Intensive Care

Transcript for: 
Intensive Care

MS. DIANE REHM

11:06:56
Thanks for joining us, I'm Diane Rehm. Standard practices in intensive care units are being reconsidered. Recent studies show prolonged sedation and immobility can slow recovery and impair brain function years later. Joining me to talk about why some hospitals are changing how they care for the sickest patients, Dr. Dale Needham, he's associate professor of medicine at Johns Hopkins University. Donna Stanczac, she's an intensive care unit nurse at Georgetown University Hospital, Dr. Jennifer Brandt is a clinical pharmacist at the Washington Hospital Center.

MS. DIANE REHM

11:07:50
Joining us from a studio at Vanderbilt University, Dr. Tim Girard, he's assistant professor of medicine at the Vanderbilt University School of Medicine. We do invite your calls, 800-433-8850, send us your e-mail to drshow@wamu.org, you can join us on Facebook or send us a tweet. Ending up in the ICU is not something we would look forward to, but let's talk about best practices. Now, I'm going to start with you, Dr. Girard, to ask you about the growing evidence that some of the ways we've been caring for patients in the ICU may not be best methods. Talk about that research.

DR. TIM GIRARD

11:08:58
Well, I thank you, Diane. Now, there have been a lot of changes in the last 10 to 15 years in the ways that we consider the needs of ICU patients. And one of the things, as you mentioned, that we have been re-evaluating, based on a number of studies done, first in an observational way and then in a more interventional way, is the comfort that the patient requires as they go through the intensive care process.

DR. TIM GIRARD

11:09:27
We do know from many studies that patients, during critical illness and as they receive intensive care therapies, experience pain and anxiety and discomfort and it's very important to ICU providers, both nurses and physicians and pharmacists and everyone involved in the care of those patients, that we consider their comfort and try to maintain it as best that we can. But we've learned that sometimes over the course of the ICU stay, a patient may be suffering adverse consequences when our intention was really to maintain comfort. And the...

REHM

11:10:08
Adverse consequences, such as?

GIRARD

11:10:13
Such as coma, for example. It's not uncommon to go to an ICU and see patients that are completely comatose, not only because of their diseases, but because of the medications that we're giving them and we're learning from numerous studies that, that kind of treatment and that putting the brain into a coma, or into a less severely dysfunctional state such as delirium, can have long term adverse consequences.

REHM

11:10:44
When you say long term adverse consequences, how soon might you see problems showing up and what kinds of problems?

GIRARD

11:10:58
That's a very good question. You can actually see problems almost immediately during the recovery phase of critical illness and what we've learned is that our previous assumption, and when I say our, I mean the ICU providers, we previously assumed that those consequences such as delirium, which is the state of acute confusion and changes in level of consciousness, were temporary.

GIRARD

11:11:24
We would see that our patients, as they improved from the pneumonia or the heart attack or whatever put them in the ICU in the first place, would have an improvement in the symptoms of coma and delirium and for 90 percent or more of patients, by the time they left the ICU, it appeared that their brains were functioning normally. But a number of very important studies, starting with those done by Mona Hopkins in Utah and then preceded with other studies done both in the United States and worldwide, have now found that patients, though they may appear to have normal brain function when they leave the hospital, actually struggle with a tremendous amount of cognitive impairment. What I mean...

REHM

11:12:08
Interesting.

GIRARD

11:12:09
...by is that they have difficulty with memory, they have difficulty with what we would call executive function, which is multitasking, planning and other cognitive tasks that you might not notice as you leave the hospital, but when you try to go about your daily life or return to work, for example, which is a major challenge for ICU survivors, you begin to notice significant problems and challenges.

REHM

11:12:40
Dr. Tim Girard of the Vanderbilt University School of Medicine. Turning to you, Dr. Needham, what about the research that Johns Hopkins has been doing on the long term effects of just sheer immobility?

DR. DALE NEEDHAM

11:13:00
Diane, we're absolutely seeing that virtually all survivors of severe critical illness have many problems with returning to their normal muscle strength, their normal physical activities. It makes it very difficult for them to return to work, it impairs their quality of life and really is a very, very big challenge. That would the number physical complaint that patients have, this prolonged muscles weakness.

REHM

11:13:24
And then, what about this delirium that Dr. Girard talked about?

NEEDHAM

11:13:30
I think that these things are very important to -- the brain and the body interact together and I think that it's very important, as Dr. Girard was talking about patients being deeply sedated and its negative affect on their brain, this deep sedation also makes them immobilized in the ICU and allows their muscles to simply shrink. And that really -- the brain and the muscles and nerves are really complications that we've often overlooked. We concentrated on people's heart and lungs and kidneys. We need to think about the brain, the nerves and muscles and -- because they play such an important role in the recovery of patients over the long term.

REHM

11:14:09
Dr. Dale Needham of the Johns Hopkins University School of Medicine. Turning to you, Donna Stanczac, you're on the front line. You see what's happening to patients. How have you evaluated what's going on with long term in the ICU?

MS. DONNA STANCZAC

11:14:32
I mean, we have seen some changes in how we do our practice. Before, we just would medicate patients. I think over time, we've developed some more objective criteria for determining how best to medicate patients who are not verbal, who cannot tell us how much pain they're in. So we have more objective ways of measuring that and determining how much pain medicine to give them and not to give them too much. We also look at our sedation, where you want to, you know, have patients at some calm measure during this most critical time period, but you don't want to over sedate them. As Dr. Girard said, some patients were in comas and we saw that in the past, that by giving too much sedations, patients had more difficulty waking up after the sedation was stopped.

MS. DONNA STANCZAC

11:15:19
So now we have things, there's a confusion assessment method that we can objectively at the bedside that the nurse can do to determine is my patient exhibiting any signs of delirium. And if that they score positive on that, then there's a number of things we can do. We can meet with the physicians and get the pharmacist involved and see, is it due to any combination of medications that we're giving them or is there anything else we can do to try and limit these problems.

REHM

11:15:48
And Donna Stanczac, are you doing that kind of evaluation sooner than perhaps you used to?

STANCZAC

11:15:58
Number one, we didn't have a method before. So with -- the confusion assessment method came out a number of years ago and actually came out of Vanderbilt and we have started using that and we do it twice a day. We do it once in the morning and once in the evening to see if there's been any change in the patient's condition, are they exhibiting any more signs of confusion or agitation or anything that would signify to us that they may be getting too much sedative and we need to think about cutting back on it.

REHM

11:16:30
Donna Stanczac, she's an ICU nurse at Georgetown University. Turning to you, Jennifer Brandt, the choice of medication and the dose, I would think, would be just absolutely crucial in dealing with a patient in the ICU.

DR. JENNIFER BRANDT

11:16:51
It really absolutely is. Part of the problem that we deal with, though, is that although we have several different drugs we can use, each patient's going to respond to it differently and so that's really where my job comes in. I help the physicians and nurses really maximize and optimize that care for the patient in terms of the drugs. Based on the symptoms that they're experiencing, we might end up using more narcotic or pain medication for -- if they seem more agitated, we may use a sedative or a different sedation. Each type of drug patients will experience different affects from that, so we have to keep that in mind for each patient.

REHM

11:17:33
And I would think the patient advocate, perhaps a spouse, a dear friend, a close relative, might also be of great help to both of you?

BRANDT

11:17:48
Absolutely. Unfortunately, most of the patients come to us already unconscious from their diseased state or from surgery, so we have never gotten a chance to meet the patient, so we don't have a good idea...

REHM

11:18:01
You don't know what normal is.

BRANDT

11:18:02
...of what their -- we don't know what normal is. We look at the patient, we go, well, that seems abnormal to us, but in fact, for that particular patient, it might be perfectly normal. So that's really where we like to have the family in and be able to talk to them and get a good idea of what the baseline is.

REHM

11:18:18
Go ahead, Donna.

STANCZAC

11:18:19
If I could just add to that, a lot of times, the families know best how the patient started, so they usually our keys to -- they alert us that the patient's not their normal self.

REHM

11:18:30
Donna Stanczac, she's a nurse in the intensive care unit at Georgetown University Hospital. Short break, right back.

REHM

11:20:04
Being in the intensive care unit is not an experience many of us would look forward to, but you need to know that there are great many changes taking place in the treatment of patients within that ICU to try to make the after experience less harmful. I have four guests with me today. Joining us from the Vanderbilt University School of Medicine is Dr. Tim Girard, here in the studio, Dr. Jennifer Brandt, she's a clinical pharmacist at the Washington Hospital Center. Donna Stanczac is an intensive care unit nurse at Georgetown University Hospital. Dr. Dale Needham is associate professor of medicine at the Johns Hopkins School of Medicine. I'm wondering, Dr. Needham, what percentage of ICU patients experience problems down the road related to that ICU stay?

NEEDHAM

11:21:20
I would say that virtually all ICU survivors experience some sort of problem...

REHM

11:21:28
Some.

NEEDHAM

11:21:28
What we're most concerned about are problems that are long lasting and really severe and those are not unusual. For example, we haven't yet touched much on mental health problems. Earlier I talked about physical problems, but perhaps a third of our ICU survivors may have clinically important symptoms of depression and of posttraumatic stress disorder from the ICU experience.

REHM

11:21:49
Why?

NEEDHAM

11:21:50
So the post-traumatic stress disorder, to tie it into delirium -- so these ICU survivors, when they have these post-traumatic stress disorder symptoms, are often related to the delirious events in the ICU. So the hallucinations they had in the ICU, the delusions, thoughts that ICU doctors and nurses were trying to kill the patients when they're in the ICU, these are very, very common and can continue for months and years after patients leave the hospital.

REHM

11:22:19
Dr. Girard, do you want to add to that?

GIRARD

11:22:23
Yeah, I think that Dale is making a really important point that there are a number of problems that patients face. And nearly all of the patients who survive a critical illness will have one or multiple long term consequences from critical illness. The work done by Christina Jones in the United Kingdom has been very enlightening in terms of post-traumatic stress disorder and has spoken directly to what Dale is saying about patients who cannot recall in an accurate way what happened to them in the ICU because they were delirious or because they were heavily sedated are more likely to then misunderstand and develop post-traumatic stress disorder symptoms as they think about those -- that time that they experienced in the ICU.

GIRARD

11:23:15
And if I could, Diane, I'd like to go back to the point that you raised regarding family members. I think it's absolutely crucial that family members are involved in the care of patients, of their loved ones as they're in the ICU both, as Dr. Brandt mentioned, to inform the ICU team of information that they might not have access to regarding the patient before they became critically ill, but also to be there with the patient as an advocate and as a comfort.

GIRARD

11:23:48
There is an important study that came out of Denmark in the last year or so that actually showed that 80 percent of patients who were critically ill on a mechanical ventilator in the ICU could be managed with only pain medication and no sedation. But one of the things that they had working in their favor in that ICU is that they had one nurse for every patient. So there was constantly someone at the bedside that could be with the patient and that could comfort them or reorient them as they got confused. And in many ICUs in the United States and throughout the world, there is not one nurse for every patient, but I think that a family member could play that very important role...

REHM

11:24:36
Absolutely.

GIRARD

11:24:36
...in being at the bedside.

REHM

11:24:38
Donna Stanczac, you must yearn for more people to be available to those in the ICU. What's the ratio of nurse to patients?

STANCZAC

11:24:53
The standard in the area is pretty much one nurse to two patients. There are some patients that are one nurse to one patient, but those typically are patients that have multiple things going on. They're having bedside dialysis, they're on ventilators, they're on multiple medications. So we don't have that luxury of having one nurse per patient.

REHM

11:25:12
Do you have any indication while that patient is in the ICU as to whether he or she is having emotional delirium? It is wrestling with demons that may be drug induced that may cause post-traumatic stress syndrome?

STANCZAC

11:25:39
Sometimes we do, but there's also a thing called like quiet or silent delirium where patients don't exhibit symptoms, so this may be going on, but they look perfectly fine. I mean, Dr. Needham...

REHM

11:25:52
Needham.

STANCZAC

11:25:53
..can probably add to that, too, that it doesn't always exhibit an outward agitated, frustrated kind of patient picture.

NEEDHAM

11:26:02
Absolutely. We -- one of the reasons I think we overlook delirium in bedside care is because we stereotype it as a very agitated thing where patients are trying to climb out of bed and may be violent, but in fact, the majority of patients' delirious experiences are what Donna described, where they're laying there quite quiet and motionless, but that does not mean that it's safe for their muscles and their brain.

REHM

11:26:26
And of course, some medications are likely to both sedate and produce these kinds of deliria.

BRANDT

11:26:38
That's absolutely correct. Some of the things that we deal with, there are basically three types of intravenous drugs that we use to sedate patients. One is Propofol. That's a drug that most people are probably familiar with from Michael Jackson. But that drug is essentially an anesthetic so patients are there, but unable to sleep, so they look like they're asleep, but not asleep. There's another drug Dexmedetomidine or Precedex, is the brand name, which is a newer drug. It is a great drug, but a fair number of patients will experience some side effects and really prevent us from using the drug.

REHM

11:27:23
Such as what kind of side...

BRANDT

11:27:24
The most common thing is Bradycardia or low heart rate.

REHM

11:27:29
I see.

BRANDT

11:27:30
It can also cause a low blood pressure.

REHM

11:27:32
I see.

BRANDT

11:27:32
So it's great when it works, but we can't use it in everybody. But that drug, the patients actually will sleep. And then another group of drugs has really fallen out of favor over the past few years and that is what we call benzodiazepine. Versed or Ativan are commonly used. And the problem is that those have actually been shown to increase delirium. And so really, although that used to be a mainstay, we've really gotten away from it in most patients.

REHM

11:28:06
Dr. Girard, are there particular types or ages of patients who would be particularly susceptible to the kinds of problems we're talking about?

GIRARD

11:28:24
In terms of the short term problems, for example the delirium that we've been mentioning, it's clear that patients who are older, which happen to be the largest proportion of our ICU patients, are at higher risk for delirium. And this has been known for quite some time from studies done outside the ICU. And it's now become clear that in the ICU, patients who are older at higher risk, as are those patients who have what we would describe as a higher severity of illness. So more organs that are not working, for example, as was mentioned earlier by Dr. Needham, the lungs, the kidneys, the heart, if more organs are not working and the patient is generally sicker, they tend to be at higher risk for delirium as well.

REHM

11:29:11
All right. We've got many callers waiting. We'll open the phones now, 800-433-8850. First to Laura in Rockville, Md. Good morning, you're on the air.

LAURA

11:29:27
Oh, hello. I have a question. I had an 18-month old who was intubated for five days for a bout with croup and she was on Propofol, Morphine and Versed and she had -- the first month of recovery was pretty nasty. There was a lot of vomiting, shaking and crossed eyes, but eventually, she seemed to return to her normal self. My question for you is down the road, will this experience affect her brain in any way? I mean, she seems like a normal five-year-old now, but has this impacted her in any way? Should I be concerned?

REHM

11:30:02
Dr. Girard.

GIRARD

11:30:05
Well, first, let me tell you I’m sorry that you had to go through that. My...

REHM

11:30:09
Boy, I should say.

GIRARD

11:30:12
...one of my own children had croup and fortunately, although they were hospitalized, it wasn't as severe as what yours went through. I would say that we do not know the answer to many of these questions about very young children. That age group poses a particular challenge when studying the effects of the brain because it is more difficult when examining, for instance, an 18-month-old child in the ICU to determine whether they have delirium. Many of the tests that we use in adults, or even in older children, have as the centerpiece the need for the patient to be able to understand the words that are being spoken to them, to understand some commands that are relatively simple for any adult. But for a very young child, may not be normally understood even if their brain is functioning fully.

GIRARD

11:31:12
So we don't have answers yet about very young children and what happens to their brains when they are critically ill and then survive and recover. We also have not done studies, at least that I'm aware of, looking at the long term cognitive consequences...

REHM

11:31:31
Yeah.

GIRARD

11:31:32
...of critical illness in children that young, but I think it's a very important question that needs to be addressed in the future.

REHM

11:31:37
And an important field to follow up on. Laura, I'm so sorry about your child, but I hope she continues to grow and thrive. Thanks for calling. To Jacksonville, N.C. Good morning, Connie.

CONNIE

11:31:55
Hi, good morning. This is a very validating conversation for me on a lot of levels. When I was 31 in 1999, I somehow contracted a staph infection that turned into septic shock, so I was in multiple organ failure. I was on a ventilator for about 11 weeks. About seven or eight of those weeks, I was in, I guess what you would call a drug induced coma. Very much do I remember -- it's strange, I don't remember much about the hospital, but I still have flashbacks, if you will, to the horrible nightmares that were caused by the cocktail of medications that I was on.

CONNIE

11:32:35
But another thing that happened, part of my illness produced something called acute respiratory distress syndrome and so because I had to be on a very strange ventilator setting, I was put in a profound sedation and was paralyzed. That left me virtually paralyzed when I was able to become conscious. I am wondering -- and it took a few years to definitely overcome that and get my muscle strength back. Are there other options available other than paralyzing the patient when a patient is on -- is in that kind of acute respiratory distress syndrome? And also knowing now what we know about the plasticity of the brain, might I be able to overcome some of the cognitive and memory deficits that I still struggle with 11 years later?

REHM

11:33:24
Connie, you've raised such good questions. Dr. Needham will take a crack at those. Let me remind you you're listening to "The Diane Rehm Show." Dr. Needham.

NEEDHAM

11:33:39
So thank you very much for that excellent question. The National Institutes of Health actually funds a fair bit of the research that I do that looks at the long term outcome specifically of patients who have survived acute respiratory distress syndrome or ARDS. And in my own medical intensive care unit at Johns Hopkins, we have been able to have some of our patients with ARDS actually awake and not deeply sedated, not paralyzed, even getting those special ventilator treatments for patients with ARDS.

NEEDHAM

11:34:11
I'm not saying that every patient can be like that, but as you point out, many years ago, I think we thought all patients needed to be deeply sedated and paralyzed with ARDS. And now we've recognized that's not the case. In fact, some of these patients can be awake, alert, out of bed and walking around the ICU with their ARDS on a ventilator.

REHM

11:34:32
Interesting. Dr. Brandt, do you want to comment?

BRANDT

11:34:35
Absolutely. Really, at this point in time, we get to paralytics when it's the last option, when the lungs just really are not compliant with what we are trying to do. But 1999, that was 12 years ago now...

REHM

11:34:54
Yeah.

BRANDT

11:34:54
...that was a whole different world. At this point in time, it's very, very rare that we would get to that point.

REHM

11:35:01
Now, one question, we've talked about family involvement. Does the family get to involve itself with you or does the family always deal with the nurse or the doctor rather than the pharmacist?

BRANDT

11:35:22
It really varies hospital to hospital. Many hospitals' pharmacists are now on the units, however, that's not the case everywhere.

REHM

11:35:31
Yeah.

BRANDT

11:35:32
I try my best to at least say hello to the family members when I'm there. Often, family members come in later at night, so I might not get to see them. But simply if they want to talk to a pharmacist, all they need to do is ask.

REHM

11:35:46
Seems to me that's an important thing for families to keep in mind. Donna.

STANCZAC

11:35:52
One of the things that, as we know, every ICU, every patient gets what we call rounded on every day. And during that rounding process, the main players are there. The attending physician is there, the bedside nurse is there. You know, the -- if it's a teaching hospital, the residents are there. And we on our unit have a clinical pharmacist who's also there. And we invite the families who are interested in participating and listening to those rounds to be there at the bedside.

REHM

11:36:21
It's usually about 6:30, 7:30 in the morning?

STANCZAC

11:36:24
Well, it depends on what service you're on.

REHM

11:36:27
I see.

STANCZAC

11:36:27
Surgeons usually go very early...

REHM

11:36:29
Yeah.

STANCZAC

11:36:29
...because they need to go to the operating room.

REHM

11:36:31
Right.

STANCZAC

11:36:31
Medicine physicians tend to go a little bit later because they have a little bit more time to spend.

REHM

11:36:36
But that's such a good suggestion to be present there when rounds are taking place so you hear everything. Dr. Needham.

NEEDHAM

11:36:46
And the way that these rounds need to change and are changing is things like sedation goals, delirium status reported by the bedside nurse, physical activity planned for the patient needs to be talked about on rounds with each and every patient every day. And coordinate the occupational therapist, the physical therapist, the nurse, the doctor, the tests, the dialysis so that the patient can be awake and be moving, getting rehabilitation while they're on life support. And rounds are a vital way of coordinating that plan.

REHM

11:37:16
Dr. Dale Needham, he's associate professor of medicine at Johns Hopkins University School of Medicine. We'll take just a short break now and when we come back, we have calls in Pensacola, Key Pines, Ravenna, Ohio. We'll try to get to as many as we can.

REHM

11:40:03
And we'll go right back to the phones. First to Cincinnati, Ohio, good morning, David, you're dealing with these very issues.

DAVID

11:40:16
Yes. I'm a 63-year-old male who has all the symptoms that you talked about the beginning of the show, was in a coma for 10 days, broke my leg in six places and that was two years ago. And I'm back at work, or trying to be at work, but still have a tremendous amount of pain in my legs, being weak and having to learn how to walk again. And again, the focus and multitasking is very much an issue for me and I did have the delirium and thought everybody was trying to kill me. And I'm wondering what I can do or where I can go for some help at this point.

REHM

11:40:54
Oh, David, I'm so sorry for your experience. Dr. Girard, can you talk about both, you know, sort of getting back to work, multitasking, the pain he's still experiencing and all the other problems?

GIRARD

11:41:14
Yes. I'm actually very glad to address that. In fact, David makes some important points that the previous caller, Connie, had made that I wanted to address at that time as well. Both of you have described the feeling of experiencing significant problems during your recovery from critical illness. And the previous caller had mentioned that it was very validating to hear that these problems are so common. I'm not sure if you've had the same experience, David, but many of the patients who contact us months or years after their ICU stay will tell us that they were not aware or that even their doctors were not aware of the significant challenges both cognitively and physically and psychologically that they might face as they recover from critical illness.

GIRARD

11:42:03
So it's important, I think, Diane, for not only the members of the ICU team to be aware of these problems, but for the broader healthcare professionals in general. Many general practitioners or internists that see patients back may -- after critical illness, may not be aware. And as they learn of these problems, they can recognize them, they can help patients like David and Connie realize that these common problems, that they're not something that only they are going through. And then they can in turn direct them to ways that they could potentially get help. And that was the second point raised by both callers, are there ways to improve or speed recovery for those suffering long term physical, cognitive and psychological problems after critical illness?

GIRARD

11:42:54
I think that we do not yet know the best ways to improve the recovery, but we're starting to explore that question, studying both physical rehabilitation that starts not only after an ICU stay, but even in the ICU itself, as well as potential cognitive and psychological interventions. So at Vanderbilt, we're studying, for example, an intervention that focuses on the problems that patients have with executive function, with multitasking, with planning, et cetera and that has been studied in other areas such as in attention deficit disorder and are applying that to the difficulties that patients have as they recover from critical illness. Those studies are ongoing, but could potentially lead to findings that would suggest that that approach would be very helpful for patients as they recover from critical illness.

REHM

11:43:54
All right. And Dr. Needham, what advice can you offer?

NEEDHAM

11:44:00
Sure. David, this organization called the Society for Critical Care Medicine is trying to raise awareness of the problems that you're talking about through a new concept called Post Intensive Care Syndrome that talks about new or worsening physical, cognitive and mental health problems that happen after the ICU and persists beyond acute care hospitalization. What that taskforce is doing is drawing together organizations like the American Physical Therapy Association, the American Academy of Physical Medicine Rehabilitation, physicians, psychologists. And it's that multidisciplinary team, David, that's very important to recovery.

NEEDHAM

11:44:38
So for problems with thinking, then seeing a psychologist and going through cognitive rehab. For problems with muscle weakness, a physical therapist, occupational therapist, rehabilitation physician. For problems with stress, anxiety, low mood, a psychiatrist. There aren't lab tests for a primary care doctor to know that a patient's having these problems. They may come to the primary care doctor and all the lab work's normal, but they have these very important symptoms that need multidisciplinary care.

REHM

11:45:05
Now, David is in Cincinnati. I wonder whether a trip to the Cleveland Clinic might be of help there, whether he might find that combination of treatment providers?

NEEDHAM

11:45:25
I think the whole concept of putting together this multidisciplinary team in one clinic is really where we need to go with ICU survivors. We do that with patients that have cystic fibrosis and patients with many other problems. And we're really trying to put that together so that patients don't have to try to find, you know, three or four different care providers.

REHM

11:45:45
Exactly. Good luck to you.

GIRARD

11:45:47
I agree completely. You know, the UK has actually been a pioneer in this area. And in many areas there, they actually have post ICU clinics and they see patients back after recovery from critical illness to specifically assess them for these various adverse problems and then to direct them as in terms of seeking out treatment. And so now in the United States and in other places, we're starting to see post ICU clinics that are trying to coordinate the different providers that Dr. Needham has mentioned and to use that multidisciplinary team to assess patients for not just one, but all of the potential problems they may be facing.

REHM

11:46:28
Tell me how long it might be before these kinds of problems show up, Dr. Girard? I mean, if you are three or four years out of the ICU and you're still having problems, you may not necessarily attribute it to an ICU experience.

GIRARD

11:46:52
That's a good point. I think that for many patients, the problems show up as soon as they start to function in a way that they were before their ICU stay. For example, a patient may not stress themselves cognitively during the early phases of recovery because they may be physically unable to go back to work. But when they get to the point where they are trying to do more rigorous cognitive tasks that previously would've been easy for them to do, they will quickly discover that they're having trouble...

REHM

11:47:27
Interesting.

GIRARD

11:47:27
...that is different than what they faced prior to their illness.

REHM

11:47:31
All right. To Cedar Park, Texas. Good morning, Bobby.

BOBBY

11:47:36
Good morning. Your show's very timely. I've got about a couple of weeks before I have open heart surgery, which is at -- just right after that, they put you in ICU. And you've gotten my attention. I...

REHM

11:47:47
I'll bet.

BOBBY

11:47:49
How do you talk to a doctor about these things? They usually take offense if you try to tell them something they may not know.

REHM

11:47:55
That's a good point. Dr. Needham.

NEEDHAM

11:47:58
Yeah, I think it's very important, Bobby, that we raise awareness around these things. And when a patient's in the ICU, they can't advocate for themselves. It's their family that needs to advocate and needs to ask around these strategies, like can we lighten up on the sedation, can my loved one get occupational and physical therapy and start moving rather than just laying in bed and I think as we see this come into the mainstream media, The Wall Street Journal very recently, page one of The New York Times about two years ago did a very big article. You know, I think it educates both patients' families and the clinicians.

REHM

11:48:35
And Bobby, let me just suggest you get a transcript of this program, take it with you to see your doctor and you'll have some ammunition in your hands. Good luck to you, Bobby. I'll be thinking about you. And to Phoenix, Ariz. Good morning, Cameo.

CAMEO

11:48:59
Good morning. In regards to the bedside assessments that your panel has been talking about, there's one population that is often misdiagnosed and mismedicated, and that's the deaf population. A lot of times, kind of the comments and assessments or the assessments that are typically used by nurses and doctors don't cross the language barrier and the cultural barrier that deaf people and hearing people have, so I'm wondering if there's any focus on that area to try to bridge that gap.

REHM

11:49:29
Surely that's where the family member comes in so importantly, Donna.

STANCZAC

11:49:36
We have interpreters for -- we are committed to providing interpretation for any patient population. We have a very huge deaf population and we have interpreters that are available 24 hours a day, 7 days a week to come in and help to manage those patients when we need them.

REHM

11:49:55
So you have to ask for it?

STANCZAC

11:49:57
The patient doesn't have to ask, the nurse just calls and requests.

REHM

11:50:01
That's good to hear. All right. And to Ravenna, Ohio. Good morning, Sharon.

SHARON

11:50:10
Hello, it's Sharon.

REHM

11:50:11
Yes.

SHARON

11:50:13
Yes. I have to say that you really have to pay attention to parents -- oh, not parents, excuse me, family members. My dad was in the hospital with a thoracotomy. He was in the ICU for a long period of time. I communicated daily with him. One day, they told me, gee, your father is hollering for you, you need to come here. I said, I'll be there immediately. I was about two hours away. I said, but are you -- is he complaining of pain? And they said, no. I said, are you giving him pain medicine? And they said, oh, yeah.

SHARON

11:50:40
I said, don't give him pain medicine. My grandfather had trouble with it. He ended up with post-surgery Alzheimer's, I believe. I can't tolerate pain medicine. Quit giving him so much pain medicine if he's not complaining of pain. Well, I drove up there and low and behold, I mean, he wasn't great -- in great condition, but he was a whole lot better mentally just by taking him off the pain medicine.

REHM

11:50:59
Dr. Brandt.

BRANDT

11:51:01
Well, certainly, Sharon, I understand the issue at hand. Unfortunately, we don't have a good handle on who tolerates which drug and how much of that drug we can give them. A lot of times, quite honestly, it's trial and error. You were definitely correct in bringing that to the nurse's attention. Sometimes it's an oversight. We think that something else might be going on. It's really a fine balance that we have to find when we're dealing with sedation and pain. A lot of times, those things go hand in hand, but you were certainly correct in bringing it to the nurse's attention.

REHM

11:51:39
Donna Stanczac, as the nurse in the ICU, do you -- if the patient's relative is called and said, you've gotta come, your dad's in trouble and the patient's relative says to you, take him off the pain medication, do you have the authority to do that?

STANCZAC

11:52:03
I don't, but what I can say is one of the most important things is, if you know that your family is predisposed to that, if you know...

REHM

11:52:10
Say it.

STANCZAC

11:52:11
...that your family -- say it before the surgery because we have, you know, a myriad of drugs out there that we can use. I had the same experience with my father, had surgery and he stopped taking the medication post-op because he said it was giving him hallucinations. So again, I didn't wanna see my father in pain, so I worked with the physician. I spoke to the physician and said, isn't there something else we can use? Is there some other medication that won't give him these same side effects, but yet make him comfortable? And we found something that worked.

REHM

11:52:39
That's the important thing, isn't it, just listening, working with the patient, finding something that works. Donna Stanczac is an ICU nurse at Georgetown University Hospital and you're listening to "The Diane Rehm Show." And let's go now to St. Louis, Mo. Good morning, Becky.

BECKY

11:53:06
Good morning. My husband was in two settings. He was at an ICU in a community hospital and then we got him transferred to Washington University, which is a major center. And first of all, the difference in care between the two -- the nurses were actually great at both, but the difference in care is substantial between the two settings.

BECKY

11:53:30
And then the second thing that happened with us was he was in a drug induced coma for about two weeks and he's fine now, but he was 34. And when he got out, we -- he had to eventually be transferred to the regular hospital setting. And when he was transferred to the regular hospital setting, the step down in care was really substantial. And I don't think the mental health issues were addressed as well. I mean, he was just having hallucinations at that time. And I think that is a real difficult transition to make for the patient. And he is resolved now and he's fine, but the transition was very difficult.

REHM

11:54:07
Dr. Needham.

NEEDHAM

11:54:08
Absolutely, I agree with you Becky, that's a very important concern. The transition for patients and their families, when they come out of a very resource intensive setting like an ICU with lots of nurses and doctors and pharmacists and therapists to the regular hospital setting is a very difficult one. There needs to be lots of communication of important medical information from the ICU team to the other team. And there does need to be the role of family, I think, plays an important role in helping with that bridge to say, no, my husband wasn't like that in the ICU and these are new symptoms. I think that's critically important. It is a tough transition.

STANCZAC

11:54:44
One of the other things that we notice, though, patients who have been in the ICU for a long time, they develop this stress anxiety of leaving that protected environment to go somewhere where they feel that they're not going to get as much attention, where they're not going to be looked at as often, so it's part of the nurse's job and family's job to reassure the patient that, certainly you're progressing. If we didn't think that you were able to do okay out there, we would never move you, but we do see that a lot where patients develop that anxiety about leaving the ICU.

REHM

11:55:16
And here's an e-mail from Tatanya, who says, "I wanna add to the subject of ICU delirium, the lack of time set aside for sleep in the ICU. Though I hear some units have quiet time, in my experience, it's not considered a priority. Because of this, people end up becoming delirious, or at least off, in spite of sedation."

NEEDHAM

11:55:49
So that is a new frontier in this kind of work that we're talking about. So Biren Kamdar is a fellow that works with me and Nancy Collop's a pulmonary sleep specialist. As we use less sedation, we've realized our patients do have difficulty sleeping at night because they're no longer comatose and there's many changes that we've done in our own Intensive Care Unit to have patients wider awake during the day and to facilitate their sleep at night, because the culture of most ICU's are 24/7...

REHM

11:56:17
Sure.

NEEDHAM

11:56:18
...and ICU's weren't created thinking of patients sleeping because they all got deep sedation. But now, we're having to reduce noise, reduce lighting, minimize interruptions, think about the safest medications to give to help with sleep if all of those environmental changes don't work. Thinking about things like ear plugs and eye masks as well for patients who aren't delirious.

REHM

11:56:39
Well, a very educational program. I wanna thank you all so much. Dr. Dale Needham of Johns Hopkins School of Medicine, Donna Stanczac, an ICU nurse at Georgetown University, Jennifer Brandt, clinical pharmacist Washington Hospital Center and Dr. Tim Girard at the Vanderbilt University School of Medicine. Thank you all so much. Thanks for listening. I'm Diane Rehm.

ANNOUNCER

11:57:15
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