Well, hello, my friends. It's good to be here with you today, and I have never given a talk on this topic before, and it was a good exercise for me to go through and gather my thoughts on something that really represents a lot of pain and suffering that many of us have gone through during COVID. And I'm glad to be here with you. I feel like that you are my colleagues. We understand one another. We know what happened to us during this time. And so I'm going to share with you some things which are vulnerable, and I'm going to open up about things that I went through that might be of help to you in some way. I'm not here to give advice, but I am here to not beat around the bush. And I may say some things that you disagree with, and I'm going to make sure that we have time at the end for some Q&A, so you can come up here and please get on one of these five microphones and keep your questions tallied down as we're going so that you can express yourself and ask them as we move. So my name is Wes Ely, and I'm an intensivist at Vanderbilt University and the Nashville VA in Nashville, Tennessee. I do not have any conflicts of interest related to this talk or this topic, and I'm going to talk about how we might harness, and this is my overarching hypothesis, how we might try and harness wisdom, humility, and compassion on our way towards healing coming through COVID. I do not claim by any means to have wisdom or to have humility or to be a master of compassion. Those are things I ask for each morning when I get up in the morning to have the ability to attain greater wisdom and have some semblance of humility, and in so doing to garner compassion for my patients at the bedside. But I'm not there yet, so I'm a student. I'm going to ask you two questions now, and at the end I'm going to add a third question. The first question you can ask yourself. It's rhetorical right now, but I want you to ask yourself, who are you? And the second one is, from a vocational perspective, what do you want your legacy to be? Now as an internist, as a pulmonologist, as a critical care doctor, I do not identify myself as those things. I am first and foremost a husband of my wife, Kim, a dad to our three daughters, a son to my mom, Diana, who now has dementia. She got it during COVID, and to my family, my siblings, I'm a brother. In this talk today, I'm going to use the power of human story, and I'm going to tell you many stories and data to address this topic of humanism and science as a way through what we suffered from during the pandemic. And the last thing I want to say is that I consider myself, and what I want to be, is a grateful servant of other people. And so I am thankful today to be here with you to share these human stories, and I don't know if this is going to be helpful or not. And as I said, I never have done this before, but I'm not going to use slides. I've just got notes up here to go through, and let's take it away. So I've been a physician for 30 years, and I was really ticking along and thinking I was having a great time doing it until COVID. And when COVID hit, there were times when I realized, as I was there with my patients, that I wanted to quit. I didn't want to do it anymore. And that was a very hard thing for me to face, to consider that this thing that I loved so much would not give me the joy that I had always had in the past. And I remember one day, I was outside of a man's room, his name is Fred Reyes. One disclosure I will say is that I have signed written permission from each of the patient's stories that I'm going to tell you today. To use their story, their names, I'm going to read to you from some stories in this book that I wrote called Every Deep Drawn Breath. I do not make any money off this book. I'm not hawking the book. It's every penny from this book, including the book advance and the proceeds in the book, go back to patients and families, by the way. This is, we've created an endowment to hire social workers to help people who are suffering go through disability processes, insurance. We have support groups for them so that they can pick up the pieces of their lives. And that's what we're doing with this book, Every Deep Drawn Breath. So Fred Reyes is a Hispanic man who had COVID. He was in our COVID ICU in the corner room. And his wife was begging me to get in that room. She was not allowed. We had no visitation at the time. She does eventually become the very first family visitor during COVID. So I'm glad, ultimately, I was able to help this dream of hers become true. But on that day, I was rounding with the nurse practitioners and the whole ICU team. And I'll never forget it. I thought to myself, oh, my gosh, it's 1990. I've gone back in time. And I am living back again the way that I practiced medicine 30 years ago. This man's on a heavy benzo drip. He's completely comatose. His family's not allowed. He's treated as if he's an inanimate object. There's something so wrong about this. And I had been working through the pain and the shame and the guilt of that decades earlier. And I found myself back in that same spot again. And it was very difficult. And I am a flawed person who thinks that I shouldn't have flaws. And in fact, shame, I think, stands for should have mastered everything. Should have mastered everything. That's the way I live my life, is that I think that I should have mastered everything. Even though on paper, and it's extremely evident all day long in my life, that I make all these mistakes all day long, I still carry too much perfectionism into my daily activities. And it's something I'm working on. But in order to get through all this with COVID, I found myself at a very weak point in my professional life and in my personal life. And I will just go out on a limb here and tell you that I actually have acquired three different counselors that I still have in my life right now to help me process all of this. And if we're going to talk about wisdom, humility, and compassion, which are the three words of the day for this talk, I'm going to tell you that these counselors have been a source of these three, we'll call them virtues, in my life because I was in a drought. I was empty and a couple of friends of mine actually took their life during COVID. And it was a very difficult time to process all this. And now where I'm going is that I've come to be able to process grief and have happiness again in my life and have those two things sit side by side. And what I'd like to do now is use some human stories to tell you about this process. And I'm going to start by going backwards in time to a patient of mine whose name was Marcus Cobb. Marcus was a man who came to me blue. He was cyanotic from eisenmingers. He had this intracardiac defect. He was told he would never live until he was 10. And he came to me in his mid-20s. I'd recently been training as a lung transplant pulmonologist when Marcus came to see me. And this crazy thing happened, which I'm about to describe to you. As I was talking to Marcus, having finished my fellowship at Barnes-Jewish in lung transplant, thinking that I've got everything together externally, I've got all this packaging, and as a physician, I've had, you know, 15 years of training, et cetera, in college, medical school, residency, fellowship, and this other fellowship in transplant. And as I was talking to Marcus and he was describing his life and how it was getting more and more severely endangered, he was having more ankle swelling, more heart failure, I started having this intense insecurity with Marcus. And this has never happened to me before or since, but on this day, I started sweating. And when I was there with Marcus, I started sweating more and more, and I was pouring sweat from my face. My shirt was getting dark blue from light blue. And his wife, Donita, and his children, Ariel, and Ty, and Lacey, and Jay, were all sitting there in the room, and I know they were looking at me going, what is going wrong with this doctor? Like, what is happening here? This guy is like falling apart right here in the exam room, and I couldn't get control of it. And I'll never forget, I felt like I was Albert Brooks on broadcast news, for any of you who may remember this movie. It was a 1987 movie, and this guy just like broke down with this intense amount of sweating, and that's what I was doing that day. As I left the room, I thought to myself, well, what just happened to me, and why? Did I make a mistake in revealing too much about myself? Did I show myself to be obviously too vulnerable, but I didn't even know why it had happened? To fully understand it, we have to go back even further in my life to when I was a medical student, because this is how I entered the world of medicine, was through the eyes of a woman named Ruthie the Duck Lady. And Ruthie's situation was very unusual. I'd seen her all the time in the French Quarter. She and I ran into one another 10, 15 times just outside of the field of medicine, and on this particular night, she came into the ER, and I was her doctor. I'm going to read to you. It was almost sunrise, and my shift was nearly over. A young man's leg fractured a set, and I'd be done. I stretched and looked up, and there in the trauma bay was Ruthie the Duck Lady, her dirty white duck quacking from a shoebox, its neck poking through a hole in the worn cardboard top. Ruthie was a local legend, a tourist attraction, and I'd spotted her and her duck many times in the French Quarter, but this was the first time seeing her here in the hospital. Blood dripped down Ruthie's split brow. Thugs had beaten her, and she had, like so many others in New Orleans, when a medical issue arose, trekked over to Charity Hospital to see us. I got right to work, cleaning her wounds and asking a jillion long-wondered questions as I stitched her up, my voice raised above the honking of her duck. When we were done, she handed me the duck in a box and danced a frenzied jig of thanks for all of us in the emergency room, her legs flying out like a Cossack's doing the hopak, and I rushed to join in. I'd been doing this dance since my college days, although never before with a duck in my hands. We all laughed together, only at Charity. There was no thought of paperwork. In all my years there, I never saw anyone turned away, regardless of insurance status or financial means. Some payments came to us in canisters of crawfish etouffee, bulled crabs, or Spicen, Cajun, and Dewey in styrofoam coolers. As Ruthie left, the new day's sun slipped through the sliding glass doors and more sick folks streamed in. That to me was complete excitement, total exhilaration. A woman in suffering came to me, I was able to fix her, it was fun, it was neat, there was no downside to it, and I thought, wow, medicine is everything I wanted it to be. And then the next patient I had was Cerebolic. Cerebolic was from a poor section of town called the Ninth Ward. She'd grown up watching the Mississippi River and the boats going up and down and had dreams of going places. And she had a baby, and she came into Charity Hospital with a peripartum cardiomyopathy, and I was dialing her dopamine, we didn't have fancy drips back then, I was dialing and counting the drops to get her dopamine adjusted so that she wouldn't stay in shock, and she died in my arms. She died in my arms, and I was so confused, to go from Ruthie to this, and I thought, you know, one of the reasons she died is we don't have enough technology here. The technology's just not enough at Charity Hospital, I've got to go get more technology. So I left there to do my internship, my residency, and was with all the bells and whistles and doing what I considered modern day critical care, this is what I want to do, I'm going to go into this field, and I was gifted to take care of this woman named Teresa Martin. Teresa was in her mid-twenties, same age as Sarah Bollack and same age as me, and we put her on the blower, she was on inverse ratio ventilation, she was paralyzed, sedated, all the textbook things that the article said to do, we did them for her, and we saved her life. It was not a repeat of Sarah Bollack, this time this extremely old woman made it and got out of the hospital, and I thought, wow, I've arrived, I'm this great doctor now, and I know how to keep people alive no matter what, and then several months later, I had my very first ever post-ICU clinic, and I don't know what made me do it, but I just felt like I wanted to see Teresa again, but I wanted to see her for egotistical reasons, to pump myself up, because I wanted a high-five from this woman and say, Dr. West, you're the best, you got me back this life I wanted. This was 1990, so many of you were not even born yet probably. And Teresa wheeled in, her mother pushing her in a wheelchair, with bags under her eyes, she looked terrible, and her mother said, why can't she bend her arms at the elbows or move her shoulders? Our mom looked drained, more tired even than when she visited her daughter in the hospital. We ran through a litany of other problems that Teresa was having. She couldn't swallow properly, or sleep, or go to the bathroom alone. She couldn't shower or dress herself. She could walk only a few steps at a time, and stares were impossible. Think in your heart right now of COVID survivors, think of the people and what we did to them during COVID, and this is their life after COVID too. So I did some x-rays of her to figure out what was going on with her joints. She had rocks in her elbows, shoulders, and knees. She had heterotopic ossification. It's a condition of too much inflammation and immobility where calcification occurs in the joints. And I showed these x-rays to Teresa, and she just had a blank stare on her face, like something was wrong with her. She wasn't engaging. So she didn't react to the disturbing images, but her mother nodded in affirmation, as if she now had the permission to talk about her other concerns. She told me Teresa's brain wasn't working properly, that she would forget things now, people's names, that she'd grown afraid. Miss Martin stopped and shifted in her seat, Dr. West, she's a completely different person now. She glanced at her daughter sitting next to her and sighed. I'll never forget that day. That was my first patient that I ever saw after the ICU, and it destroyed my idea of who I was as a physician. Now we know that she had post-intensive care syndrome, but we didn't have a term for that for another two decades. So I had no idea what that was, but I became obsessed with getting people off of the ventilator. So I set up a program, a study, if you will, that would randomize patients to a ventilator weaning protocol or not, and it worked. We published it in the New England Journal in 1996. This was the SBT study, spontaneous breathing trials. Four years later, J.P. Kress published his spontaneous awakening trial study, and this became the beginning of the ABCDEF bundle. At the time, however, I was really still under formation as a person and as a physician. And so I want to complete the story of Marcus Cobb because I think it is instructive about how I was to change and how Marcus was gifting me what I sought. That sweating experience with Marcus created a crisis in confidence for me. I felt so comfortable in transplant with the team I had worked with that I thought that everything would be right when I started meeting patients who needed lungs. I wanted to be in the trenches with my patients, but I wasn't convinced I was the right person anymore. I remember the ideals I'd had in medical school. My roommate, Darren Portnoy, went on to become president of Doctors Without Borders. He was doing TB work in Uzbekistan, and here I was having done this training but finding, you know, maybe I'm not prepared for any of this. And so I started doing a lot of outside of medical reading. I read Ignatius of Loyola's Spiritual Exercises. He talks in there about how we often fail to reach fulfillment in human relationships. And this is what I realized I was doing with my ICU patients, is that I wasn't entering into their chaos. I was treating them as though they were, as Martin Buber would put it, an I-it relationship, not an I-thou. And this Buber I-it was treating them as inanimate objects. And I started to see all these flaws in critical care and flaws in myself, and it was difficult, very difficult. My mother, as a second-year med student, had given me this book called Equanimitas. It's the Latin word for equanimity by Osler, Sir William Osler. And in his 1890 address to the University of Pennsylvania, he talks about this even-keeledness that we want as physicians, as healthcare professionals, so that we're not hurt, we're not injured, and, you know, yet this topic is about burnout, right? Burnout implies self-injury. Osler was advising to not dive deep into your patient's relationships, but he was doing it, he was describing what became, what was a virtuous approach to this, only I, in my aggressiveness, like I typically do in life, I overdid it. And I created what would have been an asset if I did it the way Osler said, I created that asset into a liability. So my patients were cheated out of a healer, and I was cheated out of the richness of the interactions that I wanted as a physician. I carried around in my pocket this quote. It was by Aristotle. It said, deep voice, slow speech, tight compartments, but the mind directed intensely at hand. It was Osler's version of that. And I thought, you know, with this, I'm equipped, I'm armed, I'm ready. But then that thing happened with Marcus, and my wife wanted to move, she wanted to go to a different place, she got a job, we were in North Carolina, and she got a job in Tennessee at Vanderbilt, and so I moved with her, obviously, and one day I walked in the clinic at Vanderbilt, and Marcus and his wife, Danita, were in the room. I was stunned. I said to them, why did you follow me here? Because I made a total ass out of myself with you that day when I sweated. And they said, when you showed us that vulnerability, we knew that you had to be Marcus's doctor. And so they had driven seven hours, eight hours from North Carolina to be there at the Vanderbilt Lung Transplant Clinic, and he got his transplant, and it was incredible. He was jumping out of airplanes, he was hiking in the Appalachian Mountains. He had this incredible relationship with his children, it was wonderful to see all this happen, and he gifted to me wisdom, humility, and compassion. I needed them, and my patient gave them to me. And I'm going to tell you the closure of the story with Marcus, it went like this. As we knew what happened, all good things fade. And this is most certainly true for the tenure of organs at the whim of a stubborn immune system. Several years later, I was about to give a lecture to a few hundred physicians at a medical conference in San Diego, when my phone rang. It was Danita. Wes, Marcus is dying, and he's asking for you. Without hesitation, I apologized to the meeting organizers, and I got my bag, and I remember running to the airport to catch the last plane back to Nashville. And as I watched the states pass away, and Grand Canyon, and go over all of that, I kept thinking to myself, I hope I make it. I hope I make it. And when I got off the airplane in Nashville, I called Danita, and I asked her, what room are you in? She said, the fifth floor, room eight. I got out of that elevator, I beelined to the room, and there were seven people in a circle around Marcus, with one space missing at his right shoulder. My mother had told me, Wes at the bedside, put your hand on people's right shoulder, and act as if they are the only person that matters to you in the world. And I filled in that circle, I put my hand on his shoulder, he looked at me and said, I knew you'd make it, and then he died. Just that fast. 10, 15 seconds, I was there, and he died. So back to humility, wisdom, and compassion, I want to talk about these for just a moment. Humility, I find there are two types. One is involuntary, and one is voluntary. The voluntary type, I must be very wary of. It's something that makes me feel self-righteous, I have to guard against that. The involuntary type is extremely helpful to me. COVID was an involuntary humiliation for many of us as physicians, as nurses, as pharmacists, we didn't know what was going on, we didn't have answers, we wanted answers, we knew our patients were dying alone, we knew it wasn't right, and yet we were doing it anyway. This was an involuntary humiliation, and it stunned me how quickly our house of cards fell down. Pre-COVID, we were hitting the ABCDEF bundle at about 70 to 80% compliance in many hospitals, some were 60, 50, whatever. But during COVID, we did a repeat investigation of that, and it was 10 to 20% all over the world. The house of cards just crumbled, and that was also humiliating. And as a physician and investigator who'd been working in this area for 20 years, that hurt. And I thought, wow, how weak what we generated was if it could fall that quickly. And so I started using what I call the two eyes of humility. One eye is towards my own nothingness, and the second eye is towards my desire to be of service to other people. And once I was able to acknowledge my own smallness in this COVID pandemic, and say I've got to get back to that second eye of humility, that desire to serve others, I started finding my way again. But this dark period is hurtful, and it's not beautiful. And I'm asking you to be thinking about maybe what you went through. And it may not have even been on the front lines at the bedside in the ICU. It could have been with your family members out in society, or it could have been an anti-vaxxer or somebody yelling at you or spitting at you, and maybe you argue with them about science. I don't know what your experience is, but I'm here to try and provoke us to think about what the experience was. For me, I realized that the nerve of my pride had to be cut. Another way of thinking about it was that the tree, the products of any tree are what they are. An apple tree produces apples, an orange tree produces oranges. If I wanted my medicine tree to produce the right fruit, then I needed to somehow cut those roots of pride, take an ax to them, and start over. And really try and figure out what kind of physician do I want to be? And that became my recovery. I started listening more. I think of that Cahill-Gabron quote when I think about people who were yelling at us about science and such, that I learned silence from the talkative. I learned tolerance from the intolerant. I learned kindness from the unkind. So these people that I disagreed with during the pandemic became my teachers. And silent and listen have the exact same letters. So I just started, for the first time in my life, listening better. And I found a way forward. Moving on towards wisdom, I think wisdom is the ability to see how my actions here in the now will affect future actions, future situations. I started realizing that it took me the eyes of humility, these eyeglasses of my own recovery as a physician, really, to learn to live in the moment. You know, I don't know if you like Ted Lasso or not, but Ted Lasso says, live in the moment, that's why they call it a present. And I found, as I was working through all this with my counselors, that I was living most of my life in the past or the future. Most of my days I was spending worrying about something I'd done or anticipating fearfully what was gonna happen in the future. And once I started living in the present moment and letting my patients teach me to do that, because they really were having to do that out of necessity, I started feeling better. I started feeling more whole. And I started wanting to be a doctor again. And that was a really good feeling. I don't really understand the process of it, but I know that over the months and the past couple of years, that's what I had to go through. So how does this apply to you? And how does it apply to us in medicine at this time? I think in medicine, we have some big problems. I think we're very myopic, we're short-sighted. I think we've created some circumstances in the way we care for other people, which I call a malignant normality. I'll come back to that in a moment. We think science and technology give us the license to treat people any way that we want. And that's not true. For example, silencing Teresa Martin in the way I did or all my COVID patients, Fred Reyes, for example, is undignified for them. And it takes away their voice. And by me thinking that I have all the answers and therefore I have license to treat them any way I want, that's really a form of epistemic injustice. Episteme means knowledge. So epistemic injustice is when I think that I have this knowledge and therefore I can act however I want towards somebody, instead of silencing them, which is a second form of injustice. That's testimonial injustice. And that's not really the way that I want to operate as a physician. I want to break down injustices, not build them up. So this malignant normality, I describe it as, I wrote in every deep drawn breath, as physicians, we generally think we are most likely to harm our patients with an errant scalpel, a central line placement gone awry, or a medication error. But sometimes we cause more harm by blindly accepting usual practice as best practice. Familiarity breeds content. And I believe this happened in critical care. I think that the familiar way that we handle patients in critical illness with the intended benevolence of sparing them from awareness of what we're doing, turns out, and we have data now, and I'll share it with you now, that it is not actually beneficent. It's not creating goodness. There's a lot of maleficence in what we do to other people. You know, let's take for a moment, a quote, and I have it at the beginning of one of the chapters in EDDB, this is actually not from our pandemic, our viral pandemic, but from the 1918 flu. Many of you know the writer, Catherine Ann Porter, and in Pale Horse, Pale Rider, this is the way she describes delirium. Her mind tottered and slithered again, broke from its foundation, and spun like a cast wheel in a ditch. She sank easily through the deeps and deeps of darkness, until she lay like a stone at the farthest bottom of life. The stench of corruption filled her nostrils. She opened her eyes and saw pale light through a coarse white cloth over her face, knew that the smell of death was in her own body, and struggled to lift her hand. And that's what I have done to people sometimes, because I wanted to keep the sheets tidy on the bed. I didn't want them rummaging around. I didn't want them to pull any tea tube out or come off the ventilator or before I thought they were ready. But the way that the medical discovery went was that, and this is just a quick delirium history, was that after JP and I published that SAT-SBT study, we started analyzing our databases, and we realized that what was keeping people back was their brain, not the neck down part. So I had anticipated that the clavicle, the diaphragm portion, was where all the action was. But when we started inventing things like the CAM-ICU and validating them, and then the RAS and validating it, and then using those tools through these JAMA papers that we had to prove that delirium was an independent predictor of death, it started waking our eyes up, waking our mind up to the notion that could we be creating an intense amount of harm for other people? Well, we then designed the ABC study where we put the SAT and the SBT together, and we proved for the first time in critical care in 2008 that you could save lives by reducing sedation. And we proved in 2007, the year before that, that by avoiding benzodiazepines, you could have people's brains operate more in the normal sphere than in the delirium or the comasphere on their brain totem pole. We could get them out of these ditches, this stench of corruption that Katherine Ann Porter talked about up into normal brain function. And then we started putting all that together into a safety bundle, which went from the ABCs to add delirium to the ABCD, and then add E for early mobility, and then I was humbled again. I was asked by SCCM to be the PI of the ICU Liberation Collaborative, and so I got on an airplane and I flew out to Palo Alto, where Gordon Moore, the founder of Intel, had his foundation with his wife, Betty. And we told them very proudly, once again, that nerve of pride was not cut. It's still not, but I'm trying. We have a bundle called the ABCDEs based on about 30 New England Journal and JAMA and Lancet papers that we think can be the answer to the problem you had, sir. He had gone into the ICU and he'd had delirium, this billionaire, and his family was not allowed to be with him at the time. And so Gordon Moore said, no money for you, like Seinfeld, no soup for you. And we said, why not? You were gonna give us millions of dollars, let's go. He said, no, there's no family involved in this. We thought, no family. Well, A, B, C, D, E, F. Let's add the F. And I didn't know at the time, but there were New England Journal papers about the brilliance of family incorporation into the ICU too in JAMA papers. So we added the F and that became the completion of the bundle. We then went on and Mary Ann Barnes Daly studied 6,000 people after Michelle Ballas had studied in her single center study in Nebraska. And the 6,000 people proved not only did the bundle work, but there was a dose response. And in that dose response, the more you engaged, the better the patients did in terms of survival and length of stay and delirium and coma reductions. Then the SCCM conducted their own study of this called ICU Liberation. And 15,000 people were run through the bundle at 70 ICUs around the country. And we saw, once again, consistency. And we thought we had it. And then between 2015 and 2020, before the pandemic hit, we, for the first time in 20 years, saw delirium cut in half in numerous multicenter trials. Delirium had always been a steady rock solid steady, 70% in ICU mechanically ventilated patients. And between 2015 and 2020, that delirium rate, that pale horse, pale rider, stench of corruption went from 70 down to 35 to 40%. Remarkable consistency and better. And then COVID hit. And we found 80, 90% benzos back. We did our COVID D study. We found that the two big predictors of delirium were overuse of benzos and underuse of family. Is that compassionate? Is it compassionate to go back 25, 30 years in data and not use the science? And does it lock people into some altered mindset where they can't find their way forward? As Viktor Frankl said, if a man or a woman has a why to live, he or she can get by with almost any how. But if you remove somebody's brain, they can't remember their why. And if their family's not there at their bedside, nobody's there to remind them of their why. Was it compassionate? So back to compassion then. Compassion comes from Latin, compasio, to suffer with. It reminds me of the African word Ubuntu. I love Ubuntu. Desmond Tutu said, you'll know Ubuntu when you see it. Ubuntu is a state of mind where you're not operating for you or for me, but it becomes a we. And it's a universal bond of compassion and humanism. That's what Ubuntu is. And I think that we have to harness Ubuntu or compassion in our lives as healthcare professionals to find our way forward. And I'm gonna tell you a short story of a person who did that. My friend and an iconic figure in critical care, Dr. Deborah Cooke. Deborah Cooke has done some of the greatest landmark clinical trials in all of critical care. And in 2012, she organized a forum on the last 100 days of life. And at that forum, the very famous bioethicist Peter Singer was present, and in the closing remarks, he challenged people to come up with a way forward. And I write here, Deborah was a little panicked by this, but from her words that day, she created the Three Wishes Project, a way to personalize death in the ICU, bringing serenity to the final days of a patient's life, ease grieving for family members, and enable clinicians to develop a deeper sense of vocation. Notice how that was bi-directional, that the patients and families get better treated and find wholeness, but so do we. Just by asking somebody, what three wishes would you want? In my own life as a physician, I incorporate this into my practice daily, and Mr. D was on the ventilator for many days, we got him off the ventilator one day, and I said to Mr. D, not what's the matter with you, Mr. D, but what matters to you? Switching that preposition from with to to. What matters to you? And he said, my wife, Wanda, and I want a beer. And he had Wanda tattooed on his fingers, W-A-N-D-A, and I got her at his bedside, and I gave a tin to the nurses and said, go get him a tall boy. And they did, and he sipped it through a straw, and one of the nurses said, Wes, why today? Why don't we do this tomorrow? And in a rare moment of clarity, I said, we may not have tomorrow. And I walked in the ICU the next day, and his bed was empty. Mr. D died that night. If it had not been for Debra Cook teaching me the three wishes, and for the bundle, by the way, which allowed his brain to work, we would not have had that moment with him. That took courage for Debra Cook to do that, you know? She had to have a lot of courage to stand up against people who thought that science is enough, and to tell them, no, it's not. And compassion can be taught, by the way. The literature behind these warm and fuzzy topics, compassion, wisdom, humility, and medicine, is growing by leaps and bounds. And if we're going to acknowledge the scientific literature behind central lines and fluid resuscitation and ventilator management, let's also acknowledge the literature in these more humanistic areas of what we're doing, and realize that we cannot practice medicine with science alone. We have to have touch first, and technology second. You know, W.E. Deming said, every system is perfectly designed to get the results it gets. And I love Deming, and he's right. Our system will produce the fruit that we design it to produce. So during COVID, if we do deep sedation, immobilization, and no families, we're gonna produce some pretty bad fruit. And there will be people buried in the ground because they lost their will to live, and didn't have a why. Deming also said, in God we trust, all others bring data. I love that quote. We have the data. We generated the data over 20 years of work. The ABCDF bundle has 40 New England Journal, JAMA, and Lancet papers behind it, and over 30,000 patients worth of data, and yet we're not doing it right now. So we have to figure out how to get it back. I think that we should be amounting an assault on inappropriate care. Do you? And what would that assault look like? In your own life, as a bedside clinician, what would be a way of correcting the errors that we accrued during COVID? I love this expression, the future belongs to the discontent. We need to be discontent about medicine right now because that will provide us the impetus to change. Our ancient tradition of medicine has a certain innate internal morality. It's numinous. We know it's there. It's toward the collective good of serving people who are vulnerable at a crisis point in their life. And who could be more vulnerable in our lives in the ICU than somebody who's immobilized on a ventilator and unable to speak, who's lost their voice? I really do believe, as I think about what pushes us forward in medicine, that the loftiest, most marvelous realities of what I encounter each day are simply the people that I meet. It's these people that I get to make eye contact with and touch and hold their hands and find out their stories. And in EDDB, Every Deep Drawn Breath, I talk about the Spanish phrase, cada persona es un mundo. Each person is a world. And each of us is a world. The complicated things we've gone through, each of us carrying around internal sufferings that are not manifested outwardly so that people don't know what we're carrying around. This drives me and should hopefully drive all of us to improve the quality of the care for these incredible, lofty, beautiful people that we get to serve. And so my closing comments, and I'd love Q&A after that, are that in order to be a servant leader, we have to have an aim for our goals. But the aim isn't enough. We have to have a system, a methodology. And so what quality improvement has, and I wrote down six steps here, we have to begin with knowledge. And I've provided you the content that there's a ton of knowledge in this area. We have to measure things. You can't just talk about it, you need to measure it and see what kind of compliance we have in the ICUs. Are we doing that? Are you doing that? We have to have periods of trial and error. The way that we change culture is not overnight. It's not by climbing Mount Everest, it's by doing small PDSA, Plan, Do, Study, Act, cycles of quality improvement. I like the expression of the IHI, what can I do by Tuesday? Fourth, we have to have teams. Everybody wants to help. Bring them in. Let them be the builders of your quality improvement. Leaders lead by listening. I already mentioned listen and silent have the exact same letters. I don't think that's a coincidence. And the last step in my quality improvement path is to kneel. My residents laugh at me because I'm so often kneeling at the bedside, but I do it on purpose because I wanna make the patients bigger and me smaller. If I can physically make myself on their level or lower, then not only can I see them at level, but I remind myself I'm not just towering over them as some controller of the circumstance. I already mentioned to you that I know now that I can't control the circumstances. One more Deming quote. A lot of people say that Deming said, if you can't measure it, you can't manage it. That's not the quote. It's a misquote. The full quote was it's wrong to suppose that if you can't manage it, you can't measure it, you can't manage it. What he was saying was there are things you can't measure that are extremely important to manage. And this is my closing is that these are the intangibles. These are the intangibles we have to deal with. And I find them in seeking wisdom, humility, and compassion. It's touch first, technology second. As I said earlier, it's eye contact. Compassion brings me to a place of desiring mercy. And if I wanna provide mercy, my working definition of that is to dive into the chaos of another person's life and provide lifting and healing. The way I used to be as a doctor, I was just diving into their chaos. I wasn't providing lifting and healing. The A, B, C, D, E, F bundle, the A to F bundle is my key to providing the lifting and healing. Whether they're gonna survive or die, that's where the healing occurs. So I'm gonna close with one last story. And it's about Shonda, my patient who had HLH. She was a beautiful young woman. And I'm just gonna read you the last two paragraphs of the story. When she had HLH, she was dying. It was happening very rapidly. She gave me what Marcus Cobb gave me. Even though I wanted to serve her, she served me instead. And as she got sicker and sicker, and we started wheeling her outside to be with her nieces and nephews, she was only 18 years old, I wrote the following in memory. Moment by moment, I tried to approach the sorrow of her dying with an appreciation for spending time with her. In the past, I would have retreated, but this time, I plunged in. Her bravery gave me the courage to be vulnerable, to shed my doctor's skin and be wholly human. As her death grew closer, her loved ones sat by her side, still telling stories, still threading their lives to hers. There was love and hope. Sadness bravely held at bay for a moment. Two hours after Shonda took her last breath, I was walking by her room on the way through the busy ICU, where so many lives still hung in the balance. I felt drawn inside, and paddling across the floor, I was struck by the silence. The machines were quiet. I peered behind the dividing curtain, expecting the room to be empty. Instead, her figure still lay there on the bed beneath the sheet. I placed a hand on her arm and looked out the large window into the waning sunlight. We had not been doctor and patient, but people, two humans, small in the big picture. And tears of grief ran down my face. Gratitude, too, for the way she taught me to hold on to the now. I thanked Shonda for the privilege of accompanying her through illness and into the beautiful forever. And those questions again, who are you? Vocationally, what do you want your legacy to be? And what are your three wishes? Thanks, and I'd love any Q&A you have, or disagreements or agreements, and I appreciate your time today. Appreciate you. Thank you.

COVID-19

pain

compassion

vulnerability

patient experiences

Ubuntu

medicine

compassion in healthcare

legacy