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Louise, ACNP, has dedicated her career to preserving lives in the Awake and Walking ICU. So what was it like for her to have her own loved one die from sedation and immobility? She tells it like it is and gives us a sobering insight into both sides of the bedside during COVID19.

 

Episode Transcription

Kali Dayton 0:03
Louise Bezdjian is one of the pioneers and main pillars of the mobility protocols in the Awake and Walking ICU. We heard from her in Episode 26, sharing her role as a nurse practitioner in sending patients home from the ICU. I have her back now a year later, with invaluable insights into her experiences on both sides of the bedside during COVID-19.

Louise, thank you so much for joining us again, I am so honored to have you back on the show. But I am also sad for under the circumstances in which we’re doing this, but will you kind of tell us a little bit about your experience with your own loved one in the ICU?

Louise 1:15
Yeah, my sister lives in Southern California. She, she’s married to Arshod. He was 74 years old. And on January 15. He was experiencing some shortness of breath. And so he went into the emergency room at a hospital that was just nearby five minutes away. And they actually tested him for COVID. He was positive but they said he wasn’t sick enough, meaning that his oxygen saturations were not low enough for them to admit him. But he had X ray evidence of infiltrates questionable pneumonia. But there’s but they send him home.

And he so that was on a Sunday. And then he went home and his disease began to progress. And I was and at that time I I kept in touch with my sister all the time. Because, you know, what we’ve seen with COVID is you know, they get the disease. And then, you know, they experience some symptoms, but it like seven to 10 days, then they begin to decompensate.

And then this inflammatory response that starts and then there, they get really sick. So I kept, you know, I kept warning my sister, I just said, you know, this may happen. It may not it doesn’t happen to everybody. But if it does, you know, you need to be sure that you get him the help he needs. So they call me on Thursday and said he’s really really coughing a lot. And he’s very, very uncomfortable. And I said and at that time they had bought an oximeter and his saturations are still greater than 90. So he really didn’t require any oxygen. And so I said, just keep an eye on him. But but you’re, you know, you’re you’re gonna have a low tolerance to take him to the emergency room.

And then on Friday, they called me in a panic because he was she said he was coughing so hard. He was blue, he couldn’t breathe. And so I said you got to get into the hospital. So they take him into the emergency room of a small community hospital. And that was on a Friday and early Friday, Saturday morning at 3am. He goes he gets intubated goes on mechanical ventilation and is sedated because he’s extremely agitated. And so and then they he get according to the report that the family got, he was extremely agitated. So they started to paralyze him. So,

Kali Dayton 3:59
He was paralyzed for agitation?

Louise 4:02
…agitation and and when he got became agitated, he was hypoxic. Okay. And we have seen that, you know, me being a nurse practitioner and a care provider for a year of taking care of COVID patients. Yes, we see that they get agitated and hypoxic. And so, you know, I think our approach was to put them on to put our patients on fentanyl because I think part of that agitation is obviously ventilator dyssynchrony.

So, anyway, they paralyze him. And they put him on multiple multiple sedatives and and the paralytic and, and they he also then is prone. And so the whole time that he’s in the hospital, he he was there for two. Well, he was there for three weeks until his death. But for the two and a half weeks that he was there he was paralyzed. For the whole time, he was sedated with and this was an all at once, but there were times when he was sedated with fentanyl, propofol, ketamine, and versed infusions.

And I, you know, and in talking with, you know, I’m here in Salt Lake there in California. And in talking with them I, you know, I couldn’t, I couldn’t, I didn’t have the heart to say to them, “this is just not the right kind of care”. I did suggest that one time, “can you see if you can transfer him somewhere outside of that community hospital?” He was he’s too sick for them to manage him. And when they even presented that, they said he’s too sick to be moved.

So, so he was prone and paralyzed for two and a half weeks, the best his ventilator settings fi02 50%, and 8 of peep. And then that he would get what they turned agitated, which I think, in my mind, was he was he was delirious, so then they would not come down again with they would paralyze and sedation him with the medications that I mentioned. And in my conversations with my sister, I would ask her, “You know, can they use something else? Can they use something other than paralytics, because he is never going to walk again, if he’s paralyzed. You know, if he’s paralyzed for two and a half weeks” -and I, nothing came of that.

And then with the practices with the ways that we are taking care of our COVID patients, you know, we tried to keep up to date with all of the new research. And a lot of it was coming out of Europe, because I think they were a little bit more prone to try some try different things and new things than we were. And so the first thing that I asked him was, you know, I know he’s on remdesivir. And excuse me. I know he’s on remdesivir. And can you can you ask them if they can extend that because with our patients we did when desert for 10 days, we didn’t just do five days, they weren’t getting any better. We put them on on 10 days. And this was under the direction of our infectious diseases, physicians.

And they said, “No, it’s not been FDA approved, we’re only going to do five days”. And then they did the dexamethasone for 10 days. And then I asked about so he’s not improving, I asked about tocilizumab. Now, understand that, Arshod only had single organ failure. So this whole time that I’m talking to them, I’m thinking, “Oh, he has a great chance of recovery, his single organ, his kidneys are still working, his hearts still working. He, he, he’s not on any and he’s not on any vasopressors for hypertension.”

So you know, I’m thinking that he’s going to be okay, he just needs more time. And so when when I asked about toclizumab, which is another medication that our ID folks, would it’s an IL-6 inhibitor to help people who go into this inflammatory response. They said, “No, it’s not FDA approved.” —Well, my goodness, you know, and neither is is two and a half weeks of paralytics. FDA approved. But with they seem to be doing that okay, without any problems.

Kali Dayton 8:32
So plenty of evidence that that is harmful if not lethal.

Louise 8:36
Absolutely. And so, you know, and so I, you know, and I’m, by this time, I am just, you know, and this isn’t about me, but I was unable to sleep at night, I was so worried about this, my sister and her daughter dealing with, you know, their their loved one who they could not see. So then I said to her, I say, “Madeline, did you ask them if you could zoom in? Maybe if he hears your voice? You know, that’ll just tell him he’s gonna be okay. He needs to just stay calm. He needs to do what they asked him to do. And maybe, you know, things will turn around.” Well, when they when they suggested that to the nursing said they said we don’t know how to zoom. Now, Kali, who doesn’t know how to zoom?

Kali Dayton 9:24
And what month is this in?

Louise 9:27
This is in January,

Kali Dayton 9:28
January. So we’re at what 10, 11 months of COVID?

Louise 9:34
Yeah,

Kali Dayton 9:34
Hospitals lockdown.

Louise 9:39
Right. And they can’t …and they cancelled. They know that they don’t know how to zoom. They have these two dogs that that are short, just loved. I said, “Record the dogs barking record, some Armenian music. Just do those things that that will sort of help him get in touch with the real world and not in this distorted delirious world that I’m sure he was in.”

There’s no question in my mind that Arshod was terribly, terribly delirious. And so they did that. And they finally I think it was like two days later, they were able to zoom and see him and talk to him and record the record the dogs barking. And according to their impression, it looked, it seemed to them, like he looked more calm, after he had heard their voice, and heard the dog’s bark. So that only occurred once in the three weeks that he was there. So, two and a half weeks, the medical team determines that we’ve paralyzed him long enough, now we’re going to stop the paralytics and let him wake up.

Kali Dayton 10:56
So he’s too weak to really fight now let him come back to his body again.

Louise 11:01
There’s no way his diaphragm was working. So they put that they shut the paralytics off. And, and he actually, you know, with with the paralytics, up, and he was still on some sedation. He really I mean, he was on 80%. And here’s the thing that, so he was on 80, he was 80%, and maybe fluctuated between 10 to 14 of peep. And that’s the other thing, they would not increase the the PEEP greater than 14. They said he was on maximum peak. Now. Also, that’s not that’s not what the critical care community does

Kali Dayton 11:39
What kind of ventilators do they have?

Louise 11:41
You just use you use as much people as you need to, to get the saturation that you want. So but he was on 80% and 2010 to 14 a peep. And, and that was just after two and a half weeks of paralytic. So then on Friday, February, the fifth, I was I was going to fly out there. That was at the time when this surge is in California were terrible. You know, people were just, they were overwhelmed with all those admissions in the ICU in the hospitals. And so my sister called me and she said, “You know, maybe you shouldn’t come, it’s not going to be safe for you.” And you know, at that time, I already received my vaccine, but I said, “Okay”, so I was going to actually fly out on the fifth. And then so I canceled my flight.

And then she called me, like, shortly after I had canceled my flight and said, they just called us from the hospital. He’s got kidney failure, and his potassium was at 6.2. And they felt like he was headed for dialysis. And you know, at that point, when I heard that, I thought, “Oh, my goodness. Now he’s got kidney failure. This is a this is going to be a different situation for us.” And so at that, at that point in time, I say, “Madeline would you like me to come out just just to be there with you?” And she said, “Yes.”

So I flew out on Saturday, February the sixth and arrived there, about two o’clock in the afternoon. He gets admitted to the ICU. Kali, like, you know, the initial admission on January the 15th. And every two, three days, these poor people would get a phone call asking about his code status. They wanted him there one of the family to make him DNR. And they would, they would say to me, you know, they want us to to make him a DNR, and I said don’t don’t do that. I said this disease takes a long time for people to recover. No, he’s only got single organ failure, there’s a chance of him that he can recover. Do not do not do that. Don’t let them bully you either. One day they got like two different groups of people to call in and ask them to make a DNR.

Kali Dayton 14:02
I feel like we’re pretty aggressive with our palliative care conversations, right? Yeah, but no one does that on….I don’t think that we would have done that in that moment.

Louise 14:11
No, you haven’t… You haven’t heard the best of it. So you know, I’m telling you, “oh, no, don’t let them bully you into making a DNR”. So I get there on Saturday, the sixth of February and I say, “You know Matlin I think this this kidney failure, you know, starting dialysis, I said it’s, it’s reasonable to do that we’ve done that without a COVID patients, but perhaps you should think about making him DNR in case if his heart stops, you know, maybe we should not resuscitate him”. Because in my mind, and I didn’t mention to them, you know, it’s like, if he survives this he’s never gonna walk. His recovery wouldn’t be pure hell. And I told her, “Matyln, it will it may take him six months to a year to even be able to do anything.”

Kali Dayton 15:10
How long will he be on a ventilator even?

Louise 15:13
Right, you know, and trach and peg. I said, you know, maybe you should think about making a DNR. And so they agreed they thought that that was that would be an okay thing. So then I said, “All right, well, let’s call the hospital and get an update.” And another thing that I thought this was really inhumane of them to do was every time so they called a morning shift, and in the evening shift, and I can’t tell you how many times they will say, “We’re really busy, we’re really busy, we can’t talk to you.”

And this, this just really was, to me, you’ve got a 12 hour shift, you can’t take five minutes to talk to a family member? Who cannot anyone who cannot see their loved one. Put yourself in those shoes. I mean, I sat down, I thought, there were times when I in my practice, stayed late so I could call and update the families and tell them how things are going. Because I thought it was very important for them to know, but they kept getting this, “we’re really busy. We’re really busy. You know, we can’t talk to you”, kind of thing.

And so then it got to the point where the family would only call once a day. And, and they felt like the evening evening coverage. Nurses were much more personable and kinder than the day staff. And so they just would call in the evening. And so, but that day, I said, “you know, let’s, let’s call,” so we called in the afternoon. And the nurses, I mean, it was just it’s, it’s like they weren’t getting any information, they had to ask questions.

It’s like, you can’t tell me in a patient in a in an ICU, was on a ventilator, that you can’t just say, “this and that’s going on, these are the labs.” And it wasn’t like this shift, it just started this was at three, four o’clock in the in the evening in the afternoon. So, right, so so they’re there, they’re trying to like, bleed this information out of the nurse. And then finally I just said ask them if the physician, “can call you just talk to the physician?”.

So she asked, and they said, “Yeah, we’ll we’ll have them call you” and this gentleman that called was actually very, very kind and very, very considerate of me, you could tell and compassionate, the compassion was in his voice. And it was just, I thought it was just a very, very kind thing for for the way that he treated them. But he did tell them you know, “He’s got kidney failure, his potassium is 6.2. We’re going to check it again. But if it’s any higher, we’re gonna have to, you know, we’re doing some things to bring this potassium down, but we’re gonna have to do a dialysis. And then the end, then he asked for consent to place a dialysis line, so they could initiate dialysis now. And he’s urine output had dropped off.”

In my practice in my facility. If somebody needs dialysis, we place the line when they need it, and we start dialysis. The time that we think they need it, especially with with a high potassium. So but you know, I said to them, “Ask them if he’s got ST changes, but they, you know that that didn’t happen because I think if you do have a ST changes, that’s even more of an urgent need for dialysis.” So, so they gave they gave consent for the dialysis catheter. And then the conversation ended and they got off the phone and I said, “Oh, you guys forgot to ask about to tell them to make a DNR” and, you know, they’re both melon and Morrow I don’t think their heart was really in it to make him DNR so they kind of just shrugged their shoulders and, and I thought, “Okay, well, that’s fine. I think tomorrow, they can place a line and start dialysis, and maybe things will be okay.”

So that night about 10 o’clock, we get a phone call from the hospital and they say Arshod is not doing well. His blood pressure is 66 over 17 And we don’t think he’s gonna survive. And so we hopped in the car, we rushed over there and we can’t get into the hospital. They’re not letting anybody in. And just at this point, I am so livid because I’m on. I’m on the other side too. I’ve let people come in. I do everything in my power to let people come in to see their dying loved one. And so the security is just, you know, giving us a runaround. I finally just said listen, her husband and her father is dying in your ICU, we need to get in there and see him. And so he opens the door. And just as we walk in, they say, “Code Blue ICU”.

And I’m like,”that’s him. That’s got to be him.” So we we rush down the hall, we get into the ICU, we have to PAPR up. I mean, we’re gowned, shield, masked. And they’re taking the crash board out of his room. And I, you know, and I said to my sister, it was his, you know, his heart. They do CPR. And so, you know, and they’re, and they’re kind of sitting there so they we stood, we stood outside of his room for a while, I think they were just a lot of people were around his bed.

And then the physician came out and he said, “Arshod, his heart stopped, we did CPR, we got circulation back, but he’s on four different blood pressure medications.” So I’m thinking, “Okay, there’s vasopressin, norepinephrine, epinephrine, and probably Neosynephrine.” And, and he said, “I don’t think this is sustainable.” And I looked at my sister, and I said, “Yeah, I don’t know what the doses of those medications are, Madeline, But that’s a lot of blood pressure support”. And then, and then he said to her, “You can’t go in and see him unless you make him comfort care.”

Kali Dayton 21:30
Even though he was dying no matter what.

Louise 21:32
Right now, I’ve done this for 28 years, 14 of those years have been as a practice, as a nurse practitioner. I have had death and dying conversations with…. I can’t, I can’t tell you how many times. I have never, ever had that kind of conversation with anyone. I have never heard any of my colleagues or the physicians I work with, say to somebody, “You cannot see them, unless you make them comfort care.”- And that’s not what we’ve done to our COVID patients.

We call them and we say, “We don’t think they’re going to survive, you need to come and see them.” We put them in a PAPR and they go in the room and visit their loved one while they’re living. So, so, my sister, you know, I think she had this aversion to comfort care. And I don’t know, I tried to explain it to her, but I think she felt like it was too much of an active, you know, to help him die. Like you’re, you know, she felt like it was killing him. So I say, “Mel, and I, you know, I think that this is, you know, this is? I think we should I mean, we should just make him comfortable.”

So she agreed, and rather than having us just leave our protective gear on, and then let them go in there and extube him because he said, “Would you do want to be in the room when we take the tube out?” And my inclination, I wanted to be in there. But he said no. And I felt like I just needed to go with him. So I went with them. I thought, “You know what, you’re going to sister and her aunt, you don’t need to be the care provider.” So I went out with him, but they made us take everything off and go into the waiting room while they extubated him.

Okay, so and they, it took a long time. I mean, they were we were in that waiting room for a long time. And I thought, “Oh, well, you know, maybe they’re doing it like we do. They’re, they’re making him look halfway decent, you know, cleaning him up?” Well, not, not quite. So they came out, they said, they said, “Okay, you can come and see him now.” So we go we go in and we’re again, we have to PAPR up and everything. And we walk in the room and I’m looking at him and I said to my sister “Mel, he’s gone.” She said, “No way.” And I said, “He’s not breathing.” And so I went over, and I palpated his carotid and he didn’t have a pulse.

And so while they were in the room, and the family was not at his bedside, he passed away. And then my niece was telling me that she saw him actually take like one last agonal breath. I didn’t witness that but she said she did and good for her because I think that that was comforting for her that she actually see him alive. The horrible thing was…. so the that securing device you know with duoderm stuff on their face on his cheek?

Kali Dayton 24:45
Yeah.

Louise 24:46
So they’ve removed that. And, and clearly he had patches of hair. That was unshaved his face was shaved but he had patches of hair, or that thing where those those patches were, that they didn’t shave. His lips or just mangled from the securing device. They had a bandaid on his upper lip. Because it was bleeding when they the when they removed the security device. Yeah,

Kali Dayton 25:16
Just beaten up.

Louise 25:18
Yeah. You know, she’s at the bedside saying, “Please open your eyes. Just open your eyes once.” and I’m just like, “Mel, he’s gone.” I mean, I, what do you…what do you do in a situation like this? I mean, he was so mismanaged in so many ways.

Kali Dayton 25:38
Yeah, what what caused what?

Louise 25:40
No, I, you know why you’d have to prove to me that that care wasn’t the thing that causes demise. Yeah, just because of the kind of care we provide. I mean, we just have a we have a patient in our ICU that’s been there for a month, who we proned for three or four days, who was terribly hypoxic. With obesity, diabetes, etc.

For Arshod, his comorbidity was obesity. He had coronary artery disease. He had an MI when he was 46 and CABG. Then and then just recently, I believe it was like in October, he was experiencing a little bit of chest tightness. And one of the, one of the graphs had had a little bit of occlusion. So they sent it, they sent it out in October. And he’s not a diabetic. So really, his comorbid condition was only obesity. He wasn’t somebody who was not in the in the connected to the health care system, because he, he made his appointments, he had a primary care, he had a cardiologist, he saw these people and had annual checkups.

It wasn’t like somebody who was an undiagnosed diabetic, who all of those things that you hear are comorbid conditions in these patients with COVID, he was not. He had single organ failure for three weeks, because he developed kidney failure on the day that the day before he died.

Kali Dayton 27:22
How much did the paralytics and 4 sedatives for weeks add to that?

Louise 27:26
I’m convinced it was, yeah, it was his care. And I know that this is your post this podcast, there are going to be people that are going to be up in arms, about what I’m saying, they can come, they can call me and they can text me, they can email me, they can do whatever they want. But I am convinced based on what we do in my facility, that his care at this at this facility was what killed him.

And I understand. I understand that people are overwhelmed. They’re getting a lot of, you know, there’s there’s a huge population of COVID patients that are coming in, you know, how we handle that? We brought in travelers and we we didn’t change our ratios. We had two to one, ICU care. And you know what, this is a life we’re talking about. We’re not talking about how much money you’re going to make or how much money you’re going to lose, taking care of these COVID patients, but

Kali Dayton 28:22
You also continued your protocols that get people better faster and get them out of the hospital quicker.

Louise 28:27
Right.

Kali Dayton 28:28
So you’ve got a situation where you’ve, you’re getting piled up, but you’re making them completely deconditioned where they cannot get out of the hospital.

Louise 28:39
Yeah! You’re overwhelming your system by by paralyzing and sedating them so that they’re in there longer than they need to be.

Kali Dayton 28:47
So let’s say you’ve ever lost came into this “Awake and Walking ICU”, how would he have been treated from day one? As far as what kind of protocols? How would he have been managed on a ventilator with his agitation and ventilator needs?

Louise 29:01
I’ll tell you how we would, it would have been managed, we would have intubated him, and if he if there was any ventilator dyssynchrony And there’s now literature coming out about the best way to manage ventilator dyssynchrony is with a opiate. So I would have put him on a fentanyl infusion. I would have I would have put him on probably, I don’t know I would have started at 50 and titrate it up to if it was and then if I needed to, I would have gone to 100.

I would have I would not have knocked him down. Well, if I had if I had to paralyze him… which we found that paralytics wasn’t even helping helping these people. So what we were doing was when we proned our patients, we didn’t paralyze them. We gave them fentanyl and dexmedetomidine or propofol if their blood pressure tolerated it when we pronedthem. But even then, we even got away we we we got away from doing propofol.

We would use dexmedetomidine/ precedex, and fentanyl. And then and then we would print them for 16 hours, flip them, and we would time it so that they would be proned about four o’clock in the afternoon. So that at 10 o’clock in the morning, we would flip them back on their back and they would get physical therapy. They would get two sessions of physical therapy, and then we will pronoun and and have them awake and participating in their care.

Kali Dayton 30:24
Now, I know listeners are going to be saying there’s no way we could do light sedation or awake proning in our patients because they’re too agitated. The only reason you can do that is because you didn’t just start them on sedation right away, and you didn’t make them delirious where they’re thrashing and fighting.

Louise 30:42
Exactly,

Kali Dayton 30:43
Unless you deeply sedate them, you allow them to be clear, you avoided agents that cause delirium, you kept them moving up until that point. Then you prone them on light sedation, and they don’t fight it because they’re in their right mind.

Louise 30:58
Right. So. So that’s what would have happened, I would have, I would have managed him and not only with fentanyl, I think these people also are anxious. Anxiety. And, and the thing about Arshod was the he’s Armenian. So I don’t know that he, some of his anxiety might have been that he didn’t really try, he might not have really had a lot of trust in the medical system either.

Right? Because I mean, he’s watching news, he’s hearing about all these people that are dying of COVID. And he thinks I’m going to be one of them. Which also is going to create some a lot of anxiety. So in my ICU, I would have put them on a little bit of Clonazepam. Just a 0.25 or 0.5- a little dose, I haven’t I in my patients, I haven’t used any more than 0.5, because I, I think that that’s a high enough dose. But I think and then we provide three, three activity. Like if he wasn’t being prone, he would have also gotten an activity at night. And that would have been just dangling at the bedside so that we can we can increase their core strength.

Kali Dayton 32:03
If he couldn’t stand up or move us that hypoxic, you at least dangle him.

Louise 32:08
Right. Right.

Kali Dayton 32:10
What is your threshold for proning? Because I hear people like your brother in law being prone, right away aggressively with not that high of ventilator settings. And that’s doesn’t seem to be what you guys do there?

Louise 32:23
Well, if they’re on if they’re on at 90%, and high peep, you know, 18,16, 20 of Peep, we prone them. And what we do is we get a blood gas before proning, and then a blood gas an hour after we prone on them. And if they’re Pa02 improved, and you know, sometimes we didn’t see an improvement. If we didn’t see an improvement, we didn’t prone them. But if we saw an improvement, we would prone them. And what we saw after two, three days of proning, when they were awake, then we weren’t dealing with delirium and agitation, which causes hypoxia. Then, after two to three days of proning, then they’re supine. And and and it’s just this disease takes a long time for for people to recover from.

Kali Dayton 33:17
But you’re getting them active in between proning. 16 hours proning and then when they’re off, you’re not deeply sedated them so then you don’t have all this build up a propofol to clear out, you’re just doing dexmedetomidine, And then taking that off, letting them get up work with physical therapy for two sessions. And then after those eight hours, they’re proned again.

Louise 33:39
Yeah, I just I I work today and I was just talking to a woman that has been in our ICU for more than a month. And so I was talking to her she we just extubated her. She had diabetes she’s she’s morbid obesity, and hypertension. And I’m talking to her and and Kali, when we prompt her, she was texting on her phone.

Kali Dayton 34:03
Of course.

Louise 34:05
Proned. Texting.

Kali Dayton 34:06
While intubated?

Louise 34:07
While intubated. Oh, absolutely. Absolutely. I would need that. Well, if she got uncomfortable, she would lift up on one elbow, just just to relieve pressure from her shoulders. And I mean, it made us all nervous because we thought she would dislodge the ET tube.

Kali Dayton 34:26
Yeah.

Louise 34:27
But she didn’t. She didn’t.

Kali Dayton 34:30
Because she knew how to protect it because she could feel it. She was in her right mind. She was connected with her environment. And we talked about anxiety, you know, all the emotional things that come with COVID. Especially at this point, when you know that it could be so lethal. I would want my phone with me to able to text my family.

If I’m in there, and I know I’ve got my three kids at home. I want to know how they are I don’t want to lay there for 16 hours and not be able to communicate with anybody. Like how much does that help? How much did it help her to be able to text her family while she was proned?

Louise 34:59
Right.

Kali Dayton 35:01
And then she actively engaged with physical therapy in between proning.

Louise 35:04
She did. So what we’ve done with our COVID patients is, you know, we bring in a foot bike. So they sit in the chair and they pedal, and physical therapy is in there and they pedal for 10 minutes.

Kali Dayton 35:19
A foot bike. That’s brilliant, because I know they were walking wall to wall, but that’s still disrupts the cardio workout, right? That way they can do continuous activity within their own room.

Louise 35:30
Physical therapy goes in the room, they’re either in their PPEs, and they and they have the patient ride the bike for 10 minutes, coaching them, and then they have them stand and walk around the bed, back and forth. If they can, some of them can’t. And then eventually… and my conversations with my patients. You know, if you intubate them, you have to have sedation for them to be intubated. I mean, that that’s, there’s no way that I would promote that we don’t use sedation to intubate somebody.

Kali Dayton 36:03
Yeah, of course.

Louise 36:04
But we let them wake up. And we, we tell them what’s going to what they’re gonna feel like when they when they’re before they’re intubated, sometimes we don’t have a chance to do because there it because it’s in an emergency situation. But we let them wake up. And we explained to them, “That tube is helping you breathe, it’s keeping you alive.” And we keep doing it, instead of knocking…. instead of turning their brain off. And you know, I know that there’s a lot of facilities that do like, like daily sedation vacations. I’m opposed to that. And I don’t even know how we could even study this. But you can’t turn off and turn on a person’s brain, like you do with sedation and think that that’s okay.

Kali Dayton 36:45
I’m actually hoping to get a physician on who she herself was an ICU patient. And she talks about the sedation vacations, the way she described, she has a book about it, but the way she describes it is just haunting. I’ve always wondered if it was like someone drowning, putting their head into the water, bringing them up and putting them back down and never could clear.

Louise 37:02
How could it not be? How can you how can you show somebody’s brain out for 16 hours and then turn it back on again and not think and not think that they’re not going to be agitated and and and ….just don’t do it! Don’t create the monster,

Kali Dayton 37:18
I think that we can bring them trials definitely have a place, you know, when we have had to paralyze people and deeply sedate people, you know. On those rare occasions. Yet, to do it as a standard, I think it’d be very difficult to implement because when you take those breaks, they come out swinging, and that it creates more work. I’ve used the example of it’s like biting off a grenade and passing it down shift to shift and someone’s gonna have to handle the explosion, when it’s their turn to do the vacation.

Louise 37:46
I’ve gotten to the point where if if, like overnight, somebody put somebody on propofol, and I want them off the propofol, so I can do activity with them. I’ve gotten to the point where and everybody “Oh, you can just turn it off. It’s short acting, you can just turn it off.” I’ve gotten to the point where I don’t even do that anymore. I wean it, I half it and I over an hour I get the propofol off. Because I think when you shut it off like that and bring them up hard that then you end up having to just go back on sedation, because you know you had them so deep, and then you turn it off. And they wake up just like what the hell is going on around me??

Kali Dayton 38:28
And so people just assume that that’s how it’s gonna be all the time. So when I say that, “our patients are not comatose, they’re not under deep sedation. They’re hardly ever even lightly sedated.” They imagine that people are just flailing and fighting and expressing that kind of terror the whole time. But that’s not been your experience, especially with COVID. Right? What, what is the discharge disposition for most of not all of your patients, even during COVID?

Louise 38:53
You know, I wish I had that information for you, the ones that the ones that actually have, like contacted us and mostly through your podcast, have gone home. I mean, they’ve like, you know, and when they, I would say all the patients that that we’ve had, you know, they’ve went to nasal cannula. And then we said we we transfer it to the medicine ward. And I, you know, we’ve hardly any trachs, the tracheostomy, so we’ve done have been on patients with pancreatitis and who develop ARDS.

But our COVID patients, the ones that are that, you know, have the comorbid conditions and, and I mean they’re I mean, it’s inevitable, you’re gonna have deaths, right? But a lot of them, a lot of them. A lot of them we avoid intubation. We do high flow, and we put them on CPAP at night just because I think they need some of that positive positive pressure. But during the day they go on high flow. You know what some of them have been on highflow for for two, three weeks, right? And they self-prone. They either lay on their side, or they lay on their belly while they’re on the high flow?

Kali Dayton 40:10
Are they still getting out of bed on the high flow. Are they What? Are they still getting out of bed on the high flow?

Louise 40:16
Absolutely.

Kali Dayton 40:17
We just had an interview with the caretaker down in one of the southern states who said that in her about her COVID unit. It was mandated it was just across the board. “Anyone on the high flow does not get out of bed.”

Louise 40:29
Oh my gosh.

Kali Dayton 40:30
So what what happens? These people can sit there for weeks on HiFlo. Except, their intubation rates were really high. And I’ve always wondered, how much does that contribute to intubated? If you’re having people rot for two weeks? How are they not intubated after that?

Louise 40:45
I mean, you you’re a healthy young lady. So you got you had the flu for three, four days, and you laid in bed, we you just weren’t, you just were not feeling well. You didn’t. And and, and you get up or go to the bathroom, you maybe get up and have something to drink something to eat. But how profoundly weak are you for a while after that? These are people that are critically ill with these cytokine releases that I think affect your muscles.

Kali Dayton 41:16
Hypermetabolic state…

Louise 41:18
To make them lay in bed and not move. It just it’s counterintuitive.

Kali Dayton 41:23
And on top of that, my friend’s dad was in the COVID unit on HiFlo. He’d been there for five days. I think by the time she talked to me about it. He wasn’t hungry, probably was hardly eating at all, was not on a feeding tube, his respirations were in the 40s. Doesn’t nutrition play a part here? And so we’re gonna have a future episode on that as well. But I feel like people on high flows are also being severely mismanaged. And that has to contribute to the intubation rates, and especially the mortality rates.

Louise 41:53
Right.

Kali Dayton 41:53
If you’re starting out to really condition before you can get intubated. You’re your chances are shot.

Louise 41:59
Yeah. How are you going to move your diaphragm? You know, a lung that might become stiff. How are you going to do that?

Kali Dayton 42:03
But your COVID patients that have been intubated for weeks are still being extubated without tracheotomies, correct?

Louise 42:11
Yes.

Kali Dayton 42:11
Have you had a trach any of your COVID patients?

Louise 42:14
Yes. And mainly because there were two that were had interstitial lung disease, and got COVID. One of them was an 84 year old guy. And we kept recommending for the family to make him comfort care. And they refused. absolutely refused. And we ended up having to trach him.

Kali Dayton 42:29
Yeah, that’s a really difficult combination.

Louise 42:35
We were so conflicted as care providers, we were conflicted. Because because we knew it’s like, you know, we tried to explain to the family, “you have an injury in your arm, you cut your arm, you have a scar, that scar is always there. It doesn’t go away. This is what’s happening in the lung. It doesn’t go away. He’s got a lung that’s full of these scars”. But it was just…. and the patient and it was difficult because the patient, you know, he was done, but they weren’t. And so we trached them.

Kali Dayton 43:07
But that and that’s such an anamoly.

Louise 43:10
That’s not because of the care they received.

Kali Dayton 43:12
That’s not because of these deconditioning.

Louise 43:14
Right? It’s because of this the nature of this COVID and his age. I mean, at 84 years old,

Kali Dayton 43:20
and ILD alone.

Louise 43:21
Mm hmm. Yeah.

Yeah. So but but when he first came in, he was doing laps around the unit. Yeah,

Kali Dayton 43:30
While intubated?

Louise 43:32
Yeah.

Kali Dayton 43:32
And then your patients are walking in. And they’re walking out?

Louise 43:37
Yeah,

Kali Dayton 43:37
Even after weeks on a ventilator. I do little surveys on Instagram. It’s been really interesting to hear kind of what’s going on around the country and even even the world. I asked, “Who had physical and occupational therapy removed from their ICUs when COVID hit?”- And about 40% of people answered, “Yes”.

Louise 43:58
Oh, my gosh,

Kali Dayton 43:59
How different with outcomes of those patients in the wake and work in ICU be if our vital therapies were removed? It’s still a common thing or people still say that physical therapists will not see their patients until they’re extubated.

Louise 44:17
Wow. Honestly, and this is going to really be controversial, but I think this half a million people that have died due to COVID in the past year. Half of that is mismanaged care. At least.

Kali Dayton 44:33
I mean, you see, you see the difference in mortality rates, you know, New York, that article that came out, you know, 88% died on ventilators. But then once it hit our unit, the mortality rates were in the 20’s.

Louise 44:49
I mean, clearly we, I mean, this is this is how how, I mean, I can remember I had I had rotator cuff surgery. So when I came back, that was when COVID was really unlike just really hitting all the hospitals and stuff. I told Polly, I told my colleague I said, “You know what? This is crazy that we’re intubating patients after six liters of oxygen. This is respiratory failure. We know how to manage respiratory failure. Why are we intubating somebody after six liters of oxygen? We can use high flow, we’re reusing a PAPR anyway. So why are we doing this?” And so we stopped doing it.

Kali Dayton 45:29
We kind of secretly stopped to do it.

Louise 45:32
Yeah, we did. We said, “No”, when you know, and so we didn’t tell anybody. We just we put them on high flow, we put them on CPAP. And you know what? I think we saved their lives.

Kali Dayton 45:42
I believe it. And even when we were we did intubate a few people, after six liters, we kept them awake and moving. Everywhere else, you get the ventilator, you get sedation. Hand in hand. And so how many people died, because of all the complications related to sedation and mobility?

Louise 46:02
You know, people need to understand that it isn’t scary to have somebody awake on a ventilator. We don’t have self extubations.

Kali Dayton 46:10
No,

Louise 46:11
A few of the self exhibitions we had, what because we couldn’t get in there. Because we had to PAPR. And they were proned. And the and the ET tube became dislodged. And it moved it.

Kali Dayton 46:23
It wasn’t even full extubation, it was dislodged. And just like Dr. Ely’s research shows that the success rate is higher, even if there is a complication that ET tube Or they do self-extubate. They’re able to stay alive because they can breathe for themselves because they have the strength. And we saw exactly that with these very rare few occasions or events that happened. They’re fine.

Louise 46:48
Yeah.

Despite the high ventilator settings.

Kali Dayton 46:51
I was looking at your Instagram page, and I saw Hurwitz, who it doesn’t hesitate to let everybody know that, “Yes, you can use my name. Yes.” So that’s why I’m saying, I’m not breaking his HIPAA. Right. You know, but he was one that had to dislodge twice because he moved. But but the unique thing about him was, he came in, right when he was diagnosed.

We intubated him, he was doing activity for a week. And then the inflammatory process kicked in, and then he was really sick. And we did prone him. And we did paralyze him. And then and then when he was able to come off the paralytics. He hadn’t lost that much, because we had done it the week before.

At 69 years old, and six weeks later, for his 17th birthday. He was out golfing, two weeks after that he walked eight miles golfing. So and this month after discharge, he was walking eight miles,

Louise 47:49
and we got a Christmas card from him on the ski.

Kali Dayton 47:52
Oh, I love it. Yeah, that’s, that is not a rare story. It just happens to be that he’s been so kind to let us share it far and wide.

Louise 48:02
And when We will, I mean, he’s, he’s our blessing. Yeah.

Kali Dayton 48:07
And this should be the standard of care. I mean, I’ve had so many people say, “I would love to work at that ICU.” And I really feel like if people understood how to implement these protocols, the why behind it all, they could recreate their own awake and walking ICU. And this is the standard be…. I agree- mortality rates would have been completely different during COVID, Had this been the standard.

Louise 48:33
You’ve got to think outside the box. This is a …..this is…. you’re influencing someone’s life for the rest of their life.

Kali Dayton 48:41
And you have to see them as human and treat them as human but it’s so easy to miss that when you just automatically sedate them you never really see into their eyes and their soul like you just did you become a body in the bed.

Louise 48:52
I used to hold I used to hold my patients hands but I’ve never I’ve never consciously done it as much with this COVID As I have because the only human touch is not their family. It’s us.

Kali Dayton 49:08
And to not have had zoom and when we’ve done zoom from the very beginning we even set up a system to so they could text the nursing station from inside the rooms on their phones. I remember throwing a huge fit because one of the transferring facilities didn’t send their phone with them because “they had COVID”-it was contaminated with the patient has COVID you cannot send a patient without their phone.

They have to be able to talk to their family that was that was that was the very beginning of it all. And yet, here you are two months later and I didn’t know how to use it with that actually. That brings tears to my eyes that how many patients were absolutely completely alone that whole time and last and delirium and their last mortal moments for and complete terror and hallucinations. You know

Louise 49:55
What if he was in my ICU I would have told them to bring the two dogs in to come see him.

Kali Dayton 50:00
Oh, yeah,

Louise 50:02
I would have.

Kali Dayton 50:03
Oh, yeah. We have animals come into the Awake and Walking ICU while patients are intubated because they can interact with them.

Louise 50:10
Yeah. I mean, we we fought and fought and fought about the visiting policy with ours. It’s like, they, in fact, I, I think I have, I have huge issues with how we even started to do that. It’s like, why, why? Why are we keeping them out, they can wear it an N95 and a mask over that and a shield, and we can put a gown on them, and they can come and visit their loved one,

Kali Dayton 50:34
…and especially with their family members that have already had COVID.

Louise 50:38
I’ll give you a perfect example, Kali. We had a guy that, that has been in our ICU, almost a month, okay. And he, he got better. We extubated him, and then he got worse. And I think and this was like a bacterial pneumonia. I think he’d like he developed like MRSA pneumonia, which did happen with some of our COVID patients. And so he was like, on 90% 18 a peep, and I suggested to the attending, I said, “I think this guy needs his family to come and visit him. I think he’s at the end of his life, and he cannot not see them, and they cannot not see him”. So they said, “Yeah, I think, yeah, and they will allow visitors. If it’s COVID if they’re, if we think they’re dying. ”

So I called his wife and and I said, “You know, I don’t know if we can get him through this. He’s on a lot of support. I think I think you should come and see.” And she said, “Well, I haven’t you know, there’s my daughter.” And I said, “Yes, you can both come and see him.” And unbelievable as and….. I feel like a jerk, actually, because I told her I thought he was gonna die. Right?

They come and see him. And the next day. He’s on 60% and 10 of PEEP. And I talked to him today. He was extubated. And I said, and I said, “Hey, wow”, I said, “This is amazing. This is amazing that you…. that your family comes to visit you and you turn around and use your you’re..” like- we extubated him! He’s on a moustache cannula.

Kali Dayton 52:16
When most facilities like you were saying, don’t even go to the kind of vent settings that he had on.

Louise 52:21
Right. And so and so the next day, my colleague is taking care of me. She’s like, “Oh, he’s doing so good.” I’m like one. I said, “No, I feel like a jerk because I told her he’s gonna die. Because I honestly thought he was”. When I said that to him today. I said, “Oh, I think it’s just remarkable”.

He said, “You know what? I needed them. I needed them.” Not us and our screwed up care. He said, “I needed them.”- They were his life saving intervention.

And he said they needed me. I said, “You’re absolutely right.” And I walked out of the room, and I thought, “What are we doing here? What are we doing?”

Kali Dayton 53:08
We’re doing all the things that we know are harmful. We’re doing all the things that we know. We know do not help patients.

Yeah. Well, what I mean, listening to that podcast you had with Wes Ely. I mean, we’ve gone back 20, 30 years.

And all the things Yeah, in every way possible.

Louise 53:26
And that’s what prompted me to call you and say, “Hey, I need to tell you about my brother in law’s experience. This is a horrible, horrible.”

Kali Dayton 53:36
I have my hope and my my desperate prayers that COVID will help us see distinctly and clearly what happens with sedation and immobility. Or we could just get used to it. And that could just be the standard of care even more so. And we could just reverse decades of work.

Louise 53:55
Interesting. Interesting how quickly we went to it.

Kali Dayton 53:59
I don’t understand. I don’t understand. But that’s coming from an Awake and Walking ICU, where that’s against our instincts. And yet, it’s almost like people were still kind of on the fence. Like they knew it was more convenient to sedate. But they knew we probably shouldn’t be didn’t necessarily know the why. But COVID should be showing very clearly, though, why people should be sick of traching and pegging and watching people be flat on the bed. So they should be sick of it by now.

Louise 54:24
And quite frankly, I mean, to be really quite honest with you, when they don’t have been later those ventilators filter 99.98% of the right, so you don’t even really need to be in a PAPR. The only the only concern is if if it becomes disconnected then you’re aersolizing. But how many times has your event become disconnected? On a patient that you’ve got on a ventilator? How many times I mean, we should count it.

Kali Dayton 54:56
I can probably count that off for like, two hands. But not all fingers.

Louise 55:01
Yeah. So I, I just I, I think we’re doing this knee jerk stuff that I think is harmful, it’s not helpful to the patient. I, you know, it’s just me and my little small world, but I hope I make a difference in my patients that I take care of. And, and, and as far as I can tell, they get to go home, they get to be with their loved ones.

And you know, the the what the virus does, the virus will do. I can’t stop that virus from doing what it does. What I can do is keep our patients strong, help them get home so they can lead some kind of normal life. And over time, it’ll be interesting to see the cognitive effects of this virus, but it won’t be because of me, sedating them, it’ll be the virus itself.

Kali Dayton 55:48
Yeah, we need to be tracking our survivors, compared to everyone else that’s had sedation, because we know that sedation breaks brains and high suspicions that the viruses as well. So you’re right. A Doctor Swami, on another episode, he gave the example of “we don’t treat tachycardia with beta blockers.” Why do we treat delirium with sedation? It makes no sense at all.

But I’m preaching to the choir, you’re the one that taught me all these things. And you do make a huge difference, Louise. Without you and all your work, your decades of dedication to this process of care and the team that you’ve built. There would be nothing to talk about here. I wouldn’t have a podcast. But I have tons of people reaching out with so many questions and wanting to implement these principles is the standard of care because of what you guys have shown is possible. And someday, I know…. someday my lifetime, this will be the norm.

Louise 56:45
I hope so. I hope so. Kali, I am proud of you how you’ve carried this forward. And as a professional, this is the best thing I could ask for.

Kali Dayton 56:55
Well, your legacy deserves to live on forever. You guys have done this for decades. You published that article in 2007. You and Polly and yet, here we are 2021 talking about the same things, trying to prove to the world that it is feasible to walk on a ventilator.

Louise 57:12
something different. Let’s talk about these people that are going home and having some kind of quality but instead of convincing people that this is not what you should do. Don’t do it!

Kali Dayton 57:22
Do it in the end, your patients in HiFlow, our self proning, they’re walking, they’re hustling out in the rooms. If they end up intubated, they’re still awake, walking, moving, hustling, they’re proned, we check to see if that’s even effective. We do that for 16 hours while they’re lightly sedated- if that. Often they’re texting on their phones while they’re proned, then they get to be up and moving another eight hours and back to proned.

Louise 57:45
And, you know, the other thing that I think, is really interesting that, that when I explained to my patients…. and you can’t do this if they’re sedated. When I explained to my patients on a ventilator, I say, “Look, this is this is our plan for you. You have a virus that’s made you very, very sick. What we can do actively is to keep you strong, so that when your medical issues are resolved, you will go home and not recover in a nursing home. So when we ask you to get out of bed when we ask you to ride that bike in the chair, help us because it will only help you.” – I have never had anyone say, “I don’t want to do that. I want you to sedate me.”

Kali Dayton 58:32
Yeah, I’ve asked that. I told patients when I’ve invited them to come on to the podcast, right? A lot of times they’re actively intubated. And I’m like, “Hey, when you get better, let’s talk about this.: And when I tell them, “In any other hospital right now, you would be deeply sedated.” They look at me like I’m crazy. And I can tell see in their eyes.

They even write it on their paper. “Why the H would I be sedated? Why would I need sedation?” And I say, “Yeah, that’s the question I’m asking all the time.” So even all the actively intubated, they’re not begging to be sedated. You’re completely…

Louise 59:05
I mean, I mean, there are nurses, travelers that say, “Well, if I’m on a ventilator, I want you to sedate me.” And I said, “Because you want to be you want to be on a ventilator for five, six more days than you normally would be?”

Kali Dayton 59:16
Because you want to “Post-ICU dementia, because you want PTSD or what?”

Louise 59:19
They look at me, and I said, “because that’s what’s gonna happen. If I sedate, you don’t do mobility, you’ll be on a ventilator for five to six more days than you normally would be. So you tell me what you need.”

Kali Dayton 59:33
But that’s not the shared perspective, right, because we educated people on the why,

Louise 59:37
You know, and we had a really stimulating discussion that one night when I was working, and somebody said something about sedating, and I said, “So, is that a treatment for respiratory failure?” And the respiratory therapist, was like, she jumped into that conversation, and she said, “No, it isn’t!” and she said, “but everybody does it!”

I said, I know it. If you can show me that sedating somebody is treatment for respiratory failure, for ARDS, for COVID, then I will be the first one to write that order. But you show me how that’s treatment. It’s not.

Kali Dayton 1:00:14
We talked about evidence-based practice- all the time. And yet in this element we are doing the exact opposite of what the evidence shows.

Louise 1:00:23
Right. So it was really, really good. And then and then it was like, “Well, what about O2 consumption?” I said, “It’s overrated. You’re not You’re not decreasing 02 consumption by sedating someone. That’s overrated.” I said, “I can get a gas, And I can see what their Pa02 is, and I can manage that. That’s overrated. If I have somebody calm, awake, participating in their care, I’m not going to come to compromise their 02 consumption.”

Kali Dayton 1:00:51
People always a ventilator to dyssynchrony. Most of the time when I’ve seen it, COVID aside, is when they’re agitated, their biting, they’re thrashing, they’re delirious. The delirium causes the dyssynchrony. And I swear most of what people are talking about, and they say, “Oh, we have to sedate because they’re dyssynchronous.” —No, you’re just sedating them because you’re making them delirious. And anytime you bring them off the sedation, they come out swinging, and that doesn’t jive with the ventilator. But they’re making the patient work for the ventilator, not the ventilator work for the patient?

Louise 1:01:24
Right. And the reason why we use fentanyl for, and it’s really pretty effectiv for ventilator dyssynchrony is because it works on the respiratory drive. Yeah, that’s why we use fentanyl.

Kali Dayton 1:01:36
And that’s how my big nuance for COVID. Because most of our patients with respiratory failure, do not require opioid support, let alone those higher rates. But COVID is a different animal.

Louise 1:01:47
Yeah, and we’re not creating addicts, you know. As soon as we can get them off. In fact, they don’t stay on fentanyl while they’re on the ventilator. We wean them off once they’ve gotten used to ET tube and can, you know, do their activity and stuff like that. Sometimes they’re just done a whiff of… just a drop of Clonazepam, and then they’re fine.

Kali Dayton 1:02:11
So I mean, for 24 hours, you’re doing the fentanyl drip.

Louise 1:02:15
I mean, they’re not fentanyl for weeks and weeks and weeks, they might stay on fentanyl for two or three days, and then they’re off. Oh, yeah. Oh, we’re not doing that.

Kali Dayton 1:02:23
No, Tyler when he talks about walking on ECMO. Talk about the fentanyl drip he had and how hard and awful it was to come off of it. And I think we definitely don’t talk about that. We don’t hear about that, because our patients are too delirious to tell us how terrible withdrawal was and how much that contributed to their delirium. But that’s something to definitely keep in mind, we do that if that’s necessary.

Louise 1:02:48
Now, it’s just I, you know, what, you’re gonna have to prove to me that what I’m doing is wrong thing, because until until I retire, stop doing this, this is the way I’m going to take care of patients. You’re going to have to prove to me that it’s wrong. And you can’t.

Kali Dayton 1:03:04
You can’t, and Louise, I don’t think any other ICU in the country and maybe even the world is sending patients walking out of the doors of the ICU. And then going home.

Louise 1:03:16
You saw that with her Hurwitz. You saw that with the Carter.

Kali Dayton 1:03:20
Yeah, I mean, everyone, no one loses their ability to walk during this.

Louise 1:03:23
I mean, Kali, you, you witness that with, with special needs patients who you can’t even…you can’t even….. it’s like, the ability to reason is not there.

Kali Dayton 1:03:35
And yet they use all these non pharmacological approaches to keep him calm.

Louise 1:03:39
And they’re not sedated! Yeah. I don’t know.

Kali Dayton 1:03:45
I could talk about this for hours. That’s why I have a podcast and I love it. So so much, and I am going to keep having you on because you are a voice of reason, Louise. You tell it straight. And that’s what we need. And you have decades of experience- so much expertise in this.

Louise 1:03:59
Thank you for giving me this opportunity, because I feel like if I can’t share this experience about what happened to them….. In fact, I’m taking this further, I’m writing a letter. I was referring to that stuff. I looked at it before I got on a zoom call with you. I’m sending a letter to the LA Times to the New York Times, and to the administrator of that hospital about the way he was cared for. And this is this is the least I can do for my poor sister and her daughter for what they had to go through. It’s horrible.

Kali Dayton 1:04:36
And yet I think it’s it’s been a little bit normal and circumstances are so difficult, but I don’t think our community is realizing how much these practices contribute to the the burden of the overflow.

Louise 1:04:48
Yep, it’s…. I… I don’t know. I mean, I’ve said…. I’m sitting there and I’m thinking, “I’m a part of the system. I’m a part of his health care system. And yet, my, my care is so different than what I’m seeing this guy get.”

Kali Dayton 1:05:08
Same country, same system, completely different approaches, and obviously completely different outcomes.

Louise 1:05:14
Yep. Yep.

Kali Dayton 1:05:16
Well, thank you, Louise, you’ve done so much and you’re doing so much Keep us posted.

Louise 1:05:19
He’s a casualty. Thanks, Kali. Keep it for going, I love you for it. See ya.

Transcribed by https://otter.ai

 

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