Pandemic or no, most Americans will, in their lifetime, be a patient in an intensive care unit, which makes Wes Ely’s “Every Deep-Drawn Breath: A Critical Care Doctor on Healing, Recovery, and Transforming Medicine in the ICU” a timely book, its message an urgent one.
Ely is a longtime critical care physician and professor of medicine at Vanderbilt University. He depicts in brushstrokes broad and fine the horror that trails after many people once they leave the ICU.
Ely reports that in the United States and Europe alone, tens of millions of people are admitted annually to ICUs. But what doctors might point to as a good outcome — i.e. the patient lived — becomes a protracted nightmare of impaired cognition, depression and assorted other problems wholly unrelated to what landed them in the ICU in the first place.
As Ely puts it in his author’s note, medicine must be more than benevolent. “The target principle of medicine must be a higher standard: beneficence,” he writes. “Doing good.”
Ely recounts the torture he has witnessed, as patients choke on air, panicked, fighting the ventilator. “It’s only possible to endure this treatment when deeply sedated and paralyzed,” he writes.
His central argument is this: the classic “sedate and immobilize” standard of care for ICU patients on ventilators should be discarded, and a patient-centered, comprehensive, evidence-based approach should be taken when treating all critically ill patients.
Much of the book tells the stories of individual patients with PICS, each more wrenching than the last. Sarah Beth Miller, an engineer at AT&T whose life was humming along until 2002 when she suddenly became critically ill. She was raced to the ICU and placed on life support, attached to a ventilator and sedated. She spent more than five weeks in the ICU, where she fluctuated between coma, delirium, hallucination, fear and confusion. When she finally returned to work, she turned on her computer and although she was recognized as an expert in complicated engineering concepts, she could barely remember what her job was. A brain scan showed such deterioration that the neuroradiologist said it looked like the MRI of a demented 85-year-old. Sarah Beth was 52.
Richard, a minister with a full life, developed a serious lung infection after routine knee surgery in 2008, and was in the ICU, on a ventilator and intubated, for four weeks. After he was discharged, his cognitive abilities diminished to the point he was forced to retire at age 53, and he remains so chronically fatigued it can take him hours to muster the energy to shower.
Ely goes well beyond the anecdotes, to findings of his own research and that of others: 80 percent of patients suffered delirium while in the ICU and 10 percent suffered it afterward. One in five ICU survivors developed PICS, and one in three develops depression and anxiety. More than half of patients with PICS still haven’t returned to work a year after their ICU discharge. So severe can the symptoms be that people have wondered if they’d rather not have survived.
When it comes to ordering heavy sedation, Ely writes, he is as guilty as any of his peers. Still worse, he writes, is the role sedation plays in decisions surrounding life support. He cites a study out of Canada of 851 patients on ventilators. Only 1 in 10 had a do not resuscitate (DNR) order on admission to the ICU. “I knew that a heavily sedated patient deep in a coma looked dead, and this absolutely had to play a part in a doctor’s thoughts,” he acknowledges. Physicians’ predictions about a patient’s outcome then influence decisions about resuscitation. By the time of death, 9 out of 10 had been designated DNR. “I thought about how many patients I may have inadvertently committed to an early death due to my use, or overuse, of sedation,” Ely writes.
Ely’s contrition is real. “As doctors, we thought we were doing our jobs,” he writes. “Our only goal was to help our patients, yet now we see the harm that happened, too.”
Ventilation, sedation and pain medications are necessary, but Ely argues for a new set of best practices, which include taking patients off ventilators for a few minutes a day, acknowledging delirium as a medical complication to treat rather than accepting it as inevitable, and establishing support groups for ICU survivors.
Ely’s hope is that ICUs can become more humane, with physicians treating the patient, not just the disease. Perhaps one lesson to draw from the pandemic, with help from books like this one, is that the ICU experience can be changed for the better, and when survivors are discharged, the celebration that accompanies their passage through the hospital lobby indeed marks the resumption of life as they knew it.
Every Deep-Drawn Breath
A Critical Care Doctor on Healing, Recovery, and Transforming Medicine in the ICU
By Wes Ely
332 pp. $27