Episode 189: The ICU Revolution at Mercy San Juan Medical Center- Part 8 with Dr. Parimal Bharucha
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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.

Sorry for the laps and episodes coming out. We have a lineup of incredible episodes coming up, but life has been fast and furious over here. For those of you going to the SCCM Congress, come join us at the sedation and mobility debates on Monday, the 24th at 3 p.m. We'll also be having revolutionist meetups for breakfast on Sunday and Tuesday. Come

and or send your colleagues that are coming. I can't wait to meet everyone. This episode is another inspiring testimony with medical director, Dr. Barucha. It is another witness to the power of medical directors that have open minds and are driven with compassion to save lives through revolutionizing the culture and care in their ICUs. Dr. Barucha, thank you so much for coming on the podcast. Can you introduce yourself to us?

Yes, Kaylee, first of all, thank you. You have been very kind, not only to help us, but also to invite me to your podcast. I am Dr. Parooja. I am actually an international medical graduate from India. I did my medical school back home, and then I did my residency in St. Barnabas, which is in New Jersey. From there, I moved to Albany, New York. And from there, I moved capital to capital to Sacramento at Dignity Health in 2010.

Since then, I have been here. It's 14 years. It will be 15 in next June. And so throughout your training in all these different places and facilities, what were you taught and how did you practice in terms of sedation, mobility and delirium management? Oh, man, that's a very, very loaded question. Okay.

So in training, in residency, as well as in fellowship, it was sedation, sedation, sedation. A patient gets intubated, the first thing the nurse will ask is, hey, can you order the Versagip?

In training, actually, going back, dating myself 2003 to 2006, Ativan was a big deal. We used to put everybody on Ativan drips. And then we figured out that, hey, that has a lot of toxicity. And so then we moved away from Ativan. I'm sorry.

And we moved on to Versed. So much better. So much better. I mean, it actually is better, but... So much better, but yes. But still better. Yes. And even in fellowship, we were still doing Propofol and Fentanyl or Versed and Fentanyl. Fast forward to 2010 to 2013, somewhere we got rid of the Versed drips mainly, and we started going to Propofol drips.

But still during the entire training, I went in fellowship in 2007 till almost until most recently. As I said, the first thing you do, you intubate the patient. And as soon as you are done intubating the patient, what goes on is an IV drip.

And a lot of myths, right? I mean, we do something from anecdotal experiences and what others have told us. The first thing, the most important thing would be that, oh my God, the patient is now waking up and is coughing and gagging and fighting with the ventilator. And that is so uncomfortable. And oh my God, we need restraints. And so as soon as, you know, there'll be two nurses, one will hang the drip and the second one will tie down the hands. So that's where we come from.

you know, fast forward to today that now after your training and your hard work for almost what, like six months to a year now, things have changed. And, and it will, it is so surprising that most of the nurses, except who have joined newly, most of the nurses will not even ask for restraints. Actually, you have to say, Hey, where are the restraints? And they'll be like, Oh,

Oh, sorry, let me get it. So we have shifted that they have, you know, they have stopped pulling with the integration tray. They don't bring the restraints in. They do not bring a bottle of Propofol with them. So things have changed and I'm so proud that we are going this way. And from your perspective as a physician, how do you see this impacting the outcomes of your patients? I know we're still like collecting data and things like that, but anecdotally when you're attending,

What changes have you seen? - So let me tell you, a few years back,

I was doing a bronchoscopy and I was giving sedation to the patient. Of course, it's conscious sedation. You do fentanyl, Versed, if need be. You know, the conscious sedation nurse then gets tired of pushing medicines and they'll be like, doctor, can you just give propofol? And then, yeah, you get a little bit of propofol. And the guy kept on needing a lot of sedation because he was constantly moving and flailing his hands and

coughing and, you know, so you keep on giving them more medicine. And then finally the procedure got done and I woke him up

And then I'm like, dude, what the hell were you doing? Are you do you drink a lot of alcohol or take pain medicines that I had to give you so much sedation? And he's like, no, I'm a surfer. And I thought that I was I was riding a wave in Hawaii and I was getting drowned. And therefore I was trying to just get back to the to the land.

And I'm like, oh man, I mean, this is an effect just for a short term, like half an hour of procedure.

OMG, guess what they go through when they wake up a week later of the sedation and oh, oh, man. So, you know, it is so naive of me that at that time I just brushed him off and I'm like, oh, yeah, I mean, that was funny. Sorry, you had a bad dream. And then you completely forget about it until someone like you comes along and opens our eyes and you're like, oh, man.

This happened to me in a short-term procedure a few years back, and I witnessed it.

He was able to talk afterwards. He was intact. I have to tell you, but not most of our patients in the ICU. Correct. But I mean, you know, the thing is that this is just a half an hour of procedure. And if he had a bad dream and a delirium that, you know, that caused me to give him more and more sedation to get the procedure done, patients who are on this long-term propofol and Versed and fentanyl, oh man, it's

That whole life goes upside down. And then when we interviewed some of the patients, you know, it will bring tears to your eyes that what have we done? And so for you as a physician, you know, you, you were bought into this much sooner than the rest of the entire critical care department, right? Yes. So how did it impact you to be having these awakenings and then to be trying to practice and trying to guide this care without the rest of your team bought in and prepared?

So that was tough. You know, when we start practicing, we get used to the culture that we are in. Compared to say from fellowship when I came to Sacramento, there were a lot of changes. And then you just go with the flow of what is happening around you. That becomes a part of your nature. And changing one person is easier than changing the whole crowd.

And especially when the crowd has a lot of other disciplines like physical therapy, respiratory therapy, nursing. And again, it comes with years of experience. There might be some nurse who has been there for 20 years who have done things in one way and to change them, it's very hard. And you have to change them in a way that, hey,

you are not stupid. This is what we did. We are all in the same boat, but things change. Medicine is an art. It changes every day. And so let's go on step by step, one step at a time, not an easy transition, especially, you know, the nurses, the respiratory therapists, physical therapists, they don't work every day. So they work three days a week. And so then when they come back, things are different. And so it's like, every time they come in, there are a lot of

bumps, but unless you fail, you don't succeed. So you keep on going with it. You keep on giving positive reinforcement, even if they get the patient out from the bed to the chair. Hey, if you give them a kudos, it goes a long way. And including for us, right? As a physician, we

We strive on success. We strive on a patient who is on multiple medicines, almost close to the death's door, getting better, getting out of ICU. That's a huge accomplishment for us. And if nobody else

acknowledges us, do we feel bad? Yeah, we do feel bad. If, you know, if families or the nurses just say, hey, you do not do this or you do not do that versus, oh my God, that was such a good thing that we thought of this. We worked as a team. Hey, the patient is so much better. Then it goes a long way. So I always, always tell my team that, hey,

You and I, we cannot survive without the ancillary staff. Absolutely not. No matter how good a doctor you are, you cannot do anything yourself. It's a village. It's a crowd. You need everybody's help. And so let's be positive. Let's show whoever is working the positive impact that they have made. Even if the patient moves a finger a day later, hey, that is better than not doing anything.

So it's better than being deeply sedated. Exactly. I want to hear your thoughts on this. I had a, I referred into previous episode about a medical director that I spoke to in 2019 that scoffed at the idea of an awakened walk-in ICU and said, yeah, the research shows stuff about that. And then he said, but you will never get our nurses to do that. What are your thoughts? So,

I would say that if you as the captain of the ship do not buy into this, it's not going to happen. You as a captain of the ship should know that you are captain because people look up to you. They trust you. So if you are not making the change that you want to see,

then it won't happen. And that it is too narrow-sightedness to know what other people can do

Unless, you know, you just take them, you just write them off that, yeah, the nurses are not going to do this. You always think that, yes, it might not happen. But think about this, that, hey, what if things happen? What if you start making the change and the nurses are going to follow you? Yes, of course. Even in my own family, if I have to, like literally 10 minutes before this, my mom, my wife and I, we had a discussion about where to put the Christmas tree. But you have to start somewhere.

If you would have just said, oh, forget it. We are not getting along and we are not going to put the Christmas tree, the Christmas tree would still be up in the garage. But now it's out and it is already in a place where we all said, okay, let's do it. So you have to start somewhere. You have to think that people that you work with are capable of doing miracles.

You have to believe in it and then go with it. And again, positive reinforcement is very important, especially with the people that we work with. They are all youngsters. They are generation Z and generation alpha. And if you do not give them feedback right away, then it won't work. So that's good points. So trust in yourself and trust in the team that you have. And without that, nothing is going to happen. And again,

The best thing is that you are doing it with an intention that the patient that you are treating is going to have a good outcome. But without, you know, if you don't give antibiotics thinking that it's not going to work, guess what? It will not work. But if you give it, hey, it may work.

So as a captain of the ship, you have to have a brighter horizon and you need to have a lot of faith in your team. And if they're not coming up to it, then it is your responsibility to bring them up to the level. It falls on you. You are a captain. Ooh, all the medical directors, the gauntlet's been thrown, right? Yes. But this it's,

One, a huge undertaking, right? It's an absolute overhaul of so many different skill sets from different disciplines, culture, knowledge, team dynamics. So as a physician and a medical director yourself, right? You are one of the medical directors. How, what was the value of having your entire team educated and trained and understanding their roles and being prepared to practice this way?

What was the value of that and being able to now lead your team to do this? The value is incredible. Even if we can say one life, and we have saved so many lives already, we have interviewed so many people, right? It is humongous undertaking. I always tell my teammates that, hey, at the end of the day, when you go home and you get fresh, look yourself in the mirror.

If you are able to see yourself through your own eyes in the mirror, then it means you have done something good. If you're not able to look at yourself, then that means that you have fallen short that day. So this is a practice I have every day. If I can see myself eye to eye, then I know that, okay, I have done something today. Um, the value is incredible. Um, and I can tell from my own experiences, um,

Like my uncle, he just recently passed away like two weeks ago. He was in India. But a lot of things could have been done differently than they have been done here. This morning, a nurse called me that his brother is in one of the hospitals for a month.

And this is in the United States. And he barely moves, but he's restrained. 30 days later in the ICU, he is very agitated. He has been on sedation. He got a trichostomy. He still has a Foley and he just got a UTI and he has not moved out of bed. So now if the same patient was in a different hospital, like for example, at our location,

A, he would not be restrained if he's not moving. Why does he need restraint? B, why does he need a Foley catheter? And C, why is he delirious? Do something to prevent the delirium. Now, again, all those things will only be part of if you have trained your team. If you have told your team that, yeah, just leave the Foley and we'll think about it. Or once the patient gets better, we'll get it out. It's somebody else's problem on the floor. Then guess what?

They're never going to leave the ICU. You are doing a disservice. But again, it's, it's a, it is not a one man show. As we said, physical therapy, respiratory therapy, phlebotomist, everybody comes into play in this and to train them. Didactic knowledge is very different than a real practice. I

um, that acknowledge they'll be like, well, yeah, he's giving a lecture for an hour. Let us just do was off or we have to do it compulsory. We have to do it as a CME. Let us just get it done and check the boxes. But when it comes to doing bedside training, like you did like every few weeks for different ICUs, I think that goes a long way and including everybody, people from different teams, put their heads together, uh,

then that makes a difference. For example, you can come and say, hey, get the patient out of bed and the nurse will be like, okay, let's go on this. Let's get out of bed. But guess what? If you have not trained the physical therapist, if you have not trained ancillary staff, how is that going to happen? The nurse can keep on barking as much as she wants. Nobody will listen. And the doctor can keep on barking to the nurse, saying, hey, do this. But

A, without knowledge, that is not going to happen. Everybody absorbs knowledge at a different pace. So patience is very important. Retraining them, re-educating them every now and then, every step of life is very important. And again, you can train, you can talk about this to the nurses every day, which you should talk to the nurse every day and the whole team because education doesn't stop.

That, okay, you got educated today. Now you're good for the entire life. No, we all forget there are new things every day. So it's constant reminder of doing what is right for the patient. So number one, education will take a long time because there are a lot of people you have to train. So you have to have patience and you also need some, um,

safety equipments that needs a little bit of green dollar bills and then you need support from your executive leadership to provide you with extra manpower to provide you with things you need for safety and I think that the return of investment on this is way higher than what you invest in

The team doubled, your hospital doubled their return on their savings compared to what they invested within a few months after turning. Yes. We haven't even hit the year mark and you guys just, the savings were monumental before you had even mastered it. Like you have, like you guys are almost there, but quickly there was a return on investment. Yeah, because this is all safe practices, good practices that we had just gone sideways. Yeah.

For years, as I said earlier, you just go with the flow. It's mainly cultural change. Yes, knowledge is very important. And as I said, knowledge, you keep on updating them. But again, what would make a huge difference is the culture. If one nurse makes a difference and if they take the lead,

then you will see all of the nurses that work with them will start following the same thing. But if six, seven nurses that you work with, if all of them are of the same opinion that, oh, you know, this is my third day in a row. The patient was delirious last night. Let's just let them sleep today. The family is not coming today. Let's just take it easy. Then guess what? Nothing will happen. They're not going to get insulated today. So why wake them up? Exactly. Um,

And then, so A is educational piece and educational piece does not stop at didactics or going through the podcast or going through the, through the pathways that you are assigned to. But it is what you see day to day. We keep on talking about delirium so much. And I have pointed out so many times, including last week that, Hey, the clock has not been changed. It is still one hour difference. And then how can you expect the patient to not get confused? Yeah.

So I am very big. You can ask everybody. I'm very big. I just walk around randomly and then I'll be like, hey, this room needs the clock updated. You have not updated the board because the doctor that you have on the board was there three days ago. We are three days later. The doctor has changed. The date has changed. The day of the week has changed. And it does not take that long to update the board. The board are meant to.

So that we can update the patients and keep everybody, you know, everybody informed of what is happening around them. But if you don't change it, the patient and the, and you know, believe it or not, the boards are right in front of the patient right across the wall. That's the first thing they will see. So you have the day wrong. The day wrong. It's Tuesday still. Oh my gosh. Like this has been the longest Tuesday. Yes. Right. It's confusing. Yeah. Yeah.

And then the lights are not on. And I, I just keep on going and putting the, you know, putting the switches on. I'm like, Hey, daytime 7am to 7pm, let the lights be on. If there is no sunlight. Yeah. I mean, those are small things. We, yeah, we talk about this didactically that, Hey, okay. We have to keep up with the sleep-wake cycle. We have to make sure we are not doing this or this sedation, but what about this routine stuff? Normal stuff that is,

so important and then having a having a physician you know medical director that's looking at the unit as a whole looking at these things beyond just um

Beyond just the orders, you're not just putting in orders. You're not just writing discharge admission orders like you are looking at what is the environment that our patients are in. And these things are usually nursing, right? This is a very holistic approach and perspective. And that's not necessarily how physicians have been trained. But you've taken this onto yourself as a steward.

as a director, as well as an attending. And you're looking at what does this patient need? And so just instead of saying, keeping siloed and saying, well, the nurses, if the nurse wants the lights off, then like, that's just the way it has to be.

you're being a leader. You're saying, yeah, remember what we've talked about. It applies to this. And, and how do these conversations go now compared to let's say a year ago, now that the nurses understand deeply delirium, when you make those suggestions and those reminders, how was that received now versus a year ago? 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.

Well, you will be surprised. It is all the way around. Now the nurses question us. So it has gone, it has gone a whole circle and which is so, that makes me so happy that now the nurses are taking the lead and saying, Hey, Dr. Parooja, I don't think that patient needs this sedation. Can we just take it off?

Or they'll be like, oh, why is the patient even on this? Versus a year ago, they will be like, can we add this? Can we add that? Can we put this on? So it has gone a whole circle. And that makes me very proud. And I always tell nurses and physical therapists that education in the United States is not easy. You have gone through a lot.

And I hate when they become just a task oriented person. And I'm like, I can get anybody to do my task. Instead of that, you should be a part of the team. I want things that we are a team. Let us all put our heads together versus that. I'm just telling you to do something and you do it. That was one of my objectives in the training was that

Each member of the team have the tools through. You can hear me? That each member of the team would have the tools to critically think through

their patients each day with each nuanced scenario because we did simulation training. We talked about case studies and didactic, but they're going to meet all sorts of nuances. Every patient is different. That's one of the challenges. It's easy to create a conveyor belt of everyone gets sedation. Everyone gets immobilized, rinse and repeat. Everyone's the same. But this means that we now have to treat patients as the individuals they are.

and meet their individual needs and be a lot more, have a lot more art and finesse in how we manage them, a lot more humanization. So I wanted them to have the tools to put their heads together and critically think through each patient as an individual to meet the unified objective and vision that everyone has. And I've always known because I'm a nurse, I'm very biased, but nurses are so protective of their patients.

And once they understand the harm of sedation and immobility, they've had successes, they see the impact, the outcomes, but they become very protective and very hesitant to sedate their patients and use that very carefully. Yeah. And as I said, I, you know, sometimes the nurses will come and say, hey, the patient is short of breath. And that's the sentence stops there. And then I'm like, okay, what more?

And then they'll be like, I do not know, but the stats are low. And I'm like, yes, you are a nurse. Why don't you think critically? Okay, before you come to me, um,

Have you looked at x-ray? Have you looked at the labs or something? So let's make an informed decision versus I tell you that, oh, okay, I think the patient is overlaid with Lasix. But you are there for 12 hours. Maybe you might think something else is happening. Maybe there is something, maybe you're not thinking of PE, which I'm not thinking. So let's work as a team. And so with this awake and walking ICU, it has become very interactive actually lately with the nursing. The other day we extubated somebody. That took the nurse out. Hey,

let's just get the patient in the recliner. Let's just stop everything. And let's see if the patient passes SBT. And guess what? The patient did. And we extubated the patient. And then after a little while, he comes and tells me that Dr. Bharucha, I really think something is wrong with the patient's neck and the cervical spine because the patient is not able to keep the head up. And he's like, I already put the sock collar on.

Can we do something about this? And I said, oh, that is a good thing. If we would have not done SAT and SBT and we would have not put the patient in the recliner, guess what? We would have never figured out there's something wrong with the neck. And what was wrong?

Oh, I can't tell. Oh, okay. But maybe even if nothing was wrong, the important thing is that we would have missed this critical finding that the patient is not able to keep the head up. There is no muscle tones. There is something really wrong with the cervical spine. And this patient was able to stand, get to the chair, pivot, everything else. We put them in the recliner. Yeah. Yeah.

Then unfortunately, because of that, I mean, later on, we had to re-intubate the patient, but you know, that's... And the patient had been sedated then? Yes.

The patient was sedated mainly because a patient gets very agitated and then desats and, um, and then had a lot of arrhythmias. So she had a medical reason, um, to do that. But again, it was, it was not even that the patient was on sedation for a long time. It was like two days and that too was on precedents, but still, um, sedation is sedation.

Everything, nothing is better than anything. So, but that same kind of patient easily could have been on propofol and deeply sedated a year ago and not extubated at that point, not in the chair, not moving. And so,

And the reintubation may have happened because of other complications or other weakness, or maybe they, you know, it could have gone so many different ways. So being on that precedence, just to keep them from a RAS of three to a RAS of zero,

That is a win. Yes, that is a win. That's what I said, that it was good that the nurse stopped everything, even including precedents. And we got them out of bed in the recliner and we extubated the patient because she passed in the recliner. I love it. I love extubating the patient.

Yeah. And she passed SBT. And so we extubated. And then, of course, I mean, can patients fail? Yeah. But I mean, she has a medical reason that if she can't keep the neck up and if she keeps on having a bobble head, then of course she's going to have problems, anatomical problems. And...

which we would have not found. But again, another nuance, like I never would have included that into simulation training, right? But that kind of collaboration, that kind of environment to be troubleshooting like that and still she was re-intubated, but doesn't mean that she automatically got propofol, that we couldn't mobilize her, we're just protecting the airway while we figure out what's going on and protect her from all the other harm that could happen while treating the current harm. And I love the example of

educating the clinicians this way as a physician. I love that instead of saying they're short of breath. Okay, I'll just go fix it. But rather leading them to critically think through so that there is more safety throughout the team. The more your clinicians are prepared and equipped to critically think through the autonomous practice at the top of their license to stay for everyone's going to be in the easier. It's going to be for you. You're the only one that can critically think through agitation. For example, if someone's calling you for sedation,

because the patient is quote agitated a year ago, you know, and the team, I would have said, yeah, okay. Put them on propofol. Yeah, fine. Just over the phone. I don't need to say the patient. Yeah. Yeah. Agitated. Maybe the rest of plus one, but no one's thinking about what's causing the agitation. It's just an auto set. Cause there's no critical thinking now a year later, hopefully if a nurse is calling you at this point, it's because they're arrest of three or four, there's some sort of dangerous situation happening.

They don't really call you for a RASA plus one anymore, right? No. And if they call you for agitation, they're able to specify what RAS score it is. Yes. And they are. I'm so proud of them. Oh, we are very proud of my team. Yes. You should be. You have such a wonderful team. And even by the time I showed up, they'd already been making so much progress just from the didactic and the things that they had learned and been working on. And yeah,

How have you seen just taking it from light sedation? Because that's about where you guys were at when I showed up to do simulation training. There was light sedation happening and mobility was a little bit later. It was like towards extubations when you were starting to mobilize your patients. Yes. Now you're saying that you're not even starting sedation on patients automatically. And if sedation is given, it's for an indication and light. And I mean, patients are actually awake.

due to mobility earlier, more aggressively. Now, how does that play into the sustainability of this kind of program rather than trying to rehabilitate everyone later on? So positive reinforcement helps. And then one of our patients who was going to be, who was already tricked, who we all had

told the family that, you know, he's not going to do well. And let's just think about goals of care. Even though he's very young, he has made a remarkable recovery. He came the other day and he's going to have a second baby. Oh my goodness. So I think that that brought tears to a lot of nurses and they realized the impact.

That this is so powerful. And it is not that you are doing something extraordinary. It is something that you are supposed to do every day. You wake up, you get out of bed and you walk.

And you go on with your normal day to day. Just because you are a patient does not mean you have to lay in the bed all day long, 24 hours a day. So that brought tears to my eyes that he is expecting a second baby. And that really saved his life with mobility. Yes. And that was the only significant difference that was made.

compared to what we were doing everything else aggressively you know in terms of the medical management but in terms of rehabilitating him as a person that was the only thing that we did and it has made wonders so um

So when stories like that come up, and again, I think that what makes a huge difference is the patients and all the families coming around, A, to show that gratitude and B, to show what they are now. It makes a huge difference. And that gives the nurses a chance

a triumph that, oh my God, this is who we treated. Oh my God, look at the difference. And each and every person who touches the patient makes a difference.

Right. So, and the credit usually goes to one person, maybe the, maybe the doctor, because it's one person that the, that the patient or the family would remember compared to hundreds of other people who have touched. And so I always tell the, you know, if somebody says thank you to me, then I'm like, no, it's the whole entire team that needs credit because it takes a village. And, and that's, that's how it has to be.

And I hope that in the next one year, two years, three years, we do not have to rehabilitate the nurses because this is going to become so much ingrown culture that if somebody is laying in the bed, the nurses will be like, hey, what's wrong with this patient? What's wrong with that nurse? How come they are not?

You know, my goal and my dream, you know, we have the garden right in the middle of San Juan. Oh, my God, that's such a beautiful, serene place. So peaceful. I would want my patients to be walking there one day. Hopefully that can happen. I mean, we have portable vents. We can go there for at least five, 10 minutes. And why not?

Why not? Why not? Absolutely. And I know that we've interviewed the trauma ICU and they're taking a lot of patients outside. Yes. So we have been doing that for quite a while, including at other hospitals lately. I even took a very sick patient who was about to, you know, not do well. I'm like, oh my God, this patient is not going to do well. He's going to pass. Why don't we just take the patient out in the bed? It's okay. Let them see the day of the life. Let them see where they are.

And that was so much better in terms of the mood the patient was in. He parked out. And even though, I mean, of course he passed away later on, but that is what he's going to remember that, oh my God, he took a fresh breath air. He looked at the sun. His family was around. There are pictures with him outside the hospital. Where I come from, at least back in the day, it was a little bit of the wild west. And we would take patients up to the helipad

And I had one of my good friends there. She did a comfort care, a final extubation on the helipad at sunset. Snuggling in the bed with him. Like it was, I mean, that's the kind of stuff that you don't necessarily get trained on. But when you open the doors for this kind of human care, you would instinctively find those opportunities to do those special things. And that's what brings us as clinicians fulfillment and keep us going.

Any, any cool stories or last thoughts that you would share with us? Oh, well, I just want to thank each and every one. And they all know my team knows that, that I look up to them and I cannot survive without them. What I am today is because of them. So, and I just want them to think that,

that each and every patient is our family member, treat them like you would treat your own mom or dad or wife or kids, right? I mean, things are very different when that comes into perspective.

One of the coolest stories is, oh my God. So this guy, and this has nothing to do with the whole, with the walking and awake ICU, but because we work for dignity, human kindness. And I think that that at the end of the day, the crux of the still walking and awake ICU, yes, it has medical reasoning and a lot of other things, important things and money saving and the outcomes are better, but you would only do this because

If at the end of the day, you touch each other as a human being. And so this gentleman was on BiPAP again on COPD, not doing well. And I saw him in the morning on the BiPAP. Again, he was not restrained. So that is good. He was not sedated. That is good. But then later on in the day, of course, you know,

The buck doesn't stop only with the patients who are sedated. The buck stops with each and every patient. So this patient was later on taken off the BiPAP and he walked like five steps and then he was sitting and I happened to go with a medical student to teach the medical student about the BiPAP. And the gentleman happens to say, oh my God, I love your sweater. And it was like this time frame because I was wearing a sweater. It was November, December last year. Yes.

or the year before. And he's like, will you give it to me? And I'm like, yes, I would. The only thing is I was very honest. I said, listen, I am only wearing a vest. I'm not wearing a shirt inside. So when I go home, I'll change into scrubs and I'll give it to you. And he's like, well, if you will not come by, then I'll think that you are just making up stories and I'm going to die without it. And I said, oh no. I said, no.

So I went, it was around four o'clock. I went to the OR, got the scrubs and gave it to him. And then his wife visits him and she's like, hey, whose sweater is this? And he's like, well, it is mine. I got it from the doctor. And I had before that I spoke and I'm like, hey, it is not going to fit you, right? And he was like, well, it's okay. I'll give it to my son. So after that, I go home. The wife takes the sweater home. I come next day.

And he's not there. He passed away that night. That was a very touching story. And I'm like, oh, my God, if I would have just brushed him off or if I would have not gone back to see him with the medical student.

I would have not been able to be so much of an integral part of his life. Like now I am a part of his family. I'm like, my sweater is in his house. His son is supposed supposedly bearing it. I hope so. But again, you know, such things connect you to each other, not as a patient doctor, just as a human being. I mean, you know, it's, it's,

That always brings tears to my eyes. But again, I was very happy that we were able to take him off the biopay for a few hours, unless he walked for a few minutes in his room and he was able to communicate and he was able to talk and he was able to tell me what his likings were. Otherwise, I mean, have you ever asked a patient, hey,

what clothes you like or no, we always see them in that stupid torn down, which is not completely covered. And, and we, we don't care at that most of the time we just let them be exposed, you know, which I hate. I always try to make sure that as much as possible, I cover them. Dignity is very important when you are in such a vulnerable state. And that also comes, you know,

in the same flow of track now, if we are going to make them walk in the ICU gown, you know, we should make sure that, hey, let's give them pants, let's give them something or like give them two gowns, wear inside out. They are human beings. We cannot just let their dignity go. So yes, walking is very important. Getting them out of bed is very important. But hey, guess what? At the same time,

it's very important to preserve their dignity yeah and allow them to communicate and be themselves yeah because someone like that it would have been easy to just give him Ativan pushes yeah and put them on the bike yeah and he wouldn't maybe have been cognitive enough to talk to his wife those final moments this yeah talk about his son talk about mechanical ventilation because that is such a huge barrier

And other times we throw these things out the window when someone's intubated. But my hope is that we see that this can be done with our sickest patients down to our most stable patients, that they're still human when they're terminal, when they are severely critically ill.

that they should be able to tell us things. And so, yeah, thank you so much for bringing this humanization to your ICUs and for helping lead this huge revolution that's happened at Mercy's Hand. Not without your help. You have an integral part. You know, you will go down in the history at San Juan.

It wouldn't have happened without revolutionists fighting for years to get this to happen. Yes. And an incredible group of such compassionate and skilled clinicians that were willing to give this a chance. Yes. And we will continue to do it.

Thank you so much. I'll be sending people to come to your Awaken Walking. I see. Yes, please. And as I said, my dream is to see patients in that garden. Oh my God. I just can't wait. Well, let's make it happen. Yes. Thank you, Dr. Brucha. Thank you, Kaylee. Have a good day.

To schedule a consultation for your ICU, as well as find supportive resources such as the free ebook, case studies, episode citations, and transcripts, please check out the website, www.daytonicuconsulting.com.