S1: From Kerkow media.
S2: Dr.. As we wrap up our Johns Hopkins series showcasing
S2: the amazing expertise and innovation from one of the top
S2: hospitals in the country, we wanted to devote an episode
S2: to really digging into some of the most significant revelations
S2: that were shared with us by these World-Class practitioners. You'll
S2: see why these are our featured moments as we relive
S2: the groundbreaking and passionate practice of one of the nation's
S2: very best in research hospitals. So join me on this
S2: special medicine we're still practicing. I'm Bill Kurtis. Johns Hopkins
S2: may be known for its outstanding research and development in
S2: all facets of care, but what stood out for us
S2: is their equal commitment toward streamlining the full recovery process,
S2: as well as the compassion for the whole patient. This
S2: attention to the patient is best exemplified by a unique
S2: and industry changing style of care in the ICU. Dr.
S2: Dale Needham shared his groundbreaking research in regard to keeping
S2: patients awake while in the intensive care unit. Now I
S2: know such a scary environment like an ICU may be
S2: the last place where patients want to be awake and lucid.
S2: But here Dr. Neném shares why keeping patients coherent and
S2: engaged is actually best practice for the health care industry
S2: going forward.
S1: Most patients don't know how critical care is delivered. So
S1: most patients, we don't need to have discussions with them
S1: around this other than when we're not giving them deep
S1: sedation and they're awake and alert and can interact with us,
S1: we can directly ask them if they're anxious, if they're
S1: in pain and give just the right amount of medication
S1: to take away any discomfort and allow them to be awake.
S1: And in fact, when we most often ask patients, are
S1: you uncomfortable, would you like some additional medications? When patients
S1: are not delirious, most often they tell us, no, I
S1: do not want your medications that give me confused thinking.
S1: Let's give a little bit of pain medication. Let's be
S1: up and moving so my back doesn't hurt laying in bed.
S1: Let's turn on TV. Let's engage with family either in
S1: person or through video conference. Let's do some things that
S1: help distract them. We're also very fortunate that we have Dr.
S1: Megan Hosie, a rehabilitation psychologist, who will address issues of
S1: anxiety through talking to patients rather than trying to give
S1: them powerful sedatives that cause confused thinking, delirium and long
S1: term cognitive impairments. So did you have a difficult time
S1: in the transition, having been in the ICU now? I'm
S1: in my twenty ninth year. There is a culture, at
S1: least in our main intensive care unit. The culture has
S1: always been patient. Comfort is paramount concern. And the I
S1: think the reflex amongst the nursing staff has always been
S1: because of the old adage to sedate is really compassionate.
S1: Did you have the same impediment that we've been trying
S1: to overcome in changing the culture of from sedation to awakening? Absolutely.
S1: Most people who practice in the intensive care unit telling
S1: them that our patients should be awake and moving is
S1: like telling them the earth is flat. This is completely
S1: different than everything that most of us learned when we
S1: were in our training and most of us have seen. However,
S1: if we go back to the early days of critical
S1: care when intensive care units were first being created, patients
S1: were routinely awake and moving at that early stage. But
S1: then the pendulum swung, just as you said, with people
S1: thinking that sedation was going to make patients feel better.
S1: But when we began to think that we didn't understand
S1: this concept of delirium and we didn't realize that giving
S1: patients these powerful sedatives also directly causes this confused thinking
S1: and jurien this confused thinking, patients aren't calm, peaceful in
S1: an amnestic state like in the operating room. These patients
S1: are having horrible nightmares and delirium, feeling like somebody is
S1: trying to harm them, that there's blood coming out of
S1: the walls, that there's rats on the floor, that they're dead.
S1: Baby is laying next to them in bed. These are
S1: all actual memories that patients have had during their delirium.
S1: So there's nothing about that that's calm and peaceful. And
S1: the biggest modifiable risk factor for delirium is our heavy
S1: use of sedatives that must change in ice use in
S1: order to provide compassionate care to our patients. These memories
S1: that I've talked about can last for months or years
S1: and are typically the same kind of memories that patients
S1: flashback to when they have post-traumatic stress disorder after the
S1: ICU that affects approximately one in four patients that have
S1: been in an ICU.
S2: As you may have heard Dr. Needham mention, there is
S2: another special tool in his belt for delivering exceptional care
S2: to ICU patients and that his rehabilitation psychologist, Dr. Megan Hosie. Dr.
S2: Hosie is the kind of practitioner that you hope you
S2: never need. But if you or your loved ones find
S2: yourselves in the uncomfortable situation of being an ICU patient,
S2: you could experience side effects that cause delirium, nightmares or
S2: even worse under those circumstances. Dr. Hosie is the exact
S2: person you want by your side to prevent or treat
S2: the psychological side of an ICU stay. Dr. Joses position
S2: is a rarity in hospitals these days, but as you're
S2: about to hear, the work she does on a day
S2: to day basis is absolutely vital when it comes to
S2: excellence in compassionate intensive care.
S3: So any time we're walking in for these patients in
S3: this bizarre p e, we've been finding that a really
S3: important tweak is to remind people what it is, along
S3: with the general reorientation that we're doing. So, for example,
S3: we'll tell people where they are, why they're there, and
S3: we'll say, I'm wearing these masks. And that's to protect
S3: us from infection, for example, because patients having hallucinations and
S3: delusions don't really understand what that is.
S1: Aside from introducing yourself, any other techniques that can give
S1: you leverage on a patient who might be half in
S1: and half out of reality to help ease their mind
S1: and their psyche.
S3: I think the main thing that we spend time telling
S3: patients is you're at Johns Hopkins. And in the context
S3: of conversation, we might say, and now that it's noon
S3: at Johns Hopkins, we'll do X and Y and Z,
S3: for example, if the nurse is bathing or providing a medication,
S3: they'll remind them what they're about to do. They will
S3: briefly mentioned that they're breathing with the help of events
S3: because often patients don't really have a sense of what's
S3: happening with that. And then finally, a really important one
S3: in the wake of covid is reminding people that their
S3: loved ones may not be in the hospital because of
S3: the visitor restrictions and letting them know, hopefully, that all
S3: of their loved ones are safe. A common delusion for
S3: patients is for them to think that something really terrible
S3: has happened to a loved one.
S1: You know, been in practice for twenty nine years and
S1: I've not seen your position in any hospital I've worked
S1: at and I've worked at several over the years. And
S1: actually what happens in the academic center is it takes
S1: time to filter down to the community and ultimately it should,
S1: because that's the whole point. And so right now, we're
S1: in the process of trying to minimize delirium by keeping
S1: our patients awake at all times and minimizing sedation. But
S1: what we don't have is you the resource from the
S1: psychological support. And so that's something that's being taken care
S1: of as best we can by nurses and physicians. So
S1: what advice do you have to us? Who are we
S1: are in this watershed area where we're trying to keep
S1: our patients awake, but then how are we going to
S1: give them the same kind of support that you were
S1: giving when we really don't have those resources?
S3: I think that right now my perception is that we're
S3: in a space where we don't give the nurses and
S3: docs a whole lot of time to be doing this
S3: extra emotional support. So that's a big shift just from
S3: a basic psychological and behavioral perspective. Whenever we ask a
S3: person to change their behavior, to stop doing something, we
S3: have to give them something else to be able to
S3: do instead. Right. And so I think ABCDE F model
S3: is one of the most common things that we rely on.
S3: So involving family, perhaps including things like Zoome and allowing
S3: the family to be a part of the patient's care
S3: whenever possible. Again, that providing really basic reorientation for patients
S3: who are delirious, ensuring that the environment is conducive as
S3: it can be to keeping people alert and awake. So
S3: that means the setting matches the time of day. So
S3: if it's morning, we have shades open. If it's evening
S3: were quiet and really promoting sleep, I think that that
S3: also means just a mindset that says this person might
S3: be having one of the very worst days of their life.
S3: And so when they're awake, alert and potentially not fully
S3: engaging with us or sort of what we would say,
S3: like refusing or being non adherent, sort of thinking through
S3: with the patients about why that might be, and sort
S3: of eliciting some ways that we can change that if
S3: the patient's not delirious.
S2: Rounding out our trio of experts related to Johns Hopkins
S2: ICU care is speech language pathologist Dr. Martin Brodsky. He
S2: is a leader in establishing communication with patients, which is
S2: absolutely integral to their care in the ICU. A speech
S2: language pathologist in an ICU setting is far from common,
S2: but Johns Hopkins and Dr. Brodsky are paving the way
S2: when it comes to dealing with swallowing and vocal challenges
S2: caused by time spent on a respirator. He is also
S2: innovating new and successful methods for dealing with communication difficulties
S2: during treatment. I asked Dr. Brodsky how he performs the
S2: difficult task of communicating effectively with delirious patients.
S1: So the reality here is, yes, once the patient is
S1: able to be interactive, we are able to work with
S1: the patient. And whether it's writing and writing has its
S1: own difficulties because of ICU acquired weakness, perhaps the patient's
S1: even restrained with soft restraints to keep from pulling at
S1: the lines, the tubes, the drains and so forth. So
S1: you have the added obstacle, if you will, of even
S1: if the patient is strong enough to be able to
S1: put a marker in their hand with a white board,
S1: it's lifting their arm off the bed to be able
S1: to write on the white board, which is another issue.
S1: How is that going to help patients ultimately speak better
S1: or swallow better once they've been liberated from the ventilator?
S1: So in the first place, working with people to get
S1: them communicating gets them more involved in their own patient care.
S1: That's a big issue for patients. We've known that for
S1: some time and getting a speech language pathologist to maximize
S1: that communication. And whether it's a letter board, maybe it's
S1: a basic communication board that says I need to go
S1: to the bathroom, my back itches, my arm is in pain.
S1: Whatever it might be is a lot more than even
S1: trying to read their lips. There's IGIS that you can
S1: use for the simple yes and no questions. There are
S1: technology that's available to track their eyes and to be
S1: able to communicate in much the way that you saw
S1: in the past. Stephen Hawking, do it now. He had
S1: a more advanced communication board, but you can see that
S1: there really is a continuum there, that we're able to
S1: meet the patient's needs and meet the communication needs where
S1: you have the communication, even with the nurse or the
S1: physicians or the therapists that walk in the room. And
S1: the patient has a question or needs to tell you
S1: how they're feeling
S2: now moving away from the ICU, we had the pleasure
S2: of having a discussion with sleep expert Dr. Christopher Early. Yes,
S2: we did chat about some rather interesting aspects of sleep
S2: hygiene and the state of the art with sleep medicine.
S2: Go out and check out the whole episode if you
S2: haven't yet. It's really valuable stuff. But what's even more
S2: unique about Dr. Earley is his interest and expertise in
S2: RLC restless leg syndrome. You may have heard about this
S2: ailment in an endless run of commercials recently. However, before
S2: this discussion, I really didn't get it. It sounded like
S2: it could be a rather minor inconvenience. But Dr. Earley
S2: shared with us the actual challenges this difficult disease can
S2: present and how he and his colleagues set out to
S2: solve the puzzle.
S4: Well, essentially, it's about three to four times more common
S4: in women than men. It basically increases in prevalence over
S4: the age group coming to a plateau at about 50
S4: to 60 years of age. But there's a progressive increase
S4: through childhood, adolescence and up through the younger adult ages.
S4: Most of our research for the last 30 years has
S4: been trying to understand the pathophysiology of this disease. And
S4: what we know is that there is a association on
S4: what we believe is part of the primary pathology is
S4: that the brains of patients with restless syndrome have lower
S4: levels of iron in certain regions of the brain. So
S4: it's the brain are insufficient state despite the fact that
S4: their blood levels of iron are normal. So it's very
S4: organ specific phenomena. And this iron insufficiency leads to a
S4: couple of changes in your brain, one of which is
S4: an alteration in this chemical called dopamine. By altering, it
S4: doesn't specifically decrease the overall amount of don't mean it
S4: basically changes this circadian change in dopamine. So dopey levels
S4: are high in the morning and low at night. And
S4: it seems to make that nater the lower point at night,
S4: lower or decreased so that you start having symptoms. So
S4: it's that lower level of dope me at night that
S4: triggers their symptoms. And therefore, some of the first treatments
S4: that we had
S1: available was the use
S4: of some of the agents commonly used in Parkinson's disease,
S4: Synovate RAPEX. Reequip the dhobi agonists, the symptoms are somewhat
S4: different in the younger age group, particularly men whose symptoms
S4: start before the age of thirty five have a very
S4: vicious form of disease. I mean, it will come on
S4: basically affect the whole life within a year or two.
S4: I mean, it was not just happen at night or
S4: during the evening and eventually they'll have it 24/7 in
S4: women at a younger age under 40, it starts to
S4: be intermittent. So the symptoms come and go and coming
S4: and going, but becoming a nightly problem by the time
S4: they reach somewhere between 40 and 50. I can't convey
S4: in simple words the experience is beyond anything any of
S4: us can imagine unless you actually have had the disease.
S4: And I can tell you, you become so, so desperate
S4: to get rid of the sensation. And obviously during the
S4: day you can walk. That's fine, but you can't walk
S4: and sleep at the same time. And so when you've
S4: missed night after night for years on end, you will
S4: do what you need to do. And some people have
S4: resorted to the use of figured out if I drink this,
S4: half the sweat, the whiskey straight, that I can get
S4: some sleep.
S2: How are you affecting treatment here?
S4: So one of the outcomes of that research I talked
S4: about was to see if I raised your body iron stores,
S4: whether a certain percentage of that could get over into
S4: the brain or your brain probably only constitutes about five
S4: percent of the total body in stores. But if I
S4: increase the total amount, even though that fraction may not change,
S4: the amount obviously would. We started with some simple studies,
S4: mostly Open-Ended designs, demonstrating the value of iron initially or iron.
S4: Then we went to intravenous iron and there's been several,
S4: essentially three randomized placebo controlled trials of intravenous iron in
S4: patients who were not anemic. We did not necessarily have
S4: an iron deficiency and demonstrated that you can get about
S4: 45 percent of patients who are going to demonstrate much
S4: greater improvement in symptoms with intravenous iron. And so that's
S4: one of the things I think that was an outcome
S4: of all of our basic research, that we can improve symptoms.
S2: We also had an opportunity to chat with the coming
S2: and eloquent Doctor Pianta about his work as a renowned
S2: Johns Hopkins oncologist. He's specializing in prostate cancer. Now, of course,
S2: all cancer is scary. You never want to hear your
S2: family doc mention the C word. But prostate cancer is
S2: specifically one of those unique varieties that needs every man's attention,
S2: starting at about 50 years of age. You've heard the
S2: saying that most men die with prostate cancer, but not
S2: from it. And though it may be true, it doesn't
S2: make it any less serious than other cancers. Dr Pianta
S2: shared with us some sobering facts about the disease, but
S2: also some very helpful advice in navigating it pre or
S2: post diagnosis. We're living in a Pretty High-Tech era. We've
S2: come a long way in medicine, but still so many
S2: men die of prostate cancer. What are we missing up
S2: here and what do we have to do to fix this?
S1: So, you know, in this time of covid and so
S1: many people dying of covid, you know, it's an infectious disease.
S1: We got to do better. And we tend to forget
S1: about these other illnesses that are plaguing the planet. You know,
S1: if you look around the world, 10 million people a
S1: year are dying of cancer in the US. Six hundred
S1: thousand people are dying of cancer. Thirty thousand men die
S1: of prostate cancer every year. And cancer of all kinds,
S1: including prostate cancer, is curable if you find it in
S1: time because we can do surgery or radiation and cure you.
S1: But unfortunately, in about fifty thousand men per year, we
S1: find the cancer too late. We find the cancer after
S1: it has escaped the prostate and metastatic cancer virtually of
S1: all kinds is incurable. And prostate cancer, unfortunately, metastasizes or
S1: spreads to the bones as really its first site. And
S1: it causes a lot of problems for guys in the bones,
S1: including pain, and eventually kills them. And we can talk
S1: about how that happens. But essentially we fail because we
S1: don't cure people, because we don't find the cancer in time.
S2: What are the signs that men should look for, which
S2: means perhaps they should come see you or someone you recommend?
S1: Yeah, so that's the problem. There are no signs. There
S1: are no signs until it's too late. And that's why
S1: we recommend in all the major medical associations recommend that
S1: starting at age 50, you should at least have a
S1: discussion with your caregiver about whether you want to get screened.
S1: The screening consists of a prostate specific blood test, the
S1: PSA blood test, as well as a digital rectal exam.
S1: And you should have that yearly starting at age 50.
S1: If you're African-American or have a positive family history, you
S1: should start that at age forty five or even 40.
S1: Why is that controversial? It's controversial because before we were
S1: smarter about active surveillance, we were probably over treating men
S1: with that low grade kind of cancer. But the whole
S1: way we treat prostate cancer has really evolved a lot
S1: over the last few years.
S2: Do you use proton therapy with urological issues like this,
S2: or do you kind of go right to you don't
S2: really need your prostate is better off if it comes out.
S1: Prostate cancer that is localized to the prostate can be
S1: cured in two ways. One is surgery to remove the prostate.
S1: The other is some form of radiation therapy that certainly
S1: involves external beam radiation therapy, which means that the photons
S1: are generated outside the body and shot into the prostate area.
S1: Or there's still some cases where we use seed the
S1: implants as well as external beam radiation therapy. When you
S1: take an external beam radiation, you can break it down
S1: into photon external beam radiation therapy and proton external beam
S1: radiation therapy and proton machines were originally designed because they
S1: can be very accurate in treating the planning and hitting
S1: their what they're supposed to hit
S2: and not doing too much other damage.
S1: Right. In sparing normal tissue. And actually, the first use
S1: of protons were for like kids with spinal tumors where
S1: you really had to protect that spinal cord. To be honest,
S1: protons work great for prostate cancer, but they don't work
S1: better because we have something called computed tomography plant conformal
S1: 3D planning, which basically means we use a CT scan
S1: in multiple parameters to draw lines around the prostate, treat
S1: just that. And so protons are just as good, but
S1: not better for prostate. So guys who want to get
S1: radiation rather than surgery, they have a choice between photons
S1: and protons. And quite frankly, it doesn't matter.
S2: And finally, in probably the most emotional moment of all,
S2: our Johns Hopkins recordings, with tears in her eyes, Dr.
S2: Megan Hosie shared with us the impact covid has had
S2: on her as a frontline health care worker. We've all
S2: lived through a year of fighting this novel and terrible virus.
S2: I hope we stop for a moment and focus on
S2: the absolute heroism that health care workers like Megan exhibited
S2: in all our hospitals all over the world. But in
S2: this once in a lifetime horror, that was our year
S2: of pandemic. There has been some good that rose from
S2: the ashes. That might just be the realization that life
S2: is delicate, brief and something to be cherished, along with
S2: healthy friends and loved ones, or even the simple appreciation
S2: of the small things in life, like a wall of
S2: fully stocked toilet paper at the grocery store, which I'll
S2: never take for granted again. We believe that we've all
S2: emerged from this pandemic smarter and stronger than when we
S2: went in. And we have many of the folks in
S2: this series, along with, of course, my best friend and host, Dr.
S2: Stephen Tayback, to thank for that. And they are the
S2: special angels. We will always be grateful for.
S1: Dr. Hosie, how has this changed your life and your
S1: perspective on practice? And are you suffering? Do you feel
S1: any PTSD from what you've been through the past year?
S3: I've never seen anything like this ever. And I think
S3: the way that it's changed my life is I feel
S3: very grateful for the medical system that I work in.
S3: I'm very inspired by all of the practitioners that I
S3: get to work with. I mean, people who in the
S3: early days said I might be negatively affected by this,
S3: but I'm going to put on my PPE and I'm
S3: going to do the best I can anyway. That's very inspiring.
S3: I think the way that it changes my practice in
S3: that it deepens some of the things that we already knew,
S3: how vulnerable it can feel to be in the hospital,
S3: how somebody whose prognosis or trajectory can change in a
S3: day in either direction. I think these are things we
S3: knew already, but have seen so much more of it now.
S3: I think your your final question was about PTSD. I mean,
S3: I would say in May and June, I was having
S3: some irritability and I was having some dreams about my
S3: patients and their families. And I think the things that
S3: made it easiest to cope with were my colleagues. So
S3: I have a bunch of psychologist colleagues. I have Dale
S3: Needham and Marty Brodsky, who you've had the opportunity to
S3: talk to already. So and all of the colleagues in
S3: the McHugh. So having that contingent of people made it
S3: really OK to like unpack knowing that there were other
S3: people who sort of understood what was happening and would
S3: be able to talk to them about it made better.
S3: What made it harder at that time, though? I think
S3: all of this is getting easier, made it harder. That
S3: time was to go to work and see the things
S3: we were seeing and hear the things we were hearing
S3: and then have loved ones or family members kind of say, well,
S3: is it really that big a deal? Is this really
S3: as hard as everyone says it is? But I think
S3: that there was some real scary early days. But I
S3: think I'm a. You now and people like Dr. Tayback
S3: know how to treat this so much better than we
S3: did in the beginning, at least here at Hopkins, we
S3: now have a funnel of support to pass our patients
S3: along to our most acute covid team can catch patients
S3: on the other side, which makes us feel a little
S3: bit more confident about their recoveries. And I think, again,
S3: the biggest way that this changes my practice is to
S3: just have that much more empathy for our patients and
S3: our providers go through together. And so I'm really hoping
S3: that once we can get through some of the severity
S3: of this and have more of it behind us, I
S3: really do think that as a system we'll be able
S3: to look back and not just think about what needs
S3: to change, but how proud we are of how we
S3: stepped up and saved a lot of people.
S2: And thank you for joining us on a tour through
S2: this special series and a special thank you to Johns
S2: Hopkins for allowing us to pick your brains here on medicine.
S2: We're still practicing. If you know a doctor or a
S2: health care worker that would benefit from listening to the series,
S2: please send them a link. And if you would rate
S2: this podcast, it helps us so much. This episode was
S2: produced and edited for Kurt Comedia by A.J. Mosley, mastering
S2: by Steve Rexburg Music by Celeste Anorectic. Stay safe, everyone.
S1: Dr.. From Kerkow media media for your mind.