Shifting Back to Story Mode — A Hospital Delirium Story
I’ve written a bunch of “how-to” posts recently and my wife tells me I have been skimping on the stories. My last post was about delirium, so here’s a hospital delirium story. Enjoy the read—then hop back to that how-to delirium post so you’re ready when your loved ones land in the hospital. Keep those minds intact!
When a Ventilator Meets Delirium
I had a Russian-speaking patient who became delirious while he was on a ventilator.
Take all that in. He only spoke Russian, was delirious, and was on a ventilator. To top it off, he was relatively well sedated and also happened to have a large bore tube going into his femoral artery (through his groin).
The Breathing Tube: A Quick Anatomy Lesson
First: when you’re on a ventilator, there is a tube that goes past your teeth. The tube is what delivers the air from the ventilator to your lungs. The tube goes past your teeth and past the back of your tongue. It goes down your throat past where your throat separates into your trachea (to let air into the lungs) and esophagus (to let food into your stomach). The breathing tube finally sits in your trachea a couple of centimeters above where the trachea separates into the right and left bronchi. That fork in the trachea is called the Carina. Those bronchi are the paths to and from each of your lungs. (Click here for a visual.)
Imagine having a tube like that stuck down your throat.
How’s your gag reflex doing?!
When the Machine and Body Clash
The ventilator is the machine that sits by the bed. It pushes air into your lungs and pulls air from your lungs via that tube. There are various settings on the machine. The usual setting is designed to follow your body’s impulses for inhale and exhale (and provide mechanical support if it doesn’t sense your body having those impulses).
The machine doesn’t always sync well with the body. It may push air in while your body is trying to push air out. When that happens you can’t exhale. It may pull air out while your body is trying to pull air in. When that happens, there’s no air for you to inhale.
If you panic, you may start working against the ventilator even more. You may enter a fight-or-flight state and start “fighting the vent,” unaware of the possibly deadly consequences of doing so.
The Snow-Shoveling Collapse
Now picture this…
Forget all that about the ventilator for a moment and take a quick trip with me:
Imagine you are at home shoveling snow. It’s cold. The breeze picks up. You’re breathing hard from the hard work. You feel a bit of anxiety for a moment and you’re not sure why. Suddenly it feels like you can’t get enough oxygen. A soreness hits you in your left arm or neck. You start to feel like someone dropped a 100-lb weight on your chest. You fall toward the ground when everything goes dark.
Waking Up Tied Down
Suddenly you wake up in a place you’ve never been. You’re unnaturally groggy and something is gagging you horribly! Some psychopath has put some kind of stiff object all the way down your throat!
You reach to try to get the object out of your throat but you can’t reach your face. Some monsters have tied your hands down! Your wrists are tied down to the bed! You hear these horrible alarms sounding as you start to fight. And suddenly you can’t get any air!
As you exhale, air is forced into your already full lungs. You try to inhale and there’s suddenly a vacuum. You’re suffocating!
You’re trying to kick yourself away but you can’t. Your feet are tied down too, strapped to the bed at your ankles. You wriggle your body fruitlessly trying to pull away as the alarms continue to sound and these horrible strangers in blue scrubs come running in and yelling “Stay still! Calm down!”
Wouldn’t it be great if you could process those words? “Stay still! Calm down!” Wouldn’t it be great if you understood English?!
Imagine you don’t. And these American torture artists are yelling things at you that you don’t understand while they start holding you down. They lay across your knees so you stop bending them. Why are they doing this to you?!
All the while you still can’t breathe. You’re suffocating as something pulls air from your lungs before you’re ready. Your captors are grabbing your arms and legs and shoulders and head. They’re holding you down. The alarms continue to clamor until things suddenly go black again…
…The stuff of nightmares, right?
Why We Sedate Ventilator Fighters
In the hospital we put someone on the ventilator when they cannot breathe for themselves. Often times they’re already passed out when this happens. They wake up with the tube in their throat in this horrible position.
When someone fights the ventilator, like my Russian friend did, we have to sedate them to get them to sync with the vent. Otherwise the vent is unable to keep them alive.
We can’t just pull it out at that moment because we have no idea if they’ll be able to breathe without it. The only way we know that is to test them on it with normal settings. We can’t do that if they’re overly sedated, and we can’t do that if they’re fighting. We have to get them to that calm happy medium.
The Hard Balance of Sedation
For my Russian friend, that happy medium was VERY hard to find. We had to sedate the bejeezus out of him to get him to sync with the ventilator. Weaning him off the ventilator was a fight because the sedation had to come down enough that his body would breathe on its own impulse. But if the sedation came down too much he was living this torturous nightmare again and again.
My Russian friend fought to the point of injuring himself and putting his life at risk. When it got bad enough we had to increase sedation, regroup, and plan to try again.
A Loved One’s Voice Breaks Through
We tried using the iPad translators that we have at our disposal but none of the interpreters could get through to him via that technology.
Eventually, I was able to coordinate it so that his wife was with us in the room while we brought the sedation down. She was able to calm him enough to reach his sense of logic and explain to him where he was and what we were trying to do.
We got him off the vent that day. That was a great day.
Delirium Strikes Again
But then I had a few days off work and came back to find him on the vent again!
Apparently he had been delirious when we got him off the vent. (See the delirium post to understand the causes of delirium.) And in his delirium, he could not follow instructions that were keeping him safe.
You see, even though he was well enough to be off the ventilator, he still had to lay flat in bed due to a large line that was going up through an artery in his groin (the femoral artery). If he bent at the waist, that line could tear his artery and cause him to bleed out.
Holding Him Down to Keep Him Safe
In his delirium he was trying to get up even though doing so could kill him. He couldn’t process this and wasn’t following directions from the translator app on the iPad. (His wife couldn’t be there 24/7.)
Our staff had to hold him down to keep him safe. He, of course, fought to the point of hurting himself. Staff had to sedate him again to keep him safe. He fought that too. Eventually the sedation was enough to keep him (and the staff) safe, but it also ended up so high that his body’s impulse to breathe became suppressed.
Get him back on the ventilator!
And we started all over.
Delirium is dangerous.
The Path to Recovery
His story ended up being a positive one. His heart recovered enough for us to get the line out of his groin. I worked with his wife again and scheduled the extubation with her and the team. I then coordinated with her and his Russian-speaking father to make sure someone he loved and trusted (and who spoke Russian) was there with him all the time. They took shifts. And with the precautions and treatments mentioned in my delirium blog, we eventually got him home.
A Card That Still Matters
I still get chills re-reading the end of that story. It was a really good day. It’s hard to express the relief, joy, and pride of those moments.
A few weeks later his father found me on the unit. I heard he’d come to the unit a few times looking for me in the weeks prior. And on this day he found me and he handed me a thank-you card handwritten by the patient. It was in English.
With questionable spelling he told me he was doing better and was grateful for our help. And more than once he wrote:
“You the good nurse.”
I still have the card and it will probably be something my loved ones find in my belongings after I pass away one day. Those cards go a long way in our biz.
If you think of it, when you or your loved one make it out of the hospital, send a couple of updates to the units they were on. We really love getting the updates, good news or bad.
Leave a Reply