Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.

Emily Silverman  

I'm Emily Silverman, and this is The Nocturnists: Conversations. For years, staff in the ICU believed that we needed sedation to keep ventilated patients calm. The idea was that the sedation was protecting patients from the discomfort, from the trauma, of being critically ill, just a push of propofol, a dose of benzos, and the patient would drift off into what looked like a peaceful sleep, but they weren't sleeping, not even close. What we didn't realize was that these patients in the ICU were still aware their minds, suppressed by medication, were spiraling into terrifying hallucinations. Their breathing tube became an instrument of torture, a routine catheter change felt like sexual assault. Some saw strange figures hovering in the air: people, animals, bizarre visions. Others thought they were in an airport, a spaceship, somewhere, anywhere but the ICU. And it wasn't just the night nurse. Prolonged sedation damaged the brain. Patients woke up weeks later, not just physically weak, but mentally changed, living with symptoms of dementia, PTSD and a kind of deep existential loss. Many couldn't return to work. Some lost their sense of purpose. We saved their lives in the ICU, but at what cost? 

Emily Silverman  

Today's guests, Kali Dayton and Heidi Engel are leading a movement to change all this. They're fighting to restore consciousness, dignity and mobility to ICU patients, so that they don't just survive but actually recover. Heidi is a physical therapist with nearly four decades of experience, and has spent much of her career pioneering early mobility programs in the ICU. She's an award-winning leader in the field and a founding member of the Society of Critical Care medicines ICU liberation campaign. Kali, an ICU nurse practitioner, trained in a unique awake and walking ICU under a woman named Polly Bailey, who you will hear more about later in this episode, in the awakened walking ICU patients were kept alert and moving even while on ventilators. And when Kali later worked as a travel nurse, she was shocked to see how sedation was being overused, leaving patients with devastating long term effects. She now works with ICUs around the world to shift their approach and hosts the amazing "Walking Home From The ICU" podcast, which takes a deep dive into this issue and features over 150 episodes with the voices of clinicians, survivors and other experts. Together, Heidi and Kaylee are here to talk about the culture of sedation in the ICU, why it needs to change, how we can start treating ICU patients in a way that's more humanizing, connecting and healing, and how Kaylee's work with her podcast and storytelling has helped her understand the issue better and spread the word about ICU revolutionism. But before we dive in, let's take a listen to this excerpt from Kaylee's podcast."Walking Home From The ICU".

Kali Dayton  

Suddenly she interrupted my thoughts with, "You were so mean! You made me walk when I was tired and scared and I thought I hated you." Yeah, I couldn't deny that, and I didn't know how to smooth that conversation over, when suddenly she reached over her walker and had me in a bear hug and said, "You saved my life, and I love you". That moment penetrated me. I remembered that her main goal and focus was to get home what she meant by "You saved my life," was not that I just kept her on the ventilator. She got back to what her life meant to her. She had the value. She went home to her partner and her dogs. She taught me that that is what it means to save a life. This survivor friend understood before I did that saving lives in the ICU is done by preserving function and allowing a full restoration of their lives as a whole. That is what this podcast is all about. It is about how to save lives, not just specific organs. The ICU I work in maintains that focus and caters all treatments to that. Therefore, 98% of our survivors walk themselves out of the hospital doors and go straight home.

Emily Silverman  

I am sitting here with Kali Dayton and Heidi Engel. Kali and Heidi, it's a pleasure to have you today.

Heidi Engel  

Thank you for having us. 

Kali Dayton  

Thanks so much for having us.

Emily Silverman  

So I was wondering if we could begin with the story of Polly Bailey, this towering figure in ICU revolutionism. Tell us who is Polly Bailey and what is Polly's story?

Kali Dayton  

Polly Bailey is a quiet little legend. She was a nurse in a shock trauma ICU in Salt Lake City Utah in the 1990s. That was an era in which Critical Care Medicine was exploring and experimenting with ARDS management, and the theory was that to inflate these stiff lungs, we needed to give high, high volumes and high, high pressure. So we were giving two and three times the volume that we now give. And so these patients, they were so uncomfortable. These were old ventilators that were not like the ones we have now. That's when we started to experiment with medications from the OR high levels of sedatives, paralytics, opioids, benzodiazepines, and we knew that it caused amnesia during surgery, but we didn't know what that did to the body or the soul of patients when it was given for days to weeks. So Polly was in this environment in which patients were deeply sedated, laying motionless while on ventilators. And the belief at that time was that patients were sleeping. They looked like it. Their eyes were closed, they were still. They looked "peaceful" and Polly didn't know otherwise, and she was just doing what everyone else was doing, until she had the opportunity to follow a patient out of the ICU and back to her home. This was an ARDS survivor in her early 30s. Her name was Joy, and she was from Polly's home community, and she witnessed personally, the psychological, cognitive and physical destruction that this young mother of little kids was facing. It took her about a year to get up the stairs. Her husband was having to help her with a bed pan. She was extremely traumatized, cognitively dysfunctional, and Polly didn't understand what was going on, other than she had high suspicions that this was from the care in the ICU. So she went back to her medical director, Dr. Terry Clemmer, and Polly said, "What are we doing all of this work for in the ICU of this is the quality of life that we send our survivors back to?" And he said, "Well, what's causing this?" And she said, "I don't know." And he said, "Check the research." But back then, in the 1990s there was very little to no research on life after the ICU, let alone the effects of prolonged, deep sedation and immobility. So Polly went back to Dr. Clemmer and said, "I really think that it's what we're doing to them. I think it's the sedatives and leaving them in bed." He said, "Well, what's the alternative?" She said, "I really think that they will do better if we keep them awake and moving." And he said that he was skeptical, but he trusted nursing instinct, and knew that Polly would keep her patients safe and let her try it, and they could instantly see a huge impact to outcomes. Patients did better. They got off the ventilator sooner. They survived. They left much better condition than those that had been sedated and immobilized. The intensivists saw how well Polly's unit was doing, how well their patients did, and then started sending them patients directly from the ER, newly intubated or about to be intubated, newly sick. And that's what really sparked this question in Polly: If it was this hard to rehabilitate patients after prolonged sedation, what if we never started it? What if we never caused the harm? And what if we got them awake and mobile right away? And that's when she started what I call now the "Bailey method" of allowing patients to wake up right after intubation and mobilize, usually within 12 hours after intubation, unless there's a contraindication. And that was in the late 90s that she started experimenting with this. The unit really started to be established in that culture in the early 2000s.

Emily Silverman  

So explain to us this radical shift. So it wasn't just "let's lift sedation in ICU patients", it was "let's never give it to begin with." So of course, during the procedure of intubation. And we'll give people something temporarily, but then let's let it wear off and let's let them wake up. Why was that so scary for doctors and nurses to imagine not continuing sedation after intubation?

Kali Dayton  

I think the main hesitation that still exists today is that when you start sedation, you disrupt the brain activity in these patients, and they become very confused. They can become combative. They don't understand what's going on. So they can try to pull out their lines and tubes, and it's really stressful and scary for the caregivers. So taking off sedation on the back end was really hard, because the perception was that these patients are so uncomfortable just from the endotracheal tube; everyone, that's in debate, will try to self-extubate because they have a breathing tube. Instead of realizing that they're trying to pull out the breathing tube because they think it's a snake, they think they're kidnapped, they think they're being sexually assaulted. Polly recognized that damage that was happening to the brain and worked on preventing it, and that's what made it so much easier and more successful. They knew how to rehabilitate patients, but working towards prehabilitating them was so much easier. Instead of taking four or five people to sit someone that can barely hold their own head up at the side of the bed, she was able to get patients standing walking, because their muscle mass and function was preserved because their cognition was intact, they could move their own bodies. So the entire team that had all this experience with rehabilitation had no problem with doing it early on, because they recognized how much easier it was for them and better it was for the patients.

Heidi Engel  

Beyond the self extubation concerns and the delirium concerns and the ET Tube being too uncomfortable concerns, there is also the concern that the patient will self injure their lungs by over breathing the vent. And there's an entire protocol called the ARDS net protocol that is evidence-based, and it is somewhat the law of the land. As soon as you've determined and defined someone's respiratory status as being ARDS, then there's a thought that that has to automatically come with sedation, or people will injure their own lungs with the way they breathe. What then happens is, pretty soon everyone on a ventilator looks like they need that sedation, because it was started to prevent them from injuring their own lungs, and then it just continued, because, as Kali just said, as soon as you start to take it away, once it's been on for a day or two days, the person waking up is usually entirely disoriented, confused, if the sedation has been on long enough to my mind, what Kali has just described for you, and what you're seeing when people wake up is you have put them in a medically-induced coma. This is the level of sedation she's describing. And we know from traumatic brain injured people, when they emerge from, for lack of a better term let's call it an "organic" coma. They go through very distinct stages of the brain coming back online, and we watch those same exact stages in our intubated, sedated patients, but we don't recognize it as, "Oh, we created a medically induced coma, something very similar to a traumatic brain injury, and here are the rancho los amigos levels of cognitive restoration that they're going to go through." And an agitated phase is a normal part of waking up from a traumatic brain injury, and so you have to ride through it. And when someone has a traumatic brain injury, you expect that. But when someone's in the ICU on a ventilator, that's incredibly scary for the providers and the families, let's face it, and so the sedation will go right back on, and now you end up in a vicious cycle.

Kali Dayton  

And in the 1990s there was a lot that we didn't understand about delirium. Dr Inouye had created the confusion assessment method, and Dr Wes Ely had just newly tested that for the ICU setting, and so we just did not understand that sedatives are so harmful to the brain back then. And there was no other explanation for this phenomenon, this ICU psychosis that was happening, and the solution always seemed to resume sedation. Dr Wes Ely had been a lot of research on delirium, delirium in the ICU, breathing trials and Polly, simultaneously in their own parts of the country, was already working on the solution, which was, don't disrupt their brain with sedation; Get them moving, let them sleep at night, let them connect with their loved ones. Humanizing the ICU. So when Dr Ely was coming out with all this wonderful research identifying the problem, he and Polly made an alliance, and she said, "Well, how about this solution?" So he went and visited her at LDS hospital and had her come out to Vanderbilt. She also visited Johns Hopkins. She was teaching them about what process of care sheet established, and that ended up being one of the first dominoes to start off what we now call the A, B, C, D, E, F bundle that was created by Society of Critical Care Medicine many years later.

Emily Silverman  

So I want to back up a bit. So let's say, God forbid, I get a pneumonia, I get a bad pancreatitis, I get hit by a car, you know, whatever it is, and I land in the ICU. I'm intubated. I'm given sedation. And there's studies that show that patients who are in this medically-induced coma, or whatever you want to call it, deep sedation, that they're not exactly unconscious. I mean, they are unconscious, but many of them have hallucinations, visions, usually negative. I remember speaking to Dr Wes Ely about this once, and he said he heard one case where the hallucination was positive. It was somebody hallucinated that their dog was asleep under their hospital bed, and that was a comforting experience, but 99% of hallucinations are not positive. They're terrifying. What are these traumatizing ICU psychosis, ICU delirium, hallucinations? To us, the patient just looks quiet and peaceful. Inside the patient's perspective, it's anything but.

Kali Dayton  

I've now interviewed dozens of ICU survivors on my podcast, and my statistics are very similar to Dr Ely's that it's usually very negative. I'm not sure why, but for some reason in this altered consciousness, this period of high inflammation in the brain, very disrupted sleep, the brain cannot get restorative sleep. There's no REM cycle three or four when you have propofol running or benzodiazepine. So during this time of neurodegeneration, all this damage happening. For some reason, their brain goes to their life's worst trauma, the darkest places, the worst fears, and a lot of times they're reliving those traumas. I don't like to call it dreams, because you're right, that doesn't capture it. I call it experiences, and they're graphic, vivid, alternative realities, that are a lot of times worse than the reality of the ICU. Even one man, he was a veteran, so he relived his worse war trauma, but then also was living the trauma and the stories that he heard from his comrades. And then this sensory input that they're having, what they're seeing, what they're hearing, what they're feeling, it gets twisted, and it seemed to reaffirm all the trauma they're having inside their minds at the same time.

Heidi Engel  

I'll add an anecdote from a patient that I treated for weeks. She was a cancer patient. She was an older woman, but she was an older woman who had an incredibly pleasant life before she got cancer. She had a house. She had a couple dogs. She had a son who she had a very good relationship with. She had a garden; she loved to garden. She loved flowers. She was a devout Catholic by faith, and she spent weeks and weeks very, very sick in our Intensive Care Unit. She had a blood cancer, and she often would have these horrible GI bleeds, but she was also on a ventilator, and she was on continuous renal replacement therapy at the same time. So a very, very sick ICU patient who we weren't even sure was going to survive her ICU stay. And she did survive her ICU stay, somewhat miraculously, and I had seen her every single day while she was there, I talked to her son every single day. So she knew me very well. And this is a common occurrence. I find in our patients that when they wake up and they are ready to leave the ICU, they don't want to talk to you about what their experience was. They are grateful they survived. They're grateful for the nursing care and the devotion of the physicians and everyone else who treated them, and they're quite sure you are not interested in hearing about this weird stuff going on in their mind. They're almost ashamed to tell you. And so if providers wonder why, well, I don't know. I've worked in the ICU forever, or even on a step down unit forever. I've never had someone tell me that there was a scary monster hanging out on top of the television set above them in their room, and they thought they were killing their family. Members, or something like that. The patients have this experience, but it's really traumatizing for them to try to share it, and they feel very reluctant, as if you will, interpret it as they aren't grateful for all the care they received. So going back to my elderly cancer patient, when I did see her on the step down floor after she left the ICU, there were days when she seemed quite sad and depressed, and I asked her about it, and I asked her directly, "Did you have really scary dreams or visions or hallucinations that haunted you from your ICU stay? Because many, many, many people do, and you were there a very long time, and it's often real, so real." And she said, "I absolutely did. I dreamt that I was constantly being just covered in blood. Blood was just pouring out of me and over me." She said "I saw flowers. I would see red flowers just falling on top of me all the time. But it wasn't pleasant. It was very scary and awful feeling." And she said "I learned to interpret that happening as I must have died and gone to hell." She said I was quite sure I had died and gone to hell. And she said "I kept trying to ask myself, was I really that bad in my life? What had I done that would send me to hell in this way." And she said it would just keep happening over and over again.

Emily Silverman  

And I've heard other people say the device that affixes the endotracheal tube to your body so it doesn't slip out ; one person said in some testimony that I was reading, "it felt like I had a necklace that was on too tight," or that something was choking me, or people who have wrist restraints, they think that they've been kidnapped by terrorists, or somebody sliding into a CT scan. I read one person, they were being slid into an oven. And so these terrifying experiences, and I'm wondering, why do you think the brain goes to these dark places? Do you think when you depress consciousness, but you're still getting all the sensory input; we here at The Nocturnists are big believers in the power of storytelling, and the mind is a meaning making machine, and we try to impose meaning with story. And so do you think that it's the brain is just lost and trying to make sense of what's going on and filling in the blanks with story?

Heidi Engel  

I explain this to family members every day, because I need their help. I need the family to make meaning of all of this for the patient, I can't do it just in half an hour, standing next to the patient, talking to them, even the nurse can't really do it, but the family members can. And so first I need to educate the family members, and then after that, their job is to help make meaning of all of this for the patient. And I explain it to them like this. "Listen, we breathe through a beautiful passive system. When you inhale, you open up your chest cavity, lower pressure means that the air passively flows in inhalation is a completely protective, gentle, passive process. Your ventilator is doing the exact opposite. Under positive pressure it is shoving air into you." And what I explained to family members is "It's as if I took the leaf blower in your house, shoved it in your mouth and taped it to your face and turned it on, and now it's shoving air into you." And there's no way anyone is going to think that feels anything other than noxious. And our brains are so intimately hard wired for obvious reasons to our lungs that as soon as your lungs are in panic, your brain is five alarm, Red Alert, something's really wrong here. So that ventilator is just signaling right to your brain: Breathing is a mess, your lungs are a mess, I don't know what's going on here, something needs to be done. But humans are incredibly adaptive, and so we can learn to say, "Okay, this isn't normal, but it's what I need to survive. I'll put up with it." And so after I explained to the families how noxious initially the ventilator is, and then I explained to them, however, we've had many, many people get used to it and walk down the hall, as Polly Bailey proved, patients can walk down the hall in a ventilator, and they actually feel better, because it's easier to make your mind and your lungs synchronize with that noxious machine if you're also walking down the hall. Walking triggers an automatic synchronizing system. That's why the walking is so important, and not just schlepping someone over to a chair. And I explain to people that your lungs were made for you to be vertical. Your lungs were made to function better when you are upright, and you are moving a little bit. And therefore, rather than it being an extra stress, it really helps, and you can see it in the affect and the interaction of the patient. Initially, the family kind of buys into what I'm saying, and then I have them sitting right in front of their loved one, looking eye to eye at their loved one, while we initiate moving of the patient. And that's when they get it. That's when they see, "gosh, I thought this person looked so comfortable, unconscious in bed, not moving a thing. But now that I see them awake and interactive and calming down and realizing what's happening, they look even better."

Emily Silverman  

And these traumatic experiences that people have in the ICU, it's not like they have them, and then they forget about them. They get PTSD. This becomes long term flashbacks, memories, and so that's a big part of this. And then there's also, like you said, Kali used the word neurodegeneration. We definitely see more than just psych, trauma, hallucinations, PTSD. We also see memory issues, dementia, and then beyond that, in the body, we see muscle atrophy and things going on in the joints and the body's been immobilized and disconnected from the brain for so long. So I was wondering if you could flush it out for us, because there's the terrifying visions, but then there's all these other sequela of deep sedation, prolonged sedation, that isn't as cinematic, but it's nonetheless important.

Kali Dayton  

The terrible irony is that throughout the past few decades, we've defined safety in the ICU as patients being strapped to the bed, sedated, immobilized and laying still and flat. When during that exact setting, we're giving sedatives that are causing absolute sleep deprivation, which, even in cases of torture, sleep deprivation causes brain injuries. So we have a lot of inflammation happening in the body that's attacking the brain. We have sleep deprivation, therefore we can't protect our brains, clean out all that inflammation, it just accumulates and it breaks down the brain. And on top of everything else that's happening, those sedatives are not only harmful to the brain, but also to the muscles. Propofol, for example, disrupts the sodium channels so you decrease muscle excitability. So even if someone is sedated overnight or a day or two, when Heidi comes in, they're sluggish, they can't really do much, and they especially can't write on a clipboard telling us what they need, what they want. So how do we manage their pain? How do we know their medical history? How do we know who they are as a person, if they can't communicate with us? But we've blocked that with these medications that are toxic to their muscles. Propofol is also a mitochondrial toxin, so you're greatly contributing to the atrophy, dysfunction and even death of your muscles. So this is not like, Oh, I haven't worked out in a few months. I'll get back to the gym and increase my endurance and stamina again. This can be a lifelong physical disability because of this mitochondrial damage that's happened.

Heidi Engel  

And skeletal muscle is an integral part of your immune system. So you're actually compromising your immune system when you're wasting muscle tissue away. And the muscle tissue is already sacristy itself to rev up your metabolism to try to fight the impact of the critical illness. So we have all these things working against skeletal muscle, and we have medical practitioners who have been taught to ignore skeletal muscle. It's not important. You'll grow it back later. However, we're also finding that your ability to actually grow that muscle back later has also been impaired when you've developed ICU, acquired weakness. We're an ecosystem. We're not really distinct individualized organ parts. So you're disrupting the whole metabolic regulating capability of the skeletal muscle. Skeletal muscle is also known to be tied to the brain, just like the whole microbiome is now being known to be tied to the central nervous system. All these systems are very much in communication with each other, and interactive. And skeletal muscle is actually a very big part of it. It's 40% of your body mass, and it's there for a reason, and it is also a defender. So when you are in crisis, it does shed myokines, which does ramp up your immune system and does free up your metabolism to fight more of your critical illness. So we're wasting a very precious resource through thinking it will just come back by itself later. Just like the brain, same thing.

Kali Dayton  

And ironically, we're leaving them vulnerable to future infections. We leave them in a condition in which now they're at high risk of losing their ability to independently breathe because they lose their diaphragm function, their respiratory muscles. We saw with COVID patients, for strong example, that that leads to a tracheostomy. They go to a care facility, they can easily end up with another hospital acquired infection, come back the ICU, and now they have less reserve to fight with. And so there's things that we think that we're doing to protect. Patients are actually harming them. One survivor used to practice law. He was in his early 30s. He struggled with terrible PTSD as well as cognitive impairments. These cognitive impairments that delirium suffers endure are at the same level as a mild Alzheimer's and moderate traumatic brain injury, and delirium increases the risks of those by 120 times. So he no longer practices law that's forever changed his life. He struggled with such severe PTSD was so shameful about it. Was afraid that he told anyone he was still having these flashbacks and getting lost into these alternative realities, even years after his discharge, that he would be institutionalized. So he had prepared to take his own life before he found my podcast and finally had a name to what he was suffering. These physical impairments take away their ability to return to work, to live independently, to care for themselves, to be caregivers to their other family members. It changes their financial status. It changes their relationships. It changes their entire life when you damage the body and the brain with these interventions.

Emily Silverman  

Kali tell us about coming up in the ICU, in Polly's ICU, where the norm was to: Wake people up, walk people, wake people up, walk people. Do not sedate. Minimize, minimize. Bring the family in, talk to the patient, that was sort of the norm in the ICU, where you came up and trained. And then you became a travel nurse. Tell us about going out into the world, into some of these other ICUs and the culture shock that you experienced, even though, in a way, it was reverse culture shock, because you were going from the extraordinary into the ordinary. 

Kali Dayton  

I had no context. No one prepared me, other than Polly. When I told her I was going to be leaving to go travel, she said, "hm things will be different elsewhere." That was it. And I was like, well, I'm 24 I'm single, I'm going to experience the world. I'm looking for different. I later told her, I said, "Polly, was I supposed to get something out of that statement, because you did not tell me what I was about to face." And so yeah, my first shift, I had a patient that was intubated, and I wanted to follow my normal routine. We all have our routines, and mine was to talk to my patient, have my patient talk to me and do a neuro assessment, get them to the chair, but I couldn't, because they were sedated, and there was nothing that could tell me why they were sedated. Their diagnosis, their acuity, ventilator settings. Nothing told me this is why the patient is sedated. So I asked the orienting nurse again, who knows? Didn't know anything about me. I said, "Can I get sedation off and get them up to," which they hurled back in horror And said, "Of course not. They're intubated," which threw me back because I said, "I know that they're intubated, but why are they sedated?" Which made this oriented nurse more concerned and said, "because they're intubated." And we went in circles about, why are they sedated, because they're intubated. I know, why are they sedated?

Emily Silverman  

They were freaked out. They were like, "Have you ever been in an ICU before?" Like they weren't sure you knew what you were doing.

Kali Dayton  

Right? The more I asked, the more they were like, "Don't you know what you're doing here? Why are you here? You don't belong here? Are you safe to care for patients here?" So I could sense that fear, and I just kind of shut up, because I realized we're going nowhere with this, and I don't know what she's talking about. And clearly she doesn't know what I'm talking about, even what I would tell physicians. I mean, used to have patients being awake and taking them on walks and stuff, their eyes would get huge, and some of the first questions were, "Do you follow them with an intubation cart?" And I had never seen a self-extubation during mobility. I rarely seen any period. So I said, "No, we just don't pull the tube out. We don't let them pull the tube out." I was unprepared for those discussions, because I didn't know why we kept patients awake and mobile and Polly's ICU. I didn't know why they sedated their patients. I especially didn't know the harm of those practices. And now, looking back years later, no one knew the harm of those practices. It was just what was done.

Emily Silverman  

I would love for the two of you to walk me through when you try to explain to people what you do, and there's pushback, and maybe some of the pushback makes sense, like maybe they don't have the resources at the bedside to navigate the agitation that happens, like you were saying, Heidi, there's a very predictable stage of layers of waking up from a coma, whether it's a organic coma, like you said, or a medically induced coma, and agitation is a normal and expected layer of that. And so to be handling that alone as an ICU nurse isn't feasible. So there's legitimate reasons why people might object to waking their patients up, but then there's other reasons that maybe are more illusions. And so I've heard you say before that people say, "well, our patients are sicker." There's all sorts of ways that people push back. So can you kind of give me the lay of the land, like, what are the things that you hear people say when they're giving you pushback about waking people up and walking patients get

Kali Dayton  

Get the list out, Heidi.

Heidi Engel  

patient is just synchronous with the ventilator, is a very common, very common one. And what I love about the difference between the awake and walking ICU and a typical ICU is that in the awake and walking ICU, if someone is struggling a little bit with the ventilator, the way they address that is, they run in and sit the patient up the sitting up and the moving is how you fix things that in that majority of ICUs, everywhere to this day, the solution to that is, oh, we'll just increase the sedation and that will chill them out. And in many ways, if all you're doing is looking at a monitor, and looking at a wave form on the ventilator, and looking at blood gasses and numbers and things, both things achieve what you want, this person becomes more in sync with the ventilator, and their numbers become a little bit more normal. However, you can't see the invisible layers and layers of damage you're doing when you use the sedation to fix this problem. But what the fixing the problem is doing is making certain numbers look good for this moment, and then you feel comfortable walking away and not paying attention to the issue anymore. The agitation is a very frequent issue, the fear of self-extubation. And then there's a control issue. I'm in charge and I'm in control, and I don't think people address it on a conscious level in that way, like, "Ha, I'm in charge here. Beep, beep, beep, beep." But I think there's some stress in interacting and trying to figure out what will help a person who can't really talk to you or communicate well or even fully understand what's going on and is scared to death, it's emotionally so much harder to tease out. What could I do to help this person be more comfortable right now than it is to just send them into what looks like some peaceful, tranquil nap.

Kali Dayton  

From a nursing perspective, it's not part of the standardized education, really, for any disciplines in the ICU to know how to prevent and treat agitation. We don't even define agitation well. Survivors will say they were trying to signal that they wanted to write, and instead they got their hands tied down tighter, and everything went black again. So we're not good at non-verbal communication. We're not good at preventing delirium, therefore preventing agitation, let alone treating it when it does happen, there's a lot of fear around falls. We have terrible fall culture. So nurses are taught that your greatest failure is if a patient falls and or self-extubates, but instead of, our greatest success is when a patient successfully walks out of the ICU. We don't have a vision of preventing post-ICU syndrome. We don't have a vision of keeping patients awake and mobile. And so anything different than what is normal is so scary. You also cause a lot of instability when you sedate patients for prolonged periods of time. So if you're trying to rehabilitate someone that's been supine for weeks, when you sit them up, they could easily drop their blood pressure. So when those are the only experiences that you have, is when you turn off sedation, patients go wild, you sit them up their blood pressure drops. It reaffirms that this is scary, that this is dangerous. Instead of understanding why those things happened and that usually those adverse events are because of what we did in the beginning that have now determined the complications later on.

Emily Silverman  

There was something you said in a previous conversation that has always stuck with me, which is this feeling that in the ICU, everything's a knob. We can tweak everything. We can dial up the presser, we can look at the numbers on the monitor, and it's almost like a little lab where everything is under our control. And there is a way in which you do have to have faith and trust that the patient will figure it out, that they'll come out of it, they'll look around, you'll be able to talk them down, orient them, get the family in. It's hard, but it's the right thing to do. And so I was wondering if you could speak a bit to that trust and surrender piece, because I feel like that's so powerful in a world where physician burnout and nurse burnout are so high and everybody's exhausted, and it does take more effort, but it's important. 

Kali Dayton  

I've had to learn that clinicians don't know how to talk to these patients. There are things that I did as a nurse, as such a naive, uneducated nurse. In so many other ways, I feel like I know I wasn't safe to practice early on in my career, and yet I did things that were so profound because my humanity was still so intact. I saw my patients as a 55 year old librarian that would benefit from having a book to read while intubated. I saw who they really were. I learned from their families more about them. They were able to write to me what they liked, what music they liked, what they preferred, and so those things made it so much easier for me to trust my patients, because I knew who they were. I knew that they understood that was their lifeline. They would sometimes write, be careful of my tube, they could tell me where they wanted their endotracheal tube to make it more comfortable. I saw them being unrestrained and being okay. I saw them suctioning their own mouths. So I just learned to trust my patients. But that's a big barrier in other ICUs, because they're not used to patients being awake, and when they are awake, they're very confused and unreliable. So that is a huge cultural barrier to see our patients as humans, to aspire to have them be informed of their condition involved, autonomous. Those are principles that are easily lost in a normal ICU culture, that once we get that back, and only by really doing it the "Polly way", this is only feasible when you really let them be awake right away and preserve their brain and their bodies to be able to be involved and contribute to their own journey fighting for their lives.

Heidi Engel  

Yeah, I think there's some confusion about what our real role is. We see our role as controlling and eliminating this tragic, acute process that has brought our patient into a state of critical illness. And I think more of what we genuinely are there to do is to give the body itself the best chance to heal. We don't heal people. We lessen the biggest assaults coming at them, but it's really that ecosystem of the individual who does their own healing. We're just supposed to be trying to facilitate that healing, and what I end up feeling like is it's something of a miracle that people manage to heal and get out of the ICU, despite how we keep trying to get in their way. Sometimes extubation is delayed because you're waiting for your opportunity to go to CT scan, and then the patient comes back from CT scan and well, it's too late in the evening. We don't want to extubate someone in the evening, because what if they need to be re-intubated in the middle of the night, and the staff aren't available to do that, and there's so much that happens that is not about the patient at all. One thing Polly had mentioned also when I visited her years ago, is she said she took a survey of her ICU nurses to ask them, "your patient is sedated, why are they sedated, what are you sedating them for?" And she said it was very disheartening for her to hear, "Well, my patient across the hall is a lot of work, and I can't watch this other patient all the time, and so this other patient is going to have to stay sedated so that I can focus on the person across the hall." So it's an entirely other way of thinking about your role as a healthcare provider, and what we, all of us in medicine, are actually capable of doing and not doing, genuinely, the best healing happens from the person within. You give that body's immune system a chance to fight, or, as Wes Ely often says that person is only going to heal when they have a why. What we need to figure out to help them heal is, what is their why in life? What is that thing in life that gives them meaning?

Emily Silverman  

So let's say the Polly Bailey method is the gold standard, awake and walking ICUs. How are we doing as a country, let say. I know that a lot of this work has gone global, but just keeping it in the US for now, if you go around the US. Some of these tools have been widely implemented. We have the cam ICU score and the A to F bundle, and all of these tools that we use at the bedside to be more mindful, be more conscious of what we're doing. Is it a spectrum where, you know, if Polly Bailey method is a 10 out of 10, we've got some ICUs that are a one out of 10. They're really sedating people, but maybe there's some ICUs that's a five out of 10 where they're kind of waking people up. They're making more of an effort. They're not at the Polly Bailey level, but they're better paint a picture for me, where are we and where do we want to go?

Kali Dayton  

It's hard to make a big blanket statement because. There is such a spectrum of compliance. When some of these great leaders, like Dr. Dale Needham, Wes Ely, when they found what Polly was doing, and they created the A, B, C, D, E, F, bundle Heidi involved in rolling that out. That was in the 2000 and teens, and they made some headway. We can see in the study published in 2019 that they did lighter sedation. They were doing more awakening trials. They still really were not mobilizing patients. I mean, of all their patients, intubated or not, across over 15,000 patients and 68 facilities, only 12% of all those patients were on their feet, bearing weight. So that's where we were at in around 2016, 2017 It was published in 2019 and then COVID hit. And we ran back to what we were doing in the 1990s deep sedation, paralytics, benzodiazepine drips. We lost a lot of seasoned clinicians, and many new clinicians came in during that fire. And so as far as being educated on sedation, mobility, delirium, it was very minimal that was not necessarily environment in which COVID patients were being admitted, and it was a hard time to make those changes.

Emily Silverman  

And what was it with COVID? Just survival mode, more patients just sedate and walk away?

Heidi Engel  

They were very hard to ventilate, so they came in with the ARDS that did not look like the usual ARDS patients. So it was a multi-pronged combination. We were all in the isolation garb, but the patient was isolated, the family visitation was ended, and on top of it all, ARDS as a disease made setting the ventilator adequately, really, really challenging. They were a hypoxic patient population that was not responding to what was typically done very well. Then you couldn't get in the room very fast because of the garb and the isolation and everything else. And so to make extra sure that the patient would remain chill, enforce the benzodiazepines came back. I had seen benzodiazepines pre-COVID, very, very rarely in our ICU. We really had made an effort to just get rid of them. They were harmful to your brain. We knew that there was a wealth of evidence to say that. And for a couple years, I think I never saw a verse Ed drip, really never. And then all of a sudden, I am in a COVID ICU, and there I am peering through the glass at the patient, and I'm looking at their IV pole, and I'm seeing a whopping dose of verse said going in on a continuous drip. And I'm looking at my colleagues and saying, "What happened? Why are we doing this?" And they're saying, "well, these patients are so hard to adequately ventilate, and we're just shutting them down because that's all we know how to do." But there were people trained during that time, and to this day, they will want to bring out the Versed drips so much faster than we used to. I have noticed.

Kali Dayton  

I think the respiratory therapists, they know how to finesse the ventilator. They know how to make the ventilator work for the patient, whereas in many ICUs it's been make the patient work for the ventilator. Yeah, not having families was a huge hit. I don't think I appreciated how much we relied on families in that ICU until they couldn't come in. It was devastating. It was so much harder to keep them calm, to treat their anxiety, to prevent delirium, everything was harder. That was a huge tool ripped out of our toolbox that I didn't realize how much we utilized. So there were a lot of things that contributed to that. I just think that we were on weak ground in most ICUs, and then we created a huge sink hole. And so now here we are in 2025 and many ICUs are trying to recover. They recognize because the evidence is so strong that they need to head this direction. But now we have these really strong barriers of misinformation, beliefs, habits, culture, things that we've been fighting for so long, but became much more pervasive during COVID.

Heidi Engel  

And people learned to be away from the bedside. I saw the harm of both providers and families just being away from the bedside during COVID, and to me, there's a hangover where providers still are sitting and looking at the computer so much of the day, and when they are doing rounds, they're still talking medical-ese and then carrying on. We have really hard patients to care for, we have limited staff, we have burnout staff, and I think we're all trying to be a little more emotionally protective at the same time, and I think all of those things are adding up to keep people away from the bedside. I also want to really touch on one thing we haven't mentioned yet, which is the use of sedation at night. Again because sedation is looked at as sleep really, or at least as getting someone through the night peacefully, it is nearly impossible to not spend your whole day doing your best to have the patient awake, the family interacting with the patient, the patient even looking good walking down the hall, and the patient gets back in bed, night shifts about to come on, and the first thing that goes on is the sedation for the night, and then you really are starting over again the next day. You can't really make the same continuous progress. I think one of the strongest benefits of the awake and walking ICU is the sedation is turned off and it just stays off. Many nurses want to wean sedation. Many nurses want to turn it down, but don't want to turn it off. They're quite sure the patient will go through withdraw, become panicked, become agitated, become extra anxious. I have nurses often tell me that, "Well, the propofol will help with the patient anxiety." Well, propofol is not an anti anxiety drug. So what's happening is we are trying to have our cake and eat it too, I think in ICUs, all over the country, which is, yeah, this makes a lot of sense. We want our patients awake. We want them interacting with their families. We know they should be moving a little bit and not become so profoundly weak when it's time for them to leave the ICU. So let's wake them up for part of the day and get all that done, and then we'll all have a good rest when we turn the sedation back on in the evening again. And the problem is, is that to me, as the person who has mobilized ICU patients for the last 15 years nonstop, I have seen it both ways. I have seen it with the patients, where the sedation is on and the sedation is off and on and off and on, and often it's the off window of time you get to come and mobilize them, and that's when the job is harder. That's when the patient is more likely to look unstable on the vent. That's when they're more delirious. It's when they're more confused. 

Kali Dayton  

And we have words that have been in our culture for now 10 plus years, like sedation, holiday break, interruption, vacation. 

Emily Silverman  

Holiday vacation. It sounds so pleasant.

Emily Silverman  

 I find with teams that make this transformation towards the Polly Method, towards awake and walking ICU, once they get to the point of letting patients wake up right after intubation, and they see how much easier it is now the nurses are listening. They're a lot more willing because they're like that was easier and safer than an awakening trial and trying to wrestle my patient that's trying to self extubate five days later. Wow, it was really easy. They could sit themselves up at the side of the bed. I just had to hold their tubing. That's easier. That's safer than needing five people to try to get them in a lift hall to the chair. So there's a lot of practical logistics that are benefited from this, but very rarely are clinicians taught how to do this, taught why they're doing it, and that's why success has been so low. 

Heidi Engel  

We have patients who are subjected to the on and off switch of the sedation all the time. And I will come into the room and everyone will say, "Yeah, look, their eyes are open. They're ready. They're nodding their head. They're following commands. They're squeezing your hand when you ask them to," and if you ask that person to write, they have no motor control. They can't write a legible sentence. They barely scribble out a word. The last time I had that happen to me, I suggested that we keep the sedation off for a while so we could allow this person to write. They were a 30 year old tech worker. I was quite sure they were capable of writing a sentence with good grammar and neat penmanship, and not the scrawled, weird words that we were having trouble deciphering that that person was currently writing. Just because they're ventilated does not need to mean that they're taken out of full consciousness and full capability. They should have a right to their own autonomy.

Kali Dayton  

I have a daughter that's non-verbal. She uses an eye gaze device to communicate, and it's taken this concept of non verbal communication to a whole nother level of conviction and personal to me, because it's easy to assume my daughter doesn't know what's going on, that she can't make decisions, that she can't tell us what she needs, but she absolutely can. She's cognitively intact. And I think how often that happens to our patients in the ICU and interviewing survivors that's part of their trauma. They are trying to tell us about their dog that's in their apartment that no one's feeding. But when they try to passionately convey that, they get lights out, they say turned off. They know when a nurse is turning them off. They know which nurse is going to turn them off. It's part of their trauma to be awake and communicating with their son, and then suddenly everything's gone. Or to be so weak they can't lift a finger, so they can't communicate. And no one can read their lips, and there's no other form of communication. I don't know why it became okay for us to take away someone's voice and their right to know what's going on and to choose what's going on with their body. We think communication is when we shake a person's shoulders and we say, "Hey, are you in pain?" And they like, barely shake their head yes or no. That's different than, for example, a podcast listener of mine said "I had a patient awake completely, right on a clipboard. They used the call light. I went in, they told me they had chest pain. We did a chest X ray, and they had a large pneumothorax, and as we were looking at the machine showing us that pneumothorax, they coded, we were able to get them back and we knew exactly what had caused it. It would have taken a long time to go through all the differentials to determine why that patient had coded, but that chest pain was a life saving symptom, and communication allowed the whole team to know what was going on that saved their life, patients can be withdrawing from home meds." Another podcast listener had a patient that was so agitated could not be off sedation until she came in. It was her shift. She's like, "Well, why is he agitated?" So she turned off sedation, gave him a pen and paper and said, "what do you need?" He said, "Wellbutrin." She got him extubated that day. Sometimes it's so simple that we overlook it. We are really good at these fancy devices, all these numbers that we can control and manipulate. But what can ultimately save a patient's life is seeing and treating them as a human being.

Emily Silverman  

I want to talk about the podcast because you've already mentioned a few different stories and anecdotes that have come up on your podcast. It's an amazing podcast. You have a ton of episodes. The podcast is called "Walking Home From The ICU." Tell us about the podcast, your experience putting it together, what you learned from it, the response that you've got, and then where people can go to find it.

Heidi Engel  

Before you say anything Kali, I have to say that Wes Ely himself, Dr Ely, who is the founder of cam ICU and ICU delirium, and the writer of every deep jog breath and a famous Vanderbilt clinical care researcher and physician. He has said that Kaylee's podcast is indeed something that belongs in the Library of Congress as an incredible archive of Critical Care Medicine as it is practiced around the world. So it's not a fluffy conversation. It is an amazing resource with a wealth of world renowned experts, researchers, patients. I mean, it's been such a gathering of the entire impacted by critical care community. It's more of a valuable resource than I think many people realize. Okay, talk about it. Kali.

Kali Dayton  

Well, I had a very humble beginnings. I still feel like it's pretty low tech, pretty humble, but I was really conflicted doing travel nursing and seeing this contrast and outcomes. You mentioned burnout. I suffered horrific burnout. I remember, I mean, I would sleep twelve, thirteen hours after shift, sometimes, because it was so demoralizing. I worked so hard and never saw patients do well, hardly ever such a contrast to the passion and fulfillment that I had in the awake and walking ICU. And I knew, as a travel nurse, I was going into hard situations, but there's something more to it than just being busy. There was a really big lack of fulfillment. I felt like I couldn't make a difference where I was at. After a few years, I returned to the awakened walk in ICU during grad school, went back to Salt Lake City, attended University of Utah. I was also working the float pool throughout that same system, throughout the city. So I was working in, I think, at least nine ICUs. So I would walk a patient on a peep of 18 and 100% one day in the wake and walk in ICU, then the next day, in endeavor, the hospital patient would be on a peep of 10 and 60% and be deeply sedated. And when I would ask to take sedation off, when I would try to and I would ask for help mobilizing them, I would have so much pushback, and so I just couldn't ignore the dichotomy anymore. So I started looking into why. 

Kali Dayton  

I sat down Polly and said, "Why are we the only ones doing this?" I didn't realize what a big deal Polly was until many years later, even since then. So she would explain some things, but what really did it for me was sitting on a plane. I was headed to Peru, and I was, I think I was going to DC at the time, and this man next to me ended up being an ICU survivor who told me what it was like to have delirium. I was six or seven years into my career, and had never heard it from a survivor. I had spent two years traveling, seeing dozens, at least, of patients. And I tried to say, "Oh, you have ICU delurium," almost like, hey. It was just confusion. It was fine. You were in the hospital. It happens to a lot of patients. But I realized, listening to him, that it was real to him, and that four years plus after, he was really still very damaged. He couldn't go back to work. He had terrible PTSD. He was sobbing to me as a total stranger on the plane. So that led me to go into Facebook groups. I was very convinced and wanted validation that he was a fluke, because if this was normal, I would have heard about it. I've worked in so many ICUs I've been doing this for years. And as I went to these Facebook groups, I didn't even have to post the question, I just scrolled and all I saw was people talking about their panic attacks, their flashbacks, their cognitive impairments, their trauma, how their lives were totally ruined. And it just mortified me. I went to the research and I found that this was in large part caused by our care, and I thought if I had known this, I wouldn't have done this. And I know the wonderful colleagues that I worked with had all the best intentions. They would not purposely hurt patients, and they especially didn't know what was possible in the ICU that I'm in now. They don't know the Polly method. And so I had this really big problem on my shoulders, and one day I had the very divine impression that I needed to start a podcast. Didn't even know what podcasts were really it was december 2019 I'd also interviewed into an ICU in another part of the country that I wanted to move my family to, and I told this group of APPS and MDs that the best value I could bring was to help them get their patients awake and mobile. And they said, "Absolutely not. You can't do that. That's not possible." So I knew that no one wanted to listen to me, whether I was a nurse or an NP, that I was just a nobody, but that I had this big ethical dilemma and moral obligation to try to advocate for more patients. So I started the podcast, and my colleagues all told me no one would listen, but they were willing to play along and be interviewed and talk about things, and then COVID hit. So I had put out about 30 episodes, 32 episodes, by the beginning of March of 2020, not knowing that COVID was coming, and it hit. And I thought, well, now that's done. No one's going to listen to that. But I had this very spiritual revelation that this is for COVID. They're going to be a lot of patients on ventilators, and this is going to impact the world and millions of people. So I kept it going, and it really kind of turned into my own investigative journalism. Though I knew how to keep patients awake and mobile. I had worked in an awake and walking ICU for, it ended up being seven years, I didn't know why. I didn't know how that ecosystem is created. I didn't know why all those pieces fit together. I just didn't know the logistics. I just was following a wave that had already been rolling, and so I just tried to pick it apart. Go through the research. I interviewed survivors, clinicians, researchers, and I learned a lot along the way that I use every day. Now it's become something that teaches people throughout the world. I just interviewed a team in Bangladesh a few weeks ago that had bed sores on almost every single intubated patient, and now they have their patients awake and mobilized three times a day, and they have no more bed sores. And that was in Bangladesh.

Emily Silverman  

And that was from your podcast.

Kali Dayton  

 In large part. Yeah, 

Emily Silverman  

you said you've learned a lot from the podcast over the years. Just curious, anything that popped up particularly memorable on the podcast over the years?

Kali Dayton  

I think I went into it really naive. I just thought, oh, I'll just prove to them that we're doing what we're doing here. So I was essentially just saying, "Just don't start sedation. Just get them up right away, and it's easier. Okay, go do it." And I thought that would be my mic drop and that I'd be done. Because I worked in a place where everyone was doing their part, everyone was practicing at the top of their license. RTS knew how to manage the ventilators. The RNs knew how to prevent delirium, how to manage agitation, everyone knew how to work cohesively together. I also didn't really understand all the science behind it, so I just was surprised continually, and I'm still digging deep into this rabbit hole. For example, I didn't realize that deep sedation contributed to ventilator synchrony. And it was a question during COVID. It was, "why is everyone talking about ventilator synchrony when an RIC it's really not happening, or am I missing it?" You know? And I would ask my respiratory therapists, who were also traveling throughout the entire system filling in on these other COVID units. And they said, "No, it's a mess out there. But ventilators are so much easier to manage here. Patients do so much better, and they really are not asynchronous on the ventilator here," and I didn't know why, so then I do an episode on it, the more I would dig, the more questions I would have, the more I'd have to find someone that had the answers. And I've just been surprised by the things that I did, not knowing why I did them, and how impactful those quote, little things are and to the overall outcomes of patients lives.

Emily Silverman  

Well. I just want to thank both of you so much for coming on the show to speak about this. It's such an important issue, and the work that you've both done close. Clinically, alone, is incredible. And then everything that you've done in the research world and now in the public communication world with this podcast, Kali, it's just extraordinary. And I know that you're saving lives doing this work, and you both speak about it so beautifully, and I would be so honored to have you care for my family members. So thank you so much for coming on and talking about this.

Heidi Engel  

Thank you for having us, Emily. It was such a pleasure, and this is 2.0 so the revolution has to continue. We still have so much work to do. 

Kali Dayton  

We'll take all the revolutionists we can get that will join the ranks. 

Heidi Engel  

Yes, it's taken a whole army. 

Emily Silverman  

Yes, for the audience, people who drink this Kool Aid, they're called ICU revolutionists. So I'll put some links in the show notes. If you want to reach out to Heidi or Kali. Learn more about this, incorporate this into your clinical practice. That'll all be there for you and Heidi and Kali. Thank you so much again. 

Kali Dayton  

Thank you. 

Heidi Engel  

Thanks, Emily.