Love and Mercy in the ICU

“The Doctor’s Art” is a weekly podcast that explores what makes medicine meaningful, featuring profiles and stories from clinicians, patients, educators, leaders, and others working in healthcare. Listen and subscribe on Apple, Spotify, Amazon, Google, Stitcher, and Podchaser.

The ICU can be a traumatizing place for patients, who are frequently heavily sedated, rendered unable to speak by breathing tubes, isolated by family visit limitations, and sometimes even physically restrained. In fact, a significant proportion of patients discharged from the ICU later develop persistent cognitive impairments and physical disabilities.

Over the past 2 decades, Wes Ely, MD, has worked to improve the care of patients in the ICU, leading landmark studies resulting in the development of delirium prevention protocols that are now adopted in ICUs everywhere. Today, Ely co-directs the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University Medical Center in Nashville, Tennessee.

In this episode, Ely joins Henry Bair and Tyler Johnson, MD, to share his career-long fight to reform ICU medicine and recounts poignant stories that illuminate and elevate the humanity of patients amid the chaos of the ICU — and in the process discusses themes that seldom appear in contemporary medical discourse, such as love, beauty, and mercy.

In this episode, you will hear about:

• 2:33 How Ely discovered medicine as a calling while growing up in rural Louisiana
• 4:27 How a fascination with cardiopulmonary physiology, combined with an interest in patient relationships, led Ely to critical care medicine
• 6:31 A discussion of how patients in ICUs can often be “de-humanized”
• 10:40 A story from early in Ely’s career that illustrates “malignant normality” — when treatment norms lead to patient harm
• 13:27 A discussion of physician burnout and how the dehumanization of patients contributes to it
• 18:53 What Ely and his colleagues have learned through years of research about the harmful standard practices of ICU care
• 24:04 An explanation of the ABCDEF treatment bundle designed by Ely and his collaborators to improve outcomes in ICU patients
• 29:37 How Ely processes the guilt and shame he feels from the harm he inadvertently caused to patients early in his career
• 36:03 Reflections on how eye contact, physical touch, and openness of the heart are essential to good medicine
• 44:51 A discussion of how Ely’s spirituality has influenced his approach to patient care
• 50:45 What it means to provide healing when patients are facing serious illness, even at the end of life

Following is a partial transcript (note errors are possible):

Bair: Wes, thank you so much for taking the time to join us today and welcome to the show.

Ely: It’s my privilege, Henry, I appreciate you having me on. And you, too, Tyler.

Johnson: Thanks for being here.

Bair: You have had such an incredible career revolutionizing ICU medicine. But before we get to all of that, can you take us to the start and tell us how you first discovered a calling in medicine?

Ely: Thanks for asking that. I am so thankful just to be on this podcast, because when we talk about the doctor’s art, I think I got into it for the right reasons — for me anyway, personally — which was that my father had left us when I was little. I was being raised by my mother in the hot and dusty fields of Louisiana. I was, I had to be a farmer because we had no money. And I was trying to earn some money for our family. And I was around these amazing people in the fields. We had huge fields of 6,000 tomato plants and purple peas and watermelons and all this stuff. And all day long, we would either plant in the spring, or harvest this produce. And I got to know these men and women that we picked with all day long.

And at first, I thought I belonged with them. But I realized over time that they would not have really a way out from this area. They were going to be migrant workers. And that was their, that was their choice. But they also didn’t really have much of an option out. And they would, little things in their life medically would become big things. You know, cuts would become big abscesses and they’d lose teeth. And so I said, you know, maybe what if I was lucky enough to study science and medicine and I could be with these people as they were suffering and be present with them at the bedside, holding their hand, helping them through harder days. And that’s why I got into medicine. That was it. I wanted to serve these people and have a role in our relationship that I could be of service.

Johnson: You know, that calls to mind this kind of ideal of, I’m not saying that you even knew what it was at the time or that you necessarily planned to go into it, but that calls to mind this sort of ideal of the country family doctor, right? Who is there for every stage of life to take care of the baby when they’re born, and the old man or woman when he or she dies. And yet you ended up going into critical care medicine, which, in some ways, you could argue is pretty far on the other side of the spectrum from the sort of country family doctor. So how how did that shift come about? How did you end up going into critical care?

Ely: Yeah, along the way, I was actually going to be a family practice doctor and envisioned myself carrying a leather bag to their homes and such. What happened was I was working at UVA with this family practitioner named Louis Barnard. He was actually the first endowed chair of family practice in the country. And we would sit in his study at night and he would talk about his life in this field. And I kept telling him how fascinated I was about cardiopulmonary physiology. I just absolutely fell in love with Guyton’s textbook of heart and lung physiology, and it just, it got me so excited about the science of the way that the body worked.

And when I started going into the ICU at Charity Hospital in New Orleans, I not only loved the physiology, but I saw that these people were extremely scared. They were on death’s door having this unexpected circumstance in their life. And I thought, well, maybe if I both love the physiology of what we’re doing in the ICU and I can establish relationships with these people at this very, very vulnerable time in their life, that could be a melding of these two things.

And I’ll stop just by saying that in the next 5 years, what I learned was unexpected, was that the field was going into a direction that would prevent me from the very thing that I loved, which was prevent me from looking people in the eyes, talking to them, having a relationship with them, because the field was in the direction of deep sedation, in a coma, immobilized on a ventilator. But I didn’t know that at first.

For the full transcript, visit The Doctor’s Art.

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