Good afternoon, everyone. Welcome to our Crosstalk session, which is titled Lung Rescue Teams in the Age of COVID and Beyond. My name is Javier Lorenzo. I am a clinical associate professor of anesthesia and critical care medicine at Stanford Hospital. I'd like to introduce my two speakers today. Keith is one of our respiratory therapists from the University of Virginia and trauma service. And we also have Dr. Danny Theodore, who is an assistant professor of anesthesiology and critical care medicine and the medical director of respiratory therapies and services at the University of Virginia. Welcome both. I like to start off with a simple question, which is what is, how do you define what a lung rescue team is and what are the roles and mission of this team? Keith, can you help us understand that? Sure. Thank you. So to me, I suppose a lung rescue team is a group of clinicians and providers that are tasked with being familiar with the literature. Maybe they have specialized training in some interventions, but nonetheless, they're tasked with being able to help other teams manage patients that may have complex respiratory failure and need help with providing interventions. Okay. Danny, what does that look like in your home institution? What is a lung rescue team and who composes this team? So at our home institution, the team would be primarily composed of a physician and it would be an intensivist. And so this intensivist could be an anesthesia intensivist, a surgical intensivist, a medical intensivist, senior respiratory therapists. We also would have some ECMO specialists on board that we'd be in contact with during this period so that everybody's in the group. And then we'd include mid-levels, which could be nurse practitioners or PAs to help assist with this. But the primary real deployment is the initial survey or deployment is from the respiratory therapists, which identify these high-risk patients that are becoming more complex or not meeting the medical management, the standard medical management, and that needs to be escalated further to a specialized team. I see. How long have you guys been doing this at the University of Virginia? So initially, the formalized team was to be fully deployed prior to COVID. Before that, we had had a team, but we had really not named it a lung rescue team. We had respiratory therapists, once again, that would identify these patients that might need an esophageal balloon catheter or adjustment in ventilator management or other means of looking at sedation, paralytic, et cetera. But we really hadn't defined that team, but that team was still composed and there were still those interconnections between the ECMO service, the intensivists, the nurse practitioners, et cetera. And with COVID now interrupting what we would call our normal healthcare flow, it's kind of become more of an absolutely essential need to have it because these patients are so more complex than what we would look at as standard ARDS management. So Keith, it sounds like the RT who is managing this patient is the one who activates the lung rescue team. Can you tell us a little bit about what are some of the indications or some of these triggers that might cause an RT to get the other team, get the lung rescue team involved? Yeah, so I think probably one of the most important aspects of this concept is understanding what conventional ventilation limitations are and what protective lung ventilation really looks like. Like Danny said, before COVID reared its ugly head, we were already sort of looking at this concept and studying it and collecting data on some patients that were sort of complicated. So in the mornings when we sign out from the night team, we sort of evaluate the patients that are in the ICUs with respiratory failure. And the ones that seem to be, where it seems to be more difficult to manage with standard approaches, then we will discuss with our colleagues like Danny and decide whether or not we should be doing something different. And, you know, another really important aspect obviously is to be familiar with the literature and to be familiar with what protective ventilation really looks like and what the risk and the benefit of implementing non-standard interventions that are now becoming standard, but things like prone positioning and the self-geomanometry to monitor transpulmonary pressure and help to dose and sort of customize the ventilation strategy to the patient. So does that mean that, is it a trigger based on PF ratios, triggers based on obesity, BMI, or disease processes, or really what gets these teams involved, what prompts the RT to escalate therapy to these teams? Can you give us some examples of those triggers? Sure, sure, of course. So a patient that is intubated for respiratory failure or even not respiratory failure, but has plateau pressures that are above 30, that have driving pressures above 15, that require PEEP, that is more than, you know, that is in the 20 range. People who, you know, patients that are just complicated, people that are maybe acidemic, so the 6 milliliters or 8 milliliters won't, aren't enough to, you know, to support the acidemia and to correct it, or people who have high BMIs that we feel like could benefit from higher PEEPs than any of those patients would warrant a consult from or to the lung rescue team. Dr. Theodore, do you attend on these teams? I do, I do attend on these teams, and as Keith was alluding to, prior to COVID, we were collecting data using esophageal balloon catheters, but we had really geared kind of our team toward looking at the morbidly obese patients, like the class 3 obesity and above, kind of similar trigger to what the MGH study was showing with Vera, and so we were collecting, you know, putting these esophageal catheters down, monitoring, and trying to see how we can improve these patients, and, you know, we were finding that, you know, in these obese patients, that what we were, from a conventional standpoint, titrating PEEP to using the ventilator management wasn't adequate enough, and so these were patients that had ARDS or just had severe hypoxia, but didn't meet the full Berlin criteria for ARDS, and so some of the people we were assuming had ARDS really just didn't. It was just the thoracic weight and actually the inadequate lung recruitment that was presenting like ARDS, because they turned around very quickly, like in under 24 hours, these patients' PF ratios were much better. They were no longer in severe ARDS, and things turned around, so that's really the beginning and kind of the infancy that has blossomed to where our trajectory is going now in the COVID era. Tell me what that looks like on a daily basis. When you're attending on this team, what does your day look like, and for how many days do you work in these teams? So, you know, I'm happy to speak, or Keith can speak, but I'm happy to speak, is that, you know, it's, you know, a lot of times it's when you're the one on service, so since we're anesthesia critical care, if we're in the operating room, we're probably not going to be on this team. It's more when we're in the ICU on service that we're following these teams. We get updates from the respiratory therapist, the head respiratory therapist, on the patients and what's going on with them and whether they need an esophageal balloon, and then once they do have that placed, we'll follow them for the extended period and put recommendations in on adjustments. I do have to say that, and this is just a shout out to our respiratory therapists, that they're absolutely phenomenal, and they have been well trained using esophageal manometry and looking at transpulmonary pressure, so they make my job exceptionally easy, and like I always say, you know, I've always appreciated our respiratory therapists, and now with COVID, it's, you know, it's shown, you know, to the rest of the world how important they are, especially in critical care, and so then we look at the numbers, we look at, you know, other factors, which is their sedation, their paralytic, we run through things, and then we will give our recommendations to the team and adjust things accordingly. For the most part, it's not an exceptionally daunting day, because I'll be honest with you, a lot of the stuff has been done up front for us from the respiratory therapists, and we're really there just supervising the team, and then, you know, making small adjustments. Yeah, Dr. Thiel, I actually want to second that. I agree that the RTs are really doing incredible work in this pandemic. I myself find my daily work to be much better because of the work that the RTs are doing, and, you know, they're coming into patients' rooms, they're monitoring, they really are doing amazing work. So, Keith, thank you, and thank you to your colleagues. So, the benefit, I heard you quote that study from MGH, which, you know, found that on patients with severe morbid obesity, they were rather nice to the lung rescue team, actually had a pretty significant mortality benefit. It wasn't a big study, it was single center, but the signal was pretty strong. So, what have you noticed to be some of the benefits of the lung rescue team? Have you been able to replicate some of the findings in the literature? We actually have been able to replicate some of this. We have a small study that's currently being reviewed for publication, where we looked at, you know, class 3 obesity and above, and we're using the esophageal balloon, and we had been collecting, like I said, been collecting this data, you know, and then the MGH study came out, and we did see benefits in these patients as far as length of ventilator time, PF ratios. We didn't power anything towards mortality because we just felt like that's not what we wanted to look at at the time. We wanted to look at other things as far as length of stay, ventilator time, etc., and we are noticing a difference. I'll say one of the big differences that, you know, we probably aren't going to put on a, on like a data sheet, is that these services greatly appreciate us coming in, and I think it brings an ease to the staff and the ICUs and to the other services that truly, you know, and Keith can speak to this too, going above a PIPA 20 would make some people faint. You know, they're just not used to that where they feel a lot more comfortable with us being able to do that and help guide the therapy. So Keith, I think we've heard a little bit about some of the advantages of this team. Can you, can you comment on the downside, if any? What are some of the disadvantages of having a group of providers that comes in and gives extra care for respiratory failure patients? So I've thought about this some, and I don't know that there's a real, you know, there's a real downside. I suppose some would say that it might strain resources some because, you know, if you're, if you're on, if you're on service for a day that, that somebody in a, you know, if you have a, if you have a specific skill set for, to place esophageal balloons, and it may be the perfect storm, and you're the only one in the, on service that day that can do that, but you're covering a different ICU, you know, that sometimes can put a little bit of a strain on, on the service, but we really do try to, try to avoid that. From a patient care standpoint and outcome standpoint, it seems like there's no real downside to having people pay more attention to protective strategies and interventions. Is there any conflict between what the primary team, the way the primary team might want to manage respiratory failure versus what the lung rescue team might be recommending, or is there like a process to resolve any conflicts that might, might come up? Was that for me? Yeah. Okay. Danny, I think you might be able to, to approach that better than me, but. Or you, Danny, yeah. Yeah, sure. I'm, I'm happy to. So, you know, absolutely. You know, when there's a primary service, sometimes the tendency is to, you know, protect it like a baby, right? And so some of the things that you do that for them aren't conventional and kind of at times feel like it's going outside of the box. There's, there's resistance. I will say that we have been fairly good about encountering that resistance and showing the evidence that we have behind it and being able to show our outcomes with other patients to help kind of say, you know, this is what we've done. I will be very honest with you. We still do meet some resistance, but we have been able to convince others, and I'll speak primarily from the surgical side, that going up on these levels of PEEP and managing this way really works. So it's, you know, we haven't run into that many obstacles, but there are occasional ones that we do. And we, you know, have to be mindful that they are the primary service and we can give our recommendations. And sometimes, you know, when you're in a trauma service, there's a lot of competing things going on. So it's kind of, it can be a juggling act, but I feel overwhelmingly we've gotten a very positive response. So you, I'm sorry. I agree with what Danny's saying. And it seems like to me, I learned a long time ago as a very young RT, that if I could explain what I wanted to do in a reasonable fashion, then most folks will get on board. You know, sometimes it may be a personality thing. And so, you know, you just have to explain why you want to do something, what the benefit versus the risk is, and then that's about all you can do. And then the primary service will either agree with you or not. Yeah. I mean, and data probably speaks a lot. So if you can show the data and you can show that what you're doing makes a difference, that's probably the best way to change hearts. So you both spoke about how this initiative predates even COVID. You probably had a workflow at Triggers. You probably have a dedicated group of faculty and providers. How did that change come April of this year? What did the scope of the team change? Obviously, I'm sure the patient population changed a little bit, but what has been some of the changes that this team has seen in scope and practice since the onset of the COVID-19 pandemic? Dr. Theodore, can you comment on that? Yeah, happy to. I think that first off to say it's shown the importance of having a rescue team, especially because now we're looking at what we thought in this respiratory virus was going to be standard ARDS and it's not standard ARDS. The responses to PEEP aren't the same as we thought. The compliance changes aren't the same as we thought. So it has really highlighted the importance of this team. With that being said, one of the biggest hurdles we've had is having the staff. As we see across a lot of hospitals that there's not enough staff members to manage all of these patients, COVID and non-COVID patients. So that has absolutely been a big challenge. So where we go from here and how we manage things is really going to be how we structure our resources to be able to handle this. I don't know, will there be a point where we run out of those resources or where we become even more limited, possibly depending on how the spikes come during the holidays in the January, February. In our area, it looks like it's going to be probably tenfold or more than what we saw before. So it could be enormous. And at that point, I'm not very sure that we will have enough intensivists and respiratory therapists to say we can do a lung rescue team for everybody. But time will tell. Yeah, no, I completely hear you on that, on the special resources here in California. We're recording this on December 21st and we're experiencing some of the worst surge that we've ever had in this pandemic. People are your most important resources and that's usually the one that you don't have enough. So what is the role now of this team in the care of COVID patients? I wonder, do you guys ever get involved before the patient gets intubated? Do you have any say on the management of respiratory failure that's not mechanically supported? So what's interesting is we have, which a lot of other places do, is we just have a specialized ICU. At UVA, they were building a brand new tower that was going to house different ICUs and it was going to have a cardiac surgery area with cardiac surgery. But of course, the pandemic changes things. And so it kind of changed the workflow and the hospital flow. So we have this dedicated area and a lot of the intensivists, which they're primarily medical intensivists in the COVID area, unless you volunteer for it, to work there, we're an integral part of starting this lung rescue team. So they're very much involved. And so I feel from the get-go, we already have involvement and buy-in from those players where if there is a need, it's already being escalated. And if there needs to be, you know, if certain triggers are met, we do go to the next level of management in which a team, you know, like additional members that are experienced will come in to help manage the patient. Great example is like if the RT in the COVID unit says, you know, like right now we're not doing so well, a supervisor RT will be paged to come in. That would be part of the lung rescue team and would help to add additional advice and management. And then that gets just disseminated to everybody. So Keith, is the management of respiratory failure for COVID-19 patients in UVA, is that any different than the management of respiratory failure? Just, you know, your bread and butter respiratory failure, or is it more nuanced, more idiosyncratic? And if so, how so? Yeah, I think that it certainly is different. It sort of snuck up on us and surprised us like it did people from around the globe. We, Danny, I'm sure would attest to this, but at first, we intubated people pretty early if they were failing conventional support, because we thought that conventional support was high risk to everybody else. And so in order to sort of mitigate that we were gone right to intubation pretty early. Now we use a lot of high flow like a lot of other places have initiated high flow nasal cannula self-proning and you know to try to avoid intubation unless it's clear that intubation is really the only alternative and from a physiology standpoint you know I think Danny talked a little bit about this already, the COVID patients don't always act like a normal hypoxemic patient. They may not be dysmyc, they may not be tachypneic, they may just be hypoxemic and so that sort of makes it a little more difficult to assess and evaluate and decide what kind of treatment they may need to. Yeah no I definitely have seen that myself and we here in Stanford we also started intubating reasonably we had a threshold that might be considered early and as the evidence came out not just showing that we could potentially rescue more patients if we provide more support with high flow and some health therapy but also just the length of mechanical ventilation that was so long. We have moved that threshold and I'm wondering what, does your home institution, does UVA have a threshold in which you know this is the point where we intubate or is that also kind of a dynamic threshold that might take into account local resources, availability of anesthesia to intubate, trajectory of the patient. What thresholds do you use at UVA to intubate a COVID-19 patient? Well you know yeah the thresholds, the thresholds definitely have changed and I feel like we're coming to kind of a middle state where people feel like this is the, with evidence this is the right way we're going like Keith alluded to. I mean we pulled the trigger early and intubated people immediately. The idea of putting a CPAP or a BiPAP on somebody was like it was a cardinal sin like you just didn't do that and now we're definitely doing that, we're not having a problem. Specifically as far as the intubation we had designed protocols with the anesthesia department and the intensivist for whichever service they were to have a plan A and a plan B and so both groups backed each other up if there was a need for an intubation so that there wasn't a delay and that one person wasn't waiting while the other person and so that's worked well and in the last few weeks we've kind of adjusted our aerosol generating procedures and what we think is appropriate and what's not appropriate. The biggest trigger that I will say now for us to intubate somebody is not just their PaO2 or the PF ratio. Some of these patients are what we would call happily hypoxic and they're doing great. They don't have any other end organ dysfunction but then there becomes a point where their mentation might start to become altered and things start to change and at that point is where we really consider it's a time for intubation because the noninvasive isn't going to work there. They're not going to be able to handle it and so now we've taken it to the next step. Understanding what the risks are with doing that but the alternative is not going to save them either so that's kind of where we have progressed and so yeah just this week there were a few patients that their PaO2 was in 50, 60, 100% and I said let's try BiPAP on them now. They're awake. They're conversant. They can speak full sentences. Let's try this BiPAP and see if this is a bridge to success and if it's not we have our answer. So when you intubate say you meet that threshold either a change in mental status or progressive hypoxemia or even that rare increased work on breathing and I agree I've seen my fair share of hypoxemia. I like the rhyme with that. Who intubates these patients? Is there a group of dedicated providers who kind of have collected expertise in intubating these patients or is it anybody that can intubate comes in and intubate? So it is primarily a group effort between the pulmonary critical care and the anesthesia department and those are the people that intubate. The agreement was that since the pulmonary critical care are the primary on this and have been intubating for a long time and our institution prior to COVID they did their airways unless anesthesia was needed but we felt that because these airways were trickier and these patients presented a lot with more severe hypoxia than we were used to it would be a team effort in which the pulmonary critical care would be in the room to intubate but there would be an anesthesiologist attending anesthesiologist with them for the airway in case there were unexpected difficulties. And so that's what we've stuck to and it's worked well and to be very honest with you not only has it worked well for the airways but it's also worked well for interdepartmental you know kind of collegial working together and developing broader ideas and plans on how we can do things. So it's been nice because it's almost merged our intensivists into kind of almost one big critical care kind of group which has been fantastic for us. We've loved it. We're kind of used to the you're the medicine people and we're the anesthesia kind of surgical and now we kind of we're working as one team which is fantastic. It's great to hear that COVID is actually bringing on silos and bringing departments together. I'm wondering if the actual sequence of events when you intubate someone and Dr. Theodore you're an anesthesiologist and an intensivist I take it that you are involved in some of these intubations. How has UVA changed that sequence compared to a normal intubation for normal respiratory failure? So the reason why I ask this because you know we here at Stanford we've given it some thought. We even look at the ASA and the Anesthesia Patient Safety Foundation recommendations for that sequence and it's not as usual. It's not you know just a regular intubation. So I'm wondering what what can you share with us that is unique and different at UVA? Well I mean I think we do I think we're fairly online with everybody else in the sense that you know of course we're using our PPE. We're donning and doffing how is expected and we're going in we're getting all the additional measures set up which would kind of be our standard monitoring during this time you know and I think that's aligned with a lot of other institutions. The one thing that we were doing which has now come back is everybody was intubated with a video laryngoscope. It was you know it was a video assist. I mean everybody. There was that overarching and I will be honest fear that we needed to be successful on the first shot because this is aerosol generating and we don't want to have to make multiple attempts because it could increase the exposure rate. And now as we've gone along we've realized that we can actually do just go back to our traditional DL and do that and do it safely. So that's that's been a very big change and the other things we do ask during this time of course is that RT is in the room that there's a nurse available. We have the pulmonary critical care. We have the anesthesiologist there both attendings. I think those are kind of the what I spoke to previously because kind of the big outlier for me was that we were still up until very recently doing video assist and I found it interesting right because after we've pushed medication and we've paralyzed I was never sure what the aerosol generating part of this was for the airway. I mean of course we're going to get saliva but if they're paralyzed and not breathing we're not really generating anything aerosolizing. But I think it was just the comfort of the team as a whole is why we went down that route. Keith can you can you mention what precautions you take when you have to perform a procedure at bedside like a bronchoscopy that may be aerosolized generating. Is it the usual tower that you bring in or you bring in disposable equipment, minimize the people in the room, what precautions do you take into account? So first let me just add to what Danny said about the intubations. I think that one of the things that we also sort of modified was we avoided even more than usual back valve masking with the patient. I think that that would be the aerosol generating part of an intubation if you did that. So for bronchoscopy, yeah we use disposable bronchs when at all possible. If you're doing a diagnostic, if you need to do some sort of diagnostic bronchoscopy then you may not be able to use the disposable, what we call the Fisher-Price bronchoscopes. But if all you were really doing was just trying to clean them out then you may be able to get away with using the disposable bronch and so that's what we do. I see. Triggers for proning, is that the same triggers as a placebo trial or do you guys have your own triggers? Fairly similar to the pro-seva trial. For us, and I can't speak for other institutions, it's kind of when we get to that point of that 12 to 14 of PEEP and we're not seeing much benefit and especially benefit in change of compliance, which is hit or miss of course, then we really look at it's time to prone. And I think the one thing that I have very much appreciated, because I remember walking into the unit and saying we're on 12 of PEEP guys, we got to go up. And then going up on the PEEP and not noticing much of a difference and then going to the next step which is to prone. There are of course steps in between as far as if we haven't paralyzed, but then proning and seeing a drastic difference. So yeah I feel like we are pulling the trigger for proning much earlier and noticing good success with it. I think one thing that we've also seen here at my home institution is our experience with proning is just quadruple. Like we have probably prone more patients in the last nine months than we have prone in the last 15 years. And we're a lot more comfortable doing so. So there's one good thing that will come out of this is that we have grown in expertise in that process. I'm sure that's the same for many other institutions. So say you're playing the role in the loan rescue team and you've been called because you have somebody who is extremely hypoxic, maxed out in vent support, he's prone, he's paralyzed, PO2s are still dismally low, 40s, maybe a little bit of an organ dysfunction. So you give the ECMO team a call. Have you guys cannulated anybody for COVID-related respiratory failure on an ECMO? And if so, how has that experience been like? So we have cannulated a reasonable amount of people. But of course we are also, I think we're a middle-sized health system and exceptionally I would say large for our area because Charlottesville is a small city. So for that it's large. So we are limited on how many circuits we have. But yes, we have cannulated multiple people. We've had really great success. I think the initial first couple cannulations, the cardiac surgeons being in the unit and trying to figure things out and this and that, there's always some hiccups. But I feel like now it goes very smoothly. And like I said, it's very much a collaborative effort in the sense that traditionally if you were put on ECMO in our institution, and I know it varies everywhere, you went to the cardiac surgery ICU. You would not stay in any other ICU because the cardiac surgeon was the medical director and so handle. Now when you cannulate the special pathogen unit or the COVID intensivist team is the primary. And they help with the management of ECMO with of course the cardiac surgeons being consulting and coming in and saying, okay, you know. So it's been fantastic and it's kind of spread this education and this experience across different departments again and allowed us to collaborate. So yeah, I mean we've had good outcomes and of course with anything we've had some unfortunate outcomes that were not related to the lungs but related to other end organ problems that showed up during the course. Yeah, and I'm sure just like anything ECMO related, patient selection probably makes a huge difference in outcomes. What has been the outcome for your cannulated patient? How long are they on the circuit? How long are they in the ICU? Have you been able to keep track of that data? So we actually have one of our pulmonary critical care intensivists, Alex Kadeel and one of their fellows is actually doing a follow-up COVID clinic. So we've actually been able to follow some of these patients and we have them on the boards. You know their pictures when they come in the clinic and you'll have like we've had a few that have been on the ventilator for 60 days and cannulated for three weeks. And so we're able to follow up and see these patients and get an idea of their experience and also get an idea of the post-COVID effects, right? And so yeah, I mean we'll look at you know when they're on ECMO for lungs and you consider lung recovery, they're usually on for a couple weeks easily on ECMO. And then if they're able to you know control their ventilation and adequately oxygenate then of course we'll transition to capping and moving from there. But yeah, the follow-up clinic has been absolutely fantastic to see the effects or the lack of effects of what we've done with these patients. Yeah, I like the idea of like the post-ICU clinic owning you know this role as we know that there might be some residual you know effects of COVID infection in our patients and we know that just for the fact that these patients are critically ill for a long time and they're in the ICU for a long time, higher rates of delirium and brain dysfunction that their post-ICU syndrome might be more pronounced. So I'd love to see more data on that but kudos to your institution for addressing the need for that patient population. All right, so let's move on a little bit on the time. Say we've intubated, the lung rescue team did a fantastic job in managing the ven, managing the peep, cronying. Now the patient has been intubated for 21 days and we're wanting to provide more mechanical wean. What considerations, Keith, can you mention, does UVA take into account when the patient is ready to undergo a tracheotomy? Can they do it, does it have to be a surgical trach? Does it have to be a percutaneous trach? Do they need to meet any infection prevention threshold to undergo this procedure or is it just business as usual? What special precautions do you take when you consider a COVID patient who needs a tracheotomy? Sorry, I know I just gave you like three questions. My apologies. That's okay. I think that, so being on the trauma service, I don't see as many COVID patients as Danny does, but I do understand and believe that initially no one was really crazy about traching any of these patients at first because yet again this is a position where you get everybody in the room and potentially a huge aerosolizing procedure, a bronchoscopy, a percutaneous tracheotomy, but I feel like now we're, and Danny can correct me if I'm wrong, but it seems like now we're treating these folks about the same as we would anybody else in terms of when they get trached. Percutaneous, if they can do a percutaneous, there's no anatomy issues, you know, vent requirements are stable, regardless of their COVID status, they'll do a percutaneous at bedside? Yes, I believe so, and I think that we avoid taking, I don't want to say avoid, if it's appropriate, then they would go to the operating room to get the trach, but I feel like we don't have the same hesitation that we might have before. Great. Yeah. Well, gentlemen, I want to thank you both for spending this time with us. I do want to end, you know, this has been a terrible year. I mean, there's no way around it. It's going to get better, but maybe you can tell us a little bit about what you do personally to stay, to focus on your wellness when everything else is going crazy at work. What kept you well? Keith, you want to go first or me? Well, hang out with Danny, that's what I do. Yeah, Keith and I hang out. I'll go first. Wow, this is a tough one because I'll be very honest with you, there are many, many a days where I feel burned out. There's no question, and I'm okay with saying that because I think that it needs to be known, right? I think that we need to actually talk about this because I think if we don't talk about this, we're doing a disservice to not only our generation of healthcare workers, but ones to come along or the ones that are thinking about coming into this, right? Because there is a big factor of resilience in this, and sometimes it can get difficult. For me, I like to do a lot of outdoor activities. I've always enjoyed doing that, running outdoors, exercising outdoors, fishing, camping, hanging out with my kids. Those things I've really very much enjoyed and it's helped me to kind of feel a balance. The other thing that I was doing even prior to COVID, but then all the time it kind of set me back was I was actually meditating. I found that it was very helpful, although a lot of times I fell asleep meditating because I was so tired from the shift, but I got to sleep, which was great. But I found it very helpful. And then also really having in it, and I'm going to raise Keith on a pedestal here, is having really great colleagues to work with and to talk with. It is just, it's amazingly just fulfilling and relieving to be able to talk with your colleagues about stuff and have that connection. Thank you, Dr. Theodore. Keith? Yeah, I agree with what Danny said. Spending time with family, you know, we have, you know, spent a lot of time outdoors, trying to, trying to, it's sort of a difficult balance, right? Because you feel like you are responsible for doing the right thing, taking care of these patients. So when you're not taking care of them, you're thinking about taking care of them. You're reading, you're participating in conferences remotely, but you still need to sort of take time for yourself and to hang out with the kids and the family and forget about things for a little while. Well, thank you both. I know that time is limited for the reasons that you mentioned, and thank you for taking an hour of your time this afternoon to chat with me and chat with our community of the Society of Critical Care Medicine. I want to thank you for all the work that you've done and good luck with the rest of this pandemic. Stay well and stay safe. You too. Thank you again.

Lung Rescue Teams

COVID-19

respiratory failure

interventions

protective ventilation

prone positioning

transpulmonary pressure monitoring

resource limitations