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What was it like as a travel COVID ICU nurse to jump into an “Awake and Walking COVID ICU”? How does true mastery of the ABCDEF bundle impact RN workload, burnout, safety, and career fulfillment? Travel RN, Laurelai, shares with us her experiences and insights.

Episode Transcription

Kali Dayton  0:00  

In episode 76 Travel nurse Alex shared her observations regarding the ease and workload and improvement in fulfillment, working in an awakened walking ICU compared to the process of care she experienced in other ICUs. This all lines up with a research that suggests that this process of care improves workload and safety for nurses. From the research we know that delirium doubles the nursing hours required for care. One episode of delirium increases time in the hospital by 10 days. 

 

We know that delirium increases the risk of line and tube removals, about 75% of falls in the ICU are in the setting of delirium, and by improving delirium, we decrease falls. We know that delirium increases workplace violence. We know that much of the psychological stress on nurses is rooted in the burden of caring for patients with delirium. Citations to all of that are on the blog at data and ICU consulting.com By automatically stating all patients right after intubation, creating a storm of delirium as well as ICU acquired weakness, and then leaving it to nurses to deal with is not safe, fair or sustainable.

 

 I think it is incredibly important to hear and understand the perspective of those that are the most intimately involved with patients. Moment by moment throughout patient’s journey through critical illness. I’ve invited another travel nurse Laurelei to share her contrasting experience in the awakened walking COVID icu Laurelei. Thanks for coming on the podcast. Can you introduce yourself to us?

 

Laurelei, RN  2:11  

My name is Laurelai. I am a nurse. I’ve been a nurse for about 13 years and working in the ICU for about five. Thanks for having me on.

 

Kali Dayton  2:20  

Appreciate you so much for coming on. And tell us about kind of what your journey was especially during COVID. And then what it was like to come into an “Awake and Walking ICU”. 

 

Laurelei, RN  2:32  

Yeah, that was a journey. So I had been in the ICU for probably about two years before COVID hit and then maybe about a year after that started traveling about a year before but it was about a year after that I decided I was going to start traveling full time as you’re aware it was a really weird in the beginning, we didn’t know what was going to happen. So some areas got hit really bad really at first and some didn’t. 

 

And so in the beginning, the ICUs room was dead in certain areas because people were afraid to come into the hospitals. So the hospital was originally working at became just really quiet. So travel opportunities came up. And I was in a position where my work was able to let me work partly from home and figure out if traveling would work for me and I just loved it. So I started traveling to Miami was the first place I went to, and it was different. 

 

The ICU I originally came from did wake up patients pretty quickly. So I was used to awake patients, not necessarily walking vented patients except for in the cardiac unit. So I was probably one of the only units I worked in that where you have vented patients who are walking. So when I went to Miami, it was completely different sedation, a lot of sedation, no walking and moving a lot of the other ICUs are the same way we were overwhelmed. 

 

They were great with staffing. Normally, you still only had two, maybe three ICU patients. But the acuity is just really high and then keeping a patient vented. There’s so many more things you have to do with them turning cleaning all of that. Eventually I was able to come back home and start working in this walking ICU and it was at the peak of COVID. So I was not used to waking up patients. I was used to it but I was working with a lot of other nurses who were not used to it. 

 

So it was kind of like dealing with their shock, my shock but the walking part was the interesting part for me. We would have patients who might even still be sedated, but we’re sitting with the side of the bed and moving them around and that was something I wasn’t used to so whether it’s sedated or not sedated especially with sedated having a sedated patient who’s intubated and you’re moving them you’re not just having PT coming in and moving legs like passive movement, right?

 

 It was we’re taking this vented patient who may not be awake yet, but maybe in a couple days we’ll be ready to wake them up. And we’re gonna continue moving their body we’re gonna sit in the side of the bed. We’re gonna let them rock back and forth we’re gonna kind of still have their body orienting their brain orient to this and it was scary at first But it was amazing because I was used to the cardiac patients who are awake and could at least follow your commands as it moved on then it was waking patients up walking them vented who they weren’t cardiac patients.

 

 These are respiratory patients. Sometimes if it were COVID, it was just in the room or getting them up moving into the chair. They weren’t COVID patients, because it was a mixed ICU. They weren’t COVID still waking them up as soon as possible, getting into chairs, getting them to stand up and then working with them, walking them around the ICU, and even into the hallways, which is completely amazing. And watching the recovery. And the recovery process. It’s kind of mind blowing, intimidating at the same time, because it’s not appropriate for every patient. But when it’s appropriate, it’s mind blowing.

 

Kali Dayton  5:43  

And do you feel like you develop those skills of being able to assess when it is and when it’s not appropriate for a patient?

 

Laurelei, RN  5:49  

Yeah, it’s actually really amazing going from this hospital. So I was at the hospital for this particular hospital that I was talking about about six months, I left went to some other hospitals and came back. And they even had results, we need to revise certain protocols because COVID was new. And like I said, especially with COVID. 

 

In general, with this ICU walking, walking patients having them being awake, it works really well for regular respiratory patients. COVID was a little different. And as you learned more, it was able to anticipate what was going to happen with those patients, because some of those patients with some respiratory patients, it’s just not appropriate to wake them up right away. Sometimes the sedation is needed, because they need that rest on their lungs. 

 

But sedation vacations, and still we are waking them up faster than I had ever seen any of the other ICUs I’ve been in. So normally, if we could it’s within range after animation where you know, you sedate them for innovation and you don’t sedate them again, they might have something to help calm them, or maybe we give them pm meds that are crushed or something through their IV. But for the most part no sedation, there were some patients that we needed to sedate mental health and their illness and their prior medical history does play a huge part in that if you have patients who are highly prone to anxiety, or have mental health issues, it is harder to wake them for keep them awake. But we still even try to do that. But that process might be sometimes a little slower, because maybe they have other respiratory issues. But it it’s remind me the original question, I’m gonna go back to what did I get better with it? Or?

 

Kali Dayton  7:23  

Yeah, did you build that skill set? Yeah. Did that become more comfortable and more? Was there more logic behind? 

 

Laurelei, RN  7:29  

For me, it wasn’t too bad? Because I’d worked with awake patients. Yeah. Or I think I saw other people coming through that product. People who came in originally who were like, “This is ridiculous. How are we ever going to accomplish this?”, and then leaving saying, “This was the most amazing experience I’ve ever had.”

 

 And I think it really plays into team collaboration. So it can’t happen effectively if we don’t have a team that collaborates well. So an interdisciplinary team that collaborates well. So in order to make this work, it has to be physical therapy, occupational therapy, our NPS, our doctors, nursing staff, our techs, everybody has to be on board. Even kitchen staff would come in, they might even notice something as they’re walking by rooms like, “oh, you’re patient!” you know, because as you’re waking patients up, sometimes they’re completely appropriate. And they don’t need to be restrained. 

 

Sometimes they actually like a loose restraint. Because if they fall asleep in the chair, they don’t want to accidentally grab their tube. So sometimes, you know, we would even have patients can you loosely tie my arm down. And it might sound really weird that they wanted that because they’re awake, they’re sleeping, someone might not be in the room. But with our patients or even maybe a little disoriented, you would have someone walked by everybody has eyes on the room. 

 

And everybody plays a part in this. It’s not just my job. It’s a nurse next to me is helping me the doctors who are walking by even like I said, it might even be the kitchen staff who’s walking by saying, “Hey, your patients kind of leaning out of the bed…” or whatever happens to be, you know, especially with COVID patients where the doors are closed, and you don’t see you see that we see them. It’s just a little you know, you’re now you have a window rather than a huge open door. But it is a team collaboration. And I think I adjusted really quickly because it just makes sense. For me, it was a no brainer.

 

Kali Dayton  9:13  

Right? It’s a totally new experience. But then once you see it work, you can’t see it any other way. It is. And so he talked about this interdisciplinary collaboration. And just earlier this week, I was doing a question and answer webinar with a team that I’m working with and some of the clinicians when they walk in ice, we’re in on it talking to each discipline. So our teas we’re talking to our teas aren’t the RNs, right? And we’re asking really good questions, but one of them was what are your staffing ratios? 

 

Turns out that this “Awake and Walking ICU” had seemingly less resources than this other ice we were working with. And they were so daunted by the aspects. You know, I think a lot of people assume this is a one to one nursing ratios for every patient that’s vented because they’re awake, things like that because they only experienced it when Between trials where patients are delirious thrashing, trying to pull their tubes, right? So they assume it’s gonna be that hot mess. But obviously, it’s not because patients are less likely to develop delirium, but even still, it does take the whole team. So kind of what are your speculations as to why with normal ratios, nursing two to one RTS or like four to 6 vented patients. Why are they so much more efficient and effective?

 

Laurelei, RN  10:25  

That’s a great question. I think a lot of it happens to be it. I think this is a nursing driven protocol there, this hospital, that NPs were the ones who did the research, came back to the hospital, got the doctors on board, and the management is very much onboard and supportive of this. Also, there might be a day where that patient might need to be a one to one just because delirium does happen, even if you’re not using sedation, right? They’re not sleeping while we’re waking them up.

 

 And in those situations, the charge nurse, the nursing staff, and the management will all have a talk a really good one to talk to this patient need a tech to sit in there with them, which we don’t have, does this patient actually need to be one to one? What are the safety concerns with this and when we truly vocalize that this is a really big concern for me, then they try and find those resources for us if but in general, the a really does boil down to the they listen to us one. 

 

So because it was a nursing protocol, I think in the hospitals on board, it’s not necessarily new, they know now that we just don’t freak out and say we have to test to be a one to one because we understand the possible potential issues. And it’s not so scary to us, because we know that not every region is going to extricate themselves, like what you said they’re not delirious anymore. But it’s hard to wrap your head around that when you’ve only seen the delirious patients. It is two to one. And one of the things is your patients help you I mean, they can push their colleagues. 

 

They’re just like any other patient, except they’re intubated, which is kind of interesting, you know. The family members learn really quickly, too. They’re like, Oh, you know, they we have writing boards. So we’ll have them write so they can still communicate with us. It is a two to one ratio for most of our patients and part of it then the other part goes back to the nursing staff in this hospital. It’s not the old nursing staff of everybody’s on their own, it is so collaborative. 

 

I’m going to lunch, I actually can take a lunch, and I know someone’s going to watch my patient, I asked them if I need help with something someone is super happy to jump in, because they know that they’re going to have you know, how I’m going to help them. It’s just the morale is I think a huge thing. We are a team. We’re a team in the hospital, and I was even a traveler. So it’s funny, even their travelers, they treat their tablet travelers like staff. So it’s not like one of those us against them situations because they realize we’re coming there and we’re going to help them. And they treated us really well. They gave us once they learned to trust us we get hard patients but it didn’t necessarily mean they were being like I’ve heard the horror stories of other hospitals, which I haven’t had to deal with, luckily, but yeah, it was just great collaboration there. You were part of a team, whether you were staff or whether you are a traveler.

 

Kali Dayton  13:07  

I missed that as a travel nurse because I started in the ICU and I was used to that kind of dynamic, that culture. I helped everyone else helped me and then I went to other units where Yeah, you were completely on your own. And sometimes the staff who was that different sometimes it was you know, it was just there just weren’t people, but sometimes there were people, but the culture was there. I remember one time I was brand new to units and they gave me easy patients, right? Because they didn’t know me. So they were all tucked in and fine for that night shift. And I went around and said hey, do you need help with a bed bath? Like it was just habit, right? 

 

Yes, they were shocked. I was it looks at that it gave me I hurt my heart. Actually, I thought, “We’re all nurses. This should be innate to us.” But so that’s what I really appreciated coming back there to the “Awake and Walking ICU”, it’s finally part of a cohesive team again, and it just didn’t seem that hard to happen patient’s awake and moving compared to when they were sedated. And I was trying to turn them put a bed bath or bedpan under them myself and do all those things by myself.

 

Laurelei, RN  14:06  

I was reading your other episode we talked about hey, look into this other episode was at 67. 

 

Kali Dayton  14:12  

76.

 

Laurelei, RN  14:12  

Yes, 76.  I loved one of the things that you guys talked about things that people don’t think about when you’re sedated and you’re not moving or even let’s just say bed bound and not moving. Even something as simple as a bowel movement can become a huge thing. bowel obstruction because you’re sedated, which slows your bowels and now maybe you either have to give more medicine or they’re not or now you’re giving them medicine and now they’re having loose stools, which causes skin issues, and you’re putting bedpans….

 

 and these patients can get up and they can move it can still be hard because sometimes it’s a two person job getting them from the bed to a commode. But it’s just so different. The one thing you were saying to you about collaboration in other hospitals, PT OT, it was great, but it still wasn’t a full collaboration in this unit. When we’re getting ready to especially.

 

When they’re, you know, there’s some patients who might have to be sedated for a few days, and it’s amazing how sedation for a few days can have you lose the ability for so much mobility and your body may become so weak. So you think, I think I read a study that was like, every, every few days, you lose like 20% of your, you know, muscle ability. So you think a patient who let’s just say had a week that it was really hard, and they needed to be seated for five, seven days.

 

 They have a hard time setting up. So PT is really great. They come to us, and hey, we want to work with your patient today. Great. How are they living? Well, you know, it’s, they’re not moving all that great. I’m gonna grab ot ot comes in with PT, because ot has to see them anyways, we need extra hands anyways. So we get nursing, ot pt. And if we happen to have attack, which sometimes we don’t, maybe I’ll be able to grab another nurse. But right there just with OT, PT. And myself, we have three people to help move this intubated person, sometimes it only takes two. Sometimes PT can do it by themselves. 

 

But that’s kind of what I mean with collaboration. Also, it’s not all on the nursing team to get them greetings. PT might be walking by working with another patient. And they’re like, Hey, did you need help getting your patients to the commode I see they need to get to the commode I can help you with that it’s the shoot ever was. I think it’s part of what makes it such a successful operation at this hospital. There are times when, especially when we get the patients, they might need to be intubated.

 

 We don’t really need any sedation, they’ve been awake the whole time they can they continue to be strong with their body for the most part, I might be able to get them up to the commode by themselves. Other times it does take more people. And the other reason that it’s so it just works is that PT ot even sometimes if we have a tech nursing team, we collaborate so well, PT will sometimes you walking by and so your call light will pop in, “Did you need something?” and the patient will point you know, commode or something. And they’re like, “Hey, your patient needs to get to him out, I have a minute before I get to other when can I help you get them there?”

 

It’s just… OT would do the same thing. Sometimes the team is so collaborative. And I think this is another reason it works so well in this unit, they might not always be there. But when any of the other members are on the floor, everyone is always so willing to help out that three minutes, it only takes three minutes, right? Which really is not that long. But if you’re thinking about it, “us and them”, it’s never gonna work. But it’s us. Right? So they’re like, “It’s three minutes. So I can help you three minutes, I can get them to the edge and help you get them to the toilet.” So it’s it all boils back down to even though it is a two to one ratio, we’re not on our own. It’s just the team there is so fantastic. Even the NPs will help us and he might be walking by him like, “Hey, I need some help over here. And there’s nobody else…” they’ll be like “okay!” and they jump in and they help us. So the doctors, you know, it’s a little different. It’s harder to find them. If they could they would. 

 

Kali Dayton  17:43  

I had walked into some of them MDs trying to help patients get to a chair and you could tell it wasn’t natural, but they were so willing to do it, you know, if they’re doing their assessment patient asks, I’ve seen that happen. And as an NP, Yeah, I was. I was like, “Sure. I’m happy to help you dangle that patient.” You know, really, that’s what it takes the most people when they are so weak and deconditioned, you know, it’s going to be a group effort. And I know it’s a big ask, it’s like, “I’m here,” especially on a night shift. I feel like my evening shifts. I’m not writing 13 notes, “please use me, I’m here. Let’s do this.”

 

 That’s exactly how it works. It’s everyone’s job. But I was just at an AACN conference presenting this and one person she…. she was almost in tears, she said “We as nurses just can’t handle anything more.” And I said, “Exactly!” But when patients are sedated in the mobile, my perspective, and my experience was that it was so much more on my shoulders to have to run the sedation, run the vasopressors, do the turning, the heavy lifting, and just logistically for the team as a whole overall, let’s say that three minutes to the commode helps keep them strong enough to extubate later that saves, you know, 3, 6 days on the ventilator, that all adds up to less work for the team. It’s just hard to measure that in the moment or even in the big picture. It’s hard to really identify exactly how much work and time that saves, ultimately.

 

Laurelei, RN  19:09  

I think you made a great point in saying like, even cost you think about that. We’re nurses, right? We get overwhelmed. It is very hard. We have some really hard days sometimes sometimes you might have a patient who’s almost dying in the other room, right? They are on all the pressors they are….you know, they are vented you are doing everything you can do and you’re still afraid to leave the room. 

 

And those situations, obviously, that’s an exception. And it might even happen… I’d have a patient who’s crashing now all of a sudden. The nursing management was so great there too or even the other nurses so great. They’re looking at it going you know I just discharged patient I’m going to take care of their patient because I realize what’s going on. 

 

So it is an ever moving situation like in every ICU I think it becomes more overwhelming for people to even process because they’re thinking “The patients are awake though!” I’ve had times where I’ve had two patients one patient is cramping. The other one’s pretty stable. They are the vented and awake one. And it’s still okay, because I might not see them as often during the day. But I know I’m like, checking in with the other nurses who are checking in on that patient. The team effort is what makes it work. 

 

And in the end, it’s the personal human toll, right? We got into this because we want to help other humans. Of course, we need to make money, right? We all have a career where, you know, we want to support our families. But we came into this to make a difference. And seeing that some of these patients don’t have to go to a long term care facility or rehab facility after this is amazing, because most patients who had been sedated for weeks and who wake up and who are okay to be transferred out, they’re not going home, they’re being transferred out to, you know, a different level of care facility or they’re being transferred down to med surg for a few weeks then to be transferred to and, you know, long term care facility afterwards. That’s the difference right there too, when we talk about cost, not just medical costs, but cost to human life, or even their quality of life.

 

Kali Dayton  21:02  

Do you remember when you saw the first vented COVID? Patient, walk out the doors? What was that like for you? Oh, my goodness. I know you’ve treated so many patients. 

 

Laurelei, RN  21:14  

There are a few that come to mind. I think the most recent you might have even gotten the video of this one, one of the most recent ones. Some of them are spectacular, right? Because some of them just didn’t get covered. It was ridiculous how fast their bodies recovered, right? Because some people just needed to be on the bench for a little bit. their lungs recovered really quickly. We could get them off and they could go home as some I saw get vented. And just because of the acuity, you know, they’re going to be fine. But because there were sedated because they couldn’t move. 

 

Other things happened…. And you know, they get all these complications, or maybe they got a VAP, you know, by no fault of our own, but just because they already had a pneumonia and now they had another infection and just watching them spiral downwards. Right, but knowing that maybe if we could have gotten them off of sedation sooner, and we could, you know, we could have woken them up sooner.

 

But seeing it for the first time, I had seen so many people that I think in the beginning, we just didn’t know how to treat we didn’t….Some hospitals didn’t have resources and watching someone walk out. It was amazing. The one that stands out in my mind….  he had been vented for over a month, but he was awake and he wasn’t sedated. We hadn’t sitting in the chair. He was playing guitar for us and someone brought in a guitar. He was playing drums and he was putting on these little concerts.

 

 Morale is a huge thing too. He did every once in a while go through the bits of delirium also, even though he wasn’t sedated because sleep is a hard thing in the ICU not leaving a room because he’s COVID for over a month is also very hard. But when you can….he can hold the phone, and he can FaceTime with someone else, even though he can’t speak and helps bring you back and grounds you in the real world. And watching him go home was spectacular. Because there were times with him. We thought, “He’s not going to make it. No, he is going to make it, but he’s not going to make it.” 

 

— But because he can participate in his care. Because he could let us know “Hey, today my breathing is not as good. I think I need to do something.”- we bring in respiratory bring him the doctor. Oh, you know what he isn’t? Maybe he needs one more peek today. He participated in his care. And I think that really went to him going home. I mean, we were all I’m gonna like I think I’m gonna tear up…. 

 

Watching him go home, you know, we were all clapping. And it was just like a lot of us just stared at each other going, “How is this even possible?”— Because a lot of us had seen just a year before 10, 15, 20 patients dying in a week. So watching him be as sick as he was just like and walk he literally walked up there that was with like, he had like a little cane. It was the most spectacular thing. His family was so grateful. You know, we’re just can’t express… “How amazing it is to see someone recover in that way who was that sick?”

 

Kali Dayton  23:59  

And I’m gonna do an episode with him. I just talked to him on the phone a few weeks ago, he was back to the weights doing incredible. Lots of setups like he and he was waiting. I think he’s in his 70s?

 

Laurelei, RN  24:11  

He was not a spring chicken. He’s not old by any means. No, you know, a year ago, a patient like that they would have said, “Oh, he’s probably not going to make it.” You know? And had he stayed sedated and not be able to move and his lungs deteriorate and his body deteriorated. That might have very well been the outcome for him sadly.

 

Kali Dayton  24:28  

Well, if there’s evidence suggesting that a muscular atrophy because it fuels the inflammatory response, it can lead to or worse in ARDS. I see it so likely those patients, people say oh, those patients in the ICU aren’t as sick. But a lot of it’s because they don’t want to get sick. Absolutely. Did you see that? 

 

Laurelei, RN  24:47  

Yeah, yes. What you said because it was kind of going back to the other point where I think if we can get them off sedation and moving, you don’t see the cascade effect of okay, now they’re having more respiration. or issues or now all of a sudden their kidneys are starting to fail or their liver or whatever, you know that cascading effects. And it is sometimes it is avoidable. 

 

But sometimes it’s not avoidable depending on how sick the patient is to say that we can’t get the patients off sedation, because they’re really sick isn’t necessarily always the truth and saying that it’s harder to take care of the patient because they’re not sedated isn’t the truth either. It’s not always easy, but we have awake patients who aren’t intubated. We’re not necessarily easy sometimes, you know. 

 

So it is just learning. You might have had an itch, I think it’s team collaboration, it’s learning that we can all lean on each other. And when we lean on each other, whether it’s a COVID, ICU, a cardiac ICU, whatever kind of ours ICU, when we have collaborative teams they worked in other hospitals are similar, the workload is just so much better, you go home happier, and the patients go home healthier and happier. 

 

Kali Dayton  25:55  

Also, there’s a recent study coming out showing that the A to F bundle improves workplace environment. And I think it’s because we have to work together to make the ABCDEF bundle happen. And also family engagement. Did you see a difference family engagement, even during COVID? And how families were utilized? 

 

Laurelei, RN  26:13  

So not all family members are capable of helping right we know that some parents and that we all know sometimes having family members around is fantastic. Other times, it’s almost like, Okay, we are also doing a nursing care on the daily members, because they might need like social help with SMS, you know, reassurance. But I think there were there was a huge part of family involvement, and it was that they would sit next to them, especially in the beginning, we, we might not have any text on the floor, it’s a two to one ratio, it’s a self care, you know, we’re doing most of the cares all on our own. 

 

So we were going back to that staffing ratio, that we didn’t necessarily have more staffing, and it wasn’t necessarily one to one, that we would use spouses or maybe children and they’d sit in there with their parents and reorient them. They were small on them, right? It’s still on us. You know, the patient is not oriented, it’s on us, you know that. But once they’re at that point where they’re pretty safe, they’re pretty safe, but maybe they’re sleeping, or they might need help grabbing something where a tech in another unit might be able to do that that family member sat there and did that. 

 

Having a family member, they’re also engaged, that engagement helps with the orientation. And then also they know their family member better than anybody else. So there are times where they might be able to say, “You know, he’s just not uh, he’s feeling he’s seeming a little, you know, off right now…” or this or that. And it cued us and even to, “Maybe we need to do another assessment, what’s going on with this patient? Is it some delirium that’s going on? And do they need to do we need to address some pain issues,” you know, things that they might not even be saying to us. 

 

You know how some patients are great at expressing pain, some aren’t, you know, and so extremely helpful. And there were even some cases where family members might be medical staff or family members might just be so willing to help and you trusted them enough that now I have an extra set of hands to get me to the commode. You know, it was kind of ridiculous, especially when they’ve been there for three weeks how quickly they almost become medical experts on different things, and they know their family member and they want to participate. 

 

So family participation was a huge part, even when we would have patients who would start to become delirious maybe at night, or maybe they were more elderly and did have that sundowning kind of thing going on. Sometimes, we could call family back and say, you know, having you around, actually really does help them it helps calm them, do you mind coming back into the hospital. And now we also keep us from having to get a sitter, or having to restrain them, or having to turn them into a one to one was just having a family member sit with them sometimes. So yeah, we use a lot of different resources so staff isn’t necessarily the only one.

 

Kali Dayton  28:45  

And again, there’s such a spectrum of capacity within families. So to assume that every family member is really helpful, but I worry about these ICU teams that still have not let families back into the ICU or have very restricted visitation hours. Yes, there are some families that you have more boundaries with for the good of the team for the patient. But I think more often than not, we’re doing our own teams and a patient a disservice by setting those huge restrictions. I mean, in my mind, family’s part of the ICU team just as much as respiratory therapist or nurse. When would we ever cut out RT after eight o’clock at night?

 

Laurelei, RN  29:25  

Well in part too is just that some of these patients, especially if they’re on a an isolation, right? Some of these patients are extra isolated. So now if they’re let’s just say a COVID patient now not only can they not come out of their room, but even kitchen staff can’t doesn’t go well there are some hospitals it’s great. This hospital system is great where they’ve actually trained some of their kitchen staff to put on peppers and go into these rooms and bring them but in a lot of instances though, these patients will get no an outside interaction unless from anybody clergy is not coming in….. you know there there was a time where you know, almost no we would go into these rooms. Which makes it even more isolating so that you tell the families that they can’t even go and visit patients. I think it’s just it doesn’t help with the psychosocial aspect of healing and realizing that we’re not just treating their body, we are treating them for a lot of different things. And if we isolate them even more, we have even more negative consequences that we’re going to have to deal with.

 

Kali Dayton  30:20  

And all the practical things that you can use them with, like you’ve described, there’s a recent study that showed that family presents for more than two hours a day decrease the rate of delirium by 88%. And then delirium doubles, the nursing hours required for care. So not just for in a moment of helping the patients and decreasing your workload by keeping them entertained, engaged, make sure their needs are met, but also just down the road, where they develop, decreasing the rate of delirium is going to make them discharge out faster, be easier to take care of down the road safer to take care of like all these things. 

 

So if we have visitation restrictions, we need to step back and really reassess what we’re doing to our patients. And our teams is going to ask to sounds like, I mean, obviously, during COVID, that ICU ended up using more sedation than was ever used before. medazepam was never used during that, the COVID pandemic and even still, but tell me about even the rascal that these patients that did have to be sedated, how deeply were they usually sedated.

 

Laurelei, RN  31:22  

So sedation was one of those things where it normally became a need only when the patient was over breathing vent so much, or maybe a trauma that, you know, obviously, traumas, they can have a trauma and some other things go on. Right, but they were barely sedated, it was just enough to keep them calm enough that the event could do its job. And you could still get movement from these patients, you know, and there’s, sometimes it was just enough that they are almost still awake, you know, and they, you know, you could, ” Can you squeeze my hand?” and they could squeeze your hand a little bit still, even the only time there were a few that, you know, had to be sedated a little bit more. 

 

But those were extreme cases where there was such the acuity of illness was so high that they would be even more but even then it was the minimum station and we were always evaluating is this good? They’re good right now. And everything was great. And they’re stable on their vents and their their vitals are stable. “Can I bring them down a little bit?” And then “Okay, they’re doing great here. Okay, great. Couple hours. Alright, they’re doing really great here, can I bring them down a little bit here? Okay, they’re struggling a little, I’m gonna bring it right back to where it was.” — So there’s a constant evaluation of what is the minimum that we need for them in order to maintain the best results for them, because the goal is to get them off as quickly as possible.

 

Kali Dayton  32:49  

And obviously, you’ve worked in other ICUs, where they do the standard awakening trials —- haha- the look on your face! That’s how I felt about them, too. I hated awakening trials! And I’ve seen teams do them at five o’clock in the morning, in a dark room, no family, no one else around. It’s the end of the nurses shift. They’re burnt out, and then they have to unmask this hot mess of agitation and delirium. So how much easier was it to approach sedation? I mean, have it be rare, have more patients become an oriented, free delirium? But then even when you had to use sedation, using light sedation, working with the team, those kinds of things? How was that easier? Or how did that compare to the workload?

 

Laurelei, RN  33:28  

I think the thing that makes it scary for most people is because the only reference point they have is the one that you were just talking about. The patient’s been sedated for days and you’re waking them up and they are delirious and out of their mind and they don’t know what’s going on. And a lot of them are trying to pool and thrashing. So this is what most nurses think of when they think of not not sedating your patient. 

 

Yes, it doesn’t happen like in general when it would be we talked to the patient, “We think we’re going to have to intubate you. And you’ve been here for a few days you’re now on the max amount of you know high flow and all you know these things…. we are going to have to intubate you. We don’t use sedation most of the time. We are going to sedate you for the intubation and in about 30 minutes you’re going to wake up and you’re going to have a tube down your throat. You might be scared. I’m going to be right here with you. I’m going to be here I’m going to hold your hand I’m going to walk you through the situation.”

 

 Night and day –because they are coming to a little disoriented, sometimes a little panicked and I could see that myself I probably would be. I can’t even scuba dive you know in circles sometimes without panicking a little bit. But having someone there and reminding them that this is what it’s going to be in the beginning maybe they do get a little extra medication maybe the doctor will side to give them a little bit of something to help calm their nerves just in that little bit. But it’s amazing to with before the end of the shift see them sitting there writing and sitting up and maybe even being moved to the chair the difference is it is so it is so night and day the and then participation in general. I mean it’s just It’s hard to imagine I’m sure for a person who has never imagined or just never been through it because you only have that one reference point. But working through it becomes pretty easy.

 

Kali Dayton  35:12  

And that is a legitimate fear for a lot of people. I’ve had nurses ask, “What do you say after they wake up?” They’re not sure. And they’re not comfortable, because they haven’t had the experience of communicating with a patient that’s intubated. Or how to work them through acclimating to the tube. Was that a new experience for you? Or what would you recommend they do? Or how do they get used to that skill?

 

Laurelei, RN  35:34  

For me, but again, I talk to my patients all throughout the care. Whether they are sedated or not sedated. I’m talking to them, I’m telling them, “Hey, I’m going to turn you now I’m going to be wiping you here.” I mean, there are stories of people remembering certain things, and they have no idea and it might seem like a horrible nightmare to them when they’re being turned and rolled. And in their mind. They’re thinking, “I was on a boat, and it was thrashing and crashing” you know, we don’t really know. 

 

But so for me, and I’ve had other times where patients have said, “I think I heard you talking to me at one point, or you were telling me something,” I’m like, “Wow, they heard that,” you know. So it’s really important for us to remember that no matter what the situation are, no matter where they are in their sedation level, that there’s still humans, right? And to give them that human decency, whether it’s still closing the curtain or just talking to them, “I’m going to give you an injection now, I’m going to be putting in a rectal tube..” whatever, you know, whatever it happens to be. 

 

So the same thing when they’re waking up, and they’re a little scared. I do grab their hand, a lot of times, sometimes it’s even stroking their head, or I used to laugh in nursing school when they’re like, “Therapeutic touch is so important.” And I was like, “Oh my gosh, I am not a touchy feely person, therapeutic touch, come on. People are probably gonna judge me for this.” But as I’ve gone through many nursing career, I’m like, “Oh my gosh, it is amazing. What stroking a person’s hair, braiding their hair, holding their hand, how this actually just makes them feel more connected to you. And just they feel a little human. And either whether they’re fully awake or not how it calms them.”

 

 I walked into a patient’s room, she was actually wasn’t my patient, once again, helping someone else out. I was good. And my patients were good. I heard some commotion on the other side, and it’s like, I’m gonna go see if I can help this patient. Like I said, past medical history plays a huge part. So if there happens to be mental illness or anything like that, it is a little bit harder. But again, it’s not anything different than we’ve dealt with before. So it is a little harder. And this is just the patient. She was awake. She had some mental illness issues. Also, she wasn’t sedated. But they did put her on a little bit later on, because she was having a really hard time. In the meantime, when we did give her a little bit of medication. She wasn’t calming down.

 

 And everybody said, “I don’t know what’s going on. How do you think we could help.” I’ve also worked in the ER side and kind of used to some of these things. I was like, “hold on a second.” Yeah, it’s gonna sound hard. But she was like trying to sit up and she’s restrained. And they had just given her the medications to help her calm down. And she was going to at that point and do more harm, which is why they decided they would sedate her just a little bit, she was having some mental health issues at this point. So mental health does play a part, right?

 

 And so sometimes you have to take those certain things into factor. So when somebody says that it’s a one size fits all, it’s not, it’s an evaluate each person, every day, every hour, whatever it happens to be, and you change your plan as it goes, yeah, some days, they might be good other days, they might not be. And in this case, this patient had been doing really great. But this was a really hard day for them. And they gave her a lot of medication. And she just wasn’t coming on, I kind of put my hand on her head a little bit firmly, like helped her put her head back, stroked her hair a little bit, the thrashing stopped, everything stopped, and I just held her hand for a second, “I think you’re fine. You can just be calm now.”

 

 And everybody was looking at me like, “What the heck just happened?” because she just stopped thrashing, laid there and was able to be calm, like we gave her the minutes and nothing happened. She just needed that extra little push over. But in some other situations, it might have been like it’s not working, we’re just gonna push more meds. So nice just remembering everybody’s human, and sometimes even touch and speaking to them, like they’re still a person. They’re there. They’re hearing us. They’re scared, they’re looking at us, because we are their lifeline. We’re their advocate. 

 

So advocating for them, whether it is maybe that day, they need a little bit help with their anxiety. Or maybe it is that day, we might need to help them with their sleep because they haven’t slept for three days now. And they’re starting to get some delirium, whatever it happens to be, we are their advocate. So whether that’s sitting with them, sometimes it is just sitting with them, like I might have time and I’m like, I want to be out at my desk and I want to be charting at my desk. But I’ll chart in the room instead so that I can just talk to them for a minute just giving them that extra little thing. 

 

So I think all of those new things make a huge difference, especially when you’re not used to working with a patient who’s waking up and a little anxious, just remembering that, well, what would you want someone to do for you in that moment? Maybe hold your hand and tell you it’s okay. Hey, remember we said this is going to happen? It’s going to be scary, but I’m right here. Remember I told you I’m going to be right here. I’m right here. So yeah, that’s just kind of part of it.

 

Kali Dayton  39:46  

Yeah, and there’s so many things that can cause legitimate fear, panic anxiety in that situation. And if we just state that we can’t really treat those things, if we just mask it. So can you give a great example of that how the team utilizes this whole toolbox, right? You’re pulling out Therapeutic Touch, comforting words, communication, trying to communicate with her. But if someone is a RASs of three or four… that can be a danger, right? So then sedation is there. Do we go straight to benzodiazipines? Heck no. But can we try a little bit of precedex? If it’s a persistent thing, we do a little bit of klonipin, hence, we don’t have these highs or lows. Or what can they tolerate? What do they need?–,but the highest RASS, or the closest to zero, I should say, possible, so that they then can utilize those tools.

 

 I mean, you can’t walk someone with a RASS of 4, but does walk their anxiety? Yes. So can we do precedex so that they can calm down enough to walk and work through it? I’m having flashbacks to…. here’s my confession. When working as a nurse and that unit other units too, but they really would tease me lovingly about it. But I sang to my patients, I remember what one time this patient actually had riggors, like, legitimate riggors, and he was so to tachypneic during it. 

 

And I can’t remember if he requested it, or I think I… in that moment, I said, “What’s your favorite song?” And he told me and I started singing it. And even though he was still shaking, his breathing, slowed way down, because there were like, seven people in the room trying to figure out what’s going on with him. It was an abrupt onset, right? I think there are legitimate riggors, but there were also anxiety and fear, like, “I’m surrounded by all these people.” So singing to him, gave his mind somewhere else to go. And he immediately slow down his breathing, and everyone just was in shock. 

 

I was shocked. I didn’t expect that I just could tell that he was panicked. And I was wanting to focus on how he was feeling, but it changed his symptoms. And he, you know, otherwise, we may have been thinking about, you know, intubation and all those things, but it changed things. And so we have this whole toolkit. And those moments were what brought me so much fulfillment and reminded me why it was a nurse and I walked away feeling like, “I changed someone’s day, but I’ll also help save a life.”

 

Laurelei, RN  42:00  

I love that you said that. Because we do this every day. It is nothing new for us. It is not scary for us necessarily, because it’s just oh, they’re crushing. We’re gonna be innovating, we’re gonna crush it to us, it’s a normal part of the job to the patient to their family. This is nothing, nothing at all ordinary, it is scary, it is traumatic. And even if they don’t even have the words to express what’s going on. And they’re thinking it’s just all medical, a lot of it is emotional. And just having someone go in and have that human touch and just seeing which is amazing that was able to calm them down touch. I actually I think I downplayed how much all of that takes takes is a part of care, until I started using it and realizing it is actually a very strong tool, one that I wasn’t comfortable using in the beginning. But it is actually one of the strongest tools that we have is just going back and, and remembering that this is a human that we’re dealing with more than anything. And maybe it is just anxiety, and they’re feeling like they’re being lost in the system and not being heard or felt or their emotions and things aren’t being valued.

 

Kali Dayton  43:09  

I’m sure nurses will hear that and say that sounds really nice. But at this time, I’m just doggy paddling. I can just keep drips running. That’s all. So do you see any kind of exchange and investments and time and efforts? When you have this different approach?

 

Laurelei, RN  43:27  

I will not lie that there are days where I fall into this. But it’s like what you said when you had that moment and you did it and all of a sudden you realize oh my gosh, this is huge. We had a what I remember was using it, but I wouldn’t use it all the time. And at one point I was at some hospital and they sat us down and they had a little conference on what does it really take? What is that personal touch really take three minutes, right? You’re getting three minutes, I am so overwhelmed. I am so busy. And there are days where you’re able to implement it better than others. But when I started thinking about it, and it was in those moments, when I’m really busy, maybe I’m gonna sit down next to the patient and explain their meds to them while I’m sitting down next to them or their family members sit down next, I was like, “I have all these pills, you sort of pills I have, I’m gonna go through them”, explain it to them. 

 

Getting eye to eye level, whether they’re in the bed, whether they’re sitting at the chair, sometimes sitting down. So that’s a huge thing. Listening to them or taking their hand for a second and explaining something to them being like i It is a crazy day to day I’m going to be right back though. That might have been a 15 second interaction, but to them, it’s a long interaction. And I realized that the end of the day, my patients were calmer. They listened to me. They didn’t push their colleagues as often. Because when I told them I was going to do something they felt heard by me and we just it seems like a daunting task. I know because I sat in that little conference and it was like You gotta be kidding me. Oh, you want me to sit down next to me. But I realized it was 60 seconds, even if it’s just 60 seconds, or after I put in all the meds or maybe I’m waiting for something to like pop up on the computer during that time. Then I’m just gonna take a sit down next the patient for a second. “Are you doing today? What is your pain today, so you’re not in any pain. Okay? Great, I’m gonna come back in 30 minutes, and I’m gonna give you your meds,”– just those little words and interactions rather than the really quick and given your assessment, I’m going in and out, and I’m going to be done. 60 seconds, 30 seconds, 15 seconds, it makes a huge difference because the patient actually trust that you’re going to come back and you’re listening to them.

 

Kali Dayton  45:29  

And it takes longer than that to scan it and run propofol and fentanyl or do a double check. When you’re swapping back out. I mean that, you know, haven’t had to bring another nurse in to scan their bags and have them it’s just a whole nother thing to do and headache. But we’re taking away that for the most part. And again, even if it’s running at so much lower rates that it’s you’re not gonna be changing a propofol bag every er bottle every two hours or every hour. And

 

Laurelei, RN  45:59  

it would just be changed out at the 12 hours because they’re just on such a small amount. But like I said, we tried to get them off as quickly as possible. But there were some patients who needed just that little bit because of vent issues, precedents was used a little bit more, which is a little bit nicer, because that helps calm them down without really messing with a lot of their other systems and being able to wake them up easier. But like you said, standing in those medications reaching over, just kind of grabbing their hand, like I am not a touch person. I don’t necessarily love touching people. But I realized there are some patients who was really well with that. So I just reach in, grab their hand and say, Hey, so we’re just doing some meds right now, or blah, blah, blah.

 

 But it’s just once again, acknowledging that they’re a human being, and I’m giving them like, I’m not afraid of them, I’m not afraid to touch them, every time I touch them, I’m not hurting them, right, some of the touches that are happening are positive touches the reinforcement touches. So that’s another thing to to remember that sometimes when we’re going in, we’re actually causing a lot of pain for these patients. And they might have some anxiety every time we walk into the room. So we can make that experience a little less traumatic for them.

 

Kali Dayton  47:06  

And I know that I would be anxious, intubated or not, if I couldn’t talk, I couldn’t communicate. If I couldn’t have some sort of control over my situation, or I wasn’t informed, I would be a terrible patient. If I didn’t have a way to communicate, I would physically act out I would imagine it just out of desperation. And I think that having that human touch interaction, allowing them to communicate, I’ve seen how that just makes everything easier throughout the entire shift. So I appreciate that so much. And now that you’re away for the weekend, walk in ICU. How’s your experience been?

 

Laurelei, RN  47:42  

You know, it’s not so bad. I’m definitely not one of those nurses who goes, “Well my old hospital that I came from…” because that’s one of the most, because I feel like there are things to be done at every hospital, whether they’re the weekend, you know, the weekend walking ICU, or whether it’s just someone who uses traditional more, because maybe it’s just different, right? Yeah, I can learn something from every hospital I go to. So when I have moments where I might be able to “Hey, Doc, I was just thinking this patient seems like they’re doing really well. I your hospital protocols might be that’s what I’m used to doing this. Do you mind if I try that with this patient?”

 

 And a lot of times they look at me and was like, I’m crazy. And some of the other nurses are like, “Oh, you got to be kidding me. You want to try and you know, whatever.” But some people are really like, and even nurses are great and responsive to it. Especially when they see sometimes that “oh, they didn’t need that much. I can’t believe they’re like, I can’t wait, how, how are they off of this and only on this and they’re still behave? You know, they’re still doing really well?”

 

It’s just changing little things without coming in and saying I know better because it doesn’t work for every patient by being able to show and like ways it’s not saying we’re better or worse because each hospital has its each hospital has its amazing qualities, right? They all have their strengths. Yep. And this is just one really unique Quirk. I don’t want to say cardio. This is really unique part to the walking ICU. But it’s it is interesting to go back again and start seeing a lot of patients sedated going back to what you said with a long term sedation and ARDS and just decline in patient status. It is disheartening to see some times when I’m like no, I think we can be doing more for some of these patients. And I’m not saying that we are willfully trying to hurt any patients. I don’t think that’s the case at all. I think it’s just knowledge and understanding that trying something different could be the difference in that patient’s care, even just their progression or the risk of you know, just going back in when where they are.

 

Kali Dayton  49:34  

And there’s so much value that you can bring to the table just having seen what’s possible and what mastery of the ABCDE F bundle actually looks like to provide them an insight into that and given that glimpse that can make a huge impact on a team. And it sounds like you’re navigating that very tactfully but also with confidence because you you’ve seen it, you’ve done it you understand the research behind it. That’s, to me that’s what nursing is. About it’s an evidence based practice and you have the right to advocate for your patients. And I love actually that you’re in a different ICU now bringing that experience to them. And

 

Laurelei, RN  50:10  

I know we’re coming to an end. But when I was in Texas, it was an ICU overflow. They were old rehab buildings filled with COVID ICU patients, it was one of the most heart wrenching experiences I ever had. And I had. I think in that time, I was there for three months, most of the patients ended up passing away. And we had two that left, one of them went home, and one of them went to a rehab. And in the beginning, there were a lot of nurses who would say, we can’t make these patients up, we can’t do this, we can’t do that. And the chance of getting some of these patients and this was Texas has been hit bad. There is an elderly population, lots of comorbidities. 

 

And those do play a part, you know, your age, your health, all of that plays a part in your recovery. It doesn’t mean though, it’s a death sentence. And I had this I got assigned to a patient at 23 years old, but he had been vented. He was a big boy, too. He was obese, which was not going to play well for him. Obviously, his lungs have complications. We were pruning him and during these different things, he started to get a little bit better. But one of the key factors was turning down a sedation, starting to wake him up and having him move around a little bit. But everybody was afraid to turn off his sedation, it was time to turn it off. Because his lungs were at the point where they were healing but his body he lost him was all mobility in his body, they finally put me on this patient. 

 

And I started advocating for him and hard I was challenging people who were not used to being challenged. We even had doctors who were travelers, you know, and we eventually got him extubated, but it took me probably a week where he was on little to no sedation, and they were still afraid to extubate them. And finally, I was like, “We have to extubate him and see how he does that.”   “How is he even awake? How is he moving?” It was probably three weeks after he was extubated that he went home. He had been in the ICU for about six or seven weeks intubated, I just don’t know that if anybody wouldn’t have advocated for him hard that he wouldn’t have eventually fallen deeper into that state of being sick, he could barely when we did extubate, and he couldn’t lift his arms, you could barely turn his head. He wasn’t able to do anything. 

 

PT was not available to me, it was very hard to rehabilitate him. He came in for maybe and I don’t know, oh my gosh, overwhelmed, they had to work a whole hospital system, including it another 60 bed, ICU and this unit. And so we get PT for maybe five minutes a day. And here he is a 400 pound man who I’m trying to try and sit at the side of the bed, I would have helped for my charge nurses. But they weren’t giving him rehab until he was excavated. So seeing these things, it goes back to after that happened. Anytime there was a patient that they thought could be extubated, they grabbed me who was the nurse that grabbed because they’re like, “She knows how to wake these patients up. She knows how to deal with their delirium.”

 

 And it was it was it was an honor for me, I loved that they saw me in that way. But it was challenging also. So I won’t say that waking the patients up is not easy all the time. But waking them up right away, and waking them up six weeks later is a world of difference. The delirium that’s there, the healing process is there, the the ability for them to help you in that situation, sit up move, how their body heals, there’s a night and day between. So I’m not saying that you can’t make a patient up after they’ve been sedated for a long time, that the healing process in their body and their psyche is completely different than when you start in the beginning. And the time you put in is actually less waking them up later, you have to put so many more reasons to they probably will be a one to one, if you wake them up weeks later, and they have all of the delirium and everything. But if you wake them up right away, you just don’t need as many resources and their outcomes are so much better.

 

Kali Dayton  53:52  

Amen, sister! You just got captured so much the podcast are right there. And that’s something that I hope that the ICU community really gets to experience. I feel like this is part of our healing journey, I to recover from COVID,

 

Laurelei, RN  54:06  

this hospital was able to get so many travelers unfortunately, you know, they like many other hospitals were hit hard and lost a lot of staff. But they got a lot of travelers from all over the world who were amazing, high quality nurses, amazing. We work together like we would have been staffed there. What I love is they were able to see this and I hope that they can take that back to their next travel assignment to the next hospital and not come in and say we know something better than you could say I have a different way can I maybe show you a different approach and learn something from the hospital and take it somewhere new also, but also bring something new. And so I just hope that we can Yeah, I mean, maybe that will be the start of something. We had so many travelers so maybe.

 

Kali Dayton  54:48  

I hope so and as nurses are really finding their voices, right they’re really having to fight against the system push back advocate for themselves. And I hope that as they find that confidence and realize their true value and contribution Under the health care system, that this becomes innate, to really propose this, instead of saying, I just have to sedate them, because that’s what was ordered. I don’t know, I’m too scared. But to say, you know, I know this research behind it at ABCDEF bundle, and I am obligated to advocate for

 

Laurelei, RN  55:15  

it, I might have a patient who was stated because they actually needed to, and the next nurse would come in and say, Why are they sedated? That doesn’t happen very often, right? It’s almost like why aren’t they sedated? So it’s like education and the opposite. And it’s amazing. And I actually have a job lined up at that hospital system, again, not at that hospital, which is I’m excited to go back. But it’s interesting to see even in that hospital, how they are different the hospital that we were talking about, and the hospital, I’m going to same hospital system, different hospitals, and they don’t have the same approach, which you think that they would. But so what I’m excited to go back and maybe just try to advocate a little bit more.

 

Kali Dayton  55:53  

I think the hospital system, yep. miles apart, basically, same community, especially during COVID disease process, same level of acuity with the COVID patients, yet the outcomes were entirely different. They had the same ventilator protocols and medication management, same staffing ratios. But they just the process changed everything. And so that’s invaluable. You’ve experienced that within the same community. And that you can attest to the difference in workload and fulfillment and your own preference. And I hope that you go back and say, I’ve walked down the street. What we’re doing here is not what has to happen. We can make this easier for everyone. So even as a traveler be leader speak up, you have so much to offer. And thank you for what you’re doing with your patients.

 

Laurelei, RN  56:35  

Thank you for what you’re doing, because I think it is a very hard topic to broach it’s hard to get people to embrace something that seems so hard, especially when they’re overworked. I mean, the nurses, thank you all your nurses and doctors for what you’re doing. I hear you and it’s hard work. We are overworked. We are sometimes underpaid and underappreciated, but you can make a difference and what you’re doing makes a difference and so I hope that more people will hold and embrace this new theory of medicine.

 

Kali Dayton  57:04  

Yeah, and and just I hope that we learn to work smarter, not harder. 

 

Laurelei, RN  57:07  

Not harder with team collaboration.

 

Transcribed by https://otter.ai

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