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In this episode, Kali talks with Kathryn, BCCCP. She tells us of her culture shock coming to the awake and walking ICU after years in units around the country and about the role pharmacists play in delirium prevention and preservation of function in the ICU. She also shares how this shift in focus has enhanced her job satisfaction.

Episode Transcription

Kali Dayton

Today we are with Katherine, she is a pharmacist and a medical surgical ICU. She has had a great experience in critical care and is excited to share it with us. Thanks so much for being with us, Katherine.

 

Kathrine

Thanks for having me.

Kali Dayton

So tell us what your career path has been like thus far.

Kathrine

So I went to pharmacy school in the Vegas area, I was an intern down there for about three years in one of the hospitals. And then after graduating, I did two years of residency. One in Memphis, Tennessee for my first year general. And then my second year was in Charleston, South Carolina, where I specialized in critical care. And then after completing that residency, I ended up moving here and took a job at our flagship hospital and ended up working in multiple ICUs. While I was there, I was there for about two and a half to three years before transitioning to this hospital. And now I’ve been here for almost three years.

Kali Dayton

And what was that? Like? I mean, three years ago? What can you remember about your initial impressions? Or how did your practice change when you came to a awaken walking unit?

Kathrine

Well, I think I think every part of the country I’ve been in practices just a little bit differently. I do remember when I went from my residency coming over here. I mean, people are just healthier. And in this city, then in the south. So um, that was one culture shock when you walk in ICU and not everybody’s intubated.

But then when I came over to this specific hospital, I even had a bigger culture shock because I had I saw people walking around on ventilators all the time. And then I just had to just start getting used to that at first, I wasn’t very comfortable with the fact that all of the intubated patients really had no sedation on board. Nothing continuous.

I mean, when I was a resident, I mean we’d have we’d have propofol on everybody. I mean, I even remember when we would, when I was being taught how to dose rapid sequence intubation meds that we would always go on the higher side because it didn’t matter because we wanted to make sure they were sedated and paralyzed for the intubation. And we wanted to make sure that they weren’t feeling any of that, which I 100% agreed with, I think my biggest fears to be awake and not able to communicate. So yeah, that’s one of the best implications for sedation, right? And so that I was totally on board with that.

But then the rationale that was given to me afterwards, because I was like, “Well, what’s gonna happen after the intubation?” they’re like, “Oh, well, we put them on sedation right away. So even if the paralytic hangs, hangs around for a little while, granted, they’re short acting, but even if it does, they will still be sedated. ‘They’re not going to feel any of this.’ ”

And, I mean, when you grow up in that kind of environment, you’re just like, “okay, yeah, that all makes sense. They’re not going to feel it, they’re gonna be ‘comfortable’, that’s great.” But here, it’s totally different. And so I actually even had to start recommending lower doses of the paralytic and sedation for the intubation. And, at first, I mean, at first, I would go with what I’m used to just kind of like the like for rocironium, I’m like a mg per kg. And because I was just so easy to remember it so quick. But then, um, and sometimes it tends to be like, “well, let’s just go a little bit lower” and I’m like, “Okay, well, that’s fine”.

At first first, I was really uncomfortable with it because like, I mean, “if they start freaking out, and I mean, I guess we’ll have more ready, we’ll just, we’ll just be ready just in case.” But then I started noticing a lot of these patients were actually fine with lower doses, which made me feel a lot better. And then, especially when we intubate a patient, and then they’re not being put on sedation, I mean, I would rather than get a lower dose of a paralytic, as long as they’re able to still be intubated.

And so moving here, I, I really had to just, in my mind, just cut the doses that are the first thing that comes to mind. And sometimes we don’t even know the weight of a patient, you kind of eyeball it, but then you eyeball on a low side. And that has worked out fine over the past couple years. And I haven’t really seen any sort of adverse event that has occurred because of us, giving lower doses and what I was trained to do, and, and then these patients are, I mean, sometimes they don’t really like being intubated.

But then we try other measures instead of full on sedation, stead of just throwing them on a propofol drip or something along those lines. And so and, I mean, really, it’s just great to see those types of patients and actually see this because you read in studies how great it is to do early mobilization, even as he’s like, simple as dangling on the side of the bed, and all of that, but I had never actually seen that in practice, like I would read the studies from, like, the institutions that were, which were published publishing them, obviously. But it was like such a big thing where I was like, man, early mobilization is great, but I don’t really see it, doing it.

Yeah, we would, in my training, we would always do sedation vacations, but then I felt like those weren’t ever really done well, because they turn off the sedation, and the second, the patient would start moving, they would just turn it right back on. And it’s like, well, it’s really not how it’s even supposed to be if we’re doing a quote unquote, “sedation vacation”, right.

Kali Dayton

I never learned those. Because, like when I started because we didn’t sedate, we don’t have to do vacations. Then when I went as a travel nurse, that’s exactly how I was taught to do it. You turn off the propofol off just long enough to see them flail. And they’re like, “so then you know, they haven’t had a stroke, turn it back on.” Because “obviously they can’t tolerate it.” And I just could feel that wasn’t right. And I’m always wondering, “okay, but what is their neuro status? Like, that tells me nothing? Yeah, other than they’re freaking out.”

Kathrine

And it’s hard to really get an accurate neuro status when they have just been weaned off of sedation. And I would always ask those questions when I was training to just like, how do you know, really where they are? I mean, if they’re, if they have, if they’ve been hanging out with a RASS of negative four, and you get them to a RASS of zero, do you really think that that point is the right time to be doing it? Or do they go from negative four to like positive two, because now they’re just becoming a little bit more oriented. And now you want to do a neuro exam. None of that ever really made sense? To me. It hasn’t worked.

Kali Dayton

Like from a pharmacy perspective. When you turn off sedation is sedation off, or the the still under the effects of that medication?

Kathrine

I mean, it’ll still linger. I mean, it depends on which what we’re using. But I mean, it’s still gonna linger in your system. And every patient’s a little bit different as far as when they would totally metabolize the drug, for the most part, like propofol would come off pretty quickly. But I have seen some patients who’ve been on propofol drips for a long time, and it takes them a couple hours to come out of it, depending on how much they’ve been on. And then those were the other things do is we would turn it right back up to the exact same dose. And really, I mean, it should have been cut. I mean, if it takes them six hours to wake up after turning it off, that’s a problem.

Yeah, so the whole time during training, and like some of the other hospitals I worked at, I just never, it never really felt right. But I was like, well, maybe I’m missing something. I mean, I’m just the learner. So I’m just trying to understand, but then coming here and seeing nobody on sedation was It was exciting, but then also terrifying. Because it’s new and yeah, because it’s new and I was like, “How are these patients not freaking out? How are they able to just be calm breathing through a straw, essentially not that I’ve been awakened intubated before but that’s what I hear what it’s like it’s like you’re breathing through a straw.”

And the we just like a walk around and see patients on the ventilator just like texting away or watching TV and just calm. And then I mean, I hear the nurses doing their CAM ICU tests. And they’re passing and I was like, “This is fantastic!”

Kali Dayton

Yeah.

Kathrine

And so it was so cool to actually see true early mobilization. See what true light to no sedation truly looks like because I mean, all through. I mean, my training was, I mean, from school through my residency, and then even that other hospital that was probably five to seven years of my life. And then I come here, and I mean, now I’m fully adjusted.

So now when I walk into the unit, if I see somebody on a Ativan drip, I freak out a little, instead of it, instead of it just being a normal thing when it used to be just a couple years ago. Standard. Yeah, it would just be like, “Oh, they’re intubated. They chose to do Ativan this time on this person, because they have a history of alcoholism makes sense. Totally fine”.

Kali Dayton

But when do you start asking if you see something like that? Like I hear you ask questions. “Why do they need it? What if we tried this other option?” How has this impacted your thought process? And then your practice?

Kathrine

I’m really every time I see it, I want to know why. So if I, if I know that somebody is on a sedating drip, even propofol, my question is always “why?”. And so I’ll start looking through all the notes. Start asking questions, just try to figure out exactly why. And then if it’s “well, they came, they came in and they were crazy. They were flailing. It’s like, okay, so when was that? At what point?” because I mean, they weren’t here when I was on when I left at three o’clock. They weren’t here yet. “So how long have they been on this drip?” And I mean, you would think that I could tell this from the chart, but I can’t always.

Kali Dayton

Yeah,

Kathrine

Another thing too, especially if they get transferred from an outside hospital. I also don’t know if say they were there for a couple days. And they never really wean them off of propofol and what was going on over there. So I just tried to get as much of a history as I can. And then push as much as I can to see how far we can take those doses down how far we can titrate it. And I mean, when we’re on, say three or three different sedative meds, because I’ve seen that before, I mean, that’s also a red flag to be like, “Well, do we need all of these? Can we take one off?” Can we just use I mean, there’s even the PAD guidelines talk about analgosedation.

So do you actually need the sedative meds? Can we just use the pain meds? Especially if they have reasons for pain. And that’s- I think that’s great. But does it even need to be a drip? can it just be intermittent? And so I mean, it has changed my view, as far as I mean, as far as it’s not, like, drips are bad. But why? versus it being a normalcy? And so now, I’m always asking why I’m always trying to figure out how we can optimize our sedation limited as much as possible, because I know as a unit, the goal is get them up, get them walking, get the mobile and we can’t necessarily do that if we have a patient on high dose propofol or even sometimes high dose fentanyl, especially when it’s a drip.

Sometimes we’re not really able to do that. I mean, granted, you have some patients who have just high tolerance. And then so sometimes if they’re getting 150 mcg an hour of fentanyl, that’s nothing to them. But for normal person, it’s something so solid be like, oh, so I don’t even even matter what starts Yeah, what’s their history and why? But it is it’s true. It’s here. It’s an exception. And I mean, gosh, I can’t even remember the last time we had anybody on a sedating drip for longer than a day without without trying to turn it off without without any sort of intervention. I mean, I mean, I guess that without one patient who’s still here, I guess the first like two to three days were a little tenuous, the alcohol withdraw. Mm hmm. And she was in she and she also has a baseline anxiety. And so we were trying to balance all of this. And I know it doesn’t help when she comes in and she’s intubated. She has chest tubes in and everything and so

Kali Dayton

she spent days being deeply sedated and so she was coming out of the sedation, that she withdraw severely delirious out of septic shock. So yeah, she was really tough and yet still,

Kathrine

yeah, tha was amazing, because I just know from because I saw her when she came in and I saw how crazy she was acting. And to see her now to see her walking around the units, doing multiple laps and interacting with everybody, it’s amazing. Because I just know that if she was at literally any of the other hospitals that I have been at, she would have just been sedated this entire time. And then I don’t even know if we would have been able to even get to a point where anybody would feel comfortable enough extubating her. And now she’s extubated. And granted, her lungs still are sick or really sick. But I don’t even know if they would have tried because of how bad they looked. And so….

Kali Dayton

She would have been trach’d for sure. Because yeah, started so weak, and she’s been here for weeks now. And no, that would never been an option, she wouldn’t be able to even lift the finger for now.

Kathrine

And she has very low muscle mass at baseline. So I mean, even when I just look at her serum creatinine, and I’m like, she has no muscle mass. So I can’t even imagine what it would have been like had she been in bed this entire time. Because since she’s been here for so many weeks,

Kali Dayton

and her anxiety would have still been there. Even with sedation, we just it would have been “easier for us”. But she still would have been terrified underneath the sedation, but we wouldn’t have been able to treat her she would have known about her family being there. Her dog. Yeah, all the other things that we’re doing so and I appreciate it, especially in that situation, because it was so hard. She was a lot of work. She was so much work to take care of. I know that if I was practicing anywhere else, I’d probably have some knocks on my door requesting and demanding protocol. And it would have been in the name of her comfort, right? That’s the perspective that would have been shared. No one ever asked me. They just were saying, “What else can we do? What you think?” And then you were offering suggestions, and we were all talking about it together. But it was never, like, “Get her out of my hair.” It was just,  “How do we help her through this delirium and keep the tube safe?”

Kathrine

yeah. Yeah. Without totally knocking her out. Yeah. But like, we’ve had a number of patients. And I want to say, she’s probably the she’s the top one. When I think of patients who I know would have just been completely sedated from the get go. She’s probably the top of my list now. Yeah, cuz I remember that. And just seeing how far she’s progressed has been amazing.

And then, I mean, we have so many patients who are on the ventilator having high vent requirements. And granted, that’s like, not my thing. But I mean, I still know what’s going on enough. I mean, when you’re on a PEEP of 18, I really don’t see anybody else going down the road of even trying to get them up and walking or moving them. But we do and it’s just it’s an it’s an amazing thing to see in the culture that has been built here.

Like it’s one of those things that I never want to change. And I would hope that as new people come in, they adapt to this kind of culture, even though maybe where they came from, like me, they aren’t comfortable with it at first, but then once they see the benefits and how great it is to limit the sedation. And I mean, we do a great job to like when we need to put patients on like, say, the anti-anxiety. So if we have to put patients on anti-anxiety meds or sedation meds that, like we limit the doses as much as possible. Only go up if they have proven they needed it. We, I mean, I try my best to schedule these medications, like especially the sedating ones right before they go to bed, so maybe can help them sleep.

I mean, I think the biggest things for delirium that I’ve seen beneficial is all the non-pharmacological things. So I mean, in all honesty, I know I’m a pharmacist, but I hate meds. Yeah, so as much as we can limit them, I think that’s gonna be the best thing we can do. I mean, family coming to help orient them during the day. I mean, the whole sleep wake cycle, I mean, even things like turning on the TV, opening the blinds getting light in, during daytime hours and trying to not let them sleep during the day and, and trying to be quiet at night close, close the door closed, like turn off the lights, like close the curtain, anything we can do to help them sleep. I think one of the biggest interruptions are labs, but I mean, I don’t know how to really fix those types of things.

Kali Dayton

If they have a continuous labs. Yeah, but the other ones…. Yeah, we’re we’re working on trying to get those later in the morning. We don’t need them at three in the morning, right. But that’s so awesome that you have that perspective. You’re not just there to do a chart check. But you see the big whole picture.

Kathrine

Yeah, and I think one of the other things that we’ve talked about in the past is that mean part of my job is collecting med histories and making sure we know exactly what the patients have been taking at home. I mean, if I see somebody thing that could affect how they’re acting, I bring it to the NP or the doctor. Say they’re taking, I don’t know, we’ve seen patients on like morphine, extended release 40 milligrams TID. I mean, just, I mean, they’re gonna have opioid withdrawal if we just give them nothing, but more of a heads up.

Like, if they started going crazy that might actually be the way we need to go is give them some opioids versus trying clonazepam or something along those lines. And so, I mean, it’s just, I love how we have such a great team, how it’s really like when they talk about an interdisciplinary team, like it’s true. And so some of the other facilities that I’ve been at, they actually…. the physicians hated the pharmacists interventions. And that was hard for me, especially being a learner and trying to put myself out there and trying to just make myself feel more part of the team, especially when you just get shot down every time because they realize you’re the pharmacists. And it makes it so hard to be able to get any sort of intervention done or take enter by those types of physicians.

But here, I can’t even I can’t think of anybody who wouldn’t at least hear me out. And I also feel very lucky because I always have a nurse practitioner close by. So instead of having to go down the paging system, I just walk around the corner and ask for clarification on something or see what’s going on. And I feel like it’s not inappropriate for me to be asking all of these questions about the patient’s like, has their status changed, like I even did to this morning, just so that I understand why we’re changing the treatment plans, because sometimes I’m not part of those discussions, which is totally fine. But I like to know exactly what’s going on. And then it helps me to when I have to pass this on to the pharmacist who’s coming on either tomorrow or covering taking over for me tonight.

And it’s just, I guess, every time I’ve even thought about, “Are we going to move one day? Are we going to like get..  should I be looking for other jobs?” If that were the case, it’s like, I don’t even know if I would feel comfortable working in the same facilities even that I used to work out because the practice, I would feel like I’d have an ethical dilemma. If I would see, patients just constantly sedated. And I know that there’s all this talk and all this movement about lightening up sedation. And I mean, I can’t speak to every single facility across the country, obviously. So I mean, there could be one that practices like we do, but from what I hear and the things because I may still have friends across the country, and I still like keep in contact with them.

I mean, sedation is an normalcy. And so like, even when I mentioned to them all, we we walked people on the vent, like who are on the vent all the time. It’s just like a big team effort. I mean, there’s probably anywhere from five to seven people walking around with a patient. And I mean, if they’re really mobile, I mean, sometimes it’s only like two.

And I just don’t know if I could go somewhere else, even within this same organization, to see patients just completely knocked out. I mean, I was even just talking to my husband recently, because we’ve been talking about getting our living will set up and I told him, if I ever go into the ICU, you better make sure that they limit my sedation unless there’s something going on. And I was like, I’m just gonna have to give you my NPs numbers. And you’re just got to talk to them about it, because I just have seen so much benefit from it.

And I’ve seen so much more harm from heavy sedation over a long period of time. And granted, we always just attributed it to delirium this I mean, “they’ll get past this”, but then there’s even more to it. I mean, even the, the postICU, PTSD and the stories that I’ve heard patients say. Like I recently went to a conference, and this was a topic of discussion. And there is a patient who was speaking about her experience and some of the things that she was saying in the like, what she thought was happening in the room. I mean, had nothing to do with the hospital. I mean, I think she she was talking about how there were like certain animals in her room and trying to like get rid of them. And it was just it was so crazy to hear those things.

Because you I guess we don’t necessarily know what kind of damage we’re doing, even if we feel like it’s a short period of time when they leave. I honestly think a lot of that has to do with the meds and so like the heavy sedation. So, being here in this ICU in this house, hospital, I feel like has now fit me the best because I have now changed my mindset with sedation. And I’ve changed how I practice and what I recommend and how I move forward with like med reviews.

Because at the end of the day, I want the patients on as little as possible. Even even if the meds aren’t necessarily fully sedating. I mean, if we have patients on meds that have a side effect of sedation or something, can we return these can we do other things. And that’s where my mind goes now, especially when we have sedating type meds in them in the middle of the day or in the morning.

And I mean, even like steroids, I try to make sure those are timed as early in the day as possible, because I don’t want them getting that at 10 o’clock at night. And sometimes sometimes when we do big dosing, I even give the second dose kind of mid afternoon, because I just don’t want that to add to their potential delirium or feeling a little, a little nuts, you know, and the more you do, like, if we were to do true bi, D, and had it 10 and 10. I mean, I feel like that would be me doing a disservice to the patient, you know, because I could, because I mean, steroids kind of wake you up. Yeah. So then they just get this whole this jolt of steroid when they need to be going to bed. And so like, those are the things that now crossed my mind, which where I can honestly can’t even tell you if those were things that I thought of prior to being in this unit,

Kali Dayton

Well, it’s not relevant, if they’re sedated. You don’t see them when you don’t see them be sleepless, right? It’s irrelevant.

Kathrine

Yeah. Yeah. So I, that’s why it never really mattered in me. And actually, those types of thoughts would run through my mind like, “well, they’re just put on sedation this whole time. So timing doesn’t necessarily matter.” But now it does. And I just feel like I play a bigger role now in trying to limit these types of things than I have ever before. And I do feel grateful to be here to be able to see these types of changes. And these are the types of things that I hope would go to other hospitals. And they would see that I wish there was a way that other hospitals could see truly our outcomes and see our patients who get discharged and are able to go home and they don’t fear the ICU. That if they were to get sick again. They would be okay coming back instead of fearing the all the hallucinations and coming back here and LTACH after.

Kali Dayton

Yeah, the whole long journey that they talk about.

Kathrine

Yeah, it’s just, it’s amazing. And I never really realized the impact of what an ICU stay can do on a patient until I started hearing the stories and hearing about patients who have PTSD from the ICU, and it’s some it’s terrifying.

Kali Dayton

Yeah, I’m with you. It’s that like there’s no going back after hearing these survivors, wow can I ever look at a patient under sedation and dare think that they’re sleeping? Yeah. I mean, we have a guy right now, that was an alcohol withdrawal. And he’s delirious. And my heart hurts for him even more than it ever did before. Because now I have some suspicions of what he might be experiencing and what his life will be like afterwards.

And it has just brought totally new insight. So it is such an honor to work with fellow clinicians that have the same vision of long term outcomes that have the big picture and every little thing that we do throughout our day for these patients, and to be able to collaborate and really talk about these things. I’m grateful for pharmacists, because you have such a valuable expertise that I don’t have. And I’m grateful that you catch things and you look at things in a different way, and that we get to work together towards the same goals.

Kathrine

Yeah, well, but that’s why I think our the whole multidisciplinary team and that approach to taking care of patients is so valuable, because there are things that I also don’t think about that, say, affects the respiratory team or that affect the PT or OT team. And just the fact that I mean, we all have our special, like, kind of narrow focus view. But then when you bring it all together, it’s just, I mean, it’s amazing, really, and the we just have such a great team, and just how we all work together and how it really is a joint effort.

And I mean, it’s in our nurses are fantastic. I mean, I can’t say enough about what I see them do. I mean, my office is like, next one of the patient’s rooms. I mean, I can’t really get away. I mean, I see I see them walk around, I see them go crazy. I see them screaming. I mean, I’m, I’m there too, so it’s not. It’s not like I’m just one of those who’s sort of watching from the periphery that’s down in a basement like it used to be. I mean, the pharmacy world has come a long way. And that I love I mean, I never knew the time of there only being pharmacists down in the basement processing orders. Because I mean, I only I mean I graduated 2012. So I’ve been out for a decent amount of time, but not very long to see the big changes. But I love being on the floor and being able to interact face to face with the nurses.

Back to med histories real quick. Like, it’s also amazing that I can go into the room and collect a med history on an intubated patient. I mean, we just have them write things down. Or they just if I have a list from from whenever just because it just imports sometimes into our system, I just read them off to them. And they’ll shake their head there. They’ll nod and sometimes I’ll try to trick them because I just don’t know if maybe they’re so confused. And some and sometimes they are sometimes they’re not.

But then I can ask them. “Where do you get your meds at?” and they can write it down for me? When that was never an option. But when they were intubated, and there was no family around and I had nobody to talk to it was like, “well, we won’t know what meds they’re on until somebody shows up or they get extubated”.

Kali Dayton

And we don’t even know their names. They’re on sedation. We get to actually know patients and they have a voice.

Kathrine

Yeah. And so I think what we’re doing and especially what you’re doing sharing this with the world is just amazing.

Kali Dayton

Well, I would have nothing to talk about if it wasn’t for the whole team. So thanks for being willing to share that with us.

 

Transcribed by https://otter.ai

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