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Hi, it’s Patrik from INTENSIVECAREHOTLINE.COM where we instantly improve the lives for Families of critically ill Patients in Intensive Care, so that you can make informed decisions, have PEACE OF MIND, real power, real control and so that you can influence decision making fast, even if you’re not a doctor or a nurse in Intensive Care!
This is another intensivecarehotline.com Podcast and in the last Podcast episode we published another client interview and client testimonial.
You can check out the last podcast here.
In this week’s episode of the INTENSIVE CARE HOTLINE Podcast, I want to share the experience from Kali as part of my 1:1 consulting and advocacy service!
Kali is currently working as a nurse practitioner. She has started her career as a critical care nurse and travel nurse who advocates on preventing sedation in the ICU.
Kali’s valuable stories are an eye-opener for families in intensive care. She believes that family members are a huge part of the ICU team and families must learn to ensure that sedation is really essential for the survival of their loved ones in the ICU.
Kali’s attestation made its way for families to seek out experienced medical professionals like us here at Intensive Care Hotline that can advocate for the lives of their loved ones at the earliest time possible.
You can listen to the Podcast here or read the transcript below.
Podcast: Critically Ill Patients Need Not be Given Sedation Right Away. I Worked in an ICU Where Patients on Ventilators are Awake and Walking & I Believe This is Normal and Possible.
Patrik: Hello and welcome to the intensivecarehotline.com podcast. Intensive Care Hotline helps families of critically ill patients in intensive care to instantly improve their lives. Today, as part of our interview and podcast series, I want to introduce you Kali Dayton. Now, Kali is a nurse practitioner in the United States and Kali, I think, has some very interesting practices to share with our intensive care family audience. Kali, why don’t you introduce yourself quickly and let us know what you’ve got to share with our audience and what you do in your professional life.
Kali Dayton: Thank you so much, Patrik. I am ecstatic to be on your show and to talk about these things that I care so much about. As you said, I’m a nurse practitioner in the United States. I started my career as a nurse in critical care and in ICU that was awake and walking, meaning patients that were on ventilators were awake and walking. And still are. I guess its present tense. They’re still doing it. And so I worked there for a couple of years and that’s what I was born into, meaning I thought that was completely normal. I didn’t know very much about medically induced comas. And this is a tertiary hospital, a referral hospital. I mean, these were sick patients. The only times I really saw people deeply sedated were maybe severe areas that they need to process.
Kali Dayton: I’m trying to think what else. Maybe an open abdomen. Severe, severe alcohol withdrawal. I mean, those were just the severe exceptions. Then as a nurse, I became a travel nurse and I started working around all different states in the United States. I would take different contracts every three months. I’d go to different hospitals and I saw immediately that every single patient in other ICU’s were deeply sedated the moment they were put on a ventilator. And I was really confused about that. I was pretty naive. I didn’t really understand what that meant for patients long-term outcomes. I just wasn’t familiar with that. It didn’t feel right to me. So, I would get these patients and I was used to communicating with patients that were on the ventilator. They’d write on the board. We’d get up. We’d get walking. So, I started asking people, because I just wanted to do what felt right.
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Kali Dayton: And I would ask doctors and nurses, “Hey, can I get them up? Can I wake them up?” And they looked at me like I was crazy or really dumb. I’m sure they even doubted that I was an ICU nurse, right? And they’d say, “Well, no, they’re sedated.” And I’d say, “Well, why are they sedated?” And they’d say, “Because they’re intubated.” And then I’d say, “But why are they sedated?” To me that wasn’t an answer because I knew that patients could be awake on a ventilator. And then I came to learn that was just a deeply held tradition of the intensive care units. So, I ended up going back to the awake and walking ICU as I went back to grad school. And in this last year, I started a podcast in which I interview survivors of medically-induced comas; clinicians, so people that do medically-induced comas, people that do not; nurses, doctors, respiratory therapists, everyone from the awake and walking ICU, as well as survivors that have walked on the ventilator and walked straight home.
Kali Dayton: And I have learned so much. And I learned from one of my episodes. The second episode that I ever did was Dr. Clemmer. He is one of the founding fathers of critical care. Was in the ICU world for 50 years since the very beginning. And he taught me that the first ventilators that were ever created were extremely uncomfortable. They were archaic, right? They just pushed air in and pulled it out. And it was really hard for patients to synchronize the ventilator to breathe with it. It was just impossible. And so they started sedating them and that was really no other option, right? Otherwise, they’re trying to breathe against the ventilator. But the technology of the ventilators evolved. It became more sensitive, more customizable for the patients. So, ventilators evolved, but our practice as an ICU did not evolve. But what’s the problem, right? A lot of people in the ICU that work in the ICU still don’t know what that means for the rest of the patient’s lives.
Kali Dayton: Because in the ICU, we only see people during that critical illness, a little tiny snapshot. So, especially if we sedate them, we don’t really know the patients. We treat them. We make sure that we get their liver, their kidneys, certain organs better, but we don’t really have a way to really evaluate the brain, right? So, we sedate them. We might take off sedation a little bit just to make sure that they can flail all four limbs, and then they turn the sedation back on. And once their lungs look better, they give them a tracheostomy and they send them out of the ICU. So, as I’ve been doing more of this research… Actually, I haven’t been doing the research. I have been studying the research because for the last 10, 15 years, researchers have been looking at patients after the ICU.
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Kali Dayton: Granted, critical care has been around for 30-some odd years, but just in the last decade or so did we start seeing or asking questions as far as what happens to people after they’ve been in a medically-induced coma, have not moved a muscle in weeks? What happens afterward? What are their lives like? And that has transformed my perspective and my appreciation for an awake and walking ICU. And I’ve learned that patients have at least a 25% post-ICU PTSD and that’s closely linked back to delirium, which is caused by sedatives. So, as I’ve interviewed survivors, what looks like to us like they’re sleeping as they’re in a medically-induced coma is not the reality at all.
Patrik: No, it’s not.
Kali Dayton: People are thrown into what we now call ICU delirium, meaning they are having hallucinations. They’re having terrors, “bad nightmares,” quote-unquote. But when you talk to survivors, it is haunting because those hallucinations are not hallucinations to them. They are vivid realities and they imagine the worst. Sexual abuse, any PTSD, any trauma from their previous life, they relive it as if it’s reality. They misinterpret everything they hear, smell, see, and they twist it into the worst. So, they think that the ICU team is there to hurt them. They think they’re in enemy lines, being kidnapped, being tortured, that their kids are kidnapped. I mean, just haunting things that we have no idea about. And the difference is, when people are awake on the ventilator, I mean, no one’s doing cartwheels in the hall. No one’s happy to be there, but they at least know what’s going on.
Kali Dayton: They know that they’re sick. They know that they’re in the ICU. They know the ventilator, that tube down their throat that is uncomfortable, they know that it’s not something horrific and they protect it. They can cope with it. There’s such a difference. And so when these survivors come out after being, quote-unquote, “asleep,” which it’s not sleep clearly, they’re broken. Their spirits are broken from living in such trauma, and also their brains are broken. They develop a post-ICU dementia. They have cognitive deficits. So, if you get on survivor groups on Facebook, and this has been enlightened to me too, is hearing hundreds of people talking to each other saying, “Hey, I have a really hard time doing simple math. I have a hard time remembering anything. I have a hard…”
Patrik: Kali, you’ve dropped out for a second.
Kali Dayton: We would never expect that, right? We think, “Well, we fixed the infection. We fixed the lungs. They should be fine now.” And yet they move on and they now have what we now diagnose as a post-ICU dementia. And that as well is linked straight back to a medically-induced coma causing delirium that traumatizes them, breaks their brain, as well as causes massive muscular atrophy. So, what these families are probably seeing in the ICU with their loved ones is that once they do take off the sedation, their loved ones can hardly move, which is really, really detrimental to quality of life. It takes weeks to months to recuperate. I say that liberally because a lot of people don’t fully go back to their baseline physical capacity. And so Patrik, I know that you’re working a lot with this question of tracheostomy. Is it appropriate? When to do it?
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Kali Dayton: What to do after tracheostomy? My interest as well is preventing tracheostomies. And I feel like a lot of tracheostomies that are current in the intensive care units are because we automatically deeply sedate everyone. And we don’t move them for days to weeks to months sometimes. And so all of those muscles that support the lungs, the diaphragm, all the side muscles, everything that helps us breathe, that has atrophied. People can’t even hold their own heads up. So, when you can’t even hold your head up, you can’t protect your airway. And so the next step is to do a tracheostomy because it’s assumed that the loved one is going to be on a ventilator for at least 20 days more, according to the research. When they become that weak they cannot breathe on their own, so the lungs can be healed. The lungs may be fine, but now there’s no muscular support for the lungs.
Kali Dayton: And so, in the United States at least, we trach people. We give them a tracheostomy. We give them a feeding tube into their stomach, right? Because it’s going to be there for a long time, because of course, those are all muscles to swallow. And we send them to what we call a long-term acute care hospital. I’ve never worked in one, and on the ICU side, we don’t know much about them because we don’t have to deal with the repercussions of what we’ve done to people. Which I know sounds very harsh, but it’s the truth. So, we call them trach and PEG and send them out. And so from the ICU side, we ship them off to someone else to fix or to rehabilitate, and we don’t know what that’s like. But as I’ve been interviewing people, it’s a very painful, tedious, and hard process.
Kali Dayton: The survivors lose so much of their dignity and their identity and becoming so debilitated. I mean, they become like adult newborns where they can’t hold their own head up. They can’t sit. They can’t stand. They can’t walk. And it takes so much work. In the United States, these rehabilitation centers are grossly understaffed. The care is poor and I think it all contributes to this longer term physical weakness, depression, anxiety. A lot of times these survivors are still delirious even when they leave the hospital and leave the ICU. They go to these rehabilitation programs. They’re still in their own world. They still are having really severe hallucinations. They don’t know what’s real, what’s not. And I think it’s really important for everyone involved, especially the family members, to know the reality of what these patients go through. If it was my family member in there, the moment that they get in there, the moment that a patient is admitted to ICU, they need to have a physical therapy and occupational therapy consultation.
Kali Dayton: Those therapists need to be in there every day, multiple times during the day. The family member needs to be up in a chair as much as possible. If it was my family member, I would really be cautious about them being automatically sedated. And so that’s where I’m starting a service in which I am providing consultation for family members. As soon as someone’s admitted to ICU, I want to hear about it. I want to get a phone call and I want to work through this process with the family members to try to discern whether or not sedation is actually necessary. Because the local ICU teams have their culture. They have their habits. We’re the product of what we’re raised in, right? They likely do not know that it’s possible to have a patient awake and walking. But once you start sedation, you start delirium. So, then later when they try to take the sedation off, it’s really hard because patients wake up or they come out of sedation thrashing, agitated, confused, and biting. It’s uncomfortable for everyone involved, even for the family members at the bedside, to watch them be so uncomfortable.
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Kali Dayton: And yet habitually we try to take off sedation, but then we feel like we can’t because it’s too uncomfortable. So, we turn sedation back on. We send them back into delirium. We make it worse. We make it longer. And we just sign them up for all of these long-term side effects and repercussions of what we’re doing. And so my plea to family members and as well as the health care side is that we really, really hesitate before we ever start sedation, that we make sure it’s actually essential for their survival and that we do as low dose and as short-term as possible. But I feel like family members are a huge part of the ICU team. This COVID has just driven me crazy because they kicked out family members from the care team. So, then nobody knows who that body in the bed is because they deeply sedate them, they leave them to rot, and then there’s no one familiar. There are no familiar noises, voices, people, faces, and family members who help bring people out of delirium and come back to reality and feel safe and secure.
Kali Dayton: When we sedate people automatically, we send them into this terror and there’s nothing familiar for them to grasp onto. I’m sure they’re just having psychotic spirals all the time. So, if I was a family member, I would call me. I would make sure that we collaborate with the ICU team to make sure that we’re looking at the big picture, that we’re not just focused on getting through that shift, through that day, that everything we choose to do in critical care or during critical illness is going to help your loved one get back to their real lives and their real self. You want to bring home the same person that you brought to the hospital. But with medically-induced comas, that’s going to be really difficult.
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Patrik: Very difficult, Kali. Even for myself, I think I’m fairly experienced, but you’re opening up a different world to me. I mean, I’m always saying that the less sedation, the better, and mobilization. I have not seen people not being sedated, and I’ve been a travel nurse. I’ve worked in different countries. I thought I’d seen it all, but I haven’t, you know?
Kali Dayton: Right.
Patrik: You’re opening up a different world to me too, in terms of, okay, what is possible. Why do you think this happens in the unit that you work at? What’s so different about your workplace there? Why does it happen there and not elsewhere?
Kali Dayton: I know what happens there and I have a lot of thoughts about why it doesn’t happen elsewhere. It all started with my colleague. Her name is Polly Bailey. About 30 years ago, back in the ’90s, about the time that you started, we gave the worst kind of drugs. Benzodiazepines, paralytics, just heavy, heavy, hard drugs, because ventilators were just evolving. Things were just getting better and we were still just stuck in this rut. And we thought that the more sedation, the more still, the more lifeless they were, the more comfortable they were, right? So Polly, as a nurse, is watching this. Never thought anything different. And then she had a neighbor come into her ICU and she followed her after the ICU. It was a young mom in her 30s, and it took her a year to be able to get up the stairs. Because this was before LTACs. There was no care center to send her to, so they sent her home.
Kali Dayton: They would literally scoop people up out of the stretchers or out of the beds and place them in the cars with their loved ones and say, “Good luck.” No rehabilitation. So, her husband was helping her use a bed pan in the bed. She couldn’t get up the stairs. She had young kids. And Polly watched how traumatized she was when she talked about what it was like to be in a medically-induced coma, and then just her quality of life and how difficult it was. That’s what made her start asking questions. And so she went to her medical director, that Dr. Clemmer, the same one I interviewed in episode two, and said, “We’re really breaking people. We cannot do this to people. I mean, we get them through critical illness, but for what? Is there a better way? Let me move them. What if they never got so weak? Just let me try.”
Kali Dayton: Dr. Clemmer was pretty skeptical, but he knew nurses and he trusted them and he trusted Polly and let her work with it. It was really difficult to implement. She was in a shock trauma ICU at the time and a lot of old staunch nurses that thought that was crazy talk, because I’m sure it sounded crazy. There was no research at the time. This is just one nurse having a wild hair, right? So, she started doing it and it was working, but it was really hard to get everyone to do it because it can seem like a lot more work, right?
Patrik: So, if someone comes into your unit from… If I was, or any experienced critical care nurse was to start at your unit that would be a big culture shock. But I can see why you’re doing it. I’ll give you another quick insight what I’ve been seeing for the nearly last eight years since I’ve been doing the blog Intensive Care Hotline. Do you know what the most visited page on my blog is? The most visited page on my blog is, how long does it take to wake up after an induced coma?
Kali Dayton: Yep. And that is because of hypoactive delirium and also sedatives. Depending on the kind of medication, they settle into the body in different parts of the body. So, Propofol’s, one of our favorite drugs, that Michael Jackson drug, it settles into the adipose or the fat tissue. So, especially in America, obesity is a thing. We have people with a lot of adipose tissue on Propofol for days to weeks, and that is just accumulating. So, even when you turn off Propofol, you still have a lot left in the body to metabolize out. Not only that, though. You’ve caused delirium. So, there’s so much we don’t understand about delirium. Why people get all those hallucinations, go into this craziness. But it’s really a brain injury . Delirium is a sign of a brain injury.
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Patrik: It is.
Kali Dayton: The brain has been hurt. So, even if Propofol wasn’t still lingering in the body, delirium can continue for a long time. Another thing is, too, when people are in medically-induced comas, they’re not sleeping. So, they’re not getting the restorative sleep, the full REM cycle, and so anyone would go crazy not sleeping for weeks.
Patrik: They’re coming out of an induced coma and are sleep deprived, literally.
Kali Dayton: Yeah. So, their brains are going to be so broken that you can have two different kinds of delirium. There’s a hyperactive delirium where people come out and they’re agitated and they’re swinging, and that’s hard. It’s hard for them to deal with. It’s hard work for the nurses, especially if someone is intubated and has an airway. People start pulling at things. It’s a lot of work. So, it is easier to sedate them. Nonetheless, it’s important to get them worn out until we use those muscles and to let the brain clear out and heal. So, if someone is delirious, because there are a lot of things that can cause delirium, not just sedation. So, sepsis, a bad infection can cause delirium. In the awake and walking ICU, if someone’s getting wild, then we have a sitter with them.
Kali Dayton: Someone’s just there. They’re tied down, which is unfortunate, and yet it’s going to be less time tied down if we don’t sedate them. We use family. We have family there, very involved to try to help them, bring them to reality. We walk them. We get them up. We move them. That helps the agitation and anxiety wear out. But in any other ICU, if someone has hyperactive delirium, they’re going to get sedated, which is going to just prolong and exacerbate that delirium. Now, there’s also hypoactive delirium, which is what I think a lot of people see. That sedation is accumulated in the body. The brains are injured and they are comatose even without the sedation. Now, in a lot of places, they start sedation usually at very high rates and just run it the whole time. They never pull it back, never turn it off to see what people are doing underneath the sedation. Are they hyperactive? Are they delirious? Could they be awake? Could they be cooperative?
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Kali Dayton: So, there is a movement to start giving vacations, to try to take breaks to evaluate, to see what their actual neurological status is. Yet when I saw that as a travel nurse, they taught it to me like you just turn down the IV pump just enough to see them move all of their arms and legs to make sure they didn’t have a stroke, and then you just turn it back on because they’re too agitated. And it felt so wrong. In my heart, I was like, “I still don’t know what’s going on with that patient. They’re agitated, but why? Are they in pain? Are they scared? Are they traumatized?” We don’t ask those questions. We just turn the pump back on because we like to have the bed sheets clean.
Patrik: Clean.
Kali Dayton: Tight. All the lines perfect. You know what? I mean, it’s a lot of work when someone’s agitated. It truly is. And yet that’s not the treatment. You don’t-
Patrik: It’s not the treatment.
Kali Dayton: It’s like treating an infection with more bacteria.
Patrik: Exactly. Kali, what do you think going forward? I mean, you and I, I believe, are educating families in intensive care, but I believe we’re also educating the ICU community, health professionals, doctors, nurses, respiratory therapists. What do you propose going forward in terms of how health professionals can get better at their craft too? Because you and I can see the downfalls of the system. You can see the downfalls of what you and I have learned in intensive care over the years. What’s the way out of the dilemma? Because I agree with you. We’re fixing people by breaking them. Quote- unquote, “fixing.” What’s the way forward here? How can we educate the intensive care community? We’re educating families already, but how do we get intensive care professionals on this bandwagon?
Kali Dayton: That’s the question I’m always asking. That’s why I started the podcast, because I didn’t know about post-ICU PTSD. I’d worked in the awake and walking ICU. I could feel that it was better. I just didn’t know exactly the why. Because again, that’s the only thing I knew until I worked elsewhere. And then when I was in grad school, I sat by a guy on the plane and he asked me what I did for a living. I told him, and the color just dropped from his face. He got tearful and he spent the next hour telling me about his ICU experience and his post-ICU PTSD. I shared that on the podcast. But his life was broken. He end up divorced and couldn’t work and he was in his 40s. In his 40s with no other real co-morbidities. I mean, he didn’t have any chronic illness. And yet he had declared himself a do not resuscitate, do not intubate. He never wanted to be admitted to the ICU again, no matter how reversible it could be, because he was so deeply traumatized.
Kali Dayton: He couldn’t sleep for a year because every time he closed his eyes to try to sleep, all the images of trees falling on him, of being stabbed, of all the things that didn’t really happen but he was living in his own brain during his ICU stay, that would all flood back to him every time you would try to sleep. I mean, here he is, crying to me as a stranger and I’m crying with him. That has deeply impacted me. And I kept on thinking, “I didn’t know this and I am pretty dang sure hardly anyone else knows this.” We are so disconnected from the life after the ICU. So, I deeply feel that the best way to change is for those that provide care within the ICU to know their why. Because we try to implement these protocols and try all these different things.
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Kali Dayton: But no one reads the research. They’re deeply engrossed in these cultures and these habits. No one says, “Hey, did you know that if you start that sedation, they could end up with dementia. They’ll probably have PTSD. They’re going to have to go to rehabilitation. And did you know that there’s another way?” So, if people knew what actually happens to people when they’re sedated and how to manage them without sedation, I think people would change. Because no one’s malicious. Everyone gets into-
Patrik: Do you think that-
Kali Dayton: healthcare because they want to help.
Patrik: Yeah. Do you think that the pharma industry would have a word to say there, too?
Kali Dayton: Yeah, that’s a tricky question. I think benzodiazepines started so heavily because of push from the pharmacology side of everything. I think that started before there was really good research and before we really knew what delirium was. So I think if they were just to promote that, we have so much research showing the damage of delirium that we should still be able to use our own critical thinking and advocate for patients.
Patrik: Yeah. Yeah. Kali, I think you’ve given so much value to our listeners here and I know everybody listening on this podcast, they usually have a loved one in intensive care and as much as we’re trying to help, I mean, you’re one step of what we are even doing, which is great. I think it’s really time to get the word out there. Because when people come to us, we can help them with almost symptom management, but we can’t fix the root cause. You’re at the coalface of fixing the root cause.
Kali Dayton: Let’s prevent the harm.
Patrik: Prevent the harm. Unfortunately, admissions into ICU have spiraled out of control, especially with COVID, and it’s unfortunately not going away anytime soon by the looks of things. You and I can only help so many people, but at least there is someone out there who is trying to give families a voice. Because I think that’s also lacking. Especially now with COVID, people are locked out of ICU.
Kali Dayton: It’s the worst case scenario. ICUs have run back to those practices from the ’90s. We spent decades trying to get these drugs away and trying to change things and we’ve struggled and then COVID hit, we panicked and everyone went back to deeply sedating and automatically paralyzing people. Rehabilitation centers are full. I mean, it is just, the virus is bad, and the virus will do what the virus does, but our treatments alone are lethal, truly.
Patrik: Yeah, absolutely.
Kali Dayton: You know that medically-induced comas and paralysis, individually and combined, can kill people. It leads to higher mortality rates.
Patrik: For sure. For sure. Absolutely. Kali, look, just mindful of the time. Thank you so much for coming on to our show and sharing this with our listeners, because I know it’s so valuable. Kali, where can people find you if they want to know more about what you do?
Kali Dayton: Yeah, definitely. I have an Instagram, Facebook and Twitter for the podcast. The podcast is called “Walking Home from the ICU”. I’ll put the account addresses into your description. I also have a website for family members as well as healthcare providers. As a critical care consultant, I’m available to help either side of the bedside, make these changes, and I would love to help families advocate for their loved ones. The sooner that they can contact me, the sooner we prevent sedation and all of these complications, the better the outcomes are going to be. I’m so excited to help the family members advocate for their loved ones.
Patrik: That’s fantastic. I’m so glad that you reached out to me a few weeks ago because I’ve been feeling like I’ve been the lone voice. There’s so many critical care nurses, doctors out there that don’t publish information, and I still can’t believe it that nobody is doing what you and I are doing to educate families.
Kali Dayton: No, the first study that came out showing that it’s possible and safe to walk people on ventilators was in 2007. We’re still way behind in making that standard. It’ll be the family members when they demand better, and then they expect their loved ones to walk out of the ICU and go home. That’s when things will change.
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Patrik: Yeah. No, that’s great. That’s great. Kali, thank you so much again for coming on to the show. I hope you can help many families just as much as we’re helping many families. I don’t think you will have a shortage of inquiries and work because there’s just so many patients in ICU that need all that help. It’s unbelievable.
Kali Dayton: Well, I care deeply about it and I think that the family members will help the whole community change and hopefully our work will fizzle out in 20 years.
Patrik: Yeah. Yeah, in 20 years. Yep. Okay.
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Kali Dayton: Thanks so much, Patrik.
Patrik: Kali, thank you so much again for coming onto the show and we’ll talk soon. Take care.
Kali Dayton: Thank you. Thank you. Bye-bye.
Patrik: Thank you. Bye.
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Podcast: They Gave My Husband Morphine in ICU to his Death and Seeking out Consulting & Advocacy Service with Intensive Care Hotline Early Could Have Saved his Life!
The ICU team is telling me and my mom to stop her medical treatment. Can they end her life without my consent?
My Brother is Critically Ill in ICU. Is it True that ICU Nurses Should Act as Advocates for My Brother?