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What is like to be intubated in your own ICU? Even when the environment and team are well known, what does an intensivist turned patient experience? Dr. Meta van der Woude shares with us her personal journey through the ICU.

Episode Transcription

Kali: Dr. Van der Woude, thank you so much for coming to the podcast. Can you introduce yourself? And I know I’m not saying your name right. So say your name perfectly for everyone.

Dr. Van der Woude: Yeah. Hi Kayleigh. Thanks for the invitation. I’m really honored to be in this podcast as a European guest. My name is Meta van der Woude.

And I’m an anesthesiologist and intensivist in the Netherlands. And I’ve worked for more than 20 years as an intense care physician in a 28 bed ICU in the Netherlands in the Southern part. And my main topics of interest are mechanical ventilation and delirium. And furthermore, I used to be responsible for the post ICU follow up clinic in our hospital, where we saw four ICU patients and their family three months after their discharge from the hospital.

And at this moment, I work as a teacher for ICU nurses and as a researcher. Excellent. And before you started working with patients and had some personal experiences, which we’ll get into when you started your career and most patients on the ventilator were sedated, what was your understanding and your perspective of sedation?

when I begin with my career it was usual that all patients were fully sedated and sometimes even relaxated for many days. And it was difficult to tell and explain to the nurses that that the deep sedation was not necessary, but even that the deep relaxation and the continuous relaxation during days.

Not what necessary was because patients will not jump out of the bed when they are laying on the ventilator. But it was really a new mindset that we had to go in. And during the 20 years of my work in the ICU We have patients more awake and we really less sedatives in the patients only during the nights when they were delirious, you will get questions from nurses who are asking them, okay, you’ll give them some Propofol that they have a nice sleep and they are being quiet for the night.

Kali: And now, what’s your perspective? I mean, now you have a very invested interest. in delirium. So that must change a lot of things for you as far as how you see it. How did you become so interested in delirium?

Dr. Van der Woude: Now, in the past, the focus in ICU was mainly on the survival of the patient, and delirium was very difficult to recognize.

And it seemed to be more or less part of the deal for being an ICU patient that you will be that you also got a delirium, and it was also not recognized as being harmful for patients. And until the beginning of this century it become clear that experiencing a delirium had consequences, negative consequences.

And it was at that time that I got interested in this topic. So I started with introducing in our ICU, the pain, agitation, and delirium guidelines. And I collaborate, collaborated also in some research in on delay prevention. And I found out that we used cICU that is very difficult and there’s also a high barrier sometimes to, to do those kind of assessments.

Yeah, even, and especially when it’s very busy in the ICU, people, nurses, won’t do the, the chem ICU assessment. For example, during COVID time, I think hardly no one was assessed on the delirium.

Kali: And I see here in the States, a lot of our newer nurses that came in during COVID, They haven’t really been taught how to do the cam, or at least it’s not reinforced.

And so when I’m training teams, that’s a big gap that I noticed is that they say, “yeah, we know how to do the cam.” And I don’t think they’re intending to be dishonest, but I don’t think they, they don’t know what they don’t know. So when we actually practice, it is when we realize that they haven’t really been instructed on how to do it.

the proper way. And so it’s hard now to really trust our delirium rates when we are not really screening for them appropriately. And what’s your personal experience with delirium?

Dr. Van der Woude: Ah, my personal experience. maybe I have to start when I how I did enter the ICU as a patient myself.
Absolutely. Then I will first start with a sketch of the situation in Netherlands in 2020.

So at the end of February, 2020, we got the first COVID 19 patients in the Netherlands in the hospital and on March 5th, the, our first COVID 19 patients was admitted to our ICU. And from that moment on, we got more and more patients day by day. And for me, for myself, I wasn’t afraid of getting COVID because I was relatively young and healthy.

And at that time, there was a lot of discussion going on in our country. And the opinion was that COVID 19 was comparable with the flu. And furthermore, our government was sure that we should not get a situation like in Italy. For example, for the United States, New York, but that was later on. Yeah, but unfortunately the same thing happens in the Netherlands as in New York and Italy.

And in March, 2020, we were flooded with a lot of patients and our government decided to lock down. And everyone had to stay home, schools and offices were closed, shops, restaurants, sports clubs were closed, visitors at home were not allowed, and we even had a curfew every evening. And in our hospital, we worked very hard to treat all the patients.

And at that time, there was a really extremely high mortality. Many patients died under our hands without us being able to do much about it. And it gave us an enormous feeling of powerlessness. And after two weeks of taking care of the very ill patients, I got ill myself and I tested positive for COVID 19.

And I stayed home and every day I got sicker and sicker and four days later, I felt so sick that I asked my husband, please bring me to the ER because I was so sick. And there I was admitted in isolation and on the COVID Mart with oxygen and started with chloroquine because that was at that moment the only medication at that time that possibly could influence COVID 19.

But unfortunately, my oxygen needs increased and four days later, I was admitted to my own ICU. And that was why I got my first personal experience with delirium. Wow. So you were a COVID 19 patient in your own ICU. Yeah. Yeah. Wow. And, and I think many of us has probably wondered what would it be like for me?

We know that ICU is a new environment, new experience for most patients is really easy to become disoriented in that really foreign setting surrounded by strangers, but you were in a setting that you absolutely knew you were surrounded by people that you knew and you didn’t. Usually really trust. What was it like for you to have delirium? Now for me, the delirium was I got something I already, I got in the end of the admission to the ICU. But at first, of course my ICU admission was very stressful for me and my family, but also for my co workers. Like you said, it’s the people you trust, but it’s also a kind of family, it’s your family members, and you’re in between your family members.

And yeah, initially they put me on high nasal, high flow nasal oxygen, but I knew that the threat of being ventilated was hanging over my head and I decided to do everything I could to stay away from it because I saw so many patients dying and at that moment I hadn’t seen any patient left.

From the ICU alive. So I was very anxious. And a few hours later, my colleagues told me that I had to be intubated. And yeah, I had a lot of questions because who could guarantee that I would survive? And I wasn’t ready to die at that moment. And I asked to see my husband. And so my husband was allowed to come for 10 minutes to visit me.

So we, we said goodbye to each other, but I knew afterwards that also a lot of nurses had to cry and about my admission because they were so afraid. It was coming so close to everyone when one of your family members is being ill yeah, that, that can also happen to you because, and when it’s without out your family, you don’t have to worry.

And that’s kind of going on with stress and and anxious situations, I think in an ICU. So, I got intubated, and after my intubation, I was put in prone position, and then I was transported to another ICU. Partly due to the because my, the ICU was was full with all of patients and partially because of the emotions in our team, because they found it very difficult to take care of me.

Kali: Yeah. Wow. I remember hearing stories like that and looking around at my colleagues, some of them in their sixties. Yeah. And it was even just imagining taking care of them or them being in one of our beds was really emotional. I’m sure anyone listening to this shudders at imagining having their, their colleagues because you love your colleagues, you really are close to them and having to be in that situation would be really difficult.

So it makes sense that why you were transferred. Yeah, yeah. And so you were on a propofol drip.

Dr. Van der Woude: I think in the beginning I was on on midazolam because that’s in the beginning there was also probably shortness of propofol. So they put all the patients on midazolam but when I woke up I was finally put on propofol.

Kali: So how long were you on midazolam for? Do you know?

Dr. Van der Woude: I’m not sure. I was the first period I was spent on the ventilator for eight days before I woke up. So I’m not sure how many days I was on midazolam. But I know that I used a lot of sedatives and so I also got clonidine and a lot of opioids to get me calm.

Kali: And what was it like to be sedated?

Dr. Van der Woude: No, I didn’t remember anything from that period, because I was prone for a couple of days. And after that I was turned on my back. And Yeah, when I was awake, I was awake the only thing I remembered is that my I was aware of my situation, but I had a lot of pain due to the tube from my mouth.

It was very painful. My jaws are very, very, very painful. And so I hated the tube and it was taken out and, but unfortunately due to riter to, I had to reintubate it. And and then they have sedated me with propofol because that should be a fair issue. sedation for intubation for only two days, and that’s why they use Propofol.

And I asked even the doctors, please give me enough because I really want to sleep because I had so much pain from the tube. So the funny thing is that as an intensivist, I found that every patient had to be awake. And as a patient, I wanted to have more sedators. So it’s just very funny to see the opposite of, of myself.

Uh, yeah. Yeah. Interesting. And you didn’t, and the fact that you didn’t have any experiences while sedated, like it was blank, right? Yeah. For many patients, they’re having active delirium, they’re having, they’re in an alternative world. For a few, it was just. Blank with some mild awareness, right? I mean, that is what we hope for when we sedate patients, but we don’t know if that’s what they’re getting when we do that, right?

So that’s very fortunate that for you, it was blank. Yeah. But in the second period on the propofol, I got delirium. And my experience was that I had very lively dreams, but they were all situated around my ICU bed. And they were also not very scary. So, for example, I saw an ICU nurse on the left side doing some things with my infusion pumps.

And then I turned my head to the left he, the nurse disappeared. And I also saw on a very large screen on the, in the, my room and the intensivist was communicating through that screen with me. And and I was even able to answer the intensivist despite the tube in my mouth. So that was really very strange that I could talk with a tube in my mouth to the intensivist in the screen.

Yeah. Yeah. And I found it. Afterwards, I found it very interesting that in between, I had perfectly clear moments. So I was awake and then I went down and I went in my lively dreams. And did you know you were having delirium? I’ve written that, yeah, yeah. And yeah, I’ve written that to the nurse and they said, I’ve never seen a patient who is telling me that they are delirious.

So, yeah, that’s interesting because I think in absence of doing full cam screening, we make assumptions. So if someone can follow commands, they’re not delirious. If someone can write it, they’re probably not delirious, but that’s not accurate. That’s interesting. That kind of reinforces the need for full cam screening.

Yeah. Because then I was going, I was going down in my dream again and then, yeah, yeah. But it wasn’t scary for you? No. I saw elephants and they were cutting their ears, but it was not scary. Yeah. It was like Dumbo, flying Dumbo elephants, and they were cutting their ears, but yeah.

I was a stranger. I was far away, so it was not frightening for me. It was like on the big screen, yeah. How long did the delirium last? No, I think it was, one evening of the night. Oh, good. And, so that’s a really brief period compared to some courses of delirium for patients, right? Sometimes they can last for days to weeks and it can be very scary and traumatic for them.

Yeah. Maybe it was also due to the propofol. I’m not sure. Right. Cause it was, you know, about day eight or 10 or, you know, around there. And so you’d been in the ICU for a long time and you’d gotten a lot of benzodiazepines and at some point everything just kind of collides. What helped your delirium go away? I think reducing the medication.

Yeah. The clouds parted. The clouds parted. The fall and the opioids. Opioids. Yeah. How soon after did you mobilize? Oh, the first time I was mobilized was when I was when the tube was taken out. So it was after 10 days then I was able the, the physical therapist helped me sitting on the side of the bed, but that, I think it was only five minutes, so it’s very heavy.

For me, it felt like being on a, on a ship in a storm. I was moving and moving and moving, yeah. When I train ICU teams and we’re talking about those early stages mobilizing patients that have been supine and sedated for so long, you have this whole vestibular reacclimation — our bodies acclimate to being supine.

So it is for many patients, very startling to be upright after being supine for so long. What was it like to realize how weak you were? Yeah, that’s very strange because, You know, I’ve seen as an intensivist I’ve seen that that patients were, had weakness. And so one of the first things that I did when I was awake was looking at my arms and legs.

to see how they got out of the battle. And I was still on the ventilator and I was totally depending on the nurses. But it’s very strange to= to see on yourself that things are really happening that you, of course, the first thing I wanted to do was, was typing on my on my cell phone to get in contact with my family.

But I could touch the screen, but I was not able to make words. It looked like I was speaking fluent Russian. And it was also very heavy to do that, because my arms were so weak that holding a cell phone in my hand and With two hands doing things on my cell phone was too heavy for me.

And that’s very strange to to experience that kind of things as an intensivist. And you’re completely dependent, totally vulnerable, helpless. Yeah. Yeah. Yeah. How long did it take to rebuild the ability to walk? I was moved to to my own hospital. After I was from the tube and I’ve stayed there for two days and then I went to a rehabilitation clinic.

And that was a special they had a special department for COVID 19 patients and especially COVID 19 patients from the ICU. It means that you went With your oxygen beside your bed, and they did a lot of controls, and they were totally admit addicted to those kind of severe ill patients on their ward.

For me, it was an eye opener how they run that board. So I met there several former ICU patients. And well, the nice thing was that in the hospital we didn’t have physical therapists because they were all busy. In the teams, in the proning teams on the ICU and on the, on the high care awards, you didn’t got any physical therapist, but in the rehab clinic, we got seven days a week, three times a day physical therapy. They, I made really quick progress and I think after. 12 days I could go home walking with a stick but in that rehab clinic, I learned to go in a walking chair and then on walking behind a walker and then still with oxygen. But yeah, after 12 days, my oxygen was I could quit my oxygen.

My oxygen needs was zero room air. And yeah, I could go home with a stick. And that’s true. That is, It’s such a miracle that you had such good rehabilitative services available. Yeah. That wasn’t the case through a lot of the rest of the world especially even after the first wave, it was, those services were pretty tapped out and it was really hard to get patients back, back home after they had had that point.

Many patients, at least in the States had tracheostomies because they became so weak and debilitated. I’m so glad that you had, still had such good care during such a crisis. Yeah. And now, you work in a post ICU clinic, you train ICU nurses and doctors. How has this experience impacted your personal approach to patient care, how you interact with survivors, and then clinicians?

Now I still experience many symptoms from the post ICU syndrome, like still having muscle weakness and poor physical condition and also cognitive problems. So unfortunately, I had to quit my job as an intensivist. So had to start with a new life and a new working career.

So that’s why I started with my with the teaching the teaching part, because before I was ill before I got ill, I was did also a lot of teaching to the residents and Yeah, now I had to start something new. And so it’s a little bit difficult to to tell my story in daily practice, because I cannot work anymore in the ICU.

But I try to share my story and my the things I have seen as patients to the nurses and and sometimes I do some rounds and tell my story so people can learn from it. How do you feel about the ADEF bundle rebirth that’s happening in the critical care community? During COVID, we Really went back to heavy sedatives, prolonged paralytics, and things like that. Now, in this era, we’re really moving towards keeping patients more awake and mobile. You have experienced how uncomfortable the endotracheal tube is. You also experienced post ICU life.

What are your thoughts now about the ABCDF bundle? I still under describe this bundle. I really like this bundle, especially because the outcome for the patients is better. For example, with early mobilization you can prevent the muscle weakness partly. But I’m not sure if you can prevent it for every patient, because when you are such a long period in the ICU, I think it’s difficult to prevent the muscle weakness and the neuropathy in the patients.

I mean, it’s, difficult and unlikely that people leave at baseline, like their full capacity, leaving the ICU. Yeah, yeah. But we can, we can prevent them from really declining or losing a lot of. Major main function. Yeah, for example the, the, the spontaneous breathing trials are of course very important to reduce the time of being intubated for patients.

And even in a crisis that can be very helpful because you can use your ICU beds earlier for a next patient. Absolutely. Yep. That’s a big thing that we’re talking about the podcast all the time is decreasing time in the ventilator, decreasing time in the ICU because we’re in a staffing crisis. Even though COVID is over, at least here in the States, we don’t have enough staff for our ICU.

So keeping patients on the vent in the beds longer is really a burden on our entire system, especially our staff. Anything else you would share with the ICU community? No, I want to tell the ICU community about delirium that delirium is not something that is as associated automatically with an ICO admission.

It’s a manifestation of acute encephalopathy which is caused by various underlying processes, like a new infection or sedated. And it’s part of the multi fillery that we see in, our ICU patients and if the ICU community is aware of this. You can even use the delirium to, to know the, the patients even better and to to recognize new problems during their ICU stay and treatment of underlying causes can help to fast recovery, for example, and hopefully less implications after the recovery of the critical illness.

And furthermore I had some ICU diarrhea. And I think an ICU diary can help patients very good to fill in their gaps to get better understanding about their disease and their delirium, because I spoke to a lot of patients, formerly ICU patients during COVID, during my rehab, and for them, it was all one black hole without any family because It was not visitors were not allowed in the hospitals, so it’s very difficult then to know what has happened in the ICU and even on the ward. Absolutely. And it’s so nice to hear that from, from a survivor, those that actually have and use their diaries because some of the research is a little bit conflicting as far as the impact of ICU diaries, but to have actual survivors talk about how much it means to them. After such a traumatic experience, that’s, that’s pretty compelling.

I love everything you’ve shared that this is, I love the term acute brain failure. It’s part of the multi organ failure happening within the body. And I think when patients are in nursing homes geriatric patient becomes confused, combative. We start looking at why did UTI? It’s always our first thought.

But in the ICU, when they become confused acutely or things change, we just shrug our shoulders and say it’s part of their ICU stay. But really it could be a sign of something happening. So I love it seen as a, as a warning sign, a symptom that requires investigation. I think your experience as an intensivist, then a patient, and now an educator is, and now a survivor is so valuable.

Please keep teaching us. Thank you so much for everything that you’ve shared. Yeah, you’re welcome. That’s a nice talk to you. Thank you.

Transcribed by https://otter.ai

 

 

 

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