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Kali talks with Louise, ACNP, who explains how nurse practitioners are guardians of delirium prevention and preservation of function for their patients in the ICU.
Episode Transcription
Kali Dayton
Louise, thanks so much for joining us. So you’ve done this, the nurse and a nurse practitioner for 27 years, what has your journey throughout the sedation evolution been like for you,
Louise
Kali, thanks for having me as a part of your podcast. I started nursing in 1992. And I started working in the ICU, taking care of trauma patients respiratory failure patients, then. During that time, we would paralyze and sedate all of our patients. And I really didn’t think too much of it. I thought that this was just a practice that it was uncomfortable to be intubated, it was a terrible experience to be intubated. So we wanted to shut off our patients brains.
And as I, as I continued to work in the ICU, there was a new school of thought that paralysis was not good. It created a lot of problems for the patients in the long term, they will develop weakness, they will develop highly myopic ease, and to the extreme cause death. So we started to promote mobility.
But I will admit, I was terrified, I thought that I was going, the patient was going to be harmed, I absolutely did not want my patient to suffer extubate, as I’m sure a lot of nurses feel the same way is not on my watch is the patient going to be extubated. But as the more I did it, I wouldn’t even wait for physical therapy in the morning. But after I did my assessment and gave them the medications, I would either dangle my patient or I would put them in a chair. And I could do that with another nurses help. And the respiratory therapist monitoring the 02. And so the more I did it, the more comfortable I became with it, the less, you know, my fear was dispelled.
Kali Dayton
And how was that culturally? I mean, was that … did that become a standard in that unit?
Louise
No. In fact, I got some of the nurses who had been there who the veteran nurses would just would just say, you know, with, “I’ll get my patient up if I have time, but I’m not going to get my patient if I don’t have time”. And when you think about it, it really doesn’t take that much time to get your patient up. If I were to… if we were to do time motion studies, I will I will bet you it’s no more than five or 10 minutes. And in a 12 hour shift, you absolutely have the time.
Kali Dayton
So how did your perspective on that change?
Louise
Well, the more I did it, the more I realized that this was really important for the patients. And you know, there was a lot of the time that I was doing all of this, there was a lot of empathy to I would think, “okay, if I was in this patient shoes, would I want to just lay in bed and not be able to move?” because I you know, I’m a person that believes in exercises, important movement is important.
And so for me, it was it was more of a routine for myself. And if I mean if that was my mother, my father, my sister, my brother would I want them to just lay in the bed and develop and develop so much weakness that they end up going to a nursing home. And that was like the nobody wants to go to a nursing home. And so as my, as my career progressed, and we actually, you know, the the disadvantage of working in an ICU and not following these patients through their continuum of care, where you see them go from the ICU to the floor, and then they end up in a nursing home.
I, you know, and I and as my as my career progressed, and as I continue to do the research and noting that and then out of our own research, what what, what I noticed was that those patients that we mobilized initially and maintain their strength, got to go home, they didn’t have to go to a nursing home, which, you know, again, that empathy piece. If that was your loved one, if that was you, you wouldn’t want to go to a nursing home. You would want to go home, you would want a normal life. You’d want to be able to do those things that you were going to do already enjoy doing before you’re hospitalized.
And so the the problem with having severe ARDS and respiratory failure, I mean, there’s there’s that piece that comes with it where, you know, your recovery is long, your cognitive deficits are there, but I don’t think we know even enough about, you know, if we don’t sedate people, if we, if we maintain their strength and don’t shut off their brains, what’s their long term outcome?
I mean, what are they like in five or 10 years? I mean, we’ve looked at, we’ve looked at standard of care where you know, these are people are still being paralyzed, and still being sedated. We’re looking at that, and five year outcomes are different. What I’d love to see is, is aggressive, early mobility, and then look at these people’s outcomes at six months and a year. And I think we’re, we’re, we’re working on getting that kind of research done.
Kali Dayton
Yeah, it’s hard to find research out there on something that’s not generally done. It’s hard to study what you don’t do. So it’s exciting to think of all the studies that we’re hopefully going to be doing with our patients, we do know that 98% of our survivors do go home. But it’s exciting to think of following them in the long term to think of what their outcomes really are. Are they back to work? Are they are their brains working? Because our practice is so different? What is it like for a patient that comes in that requires mechanical ventilation? What is your practice, like now,
Louise
um, well, our practice, now, if they come in, and they have a terrible respiratory failure, they’re on high of oxygen support, they’re on, you know, 100% 20 of peep. We try to put them on a little bit of a little bit of fentanyl just to take the, the discomfort and the and the dyssynchrony, out of being on a ventilator. And in the meantime, we are talking to them, we’re explaining to them, “Look, this is the this is a tube that’s in your throat that’s helping you to breathe, it’s it’s, it’s keeping you alive.”
And then you know, it doesn’t take but sometimes it takes an hour, and then the patient understands what the tube is there for. Rather than clouding their brains with all these medications that distort the reality, it creates delirium for them, and then you can’t talk to him. You can’t explain anything to them. And so what we do is we prevent that from happening. So, we don’t create the problem. And so the patient is on a little bit of fentanyl. And then we and then we mobilize them. We’ll start with dangling and we’ll see what their saturations do and and we maintain their strength. And in most cases, that’s enough, they start to wean off the ventilator in the most severe ones.
I can think of a few examples where we, we had this guy who had come up to the Sundance Film Festival, developed got influenza. And they sent him from the ER in Park City, to here to Salt Lake and we he was intubated he was on 100% 20 of peep. We proned him. And all he was on when he was proned, he was on dexmedetomidine and fentanyl. He was prone for 16 hours I was on that day, got the physical therapist and said, hey, when we when we turn him supine, let’s just see if we can just dangling.
Well, she took it a step further, which I was thrilled with. We proned him. And when we proned him, I mean when we put him supine, he was on 60% and 14 or 16 of peep. She turned him on to his back, and then they went for a walk and I walked 200 feet.
Kali Dayton
Wow.
Louise
This is someone who had come to us with severe terrible influenza, and he was just one of those, you know, the, the obese gentleman, which I think that was in 2000. That was 2009 it he just fit that mold of those the the most commonly affected and he within a few days was extubated.
Kali Dayton
Did he help prone himself?
Louise
Yeah, yeah, no, he did. He rolled over. And and and bless the physician that was on that night because most people would have paralyzing because he was proned.
Kali Dayton
But he wasn’t moving. He was comfortable.
Louise
He was.
Kali Dayton
He wasn’t deeply sedated.
Louise
And we would ask him if he was okay. And he’d nod his head. And he had one arm above, above his shoulder, the other one just sort of at his side and just one leg, you know, bent at the knee. This was comfort, had a position of comfort. It was like he was asleep.
Kali Dayton
That’s a powerful example. Because yeah, that’s, those are the people that we are quick to deeply sedate and paralyze. And you can’t deny his ventilator requirements. And yet, you were able to preserve his brain function. He didn’t develop delirium.
Louise
No,
Kali Dayton
He was mobile the next day. And then what happened to him?
Louise
He got to go home. He got he got back on his plane, and flew back to I believe it was Atlanta. I mean, his mother came out here. And I’ve never seen a woman so appreciative of the fact that her son was, I mean, the care she is he received, I mean, she she couldn’t, she couldn’t thank us enough. Which is really what we’re here for, isn’t it?
Kali Dayton
Yeah. He didn’t have to have a tracheotomy. No rehabilitation, he got his life back,
Louise
right.
Kali Dayton
Because of this process.
Louise
I’d love to follow, I’d love to have, you know, give him a phone call and just say, “Hey, can you do these things?” Just ask those questions and functionality and just see,
Kali Dayton
“Are you back to work? Does your brain work?”
Louise
Yeah. I mean, it would be just, it would be so nice, just to be a part of a part of me regrets not being able to just say, “hey, you know, give us your number. Let’s look, we’ll call you in six weeks in six months and see what’s going on.”
Kali Dayton
Right? Because he’s such a- such an anomaly. We’ve heard from some ARDS survivors that had the “traditional weeks, sometimes months of immobility” and their journey to recovery and not even full recovery. But that is such a contrasting example.
What role do you play as a nurse practitioner? In those kinds of experiences, or even within each patient that comes into the unit?
Louise
I’d like to think of myself as the champion for that whole process. I like to think of myself as a person that goes in and dispels the nurses fears of this is the right thing to do. And I learned, and I have multiple on multiple occasions, said to the nurse, this is the right thing to do. I mean, you almost if you don’t have this conviction that this is the right thing to do. Your patients, your patients won’t do well.
There has to be a person that champions this because you’re there’s so much pushback, there’s so much fear because the the nursing population, it changes so much and there. And there’s so many sometimes I think the disadvantage is the nurse that has 20 years of experience, because she just she did they refuse to do that. Because they just don’t don’t have time. They don’t think it’s the right thing to do. They think that we’re being cruel.
And the cruelty lies in sedating them, number one. So they end up being on a ventilator at and this is the data is out there, five to seven more days, because they’re immobile. Then somebody that you mobilize and are off the ventilator for five days before they need to get off the ventilator, right. It just use common sense. It makes sense to not do this so that they can get off the ventilator and not develop ventilator associated pneumonia, not develop the deconditioning, not develop the delirium, not develop the PTSD, not develop the depression, and not develop the suicidality.
Yeah. You I think it’s it’s almost malpractice not to, I mean, I that’s a big word I know. And it makes, it will make a lot of you uncomfortable. But you have got to think about what are we doing to these patients?
Kali Dayton
Is it in their best interest?
Louise
What are we doing? How are we going to help these people so that they can get their life back?
Kali Dayton
And that’s everyone’s desire and vision.
Louise
Oh, yeah. No one’s willing, Ill intentioned. It’s just that they just don’t know any different. Right? And so, you know, you, you so what I mean on multiple occasions, it’s telling them, “we got to get out of that box we’re in and you’ll see” and what I found too, which is really interesting is the more success they have, the more they’re willing to do it.
You know, I, I think of times when we just had to just be in the room, be in the room and keep that patient from being sedated and saying, “Just give me time.” Because we don’t do that it’s novel. You know, we use things like medications like Seroquel, we’ll use Depakote, we’ll use clonazepam instead of Ativan, because the clonezapam seems I mean, it’s a benzodiazepine. It’s the same classes at Ativan, but it seems because of its long, because of its long acting effects, it’s less sedating. And you can use less and have the same effect then. The first things one of the first things I do when I, when a patient comes in who has respiratory failure, I drop a feeding tube, so that I have access to give them oral medications and not IV.
Kali Dayton
And we I think that’s get away with really low doses of Klonopin like point two, five milligrams, and those are rare occasions as well. Right? A lot of people can get by with the non pharmaceutical therapies, such as mobility, and we’ll address in another episode, how we can address anxiety through activity, but it is amazing.
I see it time and time again, with our patients. I just had a patient say she’s requesting medications for anxiety. So I was asking her where her anxiety was coming from, and she was on the ventilator. And she said, “I’m tired of looking at the same four walls for hours on end.” And I said,”Okay, well, what do you think will help that?” and said, “I need to go for a walk.” I said, “Yep, we can do that.” And then she wrote, I don’t need meds, “I just need to walk.” And I said, “You said it better than I could have.”
Louise
and you know, I think that the, Kali makes another another really interesting point. And a good point is that we we can talk to our patients. And we should talk to our patients. And we should be able to- and especially in this day of all this technology, you know, you have an iPad, that can text you their answers.
And if you sedate them, they’re not going to be able to do that. If they’re so weak. I mean, they’re, we’ve had patients that were so weak that they couldn’t use a call light, so they’re not going to be able to type. And so, so. But if you’re able to talk to a patient and they tell you what they need, then you know- what better situation do you want?
Kali Dayton
And these survivors that talk about their experiences under sedation- they had needs they had pain, they had anxiety, they were panicked about their delusions, and they couldn’t reach outside themselves. And no one was there to help them.
Louise
I have an interesting example. There was a there was a patient- this gentleman was he had the Hantavirus. He was so sick for a week he was on 100% 25 of peep with PA02 in the 30s and 40s. And we we got him through that to the point where he was in the in the ICU for three months.
And I remember one night I went in and he was terribly confused but as I was talking to him, he was a Vietnam vet. And he was telling me that when I put the temperature probe in his ear, and it would be that beeping he thought was somebody with a gun sights set on him to shoot him
Kali Dayton
Oh, wow. yeah, they look like they’re sleeping and cozy to us.
Louise
We I mean we do this we’ve done this to our patients it makes me sick to my stomach.
Kali Dayton
But how does it make you feel as provider to know that you’ve been part of a change?
Louise
ah you know it’s it’s it’s been….. it…. to me, I have such convictions about why the change is so good that it’s worth everything that’s gone on. But… there’s been a lot of sacrifices. I’ve sacrificed personally personal relationships, professional relationships with people, because it’s such a passionate topic with everybody.
And because there’s so many much, you know, there’s…. I mean, the evidence is out there, but we don’t practice the the evidence. The last stretch evidence. I mean, you can’t dispute it. But people still use high PEEP.. So I don’t understand it. But I’m convinced that what we’re doing is the right thing. And it’s worth it. It’s worth it for my patients.
Kali Dayton
Thank you. Yeah, there’s such a contrast in practices, standard of care throughout even our own country. Despite all the research, I thought as an travel nurse. In the end, we have to do what we know is best for our patients.
In the end, we have our own ethics, our own conscience, to answer to
Louise
Yeah,
Kali Dayton
I think you’re a great example of that. And your passion, your teaching has made such a difference. I’ve seen nurses come in from other places and be really alarmed by the contrast in our practice. But through your teaching and example, those are the nurses that become some of the biggest advocates for it, because they have actually seen the contrast. They’ve seen what it’s like.
Louise
The other thing, too, is the ones that really are uncomfortable. I’ll just say, “I’ll be in there with you. It’ll be fine. We’ll see. I’ll be in there with you.” And that seems to be a good, it, it decreases their discomfort somewhat.
Kali Dayton
Yeah, they don’t feel alone in it, and they shouldn’t have to feel alone in it. I think, especially when we get patients from outside facilities that have been sedated. And then they come to us, and we say, “time to take it off.”
But there they are, by then severely delirious. It is scary, because a lot of our nurses have not seen that kind of delirium, because we don’t cause it, right? For the most part were able to prevent and avoided it. So when they’re, you know, you take off the propofol or whatever they’ve been on. And the patient is agitated and scared and thrashing. They have that panic, that they feel so vulnerable.
They’re afraid for their patient’s safety. And so yeah, it takes so much support to say “it’s okay, given hours, even days to clear out.” But once the nurse understands what’s going on, why it’s like that, and how to help the patient, and that sedation is not going to help them to that delirium, than they are right there with you. And they, they do so much work to keep the patient safe and help their brains clear out. And you can tell how excited and proud they are, because they’re so invested in their patient. The next day when they come back, and the patient sitting in a chair oriented.
Louise
Yeah, I was so proud of this nurse one time, her patient, or patient was coding. She was doing CPR. She was literally doing compressions. And she hollered out to the charge and the charges was was right there. Then she said, “Hey, will you make sure that my patient gets walked? I know the physical therapist is coming by now” I mean, while she’s doing compressions, and I was so proud of her, wow, because who does that?
Kali Dayton
Right? It’s like make sure my other patients alive. But it’s just that important to her to make sure that her patient still walked.
Louise
this whole cultural change, I mean, we we actually just a little bit of background, we actually opened an ICU to…. for the five other ICUs in the hospital that I worked in to send their delirious patients that were coming off the ventilator that was sedated. They would send them to our ICU and we would get them off sedation, treat their delirium, mobilize them, and get them up. And the first paper that came out was about mobility was early more mobility is feasible and safe. Came out of the ICU that we opened to get the patients off ventilators and had to be that specialized.
And so we I did that for I did that for 10 years of getting, you know, working side by side with the psychiatrists, and social workers, and getting these patients. Treating their delirium, getting them to sleep, getting the the mobility. And I haven’t seen a case that we couldn’t help.
Kali Dayton
No, it’s been an amazing honor to be under your guidance throughout this process because I came in so new and I still feel so new but I have learned from you that it’s worth doing the right thing for patients. So thank you so much for all you’ve done, Louise. and for sharing your true expertise with us. Thank you.
Transcribed by https://otter.ai
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