Filling in the blanks: how COVID is shaping the future of critical care medicine
The following article was written by Jennifer Baker as part of a collaboration between the Weil Institute and Michigan Science Writers, an organization at the University of Michigan that trains graduate students and post-doctoral fellows in science writing and editing. Jennifer is a PhD candidate in Microbiology and Immunology at the University of Michigan, where her dissertation research in Dr. Robert Dickson’s lab focuses on the relationship between the microbiome and acute lung injury.
The COVID-19 crisis brought critical care medicine into the global spotlight and re-exposed systemic gaps in patient care. Four years after the initial surge of cases, the Max Harry Weil Institute for Critical Care Research and Innovation at the University of Michigan is asking the question: where do we go from here?
“You should really talk to my wife. You have to understand, I basically have no memory of the 40-some days I was on the ventilator.”
I was caught off-guard, as my purpose for talking with David O’Brien, the voice at the other end of the call, was to learn about his experience as a COVID patient who experienced critical care. After recovering from my surprise and reassuring him, I wondered just how convincing I had been. Would an article featuring a patient with major memory gaps be complete enough to be compelling? As we talked, I found the answer to be a resounding yes.
Like Dave’s family piecing together his memories so he can move forward with recovery, the field of critical care can only advance by taking a detailed, retrospective look at the experiences that shaped it. The COVID pandemic, with its waves of critically ill and recovering patients, is one of these experiences, as multiple aspects of critical care medicine – including emergency services, intensive care, and rehab – are involved in restoring these patients back to health.
David O’Brien stands for the first time since his hospitalization with assistance from University of Michigan hospital staff. Image by Isabella O’Brien and courtesy of David O’Brien
Because of its massive demand on the field, the pandemic undoubtedly has been a pivotal time in critical care. While major improvements were made, giant gaps are also left to fill. To bring about the envisioned future – one that improves outcomes for all patients using lessons from COVID – the challenge is finding the right solutions for these gaps. And that’s just what members of the Weil Institute for Critical Care Research and Innovation at the University of Michigan are working to achieve.
“One of the lucky ones”
In December 2021, David, a self-described “early retired” former General Motors engineer, and his wife Michele, a social worker in the local school district, contracted COVID-19. While Michele was able to recover at home, Dave was admitted to the University of Michigan Hospital in Ann Arbor on December 18th with low blood oxygen.
“It’s a fuzzy memory, but I remember them putting me in a wheelchair and taking me down the hallway and that’s about it,” he recalled during an interview at his home in Gaines, Michigan. “I was out for a long, long time.”
For 41 days, Dave fought for his life on a ventilator, diagnosed with acute respiratory distress syndrome from severe COVID pneumonia. But even armed with a year of experience in pandemic patient management and a new technique called prone positioning that helped patients breathe, doctors were reluctant to give Dave any promise of recovery.
It was an emotional sequel for Michele and children Isabella, Olivia, and Grant, who just two months before Dave’s illness, lost Davis, their 22-year-old brother and son, to hydrocephalus after years of frequent hospitalizations.
Despite the odds, Dave woke up over a month later, requiring his wife and a nurse to convince him of the date as he insisted on making plans for Christmas. After three weeks of in-patient rehab, Dave arrived home on March 9th, 82 days after his initial hospital admission. His doctors now call him “one of the lucky ones.”
Moving beyond supportive care
One prominent aspect of the early pandemic was the lack of any available treatments, let alone personalized ones, for COVID patients dealing with their illness at home. O’Brien recalls a conversation with his family doctor prior to hospitalization, wishing there was something available to prevent worsening symptoms besides rest and fluids.
Practitioners of critical care medicine share Dave’s frustration. Weil Deputy Director and Associate Professor of Pulmonary and Critical Care Medicine Dr. Robert Dickson put it this way: “Critical care in 2023 is still basically supportive care. We provide life support with the ventilator, with other devices and medications to support failing organs, but we’re not actually tailoring our therapies molecularly to the patient in front of us. I think that’s where we clearly need to go, but there’s some major barriers to get there.”
One of these major barriers to tailored treatments is the lack of accurate, real-time data to guide decisions about patient care. If available, information on key health parameters, especially those related to biological processes that make patients distinct, could be used to make better decisions on a case-by-case basis and guide molecular therapies when they become available
"All of the exquisite molecular science in the world is useless from the physician’s perspective if it isn’t delivered to them in actionable form. We need to rise to the challenge of not just generating complex, high-dimensional data, but synthesizing it and turning it into actionable, accessible information in a way that physicians can use."
Robert Dickson, MD
Associate Professor, Pulmonary and Critical Care Medicine, Microbiology and Immunology;
Deputy Director, Weil Institute,
But even without inventing new tests or devices, the amount of data generated for every critically ill patient is staggering: up to 100,000 data points per second, making it easy to overlook details during interpretation and time-consuming to find the right information after patient transfers. As Weil Executive Director and Professor of Emergency Medicine and Biomedical Engineering Dr. Kevin Ward summarized, “There is no bigger big data problem than critical care.”
This makes the critical care data problem a multi-faceted one with simultaneous needs, including a push to ensure the accuracy of medical devices for all patients. The inaccuracy of pulse oximeters on patients with darkly pigmented skin is one such design flaw highlighted by work from Weil Associate Director and Professor of Pulmonary and Critical Care Medicine Dr. Michael Sjoding. Pulse oximeter bias entered the public spotlightduring the pandemic since these finger clips devices are used to measure blood oxygen levels, a key metric used to decide whether medical care should be escalated for COVID patients. As the result of a study led by Dr. Sjoding recapitulating this issue, health policy discussions regarding device bias have been renewed and regulatory action by the FDA is ongoing.
Developers at Weil are also moving toward devices and tests that are rapid, non-invasive, and portable. Wearable devices may be particularly useful during recovery, a period when real-time data is limited. “I would love to have a smart watch where I can look at it and see how good or bad I was doing [during] a small activity,” says O’Brien, referencing the inconvenience of carrying a pulse oximeter to track his progress. Rapid, non-invasive devices like electronic nose technology, which senses volatile markers of disease, are also a growing trend in medical device design. Weil Associate Director Dr. Xudong “Sherman” Fan has already shown success applying this approach to analyze the breath of COVID patients and is currently developing a wearable device for a wider range of diseases.
Even as methods of collecting health data improve, the information gathered is useless without reliable systems to streamline and analyze the information. Though artificial intelligence is not yet safe to use as the sole basis for making clinical decisions, it has potential to assist healthcare providers as they evaluate patients. Several AI-based methods for data interpretation are being developed by Weil members, including those that can predict patient decline from medical records, analyze chest images to detect acute respiratory distress syndrome, and determine causes of sepsis to guide antibiotic dosing.
As new solutions for data management and decision making emerge, the most useful methods will focus on clearing, not clouding, the healthcare team’s judgement.
“All of the exquisite molecular science in the world is useless from the physician’s perspective if it isn’t delivered to them in actionable form,” Dr. Dickson concluded. “We need to rise to the challenge of not just generating complex, high-dimensional data, but synthesizing it and turning it into actionable, accessible information in a way that physicians can use.”
Playing the long game
For Dave, getting back to his regular activities has been key for recovery after his hospitalization. A true outdoorsman, he is getting back to hunting and adding to the piles of firewood at the end of his driveway, while slowly chipping away at the oxygen tanks lined neatly inside his front door.
Dave especially credits physical therapy during in-patient rehab as important for his recovery. “It was monumental taking steps, Like three or four, and then 15, and then the hallway. It was three weeks of progress,” O’Brien recalled. “I wanted to stay. I was realizing how damaged I was.”
For survivors of critical illness, continuing care is just as important as the interventions that saved their lives in the ICU. Patients with COVID and other conditions like sepsis face a host of health challenges during recovery, including the inability to perform daily tasks and increased risk of recurring critical illness. Collectively termed post-intensive care syndrome, PICS is receiving increased attention in the aftermath of the pandemic emergency, as practitioners care for a growing population of survivors.
Dr. Madeline Lagina and Dr. Rachel Hechtman began their pulmonary and critical care fellowship training at the University of Michigan in the middle of the pandemic, and their practice will continue to be shaped by innovations inspired by the collective COVID experience. Photo courtesy of Madeline Lagina and Rachel Hechtman.
Dave recalls thinking a lot about the need to move his body as soon as he was able. “During recovery, I wanted physical therapy people to work me,” he said. “Mechanically, I knew I was getting all weak. I just remember thinking I wish those services were more often.”
As Dave sensed, there is increasing evidence that early movement, even while patients are on ventilators, improves long-term mobility. In the future, therapeutic vibration devices like one pioneered by Weil researchers may serve a vital role for increasing rehab services in the ICU and reducing weakness and mobility issues associated with PICS, while alleviating the burden on people- and time-intensive services like physical therapy.
“The original goal of ‘just keeping them alive today’ feels shortsighted now,” explained Dr. Rachel Hechtman, a pulmonary and critical care fellow at the University of Michigan. “It's like a balancing act at all times to keep [patients] going but also minimize any kind of harm from being incredibly ill. I think that's a systems problem, because there is no way that even the best critical care doctor in the world could keep all of that in their mind effectively for every patient.”
Beyond physical rehabilitation, meeting the holistic needs of patients is also important during recovery. Post-ICU clinics like the one at the University of Michigan, which offers social support and pharmacy consults alongside physical exams, is one way to connect recovering patients with holistic care. Billed as a “one-stop shop” for multiple forms of care, post-ICU clinics are popping up globally and are showing promise for alleviating the impact of PICS and helping patients work towards health in a holistic sense.
“Health is multi-faceted. Health includes financial stability, it includes housing, it includes socioeconomic health, it includes access to medication, emotional health and wellness, and physical health,” said Dr. Madeline Lagina, a University of Michigan pulmonary and critical care fellow who also holds a master’s degree in public health. “I think we’re just starting to understand how every single relationship with everything in your life sums to some form of wellness.”
Improving holistic services for recovering patients, among other challenges in critical care, will take a large network of collaborators with diverse expertise outside of critical care. This approach, called convergent science, emphasizes deep education of individual experts in multiple disciplines, rather than multiple experts working individually within their discipline on the same problem.
The O’Brien’s 10-year-old beagle, Duke, keeps Dave moving during recovery. Image by Jennifer Baker.
“The Weil Institute is trying to broaden the family of disciplines to get interested in critical care as a problem at any level: the cellular level, the microbiologic level, the physiologic level, the therapeutic level, digital health, devices, or diagnostics,” Dr. Ward explained. “You may have the perfect solution for a problem you’ve never heard of.”
“We’re not in a post-critical illness world”
As critical care moves beyond crisis mode, it is clear that the future of the field is already – unavoidably – shaped by our collective COVID experience. Though the pandemic emergency has subsided, “we’re not in a post-critical illness world,” reminds Dr. Dickson. If there is any value to be found in a devastating viral outbreak, it is that patients far into the future will continue to benefit from molecular therapies, methods of real-time data analysis, and resources for holistic care – engineered to fill in the blanks exposed by recent experience and pioneered, in part, by the University of Michigan Weil Institute.
Dave’s recovery is likewise far from over. He regularly follows up at the University of Michigan post-ICU clinic to monitor his improvements in mobility and heart and lung function. At his most recent appointment, Dave completed a six-minute walk down the hallway with no oxygen for the first time since his hospitalization. He never goes anywhere without his camo print backpack that holds his oxygen cylinder, and daily tasks like taking the dog out or taking the stairs still induce lots of heavy breathing. Even so, Dave is feeling stronger every day.
“I feel like I’m still somewhat improving, at least I certainly hope I am.”