All scenarios are made up, everyone came out of it okay, and all views expressed are my own. Don’t get medical advice here, folks. Do the right thing. Go see a doctor, vaccinate your kids, plant a tree.
Something smart should go here, but I’m fresh out. One of these days maybe I’ll find some more smart.
My grandmother always told me that, if ignorance is bliss, I should check to see if I have the right kind of ignorance, since I don’t appear blissful enough. Thanks, grandma.
The podcast doesn’t contain any profanity, but it may be difficult for some people to hear. Be kind to yourselves.
Paralysis and PAD–pain, anxiety, and delirium–protocols have consumed me lately. Notice pain comes before anxiety on the scale. Address your patient’s need for analgesics prior to adding sedation, or you are merely hiding their need for pain control beneath a blanket of lethargy.
I know it’s easier to hang propofol than administer bolus fentanyl doses, especially when you’re initiating hypothermia or sending your patient emergently to cath lab, or running to CT, but consider the process that brought them to the point where they required intubation. Trauma, hypoxia, acidosis, CPR–painful states.
I notice with a lot of PAD protocols that while the sedation is ordered as a continuous drip, the pain medication requires a certain number of bolus doses to be administered in a certain narrow timeframe to justify initiation of a drip. This is, to my mind, fucking stupid. This shows a certain lack of good clinical judgment on the part of the people who designed the protocol. It’s the opposite of a delirium-avoidance approach. And while I am by no means insisting that every single patient requires pain medication and sedation while on a ventilator, I am most definitely suggesting that each paralysis requires adequate narcotizing prior to sedation, and prior to placement on a maintenance drip.
With the new guidelines for ARDS and the renewed emphasis on therapeutic paralysis, it is vital that we understand the difference between pain control, sedation, and paralysis.
Another concept, and to me, one of even greater importance, is the care we show people who are undergoing therapeutic paralysis. This is the subject of my podcast. It’s a short listen, but important.
This was hard for me to say. I know I pause a lot. I considered editing those pauses out but decided to let them stand, so you could hear what I felt, trying to explain what it was like.
Have you ever cleaned tear tracks from around the eyes of a patient who is paralyzed?
Many of you have heard my healthcare story. Here’s an opportunity to hear a little bit more about what I believe about caring for patients undergoing mechanical ventilation, particularly in the context of paralysis.
I’ve been intending to update for awhile, but haven’t. Sorry.
I’ve been depressed. I’m not talking about the kind of depression where you’re bored and vaguely dissatisfied. I’m talking about the kind where you can’t sleep, where you lose all interest in the things you love, where people you don’t even know can tell something is wrong. The kind where you break down sobbing while buying dinner for your family and the person at the checkout line calls 911 because she doesn’t know what else to do.
I was sleeping a few hours a night–broken, fitful sleep–waking to the same dream over and over. My mind couldn’t lay it down. I was carrying the problem with me everywhere I went.
The problem. It wasn’t a problem. It was a person.
I can’t tell you her name, or even promise the person is a she, because of the privacy restrictions we work under as medical professionals. But I wrote a thing about her, a thing I can’t share yet, and the writing did not have the effect I anticipated.
I thought it would be cathartic. I thought it would be like burning a memory, transferring the hurt to ash to be carried away by the wind. Instead the writing ensured that her name is burned on my heart.
So I don’t give two figs for the concept of preload. I have half an article written on something else and I simply cannot make myself write it. I do not care. The only thing I care about is finding some way to honor her memory. To do right by her and thousands like her.
Her memory haunts me. When I go to bed at night. When I rise in the morning. When I go throughout my day. She’s right there, at my shoulder, as I work and I think and I write and I start IVs. I missed two shifts on different floors because my mind is consumed with her.
If this story resonates with you, please–seek help. Find someone who can understand. Talk to them. Tell them your story. Don’t try to bear it alone. The weight can crush you, and you matter too much for that to happen.