ICU Revolutionist, Kali Dayton

[00:00] Michelle: Mahatma Gandhi, Martin Luther King Junior, Rosa Parks,  Kali Dayton.
Kali Dayton is an ICU nurse practitioner, and like Gandhi, MLK Jr. and Parks, Kali is peacefully protesting the way ICU patients are cared for. Similar to the civil rights advocates before her, she fights for the rights of ICU patients. She believes they have the right to limited sedation, early mobilization, open communication, and family participation.
Kali was born as a baby nurse into an Awake and Walking ICU in which ventilated patients received little to no sedation, were out of bed walking while intubated, communicating through whiteboards, all with the crucial support of their families. Then she began traveling to ICU's across the country and found her patients automatically sedated if intubated, enduring long periods of immobilization, and if they were lucky enough to avoid death in the ICU, they were discharged to suffer PTSD and face long periods of rehabilitation.
Kali is a self described ICU revolutionist and is dedicated to educating both clinicians and families through her podcasts, Walking Home from the ICU for clinicians and Walking You Through the ICU, which is directed toward patients and families. 
And through her consulting business, Dayton ICU Consulting, she travels the country visiting ICU's, helping them to become Awake and Walking ICU's. And I'd say the revolution has begun. 
In the five-minute snippet: Did someone say free time? Good morning, Kali, welcome to the podcast.

[02:10] Kali: Thank you so much for having me, Michelle.

[02:13] Michelle: You know, it's my pleasure. First of all, you came very highly recommended. I've gotten in the habit of asking my guests for their guest recommendations, and you came recommended by three of my guests. So Annie Fulton, she is the host of the Up My Nursing Game podcast.

[02:34] Kali: Amazing nurse.

[02:35] Michelle: Yep. And then Sarah Vance, she is a critical care educator.

[02:40] Kali: Love her.

[02:41] Michelle: I know, right? And then I just interviewed Sarah Lorenzini. She's the Rapid Response RN.

[02:48] Kali: Yes. She's incredible. Absolutely.

[02:52] Michelle: So they all said, you have to get Kali on your podcast. She's doing amazing, revolutionary things. And I agree. I've looked at your LinkedIn, your Instagram, and your website, and we'll get all to that. But first, I just want to start with, who is Kali Dayton? What is your story?

[03:15] Kali: I am a nurse practitioner in adult geriatric acute care. I started as a nurse in an ICU that is very unique, and I didn't know that. And this is back in 2012, I was interviewing for my first ICU job. Didn't know a lot about ICU. And so when the nurse manager asked me if I would be willing to walk patients on ventilators, I said, yeah, of course, but you're going to have to teach me everything. And they did, and they taught me in a way, and made it sound so normal. So even to this day, when you walk around the unit, most patients, if not all that are intubated on the ventilator are awake, writing on a clipboard, sitting up in a chair, and oftentimes walk around the unit. And so I was learning so many new things that as a new nurse, you can all appreciate what it's like to be new. Everything's overwhelming. So it just led into everything else that was new. But it was so routine. It was hanging antibiotic, titrate the vasopressor, take your patient on a walk. So even night shift, I was walking my intubated patients around the unit with respiratory therapy and a CNA, pushing the wheelchair. And it was just the routine. So I never questioned it. It made sense to me that, okay, my patients are human, so of course they're going to be communicating, making decisions, mobile, awake during the day, sleeping at night. And so no one told me what it was like outside of that little bubble. And so after a few years, I became a travel nurse. And the only warning I had was from a nurse practitioner, Polly Bailey, who I came to learn, established that kind of culture and practice in that ICU. But all she said was, hmm, it'll be different elsewhere. And I said, okay, but I was 24, I was young, I was single, and I was like, yeah, I want different. I'm just going to go explore the world. That is not what she meant. And I came to realize what she meant when I knew ICU's that first time. I remember just walking there for day shift and the lights were dim, and I was like, oh, I guess the world's not starting yet, right? The patients aren't awake yet. Okay, that's different. And I got my patient assignment, and at least one of them was intubated, and I went to go continue my routine. You know, we've all got our routine, how we start our shifts, right? Mine was usually doing a full exam, including a neuro exam, and usually getting my patient to the chair to wait for physical therapy to come. But they were sedated and I didn't know why. There was nothing about their diagnosis or acuity that made it made sense to me, and I wanted to make sure I wasn't missing something. So I asked my orienting nurse, hey, can I get sedation off and get them up? And the look in her eyes, I just did not expect the absolute horror.

[06:05] Michelle: Oh, my gosh.

[06:06] Kali: And she said, what? No, they're intubated. Which made no sense to me because I just spent years having hundreds, at least, of intubated patients being awake. And I said, I know that they're intubated, but why are they sedated? And she said, because they're intubated. And we just went in circles. And so that was the very first time I'd been really exposed to the concept or the idea that a patient would automatically be sedated just because they were intubated. But I didn't know why my first ICU did things the way they did. I didn't know what patients experienced during sedation. I didn't know any of the risks. All I knew was that no one else believed me about what I had done. As far as when I tried to explain where I come from, most patients are awake, and we walk them around the unit, and they were just mortified. And they say, that's not possible, or those must not be sick patients. You worked in an LTAC, or what do you follow them with? An intubation cart? So I just didn't even know how to answer to it. Right. Because this was my norm. I never really thought through it. And so I said, no. I mean, these were a lot of times, like bone marrow transplant patients that have multi organ failure and septic shock and ARDS, and, I mean, to me, that they were sick. So ultimately, I just went with the when in Rome approach, just did what everyone else was doing. And I even kind of laughed about it. Sometimes I think back to the nursing jokes that we made at the station about just shut them up, knock them out, that kind of approach. But over time, over a few years of doing this, I really felt empty. I did not feel so fulfilled in my career. I really missed my first ICU because of how I felt there, the connection I had with patients. I also saw a huge contrast in outcomes. I saw a lot of tracheostomies and LTAC transfers and just poor outcomes. And I thought, wow, I'm working really hard here, and yet my patients don't do well. But I didn't understand why. So after a few years, I decided to go to grad school. I went back to my first ICU during grad school because it was in Salt Lake City, Utah, where I was going to go to school. And even during school, no one talked about this. And even during our case studies that we were studying, when we were learning about intensive care medicine, patients were always sedated. They'd have pneumonia and they'd get intubated, and they'd get sedated and they get hypotensive, and we'd start vasopressors. And I'm looking around the room saying, does anyone else think this is crazy? Why is Propofol running? We're giving a vasopressor to compensate for Propofol that probably doesn't even have to exist. So it led me to ask a lot more questions because I was experiencing this huge dichotomy. I was also in the float pool, the ICU float pool throughout a multi-hospital system, going all throughout this valley to like, eleven different ICU's. And only the Awake and Walk in ICU, where I came from, was the only one in that whole region that was doing things this way. So I had to figure it out. So I started to look into the research, started to ask those that had established that culture in that ICU, Polly Bailey, Louise Bestienae. And I said, help me understand, make it make sense. But what? Even though I learned a lot of things in the research that were surprising, what really put the nail in the coffin for me was I was serendipitously seated next to an ICU survivor on a plane ride during this time of exploration. And I told him that I was an ICU nurse, and the color dropped from his face. And he started to tell me what it was like for him to be a patient and intubated and sedated in an ICU. At the time that I was talking to him, he looked like he was in his mid-forties, in good health, but he'd had an endoscopic procedure and had a perforated esophagus and ended up with peritonitis and septic shock and all the things. But he barely mentioned the ventilator. All he talked about was what it was like to have his limbs nailed to the ground in the middle of a forest while trees came crashing down on him and demons came out of the sky. And he described a lot of things that, to me, I thought, and I even said, you know, it sounds like you had ICU delirium. But that meant nothing to him. He talked about it as if it was real. This is over four years after his discharge, and he was still as psychologically scarred as if it had physically happened to him. And he said, for a year after discharge, every time he closed his eyes, he was lost back in those alternative realities. I don't, at this point, having talked to dozens and dozens of survivors, I don't call them hallucinations because they are more vivid and graphic than what you and I are experiencing right now. And so, as I was listening to this man who was sobbing to a stranger on a plane ride about what he experienced in the ICU and under sedation, I thought, this has to be a fluke. I mean, I sedated dozens and dozens of people during my time as a travel nurse, and I was in so many ICU's, I would have heard about this. I was six, almost seven years into my career, and I thought, if this was a normal thing, I would know about this, right? But I had to know. So I went to survivor groups on Facebook, and they were just filling the feeds with posts about PTSD, the hallucinations, the nightmares that they had, the flashbacks, the panic attacks, the cognitive impairments. And that, to me, that patients are not sleeping when they're sedated, that we do a lot of damage to them and we send them on their way to live lives that are nothing like the lives they lived before. And as I listened and learned these things, I thought, the ICU community does not know this. The wonderful people that I worked with all around the country do not know this. And if they did, they would change this. So that kind of helped me head in the direction of starting a podcast to give a voice to survivors that would reach clinicians to help them understand the reality of these normal practices, and then also provide education and the tools to do something about it, to change it, and to follow the model of an awakened walking ICU, which is actually the true mastery of the ABCDEF bundle. We have the tools implemented in SCCM's education and things like that. We just are not using them to the maximum of their capacity and are not doing the most good that we could for patients in the ICU.

[12:15] Michelle: Yeah. Wow, that's an amazing story, Kali, and terrifying one. And I'll get into a couple of your episodes that absolutely terrified me as a nurse, as a person. I don't understand. And I've always been very naive in this aspect about why it takes so long for the research to trickle down into practice. Because, you know, in researching for this episode, I knew we were going to talk about, you know, obviously, ICU and those practices and stuff, but here's an example. So there was an amazing tool. There is an amazing tool called the N-PASS, and it was created by a Patricia Hummel, who is a neonatal nurse practitioner and a pediatric nurse practitioner. And this is the neonatal pain, agitation and sedation scale. This was created in the year 2000. We did not start using it in our NICU until 2019 to 2020.

[13:17] Kali: Oh, my goodness.

[13:19] Michelle: Yeah. So an excellent tool. We used, let's see, we used the PIPP, which is the pediatric infant pain. I forget what the other p is, but these things were not appropriate for really sick babies that were ventilated that, you know, had had multiple anomalies, all of these things. So we were kind of using the wrong tool, and we were doing the same thing that is being done in adult ICU's everywhere, where if babies are. If they're on the vent intubated, they need to be sedated. It's a cultural thing and it's, you know, I don't know if it's changing. I don't know if it's ever going to change. I would hope so. And I'm, you know, I'm looking for evidence that we don't have the experiences of the babies, per se, to say that they went through PTSD and all of these experiences, right? But we do know that they have, some of them have deficits, like, developmentally, but we don't know if that's from prematurity, from their illness, from being on sedation, so forth. But that we would ask the same things like, why is this baby being sedated so much? Well, we don't want them to move because we don't want them to extubate. And. And, you know, I would get that a little bit because if you think of a preemie that's on a ventilator and they have those lungs that are really sticky and you don't want to, you know, you always want to recruit the alveoli and, you know, you don't want there to be a pause in ventilation and. And all of delicate airways. So true. Delicate, small airways. So I get it. But once we did start using the N-PASS, we noticed that we were giving too much sedation. And so that was a great tool for us to be able to come down on the sedation because sometimes we're giving sedation but no analgesia, which those studies were showing, those babies had some poor outcomes. So, you know, those things are so ingrained. And just hearing your story about going from ICU to ICU and these practices being so ingrained, how do we get out of that? How do we change the culture?

[15:59] Kali: That has been the exploration of the past four, almost five years of my life. When I started the podcast, I was back working in my Awake and walking ICU. I was a nurse practitioner at that point. I had acclimated again to the culture there. Like I knew this was a problem outside facilities, but I was also then in this lovely little ecosystem where they had done this for 25 years or so. So it seemed so easy and simple, because now, looking back, everyone knew their role, they knew their skill set, and it was part of the culture and the process. And there were lots of things that puzzle pieces that were in place to make it seem so simple. So when I started the podcast, I was a little bit naive. I just thought, well, just don't start sedation and get them up. And to some extent, it almost is that simple. What we tried with the ABCDEF bundle in the past and in the 2000 teens, when it's first rolled out, is okay. Sedation is not the greatest for patients, but of course, you're still always going to have to sedate everyone, but just try to lighten it, take it off sooner, do a daily break, and then later on, once they're perfectly stable, now, mobilize them. But the problem with that is it's really hard to manage. It's really hard to keep everyone consistent with actually doing light sedation. We know that as of right now, we might chart light sedation, but that's not actually what's happening at the bedside. Patients are charted as being responsive to voice, but you could give them a sternal rub and they don't respond. So it's really hard to oversee that. Also, when you start sedation and you give patients delirium and you impair their neuromuscular connection with sedation, they quickly atrophy under sedation. Now, when you're following this back-end model, you know, once the ventilator settings are minimal, now you're trying to get them extubated, now you're going to take sedation off. Well, it's like a grenade going off, right? You've someone after intubation, we bit off the top of grenade, and we pass it down, shift to shift to shift, and then it's going to land on someone when some physician says, okay, let's do an SAT, do an SBT to see if we can get them off. And now you've unmasked the delirium, the horror, the discomfort, the panic that is happening unbeknownst to us underneath the sedation. But now it's unmasked, and now we've got this huge, hot mess, right? And now they're so delirious and weak that they can't write on a clipboard, they can't tell you what they need. And our teams are not trained to know how to navigate that, so we are trained to go, oh, they're moving, and we want to keep the tube safe, so we re-sedate them and we keep this going. So that's been the culture that we're into. So it really is so much easier when you don't start sedation unless they have an absolute indication for sedation, like seizures, intracranial hypertension, the inability to oxygenate with movement, there are times when it's unavoidable, but unless those indications are present, we need to be questioning it like an antibiotic. Do they need it? If they do, what type, how long, how much, right? But right now it's a conveyor belt. So then when we talk about mobilizing patients, now, we're talking about the back-end, and that requires a lot of people. When you've got someone who has not mobilized in 5, 7, 10 days, they barely have head control. And I'm talking from an adult perspective, right? These are 200-plus pound adults that need so much support to even sit at the side of the bed. Now, with our staffing crisis, that's really hard. So, going back to me being naive, I wasn't totally wrong that it almost is that simple. Don't start sedation. Tell them where they're at, keep their cognition and their coping mechanisms intact. Give them a pen and paper, their phone, let them communicate, navigate their pain with them, figure out what they need, help them acclimate to the tube. And the rest of their course will be so much simpler than later on trying to combat delirium and ICU-acquired weakness. What I didn't appreciate was how deep this culture runs. I mean, we've been deeply sedating patients since the 1990s, and different ICU's are at different levels of progression towards having patients awake and mobile. But I think one of the main barriers is our belief system. Everyone that comes into the ICU should have a very clear understanding of what sedation does, the pharmacology of it, the impact of it, the risks of it, what delirium is actually like for patients in and after the ICU, how important the muscles are for survival in and after the ICU. All these things that play into critical thinking are missing from our knowledge base within the ICU, whether it's physicians down to CNA's, everyone should know, and hardly anyone really knows. Yeah, they can recognize when the patient's delirious, like when they're thrashing and levitating off the bed. But are they panicked about it? Do they see it as acute brain failure? So as I've been interviewing lots of people throughout the world for my podcast, as I've been talking to people on social media, and now I go to teams and I do gap analysis and I train them to change these things, I've been able to get a much better appreciation for how hard it is to change this deeply ingrained culture. We've got a lot of new nurses at the bedside. Some facilities have residents that are changing every year, and so there's a lot of variables that make it hard to, one, change the culture and sustain it. And so that's really what inspired me to become a consultant, because I went from doing the podcast to presenting at grand rounds conferences. But I came to realize that I was just dropping this bomb on people, saying, hey, you're harming them, kind of killing them, go fix it. But I wasn't providing all the follow up knowledge and tools needed to actually make those changes. And it's a really big endeavor. So that's what led me to do consulting, and I'm not sure how people really make a full overhaul of these practices without some serious dedication, training, accountability and oversight. To be honest, I have seen some teams make incredible changes just by listening to the podcast, and I think that's amazing, and I'm all about that. But I've also worked with teams where I thought this wouldn't have happened without someone coming in and providing all of the support. For example, physical and occupational therapists don't receive ICU intensive education or training. They can graduate on Friday and be expected to work in the ICU on Monday. And they go all around the hospital as if they're interchangeable and all the patients are the same. That would never happen to nurses. But we don't educate, prepare physical and occupational therapists to work with these patients. So it's really hard to roll out a program where you have key players that are not prepared to participate in these procedures that do have risks with them. Now, early mobility in the ICU has been proven to have a 0.6% adverse event rate. It is much safer than we think, but a lot of that safety comes with a people being prepared to take care of these patients with high acuity and things like that. So we, so we have to have a change in knowledge. The entire team has to understand what's going wrong. The reality of what we have seen is being normal. And it's really. It's like telling them that the world is flat. It's like this thing you've always done is not what you've been taught to believe. That's hard.

[23:40] Michelle: Yeah.

[23:41] Kali: It makes me question everything else in my life. I'm like, what do I think is normal? That isn't what I think is okay. That isn't right.

[23:47] Michelle: Yeah.

[23:47] Kali: We're all products of our training and our experiences. I am not sure if I would have really questioned this had I been born into a normal ICU. I don't trust that I would have that kind of intuition or discernment to really think, what are they experiencing under sedation? Because they look like they're sleeping, so it must be fine. Even after working in an Awake and Walking ICU and going to normal ICU's, I still fell into that trap. Our culture is so powerful, so I think our beliefs really influence our culture. If we believe that sedation is sleep, then our culture will say, well, then the more the merrier. Why not just do it? And so that's where, when we provide education, now we're changing the culture, and with that, we also have to provide tools. So now that we know that this is harmful, what do we do instead? It's not just about not sedating patients. It's about the interventions needed to help them stay calm, cooperative, compliant, mobile. So in some icus, they're like, okay, well, if sedation's bad, then let's not sedate them, and then let's work on mobility on the back-end, like, later on. And I think that's really challenging because patients come with so many risk factors for delirium in the ICU, and mobility is one of the most powerful tools to combat delirium, as well as prevent and treat anxiety, discomfort, agitation, claustrophobia, all these things that are happening to patients. They can't just be stuck in a bed, oftentimes tied down with a thing down their throat, but letting them sit up, sit in the bed, walk around the unit, normalizing and experience that it's extremely abnormal. That is key to helping patients stay awake and safe and not self extubate and all those things. So this is a really big shift in culture and perspective than what most of us have been trained to think and approach with the critical care medicine. So you're asking, how do we change? I think we've got to educate, actually, like, address the hard things, say we are hurting, and oftentimes killing patients. That's the reality of it. Now, what are we going to do instead? And here are the different procedures that we're going to implement, and we're going to make sure that each member of the team is trained and prepared to play. We're going to open up the communication, we're going to change some of our routines. So it's a big endeavor, but I absolutely believe it's possible. You say, I hope. I don't know if it'll ever change. I've seen enough now, having trained twelve icus, that I know that it will change. I absolutely believe that people are willing to change once they know the why. Now they are motivated and capable of finding their how. And I've seen so much incredible heroism, people that face incredible obstacles, pushback, even persecution within their teams in order to push them to the point in which they have success. They see that it's possible, they figure out how to do it, and then everyone's bought in. But sometimes it takes those revolutionists blood, sweat and tears to bring these changes. But I do believe that it's possible.

[26:52] Michelle: Well, it is possible. I mean, you're doing it. You're doing it. So we see it's possible and you're successful, and it's like we need to just multiply you on a scale of like 1000, right, to get to all the ICU's and change. And I was talking to my sister, Jennifer, longtime ICU nurse, labor and delivery nurse, flight nurse, because I was curious, like, what did we do in our ICU, you know, here in our little neck of the woods? What are our practices? And so in terms of sedation, she was saying they use Propofol, or Versed,Fentanyl, Presdex, Ativan, sometimes Ketamine. And, you know, I asked her about, have you ever had your patients awake, you know, on a ventilator? And she said, yeah, some. Some were awake, some could write on a whiteboard. I said, what about mobilization? Some, they would get up in a chair. But it was a chair. She described it like a chair.

[27:55] Kali: Like a cardiac chair?

[27:57] Michelle: It was kind of like a laying chair or something like that. So it's like they, they went from the bed to a chair, but they were still like, kind of supine, but they were in a chair.

[28:09] Kali: Oh, a recliner.

[28:11] Michelle: Kind of like a recliner. She called it something else.

[28:14] Kali: And a lot of times I either, like, slide them over or they transfer them with a lift.

[28:18] Michelle: Yeah. Where they don't get up themselves.

[28:21] Kali: For me, I'll be honest, for me, I cringe when that approach falls under the umbrella of early mobility, because they end up being basically in the same position they were in the bed. It's not active at all. And logistically, for nurses, it takes two or three people to do that, but it doesn't really benefit the patient. But it checks the box of having them out of bed.

[28:45] Michelle: Yeah.

[28:46] Kali: So we've got to stop looking at these kind of steps as boxes checked and think, what is this actually doing? Why am I doing it? We actually achieve the goal of preventing and treating delirium. And ICU-acquired weakness. So if really smart nurses, because nurses are so smart, if they really understood how vital the muscular system is for survival, what's happening to the muscles during critical illness, what sedation then does on top of it, and then what mobility does to combat the dysfunction and the atrophy of muscles, then they would be thinking, okay, how do I get the patient to use their own muscles? How do I get them to turn themselves, sit themselves up, move their own legs to the side of the bed, walk themselves to the chair? But all of that's really hard if you don't let them move until weeks later. Yeah, now all you've got is a Hoyer. So when I hear those things, I'm like, okay, I see gaps in knowledge because I'm very confident that those are not practices based in knowledge. They're not choosing to harm patients that way. They just don't know. I'm really concerned about using Versed. That's a benzodiazepine. For every 1mg of Versed, there's a seven to 8% increased risk of delirium. Now, thinking of delirium as acute brain failure that doubles the risk of dying in the hospital. And if you have a Versed drip at a low dose at five milligrams an hour for 24 hours, you've now increased the risk of acute brain failure by 840%. And if they do survive, then they are at 120 times greater risk of long term cognitive impairments that are at the same level as mild Alzheimer's and moderate traumatic brain injury. So we need to think of this as a sedation-induced brain injury. And so Versed should be an extreme last resort. I'll be honest, in my Covid, Awake and Walking ICU during COVID they never had a Versed drip running the entire time. There was just no need for it. Most patients were awake right after intubation, walking around their rooms, sitting up in the chair. Now, if they got to the point of not being able to oxygenate with movement, then they did have to be proned and paralyzed. But first was not something that was used. We would try prostate, so they had to be paralyzed, and it was Propofol. But as soon as they could be supine and tolerate that, it was time for an awakening trial. And if they could auction it with movement, there was no longer an indication for sedation, and they were up and moving. And so it's really mind-boggling to hear so much for said happening in the community right now. Again, there are sometimes, if you have, like, cardiogenic shock, and they cannot tolerate movement, but they also can't tolerate the hypotension of Propofol. You might have to use some Versed. We've known since the early two thousands that benzodiazepines increased mortality time on the ventilator, long term damage, and yet here we are, still loving it.

[31:49] Michelle: Yeah.

[31:51] Kali: That's crazy. Yeah.

[31:52] Michelle: Yeah. And sadly, too, we use those in the NICU. So I reached out to my friend, Kathleen Wardell, who was my guest on this program, long time NICU nurse. And because, honestly, Kali, you know that saying, "If you don't use it, you lose it?"  I was trying to remember what did we sedate these kids with who were on a ventilator? And I was almost 100% right. So Versed, Fentanyl. And then she said, we sometimes use Morphine for pain. And then she worked at UCSF for a while, and they used Ativan there, and we don't use that in our NICU. So different practices, different places. But the common thread seems to be we need to use a lot of sedation, right?

[32:37] Kali: And, I mean, people love medications like Ativan and Versed because it doesn't cause hypotension and it really sedates them. It, quote, gets the job done. But Ativan is the worst culprit of delirium. For every 1 mg, there is a 20% increased risk of delirium. And I think that study is from 2013. We've known that for a long time. I hate it for the ICU and on the floors. Now, if you're giving, like, half a milligram orally for an oncology patient for nausea, that's a different story. But two milligrams for agitation? The ironic thing is, and this is not just in the ICU setting, but on the medical floor, someone's worked up, they're agitated. Now, a lot of times that's because of delirium. Now we're giving them a delirium medication in response to delirium. Would we ever do that in any other context? Would we ever give bacteria for sepsis? And yet that is exactly what we're doing with Ativan.

[33:41] Michelle: That is a great analogy.

[33:44] Kali: And we even see, you know, if you're going from or to PACU, the more benzodiazepines people get in the OR, the more emergence agitation they have in the PACU. We also see the outcomes are much better when they use less benzodiazepines in the OR. But we don't take that logic into the ICU, ironically. And so when you give Ativan, it puts them under, right, they stop moving. We've now controlled their psychomotor activity, but we didn't really treat the agitation, at least not the cause of the agitation. Was it pain, was it fear, was it delirium? Nope, we just masked it. We just took away their ability to move and express what they were experiencing. Now, about 2 hours later, the Ativan metabolizes out and they come out swinging, because they're right back at it, and oftentimes worse. So we're on this roller coaster. So you lock them in, and here we go. And it's obviously worse. In geriatrics, I'm amazed. That guide what we should and should not give geriatric patients yet in the hospital, suddenly it doesn't matter. Oh, in the ED as well, it's like, well, they're old, they're confused, but we can't manage them, so we're going to give them Ativan, which is lethal to geriatric patients. And so if you're giving brain injuries to patients that already have dementia, that are sundowning, it just, it's insane. And this can go on for days. And so they just lay there in bed, they're either too sedated or too crazy to mobilize, and they just atrophy. And we just drastically increased the workload time in the hospital, and especially mortality and the harm happening to patients. And to me, I just see it all rooting down to knowledge. We don't know what we're doing, we don't intend to harm them, but it's the culture and this huge gap in knowledge that we're all victim to.

[35:32] Michelle: Yeah, talk about the ABCDEF bundle, because I did ask my sister about that, if she was familiar with that, and she wasn't, so talk about that.

[35:41] Kali: Yeah, a little bit of context to this bundle. Back in the 1990s, we started to use heavy sedation and opioids, because we were experimenting with ARDS patients. So before that, they were mostly awake on the ventilator, but they weren't the acute or the kind of patients we take care of now. And so when they started to experiment with sicker patients, especially sicker lungs, they had this thought, okay, we've got these stiff lungs. Let's give them more volume. Like, we've got to inflate them. So give them more pressure, more, more volume. So they were giving 12 tidal volumes into these lungs. Now we give four to six. So this is two and three times the volume that we give now, right? It was the nineties we were experimenting. We didn't know, but we did notice that they could not tolerate that these were old ventilators, stiff endotracheal tubes. So, of course, these patients were fighting the ventilator and so uncomfortable. So then they started bringing up medications from the OR, benzodiazepines, barbiturates, opioids. And suddenly they synchronized with the ventilator better, they oxygenated better. And we saw that they were not moving, their eyes were closed, and we believed that they were sleeping. And so that belief spread like wildfire. So it was like, well, why not just do that for all patients in the ventilator, no matter the reason? Pneumonia, asthma, COPD, pulmonary hypertension, all these things, everybody go, so that's how we end up where we're at now. We looked back in the early two thousands, and we realized, shoot, a lot of those ARDS patients died. They looked at smaller tidal volumes. And a study from 1999, they didn't even finish the study because the big title volume group died. So at much higher rates. So they just stopped and said, okay, now we know no more 12 ML/kg but we didn't really look back at the sedation so much until later. We saw that those that did survive ARDS, though, their pulmonary function had returned to normal, their lungs were fine. They had persistent physical, cognitive, and psychological impairments. That was really confusing because they thought, well, they survived, their lungs are better, but their lives are really different. And that's how we started to realize that this was a post-CU syndrome. But then what was causing that? And they found that patients that had more sedation and longer and more benzodiazepines especially, they died at higher rates. They also were more likely to have these long term impairments and disabilities after the ICU. So that led us to really tie that into delirium. We were having delirium research happening in the 1990s, early, two thousands. And we got this screening tool to identify delirium, which helped us then look at comparing the different medications, sedation, no sedation, to delirium rates. And that's what helped us realize that we have, we are causing this harm. But then the question was, what do we do about it? So in the 1990s, Polly Bailey was a nurse in a shock trauma ICU in Salt Lake City, Utah. And at this time, there was no research about this, right? This is suddenly the norm. So she was doing just what everyone else is doing until she followed a survivor out of the ICU. Mother in her early thirties, survived, barely survived ARDS. They basically, like, lifted her from the car to, from the gurney to the car and said, good luck. They didn't have rehab at the time, so she was actually from her neighborhood, and she would go visit her at home. And she saw it took her like a year to get up the stairs. Her husband was helping toilet her in bed. She couldn't care for her children. She was cognitively and psychologically destroyed. Polly was mortified and went back to her medical director, doctor Terry Klimmer, and said, what are we doing all this work for if this is the life that we send him back to? And he said, well, go look in the research, figure out what's happened, why she's like this. She couldn't find anything. So she went back to him and said, there's nothing. But I think it's because of the sedation and just laying in bed for weeks. And he said, well, what are we going to do? What do we do about it? Go look in the research. She looked, there was nothing. So she said, I just, I think if we let them be awake and move, I think they'll do better. And he thought that was risky, but he trusted a nurse's instinct. Those are exact words. He knew that Polly would keep her patients safe, so he trusted this nurse to start experimenting, and they immediately saw a huge contrast in outcomes. These patients were able to get off the ventilators, walk out the doors, so much better. So later Polly started, was able to oversee the, a new ICU that the hospital created. And at the time, it's kind of step down unit. So they would take patients from the shock trauma ICU that couldn't get off the ventilator, and then she would rehabilitate them. And so they really became good at rehabilitation. And by the way, she didn't hire an ICU nurses because she'd already experienced how hard it was to get ICU nurses to change. So she hired nursing home nurses. She said, I'll teach you the ICU stuff, but we are going to just keep patients awake and mobile. And they said, okay, because, like me, they didn't know anything else. So she creates the new ICU, kind of like a step down. But then they saw how well the patients did with this process, and so they started sending patients straight up from the ED. And then, Polly thought, okay, so we're killing ourselves over rehabilitating these patients from the damage of sedation and immobility. What if we don't even cause this damage? So that's when she started this process of letting them wake up right after intubation and mobilize within 12 hours, usually after intubation. So that became the norm. So this is, like, early two thousands. At that point, it was pretty well established. A researcher, doctor Wes Ely, was making really huge discoveries about delirium in the ICU. And they, I think, met at a conference or something, and Polly's like, well, what are you going to do about it, though? What's the solution? We can complain about the problem, but what are we going to do about it? So he visited her in her ICU and saw what they were doing, and he said, wow, we don't do this at Vanderbilt, but this is what should be done. So he started to put together things. Society, critical care medicine said, okay, how do we follow this kind of model? If we know that sedation and immobility are damaging? How do we provide the tools for ICU clinicians to make this huge change and also navigate this for each individual patient? So that's how the ABCDEF bundle came to be. A is for assess, prevent, and treat pain. B is for both spontaneous awakening and breathing trials. C is for choice of analgesia and sedation, choosing whether or not to start it, what kind to give, how much to give, how long to give it. D is for delirium, prevent, assess, and treat delirium. E is for early mobility. F is for family engagement. So these are all tools in a toolbox to help patients be as awake, communicative, autonomous, and mobile as possible. That was rolled out in the 2000 teens, and as you can imagine, that was a really big change. So they had this really great grant. There was a study run by Brenda Punn, who's also nurse, now nurse practitioner, and they had 68 different facilities that sent a few champions to Vanderbilt to train for a few days. Huge whirlwind of education, right? Yeah, huge overhaul. And then they sent them back to their icus and said, now go implement this in your ICU. Right. I just. It makes me, like, I get all sweaty just thinking about.

[43:02] Michelle: Right.

[43:03] Kali: The pressure of that. Right. And so they did. And they made some progress. Right. They went from deep sedation benzodiazepines to lighter sedation awakening trials. But the mobility portion of the bundle was not very well complied with. Only eight, only 12% of what ended up being over 15,000 patients involved in the study, only 12% were actually bearing weight out of bed. And that's all patients. Not just intubated patients, all patients. So there was progress, but it wasn't full compliance yet. It certainly wasn't following Polly's model quite yet. Right. But we made progress. Okay. Despite the progress yet to be made, they found that going from their baseline to somewhere around light sedation daily awakening trials, seven day mortality decreased by 68%. Patients were 68% more likely to be alive in a week. How wild was that? That was medication.

[44:03] Michelle: Huge. Yeah.

[44:05] Kali: Coma and delirium decreased by 25% to 50%. So we prevented acute brain failure by 50%. Amazing. Patients were 46% less likely to come back to the ICU, and they were 36% more likely to discharge home rather than to a care facility. And they found that the outcomes were dose dependent. So the closer they got to an Awake and Walking model, the better their outcomes were. And so that those statistics are the average along over 15,000 patients. So it validates Polly Bailey's approach, but it doesn't fully capture the magnitude of impact that it has on patient outcomes. Another study was done with a little over 6000 patients, Marianne Barnes Daly. And they found that for every 10% compliance with the bundle, there was a 15% improvement in survival.

[45:02] Michelle: Wow.

[45:03] Kali: So those studies are from 2000, I would say 2017, 2019. But then Covid hit and we just panicked and ran back to the practices of the 1990s, to be honest. And we lost a lot of experienced clinicians.

[45:19] Michelle: Yeah.

[45:20] Kali: And you think about the time we didn't have the dissemination information that we have now, even the last few years of social media, webinars, things like that. So I'm optimistic that we can bring us back to what the bundle is really about, because, to be honest, we made some improvement. And in that kind of preliminary or primary implementation, it got interpreted as a checklist, because we're implementing things that we have to chart in the system, like Cam, Ras, SAT, SBT, early mobility. Right. You need to be able to track what we're doing and we have to chart it. But that's kind of what it was interpreted as things to chart. I don't think it was across the board really understood the extreme damage of what we're doing. I don't think we really taught it. As far as sedation is dangerous, lethal, they don't really like, here's not every ISOO clinician heard from survivors and got the real picture of what's going on. And then I dont think they really understood this is to keep patients awake and mobile. Instead, it was like, we dont have to sedate them so heavily and well mobilize them at some point before they leave the ICU. So the training was good, but I think we have to understand what they were up against in training 68 facilities in a short amount of time, with a few champions, an entirely new concept. But now that we have these things implemented, their EHR, people say, yeah, we're practicing the bundle, and I say, how many of your patients are awake and writing on the ventilator? They're like, like no one. How many are walking on the unit? I don't think we've ever done that. But we practice the bundle, so they don't really understand what the objective is, just that they chart these certain things, and honestly, the charting is not even accurate. When I do a manual audits in these units, 50% to 70% of these RAS scores, which shows how deeply they're sedated, are inaccurate. So the bundle has been around for a while, but it's really a time for a rejuvenation and to really redirect it towards, here's what we're going towards, because otherwise, like I said, when we see the bundle as just something to look at, once, we're trying to get them off the ventilator now. We've done so much damage that it is really hard to get them off sedation once they have delirium. It's really hard to get them off the ventilator once they're so weak that they lost their respiratory muscles. So we make everything a lot harder. For example, I trained a unit this summer, and I asked them to give me case studies. They gave me two, and between those two patients, I estimated ten to twelve extra days on the ventilator that were not attributable to the patient's condition, but rather to the care that they received and the complications they developed. And this included ventilator, social pneumonia, pressure injuries, delirium, icuquired weakness. I mean, it was just, and all of that was so preventable. These patients would have been so simple to take care of, and they would have been out the door 7, 10 to twelve days, at least off the ventilator, 10 to twelve days sooner, and probably twelve to 13 days sooner out of the ICU. So this is expensive. We also saw in a study from 2020 Husai, that the ADF bundle, again, even at a lower level of compliance, decreased healthcare costs in the ICU by 30%. We can't afford not to do this.

[48:39] Michelle: That's what it's getting to, right? We can't afford not to do this in terms of, first of all, patient outcomes and their long term, you know, stories, and then cost. Cost, you know, financially and cost, really to the providers of the care. Right. We get frustrated as nurses, as physicians, as PT/OT, when we see all these things happening and we feel powerless to change them, and we're just kind of playing pickup with, you know, trying to mitigate all these problems that are being caused by the over sedation, the immobility, all of that.

[49:27] Kali: We know that for nurses, delirium doubles the nursing hours required for care. It increases time in the ICU by 4.67 days and time in the hospital by almost seven days. It is a huge psychological burden that's been shown in the research. So my speculation, though we haven't studied this specifically, is that providing a better process of care where we don't have to work as hard patients, have better outcomes, there's more human connection, job career fulfillment, that will have better staff retention. There's also staff injuries that we could go into when you're trying to move patients that are so debilitating and you don't have equipment and all the things. Right. So there's a lot on the staff end. There's a lot on the hospital end, but especially ethically, we can't keep doing what we're doing to patients.

[50:13] Michelle: Yeah. Well, you interview a lot of patients who have survived the ICU, and I love that. In addition to all the data, being a nerd data and all that stuff, I'm also very tied into the human aspect of it and the stories. And so I want to tell a really quick story here about this is a book that's written, that was written by a neonatologist, Siraj Saigal, and it's called Preemie Voices. And what we used to say in the NICU, and, you know, I'm sure it could be said for ICU as well, is that, you know, thank God the baby won't remember these painful procedures. And, you know, all of these things that we're doing to the baby. The baby won't remember that, right? But we know that Bessel van der Kolk wrote a book called The Body Keeps the Score. And in this book by the neonatologist, Preemie Voices, a former patient in the NICU, she wasn't Preemie, she was an adult woman, she was having recurrent dreams of her feet being burned and slashed with knives. Okay? All of her life, she got to be a young adult in her twenties, and it was just causing her a lot distress. So she went to a therapist. She was in therapy for a few months before the therapist said, you know, tell me about your birth history. And the girl didn't really know a lot about it, so she asked her mother, you know, what happened to me at birth? She said, well, I was gestational diabetic. And so when you were born, you had to go to the NICU because you had low blood sugars, which is a huge part of our population, right? And so you were there for a week or so, but every few hours, they had to put a heel warmer on your heel, and they had to poke your heel to get blood, and they did that every few hours for days. And, you know, there's a correlation there, right? Here's this girl that grew up her whole life having these horrible dreams, suffering PTSD because of them and not knowing the origin. And, of course, as a baby, she wouldn't have remembered that, right, cognitively, but her body remembered, and it was manifested later in that way. So how important are those stories from ICU survivors in helping clinicians understand exactly what they need to do to change their practices?

[53:09] Kali: And the terrible irony in the adult world as well, is I've heard for years people say, well, I have to sedate my patients, otherwise they'll have PTSD. It makes sense, though, right, if you think that sedation is sleep, that they're being spared any recollection or understanding of endotracheal tube, the lines, the drains, the near death experience that they're having right then, yeah, let's. Let's sleep instead of experiencing all of this. But we actually see in research that's now about 15 years old that real recall of the ICU is protective against PTSD. The more patients could remember and understand what happened during their time in the ICU, the less likely they were to be traumatized. But the more they had foggy, unclear, and even distorted memories of the ICU, the more likely they were to have PTSD. The less sedation they received, the less PTSD they had. And so the irony is just blaring. But again, that research has to hit the bedside, and it's survivors that make it do that. They build the bridge between the numbers to the practices. Obviously, I am also a data nerd. I think this research is compelling. The statistics are meaningful, but it doesn't really impact people like survivor testimonials. So every presentation I give, I always survivors, because they're far more compelling than I am. They're far more convincing than the statistics ever could be. And that's what sticks with people. They may not remember all the specific numbers, but they remember how they felt listening to survivors, and that's what changes how they approach the patients their very next shift.

[54:52] Michelle: Yeah, I think those stories are so powerful for change, and I'm so glad that you include those. And you know another thing, I want to talk about you for a second in terms of your humanity. I listened to all of your pediatric episodes, and I found myself being moved to tears right along with you, hearing your vulnerability and just your humanity. You're so real and you're so authentic, and I appreciate that. And I'm sure all of your listeners do as well. So I just wanted to comment on that. Thank you for that.

[55:33] Kali: Yeah, I'm a firm believer that anyone can start a podcast. Right? I started it just barricading my door from my toddler during COVID while I was pregnant with my third child. And I sometimes I'd be in, like, a call room in the hospital at five in the morning, recording, right? This journey has been one of the hardest experiences of my life. You've probably heard those pediatric episodes. My second child has mitochondrial disease, and so 2021, she had seven admissions within five months into the hospital. And obviously, I would love to not have to have her go through all of that, but also in a kind of a spiritual way. It was essential for me to get that perspective of being a family member at the bedside. The kind of fear, the trauma. I mean, I have medical trauma from it. My daughter has medical trauma. She can go to a clinic to get fitted for prosthetics and or for a brace, and she just freaks out. And it's like she thinks that she's going to be deeply suctioned.

[56:37] Michelle: Yeah.

[56:38] Kali: I know, she can't tell me that, but I just know. And I just. I'm like, I know. I was there, too. I saw what you went through. I don't know if she had delirium. I hope not. So it. And now I have four kids, ten chickens. Like, life is insane. That's so crazy. So it's. And again, this is. This is very personal to me because, and especially in the pediatric, pediatric world, I know my daughter could end up on a ventilator, and her cognitive function is the most functional part of her, and it is who she is. I think one of the best ways to dehumanize a patient is to sedate them. So I fear her and myself and my family, anyone could end up on the ventilator in the ICU at any point. So I really try to remember what this is about. I wasn't trained to be an entrepreneur. I don't know anything about business, the social media and the technicalities and all these things. It's really overwhelming for me. But what keeps me going is the personal connections that I've made with survivors. I almost feel like I owe it to them to be brazen, to get out there. And also the incredible revolutionists that I've met over the years, I've always loved being a nurse. I've aspired to be a nurse since I was, like, 15 years old, when I had my own traumatic. I punctured my femoral artery falling off a bike. So that was one of the moments when I was like, yeah, I think I want to be a nurse. Not while they were, like, lifting me into the gurney, but. But, you know, it's something that I've always loved and respected nurses, but my admiration has just grown exponentially as I've worked so closely with nurses throughout the country that are fighting for these changes. I mean, it's amazing how nasty fellow nurses can be when a nurse is trying to fight for the right thing. That is very different and scary. So I have been even more honored to be called a nurse, to be among the ranks of nurses because of what I've seen with heroic nurses fighting for these changes. So, yeah, this has been a wild journey. I don't. I mean, I always prefer talking about survivors and the statistics and things like that, but for me personally, it has been really difficult and yet so rewarding. And everyone has their own personal mission. I just believe in nurses, and nurses can make a huge impact in our healthcare system and the entire world, down to patients individual lives and families. And so I invite anyone that is daunted by these ideas or feelings that they have that they should do something that is scary and overwhelming, go for it. You figure it out along the way, and you may end up somewhere and doing something that you could never have imagined, but you would never know until you took the courage to take those first steps and approach the problems that you want to fix.

[59:33] Michelle: Yeah. I feel like you embody Gandhi's "Be the change you wish to see in the world."  It just takes one, right? And there's been so many amazing people in history. Rosa Parks, you know, Martin Luther King, Jr., Gandhi. One person to say, this is not the way we should be doing things. We can do better. We need to do better. And you're doing that every day. So thank you so much for that. And so before we go, I want to hear about what you do with Dayton ICU Consulting.

[01:00:12] Kali: I now train teams to make these changes because there is so much that has to be addressed and fixed. It's really hard to bring these changes to your ICU when you've never done them yourself. It's kind of the blind leading the blind. And so I have teams reach out to me and say, we need help. I've listened to the podcast. Usually it's podcast listeners saying, now I know, and I can't unknow it. I can't see it any other way. I call it the Santa Claus effect. Right? Now that you know the truth, it kind of like, oh, it's not so fun anymore, and now we have to do something about it, right? So then what do you do? So, after hearing that for years, I was like, I've got to create solutions, right? I've got to create support. So people aren't just tormented by the harm happening in their units, but they can actually bring the changes and not have moral injury. So I do gap analysis, go through their data, their case studies. I speak with the leadership of their team to understand where are they at? What's their culture, what are their practices, what are their team dynamics? What do they believe, what are their procedures and protocols, even their policies, the order sets. We just go through all nooks and crannies of their process, and then I do webinars with every member of the team. So this is a unique time. I mean, how often do we have mandated webinars with physicians down to cnas? I mean, not down, but, like, across to CNA's, right? That it's going to be the same information that rts are hearing and PT's and OT's. So it's pretty general. But I really believe that we cannot get to the how to change this until we all understand the why. So I spend four, three webinars really talking about the why and one webinar talking about more of the how. I bring in other people from different disciplines, from different hospitals to talk about what they do and allow for question and answers so that respiratory therapists can hear from another respiratory therapist, and we can just have more of an open discussion and start to talk about the logistics. And then I give them a little bit of time to have everyone listen to those recordings catch up. They get continuing education credits for that. Then I go on site with a respiratory therapist and occupational or physical therapist, depending on the specialty of ICU. I'm not necessarily a neuro expert, so I bring neuro experts with me to make sure that we really are prepared for their specific patient population. And we spend three or four days on site, depending on the size of the unit, and we will participate in rounds. We listen to how they discuss patients and their plan of care and their team dynamics, and we weigh in on their current patients and help them apply these principles from the webinar to their current patients. We'll go to the door of the room and we'll help kind of assess the situation and guide them through an intervention. So it's really amazing to see them now be willing to do these things, but they're still scared. It's a new thing. So we get to be there to say, it's okay, we've done this before. We're here to help. We can't touch the patients because we're not licensed there. But, you know, it just, we just add that layer of confidence as well as well as kind of pressure and obligation, and then they get to see the impact of these things in lifetime with their own patients, that they can see that this works. It's possible with their patients, because everyone wants to say, well, our patients are different, right? So it's really cool to see, boom, we get patients extubated, or we get them walking, or they're awake now, and now they're communicating, and they just get to have those new experiences with more support. Right? And then we do simulation training. We do that three times a day, so two during day shift and one at night shift, because night shift gets left out of everything and they're really important. And so we're kind of there from eight in the morning until 1130 at night. And then in between we meet with pharmacy executive leadership team dietitians. We don't care. We just have a lot of meetings and just really trying to figure out what do they need. Where are they? Athenae also make sure that they understand their role in this so that everyone's really aware, bought in. And in simulation training, we go over their own case studies. So I'll paint out someone's in the bed, pretending to be a patient. With all the equipment we have, all the disciplines are represented. So physicians are sitting next to respiratory therapist, next to CNA, and here's the patient, here's the diagnosis. Here are their ventilator settings, drips, vital signs. What are you concerned about? What are you going to do? What are the risk factors for delirium? How is that going to impact their life? So we're going like, we're zooming in and out and just changing how we think about these patients. Okay, so now what are you going to do? So usually they guide them to get them awake and mobile promptly, and then I can say, okay, here's what actually happened on your unit. So this is a little bit tough because I don't want to offend them, but I think we've set the stage enough that they're like, okay, let's talk about it. We gotta confront it in order to fix it. And it helps them see, okay, that was really difficult, what we did with this patient, you know, seven extra days on the ventilator, that was a lot of extra work, but this, I could see this being so much easier. So now they're just, they see it in a new light, they see how this is applied, but there's still a lot to work to do after that. Right? Two hours is not very much time to change something so drastic. But then I continue to prepare and guide the leadership to now take stewardship of overseeing this. So the next month straight, they're going to go out and they're going to round on every room and check with every patient, go in hands on and help their clinicians implement this stuff because it's a skillset that has to be developed. So within six months, it's pretty well self propelled, but it's a whole process to get there. And then I have monthly checkups with them to see where they're at. We make little goals to start with and then we build up from there. And so I just help them troubleshoot along.

[01:06:00] Michelle: That's fantastic. What a comprehensive, in-depth consultation. That's amazing. I love that you spread it through the whole disciplinary team. Everybody needs to hear the same information at the same time. And the real time aspect of it is so important. It's not like you're just dropping this bomb of, here's what you guys need to do, and then you leave and go back to your home and, you know, call, hey, how's everything going? No, it's like you are there doing the same thing you are there on day shift. You are there on night shift. That's amazing. I love that.

[01:06:39] Kali: I wish we could stay longer. And, you know, as this builds and I can scale, kind of afford to get more help, I would love to have an _____________ you know, as a travel nurse. And just some of these experts, I mean, these people that I've trained now, they've done this for two or three years. Bring some of them onto the, those units and say they're going to be here for a month. They're going to be the experts. They're going to hold your hand because it's a lot. There's just a lot to learn. So I do think that they still deserve more support, but that's where I'm at as of right now.

[01:07:07] Michelle: That's fantastic. Where can we find you? I'm sure there are people listening out there that are saying, I want to bring Kali to my ICU. So how can they get in touch with you?

[01:07:19] Kali: My website is daytonicuconsulting.com and on that site, there is a book-an-appointment button. I'm happy to chat, and we can brainstorm about where your team is at and what you need. I have articles, case studies. The podcast is on there with all the transcripts and citations. You can search by topic. So if you're like, I want to hear an episode with a survivor. I want to hear what she's talking about. Just go look it up. It's also organized into different categories, but that's where you can make an appointment and learn more about my team and what we do.

[01:07:52] Michelle: Fantastic. And I will put those in the show notes. And your instagram is fabulous. Your podcast is fabulous. And you came so highly recommended by so many amazing nurses. Is there someone you recommend to be a guest on this podcast?

[01:08:09] Kali: I think you should interview Polly Bailey.

[01:08:12] Michelle: I would love it.

[01:08:13] Kali: She is getting close to retirement. I think she's. This is her passion, so it's really hard for her to retire. But I think nurses really need to hear Polly's story from Polly. So that boy, I mean, it's unfathomable, the millions of lives she has saved and impacted through being brave enough to ask why? Why not? What if?

[01:08:40] Michelle: I would love to interview Polly, so maybe you can introduce us. I would love that.

[01:08:45] Kali: Absolutely.

[01:08:46] Michelle: Thank you so much for that. And thank you for coming on today, Kali, this has been such an invigorating conversation. I mean, I have learned so much throughout this hour, and I'm just inspired by everything you're doing. I just think you're a fantastic nurse practitioner and, you know, an innovator and gosh, and a person. I just think you're fantastic. And I thank my previous guests for recommending you and thank you for coming on today.

[01:09:21] Kali: Thank you. That means so much. Appreciate it. Michelle.

[01:09:24] Michelle: Well, we're at the end, so the last five minutes, we're going to play the five minute snippet. It's just five minutes of fun. Kali, are you ready for it?

[01:09:32] Kali: Yeah, I'm unprepared.

[01:09:35] Michelle: Oh, it's okay. These are just fun questions. Okay? The best female role model in your life.

[01:10:22] Kali: Oh, my mom. Yeah, my mom. She came from very humble circumstances, but she has lots of natural gifts and she has endured a lot throughout her life. Not only endured, but just thrived. She's just faced opposition and challenges in such an optimistic and powerful way. She raised a lot of kids and raised them well. She is an asset to her community. And yet, as busy as she is and all the big things that she's doing, she always takes time for the one and she always is doing random little thoughtful things for people that really inspire me to kind of stop and be quiet and remember the one someone needs. Just a little gesture.

[01:11:08] Michelle: Today it sounds like mother, like daughter. It sounds like you guys are very cut from the same cloth. Okay, the nicest thing a stranger has ever done for you.

[01:11:22] Kali: Oh, Michelle, that's really hard.

[01:11:24] Michelle: I know, you can pass.

[01:11:27] Kali: I mean, I just. There are so many. I would say that I wouldn't be alive if it wasn't for a stranger that saw me fall on my bike and he laid me down and applied the pressure when I punctured my femoral artery. That was a very nice thing to do.

[01:11:41] Michelle: Very nice.

[01:11:42] Kali: And he was definitely a stranger. And I'm about 14 years old. I was like, oh, you're going to go up my shorts? But I, like, absolutely would not be alive if it wasn't for him. So my life has been saved by a stranger.

[01:11:53] Michelle: Yeah. God, that's the best thing. Okay, favorite snack?

[01:12:00] Kali: Probably the rye chips from Gordon. What's it called? The Chex mix. You know, like those brown...

[01:12:08] Michelle: Oh, my gosh. Rice, chex and wheat or kettle popcorn. Oh, gosh, I love it. I love kettle corn.

[01:12:16] Kali: Mm hmm.

[01:12:17] Michelle: Okay. What gives you butterflies in your stomach?

[01:12:22] Kali: My little family. And when people tell me that the things that they've learned from the podcast or my training have helped and tell me stories and successes I've had with their patients, that still, almost five years later, it still gives me butterflies.

[01:12:39] Michelle: Yeah. That feedback is so, so important. And my wish to everybody out there who goes on social media, who consumes social media, don't just be a consumer of social media. Participate. Tell them what you liked about it. Tell them what you thought about it. Like, we love feedback, and it's sort of like a gauge, an external gauge, I guess, of how we're doing, right?

[01:13:09] Kali: Yeah. I wouldn't still do this if I didn't have people reaching out and saying, it's working.

[01:13:15] Michelle: Yeah.

[01:13:15] Kali: I mean, even though I have 177 podcast episodes or so.

[01:13:21] Michelle: Yes.

[01:13:21] Kali: When they reach out and say, I applied this to my patient, here's what happened. I always have this thought, like, if no one else had ever reached out to me, nothing else had ever really happened, that one patient, that one moment made all of this worth it.

[01:13:34] Michelle: That's right. That's the one. Very cool. Okay, my favorite thing to do on a lazy day is...

[01:13:43] Kali: Michelle, I have four kids. My oldest is six. And I have this business stuff. I don't even remember what a lazy day is, to be honest.

[01:13:53] Michelle: Oh, gosh.

[01:13:53] Kali: It would probably just be sleeping at this point. If I had a day off, that's what I would do.

[01:13:58] Michelle: But I love it. No, here's one that goes along with your family, favorite family tradition.

[01:14:05] Kali: We go on road trips. We really like to go to parks. We play a lot of games together. We, like, wrestle together. You know, even my daughter with mitochondrial disease. Like, she's in the thick of the wrestling matches, even though she's completely immobile.

[01:14:22] Michelle: Oh, my gosh.

[01:14:23] Kali: Yeah. It's the little things right now, because we don't. I mean, my oldest is six, so we haven't really been a family for that long. It's just the little things.

[01:14:33] Michelle: I love it. It sounds like your family is very sweet and just like yourself. And, gosh, Kali thank you again so much for coming on and sharing your knowledge and your expertise and your passion. Your passion has come through loud and clear today for changing practices in the ICU, for benefiting patients lives and clinicians lives. And I thank you so much for. For doing that today.

[01:15:01] Kali: Thanks for having me.

[01:15:03] Michelle: Have a great rest of your day.

[01:15:04] Kali: Thanks. You, too.