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What is the current state of affairs with the ABCDEF bundle in many ICUs? What is it like to be trained to have patients awake after intubation to later be begging for awakening trials? Dr. Nick Ghionni, The Floating Vent Guy, shares incredible insights, stories, and thoughts in this episode.

Episode Transcription

[00:00:00] This is the walking home from the ICU Podcast. I’m Kelly Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we’ll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive.

Welcome to the ICU Revolution.[00:01:00]

As always, I’m really excited about this episode. This is all real talk with an incredible intensivist revolutionist that really gets it and is in the trenches trying to get his team to higher ground. This is a longer episode, but it was all so good and valuable that it would be insane to trim it down.

Be sure to check out the link for the sapien n CE in the show notes to get your CE credits for listening and learning you’re doing as a revolutionist. Let’s jump into the episode. Dr. Kioni, thank you so much for coming on the podcast. Can you introduce yourself to us? Yes. Kay. Thanks for inviting me. Huge fan of your work with Awake Walking ICUs, and really I also known as.

The floating ventilator guy on Instagram as of late, that’s jumped over from, as an exodus, from Twitter slash x, sort of like focusing on mechanical ventilator education. Inextricably entwined with A to F bundle. [00:02:00] So currently working palm crit, switching that up a little bit, but we will be mostly critical care.

And what made you so interested in the A B CDF bundle? I think it’s probably my residency. So in residency we, the a f bundle was very important and intertwined with rounds and we followed it and it just was like second nature that we didn’t, that like when we intubated someone, we didn’t go right to sedation that we woke them up once their intubation drugs wore off.

We talked with them and got an exam and all that kind of stuff. And when they would feel uncomfortable, we would start with Pure and fentanyl and then only if couldn’t control them with pure and. Every hour, let’s say by and going up on the dose, would we start X meine or propofol or something else?

Those are the only two things. ’cause we really, so we’ve really shied away from Fentanyl drip. We almost never, I don’t think we’ve, I’ve ever ordered a fentanyl drip in residency. In fact, the medical director of the [00:03:00] ICU, there was so adamantly against them that if you did order them, he would call you and be like, why is the patient on a fentanyl trip?

And not to get into too much specifics, but I think it’s because the medical director of the intensivist group that was running the ICU was a part of SCCM. So I think a lot of where they came from was born from the ADAP bundle. So it was like very much in ingrained in our ICU culture. So towards the end of my residency is when COVID happened and things got a little bit different.

It was a big ask. It was really impossible, honestly, to do the like Q1 hour like metal boluses because we didn’t have much PPE and like we had to do, we had to do. I think that’s the story of a lot of places, but I feel like we’ve backslid a bit, certainly, certainly with fentanyl drips and I guess maybe any IV opiate drip, like dripping it in for a sedation, and I’m sure we’ll talk about it.

The IV sedation using like opiates is not, it’s [00:04:00] the pharmac code dynamics of the different medications don’t lend themselves to be PRN on off with sedation dosing. You know what I mean? So just the experience that I had during residency was something that was carried me forward, but COVID changed everything and I know what we’re trying to get back to that place that we were, I think as a profession, like with a F bundle, really focusing on PRN medications and not having patients over sedated.

But I think it’s been a challenge recently. It was just so nice to hear you say that your patients were awake and communicating right after intubation. You were able to do a full exam. Yeah. And assess and treat their needs. Yeah. Most people when they talk about the A-B-C-D-F bundle. Even if they felt like they were pretty progressive before COVID, that’s not usually how they talk about it.

Usually it was we were doing more awakening and breathing trials before COVID. Yeah. And now it’s a struggle to get that done, but that’s amazing that your introduction to critical care was patients being awake, communicative, autonomous. [00:05:00] And how was mobility before COVID? What was your introduction to mobility?

Interestingly enough, my introduction to mobility was in Res. We were a small community ICU, so we didn’t really have like resources. I know that’s like your forte, I guess I would call it. Mm-hmm. We did as much as we could, being a smaller center, I did try to get off the ground, a QI project that involved, you’ve probably heard of it, it’s like the SOM score, SOMS, which was more like a surgical score that had to do with mobility in the ICU.

I never could get like the buy-in from everyone to put it together. So we. We hadn’t been able to get to a point where we’re doing like early mobility or walking on the ventilator, but we’re trending in that direction in some ways and certainly being more active, like at least passive range of motion and that kind of stuff.

And then towards the end of, like towards the end of my residency career and COVID happened and then took a lot of steps back. So haven’t had a lot of [00:06:00] interaction with like early mobility as far as like getting patients up and walking on the ventilator. And honestly, in the past, like four to five years between Fellowship and early attending hood, it’s been a real challenge just to get, it’s been challenge re ingraining that culture of S-A-T-S-B-T.

The timing, and I know we’ll probably talk about it, but the, you know when I say all rounds is like this is not a me thing, right? This is not a physician thing like it should be next rounding. Like the team is rounding, it’s nine 30, the sedation’s been off, the patient’s on SBT, they’re passing. Do you want to give me okay.

Or not? Okay. Real quick. And then I look and. Everything looks good. However you assess the patient can be extubated. There’s like multiple ways to do it obviously. I think we some posts on that before. That’s not like what I’m finding just ’cause of some timing stuff with nursing or RT and some, it’s been postulated that maybe we should wake the patient up on day shift because if we wake the patient up between night and day, are there gonna be eyes on the patient all the time to make sure [00:07:00] they don’t like self extubate?

You know self extubation is like a double-edged sword, right? It’s something that we don’t want, but it’s something that I don’t get too worked up about. My sort of cynical view of self extubation is that it’s the best kind of SBT because the patient’s like awake enough and can pull the two out. Then they’re probably okay.

I would prefer they don’t obviously, but I think we’ve maybe swung too much in the other direction, which is like wake them up during day shift and it just sets the day back and you, you’ve worked in the ICUs and you know that in the unit there’s like the, like the cadence of the unit, like the nurses days and.

The nurses and the physicians and everyone else’s just sort of normal rhythm. We come in, we get coffee, we get sign out, we assess the patient, we open a note, we do this, we do that. In residency, the cadence was very much, now don’t come for me, but we got daily ABGs in in my residency just because, I don’t know, that’s just how they did it and you can think whatever you want of that.

But the cadence was they would shut the sedation off around like [00:08:00] 30, I think like maybe five 30. So the night RT would get an A, B, G around six o’clock and then seven o’clock they’d be on SBT and 8, 8 30. The intense would come free round with the nurses and like the resident and say, this is like the big picture plan for the day.

And then he or she, me, the intensivist would say to me and to our team, who’s ready, who you guys think’s ready. And then we would say, oh, bit two, bit three, bit four. And then we just extubate them and that would be the end of it. And they would be like extubate. By the time we’re rounding. It just feels, and I don’t know if, I can’t obviously speak for everywhere, but just in my experience recently, it’s.

Everything’s been pushed back out of this abundance of caution for the patients being too awake or they’re too, they’re too agitated, whatever that means. And I think the, A lot of the problem is that like SATs are art because when you wake a patient up, they’re not gonna be, they’re not gonna be like, like cheery, right?

It’s gonna be like rocky, especially if they’ve been sedated. Let’s bring them back to earth, as I like to call it. So [00:09:00] you need to, it’s a lot of coaching, but if you can’t spend the time coaching and it, you can see where someone would say, oh, we shut the probe off. They’re agitated, they fail type deal. But if you shut it off and you’re in there and it’s like they are agitated, but you said What’s wrong?

And they’re like pointing to the tube, then the best thing to do would be to get the tube out, not to put them back down. You know what I mean? So there’s like this sort of SAT art, there’s like an SBT art, and I think maybe with the exodus of a lot of seasoned ICU nurses because of the pandemic, which just happened.

You’re losing that sort of like nuance, I think. And have you seen a difference between having patients awake right after intubation? No sedation communicating versus doing an SAT. And I’m gonna assume at this point teams that you’ve worked with intra and post pandemic SATs are primarily for sbt. So they’re not really not turning sedation off until we’re trying to get them extubated.

So now it’s days [00:10:00] later of sedation. Do you see a difference in how patients respond right after versus towards extubation? Okay, so I’m gonna, I’m, before I answer your question, Kaleigh, I’m gonna Yeah, force you to be Nurse Kaley again. So Nurse Kaley comes in, we always nurse Kaley, but you’re like now bedside nurse Kaley, right?

Yep. So Bedside nurse Kaley comes in and the patient’s on, I don’t know, propofol or something, I guess. You know, you guys never used sedation, but just imagine for a second. They’re on propofol. The RAs goal is zero to negative one, right? And the current RAs is negative three. So in theory you would turn that down, like you would turn it down because you’re over sedated, right?

And you can imagine that if that, like if you got to let’s say 25 or probe and they were zero to negative one, that you’ve reached the goal, right? You’ve reached the RAs goal with said medication. The question becomes could you keep turning it down? Could you go to [00:11:00] 20 and then still be in the goal? Could you go to 15, still be in the goal?

Could you go to 10 and then still be in the goal? And then maybe just, you know what, I’m gonna turn this off and see what happens. And then you turn it off and the patient gets a little restless. Would you give a PRN med? Would you say they’re a little restless? I don’t wanna go back on sedation. Lemme give a PRN.

Fentanyl. So that’s like stepwise down titration. And then. Taking the sedation off and trying to manage with pure on medication. I feel like that is such a foreign concept whenever I describe it. Because what, what will mostly happen, and I think there’s a problem with how we like order medications, is that if the Rascal is achieved with, I don’t know, like 30 of propofol or something, the real goal is like that goal but with the least amount of medication.

But how do you, like, how do you put that in an order, right? How do I put that in the order? Hydrate down until the RA is not what you want, but give [00:12:00] A-P-R-M-N so that, that’s a lot where the, like that art form comes in. Yeah. I mean I think when you ask, so first of all, and this maybe this is for listeners and people in general, but if I said, what is an SAT, I’ll get a smattering of answers and then I’ll say, okay, who should get an SAT?

And then I’ll get another smatter of answers. And the real question is like, who shouldn’t get an SAT? Right? And. I think I shared the wake Up and Breathe protocol at one point and there’s like specific people in there that shouldn’t get an SAT, right? Staus Alcohol withdrawal, active myocardial ischemia, hemodynamic instability.

Some of those I don’t agree with. Right. Like sort of there’s Spectrum. I think those are prompts for assessment. Yeah. Okay. Either way. Room for critical thinking, right? Yeah. On paralysis. And I think the alcohol withdrawal thing was, ’cause we did that in times when we were on Ativan Drip. I think that’s when sort of the wake up and breathe like timing was, we don’t really do that anymore.

So this is like 2008 that was published. Exactly. Yeah, exactly. So some of it’s like a little outdated nuance maybe, but I don’t get that. When I asked the [00:13:00] question like, what’s the contraindication? And that’s not, that’s like interns, resident, other attendings nurse, everyone’s, no. What is an SAT? Why do we do them?

Who can’t get them? Because everyone should get them. Right? So we do like this SAT for people that are continuous sedation, but theoretically the goal throughout the day should be to get it off and. Like with PRN meds, if we could, that’s a lot of dancing you need to do with everyone. And I think that’s not something that I can do as a singular physician, right?

It’s hard to be on everyone and say, Hey, we need to do this. That’s why we’ve created sort of internal checks and balances before when you had senior nurses who’ve been in the ICU for a while and got it, and this is our culture and the culture carried the new nurses through, but once 75% of the nurses left from bedside to go do whatever they’re gonna do, that nuance goes with them.

And depending on nursing education, nursing leadership, like that kind of stuff. And maybe [00:14:00] how, how involved the intensivists are with the nurses and like nursing education, you can lose some of that. I come in every week, or sorry, I come in for a week every how often? I don’t know. A couple, like every two, three weeks.

Just like for schedulewise and. I can go through this the whole week and it’s just, you know how it is, right? You teach something just if you don’t, if you don’t keep adding it, keep hammering it home, it just like goes away. I think forget like SAT is like, what is it? But just that idea of we don’t need continuous sedation to get our rascal right?

We could do other things and I think the culture right now is start at the highest and then titrate down instead of, don’t even start it and then slowly titrate up if needed. But that’s not standardized and I find that obviously the RA goal is not usually really understood. Yeah. I think even physicians a lot of times don’t really know how to objectively assess arrest, [00:15:00] right?

They see as it’s part of the order set that’s automatically ordered. They don’t really have to with it, look at it, mess with it, unless I need to go in and change it to negative five. Otherwise it’s just gonna pop up automatically. The nurses are gonna do what the nurses do. And it’s not their thing. So I find it even in simulation training sometimes when I’m like, Dr.

Smith, come assess Thera. Yeah, they’re, they’re scrambling, they’re nervous. They’re like, oh shoot, where’s, I’m like, it’s page five. It’s open book test. Like it’s okay. We’re all learning together. But the fact that they don’t know how to really assess Aras, the nurses don’t know how to do it objectively in general right now.

Yeah. So then what is that zero to negative one that is a normal Ross order, or negative one, negative two in some ICUs. Yeah. That is not being met in most ICUs as a standard, so we just accept that it’s okay to have them unresponsive to voice. We don’t expect them to make eye contact. We don’t expect them to really be able to communicate and then the SATs being done just for [00:16:00] sbt.

And that’s, I think that’s a little bit of the misinterpretation of IU liberation is we’re just trying to liberate them from the ventilator. So we don’t need to mess with this until it’s time. I see what you mean. How they meet SBT criteria. Even when you see the algorithm from Yes. 2008 SAT, and s. BT algorithm is on the same page, SATs on top, SBT is on the bottom.

They have their own boxes for criteria. So I see that they are separate, but culturally they interpret it as being together and having them on the same page kind of reinforces this misinterpretation of codependency. Yeah. Obviously you have to have patients awake to do a breathing trial. Right. Having them together makes it seem okay until we can’t take sedation off until the ventilator settings are minimal and it just holds everything back.

And there’s always this question of, well, physicians don’t lead it. Why don’t the physicians lead it? Yeah. So why do you think that is? You come on and you have a fairly [00:17:00] unique and bias upbringing. Yeah. And critical care and perspective. So they know, oh, Nick’s on, we gotta just do what he wants to do this week.

It’s so annoying. Yeah. Even someone mentioned that. Certain clinicians will pick their shifts according to who’s on because they don’t wanna work with physicians that hold them accountable and expect patients to be more awake. Why do you think there’s so much variability amongst providers?

Good question. I so, not to be too controversial, but it wouldn’t be a podcast with me if it wasn’t, but nor my podcast. We do controversy here. Yeah, I know, right? So I think it’s because everyone wants to be a snowflake and like you’re not a snowflake in the ICU, right? There’s 35 years of physicians leading this.

Didn’t like it just, it didn’t work. You know what I mean? Because I think what I think is interesting is like the history of the ICU, like in general. So you know, it’s only recent that there’s like more physician [00:18:00] presence, meaning maybe when, when we were bedside nurse Kaylee, you might never, was the intensivist always there a lot of the before, like medicine adopted.

Into like physicians into the hospital like, like hospital employed. They’re a private group, right? So private group will cover an ICU. They’d round in the morning, but they’re gone from like generously 5:00 PM till 7:00 AM the next day. Yeah. So Nurse Kaylee is like doing her thing, whatever she’s gotta do to keep the patient alive type deal.

Maybe you have residents, maybe you don’t, especially with the residency for, if there was residents in the unit, they would be doing things like at the bedside and then call the attending if they needed help or whatever it was. So like an attending wasn’t really readily available in the ICU, like only until recently that you have like ongoing staffing.

So it did make sense for the physicians for it to be like a physician led thing because for years we’re told, and I’m told and I agree that the patients, the nurses in the room with the [00:19:00] patient, so he or she will know, will be the first to know and the best to assess mental status, pain, all that kind of stuff.

So. Like why? And if we’re going off of the assumption that everyone should be not sedated if possible, then unless you have these sort of parameters that you would need to think twice about, like we said before, sort of paralysis, alcohol withdrawal, et cetera, et cetera, you know, then you shouldn’t be on sedation, right?

You can give pain medication to, to comfort the patient ’cause of the tube or whatever else it was. But you don’t need to be on continuous sedation. So there’s no reason for me to lead that portion of it because it’s not like my expertise, that’s the nurse’s expertise to understand like the rest is negative three.

I’m gonna go down the propofol from 30 to 25, I’m not doing that. Q4, Q2, whatever it is, assessment, the nurse is doing it. So it’s irrelevant my say, right? Because I all the time, right? You call the physician, you’re like, Mr. Jones is agitated, he’s trying to pull the tube out. He is trying to fight the one-on-one.

It comes by, you [00:20:00] know, they’re back sedated because you gave them verse set or something, right? And I come by and I’m like, no they’re not. They’re coming to whatcha talking about and I leave. And you’re like, man, this happened. And like every time the physician comes by, they’re the patient’s fine, but that’s not right.

So your eyes are on them all the time. My eyes are not on them all the time. That’s not my job. My job is different. So you should be leading this awakening portion of it, right? Number one. Number two is like the SBT portion. You probably know, you certainly know better than I do. Not everyone is blessed, certainly in probably smaller community ICUs, but to have an intensivist around all the time.

So the person that’s really quarterbacking the ventilator is the respiratory therapist. Why wouldn’t the respiratory therapist be the one to say, Hey, outside of anything like very specific, the PEEP is 20, the FI two is a hundred percent. If they’ve met the goals that you can like very much easily put into a checklist, like meaning this, meaning that meaning this meaning that SBT [00:21:00] candidate, we know for a fact that if the patient’s meeting those goals, it has no.

Barriers to extubation. If we should put them on SBT, if they pass and however, whatever SBT de Jo you wanna say five over eight, eight over 5, 0 5, 5 5, whatever it is. If they’re passing, you should pull the tube, right? Like we, that’s well documented. So at what point in there is there like me involved? Now if something’s different, the patient’s worse, whatever it is, then that becomes like a medical thing where it’s alright, the patient was doing well on 10 over five.

We dropped them to five over five, they really fell apart. They got the kyp, they’re whatever it was, then it’s that sort of physician nuance probably comes into play. But up until then, this is checklisted stuff and we’ve demonstrated that we can do a checklist safely do the intervention, which is like S-A-T-S-P-T and then when it comes time ultimately to pull the tube out, check with me.

Maybe not check with me. I don’t, I don’t [00:22:00] know. I wouldn’t, I like in residency. Rts were, they were like very seasoned, like 30 years. They would come to me and say, Nick, we’re gonna extubate what I, I’m like a second year resident. I’m like, oh no, I don’t think, I don’t think that’s right. Let me see. So like relying on your, relying on your colleagues to do their job and like within their expertise, I think is worthwhile.

It just doesn’t make any sense to add the physicians back into it. This has been a nursing and RT led thing for like years and endorsed by the SCCM. So I wouldn’t see a neat, I don’t, I feel like physicians getting involved with it would just be like a step back, honestly. And I totally agree that everyone should be practicing at the top of their license and be autonomous.

And that’s what I experience. And then we can walk in ICU. That’s what I’ve seen units that are succeeding with this is everyone takes ownership of their role. Yeah. But that requires that they have that skillset. Right. So when I started this podcast, I was pretty naive. I was like, just. Have your rts fix the ventilator and have your PTs come in.

And coming from an [00:23:00] ecosystem in which people have 15, 20, some of them like 30 plus years of experience in this, they have that expertise. And I’ve come to really appreciate that this huge turnover in clinicians has provided a huge gap in knowledge and expertise. And then I see that we’ve brought in these new clinicians during COVID, they’ve learned the COVID way.

Now they’re teaching the newer clinicians now the COVID way. Right? So then now there does need to be oversight. What I’ve seen when I’m with teams and in rounds is when in their normal habitat, the nurse might present and say Patient failed their SAT and SBT, and everyone strokes their shoulders and says, okay, and then move on.

We’ll try again tomorrow. They were sedated ’cause they were agitated. Okay. Where I would love to have physicians saying, hold on, why were they agitated? Why did they fail their SBT? Even if numbers are reported for the sbt. What does that mean? What does, why do you think they work? The knick? Yeah. What was the cause [00:24:00] of that?

So I totally agree that this whole process becomes safer, becomes highly reliable when everyone understands why we’re doing it, how to do it. We do this upfront. But right now, where we have all these gaps, I think we do need physicians stepping up and saying, hold on, everyone, pause. Let’s zoom out. What are we actually doing here?

Yeah. When I look at these medical reviews that I do with teams that I’m training, look over those case studies. I see everyone airing patients that are intubated for maybe something like pneumonia, and now it’s 12 days later and they’re still intubated and they’ve been, they spent the past eight days intubated because they’re sedated and sedated because they’re intubated.

I have all those questions. Where’s the rt? What are, where are the nurses? Where’s the physician? How many times did you round on this patient and no one said, hold on. What are we actually doing here? But are, are physicians actually trained and prepared to bring in that kind of [00:25:00] leadership and say, why are we still sedating this patient?

Why are they harassed of negative three when I ordered a negative one? Do you think physicians are sometimes scared of nurses? Do you think they know enough to even ask those questions? Yeah. Physicians are definitely scared of nurses at some point. I’m gonna, well, I will, I’ll let you know that. I think that, so the, I was feeling particularly spicy one day in the ICU and it was like one of these situations where, oh, they’re sedated ’cause they’re agitated.

So I was just like, okay, describe what they did. Don’t say agitation. Don’t say it. So then they start going on like the, and it’s you, you could see like, it just, they’re at, I’m like, no, don’t say agitated. What are they doing? Oh, they’re fucking the vet. I’m like, okay, what does that mean? Oh, they’re, it’s going, the alarm is going off.

Okay. What does that mean exactly? Show me what that means. So we went into the room and they shut the sedation off and the patient started waking up and they started coughing. [00:26:00] So they’re bucking the bed, the alarm’s going off. I’m like, that’s coughing. That’s normal. That’s not agitation. But as you probably know, maybe not because you don’t, I keep forgetting you didn’t work with sedation, but I’m admitted to normal ICUs.

No, I’ve worked in 11 other ICUs, so I, I mean, no, what I mean is like, oh, I know. If there’s anyone that knows it’s ka, like when you shut the sedation off, there’s like in this like haze where they’re coming back to their senses and like waking up and coughing and doing all this stuff, they’re in hell and they have a tube down their throat.

Yeah, exactly. I know, right? It’s horrible. Like interacting with the world. And it’s like, this happens in anesthesia, right? In the pa, in like the, or that’s what they want. They want the patient to wake up and cough and then they like tap them real hard and say, Mr. Jones, gimme a big breath. They take a big breath and they’re like, I’m gonna pull the tube out.

And they pull the tube out, right? But it’s with us. They start coughing and we’re like, oh my God, they’re fucking the vent. They’re agitated, turn the sedation up because they failed. And it’s not, that’s not it. So that’s where that like art form comes in at. And I know that it’s education also, but it is an art because [00:27:00] there’s a time to like push and there’s a time not to push.

And when the patients waking up and if they’re coughing aggressively, that’s like a pretty good sign. They’re probably gonna tolerate extubation, at least from like a airway clearance standpoint. I just cut, you just gotta have to ride the lightning a little bit. And then the patient wakes up with a smidge and they start giving you thumbs up.

You tell them, lift their head up off the bed. You know, you calmed them down as much as you can. Maybe, maybe this would be a good place to put in a little decks. Although I think Dex is like a double-edged sword in some ways, but that’s a whole separate issue. And then you just give it some time. Right.

And if you get to the point where it’s like, it’s like one, it’s like takeoff velocity once you get past that point. Things get a lot better. You’re able to calm them down. They’re like, you can talk to them. They’re awake. They understand that they were intubated, they understand, they’re in the ICU. They understand the tube down their throat.

They understand that it’s painful. They understand you’re doing a breathing trial because if they pass a breathing trial, the tube can come out. Like they start to [00:28:00] understand that stuff. But if you don’t let the patient like go through that initial waking up portion, you can look at that waking up portion as they’re agitated.

They failed because I, and I don’t know, I’m just like, I don’t know what people expect. What do you expect? Someone who’s been in the ICU with a tube down their throat critically ill, like, how would you look? My life is a disaster from the day to day. And like I look like, no, I look terrible. So I could only imagine what I look like in the ICU after seven days from like Mars pneumonia or something, right?

So you’re gonna look bad, right? But you have to give them the time to wake up and really demonstrate that either they’re delirious or not, or they can like follow commands or not, and sort of things. So I’m, I don’t, and you probably, I think we talked about this before, at least tangentially, I don’t, I’m not like a Frisbee guy.

I don’t, it’s worn outta something completely different. I take a very broad approach, which is how I was taught by the intensivist in residency, which is are they following commands? Can they lift their head up? Can they give you a [00:29:00] cough? Can they take a big breath? Or they’re not tachypnic or they’re not tachycardic, but that’s like the, those are patients that are like ideal.

Like not everyone’s gonna be like that. Right? Some people will be tachycardic, some people might be tachypnic. Especially, I made a point to say this, I wrote this down somewhere, but especially with COPD, right? With COPD, for sure, no matter what size tube you put in, you, you introduce airway resistance.

’cause that tube has to be smaller than your trachea. So by definition, they have to work harder, right? So for me, like COPD patients, they can look terrible and I’ll still pull the tube out because most of the time it’ll be better, it’ll be better than leaving the tube in. There’s something overt that’s like happening through breathing like 28 times a minute and don’t look that great, look like you’re working.

I also pull out the tube because like as long as they can do other things, like gimme thumbs up, lift their head up off the bed, that kind of stuff, because I know that getting the tube out will take away some work of breathing from the tube itself. So I feel like that’s it. I feel like sometimes, [00:30:00] especially with COPD, we, we set like a super high bar for them in some ways, which I, which drives me crazy because they’re never gonna get, and we’re doing more harm.

We’re like, okay, they’re not, they’re never, and we think, okay, they didn’t pass SPT criteria. Exactly. Therefore we have to sedate them and we just keep it going day after day. And that’s how I, we treat a lot of COPD patients in that awakened walking ICO, we had a really strong pulmonology group that had a lot of frequent flyers that come in and out and I don’t think I really ever saw a TRACHEOSTOMY and COPD exacerbation because we treated COPD exacerbation and got it out and then we preserve their muscle mass to be able to then.

Continue to compensate for bad lungs and that that following commands prompt, let’s, can we lean into that? Yeah. I feel like that’s, that really requires a lot of critical thinking. I don’t know about that because you today them for seven days and they’re acute pulmonary process or whatever is probably resolved, [00:31:00] but now the delirium has been caused by the sedation and they may be strong and able to independently breathe, but they’re delirious.

Does that mean that’s, they still have to, does that, that, do they then fail their SBT because they can’t follow commands because of delirium or, yeah. I really worry about that because That’s a great question. We’re gonna say that because they’re quote agitated, which I hate that, that word as well, right.

When I train teams, we ban that word as well as sleepy, drowsy. It’s all RAs scores. They’re having these symptoms because they’re delirious. They can’t follow commands ’cause they’re delirious and now they’re not gonna get passed on their SBT. They’re not gonna get expert because they can’t follow commands.

They’re gonna get sedated because they’re having symptoms of delirium and we resume genic medications. Yeah. So where does that come from? Can I give, yeah. Can I give you Nick’s guide to extubation? Can I do that? Yeah, let’s do that. I haven’t published, I haven’t published this yet, but this is my guide text patient.

So I you need two out of three for me. So it’s either following commands, like doing stuff like lifting the head up off the bed. [00:32:00] I will supplant that with if you’re strong. So if you’re not following commands, but you’re like really withdrawing and it’s like super strong, then I take that as like you’re strong enough, number one.

So I, so broadly a neuro assessment broadly vital signs, not like overly tachycardic, not overly nic, not overly hypertensive type deal, not overly hypoxic. And then the ventilator. So you need two or three. So it’s either so you get to be not following command. If like your signs are good and the vent’s good, you get to be, you know, vent looks okay, but vital signs are good and your mental status is great.

You get to be, if the vent is good, your mental status is great, but the vital signs are wonky. Maybe you’re a tachycardic or you’re hypertensive. So I just need two of those three things to pull the tube out because I learned this sort of in, when I did fellowship in neuro IU, no one’s like awake. Yeah, no one’s, no one [00:33:00] follows.

They all have craniotomies. Like they’re not, there’s work. So you’re pulling that tube out. Like they’re not gonna give you a thumbs up, they’re not gonna lift their head up off the bed. You put the suction catheter down there, start coughing. So you know, they have intact cough to some degree. They’re protecting their airway, which I think is the most overblown like assessment that you can do on someone.

’cause it’s truly impossible to assess if someone’s protecting their airway. Because I’ve ad nauseam, we’ve watched patients with for whatever reason, and. A team or their residents or the other attendings tell me they’re protecting their airway and we’re not gonna intubate them because they’re not hypoxic and they’re protecting their airway.

And ultimately I go to intubate them and their or facts are just full of junk because they haven’t been protecting their airway. It’s just not hypoxic. But that’s a whole separate issue. But certainly coughing is like pretty good sign that you can do something, at least if you have sort of a massive aspiration.

But in a neuro IU, nobody’s awake. No one’s like following commands like amazingly. People are like have, are comatose to some degree, but they have, remember nick’s two out of [00:34:00] three, right? Yeah. So neuros status is not overtly, they don’t have a large AL infarct where they’re, they have to take over CAT scan, but they came in with maybe a big stroke.

They got intubated, they got some therapy post stroke, they have some, they have some deficits, but they’re not completely awake. They’re in and out. They don’t really follow commands that great, but their vet looks great and their vital signs look. And they have a good cough when you put the suction catheter down, two comes out.

Right. There’s no, but that’s, that’s the nuance, right? That’s the like where is that in the guidelines? But that’s not something that you can guideline direct. So that comes that nuance. If you don’t like that kind of neuro patient, if you don’t extubate them early on. Yeah. Now they’re not doing the work of breathing, they’re just laying there and now it’s gonna get more complicated in a few days when now she, they have diaphragm dysfunction.

Oh, it’s much worse. It’s diaphragm dysfunction. Now you’re talking Kaylee. So you know, diaphragmatic dysfunction, if you look so [00:35:00] adeno also ad nauseum. My decree that I’m the ventilator guy in air quotes is not just like some good marketing gimmick. We teach the mechanical ventilator to like fellows and resident, or sorry, fellows and attendings throughout the country through like the NIH, which has a mechanical ventilator course that sort of started in the DMV area.

So we. Teach the ventilator in a very specific fashion, like the physiology of it, which we take great care in. And one of the chapters is about worker breathing and you could see diaphragmatic dysfunction and atrophy like very quickly within certainly a day. Hours. Yeah, hours, exactly. And this has been proven by like biopsy studies and ultrasound stuff.

So yeah, if you don’t, so all the time, not all the time. Some of the time, most of the time the patients, they’ll team or report the patient’s RAs is whatever it’s, I don’t know, negative three or something. And I’ll look at the ventilator. And they’re not triggering the ventilator, right? They’re just riding.

So that’s like a, that’s a surefire way to get diaphragmatic [00:36:00] IP dysfunction. ’cause they’re not even doing the trigger work of the ventilator. So I’ll say to them, are they triggering the vent? Like their rate is 20, it’s set at 20. Are they triggering or is the ventilator just firing? Ultimately no one knows because the ventilator’s most misunderstood sort of medical intervention we have certainly in the medical ICU.

And we’ll say, oh, they’re, I don’t, we’ll say, I don’t know. Or some sort of smattering of that. But that’s a peripheral opportunity to say that we should be the patient’s worker breathing. Now, maybe not all of it should be done by the patient ’cause they have an acute disease process. But certainly the trigger work, like getting the ventilator to know they want to breathe ’cause that at least keeps their diaphragm intact throughout their mechanical ventilators.

Stay and event comes with all kinds of stuff, right? Increased vap. That that is measured on a daily basis. That goes up by a percent every day. The longer you leave the tube in, the more you can get vocal cord dysfunction or swallowing dysfunction or subglottic [00:37:00] stenosis. We’ve seen a bunch of cases of that when I was a fellow.

Patients who get intubated for whatever reason, wouldn’t get the tube out and then they would get the tube out and they have subglottic stenosis, like younger people. Right? 30 years old. And it also happens with, it also happens with tracheostomies. Yeah, no, I mean there, which we think is so benign, right?

They don’t think anyone’s looking at, oh, I don’t know the impending, I don’t trachs benign. But yeah, no, trachs are trachs. If you have a person that has a reasonable chance of getting off the ventilator, they just need longer time. Like tracheotomy is fine, right? But if it’s like A-C-O-P-D patient who like a trach, that’s not the fix, right?

That’s just gonna make things much worse. ’cause then on top of everything else, we’ll probably get something, some sort of form of trachea, malacia that’ll just exacerbate everything. So that, that’s where you have to have real good conversation with the family and the patient if they’re awake and able to communicate and able to be a part of that conversation, which oftentimes we forget that piece of it.

Like when we talk about what would the patient want? I’m like, just wake them up and ask like what? And [00:38:00] some people are will are waking up and alert and be like, absolutely no, I don’t want a trach. I don’t want whatever it is. Other times they’re not, for whatever reason you allow on the family for that information.

But no trachs are, it’s not just, oh, they haven’t gone off the vet. Let’s just trach them and send them on their way. That’s like a big, that’s like a big deal. That’s a big, big, big deal. There’s a cultural, yeah, there’s a cultural perception that you can’t mobilize someone until they have a trach that it’s much safer.

Mm. And just trach. ’cause we haven’t studied showing that earlier trach leads to better outcomes, better survival, at least. But I don’t think it’s the trach. I think it’s because after they get a tracheostomy, now we take off sedation. Now we start to move them. It’s the mobility and turning off sedation that changes the outcomes.

And there’s nothing to say we can’t mobilize them or can’t have them awake without a trach. But yeah, anytime I post something online, without a doubt, there’s someone saying, why don’t they have a trach? Why don’t they have a trach? They should not be walking without a trach. Can I, can I ask you a question?

Yeah. The like the early trach stuff, the only [00:39:00] one that I know of off the top of my head is trach man trial, like T-R-A-C-M-A-N. And I think that was in like a neuro population who had like a big stroke. And in that situation. Early trach is better because they’re gonna be right on the vent for a long time or whatever.

The I there, there was a big COVID one. Yeah. And I don’t, the COVID one, like the COVID stuff was a bit different I feel. And I think that, I don’t know, in my opinion, like if you can be a walk and wait, sorry, awaken, like walking with a ET tube, like you’re pretty close to getting it out and I don’t know, there’s no like hard and fast rule, like when you have to like put a tracheostomy in, right?

There’s this big range. So for me, if I’m at, and oftentimes I’ll inherit people that have been on the ventilator for seven days, in my mind’s eye I’m thinking to myself, I have three or four days to really turn this around and get this tube out. And that’s always my goal. It’s never, it’s not [00:40:00] like it’s day seven.

Oh, time to put the trach in so we can get them out of the unit to the ltac because. I don’t know if you’ve had the joy of seeing the LTACs in general, but you know this just for your listeners. So don’t think that you get someone to an LTAC for like long-term weaning, that they’re gonna be weaned, right?

Because there’s 30 ventilators and there’s one rt and they’re not gonna do aggressive ventilator weaning like you would do in the ICU. Yep. To assume that we just put a trach and send ’em to the vent farm and they’ll get extubated over time. That’s, that doesn’t happen often. Now, I’ll tell you, when we put trachs in patients, like in fellowship, our goal was to get them off the vent.

So we would, we had the whole ventilator weaning protocol that was essentially like a stepwise down titration of the pressure over a few days, and then the tra collar. And then from there we would put ’em on tra collar. We would put in a pani mirror valve, get a speech eval, all that kind of stuff, then downsize them and dec cannulate.

And that was always the goal. But you know, [00:41:00] it was like, is this patient a good, is this patient. A candidate for that. So 94-year-old COPD per, not a candidate, right? Mm-hmm. That’s just not, that’s not what we should be doing. A 55-year-old person had the flu, then got pneumonia type deal. Like you should, yeah, you should do that.

And you’d have to, you’d have to educate me on if, like that’s, we have trials that say that, but I’m, I gotta tell you, I still am like, get the tube out first kind of guy. If we can do that pretty aggressively. So that’s why it’s so important. Well, to me, I’m like a 55-year-old that had a RDS pneumonia. I’m still like, I don’t think they should have had a break.

Mostly, I, I think I’m biased because I’ve treated so many of those patients that’s Yeah. I was that awake and walking. ICU was an unofficial A RDS unit still is. And even during COVID. So very few patients ever had trachs unless they had like interstitial lung disease and [00:42:00] COVID and they wanted to keep going.

Yeah. Yeah. Or they had any neuromuscular stuff and things like that, but it was not really a RDS patients. They could be intubated for three weeks and still walk out independently breathing. Yeah. So I, I just think there’s so much power behind keeping the brain and the muscles intact to prevent the trach.

So I really appreciate that’s your perspective of we’re going to prevent it. We’re only gonna do it if we absolutely have to. We’re going to involve the patient themselves in making that decision every can. Yeah, exactly. My, I remember, I remember I had a patient with a muscular dystrophy. Yeah. That she was in her twenties.

She even had a child, but had progressed to the point where she was getting aspiration and we weren’t sure. We all had our own preferences and bias, but we kept her awake and able to communicate what she wanted and she chose to have a trach. But those mo those are very memorable for me because they were so rare that we had patients have a tracheostomy.

Which I know sounds crazy to people, but No, it doesn’t. I don’t want to outdo you, but my first, [00:43:00] my first day in the ICU as an intern, this like first day, so brand fresh, new intern. We had a patient who was intubated for, I forget why, maybe A-C-O-P-D, I don’t remember. And we had her wait and she was, she was very nervous because she was, I think she was in shock too.

She was like not doing too hot. And she got across to us that her granddaughter was, who was young at the time. It was like maybe in her teen or maybe 12 or something. Like, her mother wasn’t like a good person. She was doing whatever she was doing, et cetera. But I, but in the moment, all of the, all that, the patient’s stuff was going to the daughter, right?

Her, it wasn’t a trust ’cause she didn’t have that kind of stuff, but it was like her life insurance, like whatever it was, we like changed her will, like with a lawyer with her weight. We had tested that. Like she wasn’t sedated, we didn’t give her any medications that would alter her mental status. Yep.

Like she passed her. We, she was count [00:44:00] negative, the whole shebang. And we changed her will while she was intubated. And then she wound up dying like a few days later, which was sad. Like we were able to like really change the trajectory of the end of her life. ’cause she was like just distraught that she’s not gonna survive and her daughter was gonna like squander the granddaughters, whatever it was like for college or whatever the thing may be.

Wow. You know that that was like day one. I’m like, I went home, I told my wife, I’m like, I think I’m like, I don’t know if that was legal. I think it is ’cause there was a lawyer there. So I think it’s okay, but I’m not really sure. And you know, I didn’t get called to the carpet yet and it was probably like a while ago, so it’s probably outdated.

Anyway, that’s like my experience is being, is people like being awake and being able to right on the board and do this stuff. And like the backside we’ve taken in me having to really defend like this patient should be awake if they can be. Like a pretty good try. Not just, oh, we shut the prop profile. If they start coughing, we put it back on.

But really good go at it like not when you can use PRN medication. Right? You use P fentanyl. Use [00:45:00] PRN like antipsychotics. Although I would argue that like delirium in of itself doesn’t garner you psychotic. Neither does insomnia, which I think has been more prevalent in the recent time is like the patient didn’t sleep last night, so we gave ’em some Seroquel.

I’m like, they’re, that’s not a sleep aid. That’s not a sleep aid. Like I understand you want the patient to sleep, but they’re just sedated and that’s not sleep. And so then it’s what do you want us to do? I’m like, Mike, you tell me in the plan that we’re gonna do delirium precautions, like what exactly are delirium precautions?

Because I’ll tell you right now, it’s 10 o’clock, the lights are off, the TV is off, the shades are down, the patient’s still asleep. So if you’re thinking you’re doing delay precautions, you’re not doing them. So then I go on you outta bed by now? Uh, yeah. Like I go in and turn the lights on, turn the TV on, turn up loud, talk to the patient, wake them up.

They can’t hear. They have any hearing aids. You get the hearing aids, you put their glasses on. These are all the little things that I think that’s, I don’t wanna say human touch ’cause it’s a little, that’s not cheesy, but I say that pa, [00:46:00] I say that ICU pa, that’s the nicest way possible. By the way I say that.

ICU patients are like babies, right? They need to sleep, they need to poop, they need to play. So they gotta sleep at night, they gotta poop and they gotta play during the day. So you gotta wake ’em up and you gotta play with them, put ’em in the chair, give them their glasses, turn ’em on the tv, interact, that kind of stuff.

And the sort of pushback I get sometimes is the nurses are busy. We are, we’re sick, we have patients, we’re doing this, we’re doing that. And I get that. I really do. I really get it because I’m the kind of attending that sort of makes laps in the ICU throughout the day. What’s going on? How are we doing?

Did things change, et cetera. But everyone knows that delirium is bad, but, and we want some like magical elixir, like dex fixes everything. Just swap a little decks on it. It’ll be fine. It’s not, it’s like not a panacea, right? Because I’ll tell you, if the patient’s awake and alert and calm and the dex is on, it’s because of the decks.

If the patient’s completely snowed to the gills, it’s because of the decks. So I’m like, which one is it? Because you can’t be awake [00:47:00] and alert on Dex and you tell me that’s why Dex is great and you can’t be completely snowed on Dex. ’cause I thought Dex doesn’t completely snow you. So like where’s the disconnect?

Exactly. Like they just love that it doesn’t suppress respiratory drive. But I think that’s part of the, you’ve give enough of it. I think it will. What I’m fair to say, I think it certainly decreases your cough, your airway clearance, airway protection. Especially if you, I really worry about this excavation on decks and I think that’s where we have this gap in skillset is how many times have you seen that?

How many times have you seen that? Excavation on decks. Oh, no, we, people tell me that all the time. I’ve maybe seen it like a few times. I just hear about it all the time. I’m, I’m like, oh, I hear that all the time too. Oh, the deck is great. You can extubate on decks. That’s so amazing. I’m like, if you’ve been listening to this podcast, you are likely convinced that sedation and mobility practices in the ICU need to change.

The ICU community is facing incredible difficulty with the trauma from the Pandemic staffing crisis and [00:48:00] burnout. We cannot afford to continue practices that result in poor patient outcomes. More time in the ICU higher healthcare costs and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task.

How does this transformation start? It can begin with a consultation with me to discuss your team’s current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICUI help teams master the A-B-C-D-E-F funnel through education consulting, simulation training, and a bedside support.

Let’s work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more. You really think the 0.3 dex is, if that’s what’s really bridging the gap here, like just, just turn it off. It’d probably be fine. I think Dex is great for rath of plus three plus four.

They’re dangers, they need [00:49:00] some chemical restraint, but keeping them, getting them down to a ERASA plus one or zero on that. And then considering an extubation then, right. The Dex Police is gonna come for me and throw me in jail because it, you know, like people love it. You love it. I dunno why it’s a great drug, but I think it’s highly abused.

So if they’re uncomfortable with the RAA plus one, because someone’s coughing, now they get them to RA a negative two negative three on the Dex, and then they extubate them. Now they’re weak. They’re probably delirious now. They’re just laying there on decks. But they’re safe because it doesn’t suppress the respiratory drive.

But I see that as a huge risk for aspiration. I see that as struggle to mobilize them. Our poor PTs and OTs are like, if I had to mobilize another patient at era negative two and decks, I swear it just creates more work and I think it really sets them up for reintubation. They can’t really clear the secretions.

They’re not really alive at era. Negative one, negative two. Yeah. They can’t communicate. So yes, it’s not as genic as propofol, but can they use a call light and. [00:50:00] Right in a clipboard, Hey, I have chest pain, I have a new large pneumothorax that I’m, or I’m starting having a heart attack. We can’t get those symptoms from them.

So I have a lot of concerns, and this is my theory when ICUs are like, take it from probe to pre sedex. We never have to go through this period of, Hey, you’re in the ICU, what do you need to communicate? Yeah, let’s get you suction, let’s get you coughing, let’s get you mobilizing. While they’re intubated, they’re just like, we’ll just get them to D negative.

That drives me crazy. Negative one. Get you on BiPAP and we’re good. We got them extubated. It’s success. And unfor, unfortunately, I think you might hate this, but I’m gonna say it anyway, only because in in residency, like the nurses were like so good about our rascal was like zero negative one is how we broke it down.

We, it was like two general rascals. So the, I think another good teaching point is RAs, is you don’t target a RAs negative four, right? It’s hard to do that. Just land it into that zone. You know what I mean? So it’s two general rass, like zero negative one. So like awake. And then negative four, negative five [00:51:00] comatose for whatever reason that you need to be.

I don’t know what it is, but just for for example’s sake, I don’t know. Ongoing paralysis. Let’s say you want to sort of like very sedated or ICH or, yeah. Or exactly. Yeah, good point. I don’t do a lot of neuro, but because I think neuro, yeah, neuro is a whole separate animal, but so like nurses in residency, like they were really good at keeping that prob down to the point where the patient’s just, just a little sleepy.

But if you would call ’em, they wake up, right? Like negative one, wake up, follow you, look at you. But I find that especially recent, like in the past couple years, like no one can find that sweet swat sweet spot with propofol. So it’s like the normal cadence I see is like propofol is on, they’re over sedated.

The next attending comes in and is okay, put them on Dex because that’s like better. They’re on decks and then they’re like very agitated because they’ve gone from 40 a prob. So 0.4 Ds, and then it’s like this wild swing into like [00:52:00] awakeness. Then it’s like, oh my God. Now they’re like too awake. So now we’re adding fentanyl, and then it’s like that doesn’t work.

So we add fentanyl drip. So now you went from propofol and maybe, maybe just turn the prop down, but went from propofol to sedated to now precedex, fentanyl, maybe the same level of sedation, but now you have two different drugs. So like you expose the patient to all three drugs for no reason. I’m like, why?

Why? Yeah. Like, why don’t you just leave the prop on, oh, they’re too sleepy. I’m like, then why don’t you turn it down like then? Then that’s when they hit me with the Dex. The dex is good because they can be on it and be extubated and all this stuff. And I’m like, all right, so this is like, this is what I’m talking about, like it’s like this very nuanced, like sedation like regimen and the fact that it’s been beaten into, I think a generation of healthcare providers, nurses, doctors, pharmacists, everyone that Precedex is like this elixir.

The patients are just like super not sleepy and they’re super awake and they’re, you can extubate on it. It just doesn’t, [00:53:00] it doesn’t play out in practice. And a lot of times, and I wish it did, honestly, but it just, it doesn’t. So I’m usually like, I’m a PRN Fentanyl guy upfront and I’ll go up to whatever I need to do.

But to me, I think it’s a win. If you know you’re on, you’re on fentanyl of a hundred Q2, right? And you start to get at the end of that Q2 and then need another dose, and then they’re comfortable. I often get into sort of discussions with nurses or residents or whoever about fentanyl drips, and I’m like, okay, if I break my leg, please give me a hundred of fentanyl push.

Don’t put me on a hundred of fentanyl an hour because in order for me to get up to that hundred of fentanyl an hour. You need to go through five half lives of Fentanyl to get this steady state. The half life of fentanyl is whatever, 60 minutes. Let’s just say for, I know it’s like a range, but that’s, the math is easy.

I can’t do math. So you need five hours to get to a hundred a steady state. Okay. [00:54:00] What happens is, and I know you’ll, I think you’ll corroborate, is that you start that 25 or 50 or whatever it is, the patient’s still doing whatever they’re doing. So maybe give a little baby bolus, 25, 50, you’re a little better, but you go up on the fentanyl, right?

And that happens a couple times. And then before you know it, you’re on fentanyl, two 50 an hour, 300 an hour, and then it’s like you’re on this massive dose of fentanyl an hour, and you’re always behind the eight ball. And then once you get caught up, now you’re over sedated. Now you’ve got renal failure on top of it, and oh yeah, wait, you have two renal failure on top of it.

Everyone’s obese and fentanyl’s like very lipid avid. So it stays in the body and just self doses, just like midazolam, right? That’s why using Midazolam drips was just like such a disaster because. You could shut them and dazz off, but the patient won’t be awake for another two days because they’re just self dosing.

It’s like mind-boggling. When I’m, when I say, okay, we’re gonna give some PR and fentanyl like every two hours. How much? I’m like, I don’t know, maybe a hundred, 125. Like I’ll go pretty bigger, like a bigger dose and it’ll be like, why don’t [00:55:00] we just do a drip? It’s, it’s because we’ve done so many drips that is just, oh wait, do you want me to go in there every two hours and give a prrn dose of fentanyl?

I’m like, yeah, that’s the point. And they’re like, no, we just do a drip. Like it’s easier, like it might be easier, but it’s not like the right thing to do. We should be doing the work. It would be easier in five days when they’re still intubated, when they should have been extubated three days before that.

I think you said this before, we, there’s this maybe undercurrent of kicking the can down the road. And to your point, it’s day 14. In the past 10 days, it’s just been like they failed excavation, agitation. We sedated and then we’ll try again the next day. And no one sit there critically and felt like, why did, like, why did they fail?

What are we failing for? Agitated. What does that mean exactly? Oh, when they wake up, the vent, the alarm and they’re bucking, whatever it is. And when you go to the bedside and look like it’s not any of that, they’re coughing. And that’s normal. That’s a normal, I try to paint that in in a normal way while the RAs may be plus one.

Like that’s normal stuff, right? We should expect that. That’s something [00:56:00] we should expect. So we shouldn’t be like, we shouldn’t be reacting to that. We should just allow it to happen and then manage the expectations as we go forward. And what we want is the patient to be awake and we want is for ’em to communicate with us.

Especially when you can’t get a neuro exam, you can’t get like a good neuro, ’cause like my attendings in residency would always say like, how do we know that the patient didn’t have a big stroke underneath? Because they’re on propofol, they’re not like doing anything. So part of the SAT is making sure, like they’re not, they didn’t have a big ischemic stroke type deal.

How often do we see that during COVID, where we’ve got patients laying there for weeks and now their lungs are better and now what better? But. Now we take sedation off, nothing happens. And then after a few days we’re like, oh, we should just probably roll out a stroke and it’s everywhere. Yeah. And like you wound up having a stroke and so much of that could have been prevented by proper DVT prophylaxis with mobility, being able to assess and intervene early on.

It just so the nurse Kaylee is exhausted by everything you’ve described. [00:57:00] But now I completely, when I come, when I come on and now I’m doing a waking trial that has not been done yet and it’s day four or five and the patient’s delirious and now I’m being adding, going to the Pyxis, getting more meds, starting them, but I’m stressed out even leaving the room because this patient is confused, worked up impulsive, but I’ve gotta run out and grab something or I’m ary someone else and I’m alone in the room.

That is so stressful and so much work and I’m spending a whole morning trying to get them down to this sweet spot. And then in Pete Kaley is, this is insane. Everybody stop. Don’t add more junk on until we have sat them up at the side of the bed, given them some time to clear it out, done proper suctioning, given them tools to communicate and just figure out what’s going on.

What are we treating here? Yeah, I’m not afraid of RAA plus one plus two, but you as a provider, if I’m in an environment where no one understands how to use those tools, no one’s considering using those tools, then yeah, we’re [00:58:00] having to play around with all these medications and have to be like back and forth all day about it and we just chase our tail.

And that just sounds exhausting. So when we get patients from outside facilities that had been sedated at community hospitals or whatnot, we’d have to do this. And it was so exhausting and frustrating to realize, great, now they can’t write on a clipboard. Great. Yeah. Now how do we figure out what they need?

But, or they’re just, they think they’re on Mars and we’re gonna step up side of the bed until they wear out and get exhausted. And that was just part of the routine. It was not like, Hey, I need this, I need that. I need a drip. Unless obviously they’re dangerous, they’re in full dangers. Then we’re grabbing Xme and we’re keeping them at Rasa plus one plus two, honestly, so we can set them up.

So we use these tools to facilitate the actual treatment, which was getting them up, getting them verticalized, getting them connected with their family, allowing them to get real sleep otherwise, or even opioids prevent real sleep. So we’re just continually trying [00:59:00] to chemically restrain them to mask the symptoms rather than treat it.

And Nurse Kaylee is exhausted by that kind of environment. I, I have so much respect for revolutionists of all positions that come in and are like, everybody stop. This isn’t saying, let’s try something different. In an environment in which no one knows what they’re talking about, they don’t understand the why, they’re just like, why would you do it that way?

This other way just is easier for our shift. It’s what we’ve always done. So how do you feel like. The perspective and knowledge of your colleagues impacts your ability to order those kind of things and guide those interventions. For example, if you were to say someone’s, Hey, my patient’s agitated, and you’re like, have you sat them up at the side of the bed?

I’m, yeah. Okay. And I don’t say that for a rasa plus three or plus four, I’m talking about plus one or plus two, which is usually what we call agitated. Uh, but you’ve identified, okay, they’ve described their behavior. They’re not dangerous yet. It could escalate. Yeah, let’s [01:00:00] get PT and OT in there, set them up at the side of the bed.

What’s the response from a nurse? I think for, from my perspective where I’m, where I have been recently, there’s not enough support PTT wise to even like capture people who are still maybe critically ill, right? You have to be, you have to be so much outta your critical illness for PTOT to even say, we’re gonna do X, Y, and Z and that.

You know, it’s nothing against PT ot, we just don’t have enough of PT ot. Certainly. So I think, I think if a nurse came to me and said, the patient’s agitated and wouldn’t probably even gimme a RAs, honestly, just say they’re agitated. I think the expectation is, okay, I’ll get, I’ll give you Haldol or I’ll give you whatever it is.

So resident Nick, I would go to the bedside. And what, like, what is happening? Exactly. And I found, I found multiple situations. I found the patient’s agitated. I’m like, all [01:01:00] right, what are they doing? Oh, they’re, they’re trying to get up, they’re threatening to leave, right? So I’m like, okay. So I go to the side of the bed and Mr.

Jones, what’s the problem? And something very coherent, right? Oh, I like, my mortgage is due today. I didn’t send it out before. Something very coherent, not incoherent. It’s like very famously, like for me at least, it’s famously in the sense like this. Is very specific. And I think your head’s going, I might see your head explode on the zoom call when I say this.

So I was in the ICU on the weekend and the team, the floor teams called me and they said, we’re upgrading a patient for Precedex. And I was like, okay, what’s going on? They said they’re agitated, they wanna leave and they can’t leave. And I said, all right, why can’t they leave? They said, because they’re we’re not like, he can’t walk.

And I was like, okay. So there’s only so many questions you can ask when someone’s made a decision that they’re doing something with someone, as you probably know. So I went [01:02:00] to the floor and so that you’re saying, oh, he is like being very belligerent with the nurses and screaming at them. And he even rolled out of beds like, like army crawling to leave.

So they put him back in bed, they physically restrained him. So I go there and I’m talking to him and he’s got some psychiatric disease. And I think had a prior suicide attempt, so he jumped off a roof and that’s how he can’t walk anymore. But that was like years ago. And he is been maintaining, he’s homeless un unhoused as we call it today, but has a wheelchair.

And he was at his mother’s house and there’s some contention there, and they, he called 9 1 1 because he couldn’t breathe. That was like two days ago. So he’s basically cleared for discharge. So I’m talking to him like, why, like, why won’t they let you leave? And he’s, because they don’t think that I can, he’s, I just want to go, I don’t want to be with my mother.

I just wanna leave. So I was like, all right, we can get you a wheelchair, but where are you gonna go? He said, I’m gonna go to the homeless shelter, [01:03:00] like down the street or whatever it was. So I’m thinking to myself, he’s got all of his faculties, he AO times four. Like not acutely psychotic just wants to leave, right?

So we’re essentially holding this guy prisoner in the hospital. So I’m like, why do you wanna sedate him? They said, ’cause he can’t, he’s not allowed to leave. I said, why? You said he can’t leave? And they’re so listing all these things off and I’m like, so you want me to bring him into the ICU and sedate this guy?

For for what? Exactly for expressing that he wants to leave the hospital. It’s almost, it’s almost battery in some ways. Not battery, but it’s almost, it’s like committing a crime, right? Like he’s holding hostage. This isn’t Yeah, I’m holding him ho. Exactly. Like I’m almost kidnapping him. This isn’t jail. I can’t hold someone against their will you, there is medical kidnapping.

That that’s what that sounds like. I know. So I said like, it’s irrelevant if you think that this is a good decision. Right. This he’s awake alert, he can verbalize the risk and benefits of doing said decision, which is leaving. But it’s almost like you’re, it’s almost like you’re profiling him in some way.

’cause he doesn’t have his [01:04:00] wheelchair. ’cause he left that at home. So I’m like, you can get his wheelchair right? Like someone can bring it to the hospital, he can go in his wheelchair, he transfers from wheelchair to bathroom. Like he does that by himself. He’s been doing that. And so like he can go, there’s nothing he, he can go.

It turned to this whole big thing, obviously with the hospital and like risk and the lawyer and all this stuff. Oh my gosh. And it’s, and this whole thing. So I said, guys, listen, I, I evaluated him. He has capacity to leave and he can leave. And suggesting that I chemically restrain him is just immoral and unethical and I won’t do it.

And if you want someone to do it, that’s fine, but you’re gonna have to transfer him off my service because this is insane. And so other ethics weighed in and the lawyer weighed in and they agreed, we can’t do this. While it’s a bad decision, like we can’t stop him from doing it. This all came from a call, like the patient’s agitated, he needs precedex, right?

So once you start probing, you’d be surprised what you find. And I think because we get caught in the hustle and bustle of the [01:05:00] day, sometimes we just, we look for the path least resistance, right? Kaylee comes to the bed, to the physician room and says, this patient’s agitated. I need some. How do easy peasy lemon squeezy little, how do 2.5 iv, see you later.

Thanks Kaleigh. Talk you later. But it takes more work to get up and go to the bedside and see what’s happening. See that the patient’s awake and posturing that they want the tube out and that’s reasonable. That’s, they’re not agitated. Like I agree. I want help too. They’re communicating, yeah, you need to, we need to chill, relax a bit and do this SBT, you need to relax and do some breathing and if you pass this, then we’ll pull the tube out.

And that comes back to that coaching aspect. And I feel like people get super frazzled because if you’re not work used to working in the hospital or the ICU, and this might have to do with, I think there’s been differing sort of nursing requirements. Maybe you can talk to that, speak to it more. But I think in days past, before you got into the ICU, you’d have to be a floor nurse for a certain amount of years.

And we’ve taken that away in some ways because we just [01:06:00] didn’t have any bodies to be in the ICU. And I understand that to the nth degree. That’s one of the things that’s suffered is like this. You know who, this is like a normal reaction, right? The tube is in their mouth. It’s uncomfortable. They’re gesturing, they want it out.

They’re gesturing, they want their hands untethered. If you’re in the room, like untie them, see what happens, right? Like just like I said earlier, this happened a couple times. Like people have self extubated and turn this like big sort of thing on the unit, right? Whenever someone self extubate, it’s like this big, it’s all, it’s like all the news.

Huge failure. You’re the worst nurse. You’re gonna lose your license. You get pulled into your manager’s office, you is up. Yeah. Is that how it did for nurses? Is that how it is really? Because for me, I’m just like, I don’t in a lot of units. Yeah, that’s absolutely. And I, there’s been stories where the physicians have to come in and intervene to say, Hey, they shouldn’t have any heat for this.

They had them awake, they had them riding, they were doing the right thing. They were practicing better med medicine than the rest of us. This is not a failure. They’re [01:07:00] not even reintubated. It’s fine. Oh, that’s interesting. I, on the nursing side, it’s like right up there with falls. Oh wow. Okay. Because I heard this multiple times, I haven’t been able, I haven’t looked it up, but I’m told, and I’ve been told by multiple people that we want a certain self extubation rate, right?

Like we want, do we, I don’t know. I’ve been told that I haven’t been able to cross verify. Just sounds like it’s correct. My, my residency attending would tell me that we want somewhere 20 to 30% self extubation rate over a month or something. Because if we’re too low, I, I don’t know if we’re too low, that means we’re too sedated.

Right. I think it depends on the environment. So working in awake walk in icu U self extubations were very rare. We went over two years. Oh really? That ever happening before COVID. And it was a COVID patient that had been sedated that got it out. He didn’t end up being reintubated. We obviously, we do cause analysis to say, why did that happen?

Could that have been prevented? But we recognized he’d been sedated, he was delirious, but we had to sedate him. At that point, he we’re in isolation. His family wasn’t at the bedside. Like these circumstances [01:08:00] and environment is very different now, but we still did the best by him and. He was okay in a normal environment in which patients are always sedated.

I think if you’re not having any self extubations means that they’re probably over sedated, right? I think if you’re starting to lighten sedation and trying to get it off sooner, you’re gonna have more self extubations because they’re more likely to come up out of sedation delirious, and that alone increases the risk of self extubation by 11.6 times.

But when I compare self extubation in that kind of environment versus being so sedated that they stay on the ventilator for longer, end up with a trach post ICO syndrome, death, I’d rather they be awake and strong enough to get the tube out. One physician said that I trained, he’s, listen, should I just give Starbucks gift cards for every self extubation that happens?

Because that means that they had them awake enough to get it out. So that’s so funny. I think that they are, we can create an environment in which it really is minimized. But [01:09:00] when we’re in this limbo land of light sedation or deep sedation, now face shift is taking it off. They’re gonna happen. And I don’t think they should be so punitive, but I think we should really be looking at what are we doing to create that much delirium.

Yeah. How are we mobilizing them? Are we involved in the family? Do we have sitters when they’re appropriate? So I think it’s a whole environmental thing, but when we put it down to one nurse, having their patient awake enough to self extubate and punishing them for that, we’re actually increasing a very dangerous environment there.

Yeah, and I think a, like a short story is that there was a younger patient I had who was intubated for whether they needed to be intubated or not, like up for debate, but super strong, obviously just like very altered. He actually wound up, he actually had a malaria, like really big malaria because he came back from Africa.

So it’s pretty interesting. But anyway, he’s. This is one of the situations where he is agitated and what it was, he was coughing. He’s like doing this sort of [01:10:00] squirrely worm stuff, just squirrelly worm. So I said that really not. That’s okay. Right. He’s allowed to cough. He’s allowed to be a little squirmy.

Wormy. I want him to be squirmy worm, so doesn’t get a, a deep tissue tissue injury. But it was very big deal there. It’s gonna self extubate and all this stuff. And I was like, I don’t know how much I, how much that really makes me nervous. But in days past when I certainly, when I was a resident, so this patient was in the corner, in the back corner.

No clear line of sight. Yeah. You had to like really take two steps over to like really see him in days past my in residency, my residency was the same way. It was, it was actually an OB unit that they converted to an ICU. ’cause the OB part of the hospital fell apart, but it was too long. Hallways that sort of converged at the nurses’ station.

So you really couldn’t see anyone like directly into the room. I that except for Yeah, I know. Tell me about it. Except for a few rooms, like a couple rooms right up front you could see directly into the icu. So if they ever had someone that was like. Like that, they would move them to that room. So multiple nurses had eyes on them.

So this [01:11:00] patient wound up being, of course, he self extubated like 30 seconds later after I said it’s not a big deal. And like he was fine. I shut the S station off and he was fine. He just was altered from his malaria. I was able to get him awake enough to tell me his name and where he was and he didn’t get the year, but, and he was delirious, but like he was awake enough to protect his airway again, whatever that means.

And wasn’t in immediate danger of needing reintubation. We, they talking to me after, they’re like, we self extubate. It was like a big deal. So what do you think we could do differently? I was like, the whole unit is basically empty. It was like a slower day. I was like, why did you put him in a different room?

Like in front of the nursing station and the ICU that I was in. It’s like a nice ICU that it’s like a lot of glass, like very, like a lot of natural light. Yeah. Lot of glass. Like you, there’s a lot of lines of sight into different rooms. Yeah. So I’m like, you guys put him in like the worst room that he could possibly be in.

Move him to a different room. And that was like. Like, that’s a great idea. I’m like, that’s not my idea. That’s like a, a nurse for 40 years in the [01:12:00] CCU was like, this guy’s crazy. We’re gonna put him in front of us so he could watch him. That was the kind of doing nursing homes, LTACs, the acute care floor, like those are the kind of nurses I worked with in residency.

They were, they were all seasoned 20, 30, 40 years. One was literally four, like 40 years of nursing. So I just had real good, like I had to back to your question earlier, am I afraid of nurses? Yeah. I’m definitely afraid of nurses. ’cause of those nurses, but they, they like, man, they really were able to, they really were great and they like that little, that sort of stuff.

You don’t learn in school. Like that stuff. The patient’s agitated, we don’t wanna put them down the hall, we wanna put them in front of us where we can have eyes on ’em all the time. But then they come into this environment where it’s like the answer is, comes in a bottle, it comes in a vial. Just give more of that.

Well, I’ll, Hailey, I’ll tell you what the dude I was just telling you about, he was on literally everything. Propofol, fentanyl, ketamine, the whole shebang, still doing his thing. And I’m like, it’s [01:13:00] because he’s young and he’s delirious from his malaria. I don’t think there’s gonna be any level of sedative that I’m gonna be able to combat that I could.

I just have to do the best that I can and not overdo it to get him into a point like that. We’re discussing where too much sedation, right? So now he’s on 300 of fentanyl for three days now he’s like completely gork. So when he is, gets past his acute malaria, which he did and he did fine that he doesn’t have a post IU syndrome.

We don’t get diaphragmatic dysfunction. He doesn’t get delirium. I think delirium is the thing that’s undersold is that when I gave a talk about delirium to the residents a couple weeks ago, just like off the cuff, because we were talking about the CAM assessment and this happened on rounds too. So I’m going through and I’m like, is the patient, I asked the nurse and it’s like a newer nurse, not really that new, actually a nurse that maybe needed some more engagement.

So I said, is the patient delirious? So the nurse looked at me and then they, we were outside the room. The nurse looked at [01:14:00] me, looked at the patient, eyeing them up, and then looked at me and was like, I don’t think so. And I’m like, what do you mean you don’t think so? It’s not, there’s no, it’s not like a dimmer system.

It’s like they either are or they aren’t. And did you do, did you make ’em squeeze your hand like every time you said a, because if you didn’t do that, then we don’t know. And that’s fine if you don’t know how to do it, like we can do it together. But this is, so this is the point. It’s, we’re not, I’m not looking for an opinion like are they delirious or not?

And we have a way to objectively identify if they’re delirious or not. Because if they’re delirious, then we have a problem. ’cause we can’t treat delirium. It increases. Generally stay. I see the say mortality, morbidity, all that stuff. That is like looking, if you’re asked like what was their creatinine today?

Looking at the fully bag and being like, I know 0.4, no, I think it’s okay. Yeah, that’s there. That’s a very common occurrence is that the CAM is not seen as mandatory. We don’t really know how to do it. Bless their hearts. They’re came in during COVID. We’re like, [01:15:00] here’s this like quick 10 minute explanation of this thing.

Just follow the dropdown box When it comes up. I look at, I see of it’s like very important thing. Yeah, it’s, it is the creatinine, the troponin of the brain, and yet we’re not treating it like that. So it’s nice to have a physician say, what is it actually? Or did you actually do it? Well, I mean, yeah, I, because in residency we had to, I had to say it like they’re cam negative, like that was a part of my assessment.

He. Like he, my residency attendings, maybe I’ll, hopefully I can send him this podcast so he’ll enjoy it. He was very strict, very strict guy, but he, it was like our rounds were scripted. There wasn’t any, like I said earlier, like we’re all snowflakes in the ICU. He was not a snowflakey kind of guy. This is the way we’re doing it, like five minutes for subjective, the nurse gives his or her perspective, so it was like drips ins outs, [01:16:00] concerns, A to F and then move on.

Then it was like objective assessment data done. Then assessment plan. But in, in that, it was like that was part of the neuro assessment. Are they chem negative or positive? Are they indeterminate? Like neuro assessment for every patient on every patient? Certainly patients on the ventilator. Certainly patients sedated and certainly patients who are comatose.

Right, because, and his famous saying that, I’m sure he, my. Send this to people that I did residency with was you can get an a neuro exam on a rock, right? Because even a person who’s GCs or three, you can get a neuro, there are like permanent positives in a brain dead person, right? Like they have no cough.

If they have no gag, there’s no corneal, it’s still an assessment not overbreeding the right. It’s still an assessment and, and that’s how we know if the patients had a big stroke underneath their propofol, right? Oh, I did my neuro assessment today. They didn’t follow commands. They’re not over-breathing and they have no cough gag.

They and the doll’s eyes not positive. Right. That’s a big, that’s a big problem. You know what I [01:17:00] mean? Yeah. But when you don’t like when people, I think assume providers, like certainly like students or nurses, interns, attending, whoever it is that just because they’re on sedation, you can’t get an assessment and like you can get an assessment and they’re like, that assessment’s like probably the most important thing that you do at that time.

That was one of the most alarming things to me working early on as a travel nurse was. Then how do I do a neuro exam? I remember being so confused about that being like, if I, if they’re sedated and even when I pick sedation off and they’re like, what’s causing them to be so altered? I just, I didn’t understand what I was supposed to do, but the fact that everyone around me was like, just don’t touch that sedation.

’cause they’re intubated. They, they sedated and no one seemed concerned about a neuro exam. I just wish 2-year-old Kaylee, I was only two years into my career when I became a travel nurse. I wish I’d really spoken up and been like, this is insane that we’re not doing a full neuro exam on these people. Why do we think that’s okay?

Yeah, I, no, no, [01:18:00] we, so what I like, it’s a lot more infrequent than I, like, am bedside teaching people in certain situations. But the way that I do it, honestly, if any, if anybody cares, is when I have like gloves on, I’ll just, I’ll do my normal stuff and then for me, I’ll like look at the ventilator, see if they’re triggering or not.

I’ll put this suction catheter down, see if they cough or have any reaction to it. Then I’ll just open their eyes and then with my glove I’ll pull up a little bit and then just test the corneas while I’m there. And then as their eyes are open, do a blanket thread, do a glo. And that gives me a lot of information about like what planet the patient’s on.

Because if they’re not doing anything and they’re on sedation, then that means that the very first step is to take it off. Because if we take it off and none of that stuff comes back, like that’s a big problem. Big. Yeah. Now if none of that happens, we take it off and it comes back and they’re like back to earth, then that’s even better.

’cause that means that like nothing happened and it was just a sedation, and then we can work to wean it off. And we talk about like a full neuro assessment. I, I feel like sometimes people think it’s [01:19:00] just sort of big to do, but it really doesn’t take that much longer to do that than anything else. You know what I’m saying?

You work it into your flow, but it was also so much easier when patients were awake. Yeah. Yeah. I mean, wiggle your toes type deal. Right, and like the finite things of, I’m looking at their handwriting. If I had one day, oh yeah. Multiple days in a row and I see their handwriting’s getting loopy, I’m like, I think they’re developing delirium, like we could catch it.

Oh, that’s interesting. Yeah. That early, that fine. As an np, I obviously wasn’t able to be part of sitting people up the side of the bed or walking them or whatever, but when PT would come in and say things to me, I just realized, wow, they are doing such an in-depth neuro exam that even though I went in and assessed them myself, they were laying in bed and I didn’t catch these things because I wasn’t making them do anything challenging.

Oh, sure. Yeah. Especially like walking and of itself, or I think the other, the other thing is that you actually need a lot of strength and coordination to sit up at the side of the bed. So maybe we don’t do it because we don’t think it’s us just sitting side of the bed. It’s [01:20:00] not a big deal, but that’s a big deal if, yep.

You’ve been in bed for a week sedated and on the vent, the whole shoot. That’s a lot of work. Mm-hmm. People get super gassed just from sitting up at the side of the bed supporting their back and like their upper body just with like their core on the side of the bed and Yeah. No, I agree. One of my attendings told me like one of the best ways when I intern resident, we have a lot of stroke admissions, that kind of thing.

The best way to really assess is to make them walk. They’re walking fine. Like that’s a pretty good sign that they’re probably okay. I’ve also seen people, I’ve seen people that are fluidly delirious, be able to walk. They think they’re grocery shopping. Yeah. Which is interesting. Is interesting. It’s walking is such a primitive reflex.

It is primal instinct for survival. Yeah. And so they ha can still have the strength, especially if we’re doing it early on. Right. They can still have the strength. Sometimes they don’t have the coordination, but they may have the coordination and be able to still walk while they are delirious and it makes everything easier.

So someone that is swinging their legs over the bed and trying to [01:21:00] climb outta bed or whatever, I’m like, great, let’s use that to get you going. Let’s get you gassed because I’m not playing this all day. And it just tells you a lot about where they’re at. And doing day shift. We do morning and then afternoon and sometimes these patients just could not even figure out how to put their hands on the side of the bed and hold themselves up in the morning.

But then the afternoon they start to do more on their own. And you can see the neuros, synapsis start to happen more often. Yeah, functionally, just within those two different sessions, that tells you so much about where they’re at. So I really missed that. I wish I’d paid more attention to that. Working in a normal environment where I’m like, do they have a corneal reflux?

Did they have a gag? Okay, great. I guess that’s good enough. That’s all I can really do right now. I did miss knowing who that patient was. I look back, I mean like that’s not even ethical to not give someone. A voice during their critical illness. I always wonder for someone like you, like how do you ethically deal with this when you are now you’ve had someone fill out their all [01:22:00] their full will while intubated.

How do you not, how do you not now look at patients and be like, wow, we’re four days in now. They cognitively, physically can’t do that. How do we ethically justify taking that away from someone that should have been able to do this the whole time? I just, after what I’ve seen, I don’t know how to just cooperate in an environment where I want to just fix it.

And how do you not just throw a tantrum sometimes because this, these people’s lives that we’re messing with, if not ending. Yeah, I’ve had that discussion internally with a lot of different stuff. I mean that the ventilator in of itself just because it’s a misunderstood intervention. What I’ve come to is that I just do what I can while I’m there.

I do what I can while I’m there and then I do other stuff, which is whatever. I do this and like whatever Instagram is, put it out there. Hey, hey, I, there’s a [01:23:00] different way, right? Not everyone is doing what? There are people that are doing different stuff and if you feel like something’s wrong, it probably is wrong.

And if you feel like, man, if guys don’t, don’t settle on that, people are just intubated, sedated and that’s it. Right? We should be working to get these people outta the ICU. So I just do what I can while I’m on and then I have this extra energy and like where do I put it into? And I feel like you do the most amount of good by spreading the word as far as far as I can.

So doing this and like doing stuff wherever, like either at the resident level, at the hospital level, like getting involved in the hospital, on the hospital committees, like with the nurses and doing teaching and doing teacher with the residents, doing teacher with like other attendings. Don wanna hear it?

More specifically with like ventilator type stuff. Just turn, trying to turn the clock back. And unfortunately with how ingrained it is in the unit culture, it’s gonna take time I think to unwind these things. And I think for people who see something [01:24:00] wrong with it, it’d be easy to really just collapse under the weight of like the work.

But if you just focus on doing what you can daily, it’s like that old, I don’t know, this is like, it’s so corny, but just bear with me for a second. I like that starfish analogy. Did you ever hear the starfish analogy? Like, like the storm watch all the starfish up and the little boy was throwing it back and the old band’s like, why doesn’t matter?

It matters to that one. That’s really like how I think because for me it was a big, I felt like a lot of pressure to really make everything perfect all the time. But I can’t do that. Right? And you have to rely on your other teammates. So I don’t want to tell people like what to do. I don’t want to do that.

I want to educate them and then empower them to make those decisions on their own. And you, you don’t really have a lot. People educating, I think, and for certain things, right? This stuff is really fallen by the wayside. I don’t know if it has to do with maybe is SCCM not like as vocal recently with things or the society falling apart?

It’s because there’s such a huge push in this social media aspect, right? Like where [01:25:00] I’m just gonna make up a, you know, fake nurse influencer puts out their thing about sedation and it’s intubated, sedated patient equals best patient. Follow me@nursekayley.com type deal. We’ve ingrained this culture into, because we’re so involved with this like social media aspect of things that we stopped listening to the societies ’cause they’re communicating in like an old way, you know what I mean?

Li’s communicating an old way. Like they just had their, like it was just conference a few months ago. I didn’t go, but I remember a time passed where we would be talking about like the updated guidelines. That was like all the buzz within the medical community and that’s, I haven’t, I had to seek them out.

It really didn’t seem to being shared widely. Not much has changed, I think in Patas from like 2019 or whatever to, to now more or less, but. I don’t know if SECM is seen as the A to F bundle is seen as something that can really impact ICUs. If it’s, if it is done right, done consistently and at every level.

I think, because it’s not the new hot thing anymore and people Oh, okay. [01:26:00] Assume that it’s done. So I get the, I get told all the time, oh, we already do that. We do the bundle. Oh. ’cause they talk about SATs, SVTs on rounds, but they don’t really know how to do them. They dunno. They dunno what they’re using.

What I’m told is that it’s already in the note. I’m told that they’re like, I’m like, what about the AF bundle? Oh, it’s in the note. I’m like, where exactly is in the note? Oh, we just include it in there. I’m like, that’s not the point. The point is that it’s a checklist that you stop and you do your checklist manifesto, A, B, C, D, E, F.

It’s not. If it was just in the note, then it wouldn’t be like a bundle slash checklist. It should be done separate from said note. That’s how it gets presented to me a lot of times. And coming from. I see that it came from though that ICU really inspired the creation of the A BCF bundle. We never really talked about it.

It wasn’t until COVID hit that we were having to teach nurses, our nurses how to do awakening trials and still we taught in a way of once they can be supine, these are COVID patients. Once if they were, yeah, sedated, pro, paralyzed. Once they can be supine, now we’re gonna turn [01:27:00] sedation down and see can they maintain their saturations with sedation down once they move.

Right. If so, sedation’s off that. That was the bundle because we already had the core of it implemented. We were expecting patients to be awake. We were just now having to pause on that aspect of it. So I think part of the checklist problem is that we just are documenting these things and not really doing them.

I think the A should be ask if they’re in pain, like if that alone was the cultural interpretation of that check of the A is ask if they’re in pain. That would change our practices. But instead it’s chart cpo, which implies that most patients, if not all patients are not going to be able to report their pain.

We’re just calling cpo. Interesting. The A and then S sat, tsb, T like putting those together on one letter reinforces not doing as. Yeah, I’ll see. So like we can check that off our checklist because, oh, they’re not ready for SBT, so we’re not gonna do an SAT or we an SAT. They failed their SBT. Now it’s all failed.

So, [01:28:00] and then I think C should be communication, right? Instead of choice of analgesia, sedation. I think that should just be part of the awakening trial. Do they actually need it? We take it off right away and they be awake. Okay, great. These should be communication. But anyway, so we take it as checklist approach as far as documentation.

Instead of what you’re describing is, are we really thinking through this? Are we troubleshooting? Yeah. Are we collaborating? Are we trying to get them awake and communicative? So anyways, I think it all comes down to, we think that we’re doing it. It’s checked off our list. It’s in the note. But it’s not at the bedside.

Yeah, no, I know. And I think it’s because we, it’s almost like you have to add it. It’s like added work towards the end. But I feel like if you talk about it during rounds, like the checklist becomes easier. It’s just that like we’re reaffirming like what we talked about during rounds and that’s why it’s been so funny.

’cause when you talk about S-A-T-S-B-T, like for example, like patients fail their SBT and I’m like, all right, what are they on? Like five [01:29:00] over five? And they failed. And I’m like, okay, you want me to flip them back to, I’m like, just go up on the pressure. Go to 10. How do they do on 10? Oh, they do great on 10.

They pull volumes. And I’m like, oh, okay. So you think it’s like maybe they gotta be diuresed or something. Like maybe that’s it. And no one knew. Everyone doesn’t know. So I’m like, all right, let’s just diurese and see what happens and they get better. Right. And this has to do with the ventilator aspect of it.

Like it’s like this S bt, like SBT and put ’em on pressure support. It’s like this bridge you crossed and it’s all right. We s btd, we failed. They’re on pressure support, we better come back to volume control or whatever mode they’re on. I’m like just, I’m like, they’re awake, right? Yeah. I’m like, just leave them on pressure support, like they’re breathing.

But how long did this returning to volume control is because we’ve seen a failed SBT, now we’re gonna resume sedation. Now we have to, there’s do it. So there’s that aspect of it. But there’s also the aspect of, it’s like for some reason people are only on pressure support when they’re right about to be extubated.

You know what I mean? Yeah. So if they’re not ready to be extubated, then they can’t be [01:30:00] on pressure support or they definitely can’t be on pressure support ’cause they’re not gonna get extubated. And on top of it, they’re on the ventilator and they were on decks or prop or something. So we gotta like, oh, they’re agitated.

We gotta go back on sedation. So we better put ’em back on fire control instead of just riding that out. Ride it out throughout the day. And like you said earlier, there’s that time when they’re like rebooting in their brain and that might doesn’t look great. They’re like hilarious. They’re trying to pull things.

They’re fighting. They’re fighting, they’re doing whatever. So instead of just giving little aliquots and stuff like to get them through, we just go, boop, right back to what we were doing. And then, and we’re doing the SBT right during that period. So of course they’re tachycardic, they’re tachypnic, they might hypo toxic while they’re biting the tube like, and then we’re like, oh, it all fails.

Or even worse, you start the SBT while they’re on sedation. So lung mechanic wise, we’re good, right? We’re good lung mechanic wise. But once you shut their probe off, then they get to kyp nick and tachycardia. ’cause they’re like coming back to earth. Then you count that as a fail. So what I’m [01:31:00] so in those situations, I’m like, so they passed when they were on propofol and they’re like, yeah, they failed when they were off of it.

They said, yeah. I’m like, how does that make any sense? They’re like, oh, I don’t know. But they’re just like, they have to go back on. So I’m like, so in those situations I just pulled the tube out because if their lung mechanics while they’re like sedated or fine, like that means that they’re fine, right?

Like the lung mechanics are fine. Everything you’re seeing as far as the tachypnea goes, it’s because of a delirium or agitation. ’cause they’re rebooting. So the best thing for that is to get the tube out right? That’s the most delirium thing is the tube itself. So take the tube out because that would help that.

So there’s been times where I’ve come across people that were ethnic but pulling big volumes on five. On five or five. So I’m thinking to myself like, all right, are they tick, tick because the like agitation and delirium or is it because like they have lung mechanic issues? So I just increase the pressure, go from power five to 8, 5, 10 or five.

And what I see is just get bigger volumes. I see like huge [01:32:00] volumes. So what that tells me is that the lung mechanics are fine. So all what I’m seeing is just a result of their critical illness, the meds, their delirious, whatever. So if they look and remember two outta three, right? So like vital signs are good mental status, not so great ’cause they’re delirious, but the ventilator is okay.

Then they get my two out three and they get the tube out and then we see where we land. And you’d be surprised you take out the tube. Most people like are like, oh, what happened? I don’t remember. Type deal. And then they like come back to it six hours later, like awake, like eating a cracker. Whereas you would’ve, you would’ve, oh my God, they’re Nik.

We better put the sedation back on. And then they’re chain to the event for another day or five days or weeks or five days or a week or get a trach. Yeah. Yeah. The things that I see, I’m like, wow, those little choices, those little conversations completely changed those patients’ lives. I shared a story um, many episodes ago of a patient with COVID.

He had a son with Down Syndrome that was in his early twenties. She was his main caregiver. [01:33:00] She had COVID, she knew was her ventilator setting. Were never even that high. And I’m hearing this from her husband and he’s telling me about this day to day and he’s advocating for awakening trials and they won’t do it because she has COVID now finally she’s on a ppa five 40%.

And I’m like, there’s no reason. Absolutely. Even if they’ve been antiquated view Awakening trials, there’s no reason for her to. To be getting that sedation off. And so he’s pushing, they keep saying, no, she’s too sick. She has COVID. Everything else I’m hearing. I’m like, this does not make sense. She sits there for a few days, gets an a awakened trial, she’s agitated, gets sedation resumed.

Then I think a few days that continues for a few days, she gets AAP and she dies of septic shock and it was so unnecessary. I think she could have been extubated day five if she’d been awake communicating mobile day one, which I don’t see any reason why she couldn’t have been. She probably should have been out of there.

Day five. Is this, was this nurse Kaylee or Np? Kaylee? This is np Kaylee. This is what I’m hearing from a family member over, over the phone, like a friend connecting me with them. Got, so I’m following this [01:34:00] journey so that obviously Oh, I see what you’re saying. Okay. Playing, playing a telephone game, but so from the very basis Oh, got it.

Doesn’t, doesn’t surprise me that someone would be ul like ultra conservative with the, with, with that. But you’re, that’s so you get back to the SBT criteria like she meets it. So if she’s good to go. So that’s what I mean, like anything, any, if the vent is looking good, even if she’s delirious, like the treatment for that would be to get the tube out.

Not ’cause you get into this. That’s why it’s important to know if the patient has delirium when they’re intubated. ’cause then you’re in a real pickle because you are providing genic medication in a genic environment with the main delirium generating thing. So how do we, how do we negotiate that? What I’m told, and what normally I am told by providers or residents is let’s add some Zyprexa like that all, I’m like, so that doesn’t treat it.

Remember they’re so, why would you add it? They’re delirious. I’m like, okay, are they on sedation? [01:35:00] Yes. I’m like, take the sedation off. Like, alright, so they take the sedation off and the patient’s just laying there. They’re just doing whatever, right? Oh, they’re added Zyprexa on top of sedation. Why? Because we have to treat.

Delirium and Oh wow. So long. I see antipsychotics being used to replace IV sedation. ’cause we’re trying to get through ltac. We wanna keep chemical restraining them without a drip. Oh my god. Please don’t, the L tac thing is a whole nother, I know that is even more like a sole wrenching situation, but, but what I say is I’m like, so the gen as it was taught to me, which I think is still true, is you treat delirium with the antipsychotics.

When the patient’s like unsafe trying to get out of bed, trying to pull out the lung, trying to fight the nurse, that’s when you give the antipsychotic. Just because their cam is positive and they’re a little squirmy worm, that doesn’t mean they need Zyprexa. Right? ’cause ultimately what happens is they get Zyprexa at 3:00 AM Right?

Then at 8:00 AM they’re still like completely snowed to the gills. And then it’s, oh my God, [01:36:00] did they have a stroke? You get a CT head angio, and then it’s like they’re not, it’s like you gave the Zyprexa in the middle of the night, like what did you expect was gonna happen? Happens all the time and comes in to work with them and they can’t, well they’re, they’re two and then the Zyprexa wears off and we haven’t, the deliriums still there and now the nurses don’t have the skillset to mobilize them.

And now we’re back in the same situation of RAs plus two plus three. We dunno what to do and it’s just rinse and repeat. We were respond. Deliriums still there? Tube’s still there? Yep. Still not controlled as far as like the agitation goes. But that, so you just get into, so that’s why like I think in residency we, that’s why Ian was such a big deal because we knew that we couldn’t treat it and God forbid you gave benzo in my residency.

Oh my God. You’d be like called for the gran position good. Or, or Benadryl, like just forget it. Those are high risk and lethal medications. Yeah. We should be able to explain why we give, gave them was the risk. Hundred percent worth it. But right now in a lot of ICUs, it’s first said [01:37:00] in some ICUs, it’s part of the order set when you order mechanical ventilation.

The sedation’s already pre-checked and birthed pushes are pre-checked in that I have seen that repeatedly. It’s very concerning, but no one’s bringing that up until I come in and I start asking questions, and that’s surprising to me. That should be standard. Part of a physician’s expectations and critical thinking is to be saying, why are we using these medications that were deemed very dangerous back in the early two thousands?

I think because of people that create those order sets, you might not have physicians involved in that creation or critical care doctor involved in creation of the order sets or for that. And then there’s other order sets that are specific to like, like certain things that need to have stuff in them.

For example, here, like our acute stroke order set, like the neuro checks and stuff, it’s got nicardipine in it for blood pressure over two 20. But if you’re having an ischemic stroke, like you, like that permissive hypertension thing is like you need to [01:38:00] have it so you profuse your brain. But what happens sometimes.

Different times is that the blood pressure’s 2 25, right? So the nurse is like, Ooh, over two 20, better set than nicardipine. So they start nicardipine. Now the blood pressure’s all the way down 90. No, it’s 90. Oh wow. So now they’re right. So now they really drop them. So now what do you think happens? Like they inch far gets much worse because they can’t profuse through it.

So I’ve been vociferous, we should take this off the order set. This is insane. I’m told that it’s like requirement from JCO about the stroke, something that it’s on there. Some something. So I was like, all right, whatever. That’s, I think that’s unfortunate, but, so I make it my life’s mission to tell the residents and whoever else I’m like, I’m the nurses.

Do not start antihypertensives with stroke unless you clear it with someone. Like the patient’s continuously hypertensive. And even in that situation, I reach for a PRN med first, and not just the drip, but if the, if the blood pressure’s two 70, right? We gotta bring it down some way. But we need to do [01:39:00] that in a graded fashion.

So there’s like this like nuance of 2 25. Yes, it’s over two 20, but like in reality, can we just watch it maybe for cycle of blood pressure, 30 minutes, see what happens, see where it goes. It’s stacked back down to one 90 type deal. But fortunately we just critical, critical thinking a safety net, we just, we just put in the chat, GPT, I’ll tell you what to do.

That’s the whole, right? Isn’t that I feel like yes, if someone’s Aras of plus four and it’s really dangerous and that’s the only thing you have on hand is verse that Absolutely give it. So I see the intent. Maybe physicians are like, keeps everyone safe. I don’t want nurses calling me all the time. But you do that in an environment in which they’re the clinicians providing that intervention do not have tools for critical thinking.

Yeah. Then it says give for agitation, which that’s what awakening trial criteria says as well is agitation has a failed awakening trial. Yeah. We have no objective measurement of agitation, therefore it just becomes the culture of. It’s already there and the nurses see it. They’re like, that’s expected [01:40:00] to be given.

If it’s there, I’m gonna give it. Right. So it just becomes in the culture. So that may not be the intent of whoever ordered that or whatever, but that is culturally how it’s going to be interpreted and utilized at the bedside. And so same thing with ne Nicardipine. If the nurses don’t know the risks involved with that.

Right. But it’s there and it has a certain parameter. Right. They’re not gonna hesitate. No. And that’s, and that’s why I don’t, I don’t blame them. I’m not like, it’s not, this isn’t a you thing, like it says, and I tell the residents that all the time. And the thing that drives me absolutely up a ball is when they order like PRN opiate for breakthrough pain, what is breakthrough pain?

Kaylee, what does that mean? What does that mean? What is breakthrough pain? Depends. Depends on who has it, who’s assessing it. I know, right? What is multimodal and that’s why you shouldn’t. So I’m like, don’t. Like you don’t, not that we don’t trust our nursing colleagues. Well, I don’t want them, nor did the expectation that they could read my mind.

And yeah, I would give it for this and I wouldn’t give for that. So. I put very specifically Dilaudid one milligram [01:41:00] Q2, 10 out of 10, pain only. So if the patient says, I have 10 outta 10 pain, you get Dilaudid. If you say, I got nine out 10 pain, don’t get Dilaudid. Now, it doesn’t mean that I’m not gonna reevaluate the strategy.

But when you say breakthrough pain, like breakthrough what? So my friend who’s the one who is in Washington, he is a palliative care doctor as well. He would further specify breakthrough pain. Like pain, not controlled with pain, not controlled with current medication regimen or something to that degree.

Like very high degree is specificity and all the, and like all the time, right? You order Ativan for P and seizures, but who can, I’m like the only way you could tell the patient having a seizure if they have an EEG on. Otherwise you’re just like seeing, you’re just guessing. It’s just a guess. So I try not to leave these things up for interpretation too much.

Yeah. Just because I want it to be very clear what we should be doing, especially with this agitation stuff. So when I go through the SAT thing from the wake up and breathe protocol, I’m like, it says agitation on there, but that’s. It’s a bit more nuance than that because that has a big, that has a wide range of what it means.

[01:42:00] Exactly. And just because you’re agitated. No, if you’re like trying to fight the rt, like that’s different than, I’m coughing a little bit and you have to, and if that’s the nuance, maybe they need to update the protocol. I don’t know. You’re like the SECM like guru, like maybe you tell ’em like that, even though I’m not part of the committee.

But yeah, I have a lot of thoughts, but they think that they’ve already updated it, so I don’t know. Oh, I dunno about, I mean, I think there’s some, I think there are some things that were created in the early two thousands that had ramifications that they didn’t anticipate. And I think it’s important to revisit what’s actually happened at the bedside.

Yes, we saw this SATs SVTs as improving outcomes, but that was compared to deep sedation with benzodiazepine. So we’re doing less harm, but are we really yet doing the most good? Interesting. We know that old Johns Hopkins protocol had for said pushes after intubate, after intubation, before starting drips that was doing less harm.

But is that still the most good? What’s [01:43:00] interesting that you said that? Yeah, because that helped me, I think it’s my, my, in my mind expectation, like, we’re gonna decrease the sedation to off if we’re achieving our rascal, but maybe that’s not, maybe we need to be more specific. Hey, we’re gonna get the least amount of sedation for our rascal.

So if that means like it comes off, then it comes off, we’re reaching it. Yeah. But just because we’re on propo 40 and reaching our goal, like that’s not the goal. The goal is to be add zero, but like how do you, how do you write that in A PRN? You know what I mean? Yeah. So that’s why the education part is so important.

I had a nurse that I was part of, a team that I trained. She was floating to another unit and she had a patient that had arrested in the, OR came out, was intubated, was writing on the clipboard, saying she did not want to be sedated. And this attending was not up to speed with this kind of arrangement and he was pushing for her to start prosthetic and he wrote the order, but the order was for RA is there to negative two.

And she was messaging me so distraught saying this is absolutely unethical. The patient does not want it started. He trying to make started. I’m like, but look, the RAs [01:44:00] order is there to negative two. She, yeah, she’s at zero. You don’t have to start it like that’s within the orders. So everyone wins here. So I think we don’t expect, I mean if it’s zero to negative two, we’re gonna chart negative two and still call it compliant and they may end up being a negative three, negative four.

Instead of saying happens, how do we get them the time? So it’s something I love implementing with teams is to have communication be part of rounds to say how are they communicating ing? So if they’re ara of negative one, but we say, how are they communicating? Are they’re using a clipboard? Are they texting?

That shifts the whole perspective of why can’t they use a a cell phone, but because they’re rest of negative one. Okay, so why can they need to be a negative one That’s still. Restraining them from really being awake, mobile communicative. Is there a reason for it? What is the indication for sedation? So even if it’s precedex, there needs to be a reason for it, right?

If the reason is, okay, they were rasa plus three. Okay, great. Now that makes sense why they have some precedex, but how do they communicate what they can’t? They’re negative two. Okay. Why are they [01:45:00] negative two? So if really the goal of the bundles keep patients as awake, communicative, autonomous, and mobile, then even those interventions should focus on achieving that.

I’ve used prost sticks to get someone from RAA plus four to RAA plus one, so that we can get them the side of the bed and they calm down. They start to get tired. They’re actually keeping their body and brain busy with sitting up. Now, can we stand now? Can we take some steps? Yeah. Now can we walk? Okay.

Take ’em around. Revisit that Precedex. Do you still need it? So I’m not anti sedation at all. I just think we can use it safely when we keep those objectives on focus instead of. We’re not gonna have them even be human until they’re ready to get off the ventilator. It’s why can’t they be human while on the ventilator?

Right. And if there’s, there are specific contraindications, absolutely. But we need to see them as exceptions. Not that someone being awake and mobile is exception. That should be the standard. No, and that’s as high beautifully said. It’s unfortunate, like [01:46:00] it’s been recently where like we intubate someone and as in that post intubation, like haze, what do you want for sedation?

What should I grab? And I’m just like, just grab some fentanyl. Like prn. Like what? So it’s because for so long it was like with COVID, it was like we would intubate them and then it was like, it’s like a disaster, right? They’re like, SAT’s 80, you need to keep them up and all this kind of stuff. So we’d had to like sedate aggressively, like right up front and then like reevaluate where we are.

But now when I intubate someone for, I don’t know, like septic shock or something. And they’re a little bit of norepinephrine and doing okay. Do they need to be sedated? Not really. I prefer they be awake, especially if they were sleepy before. Then we intubate them and they’re like auctioning their brain and they’re like awake and PE and can communicate.

A lot of it’s on the providers to reinforce this, but it’s a pathway. Each resistance, it’s a culture within the unit. It’s education gaps. It’s all the stuff that’s coming together that the only thing you can do is keep pushing and try to break through the noise. Especially when the [01:47:00] easiest thing to do is just get through your shift and crank the prop up.

Especially at nighttime, right? That’s like pervasive at night. It’s just like a whole nother thing. And there was, in my residency, there was like, like my, the old, my old attending, like he fall through the night culture a lot for the first couple years to really get people on board. Like we shouldn’t just be cracking the prop up so they’re sleeping and then shut it off at 5:00 AM and then they do an SAT.

We should try to keep them up throughout the night, keep them up, keep them appropriate, like off. But. If we would call their name, they’d wake up. That’s, that was like a goal. Yeah. Not just like completely snow them to the guilts. And I think if we saw propofol as a neuro disruptor that prevents from cycle three and four, that would really help our decision making because starting and turning up something that prevents sleep at night really doesn’t make sense.

That practice is fed by absolute misinformation that sedation asleep. So we gotta get to the root science of it. Yeah. Unfortunately. It’s like, how, [01:48:00] oh, the patient like it, it’s like they’re asleep, right? Like they’re, they like, that’s ver Yeah, they look like it, but that like colloquially, it’s other, like, they’re asleep.

So I, I make it a point, I’m like, they’re not asleep, like they’re sedated. Those are two different things, right? They’re not asleep, they’re not like naturally asleep. They’re sedated. And the most famous probably call as I got intern, like. It was a floor patient that couldn’t sleep, and so the nurse called me and they said, oh, the patient can’t sleep.

It was like 3:00 AM they can’t sleep. They want something to go to sleep. I’m like, and I was always like a rebel, unfortunately, like in as an intern, and I say, you can’t, there’s nothing that’ll put them to sleep. Just tell them to close their eyes and count backwards from, I said that to the nurse and they documented in the chart called the intern Gioni said, patient can’t sleep.

He, it struck me to tell the patient to close their eyes and count back from 10, but they were looking for, I don’t know what they were looking for from who knows what, like Ambien, whatever it was, but I was like, staunchly against that. I went to the bedside. I’m like, the patient’s like I can’t [01:49:00] sleep. I’m like, is this, they’re like, yeah, I’ve been insomnia for a while.

I’m like, the best thing for insomnia is the cognitive behavioral therapy and that kind of stuff, like me giving you ambiance. That’s not, that’s really not what we should be doing. I have a discussion with the patient and like they were accepted. I’m like, they’re like, yeah, I know. I just didn’t know if you can gimme something, whatever.

So it’s like when you say no to things, it. It forces you to go to the bedside and either talk to the patient or evaluate the patient, right? So if the patient says they can’t sleep or they have pain or whatever, it’s easy to just write some morphine or something. But it’s a lot harder to go every time someone calls and says the patient can’t sleep to go there, talk with them, or the patient wants more pain medication instead of just ordering it and getting it off your back, going and talking to the patient like, Hey, what’s going on with your pain and having a discussion.

That’s a lot more work. So it, this profession requires us to be at the bedside. That’s primarily where we should be. Unfortunately, we get sidetracked a lot with what we’re documentation or committees or whatever it [01:50:00] is, but ultimately, like we’re supposed to be bedside people. That’s my, I can’t do my job telework like I wish I could, honestly, it make my life a lot easier, but I can’t do that.

Like I have to be like, my job is at the bedside. It’s in the room. It’s, yeah. So. Especially when your colleagues don’t have a lot of the fundamental basics of their role. So it’s not just about not giving sedation, it’s what you do instead, but they don’t know what to do instead. So I think there’s, there’s s you can to step up and be part of that education and be the bedside guiding them through that, explaining the why, which is exhausting.

You don’t have time to go through the whole explanation. And that’s why when I train teams, I don’t even come on site until we’ve really done thorough didactic to explain what the reality is of what we’re currently doing, what the bundle’s actually supposed to be for all these things, so that when we get to the bedside, we can actually talk about what we’re gonna do instead.

The actual logistics of it, the how. But I think it’s exhausting to try to explain that as a provider over the phone and be like, no, I’m not [01:51:00] gonna order sedation. Try this instead. And then you’re gonna have, you’re gonna be blacklisted. Nurses are gonna, you’re depriving the patients of something. Exactly.

And comfort, comfortable. So you have to, so me like almost immediately, I’m, when it’s like a no. Once you say, no, we’re not gonna do that. It’s gotta be followed with, but I’ll come see the patient and like address the concern. So when the nurse comes to the residents or the providers are like, they’re giving them like they the nurses and you nurses, you know what you do, you give the clues like, oh, we are saying they have pain.

I give them some Tylenol. It’s not helping. They want something different. They’re saying their arm hurts, like they’re not looking for Percocet. What they’re signaling to you is they want you to come to the bedside and evaluate the patient. So sometimes they’ll be like, okay, we’ll order some fentanyl. I’m like, no, you’ll go see what’s happening.

Like then you’ll order fentanyl. Or if you think it’s that because all like you can, I’m sure you can hear horror stories, how people were burned because the patient had arm left shoulder pain. The [01:52:00] things that bother me when I was an intern and resident while I was covering the floor patients, when nurses would call and say, oh, Mr.

Jones’ arm hurts. We gave him some Tylenol, but he says it still hurts and I think it’s from him. Like throwing the football of the sun or something. I’m like, how old is he? I know he’s 53 and I start looking at the chart. He’s got hypertension, diabetes. I’m like, lemme go make sure he’s not having a heart attack type deal.

But it’d be so easy for me to just put in some, uh, oxy from the bed and then go back to sleep. And then you totally miss that because it’s presenting in a completely different way. So when the nurse is coming and like VOing concerns, the only thing you should say is, I’m gonna come see what the patient’s doing.

And as you mentioned, that takes a lot of time and effort. But that’s my point. It’s like that’s the whole point of being a bedside clinician. If that’s not something you’re interested in, then I’m like, I was like, you need a different job, maybe. I’m not sure. You know what I mean? Yeah. And we have to help build the environment that we want to work in working in the awake and walk and ICU as an np, if my colleagues were to ask for sedation, I knew at that point that there was gonna be a [01:53:00] darn good reason for it.

So I would put the order in and then I would go to the bedside to actually help. I knew that they wouldn’t ask for that unless it was an absolute emergency in crisis because they knew how to handle it. They knew how to assess and treat their needs, but consider your environment. Try to understand where your colleagues are at, meet them where they’re at, and then try to help them go to where everyone is gonna be safer.

That only happens when really everyone is on the same page and learning together. Right, exactly. I think there’s an opportunity for providers, since you already have so much knowledge, you have so much credibility, authority to guide them through. But something that really gets me is when providers from their office will dc, the sedation and the nurse nurses, or they say DC IT during rounds and there’s no follow up, and these nurses that are not trained to know how to handle patients, they’re left alone.

They’ve got another patient on a rapid infuser in the next room. There’s a lot of misunderstanding of the nursing workflow from the provider. So it’s easy for them to be like, okay, F bundle, just turn it off. But. [01:54:00] This requires more than just not starting or turning off sedation. Right. I think your approach really test is a testament to what providers can and should do to support their colleagues.

Hailey, this was great. I’m so happy talking to you. Geez. Yeah. I know this one for a long time, but I think this is good, like real life practical stuff. I think this is stuff that people will really relate to. Okay. Stuff that really, I think you’ve said a lot of things that people will be just slamming their steering wheels being like Exactly.

Absolutely. Hopefully. Yeah. No, I hope so. Maybe sometimes just feeling that like people feel the same way you do. So if you’re in a situation and like you feel like, wow, like nobody’s thinking what I’m thinking, I, the crazy one, like being gaslit, like knowing that other people don’t see it the way that your colleagues do ’cause you feel like it’s wrong isn’t, is important to know.

And I think it prevents burnout from you just giving up and just going with the, like going with the flow as it were, but like knowing that there’s other people like fighting the same fight. You know what I mean? Absolutely. And I think that happens, especially when [01:55:00] people are coming in with a fresh perspective and they see it for what it is.

But then everyone else that has been there for longer is no, there’s nothing wrong with this. Yeah. Yeah. I certainly, I was gaslit as a travel nurse and I fell for it. So I think this is great to have someone seasoned that really sees what’s going on out there. And I’m optimistic for the future of critical care, but I think it’s gonna require more people like you to speak up and Yeah, and to call it out.

So thank you so much for being willing to do that. Is the only thing I’ll do is we’ll tell you what I think, so don’t you worry. I’ll definitely do that. Great. Thank you so much. Thanks, Kelly.

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Transcribed by https://otter.ai

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