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For decades we have sedated patients with the belief that it is more humane to “sleep” through critical illness. Survivors have told us their experiences were not “sleep” to them. What do neurologists and researchers say about the quantity and quality of sleep during medically-induced comas? Dr. Williams Roberson shares with us her research and invaluable insights into sedation and sleep.

 

Episode Transcription

Kali Dayton 0:29
Okay, so I continue to see statements such as quote, “If I’m ever on a ventilator, you’d better knock me out.” But after hearing from survivors in Episode 4,52, 53, and 54, we know by now, that prolonged deep sedation is not simply being knocked out, but is being locked into a psychotic spiral of terror.

Yet in our discussions, we are still habitually using the word “sleep” in reference to being in a medically-induced coma. Researchers and neurologists have a very different take on how much sleep is truly occurring during sedation. Dr. Williams Robertson joins us today to share her research and invaluable knowledge about the reality of sleep and sedation. Dr. Williams Roberson, thank you so much for joining us. Can you tell us about your professional background?

Dr. Williams Robertson 1:23
Oh, sure, certainly. So I am a neurologist by training and my subspecialty training is is in epilepsy. So I’m an epileptologist, which which actually also gives me training and expertise in what’s called Clinical Neurophysiology, which is the study of brainwaves and particularly using EEG electroencephalography, to understand different I guess, the brain activity patterns. And that’s what the expertise that I bring one of the expertise that I that I bring to the to the study of delirium.

I’m really interested in the study of brain activity patterns, particularly in the ICU, and critically ill patients, and how those translate to to cognitive disturbances in the long run outside of the ICU. My background includes a number of other things, I actually did my undergraduate training in electrical engineering and computer science and worked in software development for a bunch of years before going into medicine. So that actually was a big transition. But it has allowed me to use some of my sort of technical knowledge and training to towards the the study of the EEG, brain activity as well in the context of signal processing methods and whatnot.

Kali Dayton 2:40
Oh, that is so neat. Because it from the ICU perspective, we’re treating these patients and they are either trying to climb out of bed, they’re going nuts, right? Or they’re hardly responding to us, especially in the context of delirium.

Dr. Williams Robertson 2:56
Correct.

Kali Dayton 2:56
And you are the one that comes in and dissects what is going on in the brain and, and then to have the perspective of how that impacts our long term outcomes for the rest of their lives. You are exactly who we need on this podcast. I’m so excited. So can you tell us what is happening as far as what we know what is happening during delirium? And why that is so impactful to the long term outcomes?

Dr. Williams Robertson 3:24
Very good… That’s a very good question. So in all honesty, we don’t know a lot but I can tell you what, what we hypothesize and what little bits we know. So as you’re aware, delirium is a is a syndrome of inattention, fluctuating levels of arousal, confusion, and disordered thinking. And, and these are reflective of dysfunction in brain activity patterns throughout different sort of areas and networks in the brain.

There are particular areas in the brain that are particularly responsible for arousal, maintenance of arousal, and normal sort of fluctuations in the level of arousal, such as during sleep and wakefulness, and for example, the reticular activating system and ascending, I guess, connections between that in the cortex of the brain, and that is most certainly dysregulated during during delirium, particularly delirium with hypo or hyperactive manifestations. There’s also a so the question of the confusion for example, or the inattention is a little bit harder to piece apart.

There are probably I guess, this there’s probably dysfunction in sort of sensory motor integration and sort of the the the areas of the brain in the parietal cortex that are responsible for sensory integration that may play a role and may actually be mediators of, of what some people experienced during delirium, which are parents, you know, holistic The nation’s or delusions, perhaps because of you know, sensations that they’re actually or sensory inputs that they’re actually receiving that they’re misinterpreting, if you will there overall, it’s very likely that a widespread network of areas of the brain are impacted by by whatever is causing the delirium.

And I specifically say whatever is causing the learning, because since the learning is such a heterogeneous, or I guess, I would say diverse type of entity that can present in a number of different ways, it is quite possible that or it’s quite likely that delirium is actually caused by several different things, or can be brought on by several different things, and has different mechanisms for each of those things by which it causes disordered activity,

Kali Dayton 5:51
Once the brain has been injured by delirium. What happens afterward? And what do you see in the neurology side?

Dr. Williams Robertson 6:00
Yes, so very good. So in terms of the transition to sort of long term outcomes, we really don’t understand very well, why delirium seems to predispose to, to cognitive dysfunction, and even potentially psychological dysfunction. In the long run, we see a couple of different patterns or trajectories, there are folks who experience delirium during their critical illness, they recover fine, and then they, you know, proceed through the rest of their lives without much on a way of cognitive dysfunction, then there are a number of folks who experience critical illness experienced delirium as part of that critical illness.

And definitely have sort of a decline in their cognitive function over the course of time. And certainly delirium certainly does increase the risk of that decline in cognitive function over over the course of time, we postulate that some of the disruptions in network connectivity. That’s basically where I would say that some of the disruptions of network connectivity that are, that are manifestations of the learning are likely responsible for the the difficulties that people experience in the long run, that perhaps these these disruptions, do not actually end up sort of write reregulating themselves in the same way as they would have normally.

But that is really just a postulate at this stage, there needs to be future studies that actually sort of understand what the what the trajectory, if you will, of the brain activity patterns are, that’s actually so one of the studies that I mentioned to you before, but one of the studies that I had worked on was an attempt to look at the brain activity patterns during the EEG sorry, during the inpatient stay, and try to correlate those brain activity patterns with cognitive patterns of cognitive function in, you know, at the time of long term outcomes.

And we were able to identify that in a small, you know, in a small set of patients for whom we actually had these data available, we could see very clear associations between the, the sort of frequencies at which the EEG activity oscillates, which is kind of a sign of, of cognitive function during either an inpatient stay, and visual spatial or constructional function at long term outcomes, even at 12 months out from from ICS day, we also saw, as I mentioned, functional connectivity, so sort of the the degree to which EEG signals from different sides of the brain actually seem to, you know, oscillate together, and therefore, potentially, you have evidence and working together, those were actually sort of negatively correlated with memory scores, and long term at the long term outcome.

And also, the degree to which a person was able to sort of vary their levels of what I would call delta oscillation. So fluctuations in in the activity patterns in in kind of a slow frequency ranges, those were also correlated with long term outcomes in terms of delayed memory scores. So those are very, I probably was overly complicated and overly technical in terms of those those findings. I guess the Gestalt is to understand that, even though this was a very small series of patients for whom we had this information, it pointed to an idea that we might be able to identify specific patterns of brain activity that are occurring during inpatient stay during, you know, during, potentially during during delirium, and kind of use those to predict what’s going to happen in the long run in terms of you know.

Different types of different patterns of cognitive deficits, more work has to be done, because these were very small numbers of patients. And so we’ll be launching additional studies to kind of to look at that in more detail and see if we can’t sort of figure out who is going to have problems and what kinds of problems they’re going to have. And therefore, what kinds of things we can do for them in the, you know, in the short term, or in the intermediate term to kind of help them avoid developing some of these problems.

Kali Dayton 10:29
That would be a huge development, because I’m hearing from the survivors that most if not all of them are vastly underprepared for the future ahead of them. Yeah, I am watching them talk amongst themselves saying, “I had this bad infection. And I was in ICU for a while, but now my memory is gone. I can’t focus. I am emotionally labile. And they have no idea why.” But they find constellation within themselves with each other, that they’re not the only ones going through that, but they were completely unaware that that would be a thing later on.

Dr. Williams Robertson 11:03
Yes, yeah, I have become increasingly aware, it’s very interesting. Because when I was originally trained in neurology, we would see some of these patients come to us and say, hey, you know, either they or their family members would say, hey, you know, she’s, she’s not the same as she was before the illness? And our answer was, yeah, well, she was probably, you know, had some sort of underlying problem that was predisposing her to have a cognitive decline. And now she’s had a cognitive, and, you know, there’s, it’s, it’s unfortunate, but there’s not really anything that we can do about it. And I’m excited for the future of the pop of the possibilities of being able to say, Hey, first of all, we recognize that this is a thing. And be yes, we do have something that we can potentially offer to say, hey, let’s try to either head this, first of all, try to head this off. And and secondly, you know, try to understand it better, and potentially treat it even even longer, later stages. That would be fantastic.

Kali Dayton 12:07
And your research gives us so much more reason to, like you said, headed off to prevent it. What are some of the main contributors of delirium in the ICU that you’ve observed?

Dr. Williams Robertson 12:18
yeah. So So first off, you know, people who it is true that people who come into the ICU or or, you know, initially have their critical illness and have an underlying, you know, sort of predisposing factor to delirium are, are at higher risk. So if they have underlying dementia, or, you know, cardiovascular risk factors, or, you know, for some folks smoking or other other sort of things that predispose them to worse brain health, if you will, just coming into their critical illness, then they’re at higher risk of delirium. And then, but then there are things that actually happen in the ICU, right?

So sepsis are this, you know, sort of diffuse infection and inflammatory response of the body certainly, certainly is another hits, if you will, that kind of can sort of take the brain down, and make it more likely for someone to develop delirium. And then there’s things that we actually do to them, unfortunately. So So in an attempt to keep patients comfortable, particularly if they’re on you know, on mechanical ventilation, and to also make sure that they are tolerating them with their mechanical ventilation, okay, we often use sedatives, but but we have been able to establish well that sedatives certainly seem to increase the risk of delirium in the ICU.

And so it’s important to use them judiciously, you know, humanely but also give patients an opportunity to show that they are awake, and they are, you know, that we’re not overusing the sedatives, for example, they are and perhaps that they don’t even need to be on on mechanical ventilation anymore. We call those daily spontaneous awakening trials and spontaneous breathing trials. So we really recommend that patients be evaluated for these on a on a regular basis, at least. Then there’s things other things that can happen an ICU now by its very nature ICU, as you well know, ICU care means that the patient needs almost continuous nursing care that someone needs to be checking on this patient and making sure that they are okay that they’re breathing, okay, that their ventilator is working, working, that they’re getting their medications, etc, etc, almost on an hourly basis.

And but that can be extraordinarily disruptive, for example, to sleep and to just especially to sleep and to their just general orientation. And so sleep disruption is a huge, huge risk factor for delirium in the ICU, and it’s something that’s very difficult to control. There are another a number of other things mechanical ventilation itself and sort of the constant stimulation in association with ventilation can be a risk factor. And then and then there’s things like disorientation just in terms of being unaware of patients kind of being unaware of where they are and what’s going on with them. And so constant reassurance and family engagement and, you know, constant reorientation is very helpful in that regard.

So there’s a number of there’s a number of things that we need to look into. There’s also for example, pain, pain is a huge issue in the ICU, assessment of pain and effective management of pain, without again, going overboard in terms of the the opioids and sedatives that we use to manage pain, pain, and anxiety for that matter is, is our crucial component of reducing risk of delirium, and reducing risk of long term brain dysfunction.

Kali Dayton 15:53
God, it’s so hard to find, find balance, and all of that, and I think for so long, for example, with sleep, we have thought that sedation was sleep, which I’m sure is the neurologist that makes you cringe, can you tell us about how close the sedation to sleep and what actually happens when people are lying there with a sheet with their sheets tucked in, and looking so still and calm. What’s really going on in the brain?

Dr. Williams Robertson 16:17
Laying there quietly, they could potentially be absolutely asleep. The likelihood, particularly in the ICU, and particularly if they’re on intravenous sedatives, is not that they’re asleep. Depending on the sedative, if the sedative is causing them to be quiet, and sedate, it is not as near as we can tell, almost almost nothing like sleep, if you will.

Sleep from a physiologic perspective, if you sort of examine the brain activity that’s happening during sleep is associated with very clear patterns in the in the brainwaves in the EEG, that that show sort of fluctuations in brain activity, both at the, you know, at the moment to moment level, sort of, you know, in less than a second, and also from second to second, as well as from sort of, you know, minute to minute, if you will.

Typically there are you know, when I’m reading an EEG and I see that a patient is having sleep, there will be sleep architecture, such as sleep spindles, and K complexes, that indicates stage two sleep and or there may be say vertex waves that are more prominent, sort of more prominently seen in the central parts of the head, that indicate stage one sleep or you know. Rarely in the ICU, you can also see sort of stage three sleep or even REM sleep, these things change in normal sleep, these things change over the course of time. So over the course of a night, if you speak to a sleep specialist, they’ll be able to to describe specific, you know, sort of patterns of sleep, architecture changing from different stages of sleep over the course of the night.

When someone is a sedated if they’re, you know, quiet because of you know, a continuous infusion of propofol, for example. There is there’s no there’s nothing of that same architecture there. You don’t see sleep spindles, you don’t see K complexes, you don’t see slow wave activity, you just see this kind of this kind of continuous, nonspecific I guess it is slow wave activity, but I would say not in the same pattern as when you expect them. And you don’t see fluctuations between stages of sleep in the same way that normal sleep architecture is that same thing applies to dexmedetomidine, which is another very commonly used anesthetic agents that have invaded patron in the ICU.

Although with one caveat, I will say that with dexmedetomidine, is the physiologic patterns that you see with dexmedetomidine often include structures that look very much like sleep spindles, and but they’re happening much more frequently than your your typical normal sleep patterns. And they’re not associated with the other types of sleep architecture. So while these medications could, in very low doses, potentially help folks with with normal sleep. You know, high doses that we typically give to kind of keep them sedated for mechanical ventilation purposes do not generate normal sleep.

The other thing is we can go even to even higher doses that also keep a person very calm and quiet, especially if they’re on the capital ventilation. And that is a scenario that’s more analogous to coma than it is to sleep. We can certainly induced coma with these medications. And by coma, what I mean is a state of an arousal or unresponsiveness So a state wherein if you were to go and kind of shake them, you know, they wouldn’t, they wouldn’t arouse, they wouldn’t kind of move or stir anything.

And that that is something that is even typically manifest with even, you know, another sort of pattern in the brain activity recordings where it’s either extremely flat, like there’s very few voltages that are that are being generated, or it’s in a pattern called bursts suppression, which is it’s, you know, it’d be very flat for a little while, and then there’ll be a burst of activity, and then it’ll be flat for a while, and there’ll be another person activity.

And that’s suggestive of very, you know, pretty deep coma, such as what we would normally potentially see in high dose anesthesia and in you know, insert in search for an operating room, or in cases where, say a person was in Status Epilepticus because they’d had continuous seizures, and we intentionally to put them into a coma. caveat about the operation, operating room, I should say, most anesthesiologists will agree at this stage that even first suppression in the operating room is not desirable. It’s typically not what their target is, they want to keep someone very, very sedated, but not as far as.

Kali Dayton 21:19
And as far as impacting outcomes in a surgical setting. They’re sedated for hours. Right? So that’s why it doesn’t have the same severity of delirium or the injury to the brain long term outcomes. And it almost hurts my soul to hear you talk about how they are not sleeping, because I’m imagining this happening for days to weeks, our COVID patients are being sedated for I’m seeing reports of like 60 days, people are talking about their loved ones being in comas for 60 days. How do we go without sleep? For days, two weeks, two months? How does the brain even begin to recover? How do we expect brains to be remotely functional, if we’ve deprived them of sleep for that long?

Dr. Williams Robertson 22:15
So these are very important questions that are you know, that we’re only scratching the surface of understanding. It is important to acknowledge, though that sleep is definitely restorative there’s, there’s a body of literature that as is exploring what what happens during sleep, and how that that those, those physiologic patterns during sleep activity patterns during sleep seem to correlate with, you know, re regenerating brain function, if you will. We don’t know what the physiologic patterns that are induced by sedation.

For example, are doing to the brain, we don’t know if they are allowing, you know, sort of this sort of same restorative brain function or not, my suspicion is not but but that remains yet to be seen. The other thing is that folks who are, you know, who are on heavy high dose sedation for days and weeks on end do not necessarily have the same sort of wakefulness, you know, sort of physiology and physiologic needs. So, so it’s hard to know what their or I guess I would say physiologic activity, so it’s hard to know what their sort of regenerate needs are.

Now, again, my suspicion is that with the with the high dose, sedatives kind of really sort of suppressing their brain activity, during, you know, during what would normally be sleeping, sleep. And during what would normally be wakefulness, there is, you know, that is overall doing damage, sort of net, a net deficit, if you will. But it’s, that’s yet to be proven, it’s yet to be, and it’s something that really needs to be understood in the future.

Kali Dayton 24:04
And I think we almost failed to acknowledge that the brain is an organ, as we’re taking care of these patients, we, you don’t have lab values for brain.

Dr. Williams Robertson 24:14
Yeah.

Kali Dayton 24:14
And so we’re very protective of the kidneys, of the liver. And we can see ventilator settings for the lungs, and we can try to protect those organs and treat them and we can see when they’re getting better. So we focus on all of that, and we seem to disregard the brain. And then after we’ve turned off the brain or neglected it for so long, for weeks, and everything else is better.

We’ve been out the door and we think we’ve done a good job and maybe weeks later the patient can say, Okay, I know I was in the ICU, I know where I’m at. I know who the president is. But then they’re having depression, anxiety, memory loss, this post dementia, post ICU dementia that your team is exploring. What kind of therapies can be done is there rehabilitation that can be done. I know this is all so new. But how many of these patients recover? Or do we know yet?

Dr. Williams Robertson 25:08
So we are actually actively studying these things. There’s increased interest and attention paid to the necessity for post ICU recovery centers. So we actually have a post ICU clinic here at Vanderbilt, that’s headed by Dr. Carlos even. And Dr. Jim Jackson, my colleagues, and these are Yeah, these are definitely things that need to be addressed. The I think that patients seem to get a lot of benefit from the post ICU support groups that that we run here at Vanderbilt, and that are being run in various places around the country.

And and we need to understand better who is at risk for you know, the more long term psychological and, and cognitive deficits, I suspect that there’s a number of patients. And there may be there are some hypotheses that that, you know, the mechanisms in patients who are saying younger than Let’s give an arbitrary number of 50 or 60 years old may be different than the mechanisms and those of us as we get further along in life, just because our brain physiology is a little bit different.

Kali Dayton 26:22
So what does this all mean for COVID? Now we’re having patients on prolonged mechanical ventilation in the masses. And we already talked to Dr. Wes Ely about how everything or how all the benzodiazepines are being used. Even more generously, patients are even more heavily sedated. So from your perspective, as a neurologist, what, what are your thoughts on the future of these COVID-19? Survivors?

Dr. Williams Robertson 26:50
Yes, so I think that, you know, just like everything, we need to understand that the processes more, definitely the COVID-19 survivors have an increased risk of many of these problems, both from, you know, cognitive perspective, and from a psychological perspective, not only because of their prolonged, you know, a number of those who’ve been in the ICU with prolonged mechanical ventilation requirements, but also, because even when they come out, they’re still feeling extraordinarily ill and weak, and they have very prolonged recovery from a physical standpoint, which impacts the, you know, the mental health and a person’s outlook on life.

And then so much attention gets focused in on the physical, because, as you mentioned, the the, you know, we have measurements of sort of organ dysfunction for the lungs, and for the kidneys and whatnot. But our measurements for brain dysfunction are largely based on sort of, you know, cognitive evaluation or interaction. And if you can, you know, wave and say hi to somebody, and they can wave and say hi to you, you’re thinking, hey, they must, you know, everything, you’re not even thinking that there might be a problem. And yet, and yet there is there’s almost certainly a problem, but But it’s hard to put our fingers on our for for them.

So, yes, especially in the context of the COVID, long hauls syndrome. And Frank, frankly, in the context of a all of the uncertainty globally, that has been generated by this, you know, onslaught of this, this global pandemic really sort of puts COVID-19 survivors at risk for some of these, some of these cognitive and psychological problems that we’ve seen across the board in ICU patients and ICU survivors who recover from other critical illnesses.

Kali Dayton 28:44
So the neurologist, what would you tell the ICU community? Or what would you ask of us as we treat any patient on mechanical ventilation and especially these COVID-19 patients?

Dr. Williams Robertson 28:56
Yeah. So there’s, there’s a couple of things that I would love to see. Number one is just a call to you know, remember the fundamentals. Remember to do the, you know, protocolized, spontaneous awakening trial, spontaneous breathing trials, as you know, when it’s safe, get the patient off the ventilator, get them off of sedation, make sure that they’re not on, you know, over, you know, too much sedation, these kinds of things.

Remember, to assess the patient on a regular basis to to make sure that they, you know, are oriented that they know, you know how to how to reach you in case they do have pain, that their pain is well controlled and that they’re they’re aware of, you know, family, you know, family interactions, etc. And then the other thing so, these are things to kind of limit the the risk of delirium in addition to trying to sort of encourage good sleep wake cycles and and important periods of time where the patient can be undisturbed and sleeping.

The other thing that I would say is when you’re discharging patients, so a lot of times folks in the ICU will discharge patients to the floors, and then it’s the floors that will discharge patients to home or to rehab or what have you. And so it’s important even at this stage of the ICU, I think, to foresee that this patient is eventually going to be discharged from the hospital and already sort of put into, you know, put into the notes in terms of transfer, transfer planning, “hey, this patient was in the ICU and was on mechanical ventilation and high-dose sedation for days or weeks and the course was complicated by delirium. Discharge needs need to be anticipated, which would include, you know, assessment for, you know, for cognitive dysfunction, psychological dysfunction and potentially referral to post ICU care and or, you know, psychological or neurocognitive evaluation for, for potential cognitive rehab therapies.”

Kali Dayton 31:04
Yeah, someone’s leaving the hospital with some altered kidney function, they’re gonna follow up with the neurologist or at least their PCP yet patients are leaving all the time in active delirium, still, long term care facilities, rehab facility sniffs we’re talking about patients coming to them still delirious. Or, like you say they’re able to wave maybe see where they’re at. And so we think that they’re fine. was a lot of our patients that have been on mechanical ventilation for a long time.

Whether or not there were sedated, which is usually not, not in the “Awake and Walking ICU”, they will do a MOCHA score, and then we have speech therapy come in and evaluate their cognition. Parrtially out of our own curiosity, we like to see that they’re scoring 28 out of 30 after weeks on the ventilator. But also it is important to do a more thorough evaluation. So how would you recommend that aspect of protocolized? How do you encourage facilities to do that more thorough investigation to make sure that these aren’t falling through the cracks?

Dr. Williams Robertson 32:02
Oh, excellent point. So I think I think you hit the nail on the head, right? Which is to deploy effective screening tools for exactly that. A MOCHA or a mini mental state examination, you know, add follow up a one month follow up, for example, in you know, in a post ICU clinic, a Beck Depression Inventory or, or an Anxiety Inventory, or, you know, or or a post traumatic stress. I should not say “or”, I should say, “AND” post traumatic stress inventory.

These things can be very simple. They can be, you know, five questions, eight questions, but can can, you know, give you hints or clues as screening tools to to whether someone needs further evaluation. And they’re very, you know, straightforward to implement, and can can do a world of good for patients and for their families, in terms of in terms of setting expectations.

And that’s the other thing that I would say, is to set expectations for folks. As they’re they’re leaving ICU, and as they’re being discharged home or to rehab, to say, “Yes, you may experience some, you know, some cognitive problems, and some, and even perhaps some emotional problems, please don’t hesitate to raise these concerns, because there are things that we can envision in terms of rehabilitative therapies.” To be honest, we don’t have all the answers about how to how to treat them most effectively. But we have, you know, we have some pretty good ideas, and at the very least, we should, we should be offering our, our best, you know, our best available options.

Kali Dayton 33:38
And even seems like the validation to, for patients to feel like they’re not crazy, that this is not something totally unexpected. That alone is very comforting for survivors, whereas a lot of survivors are going to their PCPs. And trying to say, here’s what happened in the hospital, and now I’m having all these weird symptoms, and they kind of shrug it off, because there’s so little education, even in the primary care world, about what has happened in the ICU and these new syndromes that we’re diagnosing. And so I love that this post ICU clinic, and I think there’s such a need to disseminate the knowledge that you are developing your research.

Dr. Williams Robertson 34:19
I would completely agree the especially, you know, at, say the primary care doctors level because not everybody is you know, at this stage, we Yes, we have post ICU clinics, here in a few places across the country, but it’s certainly not available to everyone. And so, you know, primary care doctors with as much burden as they have already need to be at least made aware of these things.

And I think that as they you know, as awareness builds and as awareness of potential interventions build more, more folks will be be equipped to at least address this as an entity that actually exists and like us thing I think that’s that right? There tends to be very therapeutic, at least to the survivors that I’ve spoken to, but then, you know, then take the next step to say, Okay, well, how can we, how can we address this, one of the things that is very important to us, and in our here in the CIB center, is just also understanding kind of what is the natural history? And, you know, how, what are people going, you know, what are people to expect over the long run. And that’s, you know, the subject of a number of our studies to try to figure that out. And I think that that would be very helpful for for folks,

Kali Dayton 35:34
I think we’re all waiting with bated breath on what your research shows. And we’re so grateful for what you have done and revealed thus far. Thank you for coming on and teaching us so much. I hope that the listeners really internalize the impact of what you’ve said. And I just implore the critical care community to take brains into consideration as we continue our protocols, and hopefully we elevate our care to protect brains.

Dr. Williams Robertson 36:02
Yes, I think that’s extraordinarily important. I think that it does a huge benefit to our patients because, you know, our, our brains to a large extent, our you know, make up who we are our identities ourselves and and, you know, protecting them is is extraordinarily important to me and to you know, a number of most of the people that I know thank you very much for for pioneering this with your podcasts and the other work that you do. It’s a pleasure to be here.

Transcribed by https://otter.ai

 

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