Transcript
Speaker: Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: Evidence-based supportive ICU care in synchrony with disease-specific treatments are the basis for improving outcomes in critically ill patients.
Speaker: The ABCDEF bundle is a collection of evidence-based interventions aimed at enhancing patient recovery and liberation from the ICU.
Speaker: In today's episode, we will discuss ICU liberation during the COVID-19 pandemic.
Speaker: What have we learned about applying the ABCDEF bundles to COVID patients, and what have we learned from COVID
Speaker: that can improve our efforts of ICU liberation for all critically ill patients.
Speaker: Our guest is Dr. Wesley Ely.
Speaker: Dr. Ely is a professor of medicine at Vanderbilt University School of Medicine with subspecialty training in pulmonary and critical care medicine.
Speaker: Dr. Ely's research has focused on improving the care and outcomes of critically ill patients with ICU-acquired brain disease manifested acutely as delirium and chronically as acquired dementia.
Speaker: She is the co-director of the Center for Critical Illness, Brain Dysfunction, and Survivorship
Speaker: the CIBS center, which has enrolled thousands of patients into clinical trials, answering vital questions about ICU acquired brain disease and other components of ICU survivorship.
Speaker: His team developed the CAM-ICU, the primary tool used to measure delirium and ICU based trials and clinically at the bedside.
Speaker: It is a real honor to welcome him back to the podcast to discuss a topic he is passionate about and has been instrumental in advancing our understanding.
Speaker: Wes, welcome to Critical Matters again.
Speaker: Sergio, thank you so much.
Speaker: It's really a lot of fun to talk to you and always learn whenever I'm with you.
Speaker: So I know I'm in the right spot when I'm on critical matters.
Speaker: Excellent.
Speaker: And we were chatting, obviously, before we started recording about what an incredible year this has been for all of us worldwide, but also in particular for critical care with its challenges, but also with the opportunities to really make a difference for our patients.
Speaker: And today I want to talk about a topic that obviously you've been a
Speaker: a passionate advocate to moving forward and has really transformed the way we think in the ICU compared to when I was training.
Speaker: So why don't we start, Wes, by maybe you could explain in general terms, what do we mean by ICU liberation?
Speaker: Yeah, exactly.
Speaker: ICU liberation basically is a gift to us as intensivists and as ICU teams because it creates a structured framework by which we can get our patients back
Speaker: where they want to be in life.
Speaker: The technology we've got makes it very easy for us to kind of dehumanize the situation in the ICU with all the beeps and buzzers and ventilators and sedation.
Speaker: And then we kind of lose the person inside the patient.
Speaker: And what ICU liberation does is through the A2F bundle, the A, B, C, D, E, F bundle, we learn and have a way on rounds with our ICU teams, the nurses, the doctors, the pharmacies, et cetera,
Speaker: to essentially focus on what matters the most to patients.
Speaker: And we're liberating them in a sense from our tendency to dehumanize them.
Speaker: And we bring them back into where they want to be, awake, alert, out of bed and so forth.
Speaker: And I think that one of the biggest paradigm shifts, at least for me and during my practice, has been that during training and the initial phase of my career,
Speaker: Like many intensivists, I was hyper-focused on what was in front of me, and we almost kind of forgot about patients once they left the ICU.
Speaker: Yet, obviously, through many research studies that you have done and many others, we now recognize that the effects of what we do upstream in the ICU have tremendous impact on the life of our patients downstream months and years afterwards.
Speaker: And I believe that really focusing on that is the most important thing in terms of ICU liberation.
Speaker: You know, I had a young woman who developed ARDS and sepsis and she, I'll never forget her, blonde hair, bright, a mother of two came in with ARDS and she was up in our unit for two months.
Speaker: And about a year later after she survived, she came back to the hospital and I expected this, oh, doctor, thank you for saving my life, et cetera.
Speaker: And she let me have it.
Speaker: And I'm glad she did because I'll never forget what she did.
Speaker: She wagged her finger, Sergio, in my face and said, you did not do your job.
Speaker: And I was like, whoa, this is an assault.
Speaker: But then it was a beautiful wake-up call to me.
Speaker: I did not do my job because my job, she told me, your job was to get me back to my life the way it was before.
Speaker: And I spent this whole year
Speaker: basically trying to walk up the two steps to get me into my house and trying to be a mother again.
Speaker: And I was left so incapacitated.
Speaker: And that was one of the driving forces in me developing the A2F bundle and saying, I'm not going to be that doctor anymore.
Speaker: I've got to keep the downstream effect, like you put it beautifully, Sergio.
Speaker: I cannot just look upstream.
Speaker: I've got to look downstream at where they're going to be in their life.
Speaker: And that kind of convicted me to not let them sit in that bed, immobilized and sedated for so long the way that I thought was the right answer.
Speaker: And it's the wrong answer.
Speaker: Absolutely.
Speaker: And you did mention that the A to F bundles.
Speaker: And I do believe, Wes, that probably to refresh the memories of those who've been only thinking of COVID or if somebody's been hiding under a rock, could you just give us a quick overview of what these elements are?
Speaker: Absolutely.
Speaker: And this is an evidence-based safety bundle checklist, essentially, like a pilot uses on an airplane to get you from LA to New York.
Speaker: That's how they get the plane safely across the country.
Speaker: Well, we got to get these patients safely through their ICU stay.
Speaker: And what we did was we took 400 peer-reviewed papers in critical care, 35 of which are New England Journal, JAMA, and Lancet,
Speaker: and put them into something easy to remember.
Speaker: Like Malcolm Gladwell says, you know, make it, if it's gonna tip, it's gotta be easy and sticky to remember.
Speaker: And it's just the first, you know, letters of the alphabet, A, B, C, D, E, F, six letters.
Speaker: And so it's A is analgesia.
Speaker: We always wanna keep pain in our mind first.
Speaker: B is both SATs and SBTs.
Speaker: So stopping sedation, stopping the ventilator and seeing if they can be liberated from that regard.
Speaker: C is choice of drug.
Speaker: and that's trying to avoid benzos and other GABAergic drugs.
Speaker: D is delirium monitoring and management.
Speaker: E is early mobility.
Speaker: And F is family engagement.
Speaker: So this A to F bundle, I just call it letter A, number two, letter F. We've published data in over 30,000 people and well over 100,000, you know, there's no telling how many people have been cared for with this.
Speaker: But what we do know is this, Sergio, the more
Speaker: you implement the steps of this bundle, the higher is the survival rate, the shorter the ICU length of stay, the less ICU bounce backs, less transfers to nursing homes, more discharges to home, and way less delirium and coma.
Speaker: So you get the person back by doing this at the bedside.
Speaker: And I think that two very important aspects of this bundle that I would like to hear your comments on
Speaker: One is that, you said it, there's a dose response.
Speaker: So there's no reason not to start today.
Speaker: And the more you do, the greater the benefit.
Speaker: And number two, no matter where you are with these bundles, there's room for improvement, right?
Speaker: It's that mastery asymptote that nobody ever gets to perfection.
Speaker: And I think that this really should be the impetus for every ICU in the country, no matter how much they think they're doing or how much they're not doing, to really push this forward.
Speaker: Those are great teaching points.
Speaker: We don't have to be afraid of doing these changes.
Speaker: And a lot of times people are afraid of change.
Speaker: At the beginning of the COVID pandemic, some doctors from Spain wrote to me and said, Dr. Ealy, we're seeing so much delirium and so much coma.
Speaker: Can't we do a large international study?
Speaker: And I was like, sure.
Speaker: So we got together with our team here at the CIBS Center.
Speaker: CIBS is C-I-B-S, Critical Illness, Brain Dysfunction, Survivorship.
Speaker: We've got over a hundred people in this center at Vanderbilt doing this research and we got together and talked about it.
Speaker: We said, you know what, we should do this with these international doctors.
Speaker: And I wasn't on Twitter.
Speaker: I've never been on Twitter before, but for this, I got on Twitter and my handle is just at Wes Ely MD.
Speaker: So just very simple.
Speaker: Um, what's that?
Speaker: Eight letters W E S E L Y M D. And with that new Twitter account, I sent out an, at a, uh, a call.
Speaker: to enroll into what we call the COVID D study.
Speaker: And that study has now been published in Lancet respiratory medicine in two weeks, Sergio.
Speaker: I was amazed by Twitter, the power of Twitter.
Speaker: In two weeks, we enrolled 2,100 patients in 14 countries, 70 plus ICUs.
Speaker: And what we learned was intense.
Speaker: There is absolutely a dose response, just like you said,
Speaker: with implementation, and I can go into more details of that if you want, but it was a truly powerful learning experience that's very COVID related.
Speaker: Well, I think that since we brought up COVID, it's a great place to maybe dive a little bit deeper into the impact COVID-19 had had on all aspects of ICU liberation.
Speaker: And I guess we can start with one of the first things, and we can go maybe by letter, but that I noticed is all of a sudden it felt that I was back in fellowship, Wes.
Speaker: and we were paralyzing using benzos and this mass hysteria where we're mobilizing patients, what happened?
Speaker: Yeah, I think that we have to cut ourselves a little slack and realize that nobody intended to hurt anybody and nobody intended to do the wrong thing, but it was super scary.
Speaker: And I was not in Bergamo or Ann Arbor or New Orleans or New York myself.
Speaker: But I have fellows, for example, in New Orleans, Bud O'Neill, Dave Jans, Chris Thomas, three former Vanderbilt trainees who were at the heart of a pandemic surge in New Orleans and Baton Rouge, where they were getting a dozen people every 30 minutes admitted into their hospital with rip-roaring COVID.
Speaker: And it was just super scary.
Speaker: But those doctors, those surge doctors, a couple of months later said, we've got to get back to our basics.
Speaker: We've gotten completely away
Speaker: from all that we knew and proved to help people and what they were doing when they were away from their basics and kind of turned topsy-turvy was just flying by the seat of their pants, deeply sedating everybody, running out of propofol, starting them on benzos and saying, oh, okay, this is a lot simpler now.
Speaker: They're quiet.
Speaker: They're in a coma.
Speaker: It's easier.
Speaker: And we know that if left to our own tendencies, we will over sedate.
Speaker: And we will say, you know what, they were freaking out a minute ago and now they're calm and I can do whatever I want on the ventilator and I can take over their body.
Speaker: And that is a very kind of tempting thing to do in the ICU is just to completely take over the body.
Speaker: But it's a very dangerous thing to do for the human body.
Speaker: It actually creates new disease.
Speaker: And even though it may seem great to be kind of the master of our domain,
Speaker: take over that person's body, it creates the seriously profound problems of post-intensive care syndrome because under our noses, they're starting to develop ICU-acquired weakness and actually dementia, and they'll end up with PTSD and depression.
Speaker: And so finding the right balance of all this is what's been the goal over the past eight months of COVID once we kind of got over that initial disastrous circumstance.
Speaker: And it's also quite interesting that we're obviously optimizing for immediate gains like improving the PaO2, yet we have no visibility on to the damage we're causing downstream, right?
Speaker: And that's what's so hard about this.
Speaker: And when you're overwhelmed, it becomes much easier, like you said, to default to this inertia.
Speaker: Now, I also saw recently, Wes… Let me comment on that, by the way.
Speaker: You talked about what we can see and what we can't see.
Speaker: You know, I was at a funeral yesterday for one of my colleagues, a dear, dear colleague, Pierre Messiaen, who died here at Vanderbilt recently.
Speaker: And one of the things that was said at the funeral was, they said, Pierre always told us the greatest things in life we cannot see, the most important things in life we cannot see.
Speaker: And it's matters of the heart and matters of the mind.
Speaker: And these are exactly the things that we cannot see as intensivists.
Speaker: We can't see how the brain is being damaged.
Speaker: and how it's going to leave somebody personally distraught and disabled to feel like they aren't themselves anymore.
Speaker: You know, and if we are contributing to that depersonalization and cognitive disability, we've got to ask ourselves a real serious question.
Speaker: How can we restructure care that will preserve the things that the person, the person we're there to serve, thinks is the most important, you know?
Speaker: Yeah, absolutely.
Speaker: That to me, those elements are found in the A2F bundle.
Speaker: They really are.
Speaker: Okay.
Speaker: That's a great point, Wes.
Speaker: And to the point of we were talking about, well, I guess the A, the B, but also the C, the choice of medication, we obviously had moved significantly away from benzos because of all the risks they have with delirium and other problems.
Speaker: But I saw that now we're seeing emerging papers
Speaker: associating heavy sedation and coma again in COVID with increased mortality that might be when there's control for other factors kind of a driver.
Speaker: Could you comment on that a little bit?
Speaker: Sure.
Speaker: So let me go, let me speak to some direct evidence from our COVID-D study.
Speaker: In this study where I went on to Twitter and we got over 2,000 patients in two weeks enrolled, we learned something very important.
Speaker: Of all of the predictors of delirium, for example,
Speaker: The two most striking predictors of this profound form of organ dysfunction were overuse of benzos and underuse of families.
Speaker: The use of benzos drove up delirium by 60 to 70 percent, and the presence of family drove down delirium by almost 30 percent.
Speaker: So what happened in COVID was we started using benzos and propofol and put everybody into a coma, and then they couldn't relate to their family.
Speaker: They had no association with family.
Speaker: So that was kind of like a, if you had to design, if a mad scientist was going to design a terrible experiment to maximize delirium, COVID was it.
Speaker: And it just became this epidemic, delirium became this epidemic within the pandemic.
Speaker: And we started seeing double durations of delirium and coma up into the 14 to 18 days.
Speaker: Whereas prior sepsis, you know, COVID is just viral sepsis.
Speaker: So prior sepsis of bacteria, such as which you and I are used to caring for,
Speaker: that delirium and coma duration is usually three to four days, six, seven days as an outlier.
Speaker: Now we're getting 15, 16, 17 days of delirium and coma.
Speaker: And we already know from our Brain ICU study that delirium is the number one driver, independent driver of an acquired dementia.
Speaker: So people are all worried right now about long COVID.
Speaker: And long COVID happens in people who aren't that sick with COVID, but in those who are sick, like we care for in the ICU,
Speaker: the worst case scenarios along COVID are occurring and essentially picks on steroids, if you would.
Speaker: They get out with profound dementia, profound PTSD, profound depression, total immobilization.
Speaker: And don't you worry, Sergio, about, you know, all these balloon celebrations of people surviving after 90 days and they're leaving in a wheelchair and we give them these parades.
Speaker: And that's wonderful.
Speaker: I'm so glad they survived, but I worry the second they get home, they're gonna be like, wait a minute, what?
Speaker: What am I supposed to do?
Speaker: I can't walk.
Speaker: I can't think and I can't go back to work.
Speaker: So where's my life?
Speaker: And we're blind to that, which is the worst part.
Speaker: But I also believe that those balloon celebrations are very much for the healthcare workers.
Speaker: And ultimately what the real celebration for us is when somebody comes back and tells us that they're functional and enjoying their life again, right?
Speaker: A year later.
Speaker: And that's really the challenge.
Speaker: And it's been very hard.
Speaker: Now, I want to peel a little bit more of the delirium and
Speaker: part because we talked about two factors you identified in the D study, which I think are fascinating, which is the overuse of benzos and the underuse of families.
Speaker: And we're obviously gonna talk more about family in a second, but what about Wes?
Speaker: There's been a lot of, you would hear people comment or post, oh, COVID causes delirium.
Speaker: And how much of this is the disease, the virus, and how much is what's happening around us, which was unprecedented.
Speaker: I've never had an ICU where every single person
Speaker: was the same diagnosis, was the same problem, similar lab, similar x-ray.
Speaker: I've never seen anything like this.
Speaker: And we obviously had changed our practice and we're totally overwhelmed.
Speaker: So how much do we know this from science?
Speaker: How much is the virus producing changes in the brain?
Speaker: How much is what we're doing or it's a combination of both?
Speaker: Yeah, we're learning this in science.
Speaker: We have a study right now called the Brain 2 study.
Speaker: It's really brain ICU 2.
Speaker: The first brain ICU study was the one we published in the New England Journal in 2013, where we showed that delirium was a predictor of dementia and that benzos were the number one predictor of the circumstance.
Speaker: So now we're doing brain two where we're collecting the brains and we're studying these brains actually in combination with Rush where you're, you know, that's your alma mater, right?
Speaker: Yep.
Speaker: Yep.
Speaker: And so we're working at Vanderbilt Rush study.
Speaker: It's an $18 million NIH study.
Speaker: And we,
Speaker: We do see the virus invade the brain and we know that from early studies by Helms and others, but it's minor.
Speaker: So the virus is getting up there.
Speaker: There's no question that it's causing some neural involvement.
Speaker: We do know that there's peripheral nerve involvement, anosmia at the nose, et cetera.
Speaker: But really the other factors like overt clotting, profound hypoxemia, the immobilization of the drugs.
Speaker: So I actually created a mnemonic
Speaker: call F COVID and you know, we hate COVID.
Speaker: So F COVID and it's the, the, here's the list of things we need to consider when somebody's delirious and COVID is F for family isolation.
Speaker: Get that family back involved.
Speaker: C O V I D clotting, oxygenation issues, the virus itself, which is a piece of it, but, and we're learning how to treat that.
Speaker: We'll get back to that in a little bit, uh, immobilization and then drugs.
Speaker: So family,
Speaker: clotting, oxygenation, virus, immobilization, and drugs.
Speaker: And of those things, ask yourself, which are the most modifiable?
Speaker: Well, family's modifiable.
Speaker: Clotting, we can anticoagulate if we know we have a big problem with DIC and such.
Speaker: Oxygenation, we can treat that.
Speaker: The virus itself, we're learning about remdesivir, and we're treating the viral inflammatory storm with steroids, and now it looks like we're probably going to have some JAK inhibitors and other drugs coming down the pipe.
Speaker: Immobilization, we can get them up out of the bed as long as we stop the drugs.
Speaker: That last D of COVID, FCOVID is drugs, benzos.
Speaker: And that is where we've got to get back on the horse and ride ICU liberation and quit abandoning what we learned over the last 20 years.
Speaker: And I think that is obviously the most important message for this episode today for all our listeners who are at the bedside.
Speaker: We talked about, you talked about the eye of immobility and
Speaker: Clearly, what I saw at the beginning, especially in the surges of March, where ICUs were overwhelmed and the nurses and clinicians were unsure of the risk they had, but it did seem that we were barely moving patients, and that probably created a lot of problems.
Speaker: Any thoughts on what we've learned about early mobility in these patients, Wes?
Speaker: Yeah, for sure.
Speaker: You know, Polly Bailey,
Speaker: was a nurse at Utah who was one of the original people to ever write about mobilization in the ICU.
Speaker: She has a paper, I think in 2008 in critical care medicine, you can look up Polly Bailey and Terry Clemmer was the intensivist on that paper.
Speaker: And there's a great story where Roy Brower from Hopkins, the original low volume ventilation six versus 12 first author in the New England invites Polly out to Hopkins and takes her bed by bed in the ICU.
Speaker: and says, Polly, what would you do here?
Speaker: And the first bed, she says, well, I'd stop sedation.
Speaker: And then they go to the second bed and he presents the patient with ARDS and says, well, what would you do here, Polly?
Speaker: I'd stop sedation.
Speaker: And as Roy tells it, third bed, fourth bed, fifth bed, I'd stop sedation.
Speaker: You know, I've been writing a book for two years.
Speaker: It's gonna come out in September with Scrutiner.
Speaker: And my original title for this thing was Death of the Benzo.
Speaker: In my computer, I still h ave a file called Death of the Benzo, but that's not going to be the title of the book.
Speaker: It's too negative.
Speaker: It's not an appealing title.
Speaker: The book's going to be called Every Deep Drawn Breath.
Speaker: And that's straight from a beautiful Steinbeck bit of prose.
Speaker: But in that book, I'm going to talk about when it comes down in September, all these things that I learned as a physician at the bedside from patients.
Speaker: It's narrative nonfiction.
Speaker: It's real people.
Speaker: real stories.
Speaker: And the single most important thing that I have learned as a now graying physician is that this is a human being I'm caring for and no amount of technology should shadow that this person has real interests, real cares and worries and concerns.
Speaker: And I can't know those things if the person's in a coma.
Speaker: I have to wake them up to talk to them to make eye contact
Speaker: to understand what matters to that person.
Speaker: And I hope that every deep drawn breath will galvanize the movement to back towards liberating people from us.
Speaker: That's my hope.
Speaker: Absolutely.
Speaker: And looking forward when that comes out in September.
Speaker: And I like both titles, but I do agree that the second one is much more poetic and probably your editors are much more enthusiastic about that one.
Speaker: Yeah, exactly.
Speaker: I had to listen to the editors on that one, but that death of the benzo thing, I thought we were almost there and COVID turned that back around the other direction.
Speaker: And when that benzo came back in the way it did, your question to me was what about immobilization and COVID?
Speaker: And you cannot mobilize somebody if they're sedated.
Speaker: You just can't do it.
Speaker: You have to start with that spontaneous awakening trial, avoiding the GABA urges, which lasts too long.
Speaker: getting them undelirious by mobilization, that is the rehumanization process of the A to F bundle.
Speaker: Yeah.
Speaker: And the last component that I wanted to touch on related to COVID, and then we'll move on to surviving COVID-19 in the ICU, was the F, obviously.
Speaker: And the D study, and also when you were part of an international survey, also talked about the effect of families there.
Speaker: Really, that was one of the most striking findings, which makes sense in retrospect, but also
Speaker: I think just illustrates how difficult it was talking with families on the phone when they weren't there, communicating with people, trying to get the loved ones connected.
Speaker: Can you comment a little bit more on that aspect with COVID-19 and what you've learned with the family?
Speaker: Sure, yes.
Speaker: In COVID-D, in almost 2,100 people, there was only 8% in-person visitation and only 9% virtual visitation.
Speaker: Wow.
Speaker: That means that less than one in five people had any association with the most important people in their lives.
Speaker: Family cannot be treated as a luxury.
Speaker: The family is an incredibly important part of the healing plan for these people.
Speaker: They're not optional.
Speaker: It's like saying, oh, is oxygen optional when your stats are at 60 percent?
Speaker: No, it's not optional.
Speaker: You can't save a person's life.
Speaker: These people are suffering from the absence of their family.
Speaker: And what I wrote an op-ed piece with Rena Odish, who's the author of In Shock.
Speaker: Y'all know who she is.
Speaker: She's amazing.
Speaker: We wrote an op-ed piece in the summer about family visitation.
Speaker: And we talked about how this is really a circumstance of injustice and prejudice.
Speaker: And we called it epistemic injustice, which is also a form of that is testimonial injustice.
Speaker: What it means is that we possess information
Speaker: that the family can't have because we have this knowledge, this amount of knowledge that we don't share with family when they're not present with us.
Speaker: And likewise, the other way around, the family has knowledge that we need.
Speaker: But when we don't have a relationship with the family and when the patient gets excluded from the family, there's all this injustice and prejudice going on.
Speaker: And we know that it has not hit all segments of society similarly.
Speaker: It's hit the people who don't have English as a first language, for example, in the U.S.
Speaker: disproportionately people who migrant workers who can't come to the hospital, etc.
Speaker: So family visitation, I think is a key part of the social justice that we need to pay attention to within the context of COVID.
Speaker: And PPE works, Sergio, we know that PPE works.
Speaker: So there's absolutely no reason now that we don't have PPE shortages that we can't have family in there seeing the patient.
Speaker: So in our unit,
Speaker: there it's open and they can come in in PPE and see the loved ones.
Speaker: You know, at first it was closed even to non-COVID patients, of course, but those days should be over.
Speaker: And I just this week found that with the surge, some of these hospitals are going back to closed family visitation and that just hurt my heart.
Speaker: Yeah, it's a problem.
Speaker: And I think it's better now, but it obviously, like you said, depending on what's going on at each geographic location,
Speaker: it's being limited.
Speaker: And like you said, the other thing that strikes a chord with me, Wes, is pre-COVID, obviously, we had a big push to include families in our rounds.
Speaker: And I always explain to families, but really thought of families as, you are the experts and the human being in that bed, and we need that information.
Speaker: And like you mentioned earlier, that's part of what we're trying to do in humanizing these patients and get the best outcomes for them
Speaker: So we should also be seeking that information, which helps us care better for these patients.
Speaker: Exactly.
Speaker: I totally agree with you.
Speaker: I would like, you mentioned long COVID, which has been, I think, in the press and a lot of interesting publications coming out as we get information.
Speaker: But one of the things that I wanted to ask you was, first, maybe we can talk about surviving COVID-19 in the ICU and
Speaker: On the bright side, it seems that if you have severe disease and you survive, your antibody response is quite robust and prolonged.
Speaker: On the downside, which is really the tragedy, is there seems to be a plethora of side effects, of complications that go on for a while that we're just barely coming to understand.
Speaker: So could you tell us just basically what do we understand by long COVID today?
Speaker: Sure, good.
Speaker: Let's get this terminology straight.
Speaker: First of all, PICS is post-intensive care syndrome.
Speaker: It's the syndrome of ICU survivors who acquired new diseases while they were in their critical illness.
Speaker: And the hallmark of PICS is a neck up problem of three things, mental health, which is depression, for example, PTSD, cognitive dysfunction, like actually acquired dementia, and then neck down,
Speaker: a motor sensory neuropathy, a myoneuropathy.
Speaker: That's what PICS is.
Speaker: So that's part of long COVID.
Speaker: For somebody who's COVID and goes to the ICU and leaves, their long COVID is a part of it is manifested as PICS.
Speaker: But what we also know is that people who never went in the hospital at all with COVID,
Speaker: I've got a patient right now who never went in the hospital with COVID and she has long COVID.
Speaker: She is a so-called long hauler.
Speaker: So a long hauler is a person with long COVID.
Speaker: And at least one in three people with COVID end up with long COVID.
Speaker: So long COVID is the scenario where long after the viremia is gone, the person has ongoing problems in their gut, heart, nerves, mind,
Speaker: um, et cetera.
Speaker: And it, oh, in lungs.
Speaker: And so for example, we could take each organ in the brain, they have brain fog, which is like an ongoing cognitive impairment, kind of a milder version of the dementia acquired after the ICU.
Speaker: They also though have the PTSD and the depression we discussed in the heart, they'll develop a myopathy, a cardiomyopathy or valvular problems.
Speaker: And in the lungs, they develop essentially a cop, a cryptogenic organizing pneumonia where the healing
Speaker: in the lung becomes like a keloid scar.
Speaker: So the lung itself gets keloided and they have chronic interstitial lung disease and hypoxemia.
Speaker: Pancreatitis can develop in the gut.
Speaker: They can also have ongoing diarrhea, dysmotility problems.
Speaker: The muscles and nerves are diseased and there's just that entire spectrum of things.
Speaker: It can even be just chronic headaches, chronic fatigue, and it looks a lot like
Speaker: like chronic fatigue syndrome.
Speaker: And so there's a lot of overlap in those scenarios.
Speaker: This isn't, some people have gotten annoyed by the term long COVID because they said this isn't new.
Speaker: Well, it's true.
Speaker: COVID is viral sepsis, right?
Speaker: So there's nothing qualitatively different, but it's quantitatively different in COVID.
Speaker: For example, in bacterial sepsis, we have clotting,
Speaker: hypoxemia and ARDS.
Speaker: In COVID sepsis, the clotting is worse, the ARDS is worse and longer, and the inflammatory storm is more.
Speaker: So it's quantitatively different, but not qualitatively different.
Speaker: It's the same stuff.
Speaker: Same with the post-viral illness that is chronic fatigue syndrome.
Speaker: Maybe the long COVID is just a worse manifestation of something that other people have suffered from for
Speaker: you know, decades from other viruses.
Speaker: Yeah, it does.
Speaker: And the question I was going to ask you, Wes, which I've been thinking a lot about COVID is starting with everybody that you meet outside of medicine tells you obviously they were impacted by COVID.
Speaker: Like talk about everything is so unprecedented, so unexpected.
Speaker: You never know what's going to happen, which is true, but it's always been true with life, right?
Speaker: life is always unexpected.
Speaker: It's just that it seems like COVID, because it impacted everybody and the size and the magnitude has just amped the volume up where everybody can listen all the time.
Speaker: And the same thing happens, I think, with a lot of what we're seeing at the bedside.
Speaker: I sometimes wonder if I had millions of cases all of a sudden of strep pneumonia, wouldn't we see like ICUs filled with ARDS, all these problems that we're seeing right now with clotting?
Speaker: how much of it is really unique to the virus, but there might be some of it, but how much of it is just, we never had so many cases at the same time in a short period of time of respiratory disease in our lifetime.
Speaker: We've had it in human history for sure.
Speaker: That's exactly right.
Speaker: Good.
Speaker: And like we discussed before we get on today, you know, in the pandemic, the Spanish flu pandemic, this has happened before and humanity has gone through these things before.
Speaker: So we continue to learn
Speaker: and we need to learn from our history but also realize that that this is a it's not as i said it's not new stuff but it's a different manifestation of things that that the human condition has has gone through in in the past absolutely and in terms of of covet and picks which obviously you've had a a tremendous interest in and and and i've had carla on the
Speaker: on the podcast in the past talking about PIC specifically.
Speaker: What are you seeing in terms of what works?
Speaker: There's been some reports suggesting that even for these long howlers, vaccination might be beneficial.
Speaker: But any comments of what we've learned new on these patients other than supportive and recognizing it?
Speaker: I think all the talk about the vaccine helping long COVID at this point, I would categorize it as anecdotal.
Speaker: Do I believe it?
Speaker: I have no idea.
Speaker: I really don't.
Speaker: It's purely anecdotal at this point.
Speaker: There are a lot of people who seem to think that their long COVID got better after the vaccine.
Speaker: I really don't know.
Speaker: For example, with the J&J vaccine, which just this morning got the big stop pulled on it.
Speaker: I think that there's something real to the vascular complications that have happened in the J&J vaccine, but it's so rare that it's 0.001%.
Speaker: So how...
Speaker: common is it that the vaccine helps somebody?
Speaker: Probably in the same rare category.
Speaker: It's vanishingly rare.
Speaker: It may be real, but I have no idea.
Speaker: So the treatment for long COVID is a good, thorough medical workup and taking one day at a time, the problems the person has, making that human being who has the long COVID realize we have no immediate fix for this, but I'm not leaving you.
Speaker: I will be with you.
Speaker: They just want to have somebody present with them as they're going through that.
Speaker: And the first thing we should do for a long COVID patient is validate what they're going through.
Speaker: Quit telling them that it's not real.
Speaker: You know, for them, it is absolutely real and it's a legitimate set of complaints.
Speaker: So the first thing to do is validate them and then to stay with them and to not leave them and to take one day at a time.
Speaker: dealing with each individual problem and doing the best we can medically to handle that person's individual fingerprint of what their constellation of problems is.
Speaker: Yeah.
Speaker: And as you say that, Wes, it just rings so true that that's the same attitude we should have with our colleagues, right?
Speaker: We need to validate what people have been through, empathize with them, and it's okay to not be okay after everything that happened, but we're all in this together and kind of keep pushing forward.
Speaker: which I think is also something that has become very, very relevant post-COVID just because of the volume again and attending to the well-being of those around us and our own.
Speaker: I love that.
Speaker: Let's talk a little bit about lessons learned.
Speaker: Not only, we talked about how we evolved in terms of what we learned about applying these bundles with COVID-19, but
Speaker: Is there anything else you want to mention about the application of the ADF bundles in COVID-19 specific patients that you think is something that is different today than what we were doing in March based on what we've learned?
Speaker: Well, with regard to the D of the delirium in COVID, we know that in sick COVID patients, it's darn near 90% delirium.
Speaker: I mean, it's a crazy high number that at some point,
Speaker: they will have prevalent delirium, not the entire time, but at some point.
Speaker: And in these people, it's incredibly important to remember that that delirium is a barometer of their illness.
Speaker: When they're getting clotting in their brain, lack of oxygen, isolation, et cetera, we have to immediately jump on how can I modify the course of this brain dysfunction for this human being?
Speaker: And the AAF bundle hits on those major topics.
Speaker: We usually use the Dr. Dre, the D-D-R-E, which is diseases, drug removal, and environment.
Speaker: So when somebody with COVID gets delirious, I think, what are the diseases that could be causing this besides the COVID itself?
Speaker: And think about newly acquired sepsis, maybe a nosocomial infection, the drug removal, what drugs can I get off that are deliriogenic, that are psychoactive?
Speaker: But then the most important really letter of the Dr. Dre is the E, the environment.
Speaker: what can I do in this person's environment to help them?
Speaker: They need more sleep.
Speaker: So I need to work on sleep, wake cycles.
Speaker: Do they wear hearing aids and eyeglasses?
Speaker: Because that's very sensory deprivation.
Speaker: If they don't have those used with, if they need them.
Speaker: And then what about, you know, day, night cycles and getting out of bed and mobilization and all these things.
Speaker: And then lastly in the E, the environment is that issue of family.
Speaker: How can I get the family back in front of them, whether it's virtually or in PPE in person holding their hand and,
Speaker: So those are the things that I learned about the bundle that I really try and focus on each day.
Speaker: Absolutely.
Speaker: And what about lessons learned from COVID-19 that you think will have repercussion or implications for non-COVID patients?
Speaker: And there's something specific about family I wanted to ask you, but just share with us your thoughts on that line of thought first.
Speaker: Well, the first thing that happens to me when we think about non-COVID patients is that
Speaker: everybody has been affected whether you had COVID or not because a lot of the hospital policies that have been put in place have affected every single person in the hospital, not just the COVID unit.
Speaker: And so if you have somebody come in with meningitis or appendicitis or polynephritis, you know, and they can't have family visit, well, now they're involved, you know, and their families are involved too, even though nobody in the family has COVID.
Speaker: So COVID has reached its tentacles out
Speaker: in a very dastardly way across the entire healthcare spectrum.
Speaker: And we just have got to keep that in mind because everybody's involved.
Speaker: Absolutely.
Speaker: And one of the things that you mentioned in the D study findings, the D COVID study was that one of the most modifiable risk factors for delirium was obviously family presence.
Speaker: And that only 9% of families actually had a, patients had a virtual visit
Speaker: And that surprised me because when I think of family interactions as a positive, I usually think that we've now leveraged technology that existed before COVID to try to connect families.
Speaker: Now it's not a replacement, but it's better than nothing.
Speaker: And I would have guessed that more than 9% of patients actually got exposed virtually.
Speaker: Any thoughts on how we can magnify that for those family members who can't be at the bedside in the future?
Speaker: Sure.
Speaker: And I'm sure that number has gone up.
Speaker: You know, that was early in the pandemic in the April, May period of 2020.
Speaker: So hopefully that number has gone way up.
Speaker: But remember, though, that there are families, especially poor families who don't have devices and who aren't on the other end of the hospitalization at their houses, don't have the ability to get onto an iPhone or an iPad because they don't even have one of those things.
Speaker: So that's part of the problem right there.
Speaker: And just like children in schools who were isolated at their house from schools had a disproportionate problem in the poor sector because they didn't have computers, these people are likewise disadvantaged.
Speaker: I think that hospitals are much more, though, aggressive about virtual communication right now.
Speaker: I just don't want to see the virtual communication, though, be treated as equal to in-person visitation because they're not the same thing.
Speaker: I agree.
Speaker: And I think that the way I was thinking about it also is that it shouldn't replace.
Speaker: But how many times have we had a family member who was out of state?
Speaker: Right.
Speaker: And pre-COVID, it didn't even occur to us.
Speaker: Let's do a video call.
Speaker: Right.
Speaker: We would just talk with them and give them information and maybe they would speak if they could on the phone with their loved one.
Speaker: But I think you're absolutely right.
Speaker: It's a second best and far from the real solution, which is to have families
Speaker: at the bedside interacting with our patients.
Speaker: Exactly.
Speaker: And you know, I'll chime in here, just another thing that we haven't discussed yet, which is for the listener, look up Maslow's hierarchy of needs, M-A-S-L-O-W hierarchy of needs or Maslow's pyramid, if you will.
Speaker: And Maslow was a famous psychologist who published this paper about Maslow's hierarchy.
Speaker: And Jim Jackson and I published a paper on the application of this pyramid in the ICU.
Speaker: So if you look up ELEEW,
Speaker: Maslow, M-A-S-L-O-W in PubMed, you could find this paper.
Speaker: And what we did was we took his hierarchy and what it does is it starts at the bottom and it says, you know, when we're at our absolute worst in life, we just fight for physiological principles like support for failing organs, mechanical ventilators, vasopressors, dialysis.
Speaker: This is Maslow's application in the ICU.
Speaker: But as you go up that pyramid, up that hierarchy, we get to more and more of what makes us human.
Speaker: Instead of just physiologic, we then get to safety.
Speaker: Can we stay safe?
Speaker: And then we get to love and belonging, like visiting with families and people being on rounds in the ICU and post-ICU support groups.
Speaker: And then we go up two more levels.
Speaker: The next one up is esteem.
Speaker: So we've gone physiologic, safety, love and belonging, esteem, which is respect, team communication, dignity, optimizing pre-illness conditions and that sort of stuff.
Speaker: And then the last one, the highest one of all in the pyramid,
Speaker: is self-actualization.
Speaker: And that really is about incorporating spiritual values into patient care, acceptance of new limitations, a new normal, if you will, for the survivor who has tics or long COVID.
Speaker: And then reconciliation of this new identity, kind of saying, okay, I know who I am now.
Speaker: It's a new normal for me.
Speaker: I accept that.
Speaker: I consent to it.
Speaker: And that way I can have a good quality of life because my actual quality of life is nearer
Speaker: to my expected quality of life.
Speaker: And this Maslow's hierarchy of needs is what we in the ICU do not focus on enough, but it's exactly what the bundle, the A to F bundle tries to get us to focus on, is that getting our patients back to that esteem, love, belonging, and self-actualization.
Speaker: Absolutely.
Speaker: And I will definitely link that paper.
Speaker: Remember that paper that you published, I think it was back in 2014 in Journal of Critical Care.
Speaker: So we will definitely link that and it's a wonderful read.
Speaker: And also, obviously Maslow's pyramid also applies to ourselves as we try to heal and find again self-actualization within our jobs.
Speaker: And it's a great read, but why we wouldn't offer our patients what we want for ourselves, right?
Speaker: So absolutely, I think a great prism to look at the care we deliver at the bedside.
Speaker: Wes, how do we get our ICU teams back on track?
Speaker: I think that what we need to do, and again, I'm not a master of all knowledge here, but we have to help one another realize that what we've been through was a lot and that people are burned out and they're sad.
Speaker: And we need to help each other process that.
Speaker: We need to take time to realize that what we went through was traumatic and that just like there's PICS, there's also PICS F, PICS family, and there's PICS
Speaker: essentially for the ICU team, because we what we went through left us with some handicaps and some depression, probably some PTSD, etc.
Speaker: And we have to care for ourselves.
Speaker: And that sort of self care will help us get healthy again and get us back to where we need to where we will be able to say, how can I serve the other?
Speaker: So we want to serve the other with our whole self and not a burned out kind of shell of ourselves.
Speaker: We're not going to be able to focus, but when we do get to that place of focus, we just have to start with small PDSA cycles.
Speaker: What we learned in ICU liberation from 2010 to 2020, that over a decade of implementation of the A to F bundle is this, you don't try to climb Mount Everest.
Speaker: What you do is you start with small hills.
Speaker: You climb a little hill and then another hill.
Speaker: And a great motto for our ICUs is, what can I do by Tuesday?
Speaker: What small step can I do by this Tuesday?
Speaker: And usually what that looks like, Sergio, is one doctor, one nurse, one patient, not the whole unit.
Speaker: But you say, you know what, Nurse Betty, Dr. Janice, let's go to our patient, Melissa, and let's see this.
Speaker: Melissa has COVID.
Speaker: She hasn't moved.
Speaker: She's been too sedated.
Speaker: Let's get Melissa awake, alert, out of bed.
Speaker: Let's employ the bundle.
Speaker: Let's round on her, saying the bundle out loud, and let's just, the three of us, the patient, the doctor, the family, you know, doctor, the nurse, family, let's figure out how to do it right for her.
Speaker: And then other nurses will see that and say, wait a minute, I want that for my patient.
Speaker: And then once we get it right, we'll be able to move to the next patient.
Speaker: So start small, one day at a time, and that's how we recover.
Speaker: We're going to essentially have to go through recovery.
Speaker: I love that.
Speaker: And what can we do by Tuesday, I think, is a great way to face it.
Speaker: And just one step at a time, but moving the ball forward to really get our patients in the best opportunity they have to recover and get liberated from this terrible critical illness.
Speaker: Wes, we could talk for hours about this topic, but I do want to respect your time.
Speaker: And as you might remember from previous visits with us on critical matters, I do want to ask you some questions that are unrelated to COVID-19 and unrelated perhaps to ICU liberation.
Speaker: Would that be okay?
Speaker: Absolutely.
Speaker: Let's go for it.
Speaker: What book or books have influenced you the most during this last 12 months or what books have you gifted others during COVID that you thought would be helpful?
Speaker: Oh man, I love talking about books.
Speaker: Literature gets me through and it reorients me.
Speaker: And I'm not going to just give you answers to medical books because I'm right now reading several non-medical books, if you don't mind.
Speaker: But, you know, I'd like to start with a classic.
Speaker: I reread Sinclair Lewis's Aerosmith.
Speaker: And some of you have probably never read Aerosmith before, but this is a book that's 100 years old, I guess, about.
Speaker: And the doctor, the title is about a doctor named Aerosmith, and they won a Pulitzer Prize back in the day.
Speaker: And it's a wonderful story of discovery.
Speaker: He actually develops new techniques for dealing with tropical diseases.
Speaker: And Aerosmith is committed to patients
Speaker: and to their wholeness.
Speaker: So it's a beautiful read during COVID.
Speaker: He thinks about what makes someone free and how to be the best doctor to get that person back to freedom.
Speaker: And so, hey, liberation, freedom, that's the same concept, right?
Speaker: Another classic, and then I'll go to some more modern books that I just reread is Steinbeck's East of Eden.
Speaker: And that's where I took the title for my book, Every Deep Drawn Breath, which is coming out with Scribner.
Speaker: uh in in september east of eden is a they made a movie out of it with james dean it was one of the only three movies that james dean ever made before he died in the 1950s and it's a book about human honesty and the kind of like the incredible journey that we can take either for the good or for the bad and and steinbeck writes about some of the the most heinous human characters ever in in novels and some of the most pristinely innocent and and and beautiful
Speaker: characters too.
Speaker: So if you really want a story about humanity, East of Eden is a good one.
Speaker: Now a couple of medical books, can I do those now?
Speaker: Absolutely.
Speaker: Okay, since we're having so much end of life, I recently read three great end of life books.
Speaker: One is Jessica Zitter's book, Extreme Measures.
Speaker: And she is pretty famous.
Speaker: She did a movie series on Netflix, which you can look her up, Jessica Zitter.
Speaker: She's an intensivist
Speaker: and an end of life specialist, palliative care doctor.
Speaker: Angelo Valandes has a great book called The Conversation.
Speaker: It's about a revolutionary plan for the end of life.
Speaker: And Valandes is a Harvard doctor who was a movie maker first.
Speaker: And so what Valandes does is he makes movies to show patients, to try and help them realize what code statuses are, to try and help people say, you know what, I do or I don't want that, but at least I'm honestly telling you
Speaker: based on a better knowledge of what code, getting a code is.
Speaker: And there's a very good set of books by Katie Butler.
Speaker: She was a journalist and she wrote an incredibly good book called Knocking on Heaven's Door about caring for her own dying patients, which is an absolutely beautiful book.
Speaker: And then she had a follow-up called The Art of Dying Well, which is more of a practical guide to good end of life care.
Speaker: And let me just end with one completely unrelated book, which I just finished reading by Anthony Ray Hinton.
Speaker: Some of you have probably read Just Mercy by Bryan Stevenson.
Speaker: He's the famous lawyer from Harvard who went down to Alabama and he formed the, what's called the EJI, the Equal Justice Initiative.
Speaker: And that book, Just Mercy is amazing.
Speaker: One of the main characters in that book was Anthony Ray Hinton, who was falsely accused of murder and was in jail with a life sentence.
Speaker: And he spent all these years
Speaker: in jail for a crime he never committed.
Speaker: Well, he is now out of jail because the Equal Justice Initiative, the EJI, got him off.
Speaker: Finally, thank you, thankfully.
Speaker: And he wrote a book called The Sun Does Shine, How I Found Life, Freedom, and Justice.
Speaker: So look up this book.
Speaker: It's a beautiful book of hope.
Speaker: It's hard to read because you have to go through what all he went through.
Speaker: But this book by Anthony Ray Hinton is an absolute beauty.
Speaker: And I hope that some of these titles help your listeners to find
Speaker: some balance in life because we have to read and learn of other people's stories to understand the perspective of our own lives.
Speaker: Absolutely.
Speaker: And I think one of the fascinating things about reading and literature is that the most important things in life, not only we can't see, but they're universal.
Speaker: And people have grappled with them now, a hundred years ago, a thousand years ago.
Speaker: And people who've been able to express that in writing have something to teach us and something that we can apply
Speaker: today to how we're processing everything that's going on around us.
Speaker: Yeah.
Speaker: Yeah.
Speaker: You know, let me mention one more author.
Speaker: Rachel Clark is a very well-known palliative care doctor in the UK.
Speaker: She's in England.
Speaker: And she wrote two awesome books, which I just read.
Speaker: One's called Dear Life.
Speaker: And it's a story of her own life and relationship with her father, who was a physician and who ends up dying.
Speaker: And then she just wrote one called Breathtaking, which is the inside scoop and COVID.
Speaker: I need to mention at least one COVID book.
Speaker: So this book about COVID in the inside the NHS and national health services in the UK, she has kind of a behind the scenes look because she is in the NHS.
Speaker: And so that book, Breathtaking, is a very relevant COVID book.
Speaker: Excellent.
Speaker: And we'll link all these to the show notes so that people can look them up.
Speaker: But thanks for sharing this wealth of titles.
Speaker: Obviously, some I've read, some I've not.
Speaker: And it sounds like a lot of good things to learn from these books.
Speaker: And we'll be looking for your book in September, Wes.
Speaker: That's exciting, actually.
Speaker: I'm very excited to read that when it comes out.
Speaker: Thank you, Sergio.
Speaker: I appreciate your help today.
Speaker: And thanks for letting me be on.
Speaker: Absolutely.
Speaker: Well, I wanted to end maybe with you asking you if there's something in particular you want to share with all our listeners, something you want every intensivist to know.
Speaker: And that can be our departing thought.
Speaker: Sure.
Speaker: Yes.
Speaker: My parting thought would just be, don't forget why you came to this field.
Speaker: You were called because you have special talents to help serve another human being.
Speaker: And you're going to be able to open up the door to a better survival for your patients by giving them extra days in life, which every day is a gift.
Speaker: But those people who would have died that now because of your service to them will have more time with their family and their loved ones.
Speaker: And by focusing on what matters to them and not what's the matter with them, you can help become the best ICU team member that you can ever be.
Speaker: And I just hope that everybody finds fulfillment in that.
Speaker: And remember, this is a vocation.
Speaker: It's not a job.
Speaker: It's a calling and it's an art.
Speaker: And it's not, you're not a technician.
Speaker: You're not just a provider.
Speaker: You're an artist.
Speaker: And it's that combination of art and science that allows you to serve that other person to the full.
Speaker: I think that's the perfect place to stop.
Speaker: Wes, thank you so much for everything you do and for sharing your time and your expertise with us.
Speaker: Always a pleasure to see you and to talk with you.
Speaker: And I look forward to talking with you soon again.
Speaker: Okay.
Speaker: Thank you, Sergio.
Speaker: Have a great day.
Speaker: Thank you for listening to Critical Matters, a sound podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
Speaker: Sound's transforming the way critical care is provided in hospitals across the country.
Speaker: To learn more, visit www.soundphysicians.com.
