Episode 183: The ICU Revolution at Mercy San Juan Medical Center- Part 2 with Dr. Lawrence Bistrong
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This is the Walking Home from the ICU podcast. I'm Kaylee Dayton, a nurse practitioner and ICU consultant. I help teams create awake and walking ICUs through evidence-based sedation and mobility practices. By hearing from survivors, clinicians, and researchers, we'll explore how to give ICU patients the best chance to walk out of the ICU and go home to survive and thrive. Welcome to the ICU revolution.

Let's talk about medical directors. I have seen when a medical director is not bought into the awake and walking ICU model, revolutionists hit an absolute wall. I've seen how progress is impeded when medical directors are just lukewarm on this revolution. There are missed opportunities to unify the team under strong leadership,

to treat the ABCDEF bundle like the sepsis bundle to create a high reliability and safe ICU. When a medical director sees and treats this initiative as just a nursing thing or mobility is all up to the rehab department,

and sits in the wings with their thumbs up, it becomes a lot harder to overcome the obstacles teams face throughout this transformation. This episode is a beautiful testimonial to the impact a medical director and revolutionist can make when their perseverance is fueled by compassion, courage, and an innovative vision. Dr. Bistrong really demonstrates the active role ICU medical directors,

should play in leading their teams to implement and sustain current and best practices and protect patients from bad culture and harmful practices. When a medical director takes patient care and outcomes personal and part of their mission and legacy, they go to incredible lengths to create awake and walking ICUs. I'm excited for you all to learn from his journey.

Dr. Bistrong, thank you so much for coming on the podcast. I've been really looking forward to your interview. Do you mind introducing yourself to us? Sure. No problem, Kaylee. So I'm Lawrence Bistrong. I'm a pulmonary care doctor here at Mercy San Juan Hospital in Carmichael, California, which is essentially Sacramento, California. I graduated real quickly in 2008 from fellowship in Southern California. And I've been at this hospital about 16 years with the same practice.

I've been IC director for about four years and respiratory director. And the previous director was somebody already interviewed Dr. Murphy with his wealth of knowledge. So I took over position when he went down to part-time.

And this whole process of the awake and walking ICU has been a godsend to our patients. And I am excited to talk more about it. Even before this all started, how were you as a critical care physician trained to treat patients on mechanical ventilation?

So it's very interesting. So even in fellowship, I remember talking to the other fellows about what's the standard sedate patients. And one of the other fellows was here behind me. He says, we put them on adivandrip. And I said, there's no studies behind any of this stuff. And that was in propofol was just coming out. So I think at that time you spent, I don't think I didn't even use fentanyl. I think we're using Versed actually even worse at that time. And so once we got propofol,

Also at that time called Dipravan with the market name or mother's milk is like the nurses used to call it. It was a great drug comparative, but I don't even remember what we gave for pain meds. I can't, I don't think we focused much on analgesia, unfortunately at that time. Yeah. So I remember that. And this is what we did for years, even though the data on delirium is 20, 25 years old now, decent data.

And I have my group, which is pretty big, has been a part of a project at Sutter 2013 with Wes Ely when they did the research and they had a year grant for this mobility project. But

Unfortunately, when Grant expired and Marion Daly left, we went back to our old habits and continued that even though we were pushing and then COVID happened. And I don't want to try to talk too much about that nightmare, but that obviously pushed our stuff back. I think what really got into this is that Dr. Murphy, my predecessor, talked about this and he went and visited your old hospital in Utah with Dr. Bellucci and came back and was shocked.

about these patients just relaxing on the ventilator, writing, walking. And it was against what he trained for 40 years and what I knew. And then I started, he recommended listening to a couple of your podcasts. And I did. And I felt like I was the worst physician. And I felt I was actively contributing to patient harm. And it was really tough for me to swallow initially.

And then we had a journal club. And before we had Wesley on it, I think you were on it also, which was good and some admin. But even then, we were recommended to read his book, Every Deep Drawn Breath. I listened to the audio book and it was fantastic. So it really opened up my eyes. And that's really what pushed me to really push admin that we need to do this. Those, your podcast,

and Dr. Yui's book. And I go to a long-term acute care facility, LTAC. And so I see these patients all the time and I was like, well, this is the way it is.

Maybe it doesn't have to be that way. Now I know it doesn't. That's haunting to have exposure to where they go to after the ICU. My theory has always been if nurses had to cross train, I think those LTAC nurses would bring a different approach to the ICU and it would influence ICU nurses to have a different perspective and approach. But as a physician, I'm just trying to imagine how haunting this was to nurses

You're reading this, hearing about this, learning about this and seeing it so graphically. How did you endure that weight? I think this is something that I think a lot of listeners can relate to.

So I think I really didn't understand it until I learned really about, and we always knew what delirium did, but like, how can we really prevent it? That was, or treat it, you know, there's really no treatment. It's really supportive care. It's just prevention. This is a disease and a condition where, I mean, if you say an ounce of prevention is a pound of cure, I would say it's an ounce of prevention is worth a ton of cure. This is really that condition. Almost like giving a vaccine for cancer.

polio back in the day. And you really can make an unbelievable impact. I didn't think much about it until I listened to it. And I still go to that LTAC. And you see these patients, they're very delirious. They've been through

two months or maybe three months even of a hospitalization where they had a surgery that went bad or some other medical condition and they are going to hyper and hypoactive delirium they get agitated guess what they do sedate them again with our least favorite drug benzos it's just a cycle and i would just tell on rounds you got to stop this what's the rast and cam and

It's very hard because they've already been through this and there really is not much prevention anymore. But it's understanding what's going on and how do we get back there. And there's one case about two years ago where the patient was transferred because their altered mental status and neurologists wanted a continuous EEG and lumbar puncture and MRI, which they didn't have on site.

And when I heard the case and my partner's transferred the patient, I said, well, this is delirium. You can order all these studies. This is delirium. They agree, but the neurologist wants it. So he comes over here and gets an MRI. Nothing really exciting. The neurologist here didn't even do an LP.

continuous eeg was remarkable and the patients were agitated and luckily one of the nurses is one of our very strong advocates for this and a champion who had him we didn't we had this patient barely he has been restrained forever i had him off restraints for 24 hours he was trached on the ventilator and the respiratory therapist over there when we sent him back i said you're gonna have a lot of work in him i know he moves around and he gets perpendicular to bed position wise

it can be done. And they didn't believe me because when they kept saying, oh, crazy. And I actually took a, I looked at our charting and I actually took a picture without the name. So it was a protected incentive. And I said, look, the respiratory therapist is charting or we're charting T-missing, not restrained. And I said, this is proof. We're not causing fraud here on our charting, our EMR. And I told them, and then eventually they just did what they needed to do.

Stopped all these meds, unrestrained him and let it wear out. And he got discharged with much better mental status. Ever since then, they've really been like trying to minimize restraints and sedation. And I think it just took the example where I said, we did it. Look, we did this and we had a patient a couple of days, but we got 24 hours of T-missing. They just didn't believe me because he kept getting sedated and back on the ventilator. So that was pretty impactful. And I always bring it up to them and I always remember his name. And I said, remember that guy? That really...

Was like your first taste of the fruits of these changes. That other people believed.

what we were doing and listen, even though they didn't believe I showed them proof. I said, why can't you do this? I know it's easier. And a lot of these facilities, they have young nurses because when you graduate, you know, when you're a nurse, you go to nursing school. It's not like you want to go to an LTAC probably. You probably want to go to a hospital. And those are jobs are very tough. They maybe don't get the cream of the crop. I'm not, I can't say to go to some of these other places and they're very young and they're not supervised as well. So it's easy to,

They just, they call for everything. And their patient load is tremendous. Oh yeah. Patients load is tremendous. It's like a med surge for, and they have LVNs also filling in. So it's just easier. Oh, patient's agitated. And they call the on-call hospital doctor and they just give Ativan or something. And it's just that cycle. It never ends, you know?

which mortifies us as ICU revolutionists. We really are fixated on what happens in the ICU, but it's discouraging to hear what happens after. That not only is there just a sense of rehabilitation, but that rehabilitation isn't necessarily happening.

Absolutely. When you brought this back to the ICU, how did you start advocating for these changes? Well, we would have patients, oh, they're agitated and they say, no, stop sedation. Sometimes I DC sedation. I probably made some, I don't know if I say enemies, but I probably made some of the nurses a little bit unhappy, but I really, we struggled with this until we had your training and people really understood. And even though I would say it again and again on rounds,

I remember another case that we had a patient, this is during COVID. He was agitated. And I said, you got to unrestrain this guy. And he had a complication. He had ischemic leg. He had to have an amputation. It was a mess for this guy. So you can only imagine his delirium.

on top of it. And then I just remember sitting in a surgical ICU and saying, we need to unsedate him. And the nurse said to me, I don't feel comfortable. I'm not going to do that because he's going to either, I think he's going to, I think I don't know if he's on the vent or on BiPAP. He's just going to pull it off and he's going to die. And we all remember that pages ripped off their BiPAP. We had to rush in a room, sometimes not even getting fully putting on our N95s or whatever. And I just got frustrated and I'm leading rounds. I'm the director.

And the nurses wouldn't listen. And there was other reasons going on. But I'd be like, I said, I just wish you could see what's happening and what the future is for this patient. I just remember saying that. And people were just worried that the patient's going to die to pull off the oxygen. That's it. I'm like, yes, that's going to happen. But we're condemning this patient to even a worse life than maybe worse condition than even maybe death. If you look at it from some viewpoint. So we kept pushing forward.

We had our new senior director of critical care, Ginger Mons, who talked to me one day and said, I want to get Kaylee Dayton here. And I was shocked. I was like, this is fantastic. We should have done this a long time ago. I'm so happy that you're somebody else is in agreement. The nursing leadership is in agreement with this because that's what I really needed. The doctors can only advocate so much because it's a nursing driven protocol.

And obviously got in touch with you and we had a proposal come out and got the admin to come in and buy it. And you came out and did your training. Let's circle back to the admin buying into it, right? Because I think that's a feat in and of itself that a lot of people struggle with getting support for staffing equipment, the training and education so often.

How did you get your administration to host this idea and be open to it and let alone go for it? How long did that take and what did you do? That's a two years. So initially, Dr. Murphy talked to our hospital president and said, I want to go out to Utah, your place and see it.

and talked about it. And he's like, okay, we'll go. And then he's like, well, are you going to support us? There was just not even an idea of this. So Dr. Murphy and Dr. Bluchy went out on their own dime for a day or so and watched your place in Utah. So I sit on the medical executive committee as a member at large, and I would hear the chief financial officer say, what as us physicians can we do to help with hospital discharge?

decrease that stay. And I said, I have an idea. And I said this before, if you put the investment up front, so you don't get these patients delirious, you get them up and moving, they won't need to go to a nursing home. Hopefully that'll decrease the risk. They'll go home. There's your answer. It's on the back end. And there was still a disconnect from what I was saying, but I was giving them a solution, possible solution to help out with this position, but just working on the front end rather than the back end.

Eventually, we set up a ginger set of proposal. We set up a meeting with myself, Dr. Parma Barucha, who's the director of pulmonary critical care from Mercy Medical Group because we have two ICU groups at our hospital and ICU director at Mercy Folsom. The two physicians from Northern California from Common Spirit who are like the regional CMOs or experts on what we call a C5 committee. That's a big committee of critical care doctors. One of them, Dr. Talabian from Sequoia.

And then the chief nursing officer for the region, Karen Buckley, used to be the CNO here, which is very helpful. And Ginger presented it. And what I got from some of the physicians, not us, but the other physicians, the more higher up in the chain, well, this sounds like a good idea. It was really going to help, but this is common in ICU. And I said, this is going to help. And luckily, one of the secretaries says, well, it's very doctor dependent. When one doctor comes in one week, they're getting a patient out of bed. When the other doctor comes in, it's not happening.

And all I kept hearing is from this one physician was like, well, I go in there and I get my patients up out of bed. I said, that's great. First of all, it's not your job. Nurses should be doing that. So when you're gone, who's going to do that?

And we convinced them to get the grant for this project. Do you come out for the education? So that was the second part. After we had the whole talk with admin, when you gave the talk and showed them how much money we would save essentially by decreasing hospital stay, event length of stay, half eyes, delirium, happier families, medication costs.

It all adds up. It's a no brainer. If you look at the math equation, if you invest, we really should interview your CFO because he understood, you know, when I presented the financial picture, you could see the light bulbs going off and he was like, we have to do this. This makes sense. We can't afford not to do this. And so I always encourage people to, even though us as clinicians, we care about the patients. We have to use the financial data to make that case because healthcare here is a business, but we can use that to our advantage.

Because this is a win-win-win for hospitals, clinicians, and patients. It's rare that all three parties are benefited from one initiative. I will give you our CFO's information and then you can set up a future podcast. Yeah, that'd be great. Because I think having a financial expert to talk about the financial benefits and hopefully we're going to have data coming out from your hospital to show the impact of this.

So just because you got this grant doesn't mean that voila, it suddenly changes, right? It's a huge fee. And for context, Mercy San Juan has five ICU. This is a big hospital system. It's a very diverse population, very sick patients. So it was a big challenge. And one of the things that I appreciated about your hospital is that you have a lot of really seasoned nurses.

that are experts, that know what they're doing, that are very well trained, they work well together. But then this is also a big change for them. How do you feel like the training was received initially? When we first came in, they were like, what does this mean? It says, oh, this means we're not going to sedate anybody and they're all going to be awake and crazy. That's how they perceived it. And probably, I probably fed a little bit into that. I said, we got to stop sedating patients. I just give like the one or two liner, but instead of looking at people,

Yeah, I think they understood that this would be a no sedation, no restraint unit. So there was a lot of hesitation with that. But then we all found the happy middle ground to say, we'll use these tools, but we're going to use them safely and appropriately. And then they really needed to understand the why. How do you feel like even just webinars beforehand, how do you feel like that impacted your sequential discussions beforehand?

on these practices once they had more education on the why? Yeah. So we did this before with the webinars, but I don't think there was any real education followed afterwards. So like you watch something and you're like, I'm required to do it. I forget it. We wouldn't get a lot of interest in the live webinars or you let it play. You're doing something else because you have to do it as a requirement. Sometimes CMEs or CMEs, stuff like that. But I think we did it timing when you were coming out.

And that was important. And it was more accountability, which was very important. When you're signing off, you were doing it, that you've done it. I think probably the best was the simulations that you were doing. And I mean, I was fooled. Like I would come by and see simulation. I thought the patient was really intubated. You had the AT tube in a good position. I couldn't tell. And this is one of your team. I was like, if you've been listening to this podcast, you're likely convinced that sedation and mobility practices in the ICU need to change.

The ICU community is facing incredible difficulty with the trauma from the pandemic, staffing crisis, and burnout. We cannot afford to continue practices that result in poor patient outcomes, more time in the ICU, higher healthcare costs, and greater workload for the ICU team. Yet the prospect of changing decades of beliefs, practices, and culture across all disciplines of the ICU is a daunting task.

How does this transformation start? It can begin with a consultation with me to discuss your team's current practices, barriers, and to formulate a plan to help your ICU become an awake and walking ICU. I help teams master the ABCDEF bundle through education, consulting, simulation training, and bedside support. Let's work together to move your team into the future of evidence-based ICU care. Click the link in the show notes of this episode to find out more.

So it was pretty good. I saw the simulations very good. I mean, you were there when I was there. We even had that one emergency on that one patient. And I was like, oh, another teaching opportunity. And I actually, the very interesting, when that situation came up and I had to intubate that patient and that patient actually asked to be sedated. He said, I don't know.

I don't want to remember anything. I don't want to know anything. I said, no, the medications are worse than what you're thinking about the side effects. And he kept saying, no, I don't want. And it was me and our ICU nurse educator said, no, you don't want to be sedated, like knowing the future. So we minimally sedated him. He did OK. But I'm just saying even the patients don't want to be awake sometimes. Yeah. A lot of what we went through with simulation training was how to prepare patients for it.

how to help the families be prepared for it, how to train families to be helpful during this process, especially that post intubation acclimating to the endotracheal tube. It's a really vulnerable and pivotal time. It's also very challenging for everyone in that room, everyone involved, how your team start to implement those things little by little. Even while we were there, we got some challenging patients, at least sitting up at the side of the bed. And there was a lot of fear and hesitation, but because

We were there. We were supporting slash strongly encouraging slash pushing them to do this. They were able to see how well it went. It was fun. One patient was intubated. I think he'd had an open abdomen, had just been recently closed.

He was, he had dementia. He was lordly delirious. And when they sat him up, one of the nurses was really panicked saying, this isn't safe. I don't believe in this. This is a nurse that was just floating. So she hadn't participated in webinars. She didn't know what we were working towards. She was, in her defense, totally caught off guard. The primary nurse was hesitant, but the respiratory therapist, the physical therapist, everyone was there helping him get up. After that, the primary nurse noted that

He was so much easier to manage. He'd been impulsive, fidgety, RASA plus one plus two. And after that, he just slept and he was so much more comfortable. And even when he woke up, he was never that restless. So they quickly could see the benefits of this. So we were not just talking about it in simulation training, but now they got to see it with their real patients. I think that really helped after we left because we were there for four days and then

It's still not a light switch. It's not like everyone suddenly has this skillset and comfortable approach to it. So how is that? How long did it take, do you think, to really get this rolling? I think it took for you to come through at least once more when you went to the neuro ICU. I think then started going. The good thing is that when you did the surgical ICU training, the trauma was also either around and not too far off. And a lot of nurses go back and forth. So that was very helpful. So I'm...

very encouraged about this and we just finished off our medical icu last but that's the one we probably were hitting really hard because that's the one with the sickest general population and maybe more bed-bound patients or what we say bed-bound stuff like that but now our physical therapy staff's like well we need orders and i said hey you can put orders under my name almost any time i think you're pretty good at knowing which patients are appropriate in the nursing are now so

I want that to be proactive. I don't want to wait till rounds to move a patient. Is that patient moving? Unless it's a hard indication, absolutely not. I still tell the nurses that you can get a patient up with a femoral A-line. They're still a little bit discomforting about that. But I'm like, yeah, we chatted about that. You guys have mobilized patients with open abdomens that are intubated. You guys are really being progressive. I...

Trained your team first, and that was in January. And I trained the next four teams, finished in May. But every time I came back to see how you guys were doing, when I was training the next team, I'd pop my head in. And each month, it was just fun to see the atmosphere shift. Obviously, their approach to me was a little bit warmer, which I don't blame nurses for being hesitant and having their guns loaded for me. That's okay. This last time in May, they were pulling me to their iPads on the unit and wanting to show me pictures and saying...

Look at this patient. They want to tell me stories. And they were really excited and proud of what they'd accomplished.

But they weren't just isolated cases. They were walking down their unit. I could see all these patients sitting up at the side of the bed, in the chairs. I saw patients walking around. So what kind of stories can you share of what your team has accomplished in the last like seven months, eight months? Well, I think the biggest thing and that's almost done is our video of

the interviews with nurses, physicians, and patients. So we got patient stories. That's really the exciting part because that's going to be the stuff that's going to be used for future education. I've had a couple of patients come back. Again, another case, I think that's really fantastic. We had an asthma patient. I just, it's amazing how much we've made a difference here. We have a patient came in, status asthmaticus, and

For anybody who's been working the last 15, 20, 20 years, we used to sedate them really bad, paralyze them to get their pH normal. And we're kidding, pH normal is not good because of brisk barotrauma and volume trauma and all that stuff. And they get pneumothorax. That's mostly gone away because we've moved to the idea of permissive hypercapnia as long as you can oxygenate a lot of these patients. However,

We still sedate them very heavily. We get there. So I remember our chiefs were like, I can't ventilate this patient. I need more sedation. I said, I can give you sedation. He's a big guy. I said, I'm not. What I'm really concerned about is the paralytic. So I'm not going to do an imbex, a sascharinium drip or anything like that. So I'll give you PRN, bec, becaronium. But I only give it like maybe twice.

three times, maybe max in 24 hours, but usually I remember once or twice, maybe once in the shift. And I say, I understand that the alarm bells sound bad. The patient's not synchronizing. However, patient is still oxygenating. What I kept saying is,

The, I have to pick the lesser of all evils and the lesser of all evils is delirium compared to any ICU-acquired weakness they can get compared to more synchronized ventilator. So we had that patient after about three to four days, I left service. I got sent a picture that he was up and moving, walking. He was extubated. He went upstairs. He was discharged home. He has come back and said hello. His wife is a nurse here. He's on our video. Yep.

And I've talked to him. He was, he had a regular job. He was, I think it was in his around young forties, maybe over thirties. I couldn't remember exactly. And it's just, I, and I kept saying to him, I kept telling all staff, remember this in the old days, we would have sedated him really bad.

We would have paralyzed him. Plus with the steroids, he would have had a high risk of isochoric weakness, that demyelinating disease, and been on the vent for three to six months with a trach, a peg. And so hopefully rehab gets out in a year. I think we've all had that experience with those statuses, Maticus, or patients who just get paralyzed and steroids too.

So I was very proud and I kept saying to the team, look what we've done. This guy is walking and still going to work. It's because we just had to deal with some annoying stuff or discomforting stuff up front in our perception, maybe the patient's perception a little bit. The amount of prevention was 10 times, you know, 100 times we got the reward. So that I think was a good example for the staff. When we have patients coming back, we've had more patients come back.

and tell us our experience in this video which will be released soon the preliminary is done i looked at it but we're finalizing it and it's going to be released to common spirit they want to release it at your i think it's nti your national trauma institute one of your national conferences you're i think you're involved with a poster or getting a presentation or something there and

This is going to be really exciting. And I, my goal and this is the same with our ICU nursing managers for us to be the flagship. And then look at what we've done. Look at our, you know, as we look at, we measure ABCDF, which is a very rudimentary way of following this. It's really, it's the way that hospital systems are tracked. Those numbers are all going to get better.

But we're more aggressive. How many deliriums have gone from negative to positive? How many are positive, negative, better? How many of our RAS scores have been better? All that stuff. And that we have to do our own auditing. And then we want to bring this out in the area because I can see this. I can see us being the flagship in this area and maybe beyond. Absolutely. And the hard thing is your hospital, like most the baseline data, it's hard to know what was reliable because...

I think any podcast listener can understand that our RAS scores aren't usually reliable. We weren't tracking levels of mobility. There was a lot that wasn't being tracked at baseline. I'm going to be interviewing Ginger about her special study. There's some still physicians who are outliers and I have to do nonstop education. The ER has been very receptive. I gave a talk to the ER last year. I took essentially, I shortened it up into a 30 minute talk and cut out a lot of the stuff, but just for their reasons. And I learned something like,

Why do they have to sedate patients if they intubate them? You know, you want, unless there's really an issue, because they intubate them, get their scans, maybe we don't need to. So a lot of ER docs would say, so I use, I generally prefer succinylcholine for my paralytics when I intubate. But a lot of people, and there's a trend to rocuronium.

And there's no data one way or the other. Officially, if you look, my understanding, but they would use rocuronium longer acting. So they would say, well, if the patient's paralyzed, but not awake, that's like torture. And I agree with them. But I said, fine, you can put a little sedation on, but maybe, you know, so that was...

That's what I learned. I was like, why are you sedating all these people? And I understand because of the medications they're using are longer lasting. So that was an educational point that they brought up to me and something I thought was very helpful. The other thing, I don't know if your listeners know, but with the ABCDF bundle, choice of analgesia and sedation, you can meet your metrics. All it means for sedation is that this is way, this has to be revised if you're not on benzodiazepines. I just, when I heard that, I was shocked. So you could essentially have a patient have at least the amperopal, dexamethamidine,

and fentanyl and still say that you're doing a good job with sedation, which is crazy. Yep. You can have propofol at 50. Right. As long as they're not on 200. Yeah. I mean, it has to change. So hopefully our societies will update that, you know? Yeah. There's a lot of updates to be done, but it's nice to see units really showing that it's possible to keep patients awake and mobile.

We're going to be doing interviews with your therapists, your safe patient handling leaders, respiratory therapists, and hearing about their roles they've played into it. But when I've walked around your units, again, everybody's up in a chair and patients are walking around the unit intubated and not. You already had a really good culture with your patients off of mechanical ventilation.

And I asked these nurses that were telling me these stories about their intubated patients walking around the unit. And I said, was that scary? And they're like, no, it wasn't a big deal. And it made me laugh because this was in May versus...

the absolute terror that they had in January. And so I think that has a lot to do with, they're doing it right away with every patient possible. Absolutely. And we have been using that special bed that I can't remember the name of it. The total lift bed. We're not here to arrest your pod people, listeners. We're not here advertising any company here. We just need to sit upright at a certain degree so the patients can get some weight on their feet, maybe lean a little forward, maybe even touch. I don't

I'm a big believer of that. I always say patients, at least have them sit up, have their feet dangle and ideally touch the ground. That proprioception is so important. It grounds them, brings them back to hopefully out of the delirium or nightmares that they're having. This is real and you're here walk. So it's just, I think that's way underestimated as a helpful benefit. And it's so nice to hear a physician and especially a medical director talking about that.

What advice would you give to other medical directors on how to lead this or how to even adjust your own perspective of these practices and your scope of practice? You as a physician, you're worried about patients getting their feet on the ground, connecting with their family. That's not something that is usually in the normal medical model, at least not historically. So what kind of words of advice would you give to medical directors?

So if you're a medical director, you've had to binge with COVID. So just remember all the isolation that patients were in. They didn't see their family. We were scared to go in the room and how bad the outcomes were. We can get those outcomes. We couldn't stop COVID, but we can get them better and rehabbing faster. We pushed the whole idea of proning. So just think of that. If you or your family member was a patient with COVID back in late 2020, 2021, and were isolated and nobody wanted to go in the room because they were scared of getting COVID,

How would that be? So essentially nobody's doing anything, but now you can sit up and just set your foot to the ground. How much better would you have been for your own psyche for that? So I think that's a big thing. It takes away the isolation. It's more involved. Everybody loves it. Family just, you always have to put yourself in a patient situation because everybody, Dr. Murphy quoted, every person is going to be admitted to the hospital about 9.5 times in their lifetime on average. So that could be an ICU one time.

Think about it. I'm going to be admitted nine times. It's not always going to be for elective surgery or delivery probably. It's probably some real medical issues. So that's going to be you at some point. So hopefully you can train that generation, take care of you as you have done for them. And this is obviously, like we said, not a night and day overnight transformation. So you guys have obviously come a very long way now, eight months later from when you first started. Where would you like to be by the end of the year?

Well, we've hired two patient care techs and we're going to hire a third ones being interviewed and prepped. Currently, we have them five days a week. If we show these outcomes, we're going to push to get seven day coverage. Because as you know, hospitals,

Despite being 24-7, I'll never understand. There's a lot of that. They still run it like a bank hours. Regular business on the weekends, things are... So you don't want lesser care on the weekends. They've had studies show that sometimes... I think it was a study show even if you had a heart attack on a weekend. This is like 15 years ago. Your mortality was a little bit higher. And if I remember that study correctly. So I think that we're just really getting this where we have more care seven days a week. And I keep expecting numbers to get better.

Now that we have these videos, it's almost ready. It's going to be easier to educate noon staff that comes on. They'll push through the, obviously, the resistors. As the data comes out, we're going to show that to admin, be very excited. We've come a long way. And we just, we need to show the return on investment to admin. And I'm not doubting that's going to happen. It's going to happen to keep this going. Eventually, they'll say the money's going to run out if you don't make an improvement. So we absolutely have to do it for our patients. And those mobility tech positions were part of

what I pitched when I presented to your team to say, probably need some more equipment. We're going to be finding what you need as we go along. You definitely need training, but you also need more staff. You barely had any CNAs. I think what I said was get your checkbook out and be ready to continue to ask your team's

What else do you need to be successful? Right. And there was talk about getting some new equipment, like some new chairs. And I said, that's all great. That's not really the answer. It's us moving patients. And we had to change what we called it. So your podcast is awake and walking ICU. I agree, but.

Walking sounds too scary to a lot of staff members. So we just say awake and mobility, because if I say walking and what happened was everybody, this is for other people on this program, kept focusing on the PT and the equipment. And I'm like, that's great. That's on the back end. If you stop the sedation or minimize it, that's what you get. Everything will follow after that.

If you still sedate a patient, forget walking them. So it's, again, the analogy is it's like at the top of the mountain and you have a little stream that gets bigger and bigger, forms a big river. If you can work on that stream or the avalanche idea is even better. You know, avalanche is really bad when it hits the bottom of the mountain. But if you can stop it up at the beginning when it's a small snowball, that's where you have the impact and you can do something about it. And I think that's why...

Your teams have been so successful because you're taking more of the preventative, proactive approach rather than what has been tried in the past as far as a rehabilitative approach. You're focused on prehabilitation. And that's what makes it so much easier to roll out and then sustain. Absolutely. Anything else you would leave with our podcast listeners? No, I am...

honored to do this podcast with you. I've been really excited about everything we've done. I'm looking forward to our data to come out and sharing that with you and the hospital and all this stuff and just continue to work on this project for Dr. Murphy stepping down and at the end of his career, me in the middle of my career. This to me is like the project for the next couple of years that we're going to make a difference here. Everything

You have to have some projects as director to follow improvements. This is it. This is a big, big one that can have an unbelievable impact. So I'm really excited. And we've done it in some other hospitals. We've done interviews. It's just exciting. And when I see the fruits of the labor is really when obviously it's exciting. So this is how I feel I can make a difference as director. Thank you so much. Thank you. It's always a pleasure talking to you. Thank you.

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