In Every Deep-Drawn Breath: A Critical Care Doctor on Healing, Recovery, and Transforming Medicine in the ICU, pulmonary and critical care specialist Dr. Wes Ely chronicles his career-long “journey back to [his] original oath – first do no harm.”
During his first rotation in critical care, Ely adhered to accepted ICU protocols, using endless arrays of interventions to “push back against death” for his medically sedated patients. While these heroic efforts often cured a patient’s original illness, Ely soon witnessed how a number of patients “acquired completely different ailments” after their ICU care. For some, a combination of debilitating physical, cognitive, or mental health complications, now collectively known as post-intensive care syndrome (PICS), would encroach on, or even devastate, their ability to carry out the basic activities from their pre-ICU lives.
In the ensuing years, Ely would uncover new details about the life-changing effects wrought by the unfettered use of heavy medication, ventilation, and sedation on ICU patients. In response to this research, Ely helped create more cost effective, less intrusive, more patient-centric protocols for ICU care, which benefit patients and their families, and reinvigorate medical personnel, approximately 50 percent of whom are estimated to experience physician burnout.
Every Deep-Drawn Breath is punctuated with compelling stories about the humans involved in the history of medical innovation; of the nurses and doctors who were Ely’s contemporary pioneers in returning humanity to the ICU; and of Ely’s patients’ struggles with delirium and PICS. Ely also writes openly and honestly about his personal and professional moments of reckoning, lending an important undercurrent of commentary on the grace humans have to rectify their past flaws.
A2F and Seeing the Whole Patient
Often presenting as hallucinations, nightmares, delusions, or difficulty concentrating, delirium has long been considered an unfortunate and unavoidable side effect of intensive care. To challenge this notion, Ely conducted numerous delirium studies, the first of which quantified delirium’s prevalence. He found that 82 percent of his ICU patients developed delirium, and had triple the risk of dying within six months compared with patients who did not experience delirium.
Further studies homed in on the aspects of critical care that caused delirium, such as the overuse of benzodiazepines and overreliance on ventilators for patients who could breathe on their own. The changes Ely’s studies suggested would not only reduce delirium, but also save patients thousands of dollars on care – savings that could cut a chunk from the “over $100 billion” Ely says is spent on critical care in the United States annually.
The protocol Ely developed to counteract entrenched ICU procedures was informed by his extensive research into standards of intensive care around the country and the world, his own harrowing “view of the left side of the [ICU] bed” when his daughter experienced a skull fracture, and lessons from a period working in transplant, which taught Ely how to “enter patients’ lives” to become “a better doctor.”
Known as the A2F bundle, the mnemonic ABCDEF reminds physicians to manage analgesia (pain), check for a patient’s ability to breathe on her own, reflect on the choice of medications to avoid unnecessary benzodiazepine use, prevent delirium, promote exercise and mobility, and fully immerse the patient’s family in her care.
Along with other inexpensive efforts, like keeping an ICU diary to help a patient understand what transpired when they were in the ICU, ensuring patients’ sleep is minimally interrupted, or using math and word games to stimulate brain repair, the A2F bundle is making a significant boost for ICU survivors, “yield[ing] higher survival rates and more time free of coma and delirium.”
Ely strongly advocates the “need for more humanity in doctoring.” On this score, he urges physicians to “find…the person in the patient, using touch first and technology second.” He also suggests improved communication between doctors and patients, arguing that it has an “almost mystical” ability to bring “us to a place of charity an empathy that crosses cultural, social, and racial boundaries.”
These efforts are particularly vital when providing compassionate end-of-life care, which Ely writes is “not only better for patients, but also leads to significantly less burnout for doctors and nurses.” Ely shares several moving stories about providing end-of-life care that respects his patients’ spiritual and emotional needs, whether they are decorated veterans or prison inmates.
Of one patient who passed away while in his care, Ely writes:
We had not been doctor and patient, but people. Two humans, small in the big picture. Tears of grief ran down my face, and gratitude, too, for the way she taught me to hold on to the now. I thanked [her] for the privilege of accompanying her through illness into the beautiful forever.
COVID and PICS Backsliding
Every Deep-Drawn Breath arrives at a critical moment. The era of coronavirus saw many ICUs initially retreat to old practices, removing the human connections the A2F bundle had stressed, and causing ICUs across the country to “[become] delirium factories all over again.” Ely argues this has “launch[ed] an enduring public health crisis for a new wave of survivors.”
COVID ICU survivors and long-haul COVID sufferers can find support and solace in the book, and by looking into Ely’s team at the Vanderbilt University Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, which offers virtual and in-person PICS and delirium support.
“The average person,” Ely writes, “will have more than one ICU stay in their lifetime.” Every Deep-Drawn Breath will leave readers the knowledge to advocate for themselves and their family members during serious illness.
The book is also a call to arms for medical personnel against the devastation wrought by oversedation and excessive interventions. With its one-two punch of published delirium research and poignant anecdotes about patients whose lives have been affected by overzealous sedation and interventions, the book will be a tremendous resource for physicians who are interested in implementing — or returning to — the A2F bundle.
Ely writes that a “health-care army of sorts” was required when the A2F bundle was first introduced to hospitals around the world. With Every Deep-Drawn Breath, Ely is mobilizing an even larger army of medical practitioners, future patients, and caregivers who will understand the importance of creating a world marked by less delirium, and more moments of deep and meaningful connection between patients and their health care teams.
With its vivid observations and heartfelt tone, Every Deep-Drawn Breath is a joy to read. Ely’s passion for his patients leaps from the pages, inspiring readers to channel Ely’s humility and love for life to brighten the future of medicine, and mankind.