded really well to it. But it’s really exciting to see the critical illness survivors respond so well to the therapy. And I 100% agree with you in terms of those handouts. You know, and just verbal education that we can get patients and families to, so they know what to expect, so that they know to seek out care. I also think you’re spot on with our teaching and academic settings that, you know, we really need to look at what we’re teaching, that we’re not just teaching people, you know, how to turn on sedation, but also how to turn it off.
And I can tell you that my students at the University of Central Florida, they do receive that information, their critical care course, and but, you know, for those who might be listening, who are faculty, this is something to think about is how can we improve what we teach. And you know, sometimes textbooks are a little bit behind. You know, it takes time for textbooks to be published. And so, you know, there’s enough out there in the literature on this, but you can incorporate this into your teaching into your classes.
Kali Dayton 39:02
They’re also on VR goggles from exercise, that has simulations that give you really intimate insight into the patient perspective during delirium and sedation. Yeah, those should be probably standardized education requirements for any clinician that is working in acute care in general, because this is not just ICU. So excited for the future of education. I think we’re gonna have a lot more modalities to provide this understanding and equip our future clinicians with his expertise.
Brian Peach, PhD, RN 39:32
Yes, yeah. I agree. Yeah, there are some very novel tools out there. And, you know, I certainly would never wish for our clinicians to have to experience this themselves. You know, as a patient, but you know, when you have these goggles and other tools out there like this that, you know, can give you at least a glimpse of what our patients are experiencing. I think that’s a great thing. There was one I years ago I did A training or I was being trained, I should say, as a graduate student, for people with schizophrenia.
And so there were these headphones, and you would listen through the headphones while you were trying to do different activities. And so they would play all these different sounds. And I’m sorry, they would play different voices. And some of them would be yelling at you and screaming curse words, and some of them were whispering in your ear. And meanwhile, you’re trying to complete a crossword puzzle.
And, you know, I had somebody that was doing a mini mental state exam on me. And she said, who is the vice president? At one point, I had to stop and say, I’m sorry, the voices? And you know, I couldn’t answer it because of what I was experiencing. So when you have tools like this, it can be so eye opening as a clinician, and and I agree, we got to look for those sorts of opportunities and embrace them.
Kali Dayton 40:56
Well, Brian, I know we’ve talked about hard things. I think post, PSD and icy dilemma are always heavy and hard topics. But you left me with a sense of hope and optimism for the future, that we’re going to have tools and solutions for our survivors. Yes. And hopefully the all of this crosses into the ICU to bring more awareness and preventative measures. So thank you so much, I believe Brian’s email address in the show notes and as well as the transcription on my website.
Brian Peach, PhD, RN 41:22
Thank you so much, Kaylee. I appreciate your time. And I really love what you were doing for this podcast. And thank you for the work you’re doing to advocate for critical illness survivors.
Kali Dayton 41:35
There’s a whole movement happening and I’m glad you’re part of it. Thanks, Brian. Thank
Brian Peach, PhD, RN 41:38
you. Yep. Thank you.
Transcribed by https://otter.ai
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