SUBSCRIBE TO THE PODCAST

How can inpatient psychiatrists help ICU teams prevent and treat delirium? How can their expertise help ICU teams minimize sedation, prevent trauma, and treat the psychiatric needs of ICU patients? Dr. Marie Rueve shares with us the role psychiatrists can play in transforming patient care and outcomes in the ICU.

Episode Transcription

Kali Dayton 0:01
Dr. Rueve, welcome to the podcast. Can you introduce yourself to us?

Dr. Marie Rueve 0:11
Yes, thank you. Thank you for having me. My name is Marie Rueve, I’m a psychiatrist in Ohio work at a large academic medical center in Ohio. And I’m actually specifically a consult liaison psychiatrist.

So in psychiatry, that’s a sub specialty area. Unlike I think a lot of other areas of medicine, like the intensivists that I work with, they sort of rotate through consults as part of all their usual responsibilities. And in psychiatry, considering that figuring some of these out these psychiatric syndromes and such out in the medically ill population, it’s actually a separate board certification to do consults in the hospital, for psychiatry.

So I have been doing this for, let’s say, consult psychiatry for about 15 years psychiatry overall for 20. And I do have a special love for the ICU, and trying to figure out all the mysteries that go on in critical care.

Kali Dayton 1:09
And it’s not that common to have psychiatrists that are specialized or really invested or involved in the ICU. How did that come to be for you?

Dr. Marie Rueve 1:19
So in one of my previous positions at a medical center in Pennsylvania, where I was doing konsult work, of course, there’s a lot of delirium in ICUs, right? We know that. And that’s probably the thing that console psychiatrists are most most often asked to see patients about is some form or syndrome of delirium, right? Agitation, hallucinations, pulling it lines into, unable to cooperate with needed care and things like that.

So I would see patients in the ICU, but the intensivists, at that hospital, were actually very interested in all things related to the PAD guidelines, which had just come out in 2013. And a couple of them were very interested in whatever help they could get to get the better practices for pain, agitation, and delirium, you know, sort of addressed instead of in their ICU.

So I was asked to help with a lot of that, that gave me great experience lots of confidence, you know, working with intensivist, like a comfort level, right, because it’s a little bit of a different arena. I feel like sometimes there’s a kind of a wall between critical care and psychiatry can be a little hard to break into who we sometimes don’t understand each other and our backgrounds where we’re coming from.

So building those relationships can be kind of tough, but I kind of took that experience into the current medical center here, which of course, we also had COVID overlaid on top of that, right. So when I came here, it was actually in May of 2020, at the beginning of the COVID pandemic, and they were in the thick of it here.

So starting to get asked to see a lot of consults for delirium in the ICU, who were already on, you know, multiple sedative agents, opiates, basically arrest negative five and a lot of cases or sometimes I say, you know, RASS 100, depending minus 100. And being asked to, you know, ADD drugs on to these patient cases, which was kind of mystifying for me.

And then when I started to ask about, what about spontaneous awakening trials, what’s been happening with those? Or CAM, or any of these other kinds of things that we get sort of blank stares back, I think there was at that time, a lot of travel nurses, a lot of distress, general chaos going on. And so I was trying to help as much as I could, but eventually had to start investigating, you know, really, based on my experience, what I learned what what had, you know, come, I sort of came up at the same time that this whole ICU liberation collaborative was going on.

It’s like all of these practices, everything we’re reading about all the safety and mortality benefits and things we don’t really seem to be totally on board with all that or we need to get back on board with it after after COVID. So I started talking to the individual disciplines like physical occupational therapy, the nurse managers in the unit, the head of RT, the critical care pharmacist that we have here, a couple of the intensivist.

And every there was seem to be like, enough threshold of interest and like, “yeah, we do need to be doing that stuff.” Some of this stuff has gotten so off track with COVID. We need to sort of resurrect things get things back on the right that we’ve formed like a steering committee. I call it the ICU liberation committee here involves all the disciplines and that was about two years ago, and we’ve slowly been trying to just re implement all the practices and get everything back up to speed.

Kali Dayton 4:47
Those who are listening may think, “I don’t think I’ve ever seen psychiatry go show up to the RT lounge, offices, and chat. Like, that is a really unique phenominon, because you’re right, we are so siloed so isolated within our disciplines, but even departments, and you’re creating this role of Psychiatry in the ICU. I love that you’re you really catch the vision.

You are integrating all of the disciplines bringing everyone to the table. I’ve seen dieticians do that. Anyone can bring in the team to the table and say, “Hey, we’re not practicing best practices.” And this is very relevant to what you’re doing. If you’re there to treat delirium, you do have a right to be discussing sedation and mobility practices and all of this, but I imagine that there were some eyebrows raised. It probably seemed a little out of your, quote, scope, initially, but hopefully your team is caught on it if you could build the dream role or position for psychiatry in the ICU. How would you define that? And what would that be?

Dr. Marie Rueve 5:55
Yeah, I feel like I’m close to it. Because I feel like psychiatry is very well positioned to help with all of these ICU liberation efforts, which of course, affect everything that the ICU cares about, right? So, you know, when you think about pain, agitation, delirium, you go into the pedis guidelines, immobility sleep, maybe more, quote, minor symptoms, although we don’t think they’re minor to patients like anxiety and things like that.

And trying to and then, sort of on a mental level, you know, we’re talking about behavior change and culture change among clinicians. I think all of those things. Psychiatry lends itself very well to being able to understand all of those different aspects of the liberation bundle and bring everybody together and try to work on team and collaboration and understanding and getting down to the reconnecting a little bit with the why.

Why are we all doing this? Why are we here? What kind of ICU do we all want to practice in? And what does that take? You know, Dr. Ely is extremely inspiring. And I get a lot of inspiration from him in terms of, you know, why are we all here? What did we all show up to work for? What did we get into these professions for?

I’m trying to help with bringing all that up to the surface a little bit, so facilitating discussions and things. So from my perspective, the perfect ICU psychiatry job is to be part of that team, to be working on all these elements of the bundle to be kind of I do kind of a combination of attending ICU rounds every day, which I did have to invite myself to. But eventually, they, you know, let me be there.

Yeah,

And then slowly, I got to have the floor a little bit more and things like that. But at ICU rounds, I can kind of get I can kind of listen through an ICU liberation lens, or a PADIS lens, right? So they’re all focused on a lot of different things at the bedside, antibiotics, anticoagulation, all these kinds of things.

And I can listen through the the liberation lens as to: how is all this coming together? What are the barriers toward extubating this person? And a lot of times that that lies somewhere in sedation, agitation, anxiety, and all those kinds of things that we can kind of fix.

How did their spontaneous awakening trial and breathing trial go? If it didn’t go? Well? What was the problem? And how can we fix the problem? And how can we think outside of our typical kind of sedation box to other tools that could fix the problem. So I have those kinds of discussions on the fly, I can adjust the intensivists that sort of accepted me enough that I can adjust the pain regimen, the sleep medications, and things like that kind of on the fly while we’re standing there at rounds.

Sometimes I get formally consulted, especially if there’s like more complicated psychiatric history, their substance use Overlay, that’s, that’s creating kind of a big mess, things like that. I’ve also taken to consulting myself on a few of these cases, which is also evidence based in the world of consults, psychiatry, there’s such a thing as proactive consultation, because sometimes the mystery is just like, I don’t know, you know, as an intensivist.

I don’t know who would benefit from seeing a psychiatrist or I don’t know, I’ve got this mess of a situation doesn’t have anything to do with psychiatry. What can you do? I don’t know.

Kali Dayton 9:21
Is part of that rooted in delirium being so common?

Dr. Marie Rueve 9:24
Right? Yeah. And it being so prevalent and I and it’s getting worse, right? I know that we talk a lot in these circles about the fact that sedation as it’s traditionally understood is basically delirio genic. And so, you know, I can sort of see that this person in the ICU has all these risk factors for delirium, right? I think the average patient in the ICU has 11 different risk factors for becoming delirious.

And maybe they’re starting in with a little bit of confusion, or they’re up during the night or whatever it is, and they’re on you know, so we’ve we’ve treated it quote With these, you know, IV sedatives that we’re giving people. But I can see that well, I might as well just jump in on this case now, because two to three days from now, we’re going to be like really rollicking, full of delirium, agitation, pulling it tubes, lines, hitting people, and whole rest of it. So let me just get involved.

Now we can help with some other ways of managing this stuff, we can get rid of this. All these things that are delirio genic, in terms of some of the standard ways to address it in the ICU, coming from outside of the ICU, psychiatry into the ICU, it’s like, to me, delirium is the same whether it’s on the geriatric floor, it’s in the emergency department, it’s on, you know, the, the cardiovascular step down unit, or it’s in the ICU.

But what I’ve observed is that the ways to address it in the ICU are different somehow, you know, are thought to be different, like this is a different phenomena. And to me, it’s really the same phenomenon. It’s the same acute brain dysfunction, the same strategies to treat it, which include avoiding medications that worsen it apply inside and outside the ICU. So that’s where that’s where I get kind of myself involved.

Kali Dayton 11:49
I’ve had almost some audible gasps when I’ve said at a conference, and maybe this wasn’t appropriate, I don’t know. But I shared the analogy “Giving sedation in response to delirium is like giving bacteria in response to sepsis.”

Dr. Marie Rueve 12:02
Yes.

Kali Dayton 12:03
And that sounds like a really crude and harsh way to say it. But is it potentially that black and white?

Dr. Marie Rueve 12:10
Yes. And I thought about similar like analogies, like how can I make you understand what I’m saying, and I’ve tried to come up with like, for giving benzos for delirium, because they seem to work a little bit right when you first give it to them.

So I sort of think of like a patient in renal failure, who’s and anuric, and then want to make they want them to make urine is like, “a benzo is like a nurse saying: ‘I have this medication that’s going to produce some urine’, and they want urine, you know, being made, that’s great. But it’s ultimately going to worsen the renal failure. So would we give that medication, you know, just to produce urine when actually we’re wrecking the kidneys in the process?”

And that’s a little bit of benzos and delirium, right? They seem to kind of calm everything down initially, but they’re adding their poison basically, to the brain, and they’re adding to the delirium and somebody, as you’ve said before, is going to pay for that down the road, that grenade is gonna go up.

Kali Dayton 13:09
Okay, that is one of my analogies, analogies who start sedation, right, maybe right, upon intubation, you bite off the grenade, and you’re passing it down shift to shift, and it’s gonna fall on somebody to have to take it off. And then you unmask this delirium, and it’s from the nursing perspective, it is very stressful, difficult, exhausting, sometimes traumatic, to deal with one study showed that delirium was one of the main psychological burdens on nurses. And I absolutely appreciate that.

Dr. Marie Rueve 13:38
Yes, I totally agree. And I think that’s one area where the ICU nurses here have seemed to appreciate my help on cases is because, you know, if I start talking about sedation, and how “that’s terrible for delirium, and we can’t be like, dripping all this stuff into these people 24/7”. And the conversation ends there. The nurses are like, “Yeah, but you know, what am I doing, do with these people?”

And so, you know, we have some other tools, right? We have some as needed medications. We have things that we’ve used for agitation for a long time, and I definitely am trying to change the culture to think more toward non pharmacologic interventions also, which would include early mobility, which I agree in my experience, just like the the 2019 ICU collaborative studies show like that’s, that’s the hardest part to get going.

That’s the hardest part to make people believe on the team that this is going to help you know, this is a treatment for delirium. I wanted to get our physical therapists a little badge for their coat or lanyard that says, you know, I am the treatment.

Kali Dayton 14:43
Delirium SWAT team!

Dr. Marie Rueve 14:45
Yes, I am the delirium SWAT team that would be even better. I am the treatment I have to go in there. I struggle somewhat with less familiar PTs and OTs thinking that they can’t work with somebody who can’t follow commands. You know, I get that a lot but but actually You have to have the conversation about like, How can I help let’s, let’s do what we can here, but but some form of working with them on mobility is going to help their brain. So yeah,

Kali Dayton 15:10
I was going to ask you how you felt about that being written in some of the policies and parameters for mobility. In some of these facilities that I’ve seen, it’s a requirement that patients follow commands to be a candidate for early mobility.

Dr. Marie Rueve 15:23
Yes, I am totally against that. I can clearly clearly say that, and that was. So the physical therapist, and who spent a lot of time in the ICU was the first conversation with a with a discipline that I had back a couple of years ago. And that’s basically one of the first things he said is, well, we can’t work with anyone who can’t follow commands.

And also, well, that explains a lot. But we’re gonna have to, you know, I didn’t say it to him right then. But you know, the conversation evolved over time, that we’re going to have to look at this from an evidence based perspective, right, and we’re going to have to see what other helps we have, that can assist with agitation, or keep people safe, if they’re not doing exactly what you tell them to every single time.

But even just during the course of a mobility session with the delirious patient, they can become a lot better at following commands, right? If you’re engaged with them, whatever they were doing at the beginning, is not necessarily the status they’re in at the end of the session. And so you can just see the treatment itself in front of you.

So it’s come it’s come a long way with the with the therapist in terms of presence in the ICU, eagerness, you know, I gave a talk sort of a question and answer session to about 30 of our PTs and OTs about early mobility, and just some of the science, the recent article that showed improved cognitive outcomes, one year after early mobility in the ICU.

And they’re, they’re very passionate in their own right. So I think, again, once they feel like, well, yeah, it’s not just me going in there and trying to deal with a person who can’t follow commands as the physical or occupational therapist, but it’s actually this whole team. They’re all trying to attend to straightening out the thinking as much as possible, calming down the agitation, normalizing the daytime, and the sleep wake cycles, having the family at the bedside, the nurses are more aware of what’s going on, and how this might help them because I spent a lot of time talking to them, too.

And so I think it’s definitely moving in the right direction, to the point where our physical therapists and occupational therapists advocated for and got approved that the bed rest order that’s in the admission orders that get removed and replaced with progressive mobility order set from the beginning of ICU admission, so that they can evaluate what’s going on.

And they’ve been working with a lot more folks, and actually, the other week, got one of our ventilated patients up and walking from the bed to the door, which was a huge, huge accomplishment went a long way in terms of ripples of excitement and motivation for all this going forward.

Kali Dayton 18:07
Oh that’s excellent. I think this is very empowering to PTs and OTs, where they can find their role their place in the ICU, we allow them more autonomy, they can do more critical thinking. Of course, you know, especially in more difficult, tenuous critical cases, there needs to be more interdisciplinary collaboration. But I love it when PTs and OTs have the skill set and the competency to do their own assessments, even with more difficult patients to say, are they appropriate?

Are they not an advocate and discuss those things, but it’s a process of conversion of evolution. I think that when we have these parameters that bar these experts from getting their job done, we just create a huge disservice for the entire team. I think it makes it much harder for the nurses because then they are left to try to wrangle these thrashing agitated patients, while we have other people saying don’t hurt their brains with sedation.

But then what do you do so when teams say, we’re just gonna focus on sedation for now, and we’ll hit early mobility later? I think that’s very difficult, because from a nursing perspective, I don’t have early mobility. And now I have patients that are awake on the ventilator. And yeah, I’ve taken out one or two risk factors for delirium.

But I’m not progressively proactively preventing it with early mobility, then they’re going to develop delirium at high rates, even still, but I don’t have anything to really control them or to keep the endotracheal tube and all the things that nurses are worried about. And I see that in these teams when nurses are seen PTs and OTs come in and help them they see the patients calm down and sleep afterwards.

The nurses relax, they feel better, they feel like okay, the patient is safer. I saw the benefit of that, and now I don’t my shift is so much easier because of them. So when we have parameters that make it so that patients cannot do early mobility, they can’t follow commands. My analogy for that is not allowing for dialysis, unless there’s renal function is happening? Yes, it doesn’t. It doesn’t make sense.

Dr. Marie Rueve 20:04
Right. And I try to bring those topics of conversation up on ICU team rounds every day. So everybody’s hearing the question, why wouldn’t they be able to get physical therapy or occupational therapy today? Right. And of course, our therapists are not at inter professional rounds. So that’s maybe a goal for the future that they’d be there.

You know, I’d love I’d love it to be reported out at rounds, you know, what’s their highest level of mobility today and things like that, right now? We’re just at the level of, yes, PT and OT can come see them. And yes, they’re not following commands, or they were agitated overnight. But that doesn’t mean that they couldn’t be successful necessarily with PT ot today. So let’s, let’s see what happens before we write that off.

And let’s be sure all these other parameters are in place to like, their RASS is appropriate. And we have maybe other medications or other non pharmacologic interventions that are helping get the kind of agitation calm down the thinking a little straighter, the, you know, ability to engage a little bit better.

Kali Dayton 21:05
Did you see at least initially some inconsistencies with the RASS and CAM scores and charting and reporting, what did you see? And how did you did you help address that?

Dr. Marie Rueve 21:16
Yes, we definitely have a wide variability with that. So we’ve done a lot of nursing education, and it’s still in process. This is another role that I feel like I have on ICU rounds, because we have a script that the nurses are asked to report off of, for the bundle elements, and then a couple of other things that the nurse managers wanted, added there.

And that’s been a big focus of our work is just like, setting out a model for this conversation to happen at interprofessional rounds. Because when I first started, it was quite disorganized, it was all over the place, the nurses were sort of left for the end. And we’re kind of asked, you know, like this question, quote, need anything. And that’s the end of it, you know, after all this discussion have been done, and none of their input have been taken in or anything like that.

So we we formulated a a list of things for the nurses to talk about, and the resident will introduce the case with like a one liner of what they’re there for the nurse then goes into this bundle report. And then it goes back to the resident for discussing discussing labs, consultations, you know, assessment plan for the day, things like that. So they they have the script down pretty well in terms of like how to pass the conversation back and forth.

And who’s supposed to say what, but we still do struggle with it being a little bit of a shell in terms of the there’s a wide variety in the nurses comfort level with being with knowing what a RAs and a cam, even are, let alone a CPOT, which was extremely new to this ICU.

And to correctly report those to include those in the bundle and not, you know, report and not just skip over them, but then also to have them be accurate. And that’s a little bit of what I try to help with on kind of a case by case basis when I’m at rounds. Not in front of everybody at rounds, but often like once the team has moved on to the next patient on the list.

I will hang back for a few minutes. If I feel like you know, I can see from the doorway that this person’s cam was going to be positive. But we didn’t report it that way. So can we just go back in and do a cam together? Let’s just see, you know how it goes. And we just do the teaching right there at the bedside or even more fundamentally with the RASS you know, the RASS is negative one and I’m looking at the doorway like that patient is not the patient’s comatose I have stopped the conversation at round someone and so “Okay, so RASS, negative one, so they’re opening their eyes to voice and they are maintaining eye contact for more than 10 seconds.”

And the nurse will be like, “No, that’s no, no, they really didn’t maintain eye contact.” “Did you have to touch them to wake them up?” “Yes,” “Well, that’s the RASS of negative four pretty automatically, you know, if you if they’re not responding to your voice, then we’re below the negative 1,2,3”.

So kind of doing those kinds of teachable moments for the whole team reinforces it somewhat. But yeah, I do have a lot of concerns, especially as we start to think about data collection and using the ICU liberation flow sheets and dashboards that are in epic, that like I’m not sure how accurate our actual data is going to be in there. Because of some of these I’ve had nurses say, “The patient’s intubated so I wasn’t really able to do a CAM”. So we have to have a teaching moment there.

Or I’ve had a lot of nurses say the “CAM negative” when clearly the CAM is positive and it’s almost like CAM negative means like, I don’t know how to do the RASS or I didn’t know how to approach it. So it’s like negative in terms of like wasn’t done and like no, that’s not what the sun with negative means.

So it’s there’s been a lot of have individual teaching moments and that’s gonna go on I tell the nurse manager there that this is going to be like a 20 plus year project, like we have to have the long term vision here for we’re going to have to continually educate an audit and model and demonstrate.

Kali Dayton 25:15
Right, because there’s been a lot of damage done during COVID. And maybe we weren’t as solid as we hoped we were even before COVID. So I think a lot of the nurses have not received formal training, everything you’ve described, I’ve seen throughout most other teams, this is not isolated to your team at all. I’ve had nurses during training, say, wow, I’ve worked here for 18 months, and no one ever taught me how to do a CAM.

Dr. Marie Rueve 25:39
Yeah.

Kali Dayton 25:39
And they were they were new to the ICU. So we may be holding them accountable or expecting things that we never actually trained them to do, which is obviously unfair, but ultimately unsafe. The Wrath easily becomes whatever was charted beforehand, whatever is usually charted whatever is prescribed, that, that very distinct point of if you have to touch them to arouse them, then it’s a negative four or lower.

That is a very misunderstood concept throughout the community. And so that alone is powerful. I mean, the way to impact outcomes, in large part is educating our teams. And something I really tried to focus on is what is our vision here? Why are these tools important? It’s not just another thing to chart, because that’s easy for nurses to perceive that we are just adding to their burden more thanks to char it’s just another thing to check off the list.

I think they really miss the vision of the bundle, how do you feel like your team is perceiving the vision of the bundle? And what are what kind of things are you doing to try to help them understand the real why behind it?

Dr. Marie Rueve 26:47
Yeah, I tried to bring up the very well established longer term consequences from this right that? Well, delirium is difficult for us to manage as a staff in the hospital, this is actually brain failure and brain, you know, injury. That’s what you know, the group from Vanderbilt has clearly demonstrated that we can think of the outcomes of delirium as an acquired dementia, or equivalent to a mild to moderate brain injury.

And that that’s going to affect the patient’s work life, family life, personal life, going forward. From here on out, so I’m always trying to refocus us back on those those bigger picture things, which gets back to a little bit like I was talking before, we were talking before recording about, you know, why? Why is everybody here?

Why come into the ICU, if we really, you know, don’t care about this stuff, which is sometimes I feel like a reaction that you can get on a, on a bad day where there’s lots of codes or whatever, like, I don’t have time for this, and all these other things are happening. It’s like, but what did we all really show up for here?

And what are we all really doing here to to help patients? Is it? Is it more about thinking about survivorship, right? Like not just whether people live or die on our shift? That’s important, but what are they surviving to? What kind of life are they going to have going forward from here, and that we have very, you know, clear evidence basis for thinking that brain dysfunction being seen in the ICU, is, is going to lead to brain dysfunction over time for at least a significant portion of people, we can’t predict who they are.

So we have to protect everyone from it. We have tried to incorporate into our education efforts, you know, more stories, more survivor videos and things like that we haven’t gotten to the point of bringing any of our survivors back. But, you know, just just to try to get at sort of that balance between the data and the stories.

What we know could be the consequences and the personal reflections on what the consequences are I found a survivor stories probably a lot coming from you to where they’re, they’re actually nurses, like their nurses who’ve been ill in the ICU. And, and are saying, Yeah, this, this is all my brain has fallen apart. Basically, toward the end of this, I can’t do anything, I can’t do my nursing job anymore.

Like that really hits home for the nurse standing at the bedside caring for people. So really just trying to connect back to that, including for the residents too, who are also just trying to survive, you know, shift shift. They don’t really know what is the difference between these different sedatives. What is delirium? They don’t really know about PICS or other longer term consequences of, of ICU care decisions.

And so I’m really trying to bring that back to why so whenever I’m going to talk to them about sedatives or antipsychotics or anything like that, I always start with a little bit of the walk through the history of a basically the the doctor elite group, the different groups that have put the evidence out there. This is what we know this is this is the story of the science of what happens to patients if we don’t take care.

This is how the bundle has been proven to Stop that damage and help people live better lives. So this is why we care about all this stuff. It’s funny just today on rounds, the the intensivist was asking the residents, you know about some different interventions with the ventilators, with ventilator patients such as proning, or paralytics. You know, what are the mortality benefits and all that kind of stuff.

And I was thinking in my head, and I’m going to have to bring up at rounds tomorrow that, you know, one of the most impressive mortality benefits comes from the ABC trial back in 2008, which was all about spontaneous awakening trials. So if you want to talk about interventions for ventilated patients that are proven to impact mortality, that’s to me should be number one on the list, because I’ve challenged the residents like show me a better absolute reduction in mortality at one year, then 14%. 14% more people are alive at the end of one year, and the only difference between the groups was the cumulative dose of sedatives as lowered through spontaneous awakening trials done correctly.

So, you know, if we’re talking about, again, mortality benefits for people on a ventilator, we can’t not talk about spontaneous awakening trials. But it was clearly left out of the discussion today on rounds. So my responsibility is going to have to be to bring this up now.

Kali Dayton 31:21
I mean, I think there is a place for proning, you know, we we’ve seen so many benefits. We also have a study coming out from France, this, I think, coming up this year. So in benefits of VQ mismatch with verticalization. Okay, awesome. So we’re going to have more proven benefits, we already have lots of proven benefits to lung function, lung aeration, secretion, mobilization, things like that for intubated patients with mobilization.

But that gets left out of the out of the conversation when we have sick lungs, it’s really baffling to me. And then, of course, when we have thick lungs, the brain doesn’t matter. Everything gets left behind. But it is part of the training, we are trained to think that way to hone in on those single organs. So everyone, we’re all a product of our training and our experiences. So having someone else there to bring in another insight to bring in the evidence to bring in more ideas and accountability to the evidence is really powerful.

Whether it’s psychiatry, I know as a nurse practitioner, that was my roll up during rounds to say, “Where are we at with this? How are they sleeping? How’s their pain? How’s their delirium?” I’m seeing some nurses, nurse leaders doing that they’re attending rounds very purposely, they’re touring the unit going around door to doors. And “Where are we at with this, this this?”

I see pharmacists bringing in these elements, anyone can bring in this discussion during rounds. I think you as a psychiatrist have a very nice expertise as far as the psychiatric and the cognitive, big picture of survivorship. But I also even though I worked in an awakened walking ICU, I used to cycle all the time, where my go to with really difficult alcohol or drug withdrawals with different psychiatric orders with delirium.

I mean, when when I hit a wall, even though we had such good protocols, and I felt like my NP group, we were experts on a lot of this, we still reached out to psych. So how would you invite the ICU community to involve psychiatric services more?

Dr. Marie Rueve 33:29
Yeah, I think a couple of things as that I would think of, you know, I see my role in the ICU too, sometimes I mentioned is like, we have to get the brain and the lungs to the point of being of extubation happening at the same time. So a lot of delays is from one or the other kind of lagging behind, often the lungs get better. But now the brain is way not ready for extubation.

So trying to see our efforts as, as all important at the same time, like you were talking about not just talking about one organ at a time and forgetting about all the other ones. The the other, you know, sort of things that come to mind is I like the term treating, treating agitation. More so then this patient needs sedation, because I think that’s a little bit clearer about what we’re doing.

And it kind of helps with like, we need to be providing something to this patient, we need to treat their agitation, anxiety, insomnia, things like that. Versus like, if we talk about it only in terms of sedation, then when we’re talking about taking off sedation, it really leaves this feeling of like deprivation. And I think for some members of the team more so than others, like nurses are worried that we’re depriving patients of something that they should be having if we’re not going to do sedation.

But it’s like, we really need to think about you know, is there actually an indication for sedation okay, if there is and they’re pretty few and far between, then of course, we’re going to do sedation if the person is on paralytics then I shut up about my awakening trials, am I all this other kind of stuff? And it’s like, “yes, negative five, that’s great for RASS.”

But if it’s not that patient who’s got an actual indication for sedation, then we actually should be talking more in terms of what are the specific symptoms, and what other kinds of treatments are there, besides putting somebody into a coma, right, we treat agitation, anxiety, pain, and all other parts of the hospital, where I also go out and see consults, without putting people into coma.

So even if they are in the SICU, and they’ve just come out of surgery, you know, we have a lot of nurses who believe that these incredibly high opiate administration’s are required because they might have pain from their belly surgery or whatever they just had. But we have lots of patients who go through surgery that respond very well to multimodal treatment, right, who don’t have their airway protected, and therefore, we cannot just like pour fentanyl into their veins 24/7 to be sure that they don’t have pain.

So that’s where I mean that from my experience treating patients all over the hospital. There’s no reason just because the person is located in the ICU, that we have to do these other like humongous things, like hitting with a humongous hammer, instead of like looking at what are the symptoms that this person has, even if they’re laying in the ICU? Great. What can we do to treat and address all of those symptoms?

So I think if you know some of my I’ve tried to come up with some triggers of like, what would be good reasons to have a psychiatrist, see a patient, I think if they’re on a lot of psychotropic medications at home, that might be a reason to, because that indicates some psychiatric history, often people can get agitated or out of sorts if they’re used to being on these psychiatric medicines at home, and then we’re not providing them in the ICU.

So that can be a thing. Substance abuse and withdrawal, it’s very difficult for teams to figure out what to do. Especially if the patient’s having pain, especially if they’re asking for pain medications, but they have all this other history, you know, how are we managing withdrawal? What other kinds of stuff can we do to help them out with comfort medications and things like that.

And definitely, I feel like if the team is having to address agitation, with some type of sedative, or my my ICU team here will try to address it with anti-psychotics to some extent, then, you know, if we’re having to do that, if it’s working great. If it’s not working so great, then that might be a reason to ask, you know, psychiatry to take a look at this and see what could be helpful here. So those are the main the main reasons why I would say, you know, agitation would be a primary reason to get psychiatry involved.

Kali Dayton 37:46
I keep thinking about this culture that I think I’ve been a part of at times, and which, in the ICU, we just assumed that because we have the sickest patients that we practice the most complex and advanced medicine, and that there’s very little anyone else outside of our club. That makes sense, right? We think, well, you understand, because you’re used to treating patients on the floor, but our patients are different cuz they’re in the ICU.

What I’m understanding is that because you do treat patients as humans, you have to actually communicate with them, you have to find the root cause of the agitation, you do have a whole nother skill set, when as an ICU, I think, because we’ve had sedation at our fingertips all the time, we can mask and mask and mask all of these things without really diagnosing and treating the root causes.

So you bring in a whole nother expertise. So there’s so much merit in having an objective, outside party come in with new eyes, fresh perspective, and a totally different skill set and expertise, to bring in those elements into our patients, especially when we don’t want to just mask the symptoms. Agitation toolkit, I, you know, we say agitation all the time, you probably can appreciate this patient is coming out of an awakening trial, they might be restless, they look uncomfortable, and we call it agitation.

But in literature, it is a RASS of greater than to this means that they’re doing dangerous behaviors or starting to pull out their lines and tubes, and or even a plus for which they’re trying to hurt themselves or others. So that can happen. You’ve seen it, I’ve seen it. But a lot of times we’re using agitation to describe patients that are restless or trying to pick up things and are uncomfortable.

So my toolkit goes through what do you do for RASS of plus one or plus two? And then what do you do for a plus three or plus four? And how do you get them back down to a plus one or plus two and then treat those root causes. So there’s so much value in having someone bring in that discussion. That expertise. I would invite everyone to reach out to your psychiatrist and your hospital. I know that psychiatrists usually really busy and if we hesitate to bother you guys,

Dr. Marie Rueve 39:57
I get that a lot but I’m Like, “No, please, this is my favorite thing to treat,” actually my favorite thing, because I think, yeah, I feel like we can really make a big difference there. And we can think about it maybe a little bit differently than the team is thinking about it. I also think it just makes sense. Everything is so sort of specialized in the field of medicine.

And you know, there’s so many different consultants on these cases. But why why not involve the specialists in treating agitation using these different medications, always with the goal, which I sometimes have to like, concretely explain to patients, you know, our goal is to have you awake, functional thinking, communicating, participating in your own decisions, being able to enjoy things that you know, can be adapted to the hospital, like visiting with your family, or reading a book or watching a movie and things like that.

So I’m not here to, you know, make you into a zombie or things like this, I run into, you know, psychiatry struggles with a lot of myths and stigma and bias and other things like that. I feel like I am kind of in lockstep with my patients in that way, right, that my mental health patients experience a lot of that in the world. Psychiatry experiences a lot of that within the field of medicine. So I’m pretty used to dealing with those kinds of things. But yeah, just trying to be very concrete about what the goal is why are we using these medications?

Or why are we using this, that or the other intervention? Or why are we trying to get to the problem of what’s making a person uncomfortable, restless, anxious, agitated, as you, you know, as we say, because we want to return them to a state where they can be comfortable, and be participatory in their care and understand what’s happening to them and work toward their own recovery.

Right, I really talk to patients a lot about that. This is like any other kind of endeavor, you’d get into as a human being where you’re trying to better yourself or heal yourself, we need to participate in movement, we need to take medications or things that are going to help us we need to be able to eat and nourish ourselves, things like that. So trying to really involve the patient in the process to toward the goal.

Kali Dayton 42:10
Yeah, I’m sure for many listeners, this is a huge shift across many people’s minds, to consult psychiatry, for intubated patients, yeah, maybe certain select patients in the ICU that are more stable, or just there for Psych specific reasons. But the fact that psychiatry can help get our patients excavated, is probably a very unique concept. But it isn’t. Yeah,

Dr. Marie Rueve 42:35
it makes a lot of sense. And we it is, it is a unique concept for psychiatry to I would say like your average psychiatrist in a hospital or who works on the inpatient psychiatric unit, you’re trying to get them to come to the ICU instead, to see a patient up there. They’re gonna be like, what note, can they talk now call me back when they’re excavated, and they can talk, you know, that might be, unfortunately, a response that a lot of people have gotten from psychiatry, I would say if you have consult, specialty psychiatry, in your hospital, you’re less likely to get a reaction like that.

But even in the world of psychiatry, you know, the professional organization for consultation liaison psychiatrist, there is a special interest group on critical care within that organization that is trying to educate psychiatrists about the how they can help patients in the ICU. And what what’s, what does it take to do that we have an article coming out in psychiatric times, hopefully, by the end of this year that kind of goes over those basics of how to help in the ICU just for a psychiatry readership.

Kali Dayton 43:39
And I think we need to allow everyone grace and opportunities to grow and evolve. So some physical therapists are terrified or obstinate, to working with patients on ventilators. That doesn’t mean we just we just cancel the program altogether. Yes, but we might need to do some education say what you do with patients that are not on ventilators, especially applies to patients that are on mechanical ventilation.

We’re going to give you some training and some experience some exposure, and you’re going to see how your skill set can grow. But also what you already have applies here. That might be that the same thing for psychiatry. What you already do outside of the ICU is what we need inside the ICU and you’re going to develop ICU specific expertise.

Dr. Marie Rueve 44:23
Yes, you’re going to pay into like, can you get pills in this person somehow? Or if not, what else are you going to use? You know? So you’re going to get into some of the the nuances of treating a patient who can talk to you’re going to learn the cam ICU, I mean, that’s validated against psychiatric examinations for delirium, but I use it quite a bit to see if mechanically ventilated patients who can’t really talk if they can pay attention or not. So yeah, get familiar with all the terminology all the tools it becomes a lot easier

Kali Dayton 45:00
Well, thank you so much for everything you’re doing. They’re on site. And for what you’ve shared with us, I think this can really open up more support more options for I see clinicians. I see liberation really is interdisciplinary. And it just grows and grows. There are so many resources that we have available that we can use if we are really working on the ultimate goal of helping patients survive and thrive during and after the ICU. Thank you so much for everything that you shared and keep us posted. Let us know how we can infiltrate the psychiatry world more.

Dr. Marie Rueve 45:32
Yes, I will keep passing on the podcast and I very much appreciate all the work and all the help you’ve given me acclimate to the critical care community culture, how people think and where some of the issues might be. So I really appreciate it.

Kali Dayton 45:47
I definitely believe that you are saving lives there. So thank you.

Dr. Marie Rueve 45:50
Thank you.

Transcribed by https://otter.ai

Citations

SUBSCRIBE TO THE PODCAST