SUBSCRIBE TO THE PODCAST

Episode Transcription

Kali Dayton 0:05
Okay, this past month or so has been thrilling. With visits to multiple teams around the United States, big webinar sessions with 1000s of attendees on platforms like Vapotherm, incredible consultations with many of you revolutionists, and even more surprises that hopefully, I’ll be authorized to share in the upcoming month.

This episode addresses a lot of common concerns and questions regarding how to improve patient comfort. When we have patients awake, we are now more aware of the need to help them be comfortable. Please check out the transcription for this episode on the website. And then you will find a link to a toolkit from Johns Hopkins to help patients tolerate the endotracheal tube.

One of our exemplary podcast listeners that has advocated for this process of care for her patients for years, has had a very personal experience that she was willing to share with us.

RN/Podcast Listener/ICU Survivor 1:44
Hi, I’m an ICU nurse who has been listening to Kali’s podcast for a while. I was a staunch advocate for sedation and making sure that my patients were not in what I perceived to be any pain or distress on the ventilator by keeping them knocked out. However, after listening to Kali’s podcast for a while, I started implementing a lot of her teachings into my own practice. And ironically, it did come full circle last summer.

For discretion, I’m not going to disclose too much of my own health information. There are various reasons why I would like to keep part of this private. But I had to have an emergency surgery.

And I’ve recorded this a couple times. Because I don’t think that I can really describe or adequately explain how terrifying it was to know that I was going to be on a ventilator for any period of time.

I have seen people come out of the OR intubated and unable to extubate for various reasons. And with my new knowledge of how dangerous immobility and oversedating your patients can be, and how many providers are still under the idea that sedation is what’s best for the patient. I was so scared that I was going to lose my agency.

I started feeling like I was almost in a horror movie where everybody’s seen those movies where there’s someone who’s locked up in a hospital or like a psychiatric facility who is sane, but nobody believes them. And they can’t get out and they can’t get help. Because nobody believes them. And that was kind of what I felt like I was like, “Oh my gosh, what if I’m trying to write in my nurse doesn’t want to listen or what if I tell them I don’t want sedation and they sedate me anyway?”

So before I went into surgery, I explicitly stated that one I did not want to be induced with benzos. I didn’t want any versed, Ativan, whatever.

And to that unless I was not tolerating the ventilator for some sort of pulmonary reason that I was not to be sedated. And I knew this could be something that was potentially uncomfortable or traumatizing to me, but at least if I changed my mind, I had the option to communicate with my providers that “Hey, I would like to take some sort of sedation at this point in time.”

I almost made myself a DNI I was that close because I was so scared that I was going to end up sedated even though I didn’t want to be sorry. Um, but the staff that I had after surgery was incredible.

I think that three weird things that like people may not think about when they’re working with ventilator patients that have I have learned was:

1: when you’re switching your E T to position because you know how you like, rotate it from center to left right to prevent pressure injuries. Don’t push the ET tube to the like complete side of their teeth, right like don’t push it up against the corner of their mouth. Because it actually gets pretty painful. And if you push it too far to the side, it actually kind of lays on your gag reflex for lack of a better word.

2: when you have a patient who is intubated, I know the ventilator associated pneumonia bundle says 30 degrees, but 30 degrees isn’t high enough. Having your head forward and like an a neutral alignment of your neck and spine is so important because if you’re at a true 30 degrees, you’re going to feel like you’re choking.

3: Sorry, I wrote these down, making sure that ET tube placement is correct. I know like three or four centimeters above the carina doesn’t seem like much. But I am five foot three. Okay, three or four centimeters above the carina. I could definitely feel it. I absolutely could feel it. And it was super uncomfortable.

One I one thing I noticed that my nurse did. That was super helpful. Actually. I know there’s this huge scare regarding fentanyl and opioids in the news. But treating my pain was really….. when I say it kept me sane. I mean that in every literal sense of the word. I didn’t have an option with analgesia, my nurse just asked me how I wanted to treat my pain.

She just assumed that pain was going to be there. Tylenol was an option. And she actually initially started me out with a very low dose fentanyl drip. And you do feel like you’re breathing through a straw at first getting used to that is definitely like an adjustment.

However, the like the perceived air hunger that I had with feeling like I was breathing with a straw was definitely almost immediately gone with like 25 micrograms of fentanyl an hour.

The other thing that she did was she let me sleep on my side. She taught me how to yank her suction because I know like, I’m an ICU nurse, but one I am not familiar with every hospital’s equipment and to the second, it’s you all of your ICU knowledge just goes out the window you just turn into like that first year nursing student and you feel stupid, but it’s scary.

So she taught me how to use the yankauer to actually like suction around the ET tube and she let me sleep on my side. And I’m a side sleeper and actually helped me keep the extremity that I had surgery on elevated during that time as well.

And when I tell you that helped so much. One, with my pain. And two, with just being able to sleep. I was so scared. But after about a week, I was out of the ICU and getting ready to go home.

The other thing that I would say is like, it’s boring.

I am someone who’s also had to be on antidepressants and ADHD medication for a few years. And I understand that restarting all of those things in the ICU isn’t always feasible. But my treatment team made it a point to restart me on my mental health medication and they couldn’t restart me on my extended release ADHD medication while I was on a ventilator.

However, they did give me a midday dose right before I work with physical therapy of an instant release. And I had a little bit of a precedex going at one point in time, because it is it’s terrifying. You’re wondering if you’re going to die.

And a lot of times we forget that our patients are just sitting in those rooms by themselves for more than 12 hours at a time in a day.

So kind of keeping me busy. And I’m not someone who watches TV. So like they got me crossword puzzles. They made sure I had my phone. I was able to listen to podcasts, I was actually crocheting.

But just making sure that I wasn’t left alone to my own thoughts and my own devices also really helped.

The one thing I’ll say it is so much harder to undo delirium that has already happened. You know once you’ve given those benzos.

So I know Kali’s talk about how much an increase increases the risk for delirium immediately. But undoing that is so much harder than just taking an extra 30 minutes to an hour. Like it doesn’t have to be a nurse in the room. It can be a tech, the Secretary sat with me at one point in time. And I know not every unit has a secretary, I know that not every unit has a tech.

But just even a chaplain is just someone to sit with you for 30 minutes.

While you’re kind of adjusting to that vent, while you’re kind of like waking up and realizing where you are. It’s so much easier than having to reorient someone after they’ve gotten benzos.

I know a lot of nurses who say that they would want to be intubated, sedated brass of negative four if they were in the ICU, and I don’t think they’ve ever had to consider being in the ICU.

And I don’t think that what they perceive the ICU to be as a patient is necessarily accurate.

Because I felt like I had agency and I felt like I was safe in the human right to communicate is so important. You know, I wasn’t going to wake up a skeleton with a stage two or stage three to my sacrum. I was going to wake up immediately after surgery.

I had support. I had a say in my treatment, my pain was treated aggressively and adequately. And I was I they made sure I needed I got the sleep I needed.

So like having come full full circle, I just cannot express to you how important it is. And I know that nobody expects to be on a ventilator, but be prepared, have documentation have things ready, like for the very, very worst case scenario. Take on the challenge of making sure that you’re awake, you know, and do that for your patients too.

Kali Dayton 12:15
For this episode, by request, we’re going to have a question and answer with Louise Bezdjian, nurse practitioner, and one of the founders of the Awake and Walking ICU. We will shoot the breeze in all things pain, agitation, and even withdrawal. Stay tuned for more episodes coming up diving deeper into alcohol withdrawal, and phenobarbital.

Louis, thanks for coming back. I think this is your third episode on this podcast. I’m so excited to have you and there’s so much to learn from you. And I asked him questions on social media. And we’re ready to learn more from you.

On Instagram, some of the questions asked about the approach and the weekend walking ICU was about the intubation process. And this is a common question that I get even during webinars.

A lot of people want to know, what is used for intubation as far as medications for sedation. How often are paralytics used? What do you do if a patient is given paralytics?

And then when do you take sedation off? And how do you handle the patients when sedation has taken off initially?

Louise Bezdjian 13:26
I think one of the most important things that if you if if at all possible. And you know, I don’t know how many times you have a patient has to be marginally intubated. But prior to intubation, I take the time to to tell the patient that they will go they’re going to have a tube in their throat. That’s the size of a big straw. And they can’t, they can’t, they are not able to talk and it’s very uncomfortable. It will feel like they’re breathing through straw. But if they if they just let us work with them, they they’ll be you know, they can acclimate to the tube. So, so that’s before the intubation.

Then, you know, I think the medications that are used vary but with rapid sequence intubation. So they’re getting succinylcholine and then some, I you know, I think sometimes they use ketamine and sometimes they’ll use a little bit of fentanyl as well. And or it’s accommodate and fentanyl. Okay, those are the medications that are typically use but I think this question that I looked at it had a rapid sequence intubation we will which would be that they will probably use a paralytic.

And so then the patient, you know, is starting to move around and there and what I’ve noticed is that they’re, yeah, their blood pressure is elevated and they’re there. They’re tachycardic and they’re tachypneic, and it’s because they’re still paralyzed.

Really, and they and they feel it and they just don’t like it. And so at that point in time, I like to give them maybe a milligram of Lorazepam or versed just to as an amnestic, just for them to not remember this experience that they were paralyzed, but they couldn’t, they couldn’t. I mean, they couldn’t communicate, but they were awake.

And that’s a one time dose. And then when they wake up, we then we talk to them again. And if they’re, if they’re on a high oxygen,

We use fentanyl, as a drip, I will bolus maybe, you know, 50 mcgs, or 25, mcgs. And then and then started drip, if they’re on high high Fi02. And then as, as they call it, and I would say that, you know, I can remember very many times that this hasn’t worked. And then so the fentanyl and then we just keep, you know, I mean, we ask the nurses to, you know, this is gonna take an hour, an hour or a few minutes of your time, but this will be worth it on the front end, because on the back end is going to be beneficial for your patient.

And so that’s basically what we do. And we find that fentanyl, and I think there is some evidence that fentanyl is the the medication of choice to influence the respiratory drive, and they’re there to keep the work of breathing and all those kinds of things. So that’s what we do for our patients. If you don’t have time, then what you can still take the time afterwards to say, you know, “We didn’t have time to tell you this, but you have a tube in your mouth, blah, blah, blah.” And just the same conversation before and after the intubation that you do. And then the I find that, unfortunately, people don’t want to take the time to just spend the time.

Because Because we in health care, especially in the ICU, we want to see, especially someone’s agitated, we want to see immediate results, we don’t want to take the time to see if we can talk the patient down and treat the patient like a human being, instead of just turning their brain off, and then turning it back on.

That’s what I call sedation, you’re turning their brain off. And then you’re and then even I mean, I don’t like this nation vacation piece of it, although I’ll take it if their practice is typically to just keep them sedated. I’ll take that taking a sedation vacation. But I don’t want to do that. I don’t want to start that.

Kali Dayton 17:48
Absolutely. I was at a presentation at an AACN conference and talked about my experience as a travel nurse having to do sedation vacations, and I was taught that you just turn on sedation enough to see them start to thrash, and then you turn it right back on. And that’s how you quote, “know that they can’t tolerate the ventilator”.

And that was really confusing to me, because I didn’t understand the purpose of it. I could still couldn’t do a full neuro exam. I didn’t know why they were agitated. And so for this oriente nurse to tell me that that thrashing was because they couldn’t tolerate the ventilator. Yet I had come from your ICU, where almost everyone was, quote, tolerating the ventilator.

They were calm, awake, cooperative. It hadn’t really crossed my mind, the ventilator alone would cause that level of agitation. And that was when you know, early in my career, I hadn’t totally put together the pieces of delirium yet. And I came to really dislike awakening trials. I was doing them at five o’clock in the morning in a dark room by myself. I was tired, I was delirious at the end of my shift. There’s no family, everyone’s hurrying to try to get everything squared away by the end of the shift. And now I’m unleashing this beast.

It didn’t feel safe, it didn’t feel productive, and I ended up just restarting sedation, because that’s what I was trained to do. I didn’t know what was going on. I don’t think that was the purpose of the wakening trials, initially.

But that’s what it culturally has turned into. So that’s what I really appreciate. Then later, going back to the Awake and Walking ICU after doing travel nursing, and not having to do wakening trials anymore. Not having to turn down sedation with my fingers crossed waiting for the patient to come out into this storm of agitation. It’s a different experience, allowing the patient to wake up shortly after intubation. And we talked about using succinylcholine.

My experience it’s pretty rare that that’s even used. Usually we’ll have it drawn up, ready in case it’s needed. But paralytics are not given every intubation and then as for Lorazepam, I don’t think I’ve ever ordered that or ever given it. But those are good like a small one time dose in case there is hypotension after intubation, that’s just to make sure that there’s no awareness.

We always have to remember that there’s a difference between prolonged sedation and then a brace sedation. So, you know, pre op, they often give a little bit of versed. It’s not a drug that I’ve ever been given an Awake and Walking ICU as far as especially for a drip. But that is a tool available in case we have hypertension, and we have ongoing paralytics on board, those paralytics last an hour, right? Yeah, you’ve got to give the, you’ve got to give the patient time to metabolize that medication. And so, you know, you’re doing, you’re doing the intubation. And they do they do they do a cut because some of the other medications aren’t as long acting is as and I think typically the medication that they use it in less potassium is higher succinylcholine.

Louise Bezdjian 20:55
But I think of succ….

Kali Dayton 20:59
or Rocc. I interviewed Catherine, way at the beginning of the podcast or pharmacist there. And she mentioned giving a smaller dose instead of one meg per gig. Oh, yeah. 0.5 and shortening the duration. And she was amazed and impressed how effective that was. That it didn’t last as long as the rest, we didn’t really have to start anything. And that was that was safer and more productive.

Louise Bezdjian 21:27
Yeah, I think the it’s interesting. I mean, a lot of my physicians that I worked with etomidate and fentanyl. Yeah. A few that that just, you know, wanted the rapid sequence. And so they would do paralytics. And, and so the nurse would come to me, and they’d say, you know, and I think you have to recognize that, that hypertension, tachycardia, tachypnea is because they are still paralyzed.

And I think people just say, “Oh, this is agitation. I got to sedate them.” So no, you know, use…. I consider versed as…. I don’t like it. I don’t, it’s not my “reach for that drug”. But, but it’s good for procedural sedation, and I consider intubation as a procedure. And that’s and Lorazepam has a longer acting, and longer half life. So that’s why I, you know, sometimes I think, well, you know, just just you just give him a little bit of her said, just one, one milligram and then just let this paralytic wear off.

And then, but if they have some kind of a renal involvement, then I probably use Lorazepam. Because you just you it may take them longer to process the medication. And then I think that was basically it.

In fact,one of the physicians actually texted me and asked me, you know, “What about, you know, what about these people that are just anxious?”

and I think this is really unique to COVID, more than I more than during my career, that I noticed this, but when people were intubated with COVID, they were terrified. And I think it’s because they were, I mean, they listened to the media stuff about, “oh, if you’re on a ventilator, you can count on dying, if you have COVID.”

And so, so I asked him, I said, “Is he just scared because he’s intubated and he has COVID? Talk to him. Talk to the patient.” And he’s like, “Oh, I didn’t even think about that. I will.” And then he came back and just said, “That was just the right thing to do.”

You know, I mean, you don’t know that they’re gonna…. you don’t know how they’re going to do. But you can just say, “We’re doing everything we can that you can get better.” Because then you’re not making any promises that that, you know, may not it may not happen. You’re just saying, “We are doing everything we can to help get you better.”

Kali Dayton 23:53
And I think we we know that being intubated is uncomfortable. We know. It can be scary to be in the ICU for whatever reason, but especially to be intubated, and especially with COVID. But the fact that communication was not one of the innate tools used, is really painful for me to hear, right?

In many ICUs. You talked in your last episode about your own family member who did not have zoom available? That wasn’t even an expectation to have any kind of connection with family, but then a lot of ICS don’t even have clipboards in the room, there is not an expectation to communicate.

So, one of the big questions asked in a few of the webinars that I’ve done actually is: “What do you say to the patient after intubation?” This is a real inhibition that people have. It’s a skill set to be able to talk to patients, and a lot of times providers are not comfortable explaining or walking patients through this process, especially when it’s a new process for them. They’re not used to patients being awake, they’re not used to expecting them to communicate, they’re not used to working them through those fears.

So, what are some of the most effective ways to communicate and things to address with patients when they’re first waking up after intubation?

Louise Bezdjian 25:08
Yeah, it’s, it’s interesting, you should say that because we almost we almost entertained the thought of just writing a script for people to just say, “This is what you say.”

I said, “Just describe to them what’s happening. Describe to them that you’re unable to, you know, independently support your lungs. So we are going to intubate you, we will put a tube in that goes directly into your trachea. And it will. And what it does is it minimizes the work of your of your lungs, it will do the work of your breathing for you. What you need to do is try to relax and we’ll help you do that. If you feel anxious, we will give you some medications for that.”

Which we use clonazepam for anxiety.

Kali Dayton 25:57
And then low dose like for outpatient, right? Like point five milligram.

Louise Bezdjian 26:02
It’s not even the doses that the psychiatrists use, it’s 0.25mg. Now, if they’re on clonazepam at home, we try to use that medication but at a lesser dose than their home dose. Because we think when people are critically ill, their ability to metabolize medications, and I can’t prove this, so don’t ask me to, but we think that they require less, because we’ve seen the effect of how it’s just some medication will snow them over. Right after that they will take it home. And we just don’t think that that sage so we, you know, and it takes some thought and effort. But But what are you there for?

Kali Dayton 26:43
It is easier to just start a drip at a standard rate. I see some team that they set the propofol even really high right away. It’s almost like COVID numbers in our heads. And we think that that’s what patients are going to go into need. And then there’s something or norepinephrine on top of it. Yep. And despite because some teams say, “No, we would never start a vasopresser to compensate for sedation.” And other teams will say, “Well, of course we do. You have to because you have sedation.”

Louise Bezdjian 27:13
That team was telling you they don’t, they’re lying to you. I mean, it’s just, you know, I’m sorry. I shouldn’t call anybody a liar.

I think you…. In fact, I’ve asked this, I’ve asked this in rounds. I said, “It’s so interesting to me. I said, we’re all smart people. So why are we starting a medication? Because there’s a side effect of to treat the side effects and the medication that we don’t need to use. Why are we doing that?” And they just and there’s no one can have a response from me. I said, “No, you’re putting somebody on propofol. I mean, I think that recommendation of the drug manufacturers recommendation is MAX 80 mcg/kg/min… And we’re starting at like 60 or 70. And it’s like, wait a sec, what are you doing? Why do you need this?”

Kali Dayton 28:14
We’re not really assessing for need, I think especially when someone calls this “COVID-care”. Everyone’s been taught this COVID care, you start these high sedatives because you assume that’s what they’re going to need because now you’ve treated all these patients with the same diagnosis and you’ve treated them the same way. And now that’s pouring into other patients.

But the aim of the ABCDEF bundle is assess, prevent and treat pain. You cannot do that if you automatically sedate them. How do you see? How do you see manifestations of pain, signs of pain? How do you ask the patient what kind of pain they’re in you talk about giving fentanyl? boluses and even a fentanyl drip if needed. Why Why don’t we start these things slow? And ask the patient what they need and help the patient allow the patient to be involved with it. And titrate up as needed. Instead of automatically masking any signs of any pain or discomfort.

Louise Bezdjian 29:13
Let me ask you this. Were they in pain when they came? So okay, there they were not in pain when they came. They were short of breath. They were hypoxic. So what’s pain? Is the ET tube causing pain? Or is the ET tube causing anxiety?

Now look, if you have a surgical patient that comes back intubated, you better treat that pain. I’m not saying you don’t treat pain. And our our intent when we use fentanyl is is really to to suppress their respiratory drive. It isn’t to say “oh, look, look, he looks like he’s in pain.” I mean, just because someone grimaces doesn’t mean they’re in pain. I mean, I’ll grimace Sometimes when my arthritis acts up or something, I don’t know.

But it, you know, and I’m like, No, I, if pain is a perception, if they cannot tell you if they’re in pain, then I don’t think that you say you, then I don’t think you reach for your opioids,I just don’t.

Kali Dayton 30:18
And what, I think you’re really good at treating pain, and use a lot of other modalities to treat pain before getting to opioids. I’ve never seen you really deprive patients of it. But you make sure that you’ve tried everything else first, and you have continuous coverage of these other medications. So tell us kind of some of your approaches.

Louise Bezdjian 30:36
Yeah. So if if someone comes in and and they say they’re reporting that they’re in pain, what if it’s especially, I think the challenge, the challenging patients are those with chronic pain. And so what we’ll do is we’ll do Tylenol scheduled every six hours, and we’ll use will typically it was like 650, or 500, extra strength. And then And then so we’ll do that every six hours scheduled. And then you, you know that one of the first things in fact, I made a note to do this, is you make sure you have an MFT. Put a feeding tube in.

Even if you can’t get into the small bowel, even if it’s in the stomach, then you have a way to give them their medications instead of IV medication, I think IV medications give you this zigzag effect. So you have relief and then and then they bought them out. We even bought him out and with his Tylenol. And then the other medication we use that we don’t think is synthetic is Tramadol. And so we’ll do Tylenol, it’ll be six hours and our Tramadol every six hours. So every three hours, that patients getting something.

And even if even if it’s…. sometimes I think it’s just a…. I don’t want to say placebo- because it’s not a placeb. What is the effect of they know you’re giving them something for pain every three hours, they’re getting something. So for them, it may even be that they’re relieved that some we’re doing something about their pain. So typically, that’s what we do.

And if they do come in with…. we’ve had some patients that had been on high high doses of opiates, we’ll start them, like I said, less than their home dosing. And then and then over a three or four day period, we’ll wind them down to a dose that we think is like they seem comfortable, they don’t have any, any vital sign manifestations of being in pain, or you know, there’s not any tachycardia, tachypnea, thrashing around.

And then just just really an end, some of these people that go through that, again, the pain medications through a pain clinic will sometimes call them and just say, “Hey, you know, this is what we did. And you might want to try to wean them off of what they were on at home. Because I mean, those doses are our big doses.”

Kali Dayton 33:02
Yeah, I think I learned a lot from you. As far as looking at the big picture, you pull up their

Louise Bezdjian 33:08
DOPL.

Kali Dayton 33:10
You contact us outpatient providers, and I think you’re really good at collaborating with pain management, seeking out other perspective is perspectives of pain is not easy to manage. Before sedating them, and taking away their ability to tell us that they have pain.

We know that CPOT certainly has a role. If patients are unable to report their pain, we do need to assess for physical signs of it.

But I take your comfort in knowing directly from the patient whether or not they have pain. And so that is an option. Unless there’s an indication for sedation, we should be asking patients what they have what they need. I like how you use oxycodone on top of that. So I’ve noticed that Tylenol, Tramadol, that that often decreases the need for opioids on top of that, but then giving off the code on doing something that’s longer acting for those patients that don’t have hypotension or concerns or contraindications for that. That decreases the need for higher dose IV pushes.

Louise Bezdjian 34:15
Yeah, and let me and then and then one other thing I want to mention with that is, and then when we get them up, and they’re and these are people that are hurting, we will give them again, fentanyl, procedural doses 25 to 50 mcgs because I want to get the most bang for my buck.

So I want I want to be able to have them walk as much as they can as far as you can. And so I’ll give him something like fentanyl, just a fast acting that doesn’t stick around for very long and and then and then have him go for a walk. Absolutely. And it seems I wish we had studies on this. But what I’m hearing from survivors is they even just being bedridden, especially during the process like sepsis, all the inflammation that settles into their joints, their back.

Kali Dayton 35:00
That is a cause of pain to be stuck in the same position. We heard in the audio clip from a nurse that’s been intubated talking about the position of the tube, impacted her comfort with it. But she’s able to communicate right on the board, tell them what she preferred as far as where the tube was located. And that changed her tolerance. Fentanyl helped with her air hunger, and then she didn’t need it later after she acclimated to the tube.

So I think when we’re embarking on this process, though, there’s lots of fear, I think we can take a lot of comfort and confidence. And knowing that the patient can be involved in that we don’t have to guess like, we are guessing when patients are sedated. And that we can really customize this in collaboration with the patient. And I think once we get gain experience with having patients that are communicative, helping direct their own care, we can see that we can make them comfortable without knocking them out. Then we started having more comfort with this process and that expertise.

Louise Bezdjian 36:01
The other thing that I think, which is really interesting to me, people with chronic pain and and I mean, there are many patients that we’ve seen that have chronic pain, there’s this anticipated pain. And so when we say “We’re gonna give you something so that you don’t hurt when you walk”- that seems to alleviate that anxiety, or that anticipation, or I’m gonna hurt or you’re getting me up, you’re making me move and so that that makes a difference as well.

Kali Dayton 37:39
Absolutely, and yeah, that’s sometimes that’s not the reward. But I mean, they will say “I can’t get up until I have this” and to say, “We are eager and willing to give that to you.” We’re not, we’re not trying to withhold your pain medication. We just want to make sure we give it in the right timing to make sure that you can get up and, and function. And so I mean, you don’t have to make a patient comatose because they’re hurting.

Louise Bezdjian 38:03
I mean, you know what, “Hey, you’re in the hospital,”- especially the surgical ones. It’s like, “You know what, you just had surgery. So let’s make the goal for your pain level between four and six. Okay.” And then and then the chronic pain, folks. “So where was your pain went? What level was your pain when you were home? An eight. Okay. Well, so what is it today? It’s eight. Okay. So you can live with that eight at home? Yes. Okay. Well, let me give you some Tylenol that.”

Because it’s not different. I mean, there may be some emotional component to right. But but that’s not something I’m going to give away with it I’m going to deal with with a drug. I just don’t think that that’s the right thing to do for that patient.

Kali Dayton 38:51
Absolutely. And, and working with the patient to say is this, “How much of this is pain, how much of this is anxiety, fear, boredom?”

And I appreciate using Klonopin, just even those low doses, especially the low doses for patients that don’t usually take any benzodiazepines at home. Just to that take the edge off. And I appreciate that the team is so masterful at assessing RASS. That, as a nurse practitioner, I don’t really hesitate to order those things, because I know especially with most of the nurses that they’re going to hold that medication at their RASS is less than zero.

They’re not going to oversedate them. They don’t want them to be knocked out. But the patient can tell us if that has helped their anxiety if they need more, if they need less. It’s really nice to be able to a true assessment of what they need and give them what they need. Right and I think the the sooner the sooner the patient mobilizes, then the less there is of that achiness and pain from just laying him back.

Then you’re creating this person who’s so sore because they’ve been laying in bed all day for three days, four days, five days. If you I mean, we have had instances. I think that’s this is a, this is our practice is they may be intubated in the morning in the afternoon, we get them up and walk them hours after.

Louise Bezdjian 40:19
There is no need, why why do you need to give your patient a day? Why?

Kali Dayton 40:24
So that we can lose that lose another 2% body or muscle mass?

Louise Bezdjian 40:30
So I mean, somebody Oh, he just got into it. I said, “Okay. So…he got intubated….And?”

“Well, I think he just needs a day off.” And I’m like, “No, no, he doesn’t need a day down.”

Kali Dayton 40:43
I was working with a team in Denver, and the this patient came in with a hypercarbia from COPD exacerbation. And they initially started sedation and granted, this team had made a lot of progress. The sedation wasn’t very high. I don’t think they wanted it to be on forever, but they still had started a propofol drip. And that could have cost him days of immobility. So I simply asked the question to the nurse, “What is his indication for sedation?”

And she was a really good sport about it. I mean, she wasn’t defensive. She just said, “I don’t… I don’t know.” – Like it was just it was a new question. It didn’t cross her mind. It was just a habit. The physician wasn’t there, I would have asked them as well. What is the indication for sedation and so we worked on weaning it down and he came out a little bit groggy, and he had hypercarbia- he was obtunded when he showed up. He wasn’t going to come out thrashing initially until the ventilator had helped clear that out.

So he was still a little bit groggy, and but we sat him up, and he started to answer questions open, his eyes started to write on the board. He was wheelchair bound at baseline. So we use a lift and got him up to the chair. And so then they were doing rounds, the team had just intubated him. This is about two hours after intubation. They were doing rounds came by his room, and he’s waving, giving a thumbs up in his chair. Nice. And the look on their face as a shock. You could tell it was it was a paradigm shift that in their minds, they’re saying, “Okay, we’ve just intubated him. He was just obtunded.” But how do you know at that point, if the ventilator is doing the work of of clans that hypercarbia unless you have those initial signs of neurological restoration? Or do an ABG.

And at that point, we could tell that his hypercarbia was improving because we didn’t have them sedated. He could tell us what he needed. And he was okay.

Louise Bezdjian 42:44
Nice. That’s good. Yeah, I love hearing those kinds of stories.

Kali Dayton 42:49
and I have seen that in that Awake and Walking ICU. There is also downtown by a drug park. There’s a detox unit down the hall. We get patients from all over that have a lot of drug abuse. So what do you do for those patients? That’s a really common question. I hear, “Well, we have a lot of drug abuse. And so these patients have to be sedated.”

Louise Bezdjian 43:17
So I think if this is going to be patient specific, so if your patient is an opiate addict, we would use, in fact, I think this is this is actually from the SCCM recommendation, we’ll use methadone. And the thing that you have to know about methadone is initial it’s got a really long half life. And as you do oral doses of methadone by day five, four or five, the half life is 60 hours. So you’re building up with your half life. So initially, maybe you you know, the first day maybe you start with 10 milligrams twice a day.

In addition to like some oxycodone for breakthrough, if they’re intubated, they can’t talk, then you, you would just use I would, I would, I would stay away from IV doses of medications for the addicts, because that’s giving them the initial high, and then they’ll just want more and more. And so we do methadone, and then we’ll do breakthrough oxycodone for them.

And when I’m talking to a pain clinic, because I’ve actually called them about a patient that we have of theirs. They really that clinic did not like using oxycodone, they said it’s the most addicting of the oral medications, and that they like they like morphine. They use morphine.

Now, I didn’t, I didn’t go to morphine. I, it’s just I’m familiar with oxycodone. And I figured, you know, five. And this is a controlled environment, right? I mean, I’m not sending this guy at home, with oxycodone, I’m using that in my, in my hospital. And then, and then we let, there have been times, many times when we’ve, like, we’ll call the pain clinic and say, “Hey, this is what we’ve discharged them on, it seems to have been managing their pain, and this is when they’re sick. So, you know, we just want you guys to know that you can probably use a lower dose. So so for the for the opiate addicts, we use weaning doses of methadone.”

And then just weaning doses, I mean, you know, you know, you’ll do two to three days of a dose, and then decrease it to three days of a dose and then decrease it until it’s just maybe minimal. And I would not completely take them off any opiates. Right? Because these are people that I mean, they’re coming in as, as opiate addicts and then refer them to a pain clinic or primary care to take care of, but if they’re, if they’re street users, I would, I wouldn’t send him with anything. Because they’re gonna go back on the street and do whatever they want, anyway.

Yeah. And then, and then you want me to talk about alcoholics?

Kali Dayton 46:26
Yeah, that’d be great.

Louise Bezdjian 46:27
Yeah. So yeah, I think for alcoholics. And I’d say, you know, this is towards the sort of towards, like, maybe the last year or two, I’m loving using phenobarbital. And so if the patient’s intubated, and one of the first things I do is get a feeling to put in, and then there is IV, well, we use IV, phenobarb, it just has such a long half life. But underneath that, I we will use some librium.

And so because you’re not, they’re not going to be forever on on phenobarbital. And the advantage of having phenobarbital and and librium is that if they do have alcoholic seizures, withdrawal, seizures, you’re covering it, you’re covering with phenol balm, and you’re covering with librium. And so then when when you’re done with when you know they’re cooperative, they’ll tell they’re, they’re telling you my withdrawals, better, I’m not feeling like I need to have a drink, then that’s, that’s when and these people, most of them that come in are, you know, they have affected liver, liver and liver injury.

And so you have to be careful with librium dosing. So this was recommended to us by our psychiatrist that you do 50 milligrams three times a day, every eight hours for the first two days. And then for the for three days, after that, you use 25 milligrams every eight hours, three more days, and then and then reassess, and see. And so for them, phenobarb’s has really has become a drug of choice. And what we do is we do, we don’t do the big loading dose, I mean, sometimes these guys are pretty big, and we’re not going to give him a gram of phenobarbital. So what we’ll do is we’ll use a 130.

And then if that doesn’t seem to be effective, maybe in in, in a little me, I don’t know, 20 to 30 minutes, we’ll give them another dose. But I don’t go much higher than, like, three 390. I do three real quick hits. And then I’ll just say, You know what, let’s let’s just get that librium started, because then the librium can kill while the phenobarb beginning to take effect. And that seems to just work really, really well is kind of funny, the, the psychiatrists, so our, our hospital is a referral center for Psych patients.

And so so they come in for detox and those kinds of things into this psych unit. And then when those people that are detoxing from alcohol are unmanageable, they’ll send them to the ICU. And it’s interesting because the psychiatrists will say, “You guys bring these people back from the dead”, you know, the way you is, they applaud our treatment for alcohol withdrawal. And this I mean, we came to this mainly because you know, what?

The ICU the practitioners on it, I mean, we’re around that patient 24/7. So we we realize we see what they do we see what they need, and so we just go from there. And we’ll just say you know what, this is just you and if we need to use increasing doses of librium. We will, but I think we just we kind of weighed out the phenolbarbital issue, because librium also does help with it. sedates a little bit and it helps with withdrawal.

Oh, and if they’re extremely wild, and the phenol hasn’t kicked in yet, then we will do dexmedetomidine. And as long as you have the phenobarb and librium on board to cover for the seizure threshold, and is great for those other symptoms. And it doesn’t take it won’t take much of a dose. And the other thing about that, that’s nice about precedex too is sometimes we’ll just put it on at night.

Because not to get sleep. I mean, you we may create delirium in a patient if we don’t treat their sleep. I mean, get them to sleep. So, so we make sure that these people are sleeping. I mean, as much as we can tell. I mean, we don’t have

Kali Dayton 50:46
We know that precedex is as close to sleep as as you can get essentially much closer than propofol and especially if any benzodiazepines. Precedex has the brain activity that’s closest resemblance to sleep. And I think there’s so much value in having something that’s longer acting like librium.

Louise Bezdjian 51:06
much safer as far as not suppressing their respiratory drive. Like if you know phenobarbital, and you don’t get these highs and lows like you do with ativan.

I remember, I don’t know 10 years ago, getting patients from the floor patients from the detox unit that were getting this seawall protocol with Ativan. And it was such a nightmare. They come out, so agitated, so confused, so delirious and just the peaks, the highs and lows.

Kali Dayton 51:33
From a nursing perspective, it’s extremely dangerous, laborious to try to chase after that, then you end up overstating them. Their aspiration risk, the delirium that happens then lasts for days to weeks afterward, the weakness that develops while they’re over sedated with Ativan, it’s all just a mess. And I remember a patient that was intubated because she sees it home during an alcohol withdrawal came and we had her on a propofol drip, and I was able to start librium and then we offer propofol drip and get her extubated. While she was still withdrawing.

That’s not always the case, but because it just it’s so customizable for each patient, and it decreased her risks drastically. But I think if she had stayed on a propofol drip that entire time, how different her outcomes and her journey would have been, right?

Louise Bezdjian 52:21
Oh, yeah, well, you would be. And that’s the thing, you can’t always have that. When, I mean, there are some physicians that will want to intubate and just put them on propofol. No, no, we want to intubate them and put them on propofol for three days to get them to their withdrawal. And that’s it. And then who, who deals with a ventilator associated pneumonia they get? Who deals with that?

Then they’re laying in bed, they’re not doing anything. I mean, all those all those secretions pooling around that ET tube, they get that micro aspiration. And then there you are. And what I’ve noticed sometimes, too, is, it’s like,ask your physician, at what point after you’ve used 40 milligrams of Ativan? Do you think, hey, maybe this isn’t working? At what point?

Kali Dayton 53:14
Well, when you have the CIWA, t’s almost like, there’s no need for reevaluation maybe once a day, you know, protocol, they don’t have to call me anymore.

Louise Bezdjian 53:24
Or see what our protocol says, after you use 200 milligrams of Valium. Maybe you should consider using something else. I mean, I, I was like, I’m not using Valium. So that. So in fact, I said to one of the developers of that product, I said, “why?” I said, “Can you just take them out?”

I said, “Really, you want someone to use 20 milligrams of Valium with its with his metabolites that deposit ounce in fat, you really want to use that?”

But, you know, I don’t have a big enough voice. But there’s another. So what we’ve noticed sometimes is when people have like people will come to us that had been getting Ativan for alcohol withdrawal. Not only do they have alcohol withdrawal, then they also develop delirium from the ativan. And so we avoid that as much as we can.

Kali Dayton 54:13
You and I have worked together on a case study where that delirium continues to be treated like alcohol withdrawal, so they continue to get benzodiazepines, even when they’re far outside the window of withdrawal. And it can be lethal.

Louise Bezdjian 54:28
Yeah. And there’s another there’s a complex if you’re patient, you know, you can tell you use your views your gut, use your gut, when you’re the person taking care of the patient. If this looks like it’s more than it’s more than just alcohol withdrawal. If this looks like a psychosis, you might benefit from using a drug like Zyprexa. And what I do is I practice and this is just during their hospital stay, and if they do have any issues then we bring in psychiatry to just come and talk to them. But but in the in the acute phase, I will take I will use Zyprexa, five milligrams every six hours the first day, because it does also has a long half life.

So I’m kind of giving them a load five milligrams every six hours. So he gets 20 milligrams the first day, and then I decrease it the next day to five, twice a day. And then And then my last my nurse to just say, you know, assess that. And if it’s too sedating in the morning, they will just give it to him at night. And so we go from four to two to just one. And he seems to just manage that psychosis and to and to the point where we can at some point, discontinue it.

Kali Dayton 55:44
Right, and that’s specific specifically for psychosis. You’re working with psychiatry on it, and reassessing for the RASS. I worry about some of these antipsychotics being used to treat delirium, which does not really have evidence in favor of, but then additionally, using it to essentially sedate them. It’s like a lot of teams are trying to get patients off of IV sedation, and transitioning just as anti-psychotics as a sedative to get them to attack. And it’s not an appropriate it seems like an abuse of anti-psychotics and it seems unsafe, because you you truly can’t mobilize a patient you they can’t interact with family, you can’t work through that delirium, yet they’re sedated from anti-psychotics.

Louise Bezdjian 56:27
And I think I think, as sleep aid, I think you’re pretty safe. I would probably use Seroquel for that. And at low doses. This is I think this is such an interesting pharmacokinetics whatever. Seroquel is that at lower doses, it’s sedating. And it just helps patients sleep like I’m talking about 12 and a half to 25 milligrams to 50 milligrams. And this is for sleep. And you have to make sure that they have an adequate blood pressure because they can they can bottom out, let’s live Seroquel, but but to help them sleep to small doses of service to date some a little bit and then it helps him sleep. Sleep is so important in a critically ill patient because they really don’t, what we do, what we the things that we do the machines that they’re on don’t let them sleep.

And so we have to just make that a focus for our we do for our patients because we think that it when they sleep well then they they participate well, they can do more, they can do more during the day. And then actually, if you actually mobilize them at night, they actually sleep better too.

Kali Dayton 57:44
I think that’s such an important tool that the team does almost maximum mobility. I mean, teams are walking even without physical therapy. They’re walking, they’re intubated patients on night shift. And that’s how they went a quiet night and continue to keep patients easy to mobilize calm, cooperative, safe during the night. I love that. And I like that sleep as part of the rounds process. We’re not just talking about what’s the creatine, it’s how do they sleep? What’s their cam score? And what can we do to facilitate more sleep? What is the family thing that they need for sleep?

And then even down to what pharmacological options do we have to help them sleep? And what’s the safest option? We don’t I think sometimes patients get out of bed at night. But is that safe? Is that the safest option? We want to be masking delirium with delirious medications or exacerbating it?

What about when patients are delirious or encephalopathic when they come to the ICU even before and especially after intubation? How do you redirect them?

Louise Bezdjian 58:49
I think the simply encephalopathy patient, that the patients that I look at that I think are itself empathic it is. It is, it is imperative, I will do everything in my power to get them to just have three good nights of sleep. Because I think, I mean, I don’t imagine that they walked into the hospitals encephalopathic.

I imagine that, that, that that was a that was a process that had occurred during their hospital stay. So depending on the diagnosis, right.

It’s what depending on their diagnosis, right, so, but me it’s just when when they do come in with their encephalopathy, they might, well, if you’re talking about a liver disease patient, then you then you do things to treat it, like lead to loss and, and sometimes we’re we’re very we’re very aggressive with lactulose.

I did a I did about a year and a half of liver disease and we would get patients that were in simpler encephalopathy and they hadn’t taken that lactulose at home and we we would put a feeding tube in a drip it that will get 20 grams every hour.

And if you guys, it’s a miracle, it’s a miracle drug. And it’s really, I mean, I think it can help make them poop and get rid of the toxins. But lactose is the one that has been studied. So we use lactulose. And then and then there’s a feeding tube and you and within 24 hours Encephalopathies cleared up. But if you don’t have if you don’t have that ability to do that, then I think one of the, you still have to, you still have to find a way to give them lactulose or I think there’s encephalopathy slash delirium, then you will do good, we’re going to need to use some medications.

The one that we typically use or, like if there’s like sundowners delirium, we’ll use that sundowning doses of Zyprexa, which is two and a half milligrams at four o’clock, and five milligrams at bedtime. And then And then, you know, your, your nurse may come to you and say, “This isn’t working” And you say, “We just need to keep trying it. And we can increase the dose if we need to. But let’s just give give the patient two three days to see how he feels.”

So sometimes I’ve done like, like five milligrams and the seven and a half at night. And after three good days of sleep, it seems it seems to help with a sundowning. And it makes me It’s sad, because there are people that are elderly folks out in the community that that that also are experiencing sundowning. And and the families are just dealing with it. Because they’ll say they’ll say they get so confused at five o’clock, and you’re like, oh my gosh, that’s so hard, because then they’re not sleeping and not just driving everyone crazy.

Kali Dayton 1:01:52
It’s still hard in the ICU and you have more support. And it’s you get to clock out after with him throughout the day, right.

But it is hard to manage his patients, especially when you have this culture and expectation for patients to be completely emotionless. And the bed. I tell people that we kind of tolerate even a RASS of one, as long as they’re not endangering themselves or others.

But when they get to be a higher RASS have to even and especially up to four, you have to use other options that their pharmacological options and tools like precedex can be used to get them to that RASS of one or zero and then be able to mobilize them and continue to wear them out for a while.

Louise Bezdjian 1:02:37
But I saw I saw one of my patients get tardive dyskinesia from haldol. And I just frightens me to use and again, I it it, they had that buckle that movement and I was just like, “oh my gosh, no, I don’t ever want to see that again.”

Kali Dayton 1:02:55
So I heard from Dr. Wischmeyer, a few episodes ago, when he got held off and talked about it was like falling into a glass ceiling and everything shattered and he fell a few stories. I mean, it was it was a rough ride on Haldol.

Louise Bezdjian 1:03:10
Yeah. So that’s why I would keep it I would reach for I would reach for Zyprexa or seroquel in that instance. Just as a as a temporizing measure there are these medications and let’s be clear, these medications that we put them on, they do. None of them go home on it.

Kali Dayton 1:03:30
Right.

Louise Bezdjian 1:03:30
I do not prescribe any of those medications to someone going home. And sometimes they do leave, they do leave from the ICU, I will not. I mean, give him a couple of days worth of librium for the withdrawal, who just has to leave, which I think he has to leave because he’s wanting a drink. Those are medications that on an outpatient basis, they need monitoring, and we don’t we’re not providing that.

Kali Dayton 1:04:00
And oftentimes patients aren’t on such high doses of anything that they’re going to withdrawal later. Right, they think is something that we face in the ICU, especially after the ICU is withdrawn from the benzodiazepines withdrawn from the opioids. And then the acute delirium on top of it, you know, which comes first the chicken or the egg, it, we can make such a mess out of it. So I think it’s hard for people to imagine how much simpler management is when we keep these interventions rare. And also the dose is very minimal.

And it’s customizable for every patient. Obviously, patients are going to have different histories baselines, tolerances, and we customize them for every patient and that does take more work, especially for a provider to have to assess, be more vigilant, be more available to adjust those doses. But ultimately, when it saves days, two weeks of an ICU stay, it prevents delirium, agitation, that and when those things are so difficult to manage, it is worth it.

The investment at the front end to make sure that we prevent those complications that do result in so much work and endangerment to the staff.

Louise Bezdjian 1:05:09
I think we do a, I think we do a fairly I mean, and this is just from reports of the professionals who treat alcohol withdrawal, I think, I mean, they really they really value the way we treat the patient. They refer to us for alcohol as well. So, and the encephalopathy that ensues, and that too. Yeah, absolutely. And what’s that? What’s a good case study that demonstrates some of these principles.

So, this woman, she was a 60 year old lady who developed shortness of breath. She does have a history of she does have a history of smoking. She has a history of alcoholism. So she comes into the ED complaining about shortness of breath. And the environment being what it is, the tests are for COVID and she is positive for COVID. So they made her to their facility, but they can support her with supplemental oxygen.

And then around day four, she develops worsening hypoxia. And they feel that they they intubate her and then she goes on sedation with propofol and Lorazepam and then eventually, profile and dexmedetomidine. And so what I think initially when, when, like a day for the what what I’m what I’m thinking in my head is she probably developed delirium from her alcohol withdrawal. And the thought and so then she’s kind of agitated and fighting the end and having COVID and, and COPD. On top of that, she became extremely hypoxic. So she they intubate her and they sedate her, she’s on sedation.

For six days, she lays in bed and doesn’t, doesn’t they’re not mobilizing because she’s too sedated. So eventually, they’re able to wean her oxygen down to 40% peep of 8. And so I think I’m going to leave it there and then talk about what our practice would have been like if she had come to our facility.

So woman walks in. And so so let’s just say she comes in, they admitted the floor, and then she comes to, and then she comes to our ICU. And then when she comes to our ICU post intubation, she’s on she’s on propofol and she’s on dexmedetomidine. So, so we immediately

with will turn the propofol off, and it and it doesn’t, and it doesn’t even matter what her oxygen settings are. Even so, she was on 80% and 10 of peep.

And so we would put it, we would, we would stop the propofol, we’ll put on some fentanyl, for the dyssynchrony of the ventilator. And then and then and then on the on the other side of it, we would knowing that she has an alcohol history.

She does this she did she did have replaced the feeding tube right when she came in. So we will put a feeding tube in and we will start her on that brand. Now she’s four days from her last drink. So she’s she’s towards the end of her withdrawal. Generally. I mean, there are some people that take longer than some that that take less time but with a fentanyl.

We would we would considering that the fentanyl does have some sedative effects, we would we would use 25 to 25 milligrams of librium every eight hours for her and then just assess as we go along. And she definitely physical therapy would be ordered. We will start with sitting at the side of the bed talking to her explaining explaining what we’re doing explaining the feeding tube explaining the ET Tube explaining everything that’s gone on and and also explaining to her that you know you’ve been in, let them know how long they’ve been in the hospital. Give them a history.

So tell her how long she’s been in the hospital what what that course of the hospital stay was how she ended up in the ICU and then reassure her. I think the reassurance is really important that reassurance. We reassure. For her, we do this quite a bit. And you know, these days, we have really good tools to actually communicate with our patients who doesn’t who hasn’t come to your ICU, that they don’t have a cell phone with them, that they can text you.

And I think that their ability to continue to text tells you a lot about their cognitive assessment, based on their ability to text. That they’re texting you, they’re moving their fingers across those keys. So you know, that their, their cognitive.

You know, they’re cognitively intact, and you don’t have to, so you don’t have to worry about that piece of their hospital stay. So that’s what we would do, we would wake her up, we would find ways to communicate with her, mobilized her, and then as soon as we can extubate her.

Kali Dayton 1:10:53
And unfortunately, she didn’t get that process of care. She spent six days sedated and immobilized on propofol. So when she finally got to your facility, what was she like when she when she arrived?

Louise Bezdjian 1:11:06
Well, when we Yeah, so when we dangled her, she could hold her head up. Well,

we were told, you know, “she’s just too…. She can’t… she’s not participating. We didn’t do activity with her because she wasn’t participating.” So we dangled her. What do you mean, “not participating?” See, my what drives me is the patient about their activity level.

I don’t say to like me, as a physical therapist, I don’t say, “I don’t think this patient is appropriate for physical therapy.” I let the patient let me know if they’re appropriate for physical therapy. Because after all, for me, that patient is in the center of my care.

So. So I say, Well, let’s try. Let’s let’s do something normal for her instead of just laying in bed for six weeks, because this woman walked into the hospital on her arm said “I can’t breathe.”

Okay, so she was functional. So, so for me, it’s like, no, you as a physical therapist don’t get to say, “No, she’s she doesn’t, she’s not appropriate for therapy.” She needs to tell me if she’s appropriate for therapy. And I know, that frustrates a lot of you physical therapists that are out there, but I’m sorry, you can’t make that call. I can’t make that call. The patient’s going to make that call. So we’re doing alone? And if, okay, you know, hey, she then go for 15 minutes. And she actually used some proprioception to straighten herself out, she put her hand on the back.

Hey, those are the those are, those are things that tell me she’s cognitively sort of there. And then, and then just push! I mean, you know, go from dangling, and then we stood her. And then by day two, she was opening her eyes nodding.

So now, after six days of laying in bed, I mean, she was horribly, horribly deconditioned. It was a horrible, couldn’t hold her head up. But by the second day that we worked with her, she would say, “lift your head up and look at it.” So she would look at us. And she was nod yes or no, to an appropriately, because, you know, you can ask them all yes questions. Because if that keeps nodding yes, then you know, so you have to ask them, like, “Are you a boy?”

Because then they have to tell you no.

So you don’t always ask yes questions, you need to just vary it, you know, change it up a bit so that you know that they’re hearing you, and they’re processing what you’re saying. And so they can respond to you. And yeah, yeah.

So I think the, you know, we just we just handle those types of patients. And she was she was a little complicated because she had, she also had alcoholism on top of respiratory failure, which, and she also has COPD. So this was a complicated patient. So not, not all of them are that complicated, but she was and, and if she, before day six, when she came to us if she had come to us it right after intubation, what we would have done was we would have shut the sedation afterward and mobilized her.

Kali Dayton 1:14:29
It could have changed everything.

Unknown Speaker 1:14:30
Absolutely. If she’s anxious than I say, “You know what, I’ll treat your anxiety. I don’t want you to be anxious.” Like I don’t, I don’t want these people to suffer. “But if you’re anxious, I’ll treat your anxiety with an anxiolytic. I’m not going to treat your anxiety with problem. I’m not going to treat your anxiety with an IV medication. ”

Louise Bezdjian 1:14:50
I will treat her anxiety. I will take the edge off.

Kali Dayton 1:14:58
We’re not going to exacerbate their anxiety by adding delirium to it.

Louise Bezdjian 1:15:02
You know, I think that there was a great article in the Society of Critical Care Medicine about patients who develop PTSD from losing days being in the hospital: depression and PTSD.

Kali Dayton 1:15:26
I’ll have to go back and find it. I’ll link into this this episode. I hear that from survivors.

Louise Bezdjian 1:15:33
Yeah. Oh, yeah, yeah, yeah, even if they didn’t have the traumatizing experiences as far as hallucinations and being lost in another reality, the loss of time haunts them for years to come. I never thought about that until I heard it from survivors now.

And like their, their family member, if they just did a diary.

And let them read it when they’re ready to I don’t think you push that on them as if they’re just dealing with all this stuff. But once they’re ready to let them read the diary,

and then they’ll just go, “Oh, wow. You know, I mean,”– I think it just, it’s just news to them, because they were unaware. And we’ll do an upcoming episode on ICU diaries, but it seems to fill in that gap. It rectifies incorrect memories, and it fills in the gaps and can really help with the trauma. And I’ll have a survivor on to talk about what his ICU diary meant to him.

And I love to do that more. I think we should do it more. Yeah, it’d be standardized. It’s like you look at the family member, they’re sitting there. I mean, they’re really not doing anything. So please, you know, just, “Louise was your nurse today. And this is what these are the things that we did, and you seemed out of it. But you know, they’re they’re really wanted to help you get better. The next day, Kaylee was your nurse today. And she use you stood up at the side of the bed while you’re on the ventilator. And you took a few steps to the right and to the left, and then that they’ve set you in the chair. And then and then that afternoon, the physical therapist walked you, you walked around the unit on the ventilator. ”

Do you know, it was so and then what what the person who’s writing in the diary is sharing their feelings and their connection with their loved one, it’s like they still get to talk to them.

Kali Dayton 1:17:24
About married couples. I’ve never gone more than a few hours without talking to my husband. I can’t imagine going a few days or a few weeks. How painful that would be. And so Amber and Tyler from the echo episodes towards the beginning of the podcast, Amber talks about how cathartic It was to be able to talk to Tyler through the diary to almost go through this with him while he was stated for this few days. And then delirious how much that was helpful and therapeutic for her wishes with this patient.

how long did it take for her to be able to be extubated then or to be rehabilitated?

Louise Bezdjian 1:18:07
She think she was in the ICU for I’m gonna say another week. But at about day, when she came to us out about day three, we extubated her.

And then she and then in I mean, they may I mean she’s still walking, she’s still doing all those things. And then we enlisted a social worker to help them get outpatient services for alcoholism. And then, you know, hooked during to the pulmonary clinic for her COPD. She was she was it was an it was untreated. But she did have emphysema that you could see in her lungs, coupled with COVID, which I imagined the two together just so we knew we knew she needed to be seen in a pulmonary clinic. So we referred her to that as well. And there.

And the nice thing about our pulmonary clinic is the attendings that work there also covering the ICU. So they follow there’s that continuity of care which I which you know, you can’t you don’t you can always get have that. But it’s a bonus when you do know that there’s so much value behind that. I think we should have post ICU clinics with intensivists available for patients that they know that they know their journey. They understand critical illness.

Kali Dayton 1:19:36
There’s so much to be said about that and we’ll have Dr. Hirshberg come and talk to us about post ICU care in a couple of episodes. I just imagined this kind of patient this is a very common scenario. This kind of course have been sedated for that long. She likely would have ended up with a tracheostomy elsewhere.

Louise Bezdjian 1:20:00
Probably. Before even day six of being intubated on a trach, depending on the unit, yeah, yeah. Yeah. Because I think, in some facilities, the trach gives you I think, if you’re billing with, like DRGs, that diagnosis related, then it would, it would be RG. So then they could continue to, because I think they have billing nowadays, it’s just so it’s so complicated, and so just puts you in a different DRG. And then they, they buys them, I think, more time.

Kali Dayton 1:20:37
Oh, interesting. Now, I never thought about that being part of the part of it. I know that in studies, we see that there are improved outcomes with quicker tracheostomy is doing it sooner rather than later. So there, there’s a lot of praise for the tracheostomy, but I it feels like a lot of it has to do rather with the fact that they get them awake and moving to the tracheostomy because of this cultural belief that it’s safer and easier to mobilize patients once they have a tracheostomy. And therefore, we can’t mobilize them until they have a tracheostomy, which is obviously erroneous. But I feel like improved outcomes are more to do with the timing of turning off sedation and mobilizing patients.

So I guess if it’s me and another ICU that will not mobilize me as the patient until I have a tracheostomy, then fine. Cut a hole in my throat, as if that means that I get to be awake and moving and get to walk out the doors.

Louise Bezdjian 1:21:29
So yeah, but you can tell me “Shut your mouth.” But I’m just saying that that there are times when I think that’s a cop out. Yeah, sorry.

Kali Dayton 1:21:39
Yep, I know. I absolutely agree.

Louise Bezdjian 1:21:42
That’s gonna get me in trouble, probably.

Kali Dayton 1:21:43
But who are we getting into trouble with that’s why I have a podcast. So we can just speak the truth. I really feel like we have a we have a pretty bad tracheostomy culture in some teams.

That I just think there’s they’re so terrified of mobilizing patients having patients awake. And for some reason, we’ve trained each other throughout the generations to believe that once we have a trach, then we can wean off sedation, but even then it’s then it’s difficult. And now we don’t have tools or the knowledge to work through the delirium that we’ve caused, even with a tracheostomy, it’s just so one, one patient, his wife reached out to me and we were talking, they had put him on 200 milligrams of Seroquel, TID.

Once he had it, once he had a trach. That was their way of weaning him off sedation. They were just trying to keep him sedated and get them to attack without having to give him IV sedation. So that’s some of the stuff that’s going on, on out there. I don’t think in that kind of process of care, I don’t think that’s when you get the benefit of the tracheostomy when you keep them sedated, and immobilized. And it’s just a mess out there. But I appreciate Louise, all that you’ve done throughout your career, you’ve dedicated decades, to 1000s of patients that have walked out of your ICU doors, and resumed their lives. And you’ve been an example throughout the ICU community. And I’m excited to continue to learn more. I think we’re running out of time, but we’re gonna keep doing more episodes together, I’m going to make sure that your expertise is immortalized?

Louise Bezdjian 1:23:18
Well, one thing that I want to leave you with is, and if you guys want to laminate this and put it in your in your office be great.

“Don’t let fear guide your decision making.”

Kali Dayton 1:23:35
This is an evidence based field, not a fear based field. Correct?

Louise Bezdjian 1:23:41
You don’t have to be scared? The more you do it, the less you’ll be, you know, I was scared when I first started getting patients up there mainly because I thought what if what if? What if What if they self extubated then it’s on me? And then I thought you know what, so what? And then never did. They never self extubate. You take those precautions, you make it safe.

It’s up to me, it’s up to the team. It’s up to the team to make sure that that patient is safe. And you can do that.

Kali Dayton 1:24:09
ICU community has gone through so much. We face a lot of fear. We were afraid to pronate at the begin of the pandemic did it became a skill set, it became a routine. That’s what early mobility is going to become in the future. This will be the standard the norm. We’re going to just like we flip patients like pancakes now when we have to produce them.

We’re going to jump get them out of bed like drill sergeants. It’s going to be innate, it’s going to be a skill and we’re going to have experts throughout our fields. And in the Awake and Walking ICUs to come. Thank you for giving me the opportunity to share. But we’ll have you back on we have a lot to learn from you. Thanks, Louise. Thank you

Transcribed by https://otter.ai

 

References

Checklist For Endotracheal Tube Tolerance

 

 

SUBSCRIBE TO THE PODCAST