A front-line critical care doc talks about why preserving quality of life AFTER an ICU stay matters…a LOT.

Key topics:

0:00 Intro

7:06 Importance of family in ICU care, especially with cultural/language issues

13:08 Testimonial injustice, the A2F Bundle, and a billionaire in the ICU

17:17 COVID & nurse burnout

20:13 Caring nonjudgmentally for patients regardless of their vaccine choices

24:56 The ethics of fetal stem cell lines in vaccine development (and some surprising truth)

28:30 Therapeutics analysis: ivermectin, JAK inhibitors, baricitinib

38:50 Allowing ourselves to feel with our patients, the importance of respecting faith paths

46:31 ICU delirium may damage higher cognitive systems and leave emotion intact (elephant and rider/system 1 and system 2)

54:19 The harm of excessive sedation and delirium as a predictor of death

58:53 PASC, Post-Acute Sequelae of COVID (AKA Long COVID)

01:03:48 Managing delirium and early mobilization in the ICU

01:09:37 Self-forgiveness, shame in medicine, and closing thoughts

Transcript Below

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– [Zubin] Hey, everyone, Dr. Z, welcome to the show. Today I have one of my favorite people, Dr. Wes Ely. He’s a critical care doc at Vanderbilt and the VA. Nashville brother, welcome to the show.

 

– [Wes] You gotta love it. Nashville’s a great town. A lot of people are coming to see us these days and it’s all kinds of music and it’s all kinds of medicine.

 

– [Zubin] So, that’s the beauty is the music and the medicine connection, right? We were talking about it before the show. Man, Wes, you’ve been on my show before on Zoom. It was in the beginning of the pandemic and we were talking about COVID and how in the early parts of COVID, we had tossed out all that we’d learned about how to do ICU in a more effective, compassionate, and less damaging way, because we were overwhelmed, and how quickly it had to come back. And this is kind of a follow-up to that because you wrote a book, I’m gonna show it to the audience, “Every Deep-Drawn Breath,” and it’s out in hard cover shortly, if it isn’t already.

 

– [Wes] I abbreviate the title of Every Deep-Drawn Breath as EDDB.  So EDDB comes out September 7th in hardcover, audio, and digitally with Scribner. It also comes out in the UK, Australia, and New Zealand with Scribe publisher in October. Remember, I wrote it as a book for anyone. It is not just for a medical audience. Readers, colleagues, and friends are free to reach out to me with any thoughts on Twitter at @WesElyMD.

 

– [Zubin] Awesome. So this book, “A Critical Care Doctor on Healing, “Recovery and Transforming Medicine in the ICU” is a must-read thing. Okay, I read it, I was like, wow. And the main point I took away is there is so much suffering that can happen at the pinnacle of medicine, at our best level of care, which is ICU, that we had historically been blind to. And now not being blind to it, we are obligated to do a better practice to prevent harm to our patients in the ICU. And you point the way to do that.

 

– [Wes] I hope so, Zubin. I hope that the readers find a place in this book. This has been a book that’s been in my mind for well over a decade. I wasn’t personally ready to write this book until the past couple of years. I don’t think I was, not that I’m mature now, but I was just, I couldn’t have handled the immensity of the story. And kind of what I envision is I envision just kind of like a hill and all these people walking along the hill to try and get somewhere. And on that hill are the doctors and the nurses and the patients, and all of us are together trying to get somewhere. And I hope that the reader finds themselves on that journey with all of the people in their life that they love, and that we, whether you’re a healthcare professional or a patient or a family, that there’s a place for you in this story.

 

– [Zubin] It’s clear that there is. I mean, when you’re reading it, you’re sucked into this thing. I’m a physician, so I have a certain bent on it, but then, you know, you tell a story in the book about becoming a patient when… I’m not gonna ruin it for people who read it, but it was about your daughter and an accident that she had when she was six. And I tell you, reading it, I was just, you’re transported into that horror of being a parent and seeing this thing happen to your child. And then going from, I’m the ICU doc, the academic ICU doc, multi-published world expert on all this stuff, transforming ICU, to being powerless in the neuro ICU, watching a nurse do neuro checks on your daughter.

 

– [Wes] And you know, it’s been almost 30 years, Zubin, and just two days ago, I was back in that location and saw the site of the injury and experienced the magnitude. And without even noticing it, I let out an . And people around me went, what’s happening? What’s going on? I mean, they thought I was having a heart attack or something. And it was totally subconscious. And I think that we all are suffering. We’re all, you know, we’re all experiencing some different type of suffering, but especially now in COVID. I just finished two weeks in the COVID ICU, and I’ve been up there in June and July as well, and it’s a different palpable sort of suffering that’s happening to society right now in this second half of the pandemic. And that’s what this, “Every Deep-Drawn Breath” is about, is about admitting that and saying, hey, here’s how we are as people, what we’re trying to live through, and we have hope, and how do we get through this? And I do it through medicine, but it’s really not a medical book. It’s literary, it’s poetry, it’s human story, and it’s humanism. And that’s why I wasn’t ready to write it 10 years ago, is I just had a lot of growing up to do. Frankly.

 

– [Zubin] You know what? When a doctor can admit that, you’re already more emotionally intelligent than probably 95% of my colleagues, including me.

 

– [Wes] I all the time spiritually ask for more humility and more ability to admit my discomforts and my weaknesses. And it really took all of that to put this together, going from my time as a non gray-haired doctor. Even a young boy, I mean, it opens up. Just a minute ago, I was in a store and some, some workers came in that reminded me of when I was a boy, I worked in the fields outside of Shreveport, Louisiana. And in those produce fields, those vegetable fields, I realized that we were on two different paths. They had a life that was going to be hard, and they didn’t have insurance, and they didn’t have… They didn’t have a safety net underneath them. And I watched the little things, and I talked about this in the book, I watched little things like a tooth become an abscess, become sepsis. Or an injury in the field, become an infection that they didn’t get sewn up. And I said, I’m gonna be committed, if I can go into medicine and be a doctor, to serving people like this. And there’s a lot of social justice that was planted in my mind as a young boy in those fields in Louisiana. And so you can see, I had to dive into all of that to write this book. And we have a lot of social injustice in medicine, and we need the face that.

 

– [Zubin] You know what, that’s clear in the book that this is really your life, but also others’ lives, how they intersect. And that idea of like this inequity that happens, you know, I think about COVID. For example, the inequity of not allowing in the early days of the pandemic, when everyone was frightened, are we gonna get infected as healthcare professionals? Should we be intubating everybody to prevent spread and aerosolization and so on, instead of doing BI-PAP and C-PAP, and you know, proning without ventilation? And then not allowing patients to die with family next to them, not allowing family to be with patients. What was your experience of this? Because it’s heartbreaking when you read your book about how important family is into orienting patients when we talk, and we’ll talk about delirium and you know, getting patients out of bed and doing spontaneous breathing trials. We used to just sedate and paralyze patients and leave them in bed in the deepest levels of sedation thinking we were doing them good. And then when they finally recovered, we would hear from them about the horrors of what that is and see the outcomes of how terribly they were doing in life. You saved their life, but you didn’t save their life. So, what were you seeing in COVID in the early days?

 

– [Wes] You know, I love that you brought this up early in this interview, and I love that you’re stressing this, the importance of family. And I’ll tell you two quick stories. Early in COVID, I had a patient who was from Mexico, and he didn’t speak English. And my Spanish is un poquito. I mean-

 

– [Zubin] Me too.

 

– [Wes] It’s not enough. So, I would talk to him everyday and find out how he’s doing. He was so happy; he was such an extroverted jovial person. He was always sending money back to his family. And he was just a beautiful person. And he made it over the hump. His respiratory failure got to a place where he was on a low-dose nasal cannula. And we sat in the room and we celebrated him. And that night I left. And we’re doing a study right now called Brain 2. It’s funded by the NIH. Our Brain 1 was in 2013, when we published in the New England Journal that there was a relationship between delirium and the acquired dementia of post-intensive-care syndrome or PICS. And now we’re trying to discover what kind of dementia people get. We’re actually collecting the brains of people who are willing to donate their brains. That night after I celebrated with him, I got the call from the ICU that there was another donor. And it was him.

 

– [Zubin] Oh.

 

– [Wes] And I said, well, wait a minute. No, no, no, no, no. I just celebrated with him. He’s off the ventilator, he’s doing better. They said, no, he died tonight. And we do now have his brain in our study as a priceless gift that he was willing to give to us, and his family, when I called them in Mexico and they were willing to give it to us. But the reason I’m bringing this story up is that it was because of his not having family present, and it was because of his Spanish-only and no English, and early in the pandemic, we did not have translators present 24/7. We now have programs that are always… We can get any language present, but we didn’t that night. And he started having a stroke. And we know that COVID patients have a prodigious problem with clotting. And he got quiet and he wasn’t talking, which is uncharacteristic. And you know, great nurses, but they didn’t know. And there was nobody Spanish-speaking to communicate with him and to let him describe, I’m having problems, I’m confused. And so, it got missed until it was too late and he died of a massive stroke. It haunts me because could we have intervened? Could we have gotten him that early and had some sort of an intervention that could have revascularized his brain? But that’s an example of the sort of heartache that happens when you don’t have loved ones at the bedside. And I think it’s wrong, I think it’s anti-medicine.

 

– [Zubin] I would go further. You know, Vinay Prasad and I on the show have said, it’s a human rights violation.

 

– [Wes] It is. In fact, it’s a type of both epistemic injustice and testimonial injustice. You know, testimonial injustice is when we silence people. One type of testimonial injustice is when we silence a patient. So, an HIV patient comes in and she’s in pain, and she asks for pain meds, and people judge her and say, she’s seeking.

 

– [Zubin] Right.

 

– [Wes] Instead of giving her pain meds. So, she’s silenced; that’s testimonial injustice. Epistemic injustice is when I have knowledge, ’cause episteme means knowledge, if I have knowledge that I don’t relate to the patient and the family, and so they are kept out, they’re excluded from that knowledge and they can’t be included in their own decision-making; that’s not right. And if COVID patients are delirious or if anyone is delirious and there’s no family there to make that interpretation or to bridge that gap, it’s a form of injustice and it’s wrong.

 

– [Zubin] I have never distinguished those two types of injustice before. That’s really beautiful to understand, because then you can intervene. Because in your book, you actually, you talk about the cultural setting for that patient, and the lack of honoring it actually leads to a kind of injury for patients. It’s actually part of this.

 

– [Wes] It totally does. And I really think that we in medicine, if we’re gonna be on that hill, and if we’re all walking along that hill, that vision I told you about, and we’re all walking together, that means that the nurses and doctors and the pharmacist and social workers and chaplains, et cetera, all of us, we’re walking hand in hand with patients and families. If we’re gonna be true in that walk, then we have to accompany each other, and we can’t have injustice there. There’s a lot of social justice in this book, “Every Deep-Drawn Breath.” You know, I was a lung transplant pulmonologist. And one of the chapters is about my time as a lung transplant pulmonologist. And by the way, this book is not a memoir. This book is narrative nonfiction. It’s a book about human beings, real patients, real names. It’s their story, not my story. But in telling some of the transplant patients’ stories, I talk about the first lung transplant, which was done in the 1960s in Oxford, Mississippi. And on that night, in one room, there was a lung transplant going on, giving a prisoner a lung, which was kind of a, have we got a deal for you? We’ll get you out of prison if you’re willing to undergo this lung transplant. He lived for 10 days. In the emergency room, a few yards away was Medgar Evers, the famous Civil Rights activist. And he came in and was murdered that night. And under the same roof on that night, these two historic things happened. And this is the sort of thing that I want to face in medicine, that we have to bring all of ourselves into this story. Because everybody listening to this show right now has experiences in their life where people need them to see who they really are and to amplify the voice of this patient or family rather than diminish it. And everybody can take part in overcoming this injustice.

 

– [Zubin] You know, you kind of nailed a piece of this here that I find very important, which is the witnessing of the patient, the witnessing of suffering. So, it’s almost a kind of, you know… And when we talk about injustice, we’re not talking about like, the kind of woke mob on Twitter that’s always shouting about injustice in a way that doesn’t seem… You’re talking about from a medical angle, if we’re all trying to get to this place, we need to do this together. And what we’ve done is we’ve taken away the voice of the patient to a large extent. And we’ve taken away the voice of the caregivers, too. How often are we listening to our nurses? How often are we listening to our staff? How often are we listening to doctors anymore? Now it’s all about money, it’s all about a business process. You know, so there’s this really wide spread injustice that seems to be happening.

 

– [Wes] You know, I want to try and keep all this straight in my head, but I want to link together… One of the great things about where we are in 2021, 2022, is that we have hope. There is a lot of hope for a way forward here. We have developed, for example, an evidence-based bundle called the A to F Bundle, ABCDEF Bundle. Well, that used to be the A to E Bundle. But a famous man named Gordon Moore, the founder of Intel, had his own bad experience in the ICU, where he experienced testimonial injustice. Imagine, a billionaire, and he was quieted because in his delirium, his family was not allowed. So, they had an injustice imparted on this billionaire. And at the end of the day, he said, I will devote some of my resources to fix this problem. And when I flew out to Palo Alto to be the principal investigator for the Society of Critical Care Medicine on our program called ICU Liberation, it was only an A to E Bundle. And they said, we won’t give you the money, over a million dollars, to try and spread this Bundle all across the United States and world, unless you include the family. And I said, well, A, B, C, D, E, F. Yeah, okay, okay. That works for me, let’s do the A to F Bundle. And so, Gordon Moore, having experienced injustice, he propagated a solution. Isn’t that neat?

 

– [Zubin] By the way, this is Moore of Moore’s Law fame.

 

– [Wes] Okay, yes.

 

– [Zubin] Who, you know, the chips double in speed every so often, he’s a Silicon valley legend.

 

– [Wes] Complete legend.

 

– [Zubin] And in fact, I interviewed one of his compatriots, Federico Faggin on the show, who co-developed the first commercial microprocessor. Now, if that guy could show up at Stanford or wherever he was, and have this happen to him, that means it happens to all of us. And you see it, it doesn’t matter what kind of VIP you are, family can be excluded. And partially, I think it’s because we, I think we get up in our own heads, we’re trying to do all this stuff, we’re so focused on the patient as a problem, we sometimes don’t see the patient. And we can be forgiven, we can forgive ourselves when we don’t know, when we’re not aware of that. But now that we’re becoming aware, and that should be a key thing. And the A to F Bundle is a formalized way of saying, you know what? Okay, we have to think about all these things in a checklist kind of way. It’s not really as much of a checklist as it is a kind of mental model and a way to go, okay, let’s not screw this up because we’re humans, we’re fallible, we screw everything up. I forget to sign the thing on my taxes, and next thing I know I’m audited. Whatever it is, right? So, these things have consequences. It’s life-and-death consequences in the ICU. And just because we’re not aware of it doesn’t mean it’s not happening.

 

– [Wes] Yeah, okay. So, yeah, you just triggered something in my head that I hope will help people think through this. I think a lot of people look at something like a checklist, like the Bundle, and they think, oh, that’s too hard, I don’t have enough time. That’s not what it is. Let me reframe this. You know, when you read an EKG, you go rate, rhythm, axis. You always do it the same order every time so you don’t skip something. If I look at chest X-Rays, I say, patient, position, rotation, inspiration, soft tissues, foreign bodies, lungs, and I go through that same list every time. And that way I don’t miss something. This becomes a way of thinking. It becomes a way of, oh, I care for patients. I’m a nurse, I’m a doctor, this is how I do it.

 

– [Zubin] Yeah.

 

– [Wes] I don’t silence them anymore. And you said something really important a minute ago. You said that it is not just about silencing the patients and families, it’s also about silencing us. And I will tell you that I came home last week on service, and my wife, Kim said to me, “What’s wrong with you? “What’s the matter?” And I said, “What do you mean?” She goes, “I’ve never seen you like this.” And I’ve been doing critical care for 30 years. You can see I’m an old man with my gray hair. I have never felt quite this way, because what happened? I said, “Honey, it’s so sad to me. “I’m at work, and all these nurses that I saw “start bright eyed and bushy tailed, “with energy and passion, they appear a shell to me. “And they’re crying and they’re saying, I’m gonna quit. “I don’t want to do this anymore.” And I think that what happens is we lose why we’re there if we and the patients are silent. So, what’s really fabulous about the idea of “Every Deep-Drawn Breath,” is that if we can all join in, in this revolution in critical care, this idea that, wow, we have 35 to 40 New England Journal, Lancet, JAMA papers, we’ve got four to 500 papers saying, this is the science; wake people up, move them, have the family there, monitor delirium, do all these things, this is how we’ll do it. It’ll just become second nature to us. Guess what? No burnout. I’m not burned out. I’m not burned out because I am spending so much time now realizing that technology got me in the ICU, but touch is what keeps me there. It’s about eye contact and hearing my patient and finding out who they are, and not what’s the matter with them, but what matters to them. That’s a burnout prevention program.

 

– [Zubin] Man. I have heard from so many frontline healthcare professionals about how they’re done, they’re just done. They don’t feel connected, they don’t feel valued. They get so upset when say, an unvaccinated patient comes in and needs to be ventilated. And then suddenly the ER is overwhelmed and the ICU is overwhelmed, and they thought they were through with this, and then it’s back, they’re back at square one it feels like. And the frustration and the exhaustion and the feeling that there isn’t the support of a team, there isn’t a supportive administration. It feels like they’re isolated. It’s almost like we can almost turn the same tools that you’re advocating in the book for our patients and turn them on ourselves.

 

– [Wes] Yeah, right, exactly. You know, and I think it all starts with listening to each other. Really listening to that nurse who’s crying to me and saying, I’ve lost my way here. I’m getting no satisfaction, I’m frustrated. Listen and silent have the exact same letters. And I don’t think it’s a coincidence. Let’s be quiet, let’s be silent, let’s listen. Same letters, just rearranged. I’ll tell you two stories about two patients. I just recently had a patient last week who was vaccinated. I actually, I had him, he was about to be on the ventilator, he was on high flow with SATs in the 70s with COVID. Just crazy. And I said, what do you do, sir? He said, I teach truck drivers. He said I could share his story, but I won’t mention his name. He said, I teach truck drivers. And I pretty much assumed he’s not vaccinated. So I said, are you vaccinated? He goes, oh yeah, I’m vaccinated, I’m double vaccinated. I was like, okay, well stop judging people, Wes.

 

– [Zubin] Yeah.

 

– [Wes] First thing. Second thing, and then he said this, “I let my guard down.” He said, I was around these people, I didn’t wear the mask, and I let my guard down, and now I’m dying of COVID. But he was double-vaxxed. And we know the vaccine works and it is our best way forward, but we know it’s not perfect. So, nobody listening say, yeah, see, I told you the vaccine doesn’t work. No, the vaccine works. And the vast majority of people don’t end up in the hospital after they’re vaccinated. This guy was unlucky and he had an underlying immune disorder. So, there it is. But anyway, the second story, the next room to him was a woman who had COVID and was the same scenario. SATs in the low 80s this time, on high flow. And she said-

 

– [Zubin] Are these young or old patients?

 

– [Wes] These people were both in their 50s.

 

– [Zubin] Got it. So, young.

 

– [Wes] Pretty young. I’m in my 50s, so I call that young. I was trained by the father of geriatrics, Bill Hazzard, and I watched him increase the age of the elderly as he got older. It was 55, then it was 60, then it was 65. So anyway, I’m increasing the age of geriatrics.

 

– [Zubin] There you go.

 

– [Wes] In my head. Anyway, she was not vaccinated. And I said to her, “Ma’am, I want to hear from you. “What are you thinking right now about that?” And she said, “I’m thinking that I want to tell my family “to protect themselves, and I was wrong.” And I said, “Well, what led you to that?” I wanted to listen. And she said, “I saw a man on TV “saying that they were trying to depopulate society “of people like me with the vaccine.” She goes, “I now know that that’s misinformation. “It’s not true, but I heard it and I believed it. “And now here I am.” So, my point in telling those two stories is that neither person did anything deliberately wrong and both were wonderful people, they were dear people. And I found myself sucked into loving them and caring for them, and wanting to be… And then kneeling down at their bedside, literally kneeling down at their bedside and holding their hand and sitting with them. And so, I’m not gonna let myself be drawn into the anger over the unvaccinated. Instead, I’m gonna accompany them and try and listen and learn their story and be part of that decision. Even if I disagree with their decision.

 

– [Zubin] Yeah, yeah, yeah.

 

– [Wes] Just a few thoughts about that.

 

– [Zubin] No, that’s, man, that’s , you talked about gaining the maturity to write the book, and that you didn’t have it, and you may never have it, right?

 

– [Wes] I’m not there yet, but I’m on a road.

 

– [Zubin] You gotta do it at some point. For me, it’s been a journey of going from the early days of just really disliking the anti-vaccine. This was pre-COVID, and making videos to that extent. Listen, we can’t tolerate this. This is not okay, kids are dying, et cetera. The righteous indignation, the villainization and the turning of a human into an evil thing that you can then objectify and hate. And that was easy to do, and it’s powerful, and social media rewards it because… And your tribe rewards it. So, other physicians and nurses who are pro-vaccine are like, yeah, you’re saying what we’re thinking. I love that! Would I get an email from people saying, Hey, you changed my mind about vaccines. Like, thank you for explaining it to me. No, never. Then COVID starts. And I started hearing from people who were vaccine hesitant, who felt like me. It was easy to empathize with them because they had rational thought. They were, well, this piece of information feels correct to me. I don’t have all the scientific training, so I’m interpreting through what I have. And it seems to me like this MRNA is gonna change my DNA and I’m gonna end up infertile and this is gonna happen, that’s gonna happen, and this scientist said it and this scientist said it. And I said, you know, what? If I were molecule for molecule you, I wouldn’t get the damn vaccine either. You’re behaving rationally, according to your best available evidence. And then that outpouring of understanding and love, and then a change in how I talk, a change in how I think, a change in how I feel about vaccine hesitancy. I go, you know what? I get it, let me tell you what I think in a way that doesn’t shame you because I get you. I understand it.

 

– [Wes] Well, I had no intention of going on this line, but that’s what’s great about your show is that it’s a natural evolution of thinking. So, let me share an example with you. I know a lot of people who are trying to make good decisions ’cause they don’t want to participate in evil. And they think, for example, and wherever you stand on this you know, that’s your decision, ’cause it’s a very divisive topic. But they think that fetal cell lines are wrong and they want to participate in a drug that was developed with them.

 

– [Zubin] Right. You’re a practicing Catholic, yes?

 

– [Wes] I am, I’m a practicing Catholic. So, I know a lot of people who I think should get a vaccine in my opinion, but they aren’t. And by the way, the Pope has said that it’s a charitable act to get a vaccine. I mean, he absolutely came out and said, this is our duty to our fellow person to protect ourselves and others as society goes. And actually there was a whole diocese in New York that said, you know, let’s be careful how we handle religious exemptions. You know, personal conscious exemptions, that’s one thing, but the religion itself doesn’t support not getting a vaccine. But anyway, about this issue of a fetal cell lines. You know, the most famous one, I forget the exact, it’s a three-digit letter, three-digit number, three letters name of this vaccine, of this cell line, the listener can look it up. It’s like GEC 657, or something like that.

 

– [Zubin] Oh yeah, mm-hmm.

 

– [Wes] 1971, I think. 50 years.

 

– [Zubin] Roughly around there yeah.

 

– [Wes] 50 years old. We talk about, in bioethics, they talk about proximate or remote direct and indirect. The participation in this is extremely remote and indirect. And it’s also true, but there’s a catch in here, so hang with me, ’cause this is, you’re gonna get, actually get a kick out of this, is that not only where these vaccines not created with this cell line, they were not created with that cell line. They were just tested with cells of this cell line to see how safe the vaccine is, and it was proven to be safe. Okay?

 

– [Zubin] That’s right.

 

– [Wes] So it wasn’t even created with the cell line. But not only that, if that is your argument to not get the vaccine, guess what other drugs were likewise tested? Tylenol, Motrin, acetaminophen-

 

– [Zubin] Everything.

 

– [Wes] Ex-Lax, Pepto-Bismol, and Ivermectin. ‘Cause I say that because many people say, I’m not gonna get the vax. I’ll just use Ivermectin. Ivermectin we know doesn’t work, but also it was tested with the same cell line. So just an interesting way of educating one another, you know, using science to educate.

 

– [Zubin] And I did a show on this, actually, because as the vaccines were coming out, this was an objection that was raised. And the thing is, you don’t come at people and go, oh, come on, moralizing about these cells. They’re just cells! No, you dig into well, okay, what’s the feeling there? What’s the moral matrix that you have that’s important to you that you think life is so sacred, the sanctity of life, so let’s talk, let’s explore that. Let’s let’s agree that that is important. It’s important to you, it’s important to me. So, how can we look at this honestly? That’s how you have to do it; it’s exactly right. Now, you mentioned Ivermectin and you’re a critical care doctor, you take care of COVID patients. Ivermectin has come up many, many, many, many, many times on this show, and there’s a group of docs that are promoting it and so on. And there’s a vast body of observational evidence that is not high quality supporting Ivermectin and the ongoing randomized control trials. Now, I and Vinay did a show about this, where we are not convinced by this data yet; we’re waiting for randomized trials. But at pre-test probability of Ivermectin being the miracle drug they say, is almost zero, because we just don’t have drugs like that that are antivirals, that work like that, therapeutics. So, what’s your experience and thoughts on that? Just because people will wonder.

 

– [Wes] Okay, I think that we should put this conversation into the context. And by the way, in a minute, let’s come to the title of this book, ’cause there’s something you and I were talking about that I want the listener to hear on the title. We’ll switch back to that. It’s very literary, and I think the listener will enjoy it. But let’s put this conversation in the context of repurposing drugs. ‘Cause that’s what this really is. And at the beginning of the pandemic, some very large, massive computer databases were put into play. This is February of 2020, so right at the onset of the pandemic. To say, of the world’s drugs, which of these drugs is the most likely to be efficacious for COVID? And without a doubt, the one that won the computer analysis were JAK inhibitors, Janus kinase inhibitors, and a famous one is baricitinib. I have no financial interest in these drugs at all. I have no stock, I’ve not received a single penny. I wanna make that very clear, from the companies. I was along with a doctor named Vince Marconi from Emory, an investigator with baricitinib, for example. But I’m not here to promote a specific one of these drugs. But these drugs have anti-viral properties, they have extremely good anti-inflammatory properties. And we now know that they save lives. As opposed to Ivermectin. Okay, so, if you’re gonna take a drug to repurpose it, let’s pick one that actually has anti-COVID properties, SARS-CoV-2, will fight the virus, will work against the inflammation, and now has evidence, data to say, we have a reduction in death. We have a paper coming out in Lancet Respiratory called “The CoV Barrier Study,” 1,500 people, largest mortality reduction to date. 5% absolute risk reduction. That’s a 20%, that’s a number needed treat of 20, which means for every 20 people treated with one pill once a day for two weeks, you have a life saved.

 

– [Zubin] So what drug is this again?

 

– [Wes] Baricitinib.

 

– [Zubin] And is this common knowledge yet? Is this out?

 

– [Wes] We just call it Bari, it’s out in a press release. I’ve already seen the galleys. This study called “CoV Barrier” with Vince Marconi from Emory and me as a senior author will be out probably by the time this show airs. And yeah, huge improvement in survival. If you view COVID as a train, like somebody gets ill, and they start getting… The train leaves the station with their illness, it doesn’t stop the progression of the illness. They can still get a little sicker, but the train doesn’t go over the cliff to death is the way I put it. And we actually, part of the way through the study, we realized that we were excluding ECMO and ventilated patients.

 

– [Zubin] The sickest, yeah.

 

– [Wes] The sickest of all, because on the NIH ordinal scale, sevens are ECMO and vent, and eight is death. So, we enrolled up to six, anybody on oxygen up to six, which is high flow or BI-PAP.

 

– [Zubin] And what were the primary end points of the trial?

 

– [Wes] Primary end points were either getting to ventilation, ECMO or death.

 

– [Zubin] Got it.

 

– [Wes] Okay? And so, people did progress from level four to level five or level five to level six, but they didn’t end up dying as often.

 

– [Zubin] Got it.

 

– [Wes] All right? So, it stopped them from dying. So, anyway, because we weren’t enrolling, this is really interesting, because we weren’t rolling ECMO and vent, we said, well, why don’t we set up a sub study, a second study of people who are already on the vent, already on ECMO, and we did. And we enrolled 100 people, separate from the Lancet paper that got randomized: double blind, placebo controlled. This is the type of science we need here is the full on, you know, the highest level randomized control trial.

 

– [Zubin] Yeah.

 

– [Wes] And do you know, that in the ECMO ventilated patients who got Bari versus placebo, there was a 15 to 20% reduction in death, which is a one in five number needed to treat. For every five of them treated, one life saved.

 

– [Zubin] Wow.

 

– [Wes] So, there is a way forward. Why not use drugs like this, that we have proven efficacy rather than a drug like Ivermectin, where if you look at the world’s literature on it, there’s nothing of high quality that lands you in that zone of, oh, this should be part of standard of care now.

 

– [Zubin] Right, and the one randomized controlled trial that they all pointed to saying, oh, well, what about this? This Egyptian trial was withdrawn due to plagiarism and fraud.

 

– [Wes] So, you have to look at the whole body of literature.

 

– [Zubin] Yeah.

 

– [Wes] You know?

 

– [Zubin] Yeah.

 

– [Wes] But that’s it. But now, about the title.

 

– [Zubin] Yes!

 

– [Wes] So, okay. So, I’m a big Steinbeck fan and we’re out in California now so that fits of it too.

 

– [Zubin] We should take a road trip down to Monterrey.

 

– [Wes] Oh, I’d love it. “East of Eden,” one of my favorite books. And Steinbeck said that “East of Eden” was about good and evil. And at the beginning of one of the chapters, there’s some of the most beautiful prose you’ve ever seen. I could read it, at the beginning of the thing.

 

– [Zubin] Oh yeah.

 

– [Wes] You want me to do that?

 

– [Zubin] Yeah.

 

– [Wes] I’ll just read where it came from.

 

– [Zubin] At some point you were talking about a transplant patient that you took care of, who had gotten his lung and you referred to, you watched every deep-drawn breath.

 

– [Wes] I did, I watched every deep-drawn breath of him, and that was an application of this at the beginning of the book, which is from 1952, “East of Eden,” it says: 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. It is a feeling in the stomach, a delight 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. So, that’s where I took the title. And to me, what it’s about, Zubin, is it’s the human condition. It’s every deep-drawn breath. And you heard in that quote that they were connecting the nerves. It’s about connecting the brain and the heart of what we’re going through as healthcare professionals, as patients, as families. And when you focus on eye contact and having somebody awake, and seeing what they’re thinking, the window to the mind, we say, and then think about their heart and what matters to them, then I think that what we can all do is we can find our way again. And that’s the hope I’m looking for. And that’s what I hope makes these nurses not be a shell. And that’s really the entire purpose of the book, is to make us recontact with our human state. Does it make any sense?

 

– [Zubin] Oh, it makes more than enough sense. And you know you had said something in the book too, about the idea that when you come into a patient’s room and you meet them, or you connect with them for the first time, there’s a process by which you say, you first acknowledge their suffering, right? Which by the way, we never do with nurses and doctors. We hide it, we repress it.

 

– [Wes] Yes.

 

– [Zubin] We’re the masters of that. Robbie Pearl, who used to run the Kaiser Permanente group in California and the mid-Atlantic states came on and said, it’s part of the culture of medicine to deny, repress and project. It’s what we do and we’re trained to do it, to protect ourselves from feeling deeply what’s actually going on. And you say, you come in the room and you say, hey, what you’re going through is really, really hard. Or what you’re about to go through is really, really hard. And I want to know I’m gonna be there with you and I won’t leave you. And that is so powerful. You know?

 

– [Wes] It is. I’ve learned that over time. It’s not something I knew at the beginning, but you know, when I was a second-year med student at Tulane in New Orleans and practicing at Charity, and the book opens up at Charity Hospital. I’m in the emergency room and this famous lady in New Orleans named the Duck Lady comes in, and I sew her up and stop her from bleeding. And she ends up dancing the Hope Act for me. We danced it together, we’re holding a duck in our hands. It’s a great scene and it really happened, it’s all true. You can look her up on the internet: Duck Lady New Orleans, and you’ll find pictures of Ruthie, the Duck Lady. But, you know, my mother that year gave me the book “Aequanimitas,” by Osler, and it was an address he gave, I think to Yale, I hope I got that right, about 100 years ago to the graduating medical school class. I talk about it in the book. And I read that and interpreted it to mean, I have to have equanimity. I have to keep that even keel and do not get outside of myself, because it’s a form of self-protection, it’s a formality, it’s a white-coat situation. And I actually had to unlearn that. I mean, there are some great points that he was making. And I think, you know, we all learn from Osler different things, but for me, that sort of sterility with people wasn’t working. I needed to let that down, let my guard down. I needed to enter in. There’s a story in there about a young woman who had HLH, and in her HLH she said to me, “Dr. Ely, I’m a fighter. “I’m a fighter and everybody knows I’m a fighter.” And she had this fatal disease. And I walked through that illness with her, and she died. And I don’t actually put this in the book, but I’ll tell you what happened. I put it in the book a little bit, but not to this degree. I was walking past her room after she had died, and I had developed this, I’ll say intimate relationship. I mean, just on all the right levels, you know? A friendship, a holding hand friendship sort of, where we looked at each other, we saw each other. And she now had died. And I walked out, I thought, surely she’s not still there. It’s been several hours. But I walked in and she was on the bed, but she was, you know, she was cold. And I went to her body and I felt her and rigor mortis had set in and she was cold. And I’m sorry if that’s hard for the listener to hear, but I looked out the window and the sun was shining in, and I started crying. And I mean, tears were flowing down my face. And I just thought, what a privilege it is to be with these people at this time, and to let that all of that be there. And I want to do that with every one of my patients. I want to experience what they’re going through and sit with them. And there are good data to say that they need to hear us say, “I will not leave you, I’ll be present. “One of us will be with you.” ‘Cause they have a sense of a worry of abandonment.

 

– [Zubin] Mm, what a beautiful story, man.

 

– [Wes] Sorry.

 

– [Zubin] See, it’s good that I keep, it’s good I keep these around.

 

– [Wes] Yeah.

 

– [Zubin] I keep ’em around.

 

– [Wes] Yeah.

 

– [Zubin] Brother Wes, I was gonna ask you this, because this bears on this. How do you keep, when you feel so openly, when you allow yourself to feel, when you let the walls of protection and projection and denial and repression come down, the common counter-argument among our colleagues would be, you’re gonna get hurt, you’re gonna burn out. You’re going to come home to your wife and your wife’s gonna say, “Wes, are you okay?” Kim’s gonna say that. How do you think about that in those terms? Because I know right now, I can see it in the comments, nurses especially, because they are this way, how do you survive when you open yourself like that?

 

– [Wes] I am not trying to pretend that that is easy. I’m not trying to pretend that that is not without its cost. There is a cost, and the cost is that I will not always feel happy and I will not always feel light, perhaps the way I would have at the beginning of my “Aequanimitas,” you know, self-protection, sterility, white-coat stuff. I no longer want that sort of evenness. I want the full range of emotion. And I find that it is what makes me a person and it is what I want to give of myself to other people, and that makes me want to be a physician. And I tell myself, this is my calling. This is why I’m here. I want to praise and reverence those people that I’m with. And I want to lift them up and let them be everything that they are in life, whatever their place is in life. If they’re going to survive and be present with us in our ICU support groups and go on to help other people, like I have a woman right now that is very close to me during COVID, and she got arterial clots to her arms and legs. So, she lost her hands and legs. She’s a quad now.

 

– [Zubin] To COVID.

 

– [Wes] From COVID.

 

– [Zubin] COVID.

 

– [Wes] Yup. The clotting of COVID. And she went deaf, all to COVID. Young woman, 31 years old.

 

– [Zubin] Oh my.

 

– [Wes] Totally healthy before, had no previous illness.

 

– [Zubin] Wow.

 

– [Wes] And she and I are so close now. I went to her house last week and sat with her in the living room. And she tells me, she loves me and I tell her, I love her. It’s completely on level, there’s nothing inappropriate. It’s why I’m here as a doctor. So, anyway, how do I handle it? Well, I get in the pool, I swim, I run, I talk to my wife, I share with my colleagues. We admit that this is hard, but it keeps us coming back. You know? People say they went to the mountains because of skiing, but the summers keep ’em coming back, right? And that summer, that rebirth, that growth, that hiking, you know, so this is my summer. It’s my spring and my summer is letting these emotions happen. I don’t want the coldness of winter all the time. That’s an analogy I never thought of before, but it works for this metaphor.

 

– [Zubin] Ah, Brother Wes. So, you know, okay, listen. I have to say, so, we’ve really been doing more and more shows on kind of personal development, spirituality, for lack of a better term. Like, really getting in touch with what is an emotion? What is a thought? How do you wake up to this idea that we’re more than this and we’re connected in some way and we’re very different than what we take ourselves to be? One of the people that I’ve spoken to has kind of described it this way. So we’re very good at repressing emotion. We’re taught from a young age to do that. And then medicine codifies it. It actually makes it, hey, you’re a wall. Like, hey, strong work. Like, hey, you know? You say this in the book, the ARDS in 10 or the kidney failure in 12. And now it’s packaged into a nice little problem instead of, that’s Joan in 12. And she has a daughter who’s just beside herself.

 

– [Wes] Yeah.

 

– [Zubin] And you know? So, we don’t allow ourselves to feel those things because they create sensations in us that we have been conditioned to believe are bad. They are to be avoided, and we spin thought and projection and story and narrative to keep them at a distance. It’s different than equanimity. Equanimity is allowing all of that, feeling it, letting it pass through you, accepting it as part of our humanity, which it sounds like is where you are. And yeah, it doesn’t mean you’re gonna be bubbling with joy at the moment you’re sitting with your patient who you were so close to who’s passed and is now cold on the bed. But you’re there, and there’s an elevation of the honor and privilege of being with this person through this cycle. But it hurts and you let it hurt. And I think that’s, he says, enlightenment is simply finally having the ability to bear a human existence, the human emotions, to bear and live them, to actually inhabit them. And it’s beautiful. Life becomes vibrant and yeah, it’s not all joy and unicorns. It’s pain and hurt. Even suffering has a meaning.

 

– [Wes] And you know, I respect everybody’s different faith path. And one of the things I love is finding out what people’s faith path is in life. And if it’s atheist and agnostic, that’s just as interesting to me. I have no problem, I mean, those are the people I want to talk to the most; learn from them, listen. Where do you find your joy? Where do you find your strength? But on my faith path, one of the things that I believe is that good can be drawn out of evil. And I believe that, suffering is not necessarily an evil, but if we view it as when it is an evil, even goodness can be drawn out of that experience. I would never leave anybody in pain. Pain is my number-one thing to take care of. But I have had patients say, “Doctor, “I would like to forego any more pain medicine “so that my mind can stay clear “because I have an important conversation “I need to have with my daughter.” And then when it’s all said and done, those two people made a connection with one another, where they dove into some element of suffering in their relationship that had been repressed for 20 years. And the amount of healing that occurred at that dying moment in that patient’s life between those two people, I view it as the butterfly effect. You know, that butterfly over here flaps that wind, the wind on the other side of the world is somehow affected; we’re all connected. And so, if we can bring these experiences up into our ICU world and allow those things to take flight, there is something that’s going to happen with all of us that’s gonna have a beneficial effect at home, at the supermarket, at the grocery, at the filling station. It’s all gonna, I just think these things are all connected.

 

– [Zubin] Brother Wes, man, I love the way you talk. I love the way talk because it recapitulates the way I’ve been thinking the older I get. Not only is it all connected, but it is necessary, if not sufficient for us to inhabit this way of being in the world, in order for our systems to change. You talk about justice in the book. We talk about justice in medicine, not only for our patients, but for ourselves. How will the systems change when systems are an expression of the underlying humans’ level of awakeness?

 

– [Wes] That’s how we’re gonna find our way forward. And you know, it all starts with just, for the listener, just do the next right thing.

 

– [Zubin] Yeah.

 

– [Wes] You know? Just do the next right thing. And grab your elephant, I want to make a comment. System 1, System 2 thinking.

 

– [Zubin] Yeah.

 

– [Wes] You know, Kahneman. It’s all in the book. I talk about cognitive rehabilitation, brain rehab. You know, these guys here, and you should teach us too, your thoughts on it, but this system 1 thinking, the elephant, and the rider are the system 2. What happens in the ICU is that the patients lose their overdrive, their more developed sense of self. And when you undergo cognitive impairment in the ICU and you lose millions of brain cells because of delirium, because I kept you pummeled with a sedative for too many days and immobilized, and mobilization reduces delirium, and waking you up reduces delirium, and family reduces delirium. So you can see, this is all part of the A to F Bundle. Delirium, E, Early Mobility, F, Family, C, Choice of Drug. You know, A, Analgesia, pain relief. All these things are a way of doing things. It’s not a burdensome checklist. It’s an ethereal way of approaching another person. It’s a guttural instinct that we have to develop and train ourselves to use that this is an entire person in the bed. This is not a person with bad lungs. Lungs are my focus. No, lungs are a part of the issue, but this is an entire human being, mind, body, and spirit, and I need to try and preserve both of their systems in their thinking, and I can’t sacrifice any part of this human being along the process. And I do think it’s important. And when these people go on to recover and try and build their life back, if they do survive, we have ways to help them find all of themselves and rebuild their previous life.

 

– [Zubin] It’s , when the public reads this book and they realize how a stay in the ICU done incorrectly, sometimes even correctly, right? We have to be honest, it’s sometimes-

 

– [Wes] Oh, it’s gonna happen. We can’t eliminate it.

 

– [Zubin] These are sick patients. But done incorrectly where people are snowed, they’re kept at a level of consciousness that’s just a click above death. And you actually made an amazing, I’d never thought of it this way, but you said when patients are that sedated, there’s a conscious or unconscious bias that is instilled in the team and maybe even the family, that says this patient is no longer viable because they don’t look like a human anymore. They look like a chunk of meat sitting in a bed, because they’ve been pummeled into sedation at a level that if you EEG them, which you’ve done, they have just basically escape burst. What do you call it? Spontaneous burst. What is it called?

 

– [Wes] I’m thinking of it. Burst suppression.

 

– [Zubin] Burst suppression on the EEG. That’s like a click away from death. And in fact, it’s associated with death or near death. And what happens then is the team says, you know what? I think it’s probably time to withdraw support on this patient.

 

– [Zubin] Yeah, and this is, every time, you know, you and I are talking about a lot of touchy-feely stuff today. It’s all based in science, though.

 

– [Zubin] Yep.

 

– [Wes] Every bit of it, we always come back to the science. And the chapter notes are full of high-impact references in the New England, Lancet, JAMA, et cetera. So, I want the reader to know that we back up all that we’re saying with these references.

 

– [Zubin] I’m gonna interrupt you for one second. So, we get touchy-feely ’cause me and Wes are awesome that way, but you need to understand who Wes is. He is a preeminent scientist. The entire back of this book is full of references. And there’s a resources for patients, families, caregivers, and medical professionals right here that is unbelievable. So, even if you don’t read all the stories, which I suggest you do, read the resources, if you’re in healthcare or if you’re not. All right, back to you, Wes.

 

– [Wes] Yeah, and that resource section, we worked very hard on that. It’s because the book is to draw you in, but then at the end, you have to have something packaged. You have to say, what’s my take home? How do I put this into play as a healthcare professional or as a patient? And one of the sections, by Audin Huslid, who’s a former ICU patient, he wrote the whole thing patient to patient.

 

– [Zubin] Wow.

 

– [Wes] So, this is from a person who knows how to live as a PICS survivor, and the struggles he’s been through.

 

– [Zubin] And PICS is P-I-C-S, post intensive care syndrome.

 

– [Wes] That’s right, and by the way, let’s get some terminology. Patients who have long COVID-

 

– [Zubin] Yeah.

 

– [Wes] Okay, there’s two categories of long COVID patients: long COVID, who never got hospitalized and long COVID who were hospitalized. So, if you were in an ICU with COVID, you have PICS and long COVID. You have post intensive care syndrome, which we’ve known about for, I tell the story in the book of how we discovered that. And then you also have long COVID because you’re a COVID patient. Patients who never were in the ICU, obviously don’t have PICS, but they have long COVID. So, the worst form of long COVID is PICS, just to get that terminology out there. Or PASC, Post-Acute Sequelae of COVID, which is another term for long COVID. Where were we?

 

– [Zubin] Oh, so, we were talking about, and by the way, we should circle back to long COVID because I know a lot of people have questions about that. But back to the idea of the, we were talking about sedating people to a click beyond death.

 

– [Wes] Oh yeah. Burst suppression and the science. Okay, here’s the science. So, we actually measured with EEG, hundreds of ICU patients. And we found that, so, if I put you on a scale of 1-100, 90-100 is wide awake, and below 60 is, I can go in your belly at surgery. You’re deeply sedated enough for me to be in your abdomen at surgery. Why would you ever put somebody deeper than that? Okay, but yet we found that regular ICU patients with ARDS and sepsis were down in the 10 to 15, five range.

 

– [Zubin] Wow.

 

– [Wes] And this was an actual numerical scale on the EEG. And what we found was that that area down in the five to 10 range, which on an EEG is burst suppression was an independent predictor of dying. So when we artificially, iatrogenically brought somebody down to that level of sedation, above and beyond their severity of illness, their age, their gender, their diseases, after adjusting for all of that, just iatrogenically getting put that deep was a predictor of death.

 

– [Zubin] That’s crazy!

 

– [Wes] Crazy. And we do it all the time. And these people were down… See, what happens is, here’s an analogy. Here’s the water, and I’m conscious now and you can see me, but if you put me sedated, I’m below the water and you can’t see me ’cause the water is opaque, okay? Now, you could keep me two feet below the water and that’s enough. But what happens is I keep the sedative going, the benzo drip, whatever, and COVID brought back the benzo drip, which it needs to go away. And they go 10 feet, 20 feet, 50 feet. And 50 feet down, that’s burst suppression. And we can’t see how deep you are. You might be two, you might be 50, I can’t tell.

 

– [Zubin] Right.

 

– [Wes] ‘Cause you’re unconscious.

 

– [Zubin] Right.

 

– [Wes] So, what we measured and we proved was that you shouldn’t keep people down that deep, but we do. Okay, now, what’s interesting is, and Debra Cook from Canada published this in the New England Journal of Medicine. She did this large survey of Canadian critical care doctors and being in a coma was much more likely to have your care withdrawn because of the fact that people looked at those people and said, they’re not likely to make it. And she didn’t even bring up sedation. But I read that article and I started showing everybody, look, wait a minute, this is what we’re doing. How many people have I inadvertently made a DNR, withdrawn support, because I biased in my judgment, made a decision that they’re no longer viable, just ’cause I can’t see their eyes and make eye contact with them?

 

– [Zubin] It’s a human thing to do that.

 

– [Wes] It’s a human thing if I can’t see you, I don’t see you. And now you look like a lump on a log, and you look like you’re not alive ’cause you’re not talking. So I can detach myself emotionally from your survivability and maybe make a wrong decision.

 

– [Zubin] Man. I’m very curious about one thing. By submerging people at this level of sedation, where they’re at a 10, right? Why do you think that’s causing harm to them and their brain and their survivability? What’s your theory on that?

 

– [Wes] My theory on that is that the brain is the CPU. That’s our central processing unit. And the brain is trying to keep all of the organs in check and moving right. And there’s great data from animal models that if you make a neurological injury, a delirium, a coma, and do nothing else to the animal’s body, the rest of the organs start going bad. So, there’s multiorgan dysfunction, which can be mediated only by neurologic injury. So, I think that the brain is trying to talk English and the organs, if they’re English-speaking organs, only speak English. And when the brain starts speaking jibberish instead, the other organs can’t understand jibberish and everything gets dysregulated, and the body cannot operate the way it should, and we have more multiorgan dysfunction. And so, we actually are creating organ dysfunction on a multiorgan level by iatrogenically taking the brain out.

 

– [Zubin] Holy crap, dude!

 

– [Wes] That’s what I think is happening.

 

– [Zubin] So, what you’re saying is, what you said in the book, the lung bone is connected to the brain bone.

 

– [Wes] Boom!

 

– [Zubin] Yeah.

 

– [Wes] Boom!

 

– [Zubin] They are one. I’ve said this in a squishy way. The mind/body continuum, it’s one thing. So, you take out mind, what happens to body? It doesn’t do well.

 

– [Wes] No, exactly. That’s exactly right, and that’s what I think is happening. And there’s a lot of data to support this. I mean, delirium is a predictor of death. We have had many, many studies saying that delirium increases the risk of death by about three-fold.

 

– [Zubin] Yeah.

 

– [Wes] At six months.

 

– [Zubin] That’s remarkable.

 

– [Wes] We’ve known that for 20 years. We published that in JAMA.

 

– [Zubin] What’s the number needed to harm on that? I mean, it’s gotta be few.

 

– [Wes] It’s very low. And we know that not only does delirium lead to death, delirium leads to four problems: increased death; increased length of stay; increased cost unnecessarily because of length of stay; and then also this acquired dementia.

 

– [Zubin] Yeah, acquired dementia.

 

– [Wes] Even if you live, you’re gonna live with this dementia, very likely, and that’s not a good quality of life.

 

– [Zubin] You told the story in the book about a woman who was a high functioning, high IQ profession, got sick, in the ICU, I think it was sepsis, something along those lines, had some delirium, came out, and had lost on an IQ test, how many points had she lost?

 

– [Wes] She had gone, this is Sarah Beth Miller, and I’ll be with her, we have… I’ll be with her very soon. We have events where we bring all these ICU patients together.

 

– [Zubin] Wow, wow, wow.

 

– [Wes] These are ongoing relationships. It’s wonderful to be in their lives. But Sarah Beth Miller was a mathematician and engineer, and she had an IQ, well, we didn’t know it at the time, but we tested her after her ARDS and sepsis, and she tested at a 113, and she just was shocked. She was like, “Whoa, what?” And we were like, look, actually, that’s-

 

– [Zubin] A pretty good IQ.

 

– [Wes] That’s pretty good. That’s a pretty good IQ. No problem.

 

– [Zubin] Above average.

 

– [Wes] And she goes, no, no, no, no. I’ve been tested, my IQ is in the 150 range.

 

– [Zubin] Oh my gosh.

 

– [Wes] 145, 150 range. So, she had lost multiple standard deviations of her intellect, and it was devastating to her. Life-changing.

 

– [Zubin] Wow.

 

– [Wes] So, we wouldn’t have known. She was the first person that we had the pre-test and the post-test on.

 

– [Zubin] So, primitive brain, emotions, heuristics, automatics, Daniel Kahneman’s system 1, Johnathan Haidt’s elephant. System 2, our modern human neo-cortex, thinking, planning, strategizing, intelligence, math, reasoning, verbal reasoning, this is what seems to take a hit in the ICU?

 

– [Wes] That’s what I think. When I read Kahneman’s book “Thinking Fast and Slow,” I went, it was a light bulb. I said, oh my gosh, that’s what their problem is. Because if you take multiple domains of neurocognitive function, which we have on thousands and thousands of patients now, out as far as 10 years, we have all these data, the most consistent domain of neurocognitive deficit is executive function and memory. And so, what happens is you’re driving the car down the street, Kahneman’s famous analogy, and you can turn the radio dial and you can tell the kids to shut up. But if you’ve got to turn left into traffic, you can’t do it because your System 2 is out. And think about what that does to somebody who’s the matriarch or the patriarch of their family, trying to lead a family, or a young healthcare worker, or a young computer programmer. This is happening to people in their 30s and 40s, not just 60s and 70s.

 

– [Zubin] And now it’s happening more with COVID probably.

 

– [Wes] And let’s get back to long COVID.

 

– [Zubin] Yeah, yeah, yeah.

 

– [Wes] So, long COVID is the entity, or PASC, Post-Acute Sequelae of COVID, is the entity whereby the virus having come in your body, trashed your respiratory epithelium, trashed your blood vessel lining, created micro clots all over your body, leaves you with deficits, cognitively, brain fog months later. I’ve got a woman who is actually in the book, and she never got hospitalized. She had a fairly mild case of COVID. And she is totally messed up. I mean, her life is never gonna be back to normal, or at least it hadn’t been for a year now. And she is trying everything to get back. And I just talked to her last week and she said, you know, I’m really having a bad week. She goes, I don’t know if this is ever gonna, I’m ever gonna get back. It’s a new normal for me. But then there are people who have cardiac difficulties and you know, POTS, postural orthostatic tachycardia syndrome, devastating. Dizzy all the time. I have a nurse friend who can no longer be a nurse. She has POTS so devastatingly disabling. GI disturbances, muscle and nerve weakness, shortness of breath.

 

– [Zubin] And this is just pure COVID, this is not PICS.

 

– [Wes] That’s not even PICS.

 

– [Zubin] Yeah, it’s not even PICS.

 

– [Wes] That’s pure, that’s a non-hospitalized person. These people I just told you about were never hospitalized. If you add on top of that, an ICU stay where you got PICS on top of that long COVID, so the worst form of long COVID, you now have ability where you can’t walk two steps. You can’t breathe, you can’t exercise, you can’t go back to work. And you know, you talk about a new normal, these are people whose lives are devastated in a way that it will take them a couple of years, maybe to even get back to a place where they feel functional.

 

– [Zubin] Do you think the vaccines, if you get a breakthrough infection on vaccine, do you think you’d have the same likelihood intuitively of getting a long COVID type of scenario?

 

– [Wes] We’ve been studying already patients on this, and the early signals are that you have a much less likelihood of the severity of long COVID that the unvaccinated are getting. And that makes sense, because the overall severity of COVID is lessened a lot if you have a baseline antibody. to fight the virus.

 

– [Zubin] Right, right. Yeah, because you may not get that systemic inflammatory syndrome that may cause… We don’t even know what causes long COVID, even in-

 

– [Wes] No, no. And there’s a lot of great connections being made with chronic fatigue.

 

– [Zubin] Makes sense.

 

– [Wes] Yeah.

 

– [Zubin] ‘Cause it’s a similar pattern.

 

– [Wes] Absolutely.

 

– [Zubin] Yeah.

 

– [Wes] So, I think that we need to realize that there is an entire population of people out there with syndromes, post-viral syndromes who have been suffering for many years, and not listened to, come back to testimonial injustice. And I think that testimonial injustice is going to play out anew against long COVID patients.

 

– [Zubin] I think you’re right. You know, it’s very tempting as a clinician to not believe these poor people because-

 

– [Wes] They look fine.

 

– [Zubin] They look fine and you’re like, but I don’t understand, there’s no mechanism. I can’t figure it out, there’s nothing I can test for. But they’re telling you, looking you in the eye and saying, my life is changed. Right?

 

– [Wes] It is. And you know, people with MECF, chronic fatigue syndrome, myalgic encephalitis chronic fatigue syndrome, they’ve been screaming at us for years appropriately ’cause they’re so frustrated. And there’s a movement underway, a grassroots movement that a lot of leaders are helping with. Nisreen Alwan is a famous doctor from the UK, who’s really helped a lot in this area. She herself has long COVID, she’s all over Twitter. And she’s trying to help people realize, we need to define this. We need to systematically collect data. We need to have a way that doctors can get reimbursed for this. We need a code.

 

– [Zubin] Yeah. A code for it, yeah.

 

– [Wes] For long COVID. Yeah, and so, all these things. And the insurance companies should have to plug in and say, we’re gonna pay for the care that these people need.

 

– [Zubin] Man, you know? One question I had, you know, looking at the book, because there’s a lot you can do in ICU to prevent potentially these outcomes. And we have to be respectful of your time too ’cause you’ve got to catch a-

 

– [Wes] We’re fine.

 

– [Zubin] Catch a flight. And you talk about it in the book quite a bit, the A to F Bundle, one of the things you talk about is mobility, which as somebody who’s worked in ICU before, it’s like, wait, mobilizing someone on a vent, how does that work? And yet, after reading your book, I was like, I want to get people walking with the tube, rolling the vent with them. What’s your experience with that?

 

– [Wes] Absolutely. In the Bundle, you know, let’s define it. A as analgesia, B is both SATs and SPTs, which is spontaneous awakening trials, waking people up, turning sedation off; spontaneous breathing trials, turning the vent off. C is choice of drug, mainly trying to avoid GABAergic drugs, like benzos.

 

– [Zubin] Versed, et cetera.

 

– [Wes] Exactly.

 

– [Zubin] Ativan.

 

– [Wes] Exactly, Versed and Ativan. D is delirium monitoring. And the way to get rid of delirium is to do the Dr. Dre. You’re, you know, you’re a rapper, you love Dr. Dre. Diseases, drug removal, environment, D-D-R-E. What Diseases are creating the delirium? What Drugs should I Remove? And what’s the Environment? And the environment part, I’ll finish. E is early mobility and F is family. So, the environment part is let’s get them woken up, let’s get them out of bed. Can you walk people on a vent? Absolutely, we walked people on the vent back in the 70s. I’ve got great pictures from San Francisco General of people walking on the ventilator all over the place. And then what happened was we escalated. This is all covered in the book. We escalated our level of care, better technology, we kept people who would have been dead, we shifted dead people into a living column. And once those previously, in the deep South, we say dog-sick people, were now in the living column, we kept them sedated and suppressed and out of it for so long that they developed PICS. So, now we should go back to the 1970s when we walked them. And we do. My advice for the listener, maybe I shouldn’t say advice. My experience is to start small. Find one patient and one nurse and say, Mr. Smith with COPD, he’s been on the ventilator for three days, there’s no real reason he has to stay in this bed. Or even the second day, wake him up, let him walk. And all you need is somebody to roll the poles, the IV poles, somebody to have a wheelchair behind him, and then usually a therapist or a nurse to make sure that the ventilator. And trail ’em all over the unit.

 

– [Zubin] Yeah.

 

– [Wes] That way, and one of the patients in the book, Janet Keith, on the day that she passed her first SBT, we extubated her. She had a necrotizing fasciitis of her face. So, most of her face had been removed. And she had a bandana on like the Lone Ranger. She called herself the Lone Ranger. And on the day that she got extubated, she was walking 60, 80 feet. Now, you think back to your ARDS patients. On the day they were excavated, were they walking 60 to 80 feet? No, and the reason is she was already walking before that.

 

– [Zubin] Oh!

 

– [Wes] On the vent.

 

– [Zubin] One of the big heroes, unsung heroes that you sing about in the book is physical therapy.

 

– [Wes] Oh my gosh, yes.

 

– [Zubin] I mean, without these guys… Because every day in bed is like, what? Two, three days of recovery, minimum. You talk about muscle loss and atrophy. How can you even see the muscle loss and atrophy that’s happening in these a ventilated patients that are sedated and immobile when they’re swollen with fluid? You can’t, so you don’t even see that they’re becoming skeletal. They’re eating themselves, you know? And mobility fights that. It probably also creates a connection between mind and muscle that strengthens.

 

– [Wes] See, the mind can then speak English to the rest of the English-speaking organs. Or if it’s German, they can speak German to one another.

 

– [Zubin] Right.

 

– [Wes] The history behind how we got to mobilization in the ICU is absolutely fascinating. It started in the UK, then it moved almost simultaneously through Houston and through Salt Lake City, and then onto California. And I bring up all these people in the book. They’re real people, real stories. I interviewed them for the book. Every quote in this book is direct audio-quoted. They’re direct quotes; I don’t make any of this up. And for example, there’s a very famous physical therapist here in California named Heidi Engel, who works at UCSF. And she’s a world leader in this area. And she is an absolute hero in the world of critical care as a physical therapist. And the other ones I’ll let the reader discover them. Chris from Houston is one that comes to mind.

 

– [Zubin] That’s so awesome. You know, ’cause we have a big physical therapy audience and they’re always begging me for a musical parody, right?

 

– [Wes] Okay, okay.

 

– [Zubin] ‘Cause I did one for respiratory therapy. I’ve done one for nurses, I’ve done one for the lab. So, I really still have been wanting to do Amy Winehouse’s “Rehab.” You know?

 

– [Wes] There it is. ♪ Doc tried to make me go to rehab ♪ ♪ I said, no, no, no ♪ But we’ve never, we just haven’t. COVID hit and we have been able to do.

 

– [Wes] Well, now is the time.

 

– [Zubin] Now’s the time.

 

– [Wes] You should do one for E-D-D-B. That’s what I call the book, “Every Deep-Drawn Breath.” E-D-D-B.

 

– [Zubin] “Every Deep-Drawn Breath.”

 

– [Wes] Yeah. The physical therapists are a major hero in the story of what I call the evolution revolution of critical care.

 

– [Zubin] I love it, ’cause that’s what it is. It’s been happening.

 

– [Wes] It’s the evolution and we’re at a revolution. In many ways, we’re coming all the way back to the beginning.

 

– [Zubin] Do your colleagues think you’re crazy, man? Do they give you crap?

 

– [Wes] They have totally thought I was crazy. I had people tell me, this is not a thing. You’re gonna lose your career. You’re an intensivist, that’s clavicle to diaphragm, dude. What’s going on up here?

 

– [Zubin] What are you doing?

 

– [Wes] I just gotta go with what I think is right.

 

– [Zubin] And you talk about it a lot in the book, but how did your experience as a transplant doc, which is so interesting because people don’t realize this, but lung transplants, you know, the five-year survival is what? 60%.

 

– [Wes] Yeah. And when I did it, it was 50%. So, it’s gone up about 10% only in 30 years.

 

– [Zubin] Yeah.

 

– [Wes] But that experience, this was my epiphany. Doing lung transplant was my own personal epiphany where I found the patient. Where I went from the equanimity and the sterility, ’cause I had to dive so deep into these patients’ lives. And I was with them before, during and after. Whereas, in the ICU, I was only with them during. No before or after. But transplant was before, during and after, and I saw, oh wow, this is what a human connection is. And I tell about Marcus Cobb and Danny West, and these stories of these people that are just so with me. When I go in rooms now, Marcus is whispering one ear and Danny’s whispering in the other. And Marcus was a real bad-ass and Danny was a comedian. And so, they’re giving me both thoughts of, remember, Wes, we taught you. Use what we taught you. And so I’m trying to use what I learned from them.

 

– [Zubin] How important to you is the idea of a sort of self forgiveness when we feel like we’ve made a mistake or we’ve not done justice to the patient?

 

– [Wes] I think it’s critical. We have got to process what we went through. There’s a lot of shame-

 

– [Zubin] Yes.

 

– [Wes] In medicine.

 

– [Zubin] Yes.

 

– [Wes] The patients don’t know that we care that shame.

 

– [Zubin] Yeah.

 

– [Wes] But we do. We know when we made a mistake. And we know when we hurt somebody. And if we don’t, we’re not facing the reality of what went on. And you know, I carried a lot of shame with me for a long time that I wasn’t practicing good medicine. And I have now forgiven myself for those early mistakes, which I recount. And this was a process of healing for me to write this book, as well. But I don’t want to live that way anymore. I don’t want to live afraid. I want to live with the knowledge that I won’t be perfect and I’m going to make mistakes. And when I make them, I’m gonna tell my patient, “I’m sorry I hurt you.”

 

– [Zubin] Yeah, yeah. You know, I’m gonna tell a story I haven’t really told publicly. But I had, you know, now I’m known, I guess?

 

– [Zubin] Known, big time. You found your thing.

 

– [Zubin] This is my thing.

 

– [Wes] Yeah.

 

– [Zubin] All right, well, but before this was my thing, I was a hospitalist for 10 years here in the Bay Area. And I had an email recently, this was probably last year, from a nurse. And she said, hey, I’m a nurse, I’m a huge fan of your stuff. But then something started bothering me. And I noticed there was a resemblance, something was gnawing at me. Who are you? Who are you? I recognize this guy, and then it clicked. Oh my God, you were the doctor who took care of me when I was pregnant and had this horrible, you know, inflammatory lung complication at this hospital, here, this year, this particular year, this and this and this. And you were, you’ve scarred me. Like, the way you treated me was terrible. You didn’t listen to me, you didn’t hear me. You misdiagnosed me and then disappeared.

 

– [Wes] Oh wow.

 

– [Zubin] And you know what’s crazy? So, here I am, you know, supposed to be so much better and mature. My first response was pure denial. This can’t be my patient. No, she’s misremembering. It’s another bald guy in the Bay; there’s lots of us. And so then I wrote her back and said, you know, I hear what you’re saying, but I just don’t remember this at all. What, when was this? What, give me more details. So, she wrote back and said, here are some more details. And immediately I was like I think I remember this case from this perspective. And then I tried to remember everything I could. It was 15 years, I mean, I forget when. It was like, mid-2000s. And I started processing, what happened there? Oh yeah, it was a complicated, I consulted a pulmonary. It was at this particular hospital. And I went through it and I said… And so I emailed her and said, can we get an on a call? I would love to talk to you. I’m just, you know that feeling of just, I bet I did something wrong, you know, shame. And I talked to her and she was a lovely human being. She explained to me, she told her story in a way that I saw her. And at the time I couldn’t, because I realized the date, where it was, what happened. Oh, that was the height of when I was the most miserable, burned out, feeling unsupported, wanting to quit. And here I was with walls.

 

– [Wes] Oh wow. So when that person wrote to you, that to me was a teachable moment for you as a human being, where you could go and find a place for forgiveness of things you didn’t even know you had done necessarily. Right?

 

– [Zubin] That’s it. That’s it.

 

– [Wes] Yeah. And so, facing up to that allows you then to have healing of injuries that are inside of you that you had long-since suppressed, exactly what you said earlier. And we owe it to ourselves to work through that, to process that, I think. And I love hearing you say that and it’s so self-effacing and beautiful that you’re willing to share this story. And yet at the same time, I want you to know that we all have those stories. Every one of us has a person we hurt because we weren’t doing the right thing for them. And I also love that you recognized that that was a period of time in your life where you actually weren’t healthy yourself.

 

– [Zubin] Yeah, yeah. And I told her all this and she told me… And it was such a, you could feel the release of this suffering. You know, on her part, on my part. It was beautiful, and that was just by phone. And I actually invited her to come on the show and everything and I said, I would love you to tell this story about how we’re often blind.

 

– [Wes] Maybe this is a way to end this, but there’s a person in the story, that was my first, it wasn’t my first patient, it was the first patient that I knew how badly I hurt. And her name is Theresa Martin. And everybody has signed releases or their families signed releases for use in this book. And Teresa Martin is a thread through the whole book, just like Sarah Beth Miller is. The way that I hurt Theresa was gargantuanly larger than what you did to that woman, I would say, okay? It was ARDS suppression, you know, immobilization, paralysis, PICS out the wazoo and all of that, but I didn’t know what PICS was back then. This is early nineties, I had no gray hair, I was a young doctor. Anyway, to write this book, I was able to find her medical records and read my own handwritten notes.

 

– [Zubin] Oh, wow!

 

– [Wes] And in my office, I’ve got those notes now.

 

– [Zubin] Wow.

 

– [Wes] And I reconnected with her son, who was a little boy at the time. And the book ends with a quote from her son. And that was my healing, my process to go through, to find. And so, writing all this down was a way for me to process the guilt and the shame that I had. And I think it makes me a better doctor, you know? I mean, I still won’t get it all right, and I’m gonna have problems. But imagine if all of us were able to process that and let down that shield, that guard, so that we can bring all of ourselves to the patient. As I said earlier, I want to praise and reverence these people that I’m serving. And I never want to lose that. If I do lose it, I need to leave, or get recovery and come back. Don’t forget, everybody out there who’s listening, who feels like they’ve lost it right now, get recovery and come back. And you’ll be a better healer than you ever were. So, what I hope for all these nurses who’ve quit or physical therapists or whatever who said, I can’t do this any longer, go get recovery. And you’ll be a better healer when you come back than you ever were in the first place. And think of all the people you could help.

 

– [Zubin] Brother Wes, brother Wes!

 

– [Wes] Thank you, Zubin.

 

– [Zubin] This book, read it, get it. We’ll put links, all of that stuff. Brother Wes, you’ve turned what is a quiet suffering for many healthcare professionals and a very unquiet suffering for patients, this idea that we could be causing harm when we don’t even know it, into a calling, which is how do we not do that? How do we see our patients and how do we stay humble and forgive ourselves in the light of our own perceived and real failures, and then grow from it? And this idea that if you are a healthcare professional, and you’re just broken by COVID, this is it, it’s okay to go work on yourself, be. Whatever it takes to recover, and then come back in a way where you’re so awake that you can bear this set of emotions and feeling again, in a way that’s just transcendent.

 

– [Wes] Bingo.

 

– [Zubin] Brother Wes-

 

– [Wes] Thank you so much.

 

– [Zubin] What a joy, my brother.

 

– [Wes] Thanks for having me.

 

– [Zubin] Such a pleasure. Guys, share the video. That’s it, buy the book. Oh, website.

 

– [Wes] Website: ICUdelirium.org. Go to: ICUdelirium.org, there’s an Every Deep-Drawn Breath page right there.

 

– [Zubin] Brilliant. I love it. Guys, we out. Thank you, brother.

 

– [Wes] Bye-bye.

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