>> Discharged from an ICU is not the end of intensive care.

Rather, it signals a change in the goals and setting in which care is delivered.

Stay with us as we talk with ICU recovery specialist Doctor Ashley Montgomery-Yates about Post-intensive care unit care.

Next on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a healthy Kentucky.

>> The Intensive Care unit, or ICU, is that place in the hospital where the sickest of the sick are sent.

Fortunately, we also find in the ICU the health care team that is up to the challenge.

Since the inception of ICUs more than 75 years ago, there have been many changes in the equipment, processes and personnel taking care of these critically ill patients.

Thanks to these changes, we have seen improved survival in patients admitted with organ failure, sepsis, or those who've undergone complex surgical procedures.

However, as the saying goes, no good deed goes unpunished.

And the same can be said about the successes of ICU care.

There are many long term complications that may develop following an extended stay in the ICU.

These may be physical, cognitive, or psychological, either alone or more commonly, in some combination.

Fortunately, just as there are specialists who provide care for the patients while in the intensive care unit, there's another health care team who provide care after discharge from the intensive care unit and the hospital, in effect, released from the intensive care unit is not the end of intensive care, but rather a shift in the environment in which it is provided and the goals that need to be met.

To discuss these points and more, we have as our guest today.

Doctor Ashley Montgomery-Yates.

Doctor Montgomery-Yates is a professor of Medicine and Senior Vice Chair, Department of Internal Medicine.

She graduated from the University of Kentucky College of Medicine and then did a residency in internal medicine, as well as fellowships in pulmonary and critical care medicine, also at the University of Kentucky.

She is currently the director of the ICU Recovery Clinic at the University of Kentucky.

Health Care doctor Montgomery-Yates Ashley.

Thank you for being with us today.

>> Thank you for having me.

>> I always like to ask people how you got number one.

What was the thing that got you into medicine?

And two, how did you land in the intensive care unit?

>> So I think I always, if you ask my parents, I always knew I wanted to be a physician.

My father was a physician, and I think on some level I enjoyed the connection that he had with people in my small Kentucky town and the role he sort of played in in health care and helping folks in, in that community.

Yeah, I was always a scientist and loved that part of understanding how things worked.

So I honestly went to medical school and thought I was going to be a primary care doctor because I really loved the whole patient wasn't a single organ system kind of girl and thought, that's what I'm going to do.

But I very quickly realized that that wasn't necessarily my calling.

I liked a little faster pace, I liked, I enjoyed what people were sick.

I enjoyed some of the intense relationships and realized the ICU was probably where I was being called.

The procedural pieces, the the hours and schedules and sort of that environment just fit with with me and who I was.

And then while I was in training, I think I, I gravitated toward.

A certain patient population in my clinic and began to understand that there was a gap between patients leaving the hospital after the ICU and getting back home to their primary care doctor, and sort of recognized that while they were in the ICU, we put tubes in their necks and their bodies, and we gave them new medicines and new diagnosis, and we sedated them.

And, you know, they came out with a different normal.

And we didn't do a lot to sort of help them transition or care for him in that space.

And so that became what I wanted to do during my fellowship.

And then when I accepted a position at UK, I asked the person hiring me, I said, can I do this?

And they were like, are you kidding?

Yes, sure, let's do it.

So then I began the ICU recovery clinic at the University of Kentucky.

>> So are you essentially a bridge between that intensive care that the patient was getting while in the hospital and the primary care physician?

I mean, it seems like you're taking this intensely sick patient who's on all these weird medications and stuff, and now you're saying, okay, go back to your primary care physician.

This is not to denigrate them, but it's a different ballgame.

This is a different patient than what they had before.

>> Correct.

It's a very different patient than what they had before.

And I mean, many primary care providers out in the community may not have even had training in sort of a high modern, high intensity modern ICU environment.

So when I start even writing things in notes, I'm getting phone calls.

I don't know exactly what that is.

What are you doing?

What's that abbreviation.

And the patients were saying were telling us when they would come back.

Yes, my primary care provider.

And they didn't.

They were uncomfortable stopping that drug or not having me see that specialist.

And so I also think it became evident to me that we were doing a lot to people, but not helping them navigate what was important afterwards.

Right.

The examples I always give are lots of our patients, especially in the medical ICU, wind up with tracheostomies and need some what we call vent weaning.

They're just weak and sick and they need some extra time to come off the vent.

So then they go to an Ltac, which is a long term acute care hospital.

They help them get off the vent, spend about a month there, and oftentimes during that time you come off the vent, but you might still have a tracheostomy and then you go to a rehab facility.

Maybe they keep the tracheostomy because you're still a little weak and they're not sure.

And then you go home and you're supposed to show up to your primary care doc, who's supposed to decide whether or not to take out the tracheostomy.

And in Kentucky, many, many people live in rural communities, right?

You drive down into some of the places where I have family.

There's not a physician down, there's not an ENT doctor or a pulmonologist down there.

So then the patients are trying to find someone in their community that's comfortable to remove this tracheostomy.

My opinion would be that we should probably do that.

We should probably own that piece of we put it in, we should take it out or manage it, and we owe it to the patient.

>> Now there's a team in the ICU.

Tell me about how that team differs from the team that you have working with you.

>> So the team that I have in clinic is multidisciplinary.

Always have a pharmacist specific to the outpatient setting.

We have an app who actually does part of her time in the ICU and part of her time in clinic.

Sometimes she has seen the patients directly, but she's very comfortable and familiar with all of the pieces of that.

And then we have a physical therapy team who does a lot of the assessments, and we have a research team as well that helps with things.

And then we have specific social workers and mental health specialists that help us with referrals.

>> Now, I must admit, this is probably more telling about my own personal experience, but I wasn't aware of ICU recovery protocols.

Is this something that's fairly unique here at the University of Kentucky, or are we going to find this everywhere?

>> So I think as far as the intensity of services that we provide, it's very unique.

We were the third post ICU clinic sort of set up in the country, and there are others around the country.

There's a whole network of people doing this work and interested in this work that I am engaged with on a regular basis.

I think very few of them are as clinical as we are, and take as much ownership of the patients as we do.

We really feel at our ICU recovery clinic that we we should help these patients navigate for an extended period of time.

We try to follow the patients through their rehab journeys and then see them the first week they're home with their family members.

We do lots of standardized testing to assess cognitive ability, physical ability, mental health issues.

We talk about medicines.

We do lots of assessments on what what are your goals?

Where do we need to get you?

How many new meds do you have?

How many appointments do you have coming up?

Do you really need to see that specific person next week?

Probably not.

We need to push that out a few more months.

So you recover because they're not even going to be able to get good data, and it's going to be a lot of energy for your family.

We fill out all the paperwork that people need for FMLA and disability, and we try to encourage people not to fill out disability to continue to work, because I think being employed is a is a social determinant of health in my world.

Like employment helps folks.

So we try to engage people in ways that encourage them to maintain their employment and work with their employers.

We try to hook them up with mental health people who understand what they've been through, lots of trauma informed care and those sorts of things, but who aren't just going to medicate them into a coma because they're anxious after what they've experienced.

And then we also try to talk to the families about normalizing the recovery.

This isn't going to you're not going to be better in two weeks or a month.

This is a long process.

And depending on what what ails the patient specifically, they may have a new normal.

And we may have to sort of adjust to that.

And how do we get there.

And then we see them about a month later, and we see them about a month later, and then we see them at six months and nine months in a year, sort of helping them navigate that space and determine what happened in the ICU.

What are we going to do to prevent that?

What are your goals and what do we need to take off your plate or add to your plate moving forward?

And then we try to communicate with the primary care doctor in this is what we're doing.

They need a repeat echo.

At three months they can get that in their hometown.

Could you order that and then let me know what it says or send me the images.

And they don't have to come back to me for that.

But somebody just needs to say, it's okay, I'll take ownership and help you navigate that space.

>> I'm impressed that you are filling out all the paperwork, because that alone is going to take a burden off everybody.

But suppose in that first month or so here in Kentucky, we've got some curvy, windy roads, especially in inclement weather.

Suppose the person can't make it to you?

>> Well, so we do a lot of telephone calls.

We do telehealth visits as well, so sometimes people can't come and we'll do a telehealth visit and and just get them on the computer and see their face.

What do you need?

Let's talk about your medicines.

Get your family on the phone.

Who's helping take care of you.

Let's let's walk through this.

Right.

And sometimes people can't come back to us.

And that's part of the picture in Kentucky.

We've got a lot of folks who have transportation issues prior to being critically ill, and we do a lot of communication with primary care doctors in their community.

If it's something people are interested in and we we do not, I do not want to make it seem as if we see every single patient who is discharged from the clinic.

>> Would you make a real effort?

>> But we do.

We make an effort.

>> Tell me about, you know, what are some of the physical changes that happened into the ICU and what causes them and what can be the long term complications?

I mean, I think that's the number one thing that happens to people.

>> That is a great question.

So I have a whole research team currently and we're looking at a lot of this.

So I have partnered with folks in the College of Allied Health and who are physical therapists with PhDs looking at the muscle biology at a molecular level.

Right.

So what is the basis for the muscle atrophy that occurs?

Why do people lay in bed for three days and suddenly are just weak and debilitated?

And I don't know that we know 100%.

I think we have a lot of evidence right now from some of the work we're doing, that it's probably some sort of a mitochondrial injury related to some of the medicines that we give, but we don't know which ones exactly and how.

And so still working through that.

But a lot of what we're also finding is that we just don't move people.

Right.

We put them in a bed, we drug them and say, no, no, no, don't move, don't move.

Instead of nope, get up, get the chair.

You need to be walking.

I know it hurts.

Come on, let's go.

Right.

And then, which is what the rehab people will tell you.

You got to move to get better.

So.

And there's connections with that, right.

Lots of cognitive issues that come out of the ICU.

People talk about delirium and hallucinations and confusion and memory issues and all of this.

And I don't know if you've ever been sick and laid on the couch and had the flu, and you just kind of don't move and your brain is in a fog.

And that's what these people feel like sometimes for weeks.

So the connection between the brain and the body is very intense.

And I think the not moving and the not cognitive acuity being there probably connects in a way that makes people.

>> Some of these patients, the cognitive disabilities is it's it's, you know, sometimes we used to call it what sundowning or ICU psychosis or whatever.

So again, is it the medication?

Is it just the stress of the illness.

How would you put that?

>> Well, I mean, I think it's multifactorial.

And what I'm going to say is anybody who tells you they know doesn't know, but but you know, I think it is the we take a human being and put them in an environment that the human body was not meant to be in.

Right.

So they're super sick and we take over basic functions.

Right?

We we are breathing for you.

We're we decide when you eat.

We decide when you go to the bathroom.

We decide when you move, when you're awake, when you're asleep.

Right.

All those things that sort of signal to your brain, hey, it's time to get up, and I'm going to go eat and I'm going to I'm going to have that signal from my foot that says, rearrange your feet or whatever.

They don't get that in the ICU.

You're sedated.

Sometimes you're paralyzed, heavily sedated.

Somebody is breathing for you.

Something's pretending to be your kidneys.

We're pumping you full of drugs to keep your brain quiet, your body alive.

It's it's very artificial.

We do it all to keep people alive.

So their bodies have time to heal so that they can get better.

That's the goal, right?

But it's it's done in a way that doesn't feel as natural as it could or as natural as life does.

It's not as natural as it could, but it it has effects.

And then I think we don't we do a great job of that.

And then we sort of just drop instead of saying, okay, now I got to help you get back, right?

We don't say, now you need cognitive therapy.

One of the things we do a lot of in the ICU is referring people, speech language pathologists to a lot of cognitive therapy.

We don't even talk about that in medicine.

In med school, I didn't have any training in that.

I sedate people, I make them a zombie for two weeks.

Then I wake them up and I want their brain just to work.

You go have your knee replaced.

We spend months doing very specific augmented rehab.

You go to the physical therapist.

I sedate your brain for a month.

We do nothing like you're just supposed to recover.

>> But you're describing when you talk about recovery.

It sounds though, recovery has got to begin.

Prior to our interventions, our therapeutic interventions.

So.

Well, you go into an ICU, what's the first thing you know?

The lights are on constantly.

So there's sleep disturbance for the patient.

Yeah.

What kind of accommodations do you recommend to your colleagues and say, hey, do we really have to do this?

Can we start doing some things differently?

How does that discussion go?

>> Oh, it goes really well.

And I'll say that what part of what the ICU recovery clinic has also given us is the voices of patients who come to clinic and say things to us about what happened to them that I can take back to the staff member, Mr.

Smith, that we all adored.

Well, he came back and said we were talking in the hallway every night and kept him up.

And his wife like, was absolutely.

That's what she wanted to talk about in clinic, how disruptive that was.

And the nurses are like, oh my, I didn't mean to do that.

So I also think that there's a lot of feedback we get from patients and families in this environment.

And my colleagues are incredibly receptive.

Right.

And I think some of this is in medicine.

It's high stakes, high stress environments round the clock.

We don't there's no you get to turn the shift off at six and go home.

The hospital is running 24 over seven.

And so I also think that people want to do a good job, but sometimes are deflecting and doing things because it's the easiest thing to do.

And if we just make the easy thing, the right thing, then they want to do it.

So things like making sure the lights are off at night and not and on in the morning, right.

We have protocols in our ICU now of the nurses go in in the morning, the lights go on, the blinds come up, people get natural sunlight building that in.

We do things like sitting people up even when they're unconscious, like, let's get you up in the bed so that you have a different feeling for your body.

We do lots of making sure things on the television aren't violent, because if you don't understand where things are coming from, you know, I always joke the TV is far away.

You're kind of laying here, you're disoriented, you're sedated, and then they put that nurse call button in your bed.

That's also the microphone for the TV.

And there's like a Western playing, and all of a sudden there's somebody shooting you on the pillow, right?

And you don't know what's happening.

So we try to disconnect from that.

We try to do a lot of calming things.

You know, if people are awake and off the ventilator, do they need an x ray at two in the morning?

Can we not do that at 630?

That's a more natural time frame.

Can we work on feeding cycles that look more natural?

Can we do things?

Can we get tubes and lines out of bodies faster so people have more control over those things?

Can I give people swabs to swab their own mouth rather than swabbing it for them, like little bitty things like that?

That can really have a big effect on people's long term outcomes.

>> Well, one of the other things that seems to happen, it's almost like going into a neonatal intensive care unit.

You've got the baby and then you've got the parent on this island.

We recognize that there's got to be some contact.

So what happens in an ICU in terms of there?

And then when you're trying for recovery to that family member who is estranged from their loved one, what is how do you handle that relationship?

And saying, okay, we're going to take this person who's in the ICU and they're yours.

Now when you go home, what does that handoff look like?

How do you how do you bring that person along?

>> Well, and oftentimes because it's different, like if you're on the floor as an adult human, you may have your spouse or your mother in the bedside, but you're still making decisions.

The doctors talk to you.

I mostly talk to the families, right.

The patients aren't communicating with me.

And if they are, they don't even remember me.

Oftentimes I see them in clinic and they're like, my wife talked about how great you were, but I don't even remember you.

Right.

So we sometimes have built that relationship beforehand.

But there's a lot of research right now, what we call picks, which is Post-intensive care syndrome.

And it's just a big fancy medical term for sort of the sequelae of the mental, physical and emotional stuff that happens to people after ICU.

But there's also something called pics F, which is pics family because the families are oftentimes as sort of devastated by all of this.

I mean, you can imagine you're sitting there and every time a bell goes off or the nurse or the doctor comes in.

Is this a good day?

Is this a bad day?

Are you going to give me bad news?

Lots of PTSD, lots of anxiety.

And then when they get home, depending on the relationships, the family is physically responsible for this human being.

Oftentimes they can't walk.

They can't feed themselves.

They're wheelchair bound for a period of time.

They got to drive them everywhere.

They have to deal with their cognitive impairment that may be there, help them puree their food while they're getting their swallow back.

I mean, there's so many pieces.

Not to mention the fact that oftentimes the family members take off a lot of time while they're in the ICU from work, and then they're like, okay, I'm going to go back and you're like, no, actually you're not.

Somebody has to help this person.

And so I think there's a lot of pieces of this that affect the family that we as physicians just don't think about, that are important.

If we want people to recover and become functional members of society again.

>> What is the typical rehab like for that patient leaving the ICU?

You've touched on it a bit with some of the people with whom you're working, but are they going to, you said long term acute care facility or are they going to a regular nursing home?

Or if they do go home, what are those support services and are they readily available for people?

>> So it depends on where you live in Kentucky.

So if you live in Lexington or Louisville, they're available.

You live in Corbin or Ashland, or maybe some of the more rural areas of the counties, maybe not.

Right.

So, I mean, I think the things that we talk about the most are physical therapy, some sort of human being that understands what you need.

And a lot of it isn't necessarily it's different physical therapy than rehab on, say, if you had a knee replacement, it's somebody working on strength, almost a pulmonary cardio rehab, kind of a structure.

We send people a lot to their local wives to do.

I have a guy I saw in clinic yesterday and he was like, I'm still doing silversneakers at the Y. He's like me and all the ladies.

But it's a structured exercise program, and a lot of gyms now have sort of athletic trainers that will help, you know, they'll put a pulse ox on your finger and monitor your heart rate.

Your watch can do it.

A lot of those sorts of things.

And my research team, we do a lot of this.

We we've partnered with some groups to do garmins where we take people and we say we look at their recovery as they come back and see us at different time points.

And we're looking at how many steps are they getting?

Are they a high activity or low activity?

What's affecting that?

We're doing muscle biopsies to look under the microscope at what the muscle fibers look like.

So trying to understand what rehabilitative services folks get and how that affects their long term outcome.

>> I guess if you would, what do you see as the biggest misconception we have about going into an ICU and coming out of the ICU?

>> I think going in, I think people think that the things that we are doing don't injure the body.

And I think that for for physicians, I think we understand that.

But I think laypeople don't.

They go in the person's in the bed, under the sheet, completely sedated, on the medicines, on the ventilator.

Maybe it just looks very calm and peaceful.

And it's physicians I think we recognize underneath there in the body.

I mean, it is a war going on, right?

And so I think sometimes people don't understand that when your loved one enters that environment, there's a lot of damage being done and that it's going to take.

I always tell people from the time you get home, it will take 3 to 7 days for recovery.

For every one day you were in the hospital.

So if you're in the.

Yeah.

And I think that's the other part people don't understand when you leave.

That's when the that's when the recovery begins.

And it's a it's a lot of resources and a lot of time.

And it doesn't happen in a short amount of time.

And some of it is just time.

You just have to give the body time to heal and time for the person to sort of put all the things back together and figure out how their new homeostasis is going to work with the world.

Right.

What can I eat now?

I didn't eat then, you know, how's my left foot is numb.

How am I going to deal with that?

Or my right hand isn't is I don't have quite the acuity I used to.

So what am I going to do with my guitar playing or, you know, all of those sorts of things.

And I have a million stories of patients who have modified their lives in return.

But it takes time and energy and effort and resources.

>> If you could in 30s tell me what is the most satisfactory thing you see when the patient during Covid, we had the cheers when people left.

And of course you had the experience when people left the hospital.

What is it that brings you that great joy?

>> I think it is when people come back to clinic and say thank you and talk about the ICU staff and how important they were in their recovery, and then also talk about my clinic staff and how important they've been in their recovery, and understanding that it's a journey and that it wasn't one group, but it's sort of that whole piece of the puzzle in helping them get back to what their new normal is and what they consider important.

>> I can imagine that must be quite satisfactory for you.

I mean, that's got to bring you some joy.

Yeah.

Well, Doctor Montgomery-Yates, I am glad that you're out there.

And I'm sure all of us here in Kentucky are glad that you're out there.

And thank you for being with us today.

Thank you for being with us today.

Also, we sometimes forget the impact that even minor illnesses have on our bodies.

I hope that you now have a better idea of the toll that having in being treated for a serious illness extracts on patients and the steps that must be taken to achieve full recovery.

If you wish to watch this show again or watch an archived version of past shows, please go to ket.org.

If you have a question or comment about this or other shows, we can be reached at KY at ket.org.

I look forward to seeing you on the next Kentucky Health, and I hope that you can stay out of the intensive care unit, but if you've got to go, please ask them if they know Doctor Montgomery-Yates because if they do, we know that you're going to have a great recovery and get back on your feet sooner rather than later.

Ashley, thank you very much for being with