(Anna Kalema, M.D., serves as medical director of UK HealthCare’s medicine intensive care units (MICUs) and sees patients in the ICU Recovery Clinic. Mark Cornelison | UK Photo.)
Brain fog and long-hauler are two terms that many have come to know in recent months due to the ongoing COVID-19 pandemic. However, the struggles associated with the terms are nothing new for those who work in places like UK HealthCare‘s Intensive Care Unit (ICU) Recovery Clinic.
“We’ve been talking about this for 10 years and nobody really listened until there were suddenly a million new people to talk about,” said critical care physician Ashley Montgomery-Yates, M.D., who also serves as UK HealthCare’s chief medical officer for inpatient, emergency and core services.
The ICU Recovery Clinic has been part of UK HealthCare since 2013. When Montgomery-Yates started the clinic, it was only the third of its kind in the nation. The ICU Recovery team consists of physicians, nurse practitioners, pharmacists, physical therapists and social workers. Together, the team helps patients work through physical and occupational therapy, medication management, coordination of care, communication with the primary care provider, and the return to life outside the confines of a hospital.
Montgomery-Yates says before COVID-19 they would receive one or two referrals per week. Now, she says they are seeing upward of 20 each week.
“The volume of humans that need this service is now ginormous,” she said. “I hope at some point we can go back down to a more normal volume, but the truth is there were probably a lot of patients who weren’t getting referred to clinics like this because they didn’t know they existed.”
The COVID-19 pandemic has caused many people to get sick – some of those becoming critically ill and ending up in the ICU for weeks at a time. Long ICU stays can lead to physical and mental issues that extend beyond the original reason a person is admitted to the hospital.
“When you are in an ICU and your kidneys don’t work, and your legs don’t work … your brain also doesn’t work,” Montgomery-Yates said. “We do a lot of things in the ICU to keep people still and calm.”
For patients who can leave the hospital, being discharged often does not mark the end of their illness, but the start of their recovery chapter. In those patients, Montgomery-Yates and her colleagues have been seeing very similar issues for years – not just in the post-COVID patient population. These lingering issues are known as post-intensive care syndrome (PICS).
There are three categories of symptoms seen in PICS: physical, cognitive and psychological/emotional. During a patient’s first visit with the ICU Recovery Clinic, they are taken through a form of standardized testing for each of those categories. Health care providers then walk the patient through their scores and explain areas where they are doing well and areas where they are struggling.
Cognitively, providers look at things like memory, attention and the ability to transition in a conversation. Based on the patient’s needs, they then recommend cognitive work that can be done at home. This may include tasks like completing multiplication tables or reading three pages in a magazine.
“If you get a knee replacement, we do not expect you to get up and start walking on your own – we give you a walker,” Montgomery-Yates said. “If your brain is still healing and you are having trouble with certain pieces, we work to find what you can do to compensate as it heals.”
More people now survive critical illnesses thanks to advances in medicine. The focus of doctors used to be on the more immediate and short-term outcomes of critical patients; however, attention recently has shifted to the long-term outcomes of those who survive these illnesses. Through that shift in focus, physicians and researchers have discovered that while ICU survival has improved, patients often do not return to their former baseline of function for weeks, months, or even years.
The struggles former ICU patients face are more known now thanks to COVID-19. The disease has also contributed to putting a greater volume of people in the ICU who would have never expected a stay there was in their immediate future.
“Our patients now are not the 80-year-olds that really didn’t do a lot of activity at their baseline,” Montgomery-Yates said. “We’re seeing more people that are functional and now suddenly they have this critical illness that still is persistent even after they come out of the ICU.”
Anna Kalema, M.D., is one of Montgomery-Yates’ colleagues in the ICU Recovery Clinic and is medical director of UK HealthCare’s medicine intensive care units (MICUs). She says that in addition to seeing a greater number of young patients, they are also seeing more pregnant and postpartum women.
“They are trying to figure out how to be a mom, nursing their babies, and all that stuff,” Kalema said. “They are struggling with feeling the pressure to be a mom, but they also can’t remember how to tie their own shoes.”
Kalema and Montgomery-Yates have also noticed that people of older generations seem to recover and adjust post-ICU a bit easier than their younger counterparts. As people grow older, they become accustomed to taking multiple medications, dealing with more frequent doctor appointments and even asking others for help.
“If you are 75 you might have some kids, or a church group, or a neighbor that you are used to calling and saying, ‘Hey can you give me a ride to the grocery or go with me to an appointment?'” said Montgomery-Yates.
The situation is very different for someone in their 30s or 40s, an age group that typically doesn’t go to the doctor frequently and who might not have that network to reach out and ask for help. Additionally, people in this age group are often busy caring for other people.
“So now all of a sudden, they are in this mode where they have to have somebody help them get dressed, remember what they are doing today – and who is taking care of their kids, or their parents, and who is going to work and earning money?” said Montgomery-Yates.
Someone who falls into that category is 40-year-old Cathy Turner, who Kalema treated in one of UK HealthCare’s MICUs. Turner, like thousands of other Kentuckians, ended up in the hospital after testing positive for COVID-19. She remembers putting off going to her local hospital when she began having difficulty breathing, because she did not want to end up being away from her two young children.
“I went, and my fear came true,” she said.