OC Spotlight is a regular column focusing on medical professionals in our community.
This article was written by Stacey Hilton for Duke Anesthesiology's annual publication in 2017 and is reprinted with permission.
Dr. Paul Wischmeyer’s journey to becoming an internationally-renowned critical care and perioperative nutrition researcher and clinician began at the age of 15 when a bout of strep throat and a prescription for antibiotics led to persistent gastrointestinal bleeding. He was ultimately diagnosed with ulcerative colitis, a chronic, inflammatory bowel disease that causes inflammation in the digestive tract, and admitted to the hospital where he stayed for the next six months, enduring a battery of tests in which he says, “I got the sense that medicine was about treating people as jobs to be done, not patients to be cared for.”
After receiving 40 units of blood over two weeks, not being allowed to eat for three months and losing 65 pounds, Dr. Wischmeyer’s colon perforated and he was diagnosed with septic shock from a life-threatening condition called peritonitis, a severe infection of the abdomen. It was then that his doctor told him that he must have surgery or he wouldn’t see tomorrow. A year later, he was one of the first children at University of Chicago to undergo an ileal J-pouch operation. Due to recurrent pouch infections and chronic antibiotic use and resistance, his J-pouch failed and he had an ileostomy placed while in college. These were the first of more than 20 abdominal surgeries that Dr. Wischmeyer has undergone to-date; surgeries that left him with less than half of his intestinal tract. Hardships throughout his personal perioperative experiences have not only propelled his passion to study the role nutrition plays in pharmacology, physiology and improving surgical outcomes, but remain the driving factor of transforming how physicians care for critically ill patients.
A Novel Perspective
“I went into research to try and find ways to treat people that didn’t create more suffering than the disease itself,” says Dr. Wischmeyer, who studied his own disease for his first research project in medical school at the University of Chicago. He examined the makeup of the stools of people with pouchitis — inflammation of the ileal J-pouch (an artificial rectum surgically created from the ileum) which is created to manage patients with ulcerative colitis. His research revealed deficiencies in the nutrients that made up the guts of those with pouchitis. Dr. Wischmeyer developed suppository drugs out of those nutrients, and at 19-years-old, he performed his first clinical trial with patients at the Mayo Clinic. This research led to a major discovery that amino acids can induce fundamental heat shock proteins to protect the cells in our guts from injury — one of the first findings of a nutrient turning on a protective stress pathway and serving as a stress signal to the cells of the body to induce recovery. Dr. Wischmeyer’s interdisciplinary research and translational approach to challenges in perioperative and critical care medicine have garnered international recognition throughout his 21-year career.
His research focuses on perioperative optimization, nutrition therapy, post-illness lean body mass and functional recovery, and the role of probiotics and the microbiome. He helped develop the first large-scale multicenter perioperative, ICU and nutrition trials group to examine the role of glutamine and antioxidants in critical illness, and conceived the first multi-center description of the effects of nutrition and critical illness on the microbiome, a rapidly emerging field in medicine in which he continues to apply scientific rigor, specifically exploring why ICU patients significantly lose the diversity of their gut microbiome and the role of stool transplants and probiotics in recovery. According to Dr. Wischmeyer, 99 percent of the genetic material in the human body is bacterial. When we become ill, undergo surgery and take antibiotics, those microbial populations shift, resulting in major implications on our physiology, cognition and neurology, and the way we recover. “We have never scientifically addressed these effects and how to track and restore patients’ bacterial signatures in illness. Applying real science to what makes us human and then applying that knowledge to help our patients prepare and recover from surgery is what makes my research unique.”
Dr. Wischmeyer also brings a unique perspective to the field of critical care by comparing the stress of surviving surgery and acute/chronic illnesses to the stress of extreme athletic performance. “We as humans are not evolved to survive critical illness or surgery and regain function; it’s superhuman,” he says. “Athletes and their trainers are masters of achieving superhuman feats, and we must learn from them.” His novel concept is that physicians can prepare patients for stress and injury and optimize their ability to recover by learning from those who are on the elite cutting-edge of exercise, sports nutrition and protein delivery. One such innovation in nutrition and exercise physiology is a muscle glycogen scanner, traditionally used by Olympic athletes, that is now helping patients avoid ICU acquired weakness. Dr. Wischmeyer’s findings with this device proved crucial, revealing many ICU patients have zero glycogen in their muscles shortly after ICU admission. He believes this technology may soon guide optimal use and timing of nutrition delivery, exercise, and anabolic recovery agents (such as testosterone derivatives and betablockers) used to counteract prolonged catabolism and hypermetabolism.
The Duke Podium
On October 31, 2016, Dr. Wischmeyer joined Duke Anesthesiology as the associate vice chair for clinical research and the co-director of the Academic Career Enrichment Scholars (ACES) Resident Research Program. He also practices on Duke University Hospital’s (DUH) critical care and nutrition clinical teams, serving as the director of its Nutrition Support Service, and was named director of perioperative research at the Duke Clinical Research Institute (DCRI), the largest academic research organization in the world. Duke Anesthesiology has provided Dr. Wischmeyer a podium to bring perioperative optimization and nutrition to the forefront of surgery and critical care across a variety of platforms. Since his arrival, he and key departmental leaders have put his lifelong goal in motion — the chance to meaningfully address “the silent epidemic of hospital malnutrition” by establishing a medical nutrition model for inpatient nutrition services across the health system. Together, they’ve designed a financially viable, multidisciplinary, nutrition consult service for hospital patients that is physician-driven, utilizing existing advanced practice provider roles, such as dietitians and pharmacists. “Research shows physicians who screen for malnutrition and provide treatment before surgery have better patient outcomes, but only one in five patients are being screened,” says Dr. Wischmeyer. “I’ve been the patient suffering from septic shock and delirium in the ICU, on steroids, with prolonged ileus, receiving now-avoided benzodiazepine sedation with no physical therapy. Duke Anesthesiology has given me a unique opportunity to design a revolutionary nutrition and perioperative/ICU recovery service model and build out my passion for all hospitals across the country to implement.”
Another model Dr. Wischmeyer helped launch this year is the Preoperative Nutrition Program, one of more than 50 initiatives of Duke Anesthesiology’s Perioperative Enhancement Team which strives to manage surgical risk by partnering with providers to develop data-driven models that can be replicated at the benefit of patients nationwide. “This department is passionate about taking anesthesia to the next frontier. We are changing the very foundation of how we care for people with programs like POET and Enhanced Recovery After Surgery. It’s like nothing I’ve experienced anywhere else.” The podium at Duke has also allowed Dr. Wischmeyer the opportunity to help shape the department’s Critical Care Medicine Division, led by Dr. Raquel Bartz. And, his role in the DCRI enables him to improve the overall quality of perioperative research by conducting both basic laboratory studies and novel clinical trials, putting real science into how patients’ lives can be improved with interventions such as nutrition and exercise, and educate providers worldwide with this new knowledge.
On August 4, 2014, Dr. Wischmeyer became a patient once again, after being admitted to the hospital with an emergent small bowel obstruction with marked bowel edema and a rising blood lactate level. He was placed in the SICU for fear of bowel ischemia, hospitalized for 23 days, lost 40 pounds, and was unable to walk down the hallway or pick up his own child; it took him two years to recover. His personal struggles and triumphs are key to his hands-on, proactive mentorship style to help develop the next generation of physician anesthesiologists who can improve surgical outcomes and the care of critically ill patients. Mentoring is a top priority for Dr. Wischmeyer — the initial reason he says he went into medicine; 94 percent of his mentees remain in academic medicine. He is a member in the FAER Academy of Research Mentors in Anesthesiology. And now, as co-director of Duke Anesthesiology’s ACES program, he lectures around his patient experience, hoping to instill in his trainees three main takeaways: 1) ICU/hospital recovery begins on the day of admission, 2) quality of life must become the focus of future trials, and 3) to never stop asking, “Are we creating survivors… or victims?”
“Making people better doesn’t mean getting the central line in, performing a successful procedure and discharging them from the hospital; we should be fighting to give them their life back when a disease or injury has taken that away. By sharing my story, I hope all medical professionals begin to see their patients as people, who are often anxious and afraid; and each time they perform a procedure, ask themselves, how would I want to be cared for.” – Paul Wischmeyer MD, EDIC, Duke University Hospital