Restoring Humanity In The ICU During COVID (w/Dr. Wes Ely)

– Hey everybody, it’s Dr. Z. Welcome to the ZDoggMD Show. All right, today’s guest is a specialist in something that we desperately need to talk about, now more than ever. But every day, this is an important conversation, which is how do we make sure we treat our patients in the ICU as the human beings, who are suffering, that they are. How do we manage ICU delirium? How do we get them moving? How do we make sure they don’t have long-term consequences of being in a place that would trigger PTSD in anyone, if we’re not careful. Now, Dr. Wes Ely is a medicine and critical-care specialist at Vanderbilt. He’s also at Nashville VA down there, and he is a world expert in exactly this. And he joins us today. Let’s just launch into it. Wes, thanks for being on the show, man.

– Zubin, thank you so much for having me. And these topics could not be more important, COVID-centric. Everything’s COVID, all COVID, all the time. And we know these patients are suffering. They feel isolated. We’re going in in spacesuits. We’re not spending enough time at their bedside. And they’re confused. They’re getting a lot of sedation. And it’s a delirium factory out there. So we’ve got to do what we can to mitigate that, and to really maximize human dignity in this process.

– I love what you just said. It’s a delirium factory. What we’re doing is, en masse, trying to save people. We’re overwhelmed, our cognitive resources are taxed just trying to figure out do we have the right PPE, how many patients are we taking care of, making sure we go through all that. And what’s left over is not enough capacity sometimes to go, “You know what? “What we’re creating here is a ticking time bomb.” They may get better, they may leave the unit, but they are gonna have long-term consequences if we’re not careful. And you were one of the pioneers. Actually you and others working in this space in determining, look it may make sense to try to avoid ICU delirium and those kind of things in theory, that these are human beings, and we wanna mitigate suffering. But you actually showed that outcomes improve when you actually care for a human being in the ICU and try to mitigate these things. Tell us a little bit about that.

– Yeah, I always like to start with the basic story though. Let me tell you, I was in Korea about a couple of months ago right before COVID broke out, and I asked to speak to one of their survivors. And a woman came in, I’ll just call her Ms. K, and I’ve got permission to use her story. She’d been in the ICU with diffuse alveolar hemorrhage for a couple of weeks, and it was a year earlier. And she was still in a wheelchair, unable to walk, unable to go back to work, cognitively impaired. So, she had PICS and the cardinal features of PICS that she had were an acquired dementia, which we call the post-ICU dementia. The NIH calls it an ADRD. It’s an Alzheimer’s disease and related dementia. And she had massive muscle loss, ICU-acquired weakness, and really a year later, still in wheelchair. Anyway, I was talking about why she had gotten so much sedation, and the doctors in the room said, “Well, we don’t stop it everyday. “What if she self-extubates?” And a nurse from across the room, a Korean nurse, screamed out, “What if she never walks again?”

– Oh my god.

– Whoa, that puts it in perspective, right?

– Yeah.

– So we do a lot of things out of fear in the ICU. I think right now in COVID land, the COVID pandemic, which is a big deal in our world. All of us are concerned as healthcare professionals, and on this show, we can point no fingers. Everybody out there is doing their absolute best, and I want to acknowledge all of the amazing physicians in Seattle, Bergamo, New York, New Orleans. And we know everybody’s doing their best. And yet, we also know there’s always room for us to improve, and what we know that you asked me a moment ago, is we have got data from over 400 papers, 3,540 New England Journal, Lancet, JAMA papers, and now over 20,000 patients from the SCCM ICU Liberation program. Bottom line, the more you comply with these concepts in the A2F bundle, the SCCM’s ICU Liberation bundle, or the A, B, C, D, E, Fs, the more you comply, the less death, shorter length of stay, less ICU bounce-backs, way less delirium in coma, and I love this one, less nursing home transfers. So, we’re taking care of our COVID patients. We can’t just focus on their hypoxemia right now. They’re coming in with bad delirium, we’re making it worse in the delirium factory, and we’ve got to be asking ourselves, what’s the long-term survival gonna look like for all these people?

– It’s so important, and I talked to a mutual acquaintance so far as Barbara McLean, who’s an APRN in Atlanta, and did a talk on the show about how they’re managing patients in the unit and how even at the end of life, these patients are dying alone. They’re talking to their families through a biohazard bag, holding a phone because we can’t have them visit. The F, the family, is part of your ABCDEF bundle that you created, family at the bedside. This is a basic, it’s not even about human dignity. It’s a human right to be with those you love, and we are depriving them of this, now out of necessity because of all these reasons.

– It is, another story. I think we all remember these stories. Last week, two weeks ago maybe with a COVID patient, this man was dying. It was his wish to be removed from the ventilator. Obviously, we’re gonna adhere to his wishes, and his son was in Atlanta. And he was gonna take four or five hours to get here, so the man and his friend made a decision to go without his the visitation. She was there with him for a moment, and I’ll just tell you three people’s stories on the back end. So, he eventually dies about eight hours later. The last time she saw him, she was waving to him through the glass, not at his bedside, not holding his hand, waving to him through the glass. She told me that she went home, cried in her closet because she asked for God’s forgiveness because she wasn’t fully present for him. She herself was afraid of being fully present for this man. In other words, she felt selfish. The son was sad that he had made a decision to go with the friend because he actually could have been there. But once she was chosen, she was the one, so he was disallowed. And the last part of the story is the next day, the resident, crying said to me, “I don’t feel like I’m a doctor anymore. “The first time I held his hand was to pronounce him dead.” We have to get back to the roots of why we’re here. We’re here to serve these people and do the absolute best we can. Now, we have to acknowledge the infectivity of these droplets, do the best we can, but we can’t not go in their rooms. We have to be present with them, and we have to be present with somebody who’s dying and show them that dignity and acknowledge that they are mind, body and spirit, not just a body with a disease.

– That’s as powerful as it comes, and the truth is, look, you know this because you have experience in this space. You also know that the science and the protocols and the tubes and the wires and the technology go hand-in-hand with that human connection. Together, you get better outcomes than if you ignore one or the other. Without the tech and the tubes and the wires, you might die, but without the humanity you are gonna die in a different way and the long-term outcomes are worse. And this has been a life’s passion of yours since you’ve been in critical care because I watched some of your talks that you’ve given. It’s inspiring because what you found is you can actually have data that shows, well look, if you go through this bundle, actually the sum of the bundle has a bigger effect than the sum of its parts, that each part is actually evidence-based. And the problem is when we’re already so cognitively burdened in the ICU, in other words, there’s so many things we have to remember, the GI prophylaxis, the DVT prophylaxis. We have to remember our different vent weaning protocols, all these other things. We’re going through these checklists. If we don’t have the checklists, we’re so overburdened, we will forget. So, people like to ridicule bundles and order sets and things like that, but people in the know–

– I think that people get frustrated if they’re told what to do, and it doesn’t make sense to them. And they think this is not, I’m not ordering a steak here. This is medicine and it’s an art, so let me do my art. That’s all fine. I appreciate that. But the truth is when you’re taught as a med student how to read an EKG, you’re taught rate, rhythm, axis, and you gotta do that the same order every time, or you’re gonna miss something on that EKG. When you’re taught to read an X-ray, your wife is a radiologist, it’s patient position, rotation, inspiration, bones, soft tissues, lines. You do it the same way every time and you don’t miss stuff. Well, when you’re taking care of a person in the ICU, if you don’t have some safety checklist like that, we know that we drop the ball. In fact, even just on rounds, patient one versus patient 20, by the time you get to patient 15 to 20, you’re getting beeped, buzzed, you spent too long, and now those last few patients get the short end of the stick, and you don’t spend as much time with them. So, what do you do instead? what you do is you take these landmark randomized trials, put them into a bundle, and the IHI definition of it is, yes, individually, they worked in the New England Journal, Lancet, JAMA, but do they work better if you put them all together as a bundle? When you’re on the airplane tonight, that pilot is gonna do a checklist to take off and also, well we’re not flying much right now, but if something goes really wrong, like a pandemic, they rely even more on their checklist. So, my argument is that right now in the midst of COVID, not only should we not ditch the A2Fs, we should rely even more on these protocols to keep us moored and to keep our treatment foundational and balanced. Does that make sense?

– 1,000%, and we talk about, on our show we talk about Health 2.0, which is this kind of mechanized, commodified, the measurement industrial complex kind of runs everything. This is not what we’re talking about. We need this basis. It’s just like a pilot in order to do the best care we can for the human being in that bed, and I think that’s what people need to understand about ICU care. It is so complex, that if you don’t do things the same way every time, you will miss something, and I know this from personal experience. Now the question is, you mentioned the A2F bundle. So, A, B, C, D, E, F, it might be good–

– You want me to tell you what that is?

– Yeah, absolutely.

– Yeah, what this looks like is, and I can sympathize, by the way, right now, with some nurses and some of our other audience listening in, thinking, “You know what? “Forget you, Ely. “I’m too busy. “Don’t you get it? “I mean we’re in New York, we’ve got all these patients.” Yeah, I do, I sympathize with that, but all this is is waking a person up each day to see if they still need these robust and super powerful psychoactive drugs. So, the funny thing is, I as an intensivist think, somebody comes in crashing on Monday. To get them under control, I put onboard the ventilator, the sedation, dialysis, whatever. For some reason, my tendency is to think, “Well, it was needed yesterday. “It’s still gotta be needed today.” Wrong, totally not right. If anything we’ve learned in the past 20 years of critical care is the sooner you remove this stuff, the safer it is for the patients. So, what is the nurse doing with the A2Fs. All you’re doing is, it’s morning. John Smith is there. Yesterday, he needed high doses of propofol and fentanyl or having read, even a benzo because we’re having shortages in drugs. But today I’m gonna turn those drugs off. I’m gonna wake him up. I’m gonna make sure first of all this pain is controlled, A, analgesia. B, I’m gonna do both SAT and SBT, so I’m turning the drugs off, see if he can tolerate the absence of that sedation, and if he is getting frustrated with the absence of the sedation, A, is a hyperactive delirium, which is not gonna be made better by turning the drugs back on, B, is that he’s frustrated by being on the vent, so I can put them on an SBT and say, “Mr. Smith, let me just let you “breathe on your own for a little while, “and if you do for 30 minutes, “we’ll take that tube out, “and you can breathe without the ventilator.” And then C is choice of drug, trying to avoid–

– So hang on one second there, just to clarify, so SAT is spontaneous awakening trial, SBT is spontaneous breathing trial, just for people who don’t work in unit. It totally makes sense because then you can actually start to tease out is there underlying delirium, and like you said, the drugs are not gonna make that better. If anything, they’re gonna make it worse. And is the ventilator, we had actually Herbert Patrick, great ICU doc, on the show, talking about how some of the magic of making patients comfortable is tweaking those ventilator settings with the RT secret sauce that can actually get them more comfortable, and you’ve spoken about that before. But anyways, I’ll let you continue just wanted to clarify.

– I love you said that because sometimes when you stop the sedation the person looks anxious and frustrated and really it’s just ventilator desyncing ’cause we don’t have our settings right. So that should not beget a ton of sedation, it should beget a good respirotherapist adjusting the ventilator or doing an SBT spontaneous breathing trial from 1996 New England Journal paper when I was a chief resident and just getting them off the ventilator in the first place.

– Yeah, yeah.

– So that’s really important. The other thing we’ve learned Zubin is that this era of really heavy sedation with GABAergics, benzos and propofol it seems like that people are saying and in COVID, hey let’s go back to that if required. I don’t see any data out there to tell us that we have to go undo 20 years and go back to the 1990s with heavy benzos unless you literally are out of the other drugs which that drug shortage would get a lot better if we got you off the ventilator sooner and created less ventilator use. So I think these things are things we have to ponder.

– I think this is something very important because a lot of people now on the front lines in New York and all like Cameron, I’m forgetting his last name is talking about we might be overdoing a lot of things even ventilation on these patients where it’s really a hypoxemia issue and so there’s a lot of nuance there that we won’t have time to get into in this show but you’re absolutely, absolutely right–

– Let’s get into it just a little bit though At the beginning we were worried about droplets and so everybody said well gosh we should intubate them and people were talking about intubating on a few liters of oxygen thinking they’re gonna tank, let me get them intubated I don’t want these droplets spewing. People are already starting to abandon that. We were using way too many ventilators to get these people on ventilation early and now they’re also saying no BiPAP, no masks. We’re saying look let’s use BiPAP, let’s use high flow, let’s keep them off the blower because really Zubin think about it, the risk of having all these people on ventilation begets now immobility, the problems of ICU-acquired weakness like miss Kim, this woman that I was with in Korea who had so much trouble. So already Zubin people are starting to rethink this idea of such early intubation because they thought this is creating too much ventilator use for people who could be managed with high flow oxygen and non-invasive ventilation.

– So when I first did a show about the medical management of COVID I actually was reiterating some of these ideas that we’d heard from Seattle and China which is, early intubation if you’re looking at BiPAP you probably, it’s already too late, you ought to be intubating. Don’t even mess around with high flow because you’re gonna be aerosolizing virus and all this and it turns out maybe that’s not true and like you said we need to reevaluate this especially in the setting of resource utilization and the incredible discomfort that can come with ventilation that could be avoided if we could go with these other things.

– Especially if you know, one of the things we’ve learned about the lung disease is it’s not a low compliance lung disease, it’s a higher compliance lung disease, in fact the paper that get noting published in the blue journal showed the compliance is up in the 40s, 50s, 60s, not down in the teens like we typically see with really bad ARDS. So that’s even more of a reason to me that we don’t need all these ventilators. If somebody can breathe with that sort of compliance, now they do have a lot of shuffling hypoxemia but we can get by with high flow oxygen to take care of that issue. So I really think that we’re learning a lot and we have just to acknowledge hey, it’s a fast-moving thing, we haven’t been through this before but the bottom line is there’s nothing that we see coming out right now that really mandates this early intubation with excessive ventilation use. In fact on the bundle, the A2F bundle, the only two that are really dramatically affected are the E and the F which is the we went through the ABCs, we didn’t hit D is delirium.

– Oh I’m sorry we actually didn’t hit C. We gotta go back and do C.

– Okay let’s get the points. C is choice of drug and there what we’ve learned is that if you can avoid especially GABAergic drugs, now benzos are the primary example of a drug that’s so deliriogenic. Propofol is also deliriogenic but if you use it for a short period of time it’s half-life space short it goes away fairly quickly. It’s only when you get to propofol in four or five days et cetera you have this risk of obviously propofol infusion syndrome and such but if you’re on it one or two days I think it’s a safe drug to use. We want to avoid any just excessive psychoactive drugs, so that’s basically what C is.

– [Zubin] Yeah.

– D is delirium management. I love this mnemonic called the Dr. DRE. I don’t know if you’ve been familiar with this but Dr. DRE is the earbud guy–

– I know Dr. DRE yeah yeah.

– And so its D, D, R, E, diseases, drug removal, environment and basically what I’m telling you is that if somebody’s delirious so if a nurse goes to the bedside and does the CAM-ICU and just tells him Mr. Smith squeeze my hand. Okay squeeze my hand only when I say the letter A and then every time I say an A they should squeeze every time they say a different letter they don’t squeeze okay. Spell Casablanca and if they can get eight out of ten right on Casablanca they’re attentive and they’re not delirious but if they don’t get eight out of ten right they either squeeze too much too little whatever then they’re delirious and that is an independent predictor of four major things the audience should know. What is delirium an independent predictor of? Death, length of stay, cost of care and acquired dementia okay? So that’s the D of the bundle and when they are CAM positive we say rather Dr. DRE. What diseases could be creating this? Definitely COVID but also congestive heart failure and COPD hypoxemia–

– Infection.

– What drugs should be creating this? Drugs that be should be removed. Any psychoactive drugs should be removed and that’s not just benzos it’s all the psychoactive sedatives but it’s also H2 blockers, antibiotics, cefepime et cetera and then the E is huge especially in COVID. What’s the E of the Dr. DRE? Environment. Eye glasses, hearing aids, human touch, sleep cycle, lights on during the day lights up and the environment is a disaster in COVID and I’d like to see us be able to pay more attention to that piece of the D of the bundle if we can get there.

– Still DRE mother flipping DRE. Dude that I’ll never forget that ’cause I had not heard that mnemonic. That’s brilliant. So that’s the delirium component. Like you said, delirium is correlated with very bad outcomes. Everything from length of stay to you said acquired dementia.

– Yeah, big time. We’ve shown this in 2013 in the New England Journal, a paper that we had been funded to do by the NIH, where we followed people up to a year and they had about a quarter to a half of them had mild to moderate dementia, and they did not have the dementia on the front end. These are general medical surgical ICU patients, not neuro not strokes, not TBIs, not bonked on the head. What’s going on? what we think is happening is that delirium is an external manifestation of basically neuronal apoptosis cell death. And over the ensuing weeks and months after the ICU, the more delirium you had, the more likely you are to have atrophy on your CT scan. So you actually have a smaller frontal lobe and hippocampus in your brain if you had more delirium on the front end. And that’s why we’ve gotta be careful with these COVID patients because it’s not just that they have the ICU experience. We think the virus is neuroinvasive. So this virus when it first started in the human body with no immune, no immune ability to fight it at all, it said, “Okay, I’m just gonna destroy “the respiratory epithelia” but then the virus starts thinking, “wait a minute, “I can go wherever I want “why can’t I just… “I came in through the nose, “why don’t I go retrograde to the olfactory bulb into the brain.” And we have evidence from SARS and MERS that there are very young particles from Coronavirus pandemics in the brain of humans and animals. So we’re actually gonna study the long-term brain outcomes here at our center. I run a center at Vanderbilt with Pratik Pandharipande, an anesthesiologist called the CIBS center. C, R, B, S, critical illness, brain dysfunction and survivorship. And so we’re gonna have NIH funding, hopefully by next week to study long-term dementia outcomes of Corona and hopefully even get the brains of unfortunately the deceased patients and study how did this virus invade that brain?

– And it makes sense to because you’re seeing olfactory disturbances in COVID patients, anosmia issues like that. So you start to wonder, so now we’ve gone through D which is crucial again, that’s a whole episode in itself, right? Talking about the D component of that delirium. But let’s get to the E of the bundle. So what’s the E?

– Yeah, it’s really at the E and the F that I think, up to D, I see no delta and just applying the ABCDs at the bedside with COVID, but once you get to the E, E is early mobility. So what it really means is, is getting people out of the bed and walking them even if on a ventilator. And we know we have great data saying that early mobility will reduce long-term physical dysfunction and improve quality of life plus, early mobility cuts delirium in half. So where are we with COVID? Well, with COVID, we can’t have them walking up and down the halls ’cause they’re shedding virus for up to 36 days. We’re now getting data 30 over a month of viral shedding. So what we have to do I think, is pay attention to the fact they can’t just sit in that bed. They can’t be lumps on a log, we have to do passive and active range of motion. And what I’m hearing from my former fellows who are down in New Orleans, and Baton Rouge is, they sent me an email today showing, “hey, we’re going back to the basics here.” And these people are getting inundated with COVID and they said, “We’re going back to basics.” They shared to me today their protocol, physical therapy and occupational therapy. And they say, “it’s business as usual, folks, “let’s get them out of the bed, “let’s walk them around the room. “Let’s do what we can “within the confines of that isolation.” They won’t be up and down the halls, but they’re not sitting in that bed. And that’s the E part. The family part is also critical, because that clearly, we cannot just open these doors to everybody. So we’re gonna have some degree of isolation. And that last part, the immobility and the isolation without the family, I think is delirium on steroids. That’s what really gets the brain to be so sensory deprived, and probably prolongs the delirium a couple of days.

– Yeah.

– And we all want to grapple with how to best approach this.

– Yeah, so basically going this A to F bundle if we make it part and there’s a website that I’m gonna link to your website about ICU delirium that you guys are running, that’s super helpful. And you can get all that stuff there. But people, I think, and you’ve actually done sort of studies of like, how many people are actually instituting this? And it’s not enough it’s not just simply not enough.

– Not enough.

– And so why does it matter? We’ve already said, because it’s one thing to save somebody’s life. It’s another thing to say what type of life are you saving? And that gets me to this piece, which is end of life, now people are dying alone, in discomfort without their families. How does this bundle actually affect our dignity if we are not getting out of the unit? If we’re talking about end of life here does is there a role for all this or should we give up on those patients?

– That, I love that you asked that question. First off, there are definite intangibles about the bundle that make it what it is. So a lot of scientists have said, which piece of the bundle created that mortality advantage? Which piece of the bundle shorten the length of stay and improve their delirium? You know what, as you said earlier, the sum of these it’s greater than the sum of the parts, the overall effect. And I think that’s because you, how do you measure what it meant to somebody that they were alive and not delirious and able to talk to their daughter before they die? How do you measure that? I had a guy not too long ago, this is pre-COVID, he was dying and I said to him, Mr. D, what matters to you? See, I flip the letters instead, flip the preposition instead of what’s the matter with you? I said, What matters to you? And he said, I love my wife, and I want a beer. And we got him that beer and he spent the day with his wife, and he died that night. Now, how do you put a price on that? And the thing is that without the bundle he’d have been delirious ’cause we stopped those drugs. The drugs washed out. He wasn’t getting the psychoactive drugs and he cleared his brain. He was able to spend that last day with his wife. So let’s talk COVID, when somebody is on a ventilator, prone, heavily sedated, they become to us I don’t care who we are, they becomes to us less of a person. We look at it as it’s a sedated comatose person in a bed. Now, I don’t mean to say I mean, I’m probably less sensitive than others. But all of us lose some degree of our awareness of how much that person is a person. Convert that over into an awake patient, looking at you, asking and involved in their decision making. Oh my gosh, it’s a person again, they have a name, they have a story, they have a passion. And the way that people work is I think, when we have passion, get out of our way. But when we’re sick and sedated and lose our why to live, then we lose that passion. You allow somebody to wake up and they realize, “wait a minute, I’m gonna to live now. “And there’s my daughter on that iPad. “Looking at me through that iPad in COVID days, “Honey, I’m gonna live now, “I now have a raison d’etre. “I have my why to live.” Like Viktor Franklin and beautiful his book, “Man’s Search for Meaning”, he said four times in that book, “if a man has a why to live, “he can get by with almost anyhow,” it’s actually a Nietzsche quote. But I think that the bundle brings that full force in our life for both the survivors and those people who are dying.

– And let me put a point on what you said the survivors. So imagine that your last experience with your loved one is one full of regret and loss and lack of closure. Now you have a family that goes out in the world damaged in a way that did not need to happen. And what you said if you apply the it sounds so reductionist, right? We’re talking about it’s a bundle there is these quickboxes, we make sure we go through it. It’s the opposite of reductionism. It’s actually a protocol in service of wholism. And so then it allows, it allows this family to have a kind of experience with someone who’s not delirious, who’s able to interact, that leaves them with a closure, that leaves them with a sense that there was a meaning in this whereas before, it would have been a meaningless act of the universe that this loved one was taken from them.

– Oh, man Zubin, you’re hitting on this is that’s so beautiful what you said. And really, if you think about it, what we wanna show other people when they’re ill is mercy. We wanna show mercy and my definition of mercy, and there’s two parts to it. Listen to the first part is, I wanna dive into be willing to dive into the chaos of another person’s life. But the second part of it is and to provide lifting and healing. So mercy is to dive in the chaos of another person’s life and provide lifting and healing. And what you just said that the bundle does do I think is allows even the dying patients in the ICU to get lifting and healing because we’re able, they are able to know who they are even amidst dying and have some connection with family and why and we have, we can have healing, even without cure. And there’s healing even in the absence of us being able to cure COVID-19. And one last thing, one last image for you. Something that I teach the medical students lot is when somebody’s dying, and they can’t take food, for example, let’s say their gut is too swollen they’re getting bloated, it’s painful, and they can’t tolerate a PEG tube or something. I actually teach the students or the family go back in our kitchen where we have those peanut butter and honey things. Grab some honey, honey on a spoon. Honey on a spoon does all these things. It’s comfortable for the patient. It tastes sweet. We love the sweet taste of honey. It’s safe they can’t aspirate it. The family or the med student feels like they’re doing something loving for the other person and during this engagement, this human to human interaction, love is transferred from one person to the other, which is lost, the chance’s lost if you don’t do the bundle, or ’cause they died just overtly deeply sedated in a coma, and you miss all of these opportunities. So it’s just an example.

– That’s so beautiful man that is so beautifully said and the idea that you said it very well. When someone’s proned, ventilated, unconscious, sedated, they are less than human when you’re overwhelmed and because all our cues of who a human is are taken, all our social cues are gone and we see a lump of physiology that we have to tweak. The minute we–

– Let’s make sure that all the listeners are getting this there are absolutely people who need to get proned. That’s not the question. We’re not bashing–

– No, no, no, no, no.

– What I’m saying is that if Monday they need proning, on Tuesday, do they still need it?

– That’s right.

– So what the bundle does, the bundle doesn’t impugn proning, the bundles doesn’t impugnate the bundle just says, when the sun comes up tomorrow, I’m questioning all this. I’m gonna stop sedation, stop the ventilator and try and go back to a lesser amount of invasiveness. That’s what the bundle–

– And I think my point is about proning is no, yeah, we absolutely need it. Remember, let’s be conscious that this is a human because it’s easy for us to turn that part of our mind off when we’re overwhelmed. I know I was guilty of it in the unit, that okay, this is a problem to solve, not a human and everything that you’ve this journey you’ve taken us on during the course of this talk has reiterated how this is again, it’s part of a calling to show mercy on these patients to lift them out in their deepest suffering. And what is the deepest suffering is in often it’s in the unit. And so I think this is such a beautiful reminder in the setting of a pandemic emergency where people are wondering, do we have enough ventilators? Do we have enough PPE? How am I gonna not get sick? That this is the central reason of the why that we do what we do. You mentioned Viktor Frankl and “Man’s Search for Meaning”. This is our why let’s not forget it. And you have tools, we have tools that are evidence-based to help us do it.

– Yeah and when people by the way, one last thing about this whole dying part is that, if you look at the data on what people are suffering during dying, pain is number 14, actually, in the JAMA papers. It’s existential suffering.

– [Zublin] Yeah.

– That’s what people are suffering from. And so what the bundle allows is to address these issues of existential angst that somebody is going through and talk to them and find out as I said, to Mr. D, what matters to you? So I guess in summary, I would say this, hey, it’s scary right now. We are nervous and we know that there is a disease out there that we can’t cure with a specific drug. But we do know, here’s what we do know. We do know from 20 years of large scale landmark randomized trials put together into a package that allows us to do good safe care, like a pilot would do getting you safely from one city to the other. We do know that that stuff works, and even the absence of hydroxychloroquine, azithromycin or whatever might or might not work, these things work, don’t abandon them. Embrace those things as the tenants of what we do for our critically ill COVID patients. And it will help those patients who are surviving, it will help the patients who are dying, and it’ll help us as healthcare professionals and the families to I think at the end of the day, know that we did our absolute best. And that’s kind of the bottom line, right? That’s what we want to do our best.

– Wes Ely, where can our audience go to learn more about this stuff? What’s your site?

– Yeah, please go to our website. It’s there’s nothing to sell you. It’s just, google ICU delirium that you’re gonna hit icudelirium.org. It’s a website we’ve had for about 20 years. We’ve updated it multiple times, but it’s got lots of NPR sketches, lots of media stuff, tons of stuff from patients and families out there Zubin. There’s patient testimonials and videos. And we just want to do our part here at the CIBS Center at Vanderbilt in Nashville VA, and my partner Pratik Pandharipande and I and the 90 researchers that we have in the CIBS center, want to make ourselves available to you, we actually have, it would be kind of bad if we didn’t mention this, we have an ICU survivor support group. And I think many of us out there need to set up a support group for these COVID survivors. What these people suffer when they leave the ICU is often greater, believe it or not than what they suffered during the ICU. And when they leave the unit and have PICS which is post intensive care syndrome and have a dementia and a PTSD and a depression. That you know these people, they lose their jobs, they lose their money, they lose internet connectivity, etc. So every Tuesday for example, at one o’clock we have a support group with Zoom and people can get on that support group and be with us. We have a neuropsychologist, Jim Jackson, who leads it and these 90 researchers that we have built here in this research group, we are devoted to you and let us know how we can help.

– That’s wonderful. Not enough people are talking about this. I’m so glad that someone who’s not just a great scientist, but is actually a great communicator and is so passionate about this, is leading this. Wes, it’s really an honor. Z-Pack, this show, share it please, make sure that we do better about using these bundles about looking at the human being in that bed in the ICU, especially during this time of COVID when everybody’s frightened, we can do so much good in the world and reconnect with the sacred nature of our calling, this purpose, this calling, which is to connect with other human beings. Alright guys, I love you and we out, stay safe.