Eric: Welcome to the GeriPal Podcast, this is Eric Widera.
Alex: This is Alex Smith.
Eric: And Alex, who do we have with us today?
Alex: We are delighted to welcome Wes Ely, who is an ICU doctor, who focuses on Geriatric Care in the ICU. And he’s co-director of the CIB Center, which focuses on critical illness, brain injury, survivorship at Vanderbilt in the Nashville, VA. Welcome to the GeriPal Podcast, Wes.
Wes: Hey everybody. Thanks for having me. It’s going to be a lot of fun learning for you and unpacking some great stories.
Alex: We’re also delighted to welcome Lekshmi Santhosh, who is Assistant Professor and Pulmonary Critical Care at UCSF, and is Medical Director of UCSF’s COVID, and post ICU clinic. Welcome to GeriPal Podcast, Lekshmi as a guest host.
Lekshmi: Thanks so much for having me. It’s really an honor to be here.
Eric: So I’m excited to do this podcast, because I just finished Wes’s book, Every Deep Drawn Breath. It is jam-packed with absolutely wonderful stories about the patients he’s cared for, a little bit of his life.
Eric: It really is honestly a fabulous book, we’re going to spend a lot of time unpacking some of those stories and some of the amazing research that Wes has done. And where do we go from here, as far as ICU care and post ICU care? But before we do all that, we’d usually do a song request. Wes, you got a song request for Alex?
Wes: Yeah, I do. How about this? Alex asked me the other day and I told him, Alex, I don’t really, I’m not good at that kind of thing. And so he suggested, every breath you take, and about 10 minutes later, I was talking to my wife, Kim Eley, who’s a pathologist, MIT grad. And I said, “Hey, they want a song request.” And she immediately batted out, “Every breath you take, obviously.”
Eric: Why was that obviously? Why is that so quick for her?
Wes: She hones in on quick, fast thinking just like Alex does. I think they have two sharp minds that the world is glad we have with us.
Eric: Well, I’ve also just started off with only murders in the building. So I got a little, a sting action in there.
Wes: There it is.
Eric: Okay. Alex.
Wes: Nice. And it really does fit in well with every deep drawn breath because you’re watching the patient, every breath they take, and a lot of the arc of the book is me losing my way with that.
Wes: Lekshmi can agree perhaps that at times we get too enamored with technology, we lose sight of the patient. And the book is us discovering the whole person that we’re there supposedly to take care of and finding our way in the entire field of critical care, but also individually as physicians.
Alex: Yeah. It really is a remarkable book, Wes, thank you so much for writing it, and remarkable in so many ways, the way it is fused with stories of patients who you’ve cared for from medical school onward, it just has incredible quotes at the beginning of each chapter, that’s mind opening.
Alex: It’s fused with information about your personal life, including, making yourself vulnerable and talking about your own stories and struggles, it’s fused with this dawning horror that what I’m doing to patients. And I think I’m helping them is actually hurting them in the long run after they leave the ICU.
Alex: And then how you meet that challenge with, and also with humility, because you work in teams, you work with so many people and you give credit where credit is due. But Wes, before we get into the topic in depth, I want to start by asking you, if you could read for us the quote from John’s Steinbeck that led to the title of your book.
Alex: And the reason… I listened to this book on Audible and I recommend people do, I was hoping to have you read the whole book because I wanted Wes Ely and his Shreveport, Southern draw reading the whole book. I will say the narrator does a tremendous job, but I wish I was more Wes Ely, so this is our opportunity to hear it. If you could please read the quote from John Steinbeck and tell us why you chose it.
Wes: Absolutely. And it was a dream come true for me to have Grover Gardner, I do, obviously the beginning and the end of the book, but he’s an iconic narrator.
Alex: Terrific narrator.
Wes: So that was really dream come true. So east of Eden, chapter 13, the beginning is some of the most beautiful phrase ever written in a novel, that’s not my opinion, many literary experts believe this. Sometimes a kind of glory lights up the mind of a man. It happens to nearly everyone. You can feel it growing or preparing like a fuse burning towards dynamite.
Wes: It’s a feeling in the stomach and the light of the nerves of the forearms. The skin tastes the air and Every Deep Drawn Breath is sweet. Its beginning has the pleasure of a great stretching yawn. It flashes in the brain and the whole world glows outside your eyes.
Wes: The reason that I chose this as the title of the book after a lot of different options, was that, there’s really three qualities that I find in this section of East of Eden it’s humility, glory, and wonder, those three things.
Wes: And if humility, isn’t a core part of our practice as being physicians, then we’ve got it all wrong. And in that section of the book, the main character, Adam, he gets extremely humbled by his wife, his partner, Kathy. He’s ultimately overtly good to a point of fault and she’s overtly bad.
Wes: And so it represents too the spectrum of humanity that we deal with in medicine. And in the glory, for me, that comes across in the quote and in the book, but also hopefully in Every Deep Drawn Breath is the glory of the other person, the I vow in our relationships, this covenant relationship that we have with patients. And then wonder, is just the wonder of the human body and how it works.
Wes: And as a Pulmonologist who trained in thoracic medicine, between the clavicle and the diaphragm, I had to learn, and I point out when I talk about Bill Hazard, that I had to learn that the lung bone is connected to the brain bone.
Wes: And that’s the arc of the book, is we begin with ventilators and the history of critical care, and we move over towards the brain, and the nervous system, and this kind of CPU of the human, the central processing unit, and then on to spirituality. So that’s the reason behind the title that may be more than you wanted to know.
Alex: Thank you.
Lekshmi: Thanks so much for sharing that, that part of the lung bone connected to the brain bone, really resonated with me. As you see behind me, my two favorite organs, lung and brain. And you talk about your realization, but I’m wondering if looking back in retrospect, in your early career in college, or high school, or medical school, did you have that early passion also for neuroscience, psychology, psychiatry, or was it truly a later realization?
Wes: Yeah. No, I definitely did when I took a Tulane neuroscience and we read Kandel and Schwartz. It was something that completely mesmerized me. And there are quotes at the beginning of the famous book, Kandel and Schwartz about the brain and delirium, which I was so intrigued by because we weren’t taught anything in med school about delirium.
Wes: Of course, Kandel goes on to win a Nobel prize, and his book about… If you haven’t read it yet, Age of Insight, which is a book about the beauty of the intersection, the nexus between art, and science, and medicine in Austria at the turn of the century.
Wes: This book, Age of Insight to me just blew my brain, and so I had this 2030 year trajectory of starting with the brain in neuroscience and med school, then getting fascinated with critical care and focusing in my opinion too much down on the thorax, losing the whole person, and then rediscovering the beauty of the connection.
Eric: Do you think that’s a problem that we have in our training that it pushes us towards losing sight of the patient, or do you think that… What do you think the lesion is? Or is there a lesion in our training?
Wes: Well, I think so much of American medicine is sub-specialized, that I do think that there’s a lesion in there, in that we can begin to think that that’s our job, to take care of that problematic lung or that specific geriatric syndrome, we’re talking to a bunch of people who love aging science here.
Wes: And even though the geriatric syndrome encompasses the whole body. I think that geriatricians have told me that sometimes they get so encapsulated by the testing to document where they are in their geriatric syndrome, that they forget that there’s a person behind that demise, and behind that frailty. So you part of this for me has been actually processing the shame and guilt of getting off track. And I think not doing a good enough job for my patients.
Lekshmi: You talk about that a little bit in your book, when you’re swimming and you have this sudden realization about, could critical care actually be causing harm? Would it be okay if we ask you to read that passage for us? I think it’s page 103.
Wes: Yeah. It’s short. And if you don’t mind, I’d like to start with Oliver Sacks. He says-
Wes: … in examining disease, we gain wisdom about anatomy, and physiology, and biology. In examining the person with disease, we gain wisdom about life. Ever since my childhood, I’d like to go swimming whenever possible to think through my ideas. I was thrilled to discover that Neurologist, Oliver Sacks swan, whenever he could and cited his time spent doing so, especially productive.
Wes: Usually, my morning workout pool was full of swimmers, even for dawn, with people starting the day submerged in their own worlds. But today it was empty, just me slicing through the water. I’d come to the pool to process my thoughts and consider the next steps in my research. But as my arms pulled lap after lap, my head echoed with the words, critical care is causing harm, critical care is causing harm. I am causing harm.
Wes: This was an important turning point for me in my life as a physician, because I had always thought that I was there to help other people. And again, at the beginning of the book, I talk about how I was working with the pickers in the fields in Louisiana, and that I felt like they didn’t have enough of a voice in their own story. And I viewed myself as going into medicine to give them voice.
Wes: But what I realized is that I had been so silencing patients the whole time. In critical care, I’ve been sedating them, immobilizing them, committing what really is a form, in my mind now of testimonial injustice, which is silencing somebody when they don’t want to be silenced.
Wes: And that idea that notion that critical care is causing harm really wasn’t apparent when we went from the 1970s through the year 2000, we just thought we’re getting better and better at saving life. But the hard thing at the turn of the century for us to acknowledge was that although the machines had gotten better, we were not paying any attention to the survival characteristics of these patients.
Wes: And we didn’t even to have a name for the Post Intensive Care Syndrome so-called PICS, until 2012. So we had a long way to go in this nascent field. And as somebody who loves geriatrics, I was fortunate to have geriatricians around me, waking me up to this reality.
Eric: And when you’re thinking specifically about the harms, in one way, you think about it, people go to the ICU, they live or die, it’s a binary outcome. But you’re potentially saying that there are other arm harms that we need to think about.
Eric: I also think that thinking about, people were trying to do their best and also trying to make… Being in an ICU on a ventilator, having all these things done to them, potentially giving people an escape from that by keeping people very sedated. So there was some potential like, “Hey, we’re doing this, not just for survival, but maintaining some quality of life,” thoughts on that?
Wes: Yeah. I do, Eric. Two thoughts jumped right out at me and that’s that… First off, in sedating them, we thought we were helping them to avoid suffering, but what we learned over time through our clinical trials, like the ABC Trial, which we published in Lancet, which was the first trial to ever document survival, and it was a lot of survival, a number needed a treat of six, I think, to save a life that less sedation increased survival.
Wes: And then a year later, we proved that it did not come along with extra PTSD or depression. So we were actually doing things that neurotically probably hurt the patient, but also the immobilization that came with that mental protection caused more harm such as blood clots, decubitus ulcers, or pressure ulcers.
Wes: And then we were putting a chemical cast on the brain, which we now know that delirium that came in the ICU from largely from hydrogenesis and disease. But the hydrogenesis part is we can do something about, was contributing to a long term dementia from any of these patients that the NIH now calls a DRD Alzheimer’s disease and related dementias.
Wes: And the second thought, is that there is an issue regarding quality of life that we all need to think more about, or I’ll just speak for myself, I need to think more about. And let me tell you a story. One day I was in the ICU and we had a woman who had ALS on the ventilator, and the resident started going off on us on rounds that, what are we doing here? Why is she on a ventilator? This is wrong, she’s got an incurable disease.
Wes: And right then the middle of rounds, her husband walked up behind the resident and put his hand on her shoulder, we did not know he was hearing all this. And he said, I hear what you’re saying and I get it. You’re wondering why does my wife deserve all these resources? And if I was her with ALS, I wouldn’t want it, but she does. And what she wants is every day she can have with me, she wants.
Wes: I began reading her poetry, finding out what mattered to her, I read her Jabber walkie, [inaudible 00:16:16] in the sloppy toes did jar and gimble in the wave. What she had done, was she had narrowed her quality of life gap. So the difference between her expected quality of life and her actual quality of life was a narrow gap.
Wes: And what we can do better in medicine is that we can help people have more realistic expectations of what their quality of life will be with cancer, or with diabetes, or post critical illness. Because if they leave with an expectation that’s too high and the actuals too low, they have a large gap, and that’s where the problem is.
Eric: Yeah. I guess another question for you then is, I often feel like physicians have underestimated people’s quality of life when they’re dealing with disability. I mean, some of this is like Alex’s work around. This is that you ask a bunch of older, disabled adults, what their quality of life is.
Eric: It’s not as bad as a lot of people would expect it would be. And I wonder too, when we’re having these discussions with ICU patients or even pre ICU, if physicians own biases will play a role around disability?
Wes: Well, I’d love to hear what Alex and Lekshmi have to say about this, but I think that what we do, what I do wrong, where I did this a lot more wrong before than I do now, hopefully, was that I would impose my judgment of what a good quality of life was onto the patient. And that does not take into account when these people have adjusted their expected quality of life and narrowed their gap. Alex, Lekshmi, any thoughts about that?
Lekshmi: Yeah. I think one thing that resonated with me that you talked about is finding out what matters to your patients, and that… In the four M’s, in geriatrics of what matters, that’s exactly what we are doing in critical care too. That’s what we must do.
Lekshmi: And you talk about the three wishes project and other ways that we can really honor what matters to our ICU patients. Even if we can’t communicate directly with them, there’s so many great examples of how you do that in the book.
Alex: And I like also how in that story, it was a resident who was talking about that, why is she ventilated? Because so often this occurs with trainees. And I think as people become more experienced, they see people who are surviving and even thriving despite states of disability or cognitive impairment or other forms of serious illness.
Alex: And when you first start out and you’re so young, you just haven’t seen those patients. And so you would imagine that this must be a horrible quality of life for this person. And I think as we gain experience and clinical practice, with that experience comes that understanding that it’s so hard to make judgements about this. And as you say, we need to understand what they view as quality of life.
Wes: Excellent, great points both of you. Thank you.
Eric: So what is, is it pixus?
Alex: I think Pixus is like an anesthesia system
Eric: The place you get your meds from, right? [laughter]
Wes: Yeah. That’s a good one. I like it. No P-S-C-S, PICS or Post Intensive Care Syndrome is really a disease that’s acquired once somebody gets into critical illness, and it can happen in on the floor too. And we should get into COVID, I mean, I’d love to talk to Lekshmi since she runs the COVID clinic there.
Wes: But let’s just define originally what this is. When somebody comes in with a cystitis, or pyelonephritis, or endocarditis, then we treat that original problem, but we didn’t know for 20, 30 years of critical care, that under our noses, they were acquiring new diseases and that when they left the hospital, they actually had new problems that they didn’t have when they came in the hospital.
Wes: And those diseases really can be summarized down to neck up three; cognitive impairment, PTSD and depression. So that’s how you think, but also your mental health, and anxiety issue that can really destroy people’s quality of life.
Wes: And then neck down, what happens is that your vasa vasorum and your nerves get blood clots, capillary beds clotted, and nerves die, and also muscles themselves deteriorate, we lose up to 10% to 20% of our muscle mass in 10 days, in the ICU sometimes. And so what you have is a motor sensory myoneuropathy, and is what PICS is.
Wes: And a lot of this is rehabitable, I mean, we can get it back. But we don’t have good rehab programs set up to do that. So I would say that most people fall into the cracks and don’t get the right sort of neck up or neck down rehabilitation that they should get. And now we better be relevant. So in 2021, we have to put on COVID, which is that three months, 100 days-ish after COVID ICU stays. Oftentimes, there is a new problem which occurs in long hauls called long COVID.
Wes: And the reason I make those distinctions is that I just published a piece in STAT News a couple weeks ago that I was really wrestling with this, Lekshmi for the past year, these people are so confusing, I need to sort this out. And I finally got three patients. I’d love to know what you thought about them, but the names were; Ray, Pam, and Carolyn.
Wes: And Ray somehow came out with OICS only, and his rehab delight, he does not really have the long COVID, [inaudible 00:22:10], all that stuff. Pam, never was in an ICU, came out great, went back to work. And then 100 days later, the bottom fell out on her, so she has full on long COVID. And then Carolyn has both. Lekshmi, What is happening in your brain about this and did that work for you, sorting that through?
Lekshmi: I really appreciated your article and you’re sharing those vignettes. And I think that’s one of the things that we as healthcare professionals and science journalists struggle to communicate, why do people keep talking about PICS in the conversation about long COVID? And I think in your STAT News article, and in the book, and in our clinical experience, we see the parallels.
Lekshmi: And as I tell our patients that whether you were in the ICU or not, we see that these impairments in cognitive function, mental health, physical function, the family caregiver support with PICS if are all very applicable to the long COVID patient population. And so even though PICS and long COVID may have a small area of overlap, it’s an important one. And the principles and everything that we’ve learned from PICS is so applicable to how we treat our patients with long COVID.
Lekshmi: One of the questions that I had for you, relevant to that was, being one of the father figures in Delirium Research in the ICU, and getting this groundbreaking research finally implemented at ICUs across the world. How did you feel personally, as you saw those gains slipping away, especially in the early ages of the pandemic?
Lekshmi: I mean, it was heartbreaking for me personally. I remember early in the pandemic, one of our administrators literally came up to our team on rounds and said, who placed that physical therapy referral for a COVID patient?
Lekshmi: And I said, I did the attending, that is the attending. And we talked about it, and we talked about why it’s important, and why we can’t let go of our standard of care. And we talked about the fear and pretty soon after some high level meetings, our physical therapist, Heidi Engel, who you talk about in the book, we’re back in the unit with our COVID patients, giving them the benefits that you need.
Lekshmi: So I was wondering how that affected you personally, seeing those real gains slip away during COVID, and how do we collectively reemerge, and claw back, and make that progress again, make it sustainable?
Wes: So incredibly relevant and important, and for you to ask that question, Lekshmi and just, I’ll reflect on that, but let’s put a few data points out there so that the listeners can actually put some science to this. Pre-COVID, we had… Once we launched the A2F Bundle, which is the ABCDEF Bundle, think of it as a safety checklist that your pilot would use to get you from LA to New York.
Wes: We had numbers internationally in the 70%, 80% range compliance wise, with this six step ABCDEF Bundle, we can define that bundle later. But everybody on the call knows that safety bundles are a thing now, and the checklist manifesto by tool one day, that sort of thing. So now we need a point prevalent study in COVID and those numbers are down in the 10% to 20% range.
Wes: It’s heartbreaking. And the reason it’s heartbreaking is for the patients, because we know that the more compliant… We have actually great data in over 30,000 patients, done by this side of critical care medicine, by Stutter Health in California, numerous different large groups, Boston, a big cohort in Boston, that says that there’s a dose response, and dose response is one of the most important things in all the medicine, most convincing things in all the medicine.
Wes: When you see that dose response, you think is a scientist, wow, this is real. And we know that there’s a dose response with more compliance with the A2F Bundle, lower death, shorter stays, earlier time back to home, less nursing, home transfers, less delirium coma, and less ICU bounce backs, all of that. So when you see the compliance rates go from 70 to 80, down to 10 to 20, that’s wreaking havoc on the lives of these patients.
Wes: Now, to answer your question, how did I feel? When we started coming up with delirium tools back in 2001, every grant I wrote was just summarily rejected. This is not science, what are you talking about? This is ICU psychosis. Doctors were calling me in their office and saying, what are you doing? You’re at Vanderbilt now, you’re not some… This is not hick medicine, you’re going to lose your career, this is not grantable.
Wes: And I really questioned if I was losing my mind that I should do something more thoracic, but I really felt like this was important. And so I stuck to it. And over time, we started and now we’ve been continuously, and it’s funded for almost 25 years, and VA funded as well for all that duration. So I think that I’ve been hardened in a good way, a healthy way, callous, if you will, to know that this is life, and this is what happens in medicine.
Wes: And fighting to create the bundle and get people to listen, was so difficult. And Heidi Engel was a major champion, the IHI, the Institute for Healthcare Improvement, major champion, working with Don Burwick, and their team. So am I sad? Yeah, I’m sad, but I’m not sad for me, I’m sad for the patients.
Wes: And we do have to claw our way back, rebuild this, I’d love to work with you, Lekshmi, and Alex, and Eric, and we need all of us to get together and say, how do we do this for the patients to get back to what we know? My fellows, last story on this topic, we had fellows leave Vanderbilt, go down to Louisiana and in the New Orleans surge, call me and say, “Wes, we’ve lost our mind down here. We’re not doing anything we know works, and we’ve got to get back to our basics.”
Wes: And three to six months later, they sent me a picture of a woman on 100% AFO2, on a ventilator, wide awake, holding up a sign that says, “Get your vaccine,” and I was like, “They’re back.”
Eric: That’s great.
Wes: And we need to get to that.
Eric: Yeah, me and Alex did some volunteering in New York during the initial surge, and we were shocked just about the amounts and the types of medications people were on in the ICU. Just blatantly everybody was on it. Again, this is when we were just learning about how to care for these patients.
Eric: I wonder because of that, how much of what we’re seeing with long COVID is something you think specific about COVID or coronavirus versus we lost our way in caring for patients in the hospital. We were doing things that increase the hazards of hospitalizations, worsen functional outcomes, worsen cognitive outcomes, both from medications, and isolation, and all of these other things that we know are bad.
Wes: Yeah. This is what I mentioned earlier that I struggle with so much over time. After you see enough COVID patients who haven’t been critically ill, it becomes excruciatingly clear that they can get overt long COVID without ever coming in the hospital and getting their sedation, okay?
Wes: So Pam in the STAT News piece is a great example of that. Her life is basically ruined, she’s disabled, she’s a young mother, she was a… And sometimes people come in and you wonder, well, maybe they had some of this before. That’s why I worked so hard to find the Pam because she was just kicking butt in life.
Wes: I mean, she had a research operation, NIH funded. She had nothing of anything wrong in her life. And so a person like that, doesn’t just make stuff up. And that’s why I said that they were being silenced too often. And we need to work against that. Just like the NCFS crowd has been silenced in lots of ways.
Wes: However, to build on what you said, so the connection that overlap that lets me said, we need to pay attention to is this, if you do get sick enough with COVID and come in the hospital, there’s no question that this overuse of sedatives, this overuse of benzos, et cetera, leads to all the problems that we’ve been proving for the last 15 to 20 years via NIH dollars federal funding to show that delirium is the number one most robust predictor of acquired dementia.
Wes: It’s a stronger predictor of death than shock in many studies. And so every single day of delirium predicts a 10% increased risk of mortality and a 30% increased risk of long term brain dysfunction. So what about those people? Well, they are nearer to disaster 100 days later when the immune problems, the disodonomia, et cetera, kick in, they’re just way closer to overt disability. And I think that Lekshmi and her running her clinic, she’s probably trying to sort through that all the time with who’s which one of these patients.
Lekshmi: And you talk a lot in your book and in other interviews that you’ve done, and I’d share this quote all the time with my trainees, that COVID is a delirium factory. It’s just a recipe with all the ingredients for delirium, especially for our older adults who are already in, even at pre COVID times at risk for delirium in the ICU. Could you tell our listeners more about what makes COVID the delirium factory?
Wes: Yeah. I’ll hold up a little stickum here that I keep on my desk. It’s very funny because residents and nurses always teach me. One of the ways that we address delirium in the ICU, is called the Dr. Dre. And I’ll get to that in two seconds, because it’s a very funny little story. But I came up with this mnemonic of six things that I think are the things we need to keep in our mind about delirium in COVID.
Wes: And I spelled Vocdif, V-O-C-D-I-F just because I could remember it. Well, I said that on rounds one day, and the resident immediately said, well, if you just rearrange the letters, it’ll be FCOVID. We hate COVID, so F COVID.
Wes: So F is family not being there. The absence of family creates a sensory deprivation for the person which allows the brain to go into delirium. We know that family provision is actually one of the best treatments of delirium. A Brazil randomized control trial showed that we could reduce delirium by just opening up family visitation, which didn’t happen in COVID.
Wes: And then the COVID part C is cloting. So we know there’s a tremendous problem with cloting in COVID that means microvascular and macrovascular. The O is oxygenation because people have destruction of their lung lining and get ARDS. And then V is the virus itself, can go into the brain and create problems.
Wes: I and D are the last two letters, F COVID. I is immobilization, our COVID patients are ridiculously immobilized. And the E and the ADCE bundle is early mobilization and the F is family.
Wes: So when you take away the E and the F, they’re left sitting in a bed all day long, and I invented this thing called the perpetual you, so they can walk around their bed just over, and over, and over again in their room. Since if they’re shedding virus, they can’t go out into the hallway, but that does not get us off the hook to do the perpetual you, and just walk around the bed as their mobilization.
Wes: And then the last one is drugs. And that’s the most [inaudible 00:34:01] of all, because these drugs… It’s crazy how the new England journal, Jam and Lancet can help us and hurt us. Early on in the COVID pandemic, a paper in the new England had something like 82% or 90% rates of benzos being used in COVID patients that had Germany.
Wes: I think people looked at that and said, “Oh, okay, well, okay, we’re using benzos in COVID now, that’s in the new England journal. Let’s do it.” That’s actually one of the ways the whole opioid epidemic started. I don’t know if y’all know that? But there was a letter to the editor, stupid little letter, one paragraph, and the drug companies started using that to say, “See, they say it’s not addictive.” So sometimes we can go really off track by a mistake in a publication or an erroneous interpretation.
Eric: Yeah. I was seeing a boatload of also antipsychotics when we were volunteering New York. And I still think a lot of people think, “Oh, let’s avoid the benzos. Let’s just give some antipsychotics for this person, helps with their sleep. Maybe we’ll do some quinidine, maybe will,” some crappy studies around improving or preventing delirium thoughts around antipsychotics and delirium in the-
Wes: Yeah. Great. And I think people on podcasts like stories. So Ned Kasum was a very famous psychiatrist at Harvard MGH. And 50 years ago, over a half of a century, he had a good idea, and this is no dis on him. I mean, he had this idea, let me use Haldo in a cardiovascular ICU to treat delirium.
Wes: What it was doing now we know was just calming the delirium and converting it from hyperactive to hypoactive, that’s what it was doing. But for 50 years, that became the usual standard of care for delirium management. We designed a study called Mind USA, which was published in the New England Journal of medicine, a couple years ago.
Wes: This was my dream to eventually decide if these drugs work for delirium. And so we used a typical Haldo and an atypical antipsychotic, so that we could test the dopamine hypothesis and alternative receptor; neuro receptor hypothesis, and neither one did anything to reduce the delirium.
Wes: So we know pretty definitively, antipsychotics don’t correct the way that the brain is thinking, they don’t correct the inattention, which is the Cardinal feature of the delirium. What they do though, is they convert you to hypoactive, and they can treat anxiety and [inaudible 00:36:35] on a ventilator, et cetera. So it’s not like it’s always wrong to use antipsychotic, just don’t do it thinking that you’re treating delirium.
Eric: Yeah. I guess another question you brought this up in your book too, how much does sleep play a role? Because we know sleep is really disrupted in the hospital. We do a lot of things that are not sleep hygienic. And if I stayed awake for 48 hours, I would start looking pretty delirious.
Eric: And how much of it both from a medication standpoint, disrupting sleep architecture, and also from a hospital system standpoint, not being beneficial at all for sleep. I just think about like the help study around preventing delirium. A lot of… One of the six main pillars is around sleep. How much do you think that’s playing a role?
Wes: Yeah, sure. I want Lekshmi to chime in here, but I’ll give you a quick comment about that. That’s where we get back to what are the key features creating delirium that we can change? You can’t necessarily change all the diseases, creating the delirium, they still have COVID, so they still have clotting problems, oxidation problems, the virus itself, et cetera.
Wes: But the Dr. Dre stands for diseases, drug removal, and environment. And I wanted to tell the funny story of how that came to be. A nurse came up to me in a meeting and said, “Wes, what do you think of when somebody’s delirious? What do you address?” And so I went into this thing called THINK, T-H-I-N-K, it’s a different mnemonic for delirium. We have it on our icudelirium.org website. If any of [crosstalk 00:38:07].
Eric: I can tell you like mnemonics, Wes.
Wes: Yeah. So I was going to go through this THINK mnemonic, and this is exactly what happened. She said, “No, no, no, shut up.” And I, “Whoa.” Okay. So she shut me up. She goes, “That’s not what I asked you. I said, just tell me what you think off the top of your head.” And I said, “Okay, I think of diseases, drug removal, and environment.” And without batting an eye, she said, “Oh, the Dr. Dre.” Whoa, that is good.
Wes: And then on, we’ve used the Dr. Dre. And what it means is what diseases are causing this problem; sepsis, COPD, I mean, infection COVID, et cetera, or/and then, what drugs should we remove? Sedation, Benadryl, anticholinergics, might be an antibiotic and H2 blocker. And then the environment, this is sleep, what you asked about, but it’s also sensory deprivation, eyeglasses, hearing aids.
Wes: Story. Mr. John Baker, lets me use his name, in the ICU, my ICU, came in with an in stemming and he got better, was doing well about to leave the ICU, and he was a gentleman, and he started cursing at his wife, and he was really not being himself. And I thought, “Wow, why is he cussing at his wife?”
Wes: And he had this book on his bed, which was a biography of FDR. And he was reading a biography of every US president. And for three days, I’d been asking, read your book, and he’s kept saying, I don’t have my glasses, they’re broken. John, his wife will bring the glasses in. So finally, when he started looking bad, I thought he’s getting septic. I ran through the Dr. Dre, disease, sepsis, and I told the fellow he’s going down.
Wes: But as a last resort, I took out my glasses in my pocket. I said, “Here, Mr. Bakker, you take these glasses and you read your book today. I kid you, not.” Everything else was negative, he was not septic, the white count was normal.
Wes: I walked in the next day, everything was fine in his brain. He was… Had my glasses on, reading the book, citing chapter in verse of FDR things underlining…. I was like, “Oh my gosh, I am the worst for three days. I left him sensory deprived,” Dr. Dre.
Wes: And sleep. As you said, Lekshmi, talk to me about sleep and what you try and do to improve that because it’s clearly part of the E of the Dr. Dre.
Lekshmi: Definitely. And in fact, sleep promotion is our residents QI project this year for the medicine residents, including in the ICU about how do we get to promote sleep? And all this whole conversation, it just shows that as geriatrics and ICU doctors, we have a lot in common.
Lekshmi: I mean, we love deprescribing. It’s a cornerstone of geriatrics, it’s a cornerstone of critical care too, of thinking, how can we deescalate? How can we de-prescribe, unprescribed to get patients to wake up to emerge? You use the analogy of the book of how deep are the underwater and how do we bring them out of the water, emerged into consciousness, get people back on track, including with promoting good sleep. So these are all just critically important things. It’s resonating so much with us.
Alex: Thank you. I wanted to make sure that we had time, because we’re coming to the end. I’d love to hear some more from Wes. You mentioned early on that, towards the end of the book, you get to spirituality, end of life care, palliative care and mentioned several people who we’ve interviewed on this podcast, including Randy Curtis, among others. I’d love to hear from you on page 220, I think 228, somewhere around there. There’s a short story that you’d like to share with us about spirituality.
Wes: Sure. I had a woman come in from an outside town with an acute abdomen. She was really in pain and this is just one paragraph of what happened with us. Shortly after one of my patients told me she was an atheist and didn’t believe in an afterlife. I witnessed the powerful end of life event between her and her family.
Wes: And as team’s scientist, she asked each of her family members three times; the cadence slightly different each time. Do you love me? They affirmed, yes. And she gave them a hug and a kiss. Then she asked twice more followed each time by another hug and kiss. No small feet of courage because she had intense pain from metastatic cancer and a fresh abdominal surgical incision.
Wes: The emotion was raw. Each family member opened and exposed. They seem to move beyond quick answers to think about the depth of their love, what it meant to them, to her. She asked not to be knocked out with morphine, wanting to be present for her loved ones. In completing her ritual, she turned to her other doctor and me and said, you’re part of my inner circle now, then reached out to grant us the same enduring gift.
Wes: We were stunned by her generosity and felt holy unworthy. And this story was so powerful because this is a woman who was just taken down to the OR, they opened her up, found she was riddled with cancer, closed her back up, sent her to us. Many people would just want to have be knocked out and she said, no, I need to go through this end of life program that I have in my head with my family members. And just sitting there with her that night, I will never ever forget how I just felt so privileged to be allowed in there, in that room as she went through that three times, do you love me?
Wes: And I just think that all of us have to remember that this is such a gift to be allowed in to these patients’ lives. And it’s why I kneel often times with my patients, I kneel down at their bed and I hold their hand and I look in the eyes and I consider it a holy ground and she was an atheist. So she didn’t believe anything in God, and I’m not revoking religion here.
Wes: This is about the, I vow relationship, this nexus between us and them, and something of almost mystical quality can happen between us, even when we have totally different spiritual past, when we allow that to happen. When patients are delirious, over drugged, over immobilized, et cetera, we can miss all of that.
Wes: And I wonder in COVID, when patients didn’t have their families there, how many people lost their way, both on the family side and on the patients side, simply because they did not have that human touch that we need to get back. That’s some of my thoughts about that story.
Alex: So beautifully said, Wes, it reminds me of a piece I wrote with Gaimeko and Lancet years ago on the death of Ivan Ilyich and the use of opioids at the end of life. And Ivan Ilyich is fictional story about this. Lori was complete jerk, right? But he has this illness, and he’s near the end of his life.
Alex: He has this epiphany, who realizes his whole life he’s just been an absolute a-hole, and he apologizes, and he has this redemptive moment at the end of life. And we worry that what would happen to Ivan Ilyich today, if he were dying? Screaming and agony from this painful condition, he would be overly sedated and never have that moment, never have that possibility of that moment. And I’m glad that this woman in this story had that moment.
Wes: Martin Luther king said that to have dignity is to be somebody, to be a person. And I wonder how our deep personalization of people strips them of their inherent dignity. It doesn’t actually remove their dignity because that’s inherent to the human, and we are all of inestimable worth, regardless of how much disease we have. Disease does not reduce our value by an iota, but you can still feel undignified by becoming de personalized.
Wes: And I think that sometimes we take people in healthcare and we put them through a deep personalization chamber, and I hope that the message of Every Deep Drawn Breath is to not do that. In fact, I have one more short story I could read to you that respects the personhood of these patients, if you want me to read a story about a geriatric couple?
Alex: Yeah. Oh, yeah.
Wes: I have a practice whereby I actively seek the wisdom of my elderly patients. In taking a patient’s history, if I learn she’s married for 50 years or more, I stop what I’m doing, sit down, and listen to her story. Two couples both married over 60 years became my life coaches during COVID.
Wes: The first was Ms. Virginia Stevens and Mr. Doyle Thomas DT Stevens, married 66 years when the pandemic broke out both 88 years old and with progressive COVID infections, they were admitted to our unit in rooms, down the hall from each other. I found DT, exasperated and grappling to get out of his bed insisting, I have to find Virginia, where they take her?
Wes: It was the only thing he could think about. The nurses said, he was belligerent with delirium all morning, that he was unable to eat until they tried a touch of honey on a spoon for hope and healing, for a few minutes, his brain cleared… That honey on the hood spoon is something that I do often with patients, by the way.
Wes: I find that they can’t aspirate it, and it allows the family member to feel like they’re doing something loving and it’s not dangerous. So I really love that honey, on the spoon for hope and healing. For a few minutes his brain cleared and he calmed down, but then he sought Virginia again, through some stellar work by the Stevens’ attending physician and nurse staff, we were able to transfer him into her room, what a difference it made.
Wes: His delirium quickly receded. I cherished the picture I have of us together, me and my yellow PPE and N95, and them mattress to mattress gripping each other’s hands as if they would never let go, smiling and recovery. On discharge, their daughter, Kara echoed what I was thinking.
Wes: We had the most kind, helpful, compassionate, respectful nurses I’ve ever seen beyond exceptional. Many months into the pandemic and exhausted beyond words, the nurses had exceeded themselves, as usual, they all assured me, they received more from Mr. Ms. Stevens, much more than they had given. Again, I thought caught a persona Essin Mundo, each person is a world.
Wes: That’s a great lesson for me in medicine. I learned so much from caring for this couple. And in fact, I was never on Twitter until COVID, but I’m on there now because of a COVID delirium study that we did actually, we enrolled 2100 patients in two weeks on Twitter. And I sent this picture out of the two of them and me on Twitter, and it got over a million hits in a couple of days.
Wes: We want to know that we are preserving the human side of medicine. And I used to think it should be technology and touch, but that’s backwards. I think it needs to be touch and technology. And I hope that that’s the take home for the readers of what I call EDDB, every deep job of breath.
Eric: So I guess my last question, you can make it brief too, is speaking to the interns or the busy nurses there. So the interns have all of this checklists, they have to replete potassiums, they’re going to get yelled at, the mag is too low, they got to put in all these orders, they got didactics to go to their incredibly busy as far, and the nurses too. You have one tip how to bring the humanity back into that work aside from all of the things on their checklists?
Wes: Well, I get it what you’re saying, I totally get it. They have all these things that they think are their chores every day. Why did we go into this in the first place? To serve other people and reduce human suffering. Those lists do some things to the matter, M-A-T-T-R of the body, but they don’t address the other two components, which is the mental health and the spirituality.
Wes: So we are tricking ourselves if we think addressing the body only, the matter is enough because we’re skipping two thirds of what it means to be a whole human person. So the way to do it in my opinion is to realize that we will, if we want a burnout prevention program and we want to practice actual medicine, then we have to incorporate looking into their eyes, finding out who they are, asking their pets names and saying, what matters to you? Not just thinking what’s physically the matter with you.
Wes: And this is something that can be taught, it is not something that comes innate or inherently. We can teach compassion, we can teach empathy. And I address that in the book, by Stephen Trzeciak book, Compassionomics. And I think that people like Lekshmi and the two of you, I guarantee you that in your life with trainees, that you are teaching people about empathy and compassion. And I hope that our listeners can take that back into their practice as well.
Eric: Wes, I want to thank you for joining on this podcast, but before we leave, we got a little bit more of every breath you take.
Wes: Thank you. That is now officially the theme song of EDDB. [laughter] I love it.
Eric: Lekshmi and Wes, big thank you for joining us on this podcast.
Wes: It’s my privilege. I loved being here. I learned so much from all three of you, and I welcome anybody to reach out to me in email, on our website, icudelirium.org, or on Twitter at Wes Eley, EMD. I’m more than happy to engage with anybody about questions that we cover today, or maybe disagreements of things that I said that they don’t agree with.
Eric: And all of our listeners read the book, it’s great. We’ll have links to it on our GeriPal show notes, on the website, Every Deep Drawn Breath. And with that, I just want to thank all of our listeners for supporting this podcast and the Archstone Foundation for your continued support. Goodbye, everybody.