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Kali talks to Jim, about what is it like to be “born” into an awake and walking ICU and then be immersed in a different culture. Jim shares with us his culture shock and ethical turmoil as he strives to maintain his best practice in a new environment.
Episode Transcription
Kali Dayton
What is it like to be “born” into an “Awake and Walking ICU”, knowing nothing else…. And then to leave? When I left to be a travel nurse after a few years in the same ICU, I struggled with the new world of dim lights and comatose patients. I was young and unprepared for such a change.
I didn’t understand the history and culture of sedation, and I struggled to find answers. I would ask doctors and nurses alike. “So why are they sedated?” And they would look at me like I was a complete idiot and say, “Because they’re intubated.” And I still wouldn’t understand. And I would ask again, and again, “Why are they sedated?” And they would keep answering me, “Because they’re intubated!”
I couldn’t relate to them. I didn’t understand what was going on. And I had a complete culture shock. Now we have with us, my former colleague, Jim, and he will share with us what culture shock he experienced in a new environment, and what he has learned from it. Jim, thanks so much for joining us. Can you tell us a little bit about your career timeline?
Jim
I am working in medical ICU in with quite a wide variance of illnesses that we treat, they’re kind of the overflow from neuro cases, strokes, things of that nature to seizures, as well as some occasional cardiac items, but most of the time, respiratory and other underlying health conditions. I’ve been working in this current facility for almost a year now coming from another facility that had a different cultures where I worked all together for roughly four years.
Kali Dayton
That sounds like this from when you were talking before. You and I have had similar experiences as far as… I was “born” in that ICU that you came from as well.
Jim
Yes.
Kali Dayton
And I was there for two years. That’s all I knew as a nurse. So similar patient population is the one you just described- a lot of the patients are on ventilators. And it was just normal. And then I had a huge culture shock going as a travel nurse to somewhere else. As you mentioned, so what was that culture shock? Well, first of all, what was it like being raised in a place where patients were awake and walking on the ventilator? What was that like for you as a nurse at that time?
Jim
Well, just just at the beginning of my nursing career. It was it was just the given it was it was what we did, it was an understanding of the best for our patients and realizing ultimately…. because even during that nursing school and all the education that’s out there. There’s a multiple factor on the side of things and even even trying to reach out to find some sort of research information in regards to ventilation without sedation there’s not a lot of information out there right now.
And so working in this environment initially was a huge asset to me because I just took for granted this is this is what goes on and as I stepped out, and I’ve worked in several other ICUs outside of the the initial ICU where I’ve learned all the sedation-less ventilation and early ambulation, it was it a very surreal experience to be… it’s the most common forms of your practice are suddenly halted. And you get into this routine of doing the best you can for your patients.
And that’s the mindset you go in and it’s horrific to suddenly…. it’s almost like getting punched in the stomach, because you’re just like “woah, wait a second- this is what we’re doing?” The idea is best for our patients and the overall best to to help our patient populations regardless of their young or old.
It’s been it’s been a surreal experience to come from from from an experience of walking extremely sick patients on high peep settings high fi02 and to and and having multiple teammates numbers there, for a physical therapist, a respiratory therapist and the entire entourage of personnel, helping one person do the best they can and striving, and also knowing in the back of your head that you can see the results. And you can see how much stronger they are, even if they only do take five or six steps.
And then you take that and seeing the positive in it. And then you’re suddenly faced with something in a completely different form. It’s much like traveling internationally, and you get off the plane, and suddenly you have no idea what people are saying to you, because you don’t speak the language.
You’re just you’re you’re you’re in a surreal moment, like panic trying to figure out, “How do I communicate this information?” And and it’s even more troubling when you start to see the decline of the patient population, because these protocols that you’re so used to using aren’t in place.
Kali Dayton
Such good points. So what part of having your patients awake and moving do you miss, as a nurse, like from each shift? What do you miss about that?
Jim
So regardless of intubated or non intubated, one of my greatest experiences as a nurse has always been able to talk to people, talk to patients, talk to patients, families, getting to know them. Getting some background, knowing whether they’re in pain, knowing what their concerns are knowing what what’s going on. If they’re having any dreams, if they’re not able to sleep, because they just can’t fall asleep, maybe they’re in pain, maybe they’re dizzy.
You can’t do this on sedation, you have no idea. And then on top of the fact that, it doesn’t take long, especially in an ICU setting to have somebody, and I am fortunate enough to say at least where I’m at now that we, as sedation is used more, we at least doing extremely well with our skin protocols. To where skin breakdown is something that is addressed right away.
But there there are other facilities out there that that literally are used to sedating in these patients, and they’re out. And very rarely do they even get nudged and moved. And then poof, they’ve got more underlying problems, and you can’t communicate with these people. Some of the greatest things is, when you’re in a in a situation where where you have a patient that’s ventilated, and they’ve got their Yonker suction in their hand their call light in the other hand, and they’re changing the channels on the TV while they’re intubated while they’re sitting in a chair.
Oh, there it is. They have that ability to see that their mind is intact to where they know: “this tube is in place to for life saving practice purposes. And if it comes out, I’m in trouble.” Does that always happen? Does it stay in place when it wouldn’t? When patients are unrestrained and ventilated?
No things happen. But it’s being able to communicate with these patients. And and it is so important. It’s the worst day of their life. They’re in the hospital the worst day of their life. They’re ventilated, and And that maybe the just first time. What about these patients have had this numerous times, horrific experiences, we don’t need to keep reliving a nightmare with these with these patients.
Kali Dayton
Yeah, that is so powerful. And the first time I ever walked into an ICU, as a student, nurse and nurse told me, “I work in ICU so that I don’t have to talk to people.” And it crushed me. And so I felt really at home in that first ICU, one that I work at, and the one you started at. Because there was a culture of wanting to interact with their patients, knowing who they were knowing what their needs. Where it is just like you said.
Jim
Yes.
Kali Dayton
So now what is it like? Now what is your connection with your patients like?
Jim
You know, I wouldn’t necessarily want to compare that the mindset that I have as to what the mindset of a soldier has. But there’s there’s definitely some similarities, when you’ve trained a certain way, in a certain position, and a certain direction, a certain attention to detail.
And and and that’s taken away from you, but that’s still ingrained in your practices. And and is there is there a time where where sedation is appropriate? Yes. And I will always say that, at some point there, there may be a time where sedation is necessary. But it is it to a to a minimal amount in certain certain circumstances and situations. But by all means, every time I I’ve said to some of the other staff that I work with, regardless of their nurses, or doctors or residents or, CNAs, they look at me with the most horrific look on their face, like, “you’ve got to be kidding me. I would have to be sedated to get through all this.”
And that, and that was my main point with them is, “No! You wouldn’t, you’d only have to be sedated for a short time to realize this is the worst experience you’ve ever had.” And it’s a difficult transition to try and prove a point that. You know, to prove a point that, it is a viable and a workable solution, that can be harnessed and used.
And again, the the biggest the biggest situation here is we’re in this line of work to help people get better, we’re here to help people to progress and if they’re not, to bring them comfort to bring them to know that they have the best care possible. It doesn’t matter where they’re at this is this is the mindset I go into.
And so it, it’s, it’s been difficult to sit and be a part of this. But also, I’m in control of this too, because as I’ve been trained. I’m so grateful for that ability and the direction from multiple NPs to the you know. You want to talk about the, I’d hate to use the terms, “Grandmother’s of this sedationless ventilation and early ambulation”. That because I know, as Kali would know, that both of those two (Polly and Louise) would not like that similarity.
They had such a phenomenal way of presenting things in their sternness, and their attention to it is what drove this and and, and I take that with me every single day. Because as the culture has been to go off in this other direction with sedation, you see the decline of of normal, healthy functioning adults to, to just slowly declining, slowly declining. And not only not only mentally but but but physically and and that is the most heartbreaking.
Because I’m used to a culture of people walking out of the of the ICU, I remember taking care of people twice my age, coming off the ventilation going to, to medical floor, and they’re out walking me because they they’ve been so well taken care of them, they’re still strong enough to move themselves that it is a it’s a good feeling to see that but to suddenly have that yanked away. Again, it’s like getting punched in the gut, you get that you’re out of place. But you got to try and do best for your patient.
Kali Dayton
Yeah, that is painful to know that certain outcomes didn’t have to happen. And what are you seeing now what is so painful for you to watch?
Jim
There’s a massive amount of it. We’re all creatures, you know, humans just have this natural ability to just follow the same protocol there. We’re all creatures of habit we get into these routines. And that I think my biggest concern is losing, getting so caught up in the culture of where I’m at. But I’m also very hard headed to try and move forward with trying to get more education with just asy ou’re doing, Kali, as far as trying to get nurses to realize that this is a possibility.
But the biggest thing is to point out factors, and I hate to use anyone even using the term as “guinea pigs” here. But when when you see certain circumstances or even regardless of circumstances, that you see multiple different ailments come in through the door of a trauma. One hospital in an ICU setting in a medical ICU setting, you start with somebody in their in their early healthy ages of 20 year old mid 20s, 30s up into the 40s and 50s.
And you have people that are that are capable of taking care of themselves- had an active lifestyle regardless of their background regardless of they’ve had any addiction issues regardless of of any other other things. They were able to care for themselves, and they were able to do it without a lot of problems.
And you see this decline in them, just in atrophy in their body. You see the decline of their ability just to just to do this simple list of things. I think the most difficult part of this is is knowing that it does not have to be this way it can be changed.
But it’s climbing a very steep uphill slope to try and get changed in any direction. And so part of this is it has been so hard to be able to push, but also trying to take things in a direction for best patient care, I can walk in with my patient who’s on a high rate of sedation, or, when combined with some high rates of pain control, and I can titrate that down. I can work my schedule in on a two to one ratio, to know that the usual protocol and routines of SBTs and making sure that I’m in a room for enough periods of time.
So I can try and orient these these patients out of this sedation. But I also get more horrified at the fact that I can do everything possible to bring this patient observation and not. And that’s what I tried to do. But again, you’re stuck in a culture of “Well, it’s-you sedate ventilated patients”.
So what happens, you come back from a shift after you’ve worked so hard to bring people down off of their sedation offer their pain control, and they are responding. And they are doing what they should- only to see that you everything you’ve done is just completely washed away.
And so it’s another uphill battle. And as days go on, it gets worse and worse, and worse delirium sets, and you’ve got more more problems with with with the mind than you do even with the body. The mind is such a powerful thing and that it is so hard for me to even wrap my head around some of this.
I come into, into nursing with a with a….. I naturally feel what people are going through. I take that to heart and seeing that fear and terror in people’s eyes- I want to try and help come up with that. And I can’t do that with sedation. But I can do that off of sedation. It’s just a battle morally, to see what’s going on.
And the amount of patients that end up having to go to rehab after the fact where I came from, originally, where that very rarely would that happen. More patients were coming back in or even having to worry about rehab. When you’re talking about a 20 year old that that’s that’s functional that suddenly has to go to rehab. Because they declined physically so much.
And then that’s not even to talk about the horrific experiences that they’re going to have with PTSD and the and the mental dilemmas that they’re going to be facing in the future as well. And it’s knowing this is the part of the problem. Because I take that to heart so much. So it’s it’s a difficult situation to know that this does NOT need to happen. There can be a more positive way to treat our patients.
Kali Dayton
And this is just reaffirming to me all the things that I felt about your patient care when we work together. You are so compassionate and you care so deeply. We’ve also been exposed to the realities of sedation, you’re talking about PTSD. I don’t think most nurses even know that sedation causes delirium, which causes PTSD.
You’re talking about functionality. That’s hardly ever a discussion in the ICU. We’re just trying to treat an infection. But we’re not thinking about the big picture. I mean, Chris Perme a couple episodes ago, she talked about how 90% of the time as a physical therapist, you can ask a nurse or was this patient walking before they came into the ICU? And the nurse can’t tell her- but you know that. You care. That’s your focus.
So how does that understanding and focus drive you to turn down sedation because…. and tell us, what is it like when you come on and a patient has been deeply sedated with no breaks, no end in sight for days, and you take it down? How is that response by the patient different than what you saw in the past when you let patients wake up after intubation?
Jim
So I will add that that there are, there are protocols in place for for SBTs. So there are moments where where patients are coming off the sedation, but, you know, coming from an environment where you don’t have to worry about that because patients were off the sedation completely, but do it.
But a lot of what’s happened is…. again, it’s like trying to climb an uphill battle- because everybody needs proof. Everybody needs the realization of what the possibilities are. And, it’s the simplest things. I’ve talked to other nurses that have been in in the same unit as us, Kali. And have now gone outside of the area and other ICU settings where their mindset now is- sedation is NOT sweet- it’s delirium. Their focus is completely driven in a different direction compared to the culture there now.
And that’s and that’s what I’ve been facing. When I sit down in rounds, and I have pharmacy looking at dosages of medication going, “Wow, this is this is this is an enormous amount of medication for this patient.” And that the usual comeback on a lot of this and in some of the rounds are the responses by the nurses, “Well, this is the only way we can keep them ‘comfortable’ “.
Well, you know, pharmacology has been forgotten in a lot of ways in this situation. Again, the culture is… that “You sedate your patient to make sure they’re ‘comfortable’ “. If they start wiggling around, guess what we get to give them a bolus because “we don’t want to deal with the squirly patient. We want to we don’t want to deal with a difficult patient.”
That the mindset is is as you know, “we’re going to sedate, we’re going to sedate, we’re going to sedate.” And again, it’s not having the ability to even know what happens after the fact. It’s it’s this closed off mindset. But… what about tomorrow? What about next week? What about, what about a month later? What about what about so the bigger side of all of this?
We’re fortunate enough to have some strong physical therapists, occupational therapists, where I’m at now they are they are phenomenal. And and I’m grateful for that. Because the biggest majority of them know that if they could get off sedation, they can do their job in such a better way. They can prevent more problems for the future. They can do their job at a in a better way. And they know this, but again, they’re faced with a lot of what I’m facing there.
They’re all for when I start mentioning, “Hey, have you ever heard of sedationless ventilation and early ambulation?” And you know,walking walking patients on ventilators?” And you know they are aware of it. They know because that’s their goal -that to help these people get better, to build their strength to help them. So, that being taken away, and just as we’re having that conversation earlier, yes, you have physical therapists and occupational therapists, and they come through and they say, “How’s this patient doing? When are you going to do your SBT so that I can assess them?”
Then it’s “Oh, well, we can’t do anything because they been on sedation, and so much sedation.” But one of my biggest goals, when I go in with it with a ventilated patient on sedation, is again, there’s a window of time here that I have to plan out my day in a more functional manner because I’ve got to organize my time to be able to spend some time in a patient’s room. Because I know when they start coming off as sedation, they have no clue as to what’s going on.
Suddenly, they’ve got a tube stuck down their throat and they’re restrained or bed and they hear beeping in the background… or maybe they don’t hear beeping. You don’t know what’s going on. And this is a recurring nightmare for them because as SBTs going on, they’re waking up and then what happens immediately after BAM they get right right back on sedation. They’re right there right back there because that’s the culture! That’s the mindset with multiple ICUs nationwide worldwide. That’s that’s the mindset, you’re going to sedate them again.
And so as this as this battle goes on, my job has been to give the best care for my patient. So as I as I go in and I spend some time with this patient and I get to pull off their sedation, I get to pull off their their fentanyl drips. Do I turn them all the ways off? Not always because some people are legitimately in some pain. But sedation is typically taken out of the picture.
And I’ve, I’ve had moments where I’ve had a patient that was ventilated, sedated. And throughout my shift towards the end of it, I have them sitting there and loosely restrained. And it’s a comforting feeling to look at them and see them holding their yankauer suction, or see them in their true form. I know that is the best for them. And I have experience with it.
And yet it’s also a little concerning when I see other staff coming in and they see a loosely restrained patient, and they panic. They’re panicked, because they’re thinking “They’re not sedated, they’re moving around! There’s problems here.” So again, it’s having to re educate and trying to, to change people’s ways, and people’s views of what’s going on. And people need to see it to believe it. You can say anything you want to the culture, but you literally have to see it to believe it. Coming from from where I did I, I saw it on a daily basis. And that was such a huge, massive benefit to me stepping into this scenario.
Kali Dayton
And it is so hard and can feel so lonely to be alone in that mentality, that perspective, that understanding in a culture like that. Have you had any good responses? Have you been able to I mean, when people run into tackle your patient and you stop them say, “no, they’re okay, they’re safe, they’re oriented, they wouldn’t dare pull out there tube.” They’ll look at you like you’re crazy. But is there ever any are there any seeds planted you start to see growth and other people? Has there been any progress made?
Jim
Very, very, very, very slow progress. Then of course with ongoing pandemic, it’s even more heightened, or more more difficult to get some positive feedback on it. But yeah, there’s been some some good experiences. One per se, was was where I did have somebody off of sedation. I had that patient literally holding the Yankauer, and there’s other staff that it had opened to sedationless ventilation and early ambulation as well. There are people on board, but they also realize the uphill battle.
But yeah, I’ve had several instances where I’ve had a patient that was sedated, that is now not sedated, that was restrained, that is not restrained, and they are very well aware that that tube is in place for their life. And, I recall one situation where I was getting ready to take a break and get something to eat. I turned to my nurse who was going to be taking my patients and told him, “Hey, I’m just gonna go take a break real quick. Don’t worry, she if she needs anything- suctioning or anything down the down the tube, she’ll hit the call light because she’s very well aware of what’s going on.”
He looked at me initially kind of panic stricken, because she was not sedated. And I said, “Well, not she’s she’s okay. She’s loosened or strained in there, she can move her arms around, she’s not going to get to the tube but I’m not going to immediately take off restraints, but eventually I will.”
Fortunately there happened to be an additional staff member that both you and I, Kali, had worked with before, that that was working there as well. During my moments of my lunch break had actually responded in a in a beneficial way too, so there was two of us there. But the comment either the nurse that was taking my patient was, “Well I’m going to turn the propofol back on once I get into the room.” And I said “No no, you don’t have to do that. Don’t don’t do that we’ve we’ve made a lot of headway so just sit out here in the nurse’s station and let her and make sure she’s okay. You’re not even gonna have to do anything. I’m not going to be very long. So just just wait there.”
Well, as he just kind of sat there and looked at me not not really understanding or knowing what to do. By the time I came back with the help of another another staff member who we, you and I both worked with, had gotten her up to a chair and unrestrained, and the aides were in the room doing our hair- getting it untangled from the glob that she was doing due to sedation.
And so they were they were doing haircare and they were doing so doing some of this care for her. As she’s sitting there looking over, and you know, her true personalities coming out. The patient is is trying to smile with an ET tube, kind of waving at us and and the suctioning her own mouth with her yankauer. She’s sitting there texting her family- and this was an older elderly woman. And as I kind of chuckled to myself, and I looked over at the nurse that was watching over this patient, he just sat there he said, “This is unreal, this is this is unreal. I wouldn’t believe it, if I didn’t see it.”
That that’s just it, you would not believe it unless you saw it is kind of the culture that people have at this point. But that’s kind of the uphill battle on some of this is to get people like that. And once you can get patients, and that’s what I’ve noticed, is that once we can get these patients to it to a point where sedation is off, and hard pressed to some nurses are to get sedation started again……… once they see that a patient is comfortable and able to handle intubation and handle ventilation….. There’s a different mindset that goes through like, “Oh, wow, this is this great.”
But I think it’s, you know, in the back of their mind, and I’ve even heard them say that, you know, that “They’re in, they’re in pain, they’re in discomfort. So what are you doing? You’ve got keep them ‘comfortable’ and get them sedated?”—– No, you don’t.
And that’s kind of, again, trying to try to re-educate and hey, remember pharmacology, hey, remember what’s going on here? With everything we’re putting into these people. We’re not keeping these people “asleep”. We’re not doing the best for them for their recovery on all of this.
Kali Dayton
They’re not really “comfortable”. Like changing that whole definition is….. that alone is a battle. But people understood the terror that they live under sedation, the pain that they’re in, the anxiety….. is the reason why when you take off the sedation, they’re thrashing.
The first time I learned SBTs, was a travel nurse. I learned that you turn on propofol just enough to see them flail all fours, and the hurried turn it back on, because “obviously they can’t tolerate being on decreased sedation.” And I remember being so confused, because I didn’t see a ton of delirium, let alone had learned that that is caused by sedation, because we didn’t deeply sedate everyone.
So it took me a while to realize that WE were causing that. I was just so young. I didn’t have the capacity to really explain it to these people. They’re not just uncomfortable-they’re terrified because they had been living in the battlefield and their brains this whole time that you’ve been sedating them.
And so as you’re taking them out of sedation, that’s what they’re doing. They’re panicked from their own reality, but it takes someone like you has experience, expertise, and the patience to sit there and work them through that and take the time for it to clear. Because it doesn’t just turn off the second you turn the button off, right.
And if it’s been on for days, it’s it’s been deposited into their fat tissue, it takes a while to metabolize. So it’s scary for people like that. It they look uncomfortable, because they are it is distressing. So for us as the caregivers, but it’s not for the patient, right. But that is a whole new level of expertise to sit there and walk someone through delirium and know that it will clear out. But it takes that experience that perspective to know where they could be on the other side of once the delirium clears out which well, yes, they can be themselves again, like you said, you’re such a good advocate of that. And thank you so much for sharing that with us. What else would you share with the ICU world, especially during this COVID season?
Jim
A lot of it is is seeing and knowing. Again, the mindset of sedation overall…. and again, I feel there is a time and a place for certain situations for sedation. Yeah, but in when it comes right down to the the “average”, I hate to even use that term, the “average”…. but when it when it really comes down to it even in the COVID situation here….. sedation is NOT sleep.
You know, and I remember that getting driven into my brain as a new nurse working in in our unit is: Sedation is NOT sleep! You know, the brain is not sleeping. I remember what you know, one of one specific intensivist we worked with there, Kali, that he was saying, “You know that the mind is not sleeping, you know that the sedation is not it this sedation is not helping them nor helping their brain” . So that is just as ingrained in my in my head.
I am I’m I’m a very stubborn individual. And, again, coming from from a background of being a patient myself and knowing uphill battles and knowing the fight just to get back to a normal, semi normal way of life. I know PTSD, I know, trauma, and I know mental dilemmas that that kick in, I know that personally. And so when I hear about what is going on with, with sedated patients…. and I hear, and I see it going on, it’s heartbreaking. It is absolutely heartbreaking.
To experience somebody that’s delirious, to experience the confusion, to experience that the breakdown of the the human body and the human soul, for that matter, is heartbreaking. Especially when you know, things can be different.
And it’s this battle, but I’m stubborn. And I’m going to continue to push just as you have, Kali, to try and educate and try and make some changes. But I also realize, it’s a tough battle forward. But I also know that that it’s the squeaky wheel. You know, the more I continue to push my point, and the more I continue to have patients off sedation, but the more I have patients that are able to do the jobs that they’re doing….they’re doing things that they can do, even they’re even on a ventilator- is is the first step.
We’ll take this in stages, and we’ll continue I’ll continue to push for this. And I’ve got a handful of other staff that are behind me, that are wanting to do this as well. And so it’s a slow progression, but I am anxious to get through this. But, you know, I remember sitting down with multiple media stories that have come out about some of the biggest battles with with the ongoing pandemic with COVID was the real battle that these patients are going to be facing after intubation– is is the PTSD, and the delirium, and just the battles in their own brain. This is going to be their biggest battle.
And as if you anyone in an ICU setting that has dealt with with COVID patients, it’s a horrific, horrific virus. And we’ve seen very strong, very healthy individuals get hit so hard, so fast, that it is frightening to watch. It’s not just the elderly, it’s just not certain, certain populations that are getting affected by this. And that’s the heartbreaking part of all this, as you see the general population out there.
But I remember taking care of a patient that was he was he is a very strong individual. And he was he was having some PTSD, within a day or two after being extubated and able to talk – he was horrified. He was afraid to fall asleep. He was, and that was the first mindset of how corona is really taking over. Also how important it is because here’s somebody who was young, who was healthy, who was recovering, and now has to deal with the the mental side of all of this. And also knowing that this is going to be a battle for him as well. But if this could be this could be prevented if we had a better understanding and a better culture without sedation.
Kali Dayton
All of our COVID patients right now that have survived have walked out the ICU, even after being prone for eight days. So you’re right. If there’s established culture, we have that same focus, despite all the challenges that faces of maintaining their functionality, and also preserving their cognitive function and keeping them emotionally healthy through keeping them awake and, and safe from delirium. Maybe doesn’t have to be so bad afterward.
Jim
Absolutely.
Kali Dayton
I’m just in touch by how much you care and your willingness to do the extra work to choose the hard way and not just going with the flow. It is so easy to say, “When in Rome” and just because it’s easier to sedate. It is you just get through your shift. I had a travel nurse just recently come up and ask for an Ativan drip. And I said, “What?” and she said, “or valium. Either.”
I was just so shocked and I said, ” but then who’s gonna clean up the mess?” And she said, “What?” She had no idea what I meant. Right? But that’s you. You’re coming in and you’re willing to to try to clean up the mess and do what’s best for your patients and that is hard. Polly knows very well how lonely that is and how hard that is to be the only one with that insight or perspective, but you have a lot of research, you have friends you’ve helped behind you and I wish you the best of luck in the revolution. I think, yes, you are going to make a big difference. Jim, and thank you so much for sharing this with us. I appreciate your time.
Jim
Appreciate the opportunity.
Kali Dayton
Thanks, Jim.
Jim
Absolutely.
Transcribed by https://otter.ai
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