Good afternoon. I think we will get started. My name is Jim Jackson, and I'm really happy that you're here. And I hope that you're happy that you're here as well. And I hope after my talk you're still happy, actually, that you're here. We're going to talk today about post-intensive care syndrome. And I noted just now that this slide is called post-intensive care syndrome issues and answers. And that sounds actually a little bit triumphalistic, I think, because it implies that we have answers. And to be sure, we have some answers. But there are some answers that we are lacking. And we do have plenty of issues. But we're really in the quest for, in the search for answers about post-intensive care syndrome. So what I'll do is I will survey for you all what it is that we do know. I'll share with you the answers that I think we have. And we'll equally talk about the many answers that we're still searching for that we don't have. So let's begin. You're familiar, I suspect, or you wouldn't be here, with this concept, this construct, post-intensive care syndrome. And this term, although it recently has started to get some legs, if you will, and some mileage, is a term that was coined by Dale Needham and colleagues at a task force meeting back in 2010. So a decade ago when I had a little more hair and things were a bit different. It describes new or worsening impairments, PICS does, in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization. So we won't spend a lot of time, but let's talk briefly about this term and what it refers to. Crucially, it refers to new or worsening problems, not just new problems, but new or worsening problems in a range of domains. Those could be physical, as Heidi alluded to. Those could be cognitive. I'll talk a lot about cognitive domains. They could be mental health-related deficits that people have after the ICU. We'll talk about those as well. But the new or worsening aspect of that is important because I think once upon a time, in our research at Vanderbilt at least, the primary people we were concerned about were the people who were quite pristine when they landed in the ICU, the people who developed brand new problems. And there were reasons from a methodologic standpoint, from a strategic standpoint, why those were the patients that we focused on early in our research. But I think it's equally true and it's important to note that if you land in the ICU with preexisting cognitive impairment and you get a little bit more demented, that's also a big problem, right? It's not simply the person who was fully functioning cognitively who becomes impaired. It's equally the person who was somewhat impaired who is now quite impaired, right? It could be the person who had a touch of PTSD before and now they have a profound amount of PTSD. So it's not just the new cases that we're interested in. It's the worsening cases as well. And we'll dig into this. So cognitive functioning is the first domain that I'll discuss. And some of this might be familiar. Some of it might not be. So we know that critical illness, we know, many people don't yet appreciate, we know, that critical illness has clear and adverse consequences for the brains and the cognitive functioning of many people. That's new news to some and to be sure it's new news to many patients because it isn't necessarily clear to people, to the uninitiated. It's not necessarily clear how disease in the lung, how failure in the organs could impact the brain and yet it does. So we know, for instance, that in the context of sepsis, the blood-brain barrier that is usually very robust and protective, that really degrades. In the context of sepsis, it degrades. We know, too, that things that are done to treat the lungs, to enhance breathing, for instance, to allow people to survive a complicated ICU stay, those things have implications for the brain. Being on a mechanical ventilator for a prolonged period of time has potential very significant consequences for the brain. We know this. There have been probably 120 or 130 studies as of now looking at cognitive outcomes after critical illness. If we define that broadly, there are probably that many. If we talk about sepsis specifically or ARDS or outcomes after MICU hospitalization, that number of papers is perhaps 55 or so. But there's now quite a large body of literature that purports to look at cognitive functioning in ICU survivors. And one of the largest, most definitive studies to date, and I've noted, by the way, that the convention center has Diet Pepsi but no Diet Coke. So I'll remember to bring a 12-pack next time I come. But one of the most definitive studies to date on cognitive outcomes in the ICU was a study called the Brain ICU Study, and that was a study we did at Vanderbilt. And without belaboring it too much, what we did was we enrolled I think about 800 patients at Vanderbilt Medical Center and at St. Thomas Hospital, both in Nashville. We tried to exclude people with preexisting cognitive impairment. And we basically followed them in the ICU, and then we did cognitive testing with them three months after they left the ICU, and then a year after they left the ICU. We used a testing battery called the R-bands. If you have questions about that, we can talk about it. I probably won't get into the weeds about that right here beyond showing you the next slide. But suffice it to say, we followed a meaningful number of patients over time in that study. And we were interested in what happened to their cognitive functioning. And this is what we found. This is going to take a little bit of interpretation, so forgive me. You'll see a reference on the side of this slide to the R-bands global cognitive scale. The R-bands is the repeatable battery for the assessment of neuropsychological status. So if you went to see a neuropsychologist, possibly an occupational or speech pathologist, occupational therapist or speech pathologist, you might get a test called the R-bands. It takes about 35 or 40 minutes to give. There are alternate forms. So if you saw me one day, you would give me form A. If you saw me in six months, you'd give me form B. If you saw me at 12 months, you'd give me form C. That addresses practice effects. At any rate, really nice cognitive test. And it gives you a global score. It assesses you in a range of domains, and it distills it down to one number. That number is a global score. And in our population, the typical global score for these patients reflected in these box plots. You'll see the boxes with the dark lines, which is median. In our population, those R-bands scores were in the high 70s, low 80s. That's what we learned. And we learned that those scores were about the same whether you were younger or whether you were older. Now some of us in our early 50s, I'm almost 52 now, we will debate whether 65 is really old or not. Right? Used to be really old. Now I'm thinking, ah, it's not too old. That's right around the corner, not too old. Some of you are saying, oh my gosh, 40 is old. So it's kind of what you're used to. But we divided this up into 65 and below, over 65. And regardless of how old you were in this cohort, you did somewhat badly, quite badly on the R-bands. When we looked at this further, you'll see a green line and an orange line. You'll see a pink line, little dotted lines. When we looked at it further, we were interested in comparing the scores of our patients, ICU survivors, with other populations interested in how their scores differed from or were compatible with how well people typically perform on the R-bands. So if you look at a normal population, people typically earn a score on an R-bands of about 100. If you look at a population of people with mild cognitive impairment, sort of an early Alzheimer's phenomenon, if you will, they typically are scoring somewhere around a 90. If you look at people with a moderate TBI, you'll see the term TBI there, moderate TBI. They're earning a score in the mid-70s. And then people with moderate Alzheimer's disease typically are earning a score of about 70. So if you look at ICU survivors, what we learned from our cohort at least is two things. One, that regardless of whether you're older or younger, your cognition is not so great. Two, in general, if you were an ICU survivor, your scores are very likely to be worse than those with mild cognitive impairment, marginally better than those with moderate TBI, and that's really important and it's quite concerning. Now, admittedly, when we developed this cohort, and if I go at this pace, by the way, this talk is going to be over at like 3.30, so I'm going to speed up a little bit here. But in this cohort, admittedly, we were looking at what might be called the sickest of the sick patients. 100% of these patients were on a mechanical ventilator. They had a very high APACHE score. They were all in the ICU, I think, at least 48 or 72 hours. So your ICU patient who lands in the ICU for a day after surgery, your person who barely meets the criteria for being critically ill, that's not necessarily the person that is reflected here, although we have concerns about those patients as well. But suffice it to say, brain ICU reminded us that we need to be quite concerned about cognitive outcomes in ICU survivors. This is just a chart, a figure that highlights this as well. We've circled populations of sepsis and respiratory failure, but in general, the entire chart is concerning, what does it show? You'll see rates of impairment again on the side there and you'll see the names of studies. So what this figure shows is that whether you have sepsis, whether you have respiratory failure, whether you are in a general medical ICU population, whether you have ARDS, regardless of what it is, you're at quite a significant risk to have meaningfully impaired cognitive performance, to have high rates of impairment. This is important because I think once upon a time, people thought, well, if John and Jane Doe have really severe ARDS, they're going to develop cognitive impairment. But if they're just your general ICU patients, maybe they're okay. That doesn't seem to be what we're finding. I'm going to skip through this slide and we'll get back to it. What does this impairment look like? It looks like a lot of things. It manifests in a lot of different ways. If you look at this slide, the figure nearest to me is what we call a ray complex figure. And some of you may have seen that if you have been neuropsychologically tested before, or if you haven't, may not have seen it. But it's a complicated geometric figure, right? There are a lot of component parts. There are some crosses. There are some boxes. There are some rectangles. There is something that I confess looks a little like a bowling ball to me. I've started bowling with my wife and kids recently, having a hard time breaking 100, doing the Fred Flintstone thing where I throw the ball up in the air and it bounces people of a certain age. We'll remember that. So that looks a little like a bowling ball. Ray complex figure. Thirty minutes later, we ask people to draw that from memory, all right? And this is an example of what one of our patients drew. We could quibble over what that looks like. Is it a tobacco barn? Is it a shack? You know, what exactly is it? We could agree that it doesn't look much like the figure that it's supposed to look like, right? So those are memory deficits that we see. When we ask people to draw a clock, as we often do, you equally see really striking abnormalities, and they differ a lot. Again, moving from your left to your right, you see a very idiosyncratic, odd-looking clock, right? Kind of a peace sign, if you will, with a few hands and a few numbers. You see numbers, strangely, on the outside of a clock in the middle example, and then on the far side, you look at a very disorganized clock, which actually looks a little stroke-ish, if you will. When we ask people to draw a clock, we're interested in a couple of things. We're interested in the aggregate performance. That is, did you draw a clock the right way? We assign points for things like whether it actually is a circle and whether the hands are where they're supposed to be, and so on. But we're also really interested in the process. How do you engage the process? Because the process by which someone engages something very simple, like a clock, can be really quite revealing. If I ask one of you all to draw a clock, and I should do this. I've never done it. We won't do it today. Never done it at a presentation. It would be a lot of fun to have someone come up very publicly, right, put them on the spot, have them draw a clock. But if I ask you to draw a clock, how would you start to do that? Do you think you'd draw a circle, and then, miss, you're nodding your head. What would you do? Yes, you. Right. Yes. Would you put the numbers in a certain way, do you think? What would you do? One to 12. So that would be one way to do it. And how else might people do that? Some people do one to 12. Some people do three, right, three, six, nine, 12. And then what would you do? Fill them in, right. Some people might say, but don't tell me if this is your approach, right. Some people might say, I draw a three, then I draw a seven, and then I draw a nine, a two, right. That would be a disorganized approach to drawing a clock. Do you agree with that? So if that's how you did it, right, you'd add a two, and then you'd add a nine, right, and then you backfill it. Or if you drew the hands first, then the numbers, right, you might get it right. Ultimately, it might look like a clock, but the process, right, the process could be very distorted, and the process could be very revealing. So what we know from neuropsychological assessment is that simple tasks, like a clock drawing task, can reveal a lot about how you engage the world, right. Because it could be that if you do something really bizarre and funky, like you draw the two, and then you draw the nine, and you draw the seven, that might be the way you're going to reengage in your job when you go back to your job, right. And that might even get you fired from your job, right. So we see some very abnormal clocks, among other problems. But cognitive impairment isn't the only issue, not by far, that we see in ICU survivors. We see a lot of mental health problems as well. What are those? I'll highlight a couple of them here. Those include things like depression. You'll just see rates here in this study, prevalence rates. This is a literature review, some years old now, but things haven't changed that much in terms of what we know. So you'll see significant problems with depression. You'll see meaningful problems with PTSD. You'll see significant problems with anxiety that our patients have. Depression rates range typically from close to 20% to as high as 40%. PTSD rates that are reported in ICU survivors are really all over the map. In the studies we've done at Vanderbilt, we typically see prevalence rates that are more like 10%, or perhaps 11%, 12%. There have been some colleagues of ours elsewhere who have reported PTSD rates as high as 45% or so. I continue to think that probably reflects an overestimate. But even if the true rate of PTSD in ICU survivors is, let's say, 9%, that's still probably three times as many people than in the population at large who have PTSD. That's three times the normal rate. Anxiety is also a problem, very common. And then there are other issues that are perhaps a little less mainstream, if you will. We see them less frequently, but they're very problematic. Things like claustrophobia. Not sure if you've interacted with ICU survivors who have claustrophobia, but we often have had people who have developed quite intense fears of being restrained after being restrained, right? Quite intense fears of being in a circumstance that they can't leave after not being able to leave the ICU. This is an interesting one, claustrophobia, because it's something that people don't often ask about, right? And as a clinician, you're aware that the questions you ask will dictate the answers people give you, right? So if you don't know the questions to ask, often they won't reveal things that they actually would be happy to reveal. They're not aware it's a concern. So really thoughtful questioning in the mental health space in particular is important. What does PTSD look like after the ICU? I'll move quickly here. This is what Sarah Wake thinks it looks like. She's an internist from Britain, from the United Kingdom, who wrote in BMJ that after her battle with PTSD in the ICU, I would make detours, she said, while traveling to avoid the sight of a hospital. I couldn't watch hospital documentaries or dramas, and I hid all my medical textbooks in journals. I enjoyed sport, but I began to avoid exercise as I was terrified of the sensation of recklessness. Even certain inanimate objects filled me with fear. I still cannot bear a shower curtain be drawn as it reminds me of closed hospital curtains and hidden death. So quite poetic, if you will, but also quite gripping, right? Classic symptoms of avoidance. Piggybacking on that a little, and this will take a little longer to read, so please indulge me, because this really is the face of things like PTSD. I'll read you an email that I received from a patient some years ago. I omitted a few details, but here's what he said. Dear Mr. Jackson, I wrote to the general delirium at Vanderbilt email address, but wanted to also reach out to you specifically. He had sent me this email. I'm newly aware of your site and program. I wish I'd known much sooner. Beginning in, I spent eight weeks in the ICU under the care of. This was a large kind of an academic medical center, a tertiary care hospital, with a long period sedated and intubated in the ICU. Even though I was hospitalized for pancreatitis, kidney failure, lung failure, blood clots, et cetera, the post-ICU experience was and is the worst part of my ongoing illness. And sadly, and this is a key that we should talk about. Sadly, no one even told us to expect it. As for my background, I was staffed into the gifted program at school at eight years. I graduated from fill-in-the-blank elite university three years. He was trying to say if anyone should know how to access things, if anyone should be educated, it should be me, but we weren't. He goes on to say I've held a series of great jobs with increasing responsibility. All should be right in my world, but after my ICU stay, I'm a completely different person. Terrified to go to sleep because of the nightmares I lived while in the ICU. I've written 50 of them down, some including sexual abuse, murder, being burned alive, et cetera. I've seen a psychologist who diagnosed me with PTSD, but not much has changed in my day-to-day living. For example, grocery shopping is a disaster. I just look at the items on the shelves. I'm confused about why I'm there or what I need to buy. My work suffers. I don't know how much longer I'll be able to go on with it. Although I haven't admitted as much to my employer, and I tire incredibly easily. I went six weeks without any moisture in my mouth or any food. I was NPO. So I'm constantly eating and drinking too much at night when I'm the most scared. I also spent many weeks in restraints from which I developed diagnosed ulnar nerve damage in my arms. I'm hoping you can offer some advice, some counsel about who to see, where to go. While I appreciate all that was done to save my life, I don't know that it was worth it, given my current condition. I completely understand the woman on your website who had leukemia and said she would prefer the cancer over the ICU stay. The past and present pain and uncertainty of my underlying physical conditions, pancreatitis, renal failure, et cetera, are a comparative cakewalk compared to seeing severed heads in glass jars and being confused all the time. This is simply unsustainable. That's really gripping, right? I mean, it's so sad, and it's from the horse's mouth, right? I mean, I didn't sit down and try to craft an email that would be like a violin playing, right, that would arrest you, you know? These are the struggles that this really thoughtful, really high-achieving, successful at baseline fellow had, who should have had, if anyone had, should have had enough reserve to be a buffer against this, but sometimes it's just not. So he engages a lot of issues that are food for thought here, and we'll lean into these. One of them, again, is that as it relates to PICS, what you start with, to use Heidi's analogy, what you start with in the bank helps, right? But at a certain point, it can be overwhelmed, right? It can be overwhelmed. It doesn't matter how much you start with. It can be overwhelmed. Second, the current state of affairs, while getting better, is that even thoughtful patients, even families who are really good at advocating, even those people, us in this room, people like us, they often don't know about PICS. They don't know about resources. Despite their best efforts, they haven't been educated about what to expect, and that's really a tragedy. So I think we need to do better. But the human toll of these conditions is really great, as outlined in the email. And the causes of PTSD that he relates to, that he references here, I should mention, are many, and that's why this is complicated. One of the causes, to be sure, is memories that form under the influence of heavy sedation, and that's something that we're really changing, right? There was this orthodoxy, once upon a time, that went like this. If we keep people really heavily sedated, really sedated, they won't remember anything, and if they don't remember anything, then they can't be traumatized by their memories, because they don't have any memories. I think that logic is fine as far as it goes. I mean, there's a logic to that. The problem is, typically it's not that people don't remember anything. It is that under sedation, people remember a lot of things that they think happened, many of which didn't happen, and they have a lot of cognitive distortions that are very frightening and scary for them. So he wrote down 50 of them. He sent me, actually, 50, and I've got a few of them here that this gentleman referenced. Memories of a baby in a jar. This is in his, you know, scrawl. Baby in a jar had been in a blender, but their face was still intact. Sarah Margaret dragging a dead baby in the room behind her. The respiratory therapist trying to inappropriately touch me. Sally chasing him with a broom. The respiratory therapist trying to kill me by cutting off my windpipe. So these are things, as you're imagining, that have some basis in things that happen, right? Some respiratory therapist engaged him in some way, right? May have tried to extubate him, perhaps, right? And in the throes of this delusion, he was convinced that someone was trying to cut off his windpipe, right? Or, as many patients have told me, you know, they're sent to imaging to get an MRI, and the MRI looks a little like the pizza oven in your backyard, you know, perhaps, except much bigger. And so I've had patients who have said, really convinced that someone was trying to burn me alive. They were trying to put me in an oven, right? Well, that memory happened to be from the same day that they went to imaging, right? So these memories are complicated because people are aware that no one tried to put them in an oven, right? They're aware, mostly, that no one tried to kill them in the ICU. But these memories created in the context of these really traumatic situations are tattooed on, if you want to think of it that way, and from kind of a neurologic standpoint or a biological standpoint, that they're often resistant to change. So what you have is patients who are living in a lot of dissonance. Because on the one hand, they know that no one was trying to put them in an oven. On the other hand, they really feel like somebody was trying to put them in an oven, and they don't quite know what to do with that. And at its worst, what this PTSD leads to, and we'll stay on this slide for a second. At its worst, what the PTSD leads to is a really profound pattern of avoidance. Now, in some cases, the avoidance you might associate with PTSD isn't that disruptive, in some cases. So I work with a lot of veterans from Iraq and Afghanistan at the National VA. They're stationed in Fort Campbell. They're part of the Task Force 160, if they're the 101st Airborne, whatever. Anyway, all good. But for many of them, their combat took place in Afghanistan. So would they want to go back to Afghanistan? No. Did they need to go back to Afghanistan if they're out of the service? No, right? Like, I think Afghanistan is lovely. But you could live your whole life avoiding Afghanistan, and you actually would be fine, right? You'd be fine. The problem is, though, with our patients, the avoidance often is like this. I don't want to have another surgery. I don't want to go back to the hospital again. I don't ever want to be in restraints again, right? This is coming up with patients I'm working with even now. So that's a problem, right? That's a problem, because a lot of these folks not only have whatever the issue was that sent them to the ICU, but they have a panoply of chronic problems. They've got wide-ranging problems that absolutely will necessitate surgery, right? And they're faced with a choice. And sometimes the choice they make is, I'm going to hunker down. I'm going to shelter in place, if you will. I know I should go to the ER, because I'm really sick. But I'm afraid that they're going to send me to the hospital, which could land me in the ICU. And I'm just going to stay. So there's a really interesting study done a couple of years ago by a colleague in New York. And he looked at people who had had a cardiac arrest. It's a beautiful study. And if you send me an email, I can find it and send it to you. Great study. Looked at people who had a cardiac arrest. And he looked at people who had PTSD after the cardiac arrest, which is fairly common, and those who had a cardiac arrest without PTSD. So cardiac arrest, yes, PTSD. Cardiac arrest, no PTSD. And then he followed them over time. And he was curious about what their help-seeking behaviors would be the next time they had chest pain. So he studied this. And he found that the people who'd had a cardiac arrest with PTSD took 2 and 1 1 times longer to decide to go to the ER than people without PTSD who had a cardiac arrest, right? So that's really concerning. That's really concerning, because with cardiac arrest, with stroke, with so many things, we're aware that seconds matter, right? Minutes matter, much less hours. So Mr. Smith, cardiac arrest history, no PTSD. He's in the ER within an hour, right? And Mr. Jones, same medical event with PTSD. He's watching the Beverly Hillbillies on TV or whatever in his recliner at home feeling anxious. And three hours later, he makes it to the ER, right? And there's a lot that could happen in the intervening time. And there are a lot of other issues, right? Where someone is told as a practical matter, you know what, man, you're not being very effective at your job because you're having a hard time walking around? What's the problem? Well, the problem is my feet, this is a real case, got bunions on my feet. Oh my goodness, just remove them. Not a big deal. Just get a little foot surgery, right? Then you can walk and do your job. No thanks, you know? I'm resigning from that job because my desire not to have surgery is greater than my desire to keep this job. So you can kind of imagine where this goes, and it's really concerning. It's not only the case, though, it's not only the case that, and I'll skip that slide. I'm going to go quickly here. It's not only the case that people are cognitively impaired or depressed. It's also that there is this interesting interaction between mental health and cognitive problems that makes all of it a little bit worse. And there's a chicken and an egg phenomenon, right? To be sure, cognitive impairment drives the development of depression, to be sure. It's equally true, though, that if you're depressed, and some people in here have probably had seasons where they've suffered from major depression, seasons where they've suffered from dysthymia. Won't ask you to raise your hand, there are people in this room, I'm sure, who've had that happen. And if you have, you would agree that your attention, your concentration during those seasons is also not as sharp. So the problem isn't just that you get one of these. The problem is that you often get multiple terribles, if you will. And indeed, often you suffer from physical debility that is really problematic. I'm not going to talk a lot about this cornerstone of PICS, because I think it's been covered nicely elsewhere. I will say, though, that physical debility is hugely common, and that a significant percentage of people who are physically disabled after the ICU also have really meaningful functional impairment. There's a beautiful poem that I like. This is actually a phrase from a poem. Does anyone like the Scottish poet Robert Burns? Any hands here? You do? Yeah, good. Not hugely obscure. So, famous poem. This is written in Scottish, if you will. So I will perhaps say this in modern English. I think this says, Oh, if some power... I'll just read it as written. Let's start with that. Oh, was some power the gifty gie us to see ourselves... I'm mashing the language. Oh, was some power the gifty gie us to see ourselves as others see us? Wouldn't it be great, is what this poem says, if we could see ourselves as others see us, right? Wouldn't that be great? Often it would be great. How is this related to physical functioning? It's related this way. One dilemma our patients often have is they have whatever new limitation they have after the ICU. They lose their toes, they're amputated. Perhaps they lose a foot. Perhaps they have some scarring. And that occurred for them in the context of an event so traumatic that they interestingly view that as much more limiting, probably, as you do, right? But they're convinced that it is, and it's so sad, and it's a problem. And it gets at the fact that psychology undergirds all of this, right? I saw a patient just the other day, actually, at the VA, and he had been in an accident. He was pursuing service disability for PTSD, and he'd had this boiler explosion, and the boiler had exploded and burned his face. And, actually, his face, to me, didn't look burned at all yet, just a little, just a tiny scar. And I said to him, you know, what do you see when you see yourself in the mirror? And he said, oh, my gosh, my face is so scarred. He said, I look like Freddy Krueger, it's so horrible. And I thought, man, this is so interesting, actually, because, you know, when I look at you, I mean, I'm not totally objective either, but probably on this point more than you are, when I look at you, you look totally normal. But you get in the mirror, right, you see Freddy Krueger, see all these scars, right? So these patients of ours, not unique to them, we do it too, do a lot of projecting, right? They do a lot of projecting. They're missing a few toes, and you may not give that a thought, right? You might not give that a look. They see themselves as powerfully disabled, right? They see themselves often as hugely limited. So we've gotta be aware of the psychology that undergirds this, and we need to be aware of this construct called learned helplessness. And I don't know how familiar people are. Do people know what that construct is? I'm not gonna call on you if you do. But think of it this way. The story goes, this may not be true story, might be, don't know. Story goes that back in the day, when there were traveling circuses in town, and they'd barnstorm, you know, in the early 1900s around the country, supposedly the way you could keep an elephant in place is you would just take a little rope, and you'd tie it around their leg, and then you'd tie the other end of the rope to a stake. You'd just hammer it in the ground, and that baby elephant would pull a few times on the stake. Being a baby elephant, couldn't pull the stake out, okay? And would be convinced now that they couldn't pull out the stake, and then that baby elephant would grow into this massive bull elephant, and you could still keep him in place by just the little stake, right? When in fact, he could have, you know, could have pulled a tree down the road if you would have tied him to a tree, but he's not even gonna try to pull against the stake, right? That's learned helplessness, and it's a big concern with our patients. It's them concluding that they don't have the agency and the capacity to do what they had done before, right? They've concluded that wrongly. We've co-participated with them in that in some way, probably, they've concluded it. And so they tug a little bit at the stake, can't do what they did before, they throw their hands up often and say, okay, what's the point? I'm gonna shut it down, not gonna try. And, you know, five years later, they haven't returned to running, they haven't returned to working, they haven't done whatever. And part of that is because, yes, indeed, there are limitations, but part of that is because they have learned the wrong thing, the wrong lesson, that their limitations are greater than indeed they are, and we've gotta figure out how to unpack that with them. Does that make sense? That makes sense, learned helplessness. Let's talk about what we can do with patients after the hospital, and I'm gonna move quickly here. Education, this is simple, right? It is and it's not, right? I mean, of course it's not, but it's something that we could do, right? You could generate a brochure in your ICU, it could refer back to the best evidence, it could be beautifully crafted, or simply crafted, and it could say some version of, you know, we're giving this to you because we wanna highlight the fact that some percentage of people develop the following problems after they leave the ICU. If you develop these problems, you know, please call us. However it would go, right, in your circumstance. But the thing that causes such problems for these patients is not necessarily, it's not necessarily that they have PTSD, I mean, they don't want it, right? They don't want cognitive impairment, that's the problem, admittedly. But part of what causes such a problem for them is it catches them off guard, right? They're not prepared for it. I mean, it just hits them like a truck. And many of them will say, man, if you just would have told me about it, I actually think I would have been prepared for it. I probably could have handled it, but I just didn't know it was a problem. So one simple, again, relatively easy, low-hanging fruit kind of way to help this is we're gonna have to educate these folks and we're gonna have to help them anticipate what happens and we're gonna have to help reframe their narrative and their narrative often is some version of, I'm going crazy, it's two things, I'm alone and I'm going crazy, right? And the reframe and the retort is you're not alone and you're not actually going crazy, right? Because there are millions of people leaving the ICU every year and if 30% of them have depression, you're not alone, right? And even if 9% of them have PTSD, you're not alone. And we'll talk about support groups shortly, which equally help ensure that you're not alone. We have an ICU recovery center at Vanderbilt. You'll see Joanna Stallings. Do you remember what you were about to say, Joanna, in this picture? I don't know. Something enlightening and profound. Yeah, probably so. I'm looking a little angry as you're saying that. Not really an angry guy, so I don't know what that was about, but this is a team meeting that we were having discussing a patient. There are a lot of models related to ICU recovery centers. There's a way we do it at Vanderbilt. There is a way people are doing it elsewhere. I'm not sure what way is the best way, but here's what I know. That in the same way that the Nike brand has benefited from the just do it slogan, just do it, our invitation to you is not, hey, go buy a sign tomorrow, tack it up over a doorway that says ICU recovery center and start it, but our invitation to you is in the support group space, in this ICU recovery space, it is consider this. It is lean into this, consider it, and don't wait to do something until you get all of your ducks in a row, right? And that's what often we do, right? And that's why people famously say the perfect is the enemy of the good. Have people heard that saying, right? I mean, I remember living that so often, right? Where there's a great option on the table. If people have been house hunting with their spouse, maybe you can relate to this, right? Where you're like, honey, that house actually is fine. This house is fine. The ninth house we've looked at, it's actually great, but we're looking for the perfect house, right? Well, if you find the perfect house, I suppose that's terrific, but the perfect sometimes is the enemy of the good. And as we interact with people around the country, many of them say, until we've laid all these ducks out in a row beautifully, we don't wanna do anything. And I would discourage you from thinking that way. Let's get our hands dirty, try to help these patients. If you have questions about how to do this, we can help you. We're imperfect too. We can help you. In this clinic, our clinic, we typically see ICU survivors within a couple of weeks of discharge. The clinic is multidisciplinary. It incorporates cognitive, psychological, and functional evaluations. In some cases, ongoing therapy. The main goal, I think, is to assist patients with critical transitions and help them make informed decisions about their future healthcare. One point I would note here, what we've learned is that, yes, ICU survivors need our support two weeks after discharge, but many of them equally need our support two years after discharge, and many of them need our support 22 years after discharge. Wish it weren't so, but it is so. Many of the people we interact with, this brain ICU study I referenced, I'm now calling folks to enroll them in a new study. They're now 13 years out of the ICU, and we have a talk on the phone, and it's lovely. I cut my teeth getting to know these people, so it's been really meaningful to me to interact with them again. And you talk to some of them, again, sadly, 13 years later, and you say, well, tell me about your ICU experience. How much is it in the rear-view mirror now? You know, it's been 13 years now, and many of them will say, you know, it's really not in the rear-view mirror now. You know, it's a defining event of my life. And that isn't that surprising. You know, I don't know how many of you have a father, for instance, who's a Vietnam veteran. You go to the VA, if you go to the Nashville VA, if you go to the Central Florida VA, you'll see someone, you'll see someone, you'll see many in the lobby wearing a jacket, right, or a hat, Vietnam veteran, and you'll interact with them, and you'll find that, yes, that happened now. It's 1967, right? Or they were in the Tet Offensive in the late 60s, and if you talk to them about the most pivotal event in their life, you're nodding your head, so you get this. That's it, right? That's it. And that's what a lot of our ICU survivors say. I mean, they really do say, I'm dividing my life into two phases, before the ICU and after. And we could argue about whether that's healthy or not. It is what it is for many. And so 20 years later, the thing that they think is the most impactful is this event that happened, you know, two decades ago. And we could wish that they were over it, but you don't just get over it, right? So we need to expand our focus from sort of barely out of the ICU two days out to include 20 years out, and the hope would be that if we do a more effective job with the people two weeks out, then they don't become the ones 20 years out, right? Who, again, see this as the defining event in their lives. Let me move really quickly here. As we think about engaging ICU survivors, there are a number of approaches that come to mind. One thing we have begun to study in earnest and have begun to engage in a bit clinically is cognitive rehabilitation. Are there any occupational therapists here or speech and language pathologists here? I don't know if there would be. They often are not linked into conversations with ICU providers, but I think they should be. There are medical patients who receive cognitive rehab quite regularly, right? They largely would be stroke survivors probably, but speech pathologists have a lot to offer. And often they don't make a connection with ICU survivors because people don't consider ICU survivors to be brain damaged, quote-unquote, yet neuroimaging would reveal something different for many. So cognitive rehab is important. Goal management training is a method of cognitive rehab that engages executive functioning, abilities in planning and organizing, shifting set, and we've begun to use it in a research context. We're about to launch an R01 studying this. We did a study many years ago now involving the Tower Test. Basically, you start with some circles on a board. You move them to form an image that looks like this. How fast you can do that and in how many moves is a measure of executive functioning in the Tower Test. And in a study we did way back in 2012, what we found was that after we used goal management training, even though controls and interventions were about the same at baseline, after the GMT intervention, the intervention group improved dramatically. So there's a signal for cognitive training. Let me skip. Support groups, hugely important. Winnie the Pooh, I think Pooh should have two O's probably instead of three, but Winnie the Pooh famously said, there's something you must always remember. You're braver than you believe. You're stronger than you seem. You're smarter than you think. That's a good message for many of us. It's a good description, I think, though, of what a support group can facilitate. It's wounded healers coming together, all bearing the scars of this critical illness coming together and finding a way to build each other up, finding a way to walk together and say, I did this, it was hard, and you can do it too, finding a way to say, you can do hard things. And it flies in the face of this learned helplessness that I've referenced, and the group that we lead at Vanderbilt is a good antidote to that. And I would encourage you, if you're able, if you're motivated, and we can talk about it after or via email, I'd encourage you to think about starting a support group. The ICU Recovery Center is a big ask, right? That's a harder place to start. And as you're starting, as you're beginning to try to engage in post-ICU care, from a strategic standpoint, part of what you want to do is you want a few early wins, right? At least I did. You want a few things that are doable, they're not hugely expensive, they don't require a lot of resources, and the support group is that. Every week, we typically have probably 15 to 18 people at our group, typically eight or nine in person, another eight or so from around the country who join via Zoom, and we engage these themes that the ICU survivors typically bring to the table themselves, and those themes are consistent. Those themes include things like, man, who am I now? You know, I was the runner and the athlete before, and I'm not now. You know, I was the patriarch of the family before, I'm not now. I was the capable person before, I'm not now, right? Loss, grieving, guilt, all these things, I would encourage you to consider a support group. Tackling other challenges that are very relevant here as I move quickly, medication management, fitness to drive, big concern, obesity, smoking cessation, let's land on this a second, low-hanging fruit, right? Many of our patients, especially in the rural South, they started smoking tobacco, you know, behind the barn back in 1954 or something when they were in, you know, fifth grade, right? And some of them, some of them have been smoking like a chimney ever since, right? And some of them would tell you that the three weeks they were in the ICU is the only three weeks in their whole life that they haven't had cigarettes, right? It's true. So that may be a pregnant opportunity for us to say, well, you've been without cigarettes for three weeks, right? So we can leverage that, right? We can leverage that, not simple. Something to think about. Two more slides. There are, according to some theorists, bridges in particular, there are three phases of transitions. There's ending and losing and letting go. Sounds like a country song, by the way. There's the neutral zone and then there's a new beginning. And what we're trying to facilitate in our ICU survivors, what we're trying to help them navigate is we're trying to help them navigate this inevitable letting go. Again, not for all of them, but for many of them, letting go, here's how I used to be before, right? I can ruminate on the fact that I'm not that person. I can fixate on it. I can be all about that. Or I can find a way to let go of that, right? But it's not gonna happen overnight. And I'm gonna operate for a time in this neutral zone, going forward and back, back and forth, until I get to the place where I'm embracing a new normal and a new me, where I'm perhaps experiencing the beauty of post-traumatic growth, where I'm, as the Old Testament refers, I'm finding some beauty for ashes, right? I've traded in the ashes and I'm experiencing some degree of beauty. And people can get there. It's not easy, but we can walk with them to get there. And when it happens, it's quite lovely. We can also help negotiate these folks through what people refer to as stages of change theory. Last comment I'll make. Stages of change theory, as psychological theorists posit, is probably the most robust way to explain change that we have come up with. That is, it appears that change takes place in a series of kind of logical steps. And you're in one of them. You're in one of them even today, as you're contemplating making some changes. Pre-contemplation. Pre-contemplation is, I'm not thinking about making any changes yet, but I'm thinking about the fact that one day I should be thinking about making some changes, right? Thinking about thinking about it. I should be thinking about thinking about it one day. Contemplation. I'm really not ready to make some changes yet, but I am thinking about it. I'm thinking about the fact that I need to make some changes. Preparation. I'm actually now preparing to make changes in action. Now I'm ready to make changes, right? Acting. What's the relevance? The relevance is that often after great trauma, right? Often after a profound life-changing experience like being in the ICU, people can be more amenable to making changes than they were before, right? They can be uniquely prepared psychologically to make some changes. And we have some people who've done this who have said, oh my gosh, that was a wake-up call for me, right? I was taken so much for granted. I was living life without purpose, right? I was spinning my wheels, all these things. And for those folks, we can gift them. We really can gift them, and they us, by coming alongside and trying to help facilitate growth in them. And what an honor it is when we get to do that.

post-intensive care syndrome

PICS

ICU discharge

cognitive impairments

mental health problems

physical debility

functional impairment

education and support

cognitive rehabilitation programs