SUBSCRIBE TO THE PODCAST

Is it *really* easier to sedate patients? Ultimately, does giving patient delirium and ICU acquired weakness actually decrease staff workload? Travel nurse, Alex, gives us the real deal.

Episode Transcription

Kali Dayton 0:28
Alex, thanks so much for coming back onto the podcast are sure you are with us in Episode 32. But can you tell us three Introduce yourself? I guess.

Alex 0:37
Yeah. So my name is Alex, I have been an ICU nurse for like nine years now. I was working in Utah at the time when we met, which was my first experience with having vented patients that were not sedated. And since then, I’ve traveled to Seattle, San Diego, and San Francisco, all of which were very different experiences in comparison to Utah. And now that I’ve had kind of a, now that I’ve had a wide range of experience in different ICUs, it’s been glaringly obvious what some of the problems are.

Kali Dayton 1:13
And I thought you were the person to address a very important topic I want to talk about this is kind of spurred on by a post that was shared in the Facebook discussion group, a fellow on college Colorado, she had a really neat post where he has this picture of a patient smiling on the ventilator, looking at their loved one at the bedside, and clearly not in any stress.

And he’s excited because he has been listening to the podcast for a long time, he actually went and toured the awakened walk in ICU. And he has been trying for months to implement this in his ICU there in Colorado. So he talks about how he has been able to have three patients thus far awake on the ventilator, and he’s sharing how much easier it is to let them wake up right after intubation and not have to let him declare out.

So he’s sharing his experiences with this great picture. And with his permission, I copy that into a post on the podcast page. And I shared that in some critical care pages. And there was an uproar, to say the least, people were irrate over this. And granted, he was saying, I think he was trying to explain this as if he was explaining it to other physicians. And he said things like, “Just tell the nurse what the goal is and say, by the bedside and hang with them and help them through this process.”

And I think the nurses found it demeaning or like, he didn’t understand the nursing perspective. But a lot of the dispute was, “this is too much work, we can’t handle so much work. And this is a touchy subject right now”,- because we’ve been through a pandemic, and then the ICUs have been flooded, and nurses have been taken on extra patients. And it’s been so much work, and they’re burnt out. So here we are saying, let’s just try something totally different. And it looks like a lot of work.

Because we like to have our quiet shifts with our patients we don’t have to talk to right. So it got me thinking a lot about how much extra work is really to have someone awake on the ventilator. And I feel like you are a good person to speak to that, because you’ve done it both ways now, and you’ve been in the thick of the COVID. Storm. So share with us some of your thoughts about how much does it impact the workload of a nurse to have patients awake and moving on the ventilator?

Alex 3:29
Yeah, so I mean, I think that, first off everyone’s definition of “work”, I guess is a little bit different. Like there is just as much work when someone is intubated, or sedated versus not, except it’s a different type of work. And it’s a better type of work. It’s better for the patient, it’s better for the nurse.

So like for example, just starting off like neuro assessments, it is easier to have the patient to be awake, they can answer your questions, you can understand whether they’re oriented, they can tell you whether or not they’re in pain, you’re not guessing based on their body movements based on their vital signs. And then that leads to you know, maybe they’re given less narcotics, because they’re not actually in pain. And their blood pressure is actually just high. Like, everyone “Oh, this patient, they’re so hypertensive it they’re probably in pain,” and then you give them narcotics, and then they’re, like, more sedated than they need to be.

Then their bowels back up. It’s like a cascade effect. And all you needed to do was ask them if they were in pain, and if they’re not sedated, they can tell you that information. So I think people are assuming that there’s more work because you know, communication, like there’s two people instead of just instead of just one nurse doing doing the work, but the communication makes the type of work that you’re doing so much easier. You know, if this patient is is not in is not in pain, then you can give them the appropriate medication.

Also, you know, if they tell you that they need to go to the bathroom, like, Oh, that’s a lot better than cleaning up a messy bed. Like nobody wants to have to find another nurse or like, historically, a lot of people complain that they work on floors where their nursing assistants aren’t helpful, or where there’s not good teamwork, or no one has time. It’s like, Well imagine if you didn’t have to find another nurse to help you turn a patient, because the bed was a mess, because you’ve given them tons of laxatives, because they’re sedated.

And so then, you know, now you’ve got a it’s bad for the patient, right, their skin is taking a hit and beam. If they weren’t sedated, they could get up, you could help them to the commode. And that provides dignity to the patient, better for their skin, less work for you. I mean, all in all, I Yes, getting the patient out of bed is a similar amount of work to turning the patient in bed. But but if you had to choose one or the other, and that’s the case, you have to choose one or the other. Why would you not choose the thing that is better for the patient, and possibly less work for you? It’s just a no brainer.

Kali Dayton 6:15
Right? And I when you start mobilizing patients right after they’re intubated, they’re going to preserve the ability to get themselves out of bed. So we’ve had other nurses talking about basically being a standby assist, and patients are getting up just mandate manning the to mean, yeah,

Alex 6:30
Because, yeah, well, I was gonna say, because right now, it’s like you can’t involve physical therapy until the patient is excavated. And it’s like, we should be involved in physical therapy, the moment they’re intubated, so that they don’t become weak, because we activate these patients. And it’s like, they haven’t moved to their arms or their fingers or toes in a week or two weeks or three weeks.

And it’s like, if they’re not on, if they’re on minimal to no sedation, while they’re intubated, they can follow commands and directions, they can lift their legs in the bed, they can move their arms, they can control the TV, they can, you know, and then you slowly progressed to using the commode and going for a walk and things. But those aren’t things that we should have to wait until a patient is extubated to be able to do.

Kali Dayton 7:12
And then what are you seeing about re-intubation rates when they’re like that?

Alex 7:14
Yeah, when patients are not sedated, it’s very clear, it’s, it seems to be a lot clearer when they’re ready to be excavated, you know, they can get, you have a better idea of whether or not they can protect their airway, it’s not as much of a guessing game, the patient can tell you, you know how their breathing feels they can, you can assess better whether or not they’ve got like, a strong enough cough to take the tube out.

And, and also, I think, like, just the process of extubation, in general can be really, people. I don’t know if people are forgetting how stressful that is. But the number of times that you have to turn off the purple fall, but like immediately start precedex and then you’re also pushing other and it’s like, you know, one just turns off purple ball and activates happily like, usually you turn it off, the doctor walks away, you have to go call them the patient is freaking out.

Now you’ve got to start another drip, precedex or something because they’re not able to handle being off the propofol because they’re rightfully so agitated, have no idea that they’re intubated. They’re confused. They’re delirious. Now you’ve read, you’re risking self extubation, possibly before they’re ready. Even if they’re restraint. I’ve seen so many patients while you’re doing an LSAT, like you’re doing some sort of sedation vacation, they wake up, they’re freaking out, and then they self activate. And then it’s like, well, that’s, you’re just gonna get reintegrated right now.

Kali Dayton 8:40
And what’s more work? Is it to suddenly have this big emergency that have to re intubate, do all the drips again, is that that to me sounds like so much work. Delirium is so much work. It’s so much work. It’s a complete rodeo, which I think people are imagining. When we say patients being away from the ventilator, they’re imagining that rodeo the whole time. I think so. Yeah. But that’s not your experience. That’s not what when you don’t know, well, delirium. They are like you’re saying, they’re cooperative.

They’re alert, they’re calm, and it’s so much easier. And when when we excavate. Usually they’ve got like, they’ve walked a lap, and then they’re sitting in a chair and they excavate in a chair. reintegration rates are incredibly low, and then we can walk in ICU because once those ventilator settings are low, the patient still have an intact diaphragm and respiratory muscles and neuro status to be able to breathe on their own independently. So extubate chances are, they’re going to fly. Yeah, be able to get out of there sooner and that’s got to be less work and less burden on the staff.

Alex 9:41
Definitely, not only are their respiratory muscles like they’re able to, you know, be on minimal vent settings for a longer amount of time. But a lot of breathing is driven by your neuro status. You know, you can’t activate until the patient is following commands and it’s like, well, maybe they’re not even on any sedation anymore, but it’s taking them Um, you know, days to wake up from it, because they’re an older individual, maybe they were septic, and you can’t activate until someone’s following your commands because you don’t trust that they’re able to, you know, be able to prevent re intubation. And so then they stay intubated for extra days because of that, and that is, yeah, that’s, that’s also unnecessary.

Kali Dayton 10:20
And when you have these situations in your units, where you’re you have too many patients, not enough staff to fix staffing crisis doesn’t make sense to have these protocols that keep patients on the ventilator longer. So you’ve got days long on the ventilator you’ve got so you’re still titrating all these sedatives, your propofol add, or fentanyl, what people are going for sad on top of that? Oh, yeah, so I’m just gonna throw up, then you’ve got basal pressors, because you drop their blood pressure because of Absolutely. That sounds like a lot of work to keep those strips running. You can titrate it appropriately. That sounds like a ton.

Alex 10:58
Yeah, yeah, it is. I think that like, the number of like, we see patients in two to three press or shock all the time. And they’re on, you know, they’re maxed on propofol, they’re versus running at eight. And it’s, well, of course, they’re, you know, max time forever. You know, it’s like, you, you think you’re solving one problem and you’re causing another and so, you know, we have to be more mindful. Some people don’t see it as as big of a no one’s mind works.

Like, let’s lower the purple fall, maybe we can also then lower the libo. It’s like, Why does your Why does Why is that not something that we’re thinking about doing? Why can we not understand that, like less sedation will also allow us to come off some of the browser’s? I mean, I’ve had patients that are on such high doses of pressors, for an entire shift that halfway through the shift, we can’t even pick up a pulse ox anymore, because they’re like extremities or, you know, not reading and it’s like, I think that, in general having less trips, obviously less charting, people are worried about, you know, speaking of charting, people are worried about restraints when you have patients that are awake on the ventilator.

I mean, you restrain patients that are sedated on the ventilator, I think that in general, you would have probably less restraints that are unnecessary, the patient is oriented. Obviously, you can determine whether or not you trust the patient. If you don’t trust the patient, you put them in restraints, and that’s the case whether they’re intubated or not. So if they’re intubated, and they’re not on sedation, and they’re oriented, I’ve seen I would say, less of those patients have needed restraints than my patients who are on sedation, but like occasionally still waking up, and then of course, they’re delirious.

You have to have them on restraints, like soon as the patient’s not delirious, you can trust them to not activate themselves. It’s people just haven’t seen it, I think is the problem. They can’t really picture it. Like you said, they picture waking somebody up from being sedated. And they picture the the crazy that goes along with that. And they can’t, they’ve never seen someone intubated and calm. I mean, I haven’t before I worked in Utah, and now it makes complete sense. But to a lot of people, I think they have trouble even picturing that scenario.

Kali Dayton 13:14
And if I’m a safety standpoint, it would be really hard sale to say, hey, let’s, let’s unleash all the delirium in your unit have bucking rodeos on every pair of ventilator? That would not be feasible. But that is the complete opposite of the reality of it. But, Charlie, that’s a really good point. You know, we really do use less restraints when we have less delirium. Yeah, we give us that sedation, we have far less delirium. And the Yeah, the burden of the charting has to be so much less what else so we have less pressure injuries, right?

Because there’s no turn Q to patient, lifting and turning themselves less skin because skin Pressure injuries but also like a score creation on the skin because they can use a call and say, I need to use the bedpan or you need to use the commode. These patients are getting up with physical therapy. They’re making a pitstop to the toilet. Yeah, easier is that is that and also when patients are out of bed, then you can change all the sheets, you’re not breaking your back to turn patients to change the seats. You’ve got an empty bed patients are up walking texts can come in and change the sheets while they’re up. Yeah, that’s got to be less work.

Alex 14:26
Definitely. And it’s like, you know, then from an infection standpoint, obviously if patients are intubated for less amounts of time, they’re they’re less at risk for they’re less at risk for infection. But other types of infections, you know, you we see so many line infections. So many Foley infections, like if the patient is not on pressors, they don’t need a central line. So all of a sudden, we can use peripherals and we’re not seeing as many line infections.

I saw so many line infections when I was in San Diego and I think it was because these patients needed central lines for way longer than you know Uh, than we normally keep them, of course, they’re gonna get infected, but you can’t run through pressors through a peripheral and seeing last line infections, you know, patients can get up and use the bathroom, use the urinal, so you can take up their Foley earlier. I mean, in general, all of those things are gonna cause less infections

Kali Dayton 15:17
and immobility, the huge risk factor for ventilator associated pneumonia is…

Alex 15:21
yeah,

Kali Dayton 15:22
so the more that they’re up, they’re coughing, they’re clearing their secretions, they’re mobilizing everything, the less likely they are to have a ventilator associated pneumonia, which has has to drive down the work that I’m the ventilator the costs.

Alex 15:34
All Yeah, the cost, right? No one thinks about that anymore. Right. And

Kali Dayton 15:39
That’s another thing too, is when I hear about units, stacking on, you know, three patients to one nurse and ICU, it makes my blood boil boil, because that has to be so expensive, because you’re increasing these risks and these rates and you’re making the staff feel like they have to sedate patients even deeper, because they want to make sure they don’t move a muscle because they can’t be there. But that is so expensive.

Alex 16:01
Yeah. Yeah, I think that like, I think that one of the important things about the ventilator associated pneumonia that people forget is that you know, patients are that that comes from patients being intubated for longer than they need to be. And so like, how do we get them excavated quicker? How do we get them, like more mobile, you sedate them less? You get them off, and you take them for a walk there? I mean, it is there is nothing that you can do. You know, there’s that precaution, but you can’t have patients using any sort of pulmonary toileting tools while they’re sedated. And so if they’re not sedated, there are so many more things that you can do to mobilize their breathing.

Kali Dayton 16:49
Which is so ironic, because amongst all these conversations, or these discussions, or disputes from this one post, a respiratory therapist even said, You can’t do pulmonary toilet on someone that’s not sedated, like being awake would impair their ability to use what the percussive vest. I don’t know where they’re coming from, and my jaw just dropped with it. You are a respiratory therapist, shouldn’t you appreciate the benefits of coughing the words and secretions changing position i. So it’s just a such a disconnect in our perspective. And it’s got to be more work for our teas as well, to have more patients on ventilators longer have more solidified secretions, they can’t clear not be able to wean them off event, it’s got to be so much more work when patients are essentially rotting on the ventilator.

Alex 17:33
Yeah, absolutely. It’s I think, like just going back to what we were saying before is that there is more work that becomes there are new types of work that become involved. But it’s, it’s a much more normal sense of flow, you know, the patient wakes up and the patient gets good sleep at night, the patient wakes up in the morning, the patient goes for a walk, the patient is able to use the commode all like things that a normal human does. There is no sense of a day when you’re intubated and sedated. It’s all the same. And we all know what happens when when I don’t get enough sleep for for 24 hours. It’s like, you know, you’re delirious. It just doesn’t there’s no normal flow to your day, you can’t expect somebody to be in a right state of mind after days and days of you know, the hours of the day not mattering.

Kali Dayton 18:22
And I feel like if we really understood delirium, especially what it means for the patient, but even what it means for nurses, we would treat it as an emergency. Like, you know, when someone’s creating goes up, we certainly step back and we look at what medications are there on how do we adjust the doses, we want to prevent that from getting worse, because we know that could lead to dialysis down line, right? That could increase mortality that could decrease your quality of life.

That’s a big deal to have someone’s kidney injured. But if we were that aware, and that sensitive to a brain injury, as manifested by delirium, we would do the same thing we look at what medications are they on? What can we do, what interventions can we do to make sure that we nip this in the bud that we decrease the duration and the severity of the delirium? And on a from a nursing standpoint, I think the nurses in the waking walking ICU are very sensitive to how much work delirium is because they’re masking it.

So they know that if a patient becomes delirious, it’s going to be a nightmare for everybody. Yeah. So they’re, they’re always talking about how much sleep do they get? What can we do to improve their sleep? Where’s the family what, you know, we look at it just like any other organ and try to implement any intervention that would alleviate that injury to the brain. But it spares a lot of drama, a lot of work and a lot of suffering.

Alex 19:46
A lot of staffing too. You know, like I’ve definitely been in situations where a patient is so is delirious, and we don’t have any CNAs or sitters available to work with them. And so now the patient’s a one to one when they don’t need to be if they weren’t So delirious and it’s like, well, you know, if we’re causing the delirium if they weren’t delirious, then they wouldn’t be in this situation.

So there’s a lot of like, people just call it I get kind of frustrated that I think the umbrella term ICU delirium is like, we expect that you’re in the ICU, and that is going to cause you to be delirious. And it’s like, well, we induced that they’re not just delirious, because they’re like, because there’s no like, med surg delirium, it’s like, because they’re like, awakened walking around. It’s like, they obviously know they’re in the hospital. So it’s like, why is it different in the ICU? Well, yeah, they’re sicker. They’ve got it back going on. But we use all of these medications and things that induce delirium. So in part, I think it is our responsibility to see how we can, you know, try and relieve that. Yeah, I mean, not by just opening the shades in the room

Kali Dayton 20:49
While they’re sedated, like how much of a difference is that going to make? Yeah, I’m like, Okay. I can keep giving this declaratives medications, but the lights are on. Yeah. Therefore, I fixed it. And patients that are at risk of delirium, we should be even more sensitive to someone’s in septic shock. We shouldn’t say, because people say, well, we can’t. We can’t avoid sedation on patients that are septic. Which makes me sound like if someone’s in septic shock, and their blood pressure’s low, you’re going to be watching the kidneys, right? And you’re going to adjust the vancomycin accordingly. We need to do the same thing.

So I’m in septic shock. We’re going to think, wow, they’re at risk of delirium. So we especially need to avoid these medications that make them delirious while they’re vulnerable. Right now, let’s protect the brain. Yeah. And how do you write when you want to have a delirious patient, you have to have a sitter, you have people on standby. And ultimately, if someone, despite our best efforts, despite avoiding these medications, becomes delirious. When we give them sedation for that, to my mind, it’s fueling the fire, it’s like giving back to bacteria for bacteremia. Yeah, if we looked at it, as an investment, to hire more sitters to have more CNAs, to sit there and have them help keep the patient safe without sedation, then that is going to save so much money, right? We’re gonna avoid all of these hospital acquired injuries and infections and effects and time, not longer term, the ventilator, that costs money.

And so I think people get defensive, because they’re like, well, our administration won’t hire more people. But if we really research this and understand it, and stay tuned, because we’re gonna have episodes on the money side of this, this should be part of our conversation, when we really educate ourselves on the effects of what we’re doing, then that becomes a leverage in our discussions. It’s not just, Hey, we’re really burnt out. And it’s a lot of work, which is absolutely true. But also, this is costing money. I think that’s the language that we have to speak for the administrator.

Alex 22:52
Yeah, but there’s not enough research about this yet. Because people we need to get people to be willing to, you know, prove that this is this is worthwhile to present to, you know, the higher up, they have no idea what’s hard

Kali Dayton 23:05
to research, what you don’t do, first of all, but also we do have a lot of research on the effects on hospitalization costs, by preventing delirium. There’s an but my problem is that yes, of course, there’s a lot of generalization and in general, decreases costs. I’m working on finding more substantial numbers.

I think it also varies by practices and by geographic location and things like that. And the end, hiring a CNA is gonna be so much cheaper. Just a CNA, it’s like yearly salary is going to be cheaper than hospital acquired infection. Yeah, absolutely. Oh, definitely. We don’t see it that way. And when we just assume that it’s necessary, and we assume that it’s going to be more work than we just shut off?

Alex 23:50
Yeah, yeah, I think I really liked your analogy of, you know, we worry about like, the periodic anti, the first thing you do is look at medications. You know, if they’ve got, you know, an EF of 10 to 15%, we worry very closely about how much fluid we’re giving them. And it’s like, if they’re, you know, at high risk of delirium, we don’t really do anything different. We just get, we should look at every patient in the ICU as a high risk of delirium. And we’re very happy to just give sedation even before we

Kali Dayton 24:21
We don’t appreciate what that means. Like, even for our own ICUs. I talked about how we just taking patients into LTACH not a problem.

Alex 24:30
Yeah.

Kali Dayton 24:30
But it actually is even the ICU’s problem because the readmission rates are so high and there’s so much work, you know, all that stupid admission, charting paperwork and cleaning the room preparing the room, all the swapping up the equipment, just stupid work, right?

But you said you come to the floor, they’re too weak to clear their secretions, are too weak to get out of bed. They can’t clear their airway. They can’t protect their airway and they end up right back in the ICU or last episode. We talked with a survivor that was basically hemorrhaging out of this tracheostomy site was readmitted to the ICU for multiple bronchoscopies. How much work is that?

Yet, if he had been given the choice, he said he would have chosen not to be sedated, then he would have stayed strong enough, he would have had a tracheostomy, he would have walked out, he wouldn’t have had to go to the floor of the tracheostomy wouldn’t have been readmitted when I’ve gone to all talk. You know, it just hears domino effect. Yeah, that when some of the admitted but if we did, if we looked at that big picture that moment, and said, “Okay, what can we do to make this more humane for the patient? How do we, what do we choose now to make sure that they get off the ventilator ASAP? And how do we make this as as easy and as quick for the staff?” I think that would all support the choice of letting patients wake up right after intubation. And yeah, without giving them delirium.

Alex 25:53
Yeah, yeah, I agree. I think like the physical aspect of it, you know, we don’t, there aren’t enough. Rehab sites for all these patients who end up needing it. insurances don’t cover them. So we’re kind of, you know, by creating people’s, like, lengthening their like, length of stay by extending the length of stay in the ICU, we’re just creating more trouble when they’re leaving whether or not that means like rehab, or LTACH or whatever it is. It’s like we don’t, you know, this country is suffering in the like availability of those resources. So if we can, if we can eliminate some of the need for that by just sedating patients last that would be overall, it would be a huge win.

Kali Dayton 26:36
I think the COVID unit and the waken walk and ICU has only discharged a few survivors to attack maybe even just one, I think they had a tracheotomy. But very few of any have gone to LTACH.

Alex 26:49
I’m pretty sure most I would say I don’t have like the exact numbers. But from where I just worked for the last 10 months, all of the COVID patients who, quote survived, if that’s what you want to call it, and there are a lot that didn’t survive, but the ones that did, you know, it took forever to get them out of the ICU only for them to go to the floor with a trach and then to be readmitted to the ICU, then back to the floor, then back to the ICU them back to the floor, maybe to an attack, then maybe back to the ICU. It’s like they almost are a prisoner of like the health care system for the entire US have it’s not like they survived COVID and then went home like I do. You never hear of that.

Kali Dayton 27:32
And I’m hearing about a units creating almost like long term COVID wings within their ICU because they they don’t know they don’t have anywhere to put them there. Yeah, to breathe on their own. They can’t hold on heads up, they can’t get out of bed. How much more work is it now to have to use a ceiling lift or all the other lifts that come in and five or six people to try to stand them up or get them in a chair?

I mean, so much work and danger and risk and trying to move isn’t like that. I was reached out to by a family member of a patient that was an ICU. Now for COVID For septic shock, that moments later and of course sedated. So they reached out to me I think he’d been on the ventilator for about 10 days. But the time they reached out, of course deeply sedated. And they couldn’t get him off the ventilator. And Jimmy has ventilator he was on you know, people 530 person. Yeah, but he couldn’t sit on CPAP for very long, or pressure support because he was too weak. He had failed extubation three times.

And they said he they the family understood they had to be re intubated because he was too anxious. And then like I said, let’s think about this. He’s credibly weak, because I found doesn’t work. I feel like that’s almost like someone laying on your chest or in your stomach or your upper abdomen. And you can’t drop your diaphragm, right? You can’t do breath. Right, right. Who does? My friend like you’re taking a little shallow breath and you can’t get a deep breath.

Right, and so. So of course, when you can’t drop your diaphragm, you’re taking shallow breaths, you’re getting anxious, and you can’t breathe. And so this guy was probably delirious, super weak, couldn’t drop his diaphragm because it was either atrophied or paralyzed. And so he had been re intubated. And I said that his daughter said, That makes so much sense. He was saying I can’t breathe, I can’t breathe. I can’t breathe and they re intubated him, put them back on propofol. And because he’s intubated, physical therapy can’t work with them. Right, quote, unquote.

So trying to help the family advocating physical therapy to come in, they said, Well, he’s intubated. I mean, that was just a hard hit. And I’m like that is that’s the answer to getting him off the ventilator is physical therapy. And so they tricked him, and now they can magically move him. I don’t know why that’s our threshold. Like, you can’t move until they have a trach what what is the difference other than now you’ve got a hole in someone’s throat now you’re risking more infections such as strict If you’re stenosis, this last episode, the survivor talks about how his trachea collapses.

Now he had a resection, he had a reconstruction, it’s still not working his scars painful. So now you’re risking all of those complications. But what finally they tricked them, they can move them. And he’s maybe working with physical therapy, maybe once a day. He’s so weak. How much more cost and work is that for the hospital and the staff to have him stuck there on his ventilator? Because we let his diaphragm and his respiratory muscles rot?

Alex 30:32
Yeah, yeah, these ICU beds, we end up with patients in them for incredibly long time because we can’t, the settings of their own, like LTACHs won’t even take them. So they’re not even like candidates to go and get physical therapy. And I’m like, Well, this is wasting a lot of money.

Kali Dayton 30:51
Absolutely. And it’s so much suffering. And so because they’re still on the ventilator, they’re still going to be sedated, and they’re still delirious, and then they get more to sedation for the delirium. They atrophied more, it’s just a vicious cycle. And it’s a cycle, that one’s got to come and just say, stop. We Yeah, we’re making it so much harder on everybody than is necessary. But I think when it comes down to work, we talked about workload, that is an important part of discussion, but I don’t think it’s going in the direction that we that it should.

Alex 31:19
No. Yeah, I think like, overall, the message that people need to understand is that like, sedition is it’s not like we’re telling you, you can’t do it, it’s always an option. But like, why, you know, getting people to be so much less averse to trying without it and understanding what that could do, you know, you have a million medications available to you, but until you have proven that you need them, why use them, you know, from, from a workload perspective, it just like it, you come in, when your patient is on no drips, like you should be excited to hear that.

Not like that they’re on like, oh, yeah, no drips running like, great. Like, you know, they don’t, it’s just it doesn’t need to change people’s frame of mind, when it comes to having a patient who’s intubated and understanding what that means for you know, how your what your day looks like.

Kali Dayton 32:14
And who doesn’t want an easier shift? Seriously, doesn’t want to get better and walk out of the ICU. And I feel like that’s yeah, part of the healing process in our field, is having people actually have the satisfaction of watching patients get better. And that’s only going to happen when we do the things that will prevent this harm. And let them say human walk into the ICU as humans.

Alex 32:35
And I do think that, you know, like, when we had patients who COVID are not like who are intubated for a really long time, and then they wake up, and then they’re communicating, and they’re smiling, and they’re talking to us, like all the nurses on the unit get excited. But there’s the same nurses that have never heard of not sedating and intubated patients.

It’s like, everybody wants the same thing. The common goal is just watch your patient get better. And I think like, you know, I don’t I want to assume that everybody is a good person and wants that, but it is definitely not like no one is on the same level. As far as you know, when you say that we’re not going to sedate this intubated patient, everybody, you know, then that’s where the huge disconnect is. And it’s like, well, we all want the same common goal. So like, here’s this new research about what we can do to get there. And here’s why you we should be willing to try it here. All the positive outcomes, just getting people to be a little bit more open to hearing about like, what that might look like, before they freak out.

Kali Dayton 33:36
Yeah, and no one wants to watch someone writhe in delirium.

Alex 33:40
Yeah, no one wants to take care of an Alltech. Patient. No ICU nurse wants to take care of an Alltech. Patient? No. Otherwise we’d go work on an attack, right? Like, no, let’s

Kali Dayton 33:49
not make them. Let’s not make them. Yeah, let’s not make them LTACH patient.

Alex 33:52
Exactly.

Kali Dayton 33:53
Let’s take care of their critical illness, their stuff while preserving their potential to function as a normal. Once that’s resolved. Yeah, absolutely. But Alex, thank you so much appreciate your insight, and the difference that you’re making out there isn’t anything else that you’d share with the critical care world?

Alex 34:12
I don’t know right now, I think, you know, just traveling to different areas. I think there have been so many travel nurses, a lot of people that got into traveling during COVID, rightfully so because of money. But what that has done is allowed a lot of nurses to be mobile throughout the entire country and see a lot of different ways of doing the same job. And I think if we could gain a lot more share the perspectives of a lot of nurses that have seen a lot of different things and kind of do a better job of distributing the information about things like this so that people can start to understand.

Then we can start to change practices. I would really like to see a lot of a lot more insight drawn from like the rest of the travel nurse community and used for for good because there are a lot of hostile polls that are always working on new things. And yeah, it would be, it would be really great to see somebody take the insight of what we’ve done over the last, you know, year and a half and ask a bunch of the the travelers what they’ve seen and what we can do better because of that. So I think what you’re doing is great. And I think I hope more people take note of it and, you know, are interested in learning more before they have their two cents to give.

Kali Dayton 35:27
And it’s exciting to see how more interdisciplinary collaboration is, is happening and being encouraged. I think sometimes we hear this principles and puts seems like such a huge shift. And people say, Well, I’m just a nurse, I’m just an RT, I’m just an OT. But in reality, I’m from my side. Those are people that are reaching out and getting webinars happening on their teams. And they’re making stuff happen. And so I just think there’s so much power even in the one to show people that it’s possible.

This fellow said that he’s had a few COVID patients now be awake on the ventilator, because certain nurses that have now listened to the podcast, who worked with the patients that he kept awake, now get come and get him. Even if someone else intubate them, they say, Hey, can we do that thing? Can we? Can we just not sedate them? Let’s see this, this works, too. So I think there’s so much power in the individual to bring this change.

I think as nurses start doing these changes, and show the rest of the team, what’s possible, you really can’t have an influence for change. So I don’t want anyone to feel like they’re just whatever position I think everyone wants to do the right thing. And anyone can be the person that brings in the voice of reason. Yeah, I’m just trying to support and evidence and all the research and all the stories, so that the whole team can jump on board. So one person can be the instigator, but they can also bring in resources that will help convince everyone else of what’s possible and should be.

Alex 36:58
So yeah, definitely gonna is it this is a good reminder for me to, you know, the people that I am currently working with now to get some of them into this podcast and to start just like throwing the thoughts out there and making people aware.

Kali Dayton 37:13
I think there’s a concern that, you know, now we’ve gotten hit by bad habits with COVID that we’re pulling back on benzodiazepines that we spent, you know, 10 plus years trying to get rid of, yeah, the teams are gonna get used to having patients the sedated that the culture is digressing over.

Alex 37:28
Yeah, it was a bit of a backstop, I think for a lot of hospitals,

Kali Dayton 37:31
So painful. And yet, I mean, I definitely think that’s a potential. But now that we’ve had to face the mess that we’ve made, that actually might be the trigger for change. My talk about things like re intubation readmission such and such, we’ve seen that on such a massive scale now that everyone’s gonna know what that looks like and what that means and be more interested in changing that. So I think this will be a point of change for the better in our field. I hope so. And your team, whatever team you’re working with.

Welcome to the webinar and www.daytonicuconsultant.com is that easy, signup for that, okay, so that we can get everyone in the same room, hearing the same information, seeing the same videos, pictures, it’ll be old news to you, but it’s kind of a jaw dropping experience for people that have never seen or heard of patients awake on a ventilator. But that really when you as the travel nurse or whoever says, let’s try this.

Now everyone else has seen what’s possible and heard the rationale as to why and you don’t have to wear yourself out trying to ship the whole paradigm yourself. Yeah, absolutely. It’s exhausting. We all know it. Yep. Thanks for coming on. We’ll probably have you again. You have lots of data to share. Thank you so much. Definitely. Talk to you soon.

Transcribed by https://otter.ai

 

SUBSCRIBE TO THE PODCAST