Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
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dedicated to investigational research and leads the global
effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
I'M HENRY MASUR, CHIEF OF
CLINICAL CARE MEDICINE, I AM
REALLY PLEASED TO WELCOME ALL OF
YOU TO THIS GREAT TEACHERS GRAND
ROUNDS AND I'M PARTICULARLY
PLEASED THAT AN OLD FRIEND AND
COLLEAGUE WES ELY FROM TULANE
UNIVERSITY IS HERE EARLY IN THE
ACADEMEC YEAR TO TALK TO US.
I WOULD LIKE
TO TELL YOU A LITTLE BIT ABOUT
HIS BACKGROUND.
WES STARTED OUT HIS CAREER IN
SHREVEPORT WHERE HE GREW UP,
WENT TO HIGH SCHOOL AND HAD
EXPERIENCES PARTICULARLY WORKING
IN THE FIELD DURING THE SUMMER,
SUMMER JOB WHERE HE LEARNED A
LOT ABOUT THE HEALTHCARE THAT
SOME OF HIS COLLEAGUES WORKING
THERE DID NOT HAVE AND I THINK
YOU CAN TELL THAT THAT
INFLUENCED THE DIRECTION HE WENT
FOR THE REST OF HIS LIFE.
HE THEN STAYED IN THE SOUTH TO
GO TO TULANE UNIVERSITY FOR HIS
UNDERGRADUATE MEDICAL DEGREES,
THEN WENT TO WAKE FORREST FOR
RESIDENCY, FOR HIS CHIEF
RESIDENT AND IT WAS THERE REALLY
THAT A RESIDENT AND FELLOW FIRST
CAME TO NATIONAL PROMINENCE
BECAUSE AS A CHIEF RESIDENT, HE
WAS ABLE TO PUBLISH AN ARTICLE
ON VENT LATERS IN THE NEW
ENGLAND JOURNAL OF MEDICINE,
NOTABLE ACCOMPLISHMENT FOR
SOMEBODY THAT EARLY IN HIS
CAREER AND THAT WOULD REALLY
MARK WHERE HE WENT LATER.
AFTER A BRIEF SOJOWRN IN
ST. LOUIS, HE WENT TO VANDERBILT
UNIVERSITY WHERE HE'S BEEN FOR
THE REST OF HIS CAREER.
NEXT SLIDE.
SO IN THE NEXT SLIDE,--MAYBE
WE'RE HAVING TROUBLE FORWARDING
THIS--I MEAN WES IS REALLY KNOWN
FOR A NUMBER OF THINGS, I DON'T
KNOW IF WE CAN MOVE TO THE NEXT
SLIDE OR NOT, WES TRAINED TO BE
A PULMONARY CARE PHYSICIAN AND I
THINK BOTH AT VANDERBILT AND
NATIONALLY HE'S KNOWN AS A SUPER
CLINICIAN AND REALLY A GIFTED
EDUCATOR AND COMMUNICATOR.
HE'S WELL KNOWN FOR HIS EARLY
INVESTIGATIONS IN ADULT REZONING
PIRATTORY DISTRESS SYNDROME
WHERE HE STUDIES
PATHOPHYSIOLOGY, DIAGNOSIS,
THERAPY AND OUTCOMES AND
ESTABLISHESSED HIS SCIENTIFIC
CREDENTIALS.
HE THEN GOT INTERESTED IN THE
LONG-TERM OUTCOME OF PATIENTS IN
THE ICU AND HE WILL TELL YOU A
LITTLE BIT ABOUT THE
SOPHISTICATED CALLED
ABCDEF BUNDLES WHICH ARE 6
SAFETY ELEMENTS ADOPTED BY THE
SOCIETY OF CLINICAL CARE
MEDICINE AND HELP PATIENTS ON
VENTILATORS, AND LASTLY HE WAS
THE LEADER IN DEVELOPING THE CAM
ICU AND METRIC INFUSEMENT
ASSESSMENT IN THE ICU, SOMETHING
THAT IS WIDELY USED NOW TO
EVALUATE PATIENTS AND TELL US
ABOUT IT.
NEXT SLIDE.
WES THOUGH HAS A NUMBER OF
DIFFERENT CAREERS.
I TOLD YOU AS A CLINICIAN, AS AN
EDUCATOR, HE'S ALSO BEEN A VERY
EFFECTIVE HIGH PROFILE
COMMUNICATOR.
HE'S BEEN SEEN ON LOCAL NEWS,
NATIONAL NEWS TALKS ABOUT HIS
PATIENT'S STUDY EXPTION ABOUT
WHAT PATIENTS IN THE ICU REALLY
EXPERIENCE.
HE PUBLISHES WIDELY IN THE
POPULAR PRESS,'VE PROBABLY SEEN
SOME OF HIS ARTICLES IN THE
WASHINGTON POST OR WALL STREET
JOURNAL AND RECENTLY, HE CAME
OUT WITH A VERY WELL RECEIVED,
EVERY DEEP KRAWN BREATH WHICH IS
TAKEN FROM A JOHN STEINBECK
QUOTE BUT THIS IS REALLY HIS
EXPERIENCE ON HEALING,
RECOVERING AND TRANSFORMING
MEDICINE IN THE ICU, AND FOR ANY
OF YOU WHO KNOW WHAT IT'S LIKE
TO BE IN THE ICU AND THE
LONG-TERM CONSEQUENCES, THIS IS
AN AMAZING BOOK TALKING ABOUT
HIS EXPERIENCE IN THE DIRECTION
HE THINKS WE OUGHT TO GO.
SO WES, IT'S REALLY WONDERFUL WE
COULD HAVE YOU HERE, VIRTUALLY
WE CAN HAVE YOU HERE SOMETIMES
IN PERSON AND WE'RE LOOKING
FORWARD TO WHAT YOU HAVE TO SAY
ABOUT COVID.
WES?
>> THANK YOU HENRY, THANK YOU
FRIEND, THANK YOU FOR TAKING
TIME OUT OF YOUR BUSY LIVES TO
BE HERE TODAY AND WHAT I WILL DO
IS TAKE A DATA DRIVEN APPROACH
TO SHARING WITH YOU, THE PROCESS
OF MY OWN LEARNING DURING COVID
AND HOW WE CAN TAKE I THINK THE
PREVIOUS 2 AND HALF DECADES
WORTH OF RESEARCH, BRING THEM
INTO WHAT HAPPENED TO US DURING
COVID WHICH WAS HARD AND
SUFFERING FOR OUR PATIENTS AND
FOR US IN THE SCIENTIFIC FIELD
AS WELL AND HOW WE CAN FIND A
WAY FORWARD AND TRY AND FIND A
WAY TO REBUILD WHAT COVID TOOK
FROM US AND I WILL BE VERY
HONEST WITH YOU THAT MY JOURNEY
IN ALL THIS THAT HENRY WENT OVER
JUST NOW, I'VE JUST BEEN
SURROUNDED BY THE RIGHT PEOPLE.
I'VE APPROACHED THIS AT THE
PATIENT LEVEL FIRST.
WHO IS THIS PERSON SITTING IN
FRONT OF ME?
HOW ARE THEY SUFFERING?
AND INSTEAD OF SAYING, WHAT'S
THE MATTER WITH YOU, SAY TO
THEM, MISS SMITH TELL ME WHAT
MATTERS TO YOU?
I MET WITH THE STUDENTS THIS
MORNING, THE NEXT GENERATION OF
NIH INVESTIGATORS AND LEADERS IN
MEDICINE AND I EMPHASIZED THIS
SWITCHING OF THE PREPOSITION
FROM WHAT MATTERS--FROM WHAT'S
THE MATTER WITH YOU TO TO, WHAT
MATTERS TO YOU.
AND I THINK WHEN WE ALWAYS KEEP
OUR MIND AND OUR EYEOT PATIENT
THAT WE WILL FIND OUR BEST WAY
FORWARD AND IN COVID SOME REALLY
BAD THINGS HAPPENED IN MEDICINE,
LIKE NONAPOPTOTIC VISITATION
POLICIES WHICH I WROTE ABOUT IN
THE WALL STREET JOURNAL IN THE
WAJO ACCIDENT AND WE MADE LEFT
TURNS IF THEY WERE NOT RIGHT, I
DON'T KNOW IF THAT'S THE RIGHT
WAY TO PHRASE THAT BUT WE DID
SOME HING THINGS THAT WERE NOT
IN THE BEST INTEREST OF OUR
PATIENTS.
LET ME SAY IT THAT WAY BUT WE
HAVE DATA TO SUPPORT MAKING GOOD
CHOICES GOING FORWARD IN A WAY
WE CAN BOTH ACHIEVE RECOVERY FOR
OUR PATIENTS, AND RECOVERY FOR
OURSELVES AS WELL, SO LET'S TALK
ABOUT FROM A
PERSPECTIVE, I WILL SHARE MY
SLIDES WITH YOU AND I WILL HAVE
US GET STARTED NOW.
BY WAY OF DISCLOSURE I
WANT YOU TO KNOW THAT I DO NOT
HAVE ANY RELEVANT INDUSTRY
RELATED DISCLOSURES, I AM NIH
AND VA FUNDED, I WAS AN UNFUNDED
INVESTIGATOR ON A COVID STUDY
CALLED CO-BEAR QUER WHICH I WILL
REVIEW WITH YOU THE DATA ABOUT
BECAUSE IT LED TO THE FDA
APPROVAL OF THE SECOND FDA
APPROVED DRUG FOR COVID BEHIND
REMDESIVIR, I DO NOT HAVE ANY
FINANCIAL INTEREST IN THIS DRUG
AT ALL, BUT I DO BELIEVE THE
DATA IS IMPORTANT SO LET'S GO
OVER THIS IN A MINUTE.
I THINK IT'S IN A LAUNCHING
POINT FOR OUR OWN PATH TO
DISCOVERY AND I WILL TELL THIS
STORY BECAUSE I WANT YOU TO
THINK ABOUT YOUR OWN LIFE AND
YOUR OWN DISCERNMENT IN HOW
YOU'RE MOVING THROUGH, DECIDING
HOW TO SPEND YOUR TIME, WHERE
DO--WHERE TO DEVOTE YOURSELF AS
AN INVESTIGATOR, AS A PHYSICIAN
SCIENTIST, OR NURSE SCIENTIST OR
WHATEVER YOUR BACKGROUND IS, IN
THIS PARTICULAR CASE, I HAPPEN
TO BE ON A TREADMILL 1 DAY,
READING THE NEW ENGLAND JOURNAL
OF MEDICINE AND A PAPER CAME OUT
SAYING THAT WE COULD FIND A
BETTER WAY TO GET PEOPLE OFF THE
VENTILATOR.
AND IN THE FIRST LINE OF THE
RESULT SECTION, IT SAID THIS 1
SENTENCE THAT CHANGED MY ENTIRE
LIFE, IT SAYS 85% OF THE
PATIENTS COULD NOT BE ENROLLED
IN THIS RANDOMIZED TRIAL BECAUSE
THEY WERE READY TO BE TAKEN OFF
THE VENTILATOR WHEN THEY WERE
SCREENED.
AND I THOUGHT TO MYSELF, WAIT A
MINUTE WHAT?
WHY WERE 85% OF THEM NOT
ENROLLABLE BECAUSE THEY WERE
ALREADY READY THEN WHY WEREN'T
THEY TAKEN OFF THE VENTILATOR
THE DAY BEFORE THAT OR THE DAY
BEFORE THAT?
SO I SET THUP INVESTIGATION
WHICH WAS THE FIRST EVER TRIAL
OF A PROTOCOL TO USE RESPIRATORY
THERAPISTS TO GET PEOPLE OFF THE
VENTILATOR SOONER AND I THE
FIRST THING I WANT TO TELL YOU
IS OUT OF 82 INTENSIVISTS AT THE
INSTITUTION.
EIGHTY-ONE OF THEM SAID IT WOULD
BE A BAD IDEA AND THAT THEY
DIDN'T WANT US TO MOVE FORWARD.
SO I HAD 1 MENTOR WHOSE NAME WAS
ED [INDISCERNIBLE], HE SAID,
LET'S DO THIS.
HE IS THE SENIOR AUTHOR ON THIS
PAPER, WE DESEEBED A TRIAL, I
WOULD REPORT, SCREEN MY
PATIENTS, ENROLL THESE PEOPLE
AND AT THE END OF THE DAY, WE
PROVED THAT TAKING THE DECISION
MAKING OUT OF THE DOCTOR'S HANDS
AND PLACING IT INTO A
RESPIRATORY CARE PRACTITIONER
GROUP THAT WE COULD DO BETTER.
SO IN MY MIND IT WAS DESILOING
THE WAY WE CARE FOR PATIENTS AND
EMBRACING A TEAM APPROACH IN THE
ICU, AND THE PATIENTS GOT OFF
THE VENTILATOR 2 DAYS EARLIER,
WE HAVE THE COMPLICATION RATES
AND WE SAVE $5000 PER PATIENT.
NOW, I WANT TO SHARE WITH YOU
THIS QUOTE FROM ANN HATCHET, 1
OF MY FAVORITE AUTHORS, AND SHE
WRITES: NEVER BE SO FOCUSED ON
WHAT YOU'RE LOOKING FOR THAT YOU
OVERLOOK THE THING YOU ACTUALLY
FIND.
TURNS OUT THAT A FEW YEARS LATER
I WAS ASKED TO GO TO A RESEARCH
GROUP BRINGS TGHTD THE IDEA OF
AGING AND CRITICAL CARE AND I
THOUGHT THAT I WAS GOING TO
PROVE A BET ARE WAY TO GET OLDER
PEOPLE OFF THE VENTILATOR BUT
WHEN I ANALYZE THE DATA FROM THE
ARDS NEST, 902 PATIENTS AND WE
GOT THE DATA TOGETHER TO PRESENT
DOWN THERE AT THIS MEETING OF
GERIATRICS AND CRITICAL CARE,
WHAT I FOUND WAS THAT OLDER
PEOPLE'S LUNGS GOT BETTER AS
QUICKLY AS YOUNG PEOPLE'S LUNGS,
BUT THAT DOWN THE LINE, A WEEK
OR 2 LATER THE OLD PEOPLE WOULD
GO ON TO HAVE MORE TROUBLE, MORE
BOUNCE BACKS INTO THE ICU, MORE
DEATH.
SO I WAS LOOKING FOR A WAY TO
DISSECT THE DIAPHRAGM FOR MY
NEXT MOVE AND PATRICK WAS SAYING
DON'T BE MARRIED TO YOUR
PREVIOUS IDEAS, BE ACCEPTING OF
THE AND PAYING ATTENTION TO WHAT
YOU THOUGHT YOU WOULD, NOUGHT
WHAT YOU THOUGHT YOU WOULD FIND.
AND SO MOVING FORWARD, I BEGAN
TO HEDGE MY BETS ON THE FACT
THAT WHAT WAS CAUSING THESE
OLDER PEOPLE PROBLEMS WAS THEIR
BRAINS AND IT WAS VERY MUCH
AN ANTITHESIS OF WHAT I'VE BEEN
TRAINED TO DO.
IN THE ICU WE WERE ALL ABOUT THE
LUNGS, VENTILATOR AND SETTINGS
AND IN FACT 1 OF THE SENIOR
INVESTIGATORS AND SPEAKER THIS
IS MORNING ON THE GOOD
TEACHER'S, GREAT TEACHER'S GROUP
WITH THE STUDENTS SAID WHEN I
WAS IN THE ICU, I NEVER HAD ANY
RELATIONSHIPS WITH MY PATIENTS,
ALL WE DID WAS KEEP THEM SNOWED
WITH SEDATION AND TRY AND GET
THEM THROUGH THE TECHNOLOGICAL
LIFE SUPPORT BUT I NEVER KNEW
ANYTHING ABOUT THESE PEOPLE.
AND WE HAVE NOW TURNED THAT ON
ITS HEAD IN THE ICU AND I WILL
TELL YOU THE STORY OF HOW WE'VE
DONE THAT BECAUSE NOW, IN THE
ICU, WE WANT OUR PATIENTS AWAKE,
ALERT, OUT OF THE BED, WALKING
EVENOT VENTILATOR, ENGAGING WITH
US AND THEIR FAMILY MEMBERS AND
HOW WE GOT STARTED WAS BACK IN
1998, 1999 WHEN WE DESIGNED THIS
TOOL CALLED THE CAM ICU.
AND WE PROVED THAT WE COULD
MEASURE [INDISCERNIBLE], WE
COULD DO IT WHEN SOMEONE
COULDN'T SPEAK TO US, WE DID IT
WITH SPECIFICITY, THE NURSES DID
THIS WORK IN LESS THAN 2
MINUTES, THE GROUP SHOWED THAT
THE TOOL WAS VALID AND RELIABLE
IN THIS OLDER PEOPLE AND THOSE
WITH HIGH OR LOW SEVERITY OF
ILLNESS SO WITH THE TEST
CHARACTERISTICS WE PUBLISHED IN
JAMA AND WE MOVED FORWARD.
BUT THAT WAS A WAY TO TELL
WHETHER OR NOT SOMEBODY WAS
THINKING CLEARLY BUT IT WASN'T A
MEASUREMENT OF HOW ACEROUSABLE
THEY ARE WERE AND CONSCIOUSNESS
IS A MEASURE OF ACEROUSABILITY
AND CONTENT OF CONSCIOUSNESS.
SO A COUPLE YEARS LATER I WORKED
WITH ANOTHER INVESTIGATOR NAMED
KIRK [INDISCERNIBLE] IN
RICHMOND, VIRGINIA AND WE
VALIDATED THIS TOOL CALLED THE
RASS, KURT PUBLISHED FIRST IN
THE BLUE JOURNAL BUT HE DIDN'T
WANT TO CALL IT SESESLER'S
AGITATION, BECAUSE THEN THEY
WOULD REFER TO AS SESESLER'S
ASS, SO WE NAMED IT RASS,
INSTEAD AND PUBLISHED THIS PAPER
IN JAMA WHICH WAS ANOTHER
VALIDATION AND STUDY.
AND THE 2 THINGS TOGETHER BECAME
THE SISTER INSTRUMENTS OF HOW WE
MEASURE THE BRAIN IN THE ICU.
AROUSABILITY WITH THE RASS,
CONTENT OF CONSCIOUSNESS WITH
THE CAM ICU AND THEN WE WENT ON
TO USE THOSE TOOLS TO PROVE THAT
DELERIUM WAS A PREDICTOR OF
MORTALITY AND THOSE WHO LOVE
STORIES OF WORDS, I AM A WRITER
AND SO I LOVE WORDS, THIS WORD
PREDICTOR HERE WAS NOT CHOSEN BY
ME, IT WAS CHOSEN BY THE JAMA
EDITOR, AND THE STATIST KALG
EDITOR OF JAMA.
DEBORAH COOK WAS THE EDITOR, I
WAS READING AND ASSOCIATE IT
WITH MORTALITY BUT I DIDN'T WANT
TO OVERSTATE MY FINDINGS BUT
THEY NO, NO, NO, YOU HAVE USED
THE APPROPRIATE STATISTICAL
TOOLS TO SAY IT IS A PREDICTOR
OF DEATH HERE SO WE'RE GOING TO
EMBRACE THAT WORD, WE'RE GOING
TO CHANGE YOUR TITLE FOR YOU AND
IN THIS CARING FOR THE
CRITICALLY ILL COLUMN IN JAMA WE
WILL MAKE THIS READER KNOW THAT
THIS IS AN INDEPENDENT PREDICTOR
OF SURVIVAL AND WE NOW KNOW THAT
EVERY ADDITIONAL DAY OF DELERIUM
IS A 10% INCREASE RISE IN THE
LIKELIHOOD OF SOMEBODY DYING.
AND THIS IS A TRIPLING OF THE
RISK OF DEATH AFTER 30--AFTER 6
MONTHS.
SO, WE NOW USE THIS AS A
BAROMETER, A PROGNOSTIC MARKER
AND IT IS SOMETHING THAT YOU AND
YOUR LOVED 1S SHOULD ALL HAVE
MONITORED IF YOU ARE IN THE ICU
AND THE GUIDELINES OF THE
SOCIETY OF CRITICAL CARE
MEDICINE AND ALL INTERNATIONAL
GUIDELINES RECOMMENDING
APPROPRIATE EVIDENCE BASED CARE
FOR CRITICALLY ILL PATIENTS SAY
THAT EVERY PATIENT, EVERY DAY IN
EVERY ICU, ACROSS THE LAND
SHOULD BE MEASURED FOR DELERIUM,
WHY?
BECAUSE YEARS AGO, IT WAS THE
CULTURE OF CRITICAL CARE THAT WE
SHOULD AND THIS AD WAS OUT OF A
THROW AWAY, FOR THE USE OF
MIDAZOLAM, FOR CALM IN THE ICU.
THIS WAS THE WAY WE WERE
TRAINED, TO KEEP THE PATIENTS SO
SEDATED THAT WE WEREN'T AWARE
OFA WHAT WAS GOING ON.
AND WHAT HAPPENED IN MY BRAIN IS
WAIT A MINUTE, OLDER PEOPLE ARE
SUCCUMBING TO SOMETHING DOWN THE
LINE AND IF IT'S A BRAIN
DYSFUNCTION AND IF THAT BRAIN,
THAT CPU OF OUR HUMAN BODY IS
CAUSING A DOWN STREAM PROBLEM
WITH SURVIVAL AND QUALITY OF
LIFE, THEN WE NEED TO KNOW ABOUT
THIS.
WE NEED TO UNEARTH THIS AND PUT
A SAFETY BELT ON OUR PATIENTS IF
YOU WILL.
SO, THIS IS WHAT WE BEGAN TO DO.
TO GET A BETTER SAFETY BELT FOR
OUR PATIENTS, WE SET OUT TO
DESIGN NUMEROUS RANDOMIZED
CONTROL TRIALS, MULTICENTER THAT
BEGAN TO PEEL AWAY THE LAYERS OF
IMMOBILITY, DEEP SEDATION AND
ABSENCE OF FAMILY, ET CETERA
THAT I THINK WERE 1 BY 1
STRIPPING PATIENTS OF THE DESIRE
TO LIVE, OF THE ABILITY TO SEE
THE PURPOSE AND FIND THEIR WHY.
YOU KNOW VICTOR FRANKLE IN HIS
BOOK, MAN'S SEARCH FOR MEANING
QUOTES NICHES FROM TWILIGHT OF
THE IDOMAINS, NICHE WROTE IF A
MAN HAS A WHY TO LIVE, HE CAN
GET BY WITH ALMOST ANY HOW.
SO WE HAVE TO SAY AS CAREGIVERS
FOR OUR PATIENTS, HOW CAN I
SERVE THIS PERSON THAT IS
SUFFERING IN MY ICU AND THE BEST
WAY TO SERVE THAT PERSON IT TO
HELP THEM FIND THEIR WHY TO
LIVE.
OKAY, A PERSON CANNOT FIND THEIR
WHY IF THEY ARE UNCONSCIOUS IN A
COMA.
THEY HAVE TO BE AWAKE AND
ENGAGING WITH THE THINGS THAT
MATTER MOST TO THEM IN LIFE AND
I AS A CLINICIAN CANNOT BE A
TRUE HEALER IF I KEEP THEM
SNOWED IN A SEDENTARIAATIVE COMA
WHERE THEY CANNOT ENGAGE AND
TALK TO ME, WHERE I CANNOT LEARN
ABOUT THEM, SO EVERY SINGLE DAY
WHAT WE PROVED AND I WILL SHOW
YOU THE DATA WE PROVE THAD EVERY
DAY, PATIENTS SHOULD NO MATTER
WHAT YOU THOUGHT WAS RIGHT
YESTERDAY, WHEN THE SUN COMES UP
THE NEXT DAY, YOU SHOULD TURN
OFF THE SEDENTARIATIVES, TURN
OFF THE VENTILATOR, SEE IF
THEY'RE STILL REQUIRED AND SEE
IF THE PERSON AND IN SO DOING WE
ACTUALLY SAVED LIVES.
IN THIS ABC STUDY HERE WE
PUBLISHED IN LANCET, WE SHOWED
IN THE CAP LANMIER CURVE A THOO%
REDUCTION IN RISK REDUCTION, 15%
IN FACT THE NEW ENGLAND JOURNAL
AND WE HAVE IT SUBMITTED THEY
HAD IT FOR A YEAR AND THEY WERE
LIKE OH MY GOSH, YES, AND SO WE
SHOWED THAT FOR EVERY 7 PEOPLE
TREATED WITH THIS WAKE UP AND
BREATHE APPROACH, WAKE THEM UP,
SEE IF THEY CAN BREATHE ON THEIR
OWN, THAT 1 LIFE WILL BE SAVED.
AND WHEN WE DID THAT, WE STARTED
A LOT OF PEOPLE IN THE WORLD
STARTED NOTICING THAT MAYBE
THERE WERE UNINTENDED BENEFITS
OF THIS,A PROACH.
LET ME SHARE WITH YOU
AN ANECDOTE ABOUT DONNIE HILLY,
SHE WAS A CEO ON MUSIC ROW, HERE
HERE SHE IS IN STRIPES WITH HER
SISTER IN WHITE, I THIS IS THE
BOOK THAT HENRY WAS SHOWING YOU
EARLIER, THIS IS THE PAPER BACK,
IT CAME OUT YESTERDAY AND BY THE
WAY, I DON'T MAKE ANY MONEY OFF
THIS BOOK, I CALL IT EDDB, EDDB,
EVERY PENNY IN THE PROCEEDS FROM
THIS BOOK GOES INTO AN ENDOWMENT
WHERE WE HAVE SOCIAL WORKERS
HIRED TO HELP PEOPLE PICK UP THE
PIECES OF THEIR LIFE.
SO THROUGH OUR RESEARCH CENTER
HERE THE CIBS, CRITICAL ILLNESS,
BRAIN DYSFUNCTION AND
SURVIVORSHIP, YOU CAN FIND US ON
THE WEB SAIT ICUDELERIUM.ORG, WE
HAVE AN EDUCATIONAL WEBSITE THAT
WE PROVIDE FREE SUPPORT FOR
COVID USERS EVERY DAY, SUPPORT
GROWFS FOR THEIR SPOUSES AS
WELL, FOR FAMILY MEMBERS AND WE
CONSIDER OURSELVES PUBLIC
SERVANTS HERE TO HELP PEOPLE
LIKE DONNA HILLEY, SO I WRITE,
DURING THIS TIME OF UNCERTAINTY
I RECEIVED A LETTER FROM DIANE
WHITTEN-VILE, HER SISTER HAD
BEEN SPENT 10 DAYS IN ON THE
VEPTALATOR IN ICU, WRESTLING
WITH SEPTIC SHOCK, I REMEMBER
SHE HAD STRUPGLED HERRIBLELY
WITH DELERIUM NOT KNOWING WHERE
SHE WAS OR RECOGNIZING VISITORS
TO HER ROOM.
SHE WAS A CEO ON MUSIC ROW IN
NASHVILLE WHO OVERSAW
MULTIMILLION DOLLAR MUSIC
CATALOG PURCHASES AND ORGANIZED
DINNERS FOR WASHINGTON ELITE.
AND AFTER SHE DEVELOPED DELERIUM
WE COULDN'T GET MORE MENTAL
CLOUDING CLEARS FOR MONTHS.
SHE HAD TRIED TO GO BACK TO WORK
ALTHOUGH SHE CANNOT SEEM TO
FULLY BOUNCE BACK.
SHE'S LOST HER SPARK.
SHE WAS SUCH A PERSONAL
PREILLNESS, SO GREGARIOUS AND
REALLY THE LIFE OF THE PARTY BUT
SHE IS VERY FLAT NOW, SHE HAS
MEMORY PROBLEMS, SOME LONG-TERM
BUT MOSTLY SHORT-TERM.
SHE LOOKS MUCH OLDER, LIKE AN
ELDERLY WOMAN, NOW AND WACHOVIAS
VERY SLOWLY ALWAYS HOLDING ON TO
RAILS, SHE IS VAJILE AND VACANT.
WHAT'S GOING ON HERE, WHAT'S
GOING ON.
ONE MORE STORY.
AFTER WE PUBLISHED OUR DATA, WE
GOT SLEWS OF TESTIMONIALS FROM
PEOPLE ON THE INTERNET SAYING
THINGS LIKE THIS, AFTER 5
MONTHS, I FELT BETTER AND
RETURNED TO WORK BUT WAS FIRED
10 WEEKS LATER, IT DIDN'T
SURPRISE ME BECAUSE I WAS
STRUGGLING TERRIBLY, I COULDN'T
ORGANIZE MY WORK, COMMITTED MANY
ERRORS IN DOCUMENTATION,
FREQUENTLY LOST THINGS, FORGOT
MEET EXPTION DID NOT MANAGE MY
TIME WELL.
WHAT DOES THIS SOUND LIKE TO YOU
RIGHT NOW IN 2022?
RIGHT.
LONG COVID.
THIS IS THE STORY OF LONG COVID
PATIENTS RIGHT NOW AND YET THIS
IS FROM A HICKS PATIENT 15-TWEBT
YEARS AGO, FOR DECADES NOW WE
HAVE BEEN CREATING A
CIRCUMSTANCE WHERE SOME PEOPLE
SURVIVE AND END UP WITH AN
ACQUIRED DEMENTIA AND THIS
ACQUIRED DEMENTIA DOES ENTAIL
THE LOSS OF NILIONS OF NEURONS
IN THEIR BRAIN AND THIS IS WELL
DOCUMENTED AND REALLY FLESHED
OUT IN EDDB, BUT NOW WE HAVE A
NEW PROBLEM WHERE PEOPLE ARE
SUCCUMBING TO THE CORONA VIRUS,
AND ABOUT 100 DAYS LATER THEY
ARE HAVING ALL THESE BRAIN FOG
PROBLEMS, IN FACT IT'S NOW 2
YEARS LATER AND PEOPLE ARE STILL
HAVING ALL KINDS OF PROBLEMS
WITH THEIR EXECUTIVE FUNCTION
AND MEMORY, THIS IS ABSOLUTELY
WELL DOCUMENTED, WE ARE DOING
LOTS OF NIH INVESTIGATIONS RIGHT
NOW FINDING THE LINKS TO THE 2
AND WHAT I WILL SHARE WITH YOU
TODAY, THIS IS UNPUBLISHED BUT
IT'S A PAPER IN PRESS, THAT WE
HAVE NOW PROVEN A LINK TWOON
DELERIUM IN COVID AND THE
SEVERITY OF THE
NEUROPSYCHOLOGICAL DEFINITES IN
COVID SURVIVORS.
SO THIS IS A WAY THAT IT MIGHT
LOOK ON A NEUROIMAGE.
HERE YOU HAVE AN MRI ON THE LEFT
OF A PATIENT WHO DID NOT HAVE
DELERIUM AND 1 ON THE RIGHT OF
SOME INTHB WHO HAD 12 DAYS OF
DELERIUM JUST LIKE DONNA HILLEY
AND YOU CAN SEE THE TREMENDOUS
AMOUNT OF ATROPHY.
IN THIS CASE, WE USE A BAROMETER
OF ATROPHY AS A VENTRAL TO BRAIN
RATIO, YOU CAN SEE THAT THE VBR
IS VERY HIGH ON THE IMAGE IN B
BUT NOT IN A, AND SO THEY HIRE
THE VBR, MORE ATROPHY OCCURRED
AND WE SHOWED THIS IN DIFFERENT
MANUSCRIPTS THAT DELERIUM IS AN
INDEPENDENT PREDICTOR OF THE
HIGHER BRAIN RATIO IN ICU
SURVIVORS.
WELL, YEARS DOWN THE LINE WE
BEGAN TO STUDY THIS IN TERMS OF
LARGE COHORT STUDIES, DID
DELERIUM ALSO PREDICT AN
ACQUIRED DEMENTIA.
AND 2013, WE PUBLISHED OUR DATA
ON LONG-TERM COGNITIVE
IMPAIRMENT, READ ACQUIRED
DEMENTIA FROM 121 PATIENTS, 34%
OF WHOM HAD THE EQUIVALENT OF
MODERATE TBI AND 24% THE
EQUIVALENT OF MODERATE TO MILD
ALZHEIMER'S DISEASE.
I AM PRIVILEGED TO BE ON
THE--THANKFUL TO BE ON THE
NATIONAL AKD--SALLY ME OF
SCIENCE AND MEDICINE FORUM ON
TRAUMATIC BRAIN INJURY AND I'M
WORKING RIGHT NONAPOPTOTIC YOU
WITH A GROUP OF PEOPLE TO TRY
AND UNDERSTAND HOW WE CAN DO A
BETTER JOB TEACHING THE LAY
PUBLIC AND OUR MEDICAL COMMUNITY
ABOUT TBI, WELL, LONG THE WAY
I'VE BEEN THINKING ABOUT HOW OUR
ICU SURVIVORS ESSENTIALLY HAVE
ATBI, AFTER THEY GET OUT OF THE
ICU, THEY DIDN'T GET AN OUTRIGHT
BONK ON THE HEAD WHICH SHOWS UP
AS A MACROINJURY ON THEIR CTs
AND MRIs, WHAT THEY HAVE A
GLOBAL MICROINJURY ACROSS THEIR
DORSAL LATERAL PREPRONTAL
CORTEX, HIPPOCAMPUS AND NUMEROUS
OTHER REGIONS OF THE BRAIN WHICH
LEAVES THEM ESSENTIALLY AD AND
TBI AND WHAT HAPPENED AT THE NIH
IS, WHICH IS INTERESTING IS THAT
FOR ABOUT 10 YEARS WE TRIED TO
GET THIS ICU SURVIVORSHIP
DEMENTIA INTO THE CAMP OF MONEY
FOR RESEARCH, FOR NIA FUNDED
DEMENTIA WORK.
WE NOW HAVE ACCOMPLISHED, NOT
ME, MEANING ONLY ME BUT
SCIENTISTS GENERALLY HAVE
ACCOMPLISHED THAT THE NIA NOW AS
HAS A TERM CALLED ADRD WHICH IS
ALZHEIMER'S DISEASE AND RELATED
DEMENTIAS, WHICH IS NOW A WIDER
RUBRIC UNDER WHICH THE ICU
ACQUIRED DEMENTIA OR PICKS
RELATED DEMENTIA FALLS AND SO WE
ACTUALLY--THIS STUDY RIGHT HERE
WAS FUNDED BY THE NIA WITH A
10 MILLION-DOLLAR GRANT FROM THE
NIA FOR ABRK AFTER THE ICU, WE
WENT ON TO GET ANOTHER
RANDOMIZED CONTROL TRIAL FUNDED
AT NIA FOR ANTIPSYCHOTICS AND
DELERIUM UNDER THE AD/RD RUBRIC
AND WE NOW HAVE THIS STUDY RIGHT
HERE WAS CALLED BRAIN 1, WE NOW
HAVE BRAIN 2 GOING ON WHICH IS A
20 MILLION-DOLLAR NIA FUNDED
COHORT STUDY WHERE WE ARE
COLLECTING THE BRAINS OF THE
THESE ICU PATIENTS ONCE THEY
DIE, WHETHER IT BE IN THE ICU OR
IN THE HOSPITAL WARD SYSTEM OR
YEARS LATER AND WE'RE LOOKING AT
THESE BRAINS WITH NEUROIMAGING
AND NUMEROUS DIFFERENT
BIOLOGICAL PATHOLOGICAL
INVESTIGATIONS TO TRY TO FIND
OUT EXACTLY WHAT KIND OF
DEMENTIA IS THIS.
IS IT PLAQUES AND TANGLES LIKE
AD, MORE VASCULAR IN ORIGIN, IS
IT SOMETHING THAT HAPPENED WITH
THIS DIFFUSED ANXIETY, INVERSED
USE OF DIAZAPENES, AND ONCE WE
GET THAT HOPEFULLY WE CAN CREATE
DATA.
BUT HERE AT 1 STUDY WE SHOWED
MEASURING AT 3 AND 12 MONTHS
WHETHER YOU WERE 65 AND OLDER OR
YOUNGER THAN 65, THAT THE PATES
ENDED UP WITH THEIR COGNITIVE
FUNCTION DOWN THERE AROUND THE
BLUE AND MAGENTA OR RED LINES OF
TBI AND AD AND WHAT WAS REALLY
STRIKING WAS WHEN WE PLOTTED IT
OUT FOR THOSE WHO WERE LESS THAN
50, THAT IS 30 AND 40 YEAR-OLDS,
AFTER THE ICU, NONE OF WHOM
SHOULD HAVE HAD A DEMENTIA AND
YET, THEY'RE DOWN THERE AROUND
THE AD TBI LINES.
IN THOSE DATA, WE ALSO SHOWED
THE DELERIUM WAS THE STRONGEST
PREDICTER OF THIS COGNITIVE
DECLINE, SO EVERY ADDITIONAL
DELERIUM INCREASED BY RELATIVE
35%, THE RISK OF LONG-TERM
COGNITIVE IMPAIRMENT.
ABOUT A THOUSAND OUTLETS
REPORTED ON THE BRAIN ICU STUDY
AND THIS IS AN EXAMPLE OF A LET
WE GOT BACK, WHEN I RETURNED TO
WORK, THE WORK I DID BEFORE
SEEMED FOREIGN AND UNFAMILIAR, I
BECAME ISOLATED AND EXCLUDED
FROM EVERYONE, NO 1 WANTED TO BE
AROUND ME, MY WIFE WAS 36 YEARS
TOLD MIVE WAS FEELING SORRY FOR
MYSELF AND I JUST NEEDED TO GET
ON WITH MY LIFE, I NEARLY ENDED
MY LIFE FOR A FEW TIMES AND THEN
AFTER 5 YEARS OF THIS HELL ON
OCTOBER 22nd, 2013, SHORTLY
AFTER THE PAPER AND CBS COVERAGE
CBS RAN A REPORT ABOUT PEOPLE
JUST LIKE ME.
FROM THAT REPORT I FOUND YOUR
WEBSITE, ICUDELERIUM.ORG, I
CRIED FOR A LONG TIME.
IT CHANGED MY WIFE'S OPINION OF
ME, FOR THE FIRST TIME IN 5
YEARS, I THINK I BELIEVE I HAVE
A FUTURE.
HIS WRITING, SO WHAT WAS HE
WRITING ALL THIS?
WELL WHAT WE HAVE DONE IN THE
PAST 15 YEARS, TAKEN THE
RANDOMIZED CONTROL TRIALS, 35-40
OF WHICH HAVE BEEN PUBLISHED IN
THE NEW ENGLAND JOURNAL, JAMA
AND LANCET, THE TIPPING POINT
SAID THAT FOR THINGS TO TIP,
THEY NEED TO BE STICKY, NEEDS TO
BE APE STICKY MESSAGE, WELL THE
ALPHABET IS VERY STICKY.
SO A-ANNAL GEEZIA, B,-BOTH,
STOPPING DRUGS AND STOPPING THE
VENTILATOR, C-CHOICE OF
SEDATION, D-DELERIUM,
MANAGEMENT, E-EARLY MOBILITY AND
F-FAMILY.
THESE 6 SAFETY STEPS ARE THE WAY
THAT THE SOCIETY OF CRITICAL
CARE MEDICINE SAYS TO TAKE CARE
OF OUR PATIENTS.
AND UPON WHAT ARE THEY BASED?
WELL I'M GOING TO ONLY SHOW YOU
THE DATA, THE TRIALS FROM THE
NEW ENGLAND JOURNAL OF JAMA AND
LANCET TO THINK ABOUT THE OTHER
400 PAPERS THAT SUPPORT THIS
APPROACH.
I SKIPPED A BECAUSE ANNAL GEEZIA
DOES NOT HAVE ANY NEW ENGLAND
JOURNAL JAMA OR LANCET PAPERS
WE'RE ALL GOING TO TAKE CARE OF
PAIN, THAT'S OUR FIRST PRIORITY,
WE CAN SEE B, THE NEW ENGLAND
JOURNAL AND JAMA ASK LANCET
PAPERS, THEN CHOICE OF DRUG, AND
MAINLY IT'S ABOUT AVOIDANCE OF
BENZODIAZAPINES, AND A COLLEAGUE
FROM FRANCE SAID 86% OF PATE
PATIENTS WERE ON BENZOs, A
DISASTER, VERY ANTIDATA DRIVEN
APPROACH BUT IT HAPPENED, IT
HAPPENED ALL OVER THE WORLD
INCLUDING IN EUROPE AND MY
HOSPITAL AS WELL.
WE WILL GET BACK TO THAT.
D-DELERIUM, LOTS OF DOTTA, E,
MOBILITY, F-FAMILY ENGAGEMENT.
JAMA NUCLEOTIDES ENGLAND
SCWOWRNAL LET'S HAVE THE FAMILY
AT THE BEDSIDE, WHAT HAPPEN
INDEED COVID, ICE ISOLATION.
CLOSED VISITATION, NO FAMILY.
THIS IS ANTIMEDICINE, MY
FRIENDS.
WE CANNOT HEAL PEOPLE WITH
SCIENCE ALONE WE CANNOT HEAL
THEM WITH ANTIBIOTICS OR VASE O
SUPPRESSORS OR VENTILATORS I
HAVE TO HAVE THEIR ABILITY TO
FIND THEIR WHY IN LIFE AND WE DO
THAT BY HAVING THE FAMILY TO
BEDSIDE AND BY ME SAYING TO MY
PATIENTS, OR THE FAMILY, HEY, I
NEED TO UNDERSTAND WHO IS THIS
PERSON?
ASK 4 SIMPLE QUESTIONS EVERY
DAY.
WHAT'S THEIR FAVORITE MUSIC?
WHAT'S THEIR PETS NAMES?
FAVORITE FOOD?
TELL ME WHAT THEIR HOBBIES ARE?
SOY IF I KNOW HOBBIES AND PETS
NAMES AND FOOD AND MUSIC THEN I
WILL LOOK AT THIS PERSON AND SAY
AH, I SEE YOU, I SEE AS A
PERSON.
AND I IN THE INTENSIVE CARE
UNIT, I SEE YOU AND I WANT TO
PROVIDE SUPPORT AND LOVE AND
MERCY.
SO THIS IS WHAT THE BUNDLE IS
ABOUT, IT'S A BURN OUT
PREVENTION PROGRAM BECAUSE THE
REASON I'M NOT BURNED OUT, THE
REASON I KEEP COMING BACK TO THE
BEDSIDE, IS BECAUSE I FIND SUCH
JOY AND LOVE IN DIVING INTO MY
PATIENT'S CHAOS AND DOING WHAT I
CAN TO HELP THEM WITH THIS
BUNDLE FIND THEIR WAY FORWARD.
NOW THOSE INDIVIDUAL REFERENCES
THAT I JUST SHOWED YOU WERE HOW
YOU BUILD PIECES OF A SAFETY
BUNDLE, BUT WHAT YOU AND I NEED
TO KNOW IS THAT THOSE INDIVIDUAL
PIECES WHEN THEY'RE PUT
TOGETHER, HAVE TO THEN BE TEST
TD TOGETHER AS A BUNDLE. THIS
IS WHAT WE LEARNED THROUGH DON
BURWICK AND THE IHI IS THAT WE
HAVE TO KNOW THAT THE SUM CAN BE
GREATER THAN INDIVIDUAL PARTS,
LIKE JACK SAID FROM HOPKINS OR
INDIVIDUALLY PROVEN STEPS MUST
BE TESTED TOGETHER TO CALL THEM
A BUNDLE, DON BURR WICK IHI, SO
HERE ARE 18 REFERENCES AND THERE
ARE PLENTY MORE SHOWING YOU THE
DATA BEHIND THIS AS A BUNDLE.
OKAY?
THEN WHY IS IT, THAT THIS WOMAN
HERE IN THE ICU SHOULD BE
TREATED WITH SEDATION,
IMMOBILIZED IN A BED INSTEAD OF
WOKEN UP EVERY DAY AND WALKED
AND ALLOWING HER FAMILY TO SEE
HER, WELL, THIS IS JANET KEY,
HER STORY IS IN EDDB ALONG WITH
ALL THE OTHER PATIENT STORIES,
BY THE WAY I RECORDED THEIR
STORIES WITH THIS RECORDER AND
THEN TRANSCRIBED THEM, IT'S A
LOT OF FUN TO USE THEIR OWN
WORDS IN THE INVESTIGATIONS, IN
THE WRITING AND JANET KEY HAD
NECK RAITIZING FASC YIETIS OF
HER FACE, I HAVE PERMISSION TO
USE THESE PICTURES, SHE AND I
ARE NOW GREAT FRIENDS.
EVERY DAY SHE WAS IN THE UNIT, I
WHISPERED IN HER EAR, SHE HAD
HER PICTURE NEXT TO HER BED OF
HERSELF AT THE EIFFEL TOWER, I
DON'T KNOW WHY BUT LOOKING
REFINED AT THE EIFFEL TOWER, I
WOULD SAN FRANCISCO SAY JANET
MISS KEY, YOU ARE A REFINED BADA
SS, AND YOU WILL GET OUT OF THIS
BED TODAY, AND SO WHILE SHE FERS
SICK LIKE THIS AND INTUBATE TD
EVERY DAY WE WALKED HER SO THAT
THE DAY THAT SHE FINALLY GOT OFF
THE VENTILATOR, SHE WAS LIKE
THIS, SHE CALLED HERSELF THE
LONE RANGER, SHE HAD THIS
BRANDON ACROSS HER FACE BAH WE
HAD REMOVED THE PORTION OF HER
FACE WITH 21 SURGERIES WITH NECK
ROUGH ATOMITIZING FASC, SO SHE'S
OUT OF THE ABOUT ED AND WALKED
DOWN THE HALL AND SHE WAS ONLY
EXTUBATED 30 MINUTES PRIOR TO
THIS PICTURE, NOW YOU WHO WORK
IN THE UNIT, YOU KNOW IF YOU
KEEP SOMEBODY IMMOBILIZED IN THE
BED FOR MULTIPLE DAYS THEY CAN'T
WALK DOWN THE HALL LIKE THIS BUT
THE REASON SHE WAS ABLE TO IS
SHE WAS WALKING BEFORE THE DAY
BEFORE THAT AND THE DAY BEFORE
THAT.
SO THE BUNDLE, REHUMANIZES THE
ICU, AND PRIOR TO COVID, IN 40
COUNTRIES AROUND THE WORLD, WE
PROVED IN PUBLIC AND INTENSIVE
CARE MEDICINE THAT WE 70-80%
COMPLIANCE OF THE BUNDLE.
WHY DID PEOPLE DO THAT?
BECAUSE THEY KNEW DATA LIKE
THIS.
HERE'S THE PAPER WE PUBLISHED IN
BARNS DAILY, WE SHOW BOTH LINES
GO UP, LINE ON THE LEFT, MORE
COMPLIANCE WITH THE BUNDLE ON
THE X-AXIS, YIELDED IN 6000
PATIENTS, INDEPENDENT OF
ADJUSTMENT FOR AGE, SEVERITY OF
ILLNESS AND WEATHER YOU WERE ON
A VENT OR NOT, YIELDED HIGHER
RATES OF SURVIVAL.
SO EVERY 10% INCREASE IN
COMPLIANCE YIELDED A 15%
INCREASE IN SURVIVAL, AND THE
SAME THING ON DELERIUM AND COMA
FREEDOM ON THE RIGHT.
EVERY 10% INCREASE IN COMPLIANCE
YIELDED A 15% LIKELIHOOD THAT
THESE PATIENTS WERE FREE OF
DELERIUM IN COMA.
SO WOO HAD MORE DATA, THIS IS
WAS THE ICU LIBERATION
COLLABORATIVE SPONSORED BY
GORDON MOORE WHO WAS THE FOUNDER
OF INTEL, GORDON MOORE WAS CRAZY
SICK IN THE ICU IN CALIFORNIA I
WON'T MENTION WHICH 1, HE DID
NOT GET TO VISIT WITH HIS
FAMILY, HE WAS SUPER MAD ABOUT
THAT, HE SAID IT WAS A MISERY
AND SO HE GAVE MONEY TO SOCIETY
OF CRITICAL CARE MEDICINE AND
SAID FIX THIS.
THEY CALLED ME, I WAS THANKFUL
ENOUGH TO BE THE PRINCIPAL
INVESTIGATOR FOR THIS PROGRAM
AND FOR THESE HOSPITALS ALL OVER
THE UNITED STATES AND PUERTO
RICO, WE SHOWED AFTER 15,000
PEOPLE, AND ADJUSTMENT FOR 22 CO
VARIANTS, THAT COMPLIANCE WITH
THE BUNDLE WAS AN INDEPENDENT
PREDICTER OF A HIGHER LIKELIHOOD
OF ICU DISCHARGE, HIGHER
COMPLIANCE WITH THE BUNDLE, HIGH
LIKELIHOOD OF HOSPITAL DISCHARGE
AND A LOWER LIKELIHOOD OF DEATH.
THAT IS THE MORE THAT YOU AS A
CLINICIAN INCORPORATED THIS
BUNDLE, GOT PEOPLE UP, GOT THEM
OUT OF BED, REHUMANIZE THEIR
CARE, ARE NOW COMPLIANT.
YOU CAN SEE, WE GO UP AND
COMPLIANCE, WE GO DOWN IN COMA,
DOWN IN DELERIUM, DOWN IN
RESTRAINT USE.
NOW I PREDICTED WE WOULD HAVE 1
THING GO UP IN THE WRONG
DIRECTION AND THAT WOULD BE
SIGNIFICANT PAIN AWARENESS.
WHY?
BECAUSE PEOPLE CAN TELL ME ABOUT
THEIR PAIN, THEY'RE NOT
DELERRUOUS, THEY'RE AWAKE, THEY
CAN SAY DOCTOR I'M HURTING SO I
WANT TO SEE THIS GO UP, I DON'T
WANT THEM IN MORE PAIN BUT I
WANT TO KNOW ABOUT THEIR PAIN SO
I ADDRESS IT.
THAT'S STEP A OF THE BUNDLE,
REMEMBER, ANNAL GEEZIA, SO THIS
RESULT INDEED ULTIMATELY BETTER
PAIN CONTROL.
WE ALSO SO MORE COMPLIANCE LED
TO LESS ICU REMISSIONS, LESS
DISCHARGES TO OTHER FACILITIES.
SO HERE'S THE BUNDLE.
ANNAL GEEZIA, STOPPING THE VENT
AND THE DRUGS, CHOOSING THE
RIGHT SEDENTARIAATIVES, AVOIDING
BENZOs, AND GETTING THEM OUT
OF BET WITH FAMILY ENGAGEMENT,
DURING COVID, THIS PLUMMETED
DOWN TO A 10-20% COMPLIANCE
GLOBALLY.
SO SAD.
SOME GOOD THINGS HAPPENED IN
COVID, SOME BAD THINGS HAPPEN
INDEED COVID, ABOUT LON BAD
THING WAS TOO MUCH BENZO, THIS
IS THE PAPER I TOLD YOU ABOUT IN
THE NEW ENGLAND, LOOK AT THE TOP
RIGHT, LOOK AT THE BENZO USE,
AND NOT A SINGLE TIME HAVE
BENZOs BEATEN OUT WHATEVER
THEY WERE COMPARED TO.
WE DID A STUDY CALLED THE COVID
D STUDY TO GIVE YOU FRAMING,
HISTORICALLY, WE HAVE DELERIUM
RATES IN VENTILATED PATIENTS
AROUND 70-80%.
AFTER INCORPORATION OF THE
BUNDLE IN 2016-2019, DELERIUM
RATES WENT DOWN 40-50% RIGHT
HERE, DURING COVID THEY WENT
BACK UP TO 80% AND BENZO USE
WENT BACK UP TO 80%.
SO THIS WAS A VERY NEGATIVE
THING THAT HAPPENED DURING THE
PANDEMIC.
WE PUBLISHED OUR COVID D STUDY,
I HAD NEVER BEEN ON SOCIAL MEDIA
BEFORE BUT THEY SAID WES, IF YOU
GET ON TWITTER, I SAID NO, NOT
TWITTER, I'M NOT GETTING ON
TWITTER, I'VE GOT ALL THIS GRAY
HAIR BUT THEY HAD ME TWEET OUT
THIS STUDY AND IT WORKED, AND IN
2 WEEKS, WE ENROLLED 2100 PEOPLE
AND WE DID THIS INTERNATIONAL
INVESTIGATION, 14 COUNTRIES, 69
SITES ANDY WOO FOUND THAT THERE
WERE 2 THINGS DRIVING THIS USE,
1 WAS SEDENTARIAATIVE, AND 1 WAS
FAMILY OVERUSE, OVERUSE OF
BENZOs, UNDER USE OF FAMILY,
THOSE WERE 2 THE HIGHEST DRIVERS
OF THE DELERIUM, I'M COMING TO A
CLOSE IN MY SLIDES HERE, WE HAVE
TO DO SOMETHING DIFFERENT
FRIENDS IN THE WAY WE SEE THE
WORLD HERE, WE HAVE TO LOOK
DIFFERENTLY AT WHAT WE ARE DOING
AT THE BEDSIDE WITH OUR
PATIENTS, OKAY?
ONE OF MY MESSAGES IN EVERY DEEP
DRAWN BREATH IS, DON'T BE AFRAID
TO GO AGAINST THE GRAIN.
LET'S SEE WHAT WE'RE DOING WRONG
FACE IT HEAD ON AND YOU AS
INVESTIGATORS OF THE NIH, YOU
ARE LEADING THE WORLD IN YOUR
RESEARCH ENDEAVORS.
YOU ARE CHALLENGING ALL OF THE
FORMS.
ONE OF THE THINGS THAT I WROTE
IN EDDB WAS THAT SOMETIMES, THIS
WILL BE A PARAPHRASE, IT SEEMS
TO BE A QUOTE PEOPLE LIKE,
SOMETIMES, THE WAYS THAT WE HURT
PEOPLE AREN'T SO MUCH A
MISPLACED CENTRAL LINE OR AN
ANTIBIOTIC ALLERGY OR AN ERRANT
USE OF VASO-REPRESSORS BUT
RATHER ACCEPTING STATUS QUO AS
OKAY AND GOOD WHEN INDEED IT
ACTUALLY CREATING HARM.
AND WHAT I FOUND IN MY LIFE AS A
PHYSICIAN, WAS I WAS CREATING
HARM IN THE PATIENT'S THAT I WAS
CARING FOR.
IN FACT, I WILL READ YOU--I WILL
LEAVE YOU WITH 1 STORY AND THEN
I WILL STOP AND TAKE YOUR
QUESTIONS.
THIS IS A STORY ABOUT TERESA
MARTIN.
SHE WAS A WOMAN WHO TAUGHT ME SO
MUCH, IN HER MID20S.
SHE CAME TO ME WHEN I WAS IN
TRAINING BACK WHEN WE DID
OVERUSE SEDENTARIATIVES AND
INVERSE RATIO VENTILATION AND
PARALYSIS, KIND OF LIKE THE WAY
WE DID WITH THESE PATIENTS
DURING COVID.
THIS WOMAN, THIS INDEXED PATIENT
OF MINE TAUGHT ME I WAS CREATING
HARM AND AFTER THIS THING I'M
ABOUT TO READ YOU, I CARRIED
SHAME FOR MANY YEARS BECAUSE I
KNEW I WAS HURTING PEOPLE SO
TERESA WAS IN THE UNIT, I TOOK
CARE OF HER ON THE VENTILATOR, I
WAS PROUD SHE HAD GOTTEN BETTER,
ENOUGH TO SURVIVE.
RIGHT BACK HERE, ACTUALLY, I
HAVE HER MEDICAL RECORDS WHICH I
GOT DURING THE PANDEMIC WHEN I
WAS WRITING THIS BOOK, AND MY
OWN HANDWRITING ON HER DISCHARGE
SUMMARY, I WRITE THIS AND YOU
CAN SEE I HILIGHTED THIS IN
YELLOW, YOU CAN SEE THIS, IT IS
IN YELLOW, BUT I WROTE THIS
PRECOMPUTERRIZED RECORDS, IT'S
PRETTY EMPARASSING, HOWEVER
AMAZINGLY ENOUGH THE PATIENT
STILL MANIFEST SINGLE ORGAN
DAMAGED LUNGS WITH GOOD RENAL GI
CARDIOVASCULAR FUNCTION.
MY OWN HANDWRITING.
I AM GUILTY.
AND THEN WAS THAT ACCURATE?
WELL, MONTHS LATER SHE CAME BACK
TO SEE ME AND HERE'S WHAT
HAPPENED.
SHE CAME IN THIS A WHEELCHAIR IN
HER 20S, ALMOST IMMEDIATELY
TERESA'S MOM ASK WHY CAN'T SHE
BEND HER ARMS AT THE ELBOWS OR
MOVER SHOULDERS, HER MOM LOOKED
DRAINED MORE TIRE THAN WHEN SHE
VISITED HER DAUGHTER IN THE
HOSPITAL, WE RAN THROUGH I
LITANY OF THINGS THAT WERE
HAPPENING SHE COULDND SWAL OR
SLEEP OR ABOUT GO TO THE
BATHROOM ALONE.
SHE COULD NOT DRESS OR SHOWER,
SHE COULD WALK ONLY A FEW STEPS
FOR A WHILE AND STAIRS WERE
IMPOSSIBLE, THE LIST OF AILMENTS
WERE DIZZYING, I HAVE NO
SOLUTIONS AND EVEN LESS EVER AN
UNDERSTANDING WHERE THE PROBLEMS
WERE COMING FROM SO I DID WHAT I
KNEW HOW TO DO, I ORDER BLOOD
WORK AND X-RAYS, THE LABS DIDN'T
SHOW ANYTHING ALARMING BUT THE
X-RAY IMAGES OF HER ARMS AND
LEGS REVEAL CALLSIUM DEPOSITS IN
HER ELBOWS SHOULDER AND KNEES,
THERESA HAD HETEROTOPIC
CALCIFICATION A CONDITION WHERE
BONES FORM WHERE THEY SHOULDN'T
T. WAS AS IF SHE HAD WROKS
GROWING INSIDE HER JOINTS I HAD
NEVER SEEN ANYTHING LIKE IT
BEFORE AND I DIDN'T KNOW WHAT TO
THINK.
TERESA DIDN'T REACT AT ALL WHEN
I SHOWED HER THE DISTURBING
IMAGES BUT HER MOTHER NOD INDEED
AFFIRMATION AS IF SHE HAD
PERMISSION TO TALK ABOUT HER
OTHER CONCERNS, SHE TOLD ME
TERESA'S BRAIN WASN'T WORKING
PROPERLY.
SHE WOULD FORGET THINGS,
PEOPLE'S NAMES, SHE HAD GROWN
AFRAID, MISMARTIN STOPPED AND
SHIFTED IN HER SEAT, SHE'S A
COMPLETELY DIFFERENT PERSON NOW.
SHE GLANCED AT HER DAUGHTER
SITTING NEXT TO HER IN A
WHEELCHAIR AND SIGHED, 2
PARAGRAPH MY AUTHOR'S NOTE AND I
WILL STOP TALKING AND TAKE YOUR
QUESTIONS, MANY PEOPLE BELIEVE
MEDICINE IS GROUNDED IN THE
BENEVOLENCE IN WITCHING GOOD,
IT'S MORE THAN THAT, THE TARGET
PRINCIPLE OF MEDICINE MUST BE A
HIGHER STANDARD, BENEFICENCE,
DOING GOOD, THIS BREEDS TRUST
BETWEEN MY PATIENT AND ME WHICH
IS THE CORNERSTONE OF MY ART AND
PRACTICE AND RETURN FOR HER
TRUST, I PROMISE ALWAYS TO TRY
TO HELP HER AND NEVER HARM HER.
EVERY TIME I STEP INTO THE
HOSPITAL, I REMIND MYSELF OF THE
ENORMITY OF THIS PROMISE THAL
COVENANT, EARLY IN MY CAREER, I
STRAYED NOT INTENTIONALLY BUT
OUT OF A DESIRE TO CONTROL EVERY
MEDICAL CIRCUMSTANCE.
I DIDN'T LISTEN ENOUGH.
OUR GREATEST TREASURE IS FOUND
IN DEEP COMPLIEWNICATION WITH
EACH RPGHT WHEN THIS IS NUT
URTED ESPECIALLY IN IMPEDIMENTS
TREATMENT OF SUBSTANCE ABUSE OF
SUFFERING, 2 PEOPLE CAN
ESTABLISH SOMETHING OF ALMOST
MYSTICAL QUALITY, A RECIPROCAL
CONNECTION THAT I THINK PRSITOUS
A PLACE OF CHARITY AND EMPATHY
THAT CROSSES SOCIAL, RACIAL AND
FINANCIAL BOUNDARIES, WE ARE ALL
1.
THANKS FRIENDS, APPRECIATE
QUESTIONS AND APPRECIATE MY TIME
WITH YOU TODAY AND IF I CAN BE
OF SERVE TO YOU ANY TIME IN THE
FUTURE, PLEASE REACH OUT, I AM
WES.ELY.ICU.ORG, AND I WILL
BRING US BACK TO OUR MAIN TALK.
THANKS EVERYBODY.
>> THAT WAS A GREAT TALK WITH A
LOT OF INFORMATION.
HOW MUCH DIFFERENCE DO YOU THINK
THERE IS IN TERMS OF LONG-TERM
COGNITIVE PROBLEMS AND PATIENTS
IN THE ICU VERSUS PATIENTS IN
OTHER PARTS OF THE HOSPITAL THAT
ARE IN LONG-TERM CARE FACILITY
WHO IS HAVE DIFFERENT PROBLEMS
BUT THEY'RE ALSO HOSPITALIZED?
>> IT'S A GREAT QUESTION, THERE
ARE ABSOLUTELY GOOD DATA PUBLISH
INDEED THE AMERICAN JOURNAL OF
MEDICINE AND THE ANNALS WHICH
SHOW THAT HOSPITALIZED PATIENTS
FOR PNEUMONIA FOR EXAMPLE WHO
NEVER GET IN THE ICU ALSO ACCRUE
THIS SORT OF COGNITIVE DECLINE.
WE HAVE A PAPER THAT WE
PUBLISHED IN JAMA IN 2010 WITH
JACK WASHINGTON SHOWING
INCREMENTAL DEFICITS IN
COGNITION AS WELL, ACCORDING TO
DIFFERENT LEVELS OF SEVERITY.
SO THIS IS NOT A PROBLEM
ISOLATED TO THE ICU.
BUT THE ICU PATIENTS ARE JUST
NEARER TO DISASTER BUT YOUR
FLOOR PATIENTS ARE ACCRUING
COGNITIVE DECLINE DURING THIS AS
WELL, THEY HAVE SYSTEMIC
INFLAMMATION AND THEY GET
EXPOSED TO MEDICATIONS WHICH
CAUSE THEM NEURONAL DYSFUNCTION
AS WELL, SO IT'S A PROBLEM
ACROSS THE BOARD, BUT THE
GREATEST PROBLEM OF COURSE IS IN
THE CRITICAL CARE UNITS WHERE WE
KEEP PEOPLE IMMOBILIZED AND
DEEPLY SEDATED AND BEAUTIFULLY,
THOSE ARE THE AREAS WHERE WE
COULD HAVE THE GREATEST MARGIN
OF IMPROVEMENT AS WELL BECAUSE
THOSE ARE MODIFIABLE COMPONENTS
OF THEIR ILLNESS.
--I DON'T THINK YOU CAN
EXPLICITLY DO THAT, I WAS IN A
UNIT LAST WEEK AND I HAD 6
PATIENTS ON MY SERVICE WITH
COVID, I REMEMBER THE NUMBER WAS
6 BECAUSE I REMEMBER THAT 3 OF
THEM WERE IMMUNO COMPROMISED AND
3 OF THEM WERE UNVACCINATED IT
WAS A DIFFERENT GROUP, 3 WERE
VACCINATED AND 3 HAD NOT BEEN
AND 2 OF THEM 2 OF THEM WERE IN
THE UNIT WITH COVID BUT NOT
BECAUSE OF COVID.
THEIR ILLNESSES WERE DISTINCT,
THEY WERE ADMITTED FOR OTHER
PROBLEMS 1 HAD COAL O CYSTITIS
AND DIDN'T HAVE ANYTHING TO DO
WITH COVID FOR EXAMPLE BUT 4 OF
THEM THEY HAD COVID, THEY WERE
SUFFERING FROM COVID, SO IN THE
CLINICAL CIRCUMSTANCE, I FEEL
LIKE IT'S NOT THAT COMPLICATED
TO TELL WHO IS SUFFERING FROM
COVID, VERSUS WITH COVID.
I THINK THAT'S NOT VERY
COMPLICATED BUT ON DEATH
CERTIFICATES ON A GLOBAL SCALE
FROM A POLICY PERSPECTIVE, I
THINK THAT'S REALLY HARD, WE
HAVE AN EASIER TIME OF IT THAN
ON DEATH CERTIFICATES.
>> THAT IS A INDUSTRY PROBLEM
THAT DAN [INDISCERNIBLE] WHO
INVITED YOU IT FOR THIS IS
ANOTHER MEETING TODAY HAS AN
ARTICLE THAT'S GOING TO COME OUT
SOON ON 44 AUTOPSIES IN WHICH
THEY SHOWED PATIENTS WITH COVID
VIRAL PARTICLES IN THE CNS, SO
IT IS HARD TO DISTINGUISH WHAT'S
THE VIRUS, LAWEDDER DALE'S THE
IMMUNOLOGIC CHANGE AND WHAT ARE
YOUR PRACTICES, SO IT REALLY IS
A COMPLEX ISSUE.
>> THERETO ME HIT ON THAT WHILE
WE GO, I DID HAVE A PIECE IN THE
WASHINGTON POST 2 WEEKS AGO AND
1 LAST WEEK IN THE BOSTON GLOBE
THAT ADDRESSED THIS.
I WILL GIVE YOU MY SNIPIT ON
THIS, I THINK THAT THE THEORY OF
IMMUNOLOGICAL DISREGULATION IN
COVID WHICH LEADS TO LONG COVID
AND ALSO FEARYY OF VIRAL GHOSTS
WHICH IF YOU LOOK AT THE IMIEWNL
REACTION TO PATIENTS AFTER
COVID, THERE ARE DATA IN NATURE
AND NATURE MEDICINE THAT SHOW
THAT THE IMMUNE RESPONSE DOES
MIRROR AND INDICATE THAT THERE'S
ONGOING ANTIGENIC STIMULATION IN
THE HUMAN BODY LONG AFTER THE
ACUTE INFECTION,
[INDISCERNIBLE], STEVEN
[INDISCERNIBLE] AND OTHERS IN
THE COUNTRY DO BELIEVE AND WE
HAVE GOOD DATA TO SUPPORT LIKE
THE PAPER YOU JUST MENTIONED
THAT WILL COME OUT SOON THAT
THERE IS ONGOING ANTIGENIC
STIMULATION WITH VIRAL GENERATE
BRAIN DYSFUNCTION.
NOW HOW DO THEY DO THAT?
THERE IS A DISRUPTION AT THE
BLOOD BRAIN BARRIER, THEY AFFECT
THE ENDOTHELIAL CELLS AT THE
BLOOD BRAIN BARRIER BUT THEY
ALSO AFFECT ASHING THE ASTRO
SITES AND DPLEEL CELLS THAT ARE
SUPPORTING THE NETWORK AND
NUTTERRING ENVIRONMENT FOR THE
NEURONS SO AT THE BEGINNING OF
COVID, WE TOOK SOLACE IN THE
FACT THAT THE NEURONS THEMSELVES
DIDN'T SEEM TO BE INFECTED BUT
IT DOESN'T MATTER IF THE NEURONS
AREN'T DIRECTLY INFECTED IF THE
GLIAL CELLS WHICH SUPPORT THEM
ARE INFECTED AND DIE AND THE
NEURONS DIE INDIRECTLY AND I
THINK THAT MAY BE HAPPENING IN
LONG COVID.
>> THANKS.
I HOPE THAT IN OUR ICU AT THE
CLINICAL CENTER WE ENCOURAGER
FAMILY PRESENCE AS MUCH AS
POSSIBLE BUT 1 OF OUR ICU
ATTENDINGS WANTS TO KNOW, SINCE
YOU TALKED ABOUT DECREASE
[INDISCERNIBLE] USE AND
INCREASING FAMILY PRESENCE OF
THE BEDSIDE SHOULD WE BE
REDESIGNING OUR ICUs TO
ENCOURAGE MORE PRESENCE.
I MEAN CERTAINLY IN CHILDREN
THEY OFTEN HAVE ROOMING IN,
SHOULD WE BE ENCOURAGING MORE OF
THAT IN THE ICU?
>> YES, I THINK THAT MANY
ICUs, I KOOBT SPEAK, I'VE BEEN
TO YOUR ICU BEFORE BUT I CAN'T
REMEMBER THE EXACT LAY OUT OF
THE ROOMS BUT MANY ICUS, I'M NOT
SPEAKING ABOUT YOURS BUT MANY
ICUs ARE LIKE SICK BUILDING.
THEY'RE SICK BUILDING BECAUSE
THE DESIGN OF THE BUILDING
CREATES SICKNESS IN THE HEALING
PROCESS.
NOW THAT'S THAT EARLIER, FOR US
TO BE TRUE HEALERS WE CANNOT DO
IT, WITH SCIENCE ALONE, IT WON'T
WORK, PEOPLE.
WE HAVE TO HAVE TOUCH FIRST AND
TECHNOLOGY SECOND.
THE BEAUTY OF THE TECHNOLOGY IS
IT CAN COMPLEMENT THE HUMAN
TOUCH BUT IF WE DESIGN A ROOM SO
THAT IT'S 2 TIGHT AND WE CAN'T
HAVE A FAMILY IN THERE AND THE
FAMILY CAN ROOM-IN LIKE WE ARE
DOING BEAUTIFULLY WITH THE
PEDIATRIC ICUs AS YOU POINTED
OUT HENRY WE CAN HAVE THE FAMILY
THERE, HOLDING THEIR HANDS,
LOOKING IN THEIR EYES AND CREATE
THAT HEALING ENVIRONMENT THAT WE
NEED, BY THE WAY, WE SHOULD
NEVER GO BACK TO NO VISITATION
AGAIN.
WE KNOW THAT PPE WORKS, IT WAS A
WRONG THING TO DO TO OUR
PATIENTS AND IT INCREASED OUR
BURN OUT.
SO WE SUFFERED WHEN FAMILIES
WEREN'T THERE.
I WROTE A PIECE IN CHEST ON THIS
CALLED MEDICINE AT ITS FINEST,
WE HAVE TO HAVE THE FACAS AMLYS
THERE FOR OUR OWN HEALING AS
WELL, SO YES, WE NEED OUR ROOMS
DESIGNED LARGE NOWOF THE WITH
WALK IN SHOWERS ASK THAT THE
FAMILY CAN BE THERE AND THE
PATIENT CANS BE WHEELED IN, TO
GET SHOWERS WHEN THEY'RE
CRITICALLY ILL ALL THAT IS PART
OF THE HOW VANDERBILT AND
ORGANIZED BY THE WAY.
>> IT'S INTERESTING WHETHER IT'S
SCHOOLS OR HOSPITALS THAT'S A
BIG DEBATE, SOMETHING WE ALL
REALIZE THAT WE OVERREACTED TO
BUT WHEN YOU LOOK BACK WAS THAT
CLEAR TO YOU AT THE BEGINNING
COVID OUTBREAK WHERE WE'RE SO
CONCERNED ABOUT THE VIRAL ISSUE,
RATHER THAN THE HUMANISTIC
ISSUE?
>> --IT WAS BASED IN SCIENTIFIC
WORRY ABOUT AIR BORNE, DROPLET,
ET CETERA, WE DIDN'T HAVE WAYS
TO PROTECT OURSELVES AND WE
LEARNED PPE WORKS.
WE NOW HAVE A VACCINE, WE CAN
HAVE FAMILY MEMBERS IN THERE, I
HAD A PATIENT LAST WEEK WHO WAS
PREGNANT, SHE DELIVERED HER
BABY, COVID, THE BABY WENT TO
THE NICU, THE WOMAN IN THE ICU
ON A HUNDRED% OF IO2, PEEPS OF
20 PARALYZED AND SEDATED, THAT
WAS THE RIGHT THING THAT DAY, I
SUN CAME UP THE NEXT DAY, LOOKED
AT THE NURSE BROOK, AND SHE WAS
1 OF OUR BEST NURSES, I HAD A
PATIENT WHO LOST HER HANDS AND
FEET FROM COVID, HER NAME WAS
AWE UMKC I HAVE PERMISSION TO
USE THESE NAMES HE HAD ARTERIAL
CLOTS IN ALL THESE AND IT WAS
CRAZY.
I SAID BROOK,RY TO TURN IT OFF,
SHE SAID SHE WILL BUCK, I SAID
WELL WE KNOW THE DATA,Y THAN
IT'S WRONG TO THINK THIS IS ALL
ABOUT HER LUNGS.
IF WE MAKE IT ALL ABOUT HER
LUNGS, WE'RE GOING TO SACRIFICE
HER BRAIN, HER ARMS, HER LEGS,
THIS WOMAN HAS TO GET HOME AND
TAKE OF HER BABIES, HER 4 KIDS
SO WE TURNED THE VENTILATOR OFF,
SHE BUCKED A BIT, WE TITRATEDDED
THING AND WE TOOK THEM ALL THE
WAY DOWN AND WE RESTARTED THEM
AT HALF THE DOSE, HER WE
TITRATED IT, HER HUSBAND CAME IN
THIS PPE, HELD HER HAND, THEY
MADE EYE CONTACT, THEY MADE THE
CONNECTION, THEY FOUND HER WHY,
SHE'S BACK WITH HER FAMILY, IT'S
THE WAY WE HAVE TO LEARN THAT
THESE ARE NOT EITHER OR, THEY'RE
BOTH AND DPR US TO BECOME THE
BEST HEALERS WE CAN BE.
>> DO YOU THINK THAT WE'RE DOING
BETTER NOW WITH COVID, AND IF E
ARE DOING BETTER IS IT THE FACT
THAT WE'RE TAKING A MORE
HUMANISTIC APPROACH, IS IT THAT
WE HAVE A DIFFERENT STRAIN OF
COVID, IS IT MORE PEOPLE
IMMUNIZED?
IT APPEARS WOOER DOING BETTER
BUT DO YOU THINK THAT'S TRUE?
I PRESUME ASTERISKS A
COMBINATION OF THOSE THINGS?
>> I SURE THINK WE'RE DOING
BETTER.
HOW CAN I EXPRESS THIS, 1 OF MY
FORMER FELLOWS BUD O'NEILL IN
NEW ORLEANS AND BATON ROUGE WAS
IN THE HEAT OF THE PANDEMIC AND
HE SAID WES, HE SAID I LOST MY
WAY.
HE SAID, I HAD THESE PATIENTS
SNOWED, DEEPLY SEDATED, I KNOW
THE BUNDLE WORKS, THE DATA ARE
SOLID, 400 PAPERS, 40 NEW
ENGLAND JOURNAL JAMA LANCET
PAPERS I'M GOING BACK TO WHAT I
KNOW WORKS AND HE SENT ME A
PICTURE OF A WOMAN INTERNATIONAL
CLASSIFICATIONIGATE BAITED AWAKE
HOLDING UP A SIGN THAT SAID GET
YOUR VACS, TELLING HER FAMILY TO
GET THEIR SACK SEEN AND SHE WAS
AWAKE AND ALERTOT VENTILATOR
WITH HIGH [INDISCERNIBLE].
WE ALSO HAVE DRUGS I HELPED
DESIGN THE CODE BARRIER STUDY
HAD IS VARICITNIB, WHICH IS FDA
APPROVED NOW, I HELPED DESIGN
THAT STUDY SO WE HAVE DRUGS,
THAT AND STEROIDS OR IL6
BLOCKERS THAT WE KNOW IMPROVE
SURVIVAL AND WE CAN COUPLE THOSE
MEDICATIONS WITH THE BUNDLE AND
SAY THIS IS HOW YOU CARE FOR
SOMEBODY WHO'S CRITICALLY ILL.
WE DON'T WANT TO GO BACK TO THE
1990S FOR HEAVY BEIN, ZO USE
THAT TERESA MARTIN GOT WHEN I
HAD NO GRAY HAIR.
IT WAS WRONG.
AND PEE HAVE TO SAY THIS IS NOT
HOW TO TREAT A HUMAN BEING EVERY
DAY WHEN THEY'RE CRITICALLY ILL.
EVERY DAY ASK MYSELF WHAT'S THE
NEXT RIGHT THING TO DO.
>> I'M LOOKINGA THE MY INBOX FOR
MORE QUESTIONS, FROM FROM OTHER
PEOPLE, TELL ME WHY YOU THINK
COVID IS DIFFERENT FROM OTHER
VIRAL PULMONARY PROBLEMS OR
PATIENTS AT THE ICU, WE HAVEN'T
SEEN NEARLY THIS MANY BUT YOU
CERTAINLY IN TENNESSEE SEE A
FAIR NUMBER OF INFLUENZA
PATIENTS IN THE ICU, WHY IS
INFLUENZA DIFFERENT FROM COVID
OR IS IT JUST WE'RE NOT REALLY
FOCUSING ON INFLUENZA PATIENTS
FOR INSTANCE?
>> IT'S NOT MY OPINION, THAT
THEY'RE DIFFERENT.
THE DATA SHOW US THAT THEY'RE
DIFFERENT.
DATA THERE'S A BEAUTIFUL PAPER
IN JAMILA AMIA COMPARING
INFLUENZA WITH COVID.
I'VE TWEETED ABOUT THIS, AT WES
ELYMD, CAN YOU FIND THESE DATA
WHEN THEY COMPARE INFLUENZA TO
COVID, THEY'RE VERY DIFFERENT
AND THE LARGE PART IS THE
VASCULAR NATURE OF THIS DISEASE.
THIS DISEASE, YOU KNOW OUR
ENDOTHEL YAWM, I THINK ABOUT
BACK WHEN I WAS A MED STUDENT
AND I THAT TOLD US RECOGNIZE
ENDOTHELIUM ON I HISTOLOGICAL
SLIDE AND THAT'S REALLY ALL IT
DOES THAT LINES THE BLOOD
VESSELS.
NO THE ENDOTHELIUM IS A ENGINE
OF PLEADING AND CLOTTING AND
INFLAMMATION AND WHEN IT'S
INFECTED, BY THIS VIRUS, YOU
HAVE A FIRE STORM OF INFORMATION
AND LOTTING THATTA OCCURS IN
THESE PATIENTS AND IT DOESN'T
ANY OUT QUICKLY, THIS DISEASE IS
SO MUCH LONGER THAN INFLUENZA,
WE ARE TALKING 3 WEEKS VERSUS 1
WEEK OF AN ILLNESS AND EVERYBODY
WHO CARES FOR COVID PATIENTS
KNOWS HOW LONG THIS ILLNESS IS,
AND THEN, YOU HAVE ONGOING VIRAL
GHOSTS AND IMMUNE DISREGULATION
WHICH DOESN'T END.
NOW SOME OF OUR PATIENTS SEE IT
IN FOR ABOUT 90-A HUNDRED DAYS
AND IT SLAMS THEM DOWN AGAIN, I
KIND OF THOUGHT THAT WAS BOGUS
BY THE WAY AT THE BEGINNING, I
THOUGHT ALL THIS LONG COVID
STUFF IS JUST A PUNCH OF PICKS
BUT IT'S NOT.
I HAVE PATIENTS, WE HAVE SO MANY
PATIENTS IN OUR SUBCENTER WHO
HAD NO PREEXISTING ILLNESS AT
ALL, GOT THROUGH MILD COVID,
THESE ARE NIH FUNDED SCIENTISTS,
PEOPLE WHO ARE TRI ATHLETES, THE
GUY I WROTE ABOUT LAST WEEK IN
THE BOSTON GLOBE WAS A 21
YEAR-OLD COLLEGE STUDENT WHO HAD
MILD COVID, NEVER GOT SICK, AND
HE CANNOT RUN ANYMORE.
HE WAS GOING TO GO FOR THE
OLYMPIC TRIALS, HE WAS RUNNING
4:15, MILES FOR 5 OR 6-MILES, HE
CAN'T RUN ANYMORE.
THIS IS A DISEASE.
AND NEVER LET ANYBODY SILENCE
THESE PATIENTS OR SAY THAT
THEY'RE CRAZY.
IT'S NOT JUST PSYCHOSOMATIC.
NOW THERE WAS A PAPER LAST WEEK
IN JAMA THAT SHOWED THAT PEOPLE
WITH REEXISTING PSYCHIATRIC
ILLNESSES THAT THAT'S A RISK
FACTOR FOR LONG COVID, ALL THAT
MEANS TO ME IS THAT THEY KIND OF
GOT A HEAD START TOWARDS COVID,
THEY WERE NEARER TO THEIR
DISASTER OF LONG ASHING BUT THAT
DOES NOT MEAN TO ME THAT THIS A
PSYCHOSOMATIC ILLNESS, THIS IT
IS AN ACTUAL DISEASE.
>> WELL, WES THIS, HAS REALLY
BEEN A WONDERFUL GREAT TEACHER'S
EVENT AND AGAIN, SHOWS THE
IMPORTANCE NOT JUST OF EVIDENCE
OF PERSONAL CLINICAL EXPERIENCE,
BUT ALSO, THE ABILITY TO
COMMUNICATE TO THE MEDICAL
COMMUNITY AND THE PUBLIC ABOUT
THIS, SO THIS WAS A WONDERFUL
OPPORTUNITY.
WE HOPE THAT THE NEXT TIME WE
INVITE YOU, YOU WILL COME IN
PERSON AND SEE OUR FACILITY AND
OUR ICU AND BE ABLE TO SHOW US
IN THE BEDSIDE.
SO THANKS EVERYBODY FOR
ATTENDING THIS AND THANKS TO WES
FOR MEETING WITH THE STUDENTS
BEFORE HAND, COMING TO THIS AND
BEING A GREAT COMMUNICATOR.
THANK YOU VERY MUCH.