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How do we bring changes to the ICU? What barriers impede the progress of our culture? Heidi Engel, PT, DPT, shares with us her continuous journey to humanizing her ICU.

 

Episode Transcription

Kali Dayton 0:29
Welcome to the Awake and Walking ICU podcast, I can tell that we have a lot of new listeners. And I am thrilled. I invite all of you to start from the very beginning Episode One, to make sure that you don’t miss invaluable stories and insights that bring context and understanding for these recent episodes. Just listen to them all.

I have recently done a webinar with the critical care department of a large hospital system. Some of the wonderful questions asked were how to bring these changes to their ICUs. This is such an important inquiry that I personally cannot speak to. I stepped into a very established culture in the “Awake and Walking ICU”.

And this unit it was established by Polly Bailey almost 30 years ago. Her story is told in episode two and 21. Yet there are pioneers around the country and world that are advocating for elevated evidence based practice and more humane care in the ICU. We will be hearing their stories and coming episodes.

This episode we have with us Heidi Engel, an extremely seasoned ICU physical therapist with a powerful perspective. She allowed herself to dream of a more humane culture in her ICU, and has elevated her team’s practices throughout the years. Heidi, thank you so much for joining us today. Tell us a little bit about yourself and your professional background.

Heidi Engel 2:02
Well, thank you for having me, Kali. I listened to your podcast while I’m walking to work walking to the ICU. And I get so much out of it, I get inspired by all that you provide to the to the patients there.

My background, I thought I would be a physical therapist for about five years after I graduated with a bachelor’s in physical therapy because that’s what the degree was when I went to college in the 1980s. And here I am 33 years later, still a practicing physical therapist. So I fell in love with what I had to do. And particularly working with people who are critically ill. I established the ICU early mobility program in our medical ICU.

I started that project in 2008. And I started it because a patient and family member were adamant that he shouldn’t get be awake and move, even though they were attached to a ventilator. And they were my inspiration, I think the patients in the family have just kept me going against multiple barriers. And with a lot of hard work in this collaborative project to to have our patients be awake and mobile in the ICU since 2008. So I work full time as a physical therapist in our medical and surgical ICUs primarily. And I work in a large academic medical center where we have a transplant services of all sort and a lot of tertiary care. So we tend to very sick patients. And it’s been incredibly rewarding to be able to work with my colleagues in respiratory therapy and nursing and of course physicians and pharmacy as well to help to help patients wake up and move.

Kali Dayton 4:22
So I’m trying to think back to 2008 and what the culture was like back then everyone was deeply sedated. Nobody moved. What drove that patient and or the family members to even envision their loved one being awake and walking at the time. What was it like for you to imagine that against everything you’ve ever known?

Heidi Engel 4:44
So at that time, the way my job worked is…I was service-based and so I was on the liver transplant service and the hematological oncology services. And those are services that obviously deliver patients to to the ICU fairly frequently, and so I would follow those patients into the ICU from the floor. Or sometimes I’d even receive a consult, to do physical therapy with one of those patients in the ICU. And this really was I’m talking about 2006, 2007.

And I’d walk into the ICU, and I would look around and I wouldn’t understand the equipment, and I was very intimidated. And the nurse would just look at me and say, “I don’t know why you’re here”. And I’d say, “I don’t know why I’m here either”. And they’d say, “Okay, do you want to do passive range of motion?” And I’d say, “You can do that”. And they’d say, “right.”… and I go away. And it just felt wrong.

It just seems like there has to be something I could I could do for these patients. And so this gentleman was a nurse, not from this country. And his wife was a nurse and his sister was a nurse. They were all nurses. And I don’t know, honestly, I cannot say why they just felt like it. They were none of them were critical care nurses. So maybe they didn’t realize what the equipment was about. But there he was in the ICU.

He’d been lying there for a while he had a liver transplant with multiple, multiple complications. And that’s why he was still in the ICU. On the ventilator, and but he was awake. Because of his liver transplant. The liver team was reluctant to give him sedating drugs and his encephalopathy, and they just wanted to wake him up and get this moving. So he was awake, his family was at the bedside, I had a consult because they had badgered the doctor to write it.

And the nurse said, “I don’t think that’s a good idea. He has an ET tube down his throat.” And his family was waiving me into the room. Um, and he did incredibly well. I sit, I looked at the patient, and he looked terrific. He was awake, his vital signs were fine. And I asked him, “Would you like to get out of bed?” and he nodded his head. And I had never even seen anything like this before. And so I thought, “well, he’s willing and his family’s willing to help me. And let’s just do this.” It seemed to make sense.

He did fantastic. And as a result, I could not get him and his family out of my mind. And I went to the liver transplant fellow. And I said, I think this gentleman did so great, because we actually got him up moving while he was still in the ICU. And the liver transplant fellow said, I think you’re absolutely right. And I said, “I think we needed some sort of regular mobility program in the ICU.” And he said, “Yes”. And I said, “You should start that.” And he said, “No, I’m a fellow I’m leaving in a year. You are here all the time you get it started.” And I thought, “But I’m just a physical therapist, how can I? How can I create change in the entire hospital for what all these people are doing and in the ICU, physical therapists take orders, we don’t start programs.”

But he really encouraged me and I did some research, the only thing that was published that was very compelling. It came from LDS Medical Center in Salt Lake City. And they had pictures of people of walking on a ventilator. And I did not even know this was possible. I thought that was impossible. And I just looked at these photos in these studies of people of walking in the ICU on the ventilator. And I said, “Wait a minute. If you can do this with these patients, why are why aren’t we doing this? Why are they all lying in bed sedated?”

So yeah, the culture very much at the time was the patients on the ventilator, what they really need is to be kept very still and left alone, maybe past the range of motion, deep sedation, and then they’ll come off the vent. And the idea behind it was that “this was the most compassionate thing you could do”. That being in the ICU and on ventilators so traumatic, that they would not want to have a memory of it and their bodies really needed to be in a full state of rest.

And Kali, I have to say that to this day. I hear the word “sleep” used for sedating patients. I hear it from the nurses. I hear it from the doctors when they talk to the families. “Oh, we’re we’re putting him back to sleep now. He’s really sleeping now she’s really sleeping now”. Oh, and I will tell those practitioners, “No, don’t say ‘sleep’. This is not sleep, this is sedation, they’re very different things.”

I mean, I think one of the best ways we could change the culture in the ICU is to stop using the word “sleep”, when what we really mean is sedation. It is very different, they have a very different impact on the brain. And I think if a family member heard, “okay, we’re now sedating him again, goodbye” on the phone instead of “okay, and putting him you know, back into sleep again”. I think the families would hold us more accountable to what we do. And I think families are credibly compelling advocates for the patients.

Kali Dayton 10:59
I think that’s completely true. I think if family members really knew what their loved ones were experiencing, they would have a totally different level of advocacy. And if we as clinicians understood, okay, I’m now going to put them into delirium. I’m now going to put them in a world of tear and trauma. Bye bye, I it would completely change. how often and how long and how deeply we sedate people, it would completely change how quickly we are, how quick we are to grab the profile.

Heidi Engel 11:35
Yes, I hear it called “sleepy medicine”. I hear in little high pitched voices, people refer to it as “we’re putting this the medicine back on them now”. And it makes me cringe. Because while the patient on the outside looks flacid and calm and as if they were sleeping. So we understand the analogy. And inside when you talk to the patients after they wake up, they’re having terrific hallucinations of being terrorized torture drowning in the phenomenological research that’s done in Scandinavia, and it’s very compelling research to read, they interview patients. And they receive pretty consistent reports of sensations of drowning. “I felt like I was drowning, I felt like I was deep underwater. And it was very distressing. And it was very real.”

So, you know, in a way, if you wanted a more accurate analogy, perhaps you would say, “I’m going to shove them back under water now. Talk to you later.”

Kali Dayton 13:00
“I’m going to take away any opportunity to explain to them what’s going on and allow them to understand reality and cope.”

Heidi Engel 13:06
Yeah. And I encourage everyone to, to look at some of the Phenomenological Research that’s published from the people in Denmark in particular. It’s very compelling interviews with with patients, and it’s done in very systematic and thorough ways.

Kali Dayton 13:29
We can add a link to that research on our blog.

Heidi Engel 13:34
Yeah, let’s let’s do it. And, um, you know, that’s why Thomas Strom, who works in Denmark. That’s where his research has been. He also was someone whose initial research was very inspiring to me, because it’s about the no sedation ICU, he was one of the first people to publish something that said, no sedation, ICU.

Kali Dayton 13:59
And what else has changed your perspective, or even your understanding and practice with early mobility?

Heidi Engel 14:08
The patients and the families are empowered. And I think one of the most, there are two gifts we give to patients in the ICU, we wake them up and mobilize them. And when I initially got started, and I would have my first early sessions of mobility where all the patient could really tolerate well is perhaps sitting on the edge of the bed for a little while. And then they would be exhausted. I initially thought, “I don’t even know if I’m doing anything worthwhile here.”

But there’s something about the early investment gets you the greatest return that I have learned over and over again. That the earlier, I can get to see our critically ill patients. And obviously they have to go through a period of some initial stabilization that should be days and not weeks. And the earlier and consistent investment of mobility gets us the best returns.

So we have been able to have planned consented tracheotomy is cancelled, because we instead chose to consistently intensively mobilize the patient. We have patients leave the ICU and go out to the floor and the step down floor nurse anticipates this patient came from the ICU, they’re going to be a maxisys transferred to a chair, they’re going to be delirious cognitively impaired. And we’ve accepted that as a norm, which is crazy. And instead, we have our patients come out of the ICU and they call back in and they say to the nurse, “I need to go for a walk.” Now the nurse says, “Oh, let me get someone to help me.” And they say “No, I can do it. Just hand me that walker over there.”

Kali Dayton 16:12
Love it.

Heidi Engel 16:14
Yeah, we can send patients home, we can empower patients to advocate for themselves and their ability to return home. We can help them overcome so much learned passivity that we drum into them. Mmm. Yeah. So the early investment gets much greater return than I anticipated it would. And it’s still true with with COVID-19 as well.

Kali Dayton 16:45
Yeah, and the COVID-19 patients are so much like a classic ARDS patients. And you define early as in within a few days. But that’s not the standard definition across the board. Can you talk to us a bit a little bit about some of our subjectivity, when we use the terms, “early mobility”?

Heidi Engel 17:12
“Some activity”- so there’s no clear definition of “early mobility”, either in terms of when it should start. Prior to COVID-19, based on what the evidence said, I presented the definition as within 48 hours of the patient’s admission to the ICU because in what is published out there, and the quality of the research is not great, and not a large number of have have enrolled participants in these studies.

But what the research has shown is that timing matters. And earlier is is better. And studies with the most compelling results were ones where they started early mobility within 48 hours of the patient’s admission to the ICU. So when I started our ICU early mobility program, and we went full steam ahead starting in 2010. That was the goal to initiate physical therapy for our ICU patients, at least two thirds of everyone in the ICU and have that be within 48 hours of their admission. COVID-19 has disrupted the timing substantially. And I understand that that’s true across many medical centers and and it’s alarming to me what we are now starting to mobilize our COVID-19 patients more like weeks into their intubation as opposed to days. And I haven’t figured out how we’re going to fix that yet.

Kali Dayton 19:15
How do you see that impacting their outcomes?

Heidi Engel 19:20
Ah, the the rate the delirium and the extent of the delirium is more profound, the delirium especially, um, obviously, the levels of weakness, and it’s all more pronounced one thing. This is why I don’t I don’t know how we’re going to end up getting around it. I mean, the one thing that’s incredibly gratifying about the COVID-19 population in particular, that’s different than what I’ve seen in the past with our other ARDS patients is they make giant leaps and bounds forward in their progress.

Once you do start mobilizing them, so once they are medically stable once they really are not needing the ventilator anymore, or they’re excavated, um, they make fast progress, like nothing I’ve ever seen, which is great. The problem with that is, I think that everyone sees that, and it just reinforces all the prolonged deep sedation that we’re doing out of the compassion, thought of it has to be done for that way in that long in order to protect the lungs. So part of the lung protective ventilation strategy has involved keeping folks on very low tidal volumes, and waiting for the lungs to clear. And that’s also involved deep sedation. But I think we still struggle with determining when to when to change that process, when to be able to switch up what we’re doing, have the patient more awake, um, allow them to, to initiate more breaths on their own. It’s taking us longer to reach that point than we had in the past.

Kali Dayton 21:35
Yeah, I think there’s a lot of fear involved. In Episode 14, I talked about the “Awake and Walking ICU” and how some of our protocols are not validated in research, because we don’t have a control group. And it’s hard for other places to research that they don’t do. So we walk people in higher event settings. I mean, even to if I were to have 100% people, high PEEP, you know, higher settings, but as long as they’re oxygenating, we’re rolling, because it gets their lungs better, quicker, as well as maintain their strength and their cognitive function, all the things that we know, need to happen while someone’s on a ventilator.

But it is hard. And it’s scary in other places to try something new, to do something that’s not in evidence or research yet. And yet, we have all this research showing that it’s so harmful to keep them immobilized and deeply sedated for so long. And yet here we are with these patients in severe respiratory distress and failure in the masses, and our resources are stretched. And so we’ve reverted back to those practices that we know causes long term long term harm. And we’re already seeing these patients coming out in the masses with PTSD, cognitive deficits, and having severe disability even so quickly after their hospitalization.

So I don’t know. I think every unit is different. Every culture within the unit is different. Protocols are already different. I know that in the “Awake and Walking ICU”, we already had a culture where mobility was normal, it is normal. And so the alterations have been minor, because we already had a strong system focused on keeping people functional and stronger and the critical illness. And so I know that it is possible, because we’re seeing it and people are being discharged straight home, they’re walking out of the ICU.

Yet there is a spectrum sometimes people do have to be paralyzed and proned for much longer. And that, of course, is a huge setback. And so not every patient is the same. There’s not one mold fits all, especially for every unit and staffing ratios and capacity. And yet, even with COVID-19 It is possible to optimize outcomes. Um, what kind of barriers are you seeing in your, in your practice or in your facility to optimizing your role as a physical therapist, even before and now during COVID-19?

Heidi Engel 24:22
Sedation has always been the the biggest barrier, a solution and I have to say. The ARDS net protocol is a very specific protocol and we don’t want to deviate from it. And it’s been challenging to figure out how we can maintain utilizing the ARDS net protocol is a way to protect the patient’s lungs, but still also allow them to read receive what they need from the ventilator to allow for activity comfortably. Because obviously, if you’re lying in bed and all of the ARDS net that research initially was done on patients simply lying in bed and sedated, so that’s a very different state of being then awake and walking down the hallway, that means the ventilator will need to be changed to accommodate the different way the person’s going to be breathing.

And the protocol doesn’t doesn’t specify anything for that ARDS net research was done all on the practice of keep people in bed and sedated. So I need a new ARDS net protocol. And when you’re mobilizing allow the ventilator to be transitioned to this or allow for a you know, marginal increase in tidal volume. Maybe instead of six milliliters per kilogram, it’s going to now be you know, nine will be allowable because they’re walking down the hall.

So something so when you’re in an institution that it hears very tightly to that protocol, because that protocol, dude changes from damaging lungs with the ventilator in the 1990s, to now, having people with good lung function after the ventilators taken away and allowing us to take away the ventilator sooner than in the past. Now we need, you know, just like they’ve updated this sepsis guidelines, we also need an arts net update guidelines so that it accommodates for the awake and walking down the hall patient, please direct people to turn off the sedation and allow for this type of tidal volume and respiratory rate and to have the event set on something different.

So the patient is capable of getting up and walking in the hall. Sedation has always been a barrier. And at our institution we had gotten pretty good about we had really eliminated the use of the benzodiazepines, which are the most superior genic sedating agents. So I hardly ever saw anyone prior to COVID. On the benzodiazepines are on, Versed. And now it’s back. And I can’t I just can’t believe it’s back. Some of it is back because we take transfers from outside hospitals.

And if a patient comes in having received weeks of a benzodiazepine drip, you can’t, you’re stuck, you can’t suddenly take it away, they’ll go into severe withdrawal. But some of it is just a need in order to achieve a deep enough level of sedation. For the COVID patients. Yes, sedation has always been the greatest barrier. It is it is not sleep, as I hear it being referred to frequently by providers. And I think it’s the word sleep is used when we are genuinely just dating someone, which is something very different from sleep, your brain does not react to sedation nearly in the same way as it reacts to sleep, as sedation is very delirio genic it creates hallucinations for the patient. And sleep obviously is restorative and, and restful. And so when we use the term sleep if we if we tell family members, the patient is sleeping now or we’re we’re putting the medication back on to to help the patient’s sleep or to let them sleep again. I think we’re providing information that sounds very comforting and reassuring.

But I think we should be more specific and accurate in what’s being done which is sedation. It’s not sleep. So I think I think if we can detach all the compassionate good intention, and euphemism we apply to sedation, maybe it would become less of a barrier. But I can’t mobilize someone who is a RASS of -3, or -4. Generally no one even really necessarily expects me to or wants me to try. My expectation in what I’ve always said is “I want to stop talking about ICU early mobility and rename it “ICU Early Walking”.

That is the standard I’ve tried to adhere to in our program and to teach to anyone who comes and works in physical therapy in our ICU. Our goal is this patient’s going to get up and walk. Our goal is not that this person’s gonna sit on the edge of the bed for a few minutes, and then I put them back. When we did the ICU liberation collaborative, which was 60 Different ICUs from across the country, we asked people to keep very specific data collections on wood, which elements of the eight F bundle, they were able to accomplish the mobility levels, and this was a year and a half program where people had to apply to the program to be accepted, they received a lot of teaching and a lot of mentoring.

And through that program, folks really improved their delirium assessment and their pain assessment and decreasing their levels of sedation. But mobility levels still remained extraordinarily infrequent and extraordinary low in intensity, just like all the research all around the world that has has demonstrated very few of the patients are getting out of bed and walking. A lot of the activities still remains bed level. And there’s there’s a wide range of problems with keeping the activity and the definition of early mobility as a bed level exercise.

Kali Dayton 31:44
And you have to or the awakened walking nice to you. And it sounds like that’s the vision that you have for your ICU, that it’d be early walking that be the standard. What what impedes that from being the standard sedation? Can you speak to the role of the physical therapists staffing ratios? What else impedes that progress?

Heidi Engel 32:13
The “Awake and Walking ICU”, I observed had an entirely different way of managing the ventilator and delivering sedation to the patients than I have seen in any research in any other of the ICUs I’ve been to. We’ve done a great job of normalizing mobility at our ICU we receive, we have traveler nurses who come from, you know, work experience in a lot of different other other different places. And they will say, “Wow, you know, I’ve never been in an ICU that mobilizes patients this much or to this extent.”

Um, and yet, we don’t look like what I observed in the “Awake and Walking ICU”, I think what the “Awake and Walking ICU” has achieved is that everyone has determined that the patient to be out of bed or walking in the hall is just completely normal practice. There’s nothing unusual about it. There’s nothing extraordinary about it. It’s just part of the patient’s day, it’s part of what needs to get done. It’s on the same level as delivering their antibiotic medication. It’s on the same level as toileting. It’s just another thing that has to be included in the patient’s day. And we we are not there yet.

And there is a great deal of skepticism about the patient’s can tolerate to be awake, that the patients can have the ventilator change to accommodate how different they need to be able to breathe if they’re blocking in the hall versus lying still in bed. So working on it, but culture barriers and then and then experience you know when when what you know, is an inner body that looks like they’re peacefully “sleeping and resting”, you feel like you’re delivering the most comfortable, compassionate sorts of care. When you have to go through the process of waking someone up who is unsure what’s going on confused. Especially If they’re young, and they have strength, and the last thing they knew is they perhaps passed out in their apartment, now they’re waking up in an ICU tube down your throat can’t talk, hands tied to a bed rail. In strange sounds, sensations of pain, discomfort. You know, obviously, when that person is first waking up, if that’s all they know, they’re going to panic, their vital signs are going to change dramatically.

They’re going to over breathe the ventilator, they’re going to get anxious. They’re going to start fighting and thrashing. And if we treat that with sedation, all we’re doing is creating more harm to the person and more distress. If we can go in and adapt the ventilator to the patient’s needs, sit them up, have them open their eyes, let them look around, let them explain to them what all the equipment is explained to them what happened. We are making a fantastic early investment that will give you a person at the other end who goes home and lives their life again, instead of yay, they survived. Okay, they’re disabled. But that’s because they were so deeply sick, which seems to be the outcome we are accepting of. And it, it might look good as a data point, it might look good to us, because we don’t follow them home from the ICU. But if you speak to the patients, it’s it’s terrible to enter the hospital as a walking, working, functioning person with a whole life story around you. And to then leave as a disabled human being.

Kali Dayton 37:10
And it is so conflicting for someone like you that deeply cares. And you know that it didn’t have to happen that way. You know that there’s a better way to do it, that we can truly preserve people’s function and livelihoods and quality of life. And so I hear you on Twitter, I saw you on Twitter, and I seen your, your tweets that you have so much fire and passion for this and so indignation when people have outcomes that didn’t have to happen. What was that like for you? And how do you work with a staff? And when have you had moments in which there was hesitation or doubt, but you helped your team work through that and you saw success in your patients?

Heidi Engel 37:58
Yeah, um, I don’t think I have really been the driving force to to convince people, this is the best thing to do for the patients, I really, truly believe that the patients and the families have have done the work for me. And I’ve just been a willing participant to go in and take the risk. And give it a try. And I you know, I often say when I give presentations, so here I am, I’ve been a physical therapist for 33 years, and I will still read a medical chart. I will still go to the bedside and look at a patient and I will still think it’s just not gonna work. They’re too sick. They’re too heavy. They’re too crazy.

They’re too you know, there’s just all these barriers to why this is a good idea. And I pushed myself past it, because I know now from experience that if I push past that internal dialogue I’m having with myself that “this just can’t work”. And I give it a try that very often nine times out of 10 the patient surprised me because they greatly surpassed my expectations. And I think I think we need to empower the patients to be people first. And I think we need to give them credit for understanding what is going on with their bodies and what is not, and for wanting to participate in being awake and understand what’s going on with their care.

So I think we I think we have too much of an almost paternalistic attitude towards towards patients in general. And that we create a lot of learned how wiseness in our, in our patients, it’s much easier to empower them and allow allow them to be engaged in their in their care. And, and ultimately, you can see that when you just quiet the voices inside your head that tell you “this is not going to work”.

Go in and try understanding that if the patient does start to decompensate, while you’re getting them up moving, you lie them back down, you stop the treatment, you have your colleagues together with you, I as a physical therapist cannot perform ICU and mobility by myself or as a console service is absolutely a multiprofessional team sport. I rely heavily on our fantastic, extraordinary respiratory therapists who go in and manage the ventilator and do the suctioning while I’m moving the patient. So I can focus all my energies on optimizing the mobility of the patient and optimizing their willingness to participate their trust in us to do this their motivation level, and empower the patient, you know, have them be active participants in their care.

And then at the same time, learn who they are as people. So we can inspire them to return to their life story and the things that bring meaning and purpose to their lives. So in order for me to focus on that, you know, I need the helping hands of the nurse to minimize sedation but treat pain adequately to manage pressure medications that the patient requires pressure medications, and to maybe give you an extra set of hands. Or to manage the lines, we have a lot of patients on continuous renal replacement therapy. And we have a protocol that allows the nurse to disconnect the renal replacement therapy for two hours to allow for patient mobility.

So we might need to schedule the nurse to take the patient off of the continuous renal replacement therapy. And then we might need to schedule the respiratory therapist to manage and switch over the event. And they need to change the event settings. So the physician needs to have an order set that allows the respiratory therapist to to change the ventilators parameters to make the work of breathing less stressful for the patient while they’re exercising.

And then the patient can walk down the hall and my energies can all be focused on movement and motivation and returning this person to their personhood while my colleagues work on the medical management of the equipment, and the patient’s hemodynamic stability,

Kali Dayton 43:07
I love that aspect of physical therapy that I’ve been learning about through this podcast and interviewing physical therapists, is that you truly see these people as humans. I think sometimes there’s so much going on the ICU, and I think it’s really easy to see a diagnosis specific organs, procedures that need to be done, but physical therapists come in and say Who are they, as a person as a whole? What were they doing before and had the vision to return them to that. And I think incorporating that aspect and that perspective into our interdisciplinary collaboration is invaluable. You tweeted a really cool story about a patient that cried when she got into charity. Do you mind sharing that with us?

Heidi Engel 44:01
Remember what story it was…

Kali Dayton 44:07
She was in pain, I think…

Heidi Engel 44:09
yeah, we had, you know, we had so many patients. It’s fantastic to to talk to the patients after after they’re leaving the ICU. So after they’re extubated once they can talk to you to ask them about their experience of mobility. They say the most profound things and, and that genuinely keeps me going back to do the very hard work of the initial therapy sessions because the the initial therapy sessions can be tense.

We don’t know how this person is going to react really. We don’t know if hemodynamically they will remain completely We stable throughout the session. But we should be obligated to give it a try. And it’s messy. It’s ugly, I understand where the sedated patient lying in bed with their eyes closed and all the equipment neatly tucked in around them. I get it, I get why that looks better on the outside, that seems like this is a compassionate relaxation we’re providing. And that thing where you’re first getting them up moving, and they’re panicking, and they’re maybe getting agitated.

That looks really messy and hard and awful. It is sometimes messy. It is difficult. It is not awful at all the patients and typically the patients, like the woman you’re referring to there, it’s not like they’re athletes, and you’re saying thank god, you’re letting the exercise again, these are folks very often that lead you know, pretty normal lives not moving especially much they’re eating average, somewhat sedentary American life. And they are still so grateful for for the aspect of moving.

Recently, I had the opportunity to speak to one of our COVID patients who’ve been in the ICU for a long time. And she was an older woman who just was heavy set. And she is not someone who you know really had a pre morbid desire to move or walk or exercise a lot. And but what she said to me, she said, “I will never forget those first times that you that you helped me up. Because I really felt like I was myself again. I really felt like I could breathe again.”

Oh, you know what? Now I’m remembering the story about the woman who got in the chair for the first time and cried. The woman who got into the chair for the first time and cried. Oh, yes, she was someone who had a cancer that had gone all over her spinal cord. So she had a very rare, very specific type of tumor that invaded her spinal cord and required very complicated neurosurgery to cut tumors off the space next to her spinal cord. So she had become really quadriplegic in the process of these tumors growing around her spinal cord.

And I think she was pretty much convinced she would be living the life of a quad. But once they did the neurosurgery and started treating the cancer, she was getting her logic return. And so after weeks of really being very dependent in her mobility and in bed she was still on the ventilator. But we yeah, we stood her up, we got her over to the chair. And it was her first time in the chair. And this is literally after I think a month in bed with all the complicated neurosurgery and cancer treatment and the quadriplegia from the tumors, on the ventilator, and ARDS. And she got in the chair and she was able to write she could hold a pencil and she could write on a on a clipboard. And when she started crying, we were afraid that she was crying because she was in too much pain. So we handed her the clipboard right away and said, “What’s wrong?” And she wrote on the clipboard, “I’m so grateful to be in the chair. I’m so thankful to be up.”

Yeah, and I receive that message from patients over and over and over. One last thing one other thing I would like to mention Kali is we teach a course. I don’t teach a course, the respiratory therapists, clinical specialists teach the medical residents a kind of mechanical ventilation 101. A we send our physical therapists to that course when we can.

We’re going to be working in the ICU. And what’s great about this course is the you can try being on the ventilator. So the respiratory therapist sets up the vet in the circuit and you plug your nose and you hold the circuit in your mouth and you’re essentially feeling the sensation of mechanical ventilation and I have Physical Therapists lie down while they’re on the vent. And then I asked them to sit up while they’re still on the vent. And then I interviewed them. And I say, “Okay, how did it feel lie down?” And these are healthy, normal working in the hospital, physical therapists, and they all say, “Oh, it really gave me a sensation of anxiety, it really gave me a sensation of distress.” And I said, “How did it feel to sit up?” And they say, “Very initially, that also felt distressing and uncomfortable. But really, within 30 seconds to a minute, I realized and understood that it felt much easier to breathe, sitting up, then it did line down on the ventilator.”

Kali Dayton 50:55
And that’s what our patients say, Right? Is, “thank you so much, I can finally breathe.” Because physiologically, we know the lungs can expand better when we’re upright versus laying down. But we forget that when someone’s on the ventilator, we trust the ventilator will do all the work. And yet it is still so distressing for them to be in a compromised position that they don’t have to be in all the time.

Heidi Engel 51:23
Yeah, I mean, that’s why we’re proning patients, right? Because lying on your back is the worst position you can lean in, to actually open up all the alveoli and diffuse oxygen to all the various parts of your lungs.

Kali Dayton 51:40
Now, that’s a great practice. And I think nurses, residents, doctors, a APPs, everyone should feel what it’s like to be on a ventilator. But I love that you’d have to do both positions. And that can give us greater empathy and greater reason to get people up. Again, that’s all part of changing the paradigm changing our perspective, and our understanding of what patients are experiencing. I am so grateful for all of your advocacy and all of your good experience and work. How do we better mentor our community? And who have been your mentors throughout this process of evolution?

Heidi Engel 52:23
How do we better mentor our community? I think we’re we’re doing that effectively, as best we can with ICU delirium, or with Patient Testimonial. I would love to see now that COVID is pretty interesting right to to having been an ICU practitioner for as long as we have. And, you know, now all of a sudden, it’s not uncommon to hear people talking about ventilators on the radio or on the news, or reading it in the newspaper or to hear the term air DSP, something that you see in a popular press newspaper article.

So we have gained some attention due to COVID-19 of more of the popular media. And I think that’s very good. I’ve been disappointed in the tone of it at times because it’s focused solely on the disabling aspects or the ventilator shortages or it, I would love to hear much more emphasis in the popular press. And I’m hoping more of the great articulate leaders in our fields such as Dr. Wes Ely or Dr. Dale Needham, or Polly Bailey, the nurse practitioner.

I would, I would love some of those very articulate many years of experience leaders in our field to to be able to to have a greater voice in the popular press, and not just in our medical communities. I’m to advocate for the awake and walking patient in the ICU and the incredible difference that makes in the patient’s life for years, years and years going forward. Because I feel like the doom and gloom side of being an ICU patient or having been a patient during the COVID-19 surge, that’s now in the popular press.

But let’s also talk about what can what can help restore someone’s life. Let’s spotlight some of the positive aspects of critical care that everyone should know about because chances are someone you know can end up in the ICU now due to the COVID-19 virus. You never would have expected that in the past and when your loved one does go into the ICU, what are some things you might want to talk about and advocate with the practitioners?

I do think it’s going to be a similar experience to what I’ve noticed in our ICU and in speaking to groups across the country. In the compelling patient stories and the family testimonials, of how vital it is to be awake and moving as, as a critically ill patient, a vital that is. I think, especially if that can get into the popular press, the regular CNN programs, and the 60 minutes programs, and CBS Sunday Morning, or any of the very mainstream popular press, the New York Times Washington Post.

Let’s get these publications to start talking about this aspect of critical care now that they’re talking about critical care anyway, in terms of my own personal mentors, I’m Polly Bailey, the nurse practitioner at Intermountain was an incredible source of inspiration not not just to me, but also to to Dr. Dale Needham, at Johns Hopkins who everyone knows is kind of the the world leader in ICU, early mobility. For everything he’s done all the research and all the advocacy he’s done. But, but Polly is the inspiration behind the inspiration. So I have to mention her and I have to encourage people to to read her 2003 article about the walking that she achieved in in their ICU.

Kali Dayton 57:12
And a great interview on episode. I think it’s, let’s see, I think it’s where is it? Episode 21, Polly tells her story, which is Yeah, completely inspirational. And she was very alone and very visionary, for her time, and even still.

Heidi Engel 57:35
She was and I will never forget her saying that she would show up in present her mobility results and achievements at conferences, and people would call her a “liar”.

Kali Dayton 57:56
She has faced so much opposition in her career. But has been extremely driven by what she’s seen and what she’s done. She’s seen patients walk out the ICU as a standard. And in the end, she’s only cared about what’s been best for the patients. And that has inspired me even to this podcast because I know that these are possibly controversial topics because it goes against the grain of our culture. But Polly’s inspired me because that’s what she has done her whole career. She’s done something that’s been very different, very against the grain. And yet the best thing for patients because she just cares about people and so that’s what’s serving me as well. And so I’m excited to hear someone else that’s received the same kind of validation from Polly’s work.

Heidi Engel 58:48
Yeah, I mean, Margaret Heritage, you know, I think if you asked Dale Needham, what some of his early inspirations were, I’m pretty sure he would agree that Margaret Heritage, the pulmonologist out of Toronto, Canada, in all her great groundbreaking research on the disability we were causing in patients as a result of our critical care practices. And Polly Bailey I’m pretty sure Dale would mention both of those women.

Um, but then I have to mention Dale myself, because in the early phases of our program, it was only the very generous sharing of information and data from from Dale Needham at Johns Hopkins that compelled people at my institution to think about us changing our practice and then I can’t say enough about you know, everyone finds Wes, Dr. Wesley at Vanderbilt and his all his colleagues at Vanderbilt in their in their delirium research and their critical illness Brain Injury Center that they have now and all the research they’re doing. Brenda Pun, and the folks there at Vanderbilt have been extraordinarily inspiring. Very similar to, I mean, the groundbreaking work that Wes Ely done is phenomenal. But he also brings what you just mentioned about Polly a level of compassion and drive towards restoring the humanity of the patients is being his central motivation. And he’s been an incredible source of inspiration for me, too.

Kali Dayton 1:00:37
There’s so many wonderful and deeply compassionate people in our field that have really dedicated their careers to changing the ICU community and culture and practices that we can learn from. And so I will put more links to the most research on the blog so that we can all read and really have access to all the wonderful research that’s out there. And any other listeners that want to share their success stories, ways in which their culture has changed, please reach out to me. I think the more that we share our personal experiences and successes, the more we can understand and relate to each other and the same struggles that we’re all facing. Heidi, thank you so much. Any last thoughts for the ICU community?

Heidi Engel 1:01:28
Last thoughts for the ICU community? Ah, you know, I spoke to Polly Bailey when I was starting our program in 2008. And she was a beacon of hope and light because she was one of the very few people who was actively engaged in walking mechanically ventilated patients. I don’t believe she ever defined early mobility as anything other than that.

And she said to me, When we were getting started, she said, and I’ve done a lot of different things in my life. She said, “This is going to be the hardest thing you ever do. But do it anyway.” And I, she’s such a wonderful person. I just kind of thought, “Okay, I believe you. Yikes.” Um, but I’m so grateful that she said that to me, because, yes, it’s been the hardest thing I’ve ever done, because of the barriers because of the negative pushback because of, you know, you feel a little bit like you’re swimming upstream sometimes. Um, but I keep Polly Bailey in my head because she succeeded in achieving what I hope for for all of our patients or patients are awake and walking down the hall daily, and it’s just another routine thing for them to do. And I keep that in mind. Her thoughts, then it is hard that yeah, it’s gonna be hard. But that’s okay. The reward is far greater than the amount of effort you have to put in.

Kali Dayton 1:03:16
I that is the perfect final note. I think anyone that attempts to change these deeply ingrained practices will find all the barriers that you have found. But coming from the awakened walking, I see you, I add my witness that it’s possible and it is so fulfilling. And it is the standard of care that should be out there. And so thank you for all of your strong work and all of your advocacy and moving our culture towards that. Heidi, thank you so so much.

Heidi Engel 1:03:52
Thank you, Kali It was really great talking to you.

Transcribed by https://otter.ai

 

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