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Dr. Badke, MD, shares what it was like to shift perspective and culture as a new intensivist in the awake and walking ICU. He explains what role the physician plays in helping patients walking home after the ICU.

Episode Transcription

Kali Dayton

Dr. Badke, thank you so much for joining us.

Dr. Badke

Thank you for having me.

Kali Dayton

Tell us a little bit about your career path, what your experience has been what’s led you to be here now?

Dr. Badke

Okay, well, so I am trained in pulmonary critical care, I did my medical school training at the University of Washington, and then I went to Chicago at Northwestern and did  residency. And then I did fellowship in pulmonary critical care at the University of Utah. So I’ve seen different kind of hospital environments and different kind of ways people take care of critically ill patients. And ultimately, I ended up here primarily just because I like Utah a lot. And, you know, after fellowship, I, you know, wanted to kind of stay in critical medicine. And this provided me kind of a good resource to continue taking care of patients, but also kind of have kind of an academic, or at least kind of, I guess, more of a research based approach to taking care of patients.

Kali Dayton

You’ve been such a great fit for our team. It was probably a little bit of a change or transition as it is going anywhere new. Um, what were some of the changes that you saw? And what was that like to have a shift of perspective?

Dr. Badke

Yeah, so I mean, I think, like I kind of alluded to earlier, I think every every institution kind of does things a little differently. And obviously, the culture has some influence on that. And I think just in regards to managing patients on the ventilator, I certainly have seen kind of different kind of approaches. I remember in in residency, the usual order set was to get the patient intubated, and then start a fentanyl and Ativan drip together. And then, you know, once you’ve resolved their kind of septic physiology, or whatever they’re being intubated for, you would then kind of stop the sedation and kind of see what happens.

Kali Dayton

What usually happened?

Dr. Badke

Well, you know, sometimes when patients would kind of wake up and, you know, we would, at that point, they could have been probably extubated earlier. But they wake up and then we just pull the tube out. Sometimes, certainly, people would be super anxious, and you know, we’d have to give them more sedation, to try to kind of get things calmed down.

Often it ended up, like I said, I think people were intubated longer than they needed to be. And then when I started fellowship, you know, those drugs, specifically were becoming less used, and we’re using more propofol with kind of as needed fentanyl, that was kind of the usual kind of cocktail. In general, you would intubate somebody put them on a propofol infusion, in the same thing, kind of wait till their physiology improved.

And then, you know, each morning you do this kind of SBT where shut profile off, see what they did, if they were awake and, you know, improve their kind of respiratory mechanics, then we try to extubate them. So, so that was certainly kind of what I did up until kind of coming here.

And then when I came here, you know, propofol rarely ever used in kind of ventilated patients.  Sedation and generals kind of avoided, which is certainly a kind of a cultural change that that I hadn’t seen before, necessarily.

Kali Dayton

And what was that like for you? Did it concern you?

Dr. Badke

Well, I think that I think, not necessarily that it concerned me. I think what was more reassuring was this the kind… that of the staff was not concerned. I think a lot of, you know, our from the physician or critical care physician perspective, sedation was more an issue of whether the nursing staff and the day to day kind of staff take care of the patient,… how they felt and whether they felt comfortable,

Often, sedation was driven by, hey, you know, “this patient’s out of control? Let’s give them something for sedation essentially?” And, you know, from my perspective, I didn’t necessarily mind ordering that. You know, but avoiding it, I certainly felt like was probably better. And here seeing how calm the nursing staff was, and the culture kind of just revolved around kind of avoiding sedation, and everyone kind of knew that it made the whole process a lot better.  and from my perspective, I thought would be, you know, you know, I was a little surprised, just with that. You know, and then, the mobility aspect of what we do here is also kind of more than I was used to.

Kali Dayton

What had you seen across the board? Before?

Dr. Badke

Well, I think, well, I guess, so in things kind of have evolved, just like sedation has evolved. You know, I think in residency, there was always, maybe one or two patients on the unit that somehow magically was able to survive with the ventilator off sedation. The majority of the patients were, you know, “asleep”, or whatever, sedated. And, you know, then in fellowship, certainly, mobility, and physical therapy became a higher priority. And so we had more staff to help out with that. And with that, people are getting less sedation.

And then, you know, here, at least when we kind of really focus on mobility, and getting people walking as soon as they’re on a ventilator, you know, it’s made a big difference, I think for patient outcomes too.

Kali Dayton

What was it like the first time you intubated someone here? And then asked?

Dr. Badke

You know, one of the kind of standard things is least in fellowship was, you know, you would be putting all the orders and so you get the patient intubated. And then you put the vent orders and and then with that, you put in sedation orders. I often would just kind of ask the nurse kind of what they wanted. And so I did that here. And I said, you know, “Do you want…. should I just order a propofol infusion as needed fentanyl? ”

And they just kind of looked at me, like I was crazy and said, “No, we don’t use propofol here. Unless we, you know, if we don’t use it here.”  It’s that was kind of surprising. But kind of, you know, makes me realize you don’t you don’t necessarily need it.. And again, I think it just kind of goes back to the comfort level of the staff here, when it comes to kind of managing ventilated patients.

Kali Dayton

Yeah, I think culture plays a huge role in that. And I too, walked into this culture, I didn’t have to work on building it. It just was already here. And it’s continued. Once you see that, there’s no going back. It’s hard to then choose to sedate people and you’ve seen  how much benefit there is to them being awake and mobile.

Dr. Badke

Yeah.

Kali Dayton

What have you seen the patient outcomes that’s been impressive to you?

Dr. Badke

Yeah, I saw I will see some of these patients in clinic, you know, from a pulmonary perspective, you know, if they have bad pneumonia, or ARDS. I’ve seen some of them in clinic and they’re remarkably functional. Obviously, they’re, they’re not back to kind of what they were like, before their illness, but certainly they are living kind of independent lives and, and doing remarkably well. Considering how sick they were.

Kali Dayton

Do you see a lot of them able to go back to work?

Dr. Badke

I think so. Or at least some form of work. It may not be the exact thing they were doing beforehand. But anyway, sometimes it just depends on kind of the job they were doing. If it was a very physical, kind of intensive job. They’re not back to there. But certainly they are kind of at or close to kind of getting back to where they were before they got sick, which I think is important.

Kali Dayton

Yeah. Do you ever ask them about PTSD?

Dr. Badke

I personally haven’t. So no,

Kali Dayton

yeah, I think that’s probably kind of a new direction that we’re starting to head but no new research. Um, what was it like to see someone that you just intubated walking on the ventilator?

Dr. Badke

Well, I think again, it kind of shows you you know, my going through training, it was, again, you know, the people there was “just a very rare kind of, you know, person that could tolerate the ventilator without being sedated.”— That’s what my thought was that like, it’s just, you know, certain people can tolerate the ventilator, so people can’t.

And now kind of, as we’re within this environment, it looks like everyone can tolerate the ventilator. And walking them is even better in terms of kind of helping their anxiety and kind of normalizing the situation as best we can. I think that’s what walking, or at least mobility, does is it kind of normalizes. You know, the situation for patients. Just like the ventilator while can be uncomfortable, shouldn’t necessarily impede- just like a nasal cannula doesn’t necessarily appeal kind of function. So I think that, you know, again, as my kind of training kind of has kind of evolved, that’s become more of an everyday kind of thing, and now it is an everyday kind of thing.

Kali Dayton

And so as a physician working with this really cohesive team, what do you feel your role is in this protocol, sedation and mobility, and improving patient outcomes in the short and long term?

Dr. Badke

Well, you know, from my job is not really that I feel like influential, I really do think it’s driven by kind of the comfort of the nursing staff, the physical therapists, the respiratory therapist, and in my role is more kind of supportive. And obviously, kind of making sure that there are kind of medications available for anxiety and analgesia if we need them, but to focus on not necessarily sedating people, but to keep them as functional and as alert as possible. So, again, my my role is more to kind of enforce that, but not necessarily. I really think the staff here is what really kind of makes the change. Yeah,

Kali Dayton

I felt the same way. But having physician support and making those changes and continuing this little bit of a rogue or different kind of protocol has made a huge difference in it’s empowered and comforted the staff to continue on doing things that are different. So thanks for all your support and your awesome role in the team. So thank you. Thanks, Andy.

 

Transcribed by https://otter.ai

 

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