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Kali talks to Alex, about what is it like to jump into an awake and walking ICU as a travel nurse. Alex shares with us her first shock and impressions upon entering a different culture and she teaches us the changes and wisdom her practice has gained.

Episode Transcription

Kali Dayton

What is it like to go from a normal ICU with a culture of standardized deep sedation for all patients of mechanical ventilation to an “Awake and walking ICU?” ICU travel nurse, Alex give us personal insight into her own culture shock.

Okay. Today I am with Alex. She is a travel nurse from the West Coast. And she came to the awakened walking ICU with lots of experience and a different perspective. And so we’re going to talk today about her culture shock. Thanks for joining us, Alex.

Alex

You are so welcome.

Kali Dayton

So what was it like coming to the awakened walking ICU, initially?

Alex

Well, I first got here, and I didn’t have any knowledge that you did not sedate vented patients. So I walked in and I got my assignment and the patient was a week and I was just really confused. But I was well, yeah, I mean, without any introduction. At first, I was kind of just like, “I don’t, I don’t understand,” like, without being told this what they were doing, or any of the…. I could see the rationale immediately. I was like, “Okay, I understand, like, why we’d be doing this,” but I just didn’t know the steps and like how that how that would even look. So I felt unprepared. But at first at least.

Kali Dayton

And what could what was the shock? What was initial gut reaction?

Alex

Um, if I mean, my first thought and like most of my friends when I told them that they work in like the ICUs on the East Coast, my first thought was, like, “If I’m ever intubated, like, I would rather be sedated.” You just think that that’s like, it’s kind of inhumane, like, people want to be sedated if they’re on the ventilator, because why would you want to feel that? But then yeah, so I guess I was just like, “Wow, this seems cruel.”

Kali Dayton

Yeah. And was that patient that you first saw? Were they struggling? Were they anxious? Were they writhing? Where they pulling out the tube?

Alex

No, we walked in the room, the patient was just like, chillin. And they’re just like, hanging out their family. They’re writing comfortably being able to communicate. And I was like, “This is odd. Like, I wonder if this is a one time thing.” But then, but then I repetitively saw patients that were like, way, chill on the vent and not sedated. And that was like, after you keep seeing that, then you feel a little bit more comfortable with it. But yeah, at first, I was kind of just like, “what, how, how?”

Kali Dayton

And so you reached out to your other friends? Yeah. What did you say to them? How did you explain it?

Alex

I literally group texted all my friends that work in the ICU and said, “Do all of you sedate your vented patients?” They said, “Are you kidding? Of course!” And I was like, “Well, actually, they don’t here in Utah.” And they were all like “What?” Like, everyone was shocked. I thought maybe I missed something. Like, we just didn’t do that in California. And I checked on all my friends who work in Boston, in New York, and I was like, “Hey, you guys do this?” And they’re like, “No, never before.” So I was like, “Okay, this is just a Utah thing.”

Kali Dayton

But yeah, for now, maybe? Yeah, I think it’s starting to move. But um, what was it like to walk patient for the first time on the ventilator?

Alex

Um, I mean, it was helpful to have respiratory there. So I was like, “I don’t know if this patient is going to like…like, I don’t know,” I just like didn’t know like, yeah, I would have like increased oxygen needs, which sometimes I do usually, like walk them on 100% I guess just fine. It’s like walking someone on more oxygen. And they’re on baseline when they’re like, on a nasal cannula or something, right.

But yeah, I kinda was just like, “If they’re not sedated, they’re fine.” You just assume that like, someone’s not me walking on a ventilator. So you just don’t it doesn’t make sense in your head. I couldn’t really picture it.

Kali Dayton

Yeah.

Alex

Then we did it. It was super easy. But I mean, you’re holding a lot of things. But like, aside from that, it’s still easy. They’re fine. And the patient was ready for it. It was great, actually. I mean, it’s obviously very good for the patient. Like, it makes so much sense. You’re on the ventilator, you’re wanting to get better you’re walking. It’s like, Duh.

Kali Dayton

So yeah, with that, how’s your perspective changed?

Alex

Yeah, I mean, it’s just like, it might be hard to as travel or to like, go back to seeing patients like on the vent all the time, sedated. I feel like I’m going to be really, like, supportive of trying to wean sedation and probably get a lot of pushback. So I’m actually not really looking forward to that.

Um, yeah, I think that it clearly seems like it has benefits to the patient. And so like, it added benefits, early mobility, which I worked a lot about a lot in my last job. We really didn’t talk about, you know…  we talked about getting patients like extubated earlier, which seemed easy because a lot of them were cardiac surgery patients. So they weren’t here for respiratory or anything. So it was kind of a little bit different. But I think that like talking about early extubation is great, but when that’s not an option, talking about like, weaning sedation is more important, but it didn’t seem like we’d reached that topic yet.

Kali Dayton

Right, and how do you see a difference in outcomes? Granted, you weren’t working with real respiratory failure cases that usually require extended amounts of time on the ventilator…. But why do you see this benefiting the overall outcomes of patients?

Alex

I mean, it just seems like with early mobility and less delirium, like less concern for “why are they confused?” Or “Is it because they’re on sedation for so long?” Just seems like they’re obviously going to spend less time in the ICU. It’s great. I mean, it’s money saver, it’s better for them. Like, I don’t see any bad outcomes, really!

Kali Dayton

Isn’t that awesome?

Alex

Yeah. It just seems worthwhile to try everywhere. It seems like this is like should be news that more people are talking about.

Kali Dayton

Right. But I think the standard is kind of your same perspective. People don’t even know that’s possible. We just….  especially when we started careers, we just do what we are exposed to. It just no one really questions it.

Alex

I hadn’t even thought of it. I mean, I was like that early mobility champion. And here I am, like not even considering like, “Turn off sedation.” – Like, why would we do that? Like, yeah, it wasn’t at all. It didn’t seem like an option.

Kali Dayton

We just cut the cord between sedation and ventilator.

Alex

Yeah, right. It just seemed like they go hand in hand. Like if you are we’re gonna like have a doc write an order for a Ventilator Bundle,  it would come with an order for sedation, right? But it like almost always does, I guess. But yeah, it doesn’t have to.

Kali Dayton

Yeah. So now, what would your personal preferences be?

Alex

As far as like sedating versus non sedating?

Kali Dayton

I mean, they’re really you were on the ventilator?

Alex

Oh, I mean, yeah, I definitely don’t want to be sedated. If I don’t have to be like, I didn’t know, it was possible to have, you know, good experience on a ventilator not sedated. Yeah. I think like when you’re initially like, if the patient is initially confused, it is kind of a hard, you know, experience there. And sometimes you do have to use sedation, right? They’re really confused. They’re fighting the ventilator. That makes sense. But I think like giving all the patients an option to not be sedated. And then sedating. Once you like know whether or not you have to is like the route that you should go not like sedate everyone, assuming that everyone needs it, right? Like give everyone a chance to not and then kind of backtrack if you need to.

Kali Dayton

And you’ve seen some like recent, we’ve had some recent kind of hard cases where I’ve had some light sedation?

Alex

Yeah.

Kali Dayton

And how do you see that managed differently as far as getting sedation off quicker? Do you see a difference in goal when we use sedation?

Alex

Yeah, definitely. I mean, I think like, I wouldn’t say that Doc’s here are necessarily stingy about it. Because if a patient needs it, like they’re happy to write for it, but we use things like we use, like small doses of precedex or fentanyl, or, you know, rather than like, just like overloading people with propofol and everything else. I mean, it’s like, and then as soon as you’re ready, like the patient looks a little bit more like they’d be ready to come off of it. It’s very easy to take off. And it’s yeah, it’s a lot easier to transition. It’s not just it’s not so abrupt, it doesn’t seem.

Kali Dayton

So I had a nurse online say, I’m sure with good intentions, but “I want my patient so sedated. I don’t want a muscle twitching.” So now, what would you say? What would you say to that? Besides “woof”? hahaha

Alex

I mean, like, if you’re trying to come at it from like, another perspective, you could, you could offer her the fact that it’s like, way easier to do your assessment when the patient’s not sedated like that, like, how do you? How do you know what the patient’s functionality is? Or what like any of their mental capacity is? If you’re not…. I mean, being able to complete like, at least 50% more of your assessment, because the patient is not completely knocked out is super beneficial to helping you shape their care and get them, you know, out of being in that state.

So it doesn’t make any sense to me. I mean, yeah, from like, an easy, standard perspective. But that’s just a nurse who’s probably been at the bedside in the ICU for way too long. Like to see somebody like a vegetable, that’s not what we’re here for. And make me your shift a little bit easier. But like, that’s not the bigger goal over here for.

Kali Dayton

Awesome, I love it. Anything else you would share with the critical care world?

Alex

I don’t know, not at the moment. I think that I think that it’s important for travelers who are like getting all these different experiences to go out and try and give back in a way that like, brings information to new hospitals. It’s like, the easiest way for information to circulate. So I would like to see hospitals maybe ask for our like travelers opinions a little bit more.

The last facility I was at, like asked what they were having a lot of trouble with CLABSIs. And they’re like, “hey, as a traveler, what have you seen another facilities?” and I was able to sit down with their team, and like, give them a bunch of information. And they found that super helpful.

So it’d be really interesting to watch more hospitals, maybe involved travelers and their decision making, like when they’re trying to rewrite policies and stuff like what are you seeing other places? Because otherwise, I don’t know. It just there’s a lot of information out there. And it’s not being transferred quick enough, because each hospital is doing something great, but we’re all working so independently, like in silos and it’s not. Yeah, it’s, you know, it’d be beneficial if we all worked a little bit closer together.

Kali Dayton

Yeah, that’s how we get stuck in a rut. Yeah, exactly. That’s a good point. Well, thank you for sharing your expertise and your experience.

Alex

You’re so welcome.

 

Transcribed by https://otter.ai

 

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