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What barriers do we have in our ICU culture that prevent us from appropriately addressing delirium? What can we do to foster a better approach to helping delirious patients that are difficult to care for? Dr. Swamy gets real as we discuss the reality of delirium from our side of the bed.
Episode Transcription
Kali Dayton 1:12
Hello, on a recent poll on the Instagram page 87% of responders reported that their units automatically sedate everyone right at intubation. This is consistent with an alarming experience I had in grad school.
I was in class listening to a classmate give a case study of a patient they had worked with during the rotations. The patient had pneumonia but was not in septic shock. They reported that the patient was endotracheally intubated, and propofol was started. But the patient’s pressure got soft. So norepinephrine was started as well. This made me instinctively scoff, and I looked around at my classmates to get a non verbal agreement that that was silly.
But no one seemed remotely fazed or concerned at all that we were adding on more medications to respond to medications that weren’t necessary. So the presentation continued and norepinephrine was mentioned again. And I suddenly couldn’t contain myself and I blurted out, “Why? Why was he sedated? And why are we adding vasopressors to support unnecessary sedation?”
So this was a room full of seasoned ICU and ER nurses, and it was crickets. No one said a word until the presenter said, “because he was intubated.” I felt bad for the outbursts and tried to calm down and briefly explained.”Sorry, I just… I work in an ICU where that patient would not have been sedated and wouldn’t be in that situation.” And then I slipped down in my seat, realizing how alone I was in my perspective, even in an academic and research based environment.
On a side note, a classmate among all the others rolled his eyes and laughed at how delusional I was. He ended up doing his residency in the awake and walking ICU, and then work through after graduation, we still laugh about the irony of how crazy he thought I was, and how big of a believer he is now about avoiding sedation. So I think it all comes down to our understanding of delirium. I think delirium is probably one of the most under diagnosed and mismanaged ailments in the ICU.
It drives up mortality rates, increases safety hazards, prolonged time in the ICU, and ultimately burns out our good staff. But listen, we don’t treat bacteremia by injecting bacteria into their veins, yet we continue to respond to delirium with sedation. I recently saw profound tweet by Dr. Swamy concerning the need for change in our approach to delirium. I knew I had to talk to him more about this and his contributions to critical care. Dr. Swamy. Thanks for joining us.
Dr. Swamy 4:05
Yeah, thanks so much for having me. I’m excited to be here. excited to have you.
Kali Dayton 4:09
So tell us about you and your professional course.
Dr. Swamy 4:12
Sure, so I am I would describe myself as kind of a junior attending so i i finished my training at Boston Medical Center last year, we finished off my training right during the the the peak of the COVID so it added an extra edge to my skills I guess I’ll say. You know, it was great training in Boston at Boston Medical Center safety net hospital and also at the the VA here got a lot of really broad exposure on the medical side and and I love the ICU.
So I now work I have kind of an interesting combination of jobs but I work at the at the intensive care unit as an intensivist in Cambridge Health Alliance, which is very different but also very much the same still safety net hospital and I take care of a lot of Medicaid patients all that and I also work for Medicaid at the state level. And so part of my job is to is doing health policy and that kind of stuff is medical director for MassHealth, our state Medicaid office. So I have kind of an interesting role where I get to see the patient from really up close in the ICU, one on one, to really zoom down and take care of like the population health.
Kali Dayton 5:19
Yeah, how does that impact then? Your experience in the ICU, when you see them after the ICU or in normal life?
Dr. Swamy 5:28
Yeah, you know, definitely. So it’s, I think that through all of my training has really, in the starting, I would say, for example, as a resident and I was going to the ICU the first time, it was so hyper focused on that moment in the ICU, and I was really just seeing them as this person who’s really sick, who is, in many ways feels like hardly a person, when you first go into the ICU and see people, lots of lines and tubes, they’re out there sedated.
And then over time, over the years, I sort of was able to even then kind of really start to see the person underneath the the breathing tubes and all of that, and, and to start to get to know people’s families a lot better. And still in that episodic sense of still kind of, I’m taking care of this person in the ICU, and only only later when, you know, through my pulmonary clinic experience, and just with more experience and time, was able to see people who had been in the ICU and then had had, were no longer there, doing well again, and seeing all the issues that came from the ICU that they kind of maybe carried with them.
And also just, you know, some of the big wins to the people who really recovered in an amazing way. And I think that added a lot to my perspective, because I was able to kind of get out of the sort of immediate hemodynamics moment and really start to think of this person’s life and and that the the role that we have in their lives when they’re in the ICU and the tremendous impact that we can have both for certainly for good, and in many ways for good, but also about the harm that we can that we can either do or prevent when people are in the ICU.
Kali Dayton 7:06
And I worked as a nurse and ICU for years, and I had never really talked to survivors until I sat next to him on a plane and I heard about his PTSD. And so that big picture really wasn’t a lot of to me until 5,6 years after being immersed in only the ICU. And so I’ve kept feeling like if we all had the perspective that we could all meet with survivors, that it would change how we manage them in that moment.
And so you put out a really profound tweet that I wanted you to expound more upon. As far as how do we treat a patient that is agitated, thrashing wild? We all know what we’re talking about. We all have delt with that patient. And it is almost like an auto set instinct in us to just sedate them. Because we feel that it’s “safer” and “more humane”. It’s easier, all the things, but you brought up some really good points. Will you tell us more about how all of your experiences have led to this perspective on delirium for you?
Dr. Swamy 8:09
Yeah, yeah, absolutely. So I think it’s, it’s something that I actually think we don’t talk about that much. And when we have a patient like this, it’s almost we try to shield our medical students from it, right? It’s kind of like, a little bit pretending like it’s not happening. And what I’m talking about is a patient who is just floridly, agitated, delirious, extremely vocal, right? Like, often, this is the person when you walk into the unit, you can hear someone just screaming or moaning, and it feels like it’s endless. And it’s really challenging.
It’s challenging in so many ways to take care of that patient, for many reasons, first of all, first of all, it’s challenging, because I think there really aren’t any amazing things you can do in the moment, once that situation has arisen. And what ends up happening is, as you said, people tend to reach for sedation right? And on the other hand when I think there’s also cases where we just have to endure this person who seems like they’re in agony is seeing us really as the as the aggressors, right?
So often, and and yet to try to keep take care of other patients or you know, in the unit, and I think we get used to it, we get numb to it, I think in a large way. Where we’re kind of like, “oh, yeah, that’s happening…” and of course there’s kind of like a gallows humor that comes out of it, which I think is often really inappropriate, but but a reality. Because we’re in this this situation where….. I mean, how few other people outside of healthcare really deal with something like that? Right and, and have to actually have that in their work environment?
So I think it’s interesting the effect on us, but it just really made me think, what is it like when a different family member comes in? Not that patient’s family member, or what does it look when a medical student comes in? Who’s people who aren’t used to this environment? And I think that’s what shocks them is, first of all, here’s this person suffering, why isn’t someone in there? Why isn’t someone doing anything? And then second of all, how are you all just just kind of working and ignoring that? Which is such a human thing to say like, someone’s there- someone suffering someone’s screaming.
So it really made me think cuz I had a patient like this recently. And I realized that the way that I kind of try to approach that is really different than then I think our sort of medical culture wants and trains us to in many cases. So I think often, the approach to that is to, as you said, make the problem kind of go away, right. And it’s to use anxiolytics, it’s to use anti-psychotics, benzodiazepines, it’s to use sedatives, hypnotics, whatever, to try to just make make that person quiet.
And I think in a, to a degree, we feel like we are doing that to treat them. And sometimes that’s true, if there’s real psychosis or something that certainly treating psychosis is really important. But other times, I think, I feel a little bit like we’re more treating ourselves than we’re treating the patient. Or treating even maybe the family. The family is coming in and saying like, “how could this be?”- and in the ICU, it’s especially it’s even different from the floor.
Because in my experience, a lot of the time this is someone who’s not that stable- hemodynamically, from respiratory status standpoint, and that’s the only thing sometimes keeping them from getting deeply sedated because they’re going to get re-intubated. And so we’re just, you know, we’re not always jumping it up. But we’re getting boatloads of halidol, lots of benzos. And I worry. I worry that that prolongs the situation, it really makes things I think worse.
Kali Dayton 11:46
Oh, it does. And in the research, we’re seeing that the more sedatives people get, the more likely they are to be intubated, and especially re-intubated. So you’re kind of talking about…. you’re alluding to the intubation as far as patients that are delirious post extubation. And likely delirious because we gave them so much sedation some so much.
And now it’s off because we don’t want to suppress the respiratory drive, and but yet, they’re deconditioned. They’re gonna have poor airway clearance, poor secretion clearance, and then we’re inclined to give them more sedation because they’re being too noisy. And so yes, this research shows that we’re going to make them be re-intubated because we didn’t do what was going to help the long term outcomes in that moment.
Dr. Swamy 12:30
You really have this this brief window where they’re not taking PO, and they obviously can’t take PO. Whether they had a whole bunch of meds they were taking before that were po meds for behavioral health disorders or whatever, they can’t take that nutrition. They’re not getting it. There’s this brief time and, and you have to ride it out. And it’s extremely painful to ride it out. It really isn’t an easy thing.
But the truth is that the more you give them, you’re risking reintubating them, and if not reintubating them, you’re still risking prolonging this I think this delirious and agitated state. Whatever the reason is, whether it’s alcohol withdrawal, or it’s an underlying psychosis, or it’s just florid delirium due to like ICU, delirium. Whatever it is, I think, the more fog we add to the brain tends to just make things worse. There’s usually a sweet spot, I think you do have to use some kind of PRN, you have to be able to do something. I agree. But there’s a line where it’s kind of like, you know, we’ve tried, we’ve tried haldol all and ativan several times now, and I didn’t see a big change.
And so I totally I think documentation is a big part of that, because otherwise the next shift comes in and everyone reaches for the same things. Everyone reaches for the same things. And we like to have medications as the answer. Right? Like, it’s, it’s the way we’re trained, you know, blood pressure. So I have an answer for that. It’s different, I think with the brain, though.
One of the things that really struck me about dealing with delirium in the ICU was that was again, the impact that it has really on on patients and families that come in and and the impact that patients and families can have on delirium. And what I mean by that is that, first of all, people don’t know what delirium is, that became evident to me pretty quickly, but they are able to tell very quickly that, you know, “my father, my sister, whatever is not themselves right now.” And so I think on first, it’s really important to note that family members can are acutely sensitive to detecting delirium, maybe better than us, especially hypoactive delirium.
I think also they really have a role in kind of the treatment of delirium. They help so much with reorientation. A big for me, something that was really important was getting that language out about delirium, and the role of the family to the general public. And part of the way that I’m doing that is actually in a card game I’m working on called the “Critical Care the Game”, which is a card game about the ICU. It requires no medical knowledge to play.
And I think you know, each of like 200 cards is really filled with information about what the ICU is what ICU medicine is, like, really concise, plain language, text, I’m working with Sarah Merwin, who’s kind of like a patient language expert. She wrote a book called “The Informed Patient”. And we are writing these descriptions of things like delirium, hypoactive, delirium, agitated, hyperactive delirium, and then also things like delirium precautions, right?
And the way that it works, you know, you’re, you’re an ICU clinician taking care of ICU patients, and you use all these, they patients come in with some diagnosis, like sepsis, and they start to accumulate complications, like delirium, and other things. And as these things start to happen, there’s all these interactions where you can be more likely to get complications and such, and you use different kinds of therapies to heal your patients to get them better.
And I think what I really love about the way that we’ve designed this scheme is that some things really just help patients like delirium precautions, just help patients and there’s all this stuff in there about what that is. And and then there’s, you know, the the, the physical therapist card, for example, is is, is really powerful, it makes a huge impact, really getting to that early mobilization and the teamwork aspect. But other things really are a double edged sword, like, for example, the benzos card, it can relieve some some of the suffering, but at the same time really causes more injury and can can kind of raise that risk of delirium.
So all of these pieces kind of fit together in a way that what I’m hoping what I’m seeing is that when people who have no medical background play, they sort of start to get it, and suddenly they’re speaking the language. And they’re saying things like, “Oh, well, you know, I really want to use the benzos, because they this person is clearly suffering. But at the same time, I’m really worried about what that’s going to do to their brain.”
And hearing that come out and just saying, “wow, people really get it” and people saying,” I really want to, I really want to get the physical therapist involved in this patient’s care, because that’s what’s going to get them up and feeling better. And it’s going to help with their suffering and all this stuff.” So it’s, I just love that we built this thing where we’re not explicitly telling people any of this.
But in playing the game, and six working together to take care of these patients is cooperative, of course, they’re able to learn all of these ICU concepts that are so kind of near and dear to my heart. So really excited for the game critical care the game, it’s going to be coming out on Kickstarter, probably in July in the summer, and I can’t wait to share everything about the ICU that I love, and all of these kind of pearls about about ICU medicine, really with the whole world.
Kali Dayton 17:59
I think delirium isn’t part of our normal communication. And a lot of it depends on the environment. Some environments are much more aware of it well educated, almost fixated on it. And I think that’s kind of part of the Awake and Walking ICU’s success is that every level of the team understands what the learning is. Just like you go into any other hospital, and we’re going to understand what acute kidney injury is, we’re gonna know what causes it, how to treat it, the repercussions of it. But when it comes to the brain, like you say, it is a brain injury, but we’re not so fluent in that language.
Dr. Swamy 18:30
How hard is not that we get a CAT scan for someone who has acute kidney injury, and yet someone who has florid delirium right in front of you, the first thing people give us is, Ativan, is benzos. So, it’s shocking, I think, but it’s like when you know, when you read ,when you understand you read the literature…. there’s so much! There’s such a world of understanding about this, but I think it’s just that the approach to that patient for so long has been this.
And and I think it is tricky, because, you know, some of those drugs actually work well for alcohol withdrawal. But alcohol withdrawal, delirium is different and even and I think fino bombshells looks so much better. But even though there are cases where kind of that might be more of the right answer, but the problem is that just like there’s not one kind of kidney injury, there’s not one kind of delirium, there’s not one kind of agitation, but we use a kind of one, one kind of approach.
Kali Dayton 19:30
Yeah, it’s impossible to do personalized care when we have sedatives as part of our protocol.
Dr. Swamy 19:37
Yeah,
Kali Dayton 19:37
…and when the team doesn’t have a vision of the long term outcomes. So I’m sure as a new resident or new attending, you’re going to have old nurses coming to you and asking for these specific drugs. And those are your buddies. You don’t want across nurses, right?
Dr. Swamy 19:51
Yeah,
Kali Dayton 19:52
You’re going to feel pressure to give them what they want. And, you know, what does the nurse for years and now I’m a nurse practitioner, there is a difference in how hard it is for me. So as a nurse, I was the one holding the hands down wrestling, working so hard to keep them safe in bed while not using sedatives. I recognize as a nurse practitioner, it’s easy for me to be like “No, that’s going to make the delirium worse, worse, you deal with it.”
Dr. Swamy 20:17
Yeah, yeah.
Kali Dayton 20:18
And so when you’re trying to navigate interpersonal dynamics, there’s a lot of pressure to order those things, because it is, ultimately the nurses and the techs that are the ones that have to pay the price for it.
Dr. Swamy 20:30
You know, I think that you actually hit on the way that I approach this, because I think a lot of time we abandoned the nurses and the techs, to dealing with this patient, right? I can leave and go chart somewhere else- they cannot. And I think the way that I try to build that credibility, and to build up that partnership, so I’m not abandoning you, I know, this is a big ask, I know, it’s not easy, is just to stay there with them. And I think that that the same goes for, you know, during COVID, proning.
Proning was sometimes for places that weren’t staffed or resource are able to just turn to You know, this is a new thing for a lot of ICUs, it was a big ask to say this person needs to be proned now. It changed. I think, obviously, people people started to develop that because it had to be done. But in the starting, it was not a simple thing to just say, “hey, this person needs to be proned” and walk away, move on. So what I did was I would go and help with proning.
This, you know, not it’s, it’s, it made a huge difference to just be hands on with the patient. Because I think a lot of the time, what I hear from the nurses is that I don’t really know what’s going on, I’m seeing this patient for a moment in time, they’re seeing them for hours on end. And that’s true. It’s totally true. So the answer to that, to me is to just really be able to spend more time at the bedside come running anytime and tell them to call me or come running, sit right outside with them. Putting those hours in the same uncomfortable environment and be uncomfortable there with this patient, and this nurse and whoever else and and then I think you can build the credibility to be able to say things like that.
Kali Dayton 22:12
Yep, that is such a good point. And, and when we talk about concepts like I have seen that in these cases that you’re talking about when someone’s agitated, delirious yelling, you get them up and walk them. You hustle, I wear them out until they pass out in bed and get real sleep. Yeah, it’s easy for me to say, “Just get him up, move them.”
Dr. Swamy 22:32
Right.
Kali Dayton 22:32
But say, “if you need help, I’m happy to come in and get them up with you.”
Dr. Swamy 22:37
Yeah,
Kali Dayton 22:38
and there’s a sense of security, because especially at night, people are sundowning they’re getting even more at night. Physical therapy is not there, yet an extra hand, walk the talk, right?
Dr. Swamy 22:49
There’s… the partnership is so important there because it goes both ways. And I need to listen, when the nurse says “no, there’s these very real reasons why that’s not a good idea.” But unless we have that kind of mutual understanding of what we’re trying to get done, we can’t get there. For example, you know, the nurse has such keen insight into what’s going on.
And what’s practically involved in doing things for this patient. And, getting on the same page isn’t can’t be assumed. For example, for example, maybe it’s the tethers that are the problem. And the nurse doesn’t know that I think it’s actually perfectly reasonable to turn off this, this and this drip to, you know, to time these meds differently or whatever, right? They have a ton of work to do. They’re really kind of hyper zoomed in on “I need to do this, this and this”. They’re not thinking, “Can I turn this off? Can I stop this?” Of course they are sometimes. But that’s kind of a decision we make together. So you can get rid of tethers you can do all these things and like create a better environment, and then everyone’s on the same page.
Kali Dayton 23:51
Oh, that’s great. That’s why delirium should be part of our communication during rounds, right? We have pharmacist, everyone’s there. And so they can change all those timings and collaborative kind of way to make sure that we’re working towards all of those same goals and preventing delirium. Otherwise, it’s all down to the nurses. And that’s not fair.
Dr. Swamy 24:13
It’s not just not fair. It’s not practical. It’s not the way you’d want your family member to be cared for, right? You really want it to be that everyone’s so much on the same page in my kind of like dream ICU, that that the physical therapists are, you know, when they’re gonna come? And everything is kind of, it’s not just everything’s around the physical therapist, everything isn’t around everyone.
Everyone’s on the same page, the patient’s schedule, should be so obvious for everyone to look at and see, “oh, okay, physical therapy is gonna be coming in this time. That means we should turn the meds like this. That means that we should try to be there to help,” or whatever, you know. Think about getting different consultants on the same page. How hard is it just to get two different teams like, you know, a consultant in the room at the same time as a family member? It’s so hard, but that’s the kind of collaboration That really makes a huge difference for patients and families and for staff. It makes it makes the lives of staff better.
Kali Dayton 25:09
Yeah. And preventing delirium makes everyone’s workload so much easier.
Dr. Swamy 25:15
Everyone’s.
Kali Dayton 25:15
But if you don’t have the infrastructure in place to have those protocols to have that consistency and care, then then it’s it’s not practical like you say, and you say, your dream ICU and I am always talking about this “Awake and Walking ICU”. But it really is the dream ICU. This is why people come into it. Everyone is on the same page about this. We’ve talked to previously about how the ICU actually hires a lot of new grads, nurses that are new to the critical care world, because they start fresh, and this becomes normal.
And we start out with a very clear education on what delirium is, and how to prevent it. We have protocols in place to prevent delirium on most everyone. And so when physical therapy comes in, in the morning, patients are awake because they were never sedated. Right? And oftentimes, they’re already in the chair. The nurses have already gotten them up in the chair. They’re writting on their board saying, “What time is physical therapy coming?” The team rounds in the morning have already kind of talked about, “okay, this person has an MRI right now, this person has this, this patient’s doing poorly. Okay, what are you walking your patient, okay.” And they already have a plan to help each other walk their patients according to their needs and what’s going on.
And so, one thing that I wish you did is that to have physical therapy in rounds with us. But in reality, while we’re doing rounds, we’re seeing our vented patients walk around walk.
Dr. Swamy 26:34
Yeah, yeah.
Kali Dayton 26:35
So they pass by and wave at us. We’re like, “oh, that’s the one we’re talking about. Hi!” and then physical therapy comes back and reports to me as a nurse practitioner and tells me they tell me how their brains doing, how their stamina is doing the respiratory status, they gave me so much feedback.
And the nurses are part of that. So closely in round, they’re telling us how much sleep they got. They can smell delirium, the slightest of delirium from a mile away. And again, most of these patients are on mechanical ventilation, well, they can say, “hey, their handwriting is getting a little bit looser.”
Dr. Swamy 27:06
Oh, my God, wow.
Kali Dayton 27:06
“they’re, they’re not saying they’re not writing as complete sentences as they did before.” Like they know, they just know their patients. But if we automatically sedate them, we miss that boat, and then we cause so much more work on the back end. When we extubate them, and they’re screaming, and they’re too weak to get up. And and all the problems-
Dr. Swamy 27:25
you can extubate them that easily.
Kali Dayton 27:26
And we can! I mean, once they get to that point because their their success rate is so much better. But that perspective of even an intubated patient that is agitated or thrashing or delirious. You know, you got a kidney injury, you’re not going to give him more contrast, to treat that injury. You have a brain injury, you’re not going to give them more sedation, right, because they have a brain injury, because they have delirium. And so I just loved your perspective on that. But it is, it’s a big change in our community.
Dr. Swamy 27:57
It’s a big change. But you know, it’s also really cool, because when you said that the physical therapist walks in, and the patient’s already in the chair, that means the physical therapist is working at the top of their license. And that’s, that’s kind of what we want, we want everyone to be able to do that, you know, I hear all the time from physical therapists, we’re not the only ones that can move the patient. And I mean, our nurses definitely do a ton of that. Absolutely.
But it’s not the same kind of all hands on deck to move this patient. Right, everyone’s stretched, everyone’s busy. But I really think that there’s a level of coordination that can kind of make things move a lot better. And people work together more. And I it just gives more hands on time of the patient, which is really what a lot of doctors want to, but can never free themselves to be able to do.
Kali Dayton 28:40
Yeah, and I, the physical therapists know their stuff, they did not get their doctorate to do passive range of motion. Yes, nurses can do that. But they always have time for it knows. And should that be the only thing that we do with patients on mechanical ventilation, I actually just did a little survey on my Instagram page. And I asked how common is it for physical therapists not to see patients until they’re excavated? And I think almost 60% of people said that that was comment that was in place, neuroses, it made me want to bang my head against the wall, because you miss so much time, so no one’s moving for weeks.
Dr. Swamy 29:14
it’s really takes a huge investment, though, to make an ICU where people were the physical therapists who were also going through the rest of the hospital doing all their evals and everything. It takes a big investment. I think that’s why, but some of this comes from the ground up and just recognize it, for example. I mean, I think my residents all think of me now is just like this, “benzo-hating person”, which is kind of true.
Kali Dayton 29:39
I love it.
Dr. Swamy 29:44
But I think the other hand that only goes so far, I mean, I think it has a huge impact, but really, we need much, much more concrete ideas of how to staff and where the money has to be there in order to do these things to staff to be able to function at that level. But that is going to it makes a huge huge difference for patients getting out of the ICU faster and out of the ICU better, too.
Kali Dayton 30:06
You’re working for Medicaid? I wonder, does that impact your perspective? Because decrease in sedation, implementing all these more humane practices also saves money.
Dr. Swamy 30:20
I hope we can make those kinds of changes, it’s incredibly hard as you can imagine. So I think I think what we really need is kind of what you said, we need to start with people knowing what a better way to do it is, because I think we have a long way to go. And I think there are still, you know, on the other hand, what that means is that there’s really low hanging fruit. There’s really low hanging fruit, and just being able to say, “Just try not to use benzos”- that one thing will make a huge difference. We see it, I mean, we’ve had people who, who were on a versed that drip for however long, then they get extubated and, you know, weeks later, they still have benzos in the urine. You know, it’s and it’s just, you realize, when you start to see that, that, “wow, this stuff really hangs around and really messes with you for a long time.” And it’s just not the best drug to use.
Kali Dayton 31:13
But you know, what, I don’t think most nurses know that. They really don’t. They’re just born into this environment. And they just think that’s normal. It’s normal drugs are not gonna question it. I feel like we have to make the research more available and applicable to people to understand that. You know, we’ve, in the recent years, Medicaid, and all these insurances have started refusing to reimburse for things, such as hospital acquired infections, and pressure injuries and things like that. And we have in the research that delirium has all these very expensive repercussions,
Dr. Swamy 31:49
They are very expensive, really bad for people. But I think what’s amazing is I really think a lot of people still feel like it’s inevitable. And it’s, and it’s not inevitable. It’s not inevitable. You can dramatically reduce the rates, even without all the “dream ICU infrastructure”- you can still do so so much just as one resident, one doctor, one nurse, you can make a huge, huge impact.
But it’s uncomfortable to do that, because it means that you’re going to have to be doing medicine in a different way. And I think part of that’s hardest that people see people are delirious, and they think that they’re suffering, which they are, but they think that the answer to that suffering is benzos is sedation. And I just I think that is a fundamental concept that isn’t true.
Kali Dayton 32:42
t’s not it just masks it.
Dr. Swamy 32:46
It just masks it. It makes it worse. I think you can’t sedate away delirium.
Kali Dayton 32:50
No, no, it just exacerbates and prolongs it. Yeah. And I think if our community understood even that concept, it would change that moment, that split moment of their flavor, flailing they’re screaming, what do we do? If we understood that one truth, then yeah, then it means wouldn’t even be one of the options that we wouldn’t even an option.
Dr. Swamy 33:11
It wouldn’t even be an option. But it’s hard because, you know, our our culture is to treat things with with things that fix them. And it’s really hard to say non pharmacological approaches to this. Because they feel so intangible. It’s not an order I can put in, I don’t get to see a result of it. But when you do the the ABCDEF bundle, you get results! You do a lot of the elements of the bundle and you start to see big changes. It’s been really hard with COVID Because without family at the bedside, that’s it- delirium. Now it really is inevitable.
Kali Dayton 33:45
The COVID ICU in the Awake and Walking ICU ICU delirium rates actually are not that high.
Dr. Swamy 33:51
Wow.
Kali Dayton 33:52
Because we don’t start sedation right?
Dr. Swamy 33:54
Well, yeah, yeah.
Kali Dayton 33:55
And yet, not having family presence is a huge obstacle. Yeah, even still, because they are such an important tool in preventing and treating delirium.
Dr. Swamy 34:04
Especially hypoactive delirium, so much worse. So underrecognized. But when you see it, when you find out that your patient is quietly telling someone else that you they think you’re trying to kill them, and they say it very quietly, and you don’t notice it, and then you bring their family in for one visit and all goes away. Unbelievable. But they hit the policies and everything’s, you know.
Kali Dayton 34:28
Dr. Ely has some really important insights on trying to encourage hospitals to change that policy because, it’s again, very expensive, very harmful, detrimental. All the things..
Dr. Swamy 34:40
None of us would tolerate that your family members were there.
Kali Dayton 34:44
No, oh, no, no, I’d be storming the palace that’s for dang sure. A thought that came to mind. You do rotations for a week at a time, right? Yeah. And as an NP I started doing that too. And that I think that as well changed my perspective. Whereas a nurse it was three shifts. The week but it was sometimes they were sporadic. I tried to put them together, but then you don’t see patients over the spectrum of their course. And so you just see them for that one shift. So you’re just kind of putting a bandaid on the collapsing dam. And you’re not there to watch it break. Or you’re the unfortunate one where it’s broke, broken, but you didn’t see how that happened. And so it’s really hard to piece together the big picture when you just get a 12 hour clip.
Dr. Swamy 35:24
I think it’s totally true. And I think continuity goes a long way in the ICU. And I think I think that’s something I didn’t really understand when I was in training, because it felt so much like you’re doing these minute to minute things. And that’s what ICU medicine is and it’s really not, there’s so much of what you’re doing that has an impact over days to weeks, that has a huge impact and what you don’t do when you could can can totally alter a patient’s life.
Kali Dayton 35:53
And your assessment changes day to day, not just because the patient changes, but because you know that patient better especially if something’s so subtle as delirium. Looking into a patient’s eyes, and being able to really sense if they’re there or not, or their level of anxiety like it, you have to really know that patient and that’s where nurses can be so powerful. But continuity for everyone can be I think that could change everything.
Dr. Swamy 36:14
Yeah, yeah, I think that’s it’s, it’s hard when you see, ICU medicine really, as something that is just totally fragmented and just responding to moment to moment changes in… you know, it’s kind of like, “oh, tachycardia= beta blocker”- we don’t do that! We don’t do that. We know you don’t just treat tachycardia with a beta blocker. But that is how we treat delirium. We, you know, we treat delirium in ways that we would never treat a human anatomic abnormality. We wouldn’t just suppress it, we would try to understand what’s driving it and fix that thing.
Kali Dayton 36:49
I love that analogy. Can I snag that quote, you want it unless you understand the root cause of it, you’re not really treating it?
Dr. Swamy 36:55
Yeah. And I think it’s also really true that that’s why I really, I really tried to in my when I talked to the residents about delirium. So every third or fourth slide is a quote from a patient about delirium or a painting they made or something, because I didn’t get it. I didn’t get how intense it is, how bad and terrifying it is. It’s not just someone who’s reaching for the tube.
It’s living in an alternate world where everyone is trying to kill you, where people are putting knives in your body against your will. And it’s just I think it’s it’s horrific. It’s her. And when you realize that it’s uncomfortable, I remember this is when I read Dr. Rana Awdish’s book, “In Shock”, when I read her book, it’s called “In Shock.” And Rana Awdish is an intensivist at Henry Ford.
And she was a patient for a long time over and over again, in her own ICU. And she describes how, how just eye opening it was and how terrifying it was. Like, for example, she has an incredible description of, of spontaneous awakening trials and how they were actually something that I think of is so important to quality, to patient care, to getting people extubated, how it was this horrific experience for her where she would be like, like, suddenly awoken, unable to breathe, panic, panic, panic, and then out again.
Kali Dayton 38:27
I’ve always suspected, that’s what it was like. And I’ve been asking survivors, and most of them were lost in their delirium to even connect with their environment that much during those brief breaks. If they got them. A lot of them did not even get breaks. But I feel like, what, because when I seen it, you know, they turned on the pump, just enough for them to flail off for and then they put the pump back on.
Dr. Swamy 38:50
Yeah, that’s not the purpose of them.
Kali Dayton 38:50
I was, I was like being having someone putting your head under water pulling you out to get a breath. Yeah, but not really catching your breath and throwing you back down underwater. So she validated that. Does she have a TED Talk?
Dr. Swamy 39:03
I’m sure she does.
Kali Dayton 39:04
I think it has heard her TED Talk. I’ll have to read her book.
Dr. Swamy 39:07
Her book is incredibly, when I read that book. It’s the only book I can say this about that it instantly changed the way I practice medicine. The second I read that book, I treated patients in the ICU, it’s still hard because it’s really hard to be in the ICU, and to really be there and to really feel it and to know what’s happening and to tolerate it. And it’s honestly it’s not, it’s not easy.
It’s not reasonable even to always be like that. You have to be able to have a little bit of distance, right? But there’s a right way to do that. I think in a wrong way. It’s too easy sometimes to just be really casual in the nursing station and and you know, patients are suffering incredibly there. So there’s a balance there, but it is I really I think a lot of my research has been on staff burnout in the ICU nurse burnout in the ICU.
And it is you know, the real relationships and the work environment, I think are key to this. And it’s hard for nurses to be in the environment or someone is thrashing around agitated fighting them. And there’s no, there’s no help for them. There’s no help to make that better. And how many times do you go through that before? You just can’t? Just can’t bear that, right.
Kali Dayton 40:21
Yeah. And to that, I would also, I would, again, reaffirm that the incidences of that happening are so much less when we never start sedation. Because I’m sure it is so difficult to have that on every patient. You start sedation on every patient. At some point, that grenade is going to go off, you have to unleash the beast on someone and that is going to make someone exhausted. Even in the Awake and Walking ICU, delirium is rare. But when it happens, the team doesn’t even want to start sedation because they don’t want to drag that on forever.
Dr. Swamy 40:53
You don’t want to drag it on, you got to just deal with it.
Kali Dayton 40:55
But it’s exhausting. And I think those moments are reaffirmations of what we do, because they’re like, “Wow, no way, I’m doing this on every patient, no way, we’re going through this, putting other people through this, because it is so much work.” And it’s I mean, it’s a hazard, you’re losing lines, you could lose an airway. I mean, it’s, it is hard.
So I think as we understand the patient perspective of what’s really going on, then we can be more motivated to prevent it and to have that culture and that infrastructure in place to prevent most delirium, and we have delirium, we’re not already so burned down, that we’re just going to mask it to set them up. We’re gonna have some compassion left and be able to treat the cause of it.
Dr. Swamy 41:38
Yeah, you have to ride it out. It’s really painful, it’s really hard to ride it out. And, and it’s, sometimes it’s just not it’s, it’s not tolerable. And I think my role as the doctor is to try to find whatever way I can to support that nurse who’s in there a lot. To support the family that has to see that and reconcile it. And obviously, to support that patient. Really to try to find ways to model and reaffirm the patient’s dignity and humanity at a time when it you know…. I think one of the challenging things is that the ICU has a certain there’s certain incentives that will push everyone to act in a certain way.
And an example of that is that people will always trend to more sedation, they’ll just that’s the natural trend, we’ll get the things that get increased don’t automatically get decreased. You know, like, it’s, there’s some issue where someone needs more they’re on it, they need more fentanyl, whatever, more…. they get more, but it doesn’t, you know. Once you have all the drip, set up, the drips or drips, they stopped being boluses.
And, you know, I think that’s a real trend. The same is true for paralytics. You don’t you shouldn’t hardly ever really need to use a lot of paralytic. And yet, once you once it starts with a bolus. And the next thing you know, it just is like, all of these things are wrong, and they come back the next day. And why is all this stuff on. So I think you have to have that conscious understanding that the ICU pushes that certain things happen. And we have to intentionally reconcile all of that. So maybe someone is, is is sedated and we wake them up, and they end up needing to go back on sedation that’s happening in most ICUs. And most places, the the level of sedation they’re on shouldn’t be the same as when you started, you should at least be bringing it down to the least.
Kali Dayton 43:29
So yeah, and the indicators for sedation shouldn’t just be agitation. Because again, it’s going to be the same thing whether someone has an airway or not like they’re if they’re delirious, sedation is not going to be the answer.
Dr. Swamy 43:46
Yeah.
Kali Dayton 43:46
And we have to change that communication as well as well. “They couldn’t tolerate the ventilator.”- Was the ventilator, or was it the delirium?
Dr. Swamy 43:53
Yeah, yeah. And a lot of times, it might be the ventilator, but they, I think it’s not easy to be able to really sit there and spend time with the ventilator and to understand the ventilator is really intimidating. Yeah, it’s really intimidating for a lot of people and, and sedation is not intimidating. It feels like the right thing to do feels like it’s humane. It’s easy, it’s gonna work.
So in the moment, so I think it’s, it’s challenging to say, “no, no, no, let’s actually play with the ventilator more, let’s actually try different things with the ventilator.” Because if they’re not comfortable….we may be able to fix that with the ventilator.
Kali Dayton 44:28
Make the ventilator work for the patient or the patient for the ventilator. And I have to give my respiratory therapist more credit to because I think I you know, it’s a skill set for nurses to be able to talk to someone. Work them through the anxiety that that discomfort at first. That’s a skill set that we don’t teach, unless we have the occasion to right? So if you’re sedating everyone, you don’t learn how to work patients through that. But also for respiratory therapists.
Dr. Swamy 44:52
Yeah,
Kali Dayton 44:52
When they’re always on assist control are always on the settings and they’re sedated. They don’t have to adjust anything but our respiratory therapists sit there and they just…. They can just whisper that ventilator to just go right with the patient. And so I think ventilator settings is actually a huge part of that as well, as far as being able to target a ventilator.
Dr. Swamy 45:08
Like everything else that gets into staffing.
Kali Dayton 45:15
and culture. I mean, I think RTs are like four to six patients to 1 RT. So it’s not that I stopped being so much better necessarily, then COVID is different, but the normal circumstances and it is, but the culture I think, makes maintaining that a lot easier. So, you know, so many good principles. Thank you so much. Anything else you would you share with the ICU community?
Dr. Swamy 45:42
You know, I just I really appreciate my colleagues in the ICU community. I think that that, in a time when there was so much uncertainty, and when people were really practicing in wildly different ways, I still felt like we were supporting each other, you know, there was a incredible amount of tension on how to treat COVID so much, so much argument about how to treat COVID.
Right? So much argument about what when to intubate what to use, like, what drugs to use, what not to use all that stuff. And I think that that debate actually ended up for me making me feel like the ICU community really rose to the occasion to check that challenges on I think now we have to rise to the occasion to say, you know, a lot of bad things happened during COVID.
People got you know, I feel like ICU medicine rewound like 20 years, 30 years and a lot of ways, sedations, paralysis, this stuff is being used so much more than it was before. So much more than I think it needs to be and I think we have to.. and invasive devices, Foley’s are in all the time. So I think we need to like unlearn and we need to really be leading that to kind of reset a little bit and recalibrate.
Kali Dayton 46:48
Bring the research back in. It’s still there. It’s still true. It still applies, especially now.
Dr. Swamy 46:54
Absolutely.
Kali Dayton 46:55
Thank you so much. That was powerful. I appreciate all that you do.
Dr. Swamy 46:59
Awesome. Thank you.
Transcribed by https://otter.ai
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