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Every Deep-Drawn Breath: A Conversation with Wes Ely
3 Plays4 years ago
As we start a new year, we look forward with the hope to grow and improve critical care medicine. In today’s episode of the podcast, we will discuss a path forward focused on healing, recovery, and transformation.
Our guest is Dr. Wes Ely, professor of medicine at Vanderbilt University School of Medicine and co-director of the Center for Critical Illness, Brain dysfunction, and Survivorship (CIBS Center). Dr. Ely is the author of Every Deep-Drawn Breath – a wonderful book that will guide our discussion in this episode.
Additional Resources:
Link to the CIBS Center website, which contains a wealth of resources for intensivists on the topic of delirium: https://www.icudelirium.org
Kaleidoscope by Wes Ely: https://pubmed.ncbi.nlm.nih.gov/25599355/
Don’t give COVID-19 long-haulers the Silent Treatment by Wes Ely: https://bit.ly/3GfgJbC
ABCDEF Bundle and Supportive ICU Practices for Patients with Coronavirus Disease 2019 Infection - An International Point Prevalence Study. K Liu, et al. Critical Care Explorations 2021: https://bit.ly/3qepqgS
Caring for Critically Ill Patients with the ABCDEF Bundle - Results of the ICU Liberation Collaborative in Over 15,000 Adults: https://bit.ly/3FeX0Hw
Books Mentioned in this Episode:
Every Deep-Drawn Breath by Wes Ely: https://www.icudelirium.org/every-deep-drawn-breath
In Shock by Rana Awdish: https://amzn.to/3JY9p6n
Arrowsmith by Sinclair Lewis: https://amzn.to/339MJ2m
East of Eden by John Steinbeck: https://amzn.to/3JXpRDN
Recommended
Transcript
Introduction to Critical Matters Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
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And now your host, Dr. Sergio Zanotti.
Impact of COVID-19 on ICU Care
00:00:33
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The COVID-19 pandemic has impacted ICUs all over the world in unprecedented ways.
00:00:39
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The last two years have been extremely difficult and challenging for critical care clinicians, ICU teams, and most notable for ICU patients and their families.
00:00:49
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As we start a new year, we look forward with hope to grow and improve critical care medicine.
00:00:55
Speaker
In today's episode of the podcast, we will discuss a path forward focused on healing, recovery, and transformation.
Introduction to Dr. Wesley Illy and His Book
00:01:02
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Our guest is Dr. Wesley Illy.
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Dr. Illy is a professor of medicine at Vanderbilt University School of Medicine with subspecialty training in pulmonary and critical care medicine.
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Dr. Illy's research has focused on improving the care and outcomes of critically ill patients with ICU-acquired brain disease, manifestly, acutely as delirium and chronically as acquired dementia.
00:01:23
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He is the co-director and the founder of the Center for Critical Illness, Brain Dysfunction, and Survivorship, the Sib Center, which has enrolled thousands of patients into clinical trials
00:01:32
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answering vital questions about ICU-acquired brain disease and other components of ICU survivorship.
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His team developed the CAM-ICU, the primary tool used to measure delirium in ICU-based trials and clinically at the bedside.
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Dr. Ily is also the author of Every Deep Drawn Breath, a wonderful book that we will discuss today, and more importantly, a book that every listener of this podcast must read.
00:01:56
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It's a real honor to welcome him back to the podcast.
00:01:59
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Wes, welcome back to the podcast.
00:02:01
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Thank you so much, Sergio.
00:02:03
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It's really nice to be able to spend time with you today and hopefully talk about things that matter to your listeners.
Motivation Behind 'Every Deep Drawn Breath'
00:02:09
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Absolutely.
00:02:10
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And like I mentioned in the intro, it's been a tough two years.
00:02:13
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We're starting a new year.
00:02:14
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Every new year we have new resolutions and new hope.
00:02:17
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But I think there's a lot to talk about in terms of healing and recovering our ICU teams.
00:02:22
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And I would like to start with the book, Every Deep Drawn Breath.
00:02:27
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It's a phenomenal read.
00:02:29
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I really enjoyed it.
00:02:29
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And we were talking
00:02:31
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before we started recording, just how vulnerable one can become when you write an account like this, and how I feel that I know so much about your life right now and so much to share.
00:02:43
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But the idea really is to use your arc as a clinical investigator and finding your purpose and wonder in terms of applying those lessons to every critical care clinician and every ICU team and caring for our patients.
Writing Patient Stories and Raising Awareness
00:02:57
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So tell me a little bit about the genesis of the book.
00:03:01
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Thanks, Sergio.
00:03:01
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I appreciate that question.
00:03:03
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You know, I have been practicing medicine for over 30 years and I've gotten a lot of gray hair during that time.
00:03:11
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And it's really been my goal the whole time, like it is yours and your listeners, to serve others and just to do the best job I can at being a physician who sees the entire person.
00:03:23
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And I realized along the way that I was just carrying a lot of shame and guilt
00:03:28
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around because I didn't think I was doing that well enough and I was doing it in ways that ended up hurting them.
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So after designing numerous cohort studies and randomized controlled trials and publishing all these hundreds of papers and such, I realized that we were only getting the message of how to do a better job and be more humane at the bedside to those who were reading the scientific papers.
00:03:51
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And I thought, there's a whole world of the patients and families out there who need to get autonomy and need to be empowered
00:03:58
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to advocate for themselves, and so I thought maybe a book would do it.
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And the book is not a memoir, it's a book of narrative nonfiction.
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Every patient in the book, every name is true, there's no made up stories.
00:04:11
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This is, and I didn't even hide any patients' names, it's, you know, you can look these people up on the internet.
00:04:17
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In fact, we have a photo gallery where you can see all their pictures.
00:04:20
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And so it's a devotion to them.
00:04:23
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It's a mission to raise money for them.
00:04:25
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Actually, every penny for the book, including my entire author, advance, et cetera, is being donated into a fund for patients and families of COVID and other ICU illnesses.
Foundation for ICU Survivors
00:04:36
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And I hope that people find their hearts there, Sergio, and that they find that it helps them process their vocation and makes them better at what they do.
00:04:46
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And for the patients and families who read it, the non-medical people,
00:04:49
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I hope it helps them realize that they have a way forward after critical illness to a really full life.
00:04:55
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Absolutely.
00:04:56
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And I think that the arc that you describe over those 30 years has a lot of elements that are obviously universal that not only apply to clinicians and critical care all over the world, but like you said, apply to human beings who have to deal with critical illness.
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And I definitely want to tap into some of those.
00:05:15
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I also want to reemphasize something that you mentioned.
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which is the proceeds of the sales of this book.
00:05:20
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I believe that you should always buy a book to read it, but in this case, you're gonna have a double whammy in terms of benefit because you will read a great book, but you'll also be helping advance survivorship in the ICU, an area that, as we'll discuss post-COVID, is gonna be even more important than it was before.
00:05:37
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It's really true, and let me just chime in on that.
Patient Autonomy and Book's Humanitarian Mission
00:05:40
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What if ICU survivors
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had a way, a group of people who could help them figure out how do I apply for disability?
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How do I navigate the social structures of my re-entry into the world?
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And how do I even deal with insurance claims, for example, etc.
00:05:57
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So the, I call every deep drawn breath abbreviated EDDB, every deep drawn breath.
00:06:03
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So we're setting up an EDDB foundation for survivors.
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And what we're doing is we're going to hire insurance specialists, disability specialists, and social workers and make them available to critical care survivors from anywhere, all over the United States, Canada, Latin America, Europe.
00:06:20
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And they can come to our CIBS Center.
00:06:22
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That's our research center here at Vanderbilt.
00:06:24
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And the CIBS is C-I-B-S.
00:06:26
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It stands for Critical Illness, Brain Dysfunction, and Survivorship.
00:06:31
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And so the idea was, let's write a book.
00:06:35
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That is not even really a medical book.
00:06:36
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I don't even think EDDB is a medical book.
00:06:38
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I think it's a book about people in life and with these the bravery of these people's stories.
00:06:44
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And there's a ton of social justice in there, too, because medicine within medicine, the goodness of medicine.
00:06:50
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We have a lot of elements of injustice, too, and we have to fix those things.
00:06:54
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So, yes, the reader will know that they are part of this mission.
00:06:59
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And to that end, you know, once you read it, leave a review on Amazon, leave a review on Goodreads, because when you do that, it draws more people in.
00:07:06
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And then we make more money for this foundation.
00:07:08
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And we're going to we're going to have this set up for, you know, for in perpetuity going forward to help these people rebuild their lives.
Impact of the Book on Clinicians
00:07:16
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And I'll push back a little bit there, Wes, on your comment that it's not a medical book.
00:07:20
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I would say it also is a wonderful medical book, because I can guarantee that any clinician who reads this book and looks at the resources you put there.
00:07:29
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be a better physician period i hope so i believe it's a medical book as well i did get nerdy with it i mean anybody who reads this book will find the complete references for any of the science that i put in this book and there's an immense amount of science in there i just wrote it in a way that non-medical people would hopefully find it easily easy to follow and you know
00:07:52
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My cousin is a Rhodes Scholar, so he's actually a very smart guy, but he called me yesterday, he's 70, in his mid-70s, and he said, Wes, I would never read a book like this, but I just found it so captivating and I couldn't stop.
00:08:04
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And, you know, he'll never look at those chapter notes with the references, but for the scientists listening, all the references are there and you can find the papers.
00:08:13
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Absolutely.
00:08:14
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And if you're a graduating fellow and you don't know where to start, pull those references and you'll be an expert.
00:08:20
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There it is.
00:08:22
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Excellent.
00:08:23
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So they say that that that everybody has a book in themselves.
00:08:28
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But unfortunately, very few people share share that book with with the world.
00:08:33
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But tell me about what has been the most rewarding of this whole process, because I'm sure it's been a journey.
00:08:40
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I think that.
00:08:41
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being able to pay tribute to these brave patients and hearing their story.
00:08:47
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I really kind of consider myself a pencil.
00:08:50
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I listen to people's stories and I write them down.
00:08:53
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And I've been doing that ever since I was a medical student.
00:08:55
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And I had had these stories just piling up in my life.
00:09:00
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And you know, what's really funny is that I was
00:09:03
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cogitating about if I should ever write a book.
00:09:06
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And Rinna Odish, who wrote In Shock, which is a legendary book in critical care, was in my office one day and she said, you should write a book.
00:09:14
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And so I just listened to her and I did.
00:09:16
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And she was the one who sparked me to do it.
00:09:20
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I have drawers full of their stories, I have transcriptions of the actual words these people said, and so the quotes in the book, I really took an investigative journalism approach, and they're all verbatim quotes.
00:09:31
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I mean, I didn't make any of these quotes up, they're verbatim, and that's what made it so much fun, is that I knew I was being truthful to their story in honoring them, and that's really been fun, and to be able to put together a photo gallery with all their pictures, and have people be able to go and find, oh, there's Marcus Cobb, there's
00:09:49
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You know, Clementine Hunter, there's Maya Angelou, there's John Prine.
00:09:53
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I mean, they're in the book, too.
00:09:55
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So that's been a real honor to show these people for who they actually are.
Seeing Patients as Whole Individuals
00:10:00
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And I think it points to maybe one of the first big lessons, right, which has to do with humanizing the people we treat and really understanding the humanity in those patients that lie in our ICUs.
00:10:16
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which I think is often something that we lose.
00:10:18
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I only practice critical care.
00:10:20
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One of the things that I have learned through your work, Wes, and your team is that there's a lot that happens after I have high-fived my team when somebody left the ICU and proclaiming victory that is not so bright and sweet, right?
00:10:36
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It's so difficult.
00:10:37
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And at the beginning of the book, I talk about the first patient I ever had.
00:10:41
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Her name was Sarah Balik.
00:10:43
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And she was a young woman who had had a baby
00:10:46
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And just in terms of humanizing her, you know, listen to this just paragraph.
00:10:50
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She has this peripartum cardiomyopathy and she's,
00:10:54
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basically in shock in the ICU and I'm a student and she says, what's happening to me, Dr. West?
00:10:59
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She asked again and again, or why can't I be home with my baby?
00:11:03
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Unsure of myself and my nascent knowledge, I fumbled through some facts.
00:11:06
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Her blood pressure was too low.
00:11:08
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Her heart was failing.
00:11:09
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We hoped it would improve.
00:11:11
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We both knew she was likely to die.
00:11:13
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I could see it in her eyes and I'm sure she could see it in mine, but she continued to trust me and my medicine.
00:11:19
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And you know, I'll never ever forget her and her eyes, the way she looked at me,
00:11:24
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I feel right now I can feel her skin, me touching her hands, holding her hands.
00:11:29
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And I won't tell the reader what happens next in her life, but I'll never forget any of those details because she was an entire person to me, just like your patients are entire people to you.
00:11:40
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And that's why medicine is more, our goal has to be more than benevolence.
00:11:44
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Benevolence just means doing good.
00:11:47
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I mean, wishing good, hoping for good, but beneficence is actually doing good.
00:11:52
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And all of us know along the way that despite our desire to do good, sometimes we don't.
00:11:58
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And so critical care in the 90s and early 2000s was causing an immense amount of harm.
00:12:04
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And we worked for 15, 20 years, enrolled tens of thousands of patients in trials to get it better.
00:12:09
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And by 2018, 2019, we had made a ton of progress and then COVID hit.
00:12:14
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And we have had a major backpedal in the degree of goodness because now we're doing things to people that we've already proven hurt them and cause long-term cognitive dysfunction and physical disabilities.
Regression in ICU Care Due to COVID-19
00:12:27
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we're going to have to find our way back Sergio.
00:12:29
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Absolutely and I want to touch on two points and a little bit deeper on that one is that what you described that first patient and charity when you were a medical student and it's important for all our listeners to remember that we all had that at one point that connection and that sense of wonder and when we lose that it's important for us to dig deep and try to find it again
00:12:55
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right?
00:12:55
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That's what took us to medicine in the first place.
00:12:57
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And I think that sometimes I see colleagues forget that or lose track of that.
00:13:03
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And I think it causes a lot of harm, not only to our patients, but to our colleagues as well.
00:13:10
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And the second thing that I think is also important there in terms of COVID, what we'll touch about is how COVID impacted our progress.
00:13:23
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But before we go to that,
00:13:24
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One last question regarding the book itself is, what has been the biggest surprise, Wes, with publishing EDDB?
00:13:34
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Well, I think the biggest surprise is that people who, like us, who do medicine and think that we need to get our directions from the published peer-reviewed literature have come out of the woodwork to me and say, whoa, you've
00:13:49
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this book EDDB changed the way that I think and I don't want to live the way I used to as a doctor or nurse
Challenges in Implementing ABCDEF Bundle
00:13:56
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or a respiratory therapist anymore.
00:13:58
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I want to be a different sort of healthcare professional and what a privilege to be part of their journey now but also how amazing that I could bring to life these patients on the pages of EDDB and these people could find their heart and say
00:14:16
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oh my gosh, with all my science, I'm now going to become a new kind of healthcare professional, a new kind of nurse, pharmacist, OT, PT.
00:14:26
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And that's just a real gift to me to be a part, a widget in their journey.
00:14:30
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Yeah.
00:14:31
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And I think it speaks to the power of story, right?
00:14:34
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We've known this, I mean, for centuries, that the only thing that really moves us is stories.
00:14:41
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And data might be interesting, but it's stories that move people to action.
00:14:46
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And maybe that's a little bit lacking in the scientific literature.
00:14:50
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Obviously, we need the data, but I think when you can connect data that's been scientifically rigorously obtained with great stories, you have a winning combination.
00:15:02
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I hope so.
00:15:04
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So let's talk about COVID.
00:15:06
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You did mention it, and we've talked about this in previous episodes of the podcast.
00:15:10
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but clearly you have been pushing forward and moving our assumptions of what we were doing in critical care as being positive to recognizing that it can be harmful and recognizing that there's a better way forward.
00:15:25
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And we were definitely, I think, making progress in many places.
00:15:28
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And then COVID-19 came and it feels like it's back to 1990s.
00:15:33
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So what happened, Wes?
00:15:36
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Yeah, let me just read a little bit from EDDB.
00:15:40
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This is in the epilogue where I come back to COVID.
00:15:43
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COVID is strewn throughout the book.
00:15:47
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Listen here.
00:15:48
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If mad scientists had schemed to create the greatest number of people with delirium and PICS, post-intensive care syndrome,
00:15:55
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COVID-19 and our early response to the pandemic would have been their devious ploy.
00:16:00
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In the initial panic, we focused on getting our patients on ventilators, sedating them heavily, and didn't pause to think about the downstream effects.
00:16:07
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We isolated our patients to save our supplies of PPE, stopping early mobility and physical therapy sessions, and we prevented friends and families from visiting.
00:16:16
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Dr. Robert Heise, ICU director at University of Michigan, told me, doctors had a fear of exposing nurses and ourselves to the virus.
00:16:23
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This drove our willingness to deviate from established practices.
00:16:27
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Keeping sedation going should immediately trigger fear, but it didn't.
00:16:31
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That worry was drowned out in our minds by earned fatigue, sore noses from N95s, hunger, and the need to go to the bathroom on a long shift wearing PPE.
00:16:41
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And the patients don't know about PICS yet.
00:16:44
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And then one more paragraph here.
00:16:46
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When I spoke with Elizabeth Riviello, ICU doctor at Beth Israel, Harvard in Boston, her words were similar.
00:16:52
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The risks of PICS in patients who we sedate too heavily and too long is less dramatic and further away from our thoughts than the need to save their lives immediately.
00:17:01
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We give in to more immediate fears and we keep people sedated.
00:17:05
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And that's really what happened, Sergio, is that we gave in to the old way of doing things, even though we know through absolutely hardcore science, Lancet, New England Journal, JAMA papers, that it hurts people, we gave in.
00:17:20
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And right now, as we speak, thousands of people are getting a 1990s form of critical care that we had to unlearn
00:17:31
Speaker
between 2005 and 2019, and now we're going to have to unlearn it again.
00:17:35
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Because new trainees, they think this is how you practice critical care now.
00:17:40
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Absolutely.
00:17:41
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And it's also interesting, Wes, that you mentioned this.
00:17:45
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And I think there's a quote in the book that Mandela made regarding his hope for actions to be based on hopes versus fears, right?
00:17:55
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Yes.
00:17:55
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And we definitely acted out of fear.
00:17:58
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And what I find remarkable is that
00:18:01
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every wave pushed us back again.
00:18:04
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We thought we had learned, but then you realize you're in the midst of another, like the last Delta wave here in the South of Texas, you're back where you were before.
00:18:13
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And I think that it's been very difficult and we definitely have to find a path forward.
00:18:18
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And we'll talk a little bit about that.
00:18:20
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But what I would like to ask you, Wes, is just to hear some of your comments in terms of, obviously you've been a big reason why
00:18:29
Speaker
A lot of people talk about the A to F bundles in the original ABC trial, but also as these continue to grow, you're focused on delirium.
00:18:39
Speaker
But it seems that, like you said in your eloquent paragraph, that we couldn't have planned a better ploy to destroy the A to F bundles than COVID-19.
00:18:49
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And if you can maybe comment on, I'll give you a couple of the elements, and you can just comment on what happened and what we have learned.
00:18:56
Speaker
So maybe we can start with the ABCs.
00:18:59
Speaker
Sure.
00:18:59
Speaker
Absolutely.
00:19:00
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Just for the listener, you know, so a, it's funny, back in 2005, when we designed our first ABC study, which was published in Lancet.
00:19:09
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And that study, by the way, for the listeners is the first study to ever show an overt survival advantage reduction in mortality, just by reducing sedation.
00:19:19
Speaker
And we did it, it was clear cut, we had a 15% absolute risk reduction in death
00:19:25
Speaker
just by cutting propofol,
Managing Delirium in ICU Patients
00:19:27
Speaker
fentanyl, and benzos in half.
00:19:31
Speaker
And that's why it was published in Lancet.
00:19:32
Speaker
And then it was called the awakening breathing coordination, but then we added delirium as a D, and then E as early mobility, and F as family.
00:19:41
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And what happened was the pain gurus were mad that pain wasn't explicitly listed.
00:19:47
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We always covered pain first, but we eventually made the A into analgesia.
00:19:51
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So now A is make sure we cover pain, analgesia, and then B is both SATs and SBTs, which is turning off drugs and turning off the ventilator every day.
00:20:00
Speaker
That's two New England Journal papers, one of which was my SBT paper in the New England in 1996.
00:20:06
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That was my chief resident research project, actually, which was kind of a great way to start in academics in the New England Journal.
00:20:14
Speaker
I got lucky with that one.
00:20:17
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But we know that this ABCDEF bundle works, and the ABCs is really just making sure their pain is controlled, waking them up every day, and turning off sedation just to see how things go.
00:20:28
Speaker
And one of my fellows who
00:20:31
Speaker
Bud Hollis, but Hollis, Bud O'Neill, he's from Vanderbilt, but now he's back in Louisiana.
00:20:36
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He was telling me, and this is in EDDB, that during the New Orleans surge, I know if you remember, it was New York, Michigan and New Orleans, which were really surging hugely at the beginning.
00:20:47
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And he said that there's a quote, we hear some physicians recommend radically new approaches to COVID-19.
00:20:54
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All I know is that deviating from life saving methods proven over 20 years will be more harm than good.
00:21:00
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For my patients, I'm sticking to the A to F bundle.
00:21:04
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We know it works.
00:21:05
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And just what a beautiful, you know, succinct way of saying
00:21:10
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hey, why would we not do what we know works?
00:21:16
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And we have to realize that humans deviate all the time from things we know best to do because human factors enter in like, I'm tired, my beeper went off, I need to go eat.
00:21:27
Speaker
And so then you don't mobilize your patient, you don't give them the rehab they need, or you don't connect them with their loved ones, and then they suffer.
00:21:37
Speaker
Yeah, absolutely.
00:21:38
Speaker
What about delirium?
00:21:40
Speaker
The D. You know, we were talking before we got on about the nurse, now she's a DNP, Doctor of Nursing Practice, Brenda Punn, who's been with me since the very beginning.
00:21:54
Speaker
She knocked on my door in 1998, and that knock, I opened the door, and I was actually the Director of Lung Transplant at Vanderbilt at the time.
00:22:05
Speaker
she said, hi, I'm a nursing student at Vanderbilt, and I heard you're doing, maybe thinking of doing some work in delirium.
00:22:11
Speaker
Do you have a nurse yet?
00:22:13
Speaker
And you know, we've been working together for 25 years.
00:22:16
Speaker
She helped me develop the CAM ICU.
00:22:19
Speaker
We went on to prove that delirium is one of the most robust predictors of death in the ICU.
00:22:25
Speaker
It's also a predictor of three other important things, increased cost of care, increased length of stay, and increased dementia.
00:22:33
Speaker
So the D of the bundle just says to us, Sergio, every patient every day should be evaluated for are they delirious or
Role of Family in Patient Outcomes
00:22:42
Speaker
not.
00:22:42
Speaker
And if they are, then we should hit them with an approach to reduce that delirium duration.
00:22:49
Speaker
And what we use is called the Dr. Dre.
00:22:52
Speaker
It's just D-D-R-E, which stands for diseases like sepsis or COVID or COPD or, you know, whatever could be creating the delirium.
00:23:03
Speaker
Diseases, drug removal, and that's not adding drugs, but getting rid of things that are psychoactive, benzos, for example, or propofol, and then environment.
00:23:13
Speaker
So DDRE, diseases, drug removal, and environment.
00:23:16
Speaker
At the environment, you just think to yourself, how can I restructure this patient's diurnal cycle, make sure that day is day, night is night, and then also put their eyeglasses on, put their hearing aids on, talk to that person, and most importantly of all, get them out of bed,
00:23:34
Speaker
and in touch with their loved ones because mobilization and family which is the e and the f that cuts delirium and both of those cut delirium in half and if we cut delirium in half we're going to see people surviving more often we're going to see them having less dementia and getting out of the hospital and back to their their life you know back to where they were before absolutely and i think that if you look at the the dr dre mnemonic and you apply that to covet
00:24:00
Speaker
You got a disease that is novel and involves the whole body.
00:24:03
Speaker
Like I think you mentioned in the book, the lung bone is definitely connected to the brain bone, right?
00:24:09
Speaker
I mean, so clearly it impacts.
00:24:11
Speaker
You got a boatload of drugs that are now on top of that, that we weren't using as much.
00:24:18
Speaker
So there's plenty of opportunity for removal and you've totally destroyed the environment.
00:24:23
Speaker
You have now the worst environment that I have seen in my career in an ICU.
00:24:28
Speaker
with PPE, isolation, and negative pressure, makeshift fans that make constant noise, and no families.
00:24:37
Speaker
So clearly, I mean, like you said, it's like the perfect storm.
00:24:40
Speaker
I remember when we were in the no isolation period, and right now in 2021, we have open visitation in our ICU.
00:24:47
Speaker
So if you don't have COVID, the doors are wide open and people just come and go.
00:24:52
Speaker
It's the old way, which is wonderful.
00:24:53
Speaker
And I know there are people listening who don't have that yet,
00:24:56
Speaker
and I'm saying it on purpose so that you can advocate for this humanism because people die of loneliness.
00:25:02
Speaker
People die of not having the people they love around them because they forget their purpose and their why.
00:25:07
Speaker
You know, Viktor Frankl said in Man's Search for Meaning four times, he quotes Nietzsche when he says, if a man has a why to live, he can get by with almost any how.
00:25:21
Speaker
And that beautiful quote that Frankel, you know, said four times in his book after he got out of Auschwitz really helps me every day to remember, I need to help my patients find their why to live.
00:25:32
Speaker
And what is a better why than your wife or your husband or your son or your uncle or your best friend?
00:25:40
Speaker
So we've got to get them back in there.
00:25:41
Speaker
So Vanderbilt's reopened visitation.
00:25:43
Speaker
For COVID units, the patients go, the families go in with PPE into the COVID room.
00:25:48
Speaker
even when they're on the ventilator and everything.
00:25:50
Speaker
So we've gotten that improved dramatically.
00:25:52
Speaker
But what I was going to tell you was this story was that the very beginning when we had none of that, and we were practicing what I call anti-medicine, I said to the, I had this young woman, she had lupus and she was dying of lupus cerebritis and
00:26:06
Speaker
her family has allowed me to use her story, but I won't mention her name or anything.
00:26:09
Speaker
But I said to the administration, I'm bringing her family in.
00:26:12
Speaker
And they were like, no, you can't.
00:26:13
Speaker
I was like, well, no, they're coming in.
00:26:16
Speaker
And I just said, no, they're coming in.
00:26:17
Speaker
So the mother and the husband, the mother and the father came into the room of this young 20, upper 20s year old woman.
00:26:26
Speaker
And when she took her mask off to be with her daughter, I,
00:26:32
Speaker
knew her.
00:26:33
Speaker
These people did not have COVID.
00:26:34
Speaker
This was a non-COVID room.
00:26:35
Speaker
So she was able to take her mask off and talk to her daughter.
00:26:38
Speaker
And she was a checkout person at my local grocery store.
00:26:42
Speaker
And we knew one another.
00:26:44
Speaker
And I thought, wow, this is what humanity is all about.
00:26:47
Speaker
If I had not allowed her in here, I wouldn't have even known that my patient was this woman's daughter or ever made that connection.
00:26:53
Speaker
And that's no way to be a physician, right?
00:26:57
Speaker
That makes no sense.
00:26:58
Speaker
So we have to make sure that we uphold the values and the principles of our profession.
Human Connection in Medical Practice
00:27:06
Speaker
And I think you speak about that a lot in your journey in the book is so many of us, when we were asked what's most important, especially at the beginning of COVID would say peep, proning, this, that.
00:27:24
Speaker
And it's not, right?
00:27:25
Speaker
I mean, clearly it's about understanding the person who lies in that bed and everything that surrounds them.
00:27:33
Speaker
And I think that's something that we definitely have lost during COVID in many places.
00:27:39
Speaker
Completely.
00:27:40
Speaker
Absolutely, we've lost that.
00:27:42
Speaker
And we can't afford to lose that because if we do, we disconnect ourselves as people from these human beings that we're there to serve
00:27:53
Speaker
You know, when Osler talks about equanimitas and his famous speech that was 100 years to the date that I graduated from medical school, my mother gave me that book, you know, when I was a medical student and I took that, I really, it became an overused asset for me because I thought that equanimity, that even keeledness is the way I've got to practice.
00:28:17
Speaker
And I think I allowed myself to remove
00:28:21
Speaker
the interpersonal connection, the deep interpersonal connection for my patients.
00:28:25
Speaker
And I don't really want to live like that as a physician anymore.
00:28:28
Speaker
Equanimity is a good thing, no question, but it can be overused.
00:28:34
Speaker
And in COVID, it's really easy to overuse that because there's already so many forces pushing us to distance ourselves with masking and everything.
00:28:41
Speaker
So we have to, I have to actually fight against that now to get back kneeling, holding their hands, looking in their eyes,
00:28:51
Speaker
and to establish that really intense personal connection that I know they deserve from me as their doctor.
00:28:57
Speaker
Yeah.
00:28:57
Speaker
And I think another way of looking at equanimity is also a very highly discussed and valued virtue in the stoic philosophy.
00:29:08
Speaker
And what Marcos Aurelius, and I mentioned him in previous podcasts about with delirium with you, would probably argue is that what it really means about is focusing on the things we do control.
00:29:18
Speaker
Right.
00:29:19
Speaker
And having that even keel on what we control and we absolutely control how we treat other human beings.
00:29:24
Speaker
And I think that's there's a difference of being being even killed and not necessarily being detached.
00:29:33
Speaker
Right.
00:29:33
Speaker
So the idea is you have to lean in more to our to our to our patients lives.
00:29:37
Speaker
And I think that's where we've been wrong many times and with COVID even worse.
00:29:41
Speaker
Oh, I love that you brought up Marcus Aurelius and stoicism.
00:29:45
Speaker
And I think about what you said about what we can control.
00:29:48
Speaker
And I think as a doctor, no, just forget that as a human being, as a person, it takes courage to change the things that we can change.
00:29:59
Speaker
And, but we have to seek out and try and cultivate courage to change the things we can.
00:30:06
Speaker
And those aspects that we can't change, of course, you know, that's out of our control.
Scientific Studies Supporting the ABCDEF Bundle
00:30:11
Speaker
But there are so many ways right now in medicine that we can modify care for patients to improve the ability of the A to F bundle to be enacted.
00:30:24
Speaker
And by the way, the A to F bundle has got 35 to 40 New England Journal, Lancet, and JAMA papers behind it, and over 400 peer reviewed papers generally.
00:30:32
Speaker
So for anybody who thinks this is warm and fuzzy, think again.
00:30:36
Speaker
This is hard science that we're talking about applying
00:30:38
Speaker
But the beauty is that it brings a human touch into the arena of technology that we live in.
00:30:45
Speaker
And so it's allowed me, Sergio, to push touch in front of technology.
00:30:51
Speaker
The A to F bundle allows me to put touch first and technology second, whereas for 20 years, I was kind of living with that in reverse, which I no longer think is the best way to practice medicine for me.
00:31:01
Speaker
Absolutely.
00:31:02
Speaker
And I want to wrap up the A to F bundle discussion with the last two elements, which are E and F.
00:31:07
Speaker
which are, I think, well, I don't know, maybe that's, but probably of all the elements, the ones that were assaulted by COVID the most, and yet these are not, oh, it's great to do if we can, optional, because as you said, and you can talk about this, both early mobility and family presence have a real therapeutics benefit on
Therapeutic Benefits of Early Mobility and Family Presence
00:31:31
Speaker
outcomes.
00:31:31
Speaker
And if you could comment on what has happened and why it's so important for our clinicians
00:31:36
Speaker
to go and tell their administrators, I'm bringing in the family of this dying patient.
00:31:41
Speaker
What you're telling me makes no sense.
00:31:42
Speaker
We got to get up and walk these patients.
00:31:45
Speaker
We do.
00:31:45
Speaker
And, you know, there's a great story of Polly Bailey going to Johns Hopkins.
00:31:50
Speaker
Polly is in the book a lot.
00:31:52
Speaker
And she was one of the first people in Utah that helped to start the mobilization movement, along with Chris Permy, who's a physical therapist in Houston.
00:32:00
Speaker
And her story is amazing for the reader.
00:32:03
Speaker
She
00:32:04
Speaker
comes from Latin America, gets lost on a ship at sea, just with a desire to be a physical therapist in the United States, and she has to climb down a rope to get into a dinghy in the New Orleans Harbor, a couple of miles away from where I was actually a medical student at the time.
00:32:19
Speaker
She walks the first people on the ventilator in the United States, and then years later, Polly Bailey does the same thing with Joy Sunloff.
00:32:26
Speaker
All that is told in the book,
00:32:28
Speaker
And when Polly was asked by Roy Brower, the famous six versus 12, you know, intensivist at Johns Hopkins of Ard's Net fame to come to Hopkins, every bed that they went to, Roy said, well, Polly, what would you do now?
00:32:42
Speaker
And she tells the story that, well, and he tells the story too, I would stop sedation.
00:32:47
Speaker
And they get to the next bed, what would you?
00:32:49
Speaker
It's like a broken record.
00:32:50
Speaker
I would stop sedation.
00:32:51
Speaker
And it brings me to something I want to share with the reader from chapter nine, which was the chapter on awakening change.
00:32:56
Speaker
Can I read just a couple of things from that?
00:32:59
Speaker
Go ahead.
00:33:00
Speaker
Okay.
00:33:02
Speaker
In March 2012, I stood outside a daffodil yellow cottage with a red tiled roof on a cobblestone street in Odense, Denmark, 100 miles west of Copenhagen.
00:33:12
Speaker
Two centuries earlier, this quaint building had been the childhood home of writer Hans Christian Andersen, and as I peered through the windows, I wondered if I might be about to encounter my own modern-day fairy tale.
00:33:25
Speaker
And the reason I begin with that is that a few months before I was there in 2012, Thomas Strom had published this paper in Lancet of no sedation.
00:33:35
Speaker
And see, no sedation allows you to wake people up and then allows you to do what you just asked to talk about, E and F, which is early mobility and family, because if they're sedated, you can't mobilize them and they can't interact with their family.
00:33:47
Speaker
So the E to F hinges on this thing that Thomas Strom brought in.
00:33:52
Speaker
And at the end of the chapter,
00:33:54
Speaker
I talk about when I came home from that, and this is the title track of the book, so I want to read you these two paragraphs, because I got home from there and I thought, you know what, this isn't a fairy tale.
00:34:04
Speaker
And last week, Sergio, I had a woman in the ICU who was a new mother, had just delivered a baby, and she was on 40 of propofol, 300 of fentanyl, deeply sedated when I came on service.
Incremental Changes in ICU Practices
00:34:15
Speaker
And I thought, no, we can't do this to her.
00:34:18
Speaker
If we do this to her, she won't be able to take care of her four children.
00:34:21
Speaker
And so we dramatically restructured her sedation approach that day.
00:34:25
Speaker
By the end of the day, she was on 70% instead of 100% FiO2 on pressure control.
00:34:31
Speaker
And we were inching way stronger towards the issue of no propofol.
00:34:35
Speaker
She was on no propofol, no benzos, and it was a much better thing.
00:34:39
Speaker
But when I got home from Copenhagen, I wrote this in the book.
00:34:45
Speaker
Since my mother's summer book club, I'd loved reading Steinbeck, inspired by his empathy towards the underdog.
00:34:52
Speaker
In his magnum opus, East of Eden, there's a passage that describes the exhilaration of being alive and how the joy colors the world with promise.
00:35:02
Speaker
Quote, sometimes a kind of glory lights up the mind of a man.
00:35:06
Speaker
It happens to nearly everyone.
00:35:08
Speaker
You can feel it growing or preparing like a fuse burning towards dynamite.
00:35:12
Speaker
It's a feeling in the stomach.
00:35:14
Speaker
a delight of the nerves of the forearms.
00:35:16
Speaker
The skin tastes the air and every deep drawn breath is sweet.
00:35:21
Speaker
That was how I felt after Odinza.
00:35:23
Speaker
I returned home to Nashville with a sense of excitement and urgency and freedom I had not felt before.
00:35:28
Speaker
I didn't have to practice medicine in the same old way.
00:35:31
Speaker
As our girls finished up their homework, I talked with Kim, my wife, walking with her through the soft dark of our neighborhood.
00:35:37
Speaker
I heard the enthusiasm in my voice.
00:35:39
Speaker
I could hardly wait to get back to the hospital.
00:35:42
Speaker
In my mind, I was already seeing my patients out of their beds and walking the wards just days after being admitted to the ICU.
00:35:49
Speaker
How will you do it, she asked.
00:35:51
Speaker
And that's, Sergio, where we have to start with the question, how will we do it, right?
00:35:58
Speaker
And why don't you think out loud with me a little bit, Sergio, about you are director of all these ICUs.
00:36:03
Speaker
How do you see us doing it?
00:36:04
Speaker
And what's the way forward?
00:36:06
Speaker
I'd love to learn from you.
00:36:07
Speaker
Well, and I think that
00:36:10
Speaker
You mentioned also this in one of the, when you started teaching before COVID, the A to F bundles is what can you do next Tuesday?
00:36:18
Speaker
So maybe you can say, what can I do the next time I'm rounding in the ICU?
00:36:23
Speaker
Right.
00:36:23
Speaker
And there is opportunity with every patient to start moving the needle.
00:36:28
Speaker
And we'll talk a little bit later is as we try to find the path forward, I do believe that we should just take a beginner's mind, like we've never heard of A to F and start from zero.
00:36:39
Speaker
and applying that to our patients step by step at every ICU.
00:36:44
Speaker
I also wanna mention, Wes, that I think that the Odenza experience, it is also very important in terms that no matter how good you are with this, I mean, you've been studying this your whole life, yet you go to a place that's teaching you a new trick and you're in wonder, right?
00:37:00
Speaker
So no matter how good an ICU thinks they're doing the A to F, there's plenty of room for improvement.
00:37:06
Speaker
So I don't want to hear that, oh, we do it already.
00:37:08
Speaker
No, no.
00:37:08
Speaker
What can you do tomorrow to move the needle?
00:37:11
Speaker
And one patient at a time, I think you start moving in the right direction.
00:37:15
Speaker
And then you obviously want to be able to capture what you're doing to measure it so that we really can manage and move
Dangers of Depersonalizing Patients
00:37:20
Speaker
forward.
00:37:20
Speaker
But I think that's really the way forward, just the baby steps.
00:37:24
Speaker
Like you saw this patient who's heavily sedated and just working on that individual patient starts moving the needle.
00:37:31
Speaker
Exactly.
00:37:32
Speaker
That's a beautiful way of putting it.
00:37:33
Speaker
And I want to give people a way of measuring in their own mind how they think they're doing with that.
00:37:38
Speaker
You know, I talk in the book about my own personal kaleidoscope and the way that I like to look at the unit as a kaleidoscope with everybody's bright colors that they bring in.
00:37:47
Speaker
And I've been mesmerized by kaleidoscopes all my life.
00:37:51
Speaker
I wrote a piece in the Annals of Internal Medicine entitled Kaleidoscopes.
00:37:54
Speaker
If somebody wants to read that original piece, it's in the section called On Being a Doctor in the Annals of Internal Medicine.
00:38:01
Speaker
But the reason that the kaleidoscope works for me in my life as a doctor is that when you look through a kaleidoscope, you see reds and greens and blues and oranges and all the colors.
00:38:10
Speaker
And that's what people are to me.
00:38:12
Speaker
People are all of those fascinating things that make them up.
00:38:17
Speaker
You know, their love of pizza or Chinese food or whatever it may be.
00:38:22
Speaker
And then their love of art and music and all these things.
00:38:26
Speaker
So is it okay to run them through
00:38:30
Speaker
what I'll call a depersonalization chamber, where instead of seeing them in color, we see every ICU patient now in gray tones.
00:38:38
Speaker
So everybody runs through the depersonalization chamber, and now all we see is lumps on a bed where Thomas Petty said, it looks like to me that they're dead except for the monitors that tell me otherwise.
00:38:49
Speaker
And Thomas Petty makes an appearance in the book.
00:38:51
Speaker
He's there.
00:38:52
Speaker
It's amazing that he and I got to interact, and I got to meet him and learn from him
00:38:59
Speaker
we can't fully take care of a human being in gray tones.
00:39:04
Speaker
It doesn't work because real people don't, they aren't in black and white, they're actually in color.
00:39:10
Speaker
And when we practice critical care, like they're in black and white, it depersonalizes them.
00:39:17
Speaker
It takes away their dignity.
00:39:19
Speaker
It doesn't take away their dignity, but it hides their dignity because dignity is innate.
00:39:23
Speaker
It's innate in every person.
Long-Term Consequences for ICU Survivors
00:39:26
Speaker
but it hides it and it doesn't let it shine like it needs to.
00:39:30
Speaker
And I hope that people will think about that and ask themselves this question, am I practicing in gray tones or do I see this person in vivid color like as if it's a kaleidoscope?
00:39:43
Speaker
I think that's a beautiful analogy and I would definitely reference in the show notes a lot of the books and the articles that we're mentioning.
00:39:53
Speaker
I would like to touch a little bit on
00:39:55
Speaker
surviving COVID-19 in the ICU.
00:39:58
Speaker
A lot of what we hear about is the people who have died from COVID, which obviously is a really almost incredible number of patients.
00:40:08
Speaker
But I think that the next couple of years, there's going to be a lot more suffering from those who survived as well.
00:40:15
Speaker
And I would like to hear your thoughts on long COVID, long COVID versus PICS.
00:40:20
Speaker
What should we be focusing on as we move forward?
00:40:24
Speaker
Sure, yes.
00:40:25
Speaker
You know, for the listeners, so long COVID, it looks like right now that at least a third of people after COVID experienced long COVID.
00:40:33
Speaker
And the sickest of all COVID patients who went through the hospitalizations have in addition to that PICS, post-intensive care syndrome, which is, PICS is the acquisition, the rapid acquisition in a matter of days of neck up problems of dementia, PTSD, and depression.
00:40:52
Speaker
and the neck down problems of muscle and nerve disease that physically and cognitively disables people.
Long COVID vs Post-Intensive Care Syndrome
00:40:58
Speaker
But then about a hundred days after the ICU or after the hospitalization is when long COVID kicks in.
00:41:05
Speaker
And I used to think of them as the same thing, but now I realize that there really is a distinction because people who were never hospitalized at all can a hundred days out get this long COVID problem, which is a, it's a dysautonomia and it's a problem of, you know, like POTS, for example,
00:41:22
Speaker
postural orthostatic tachycardia syndrome, GI problems, and a bunch of brain fog, the brain that just takes a dive and can't process, you know, from executive function to memory.
00:41:34
Speaker
And I wrote a piece actually on this combined problem of PICS and Long COVID for STAT News.
00:41:40
Speaker
So if somebody wants to read on this, they can just Google STAT News Wes Ely and you'll find this piece that I wrote just about a month ago or so.
00:41:47
Speaker
And I featured three patients.
00:41:49
Speaker
And one of the people was Pam and she was never hospitalized.
00:41:53
Speaker
And she got, she was a scientist.
00:41:56
Speaker
She had this amazing life and she never, you know, had any of the problems of PICS, but she a hundred days out, she's now retired.
00:42:05
Speaker
She had to resign as a scientist, as a career scientist because the long COVID has been so bad.
00:42:09
Speaker
And then Carolyn was in the ICU.
00:42:13
Speaker
and developed PICs, and had 100 days later this drop off of a cliff with long COVID, and then the last person in the piece is Ray, and he went through the ICU, got tremendous PICs, but never got any of the long COVID stuff in addition, so these can happen differently for different people, but you are absolutely right that we have a driving unmet need as a society to recognize this public health disaster, which is going to be
00:42:40
Speaker
long-term consequences of this of this viral sepsis that people get this this uh this pandemic and we are just barely scratching the surface on the magnitude of this problem from a societal perspective but for example i don't have an administrative assistant right now because i can't find anybody filled the position because there's so many disabled people out there that we really have a workforce problem in the united states and around the world that's just one aspect of the financial piece but the heartache is
00:43:06
Speaker
is the way that the people are suffering, cognitively and physically.
00:43:10
Speaker
And they're doing it oftentimes in silence or feeling silenced, which is a form of testimonial injustice.
00:43:16
Speaker
And that's just not right.
00:43:18
Speaker
And you did mention about the perils of loneliness.
Addressing Loneliness Among ICU Survivors
00:43:22
Speaker
And I think that for ICU survivors, but also for clinicians, one of the biggest dangers that I have always seen is the
00:43:32
Speaker
the illusion that what you're suffering is unique to yourself and you're the only one.
00:43:37
Speaker
I think there is so much to be shared, right?
00:43:40
Speaker
And all these things that you've described in PICS, the individual patient might think there's something just wrong with them and that they're the only one going through it and nobody understands it, but there's actually thousands of people with similar problems.
00:43:53
Speaker
And I think the same analogy could be made to the suffering of some clinicians.
00:43:57
Speaker
I mean, especially during COVID in terms of moral distress and burnout,
00:44:01
Speaker
just recognizing a lot of the feelings that we have are not unique and sometimes recognizing and talking with others about them is the first step forward.
00:44:12
Speaker
I completely agree with that.
00:44:13
Speaker
Everything you just said just completely resonates with me.
00:44:16
Speaker
And I'm so impressed with your, you know, you're running all these units and you're such a, you got such an administrative load, but you have got such a tight connection with what matters to people.
00:44:28
Speaker
And I love that thing about switching the preposition from
00:44:31
Speaker
what's the matter with someone or with an institution to what matters to someone and to us in our practice of medicine.
00:44:40
Speaker
And one of the concepts there is that I want to live by putting principles above personalities.
00:44:45
Speaker
So these principles of the humanness and humanism that we have to put first, that principle needs to override my own personal desires or my personal needs that day.
00:44:57
Speaker
And I think in our units, in our practice of critical care,
00:45:00
Speaker
If we can put the principle of humanism first, then we will find a way to implement the A to F bundle.
00:45:07
Speaker
Absolutely.
00:45:08
Speaker
And I'm a big believer in first order principles, which are usually the answer to any gray zone.
00:45:14
Speaker
And unfortunately in medicine, patient-centered care is lip service.
00:45:19
Speaker
But really that should be elevating the human part of each patient should be the first order principle.
00:45:26
Speaker
And when we really work around solving for that,
00:45:29
Speaker
I think we all win.
00:45:31
Speaker
I think this is a great place, Wes, to move forward and talk about lessons learned and the path forward.
00:45:39
Speaker
As I mentioned at the introduction, we're looking forward with hope with the new year, and we have a lot to do in terms of rebuilding our teams and healing ourselves and our patients.
Paths for Healing Through Human Connection
00:45:47
Speaker
And I would like to explore this through three different areas.
00:45:52
Speaker
Number one is, and most important, the human being in that ICU bit, our patients.
00:45:58
Speaker
Number two is the individual clinician, which is our listeners.
00:46:01
Speaker
And number three is the ICU team, which is what the listeners on the podcast can do to help those around them.
00:46:08
Speaker
So I would like to start with the human being in the ICU bed or our patients.
00:46:12
Speaker
And there's a quote that you mentioned often in the book, which I believe was something that a Spanish colleague shared with you, which in Spanish says,.
00:46:23
Speaker
Could you explore that a little bit more?
00:46:26
Speaker
Yes.
00:46:27
Speaker
Cata persona es in mundo means each person is a world.
00:46:31
Speaker
And if you think about the depth of the human condition and who we are, there is just a world inside of each individual person.
00:46:41
Speaker
And endowed inside of us is such a complex matrix of thoughts and beliefs and hopes and dreams and sadnesses and sorrows.
00:46:53
Speaker
And if we want to fully understand
00:46:56
Speaker
dive into the idea of healing.
00:47:00
Speaker
And if I want to be a healer for someone, then I've got to be willing to deliver mercy.
00:47:06
Speaker
And how I deliver mercy is to my working definition for that at the bedside, when I think about my life generally, mercy wise is the willingness to dive into the chaos of another person's life and provide lifting and healing.
00:47:23
Speaker
And I want to break down the first and the second half of that definition because
00:47:26
Speaker
Diving into chaos is what we do all the time in the ICU.
00:47:30
Speaker
But if we don't do the latter part, which is the providing, lifting and healing, then we're not providing true mercy, we're providing false mercy.
00:47:38
Speaker
And I don't want to be a bearer of false mercy.
00:47:40
Speaker
I want to be a bearer of true mercy.
00:47:42
Speaker
That is what I want to bring.
00:47:43
Speaker
So in order to do that for each individual human being, Sergio, then I have got to pay attention to their spiritual values as well as their mind and their physical.
Holistic Approach to Patient Care
00:47:54
Speaker
A person is not just matter, M-A-T-T-E-R.
00:47:57
Speaker
They are matter, M-A-T-T-E-R, but they're also body and mind and spirit.
00:48:02
Speaker
And so I was going to read to you just a short thing from the book about spirituality.
00:48:08
Speaker
I had this woman, and she was an atheist.
00:48:11
Speaker
and she was a biochemist, and I had this very intense experience.
00:48:16
Speaker
She came in with an acute abdomen, she went to the OR, and they opened her up, and she was riddled with cancer, and sent her back up to my unit.
00:48:25
Speaker
And I'll read you that story and one of this guy named Mike Melton, who was an ALS patient and designed bikes for Lance Armstrong.
00:48:34
Speaker
But listen up.
00:48:34
Speaker
So I witnessed a powerful end-of-life experience between my patient and me,
00:48:40
Speaker
She was an atheist and did not believe in the afterlife.
00:48:43
Speaker
An esteemed scientist, she asked each of the family members three times, the cadence slightly different each time, do you love me?
00:48:51
Speaker
They affirmed yes, and she gave them a hug and a kiss.
00:48:55
Speaker
Then she asked twice more, followed each time by another hug and a kiss.
00:49:01
Speaker
No small feat of courage because she had intense pain from metastatic cancer and a fresh abdominal surgical incision.
00:49:09
Speaker
The emotion was raw.
00:49:11
Speaker
each family member open and exposed.
00:49:13
Speaker
They seemed to move beyond quick answers to thinking about the depth of their love, what it meant to them, to her.
00:49:21
Speaker
She had asked not to be knocked out with morphine, wanting to be present for her loved ones.
00:49:26
Speaker
In completing her ritual, she turned to her other doctor and me and said, you are part of my inner circle now.
00:49:32
Speaker
They reached out to grant us the same enduring gift.
00:49:35
Speaker
We were stunned by her generosity and felt wholly unworthy.
00:49:40
Speaker
You know, I love that story because our involvement in the spirituality of other people crosses all sorts of cultural, religious and socioeconomic boundaries.
00:49:52
Speaker
It distills us down and breaks us down into our our basic parts, which is I'm a person and you're a person.
Focus on Healing Over Medical Services
00:49:59
Speaker
And let's start there.
00:50:00
Speaker
And the second story, when I diagnosed Navy veteran Mike Melton with spinal cerebellar ataxia, a progressive degenerative disease like ALS, he wanted to figure out a way to marry his girlfriend, Jamie, the love of his life whom he had met on a cycling trip.
00:50:16
Speaker
Mike built bikes for US cyclists and Tour de France winner, Greg LeMond and others, which I mentioned earlier, Lance Armstrong, and the US Olympic cycling team, pioneering the use of carbon in the industry.
00:50:28
Speaker
He always sported a red, white, and blue bandana, even with a hospital gown.
00:50:33
Speaker
A few calls and several hours later, a priest was standing at Mike's bedside in the ICU.
00:50:38
Speaker
Our team had decorated the room with white flowers and ribbons and soft music played.
00:50:43
Speaker
Jamie, all smiles in a flowering green dress, stood next, I should say flowing, a flowing green dress, stood next to Mike, who removed his bandana and they received the sacrament of matrimony.
00:50:56
Speaker
Their young son, Zachary, clambered up in the bed and laid his head on his father's chest.
00:51:01
Speaker
Later, Jamie told me, we both had some resentment about not getting married earlier.
00:51:06
Speaker
She took a deep breath, but this ended up being the perfect time."
00:51:11
Speaker
And you know, that's the sort of thing that I think we need to give ourselves permission to do with and for people as human beings in the ICU.
00:51:20
Speaker
And I hope that that kind of draws us down into
00:51:22
Speaker
what as clinicians and as team members we have to do then to uphold that level of humanity, right?
00:51:29
Speaker
Absolutely.
00:51:30
Speaker
And I think before we move on to the clinician, what comes to mind and something that struck me as I was reading EDDB was that I've heard a lot of people complain about the term provider, but they've complained for the wrong reason.
00:51:46
Speaker
I hear people complain because it doesn't necessarily mean
00:51:49
Speaker
credit the effort of becoming a physician versus that versus this.
00:51:54
Speaker
But ultimately, I think that you nailed it, Wes.
00:51:57
Speaker
The reason why provider is such a perverse name for us is because it doesn't represent what we're supposed to do, which is heal.
00:52:05
Speaker
So we are supposed to be healers, not providers.
00:52:08
Speaker
And that's something that I think really struck me.
00:52:10
Speaker
And you did talk about that a little bit in the book as well.
00:52:12
Speaker
And both of these stories illustrate that.
00:52:16
Speaker
That's wonderful.
00:52:17
Speaker
And if you don't mind, I'm going to use that.
00:52:19
Speaker
I'm on Twitter, by the way, for anybody, at Wesley MD, just at W-E-S-E-L-Y-M-D.
00:52:26
Speaker
And I'm going to cite you and quote you on that.
00:52:29
Speaker
You're on Twitter too, right?
00:52:30
Speaker
Yeah, I'm not as active, but I definitely will find it.
00:52:34
Speaker
I'll quote you on that because that term provider, I do talk about an EDDB, and you eloquently stated just now why that term is perverse.
00:52:45
Speaker
This is an art, not just science.
00:52:48
Speaker
So we have to realize that we are there to be healers.
00:52:54
Speaker
The next group of people that I really worry about, obviously, other than our patients, is our colleagues and the individual clinicians.
00:53:03
Speaker
As we mentioned, Wes, I obviously deal with a lot of colleagues, intensivists, advanced practice providers in critical care.
00:53:12
Speaker
And in a long time, I have never seen people so down.
00:53:16
Speaker
So I was reading the book and I mentioned, I mean, this tells your story since 1985 and before that, but I mean, your whole arc in medicine, but it's also, I think has elements that can be very useful for anybody who's trying to move forward and kind of rekindle their professional life
Rediscovering Purpose in Medicine
00:53:37
Speaker
as a healer.
00:53:37
Speaker
And, uh,
00:53:39
Speaker
I mentioned to you that a lot of my friends always make fun of me because I always think in threes, but the three kind of themes that emerge as a path forward for me as an individual from reading your story in the book were wonder, purpose, and human connection.
00:53:57
Speaker
And I would like you to maybe expand or dive a little bit deeper on each one of those and how you see that.
00:54:06
Speaker
Sure.
00:54:06
Speaker
Absolutely.
00:54:07
Speaker
I love those three terms.
00:54:08
Speaker
And, you know, in the,
00:54:10
Speaker
the epigraph from East of Eden, I think that Steinbeck is writing about wonder and purpose, and he's talking about just being amazed by the human body, and amazed by the way that it works, and the way that it is when it's working well, and the way that it is when it's not working well, and pathology enters in, such as in COVID, but in either circumstance, we can be, we can sit there in wonder,
00:54:36
Speaker
at the beauty of the human condition and the way that cells work and everything, which can then give us a purpose to restore health, to do the best we can to restore health.
00:54:48
Speaker
And sometimes, Sergio, it's not possible to restore, to cure someone, but you can always provide caring and loving, which can restore healing, even in the absence of that cure.
00:55:02
Speaker
And so I think, for example, the bundle
00:55:05
Speaker
provides humanism at the bedside, not just in healing, not just in survivorship, but especially at end of life, because we have immense purpose at the end of life for our patients to help them resolve relationships and find meaning in those last hours and days.
00:55:25
Speaker
And the entire 12th chapter of the book is on end of life in the ICU.
00:55:29
Speaker
And there's a beautiful story in there about Colonel Victor Correa.
00:55:33
Speaker
He was a 911, 911,
00:55:35
Speaker
hero.
00:55:35
Speaker
He was at the Pentagon when the plane crashed into it.
00:55:38
Speaker
And he saved people's lives by carrying them out on his back.
00:55:41
Speaker
And he had a dislocated hip after that, but walked to his house in Alexandria, Virginia, actually walked to his house on a dislocated hip and had human flesh on him.
00:55:52
Speaker
It was a brutal story.
00:55:53
Speaker
But later in his life, I was able to become his physician.
00:55:56
Speaker
And in caring for him, I saw the wonder of
00:56:02
Speaker
his amazement of his own life.
00:56:03
Speaker
And he gave me purpose as a physician to help him provide a beautiful, peaceful end of life process.
Compassion as a Teachable Skill
00:56:13
Speaker
And you know, when he took his last breath, his wife looked up at the clock and she said, it's 9-1-1.
00:56:19
Speaker
It was 9-11.
00:56:20
Speaker
And she was just blown away that this 9-11 hero died at 9-11 in the morning.
00:56:24
Speaker
And
00:56:29
Speaker
That's the sort of thing that just makes you stop dead in your tracks and say, life is amazing.
00:56:36
Speaker
And for me to be a part of that and to get to have the privilege of being with them, whether they survive or die, that to me is that human connection, which is the third thing you asked about.
00:56:46
Speaker
So there's your wonder, your purpose and your human connection.
00:56:50
Speaker
And don't cheat yourself from it because
00:56:52
Speaker
If you cheat yourself from this sort of human connection, that's how we get burnout because we're not finding, we're not getting the payback for being at the bedside with these people we love.
00:57:02
Speaker
Instead, we're experiencing what we call moral injury.
00:57:06
Speaker
And moral injury is something where we know we're doing something wrong and we're kind of forced to do it anyway.
00:57:13
Speaker
Well, I don't want to live that way anymore as a doctor or as an ICU team member.
00:57:17
Speaker
So let's establish human connection.
00:57:20
Speaker
And I do it by kneeling down
00:57:21
Speaker
holding hands, looking in eyes, and just finding out what matters to that person.
00:57:28
Speaker
Yeah, definitely.
00:57:28
Speaker
I mean, by slowing down, listening and asking questions, right, you can definitely connect with people a lot better.
00:57:36
Speaker
And that's something that we should all be doing a lot more, not only at the bedside, but also elsewhere.
00:57:41
Speaker
And I think that that's a beautiful story that illustrates, I mean, like you said, I mean, the wonder, the purpose, and that human connection, which you also talk about
00:57:51
Speaker
ultimately in our work of life as healers is compassion, right?
00:57:55
Speaker
I mean, how do we really suffer and make things better for other people?
00:58:00
Speaker
So that compassion, which is hard to find sometimes these days, with all the, that has happened in the last two years.
00:58:09
Speaker
And compassion can be taught.
00:58:10
Speaker
I cover this in EDDB.
00:58:12
Speaker
There's a book called Compassionomics by Stephen Treziak.
00:58:16
Speaker
And compassion, the main point they make is that the literature, the scientific literature actually tells us that compassion can be taught in 30 seconds.
00:58:26
Speaker
You can teach people how to deliver a compassionate human connection in 30 seconds.
00:58:32
Speaker
Ms.
00:58:32
Speaker
Smith, I don't understand what it is you're going through.
00:58:37
Speaker
I don't fully grasp the degree of suffering that you're experiencing, but I want to promise you that I'm going to stay with you and I will not leave you.
00:58:45
Speaker
We will be here at your side to help you walk through this.
00:58:48
Speaker
So please let us know what you need and we will be here for you.
00:58:52
Speaker
That's it.
00:58:53
Speaker
That's your compassionate message.
00:58:54
Speaker
That establishes the connection that she needs to hear and you build on that.
00:58:58
Speaker
Yeah, absolutely.
00:58:59
Speaker
And Steve, obviously, is a dear friend of mine and he's been on the podcast and talked about compassionomics, but
00:59:04
Speaker
But again, I think it just illustrates that a lot of the things that are true are things that have been around for a long time, right?
00:59:10
Speaker
And we just have to kind of rediscover them or remind ourselves that they're important and that they're small interventions that we can do every day, right?
00:59:20
Speaker
Like next Tuesday or next time you're on rounds that can move us in that direction and move the needle for somebody else.
00:59:29
Speaker
You know, there's a lot of social justice in the book.
00:59:31
Speaker
There's a lot of things about segregation of blood years ago.
00:59:34
Speaker
There's stuff about how we did a first lung transplant on a prisoner.
00:59:39
Speaker
I talk about taking the shackles off of a prisoner and to try and create a more just society within the context of medicine as well.
00:59:50
Speaker
And there's a story right at the end of the book about Clementine Hunter.
00:59:54
Speaker
I know we're getting a little long on time.
00:59:56
Speaker
And I was wondering, maybe we can move
00:59:58
Speaker
to closing with the story of this true human, amazing person that I knew as a boy.
01:00:05
Speaker
And I think the listeners might enjoy it.
Resilience and Bringing Light in Dark Times
01:00:08
Speaker
I think that that would be wonderful, Wes.
01:00:11
Speaker
Why don't we go to, instead of, usually a lot of the listeners know, and you as a previous guest, a repeat guest know that I like to ask some closing questions that are unrelated to the topic.
01:00:21
Speaker
We talk about books.
01:00:21
Speaker
We've been talking about books a lot, but I did want to mention that at the end of every deep drawn breath,
01:00:29
Speaker
there is a couple of resources, not only, there's a wonderful resources for families and clinicians about the A to F bundle and how we can humanize our ICU.
01:00:40
Speaker
But there's also what I found super interesting is a very long look, a list of books to explore.
01:00:46
Speaker
So I think that I would encourage everybody to pick up the book and then look at that as well.
01:00:51
Speaker
And once you finish with every deep drawn breath, you will find a, I'm sure a wonderful,
01:00:58
Speaker
a variety of books that you can explore that many of which I have read and many of which I have not, that I definitely will.
01:01:04
Speaker
I just wanted to mention that.
01:01:05
Speaker
So why don't we go to Clementine's story as a closing part of the podcast.
01:01:10
Speaker
Fabulous, thank you.
01:01:11
Speaker
And yes, in that resources section, which worked very hard on, there's also a bunch of stuff for families and patients
01:01:18
Speaker
about how to pick up the pieces of their life through PICS.
01:01:21
Speaker
And one of the sections was written by a former patient named Auden Husslid.
01:01:25
Speaker
And he really did a great job.
01:01:28
Speaker
He was a Wall Street guru and got PICS after a critical illness.
01:01:33
Speaker
And he really pours himself out on the pages to help people realize how to get through PICS.
01:01:38
Speaker
So I just want people to know that that resource is there to tell your patients and families about.
01:01:45
Speaker
So Clementine...
01:01:48
Speaker
was a beautiful person that I knew.
01:01:50
Speaker
She's a very famous folk artist.
01:01:53
Speaker
And I'll read to you from the epilogue this story.
01:01:58
Speaker
I remember well the first day I met Clementine Hunter.
01:02:01
Speaker
I was nine years old and my Uncle Warren and I had started early that morning rumbling down the road in his Datsun pickup in Louisiana.
01:02:08
Speaker
A new mattress wrapped in my grandma's homemade quilts bounced around in the back.
01:02:13
Speaker
Uncle Warren collected art.
01:02:15
Speaker
encountering little known artists by word of mouth or by seeing their works propped up outside their homes.
01:02:20
Speaker
Clementine was the first artist he had brought me to visit, and we were taking supplies to her.
01:02:26
Speaker
By the way, the reader will find out earlier that my father left us when we were little.
01:02:30
Speaker
So I was raised by my mom in a little four room house.
01:02:32
Speaker
We had no money.
01:02:34
Speaker
And Warren, my uncle, who's driving with me that day, kind of became my surrogate dad.
01:02:39
Speaker
Clementine, I wrote next to him, paints, brushes, and canvas on my left, my arm draped out the window on the right.
01:02:46
Speaker
It's hot in Louisiana, and morning was the rare time of day when I felt cool air blowing on my face.
01:02:51
Speaker
I breathed it in, riding beside my uncle, bounding down tar roads from Shreveport to Melrose Plantation, where Clementine lived.
01:03:00
Speaker
Uncle Ward turned down a dusty driveway and stopped in front of a small shotgun house.
01:03:05
Speaker
It's white paint chipped and weathered by the relentless southern sun.
01:03:09
Speaker
Clementine was there, sitting on the front porch, just like every screen porch I ever saw, with rips in the old metal screens.
01:03:16
Speaker
Bent over and smiling, she swung the door open, making its rusted hinges squeak.
01:03:22
Speaker
She must have been in her 80s.
01:03:24
Speaker
How y'all doing, she asked, welcoming us.
01:03:27
Speaker
An easel was on the porch, and another just inside the front room.
01:03:30
Speaker
Red, green, yellow, and white oil paints were smeared across her worn hands.
01:03:36
Speaker
and I could see a painting she was working on, a baptismal procession with black women dressed all in white, strolling from the hilltop church towards the pond below, where a full-dunk baptism was taking place.
01:03:49
Speaker
Uncle Warren had told me she was a memory painter, transferring scenes in her mind onto canvas.
01:03:56
Speaker
Seeing me looking, she leaned in and hugged me and led me inside to the other easel with the beginnings of a new painting, this one of the honky-tonk will be for you, Wes.
01:04:05
Speaker
She said, I call it Saturday night.
01:04:08
Speaker
I leaned in and watched her paint, thick brushstrokes of bright color.
01:04:12
Speaker
As she worked, she told me life was hard and that people fight and suffer, but they danced too.
01:04:19
Speaker
The painting would remind me of that.
01:04:21
Speaker
You'll have to make up your mind.
01:04:23
Speaker
What you're going to do more of, fight or dance.
01:04:26
Speaker
Later, Uncle Warren and I heaved the mattress off the truck and laid it in the place in the back room, taking the old shoddy one away.
01:04:33
Speaker
As the evening skies and tints red faded to pink and then into blackness, we headed for home.
01:04:39
Speaker
Clementine waved goodbye from her front porch.
01:04:41
Speaker
She had a better night's sleep in store.
01:04:44
Speaker
When the painting Saturday night was finished, Uncle Warren bought it for me, and it now hangs in my house, memorial of that day and all the other days I spent with Uncle Warren and Clementine.
01:04:53
Speaker
We often took her paints and brushes, sometimes homemade red beans and rice, with spicy Cajun sausage, small things to make her life easier.
01:05:02
Speaker
Now I know that her ancestors were slaves who'd worked at Melrose, picking cotton from morning until night, and that Clementine herself had once worked in the fields, then as a housemaid and a cook.
01:05:14
Speaker
I'd seen the two-story house with this white column across the street, the brick walk curving under an oak tree draped in Spanish moss.
01:05:23
Speaker
Clementine received no formal education and never had the chance to learn to read or write, but one day in the 1940s,
01:05:30
Speaker
Some guests who were artists had left their paints in a drawer.
01:05:33
Speaker
As she cleaned up, rather than throw them away, something drew her to scavenge a discarded cloth window shade from the trash and paint a scene from her memory.
01:05:44
Speaker
That started a habit, a calling, and she created one painting after another, depicting life, often painting of the same theme, picking cotton, weddings, funerals, Saturday night, going to church, until she died at the age of 101.
01:06:00
Speaker
She became one of the most famous of all Southern folk artists and was even invited to the White House.
01:06:05
Speaker
Her work had been displayed at famous galleries such as the Louvre in Paris, the American Folk Art Museum in New York, and the Oprah Winfrey Collection in Chicago.
01:06:14
Speaker
Clementine was treated as other throughout her life, dismissed as poor and inconsequential, depersonalized until her paintings were discovered.
01:06:22
Speaker
For me, her story is one of light and darkness.
01:06:25
Speaker
In my mind, she's always standing on her porch painting
01:06:30
Speaker
following her calling.
01:06:31
Speaker
She taught me there may be pain and violence in life and that I could go out in the world and help create more hope and healing.
01:06:40
Speaker
And I wanted to close on that, Sergio, because right now we are experiencing darkness and we need light.
01:06:47
Speaker
And we need hope and healing.
01:06:49
Speaker
And I do think that you and what you're doing and all of us can gather together and muster up the energy and the drive and the passion to make sure that we do what's right by these people who are suffering under our care.
01:07:02
Speaker
And we know how to do it.
01:07:04
Speaker
We've already scientifically proven that.
01:07:06
Speaker
But the question is, will we stop long enough to re-gear our care to provide that sort of beautiful,
01:07:16
Speaker
medicine and healing for all these people suffering.
01:07:19
Speaker
And so in Clementine's name, I'll leave you with that story.
01:07:23
Speaker
A beautiful story.
01:07:24
Speaker
And I think it's a perfect place to stop, Wes, with a real call for action for our listeners and for ourselves.
Call to Action: Reflect on ICU Care
01:07:31
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I want to thank you for shedding light into the life of our patients, but also into our careers.
01:07:37
Speaker
And I really would encourage everybody who's listening to buy this book, beat it, and let us know what you think.
01:07:44
Speaker
Wes, thanks for your time.
01:07:47
Speaker
Hope to have you back on the podcast soon and hope to see you in person soon.
01:07:51
Speaker
Me too, Sergio.
01:07:51
Speaker
And thank you so much.
01:07:52
Speaker
And for all your listeners out there, please just let me know.
01:07:55
Speaker
Circle back with me.
01:07:56
Speaker
If you do take a look at EDDB, I'd love to get some red ink and calibration from you.
01:08:01
Speaker
So I want to keep getting better at communicating.
01:08:03
Speaker
Appreciate you.
01:08:03
Speaker
Bye-bye.
01:08:07
Speaker
Thank you for listening to Critical Matters, a sound podcast.
01:08:10
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
01:08:16
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
01:08:21
Speaker
To learn more, visit www.soundphysicians.com.