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Post-Intensive Care Syndrome (PICS)
15 Plays6 years ago
In this episode of Critical Matters, we discuss what happens to patients who survive the ICU. Our guest is Dr. Carla Sevin, Director for The ICU Recovery Center at the Vanderbilt School of Medicine. Dr. Sevin discusses current concepts regarding the post-intensive care syndrome (PICS) and shares her views on how we can prevent, identify, and treat it.
Additional Resources:
Link to Society of Critical Care Medicine webpage containing a host of resources related to the Post-Intensive Care Syndrome (PICS): https://bit.ly/2S34Xam
Link to Understanding Your ICU Stay: Information for Patients and Families booklet: https://bit.ly/2SN6S7u
Link to the CIBS Center website, which contains a wealth of resources for intensivists on the topic of ICU liberation and survivorship: https://bit.ly/2HfdQ0n
Link to review article, Treatment of the Post-ICU Patient in an Outpatient Setting: https://bit.ly/2UUXkVg
Books Mentioned in This Episode:
In Shock: My Journey from Death to Recovery and Redemptive Power of Hope by Rana Awdish, MD: https://amzn.to/2SOLwX6
A View from the Edge — Creating a Culture of Caring by Rana Awdish, MD: https://bit.ly/2E6t1FF
Recommended
Transcript
Advancements in Critical Care Medicine
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now, your host, Dr. Sergio Zanotti.
00:00:22
Speaker
Over the last decade, we have seen significant advances in critical care medicine,
00:00:26
Speaker
These advances have resulted in a growing population of ICU survivors.
00:00:30
Speaker
As intensivists, we have been very good at focusing on immediate threats to our patients and solving urgent clinical issues.
00:00:38
Speaker
However, this short-term focus may have contributed to us not recognizing the complexities and difficult road critical care survivors have once they leave our ICUs.
Focus on ICU Recovery and Post-Critical Illness Care
00:00:48
Speaker
Today, we will talk about what happens to critical illness survivors.
00:00:52
Speaker
Our guest is Dr. Carla Sivin,
00:00:54
Speaker
director for the ICU Recovery Center at Vanderbilt, medical director for the Pulmonary Patient Care Center, and an assistant professor of medicine at the Vanderbilt School of Medicine.
00:01:04
Speaker
Her professional interest and experience focused strongly on inpatient pulmonary and critical care medicine, as well as the care of patients after critical illness.
00:01:13
Speaker
Since 2001, she has led the development and implementation of the ICU Recovery Center at Vanderbilt.
00:01:19
Speaker
In addition to her clinical work,
00:01:21
Speaker
She has worked with the Thrive Task Force for the Society of Critical Care Medicine to further awareness, research, and education about post-intensive care syndrome, or PICS, and in 2017, started the Thrive Post-ICU Clinic Collaborative.
00:01:36
Speaker
Through these efforts, she has had the opportunity to speak with patients, caregivers, intensivists, primary care physicians, allied health professionals, and hospital administrators about the pressing need to define this syndrome and develop a means to diagnose and treat it.
What is Post-Intensive Care Syndrome (PICS)?
00:01:51
Speaker
She's a true pioneer in defining the role of ICU aftercare programs in our changing healthcare environment and an expert in the benefits and barriers to creating such programs and practice.
00:02:01
Speaker
Carla, welcome to Critical Matters.
00:02:04
Speaker
Thank you so much for having me.
00:02:06
Speaker
So I think that, as usual, a great place to start is defining what we're going to be talking about today, which is the post-intensive care syndrome.
00:02:14
Speaker
So when I say post-intensive care syndrome, what do you think about
00:02:20
Speaker
Well, there is a specific definition, which is really what I should say is a nonspecific definition because it's pretty vague, but it's a name that we tried to put on a constellation of symptoms that we were seeing in patients who had survived a critical illness.
00:02:36
Speaker
So the definition is newer worsening impairment in cognition, mental health, or physical function, any of those three domains, after critical illness, and something that persists beyond the acute hospitalization.
00:02:49
Speaker
And one of the things that I have noticed as we become better in caring for these patients, for critically ill patients, there's more survivors, is that we also have seen the emergence of new categories of patients, such as the chronically critically ill or the hospital-dependent patient.
00:03:04
Speaker
Would those patients fall in this category, or we're talking about a separate population within survivors?
Challenges in Recognizing PICS
00:03:11
Speaker
Well, those conditions can certainly coexist in the same patient, but not at the same time.
00:03:16
Speaker
So chronic critical illness and a chronically hospitalized person is still dependent on some sort of life support, usually mechanical ventilation, that's keeping them institutionalized, perhaps in a long-term acute care facility or a nursing home that does ventilator support.
00:03:32
Speaker
But the patients who have post-intensive care syndrome are, by definition, have left the hospital
00:03:39
Speaker
and are trying to return to some kind of baseline and are struggling with impairments in these domains.
00:03:45
Speaker
So I think that's an important aspect just to make sure that the audience understands who we're really talking about.
00:03:49
Speaker
So this would be really patients who have graduated from the ICU, left the hospital, perhaps a short stint in rehab, but are really back home trying to get back to what normality would be for their lives.
00:04:02
Speaker
Is that correct?
00:04:03
Speaker
That's right.
00:04:06
Speaker
Before we go into the details about the specific domains, you talked about three components, cognitive, psychiatric, and physical functioning.
00:04:14
Speaker
Why is this important?
00:04:15
Speaker
Why should we care as intensivists?
00:04:17
Speaker
What's happening with these patients?
00:04:20
Speaker
Well, this is really a hidden public health problem.
00:04:24
Speaker
I would say a public health catastrophe.
00:04:26
Speaker
There are about five million people each year who are at risk for this so-called syndrome, post-intensive care syndrome.
00:04:33
Speaker
That's about three times the number of people who get a new cancer diagnosis in this country every year.
00:04:39
Speaker
So this is a huge population, but it really runs under the radar.
00:04:43
Speaker
And part of that is because we, as intensivists,
00:04:46
Speaker
don't really acknowledge or have good awareness of what post-intensive care syndrome is or that our patients would have any sequela after the ICU.
00:04:54
Speaker
And then, you know, the patients are being seen by primary care doctors, if anybody, and those physicians don't necessarily have a lot of time or education dedicated to this problem.
00:05:07
Speaker
And then, worst of all, patients and families themselves have
00:05:11
Speaker
no name for the problems that they're experiencing.
00:05:14
Speaker
As one patient told us, I didn't even know what to Google because I didn't know the name for the problems that I was experiencing or necessarily understood that they were related to my critical illness or my critical care.
00:05:27
Speaker
So as you said, a big number of patients, a big under-recognized population, and it seems that
00:05:34
Speaker
a big failure in terms of being connectivity and follow-up care with the people who are seeing these patients and knowing what can happen to them after surviving critical illness.
00:05:44
Speaker
And I guess a failure on our part in not really recognizing what happens once they leave the ICU.
00:05:52
Speaker
Absolutely, and I really love talking to other intensivists in other parts of the country and other parts of the world.
00:05:59
Speaker
And even, you know, after I give a talk about post-intensive care syndrome with all kinds of examples from my own patient population, almost invariably there's a comment in the audience that says, well, this doesn't really apply to my patients because they don't have these problems, and I know this because they don't come back.
00:06:17
Speaker
And I think that is a false assumption to assume that if you're not seeing your patients again, that they're not having these problems.
00:06:25
Speaker
First of all, they can't come see you because we don't
00:06:28
Speaker
Most of us who work in ICU don't necessarily have an open opportunity for patients to come see us after the ICU, either as a regular outpatient or in a structured post-ICU clinic.
00:06:42
Speaker
And also, a lot of patients lack awareness.
00:06:46
Speaker
Part of the cognitive dysfunction, which I'm sure we'll get into a little bit, is that they lack awareness of their deficits
00:06:52
Speaker
and lack the executive function to try to seek help for the problems that they're experiencing.
00:06:59
Speaker
But that doesn't mean that they're not having problems.
Impact of PICS on Families
00:07:01
Speaker
And I think that it's very interesting.
00:07:03
Speaker
You mentioned that patient that didn't know what to Google.
00:07:06
Speaker
But I think it speaks of a not uncommon pattern in disease where a lot of patients, especially with some of these newly identified syndromes or anything that affects their psyche, believe that it only happens to them.
00:07:22
Speaker
And then they're extremely surprised to find out that, like you mentioned, millions of patients who've been through a similar experience are having similar problems.
00:07:31
Speaker
And I think it just speaks to how little we know about this.
00:07:34
Speaker
Absolutely.
00:07:36
Speaker
And even if we don't have great treatments to offer, being able to name something and educate patients and reassure them that this is not normal, but it is a common side effect of being in the ICU is very important.
00:07:50
Speaker
provides a lot of reassurance to patients and their families.
00:07:54
Speaker
So Carla, before we dive in a little bit more into the specific components of PICS, can you tell us a little bit about, I also have seen in the literature, the emergence of PICS-F, or post-intensive care syndrome for families, and tell us what that is.
00:08:11
Speaker
Yeah, this is a really interesting concept, which I think is, even for people who think about post-intensive care syndrome a lot, kind of the next frontier in the areas that we need to research, understand, and treat.
00:08:24
Speaker
So in the ICU, we're very comfortable talking to families and developing close relationships with families over the course of a critical illness.
00:08:31
Speaker
We're constantly updating them about their family member's condition, and we kind of form a tight bond with a lot of these families through
00:08:41
Speaker
the trauma of critical illness.
00:08:43
Speaker
And yet, when we see patients in the outpatient setting, if we do indeed see patients in the outpatient setting,
00:08:51
Speaker
there's a lot of uncertainty about our relationship with the family.
00:08:55
Speaker
Are they our patient?
00:08:57
Speaker
Are they our subject?
00:08:59
Speaker
Should we be seeing them together with the family or separate?
00:09:03
Speaker
Should we be administering screening tools to the family members?
00:09:08
Speaker
And I think all that needs to be worked out.
00:09:11
Speaker
But certainly families are suffering equally in post-intensive care syndrome.
00:09:18
Speaker
Perhaps even more, we have certainly experienced in some families where the patient has no recollection of the ICU stay, but the family members are suffering incredibly from post-traumatic stress due to having, unfortunately, been awake for the whole episode and having these really existential threats to themselves and their family members.
00:09:43
Speaker
Certainly, the post-intensive care syndrome can affect families directly in the effects that family members experienced while they were in the ICU, but then also indirectly in the post-ICU period where we're discovering how
00:09:58
Speaker
relationships and roles within the family and in society really are changed and impacted by the critical illness.
00:10:08
Speaker
And with some funding from the Society of Critical Care Medicine, we're just completing a qualitative study that interviews patients and clinicians, but also family members, about what actually helps them and what hurts.
00:10:24
Speaker
them in the post-ICU recovery period.
00:10:27
Speaker
And a lot of what has come up is this changing of roles and the conflict that comes up in the family.
00:10:33
Speaker
And some of this can be quite severe, resulting in the end of relationships and even marriages, and is, I don't think, something that we can ignore when we're trying to address problems in the post-ICU period.
00:10:47
Speaker
And I think also what's interesting, at least from my perspective, and I would love to hear your comments on the family involvement or the PICS-F, is that it may also happen in the families of non-survivors.
00:10:59
Speaker
So these are usually people that truly fall off our medical radar, patients who die, but the family might have severe consequences for months to come related to that ICU stay.
00:11:10
Speaker
Yeah, absolutely.
Role of Primary Care in Post-ICU Care
00:11:11
Speaker
And we have nothing for those people, right?
00:11:13
Speaker
We don't have any entree for them back into the medical system.
00:11:17
Speaker
I've had, on rare occasions, a family member call and just want to, you know, call my office and want to talk about certain aspects of the critical illness course in their person who died.
00:11:32
Speaker
And, you know, I'm hearing a big
00:11:36
Speaker
medical center in Nashville at Vanderbilt, and so sometimes I run into family members in the medical center or in the town after their person has died.
00:11:48
Speaker
But those are really superficial interactions, and we really have nothing in terms of knowledge or therapy for that group of patients.
00:11:58
Speaker
And I think that like many other things that we're learning in critical care, the first step, like you said, is awareness and being able to recognize and share this information because even though we don't see these family members, primary care physicians do see them.
00:12:12
Speaker
And being able to recognize that the critical illness of a loved one may have an impact on their own patient is, I think, something that obviously we need more of our primary care physicians to recognize and understand.
00:12:24
Speaker
Yes, I agree.
00:12:25
Speaker
And I think, you know, our primary care partners, I can't admire the job that they do enough.
00:12:32
Speaker
And they're so well-versed in kind of the holistic approach to patients and families.
00:12:38
Speaker
And you're right, they are the ones who are providing most of the post-ICU care for patients or families, at least in the United States.
00:12:46
Speaker
And we could do a better job of supporting them in that.
00:12:51
Speaker
So before we go into more of the risk factors and start talking about prevention and other strategies, could you dive in a little bit deeper, Carla, into the three domains that you mentioned?
00:13:02
Speaker
So the syndrome is a new or worsening symptom in a cognitive function, psychiatric function, or physical
Physical and Cognitive Impairments Post-ICU
00:13:12
Speaker
function.
00:13:12
Speaker
Could you give us concrete examples of what are some of the things that our patients go through in those domains once they leave the ICU that you're seeing on a regular basis?
00:13:22
Speaker
Sure, and let me just preface this by saying that we try to see patients quite early after the ICU, so these deficits are probably most severe in that time course, but they evolve over time.
00:13:36
Speaker
The things that we see most commonly are I'll start with the physical function since that's something that's probably the most familiar to us as physicians.
00:13:45
Speaker
This population is routinely weak.
00:13:48
Speaker
We do a six-minute walk test to get a kind of idea of what their global physical functioning is and endurance.
00:13:55
Speaker
That's routinely 50% predicted or lower in the post-ICU period.
00:14:03
Speaker
includes all comers from, you know, 18-year-old dock workers to 90-year-old church ladies.
00:14:12
Speaker
You know, the physical impairments are profound.
00:14:16
Speaker
And even sometimes after a relatively short ICU stay, which is interesting, and some of the risk factors that we see for the critical illness, myopathy, and polyneuropathy weakness is, as you would expect,
00:14:32
Speaker
getting steroids, getting paralyzed, prolonged immobility, a lack of early mobility or aggressive rehab, certain medications, hypoxia.
00:14:44
Speaker
ECMO is, you know, something that we're starting to do more at our center, and those patients are really the sine qua non of the post-ICU weak patient.
00:14:55
Speaker
And this weakness in the peripheral neuropathies can have a lot of downstream effects.
00:15:01
Speaker
So, for example, if you can't weat, if you can't walk and you can't feel your feet, you can't drive, your reaction time may be slow, you can't get to work.
00:15:13
Speaker
You know, we're a car-based society.
00:15:15
Speaker
So unless you have a lot of support, even just the weakness in isolation,
00:15:21
Speaker
can have a profound impact on your life and your ability to get back to your normal function.
00:15:27
Speaker
And the really sad part about it is that there's only one treatment, right, that's inpatient or aggressive rehab, whether it's inpatient or outpatient.
00:15:37
Speaker
And for a variety of reasons, you know, our patients don't always get as aggressive a rehab program as they need to get back to their baseline function.
00:15:46
Speaker
And what is paid for by insurance
00:15:49
Speaker
or covered by the hospital may be just the barest minimum.
00:15:54
Speaker
I like to tell my patients who, you know, we started doing the six-minute walk test just out of scientific curiosity to see if our pragmatic clinical population was as weak as what was described in the literature, and they were.
00:16:10
Speaker
But what was interesting is that the patients responded very interestingly to having some objective data
00:16:18
Speaker
some objective measurement of their weakness.
00:16:21
Speaker
So, you know, they would say, I'm fine, I'm going back to work.
00:16:24
Speaker
And I would say, well, your six-minute walk distance is 47% predicted.
00:16:27
Speaker
And they're like, oh, my God, 47%.
00:16:30
Speaker
And that really motivated them to do the only treatment, which is more physical therapy, even though that is difficult and often expensive to do.
00:16:40
Speaker
But I like to tell them about one of our super survivors who was on the vent for 18 days.
00:16:48
Speaker
She had high dose steroids, she was very, very weak and had persistent respiratory failure.
00:16:53
Speaker
Went to an LTAC, went to inpatient rehab, went to outpatient rehab, and after her outpatient rehab ran out, she hired a trainer and went to the gym for 180 straight days.
00:17:06
Speaker
And, you know, unfortunately, that is sometimes what is required.
00:17:10
Speaker
And I think that your findings with a six minute walk test, I think it really touches on several, I think, important points.
00:17:18
Speaker
One is that both patients and ourselves probably are overestimating what patients can really do.
00:17:25
Speaker
And when you get objective data, it's like irrefutable.
00:17:27
Speaker
Wow.
00:17:28
Speaker
I mean, right.
00:17:29
Speaker
47%.
00:17:29
Speaker
That's not so good.
00:17:31
Speaker
And number two, I think, like you said, in terms of motivation, having an objective target, I can see it's improving.
00:17:38
Speaker
So it was 47 and now it's 67.
00:17:39
Speaker
I still have a far way to go, but I made significant improvement.
00:17:44
Speaker
And I think that that's something that also might be very useful for patients just thinking of that in that way.
00:17:52
Speaker
Right.
00:17:53
Speaker
And conversely, I've had a couple of patients react kind of angrily like, hey, I thought I was doing better.
00:17:57
Speaker
And now you're telling me this is so bad and I feel terrible.
00:18:01
Speaker
And, you know, they were kind of depressed about it.
00:18:03
Speaker
But then on subsequent visits, they had really taken that advice to heart and gotten better and then seen that improvement and were very, you know, felt very validated by that.
00:18:13
Speaker
Excellent.
00:18:14
Speaker
What about the cognitive and psychiatric aspects of the syndrome?
00:18:19
Speaker
Yeah, so the cognitive function and the psychiatric function, you know, I'm not a neuropsychologist and I didn't go to a psychiatry residency, so a lot of this I had to learn from some of my excellent colleagues in those fields, including Jim Jackson, who works with me in the clinic.
00:18:36
Speaker
So we do a brief cognitive screen and sort of psychiatric, some psychiatric diagnostics.
00:18:44
Speaker
in the clinic.
00:18:45
Speaker
The cognitive screen is very, very interesting to me.
00:18:49
Speaker
So, you know, we all learn the mini mental status exam in medical school, and I think that's probably the lowest level cognitive screen that you can do.
00:19:01
Speaker
But even that is markedly abnormal in a subset of our patients.
00:19:05
Speaker
Interestingly, though, I've had some delightful conversations with people, and I did not find them at all impaired, especially people who were previously high-functioning.
00:19:14
Speaker
And then Jim would go in and ask these many mental status questions or the Montreal Cognitive Assessment, which is MOCA, and they were dramatically abnormal.
00:19:26
Speaker
We had a patient who was very high-functioning who had already returned to work part-time,
00:19:34
Speaker
Both I and his wife were pretty stunned to hear that he didn't know the ear or who the president was.
00:19:42
Speaker
So I think the lesson there is that you have to ask these specific questions in order to assess cognitive function.
00:19:48
Speaker
And certainly you can, you know, there is an eight-hour neuropsych evaluation that can be done to evaluate cognitive function in depth, but that is, in my opinion, not what is needed so much as sort of
00:20:01
Speaker
gross estimation of whether this person is having deficits severe enough that they require, you know, additional therapy or at least some counseling that perhaps now would not be a good time to go back to work as a CFO or whatever their job was before they got sick.
00:20:20
Speaker
So the cognitive function, especially in the domains of executive function, is highly affected.
00:20:28
Speaker
And again,
00:20:29
Speaker
Even in young people with a relatively short ICU stay, we can see some pretty profound changes in cognitive function.
00:20:37
Speaker
And the therapy for that is not clear cut.
00:20:39
Speaker
We're working on, you know, some cognitive rehab that can be done, and certainly there are some resources that you can refer patients to in the community.
00:20:49
Speaker
But I think the identifying, naming, and counseling patients and families is probably
00:20:57
Speaker
the best thing that we can do in the early post-discharge period.
00:21:00
Speaker
It also helps, as you alluded to, the PICS family, it really helps relationships within the family when you can name cognitive deficits as the reason why your loved one is going to the store and coming back with none of the things that you asked for.
00:21:18
Speaker
It really helps intervene on some of the intrafamilial conflicts that can arise after critical illness.
00:21:27
Speaker
And I think that that's a great example of something that we tend to totally underestimate.
00:21:34
Speaker
We have conversations with some of our patients.
00:21:36
Speaker
They're highly functioning people at baseline, and it seems everything's okay.
00:21:40
Speaker
But when you dig a little bit deeper and use the right tools, you're surprised to find that there's significant problems there.
00:21:46
Speaker
And I think that that's something that we really haven't thought about much as a community of intensivists with a lot of the people who leave the ICU.
00:21:54
Speaker
So definitely important.
00:21:57
Speaker
What about from a psychiatric standpoint?
Addressing Anxiety and Depression Post-ICU
00:22:01
Speaker
So in the psychiatric realm, all of the things that we think of as being your major psychiatric diagnoses, anxiety, depression, and PTSD are all found at higher rates in the post-ICU population than in the general population and even some other sick populations.
00:22:22
Speaker
Interestingly, we looked at our first three years of patients
00:22:26
Speaker
that we saw in clinic, which is admittedly a somewhat self-selected population.
00:22:33
Speaker
This was a clinical population, not a study population.
00:22:36
Speaker
So, you know, you had to have the wherewithal to actually get to clinic to be seen.
00:22:41
Speaker
But we saw a lot more anxiety than PTSD.
00:22:44
Speaker
The PTSD rates were lower
00:22:47
Speaker
and the anxiety rates were higher compared to the published literature.
00:22:52
Speaker
And we think that's because we were seeing people so soon after the ICU.
00:22:56
Speaker
So a lot of anxiety after a critical illness is, I think, to be expected.
00:23:02
Speaker
But if it goes unchecked or untreated, then it can evolve into PTSD.
00:23:06
Speaker
So that's one area where we can potentially be intervening in the post-ICU period if we see patients soon enough and actually preventing some of these long-term problems.
00:23:16
Speaker
And some people, of course, also have pre-existing psychiatric problems before they get critically ill, and teasing those out is something that we try to do, although, you know, not to the extent that you would do in an appointment that's purely psychiatric.
00:23:35
Speaker
And I would also say, you know, I'm very lucky to have a neuropsychologist in my clinic, but I don't think it's necessary to have a neuropsychologist, you know, if you're saying,
00:23:44
Speaker
I'm not going to see my patients after the ICU because I don't have a neuropsychologist.
00:23:47
Speaker
A lot of these tools can be done, you know, by anybody or somebody who's trained a speech therapist, do a lot of cognitive evaluations, social workers, and, you know, other counselors could administer some of these tools for you and help you at least get an idea of what the problems are for your patient.
00:24:12
Speaker
And in terms of how you see these present, Carla, they're all linked to each other.
00:24:16
Speaker
I would imagine that the more physical dysfunction I have, the more I recognize I have difficulty with my cognitive function, the more anxious or depressed I would get.
00:24:28
Speaker
Do you see them all interconnected just as the overall burden of critical illness, or are some more prevalent sometimes in the individual patients based on different factors?
00:24:38
Speaker
Yeah, they certainly can be, but they don't have to be.
00:24:42
Speaker
And some people have, you know, their physical function is right on track, and their cognitive function is doing pretty well, but they have debilitating anxiety related often to the fear of getting sick again, getting re-hospitalized again.
00:24:58
Speaker
So certainly you can imagine if your physical function is quite bad, you're going to be depressed, and that's going to affect your cognitive function.
00:25:04
Speaker
So they certainly can be tied into each other.
00:25:09
Speaker
As much as I would say that these patients are more alike than they are different, there are certainly some unique characteristics from patient to patient, depending on their situation.
00:25:17
Speaker
And in terms of risk factors, you did mention some of them earlier, and obviously the burden of critical illness itself, I'm sure, is a big driver of this.
00:25:26
Speaker
But could you comment on some other risk factors that might be of interest or particular that you've seen with your research and your experience in these three domains or for PICS as a whole?
00:25:37
Speaker
Yeah, so we actually, you know, when we started our clinic, we didn't really have a good model for how to recruit patients for the clinic, but we knew what some risk factors were for especially the cognitive dysfunction in the ICU.
00:25:55
Speaker
And certainly delirium is a massive risk factor.
00:25:59
Speaker
It portends poor prognosis overall.
00:26:02
Speaker
Those patients are more likely to have morbidity and mortality related to their
00:26:07
Speaker
critical illness, but it also predicts more cognitive dysfunction after the ICU.
00:26:14
Speaker
So if I see somebody in the ICU who is delirious, especially if they have prolonged delirium, so the time that they're delirious is correlated with outcome as well, then I am definitely going to try to get them to come back to clinic so that we can assess their function after the ICU.
00:26:35
Speaker
And some of the risk factors, just like the domains of impairment, are paired together.
00:26:43
Speaker
So if you're on mechanical ventilation, you're probably going to be sedated, so you're more likely to have delirium.
00:26:51
Speaker
And all of those things are risk factors for poor prognosis and for PICS.
00:26:57
Speaker
Others would be hypoxia.
00:26:59
Speaker
Again, maybe you're on a ventilator because you're hypoxic.
00:27:03
Speaker
Sepsis and
00:27:05
Speaker
shock.
00:27:06
Speaker
So I mean, obviously these are all things that are very common in our ICUs and understanding the risk factors and understanding why these people develop this syndrome I think is the first step in trying to prevent it from happening.
00:27:19
Speaker
So most of our audience, I suspect, does not practice in an ICU survivor clinic, but they do practice in ICUs.
00:27:27
Speaker
So what are the things that we can take care on a daily basis or things that we should be focusing on a daily basis
00:27:33
Speaker
to try to lessen the or mitigate the likelihood of them having severe PICS once they leave the ICU.
Preventing Delirium for Better Outcomes
00:27:40
Speaker
Can you talk about some of those interventions that we should be focusing on as a preventive measure?
00:27:44
Speaker
Right.
00:27:46
Speaker
Well, first of all, number one, do your day job.
00:27:49
Speaker
Provide excellent critical care, right?
00:27:51
Speaker
Because if the patient doesn't survive, we're not going to have any of these problems.
00:27:54
Speaker
And I don't want to suggest that we should not be, you know, focusing on critical care.
00:27:59
Speaker
But while we're doing that,
00:28:01
Speaker
preventing delirium and other complications of our care can have a big impact on these patients for their long-term recovery.
00:28:09
Speaker
So, you know, not that long ago, even, you know, when I was training, people would be delirious and we'd be like, well, they're delirious, you know, there's nothing we can do about it.
00:28:18
Speaker
And we didn't really understand what a bad marker of disease that was.
00:28:24
Speaker
But now that we know that, we should be very aggressive in trying to prevent that, and that means trying to organize our units to have the lights on during the day and try not to interrupt sleep at night and avoid delirogenic drugs, which for the most part are going to be sedative.
00:28:44
Speaker
So, you know, avoid benzodiazepines when we can and keep our patients as minimally sedated as necessary.
00:28:52
Speaker
to protect their life support devices, treat pain, which is a cause of delirium, and then, you know, prevent other complications of our care that can extend from the critical illness like clots and pressure sores and bleeding and malnutrition and hospital-acquired infections, all of which will extend the critical illness and thus the risk for impairment after the hospital.
00:29:17
Speaker
So one of the emphasis from the Society of Critical Care Medicine and has been the topic of previous podcast episodes has been the implementation of the ATF bundles or the ABCDF bundles, which include a lot of the things that you're mentioning.
00:29:32
Speaker
I know that there's data suggesting that there's a dose response to the implementation of these bundles in terms of short-term outcomes that are very important for our patients.
00:29:43
Speaker
Do we know what effect they have on the incidence or the severity of PICs?
00:29:50
Speaker
Yeah, so we're looking at that again.
00:29:51
Speaker
You know, we're a little bit stuck with this definition of PICS, which is kind of vague.
00:29:56
Speaker
And we don't have a PICS screening tool that we can deploy out into the community and say, you have PICS, you don't have PICS.
00:30:03
Speaker
So it's very difficult to study PICS as a whole, although, you know, there is some research looking at various aspects of PICS, for example, the cognitive function.
00:30:16
Speaker
So absolutely, by implementing the ADEF bundle, you will decrease
00:30:20
Speaker
delirium and therefore improve long-term cognitive outcomes.
00:30:24
Speaker
But, you know, whether you can say in general people will have less PICs, I can't point you to the evidence that that is true, but I suspect that is true because, again, if you're not delirious and you're not being sedated as much, you're going to come off the vent sooner, you're going to be out of the ICU sooner, you're less likely to have these post-ICU complications.
00:30:46
Speaker
So it seems logical that we would be decreasing a number of long-term adverse outcomes by implementing these bundles.
Screening and Assessing for PICS
00:30:55
Speaker
And Carla, we talked a little bit about how you screen for this, but can we maybe expand on the diagnosis and recognition and more about like the specifics?
00:31:05
Speaker
How do you identify it in these high-risk patients?
00:31:08
Speaker
When do you test first?
00:31:10
Speaker
I'm just curious how you do it in your practice.
00:31:12
Speaker
Yeah, absolutely.
00:31:15
Speaker
Well, like I said, there's no validated screening tool for PICS per se.
00:31:19
Speaker
There are certainly a lot of existing tools that are out there, and the clinic collaborative that we host through SCCM is trying to put together a kind of toolkit so that you can see who is using what.
00:31:34
Speaker
But most teams who are seeing post-ICU patients have employed a variety of these existing tools to try to pinpoint deficits in the various domains.
00:31:46
Speaker
So the other question is, when do you test?
00:31:49
Speaker
So some of the earliest data for post-ICU impairment really came out of the UK, where they tried to implement post-ICU programs quite early, like 20 years ago or 30 years ago in some cases.
00:32:04
Speaker
But most of those assessments were done quite distant from the ICU stay, even three or six months after the patients went home.
00:32:12
Speaker
We see patients very early.
00:32:15
Speaker
after the ICU stay, and that is clearly a different set of problems, especially in the U.S. We have very fragmented care.
00:32:25
Speaker
We have a lot of patients who don't have an established relationship with a primary care doctor, and there's just a lot of care that falls through the cracks in the immediate post-hospital period.
00:32:38
Speaker
So all the things that you're writing for your patients at discharge that you think that they're getting,
00:32:43
Speaker
like their flu shot and their rehab and their DME and their home health, in many cases, they're not actually reaching the patient.
00:32:50
Speaker
And there's, I think, a lot of low-hanging fruit there in terms of what we can intervene upon.
00:32:57
Speaker
On the psychological side, like I said, we see more anxiety than PTSD early after the ICU.
00:33:02
Speaker
But if we check them at three months or six months, we would probably see a different picture, maybe more PTSD.
00:33:10
Speaker
And then cognitively, doing some kind of cognitive assessment so that you can encourage patients not to make bad decisions with their current functioning, I think is quite important.
00:33:22
Speaker
And I'm not sure that it has to be very in-depth because, again, a lot of this cognitive impairment, some of it will improve over time.
00:33:29
Speaker
But interestingly, we've seen a couple of patients who self-referred to our clinic after being in the ICU a long time ago, even 10 years ago.
00:33:39
Speaker
and did not have any post-ICU care, per se.
00:33:44
Speaker
And they come in and, you know, we have – sometimes we just do have Jim Jackson see these patients because the neuropsych issues are more prominent.
00:33:53
Speaker
But we had one man who was accidentally scheduled for the whole nine yards, and he had the pharmacist evaluation and the nurse practitioner visit and the cognitive eval.
00:34:06
Speaker
It was really disheartening to see how similar his problems were to somebody who is just getting out of the hospital.
00:34:13
Speaker
The difference was that he got out of the hospital, he went back to work three weeks after discharge, he struggled in his job, which was a high-level financial position, and eventually lost his job, never regained his previous level of physical functioning, was on a ton of meds,
00:34:34
Speaker
to help him sleep and to help him wake up and to this and all kind of trying to address the problems of post ICU syndrome.
00:34:42
Speaker
And 10 years have passed without any improvement.
00:34:44
Speaker
So on the one hand, that's very sad.
00:34:47
Speaker
On the other hand, that's very motivating to help us try to get to patients at a time point when we might be able to intervene on some of these recovery trajectories.
ICU Recovery Clinics and Early Interventions
00:34:57
Speaker
And as far as we can tell, that requires seeing them as early as possible.
00:35:02
Speaker
We aim to see patients
00:35:03
Speaker
two weeks after hospital discharge, but we succeed on average about four weeks after hospital discharge.
00:35:09
Speaker
And let me ask you, so if I were a patient at Vanderbilt at your practice right now in the ICU, when I'm ready to get discharged, would I just basically be told we have this clinic, come to the clinic in two to four weeks?
00:35:24
Speaker
Do you screen people at that point?
00:35:25
Speaker
I mean, you did mention the six-minute walk, but are you doing testing on discharge?
00:35:30
Speaker
Are you tagging patients?
00:35:32
Speaker
as they leave the ICU as high risk?
00:35:34
Speaker
I'm just curious in terms of how exactly would it look if I were the patient?
00:35:39
Speaker
Yes.
00:35:40
Speaker
So we do tag them as high risk.
00:35:42
Speaker
We put them on the list, so to speak, while they're in the ICU.
00:35:47
Speaker
And of those patients who we think will be good candidates for the clinic, meaning that we think that they have a chance to return to baseline and be discharged from the hospital, about 20%
00:35:58
Speaker
will not survive the hospitalization.
00:36:00
Speaker
And when those that do survive, when they leave the hospital, we say, yes, come back and here's your clinic appointment.
00:36:09
Speaker
As advised by some of our former patients, they said, you know, you should not make this optional because patients don't know what they don't know.
00:36:15
Speaker
You tell them this is a mandatory part of their recovery so that they'll show up because in many cases they lack the insight into their disabilities.
00:36:27
Speaker
to voluntarily come to a clinic.
00:36:29
Speaker
So we try to make it seem like a normal part of their care.
00:36:31
Speaker
That being said, a number of them will still not come to clinic for a variety of reasons.
00:36:37
Speaker
They are cognitively impaired and they're weak and they can't drive for the most part, so they need a lot of help, and those are a lot of barriers to overcome.
00:36:49
Speaker
There's still a lot we don't know about what the unmet needs are in that post-discharge period.
00:36:54
Speaker
And we actually have just embarked on another study called Assessing Post-Intensive Care Syndrome together with Intermountain and Johns Hopkins and the VA in Salt Lake and Beth Israel to
00:37:09
Speaker
look at exactly that population, patients who are critically ill but we expect to discharge to home, not go to a rehab or an LTCH, and what are those needs in the post-ICU period?
00:37:22
Speaker
What are people not getting?
00:37:23
Speaker
Are they getting what we think that they were prescribed at discharge, and how can we intervene to try to reduce some of the sequelae of being in the ICU, including early readmission, which is a big problem?
00:37:36
Speaker
One of the things that you mentioned earlier, which obviously is no news to our audience, is the fragmentation of care and how that impacts patients.
00:37:45
Speaker
I was wondering, Carla, are you doing anything special with those patients that don't leave, don't go home, but might be going to an LTAC or going to a rehab in terms of flagging them or including this information as part of their discharge summary?
00:38:00
Speaker
Because I think that
00:38:01
Speaker
That's one of the things that I always wonder with delirium.
00:38:03
Speaker
We treat delirium, we talk about it in the ICU, and then they go to the floor, and a lot of times there's a big voltage drop, and nobody's really aware that grandma needs her glasses and her hearing aids, right, all the time, or she will get confused.
00:38:16
Speaker
And how do you manage those transitions of care with this population?
00:38:21
Speaker
Yeah, it's really tricky.
00:38:23
Speaker
At our center, you might go to the floor, or you'll go to...
00:38:28
Speaker
inpatient rehab or LTCH, if you go anywhere other than the floor, that is outside our system.
00:38:33
Speaker
So it's hard to reach those patients and their family members.
00:38:38
Speaker
So the first thing that we do is make sure that we have, like, three contact numbers for everybody.
00:38:42
Speaker
I was really shocked when we started the clinic that we were just not able to reach people a lot of times because they were so debilitated that even if they went, you know, home in quotation marks, they were not at home.
00:38:53
Speaker
They were staying with family.
00:38:55
Speaker
They were, you know, couch surfing.
00:38:57
Speaker
They were – their girlfriend broke up with them, so they were in somebody else's apartment.
00:39:02
Speaker
And not only could we not find them, but Home Health couldn't find them with their IV antibiotics and PT, OT couldn't find them.
00:39:09
Speaker
So contact information is key.
00:39:13
Speaker
We also started –
00:39:15
Speaker
Visiting the patients.
00:39:17
Speaker
So a lot of our patients, when they leave the ICU, are still pretty sick, and some may still be delirious.
00:39:24
Speaker
So we try to make a visit on the floor before they leave the hospital, and we give them a little brochure that has some information about post-ICU syndrome and some of the things they might run into.
00:39:35
Speaker
And if they do run into those things, to call us, that we can help them.
00:39:39
Speaker
To give them some sort of written information and wherever possible, talk to the families
00:39:45
Speaker
because if they are going to come to the clinic, it's the families who are going to drive them there to make sure that we sort of have the whole unit on board and make that personal contact at the point of, you know, before they actually leave our facility.
00:40:00
Speaker
But it is difficult when patients go to inpatient rehab or to an LTCH or to a skilled nursing facility.
00:40:07
Speaker
We try to guesstimate when they might be out of there and schedule an appointment just to have it on their discharge paperwork.
00:40:13
Speaker
But it's often a challenge to try to reach them after that point.
00:40:17
Speaker
And one of the things that I'm always interested as an internist at heart, obviously, is differential diagnosis.
00:40:24
Speaker
So we're talking about how we diagnose, we're talking about the syndrome, and that's not very specifically defined.
00:40:30
Speaker
But there clearly are some organic causes that might cause some of these dysfunctions.
00:40:36
Speaker
Any comments on some of the things that we should be thinking about that could be or sharing with our primary care physicians and colleagues of things that might mimic PICS but might have an organic cause that can be treated differently?
Distinguishing PICS from Other Conditions
00:40:49
Speaker
Yeah, so, I mean, I think, you know, these patients, for the most part, did not have these problems before they had the, you know, chemical imbalances that either illness or we induced in their bodies and their brains.
00:41:03
Speaker
But you're right, you know, PICS is not protective against other things.
00:41:07
Speaker
I think having some ability to follow patients longitudinally, which a primary care physician would be doing, is going to be your best solution.
00:41:19
Speaker
strategy for figuring out what is normal PICS and what is something else.
00:41:24
Speaker
What we try to do, we see most of, you know, we're intensivists, so we're not interested in taking over primary care from somebody, but we see patients for one or two visits just to tie up the loose ends of things that are clearly critical care related.
00:41:39
Speaker
So, you know, for us, if you have a
00:41:42
Speaker
quote, temporary IVC filter or trach or line.
00:41:47
Speaker
So those things clearly need to be addressed.
00:41:50
Speaker
We do a fair amount of wound care and telling people that their hair and their nails will grow back, which they find very disturbing.
00:41:57
Speaker
But once we get all those things tied up, then we send a letter to the primary care physician if they have one.
00:42:03
Speaker
And if they don't have one, we try to get them one.
00:42:06
Speaker
saying, you know, this was the critical illness, which is already more than most primary care physicians get, right?
00:42:12
Speaker
This is what went down in the ICU.
00:42:14
Speaker
These are the problems that we identified as being related to the ICU.
00:42:17
Speaker
This is what we think should be done about it.
00:42:20
Speaker
And that, you know, really gives the primary care physician a kind of signpost if something is out of the, you know, out of the realm of
00:42:29
Speaker
what we've described.
00:42:31
Speaker
But truly just seeing patients post-ICU, the more patients you see, the more you learn not only about what post-ICU syndrome is, but, you know, what we could be doing differently in the ICU to prevent these problems from happening.
00:42:47
Speaker
So to me, that's been the most gratifying part of seeing patients in post-ICU is to help us be better ICU doctors.
00:42:56
Speaker
And part of that is medical, part of that is system, and part of that is, I think, prognostication.
00:43:04
Speaker
So we do a lot of prognosticating, life and death prognosticating for families in the ICU, based almost exclusively on our experiences in the ICU.
00:43:16
Speaker
And, you know, that is not always correct.
00:43:21
Speaker
We are not the best prognosticators.
00:43:24
Speaker
and seeing patients after the ICU has really made me both more optimistic and more pessimistic in certain situations for recovery in patients that we just didn't see long enough to make a good prognostication about.
00:43:38
Speaker
Well, and I think that also a lot of been written about heuristics and the heuristic of availability, right?
00:43:44
Speaker
We tend to remember...
00:43:45
Speaker
these very vivid cases that might not be positive, but it's very hard to, without follow-up, to really objectively understand what happens to these patients.
00:43:53
Speaker
And I think that that information probably is something that you do gain as you see these patients after their ICU stay with more frequency.
00:44:01
Speaker
Now, is it...
00:44:03
Speaker
One of the things that I'm interested in, you talked about how you have started this clinic and what you do at Vanderbilt, but I also think that in a lot of smaller practices, the volume might not be there to have a clinic on a regular basis.
00:44:18
Speaker
How do you work with primary care physicians in your community to try to make care for these survivors better?
00:44:25
Speaker
Well, you know, I think the first thing is just being available, right?
00:44:29
Speaker
So, um,
00:44:30
Speaker
I have a colleague in Kentucky, Ashley Montgomery Yates, who runs a clinic, and she was sort of running it by herself for a long time.
00:44:39
Speaker
But every PCP, it seems like, in Kentucky had her cell phone number, and there was a lot of communication, direct communication between her and the primary care physicians in her community so that she was able to make that ICU knowledge available
00:44:59
Speaker
to her colleagues and their patients, even if, you know, a clinic appointment was not in the cards.
00:45:05
Speaker
And so, you know, providing awareness, and I think the Society of Critical Care Medicine is trying to do this as well, you know, going to primary care conferences and trying to get the word out, like, this is a thing, you know, and if you need more information,
00:45:26
Speaker
it's out there to help you take care of these patients.
00:45:29
Speaker
Interestingly, there was a study in Germany that actually looked at it.
00:45:34
Speaker
So in Germany, most people have a primary care physician.
00:45:37
Speaker
It's a much more unified healthcare system.
Training and Strategies for Primary Care Physicians
00:45:40
Speaker
And what they did was train the specific primary care physician for each sepsis survivor in post-ICU syndrome, and they had a case management portion.
00:45:52
Speaker
And they didn't have a big outcome change in healthcare-related quality of life, which was the primary outcome.
00:45:58
Speaker
But the physical function actually did show a trend toward improvement, and I thought that was a really interesting approach since primary care physicians are providing the bulk of the post-ICU care.
00:46:11
Speaker
But there's also some good literature out there.
00:46:15
Speaker
Actually, one of my favorite articles about post-ICU syndrome
00:46:20
Speaker
appeared in the American Family Physician Journal, I think it was in 2009, which was a very succinct and good summary of here are the problems, here are the risk factors, here are the things that you can do, which I still refer to to this day.
00:46:36
Speaker
So the primary care physicians are certainly our partners in that.
00:46:40
Speaker
That being said, there are things that are obvious to us as intensivists
00:46:47
Speaker
you know, and this is where we kind of sell ourselves short as a subspecialty.
00:46:51
Speaker
We are subspecialty care, and we need to be available to provide that subspecialty opinion throughout the arc of recovery.
00:47:00
Speaker
So, you know, a surgeon might only want to operate, but they're not going to just say follow up with your PCP after you have a CABG, right?
00:47:08
Speaker
They're going to be available for the typical
00:47:12
Speaker
problems that might occur after a surgery.
00:47:14
Speaker
And I feel like we have a responsibility to either provide that care or set up a system where that knowledge is available to patients and families after the ICU, as well as other physicians.
00:47:27
Speaker
And when I'm a patient at your institution and I leave the ICU and I leave the hospital, will I get information about PICS?
00:47:35
Speaker
Is that something you're sharing with families and how do you do that?
00:47:39
Speaker
Yeah, we have a very homemade brochure that just says this is PICS and these are the kinds of problems you might have.
00:47:45
Speaker
And if you have them, we'd love to see you.
00:47:48
Speaker
And here's the number to call.
00:47:50
Speaker
Actually, we did a study that hopefully will be published soon looking at readmission risk in this population.
00:47:57
Speaker
And we provided as part of the study a 24-hour hotline that was staffed by our nurse practitioner intensive service.
00:48:08
Speaker
that patients could call 24 hours a day.
00:48:11
Speaker
They could call this number if they had problems after the ICU, and almost nobody called it.
00:48:15
Speaker
I think one of the fears as intensivists is that we will be overrun by ICU survivors asking for our advice, and that simply has not been our experience, even when we try to make it very easy for patients and families.
00:48:30
Speaker
But for the patients and families who are able to reach out, we should be available for them.
Telehealth and Peer Support in PICS Recovery
00:48:37
Speaker
What do you think is the next big thing or what's coming in the near future that excites you in this field, Carla?
00:48:45
Speaker
Well, one thing is, you know, as I mentioned, this population is kind of hard to reach, and coming back to the hospital is difficult for them on a number of fronts.
00:48:54
Speaker
We're starting a telehealth pilot that is trying to reach out to patients via telemedicine, and certainly with the new CMS rules, there seems to be some
00:49:05
Speaker
progress in the understanding and acceptability of telemedicine in reaching disadvantaged populations, so I'm hopeful about that.
00:49:15
Speaker
There have been some attempts to try to do some self-directed education and recovery training through, for example, smartphone apps, although, again, I think that these patients have enough problems with executive function
00:49:31
Speaker
and motivation that they need a structured program, at least in the beginning.
00:49:38
Speaker
Peer support is an area that's really had a lot of growth in the U.S. and abroad over the last couple of years, thanks in no small part to the peer support collaborative through SCCM.
00:49:50
Speaker
And more and more people are trying to offer that to patients.
00:49:53
Speaker
I think that's a big help for patients who are especially a little bit later in the
00:49:58
Speaker
recovery trajectory, and they're ready to talk about some of the issues that are still bothering them.
00:50:05
Speaker
In fact, we had, it's interesting, we had, this is why discharge paperwork is so important.
00:50:11
Speaker
We had a patient come in a couple weeks ago to clinic, and she, we were searching the chart, be like, who is this person?
00:50:18
Speaker
We haven't seen her recently.
00:50:19
Speaker
And it turned out that she had had a critical illness in 2012, which was the year we opened the clinic, and declined to come to clinic.
00:50:28
Speaker
at that time, but here she was, you know, all these years later, having troubles with sleeping and nightmares and some post-traumatic symptoms, and she pulled out her paperwork from her discharge all the way back then and saw her appointment and came back to clinic.
00:50:46
Speaker
So it may be never too late, you know, for some patients.
00:50:51
Speaker
But they might have different needs at different stages of recovery.
00:50:54
Speaker
Well, like they say, the best time to come to clinic was eight years ago.
00:50:57
Speaker
The second best time is today, right?
00:50:59
Speaker
Right.
00:51:02
Speaker
So a quick question in terms of this topic with families.
00:51:09
Speaker
Are there brochures available through the SCCM Collaborative that people can use at their hospitals to share this information so they have to reinvent the wheel with family members?
00:51:18
Speaker
Yes, there is a brochure that you can order, I think, in bulk, and we can get the link from SCCM.
00:51:27
Speaker
And they have some information on the website as well, including a soon-to-be updated referral list of existing post-ICU clinics and peer support groups that are active in the U.S. So if there's something near you, we are certainly happy to see patients
00:51:46
Speaker
from near and far, but we've had a couple of colleagues call us from other states and say, hey, this patient called me from Tennessee, and they were looking for post-ICU care, and we were just down the road.
00:51:57
Speaker
So I think there are some clinics out there where you can get some specialized care, and we want that referral info to be available to everybody.
00:52:08
Speaker
So we'll definitely include, I mean, the link to the SCCM website and other websites in the show notes.
00:52:15
Speaker
As we be respectful for your time, Carla, I think that we'd like to usually end the podcast with asking our guests some questions that tap into their wisdom that are not related maybe specifically to the topic that we discussed.
00:52:28
Speaker
Would that be okay?
00:52:30
Speaker
Sure.
00:52:31
Speaker
So my first question is, what book of books have influenced you the most or what book have you gifted most often to others?
00:52:40
Speaker
Well, the book that I've really been excited about in recent times has been In Shock by Rena Adish, and we were so lucky to have her here at Vanderbilt a couple weeks ago, too.
00:52:53
Speaker
You know, I think she's an intensivist who herself sustained a critical illness, so has been able to really make a call to action from both sides of the fence there.
00:53:04
Speaker
It's a fantastic book for anybody, but especially for intensivists.
00:53:10
Speaker
It really gave me some additional understanding of critical care from the standpoint of a physician as well as the patient.
00:53:19
Speaker
I really loved it a lot.
00:53:22
Speaker
Sorry to interrupt.
00:53:23
Speaker
I did not read this book, but we definitely put it in the show notes.
00:53:28
Speaker
But if I recall correctly, she's an intensivist who had a postpartum complication, and she wrote a piece at the New England Journal of Medicine.
00:53:34
Speaker
Is that the same person?
00:53:37
Speaker
She did write a piece.
00:53:40
Speaker
She wrote a whole book about her experience, but excerpts did appear in some other publications.
00:53:52
Speaker
And she's back to practicing intensive care, which is fantastic.
00:53:55
Speaker
So we'll definitely include that in our show notes.
00:54:00
Speaker
So my second question is, what do you believe to be true in medicine or life that most other people don't believe?
00:54:09
Speaker
Well, this has really changed for me over the years of my practice.
00:54:13
Speaker
I think when you're in training, you tend to have a very pessimistic view of some of the patients' illnesses that we see in the ICU.
00:54:24
Speaker
And through seeing patients in the post-ICU clinic, including a couple who I straight told their families would not make it,
00:54:33
Speaker
It's very, very humbling to see somebody survive against all these odds.
00:54:38
Speaker
And so I just have to emphasize that prognostication is not a science, and the more we look at the whole trajectory of recovery after critical illness, the better we'll be able to take care of patients in the ICU.
00:54:53
Speaker
It's not a natural experiment when we are affecting the outcomes by limiting
00:55:01
Speaker
life support.
00:55:02
Speaker
Certainly, there are plenty of instances where we do that appropriately, but I think there are a lot more gray areas that we don't give ourselves or our patients credit for, and we just need to learn more about that.
00:55:14
Speaker
Yeah, and I think having a healthy dose of humility and understanding that what we think to be true today might be proven otherwise over time, and just being able to accept that, I think,
00:55:29
Speaker
on a regular basis is very important in our practice.
00:55:31
Speaker
I agree 100%.
00:55:31
Speaker
So true.
00:55:35
Speaker
So the last question for our closing question is, what would you want every intensivist who's listening to this podcast, every provider to know?
00:55:44
Speaker
Could be a quote or a fact or just a comment.
00:55:49
Speaker
Well, one of my favorite quotes is also the motto of the medical school here, which is the well-known aphroism from Hippocrates.
00:55:58
Speaker
life is short, the art long or something like that.
00:56:01
Speaker
I'm probably misquoting.
00:56:02
Speaker
But the second stanza reads, the physician must not only be prepared to do what is right himself, but also to make the patient, the attendants and externals cooperate.
00:56:14
Speaker
And, you know, that's not always easy to do in modern health care, but it's the job we agreed to do.
00:56:21
Speaker
And I think as we become more and more specialized in
00:56:26
Speaker
Intensive care in all aspects of medicine, taking that responsibility for systems, even though it's hard work, and building systems that get the right care to the right patient at the right time is our responsibility.
00:56:39
Speaker
And I think that it's a great place to end the conversation, especially in a world where we talk so much about physician burnout.
00:56:47
Speaker
Being able to always go back to first principles and remember why we started doing this, I think, is a good antidote for that situation as well.
00:56:58
Speaker
Absolutely.
00:56:59
Speaker
Well, Carla, it's been a delight to talk with you about this fascinating topic.
00:57:02
Speaker
I'm sure that as we learn more, we would love to have you back on the podcast and teach us what's new in the future.
00:57:09
Speaker
So again, thank you so much for your time and for sharing your knowledge with our audience.
00:57:13
Speaker
Thank you.
00:57:17
Speaker
Thanks again for listening to Critical Matters.
00:57:19
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.