SUBSCRIBE TO THE PODCAST

Posting a video about the role of communication for sedation management to help prevent post-ICU syndrome sparked important discussion and the sharing of valid concerns.

@pulmtoilet comes back to the podcast to address the cultural and educational roots of the the current state of affairs to dissect why communication prior to sedation is a hot topic in the ICU community.

Episode Transcription

Kali Dayton’s Zoom Meeting

[00:00:00] This is the Walking Home from the ICU podcast. I’m Kali 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 [00:01:00] revolution.

Audio Only – All Participants: Dr. Ghione, thank you so much for coming back on the podcast. Can you give everyone just a quick rundown of who you are? Who am I? Nick Ghione. I am an ICU/pulmonologist currently in Virginia. I do all ICU, a little bit of like sort of CVICU. But my day job, my other time job is being @PULMpoet on the socials, which focus on like mechanical ventilator education and advancing the field of ventilator education and making people more comfortable with it, empowered, et cetera.

But also, pretty Invested in general ICU care, so just, getting- making that better, lifting that up. And you were on a past episode and it was so good it’s more just like rambling about, I think, where from my [00:02:00] perspective being an intern, say, I guess at this point 10 years ago, which is probably disgusting to say, but…

And then at my hospital initially where I started, which was a community hospital like very much community, like the most community hospital you could think of, and how because of the intensivist group that was there, we were pretty deliberate about the A to F bundle more or less, so SAT, SBT sleep protocol, like music therapy PRN analgesia first before we did continuous sedation.

Never ever fentanyl drip, like never. If we did a fentanyl drip, the medical director would call and be like, “Why are you using fentanyl drip?” That’s how neurotic it was. And then I think, probably around COVID time, I would say, not probably, like around, COVID and that all changed.

And we, and, we knew a change from a national perspective. I think Wes talked about this at some point, like there was sort of- like 64% of COVID patients received- Yeah … benzos. Yeah. How we backslid. [00:03:00] But I wonder if that’s honestly just I think staying on the benzo topic for a second I think if you’re not in a, I don’t want to say academic because it’s not even academic.

I think depending on who your intensivists are, I think some of them still reach for a benzo pretty quickly. Steven Ramsey talked about, he said like they get people on a lot of benzo and stuff when they get people transferred in. So it really doesn’t surprise me. I think people use benzo more than we might think.

Like we, we think, like we know it’s taboo, but I think a lot of people don’t think that it’s taboo, I still think it’s a big it’s like textbook- … thing going on … they’ll be like, even physicians will say, “Oh yeah, we try to avoid benzos.” But one of the things I have teams do is run sedation reports.

Tell me in reality. ‘Cause obviously if you’re dependent on sedation to keep patients, quote, “calm,” or you- that’s your auto-set and then you’ve got like a hypotensive patient, you end up doing it- … but in your mind you’re it’s justified because- Yeah … of course they have to be sedated, but we can’t use these other [00:04:00] options.

But that’s the exception, but then the exception becomes pretty common. Yeah. So when I’m at conferences I’ll p- have people raise their hands if they still see versed at the bedside- … pretty commonly. And, but maybe a fourth of people raise their hand. Yeah. No, I think I, I would agree with that.

I mean- Recently we were taking care of a patient w- on, who had alcohol withdrawal, and one one of the… Someone brought up “What do you think about Ativan drip?” And I was like, “Are you…” I was like, “Wait a second. What? Ativan drip? Are you this…” So we’ve come- Wow. This is 10 years old. I mean- Oh, my gosh

like, where, let’s have a reset and think about, our goals in the medical ICU for alcohol withdrawal, and what we do to keep patients safe and the staff safe because the patient was he was pretty combative, yeah. And he had gotten a significant amount of sedation, and got, got what, in my estimation, not pri- I would’ve done it a little bit different, but at the end I think we were where we would’ve wound up.[00:05:00]

But he was still combat- pretty aggressive. Yeah … so but I don’t know at that point if it was, like, alcohol withdrawal or he just delirious, and now he’s being, hyperactive delirium. What do we do with that? Then it’s a different, it’s a different thought process or different sort of list of medication, for safety.

And I think a common thread in the, your Instagram post that got a lot of traction was, like, this staff safety issue, right? And I tell the nursing staff and the house staff, whoever I’m working with I don’t allow unsafe, right? If the patient’s- … out of hand, then we’ll call code gray or whatever. And, the security will come, hold them down, we’ll give them meds, and then that’ll be that, right? Then we’ll deal with the fallout after. That’s not what we’re talking about, right? We’re talking about mostly, I think, and you can correct me if I’m wrong, but, you have the ventilated patient, and it’s really just the alarm dinking, right?

The vent alarm’s going off, they’re squirmy. Maybe they’re reaching maybe they’re [00:06:00] reaching for the tube or they’re just moving, right? ‘Cause you’re, ’cause they’re restrained like, when you’ve restrained someone, your natural tendency is to fight against it.

Whole lot of, yeah. This is a complete side note, but I think it dovetails well. It was like when… My dog is right here. So she’s two, so my trainer, ’cause I don’t know anything about dogs, I need a trainer to tell me what to do. But he said “If you want her to sit don’t pull the leash,” because your natural tendency is for her to pull back, right?

So then you just get in this pulling contest. So he’s just “Give her some tugs,” right? Kind of tug. Like tug. That way it gets her attention, and then she’ll focus her attention on you. I think a- certainly with physical restraints I feel like that’s what it is sometimes when patients are awake, or delirious, or they’re trying to move their arms, or they want- they gotta pee or whatever it is they’re fighting against these restraints.

And then as they realize that they can’t move they get more and more worked up. Panic. “Why can’t I move,” right? And it’s just the natural tendency. And then- Whether it’s because we’re uncomfortable with [00:07:00] that or it’s what we see done, our reaction is they’re agitated and we treat agitation with sedation.

And that’s just not, it’s the wrong mental framework to be in, I think. And I think that a lot of the comments that you, and we I guess since I was on it, even though I didn’t make a cameo in it, which is unfortunate, but you guys did a great job. I think that a lot of comments that we got, it’s just like we need a mental framework change in a way.

That video for those that didn’t see it I collaborated with The Life Support MD, that’s her handle on Instagram. She’s great. And we made a video, and we wanted to make it about post-ICU syndrome. And- Def- I don’t- definitely didn’t go that way, that’s for sure.

The one that- Definitely didn’t go that way. Yeah. Well- It took on a different life. Yeah. That, that was the intention. She said, “I want to make with something with PICs awareness coming up,” the March for PICs and all these things. And so I said, “Yeah. And what I would love to see at the bedside is us considering post-ICU syndrome when [00:08:00] we’re making decisions.”

And I think there’s not a lot of awareness of post-ICU syndrome in general- … let alone in our decision-making in critical, what I would call, a crossroad moment of this could go one way or another- Yeah … not just for this next hour, but for the next few months and years of this- Right

patient’s lives. And we’re not thinking about that in that moment- Yeah … at the bedside. So- Absolutely not … let’s make a video about that. So I clearly I wrote the script. She made some adjustments,

and we made this video where it starts out with me as the nurse in a stupid a blonde wig saying, ” Hey, Mr. Jones is agitated. Can we get some sedation?” And she says what’s his RASS?” Which really I wish we would all speak in RASS, and so I was trying to demonstrate- Right

agitation is a whole spectrum, right? Which we can talk about. But I say, ” plus one or plus two.” And she says, “What’s causing that?” And I say, ” ’cause he’s intubated and miserable.” Yeah. And I said that because that’s what we hear all the time in these comments. Yeah. And that’s what I was [00:09:00] told, as a travel nurse when I started doing SATs.

I come from, an ICU where we didn’t even sedate patients, so SATs were new to me. Yeah. And I was told when you see them start to get agitated- That’s how you know they can’t tolerate the endotracheal tube and the ventilator. That is the mindset of you take off sedation- Yeah

you see them in distress, it’s just the ventilator, it’s just the endotracheal tube. Everyone’s gonna be that way. It makes sense. Just fix it with sedation. So I was trying to portray that of I don’t know, they’re, he’s a RASS of plus one or plus two because he’s intubated. And trying to show the provider leaning in more and providing more critical thinking and education to say , did you ask him?”

And I say- … “No, he’s intubated. He can’t communicate.” Which- … it, or at least he can’t talk, which is what I also- … hear all the time, is they can’t communicate, so I don’t know what they need. Yeah. But yet I know what they need because they’re intubated, and I would hate that for myself, so I’m just gonna take that away with sedation.

So the physician goes to the bedside and s- gives him a clipboard and opens up the windows, and things that [00:10:00] sometimes we don’t think about because we’re panicked, right? Yeah. In that video I have this patient trying to k- trying to talk, and head’s coming off the pillow- Right

and pulling on restraints, and the alarm’s- … going off on the ventilator. And even for me when I watch that it makes my blood pressure spike a little bit. It’s stressful. No it’s definitely- It’s not actively dangerous … it’s definitely stressful. I try to tell the nurse, whoever I’m with you know- This is normal. It’s normal for them to feel this way, it’s normal for you to feel this way, right? The vent’s alarming, he’s moving, he’s coughing, he’s gagging. His eyes are tearing. That’s traumatic and yeah, it’s traumatic.

But there’s no, there’s not a great way around it, unfortunately. Some of it, right? We can do some things. And not that pushing two of versed I don’t … does that really … does that change anything? I’m not sure. No, but it it starts that- that benzodiazapine rollercoaster.

Fine, now he’s snowed and he’s not gagging anymore, and but what if you wanted to tell, like they were trying to tell you something? Or, if you gave him, got through that.

And I said this before in a a video, [00:11:00] but anesthesia does this all the time, right? They do this. That’s how wa- people wake up in the OR. They’re gagging, they’re coughing. “Mr. Jones, take a deep breath.” And then he takes a deep breath, and you pull the tube out, and then you go on your merry way.

A- anesthesia’s- Right, and but that’s the difference, is that they’re about to extubate, which we should probably get to as well. People thought why not just extubate this patient?” Yeah. But, I didn’t include all

the details of the case. But easily, if we’re doing a full wake and walking approach, that patient could’ve been on a PEEP of 14 and 80% or whatever, first of all, let’s just start from the beginning, that, every major critical care organization, physician, nursing, all endorse light sedation practice, right? Awake, RASS zero to negative one.

So just from like a guideline-based perspective, this is what should, we should be aiming for. So my retort to anesthesia’s gonna extubate it has nothing to do with extubation, right? It has nothing to do with extubation [00:12:00] because that’s not what we’re focused on at that point in time.

What we’re focused on is can we get this patient to a RASS of zero? Now, if their RASS is zero or, we’re lightening sedation and they’re coughing, they’re gagging, et cetera, There’s other things you can do to mitigate the feeling of the tube. Mainly, and I just did this the other day.

I won’t say when, because, I don’t want to connect the dots for anyone. That’s it. But- Yeah. Yeah. But we stopped sedation- The dude’s, he’s squirmy worms, just squirming. And he’s not directable. I told you this. I squirming around, and it’s like, and everyone’s like, “What do we do?”

I was like, “Just get 50 of fentanyl.” They’re like, “Oh, you want to go up on sedation?” “No, just get 50 of fentanyl.” Give 50 of fentanyl, he calms down. I’m talking, trying to talk to him. “Mr. Jones, can you hear me? Give me a thumbs up. Lift your head up.” Because he’s pretty strong dude, so I’m like, “I think I can extubate this guy.

He just got to give me a little bit on the neuro side, to feel a little bit more comfortable.” And, one of the, the residents [00:13:00] or nurse was like, “Oh, “… his hearing aids in, so he might not be able to hear you.” I’m like, come on. This is yeah, let’s put his hearing aids in- That’s the 101

yeah, let’s put his hearing aids in. If he has glasses, let’s do all that stuff. But these are the things I think we, do we set patients up for success when we do SATs is a question. So then you do that, and then they’re squirming. They’re s- tied. They’re coming out of this haze.

And then, the first sign of distress, we’re “Oh, failed.” Sedation back on, back to whatever we’re doing. I know it’s not the approach we should be taking. We know that through years of critical care literature and the guidelines and, like, all this stuff, but there’s just still this pervasive undercurrent of, either not knowing what the recs are or thinking it doesn’t apply in that situation, or maybe not knowing the tools to maneuver around it.

You know what I mean? In everyone’s defense, if you look at the SAT/SPT really famous algorithm- Yeah … and [00:14:00] the traditional guidelines that we’ve had, when it looks at for SAT and SPT failed criteria, it just says agitation. Yeah. What does agitation mean? So when I train teams, one of the goals is to not speak in a subject- subjective terms anymore.

No more drowsy, sleepy, agitated. That everyone speaks in RASS. So the RTs, PTs, OTs, SLPs, everyone learns the RASS and speaks in that. So in that moment, theoretically, for that video, you would want the nurse to already be saying, “Hey, he’s a RASS of plus one.” Yeah. And that communication now. Also, what do you do with those?

And that’s something that I really hone in on because we don’t ever talk about what to do, right? It’s culturally- Yeah … passed on, do an SAT. When do you do an SAT? Why do you do an SAT? How do you do an SAT? I find in a lot of teams they’re still doing them at [00:15:00] 5:00 AM. Yeah. And even some of, some leadership physicians will really defend that because in some studies they show higher rates of extubation that day or lower time on the ventilator when you do a super, super early SAT.

But to that I would say you’ve never been the bedside nurse doing those. At 5:00 AM, at the end of your shift, w- with very little resources available everyone’s scrambling at the end of the shift to get everything done. You’re in a dark room by yourself. Yeah. No families nearby, and you’ve just, you’ve entered into this process where the patient, your patient, has likely already been set up for delirium.

You’re gonna unmask it, and you’re the lone nurse to deal with that- It does not make sense. And so of course then it’s like if they’re agitated, whatever that means, that justifies the resumption of sedation. And that’s how I learned as a travel nurse, is it’s 5:00 AM, take it off, see them squirm, put it back on.

And [00:16:00] so that’s perpetuated. When would you do it then? Like, when would be the, do you think would be the optimal time to do it? ‘Cause it, this comes up not infrequently and is it a day shift problem, is it a night shift problem? And, the night shift nurses will say exactly what you said.

… Which is And I, I agree to some degree. It’s it would be hard to really do this. I mean- This very, this medical intervention at the end of your shift, And you’re alone And you’re alone and everyone’s like- And I, as a nurse, I’m very defensive

off with you maybe. I’m like, d- like, when I ask teams who carries the main burden of agitation management and- … delirium management, the nurses raise their hands. Yeah. I’m like, “Yeah, but whose job is it really?” And everyone should raise their hands. But in that moment- they are it. RTs are especially spread thin on night shifts, right? A lot of teams, they don’t even necessarily have an attending at the bedside or even on site. So it just doesn’t make sense. So when would you actually do it? I guess it depends on where the team [00:17:00] is at in the spectrum of compliance with the bundle or their focus, right?

Because what we try to create is an ICU in which sedation comes off once those paralytics have worn off after intubation- … unless there’s an indication for sedation. And so that alone, you’ve already got RT coming back in to check the ventilator, family’s still probably there, and the patient is not likely to be so delirious.

They’re much more likely to have their cognition and their fine motor skills intact to write or to text. So that’s what we want to create, is this front-end approach of we have a whole toolbox full of interventions and people to help navigate and troubleshoot keeping them awake, comfortable, compliant while intubated.

Because we all know what it’s gonna be like in a few days once they’re now too confused, too weak, too dysfunctional to text or write. They’re so delirious they think that we’re their kidnappers. And now how could we possibly [00:18:00] get them to just chill out, right? And so that’s what we want to create.

And so I feel like if a team is still doing a daily SATs, SBTs, they’re still up against a lot of challenges. Their rehab needs are gonna be higher than they should be, right? Mobilizing someone a few hours after intubation or within 12, 24 hours that’s gonna be so much easier than in five days.

There are going to be nuances. There are going to be exceptions, right? If patients absolutely have to be sedated, we’ve got this huge rash of methamphetamines and tranquilizers out there right now. If they come in at a RASS- Right … of plus four, that’s on a different conveyor belt, right?

But even still, do they have to be a RASS of negative three or negative two? And we say that we’re doing light sedation. Like, all the guidelines do that, and all these people will say that they’re doing that. But in one really recent study that came out last year, they looked at over 10,000 intubated patients- And found that 75% of them were deeply sedated, which was 2.8 times the amount of deep sedation orders that were in.

And I’m gonna guess the amount of deep [00:19:00] sedation that was documented. So I don’t think that we are actually doing light sedation, but the the point I was trying to make with the video is why not just communicate with them first- Yeah … before running to that? ‘Cause even light sedation, even if they’re a RASS -1, -2, can they hold a clipboard?

Can they mobilize? Can they engage with their families? Can we actually utilize these tools to prevent and treat delirium if they’re a RASS -2? And have we actually treated their cause of distress? But that was a very offensive proposal. Yeah, I know. Well- People got really defensive. Yeah. That’s possible, meaning There’s a way to intubate someone, have a paralytic on board, have sedation, and then, take the sedation off, and then they’re, I gotta be honest I should try this soon, which is do that, ’cause that’s what we did in my residency, the attendings used a lot of succinylcholine, which as critical care in general, I think we move more towards rocuronium, which sticks around [00:20:00] longer.

So then it’s make sure you have your post-intubation sedation already on board, and it was like, just like a barrage of content about that. And, don’t get me wrong, like I don’t want anyone to have paralysis awareness certainly, right? But- Yep … at some point we need to stop the sedation, and if our goal is RASS zero to negative one, which is a slight sedation target.

Which is also funny because I think, I don’t know where I read this, or maybe you told me, light sedation’s like negative one to plus one, right? ‘Cause plus one I think is restless or… I think you don’t- Yeah it’s fidgety, restless.

Fidget, I don’t think you get into true- Danger … a- agitation danger until you get to two, three, four. Should the, Should we rethink our RASS orders to negative one to plus one so that gives you a little bit of leeway, and then this gets into these parameters which sometimes when they’re, when people write parameters I’m like, how do you want the nurse to do that?

Like, how do you want the map to be over 65 but the systolic to be less than 140? What magic blood pressure are you gonna really land this plane [00:21:00] onto to get that specific more than, like less than 140 but more than 65? It’s a really narrow window. So I almost think the zero to negative one is is too narrow of a window to some degree.

It’s easy to fall into deeper than that. Should it be negative one to plus one? Shouldn’t the expectation be if you’re, like, more awake and you got this plastic thing in your throat it, you’re gonna be uncomfortable, but why are you uncomfortable?

Is it just the tube? The tube is uncomfortable? Then give, some bolus PRN pain meds. And these are the kind of things that, like- Yeah … the teams have to really work through, ’cause you could put things on paper, but if the team isn’t trained on what to do instead of sedation- Right

it’s gonna backfire. So there are things that, like, when I train a team that we work on, that I’m like, “Yeah, you couldn’t just write this on paper and drop it into a normal team right now.” It’s not just about not giving sedation, it’s what you do- instead. But we change order sets. There’ll be an intubation order set in which there’s a propofol drip for two hours after intubation, just assuming that everyone’s gonna use paralytics and assuming it’s gonna be, I feel like two hours is just safe [00:22:00] enough.

And in my mind I’m like, “That’s like procedural,” right? That’s if you went to the or you got a colonoscopy. It’s nothing like the risks of prolonged sedation. Just think of sedation as sleep deprivation. Okay, you can go two hours without sleep. Now, we know even, that’s a whole other topic, but even in the OR, depth and duration of sedation can really impact patient outcomes, even for that narrow window.

But let’s say comparatively, two hours is nothing. Then it’s time to circle back. So then how do you do that? You’re bringing in the RT. They’re gonna come back and do event check anyway, so it’s “When are you coming back? Okay, perfect. We’ll do that then.” It’s the family education.

To tell the family, we make little intubation cards that I give teams to make their own or whatever, but it’s for the family. And so when you’re sending them to the waiting room, or if they’re coming up from the ED, I think these should even live in the ED. So as they’re coming up and waiting for everything to settle in the ICU, they’re looking at this card that has a picture of a patient awake and texting on a cellphone, and it says, “Your loved one is gonna be awake.

They’re going to cough-” … gag, alarms are going off. Your job is not to [00:23:00] panic, to help them communicate, help them see the tube, help them understand what’s going on. So now you’ve- … already got an extra hand to do all these fluffy things that sometimes we’re too overwhelmed to do.

Give them a clipboard. Give them- … their cellphone with camera on reverse. So most family members, will benefit from having that job that they can focus on and feel like they have some control in this very scary situation. Also, that we as the team, we know they’re an alarm’s gonna go off.

We plan on that. It’s not an emergency. Like- … we are setting up saying that we’re gonna get through this. And that’s where teams find their most success. If I were to just focus on SATs, SVTs, and education, we would just be in the same rut. But- … having this post int- pre- and post-intubation process if we’re able to prepare them prior to intubation, that’s a prime time.

And I think it’s episode 134, it’s Dr. Makita Fujita, and he talks about visiting my awake and walking ICU- Yeah … and coming back and picking an easy patient- … and doing that. And [00:24:00] that’s- Yeah … that’s where you get the team to be bought in. Because if all they’re experiencing are SATs, where patients are coming out confused, panicked, you see the tear- Right

in their face, they can’t communicate. No one wants to do that. No one is bought in. But if you see someone coming out of sedation after intubation, texting on the cellphone, and the RT’s able to manage the ventilator much more easily and appropriate, and they’re connected with their family, you’re like, “Oh, this isn’t torture.”

“Oh, I know what they need.” And that’s what’s cool for me, is to watch these teams, when I go back and follow up with them, they’re like, “Yeah, I thought this would be so much extra work, but in so many ways it’s just as hard or it’s way easier than what we were doing, and it’s a lot more fulfilling.”

There was a lot of there was a lot of comments that were, like- you’re- that’s torture. You’re torturing them. I never want to be unsedated on the vent. And then you always have “I’m an ICU nurse. I’m an ICU APP. I’m an ICU RTM, ICU doc.” “You better, sedate me while I’m on the ventilator.”

And it gets to this point of, [00:25:00] discomfort, like watching people on the vent or something, and maybe to that, to your point, like coughing and coming out and et cetera. But what’s, what do you say to that general comment of torture? And I know people say it all the time, and you’ve you’ve addressed it a thousand times, but just like specifically, ’cause I’m f- I think you’ll probably get this out semi-soon- be connected. So to everyone that’s “I’m…” And I, and you can all like role play. I’m an ICU nurse. I would never wanna be awake on the ventilator. That’s torture. Like, how dare you suggest that, someone’s not sedated with anything?”

I always invite them to listen to the survivors, ’cause they are the most compelling and educational. I totally understand that that sentiment because if all you’ve ever seen is patients thrashing, writhing, unable to communicate, panicked, alarms going off just miserable, and of course having a tube down your throat is not comfortable.

The compassionate nursing heart is like [00:26:00] I want my patients to be free of any pain or discomfort, and when I sedate them, they’re not moving, their eyes are closed, they’re sleeping, the ventilator’s not going off. They seem so comfortable. That’s what I would want. That makes perfect sense if you haven’t understood the reality for most patients, if you don’t understand the big picture.

So I always say it’s… I think everyone should have that choice. That’s fine if you want to make that your personal preference. But for our patients, they have a right to have informed consent, whether it’s their families or them, if we have a chance to explain, if you are sedated, your risk of dying drastically increases.

You’re likely to lose the ability to sit, stand, walk, swallow. You could end up with delirium, which will double your risk of dying, which will increase your risk of long-term brain injury by 120 times. This could change your life forever. Or we can try to have you awake right away. What would you like to communicate?

Pen, paper, cell phone? Okay, perfect. I’ll have that right on your hip when you [00:27:00] wake up. You’re gonna be restrained. Our goal is to get those off, but that’s just to make sure you don’t go for the tube right away. We’ll get you untied so you can tell us what you need. We’re gonna treat your pain. Part of that intuba- post-intubation order set is fentanyl pushes.

Those would just be all, like one or two pushes automatically ordered, have that ready to help with the air hunger, viscous lidocaine for intubation. So that helps with that, that topical pain management and things like that. But if we’re telling patients beforehand, if it’s appropriate, like obviously, if they’re already seizing or whatever, we know that they’re gonna be sedated.

Yeah. We don’t have to tell the family in that moment, but we might have to say, as they come out of sedation, they might be very confused because the sedation can cause delirium, right? But if, but we can’t teach those things to the families and the patients if we ourselves don’t know those things. So when I see those comments, to me it says we’re not educating our teams about the patient perspective and the big picture of these normal [00:28:00] interventions.

We are still plagued by these myths and this misinformation within our own system, and also they’ve never had the opportunity to have a patient awake promptly, communicating, mobilizing more easily- … even with severe critical illness. And so of course, this has been their own, only experience, and so we’re very confident in what we’ve experienced and what we’ve done.

But are we open to learning a different, maybe better way? Yeah. And I think that that like I gotta tell you, I find it hilarious that- Not hilarious, shouldn’t say that. I find it it’s it’s funny and interesting that we throw this torture word around a lot, right?

Oh they’re not sedated, they’re… You’re torturing them. They’re not sedated, you’re torturing them, whatever. Then I can walk, I walk around any ICU and watch people be tortured with the ventilator, but… And just because it’s not alarming and the patient’s laying there we assume that they’re fine, right?

That they don’t have, and they [00:29:00] don’t have pain whatever, right? Pain is like, this feeling of pain, torture, et cetera, it’s like a subjective thing, right? So the best way to know is to ask them, “Are you in pain? Are you uncomfortable?” “Can you not breathe?”

Like, all that kind of stuff. And the only way to do that is to have people awake enough to interact with you. And, what I, what is particularly frustrating is that I think as a general, it becomes almost paternalistic. Like the, like we are, like, I don’t want them to be tortured, therefore, we’re gonna just do X, Y, or Z.

But when you put it in this risk/benefit scenario, And that, that’s not to say, so let me qualify what you said. They’re more awake. Let’s say you did this with someone. You said, “Listen, sedation, et cetera.” I think the thing to highlight is yeah, if they’re sedated less, things like self-extubation will happen more, right?

No, that’s, that’s- Name of the game … that’s what people fear. Yeah. That’s not what we see. For the huge ABCDEF bundle study that was done with including over [00:30:00] 15,000 patients- Yeah … their sedation use drastically decreased, yet self-extubations, unplanned extubations in general did not increase.

But seven-day mortality decreased by 68%. We see in the research that delirium increases self-extubation by three to 11 times, depending on the study, right? But we see in that huge ABCDEF bundle study that delirium decreased by 25% to 50%. So you would think that self-extubations would go up if they’re able to move and get to the tube more easily, theoretically.

But in reality, when we get them awake and prevent delirium or minimize delirium severity and duration of delirium, they’re more likely to understand what’s going on and protect their own tube. So I was just, No, that’s a good point- But- … ’cause n- this is, and that’s my problem, right? I’m still thinking of it from a perspective of everyone has delirium, ’cause to be honest with you, I see a lot of delirium in the hospital.

And then I’m like- So then I, trying to negotiate with everyone like, “Hey, we should keep him more awake,” [00:31:00] but they’re delirious, and then you’re also- to your point- … in a tough spot ’cause you’re, like, you’re in an environment where, you say do an

SAT, but okay, so we take sedation off, but does that mean that we’re gonna have family right there, that we’re promptly gonna be sitting this patient up, getting them oriented? Are we gonna be wearing them out with mobility so that they then chill out the rest of the day? Are we, like, mobilizing them at night so that they can get actual real sleep?

Like- Yeah … it’s a whole environment. To dovetail, like, on my previous story that may or may not be true and may or may not have happened to me where I am and probably from residency, but that patient that I was talking about earlier who was delirious and squirmy and stuff, I’m like, we’re gonna pull the tube out.

I think it’s gonna be fine from a breathing perspective, but he’s delirious for sure.” That is Pandora’s box. I don’t know what’s gonna happen. Leaving the tube in is definitely gonna make it worse, so we just need to pull it out.

But, his wife came, and she did a great job, like, redirecting him. He just kept perseverating on a [00:32:00] certain topic. And, I stood there, me personally for everyone that says the providers don’t do anything I stood there and said, “Mr.

Jones,” “Where are we?” He didn’t know where we were. He thought we were, like, in, I forget where he said, but somewhere that wasn’t the hospital, obviously. And then he just kept saying the same thing over and over again. And there was, like, some concern the week prior for neuro injury from, like a…

He had might’ve had an ischemic stroke which is why- one of the reasons he came in. But nothing crazy on the imaging, so I’m like this is probably just delirium. I only saw him in that sort of mode, but he’s, a normal dude. And so him acting like that is not normal.

And that’s also, as a sidebar, like delirium, once you see it like you can just tell, like they’re delirious, right? There’s no there’s like little like behavioral cues. So some people can be, appropriate and delirious, right? So they know they’re in the hospital, they know it’s 2026, they know that like they had a surgery, they know their birth date.

But once you probe a little bit deeper, like you can tell they’re delirious or they show you they’re [00:33:00] delirious. But he was just like overtly delirious. But anyway, she stood there and was like, kept redirecting him. “Who am I? Where are we? Who am I? Where are we? Who am I? Who am I?”

He’s like, “You’re my wife, you’re my wife, you’re my wife.” And she kept like really redirecting him and like that’s all you need. And we understand, I think, the nurse can’t be doing that, right? And I think like a lot of the comments were from the perspective of the patient has delirium because most of them are delirious because of sedation and stuff.

And as we know, you can’t like cure delirium and you can’t like rescue them from delirium easily. Definitely not- not instantaneously, but- Yeah, not instantaneously and definitely not with meds. And then it’s a lot harder to get them better enough and like undelirious than to prevent delirium in of itself.

And I think that we haven’t shown enough people, like you can be intubated on the ventilator and like not get sedated and then not be delirious and then get extubated and move on with your life. Whereas a lot of people get stuck unless they get extubated quickly They get stuck in this rut [00:34:00] of, then you’re starting to do stuff to take the prop or the dex off.

Let’s start Zyprexa because we’re not sleeping. I’m like, that’s not for sleep, so just, let’s reframe this discussion. And that’s, that’s from the providers also that just giving some Zyprexa at night, like we’re gonna help them sleep, it’s just not gonna help them sleep.

Just not how it works. It’s just a different form of chemical restraint- Yeah, exactly. So you’re just- … that’s not as teratogenic as- … other things. You’re just restraining them. As you point, they’re just restraining them chemically. But the goal should be what you said, which is, and I… This is from the guidelines, so it’s not like some fringe idea.

The, the idea should be we don’t sedate them immediately after intubation if, unless we need to because of our RASS score. So dovetailing again on this patient, like I got all the sedation off. I gave him a couple pushes of fentanyl ’cause I thought he was uncomfortable. Then when we took the tube out, he was still squirrelly.

He was trying to pull the tubes. He had a bunch of tubes in. So I was like, “Put the dex on.” So then everyone’s like, “I thought you wanted it off?” I’m like, “Yeah, but we tried. He’s gonna pull out his chest tube, and then [00:35:00] that’s gonna be a problem, so just put it on 0.1.” And then, so 0.1, he’s still going, he’s still squirmy.

0.2, still squirmy. 0.3, squirms less. Wife redirecting him. Lights on, shades up, lot of light, TV on, right? So now he starts to like get back to earth a little bit. So the- my point is there’s nothing wrong with a little bit of sedation if you’re exhausted the other options, but like you have a specific indication for it, i.e.

he’s actually gonna pull a tube out. But not just because the vent is alarming because he’s coughing on the tube, that’s gonna make him cough. You know what I mean? And that, I think the latter is what happens a lot of times, and then that just sets you down this delirium kind of like rabbit hole.

And then the nurses or whoever I don’t know, SLP or PTs or respiratory That make these comments about this torture, and it’s hard, and we don’t have the staff, and the patient’s unsafe and, my license is on the line. Like, all this is from the perspective of they already have delirium, and there’s no way to control the delirium.

It’s definitely humbling [00:36:00] when you see someone with delirium because there’s nothing you can do about it. There’s literally nothing. There’s no medication for delirium. There’s no give more insulin bolus some fluid. They’re just delirious, and that’s just what it is.

And it’s hard for ICU clinicians where we love control, and we love seeing immediate gratification for our interventions, right? You give fluid bolus, you see a blood pressure change or a urine output increase. You give, you increase the vasopressor, change in blood pressure. We love- right

to see that we can control certain things that are going wrong. Yeah. And with delirium, it’s not so cut and dry. It’s rarely instantaneous. Now, I will say- Yeah … that in your scenario- … I would’ve offered the suggestion to sit him up- Yeah … at least the edge of bed. And that’s where we see probably the quickest change in delirium.

Not that it just immediately goes away, but that fidgeting quickly changes. And if you think about, I know we’re both parents, so wearing out your fidgety kids is a- Yeah … survival s- strategy. Yeah. And so I think when- Wearing out the dog is a for- survival strategy,[00:37:00]

too. It’s- that’s what- Yes, dogs- … whatever it is, right? Or even ourselves. If we’re stressed, we’re anxious we go on a run or we do something hopefully that’s healthier than other coping mechanisms. But- Same strategy. These people are panicked, tied down, flat in bed, or 30 degrees, but that’s still…

30 degrees is not enough for dyspnea, right? So we’re ex- Yeah … especially if they’re body habituses. So we’re thinking about what all is causing this. Sitting them at the edge of the bed will help with their breathing, the itch on their back, … being able to connect with their wife better.

And wearing them out, if they’ve been down for a while, that’s gonna exhaust them. That’s like running a marathon for them. So in that scenario- my nursing perspective is “Yeah, I’m not doing this all shift,” right? I’m with all those nurses that are like, “I can’t be in and out. If he escalates while my back is turned- Right

I’m not about that.” But- Which is, which was a lot of the comments also. Like- Yeah … “I can’t be in the room. We need more staff.” Yeah. And the staffing aside, and I don’t know, I don’t know what the right… a lot of comments were like, “Then give us one-to-one staffing.” And I don’t, I don’t [00:38:00] know what the right answer to that is.

I’m not a nurse. I don’t know the ins and outs. I know that the hospitals, are expecting everyone to do more with less. So you know, whereas an RT, like a CRT patient might be one-to-one, or like a vent might’ve been one-to-one like in a previous life. Now it’s like that patient, that nurse has two patients or whatever, and maybe CRT is like mostly one-to-one now ’cause of all the documentation.

But- It should be, but again, it depends on the state. There are some states that will still double and triple those CRT patients. So which is which is crazy. I think. And that’s, that’s a discussion for another day, another topic. And- Yeah … like we talked about, I think, before we hit record there’s, certainly there’s extremes, right?

Like the patients that like, like about to bite through the tube because he’s, took a bunch of like methamphetamine, that’s one thing. The patient that is on CRT and they’re on ECMO, and like there’s a cannula in their neck and they can’t move, like that’s another thing. But most of these patients, I think, fall somewhere in the middle, which is Meemaw comes in with her UTI sepsis.

She gets intubated, and you just gotta ride that out, and she’s 75. She has dementia, [00:39:00] hypertension, diabetes. She gets UTI. She’s really sick. She’s on pressers, right? That person- I think will be sedated. I think if you took your random intensivist, random ICU nurse and pluck them from the country and you’d say, ” are they gonna be on some form of sedation, dex prop, whatever?”

I think people won’t even think twice about it. Yeah, of course, they’re intubated. That’s just the way it is. But I would offer the analogy that with that kind of patient and that kind of brain that you’ve described, that’s like taking her, she already had an AKI from septic shock and blasting her with super high dose vancomycin and being like, “Yeah, but she’s we just have to because- she just has an infection, so we have to just give her- Yeah … this dose of this nephrotoxic antibiotic because, we just, that’s our main priority.” So we think about that with sedation being neurotoxic and her having all these risk factors for delirium and already having dementia.

Ah it’s just we’re, like, that [00:40:00] organ’s not so important. We’re just gonna ride it while we treat this one thing and cause this further organ damage. It’s the, but the point is that we’re not thinking about that, and that’s what the point of that video was, to say- What if we paused, zoomed out, and what if our teams had more in the toolbox for- Yeah

ventilator management, pain management, agitation management, and we all as a team collaborated to make that happen rather than just starting sedation, destinating these patients to have delirium, and then leaving the nurse to deal with it? And there are things in that video that were very intentional, let’s call PT and OT and see which one can bump him up on their schedule.

So that’s also to imply that we’re gonna have a delirium SWAT team come in and get him up- … right away. We’re gonna prioritize that through communication. We’re gonna have separate treatment sessions with PT and OT instead of them together so that we can get more sessions. That’s more people wearing them [00:41:00] out, laying eyes on them, babysitting them, and that’s helping the nurse more.

‘Cause if we were to go to any ICU, like any normal ICU, and say, “Okay, let’s take sedation off of everybody that doesn’t need it,” it’d be a shiz show, and you would absolutely- … need one-to-one because most of these- … patients are gonna come out thrashing crazy. The team’s not gonna have the bandwidth to provide all of this care.

If you’ve been listening to this podcast, you’re 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 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 [00:42:00] 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 ICU.

I help teams master the ABCDEF bundle through education, consulting, simulation training, and 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.

Audio Only – All Participants: That’s not what we’re working towards. And so when we start to this transformation with teams, it’s let’s start with the next appropriate patient for intubation and follow this process of pre- and post-intubation. And we’re gonna gradually increase that, and we’re gonna build that up so that we get to the point where most patients are awake shortly after intubation.

We’ve now minimized delirium and ICU-acquired weakness, and [00:43:00] now we have the bandwidth to deal with these nuanced situations in which someone is confused and agitated whatever that means, right? And there’s also- Yeah … we need a a systematic way to deal with agitation. So I have an agitation algorithm which I can link into the show notes, but we published it in, I wanna say Critical Care Nurse.

But if they’re a RASS of one or two, and this makes people roll their eyes initially, but it’s actually quite profound. Establish communication. Identify the causes of distress. Treat those causes. Reevaluate. Just like we do with any non-intubated patient, it still applies. Yeah. My daughter is non-verbal She gets fussy when she’s trying to tell me something.

I don’t just say, “Shut up. Shut up and deal with it.” I say, “Okay what’s up?” I give her AEC device, and she tells me that way, or we go through different questions. And sometimes I can nail it on the head right away, and sometimes I’m like, “Man, I don’t even know,” and it’s something super random that took me a long time to figure out.[00:44:00]

I don’t just give up, though, ’cause I’m like, “You are an autonomous, smart kid. You are seven years old. You have needs. I’m gonna figure it out and treat your needs because I respect you as a seven-year-old. I’m not just gonna tell you to shut up because you’re fussing and you can’t talk.” But sometimes we treat our patients that way. And so if they’re RASS a plus one or a plus two, that’s not dangerous yet. But it’s a sign of something’s wrong, and it could escalate if we don’t treat what’s wrong. But if they’re a RASS a plus three to a plus four, that’s dangerous behavior.

Absolutely we need some chemical restraint, preferably Precedex ’cause it has the lowest risk of delirium. But people are always like, “Oh, we have all these side effects from Precedex.” And to that I ask then what’s your RASS goal when you’re using Precedex?” If you’re trying to get them down to a negative two, negative three- Yeah

of course you’re gonna have a lot of side effects. But if we get them to zero to fidgety on that Precedex, and then circle back to those four steps, one, we’re a lot likely have such a high dose, and two, could we even shorten the duration of that? Do we even need that after we’ve mobilized them, and given them a way to communicate, [00:45:00] and gotten their family involved, and managed their pain, and adjusted the ventilator?

Do we then really need that Precedex for days on end? Yeah. I don’t think we do. Isn’t to minimize it, but I tell the residents certainly that when I work with them because it’s in the medical ICU, is I’m like, the ICU patients are babies to some degree, right?

They revert to this baby-like state, which is- … they need to eat, they need to sleep, they need to sleep at night, not during the day, and they need to poop. That’s all we need to do to provide good ICU care and, minimize their the disease process and stuff, but we get so focused on these interventions fluids, no fluids, steroid, like, all this stuff and really miss out on, don’t see the forest through the trees and just this simple stuff, there was at least a few people I think that took particular offense to, like, when I think she said “Did you ask him what he needs?” It’s like of course we asked him. Why wouldn’t we ask him and stuff? But I gotta [00:46:00] tell you, I don’t know if that’s been my experience with in general they’re agitated and I, I’m not the f- I’m very rarely the first call, right?

‘Cause I have residents and APPs and whoever. But if I’m, like, walking around and the patient’s all agitated and stuff and I could just see the panicked look on everyone’s face, I’m like, “What’s going on?” And they’re like, “Oh, he’s, I don’t know, he’s agitated. He’s pointing the tube, the peaks are high.”

I’m like what’s his RASS? Is the CAM positive?” I get deer in headlights when the CAM question’s asked. I’m like did you assess the CAM?” “Do you know if he’s delirious?” So that’s a whole educational thing, and I think it does come down to is he in a situation where the person can tell you what he needs, right?

Either by communicating on a board or with a thing or whatever it is. If he can’t, then, like, why can’t he? Why can’t he communicate his needs? Is it because he’s delirious and, he’s trying to pull the tube out? That’s one set of people. But if you could scream at him John look at me,” and he looks at you, then work through these simple cues to [00:47:00] try to reorient and then move down the what-he-needs pathway.

I feel like that’s a lot better than obviously just, reverting to fentanyl bolus or maybe fentanyl bolus ’cause if he’s having pain, ’cause most of these people have pain that’s undertreated, which we should also say even if you’re sedated on prop and dex or both or whatever it’s not any pain relief, so which is just kind of- And also they’re chemically restrained.

They cannot- Yeah … express their pain. Exactly. So CPOT of zero on someone that is sedated- Means very little to me. I think that, A, we should think of it not just as assess pain, but ask. Ask them if they’re in pain. So yeah, thank you for bringing that up. Yeah. It’s my hot button. Yeah. They’re, you want to talk about torture, like it’s probably painful to have all this stuff done.

So if you’re, unless they’re on a fentanyl drip, which I don’t love fentanyl drips because, my goal always, just me personally, is to get them extubated. There’s nothing I like doing more than extubating people. I try to extubate as many people as I can. I’ve extubated, and most of the time it goes just fine, to be honest with you. [00:48:00] Very rarely does it not go fine. But the problem with the fentanyl drip is when I walk around and say, “Is he on SBT?” “Yes.” And I’m like, “Oh, okay, is he awake?” He’s like, “Oh yeah, he’s pretty awake.” And I walk in the room and he’s on 50 of fentanyl still.

I’m like, “Why is the fentanyl on?” They’re like, “Oh why? We’re gonna extubate?” I’m like, “Yeah, but, the fentanyl’s on. It should be off.” It’s- It’s not a proper SAT. Yeah. It’s not a proper SAT. And then does he, why do we need a fentanyl drip? If he’s having pain, then, bolus it.

And then it’s like he’s gotten three boluses in a, in two hours or something, so we put a drip on, which I guess is fine for that, in that moment. But then, I tend to use a lot more oral opiates, like down the tube, right? Like oral oxy, whatever it is. ‘Cause just like with all other pain management, we shouldn’t be on like a continuous drip, like a drip of an opiate if we can do it.

The we seem to know this with like palliative care, right? If a patient has cancer or something, we don’t want to put them on a drip. We want to get their oral regimen titrated up. [00:49:00] Like, why is it different with ICU patients? I still haven’t figured out why. I think we worry about like longer-acting things in certain situations where they’re like maybe more hypotensive or whatever.

I think we just like the control of the quick titration and whatever. And I still see, even though I don’t love C-pot, that really should be what we’re titrating fentanyl to, but I see C-pot being titrated to RASS. I think multimodal pain management can- the really refined multimodal pain management is difficult when someone is chemically restrained.

So we feel more secure of just blasting them just to be safe. Whereas in my experience in an MSICU, obviously we have like surgical pain and nuances, but patients that are there for like respiratory stuff, rarely do they need much pain management just for the endotracheal tube- … to be honest.

A- and we can have that discussion with them, and they can tell us if they want it or not. It’s not that we deprive. It’s that we offer it. We start low, titrate up, but if they do have real pain, it’s multimodal. We layer it with- Yeah … I know we scoff at acetaminophen, but but seriously, [00:50:00] we layer it, but we don’t say, “Absolutely no opioids.”

It’s, “We’re gonna- you’re gonna get these boluses while we lay this layer of long-acting enteral management on top of it.” But I see trauma ICUs are often really good at that. But I don’t know. Honestly, medical ICUs, it’s just they just like their fentanyl drips because that’s what they’ve known.

Yeah. So I think while well done, why do you think the video landed in a certain way? Is it because everyone… Because a pro- like, a, a large proportion, a large swath of the critical care community still sees, either sees and does or, hasn’t broken away from this like, if you’re intubated, you need to be sedated so you don’t remember what happened to you because it’s so much torture that, and you would never want that for yourself, so we have to do it.

But I still… The thing is I… It’s crazy because, in 2000, like the first SAT study, whenever it was in 1999, 2000, like that was, the, [00:51:00] the point was that was the prevailing theme, right? That we need to not remember our ICU stay, and then we’ve shown maybe we shouldn’t do that.

And now it’s reverted back. It’s is everything all just new again? Or is it because you can make a cool TikTok video about I would never wanna be not into- sedated if I’m intubated, so and I’m an ICU nurse type stuff. Like, why do you think- Same, girl.

Same … why do you think- that’s what all the comments are … people are- Those videos get shared tens of thousands of times. Yeah. Do you think it’s just is it a, just a meme? Is that, you know- I think it’s, I…

Yes, it’s a cultural thing. It’s a funny thing. It’s I even experienced it in, what, 2014 as a travel nurse. It was like, oh, if you don’t just laugh about sedation, you’re not in. You’re not the cool kid on the block, right? And I would hope that things are a little bit different now.

Maybe there’s more awareness, and I think there is. Obviously it’s discouraging to see comments, right? It feels like the naysayers are so loud, and they’re so negative, but at the same time, I do see a lot of shift in awareness. When I go to these conferences, and which [00:52:00] I know is a biased group, but compared to the climate and this feeling in the hallways at these presentations back in the day, Obviously it was during COVID, but there was a lot more hesitation, resistance.

But now, like at NTI, any presentation that was on delirium or mobility was flooded, like totally full. People were really anxious, and what they wanted was tools to practice it, right? So that tells me that there are more people that are willing, interested, and aware, but also that bedside application and mastery is still really lacking.

Those revolutionists are still finding a lot of resistance, and I think the social media stuff adds to that resistance, but I don’t think it’s everyone. But certainly they’re loud. I think a lot of it’s because they’ve never heard it from survivors. So- … that’s where I always usually start is the why.

And like right now I’m working on the online courses to try to make this a standardized, like easily accessible thing or whatever, and someone’s like- Yeah … “You’re just trying to sell courses.” I’m like, “I’m not,” but also I think I found an effective way to teach [00:53:00] it, but it’s, I can’t teach it like live every time to everyone.

So yes, I’m making these courses. Sometimes it feels silly to teach some of these things, but no, we can’t even talk about sedation management unless we understand that propofol is sle- sleep deprivation. We can’t even start on SATs unless we understand what patients are experiencing under sedation, and that’s where I think most ICU clinicians have never, ever heard it from patients because they’re too dysfunctional.

They’re still in the thick of delirium coming out of their SATs. They can’t communicate. So we assume, oh, my patients have never said that. Yeah. Can your- … patients talk? Are they, do they feel safe enough to tell you? Are they functional enough to tell you? So until we establish the why, the, these myths and these jokes will be perpetuated.

There are a lot of things that I think they saw in the video that just seemed too unrealistic compared to their experiences. For example, a lot of people were like, “Yeah they’re gonna write on a clipboard.” And I totally get that ’cause I think we’ve all seen the crazy delirium or sedation [00:54:00] handwriting.

Yeah. But also this goes back to have you really had a patient awake right away? And even if they are in delirium, ’cause right, delirium can change obviously your executive functioning and your fine motor skills, but there’s a spectrum of delirium. So I’ve absolutely had patients who are awake right away, they came in with delirium already, but you give them a clipboard and they’re writing clearly and things that make sense to them.

But then there’s also patients that have been sedated, and now they’ve got the propofol disrupting the sodium channels, you’ve got massive atrophy, you’ve got even more brain dysfunction, and yes, they can’t write. So I was like, ooh, that was so insightful that people have never experienced someone really clearly write on a clipboard, and it’s not because of critical illness necessarily.

It can be, but it speaks to so much of when are we giving patients the opportunity to communicate? And they’re like, “Yeah, of course, clipboard, whatever.” I can’t tell you how much that infuriates me to be honest with you, ’cause it, it feel, it almost feels like bullying in a way, [00:55:00] you’re bullying, like- Like what am I trying to say? Let me think. I gotta say this gingerly. You give them a clipboard, it’s just a bunch of chicken scratch. You have no idea, and it’s just oh, Nick’s delirious ha, whatever, just like crank the prop. It’s and you’ve said this before and other people have said it, like it’s dehumanizing, and I really make it akin to one, when patients have BiPAP on, and I think you had that voice BiPAP thing, which I thought was cool.

I- but like one of the… like a bunch of the comments on it were like oh, the patient just said that, like they want water now or, they can’t, or like whatever, they can’t breathe, they want off. It just feels like just like mean girl bullying bullshit. You know what I mean? And like from the nursing RT side, even like the provider side, and like that just, it just frustrates me so much.

And then it also when a patient has like asthma or COPD exacerbation and they’re like, on BiPAP or whatever and they’re like, they’re breathing fast and stuff, and someone says, “Oh, they’re just [00:56:00] anxious.” So I’m like, “All right do you know what it feels like to be obstructed?”

And maybe like I get particularly fired up ’cause like my wife and daughter have asthma, so not that they’ve been like critical like that, it’s not, like it’s real shit. I’m like, “Do you know what it feels like to be obstructed?” And then they’re like, “No.” So I make them, take a total, like a, a big breath in, like all the way, and then just exhale a little bit, and then you do that 30 times, right?

And you just feel like super full. And I’m like, “How do you feel?” They’re like, “It’s uncomfortable.” I’m like, “So do you think you’d be anxious if you couldn’t get the air out?” And they’re like, “Yeah.” I’m like, “So don’t…” When someone has a COPD exacerbation, and oftentimes it’s easy to, definitely for them, it’s easy to disregard them because it’s like they did this to themselves, right?

Like they smoked for a long time, like this is just their fault, whatever. Which is, that’s just your own sort of- Gross … insecurity and unco- yeah, your own insecurity coming through. It doesn’t, it like mitigates how they’re feeling and like it’s really no- the lack of education on your part, which is why you can’t identify like what’s happening.

[00:57:00] So when I see that, like the chicken scratch thing, like it makes me feel that way for some reason, that it’s just like you wanna talk about not making fun of people, like I feel like that’s really making fun of people, and it’s just it’s not cool.

I think it’s bullying to some degree. By the way, it’s your fault. So w- that might be, like I might get drug through the streets. It’s our fault, right? They could write before, and now they’re delirious as hell because they’re on a bunch of prop and versed and all this other stuff because the vents dinging p- probably because your vent settings are terrible.

And then they can’t write, and then it’s “Oh, they can’t write. They’re delirious, ha, whatever. No big deal, NBD, move on, make a TikTok about it.” That’s just, it’s just like such not the right way to go. I don’t know. And there are also videos making fun of families or just saying, Yeah.

The- Like scenarios of get the families to not touch them, cause they, the families touch them and the patient responds, and the nurse, they’re like, “Stop. Stop messing up- Yeah … stop riling them up.” And I’m like, oh, my gosh, if you understood the patients like [00:58:00] desperately trying to connect with their loved one saying, “Get me out of here.

They’re trying to kill me. Help me. Save me,” right? Yeah. Because of the sedation that we’re giving and all the other things that are causing that delirium, but that family member is their safe place. Their like- … connection to reality, and we’re trying to keep them away and keep them disengaged.

And so it’s such a flip for them to say, “Tell the family what’s happening. Tell them what this is gonna lead to, and tell them what their job is- Yeah … and let them help.” But if the goal is to just keep them motionless, yeah, that family might mess that up. But thank goodness. Yeah. I think most people get that too when you tell them like- we’ll qualify this with certainly I’ve come and run into families that were, like, either, combative themselves for whatever reason in their, behavioral stuff or whatever.

So not everyone is conducive to that. But most people, if you have ever had a kid in the hospital, which I have, I’m sure you have most likely. Yep. Yeah. It’s this weird sort of what do I do now? Oh, I could do that.

I can, [00:59:00] feed her. I can change her or something, right? So I can’t imagine having a family member in the hospital and then now not only is the patient helpless to some degree, but the family’s also helpless to some degree. And maybe some people they’re used to doing stuff for them, or if that person’s really independent and they’re not used to seeing them having everything done for them, it’s like, that’s traumatic also.

And it’s panic-provoking. If you want people- Yeah … we make fun of families for being crazy invasive, not knowing what’s going on. I’m like, “Okay, then give them a job.” Tell them what to do today exactly … something to focus on, and they can be really helpful.

Obviously some are just not capable of much, but like most family members, they can sit there and play Uno with them, they can help them write on a clipboard. They can sit there and repeat the same thing, “You’re in the hospital. That tube’s helping you breathe.” They can do that, and if they knew that could save their lives, of course they’d be willing to.

Most families, right? But do we utilize that resource- … or do we try [01:00:00] to block them from- … being engaged. And then we complain about being left alone to deal with everything. Yeah, and that’s a lot of the comments of bring COVID back when there’s no families in the hospital and all that kind of stuff.

That was… it wasn’t easier in, in any way, not having them there to, to do that to do that stuff, corral them at the bedside, redirect, constantly redirect. Talk about stuff like, “Oh, John’s at home,” and “Jimmy’s in school and he’s,” sends his love.

And I told you, I think I told you before, I had an attending who that I worked with, his name was Dan. I won’t say his last name. But he w- when he, if someone was, like, sedated or whatever and he went into the room to examine them, he would scream their name. “John, you’re in the hospital.

You’re safe.” “We’re taking care of you. Your family knows that you’re here. They send their…” Just talk to them, and just would sit there and talk to them for five minutes. And I’m like, “Man, what the hell are you doing, man?” And and then it’s like thinking about it maybe they…

People ask us all the time “Can they hear us?” And we’re like, “Oh, I don’t know. I think so.” No. Yes, they can. I know, but like- They hear and they feel … yeah. No, I know [01:01:00] that. But what I mean is y- make that your your point of reference. So if they’re chicken scratch or something, right?

And instead of scoffing and “Oh this was useless,” or, “Oh,” the “the dumbass resident wanted me to just give them a clipboard and see if they could write and I’m wasting my time.” Say, “John, I can’t understand what you’re writing, but we’re gonna work to get what you need,” or whatever, right?

Like reassurance. And but it- We also need better communication tools. I’ve trained, I’m going on 16 hospitals now- I think like one or two already had clipboards in every single room and/or letter boards and picture boards. Yeah. See those. But also letter boards in that kind of patient, like that’s not very useful.

So like sometimes we’re stocking the communication tools with really, I would say asinine tools that are like- Yeah … gonna leave a bad taste in nurses’ mouths. If you’re taking a delirious patient who just came off of sedation, giving him a letterboard, that’s not gonna make much sense to them.

So are we really providing useful tools? Also training everybody, not just nurses, RTs, [01:02:00] PTs, OTs. SLPs, they learn this stuff in school, but do they know how to translate that into the ICU setting? Are they allowed to? Anyways, we need so much communication resources. It drives me nuts that we don’t have AAC devices, like eye gaze devices in the ICU, ’cause my daughter’s had hers- Yeah

since she was two. So I think there’s so much opportunity, but without everyone expecting, like having the standard of every patient possible should have access to communication as a basic human right, then it just seems like a fluffy backend thing, and it screws everybody over. Yeah. There’s just not an established culture and standard of expectation for communication, and I think that’s what was so shocking for people to be like, “That is unrealistic that someone would write that on a clipboard.”

And I’m like, “Not in my experience, and not in the teams that I’ve trained now.” That’s one of the first things- Oh, I mean I- yeah … they notice, how communicative they are. Yeah. No, I’ve, I sent you the pictures before of people writing stuff to me on clipboards. It’s usually basic, it’s like basic needs, like [01:03:00] water- … “where’s my wife?” Like that kind of stuff. But it’s nothing like, they don’t write a novella. It’s just like water, and you’re like- Oh, and sometimes it’s things like, some- these are my own stories or things that like podcast listeners have told me or teams, like one podcast listener said that their patient was just that patient, just unmanageable, crazy.

Just sedate the crap- … out of him, but then they can’t get him extubated, right? And so she goes in. She wakes him up, and she’s like, “Dude, what’s going on? What do you need?” And he writes, almost allegedly, “Wellbutrin.” He was withdrawing from Wellbutrin. They got him Wellbutrin, and woo, magically he’s good to go.

Gets extubated, right? That was a clipboard. One patient was totally off of sedation, used the call light, had already written on the clipboard, “Chest pain.” They do a chest x-ray, and they see a large pneumothorax. While they’re looking at it on the machine in the room, the patient has an arrest, and they know exactly- Right

what caused it. That saved his life. Had he been a RASS of negative one, negative two on Precedex, all nice and cozy, he would’ve died. Yeah. Like almost definitely. When, how long would it have taken to realize what was going on, right? Yeah. [01:04:00] The, the basis of medical everything is like, what are the symptoms?

Yeah, when the interns are, like, presenting cases to me and they’re like, “Mr. Jones came in, blah, the white count was 40,” blah, blah, and they go through this whole thing, and I’m like, “Why’d he come to the hospital?” They’re like, “What do you mean?”

I’m like “If you said to him, ‘I came to the hospital today because…’ What would he fill that in with?” And it’s like, “Oh, he said that he’s, I don’t know he’s dizzy.” Whatever it is, right? And because we, anchor on certain things, definitely the, the objective data and it’s it shapes our diagnosis and treatment thereafter.

I guess that worked for some people, but the patients where we don’t really know what’s happening I’m like, you could ask you could ask him. There was one lady that, that where a patient, they have AFib. I’m like, “Are they on anticoagulation at home?” She’s like, “Oh, I don’t know.

Let me go check the chart.” I’m like… I was standing outside the room. I’m like Miss Jones, do you take anticoagulation at home?” She’s like, “Yeah, [01:05:00] I take Eliquis.” I’m like, all right, so that, no chart checking. Just ask what the problem is or what they feel. But in the ICU, w- we start and then it’s intubated, sedated, then, some sort of mixture of either ineffective management or failed SATs or, potpourri of stuff.

The patient gets sicker, we add stuff on, and just, and it just snowballs. And then, nurse X or APP Y or doctor whoever pops in that day then sees them four days after. Now, the wheels are completely off, and then maybe they see this reel on Instagram saying “You should ask the patient what the problem is.”

And then it just looks so simple, and then it’s man, I’m here. It’s not simple. What are you talking about? But the point is you’re in the middle of it. The, the point is to not get to that point. The point is to not have them delirious. When I was a resident, if the patients got delirious it was like, it was funny because it was like a big deal.

Because it is a big [01:06:00] deal. You know what I mean? It’s a medical emergency. Yeah. So the intensives be like, “Oh, they’re delirious now.” My mentor, who is, like I told you before, I brought him up before, he’s- has his own issues and stuff, but he was a damn good intensivist, but he’s, that that stuff was important.

Are they delirious? What’s their RASS? Are we SBTing? Can they have sleep protocol? Even people intubated, right? The sleep protocol we did very aggressive sleep protocol, so it was like, if they don’t need to be, like, cue at one hour BPs or whatever, which most people don’t need can we leave them alone from 11:00 to 5:00, or whatever it was, 11:00 to 4:00.

I can’t remember. And we did that, and we did it for people and, I think it was better. But everyone is seeing it from the point of view of they’re delirious, they’re fighting, they’re thrashing, the vent’s alarming. And Kali’s “I just need to give him a clipboard.” Yeah, get real, dude.

This isn’t you’re… Have you even been a nurse? Do you even know what I go through? Yeah, I’ve definitely lived, like- Yeah. It’s the- And I felt the contrast working in 10 other normal ICUs and doing those SATs and trying to [01:07:00] communicate and trying to do things, and especially when I was the only one that with that perspective, right?

Or caring about those things. I’m like, and I gave up. I was like, “Oh, I guess this is what we do here.” Yeah. “And it must be okay. If everyone else does it this way, it must not be a big deal.” Yeah the bystander effect is definitely real in the ICU. Like- Yeah … if everyone’s okay with it, then it must be okay.

And then, some, a trailblazer comes along and is “This isn’t, this isn’t okay. This is not how it should be. It could be different.” Because when it, I think all of us, I’m gonna say all, even though I don’t know for sure, but we all come to work with the best intentions in heart, right?

And with the best things in mind for the patients. And I think there was one commenter that, is just yeah, that random dude who never answered me, actually. It was annoying, but you start to do these things which is like either ingest or make fun of or whatever is like this defense mechanism ’cause either you’re burnt out or you’ve lost your sort of like passion for what you’re doing.

So why would I give him a clipboard? He’s not gonna be [01:08:00] able to write anyway, so like it’s just a waste of my time. The vent’s alarming, I have other stuff to do. Just go up on the prop and, deal with it later. And then you know how it gets in the ICU, like 8:00 becomes 12:00, then it’s lunch, then it’s 2:00, then it’s like almost time to go home.

You know what I mean? So these things just snowball. But there is, there is a different way. There’s a different approach to doing things, which is not relying so much on this, on like chemical restraint and trying to like work with the patient and understand like what they need. Are there gonna be patients that are combative or whatever that you can’t, or their disease process, like yes.

But in your run-of-the-mill medical ICU in the country, is that who’s in it? I don’t think so. I don’t, I really don’t, it’s hard to sift it out because we make them into that Yeah. I mean from Mimo comes in with her UTI and gets intubated.

Like she’s not some- … she’s not hopped up on methamphetamine like trying to fight you, right? She’s got sepsis, UTI, intubated for- Yeah … work of breathing or AMS, whatever it is. And you don’t need to be so restrictive with the ventilator, right? You can [01:09:00] this gets back into the vent management piece of it is if you set the vent up to some degree to work with her maybe it’s not gonna alarm and she won’t feel as uncomfortable and won’t be as squirmy and won’t ding as much.

And let’s say she gets intubated at 9:00 in the morning, you get her up at 1:00 in the afternoon the dust has settled. And you get her walking around the unit, which sounds crazy, but she just walked into the hospital hypoxic- or hypotensive or whatever. So you get her walking around and now she’s calmer, she’s more oriented. Maybe she doesn’t have delirium. Even if she has delirium, we’re already starting to clear it out, at least not exacerbating it. We wear her out. We get her walking again that night, which sounds crazy, but I’ve done it with RT and a family member pushing the wheelchair.

She can still walk on her own. It doesn’t need a whole line. Yeah. She came in. I also say that too at time for certain situations, like the patient came in a certain way and now just ’cause like there’s a breathing tube in, like they were, like they walked in here We didn’t cut her legs off.

Yeah, exactly. But they’re- So it’s like- Yeah … okay, let’s just sit her up and see just like how her blood pressure does. Yeah, no, she’s got some- Yeah … [01:10:00] sepsis. All right. She’s doing okay, then let’s let her like walk to the chair. Okay, great. So for me, it’s been fun, these teams are so nervous about everyone being agitated, thrashing, requiring five people to sit up at the edge of the bed and I’m like, “Watch this.”

We get a 360-pound patient walking himself to the chair and they’re like, “Oh my gosh, I just had to hold endotracheal tubing.” And I’m like, “That’s gonna become the norm.” And then yes, this patient’s hanging out, writing a clipboard, chilling because now we’ve treated his, benzo and opioid withdrawal, and now he’s okay.

So it’s just those simple questions of- what is causing this behavior and this distress? But it’s been my experience that’s not the standard thought process, and not just on nurses, but on the entire team. We just run to our one tool in our agitation management toolbox or whatever, and it’s sedation.

But that could be to the detriment, even death, of our patients, and that’s not what we’re thinking about. Yeah. And so the video was not to be offensive, [01:11:00] but in fact it was to show here’s the critical thinking that should be happening at the bedside, the interdisciplinary collaboration.

Some nurses were offended that a physician would come to the bedside to troubleshoot that situation, and other people were like they- no way they would actually come.” So I think there’s a common theme of nurses are like, “We’ve got this. We don’t need help,” but also we don’t have enough help.

Yeah. Well- And also we don’t want- we wanna have full control ’cause we know what we’re doing, we don’t want anyone else to interject. Or, but also we don’t wanna be left alone to deal with it, but we want full control but not all the responsibility. Yeah. The physician not at the bedside or whoever, like provider not at the bedside, or they would never come to the bedside I would empower them to say “The patient’s agitated,” et cetera “Come- can you come assess them,” right?

But not all providers are prepared to do that. Not all providers know- Yeah, that’s true … how to troubleshoot. And they’ve been, they’ve admitted to me, they’re like, “We actually don’t know what to do with that.” Like- Meaning the vent or just in general? Just in general. Or like agitation in general?

Like- Yeah … just in general, ’cause they are also used to just throwing in an order and then it shuts the nurse up and it’s [01:12:00] good. Yeah. And I think, and that’s, I think, the problem, because it’s easy to do that. It’s easy to just put in, “Oh, all right, just give him two of Versed and move on your way,” or whatever.

But that’s… I think, like- That’s that’s lazy, right? That’s like lazy doctoring. I’m gonna say doctor ’cause I’m a doctor and- Yeah … my, when I talk to the residents and stuff you- it shouldn’t be, like, the easiest way out that you take the nurse, just shut them up, give them an order or whatever.

And it’s not because the nurse is bringing you something. They have a concern, so you should go address it. Because maybe their patient’s thrashing and, the nurse sees that and they’re reacting to that, like not pull the tube out, whatever.

But maybe they do have a pneumothorax. Maybe they do are bleeding. Maybe they’re having an MI. Who knows what the reason is? The, again, the patient can’t tell you, and I bring this up to, I bring the I say this to the resident, like to the teams a lot when I round. I’m like, another reason to get sedation off is You know, how do [01:13:00] you know that the patient didn’t have a stroke underneath, right?

They can’t- they’re sedated so they can’t move or talk, right? Whatever. We saw that in COVID a lot, right? We- yeah. Then you do the SAT and they’re like, “Oh, now they’re not moving their left side.” I’m like, “When did they move it last?” “Oh yesterday.” It’s like, but they’ve been on prop 50 for the past 24 hours, so they’re not gonna move.

So when the nurse does their, neuro checks or whatever it… They’re sedated, so it’s just oh, they’re sedated, no big deal. Whereas if they were awake and interactive to some degree, you might notice like, wow, he’s not really moving his right side. So then it’s like, when’s their last known normal?

It’s like, I have no idea. They’ve been sedated, right? It’s like a different animal. Just another reason. So when these things happen to these people it is our responsibility. They didn’t come in on propofol so everything we do after that is a direct result of what we’re doing to them.

So if they’re intubated, et cetera, if they’re, like, sedated and something happens underneath that we didn’t know that responsibility falls on us. And some things will happen, right? People will have strokes just [01:14:00] the way it is. But, there’s a different way you can do this, which is not lean so heavily that the patient doesn’t move at all in bed.

And then forget the the DTIs, right? There’s been so many… this DTI thing I feel has gotten a lot more traction in the past year or two, maybe during coronavirus. And after that there’s a lot more awareness and education awareness responsibility rounds on deep tissue injury sacral wounds and stuff.

What do you… they’re sedated, they’re not moving. That’s the pressure point. You’re gonna get an injury. No matter what you do, no matter what bed you put them on, no matter what, Q2 turns, whatever it is. If they’re sedated and they’re not moving, they’re gonna get a DTI and that’s a big problem because that leads you down a whole nother path.

And yet we put all the liability on the nurses for deep tissue pressure injuries- … CAUTIs, CLABSIs- Yeah … and that- … self-extubations the DTI thing I think is ridiculous to put on the nurses, like as a, as like a failure of nursing or something.

It’s ridiculous to put that on them, but like that is often a result of other things that we’re [01:15:00] doing, right? We don’t want anyone to self-extubate, so they’re all sedated, but like then they get DTIs, and it’s like this just like circle that goes round and round.

They get delirium, and then when you’re finally doing your SATs that you’re supposed to do while trying to manage all this other stuff, and they’re so delirious, and they get the tube out, that’s your fault. But really it was like the fault of everybody the past five days.

Yeah. Yeah. And so we set everybody up for failure. And so the nurses… I just think we need to shift that, that instinct of protection from liability to let’s keep patients awake, functional, moving, brains clear so that we can get them extubated and out of there as soon as possible. And I think down the road hospitals and maybe even clinicians will be held liable for brain injuries, unnecessary deaths rooted in sedation and immobility.

All of this just showed how much unawareness we have, or this oxidazical perspective of delirium as just transient confusion, and we’ve got [01:16:00] bigger fish to fry. Yeah. The delirium is important. I don’t know. There’s- … like identifying is like important- it’s a cute brain failure.

Do nephrologists sit around and try to get people to care about the kidneys? Or are we pretty much aware that the kidneys are essential organs for survival and we are, like, pretty concerned about them when they come to ICU? And yet when it comes to the brain we’ll circle back to it.

We’ll get to it later. Yeah. Unfortunately we do, and then, when they’re delirious they’re, they- It’s so hard I don’t know how to better convey to the community in general that that by providing this education or this perspective I get it.

And that’s why I’m passionate about it. ‘Cause I’m defensive for nurses, for the entire team, also for patients obviously. But, like, when I go to the bedside and I see people spending four or five clinicians to sit someone up at the edge of the bed on day five or three and they’re so delirious, I’m like, “That’s like running a mini code,” and you can’t do that throughout your entire team.

It’s so inefficient [01:17:00] to sedate patients as a standard. I don’t know how to translate this is gonna be easier for everybody. And how can we support nurses without demeaning them? That’s never my intention. The questions, the character that I played was mixed between a new grad, and all these questions that I got from travel nurses, seasoned expert travel nurses that came, and they’re like, “This guy’s moving around.”

And I was also asked for an Ativan drip because the patient was a RASS of plus one. My answer was, “Who’s gonna clean up that mess?” Yeah. Not, not you in the moment or not whoever in the moment. It’s- No it could be us- No … when we come back in three f- or five or seven days.

It could be us. That’s a… and that’s the issue. When you take over and you’re getting to the middle of it, you’re like, “Man, I wish would’ve did this a little bit differently ’cause now I’m like, we’re kinda stuck.” And, does that come back to the culture of the ICU?

But no, it does come down to this like, it almost reminded me of OB in some ways, where it’s like, like the collective experience of the group weighs in a lot on how they see, like, how it’s going.

And that’s why I think the [01:18:00] collective experience needs to be like, we shouldn’t be sedating people and taking away how they communicate. Because it just makes everything harder. If you couldn’t get- But that, that takes time to develop. You know what I mean? If all- Yeah

anyone’s experienced is back-end SATs who would question that? All this collective experience of sometimes decades of experience. They’re like, “I know how this goes. I’ve gotten punched before. I’ve had patients self-extubate. I’ve had them fall.” Yeah. “I know how this goes, and I’m gonna nip this- Right

in the bud right now and knock them out.” It’s hard to question that. It’s hard to question it, but my only question would be like is that better? Is that better? It’s another day on the ventilator. It’s another day getting a pneumonia. It’s another day getting a DTI. It’s another day getting a DVT.

We don’t- I don’t know we need to think about these things in risk-benefit situations, right? There is, and I know- I already know what you’re gonna say, but I’m gonna stay with my thought, is that there’s inherent risk of awake walking, right? The patient you [01:19:00] talked about earlier walked to the chair.

Could he have tripped and fell? Sure. Could he have pulled the tube out by accident? Sure. There it’s not that there’s no risk in this stuff, right? That’s not the point. The point is what we’re doing if there’s a different way are we mitigating the risk the best we can, number one.

But number two is it’s not that sedating them is any better. It’s not any less risky. It’s not any, it’s not getting them any closer to getting out of the ICU extubated. So if your point for intubating someone for sepsis was to get them better and extubate them and then they go home, which I think most people would agree is the point when you come to the hospital is you get said thing treated, and then you go home back to your life.

You go back to work, you go back to school, you go back to your family. And then when you look at the ICU literature, people who survive critical illness, definitely like ARDS at a year, I think, what a lot of percent aren’t back to their baseline, right? 60%, I forget the number- Yeah … off the top of my head.

But a tremendous amount of people aren’t back to their baseline because they lost muscle mass, because they’re delirious, they, now they have [01:20:00] dementia, they have PICCs, whatever it is. They have myopathy and neuropathy, what- whatever it is. That, you making that decision in that moment to resedate them, pushing the button, giving them 100 of fentanyl, asking for two of Versed, going up on the decks, like, that in that moment that doesn’t mitigate any risk for them long term.

That just makes, the next six hours more easy, right? Or you feel better. Oh, they were, tearing and trying to fight and the restraints and all this stuff. We had to hold them down. I went up on the prop and now they’re asleep. Which they’re not asleep, we know that, but that’s, what we hear.

Perception. Yeah. We haven’t done anything to help them. So you wanna talk about provider burnout from nurses, like everyone down. A good way to burn a team out is to not see anyone get better, and I gotta tell you, you know what’s funny? And this may or may not be true.

Remember, I may or may not have been at a job or a past or current job or a resident or an attending. But when I did that, when we extubated that guy, gave him some fentanyl, we like put on a scooter, decks, we had his wife talk to him, et [01:21:00] cetera. It was a new nurse for sure, because the nurse was precepting and she was like, “I’ve never seen that done.”

I was like, “What?” She’s like, “I’ve never seen anyone do what you did.” I’m like, “What did I do? I didn’t do anything. We just… I talked to him.” But so that- She’s like a human. Huh? Yeah. So that, for for me in that moment I’m like, you know what? This this is it.

It’s just because we haven’t seen it done. So when people say the provider would never come, the doc would never come, if there’s docs listening, be that doc. So when Kali says, “Hey,” the, they’re fighting, whatever. Don’t just say, “I’ll throw something in.”

Go to the bedside, see what the problem is. Can you talk to the person? Can they communicate? “Mr. Jones can you look at me? Lift your head up, give me a thumbs up.” That’s important ’cause if they’re not doing that there’s an algorithm for that. They’re delirious, which is a whole issue.

Do they have a stroke? Are they stroking now? Do they… are they delirious now ’cause they’re having a stroke? Are they seizing? There, there’s a whole thing to be said for that. This is a medical emergency. Yeah. And- It’s not just “Oh, [01:22:00] yeah, join the club of confused patients.”

It’s- it’s just- It’s, “Oh my gosh.” When you get called for… If you were just as like I guess any specialty, but if I was a medicine resident, right? And the nurse calls and says, “Mr. Jones has chest pain,” and then I’m trying to triage it in my mind like, “Oh,” “Is it…”

“When did it start?” “Is he nauseous? Does he have jaw pain?” There’s only so many questions I can ask the nurse, right? They’re just like, their job is to say, “Mr. Jones rang the bell, ‘I have chest pain.'” And then a good nurse will get an EKG, ’cause it’s not hard to do. They’ll get vitals.

So a good nurse will call me and say, “Mr. Jones has chest pain. Their vitals are blah, blah, blah. I got an EKG.” “He says it started just now. He’s nauseous.” “Can you come assess him?” You know what I mean? But I wouldn’t be on the phone and be like, “Oh just give him some morphine or give him…”

Like I, because that’s where the nursing ends and where the providering begins. So for me as the doc, I have to go there and is he having a STEMI? Is he having an NSTEMI? Is this [01:23:00] pericarditis? Is he, does he have muscular pain? Whatever it is. But I have to make that sort of estimation.

So it’s the same thing in the unit when the nurse is like, “They’re agitated.” While we agree that’s a terrible way to describe their behavior, if I probe and like what “What are they doing?” And either they can’t tell me or they don’t know or they’re just agitated, “I just want something,” like that’s a very important separate, like, decision tree.

You’re either gonna sit on your ass and order two of Versed and go back to whatever you were doing, or you’re gonna get up and go look and see what is happening. And then, from that point it’s like, all right, are they, are they delirious? Is there some other issue? Are they having a stroke?

Do they just need something? Does their back hurt? What is the reason? What’s causing the delirium? How are we gonna treat it? Like, how are we gonna get them access to mobility, family, real sleep? Or are we just gonna mask it? Exacerbate and prolong it. Which doesn’t- that doesn’t get them any better.

So when everyone says, [01:24:00] “Warren, the comments are gonna eventually become, ‘Yeah, fuck that. Just sedate me.'” That doesn’t get you any better, right? I don’t know what else to say. It doesn’t get you any better. It makes things worse, certainly.

What’s worse? Is it worse to just sedate someone into submission or to leave them, they’re delirious, but we’re gonna do this maybe try not to sedate them, just, get what they need try to communicate, get them up and moving.

Have PT and OTC them separately or whatever. Have RT sort of fiddle with the ventilator, like can we change stuff? Will the 10 to 15% or whatever thing happen that they pull the tube out, and now they’re extubated and then, either they get reintubated or they’re like, “Oh, you know what?

They’re actually fine. We could just let them go for a bit.” While if you go the other route and like you don’t sedate them, you try to work through it, certain things could happen, right? It’s not like just sedating them is like the answer. It’s not like that’s without its own- Or the safe thing to do

or [01:25:00] without its own risk, or the safe thing. Exactly. The safety thing is particularly frustrating because like that’s such a relative term. Because none of what we do is safe.

Right? So just, I think we need to agree that none of what we do is safe in the ICU, which is why I try to tell the residents, it’s like none of this is normal. It’s not safe, so just, like that’s not the bar. Like none of this is okay, right?

This is all very bad. They have organ dysfunction. They are sick. They could die at any moment. But there’s like sort of degrees of, badness. So to, to look at it from like this lens of “I want to be safe,” that’s really not where you should be looking at it from because none of what we do is safe.

All the meds are nephrotoxic. All the things are dangerous. Every procedure you do can have a complication that leads to something happening. We, put an art line in because they’re on two of norepi and I need to get blood, and then you put a art line in, you dissect a radial artery, then their hand falls off.

Like that happens, right? Like that happens. None of what we do is safe. So like safety, like this sort of like mythical idea of that like this is [01:26:00] like complete safe, like this is safe, it’s just not, it’s not real. So I think we need to get out of that mindset that sedating them is safer because we want to keep them safe, we want to keep the staff safe.

Like I do. Like I want to keep everyone safe, I think what’s normal- … it’s not … and familiar feels safer. Yeah. Certainly. There’s this sense of I know how to do this. I have done this- … a million times. I’ve seen X, Y, and Z. It feels safer. And especially where this is not like- you like accidentally bolus norepinephrine and the blood pressure skyrockets- Right

right? You know- … immediately that was bad. But with sedation, you don’t know immediately that it’s bad. You’re like passing on a grenade that explodes days, weeks, years later. So you don’t get that immediate feedback and you also don’t get negative affirmations.

Someone self-extubates and we make it a nurse problem, we report the nurse or the nurse like gets this bad rep or, beats themselves up. That reaffirms that’s the worst- Yeah … case scenario. No, and I know, and like that’s why, I try to [01:27:00] make it like very clear that, the buck ’cause the man attending, like it’s, like this is all my fault.

Like this is me, right? So whatever happens here, this is my, this is a me thing. Obviously if someone does something insane that I can’t stop then that’s if like the intern pulls out the endotracheal tube, like I can’t stop that. But, our approach is, falls on me.

So self-extubation particularly frustrates me because that’s happens, right? This is akin to shit happening. Shit happens, right? They pull the tube out. It’s gonna happen. So I don’t know why that’s a metric. Obviously if you’re pulling 100% of your tubes out that’s a question.

And I’m never able to find this data that says we should have a certain amount of s- of self-extubation ’cause that means the unit is not s- overly sedated. I don’t… I always heard that, but I’ve never found an actual study. Does that exist or we just say that? Is that just a thing?

It doesn’t exist, no. I have people track their self-extubation rates as well as- Yeah … their tracheostomy rates. Yeah. ‘Cause we also we wanna see those go down over time. But that’s not something that people are usually tracking, ’cause it’s like- Right

They’re on a vent, of course they’re gonna [01:28:00] end up, no. I know you you wouldn’t wanna… Yeah, you don’t wanna, you wouldn’t wanna track your, like, bad outcomes. But I don’t know is self-extubation a bad outcome per se? It’s not the smoothest outcome per se, but it’s not…

Is it bad? If the patient’s awake enough and they pull the tube out I often joke it’s the best SBT, right? Some, some studies have shown that survival is actually higher in the self-extubation group. You’re strong enough to pull it out, you have enough awareness- … to pull it out, et cetera.

In all fairness, those are in studies where sedation’s not coming off until ventilator settings are minimal and they’re close to extubation. Yeah. I obviously- Yeah … i’ve walked patients out of PEEP of 18 and 100%. That’s a different risk pro- profile. And yeah.

But also at the same time, we’re like, this is a high-risk patient. We need them to have a clear brain. We need them to mobilize ’cause they’re gonna be intubated for a while. So we’re looking at the big picture and using them to help keep that tube safe. Whereas if we sedate them until- Yeah

their ventilator settings are minimal, now they’re gonna have diaphragm dysfunction, and if they lose the tube it’s even more dangerous. So yes, it’s dangerous with high ventilator settings, [01:29:00] but let’s keep their brain intact so they protect their own tube. And then if it happens later on or during that time, at least they have some muscles and drive to breathe.

So it’s a lot of big-picture risk versus benefit analysis in the moment that, again, doesn’t happen when you have a conveyor belt in your ICU. What happens to the patients in the unit to some degree is the collective we’s fault, right? We do stuff to them, things happen. But I feel like the, like this sedation thing is particularly, Some things we can’t we’re just reacting to. Reacting to physiology, reacting to their illness. We’re reacting. Some things we have some control over, and I think this is one of the things that we have some control over, so it’s particularly frustrating when we’re talking about things that not only are, like, guideline-directed,

So it’s not like this isn’t a fringe idea like, you know- I didn’t make this up Yeah, this isn’t a fringe idea like ivermectin’s a fringe idea, right? This is the actual guide- your own society’s guidelines, SCCM, [01:30:00] ATS, CHEST. The nursing guidelines, so I guess ACCN, whatever. These are your own guidelines that you’re arguing against to some degree.

Or so, and not that I’m, like, a a guideline I don’t treat them as the end-all be-all. But the point is the experts have gotten together and say, “Yes, we should approach this in a certain way.” But it, the disconnect from the guidelines to what we actually do is just so vast, that when you make this type of content and people get so in- inflamed by it, it just shows you, like, how big the gap is between what the brass thinks we should be doing, what’s happening in the trenches, let’s say, and then maybe where, like, where the hospital administration sort of CMS stuff falls in the middle of it, right?

They the guidelines say to do X, CMS says to do Y, but we can’t execute this stuff, either w- lack of resource, lack of education, lack of support, or a mixture of all three. And then we’re, then we just start infighting with each other, right? Which isn’t is never never helps.

And in everyone’s defense the guidelines could be clearer. When you look at Denmark’s [01:31:00] guidelines, for example, they say minimal to no sedation. Whereas our guidelines here, no sedation never comes up. So- … it could be clearer, but I think they’re very hesitant to inflame people, right?

If you were to say no sedation, people would be like, “That’s not possible.” But when you look at this in a practicality sense, especially if you’ve done it with the standardized no sedation after intubation unless indicated then it just makes sense. But also, if you’re trying to suddenly take sedation off of everyone, in an- Right

environment where you’re just, that, that is your auto set and you don’t know what else to do- … then that’s I think they’re hesitant to just suddenly say, “No sedation,” and then people don’t know. They don’t have the infrastructure- … to know how to navigate the replacement interventions.

And it, I don’t, I don’t want it to seem like we’re just lambasting. So I think what I would do- is if you’re someone in the ICU, take a patient that has a single organ dysfunction like a pneumonia or like [01:32:00] an sepsis or whatever, and if they’re intubated before we and we shepherd them through the post-intubation paralysis thing, whatever, and you’re at that moment where, the prop is on and the RASS is deep because we don’t want them to be awake, aware, try to get them awake and just see what happens.

And when we do that, I find that it often goes better than you think. There’s, you’re very worried about what’s gonna happen, and sometimes it does certainly that people get really wild or whatever and because they’re sedated and all that kind of stuff. But the patient that you just intubate, just take a moment and be like, this Kali lady really wants me not give sedation.

I don’t know what her problem is. Maybe just try it and see what happens. All right? Just try it and see.” And I- And do it strategically, right? I think you should- Yeah … have your RT, nurse, and family member there. Before you even take sedation off- Yeah. And- … have the head of the bed up high, have a tool for communication right there and can, get the family [01:33:00] member their job, and go for it.

Just take it off and know that they’re gonna cough, gag, but work ’em through it. It’s like taking an SAT but bulking it up on the front end. This is an SAT. Do they actually have an indication for sedation? Exactly. That’s the purpose of an SAT. And just because they’re not ready for an SBT doesn’t mean that we can’t or shouldn’t be doing an SAT early on.

But you’ll find that it’s much easier doing it early on. And certain things are not just nursing-owned. I was- Right … upset by this mentality of nurses being protective of communication. Oh, yeah, like a physician would communicate with patients or use the clipboard. That’s a huge red flag.

So the RTs should know how to communicate with patients. PTs, OTs obviously usually do better than the rest of us. Yeah … but the physicians, APPs, residents, interns everyone should know what tools to use, what patients want to use, and be prepared as they walk into a room. But the fact that we would just be like, “Oh, the nurses are just in charge of take, turn off sedation and dealing with it,” that’s gotta go.

It’s a team- Yeah … wide [01:34:00] approach. No, it is a team-wide approach. That’s why when the nurse comes to you and says they’re agitating, whatever your reflex shouldn’t be, “I’m gonna order something.” The reflex should maybe that’s what the nurse wants. I don’t know. I’m not gonna say that.

Maybe that’s what, they know how this goes, right? They’re, and we’re just gonna order something. But what the nurse is really, or the RT or whoever is saying is they’re doing something. I don’t know what else to do. Can you help me, right? Yes. And so they’re coming for your assessment.

And not that I don’t trust the nurses, obviously I trust them, but- When it comes down to it, and this is just from a provider, and I think I can say provider, certainly doctor point of view, is that when I write the two of midaz, like that’s me. Like that’s my ass for that order. So if they were having a STEMI and oh shit, they were like Ramey earlier and there was like some ST elevation on the monitor, now it’s six hours later and they’re dead.

Man, did they have a STEMI and, we just sedated them through it? Like that’s a u- that’s like an us, that’s a me thing. Like that’s, like I have to carry that. So before you [01:35:00] write these orders for these PRN sedations for agitation it would behoove you to go find out like what is happening exactly, and then working through the problem from there.

And so Take all the risks into consideration. That was the point of the video, was just- … the whole team coming together to being like, “Why is he behaving this way? How- what are we all going to do to treat this and to keep this patient safe?” And that was obviously very controversial, but I still stand by it.

I’ve seen it work repeatedly. I worked in a wake and walk in ICU for seven years, and that was the process that we went through. Obviously nurses weren’t really coming for me, to me for sedation unless it was actually indicated. That’s a that’s a point that I think you made earlier, but I wanna highlight, is that up front, right after intubation, once the paralysis has worn off you’ve at that point have no more indication for sedation, right?

For the- unless there’s something nuanced, right? Sure. They’re- Intracranial hypertension, whatever. Yeah, they, they have, [01:36:00] exactly. But most patients- … mechanical ventilation is not an indication for sedation. And maybe that’s a point worth highlighting that we don’t get, is that the vent in and of itself is not an indication for sedation.

So once the paralysis has worn off, you no longer have an indication for sedation, so should you stop it at that point in time, they emerge, they’re coughing, they’re, whatever. You’ve talked them through it, give them some fentanyl, they have pain. Do whatever else that are non-pharmacologic or other pharmacologic measures are, acetaminophen or lidocaine patch or music therapy, whatever it is.

Then, despite all this, they’re trying to rip the tube out or they’re punching the nurse, whatever, whatever it is. Then at that point, now we have an indication for sedation, then what’s our, gonna be our game plan for… the point is to get it off. So we started it because they’re agitated, they’re combative, they’re trying to pull the tube out, they’re fighting people, they’re kicking.

We have an indication now. But what are we gonna do to get it off? Are we gonna do they have schizophrenia and we need to give them their meds? [01:37:00] Are they actually withdrawing from some other substance that we didn’t know about? After we talk to their family, oh, he’s actually an alcoholic and he hasn’t drank in two days ’cause he lost his job.

There’s things to be said to treat the reason why they’re agitated. It’s not just, they’re agitated because the tube’s in. Unfortunately, I think what happens is, and maybe this is the difference, is get intubated, the sedation never comes off, they get delirious, and then we go down this agitation spiral, and then this is just where we wind up.

And there’s so much to be said, like a whole nother discussion about psych management in the ICU. When I train teams, I’m like, “Give me time to sit down with your psychiatrists- Yeah … because we’re gonna, we’re gonna really talk about their role in the ICU,” ’cause they’re not comfortable.

They’re like, “Let me know if, when you need a discharge planning or whatever in place.” Let me know when they’re extubated is the point. When they’re extubated, that’s what they say usually. But it’s like by then you’ve been off your Librium for X amount of time. Like- Oh, yeah. No, … it’s too much.

But the pharmacology, the pharmacokinetics is really tricky. But right, it’s not just about not giving sedation, it’s do we have proper pain management, psych [01:38:00] management, withdrawal management in place? And I often find that because we’ve had this Band-Aid of sedation, the expertise, the critical thinking throughout the team is, a lot of times, lacking.

So it’s important to build that up as we take off this Band-Aid to be like, we have this whole other reservoir of tools that we know what to use and how to use it instead of sedation. ‘Cause it’s unrealistic to just take sedation off and then not have those tools available, if that makes sense. And we have to set a standard of our goal is to keep patients as awake, communicative, autonomous, and mobile as possible.

So if someone’s on methamphetamine high, like obviously we can’t have them a RASS a plus four, but can we get them to a RASS of zero with dexmedetomidine or other things, right? So that we can at least mobilize them. Or do we just wait until, like we’re watching the clock, it’s been 12 hours since they came in, now we take it off, they’re not on an amphetamine high anymore, now we gotta hustle.

But like there’s not a real prioritization or urgency about mobility. But I always say it’s like an [01:39:00] antibiotic. We don’t just skip a dose at night, but at the same time someone comes in with a sepsis or an infection or whatever, we know that they need antibiotics. But what if we were to be like, “Oh they have an AKI right now.

Let’s wait until the AKI gets better and then circle back to the antibiotic”? You have to give it at some point, but like giving it early on, even though it might come with some risks or difficulty, is actually gonna be much safer for the patient in the long run. ‘Cause trying to catch up on that infection once it’s grown and spread and it’s far worse, that’s gonna be a whole nother challenge.

So the same thing with delirium, it’s we gotta give this mobility early on, otherwise if we don’t, later on it’s gonna be a much bigger mess, and we can’t necessarily take back the damage that’s been done by waiting- Yeah … for that mobility. So just so many shifts in knowledge and perspective and team dynamics and skill sets that have to happen, but most people are like, “We already do this.”

Yeah. The box is checked. We do the bundle, blah, blah, blah, just sedate them and we’ll circle back to SATs later. Yeah. Unfortunately, I th- and I, [01:40:00] at the very least, hopefully this- some people I think will just shut it, be like, “Oh my God, that crazy video,” whatever. “It’s impossible to do.” But I do think there will it’ll light some at least curiosity.

‘Cause again, I think most people want to come to work to do the best job that they can, and that’s why you see like sort of this uptick in like people attending conferences, and obviously it’s a biased group, but still they want to learn this stuff. And there’s not great teachers out there at the moment, like for that specifically.

But I think, maybe in the next, in this next leg, like that’s what it’s gonna be is like, reorient- reorienting ourselves to like actually doing the bundle but, going a step beyond that and not just allowing people to be sedated for the, for the sake of it in a way or to, for some, silly reason like agitation or whatever.

But- No, I think we’re headed that way, but I appreciate you coming on and addressing those comments and all the crumbling [01:41:00] foundation underneath those comments that I think are the real problem, not just that people object, but it’s why they object. And so I appreciate you doing what you do at the bedside and all your ventilator education.

Absolutely follow Nick. I’ll put his handle in the show notes. We’ll have a lot more collaboration. I know people are like, “Stop talking about courses,” but he’s gonna be doing a high level ventilator management courses for our providers and RTs, which is gonna be really important. I think that’s a key piece of awake and walking ICUs that also is missing.

Thank you so much. Kaylee, thanks a lot. I appreciate it. Always talking to you about this stuff.

[01:42:00] To schedule a consultation for your ICU, as well as find supportive resources, such as the free e-book, case studies, episode citations and transcripts, please check out the website www.daytonicuconsulting.com

Transcribed by https://otter.ai

SUBSCRIBE TO THE PODCAST