Hello everyone, my name is Megan Lanefall. I am the David E. Longnecker Associate Professor and Vice Chair of Inclusion, Diversity, and Equity of Anesthesiology and Critical Care at the University of Pennsylvania. I'm delighted to be the moderator for this SCCM Luminary Lecture. I have two amazing co-chairs for the SCCM Congress with me, Beth Taylor and Lillian Emlett, who are going to introduce themselves. So I'll start off with Beth. Can you tell us a little bit about you? Sure, I'd be happy to. So I'm Beth Taylor and I'm one of the co-chairs for the Congress this year. My other hat is that I work as a research scientist at Barnes-Jewish Hospital in St. Louis, Missouri. And my third hat is I'm a nutrition support specialist, so I'm coming at it from a dietician point of view. Thanks so much, Beth. We all have a bunch of hats. We need some more heads to wear them. Lillian? My name is Lillian Emlett. I am Associate Program Director for the IAMS SCCM Training Program at the Multidisciplinary Critical Care Training Program at University of Pittsburgh Medical Center. I'm also a simulationist, which means I teach mostly with simulation. And I like to teach communication skills and airway management skills. Great. So thank you both for joining. The purpose of the Luminary Lounge is to have a chat about what it's like to have a career in critical care, which I think we can all relate to. I have a series of questions that I'll pitch back and forth to you all, but I'll be monitoring the chat as well for questions from the audience. So if any of the audience members have questions, feel free to type them in. There should also be a way for you to vote for the questions so that the questions that get the most votes sort of float to the top. So if you see one you like, go ahead and vote for it. I'm going to start off with sort of a broad question about how do you set about finding your life's work? As we think about careers in critical care, we come from different backgrounds. We sort of decide which ways our careers go. And how do you think about, especially for folks that are just getting started, how do you set about finding what your niche is going to be? Why don't I start with Lily? So I have to admit, for me personally, it ended up being that someone made the recommendation that education might be a way to go for me. I think it does matter that those around you sponsor and mentor you and sort of tap you to say you might want to go in that direction. It might be just as simple as that. And once I started my master's in medical education and started taking on simulation simply because it was clearly an area where I knew something already about, it dovetailed pretty easily. I just kind of wanted to fix it. I just wanted to fix the curriculum. I fell into it. And then from there the rest is sort of history as you sort of learn and grow and find a different fork in the road. Those roads will come to you whether you sort of like it or not. You mentioned that you got a master's. Can you talk a little bit about the decision to do that? Because you know we all come to this profession with a lot of training. Oftentimes people ask me well how do I decide if I want to get yet another degree or another credential? How do you sort of weigh the pros and cons of that? I mean so even 15 years ago it was pretty evident that for people who want to do medical education leadership and or sort of education with a capital E rather than like a lowercase e. I mean lowercase e just means you know normal bedside teaching. But capital E meaning scholarship, programs, leadership, administration. Those required a little bit more deeper dive into theory, management, planning and research. So getting the master's seemed just sort of normal at that time. Although honestly it was really a minority amount of people who actually went into it. Now as you probably can see there's tons of programs online, virtual, hybrid, in-person that can actually work out. And Beth how about you? You talked about the hats that you wear. I don't know if you started off with that plan but but how do you think about creating a niche? Well I think it's probably similar for any profession. Obviously as I went you know from as a dietician. But you start out more general and kind of experience different things. And I did that. I worked in many several areas of the hospital. But then I got into critical care. And it's like within a year I knew I'd found the place where I wanted to belong. Where I really enjoyed the work, the challenges, the changes. Because we all know that care of these patients can change from minute to minute. It probably didn't hurt me that I had two great mentors. So when I entered the surgical intensive care unit where I worked for about 20 years at Barnes-Jewish Hospital. I came in under the direction of Tim Buckman and Craig Coopersmith. So with those great mentors and really taught me to think outside the box. So I think Lillian brought up a really good point. It's where you feel that mentoring. And where people encourage you to go beyond what you thought your normal boundaries were before. And so that's how I ended up in critical care. And absolutely loved it. And even though I've moved after obtaining my doctor degree. I kind of decided to do research in that area. That's great. I think we're very lucky. Yeah I was just gonna say you mentioned a couple of luminaries. And now we've got one with us. So I'm gonna pivot over to Dr. Berry. And I'm gonna start with a brief introduction. But I have to thank our two co-chairs Lillian and Beth. Thank you so much. And I hope that the audience learned from you as much as I did in that brief little snippet of time. I want to transition to introduce Dr. Berry. Who is a surgeon, an intensivist, a researcher, and a master of critical care medicine. Who is a past president of the SECM and a luminary in the field of critical care. Dr. Berry received his bachelor's in medical degrees from Boston University. He trained in general surgery, trauma, and research. And then joined the faculty at Weill Cornell Medicine in 1984. Dr. Berry has distinguished himself in research with a special focus on multiple organ dysfunction syndrome, the host biologic response to infection, and the pharmacotherapy of sepsis and infection. He's been a leader in multiple professional societies aside from SECM, including the American College of Surgeons, AAST, and the Surgical Infection Society. He is a consummate clinician, researcher, teacher, and administrator. And it is my great delight to moderate a conversation with him today. Dr. Berry, how you doing? Well, thank you, Megan. How are you? It's good to see everyone. I appreciate everyone for joining. Yeah, it's great to see you. On the evening. Yeah, it's a little snowy for us. I don't know how you're doing over there. We're expecting it momentarily. And they're telling us a foot between now and Wednesday morning. The great fun of living in the Northeast. So I had the distinct challenge of collapsing a very, very weighty CV down to about a paragraph. So I'm curious, what's the most important thing about you that someone might miss if they're reading your CV or your biosketch? I would say probably the most important thing that people would miss is that I have had a relentless and really single-minded focus on goals throughout my entire career. And the other thing that people would really miss just from looking at a CV would be how devoted I have been to the educational aspect of the mission of the mentoring, particularly as I have entered the later years of my career here. My focus is on the relentless promotion and eventual success of every one of my residents who number now more than 250. Outstanding. Thank you. So as you know, I have some questions for you, but I'll also be monitoring the chat for questions from the audience. And there is a question from the audience that I'd like to pose to you. The question is, what quality or thing that you have done in your early 30s has contributed the most for you all, for you to become a leader as of today? Well, I don't think that I can really point to one thing in my 30s, because there were important things all the way along in my 40s and even in my 50s. In the latter case, I would say going back to school and getting a master's degree in business administration really, really helped me with both understanding and helping to lead several professional organizations, not the least of which was SCCM. I went to business school and the next thing I knew I was treasurer of the organization, but by doing so I was ready. Going back to my 30s, I would say probably the most important thing I did was taking two years off with NIH funding to get formal training in research methodology. Back then, we understood very little about ARDS. Even the pathophysiology was a mystery to us. And so I spent two years in the laboratory working on the pathophysiology of ARDS, not just to advance our understanding of the disease, but to learn about the pathophysiology to learn how to ask questions and answer them. And that paid dividends every day for 30 plus years. Thank you. We heard from Dr. Emlett about the decision to pursue a master's degree, and you've mentioned the MBA. When do you decide to do something like that? I'm sure you sort of considered it at various points in your career. Was there one moment or one sort of thought that you had that said, okay, now is the time I should do this? Well, there was a moment, but it's not something that you realize until it's happened. And the moment for me was being elected treasurer of the Surgical Infection Society without really a portfolio of skills to be able to manage that. I've always been interested in personal finance and paid attention to those kinds of things in my spare time. When I would go home, I would be more likely to pick up one of the business publications than the annals of surgery. But that said, it was the decision by my dear colleague and now spouse, Lynn Heido, to go to business school herself that really stimulated my interest. And I had no idea going in ahead of it, other than I wanted something in healthcare. I didn't see myself leaving medicine. So I found a program that was healthcare management and was physician only. And it fit my schedule perfectly. It fit my needs perfectly. And all of a sudden I had a new toolkit that included finance and accounting and marketing, and very, very importantly, strategic planning. And that latter aspect I brought to bear for the benefit of several organizations, also including SCCM. That's great. I want to ask you more about your research, but since we're in the management strategic planning space, you told me a great story when we met before about the SCCM and Hurricane Katrina. And I'm wondering if you can share with us how that training that you learned in management and planning helped shepherd the organization through a very difficult time. Well, I was fortunate to be elected to SCCM council in the mid-90s. And at that time, people could be reelected three times. And so it was possible to be on the council for 12 years. I was on the council for nine years before I was selected to advance up to the executive committee, which itself is a five-year path culminating in the presidency of the organization. But in order to get ready for that, I was asked to chair the strategic planning committee of SCCM for a two-year period. And during that period of time, I approached it as an academic undertaking as well as a practical one for SCCM. How can we do this better? How can we make sure that we are accomplishing what we needed to accomplish? I was struck very early on that the planning horizon for SCCM was a very short-term horizon. People weren't really thinking about things more than one or two years in the future, which has to be done for managerial purposes, but really is not strategy. You need to be positioning your organization for the future. So I led the group through an exercise called scenario planning, which is envision the worst thing that could possibly happen, double it, and then try to find your way out of it. And what we did was we planned for the catastrophic loss of our convention venue. And how would we find another place to hold a meeting? And so it was Labor Day weekend of 2005. And I'm sure pretty much everyone was glued to the television, watching the destruction of the major American city and all of the heartbreak and misery that that caused. But in the meanwhile, we were going to have our meeting there in another four months and all of a sudden we had no place to meet. So with one eye on the TV and one ear to the telephone, SCCM council was working behind the scenes. And what came to the fore as a result of that was that staff took our discussion of scenario planning back to SCCM headquarters and actually scenario planned for the catastrophic event that we had foreseen. And so they were ready with a database of all 40 U.S. convention centers big enough to hold the meeting and the contact information and the floor plans. And so we had a new home for our upcoming meeting within 24 hours in a great venue back to San Francisco, where we've had successful meetings many times in the past. But we had to beat out about 40 other displaced organizations to do that. I'm absolutely convinced that being prepared and being ready, being light on our feet, saved the day for us. And preparation has been a theme of mine for my entire career. In fact, it was the theme of my SCCM presidential address back in 2008 in Honolulu. Thank you so much for that great story. Now, let's back up a little bit, because a conversation with you would not be complete with talking about some of the work that you've done in research. And as you think back to the beginning of your career, as you think back, even when you decided to take that fellowship, how did you make that decision? You know, I counsel, I mentor trainees who try to decide, do I want to do research or not? Do I want to do dedicated research or not? Do I want to do dedicated training and research? What was it about that sort of spark that made you say, okay, I need to take time off and really get good at this? Well, for first things, I had an incredibly inspirational mentor, a surgeon by the name of Tom Shires, who was a writer of textbooks, president of the American College of Surgeons, and who other people call the greatest academic surgeon of the second half of the 20th century. And so mentorship and inspiration surrounded us, enveloped us. But as a second year resident, we collectively as a group of residents realized that although there was no pyramid, there were 11 of us who wanted seven categorical spots. And so some of us were going to have to decelerate, you know, and we asked for a meeting with Dr. Shires. I personally went into the meeting, not even entirely sure that he knew who I was or what I wanted to do. And we laid it out for him. And we said, we understand the situation here. And we're just hoping to hear from you how this is going to work itself out. And in that meeting, he offered the opportunity for four of us out of the 11 to go anywhere in the world and study any aspect of surgical physiology paid for by the department. We did not even have to go look for funding. He was making this kind of commitment to the academic careers of second year residents to have basically just finished our PGY one year, and we hadn't really proven ourselves at all. But here was this commitment, this level of trust. And I found a place to go and study respiration physiology research at Albany Medical College and was one of four who was permitted to do that. When I came back two years later, it was clear that the whole situation within the residency had changed for me personally, that I was tracked for an academic career, and I was going to be supported fully every step of the way. It's quite a tailwind to have behind you. And how do you think we're doing now with providing a similar tailwind for emerging investigators? Well, the funding is always an issue, ever more than ever before. And I think that training grants, T32s and the similar are crucially important to creating young investigators who have the toolkit to have a successful academic career, not just in surgery, but certainly in any discipline. And of course, there are a lot of distinguished careers now. They don't have to be research focused. One can get the MBA, as we've talked about. One can even do a combined MD, MBA now, in addition to the MD, MPH. There are now masters of science programs in clinical investigation. There's one at Penn, to which I sent one of my residents who has now joined you. We kept her. You kept her. I wanted her back, but you kept her. So there's numerous pathways. But what you have to also have is the drive and the focus to do it. It's one thing to go into the laboratory marking time. It's another thing to go into the laboratory with a clear plan to work on a problem. Being assigned someone else's project may or may not work. Going in with your own idea and figuring out how to answer it is a far different motivator. It certainly was for me. And of course, truth be told, it helped a great deal when my very first experiment worked. That does help. That does help. It does indeed. So I can relate to being a trainee and thinking that I wanted to do research and trying to come up with my question. And so I'm curious how you came up with your question, to start, and how you deal with the folks that say, oh, don't do that. Do something else. Well, the second part first, no one said that. Good. But I also had to, under the aegis of my training program, study and plan for six weeks, do the literature research, come up with the research plan, the methodology, and essentially go through the exercise of writing a grant to my mentors in the lab in order to be able to be permitted to start actually doing experiments. So it was a well thought out process once it began. But what was the stimulus? The stimulus was a horrible circumstance when I was a second year resident. I had been advised by people important to me that it appeared that I had an affinity for critical care. I spent two months in the surgical intensive care unit, and I had zero mortality. And people took notice. But quite honestly, this was 1979, eight years before the first examination in surgical critical care would even be offered. And so I was being asked to think about a career path that didn't even exist. And so you've got to have very sharp focus and a very clear idea of what you want to do. The touchstone for me was a 17-year-old boy who was injured in a motor vehicle crash and had bilateral comminuted tibial fractures, who did not get operated on on a timely basis, and died from the fat embolism syndrome, which of course is now known to be just another pathophysiologic mechanism of ARDS. In fact, at this time, the first papers dealing with early fracture fixation as a way to prevent pulmonary complications hadn't even been published yet. So these were murky waters with just a sense of where we wanted to go. And so I found myself into a laboratory that focused itself on the pulmonary microcirculation and the effects of microembolization on the pulmonary circulation. So my idea to come in and create an animal model of long bone fracture with lung injury was exciting to them and yielded real results. What we learned during the course of all of this, I was working with a PhD student, a postdoc in exercise physiology and a postdoc in neuroanatomy, all together. So we had a very broad view of what we were working on. But by the end of this, we had models of pancreatitis, we had models of DIC, we were using pit viper venom to defibrinogenate animals, and working collaboratively in the lab with a model that we knew we could bring to bear in many papers, in many aspects, ended up, for me, with the great fortune of an extraordinarily productive time in the laboratory with more than 20 peer-reviewed publications in basic science journals. I couldn't have asked for a better story. So you mentioned basic science, which is a very important aspect of what we do in critical care investigation. Cheers, everyone. Cheers. I've got my water. But we don't, you know, sometimes it's hard to go into basic science. So I'm curious what your thoughts are on how to promote basic science investigation in critical care when, you know, I'm a health services researcher, so that's near and dear to my heart, but how do you get people excited about the lab? I think it's, I think you really have to be a self-starter. As I said before, if you're assigned to a laboratory and given a project, you may find it interesting, you may hate it. You know, you may have a mentor who just wants to get the work done, you may have a mentor who's constantly whispering in your ear about, this is the best place to put this, this is the best place to put that. Not knowing any better at the time, I wanted to publish in surgical journals. I wanted to be known amongst my colleagues in my primary home. I wasn't even really thinking about critical care medicine yet. I was thinking about being an academic surgeon. I recognized that the work that I was doing could be taken in a couple of different directions, but my mentors said, you've got your entire career to publish in surgical journals. You know, let's send this paper to circulation research, or let's send this paper to the journal of applied physiology. They, of course, were right. And so, you know, a little nudge in the right direction, getting excited about what you're doing, getting recognized, getting invited, not through your mentor, but yourself, getting invited to speak at international conferences about the animal model that you're using. You know, that's where my motivation came from. That's where my satisfaction came from. But that said, basic science is not for everyone, particularly now that research funding is so difficult to get. For someone who also wants to be a clinician, you know, having enough of a presence in the basic science laboratory to compete with full-time researchers for research funding is really, really difficult. And so, there are lots of ways to contribute other than doing basic science. And in fact, there was a point in my career, about 15 years into it, when I realized that I was going to have to shift focus as well, and let me take my skills and knowledge in a slightly different direction, focus on translational research, and move my work to the bedside in the ICU. And, you know, I like to think that I was in the forefront of people who showed that the ICU could be a research laboratory. So, you mentioned the multiple hats that you wear. As an anesthesiologist, I am an amateur anthropologist of surgeons. I watch surgeons all the time. It's part of my job. And I'm amazed at- We don't watch because, you know, you've got the- You're doing something. You've got the ether screen there, so we listen. Oh, that's true. That's true. We listen to the beeps. That's good. You know, the good surgeons listen to the beeps. The good surgeons, they pop up and they notice, you know, when the SAT is 93. They pop up even before I say anything. And actually, the best retort that I ever had from that was actually from an anesthesiologist who was very important in SCCM back in the day, from Gainesville, Florida, by the name of Tom Furman. And I said to him, what's all that racket up there? And he said, I'm surprised you can even hear it, though, the sound of the suction. I love it. One of my instructors in anesthesia always told me how to find all the suctions in the OR. He says, there are always three. You think there are two, but there's always one hiding, and that one has the most blood in it. So it's a nice dance we do. But I'm amazed at how many different hats surgeons wear. So you're in the OR, you're in the clinic, you're at the bedside. If you're an intensivist, you're in the ICU. If you're a researcher, you're doing research. How do you think about anything that resembles balance? How do you think about doing a good job in those different areas? Well, I am decidedly not the poster child for work-life balance, that's for sure. You know, I spent literally every waking moment of my professional career thinking about how to make sick patients better in one guise or another. But I'm a big believer in some of the writings of Malcolm Gladwell and his idea that expertise comes from just working hard. You know, the concept of the 10,000 hours. I put in about 10,000 hours actually to being a resident before there were work hour restrictions. I put in about 10,000 hours during my first two years of residency. My next three years of residency were another 10,000 hours. And then ICU and everything else and all of that, you know, for the first eight years on the faculty, I was the only intensivist. And so over my career, I've probably taken care personally of 30,000 critically ill patients in addition to doing about 10,000 operations and 800 publications and everything else. The secret is that as you accrue experience, it just gets better, it gets easier. And the secret to all of this is pattern recognition, continuous observation, continuous application of new data, new facts, in comparison to what you already know. Does this help you understand better? Is this a red herring? Is this superfluous? You've got to be laser focused. You've got to be willing to stick with the task until you're finished. When you become a junior attending surgeon, you learn the stark reality that there's nobody behind you whispering in your ear anymore. And you've got to figure out a way to get the bleeding stopped yourself. That approach, I applied to everything I did. And you have to be really, really good at managing time. The hardest thing to learn is when to say no. That's the hardest thing to learn, particularly as somebody junior, wanting to get ahead, you know, wanting to really contribute, you know, maybe you can't review that paper. Maybe you can't be on that phone call. You know, et cetera. But there were a couple of things that I said I was never going to give short shrift. You know, I was never going to give the patients short shrift. I was never going to give my two environments, the operating room and the ICU, short shrift. And interestingly enough, I decided that I was never going to give my society short shrift, because that's how we develop ourselves and renew ourselves. So I've had to figure out which societies are my home. Clearly, SCCM is my home, but you know, we all wear multiple hats. So how do you think about that idea of having multiple professional homes? How do you, you know, you could travel all year long if you wanted to, you could be a part of 100 different societies. So how do you prioritize? Well, and there were times when people referred to me with tongue only partly in cheek as the Delta Airlines Professor of Surgery, because I was on airplanes a lot. You know, one year, the year I was president of SCCM, I logged about 300,000 air miles. And the one thing that stopped that year was the research. You know, I still was taking care of patients because I did not want to leave my partners, you know, hanging in terms of the call school schedule, anything like that. So the time that I had to devote to SCCM during my presidential year, which was about one third of my time, came out of my research program. It was a decision I had to make. Everyone else will balance the pros and cons and the pluses and minuses differently. But for surgery, it's especially challenging, I think, to a certain degree for anesthesiology as well, because critical care medicine is not a first home for us. We have to want to be in critical care medicine. You know, otherwise, we just spend all of our time, you know, operating and rounding and, you know, and all of those kinds of things or, you know, being in the operating room, which is a very easy thing to do, because there's no shortage of work to do just in one domain. So first and foremost, I think you have to pick what's important to you. And as far as joining societies, find your passion and pursue it. You know, things are a lot different now. When I was starting, there were no monetary constraints on belonging to societies. At one point, I belonged to 25. And I was active enough in five of them to become president in a trauma society, in an infection society, in a critical care society. So in multiple disciplines, nowadays, with money being the way it is, and people told, well, you've got $3,000 to spend on, you know, conferences and CME and, you know, journals and society memberships and all of that. It's difficult. And people are having to make harder choices than I did. But I think the principles are still the same. You know, where's the interest? Where's the like-minded people, you know, who you can have dialogue about, get the next idea for the for the next experiment or the next grant, get feedback on what you're doing. And so I had two homes, really, SCCM and the Surgical Infection Society. SCCM primarily for the clinical care of the patient, and the Surgical Infection Society was really my research home, still is. Great. Now, you talked about expertise and you talked about the 10,000 hours, and that brings to mind the tension between the time you need to become an expert and the desire to achieve some degree of what some people call work-life balance, others call work-life harmonization or integration. And especially we're seeing millennials talk more and more about this, millennials of all genders say, you know, I want to achieve something that looks like balance. So what kind of guidance do you give to your younger colleagues who are thinking about how do I, how do I try to do it all, but still be a very capable clinician? Well, I think first and foremost, you have to protect your time off so that it is indeed time off because there are only so many hours in a day. And if you want to be an expert clinician, you know, and write papers, there are going to be great demands on your time. And so you're going to have to decide what's important to you. A mentor of mine many years ago once explained academic surgery to me in one sentence. He said, Phil, here's academic surgery. You go to committee meetings all day, you operate all night and you write papers all weekend. And, you know, that worked for me. There are a lot of people now from whom that would not work. But you know, if you really want to get expertise and you really want to lead, you're going to have to find the time for it. And that time is going to have to come at the expense of something else that you'd really like to be doing. Now there are lots of ways to lead. You don't have to lead from the forefront. You can lead by being a team member. You can contribute by being a team member. But for me, the model was I was not happy unless I was going 300 miles an hour with my hair on fire. All right. So I'm going to ask you about mentoring women in critical care. And you mentioned one of your female trainees. You know, if I looked for female mentors all along my career, I would be disappointed because there aren't enough of them. So how do you think about being an effective mentor to a female trainee? And when do you sort of ask for help? When do I ask for help as a mentor or when does that? Yeah, because I imagine there are some things that you've really got a handle on and there are going to be some other things where you won't necessarily be able to draw on your own life experience. So how do you think about meeting all the needs of a female mentee? Well, you know, there are some things that a male mentor just has no frame of reference about in terms of mentoring a professional woman. Exactly. So when those kinds of issues come up, I say, would you like to talk to one of my former woman residents who has walked this path and had success? And so I stay in lifetime contact with every former resident who desires that contact. In other words, I'm not intrusively in their business, but everyone knows that I don't care if you finish 25, 30 years ago, you know, I'm still around and at your beck and call. And so, you know, we have an acquaintance in common who's a former resident of mine, but I have another resident who's doing very well at Case Western Reserve, just got promoted to associate professor. I have another former resident who's doing very well, just got promoted to professor at the University of Oklahoma and got a research chair. I'm still in contact with these people. And I guess to think about it for a second, what I've created is kind of a mentoring network. So a female critical care fellow was in my office a couple of weeks ago to have the, it's time for me to start looking for a job conversation. And of course, the first questions you ask are, you know, what are you looking for in life? Are there any aspects of your life that might be primary determinants or primary constraints on what you're trying to do? And just understand their situation from their perspective and try to see their way through. And I realized there were some questions I could answer and some I could not. And so I said, let me see if I can get you on the phone, you know, with a woman that we've trained about 20 years ago, went through the Navy, did her trauma fellowship at Penn, and now is doing trauma at a big level one center in Florida. So I texted her and I said, you know, how about talking to this person? They said, absolutely. So I think what I've done is I've created a network of my former trainees who helped me help the new trainees. That's great. So I want to ask you about the evolution of critical care over the course of your career. And I'll ask you about a couple of different technologies, changes, and sort of see what your perspectives are. There's a podcast I listen to that has people choose overrated or underrated. So maybe let's try that. Point of care ultrasound, do you think it's overrated or underrated? I think it's pretty close in the middle to slightly overrated. Let me just preface my remarks by saying that I am a little bit of a troglodyte when it comes to new technologies, because I trained in an era when there were no new technologies. And so, you know, my tools were eyes and ears and hands, and a couple of very rudimentary ventilators. When I was a medical student, some of the drugs in phase three trials, and this extended into my junior residency, were propranolol, cimetidine, dobutamine, amikacin. These were all investigational drugs. So when I was a resident, we didn't have any of this stuff. And so we learned how to take care of the patients really pretty good without any of it. And so everybody says, well, what about this? And I say, what about putting your hand on the patient's belly? Should we feed the patient today? Well, does the patient have bowel sounds? And that, of course, is meant with blank stares and silence. So that's my perspective overall. What's next on your list? How about simulation? Simulation is fabulous, because it's harder and harder to get people to 10,000 hours. And also, the idea that trainees can practice on patients is now an anachronism. And so the person who comes to the bedside needs to have some semblance of skills. And it's not just in critical care. The old surgical maxim of watch one, do one, teach one is never more. And for laparoscopic surgery, for example, there is a basic skill set that you have to acquire before you even really should set foot in an operating room. So simulation would be something that I am a big proponent of. How about family-centered rounds? I'm a big fan of family involvement, but we could talk about this one. I would say that my feeling about that has matured to the point where I would be slightly on the positive side of that. On the one hand, when you're dealing with a very busy person who's going to make rounds in three phases between cases two, three, and four, rounds have to be crisp. And you can't stop and have that kind of conversation during work rounds, is my opinion. You have to find time to have the conversation. You have to find time to make sure that the family's needs are met. And I'm not sure that work rounds in the morning are exactly the time to do it. All right. How about telecritical care? Telecritical care, I think, is a technology that is still in search of an application. We were the first at Cornell to install it, and we were the first at Cornell to remove it. Oh, dear. OK. And what we found was that in the big centers, there's plenty of people around, even at night. And telecritical care was wasting a lot of time generating a whole lot of false alarms that needed to be followed up on. I think telecritical care is finding its place now that we go to or going to networks and health systems. I mean, look, even 50 years into critical care medicine, we still don't have enough intensivists. There's not enough intensivists to have a person at every bedside for every sick patient every minute. There just isn't. At the big centers, there is. Out in the network hospitals, particularly on the evening or night shift, I think it can be very beneficial. So I see its greatest role as being connectivity and a great enhancer of communication between network hospitals and the mothership. That makes a lot of sense. I think that's it for my overrated underrated. I know we're going to run out of time soon. I feel like I would be remiss if I didn't ask you about COVID and what you've learned and sort of, I feel like we're all learning at warp speed right now, but maybe there's some old lessons that have come through again and some new ones. So some reflections about that would be lovely. So obviously, New York City was hit hard in the first wave. And we got our first COVID patient on March 23rd. It was a real challenge for us because we could see it coming, but we didn't know exactly what was coming. And our mission in the surgical intensive care unit changed twice in the space of 72 hours. Initially, we were going to be the non-COVID medical surgical ICU. Well, that lasted about 24 hours. And so to get ready for that, we had to empty three or four COVID patients out that we had already accumulated. So we moved patients out, we emptied out, and we filled up with non-COVID medical surgical critical illness. Well, that lasted about 24 hours until the emergency department was completely overwhelmed. And they decided rightly, I believe, that the full-time intensive care units with the full-time intensivists ought to be taking care of these incredibly sick patients. So we had to empty out a second time. And then we got 20 critically ill patients in 19 hours. Wow. I mean, it was just nuts. And they were really sick. They're the sickest patients we'd ever seen. In our first go-round, the mean Apache 2 score was 28. We did not have anybody who was not on a ventilator. But the thing was, here was this disease that we didn't really understand yet. I'm not sure we do now. And all of a sudden, we had 20 patients who, at least by one set of definitions, were all the same, 20 identical patients, as opposed to a liver transplant in one bed and someone with multiple fractures in another bed and perforated diverticulitis in the third bed and all of that. So in a way, you could keep them straight by their primary diagnoses. But we couldn't do that. So we had to learn about the diagnosis and change the way we communicated about these patients all at the same time. Meanwhile, we were charged by New York State to double our ICU bed capacity, double. So we had to decommission our operating, our main OR, except for four rooms. We had to turn 19 operating rooms into three-bed ICU cubicles. We had to create ICUs out of general wards. The problems along the way were just amazing. We didn't have enough electricity. We didn't have enough oxygen. And so we didn't have enough ventilation. So we were having to upgrade all of these systems. And then, Megan, where do the people come from to staff all these new ICUs? So to the enormous credit of my nursing colleagues, they put together in 24 hours a crash six-hour program in the fundamentals of critical care nursing. And in 10 days, ran 412 nurses through that program, all of whom, well, I wouldn't say all of whom, because the CRNAs can find their way around an ICU. Many of them had been ICU nurses in the past. That's a popular path for critical care nurses. But most of them had never set foot in an ICU before. And we trained over 400 of them in 10 days and said, you are going to be expected to be part of the critical care team. So it was an extraordinary undertaking and an extraordinary accomplishment. And my hat's really off to them. Yeah. Well, I can say, you know, we're not too far away from you in Philadelphia, but you got hit much harder. And we learned quite a lot from your experience. Well, the other thing that I was doing is I started blogging. The blog is on the Surgical Infection Society website. Now, if you go back, I was blogging actively between March and June, chronicling our path and trying to figure out what our mission was going to be, you know, how sick these patients were. And it turned out that we were about 10 days ahead of other cities that got hit hard, like Boston, such as Philadelphia and everything. And so many people have told me that reading that blog gave them a week or two advance notice of what was coming and really helped them prepare. Well, thank you for doing that. I have found our chat window. It was in a place other than I thought it was. So I have a few questions for you from the audience. How many about? So just like eight minutes that are left? About five. But we'll see. We'll see what we can get through. The most popular question is from William Miles. What areas over the last 50 years do you feel are the most significant multi-professional contributions to critical care? As a surgeon, which ones contributed and influenced surgical critical care? Well, I think the single most important paper in critical care of the last 50 years is the low tidal volume ventilation paper that was published in the New England Journal of Medicine. That was so impactful that practice was already changing from people hearing that paper in the audience. And practice was already changing months before that paper was published in the New England Journal of Medicine in November 2001. We were going about mechanical ventilation in patients with acute lung injury all wrong. And even though the study ended up including patients who were less sick than the sickest of them, they were including patients with PDF below 300 in that trial, which should have underpowered it. But even at that, it was a statistically significant result. So across the spectrum, I would say that low tidal volume ventilation, avoidance of barotrauma, is the single biggest advance in critical care in my lifetime. From the surgical perspective, I think it has been the application of damage control principles developed in trauma to the management of the infected abdomen. We don't see the horrible wound infections that we used to see. And we don't see abdominal compartment syndrome to the same extent that we used to see. That was a tough sell early on, you know, leaving the abdomen open. But from the surgical perspective, I think that's where I'd put my chips on red. Sounds great. The next question is from Ashish Khanna, and he asks, when in your illustrious career did you start feeling settled? When did you know that you were on a trajectory that you wanted to be on, and what are the best tools to gauge that? I don't think I ever felt unsettled, and thank you for your question, except for the discomfort that comes from a relentless quest to be better. I mean, I've had a blast. Most everything worked out well for me along the way. And I was able to leverage that into a lot more success. A setback, you pick yourself up, dust yourself off and get back in the batter's box. You know, you just got to have the attitude that, you know, it's your plate, it's not the pitcher's. And if the pitcher wants to come high and inside with some heat, you just bail out, dust yourself off, get back in there and smack it right back at them, or her. I love it. The next question is from one of our co-chairs, Beth Taylor, and she says, as a researcher and a bedside practitioner, what do you think about the way research has been shared during the pandemic, early release, prior to peer review? And I would add preprints to that. As we all rush to do the best for our patients, how should we approach early release data? Well, that's kind of a longer answer, because I think in critical care in general, particularly with the way we now communicate, we have been very quick in our well-intentioned attempt to do the best for our patients to jump on a new paper and say, boy, this is it. And we've got an egg on our faces a couple of times. Droger-Cogin Alpha activated, tight glycemic control, and I could find other examples. And so there's caution in saying that a new report is going to change things. Now, there may be some reports that are going to change things. So I have papers on preprint servers. I mean, that's the way the game is played now. But I don't think that you can use it really for anything other than hypothesis generation. And the other thing is that for people who are working in a very dynamic, very rapidly acting field, who want to be first to make a finding, you almost have to do that. Because nowadays, with things moving so fast, March and April, when we were looking at COVID, a lit search that you did could be obsolete three days later. That's how fast it was moving. And if you really think you have the first observation, nowadays, I think you have to put it on a preprint server. But the people who are reading it need to take it with a grain of salt. In a way, it's scholarly territory marking. Well, we've got two minutes. What I hope is a quick question for you to close things out. How do you keep up to date with all the information that's flowing back and forth? If you had to name one source, where would you send folks to try to keep up to date? I don't think there is one. I think the simplest thing that you can do, which is very time effective, is that many of the important journals allow you to sign up for free to get the table of contents sent to you every month in email. Just scan the table of contents quickly. You can look at 10 journals in two minutes doing that way. And you don't need to read every paper. Of course, people don't read journals anymore. They don't even read papers anymore. They hardly read abstracts. Everybody wants a visual abstract, which I don't really think is that helpful in the long run. Because if you're really going to understand what somebody did, you really got to roll your sleeves up and look at the methodology and decide whether this is valuable or bogus, honestly. But that's one way to do it. But honestly, the stimulation for me has been my residents. Every year they're smarter and more accomplished than ever before. Some of my faculty colleagues and I joke that we probably couldn't get into our own residency program anymore. So staying one step ahead of them, which I'm responsible for because I'm overseeing their care and also overseeing their education, means that I have to read what they're expected to read before they read it. All right. Well, that brings us to the top of the hour. I can't tell you how thrilled I've been to have this conversation with you. And thank you so much for sharing your time and your expertise with us. It's been my pleasure. And my thanks to everyone who donated their precious time to sit in on our conversation. Thank you so much. Thank you.

SCCM Luminary Lecture

Dr. Philip Barber

critical care career

mentoring

continuous learning

research advancements

surgical critical care

COVID-19 pandemic

healthcare professionals

work-life balance