Conversations: Wesley Ely, MD
SYNOPSIS
Emily speaks with Dr. Wesley Ely about the harms of deep sedation in the ICU, and how he's transforming critical care one patient at a time.
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GUEST
Dr. E. Wesley Ely is a Professor of Medicine and Critical Care at the Vanderbilt University Medical Center and serves as Co-Director of the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center. He is the Associate Director of aging research for the Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC) in Nashville TN. Dr. Ely is the author of Every Deep-Drawn Breath, a recent winner of the 2022 Christopher Award for Literature. He is donating 100% net proceeds of his book to help COVID survivors and family members rebuild their lives. Follow him @WesElyMD.
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Supplemental materials for Every Deep-Drawn Breath:
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Hosted by Emily Silverman.
Produced by Emily Silverman and Jon Oliver.
Edited and mixed by Jon Oliver.
Original theme music by Yosef Munro. Additional music by Blue Dot Sessions.
The Nocturnists is made possible by the California Medical Association, and people like you who have donated through our website and Patreon page.
TRANSCRIPT
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The Nocturnists: Conversations
Emily in Conversation with Wes Ely, MD
Episode Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Emily Silverman
Patients in the ICU are sick, really sick. To save their lives, we often attach them to ventilators and sedate them. But what are the harms of this practice? And how do we reduce those harms? You're listening to The Nocturnists: Conversations. I'm Emily Silverman. Today's guest, Dr. Wesley Ely, is a professor of medicine and critical care at the Vanderbilt University Medical Center, and he serves as co-director of the Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center. He's also the Associate Director of aging research for the VA's Geriatric Research Education and Clinical Center (GRECC) in Nashville, Tennessee, and the author of the book, Every Deep Drawn Breath: A Critical Care Doctor on Healing, Recovery and Transforming Medicine in the ICU. Dr. Ely is donating 100% of the net proceeds from his book to help COVID survivors and their families rebuild their lives. He can be found on Twitter @WesElyMD. Before I spoke with Wes, I asked him to read an excerpt from his book. Here's Wes.
Wes Ely
"I've known Sarah Beth Miller since 2003, when her ICU doctor referred her to Dr. Jackson and me for neuropsychological testing. With short gray hair and a dimpled smile, Sara Beth radiates positivity. She grew up around horses on a farm in Goodlettsville, not so far from Nashville, and is well versed in getting right back on the horse that throws you. She's in my office telling me about the recent passing of her mother. She speaks with eloquence and verve, her eyes bright with tears, but also joy. She's not one to dwell on sadness. Sarah Beth's story is both unique and familiar, one of critical illness emerging out of the blue and pushing a life off track. When she landed in the ICU on May 27, 2002, everything was humming along nicely. She was 30 years into a career with the phone company, one of the first female engineers hired by South Central Bell in Tennessee, and still there when it became AT&T. She was looking forward to a relaxing Memorial Day weekend. Instead, after struggling with a high fever and exhaustion, she was brought to the emergency department where she collapsed, unconscious.
Over the next twelve hours, Sarah Beth developed pneumonia, sepsis, and acute respiratory distress syndrome or ARDS. Her lungs filled with fluid and her heart and kidneys started to fail. She was raced to the ICU and placed on life support, attached to a ventilator and sedated. She almost died. She fluctuated between coma and delirium, hallucinating, scared and confused. Her next clear memories were of firework celebrations, heard from her room on July 4th. She'd been in the ICU for five weeks.
When Sarah Beth was put in touch with Dr. Jackson and me about a year after her discharge, she said something was very wrong with her. She just didn't know what. She spent the first few months after her near-death experience recovering at home, trying to regain her strength. ‘I couldn't even pick up a fork,’ she said. Her mother moved in with her. There was no other way she could survive. They corralled her sister Diane and brother Ken to help with the day-to-day. Sara Beth received physical therapy, but it didn't help much. And getting up and down even a few stairs proved Herculean. After three months, Sarah Beth figured she should head back to work. It was what was expected of her. She'd been in the hospital and now she was out. She had been sick, she'd survived. And it was time to move on. She mustered the courage and physical energy to head back to her job, ready to pick up where she left off. But it wasn't that simple. ‘The first day at the office,’ Sarah Beth explained, ‘I turned the computer on, looked at some stuff, and thought, Hmm, I wonder what I'm supposed to do. I called my workmate, Donna. Well, she said, run your reports. What reports?, I asked.’ Sarah Beth had studied differential equations, complex numbers, and math theory in college. At the telephone company, she'd been recognized as an expert in complicated engineering concepts. Now she could barely remember what her job was."
Emily Silverman
Thank you for that reading. And thank you for being here today.
Wes Ely
Hey, Emily, thank you so much. It's really going to be fun. I look forward to talking to you and unpacking some of this.
Emily Silverman
So at the very beginning of your book, you bring us to your early life before you were a doctor, and you talk about working as a farmhand in Louisiana and how that was really influential for you. So tell us about being a farmhand.
Wes Ely
You know, when my dad left us when I was little, my mom was raising three kids in Louisiana and we didn't have any money, we lived in a four-room house. To figure out a way to make some money, one of the guys that was dating my mom had this huge farm, and so I said, “Can I work for you?” And he paid me $4 an hour, cash, and I would work about 70 hours a week out in the fields. We had 6,000 tomato plants and green beans, cantaloupes, watermelons, okra, etc. And I would just get up in the morning when it was dark, I'd ride my bike to the fields. We had a lot of migrant workers who we would get to the fields to help us pick, but I picked right alongside them. And it was really there that I started paying attention to the difference in my life and theirs. And I remember that summer reading Maya Angelou's, I Know Why the Caged Bird Sings and how she'd been silenced, and thinking that if these guys were to scream, who's going to hear them, who's going to be listening to them? And I started kind of in my young mind, wondering how can I help people who are silenced and don't have enough of a voice in society.
Emily Silverman
And then we have this story of you deciding to go into medicine, deciding that that was the way that you wanted to help people. And you paint a picture of yourself as a young doctor. You describe yourself as eager, earnest, and hungry, and you describe a drive or a desire within yourself to push death away. So tell us about that phase in your life.
Wes Ely
Yeah, one of the first patients I had was Sarah Balik. Sarah had grown up in these clapboard shotgun houses right near the Mississippi River, and she was a dreamer. She saw the boats going up and down the Mississippi River and she wanted to go out and explore the world. She got pregnant as a young woman and had this baby. And then I came on the scene as a medical student to care for her at Charity Hospital, kind of like the old style, twenty beds to a room, old ward style hospital. And she had peripartum cardiomyopathy, which means that her muscle of her heart was diseased somehow, as a result of this pregnancy. So we had no electric pumps to deliver medicines, and she had to have dopamine to keep her blood pressure up. So it meant that I had to dial up and down with my finger on her IV pole to increase or decrease the number of drops for her dopamine. The beauty of that though, was that I was right there with Sarah. I was holding her hands, I was looking at her eyes. She had these beautiful, tawny eyes. And we got to know one another, even though I had no real knowledge of critical care. I mean, I didn't know what I was doing. I was just a medical student titrating dopamine. And I was just doing that to whatever the blood pressure goals were. But in the middle of all that she kept asking me,
“Dr. Wes, what's happening to me?” And I was just fumbling around. I mean, you know, “Sarah, I know your heart is failing. I'm here to provide medicines to get your blood pressure up.” But the whole while she knew she was dying, I knew she was dying. And what happens is she does code and everybody rushes into the room to intubate her and to code her and give her CPR. And I just kind of faded off in the back and watched all of that until she died, and then was left going, wait a minute, I was just holding her hand. I was just talking to her. And now she's not alive. How do I process that in terms of this desire to serve? Have I failed her?
Emily Silverman
So you go into ICU medicine, and you start taking care of patients who are critically ill like Sarah, and saving lives, you know, walking people back from the brink of death. When did you start to notice that the patients who you saved weren't doing well after they left the ICU?
Wes Ely
I had this woman named Teresa Martin and she was also young, my age. And when I had her come back to the clinic several weeks later, I thought we were going to have this high five time where, “Oh man, Dr. Ely, you're the best! You saved my life and I'm back at work.” And instead she gets wheeled in there with her mother wheeling her in the wheelchair. And she kind of has this blank stare. She's looking at me. She can't really move her elbows, shoulders and knees, which I was totally confused about. I thought to myself what is wrong with her body like we saved her life, why can't she get out of this wheelchair? And nobody had been describing Post-intensive care syndrome at that time. It will be another twenty years before we formalize that name of PICS, post-intensive care syndrome, which is muscle and nerve disease, dementia, depression, and PTSD. But that’s what she had in spades. And I got X-rays of her joints, and there were rocks in her joints. She had calcified everything. It's called myositis ossificans. She basically had rocks growing in her joints. And her mother was just asking me, “Dr. Ely, what's wrong with my daughter? Like, she's not even the same person anymore. How do we move forward?” And I carried that with me in the next five to eight years, and walked around with, I think, shame, because I knew that I was doing it to other people, too. And that even though they were living, they technically were living a different life than they ever asked for. When I was writing Every Deep Drawn Breath I was able to get the records of my own handwritten notes. And in Teresa's off-service note that I wrote, I now have highlighted in yellow to remind me of how wrong my thinking was. It said, “She's on a ventilator, she's paralyzed, she's immobilized.” And then I wrote this sentence: “Despite all of this, she still only has single organ failure.” And it would be months later, when I would realize that that was so crazy to think that she had single organ failure. She had total body failure. And that sent me over the next 25 years of researching and analyzing, “Who am I as a physician, and where have I gotten off track?”
Emily Silverman
So you embark on this journey of uncovering and describing and characterizing PICS, post-intensive care syndrome. Can you just give us a really brief snapshot of what it is and what it looks like?
Wes Ely
Post-intensive care syndrome was defined in 2012, Dale Needham, and colleagues. And what it is, is this constellation of diseases that occur in the human body during critical illness. So you come in with a bad gallbladder, or a kidney infection, or pneumonia. And under my nose, as I'm caring for you, the patient evolves into a problem where throughout the body, the cells of the different organs didn't get enough food and water, essentially, during shock and because of medicines and sedation, etc, and immobilization. And the person develops actual dementia, where millions of neurons are lost. And Sara Beth Miller, who's in the book, we described her brain as like wilted perennials on the MRI because she's actually lost brain tissue in her frontal cortex and her hippocampus. She can no longer do her job because her actual brain tissue has shrunk and atrophied. In addition to that, she develops chemical depression. About a third of patients with PICS have depression, and about 20% have PTSD. So it's really four things: the dementia, the depression, the PTSD, and then this profound muscle and nerve disease. And these people are forced to live with this and recover in the weeks and months and years after their critical illness. And that's what PICS is. And I want to just tell you that what happened in real life was that my wife is a pathologist, and I had been sent to do lung transplant training. So I became a lung transplant pulmonologist. And when I got back from lung transplant training, I was told to start this program in North Carolina, but my wife was getting bullied around by a bunch of old white me, just to be quite honest. And she was the victim of a bunch of bigotry, etc. So she took this job at Vanderbilt. And I followed her here. And when I did that, it changed the course of my observations, because I had to start seeing patients in a clinic after the ICU, which wasn't happening at the old Medical Center. And it was there that I started seeing these people back in the clinic, and they were telling me, “I have to quit my job, I can't do my job anymore. I can't remember people's names at parties. It's super embarrassing.” And I was faced with answering this question to myself, “Is why are their brains all messed up? And then why can't we just measure some marker of this on the front end of illness?” And so I started calling all these delirium experts. And what I found was that every research paper had this recurring sentence in it, which was, “mechanically ventilated patients were excluded.” And I thought, darn it, that's exactly who I want a study of– these ventilated patients. So that meant I had to go backwards and invent a way to measure delirium, even when I couldn't talk to people. And that ended up with the CAM-ICU. And it was nothing I ever planned to do, I was a clavicle to diaphragm doctor, you know, a lung doctor, but here I found myself fascinated by the brain.
Emily Silverman
I want to walk back to something you just said, which is that you started to see your ICU patients later as a follow-up in clinic and that's when you started noticing. That's when you pull up the X-ray and you say, “Oh, my God, there's calcifications and rocks in this woman's joints. How did that happen?” Was that normal? Was that standard? Because what I have seen is ICU physicians are in the ICU, and they don't really see their patients after discharge. So can you maybe paint a picture of how that's changed over the years? Do ICU physicians have clinics where they see their patients as a follow-up? Or is that something that is still growing now? And how do you think that might shift the way ICU physicians think about their work in the ICU?
Wes Ely
Oh, wow. Yeah, it's such a great topic. Just this past hour, I was doing a zoom with the University of Chicago. And they were asking me, “How do I start a career in ICU survivorship clinics? How do I set up that ICU survivor clinic?” And last week, I had a young pulmonary critical care fellow from Boston ask me the same question. It seems as though, Emily, every week now I'm being contacted by somebody around the country or the world who wants to set up a clinic to see their ICU patients in recovery. And what I think we're learning here is that our job as an ICU physician, whether you're a hospitalist or fellowship-trained, that recovery begins on admission. Recovery to these people begins on admission because that's when they're starting to develop all these other PICS related problems. And so in the ICU, now, I say to the patients and families, it's not going to be the same when you leave the hospital. Last week, I was at the VA ICU here and I had a COVID patient who was on the ventilator for 10 days. And when he got off I said to him, “Stephen,” that’s not his real name. I said, “Stephen, you're going to have trouble with your thinking, your walking, depression, and maybe even horrific memories and PTSD-type problems. I want you to come see me. In my clinic, we have a center at Vanderbilt called the CIBS Center, Critical Illness, Brain Dysfunction, and Survivorship. And you can come in for free. You can be part of our support groups. And you'll have a community of people that you can cry with and laugh with and share stories with. And this is the sort of thing that's happening around the country now that the old way of being an ICU doctor and only taking care of them during the throes of illness is now recognized as inadequate.
Emily Silverman
Are ICU doctors excited about the prospect of having these clinics? And I asked that because just being in the world of medicine myself, it seems like sometimes what draws people to ICU medicine is the environment of the ICU where there's a knob for everything. And you can dial things up and dial things down and feel that satisfaction of blood pressure's up, kidney function is better. And that these people aren't necessarily like clinic people. They're not people who have really liked the outpatient setting. And so that's why they chose to go into ICU medicine. Some of them are people who maybe in another life would have gone into emergency medicine. So are you facing any pushback or resistance from the phenotype of person who goes into ICU medicine? Do they want to have these clinics? And have that be their responsibility? Or would they rather just stay in the cave of the ICU?
Wes Ely
First off, there's a place in EDDB, where I talk about how expensive it is to build an ICU room. A room at the Ritz is about $400 per square foot. An ICU room is about $3,000 to $4,000 per square foot. So in a sense, it's the fanciest bedroom in the world, if you want to look at it that way. And those beeps and buzzers are what drew me in and what draw other people in. But I say it's kind of like, you may have heard this expression, where people who go to Colorado in the summer, they say the mountains in the snow got me here, but the summers kept me here. And for the ICU, the snow skiing part is the exciting part. That's the procedures, the intubations, the central lines, etc. But what keeps me coming back are the people. It's the relationships, it's looking in their eyes, finding out what matters to them, not what's the matter with them, what matters to them. And so I'm finding more and more, especially during times of COVID. When we didn't have the families there, the doctors are facing up to the fact that the procedures and the beeps and buzzers aren't enough. That we lose our way. That we become burned out and crispy fried as clinicians and healers if we don't have something much more lasting and enduring as part of what we get from being a doctor and a nurse and a PharmD, etc. And this is the human side of medicine that we absolutely had gotten away from and lost earlier on in the ‘90s and early 2000s with the critical care that we are now building and getting back. And we're going to have to recover from that.
Emily Silverman
As you were discovering PICS, there was some research that had to be done to understand what was happening in the brain of these patients who were intubated, ventilated, sedated. And you keep using this metaphor in the book of being underwater, which I really loved, because I could visualize it. And you write "Once these patients were no longer responsive to voice or painful stimuli, we lost track of their brain altogether. We knew they were unconscious, but had no idea exactly how far they had descended. Were they five feet under? Ten? Fifty?" And then later, you talk about some studies that were done with EEG to really look at what the brain was doing while these patients were lying on the bed in the ICU. Tell us what that study showed. Because for me, that was a moment in the book of like, Oh, my God, how did we not know?
Wes Ely
Yeah, exactly. Well, what was really helpful was that people were trying to figure out using kind of like a modified way of doing an EEG, with just a couple of probes on the head instead of like 20 probes, can we process the EEG and make a number from zero to 100. And so this was called the BIS, or the bispectral index, but now we have others. But let's just take that number from zero to 100. So you and I right now are awake and alert, and our brain in this process, we will be in the 90s. And as we sedate you on the ventilator, we would take you down into the 70s perhaps. If I was to be in the OR with you, and I use the bispectral index to make sure that I had you deep enough to have my hands in your belly through an incision, 40 and 50 would be adequate. Like we could have you completely, generally anesthetized and 40 and 50 amount of brain activity would be plenty deep. So most of the people in the ICU, of course, don't have these EEGs on so we didn't know where they were. And you know, it's nice if somebody is above the water, I can see their eyes, but if their head’s below the water, and if the water is opaque, and brown and murky, I can't see how deep you are. So that's why I was getting it–are you five, ten, fifty, one hundred feet deep. So we started putting these EEGs on people who were just regular old medical ICU patients on sedation, just garden-variety, you know, ARDS, pneumonia, asthma, COPD, and we found that their BIS was down in the five to ten range. And sometimes it was completely burst, suppressed where it was almost near zero. And then we did the statistical analysis. And we found that even after you adjusted for how sick the person was by severity of illness score, their age, their organs that were down, that BIS number predicted death, independent of everything else, meaning that I had iatrogenically taken your brain so far down in sedation, that it almost caused like a flatline EEG, if you will. And I looked at these numbers, and I thought, “Oh, my gosh, that's what we're doing to people. This is criminal, and dangerous.”
Emily Silverman
And there are people who survive this who go on to tell the tale of what it feels like to be on the ocean floor, so to speak. And just share with our audience a little bit about what it feels like from the inside through the narratives of your patients, of course, like we had the one guy who kept seeing a jaguar in the ICU like, what sorts of perceptions are these patients experiencing when they're so deep under?
Wes Ely
I'll tell you a few stories. So Kyle Mohlakeng was one you just brought up. This Rock Hudson, good looking guy, he had pancreatitis, and he was in the ICU on the ventilator. And his wife was doting on him trying to help him, nursing him. And he kept looking at the monitor all day long. And she thought, Oh, that's so great, Kyle, you're paying attention to your vital signs. But Kyle now describes that what he saw up there was this black Jaguar, waving its tail in pounce position, ready to jump on them. And he was thinking, Wait a minute, there's this apex predator in the room here, and we're not paying attention to this. I'm about to die here. He was absolutely petrified. And he says, the problem is that to this day, he still has that memory. Another guy named Anthony Russo, and I actually watered this down for the book so you're going to hear the full version of this. But he had H1N1. He had a dream every night when he was on the ventilator, but he says it was more real than a dream. So it wasn't a dream. They all say the same thing, too. It's not a dream. It's more real than a dream. And he had three people put in front of him with bags on their heads, and he had to shoot one of them. And every night he'd switch the person he shot because every time they pulled the bag off the person, it was his daughter... Yeah, crazy. And now 10 years later, every time he goes to sleep, he has that reality back in his life. He owns a winery, a vineyard out in, in Cali, and when I walked around with him on his vineyard, he was completely unable to sit still, because he said if he sits still too long, that's what comes back to him. So he's clearly suffering from PTSD. In all of these stories thousands and thousands of these delirium stories, only once have I had a peaceful story where somebody hallucinated a dog under their bed, and that was peaceful for them. But most of the time, it's things like I'm having to run drugs for a drug cartel, or that their loved ones are out to kill them. And they can't trust anybody. And it's hard to hear.
Emily Silverman
It is hard to hear. So one of the turning points in your book is this trip that you take to Denmark. And you walk into this ICU and it's like a totally different universe. The doctors there are doing ICU medicine differently. So paint a picture for our audience. What was the old ICU model? Like if you walked into an ICU, what would you see? And then what did you see when you walked into this ICU in Denmark?
Wes Ely
What I've been doing for 15 years as an intensivist, was seeing patients, as Tom Petty (the doctor, not the musician) always wrote, lying in bed looking as though they're dead, other than for the monitors that tell us otherwise, people still tied down, not out of the bed not communicating. And maybe family members sitting around like it's in a morgue. And everybody's thinking maybe this person's not going to make it. Well, when I walked into the ICU in Denmark, at Thomas Strøm's ICU, what I saw was light coming through windows, rooms that were well, well illuminated, like daytime and not dark, people writing on pads of paper as they're on a ventilator, communicating, and even kind of laughing almost with their loved ones. They were still really sick people, so sometimes they weren't laughing of course, they were sick, and they were miserable. But they were still communicating. And some veil had been lifted on this depressing dark thing into a place where people were engaging and getting out of bed and walking even on the ventilator.
Emily Silverman
So what were they doing right?
Wes Ely
What they were doing right is that they realized that just because you put a plastic tube down somebody's throat doesn't mean you have to have them at the bottom of the ocean floor, in terms of their brain, and that the rest of the body could get better and heal better if you were actually communicating to this human being, where they were able to express, oh, here's where you are, Mr. Smith, and here's our goal for you now, and they could remember why they were to live. I viewed it as testimonial injustice, what I was doing was silencing people. But what they were doing was letting people speak up and be part of their own healing plan. Even though they were sick, they needed to be part of this healing program.
Emily Silverman
Your career has been focused on developing these tools and protocols that we use in the ICU now to help people stay awake and help them stay engaged. And so we talk about in the book, the SBT, spontaneous breathing trial, we talk about the CAM-ICU score, which measures confusion, we talk about the A to F bundle. Give us a taste for the audience, like pick one or two of these tools. What is the tool? How is it used? And how does it help patients to have a better ICU experience?
Wes Ely
When I was a chief resident at Wake Forest back in the mid 90s, I got this paper in the New England Journal, and it was trying to figure out the best way to wean somebody off of a ventilator. And I thought to myself, they are starting this at day three or day four, why not start this on day one, every single day, turn the ventilator off and see if the person can breathe on their own. And that wasn't considered traditional because they were worried that it might make somebody have a heart attack and might hurt them. And I was worried about that. But what I did was randomized 300 people into two groups. And every day half of them got their ventilator stopped and the other half didn't. And that actually worked. And they had two days less than the ICU, two days less on the ventilator. It cut complications in half. It saved $5,000 per person. And this was in the New England Journal of Medicine and it became known as an SBT, spontaneous breathing trial. Andreas Esteban had pioneered this work. Before that, though, we were the first people subjected to a randomized trial using respiratory therapists to usher in this new way. Years later, I started seeing these people being confused on the ventilator. And I thought, well, we've got to measure how often they're confused on the ventilator. And there was no way to do that. So I asked Sharon Inouye, a famous geriatrician, if I could take her tool that she used in the wards and modify it. And we did, we modified it, it became a 30 second tool. And at the bedside with no fancy equipment, you just ask a person, “Mr. Smith squeeze my hand. Every time I say the letter A squeeze my hand and if I say a different letter, don't squeeze.” And as this went around the world and we started using different languages, the word we use the most often is Casa Blanca. So we spell Casa Blanca, and we want them to squeeze on the A's, and not squeeze on the non A's. And if they can get eight out of 10 right of those sins of omission or sins of commission, then they are thinking clearly and they are not delirious. It's that simple. And that turned out to be one of the most robust predictors of living and dying, and also a predictor of whether or not you develop dementia. And so now people in 40 languages all over the world use this CAM-ICU confusion assessment method for the ICU. It just takes 30 seconds, it's easy. And the A to F bundle, essentially, I got this from Malcolm Gladwell. Malcolm Gladwell wrote the book, The Tipping Point. He said in order for something to tip, it has to be sticky. So let's make it simple and sticky. The alphabet is about as simple as it gets. And so we just have six things in the ICU that are a safety checklist, that a pilot might use to get you across the country, except these are adapted for ICU patients. And we have 400 papers proving that these are the way to go. It saves lives, people spend less time in the ICU and in the hospital. They spend less time delirious and comatose. And they more often go home instead of to a nursing home. So those are some tools that we've built and I think it hopefully standardizes critical care and makes it better for people.
Emily Silverman
As you were doing this research, you take on a research mentee. And there's this moment in the book where there's this big conference, and they invite you to go present your research at the conference and you can't go because you're supposed to be on service in the ICU. So you send your mentee to go present in your place. And it doesn't go well. Tell us about that.
Wes Ely
Well, the Dean at Vanderbilt at the time, now is Dean Balser or Dean Jeff Balser. He sent me this young green behind the gills doctor named Pratik Pandharipande. He was from India. He had trained in New Jersey. And by the time he came to me and asked me, “How do I become a researcher,” I had an ongoing research project that he eventually became a major part of. And when it came time to present our data in Berlin, he got on an airplane, his father flew from India to meet him there. Imagine this huge room with all these iconic figures in critical care. The doctors had been doing it for 20-30 years. They think they know everything. And Pratik presented these data, where we had proven that cutting sedation in half, that's turning propofol off turning benzos off, actually saved lives, a 15% improvement in survival. That's a huge difference. So for every six, seven people treated with this protocol, one life was saved. And they just lambasted him. They said, “This is unethical. We already do this. We don't need you young upstart coming to tell us what to do and how to run our ICU.” And Pratik was too young to defend himself. He didn't know to say, “You're wrong. You think you're doing it on paper, but I've got lots of data to say that you're actually not doing it in real life. And the human beings you care for are still suffering, and you need to pay attention to these data.” Instead he cowered, became embarrassed, and they thought that they had won. But ultimately, in the end, Lancet published this paper and it's now part of usual care all over the world because data speak louder than opinion.
Emily Silverman
I want to talk about this pushback in two categories. So we have the research pushback and then we have more clinical pushback. Starting with the research pushback, you said even before you started your research you got pushed back. You were told, quote, “This research is a dead end. It won't be funded by the NIH. It's going to stunt your career. Pay attention to lung physiology and the science of the thorax.” You decide to submit grant proposals anyway. And you get review comments from the field’s leading neurologists and other folks. And you describe them as a tragic Greek chorus, where they say the focus on delirium doesn't belong in the field of critical care. What was going on there?
Wes Ely
People are territorial, and the neurologists and the geriatricians and psychiatrists thought we've got the hold on delirium. We're the ones who do delirium research. And don't come telling us new ways of doing this stuff because we've been doing this for 10-15 years. And I’m coming in as an ICU doctor with no valid tool, where they think you can't measure delirium if you can't talk to someone. And I knew we had to measure delirium, even though we couldn't talk to somebody, and you can't talk if there's a tube between your vocal cords. That's the idea there. So we had to modify our approach. But they didn't want to hear that. And the first three or four years of submitting these grants, they were resoundingly rejected. And that's when people called me in their office and said, “Wes, you're losing this game of academia. Because to be an academic, you've got to pull in NIH dollars and that's not where critical care doctors get their grant money right now.” And they really advised me to quit and to go back to the science of the thorax. And I just couldn't live with myself knowing that I was hurting people's brains. But at the beginning, it was not an easy sell. And I had to find people who would listen long enough to help me build this area of research.
Emily Silverman
I love the moment in the book where you open a notebook and you write down, “Hypothesis: the lung bone is connected to the brain bone.” And it's such a great example of how medicine has become divided into the silos by organ, let's say. And, as you say, people, doctors because we know doctors are just people, researchers are territorial. They like their little corner of the research world, and they want to protect it. And it reminded me of this book Arrowsmith, by Sinclair Lewis, which you mentioned in the book, and I think is now sitting right on your desk. He's holding it up. And this book is a novel, and it's all about the quest for truth. And it's this young doctor, and he's going from town to town and context to context just trying to do the science. And he keeps bumping up against all these problems, like branding and money and egos, and I won't spoil the ending. It has an incredible ending. But I'm just wondering, like, as somebody who has been in the research world and bumped up against ego and people being territorial, like, what advice would you have for someone out in the research world for how to navigate that? Or do you have thoughts on how we might restructure the world of research to foster more interdisciplinary collaboration and get away from these silos?
Wes Ely
Since you brought up Arrowsmith and since I have it in my hand right here, I opened it to a page where I had a sticker. I wasn't planning to read this, but let me just read you a few sentences of what Arrowsmith says. He says "Give me unclouded eyes and freedom from haste. Give me a quiet and relentless anger against all pretense, and all pretentious work. Give me a relentlessness whereby I may neither sleep nor accept praise to my observed results." So stop there for a second: "that I may not accept praise to my observed results." You know, there's such an ego in medicine. And it's the easiest thing in the world to think that I am good because I got this big paper in a journal, and I'm the cat's meow to medicine, etc. But the truth is that I and all of this work, I've been merely a widget. And I really believe that it's a widget role to play. And we're all replaceable. And the way I'd rather approach this is the following. When I kneel down with my patients, it reminds me that I am small. And it also puts the patient in the driver's seat. When I'm kneeling with them, and I do find myself more and more kneeling at the bedside and holding their hands and looking in their eyes, then they are above me. And it helps me remember that I'm there to serve them and not the other way around. If I bring that over to my academics, it has to be the same way. I'm not doing academics to pump up my own ego, and to become the biggest grant getter. I'm doing it to answer a question to help a person. And if I can keep myself organized like that, then what we've done here in the CIBS center, and I don't want to claim credit for this, in the CIBS center, we have 120 people doing research across 12 different departments at Vanderbilt and other medical centers. We've created an interprofessional group of people, where we share our sorrows, we share how we've made mistakes, we try and lead with our errors that week. And that puts us in a position of learning. I love Tao Te Ching 65, which says that the ancient masters taught the students to unlearn. Because if they think they know everything, they can't be filled with new knowledge. But if they know that they don't know, then they’re in a place where they can receive new knowledge. And that's kind of the approach I've tried to take both at the bedside and in research and that's helped me to stay on track.
Emily Silverman
Thinking about pushback, less in the research setting and more in the clinical setting, people back in the day were very attached to benzodiazepines. They were afraid to lift sedation. It was convenient to care for a patient who was sedated and who wasn't awake and pulling at lines and interfering. One veteran nurse in the book told you that she, quote, "went into critical care precisely because the patients were still, most of the day and night." And you also talk about this critical care nurse Jet who tried to make change. And she said, "I went to the ICU in my small hospital and told them about the bundle. Here's A and B and C. I explained everything and the nurses nodded. Uh huh. Uh huh. I said, so this is what we have to do. This is the cool new stuff. And they said, Great. Two weeks later, I went back, and you know what they had done? Nothing." And I loved that scene because it was such a great example of how hard it is to take the new knowledge and the new data and put it into practice. And so I'm wondering, how did you and your allies transform ICU culture on the ground?
Wes Ely
The way that we did it was by the power of human story. And the mistakes that I made at the beginning were that I thought that if you took this SBT New England Journal paper, wrote it down on paper and told everybody, this is our protocol, we're going to now follow that they would do it. And what I learned time and time again, was that they wouldn't. And the reason was that you're dealing with human factors. They have to believe in something or they won't change. And also, I was discounting certain members of the team. In Everett Rogers’ book Diffusion of Innovations, there's this famous graph with early adopters and late adopters. And what I was thinking was, “Oh, I'll just grab a hold of all the early adopters, and shame the late adopters.” What I realized in the end was I had to do two things differently. One was don't try and make all the change occur at once. Do it by small stories. Let one nurse treat one person and let the other people observe that experience, so that the power of that human story can convince someone. And the second thing was to take the early adopters, yes, and let them be the ones walking them earlier and getting rid of the benzos. But watch the late adopters and go to them and say, “Teach me what you know that is why you don't want to change yet. Let me learn from you and your history and memory of what was tried before and failed, so that I can not commit that same error again.”
Emily Silverman
So walk me through the process. Let's say there's an ICU in a hospital. And you know, Jet comes in and tells them what to do and comes back two weeks later, and they've done nothing. You say sometimes starting with just one nurse and one patient is the way to go. So what happens? Do you have that nurse lift the sedation? Do you have everybody gathered around watching? Like, can you just walk me through actually what happens?
Wes Ely
Yeah, absolutely. I'm glad you asked. So in that ICU that nothing happened, let's just for the sake of making it easy to talk about, let's take these two extremes. Let’s take an early adopter nurse and a late adopter nurse. And what I want to do is I want to find that early adopter and say, “Look, Jan, you're into this, right? Like, do you want to try and do this?” “Yeah, I'm totally in, Wes. I want to do it.” “Okay, here's what we're going to do. We have our slogan, “What can I do by Tuesday?” So today's Monday. So tomorrow, how about I meet you at Mr. Smith's bed, your patient, Mr. Smith, and we're going to meet there at nine o'clock. And it'd be you, me, a pharmacist, and a PA or an NP. And we're going to run through the A to F bundle, we're going to let you present. Okay, so you're going to say it out loud. You're going to tell me where's their analgesia. How are we doing and stopping drug and ventilators. How’d they do with that. What about what's the choice of sedation being used. Let's run through the Dr. DRE, which is a mnemonic for how do you approach delirium in the ICU. It's diseases, drug removal, and environment. We'll take, we'll run through that. Early mobility, we'll talk about whether or not we can get him out of the bed, and then F for family. “Okay, Dr. Wes, tomorrow, we'll meet at nine.” And so we do. We meet there at the bed at nine, she presents the data on the A to F and that takes about 20 seconds. And then we try and do it. We try and get the person out of the bed, we turn the drugs off, we let them wake up. And we see what goes right. What goes wrong. What actually worked and what was a mess. And it was, “Okay, today's Tuesday. Let's fix these three things and do those differently tomorrow. Let's meet back here Wednesday at nine.” “Okay, fine.” So one day later, we'll be back Wednesday at nine with the same patient, same nurse, same table, and we do that three or four days in a row and we keep fixing things because it's called small tests of change. PDSA cycles: Plan, Do, Study, Act. So we plan it, we do it, we study what we did, we act to change, we do it again. And after five or six days of that, moving on to the next week, we've gotten something in our unit that works. Now we go to the second nurse who wants to do it, and she's seen it happen. She goes, “Well, I want some of that.” So we start growing it slowly like that. But then there's this also, this other person, this late adopter, and I'm going to make sure they feel included. “Tom, you've been in this unit for 15 years. You've seen things come and go. Why do you think this is a bad idea? Let me understand what your, uh….” And he tells me stories about what he tried, what he didn't try. And I learned from Tom. I say, “Tom, I believe in you, I want to understand.” I'm not trying to be patronizing. I'm being very sincere. He knows that by the way I'm handling it, even though it may sound kind of crazy right now. But that's the way we would do as we build these relationships. And then over a period of weeks and months, we birth this program.
Emily Silverman
It's amazing to hear this because this work is not easy to do. Just thinking about the barriers that you bumped up against choosing to do this research, getting pushback on the research, getting the data, presenting the data at the conference, getting rebuffed at the conference. And then bringing the data into the ICU and having to do this person by person and nurse by nurse, I just can't overstate the admiration that I have for you and your allies and your team. It's awesome to hear about.
Wes Ely
You know, the guy who invented Intel is Gordon Moore. He's a billionaire. And there's a thing called the Gordon and Betty Moore Foundation. His wife's name is Betty. We have to stay so humble in all this. I mean, obviously, I have a ton of pride and I need much more humility. So I'm not saying that I'm humble. But on this particular day, I got it right. I was flying out to Palo Alto. And on my iPad, I drew up the ABCDE bundle, there was just the A to E. And I got in this room. It was a beautiful room with this huge tree for a table. They had this fallen tree that was created into a table that was beautiful. It's called a LEED building like these green buildings. And we're all sitting around the thing and they said, “Well, how are we going to liberate people from ICU? We're going to give you some money.” And the reason was that Gordon Moore had gone into the ICU. And this is public knowledge, he had had a terrible experience. He was delirious, his family was not allowed in there. So right there, the D and the F are a disaster, he was not walked enough. And he got out and said, “Look, I'm a billionaire, it was horrible for me, it's got to be even worse for people who have nobody speaking for them. I'm going to put millions of dollars into this program and let's create something new for people.” So that was why I flew out to the Gordon and Betty Moore Foundation and was presenting them with this A through E bundle. I said, “This is how we should do it.” And they said, “Nope, we're not going to give you any money.” I said, “Well, why not?” They said, “Well, because Gordon says that family has to be included.” And I thought, okay, family has to be included. And that'll get us money. A B, C, D, E, F family. Okay, done. You've got it. It's now the A to F bundle. And what I didn't know was that there were great data behind it: The New England Journal, JAMA papers on family. I just had been ignorant. So here's the humility of saying, “You know what, I don't know everything. Let's fix this the right way. Let's listen to each other.”
Emily Silverman
So what do you think is next for you for the ICU? What are the new questions that are coming up? What's at the forefront of your work these days?
Wes Ely
FantasticI ! I love that you asked. I'll give you two good ones. One is that we don't know what kind of dementia this is. And when patients get out of the ICU, and they have a dementia that goes on for two or three years, we have not been collecting the brains in the past that we have with Alzheimer's disease. So we now have a $20 million grant from the NIH, the National Institute of Aging, actually, called the Brain Two study. The Brain One was our 2013 New England Journal paper where we proved that delirium led to dementia. So Brain Two is we're actually having these beautiful, brave people donate their brains upon death and we're creating a brain repository where we can study these brains and see exactly what kind of dementia is this. Is it plaques and tangles, is it from the drugs that are causing toxicity to neurons? We don't know yet. So that's one big area, what type of dementia these people suffer from, which will then open up the door to prevention and treatment. The second one is just something completely different, which I'll share with you is that when we rebuild this bundle, I want to now complement that with apps like, there's an app called VoiceLove, where you can turn a phone into a walkie talkie. And the family members can leave their own voicemails for their loved one that they can play right out of the bed into their ears and they can hear their brother or their sister or their mother, telling them how much they love them, even if they're in a different country. So that's one way. But the other way is, instead of just audio, how about creating diaries for people during their ICU experience? And we have phone apps now that we're working with and researching to make them where there's text, there's videos, and there's pictures of what happened to them. So that Kyle Mohlakeng could see a picture of himself in the ICU and his monitor does not have a black jaguar above it. You see, so he'll know. Sometimes it's just that one picture that unlocks the whole thing for somebody. So when we rebuild this, we want to use modern technology too, and I'm hopeful that we can really do this even better in the next decade than we did in the past two decades.
Emily Silverman
Over the course of your life and your career, you often turn to literature for guidance. And in the book you mentioned Sinclair Lewis and Arrowsmith, which we've already talked about.
You mentioned Saul Bellow, Rebecca Solnit, John Steinbeck, F. Scott Fitzgerald, and others. We are The Nocturnists – we're really passionate about storytelling and medicine and the intersections. Tell us, in closing, about using stories as a guide.
Wes Ely
When I was a boy, my mother and I would sit up late at night, as she was grading her papers from her students. And we would turn to poetry. And we would read all these beautiful Shakespearean plays together, and it was just a joy. And one of the things that I find keeps me whole as a person is returning always back to literature. And whether it's "’Twas brillig, and the slithy toves did gyre and gimble in the wabe", you know, this Jabberwocky poem, or a remembrance of the way that F. Scott Fitzgerald describes the lost generation or whether JD Salinger talks about Franny and Zoe, and when they were doing their radio show, these are the things that I keep coming back to, because they really are descriptions of who we are as people, and they are studies of the human condition. And in fact, the title of Every Deep Drawn Breath comes from Steinbeck's magnum opus, East of Eden, for which he won the Nobel Prize. And I'd like to just read you the epigraph here, which 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's 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." And the reason, Emily, that I wanted to read that to The Nocturnists’ audience is that that's at the beginning of chapter 13, in East of Eden. And he's about to go into one of the most gut wrenching things that you could ever imagine happening between two people, where one person wishes good, and the other person wishes total evil. And these two characters juxtaposed, kind of as bookends, the extremes of the human condition. And yet in that quote, is this uplifting of us that we are sinew, and nerves, and breath. And the glory of that in medicine is that we get to serve people who are made of all of that reality.
Emily Silverman
Well, I can't think of a better way to end than that. Thank you so much for that reading at the end there. And is there anything else you'd like to share with our audience?
Wes Ely
Just help us bring other people into the story. We need your help. We want everybody to share that they can become advocates for their loved ones at the bedside, and that we have to be advocates for our patients. And that starts with touch first, and technology second.
Emily Silverman
I have been speaking to Dr. Wes Ely. His book, Every Deep Drawn Breath: A Critical Care Doctor on Healing, Recovery and Transforming Medicine in the ICU, is available now. Pick up a copy. I had an awesome time reading this book and hearing about the science and the medicine, but also about your journey in transforming medical culture. So thank you so much for writing this book, for doing the work that you do, and for being here to chat with The Nocturnists’ audience.
Wes Ely
It's been my pleasure, my great pleasure. Thank you.