SUBSCRIBE TO THE PODCAST
Kali talks with Patty, a nurse, about what was it like in the early phases of the “Awake and Walking ICU” and how the new practice was introduced. We ask how the culture revolutionized in spite of opposition and who rejected the change? How did nurse Patty go from incredulous to emphatic?
Episode Transcription
Kali Dayton
Over 20 years ago, research was starting to understand the long term effects of sedation and immobility. Yet even back then, the cultural cement in critical care had already long dried. Sedation was pulsing through its veins.
When the “Awake and Walking ICU” was being born, what was it like for seasoned nurses? How was such change introduced? Who embraced it, and who rejected it? Patty and Stephanie join us today to share with us what it was like to be part of a cultural revolution.
Today, I’m here with Patti and Stephanie, some of the pillars of our ICU and some of my main mentors. They’re gonna share with us what it was like 20…. how many years ago?
Patty
I would say 17 years ago.
Kali Dayton
Yeah, when this kind of culture and process started. So Patti and Stephanie, thanks for joining us today.
Patty
You’re welcome. Thanks for having me.
Kali Dayton
So I know, Patty, you started in a shock trauma ICU. What was it like back then?
Patty
Sedate and really no activity… And had the attendings, nurse practitioners, taking care of all the patients?
Kali Dayton
And so how did this concept of totally flipping that culture come to pass? Who, who came and said, “Let’s wake them up and move them?” And how did you feel about that?
Patty
I do believe from the respiratory unit, the nurse practitioners came up Polly and Louise, and they were like, “we should start moving our patients.” And that’s how it sort of got implemented.
From the “old fart nurses”, we got a lot of pushback, because they didn’t want to do that. And I think it comes because of fear, uncertainty, vent settings, yada, yada, yada. But we were able to weed out all those stuff. And then we were able to get them at least to the chair for the first six months and then slowly graduate to ambulating.
Kali Dayton
And how did that feel for you like when you first….because you had taken care of patients that weren’t moving the whole time. So were you excited about that? Or did you have some questions?
Patty
Yeah, totally. Questions, right? Like, “Really? You really want to try to move the patient with the tube?” you worry about the tube, you worry about hemodynamics, we still have the swan and stuff like that in trauma patients, like how much can they do we have a line in the groin, just different stuff that people were just really worried about, but we did it.
Kali Dayton
So we started by just getting them to the chair… was there a lot of buy in by the staff in general?
Patty
I would say 50/50.
Kali Dayton
Okay.
And then how to go from getting to the charity, actually walking on a ventilator?
Patty
I think we asked for a physical therapist, I think, and then they will help us mobilize the patient is how it worked out.
Kali Dayton
So you were doubtful at first?
Patty
Totally.
Kali Dayton
Which was funny for me to hear, because I’ve seen you guys as some of the biggest advocates! When I came as a nurse, I didn’t know anything, right? But I saw you guys being so natural, so comfortable with it. That’s hard for me to imagine you ever be obstinate or doubtful about it. So how did that change for you? What changed your perspective and your practice?
Patty
I would say they got off the bit much quicker. They were able to still keep their muscle muscle strength, right to be able to breathe and move. So that was really good to see. I think. What else?
Kali Dayton
Stephanie, you’re one of them.
Stephanie
Well, what do you say my perspective is much different. Because our working in med surg ICU, we when we get the patients from shock trauma, and they had been sedated, it seems like when they took off the sedation, they sent them to us, and we got to deal with the delirium.
Kali Dayton
Okay.
Stephanie
And it was a lot of agitation, and lots of sitter patients and trying to keep them in bed. And yeah, it was difficult. It was physically exhausting.
Kali Dayton
Yeah, it is way more work when they’re delirious.
Stephanie
Way more work. Yeah.
Kali Dayton
So then when?
Stephanie
Yeah, yeah. So at that point, I mean, it was a lot more physical therapy. Let’s try to get them up. Let’s try to get them tired. So they’ll maybe get some rest…
Kali Dayton
and not wear you out.
Stephanie
Yes, that were us out.
Kali Dayton
That’s different aspect too.
Stephanie
it was a totally different totally. Yeah.
Kali Dayton
I just had a friend text me he’s, you know, he wants to incorporate this kind of culture into his Ico and so he texted me said, “I tried to wean the sedation off this patient, but they’re really agitated. What what do I do?” I said, “Get him up.” But “he’s agitated?”
I said, “but get him up.” And so he did. He had no support, like no one would help him walk the patient. So he just took steps with him. And the patient had just been there for a little while. But a wore him out so much that he slept all night he was said, “I can’t believe that worked, I’d never would have thought of just moving the patient been the treatment for anxiety.” But his night, as nurse, was better because of it.
Stephanie
Exactly. We found that to be true as well as the more agitated they got. It was like, “Okay, it’s time to get him up. Let’s get him walking, moving, if we can, and are up in the chair and wear them out.” And then if they would rest and sleep, their brain would start functioning better.
Kali Dayton
And you had a better day,
Stephanie
and a better day the next day.
Kali Dayton
And so after seeing what it was like to have people sedated and immobile, and then to have to the crazy delirium from all that. How does that play into your practice? Now that you’re getting people from day one? What does that do for your practice? And how you approach managing patients on the ventilator?
Patty
We get them up! I think that’s really helpful, I think, because the day and nights that it gets confusing, right? So we try to have that day night routine, see what they could do, because they’re not coming in kinda, they’re coming in walking. Mm hmm. So, and minimal sedation as possible, feel their brain functioning clearly. And so they can interact.
Kali Dayton
And well, how do you see patients? I know that, you know, you guys have done this for so many years. 12 hour shifts are long, but what do you see when you’re managing patients as far as what is your vision for them? Because I hear you guys talk about things. And I hear you talk about weeks from now. And I’m always amazed, why not just get through your shift and do what is convenient for now, what do you see for those patients?
Patty
I see them getting better if they can move. So….. that’s what I do, right? Like, so my thing is, is basically get in there- I don’t care how much support they’re on, get them up on the side of the chair. That’s the first step, the first thing I would do, I would assess them and get them up in a chair.
If I have to time down, and restrain them, that’s fine. And then have the sitter help me for sure. And then keep doing that. And then in the afternoon, when you get them up much stronger, they’re able to do more stuff to in the afternoon. So you can calculate all the days they keep doing that day and night, and evening, they’re going to be able to keep their strength.
Kali Dayton
Right, you don’t put it off. So…. you come in with someone that’s maybe a little shocky or a lot shocky. Um, they’re really bad respiratory failure. You do whatever they’re capable of in that moment. But I think there’s such an inclination to wait till later, right? “We’re going to just treat the infection now and then get them up later.” But from your experience, what does that do?
Patty
This prolonged being intubated? Yeah. And your weakness continues? Right. Your weakness continues.
Stephanie
I think back. I mean, it was scary thinking. “You want me to get this patient up in they’re on pressors?” And I mean, it was frightening. And now I don’t even think twice. It’s like, “Well, we can do that.”
Kali Dayton
And we’re not whipping people that are on are crawling blue on the ground. Right?
Stephanie
right.
Patty
That’s correct. That is correct. But you have to make common sense decisions, right? If they sit up and they’re dropping the pressures, and they’re almost foot pressors. Well, we try again, in a couple of hours, right? Maybe there’ll be better, you know?
Stephanie
Yeah, see what they can tolerate?
Kali Dayton
Yeah. I think even sitting up there holding their heads up. And that’s going to help them get excavated later. Swallow later, all the things…
Stephanie
Work their core.
Kali Dayton
Yeah. And so when we get patients from other facilities that have been down for weeks or more, what about like? Like, how do you just took care of a guy that was prone for eight days with COVID-19? Correct? So when you first got him up, what was that? Like? That was just eight days.
Patty
Yeah, so I slowly titrated that sedation down to see where he’s comfortable. But he couldn’t even hold his head up. He could even sit up. He was flimsy all over like nothing. He was just like, jello.
Kali Dayton
Did that scare you?
Patty
No, I just knew he was weak, because he was sedated.
Kali Dayton
I think everyone’s really afraid of falls- this big liability about falls. So how did you ….What gave you the courage?
Patty
No, because we have our physical therapist, and then I had another nurse helping us out. So one, you know, held his head up, so we could support his head and then the other held his back. And we just sat there for 15 minutes with them. I mean, that’s all he was able to do after those eight days of straight shot sedation.
Kali Dayton
Which I think mobilizing patients isn’t a general ICU skill. Because when you just trach and peg them and send them to LTACH, you’d never developed that skill of moving an adult sized newborn. Right? But you as a team, you guys were comfortable with that.
Stephanie
And that’s the key word isn’t it? — TEAM.
Kali Dayton
Yeah, I think what I hear from the PT world sometimes is they don’t have very much support from the nurses that the nurses will even put up excuses of “well, the patient didn’t sleep well that night” or, or “they’re tired right now” or they’re, you know, “we’re busy.”
Patty
They’re lazy, right? Right?
Kali Dayton
haha I didn’t say that! But I see you guys…. But physical therapy comes in, and a lot of times, you guys already have your patients up in the chair, they’re writing on a board saying, “I’m ready to walk with PT”. So how do you see your relationship with physical therapy?
Patty
Pretty positive. I mean, we rely on the help. You know, they’re very helpful. They’re like, “Hey, do you want me to take them to the bathroom for you?”, whatever. They’re part of our team.
Stephanie
They’re invested as much as we are. And also the respiratory therapists are amazing.
Patty
Yeah.
Stephanie
And it takes a lot of time for them to come in and help us walk people on to vent.
Kali Dayton
And how do you coordinate that? With the respiratory therapist? As far as like, when you come on? You see, “okay, we’ve got seven vented patients, and they’re all gonna walk.” So who does that? When? How do you coordinate that as a charge nurse?
Patty
Physical therapy? That’s right.
Stephanie
And usually it’s between the bedside nurse and respiratory and PT,
Kali Dayton
They coordinate, make a plan, they all find a time that works for them. It’s just amazing. It was so much going on. It always happens. I mean, these patients walk three times a day. Do you ever feel like that’s excessive for your patients?
Stephanie
No, no, I did at first. Absolutely.
Kali Dayton
How did you find time for it?
Patty
In between 10 to 12. hahaha There’s downtime when we don’t have to give meds. I think that’s a good time to do it. After you do your 10 o’clock vitals and boom, you conquer your activity.
Kali Dayton
I like that. So there’s kind of an ingrained timeline. Yes. Same thing in the afternoon. Yes, it’s just a little more calmed down- we aren’t doing rounds at that point.
Patty
I’d like to after two o’clock, I think is good. And then we sit down until…
Kali Dayton
and the evening we don’t have a physical therapist, and yet, still does it. They still get them up.
Stephanie
They’re as passionate as anybody.
Kali Dayton
I just think it’s it being safer. We’ve done it from day one, because you don’t have to come back as severe weakness. Patients are already walking sometimes without, oftentimes, without a walker anything. So there’s not a huge fall risk. It’s just getting that stupid ventilator and oxygen ready?
Patty
And have someone hold your pumps and everything else?
Kali Dayton
And chest tubes? And yeah, vacuums and all the things but yeah. That’s pretty amazing. And how do you teach other nurses to do it? Or what do you do when other nurses come and they have a totally different background and culture?
Stephanie
Watch and learn. They have no other choice, right? hahah That’s right, watch and learn and you’re doing it and I think they feel comfortable. Like once they see us making adjustments easy, like putting the tube somewhere else that the patients are not gonna pull. I think they just see that done. It’s easily doable.
They PT coming in, they say that tech coming in to help they see everyone just taking their place.
Kali Dayton
And it is a magical orchestration. Like I remember, when I was a brand new nurse, I had no idea but everyone just kind of carried me through it. And but it was “Welcome to the unit, This is what we do.”
Patty
Yeah, no choice. Please hold the tube.
Kali Dayton
Yeah. haha
And how has that impacted your career as far as fulfillment in your career?
Stephanie
Oh, it’s very rewarding. Extremely rewarding to think of how many people do not have to go to a care facility and can actually go home and be functional. And it’s just, it just boggles the mind sometimes.
Kali Dayton
Especially in such long and productive careers as yours, how many people have you, not just like, maintained a heartbeat or got their lungs better, but you’ve preserved their functionality, their humanity? Because you let them be awake and be human moving while here? ‘
Patty
Yes.
Kali Dayton
What other pearls of wisdom would you share with the ICU community?
Patty
I don’t know… except move them. Get them up and moving. Like, that COVID patient walked out of here.
Kali Dayton
Yeah.
Stephanie
Yes.
Patty
Pretty impressive being in the hospital almost 3 weeks?
Kali Dayton
Yeah.
Patty
So it’s better to be active and be proactive for your patients, because they’re not going to be. Yeah, you don’t want them to lose their strength.
Kali Dayton
Well, you’re kind of a “tough to love”, Patty. I mean,
Patty
yeah.
Kali Dayton
You get the patients that are obstinate and don’t want to move because we know that you get them one way or another to get going, but
Patty
haha I don’t know why.
Kali Dayton
That’s why because you come in, you’re like, “Here’s how it’s gonna go!” Right? But you both do it so lovingly, that that patients trust you, they’re willing to do it. They see the confidence and the vision that you have.
Stephanie
And there are those patients that are so frightened.
Kali Dayton
Uh huh.
“Oh, I’m gonna fall…” and if you just take it slow and easy… our physical therapists are amazing at talking them through everything. Yeah,
That’s true. I hear you. I mean, you have such a nurturing voice. You just come in here like, “here’s what we’re gonna do. It’s gonna be great. It’s gonna be fun. “But you do amazing work and you change so many lives and giving people their true lives back. Thanks for all you do and for teaching our team and preserving our culture here all these years.
Stephanie
Well, thanks forall you.
Patty
Yeah, thanks for all you do too.
Kali Dayton
Thanks for sharing.
Transcribed by https://otter.ai
SUBSCRIBE TO THE PODCAST
