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What happens to our culture and practice when patient volumes and needs exceed our ICU capacity? How does this impact short and long-term outcomes? Dr. Dixie Harris shares with us the reality of ICU care in NY during the COVID19 pandemic.

 

Episode Transcription

Kali Dayton 0:00
You were listening to walking home from the ICU, we will be exploring how to save and preserve lives in the ICU. All opinions and views shared are unaffiliated with any organization.

These past 40 episodes we have discussed in length how avoiding sedation and increasing mobility in ICU patients improve overall mortality and quality of life. We have been developing this understanding throughout extensive research over the past 20 to 30 years. Yet, in the past two to three months, our critical care community has been flipped upside down. After all the progress we have made in improving outcomes of ARDS survivors. We have now seen an 88% mortality rate in patients on ventilators in New York.

Unknown Speaker 1:10
What happened? Is it just this new virus? Or are there other factors impacting patient outcomes. We learn what happens when our best practices, our resources, and our advancements, and sedation and mobility in the ICU are no longer available to us. Dr. Dixie Harris gives us insight into the importance of maintaining adequate staffing ratios, hospital resources, and cleaving to the sedation and mobility practices. We know drastically change outcomes for the better.

Kali Dayton 1:44
Dr. Harris, thank you so much for joining us. Can you introduce yourself and a little bit of your career timeline?

Dr. Dixie Harris 1:49
Sure. My name is Dr. Dixie Harris, and I’m a pulmonary critical care and sleep physician. And I initially after training I practiced in Pennsylvania for 10 years, and then I moved to the current place I’m practicing. And I’ve been here for almost 15 years.

Kali Dayton 2:10
And you had a very recent, I don’t want to call it adventure, but a big experience up in New York. Yes, I had the opportunity to travel to New York State to be part of a disaster relief team during this COVID crisis.

And what was that like? I mean, we’re here in Salt Lake City, Utah, we’re facing COVID. But you’ve stepped into a totally different COVID world? Can you give us a little insight into what those circumstances were like?

Dr. Dixie Harris 2:41
So we were before I went, I kept hearing reports of certainly what happened in Italy. And then subsequently what was happening in New York, and you’re seeing reports of volume of patients going into the hospitals, volumes of patients going being taken by ambulance to the different hospitals, and you just knew the numbers were increasing and increasing.

And I had an urgency that I needed to go help. Here where I’m practicing, because we have shut down most elective cases. My practice has been fairly slow. My primary practice is outpatient pulmonary, but I’ve been doing critical care for 30 years. And I just knew they needed help on the ground. Thus I answered the call and the call came out can you come help? So I went out. When I went out. I went to a community hospital I went I didn’t go into Manhattan, I went to a hospital very similar to almost any hospital midsize hospital, anywhere in the country. And what I saw is a hospital full of very hardworking, tired providers, and all working very hard together. When I came on shift from my first ICU shift, I was really over overwhelmed by the number of patients they had in their ICU in a very small footprint because they were double boarding patients and also the acuity of every patient that was in that ICU.

Kali Dayton 4:18
What was that acuity like kind of describe maybe ventilator settings and all the complications that were occurring.

Dr. Dixie Harris 4:27
So it was surprising to me as far as a handoff rounds, and then even during team rounds as we went through the unit. Everything was incredibly abbreviated. “Okay, this is a 45 year old person they’ve been on the ventilator. This is day 21 And they have COVID and they are on Dilaudid fentanyl. They’re also on some precedex, and they’re on rocuranium.”

Their vent settings were just really abbreviated because just of the volume of patients we had to go through. So the typical report would be 14 350 18, and 90%. So to translate, the first number would be the respiratory rate. The second number would be the tidal volume, the third number would be the PEEP and the last number would be the fit. So again, no level of because we had so many patients to go through no level of okay, while the patient is on these particular settings of or this rate of, for example, of fentanyl drip, we’re giving this amount of medication, and we’re keeping sedation to this level, there is no level of what the peak pressures were applied to pressures where it was simply, these are the meds. They’re on day, five of seven of this antibiotic and then we went to the next patient. So it was the bare bones.

Kali Dayton 6:09
And what was staffing like?

Dr. Dixie Harris 6:11
The staffing was most of the times it was four patients to one ICU nurse. And the patients were all intubated. And about a third of the patients were on continuous dialysis. So many times the most experienced ICU nurse was the one that’s had continuous dialysis in there for so there wasn’t a separate nurse for dialysis.

Kali Dayton 6:37
And did you have exclusively ICU nurses or sounds like what I’ve heard from other reports that there were nurses that were willing to help from all sorts of specialties.

Dr. Dixie Harris 6:45
So we had ICU nurses, we had Cath Lab nurses, we had endoscopy nurses, basically, nurses that typically were in more monitored set coming from monitor settings like surgical nurses, pacu, nurses, Ed nurses, those would be kind of manned up to ICU. Many times, they would team, a nurse who hadn’t been an ICU nurse, and they team them with another nurse. And maybe they each would do three and three. So three patients and three patients. You know, the typical nursing ratios, where I’m from is, if it’s continuous dialysis, it’s one to one nursing. And otherwise, it’s typically two to one. It’s very rare to have a three to one nursing ratio.

Currently, where I’m working in, and in truth, where the hospital I went to, it was very clear that the nurses were extremely well trained, and they knew best practices. It’s just the limitations of the volumes of patients.

Kali Dayton 7:50
And how did that affect patient care when those Reese’s resources were exceeded? And those kind of staffing ratios? I mean, I’ve worked as an ICU nurse for many years, and I cannot imagine taking care of that acuity of patients four to myself. That would be a huge struggle.

So how did that impact practices and then outcomes?

Dr. Dixie Harris 8:13
So the big lesson I learned after going and spending two weeks there was the primary reason we have such good outcomes in this day and age for patients with ARDS and respiratory failure, and all patients in all different ICU, surviving sepsis, all of that. The reason why we have that is because our phenomenal team based care, which includes phenomenal nurses and respiratory therapist, physical therapist, and family at all of them working together, in addition to the physicians and the advanced practice- APPs.

So I came away with very clearly when you do not have that whole team working with the patient, including pharmacist because we have a very limited supply of pharmacists, then the outcomes are are, are significantly decreased as far as survivals. What I saw was almost 90% fatality rate, where I went when patients were on the ventilator with acute COVID respiratory failure and ARDS,

Kali Dayton 9:27
Which is so sobering to hear, because we’re not used those mortality rates. Like you said, in most under normal circumstances, and most hospitals, it’s not like ARDS is a new thing. But those mortality rates are huge. And you’d mentioned earlier about feeling like you’d gone back 20 to 30 years in practice.

Dr. Dixie Harris 9:46
Yeah, so I’ve been practicing for many years and when I first came out of my medical school and then started residency fellowship that was right when ARDS net was beginning.

Unknown Speaker 10:00
And that was when we were developing these huge national level standards of practice. That’s when we were learning about low tidal volume ventilation. That was before it became standard. All these different currently, like best practices, every ICU knows how to do in the United States. That’s when I trained I trained, we were given the patient’s heavy sedation, and it’s very common if they had ARDS, they were on paralytics. And that was in the 80s. And then I, I subsequently have been working all the way through as we’ve advanced in our care, and we’ve improved the mortality all these 30 plus years. And then all of a sudden, I walked back into an ICU, when, in truth, for legitimate reasons. If a nurse has four patients, they have to keep the patient’s fairly well sedated. Because if a patient is on 20 of PEEP 100% FI02 and they accidentally extubate themselves, then what do you?

Dr. Dixie Harris 11:02
You have to get anesthesia…., it’s, and they did have patients who had self-extubated and died. So they knew they had to heavily sedate the patient. They didn’t have sitters, they couldn’t be at the bedside the whole time.

Kali Dayton 11:16
So if you could pick up those patients there and transport them to a place that wasn’t overloaded- how would those practices look different? Especially an aspect of sedation and mobility.

Dr. Dixie Harris 11:29
So the interesting thing about what I did is I went from two weeks of night shifts at this facility. And then I came back to my home facility and work three night shifts. And it was night and day I went from the 1980s care, again, this hospital system where I work and the nurses knew how to do great care. It’s just you had too many patients.

So then I came back to a facility where I had many my nurses were one to one on the patient, especially in the COVID section. We only had half a dozen COVID intubated patients, so it was very manageable. And the patients were getting every bit of care. They were getting turned they we were proning in New York, have proning teams. But when we are proning here, we’re better able to keep track of every little irritation, not even, you know, lesions on the skin- just it’s just starting to get red, we’re able to get right on top of every every little thing that can go wrong. We were able to handle here.

Where I live immediately before it became a really big problem. Whereas in New York, many skin lesions can break downs what happened. So we’re not moving the patients. Certainly in my time there and I arrived there just after surge. I did not see a single patient walked on a ventilator, or even sat up. Mind you I was nightshift. But still I didn’t hear about that.

Whereas in the unit, I covered a night shift where I am. We were sitting patients on the side of the bed still even in the evening and moving patients and keeping track of all those little things that nurses do all the time when they can pay attention. And they only have one or two patients. Now when you’re four to one, that kind of acuity and running to use dialysis machines, you physically cannot do anything. But keep those debts that sedatives running. And if you can keep things continuously hung you’re you’ve been successful.

Kali Dayton 13:35
And so what does it look like for patients that had been so deeply sedated and even paralyzed for how long and then what that look like?

Dr. Dixie Harris 13:43
So many of the patients were paralyzed for days. Again, they of course knew you want to minimize paralization. But part of the problem was trying to keep the patients adequately oxygenated ventilated. They were fighting the vents.

And also, we had ventilators that were much older we saw we saw events that were over 20 years old that didn’t have all the sophisticated details that the newer ventilators have. So all the different bells and whistles that we have now that we can use it can make it more comfortable for somebody to be fully awake, not on sedation on mechanical ventilation.

You just had these workhorse vents that were just I kind of like thought of them more as like a piston engine like it was just… pushing the flow of the air into the lung. And no release no pressure release… now it wasn’t… there was nothing gentle about it. And so then you know you’re using old equipment, because you obviously a hospital is not going to have enough ventilation you’re getting them from FEMA and other places and then you have to sedate the patients you don’t have enough people to watch make sure they don’t self extubate or make sure they don’t pull out lines. And then this is what you have. Then you have care that what we did 30 years ago, but we’re certainly not delivering now.

Kali Dayton 15:06
That is so interesting because I think our second episode, we talked to Terry Clemmer, and he gave the history of ventilators and sedation and talked about how really sedation was started because of those archaic ventilators because they are so uncomfortable because they’re insufferable. But the point was, now we have all these advanced ventilators that are so much more personalized and customized for patients and much more comfortable… But in those circumstances that’s not there anymore. So sedation is not an option, especially with four to one nursing.

So when patients, the few that were extubated, what, what were the struggles after extubated, and what are their outcomes look like?

Dr. Dixie Harris 15:45
So very few successes, frankly, for patients getting extubated. But for patients I saw one patient I can remember in particular, I had gotten extubated two days prior to me arriving and I was there for two weeks, that patient stayed in the ICU, mostly because of high oxygen requirements was usually on bilevel for hours on end during the day and at night and was slowly being weaned up.

The problem was this patient had been intubated for about 25 days have been on paralytics for about 10. And so when I was seeing the patient, initially, the first of my two weeks, the patient could not lift her hands or even her fingers off off the sheets. By the time I left, because she was a great patient to go visit, she could actually kind of barely lift her whole hand and do a slight wave. Now mind you, she was fairly alert and very cooperative. She was lucky in the fact to me, even though she had had heavy sedation and been paralyzed for so long, she was still fairly lucid. So it was fortunate in that fact that she seemed to be fairly aware of what was going on. And that was not with all the patients I saw that were activated.

Many of them were really had a hard time communicating the one thing about this disease, it also affects the trachea and irritates the trachea. And so when you activate him, they have a lot of secretions and a lot of swelling and irritation. In fact, several patients had to be re intubated because they couldn’t keep the secretions out of their airway. But the point of it is they had many of the patients had a very hard time talking after extubation and again, communicating.

Kali Dayton 17:41
and what role do you feel immobility or the weakness played into those re intubations? Or the struggle to create those secretions?

Dr. Dixie Harris 17:49
Oh, is it we did? You know, first off, we did everything we could not to re intubate the patients. But it was very clear they had a hard time even just swallowing a lot of it was a combination of they’ve been in bed the most I’ve done is prone. Nobody has been mobilized because again, you had too many patients. And so even the patients couldn’t even hold themselves up swallowing any kind of use of accessory muscles to breathe it was that was non existent. So we would in fact, we would because of the weakness have to keep patients intubated longer. To make sure when we excavated them, they didn’t have to be re intubated. And we have patients who had to be re intubated. Seven days later, on re intubation still extremely weak. After being excavated for seven days, they were extremely weak and couldn’t handle their secretions.

Kali Dayton 18:51
I know I take for granted how much muscles play in the whole respiratory system and to lung volume and coughing and all those important things that keep us functioning on our own. And fortunately, it is a rare occasion that that becomes an issue with our extubations now.

But when we go back into those practices of deep deep sedation, prolonged immobility, those become problems. And when we’re so tight for beds and staff, the last thing we need is reintubation especially when we’ve worked so hard to get them liberated to begin with, what would you share with those of us around the country and even around the world that are treating COVID- But we’re not overrun yet. There are lots of there’s lots of fear. There are lots of different ideas and philosophies as far as how to manage these patients. But as far as preventing harm and sticking to what we know works, What recommendations would you get after what you’ve seen?

Dr. Dixie Harris 19:51
So the most important thing is not to disregard or put aside. Best practices. When you can handle the volume. So in the best practices is everything from appropriate nursing ratios- mind you, these patients can be very sick, and maybe they need one on one nursing not two to one. Maybe you need a sitter with a patient so you don’t have to sedate them. So much so that somebody can be there, make sure they don’t pull their lines out there et tu bout, have physical therapy go in the room, we have the circuits are all closed, I was in COVID ICU for two weeks.

I was careful with my PPE, and I came back negative. So you wear your PPE, it’s a chance that you could get infected, but be very careful, and you have a very good chance. And I went with out becoming infected. I went with a large number of providers and none of us came back positive, which means if you have the time you can protect yourself. And then you can do the best care for your patients.

So again, it’s a balance between protecting the providers. And then taking care of the patient, I will say that this is a very lonely disease that patients in the way it is set up and the current standard now is for families not to come see the patients. And everybody who does interface with the patient is number one, we are told to minimize our physical exam, to minimize our contact with the patient. But all of that then means the patient is very alone fighting this disease.

So the patients are maybe on mechanical ventilation, or they may be on high flow oxygen. Either way, we need to do what we can to support them, minimize sedation. But if you minimize sedation patient’s going to be awake and being on a ventilator in an ICU. And the only people you see are wearing PPE, and you never even hold somebody’s hand without a glove on. That’s a very scary time for the patients. We don’t we didn’t have family at the bedside unless the patient was about to pass away. And then we would allow family members if they desire to come to the bedside. In my opinion, I I don’t think that’s the best care for our patients. I think the patients will do better if the family is there, participating in rounds participating in medical decision making, and providing emotional comfort and support for their loved ones.

Kali Dayton 22:42
And that’s a huge consideration. I think we’ve been focused on PPE and social distancing, and all these other factors. But now we’re seeing that the things that we take for granted like family presence is making a huge difference in their rates of delirium and their overall outcomes and their motivation to work and to do physical therapy. So that is your recommendation to actually continue to involve family.

Dr. Dixie Harris 23:09
I would I mean, we we that was one of the jobs of the attending physicians was to call the families and update them with anything that new happened. And every day, families got called, sometimes multiple times a day, in addition to the patients, were able to be shown their family on iPads through FaceTime, mind you, we just had nurses available to do that, or the physicians to go in or APPs to go into the room.

So we didn’t have even necessarily communication teams, we’re starting to get into that. But again, it’s always this balance between minimize exposure of people to the code possible. COVID. So you’ve tried to minimize people in the room, ICU versus the need to have the team there to take care of the patient. As far as family I think what what happened, in my opinion, I think that the COVID from a provider standpoint, a caregiver standpoint, is a hard disease.

It’s physically hard to take care of patients when you’re always wearing PPE and you’re always focusing on washing your hands and you get these facial abrasions from wearing and N95 Mask your you feel like you’re always breathing and feel like you’re getting co2 narcosis and it’s it’s very uncomfortable, you learn to live with it. But almost always you’ll see people the minute they get out of the COVID presence they have their mask the NIT five off.

So you know even if you’ve been dealing with it for five weeks, you’re still not wearing the mask as soon as you can get out of an area- you just want to breathe. You just want to get out of that mask and breathe so physically, mentally this this disease has its is a fairly complicated disease. And it’s as complicated physiology. And things we don’t know about or recognize all sudden pop up as something very significant.

The most, the newest one is with the with the children now, but all these different things we’re identifying that’s happening as comorbidities or other other organ systems being involved with the COVID, we’re just learning. And the other thing is we’re learning about the different potential therapies with different medications, and medications. Like, frankly, I have some of them I’ve never even heard of before. And before COVID, and then even the new trials, so you’re having to, like mentally learn about new medications. And there’s the whole learning curve to learn what side effects to watch for. and such.

So there’s, and the information is coming in, just like a rush of water. And the always, there’s actually almost too much information, but then yet, not enough good information. So it’s in very hard to find good places to find information, especially when you’re working 12 hours a day. So how do you find the information you need, and you find it cold out, but that’s good information, reliable, actually accurate, accurate, reliable, and mind you things are changing by the week. In fact, when I went there, the person who was running the ICUs told me, Well, we have our guidelines, I’m going to give you a copy of the guidelines, but they tend to change every two to three days.

So physically, mentally, and then emotionally, this is a very hard disease to take care of. Because number one, we’re not used to losing such a high percentage of patients. And we’re not used to seeing patients who otherwise fairly healthy can can die from this disease, or younger, younger patients. I saw patients in their 20s and 30s. Typically, it was 40s 50s and 60s, who had underlying diabetes and hypertension, but not all of them. So you know, people say, Oh, well, I’m 50 years old, but I have no diabetes or hypertension, that doesn’t mean you’re free and clear.

If you’re 20 years old, doesn’t mean you’re free and clear from this disease. So so the point of it is, is it can hit any age. And in truth, we’re not used to losing 4050 year olds very much and 30 year olds i. And that’s very hard. And the fact is that you’re taking care of these patients for weeks, not days, weeks in the ICU, and you’re working so hard in these patients are putting so much energy and then because the patient patients, families aren’t there, you’re and you’re having to call him and get him on the iPad, you’re also having to give some support to the families that are calling in. And then you have to give support to the emotional support to the patients.

So it’s it takes a huge emotional toll. One of the nurses I worked with said she her practice was during this big huge surge was before she started her shift, she would make sure she cried really well at home. So that she when she went to her shift, she could do 12 hours focused and not become emotionally overrun.

Kali Dayton 28:27
She didn’t want her mask to get wet.

Dr. Dixie Harris 28:28
She did not want her mask to get wet. Yeah,

Kali Dayton 28:31
How long did you have to use those masks for

Dr. Dixie Harris 28:33
The place I went actually was very generous with a mask. But again, I was like everybody else we put a surgical mask over our in 90 fives. And I ended up only using two masks the whole time I was there. So I was trying to be respectful of not overusing the PPE. Yeah.

Kali Dayton 28:51
And this is such a valuable insight as well for the general public. There’s, it’s really hard to know what it’s like in the ICU until you’re on the wrong side of it or unless you work there. I you know I’m in the ICU. I’m just so amazed and touched by how much these caregivers give and care and have sacrificed in these circumstances. But the whole COVID pandemic is so complicated. There are so many repercussions of all the measures taken. What would you have the public understand about what’s going on in the ICU quality of care what is available, and how that it relates to social distancing?

Dr. Dixie Harris 29:30
So that’s a great question and point to bring up. So if you come to the ICU where I am now, we’re going to be able to give you the best care possible. If you go to the ICU where you’re having a huge surge where the ICUs have been tripled and quadrupled in a hospital you will not get the best best care you’ll get the best care they can pass Give given the circumstances, but you just won’t be able to get the best care.

And so the most important thing we do by social distancing, because number one, we don’t have a preventative for the COVID. Other than social distancing. We don’t have early treatment. We don’t even have easy way of surveillance, we don’t have a great treatment identify currently, when you get it, and we don’t have immunization, and and the virus has not, as we can see, has not decreased how the severity of it. And so it’s a highly failure, it’s a high percentage of fatalities with this. And it still remains as infectious as it when it showed up. So all those factors, we have one tool in our toolkit right now, which is social distancing, as we in the healthcare community and the scientists work on, do we have some medical indications that we can give?

Is there something we can give early can we identify hotspots early before they become big hotspots. So we all have a level of let’s try to keep from spreading it. Because again, what we do know is patients, people without symptoms of the disease are actually spreading it in the community. So that’s, that’s what’s happening. And until we have a way of identifying that anybody can potentially be spreading the disease and not even know they have it. So if everybody wears their mask, when it’s when it’s called for, and follows their recommendations from their department health now, I will say that different states will have different mandates according to what is happening. And you’re always, you know, to bring it down to very simple. You wear your mask, as recommended, so that you will have an ICU bed if you get super sick. So that’s a simple way of saying it. Because if I get sick, I want to have an ICU bed. If I if I’m one of those small percentage that gets very, very sick with this disease,

Kali Dayton 32:20
I don’t want to share my nurse with three other patients.

Dr. Dixie Harris 32:24
And I don’t want to share my nurse. I want to have my nurse, I want to have I want to have all the attention that I know that US healthcare can give.

Kali Dayton 32:33
I want to pulmonologist like you right at my ventilator and not a resident going off of what they’ve learned off of YouTube.

Dr. Dixie Harris 32:41
Yes,

Kali Dayton 32:42
They all plays a role in mortality. And it’s, it’s very humbling, I think everyone should feel their own mortality as a reality right now. And we’ve considered those that are at risk as those above a certain age and you know, compromised. But what you’re saying is, our risk factors, especially in America are even bigger than that. hypertension, obesity, diabetes, an age and age.

And all those things come more with age as well, right. And so we’re not just protecting ourselves, we’re protecting our loved ones that carry those risk factors and anyone in the community that carry those risk factors, and ensuring that we have a bed or they have a bed, and nurse and all the resources available to get the best care to have the best chance, kind of start my own hashtag, hashtag, give us a chance to give you a chance. And I think it the commander. So what it’s like in the ICU, especially up in New York where you went when things were getting better. But we’re all capable in all areas of over and human resources and not being able to give the best care that we can and want to give. So thank you so much. Is there anything else you would share with the ICU world or the general public?

Dr. Dixie Harris 33:53
No, I’m actually came back very positive, that we can do it. I will say that the the people in New York are amazing. They’re the most tough, honorable people I’ve ever worked with people who are willing to work five weeks in a row without a day off 16 hour days, many of them and all doing that because they This was their calling. Again, this could happen to any community in the United States. So we have to respect the disease. And that’s probably respect this COVID disease as the most important thing because it can hit the community. It can sneak in and hit any community at any time.

Kali Dayton 34:37
We’re not reopening things because the risk is gone. But because beds are available.

Dr. Dixie Harris 34:41
Beds are available and if everybody does what they’re supposed to be doing, we can continue keeping the numbers of patients coming in to the hospital coming into the ICU with the COVID 19 disease to a manageable level.

Kali Dayton 34:58
Hey let’s do it go team thanks so much.

Transcribed by https://otter.ai

 

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