Episode 111: Occupational Therapy in the Trauma ICU

SUBSCRIBE TO THE PODCAST

What is like to be an ICU delirium survivor and intensivist? How did Dr. Wischmeyer’s own nutrition research transform his outcomes during his most critical ICU stay? He shares his journey with us in this episode.

Episode Transcription

Kali Dayton 0:00
Being a patient in the ICU brings a breadth of wisdom and insight. I’m excited to have an intensivist frequent ICU patient and delirium survivor, nutrition researcher, dancer, and incredible human being Dr. wishmaker on the podcast this episode. Dr. Wish Meyer, thank you so much for coming on the podcast. Can you introduce yourself?

Dr. Paul Wischmeyer 0:58
Sure, my name is Paul Wischmeyer, and I am a professor of surgery and anesthesiology at Duke University Medical Center and School of Medicine. What that means in real life that I do is actually an intensive care physician. So I practice in our intensive care units. And then I also am the director of the TPN nutrition service at Duke. And so my typical day there is I spend so my time, a lot of my time, more than half of the doing research in the areas of nutrition and exercise to help ICU patients and surgery patients recover. And then so my time as an ICU physician, and they work in our surgical and trauma ICU, and then some of my time on my nutrition and TPN team working with them. So a little bit of little bit of everything every day is a little different.

Kali Dayton 1:48
Well, I had been admiring your work for a long time, you have quite the following on Instagram, you’ve been coming out with a lot of studies lately. So I would invite everyone I’ll put on the blog, your handle for Instagram so we can keep lay up on the latest and current with your research that you’re doing. And then you’ve had a lot of a lot of personal experiences in the ICU as a patient. Do you mind sharing kind of what your journey has been?

Dr. Paul Wischmeyer 2:14
Sure. Yeah. I mean, the reason I went into medicine honestly was when I was 15. I was diagnosed with inflammatory bowel disease, ulcerative colitis, and suddenly went from being sort of your normal high school student playing soccer playing basketball on my my JV team and to suddenly being told, you know, you’re going to come into the hospital, and you’re not going to eat for the next six weeks, and we’re going to put an IV in your arm and we’re going to feed you through your arm and and this is just how it’s gonna be. And that was really shocking.

I’d never been in the hospital before. And so for all this to kind of evolve very quickly over the Christmas holiday in my freshman year of high school. Now, I suddenly went from being this normal kid to suddenly I was in the bathroom 15,20 times a day and bleeding and my hemoglobin was low. And you know, I think from the very start as a patient, I realized a couple of things.

One, that doctors weren’t very nice people, at least a lot of doctors I interacted with, and I really felt like and still do sometimes. And I think this is a big part of why I went into medicine is that we’re I think patients are often seen as jobs to be done or boxes to be checked on a list and, and I think sometimes and how busy physicians and especially young physicians are in their lives. They forget there’s a person laying there that that is filling in suffering and experiencing all these these things you’re doing to them.

And you know, it started early just with the simple procedures now, that course we anesthetize people for but things like colonoscopies and, and central line placements and things I think that we often take for granted, you know, I found it’s unbelievably barbaric at times, I, you know, be laying on the table. And, you know, this was before they use sedation for any of these things, and I would move or something and they would blame me for why the procedure was taking so long. And they would tell me, “If you just held still we’d be done sooner.” And “This would all go better if you know…” or even when I had my first centralized place for TPN.

I can remember the big gastroenterology fellow digging around in my chest for subclavian line and even at 15 I realized I said to him after about 45 minutes, I thought to myself under the drape, “Aren’t you awfully close to my lung?” And he even said, “Oh, maybe I am and we should come back tomorrow.” And so I think we forget that, you know, we just see a procedure to be done. But underneath that drape is this person who can’t see anything other than they know the giant needles coming into their neck, and it’s pretty terrifying.

And so I think I realized that, “gosh, I think I want to go into medicine and I hope I can help physicians be better understanding what it’s like to be that patient under the drape and to be that patient who’s undergoing this procedure who’s you know, so confused and delirious. They don’t know where they are and they don’t know where they are.” And I think a lot of his experiences really changed sort of a who am I am as a physician, but be who I am as a person and I really I try to convey that to the people I work with.

Kali Dayton 5:02
Wow. How do your personal experiences with delirium impact how you approach patient care as an intensivist?

Dr. Paul Wischmeyer 5:10
So pretty significantly, you know, I think my first experience with delirium was when I was 15. My colon perforated and I got peritonitis and I was rushed to the ER and woke up in the surgical ICU. And I can remember seeing, feeling like I was in the woods, I remember it vividly. Actually, I thought I was in the woods, and there were deer and trees. And it actually was all very pleasant. And then I remember telling the surgical resident about it.

And of course, when I was 15, the heavy seeing child’s sight because they thought IBD was a psychiatric disease, vaccine or stress related disease. And then that surgery residency site resident said, “Oh, we can fix that, we’ll give you this big dose of this drug called haldol.” And so they gave me this big slug of haldol. Well, the first time I got it… Suddenly, within a few minutes, I felt like I fell down, like 10 or 12 floors. My hospital room suddenly had multiple floors and stairways between the floors. And my body fell down this and I shattered on the on the ground, like this bright lit ground and my body shattered into 1,000 pieces.

And then each piece had a tag on it. And I had to go up and down the stairs of my hospital room, putting my body back together piece by piece, each of these little tags being being part of where I was supposed to put each piece. And I spent the whole night doing that it seemed like and I remember telling the resident the next day, and they said, “Oh, we just didn’t give you enough of that drug. And so we just need to give you more, you’re still having these delirious moments.”

And so they gave me a bigger dose the next night. And then I started to hear voices, suddenly my arms went back and my eyes rolled back and I was like cramped on this position. And the nurse didn’t know what was wrong with me. I was a crazy teenager. But of course, anyone who knows a little bit about some of these drugs and worked in ICU at any length of time, we know that’s a dystonic reaction. But that wasn’t recognized till the next morning when the Chief Resident came in, and realized that I had been just tonic the whole night and gave me a little Benadryl, but I had a tremor for a month after that.

And so I think it made me realize that, you know, not only can delirium be really disturbing to patients, but the treatments that we give people for them, although they make them quieter and calmer, don’t always put them in a place that’s very pleasant at all. I actually wrote a paper about that falling off the balcony of my room experience and got an A plus plus in college, and a college essay. But it was really, it was really compelling.

Right, it took what was actually not so unpleasant delirium and made it very unpleasant delirium, although I guess I was quieter and easier to care for, it wasn’t always so pleasant. And so I think it’s made me really acutely aware of it. I experienced it. Your listeners wouldn’t know, but I just had a major surgery in April as well underwent a 13 hour operation for adhesions, and ended up in my own surgical ICU where I work.

And I’d never really experienced sort of the scary delirium, the anxious delirium before where you knew what you’re experiencing wasn’t real, but you couldn’t help believe it was real, like you felt like people were out to get you and people were chasing you. And you had this very distorted view of the world. And the anxiety that was that was really compelling.

This last hospital stay, I don’t know if it’s age, or how sick I was, or that I developed peritonitis and was in the ICU more than a week. It was really terrifying, and really compelling. And so and that was me being quite mobile, and even, you know, quite active after surgery, trying to mobilize and things. The only thing that made it better was precedex. Honestly, none of the other meds made it better.

And I don’t use any psychotics, except for when patients are risk to themselves or others. And so I’m not a believer and and antipsychotics. Some of it’s the data and some of it, obviously, is my experience with them. But yeah, the data, of course, isn’t good for them either. So for those of you who are providers out there, right, we know, there’s no data, there’s some great reviews and meta analyses on that, that they don’t treat delirium. They will make hyperactive delirium into hypoactive.

I experienced that firsthand, it does make you sort of locked in a little bit chemically. But a lot of times, the experiences you’re having you’re locked in are really unpleasant. And so I try to avoid those and try to use obviously, the non pharmacologic things every day on rounds. I’m the first one to open all the windows. And I tell every patient that I see that the bed is bad for them, and that if they can spend every moment out of the bed and in a chair, except for when they’re sleeping or having procedures done, that’s what they should do. And so I’m a big believer in those but I was blown away by how effective precedents was, in really taking away that fear and anxiety that I had. I’d never received it before as a patient and it was really profound. Now the problem with that is, of course, you can’t go to the floor on it. And so we try to get people off of it. And we were they were trying to get me off as well. So I only got it for a day or two but

Kali Dayton 9:38
You were still able to interact, communicate. You were a RASS of 0?

Dr. Paul Wischmeyer 9:41
Yeah. Yeah, I you know, aside from the period I spent intubated, which, ironically, being intubated in your unit. It was interesting too. What I remember being intubated was ….looking…. I thought I was caring for a patient in the bed not actually being the patient in the bed. When finally extubated me, the attending obviously I knew and the respiratory therapist I knew. And I said to them, I’m like, “oh my god, I have quite a story to tell you guys, I just had this intense dream that I was caring for a patient in this bed and talking about extubating them. When the reality was that was them telling you to extubate me.”

What I remember is I was on the other side, and it was really vivid. I don’t remember being intubated. Actually, I remember seeing someone else in the bed intubated, and, and, and somehow caring for them. And it was really real, it really felt very real. But the layer my experience, then the next few days, I knew it wasn’t real. Like I felt like I was being chased by terrorists at times or I was sick people were coming to get me and it was every time I closed my eyes, I would feel these intense like I was at a part of a story suddenly, and people were out to get me. And when I opened up my new wasn’t real, but I couldn’t make it go away. And so it was this really paranoid delirium, almost. We see our patients get all the time, right? We can’t understand why they feel this way. But it was really scary, even though I really knew it wasn’t real. I still couldn’t pull myself out of it a lot of times. And so it was… it was… it made the hospitalization in the ICU stay tough. The nurses were amazing. I mean, they were so understanding, but

Kali Dayton 11:09
but it was precedex because you were agitated?

Dr. Paul Wischmeyer 11:12
Yeah, I asked. Well, I think they started after I’d been intubated. And given the the delirium I was describing, they started it. And then while I was receiving and I said, “God, I feel much better.” I was able to vocalize that. Of course, unfortunately, the next day, they and we all want it stopped, because I wanted to try to get out of the ICU. But that next two nights, of course, it’s hard to get a floor bed nowadays and so patients stay in the ICU much longer. We couldn’t get one. And so I was stuck. And so it was it was the next few nights were pretty unpleasant. And I wasn’t maybe the nicest patient either, because I was so…. it seemed really real. I was really scared at times, even though I knew I was probably safe.

Kali Dayton 11:50
How did mobility help during that delirium?

Dr. Paul Wischmeyer 11:54
I mean enormously, right? Obviously, this delirium primarily came and I think it’s true for our patients that we care for too…. was at night, right? So during the day, I would spend the majority of the day in a chair or walking. I walked round and round and round the ICU. And you know, they wouldn’t let me go very far. But so I just walked circles, but that is tremendously helpful. And maybe a little bit we’ll talk about sort of the nutrition and the recovery pieces that that are so important. BZWTYXRUut that definitely helps, right, you get out of the room, get off your get up on your feet, and out of the bed, it goes away, largely, almost entirely. But then of course, night comes and you need to sleep and have some pattern and the nights are really difficult.

Kali Dayton 12:35
What would you have the ICU community understand and then change but how we approach sedation and mobility in the ICU? As an intensivist and a survivor?

Dr. Paul Wischmeyer 12:46
Yeah, I mean, I think I think we really need to drive home to our providers, our patients and their families, especially that, you know, I think people will see people who are quite sick and think, “oh, they need to be in bed, they need to rest. And that’s how you get better.” Well, that isn’t how you get better, right? Clearly, there’s, there’s times right at the beginning, when people are so acutely ill the you know, they’re too sick to move, but there’s very few people that are too sick to move. That’s pretty rare.

You know, I had that big operation and was you know, and they were for 13 hours. And within 12 hours, the next morning, I was up walking. And you know, that’s the key role of regional anesthesia. Right, I had an epidural. And it worked really well. I have three of them. Actually, I was hospital about a month and I have three epidurals, they’re so essential. So regional anesthesia is so helpful. They’re getting people mobilized.

But I think setting the expectation with the patient and the family, and with the providers that the bed is really what is the most the biggest risk to the patient, once they get past whatever reason they’re there for is something we maybe don’t do a great job of expectation setting with, even if they’re not walking, even if they just sit in the chair all day. You know, the core muscle you use that requires and the clarity of thought it requires to keep yourself upright and engaged. Because you’re much more likely to do that, if you’re out of the bed, I think is so helpful.

And, you know, my experience through my life and I’ve had 27 different surgeries and been in the ICU quite a few times never quite as sick as this time but has been typically I lose 40 or 50 pounds. It takes me one to two years of aggressive exercise and nutritional recovery to get back the same weight and strength that I had before I had those operations or ICU stays.

So this day, we really went to with a different mindset. You know, this one was elective, some of them might have been emergent. So let elective surgery helps because you can plan for a little bit but but then I had a couple of really serious complications. I had a GI fistula form and had two more emergent operations still pouring out of my abdomen, I was really quite sick, sicker than I’ve ever been before. Didn’t eat for three months. I was on TPN.

But, you know, we in the nutrition field, I’m going to make a plea for all of us to really update how we practice have really, I think worked hard last 10 years to move the field forward. And one of those things that we’ve done is a group of us from around the world led by the Europeans got a grant from European nutrition society. Need to build a better metabolic card a better indoor kilometer. Because, you know, we would never give pressors without measuring a line or having an airline present, we wouldn’t put people on ventilators without measuring blood gases. But we feed people all the time with no data as to how much to feed them. And we know that the equations are completely inaccurate for the most part, and, really, we’re overfitting and underfitting all the time, which has its own morbidity and mortality associated with it.

So we really needed a device that would measure and so we worked with a company through this grant to build this what we think is a better device. And then we did the validation studies across the world. Duke was one of the centers in the US that did it, and I was helpful there. And this device is highly accurate measures and five minutes can be run by a dietician or a nurse, or, you know, we’re really advocating for nurse and dietitian teams to run these in the future. And it reads in 15 minutes, and it calibrates itself. And so I was lucky enough, of course, we have some of these devices, Duke to be able to know what my metabolic needs were before and after surgery.

And so when I was on TPN, the device was showing I needed 3,000 calories at rest. But then with my rehab, I really needed 4,000 for the activity factor. Well, no one else would ever read a TPN for 4000 calories without having data to support it. And so I’ve always given myself 2500 or 2000. “That was enough, I’m healthy.” But I’ve always lost so much muscle and weight that I’ve weak months to years afterwards.

Well, this time, I gave myself 4000 calories, and I lost at most 10 pounds, even being septic and peritonitis, and edema and all the other things. And I gained all that weight back within a month of discharge while still on TPN. And eight weeks later, I was my wife and I danced competitively, we Tango dance, and I was able to lift her over my head eight weeks, the minute my surgeon said I could pick up more than 10 pounds. I said “Well, can I start dancing with my wife again?” and she said “If doesn’t hurt, do it.”

And so I was just a strong, I’ve never had that happen before. For 25 years I’ve taught it’s mandatory to lose strength and have the ICU acquired weakness and the physical dysfunction. And it takes a year to get better. That’s not true, I was the sickest I’ve ever been. And by using these more personalized metabolic cart guided methods, starting TPN and early, I started within 48 hours, which now the data says TP and reduces infection in surgical and ICU patients when given earlier. Some new trials come out and definitely doesn’t increase the risk, I was able to keep my weight to keep my strength.

And clearly early mobility played a role in that. I was walking the whole time despite being sick and moving. And I worked with the occupational therapists to learn to do band exercises that wouldn’t stress my incision. And so I did those at home and in the hospital. But nonetheless, most of it was walking in the hospital and then just getting the right nutritional delivery. And I didn’t lose weight, and I didn’t lose strength. And it was night and day. And it’s totally changed how I teach our residents. I just taught a lecture today to our ICU fellows. And I said, you know, guys, I used to say “You had to lose weight, there was nothing we could do about it.” Well, it’s not true.

Kali Dayton 17:53
I have so many mixed feelings about all of that. I mean, it’s so exciting to know we have this technology, that you have these outcomes that you’re doing this with patients. At the same time a little bit pained knowing that, for decades, patients have suffered so much that could have been prevented. Yeah, these three things, right? I mean, sedation management, obviously mobility, and nutrition. How do we standardize this?

Dr. Paul Wischmeyer 18:18
Yeah, it’s tough, right? It’s, I always lead on my lectures. And I say, you know, “That really critical thing on rounds everyday we need to be doing is not only what do we need to do for the patient to get him through today. But what can we do today that ensures they have a life worth leading a month from now when they leave the hospital?”

I mean, and so recovery has to start the day of ICU admission, or for surgical patients cancer patients before, right prehabilitation is really important too. But it’s got to start the minute they hit the unit. Right? It’s it sounds as though you were in one of those units in Utah. And I know some of the people that were there with you that did early mobilization. I actually was a fellow with JP Kress when he was doing the Stryker trial, the first trial that really showed that you could mobilize an ARDS patient and walk them around the room while they were ventilated and do it safely. That trial was going on while I was a fellow at University Chicago with JP and he really was a leader along with the physical therapist he worked with and teaching us we could do this, right? And I know you experienced it firsthand.

That has to become standard of care. And and I see patients that aren’t even…. had never been intubated that I don’t see get out of bed for weeks and weeks sometimes….and we have to change that mindset in that culture, but even an intubated patient, right. It’s somebody who could mobilize and I know, you know a lot about that, and so few hospitals do it. And it’s so….

Kali Dayton 19:34
We have to we have to overcome this assumption that that is just par for the course. Right? And so your experience really exposes with an extreme example of how different this could be. I mean, you know very well, what your normal outcome is. And something like the metabolic carts, obviously, it’s going to be an expense, but what do you have data-wise showing the outcomes and maybe even the transit healthcare savings?

Dr. Paul Wischmeyer 20:01
So there are now two meta analyses that show that the use of indirect calorimetry or metabolic cart to guide nutrition deliver in the ICU reduces mortality by about 20 to 25%. So there’s two published meta analyses that show that. And so we, you know, we do try to sell this concept to our health care hospital administration. And, you know, we showed them how you can code and bill for doing metabolic carts and dietitians can run it. So it’s not like you have to add physician time or, or add, like those of us that are really expensive to hospitals will do this.

But in the end, they said to us, “Yeah, that’s all nice….” we showed them the clinical improvements they can come up with. All of them at the end of the day, our our, our CMO and others said, “This just seems like the right thing to do, obviously, right?” It comes back to the idea that again, we wouldn’t give vancomycin measuring vanco levels. We wouldn’t give, you know, norepinephrine without measuring blood pressure. We shouldn’t be giving nutrition without measuring what our patients need.

And they in the end approved a team for this and a device to get this. The devices aren’t that expensive, actually relative to most instruments, because it’s this was obviously the right thing to do. But that said, we do have data, we do have all that kind of cost information that goes in and you have listeners out there who work in hospitals and want to get this we can share. We’re writing a paper or dieticians, myself on how to sell this to, you know, a hospital administrator, right? What’s What’s the case for metabolic cart team and your hospital. And so we have all of the sort of benchmarking and cost data and evidence base already compiled, because we really want to help people do this better.

Kali Dayton 21:35
Oh, that’s great. And when you have that out, we’ll include it on the blog, as well as links to the studies that you’ve mentioned or alluded to. How can we also have a more collaborative team between PT, OT nutritionist, nurses, how do we bring this all together? Obviously, we can. Nutrition, that alone makes a huge difference. But how do we compound that with mobility?

Dr. Paul Wischmeyer 22:00
Yeah, so it’s so critical, right? So our medical ICU, Dan Gillstrap, who’s our medical director here at Duke and our medical ICU had a really cool idea during COVID, because he was really frustrated by the lack of mobility, right? COVID Patients are the hardest take care of because they’re isolated, and you have to gown up and glove up and mask up to go in their room.

And so he started a mobility rounds. Every day at 11 o’clock, and he is unbelievably committed. He goes around with his PTS, his speech and swallow folks, his RDs, one of the fellows, the ICU fellows, and then each nurse at each bedside, and then OTs and PTs and all the other folks. They go around, and they see each patient for about five minutes. And their only focus is, are those things, “Are they being fed? Have they been out of bed? What are we doing for delirium? What are we doing for speeches and swallow?” obviously. Then a case manager talks about sort of, “where’s the family at and all of this?”— and because I can’t emphasize enough the role of the family, right?

I think there’s some really cool trials too, that have come out in the last two months that have shown that family presence in the ICU is reducing length of stay and improving outcomes clinically, right? Because I think we we all unfortunately, we’re doing ourselves a disservice keeping families out of the ICU during COVID. And I can say from a patient’s point of view, that was devastating I am one of the reasons I chose to have this big operation electively was I was hospitalized in Hawaii on a vacation with a bowel obstruction in February. And they wouldn’t let my wife in a disaster when I’m sick.

And the physicians there had a really hard time they’d never seen a patient like me and did some sort of medically questionable things just because they’d never seen a patient who had such a complicated gi anatomy and, and I was a mess. And it was really scary. And you know, if I just sort of had my wife there with me or a family member there with me, none of a lot of the things that happened during that hospitalization wouldn’t have happened. And I don’t know how people survived without their families. I, my heart was out to everybody and COVID, who was stuck without a family member in the room.

It just broke my heart and our own unit when I was watching it. And as a patient, I, I can’t even tell you how important that family piece is. And so I think that’s essential as well. But anyway, we do these rounds. And I’ve been really amazed how successful they’ve been at mobilizing even intubated patients, suddenly, when we weren’t doing that in our NICU at Duke before. Now, they’ve been very successful doing it. So it takes a champion and then it takes the team, obviously, to work with the champion perhaps is whoever that person could be.

And it doesn’t have to be a physician, although I think physicians knew do need to be engaged in all of this. But that was one thing that I watched be really successful in our institution. And then I think in institutions that habit, our research work, we just got to be great for the NIH to do a home high intensity mobility therapy program where we’re bringing our ICU physical therapists into the post hospital setting to coach so we give patients an iPhone and an iWatch.

And we do basically a Olympic style to Cpet testing like an Olympic athlete would have a VO2 test we have a Bluetooth mask we do in the hospital room with patients and we get their VO2 peak and tie that to heart rate. And we teach them to do intervals doing steps or other things. Then they go home and they do that for three months and they’re physically therapist from the MICU who cleared for them in the hospital, coaches them at home over the video.

And we have the heart rate recording on the watch. And then we titrate up and down their exercise mobility and strength. They do some balance and strength training too. But a lot of it’s as high intensity, heart rate, guarded titrated, to their ability, personally training that we did in the NHK was about a $4 million grant to do that. We’re working with Vanderbilt, and UAB and Ohio State to do that trial. And so I think if we can engage our physical therapists outside of even the ICU and create this continuity of care, I think that’s an exciting opportunity to to really improve upon what we’re doing in the ICU.

Kali Dayton 25:38
Oh, I love that. And that’s that’s your big focus, right? Building the bridge between the two worlds because you’ve lived both of them? Yes. And I loved what you said about the terminal life after the ICU by what we do the moment they come into the ICU as a survivor. What would that mean? What would that meant to you? Or maybe in these other hospitals, where you’ve been at? Had that approach been taken?

Dr. Paul Wischmeyer 26:02
Yeah, I mean, I think a real emphasis on the, sort of the, the things we know, create survivors of patients, right? Things that reduce delirium, and the focusing on mobility and getting out of the bed, even if it’s just to the chair, right? I mean, even just being in the chair, and that’s, I have to tell you, the whole time I was in the hospital, I spent probably more hours in the chair than I did in the bed. And I would consciously try to stay in the chair, even, even though I didn’t necessarily need to be, right?

Just there’s something about being out of that bed that I think is so important. It you know, and we can look at the medical reasons, right, it reduces blood clots, and it reduces pneumonia, and it strengthens your core muscles and improves your ability to deep breathe and to cough. But But I think, cognitively and mentally it’s huge to write it. It just It forces you to engage. And I think I think just really even working with the most challenging patients to get to bed just to get them into a chair is a huge step forward. And then clearly, I think we need to all be better at mobilizing people Vinod or not, to walk into and to get around.

And I think that’s going to take, you know, clearly we don’t have enough nurses or physical therapist, but it’s going to take more staff. I mean, I think that’s a really key part of what this is going to take and commitment to do that. And those are hard people to find right now after COVID. But, but I think, really emphasizing the other things like the nutrition, I think there’s a role for anabolic agents like testosterone, like Sandra and I was a burn intensive care physician for many years in both pediatric and adult settings before I came to Duke. And you know, in the burn world, where I really think critical cares is done amazingly well, they have incredible focus on physical therapy. But then as part of that, we often we give almost every patient that comes in Oxandrolone, which is anabolic agent, because we know that the anabolic hormone levels in our patients dropped to zero within three or four days of ICU admission.

And so if you were in a third world burn unit in India, or South Africa or, or anywhere in the world, you’d be getting this drug, this anabolic agent has been shown to reduce mortality, to reduce length of stay to improve healing. And we really like Oxandrolone, because it’s oral, and it doesn’t realize a woman or man can take it for long periods of time. But we don’t have that a dupe. But we I use regular testosterone quite frequently in patients. And I’ve had really good luck, especially in the quite elderly folks who really have for anabolic signaling, right, you can give them all nutrition and exercise you want. But if they don’t have a signal to create more muscle, if they have a lot of anabolic resistance very hard for them.

And I’ve had really good luck, especially in the 80s and 90 year olds, adding an IM testosterone shot every two weeks, I have to get it because my don’t reabsorb cholesterol. And so mine’s very low. But I just learned that about a year or two ago. And so that was another small difference right in the stay for me is I didn’t know my testosterone levels were low because of my underlying short gut. So I’ve been put back on that. And then I stayed on that. And I think it did help me recover. And I’ve definitely watched other patients who had help recover. And I think that’s the other three things, exercise, rehab, nutrition, and then anabolic signal isms patients who need them, I think is another chance we have because if these people were burned units, they would be standard of care, they’d all be getting them. You can’t even do studies in it. It’s so common in around the world, but it’s never really made in any other unit.

Kali Dayton 29:13
That’s really interesting. And I think culturally, we don’t really value the muscular system. We don’t talk about it, we don’t panic when it’s failing, we don’t preserve it. So what you’re describing is this deep, almost reverence for the role that the muscles play and surviving the ICU and then quality of life after and I’m just impressed by your own athleticism and your own focus and preparation for surgery by building up your muscles knowing that that was going to not just be about aesthetics or eat able to dance, lift your wife but for actual survival.

Dr. Paul Wischmeyer 29:46
It is you know, when we coach patients like we coached a lot of patients before big cancer before bone marrow transplant to it’s not just surgery, but before surgery before birth transplant. We say that you’re training for the marathon of your life. This is just like training for a marathon and you have to be ready and you have I have that mindset that I’m going to have to work just like I would work at, like, if I was gonna run a marathon, I’m gonna have to work at it, I’m going to train my nutrition is gonna have to be good, I’m gonna have to be persistent consistently exercise and all the other parts of my life. It’s the same, right?

And I think that is the message, we really need to be conveying to people that there’s so many things they can do before they undergo this big hit if they can anticipate it like transplants, whether they be your organ or bone marrow transplants, and just beta major surgeries. But in recovering from COVID, or critical illness when it’s not anticipated. It’s not so different, right? It’s there’s a training component to it. And we know there’s a growing body of data that shows that the muscle mass you go into the ICU with is highly predictive of your survival of the ICU independently of it just by itself, right?

So we measure muscle mass by ultrasound or CT scan. And we know that the muscle mass you go into a major operation with or cancer chemotherapy with is highly predictive of your survival and complication rate. So your muscles really your metabolic reserve to survive that injury to fuel your immune system to fight off infection, and to give you that chance to recover. And so we’re getting better at measuring muscle mass, there’s now single slice CTS 10 techniques, Harvard’s actually billing Medicare for them successfully, they have less radiation than the chest X ray and you can get muscle mass in about five seconds.

We do it by ultrasound, we have a muscle specific ultrasound called the muscle sound device that was built for athletes was built for tour de France, athletes and bikers. But we use it in the hospital all the time. And you can in a few minutes with a little pro. That’s about as big as your iPhone, it plugs into your iPhone, and it’s Ultra Pro that gives you really precise muscle measurements and can tell us if the patient’s eating. It tells us about muscle glycogen using an ultrasound technique. And so I think you’ll say the muscles really critical recovery and survival.

Kali Dayton 31:44
Do you use that technology to track muscular atrophy?

Dr. Paul Wischmeyer 31:48
Yes,

Kali Dayton 31:48
During critical illness that that’s incredible. I’m just wondering, you know, when patient comes in and shock for whatever reason, we are panicked about perfusion to the vital organs. Yep. But every patient that comes in, we should be panicked about feeding and utilizing them preserving the muscles in the same way making sure that that organ is preserved just like we do with the kidney and the liver and the brain. And we how do we make that shift? You’re doing so much to advocate and even provide the evidence behind it? How do we culturally make that shift? That’s the big question this podcast, repeatedly: the culture!

Dr. Paul Wischmeyer 32:25
I think promotion of the data that shows what a key role, say your existing muscle mass plays in a your risk of adverse consequences and survival and be in sort of key role and metabolic reserve is is one of the first steps I think a lot of people don’t know that’s true. You know, one of the interesting things is a lot of critical care physicians are now beginning to learn is I often ask my residents this, “What is the best BMI to be to survive critical illness, trauma, cancer, you know, like, what do you think the best BMI to be is?” And they often will say something in the 20s. Right?

But that’s not the answer, the answer is 31. And so the we know there’s a straight down line of survival increasing as BMI increases all the way up to 40. And ARDS and other lung injuries and critical illness as well. And mortality really jumps at BMI is below 25. So lots of very healthy fit, people having a mindset sit between 20 and 25. But what we’ve shown is, for every one point lower your BMI is and this was in the blue journal at one of the big kernelcare journals, you have a 7% decreased chance of recovering functional independence after ICU.

So, again, if you’re talking about a BMI difference of 10, that’s a 60, 70% difference in functional recovery from 30 to 20. And we have hints from some of our TPN studies that show that people with low BMI who don’t get TPN have much higher complication rates and potentially even mortality as well. So even BMI as of 20 to 24, that we sort of think of as a healthy number, those are not the best BMI is to be to survive Most illnesses and cancer. And that all comes back we think to muscle mass, right? BMI is a poor man surrogate for muscle mass. And so I think we could show if you’re have a BMI of 31, and you have very little muscle mass, you don’t do nearly as well as someone who has a BMI of 31 that has a very high muscle mass. And so it’s really your metabolic reserve that’s very predictive of not only your survival, but then your ability to function and recover as well.

Kali Dayton 34:19
Amazing. And now we have the data, we have the technology to track all of that, as well as make the actual changes in practice. We just have to bring it to the bedside. Right. Yeah. Any other recommendations you would make for the ICU community?

Dr. Paul Wischmeyer 34:35
Yeah, I mean, I think the other big change I’ve watched happen to Duke and I think a lot of us have pushed for this. And now it’s really catching on as we do start TPN and much sooner. Right? We have this really large body of data now. There’s been four large randomized trials and 1000s of ICU patients published in JAMA Lancet, New England journal that have shown that TPN is not associated with infection in any way, shape, or form and the new Aspen nutrition guidelines which are sort of the guidelines we use in the US in critical care They say it’s just a safe to start peeing early as it is to start eating early and they can be used interchangeably, which is a major course deviation from what most people were taught to pee and associate with infection, and you should not use it almost ever.

And, you know, that’s just not true anymore. And our guidelines reflect it. And even our data now is showing some of the last few studies have been done show significant reductions in infection when pain is given early, when penetration is given early. And so we have moved in our ICU we have some studies going on in this area. But we do a clinically to if if a person comes in with a major abdominal wound or abdominal trauma or a major abdominal surgery, especially open abdomens, we start keeping a 48 hours, whether they’re well nourished or not, are malnourished, because we’ve we’ve been able to shore dietitians out of it, they don’t get fed for a week. And by that time by a major physical injury like that is really going to put them to die.

And I was that person, right? I was that patient, where in the past it took, I could lose 20 kilos in 17 days, I have pictures of me from when I was sick. And to those 14, because I didn’t get enough nutrition early enough. We waited too long, we didn’t give enough. And so now I think the earlier use of TPN correctly by a knowledgeable dietitian or pharmacist can really be something that people could change right now in the ICU and really make some I think good inroads.

And then I think the additional metabolic cart, I think learning to use your occupational physical therapists to use those rubber bands, right? Those are bands that are like about $1 apiece, can do amazing things for for a the mood, but be the strength and recovery. And they can do it safely. They don’t stress to the incision, they don’t stress the patient, they can come in all different sizes. So I think there’s some really simple practical things that people can do that can make a huge difference. And then getting families back in the ICU, I think this, I hope we never go through.

And if we go through another pandemic, we never go through a pandemic where we keep the families out. And I know that there’s been a lot of backwards back and forth about oh, we don’t want the families to come in and spread infection or get infected, but patients need their families. I can’t stress that enough. And I think that’s I hope that message continues to be heard.

Kali Dayton 36:59
There is so much to dissect from the pandemic and how we’ve handled it and the outcomes. Families. Absolutely. And just speaking of nutrition, I’m thinking about what I was hearing from many teams saying that they weren’t really feeding their patients on high flow that we’re barely eating… any thoughts on that? How did you manage that? Because I, I know in that walking COVID ICU, we were doing feeding tubes on patients with high flows that weren’t eating, they were eating enough. And we were intervening. But many teams thought well, their swallows is intact, therefore they don’t need a feeding tube.

Dr. Paul Wischmeyer 37:34
Yeah, we actually just published some data around this, we use the Premier database, which for those who don’t know what that is, it’s a giant hospital databases, 900 hospitals, millions of patients, we were able to get 75 hospital cohort that contributed their COVID data. We found Twitter 265,000 COVID patients. And we found about 900 of them out there in the ICU on a ventilator. And we looked at because we’d heard that same story that even the ventilated patients because COVID infects the gut, right? There’s these as two receptors in the gut. And so COVID causes a lot of Gi problems. And so they’re really hard to feed.

And so we said, “Well, let’s see what’s actually happening in the US across hospitals.” And we found that about 40% of COVID patients on a ventilator, right? Who could have had a two done feeding them didn’t get fed till after day three. And the average time to feeding in those patients for TPN or enteral enteral nutrition was 10 days. So about half the COVID population across any given hospital in the US, if you extrapolate this out, isn’t being fed for 10 days at all. And so that includes enteral or TPN. And so I think that’s devastating. Right?

And that doesn’t include the high flow patients, I think what you describe is a really unique challenge, right? The patient on high flow who is too short of breath to eat, right? I mean, and that happened all the time, it’s still happening right now we have a lot of COVID patients right now like that we did put feeding tubes in those patients frequently. I think that is a really important intervention you can make for them, because it’s just eating as a lot of there’s a lot of work of breathing and eating.

And it’s very hard for these patients to do. I will also advocate that the thing to emphasize those patients is they need to be drinking oral intuition supplements, the high protein oral intrusion supplements to boost the insurance but low protein drinks. They have really robust data that they reduce mortality and improve outcomes and lots of studies. Now there’s like from the Premier database again, and there’s about a million and a half patients study that showed that just putting those on the trays of patients reduces length of stay 20% and saves every dollar you spend on those little drinks, saves $52 in hospital costs. So that the most cost effective intervention actually, that we’ve seen described in the literature, they’re better than the influenza vaccine, they’re better than aspirin. They’re better than all kinds of Preventive Medicine things, but very few people think they’re important to give and don’t.

I think the key message that I give patients is these drinks are not optional, and they’re not food. These are medicine. These are going to change your recovery and give you the chance to get better and keep you strong and keep your immune system fortified your immune system depends on amino acids to function. So I know you may not love the way they taste, but we don’t love the way cough medicine tasty there, but we take it. And so these are two or three of these a day is essential to your outcome and your survival. And so I, I talk about them as medicine. And I think that would, I think be a good step for anyone else who’s seeing patients. Those little high protein drinks are really critical to recovering. We have really robust clinical trial data, randomized clinical trial data, just show that.

Kali Dayton 40:23
I have learned so much by doing this podcast and I get little pings of guilt, and little moments and I was… when it comes to mobility…. that was the approach taken in that “Awake and Walking ICU” is: “mobility is life saving intervention, it’s not optional, it’s like refusing an antibiotic”…. But Never did I think about a boost being one of those.

Unknown Speaker 40:43
Those little boosts …. They are lifesavers. There was a large randomized trial that was done in 76 centers, where they gave them for 90 days after discharged from hospital. And it reduced mortality by half in the group that took them. And so I mean, really compelling randomized trial data. I mean, there’s been smaller trials have shown that but this was a large, almost 700 patient trial 76 centers across the US really compelling data for their benefit. So I can’t emphasize enough to people that little simple things like that huge difference in in what we can do for people and they’re inexpensive, they’re safe, they’re you know, all all the things sometimes pharmacology is not these, really check all the boxes.

Kali Dayton 41:24
Wow. And then just thinking when patients come into the ICU, there’s so much going on, we’re so pressured to start all these things quickly, the fluid, the antibiotics, that all them, test everything, but I guess Nutrition has to be right there along with it, the things that we’re grabbing right away, and which is such a change in perspective. But all of this requires a change. And I have to ask, just for my own curiosity, was there a change in the culture or the morale of your team with these mobility rounds?

Dr. Paul Wischmeyer 41:51
Yeah, so you know, it’s an ICU that I don’t work routinely. And so it’s been interesting to watch from afar, right? I work in the surgical ICU. And, you know, the medical ICU really started this in the midst of COVID. And it is neat to watch them I it you know, and and Dr. Gillstrap will will say, you know, I really it took some time, to convince people this idea that we could get these people out of bed on a ventilator, right? That was really scary for a group that had never done it before. And I think this is true in most ICUs around the country.

But soon what it became very motivating and like, people were proud, it was like a badge of honor, they could do it and, and that they could work as a team to make that happen. And they all became almost sort of begin to expect that it was going to happen where before it was like oh my god, I can’t believe that whatever happened. And then now it’s like when it’s not happening, “what’s wrong?”

And so it’s really led to a shift in thinking. And so we’re trying to find ways now in our surgical ICU, we don’t, we are attending switch a little more often. And all of us sort of are spread a little more thin. And Dan has made like we had one attending up there who made a real commitment to be there every day to do this. And so we’re trying to find ways across our group that’s maybe they’re sort of less less consistently, how can we work together to make this happen, because it’s been so successful, another one of our ICUs.

And so I think it really shows what it shows us though this can happen. And one person who puts a group of people motivated people together can make a change. And so I thought, you know, these these rehab rounds were were super successful, and we interact with them. For our study, too, they’re a great way for us to find out about patients who could be good candidates to go home and our exercise trials and, and so we interact with them a lot, it’s really pretty neat.

Kali Dayton 43:29
And you get to see the difference in outcomes that it really makes in the long run, which is what we don’t usually get to see in the ICU is what happens and how did our interventions make an impact, right? Other than you pretty quickly see the difference in outcomes as far as their discharge, disposition and length of stay and things like that their functional status, leaving the ICU. But that’s really neat that your PTs get to see how they’re doing after and what their lives are like, and then bring that back to the team, I think that would make such an impact in our perspective of our patients. And I I know that we’re burnt out we’re traumatized. People are leaving in masses.

Yeah, I have caught so many glimpses of hope through teams doing these changes. And I think this is part of our healing from the pandemic is to change our process of care and have a difference in our environment and our approach and really remember why we’re in critical care again, and as I’ve worked with teams and seeing them make those changes and hearing what they tell me about their morale and their fulfillment in the courier that’s exciting. And I think that’s what our clinicians deserve is to actually see patients get better and serve and succeed.

Dr. Paul Wischmeyer 44:39
I agree. I agree. It’s so critical. I mean, it’s so easy to get caught up in all the challenges of what we do every day. It’s it’s those are the moments I think that make it all worthwhile.

Kali Dayton 44:51
And change is hard, but someday this will be as routine as given an antibiotic, you know, talking to you about about nutrition, assessing for it mobility will seem like really big, extra laborious things. And we do need to have the right staff support. But I just think about how protein was so difficult and laborious at the beginning. It was daunting. It took nine people in the room, we had to think through every little twist and turn. Now they flipped them like pancakes is what I say, No, it’s a routine. And that’s what we’re going to fall into this routine of thinking about and acting on these elements of survivorship. So thank you so much for everything that you’ve shared. And I will put links to everything that you’ve shared, as well as your Instagram, because I think we have a lot more to learn from you.

Dr. Paul Wischmeyer 45:35
Yeah, if I can, if I can just leave you with one thought. Because it really is. The fundamental is not my medicines, just remember, there’s, there’s a there’s a patient laying there. And I think all of us as patients need to advocate for that. But all of us as providers do, too. And just if you can forbear me one story that really struck home for me and may make someone else reconsider how they act every day, when I was sick at the hospitals that before, at one point, the hospital I worked at for 15 years had surgery, much like this one this I had this year, this was a number of years ago, I had an epidural and, and in the bathroom, I had an ostomy.

And I was trying to change my ostomy. And I was bleeding. And I was naked. And I was in this little tiny bathroom and just almost in tears trying to struggle with my ostomy and my incision and everything. And the pain team came around to see me right. And there’s eight people on the pain team. There’s medical students and residents and nurses and different team members, many of whom I’ve known for, in this case, 15 years, these are people I’ve known, and I was a professor there as well and in their department. And they can knock on the door and they say, you know, we need to check on your epidural. Right? We need to check your back, it takes about 30 seconds to do and I said, “Could you guys come back later? I’m in the bathroom, and I’m naked, and I’m having all these issues…” and and they said, “Well, no, we have a lot to do today, we just will just come in anyway.”

And so they piled eight people into my little bathroom, just to touch my back for 30 seconds. Because they didn’t want to come back later. And these are all people I knew. And I’ll never forget, I’ve never felt more vulnerable and more violated in my whole life than I did then it was by people I knew. And thank my wife walked in moments later and threw them all out of the room and told them never ever to come back. And and we said to each other, we saidm “Wow, if this is how they treat the people they know, how are the people they don’t know getting treated?”

And so I think what they probably imagined was no big deal and was was was just part of the day, for me is one of the single most traumatic memories I’ve ever had of having all these people come in. And one of the more challenging moments that I’d ever faced, sort of which they didn’t know, of course, but the reality was, you know, all I asked them to do was come back later. And that was too much.

And so I just think, you know, when a patient says I need a minute or or, you know, when it seems like it’s a hassle for you to give a patient a break for what seems like something trivial, it often is not something trivial. And there’s a person in their suffering. And maybe they really just need a minute. And you know, I’ll never forget that moment. And I think it really spoke to me that it makes all of us have to look at what we do every day. And remember, there’s a person in there who’s suffering and sometimes they deserve us to give them a minute.

Kali Dayton 48:19
Wow, thank you for sharing such a vulnerable moment. And again, another pang of guilt because I’ve easily fallen into the conveyor belts routine of patient care. And I think especially when we have a sedation, deep sedation and mobility culture, you don’t look in a patient’s eyes, you don’t hear their voice. You don’t know who they are. It’s so easy to treat them like they’re a product and a conveyor belt.

Dr. Paul Wischmeyer 48:48
No, they’re not a box to be checked.

Kali Dayton 48:51
And you coined the phrase, “Create survivors, not victims”.

Dr. Paul Wischmeyer 48:55
Yeah.

Kali Dayton 48:56
And I just think that is such a huge part of humanizing the ICU is seeing them as a person listening to what they say, their requests, understanding their personal experience in that moment. Thank you so much for giving that perspective.

Dr. Paul Wischmeyer 49:09
Yeah, I just I always hope that, especially for the folks that medical students, the young nurses, the young clinicians, you know, it’s sometimes seems trivial to us, but it’s it’s definitely not trivial to to the patient and for those of us laying in the bed.

Kali Dayton 49:27
No, and I’m hoping the next generation brings in this change, this touch, they’re coming in with new energy and help they can help preserve that kind of compassion in the ICU.

Dr. Paul Wischmeyer 49:38
And on the flip side, I have to say I’ve never received such amazing care as the Duke surgical ICU nurses gave me as one of their own right it’s tough to take care of your attending ,I think, and, and someone that you’ve worked with every day for years and they were unbelievable. The best care we’ve ever gotten. So I mean, clearly, it can be that good as well. And even in the midst of the pandemic, and And so the burnout that’s caused I watched a team of nurses care for me in a way that was unbelievable. So it can go both ways.

Kali Dayton 50:08
Now, these teams are absolutely resilient. And they’re there for the right reasons. And I’m so grateful for everyone that’s out there. Giving themselves not just their time, their talents, but just giving them their their heart like when you’re burnt out. That’s the last thing you have left. But they continue to give it and I think that’s why they stay.

Dr. Paul Wischmeyer 50:28
Yeah.

Kali Dayton 50:29
Thank you so, so much, Dr. Wish Meyer and we’re going to stay in touch and stay in tune for everything else that’s coming. Thanks so much.

Dr. Paul Wischmeyer 50:36
Definitely. Thank you.

Transcribed by https://otter.ai

References

Earlier TPN Use:

Gao X, Liu Y, Zhang L, et al. Effect of Early vs Late Supplemental Parenteral Nutrition in Patients Undergoing Abdominal Surgery: A Randomized Clinical Trial. JAMA Surg.2022;157(5):384–393. doi:10.1001/jamasurg.2022.0269- link: https://jamanetwork.com/journals/jamasurgery/fullarticle/2790269

Harvey – NEJM Calories TPN Trial: https://www.nejm.org/doi/full/10.1056/NEJMoa1409860

Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, Costanza MC, Thibault R, Pichard C. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet. 2013 Feb 2;381(9864):385-93. doi: 10.1016/S0140-6736(12)61351-8. Epub 2012 Dec 3. PMID: 23218813. Link: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)61351-8/fulltext

Doig GS, Simpson F, Sweetman EA, Finfer SR, Cooper DJ, Heighes PT, Davies AR, O’Leary M, Solano T, Peake S; Early PN Investigators of the ANZICS Clinical Trials Group. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA. 2013 May 22;309(20):2130-8. doi: 10.1001/jama.2013.5124. PMID: 23689848. Link: https://jamanetwork.com/journals/jama/fullarticle/1689534

NUTRIREA-2 TPN trial: https://www.thelancet.com/article/S0140-6736(17)32146-3/fulltext

New Metabolic Cart Use:

Energy delivery guided by indirect calorimetry in critically ill patients: a systematic review and meta-analysis Link: https://ccforum.biomedcentral.com/articles/10.1186/s13054-021-03508-6

New Metabolic Cart Validation paper- link file: Oshima-2020-The-clinical-evaluation-of-the-new–1

Review article on Metabolic Cart I authored #1- Point-Counterpoint: Indirect Calorimetry Is Essential for Optimal Nutrition Therapy in the Intensive Care Unit: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8276639/

Review article on Metabolic Cart I authored #2- Indirect calorimetry in critical illness: a new standard of care? Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8367824/

COVID-19 Metabolic Cart Nutrition Care Data: Prolonged progressive hypermetabolism during COVID-19 hospitalization undetected by common predictive energy equations : Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8328525/

COVID-19 Metabolic Cart Nutrition Care Data: Persistent hypermetabolism and longitudinal energy expenditure in critically ill patients with COVID-19 Link: https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03286-7

ICU Nutrition Basics:

Nutrition therapy and critical illness: practical guidance for the ICU, post-ICU, and long-term convalescence phases: Link: https://ccforum.biomedcentral.com/articles/10.1186/s13054-019-2657-5

A guide to enteral nutrition in intensive care units: 10 expert tips for the daily practice : Link: https://ccforum.biomedcentral.com/articles/10.1186/s13054-021-03847-4