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Are lung-protective strategies only implemented when patients are sedated? Is walking on the ventilator safe for the lungs? How do we transition from “sedating to keep patients safe” to “walking to keep patients safe”? Dr. Ali Fazili from the “Awake and Walking ICU” shares with us his expertise.

Episode Transcription

Kali Dayton 0:28
Hello, and welcome back. Thank you for your excitement and support of the webinar and consulting services. Thus far, I am grateful for the good teams I’ve met with and the upcoming collaboration with more teams this summer and fall. Check out the website, www.daytonicuconsulting.com. To sign up for a webinar and intro and consultation.

I would love to share the research through case studies, pictures and videos with your whole team. If you believe in changing outcomes through updating sedation and mobility practices, then let me help you get the rest of your team converted webinars thus far have come from one nurse or one PT, one OT or one fellow, convincing the team to just sit and listen for 60 to 90 minutes.

This has already brought changes in discussion, attitude, practices and outcomes. Once everyone understands the why, and sees what is possible, then is the discussion turns to how do we start. I will also be offering financial presentations to help administration and stakeholders be convinced of the incredible financial benefit of having a well staffed and interdisciplinary awake and walking ICU team.

This episode we have Dr. Ali Fazli from the “Awake and Walking ICU”, here to clarify concerns about lung protective strategies and advice on how to start shifting our culture towards becoming an awake and walking ICU. Doctor Fazli, thank you so much for joining us.

Dr. Ali Fazili 2:00
So I’ve been working at hospital ICU since 2016. And prior to that, I worked. I’ve been in Utah since 2002. So I worked in Cottonwood hospital, when it was still open between 2002 and 2007. And then from 2007 to 2015, I was and then I left you with her for about a year and was in another facility in New York state. So that’s kind of my experience.

Kali Dayton 2:35
You had worked in multiple facilities, and even more when you were doing your residency and fellowship. So what was it like after all of those experiences to go to this hospital, and suddenly see patients walking on ventilators?

Dr. Ali Fazili 2:53
So, you know, after finishing fellowship, and at least in the first few years of my practice as an intensive care physician, we did not see any thing like what we what I was exposed to a hospital and to some extent, because that culture had transferred from hospital as well in in when IMC opened, but not probably to the same level as is done at hospital.

So it was really initially it was really surprising that patients were awake. And you know, first of all, it was surprising to see awake patients on the ventilator to begin with, you know, immediately after night after finishing training or a few years after that. And also, then to see that these patients were actually able to participate in different kinds of therapies, and especially in mobility, and being able to walk while on, you know, not in significant amount of support from the ventilator was really surprising.

And, you know, kind of didn’t think I didn’t know, at that point. I had never thought that that would be something that would be possible. But obviously, we learned that, you know, a lot of the people that hospital were pioneered this kind of work showed us showed us that it was indeed possible and had some important benefits for patient care.

Kali Dayton 4:32
And I just recently was doing a webinar with a team and every time I present this approach, and so pictures and videos, jaws drop and it’s pretty compelling. But I had a pulmonologist have a lot of valid questions about how to protect the lungs during ambulation. The concern I think across the board is about being able to continue lung protective stuff prodigies during mobility. And part of the discussion is that I think from a pulmonology standpoint, the intensity sustained. That’s partially why we sedate, quote, unquote, so that we can control the settings, then the minimum deletion the volume because they’re sedated. So how would you explain what happens to lungs, and if this is a risky procedure, to walk on the ventilator?

Dr. Ali Fazili 5:32
I mean, as with every team, one has to make these decisions in a global context of the patient’s well being, in terms of, you know, is the patient, how sick the patient is, have we kind of gone through the different, you know, kind of risk assessment in terms of the mobility element here. And I think a good resource for that is the ABCDEF bundle.

And especially that has really good guidelines on how to do this safely, you know, on the E element, which focuses on early mobilization, and you know, if we once we have been a, let’s say, a sick, ARDS patient, who is just arrived, obviously, you know, we stabilize the patient. And, again, our focus is more that the patient is getting the care, that is evidence based?

In terms off, if we’re giving him the right tidal volumes, the ARDS net, six mils per kick, ideal bodyweight tidal volumes is, I think, the main element of that and then deciding on whether the patient should go with what kind of peep settings whether you do the ARDS net normal p protocols, or high P protocols, based on the severity of the patient’s illness.

And then once they’re stabilized in our, in the, in our ICU, we actually try and shy away from continuous sedation as much as possible. We target pain, primarily anxiety, and sometimes initially, maybe for the first six hours, 12 hours, they may need something for anxiety in form of a drug, but usually after the after their pain has been taken care of. And I think the other element, which is really important is nursing staff, and their ability to communicate with the patient on what the goals, you know, what the goals of treatment are, without sedation, or minimizing sedation as much as possible.

So that takes some amount of experience with the nurses some amount of training, to have that comfort level for the nurses themselves, and then to be able to convey that to the patients that, you know, they’re being taken care of that they’re not, you know, awake on a ventilator, and being, you know, they’re not in an abandoned state, that there’s always someone there who is constantly monitoring them. And I think our nurses are amazing that way, that they always have that expertise, that they can calm the patients down.

And I think once the patients realize that, you know, there’s someone at the bedside, you know, within reach very easily, they would prefer most of them prefer not to be, you know, asleep. So I think that, in terms of, so that’s number one, in my mind is the mindset is, and then obviously making sure that the patient is safe. He’s not like on four different pressors and, you know, PEEP of 20, you know, unstable, but once they have been stabilized, and they’re tolerating the ventilator, okay, they’re hemodynamically stable, then I think, you know, in small steps, you know, we’re not saying like, “Okay, start with walking the patient, 100 feet right off the bat.”

But, you know, “Get the patient up-can he dangle at the bedside?” make an assessment with, you know, have physical therapy there. Can they, if he’s able to do that, you know, what’s his core strength? What was his baseline prior to getting sick? You know, after those assessments, if it looks like he this patient is look strong enough, then you know, we do bedside standing dangling at the bedside and standing for some time and if that if you tolerate that and other parameters are allow for the patient to move, then we go ahead and have the patient walk, even while on the ventilator, making sure that with monitoring their, you know, hemodynamics, their saturations?

You know, it’s at least theoretically, it’s, I think, a good question what happens to their tidal volumes when they’re walking, I don’t think that has been specifically looked at any in a study, like, what happens to their tidal volumes when these patients are walking. But again, the walks are, you know, in the scheme of things, if they’re able to walk, let’s say, even three times a day, it makes up probably, you know, less than, less, definitely less than an hour, probably less than 30 minutes of total time on the ventilator while they’re walking.

And there’s, I think of paper, in kind of a review paper in intensive care medicine, or other journal of intensive care is from I think, July of 2016, which has a nice review on risks and safety and off, you know, different studies that have been done. And And overall, it’s, you know, I would say, done in the right patient population, and after making sure that we have kind of looked through the possibilities of, you know, what the impediments may be, or what the risks are, I think it’s a very safe, safe procedure. And in our ICU, it’s been done for longer than I’ve been there. It’s been done for probably close to 20 years.

Kali Dayton 11:46
Yeah, he probably started it back in the 90s. And so you’re right, there isn’t research, clearly defining what happens to the tidal volumes during these mobility sessions. And I think people assume that we’re having to stick chest tubes and people all the time. But it’s really rare.

Dr. Ali Fazili 12:06
It’s, by and large, it’s, you know, I haven’t encountered any patient that has had any in my ear, when the patient that I’ve been taking care of while I’ve been on service, I haven’t come across any complications with adverse outcomes. I think we had one patient who had a PE, post ambulation. But other than that, I haven’t come across, you know, events like cardiac arrest, or even serious arrhythmias. No, no, I haven’t come across any new metastases or, you know, bleeding episodes or, you know, patients. So I think in those from that standpoint, I think it’s fairly safe. Obviously, you know, with the right checklists.

Kali Dayton 13:00
Right. And it is a process of ongoing assessments continually. It’s not just throwing everybody out of bed, blue, an army crawling on the ground. It’s a process and you make a really good point that it is a skill set. I had a team reached out asking that the nursing staff at make a video showing how to talk to patients as they’re waking up after intubation. I hadn’t thought of that. And when I asked the team, their….

Dr. Ali Fazili 13:30
Expertise, sorry, the expertise of the nurses in, I mean, not just in patients who are intubated, and for baseline without any, you know, neuro psych problems. But we have patients with, you know, drug dependency, alcohol, you know, disorders, independence, and even those patients when they’re intubated. The nurses are amazing. They can take and really kind of get to the patients, you know, why are they anxious, and help them just with being there and talking to them? I mean, obviously, not 100% All the time. We do need so impatient with alcohol withdrawal or delirium. Sometimes do you need to use medications but not not that often?

Kali Dayton 14:26
And the nurses, I think, has it a deep understanding and respect from ability and how much easier it is to take care of these anxious wild patients after they’ve been mobilized that they innately use that as a tool. So I someone commented on a picture on social media, saying, This is why I work night shift, I would never do this. And I had, I almost laughed, but it’s really not funny. Because irony is that night shift at they do this mobility even without physical therapy present. It’s nurse driven and they will do multiple sessions. If you’ve got a patient that’s really agitated, then they sit them up at three in the morning. And that might bother a lot of people to hear because it sounds like a lot of work. But it’s also a lot of work to take care of the same patient for weeks extra, because they got so deconditioned, they were stuck on the ventilator.

Dr. Ali Fazili 15:21
Deconditioned…… And also, you know, it’s pretty clear now that the longer the patients are sedated, the longer they’re spending time in ICU, they have, you know, the post in some intensive care syndrome with further neurological and functional disability, possibly depression, post traumatic stress.

So all of that, I think, is complicated or worsened by the patient being, you know, sedated lying in bed deconditioned. And I think in you know, it’s, as you said, it’s not uncommon at this ICU to have patients who are, you know, agitated, at any hour of the day. And the nurses say, Okay, let the first thing we’re going to do is, you know, the patient can walk, let’s take him for a walk.

Kali Dayton 16:15
And ultimately, it’s gotta be less work, to go take a lap, even if it takes, you know, a little extra staff at that moment to be involved than to sit there and try to ride this rodeo your whole shift. And that’s, it’s worth it.

Dr. Ali Fazili 16:34
As you know, Polly, Polly Bailey, she will always say that the best thing for delirium is restorative sleep. And I think with any amount of physical activity, the patients do get some amount of restorative sleep, they get kind of in some semblance of, you know, a circadian rhythm going. So I, you know, in terms of safety, I think once you have kind of ruled out major issues of hemodynamic instability, and the patient is not on, you know, very high levels of respiratory support,

Kali Dayton 17:15
….Or rapid infuser. It’s not, it’s not every moment that I see that you’re going to be walking, but it’s not common.

Dr. Ali Fazili 17:26
But I mean, even you know, we have had patients who’ve come in with severe ARDS and have been on, you know, people 15 or above, but, you know, young patients who had severe either influenza, or sometimes some other kinds of pneumonia, with ARDS, and we’ve been able to get them up. These are patients who are in their 20s 30s, and even walk them on, you know, fairly high levels of respiratory support, and do it safely.

Kali Dayton 18:00
And we’ve had survivors on the podcast that talk about walking on a PEEP 18, even 20. And walking out out of the ICU, but I think those numbers make people hold their own breaths. And it makes people really nervous. But you make a good point that it’s weighing the risk versus benefits. I mean, we have never seen harm, bear trauma from walking patients, even in higher settings, the time of possible increased volumes that patients received during mobility is minut, compared to the other 23 hours that they’re under controlled settings. And then considering the host Aquila of what happens to the sedation, it’s not…

Dr. Ali Fazili 18:47
It’s unknown on, you know, if the patient is walking, it is able to walk. And if you takes no more than six mils per kilogram breath, which again, you know, if when patients are on a ventilator, and we have them a set for six mils, kick but they’re not always just reading six mils per kg with every breath.

So depending upon their, you know, compliance and dynamics of their respiratory system, and that changes breath to breath. So it’s, I think, that is an you know, as we know, that is a really important goal is six mils per gig, and as you know, evidence based definitely, but I think restricting patients and sedating them to just get six mils per cake probably is kind of stretching them a bit too far and probably is counterproductive.

Kali Dayton 19:48
Yeah, I think you make extremely good point. And yet when patients are completely sedated, I’m sure it’s rare to see anything besides exactly what the ventilator gives them.

Dr. Ali Fazili 19:58
It takes work There’s enough at least there’s enough data on that, that, you know, you know, spontaneous awakenings, spontaneous breathing trials, minimizing the amount of sedation overall, there’s more than enough data on that that’s, you know, a good practice. I think the reluctance from that step to mobility is, you know, it’s it’s natural, unless you start doing it.

And maybe, you know, in some instances, maybe you do it on patients who are not on those high level of support, you dangle them, you have them stand at the side of the bed, did you gain some experience with maybe slightly lesser sick patients who are not on peep of 18 or 20. But we’re somewhere in the middle of the spectrum until you till you gain confidence in your program, that this is a doable goal, but I think it’s it’s first, I think, in my mind, I would say is, it’s one you make that decision of change of culture, okay, this is what we’re going to try and accomplish. And then you said, you know, kind of goalposts stretch, okay, we’re going to try it on this patient population to gain some experience. If you know, and as you gain more comfort, then you kind of increase the spectrum of patients that you use it with.

Kali Dayton 21:27
That’s a good point. Because when people say, Well, my patients are too sick. I refer back to these extreme examples. But that’s not necessarily a comfortable place to start to, they already feel like it’s high risk to even have anyone awake on the ventilator, then starting out with more stable patients, just to even have the visualization of a patient with their eyes, open, calm, and up on a ventilator, I think that is a big start to changing the culture, because seems like for this scene is bleeding. And so I’ve never done it.

Dr. Ali Fazili 22:04
In terms of trying to change, practice, it’s really hard, we get kind of routed to something that we are been doing for years. And then if there’s something new that comes up, it’s hard to change your practice. But I think, you know, I would say we should start where, you know, any program is start at their comfort level, rather than impose a certain level, okay, you need to do this, but start where they are, and then kind of as they become more comfortable with different aspects of this, then kind of inch up.

Kali Dayton 22:49
Yeah, and I think that’s a good point. And teams that have started implementing this, have applied this kind of approach, starting with the more stable patients. And then they start to catch the vision and they get excited, and the rest of the team starts having more buy in. And then they start asking themselves, who else can we do this with? How else can we apply this? What else can we do? And so I think that’s, that’s a very good example for, and especially for those that are wanting to implement this with their teams. I think we expect this day and night, almost like cardioversion, we want electric cardioversion with most probably more like an amiodarone drip for AFib rather than an instant conversion. And so it’s going to be gradual. For the

Dr. Ali Fazili 23:32
it’s, it’s, it’s, it needs resources, it needs training, especially I think training both for the nurses, it needs the leadership to be on board. It needs the critical care physicians to be on board, physical therapy, occupational therapy. But I think if the leadership is on board, the physicians are on board and nurses get adequate training on the process. I think it’s it’s something that can be and should be done.

Kali Dayton 24:07
And as well as support nursing, nursing ratios cannot be three to one. Right? It’s what I’m hearing is happening a lot of places. And so I think this is a very clear example of how those ratios deeply impact patient outcomes. When you have ratios three to one, then you’re probably going to depose today and never touch any of your patients. I’m going to come back to some of the questions that people have about the ventilator.

A lot of people are really nervous about ventilator dyssynchrony. They feel like they have to sedate because patients are so distinctness and we know ventilator dyssynchrony is a very valid and real occurrence. But I asked some of our respiratory therapists, some of the nurses, how often do you see the synchrony with these patients because I felt like it was very rare. And cash one of those three therapists that you know, I think I only see it are delirious patients for the most part unless they’re severe, severe severe ARDS.

And I thought that was interesting insight. He said only when they’re coming out of sedation, you know, if they come from another setting, and we take off sedation, that’s when you really get all the alarms and the honking and the thrashing and erratic breathing. So I was just hoping to talk a bit a little bit about your perspective on ventilator dyssynchrony, and how we can, how we can identify what’s real dyssynchrony and how we can better treat it.

Dr. Ali Fazili 25:31
But that’s still that’s a long work, pretty extensive topic by itself. But I think in the current day and age, I think with most with the ventilators that are available. And with the expertise now on mechanical ventilation, Drew dyssynchrony, I think is not that common anymore, in some subset of patients definitely is. But again, you know, if you’re visibly seeing that there is a patient is in distress, and they are their work, breathing is high, and they’re really struggling, that’s a different situation.

But then even in those circumstances, then you kind of look to kind of have a float flowchart of some sort of tree that you go through what why is this happening? Is the patient in pain would be the first one to think of is the patient anxious is is the patient significantly hypoxemic despite whatever settings he or she is on. So, you know, addressing the physiological issues in a systematic manner, trying to pinpoint or diagnose what exactly is causing that distant chrony or asynchrony.

And then based on whatever assessments you’ve had, and then treating one of those, like, if the patient is in pain, okay, let’s take care of the pain, when the patient is anxious, and is anxious enough that they cannot be helped just with, you know, reassurance at the bedside, then let’s take care of the anxiety. And we need, you know, if we need a certain medications, or if the patient needs to be on, let’s say, dexmedetomidine, for some time, or even for propofol not as an in in, you know, independently just forever, but you know, to tie it over a situation for some time to you figure out exactly why is this happening?

Kali Dayton 27:52
with an appropriate RASS goal…

Dr. Ali Fazili 27:55
you know, see what their RASS what their CAM ICU is, and, you know, assess, assess the patient based on that. And then, you know, kind of go through an algorithm to figure it out. But I think I agree with what you said with, you know, with the comments from respiratory therapy that more so the, you know, the asynchrony is associated, we’re seeing more patients were delirious.

Kali Dayton 28:23
And I think there’s understanding of the respiratory system, I think we think of the respiratory system as the lungs. And if we’re on a ventilator, then we’re taking care of the lungs. But in my mind, it also involves the muscular system, and the brain. And if we’re allowing the muscles to deteriorate, and we’re entering the brain with sedation, then we’re really not benefiting the respiratory system.

So I liked your approach of going through all the physiological options or factors that could be impacting the ability to synchronize with the ventilator. And I think, because that’s a big word that’s been used with COVID patients, is that these patients are so to synchronous. But they’ve also been receiving lots and lots of benzodiazepines, heavy, deep sedation, the delirium rates are extremely high. So this seems like possibly, that this is this dyssynchrony is being misdiagnosed that it’s probably more to do with delirium than then the lungs themselves.

Dr. Ali Fazili 29:26
So interestingly, there was a paper in Lancet in January 8 on prevalence and risk factors for delirium, and critically ill patients with COVID. And they had I think this was about 69 ICUs in 14 countries. And some of the numbers on their findings were mind boggling.

So it says infusion with sedatives while on mechanical ventilation was common. 64% of patients were given benzodiazepine. beans for a median of seven to 10 days, and 71, almost 71% were given proper fall for seven median of seven to 10 days. Median RAS scores while on invasive mechanical ventilation are minus four. And at 1.6% of the patients were comatose for a median of 10 dates, and were delirious for a median of three days. So it’s like, and there were a couple of other papers also that the risk of delirium in patients with COVID is higher. But all of these patients are on, at least on those studies were on lots and lots of sedation.

Kali Dayton 30:49
That recorded days with delirium. If patients are receiving negative four, you can’t camp score him. So we’re, in my mind, I just am very confident that they were delirious for far more than three days, and COVID survivors, the things that they’re complaining of, testified to me that they were deeply delirious for weeks, not just three days in which they were off of sedation, and too weak to thrash around to them, they could finally be allowed to, quote unquote, wake up

Dr. Ali Fazili 31:22
this group of patients, you know, without having family present. I think that’s another element that helps with delirium return is having family members, you know, be part of the care of the patients. And with COVID, that’s been really hard to do, and I think has also increased the risk of delirium in these patients. So I mean, in our ICU, we, you know, the risk of or the rates of delirium in COVID patients haven’t been any higher than our baseline. And nobody gets, you know, if somebody has been on, I don’t, I can’t recall, even are the sickest of our patients being on continuous sedation for 10 days.

Kali Dayton 32:10
Has the word verse said, even been used among anyone or any discussions?

Dr. Ali Fazili 32:15
No, we don’t have anyone on her said, we don’t use benzodiazepines hardly ever, it’s for an even in alcohol withdrawal, we probably use some other medications more phenol BB, or librium, if they can take off medications. So we, we try and minimize benzodiazepine use as much as possible. We will use clonazepam through a feeding tube for anxiety.

Kali Dayton 32:45
Not to not for sedation not to come come with hosts.

Dr. Ali Fazili 32:49
So these numbers from this paper were just shocking.

Kali Dayton 32:54
That was Brenda Pun and Wes Ely,

Dr. Ali Fazili 32:59
so… Brenda Pun….

Kali Dayton 33:01
We did an episode with them and Episode 54, I just want to invite anyone that’s hearing this to go back and listen to their further discussion of that study, because that is extremely disturbing, essentially, if you listen to the survivors, even before COVID Talk about what it was like to be deeply sedated.

And many of those survivors probably didn’t get that high rate of benzodiazepine administration like these COVID patients have. And so when they talk about COVID, being so neurotoxic and all these long haulers. Clearly it affects the body long term. And yeah, I wonder how much of that is from what we’ve done to them in the ICU.

Dr. Ali Fazili 33:43
And I mean, you can also see this is happening here with all the resources that we have, I have, you know, family and friends in Kashmir, in India, in Buxton, all over Southeast Asia. So, you know, and there with the COVID search they’re having, and the pressures, their ICUs are under the harm the harm that can happen with an approach to Okay, let’s just sedate this patient and, you know, kind of put them on autopilot at that point. You know, they’re, it’s a recipe for disaster.

Kali Dayton 34:28
I am so sorry for what’s going on in your country, your people. I can. I try to be aware of what’s going on, but it’s painful even. For me, it’s distance from it. I’m so sorry for everything that’s going on there. And I think there’s a lot to be gleaned from these places that have been in crisis, New York alone, mortality rates were so high for COVID but a lot of it was because they were so deeply sedated and untouched and they spent weeks like you said on auto autopilot.

There’s no way you can survive sedation and immobility for that long. COVID aside.

Dr. Ali Fazili 35:04
Yep.

Kali Dayton 35:06
And so I think you make up so many good points when we hear the word dyssynchrony. But I would invite everyone to really think about what’s actually going on with the patient? Are we just hearing an alarm? Are we just seeing agitation? Or are we seeing coughing, erratic breathing, to cap Nia and just turn on sedation right away without really using critical thinking and assessments?

Dr. Ali Fazili 35:31
I mean, currently, we have a patient in the ICU, who is really sick, he was on Highland high levels of peep, and has, you know, his own CRRT was on CRRT. So non COVID patient, but intermittently would get, you know, almost like a panic attack. And but the nurses were able to, you know, talk to her to help her with the anxiety episode.

Yeah, did we, you know, we were trying a little bit of low-dose precedex, for some time, that helped with, you know, these episodes when, you know, she would start desaturating, not from anything physiological happening, but she would just get really anxious. And she, you, if you saw her, you could see that she was fearful, having almost like some, to some extent, from prior medical issues, like a PTSD like experience.

But with, you know, minimal amount of sedation, not sedation, but anxiolysis and with, with the, with the nursing staff, and the rest of the team, which she would she was able to, you know, do her physical therapy do dangling at the bedside, and then start walking.

Kali Dayton 36:59
And that seemed to help her anxiety. It did, for sure. And when you hit

Dr. Ali Fazili 37:05
evidence that she was getting better,

Kali Dayton 37:08
right? When you got to feel so trapped, being stuck in a bed, if they’re tied down. If they are in high pressure settings, it’s got to be very anxiety inducing. And yet, we’ve got to break this myth of thinking that sedation helps anxiety that is continually something that I’m hearing from people in the community that I’m having conversations with is because they’re like, “Well, I would be so anxious on a ventilator,”

I might be too… but I don’t think sitting mean to delirium thinking that my kids are kidnapped or that I’m being abused. I don’t think that’s going to help my anxiety. And I wouldn’t we understand what medications really do to people’s anxiety, that it induces anxiety, then we’re going to use those other tools, like you’ve mentioned, to actually address the cause of the anxiety and really treated and not just give patient like that more PTSD to deal with later.

Dr. Ali Fazili 38:06
We need to get as caregivers we are kind of, you know, it’s on from from a caregiver standpoint, it’s uncomfortable to see patients in that state. So, and we’ve been primed over the years to, you know, everything has a magic pill or quick answer. So we grab, grab those things, we grab on to those things. But if we think about the alternative modalities, which take a little bit of time, they take effort, they take a change of focus.

But if we think of those things as equally or probably more powerful, then grabbing two milligrams of Ativan, or 20 milligrams of propofol and a propofol drip. But, again, from a caregiver standpoint, I think that’s, you know, it’s a natural tendency to try and help the patient in some way and it’s uncomfortable to see them struggle. But I think if we take a step back, take care of the immediate issue. And kind of do what you know, all of us basically are trained to do is kind of think through the problem. And just reflexively jump for a quick solution. And I think, you know, all of us can get to that point.

Kali Dayton 39:38
So well said, and this is coming from a provider that’s taking care of severe ARDS. And now COVID, I see you a referral for all hospitals treats really sick people, that if they had delirium, they probably would have this quote unquote dyssynchrony. And I think if we bring in more humanity, we’ll be able to better diagnose what’s actually going on the patients and weigh the risk versus benefits before using sedation to say, Is it is it worth worsening the anxiety just to get the ventilator alarms off?

Is it worth worse? paying the price of the quality of life later, just to have a quiet night for the nurse. But you’re right, it is a skill set is the perspective and it’s a culture change. But you make very important points and so grateful for you coming on and sharing this with us. Is there anything else that you would share with the ICU community?

Dr. Ali Fazili 40:31
No, we think it’s I would just say that, you know, think about this process, kind of, you know, do it in a stepwise manner. And the first step I think, is the willingness to do it, to see it as a goal. And once you have that first step, okay, we’re going to try and do this, then the next steps can follow.

Transcribed by https://otter.ai

 

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