ICU Delirium & Alien Abduction

For years, health care professionals
believed that all measures taken in
intensive care units (ICU) were for the
patients’ own good.
Patients were tied down so they couldn’t
pull out their lines or tubes. They were put on
machines to help them breathe. Intravenous
lines were inserted to deliver life-saving
medications. Powerful drugs immobilized them.
The drugs gave patients the desired amnesia
about the trauma they faced, but it also gave
them something less desirable — delirium.
“As a nurse,” said Michele Balas, Ph.D.,
assistant professor in the UNMC College of
Nursing, “I remember thinking, ‘I don’t want
them to remember anything we’re doing
to them.’”
But the drugs also contributed to
something less desirable. Two-thirds of ICU
patients show signs of “ICU delirium,” or acute
confusion. “For years we thought that was just
a normal condition, something that happens
to all old people when they are in the ICU, and
that they would get better before they went
home,” Dr. Balas said.
“But in the past decade we have found
that we’ve been so wrong.”
While the ICU keeps patients alive, it
turns out the delirium can have lasting, even
deadly effects. It is an independent predictor of
higher mortality. Delirium often causes a loss
of functional and cognitive ability such as an
inability to balance the checkbook or help kids
with homework. And older adults are more
likely to go straight from the ICU into nursing
homes or other long-term care facilities.
Up to 80 percent of people who are put on
ventilators in ICU will experience delirium, Dr.
Balas said.
“You never go home quite the same as
when you went in.”
Though all of these measures are done
with the best of intentions, the long periods of
immobility and ensuing muscle atrophy, along
with the drugs, not only erase memory, but
also distort reality.
Studies have shown between 15 percent
and 40 percent of ICU patients face symptoms
of post-traumatic stress disorder.
Except the people Dr. Balas calls “ICU
survivors” often don’t fully remember their
traumatic experiences. They’re not sure if
they really lived through them or not. They
don’t know why they suffer from depression,
anxiety, delirium and the rest. They don’t
know why their brains don’t work the way
they did before.
Some are left with emotional triggers,
shadows of memories, horrific flashback
fantasies that rival an alien abduction,
paranoid nightmares from somewhere out of a
doped-up benzodiazepine fog.
“They think they’re crazy,” Dr. Balas said.
“They’re embarrassed to talk about it.”
But Dr. Balas is talking about it. In fact, she’s
all but shouting that something needs to change.
Dr. Balas and her interdisciplinary
team, which includes William Burke, M.D.,
professor of psychiatry, are trying to find a
way to decrease or even prevent ICU delirium.
Their interdisciplinary team of clinicians and
researchers are in the midst of an 18-month
$300,000 Robert Wood Johnson Foundation
grant-funded study to test an evidence-based,
nurse-led program called the ABCDE bundle
— Awakening and Breathing, Coordination,
Delirium monitoring and management and
Early mobility.
The goal is, for a little while each day, to
let patients wake up, get them off the drugs,
take off the ventilators to let them breathe on
their own, get them up and moving, and look
closely for signs of delirium to address it in the
early stages.
Evidence has shown that patients who
breathe a little on their own each day are off
the ventilator more quickly, Dr. Balas said.
Those able to touch base with reality every
24 hours are less likely to slip away, she said.
But it won’t be easy. The ‘C’ — coordination
— is key. It takes an interdisciplinary team
effort — all members must talk to each other
and appraise the patient’s condition beyond
meds and vital signs.
“The problem is changing the culture,” Dr.
Balas said. She admits it herself: “Patients are
much easier to take care of when they’re down.”
But we never fully realized, until lately, all
that was really going on, while they were down.
Part of the project will be building a
website, which will be the first step toward
establishing a national support network for
ICU survivors, Dr. Balas said.
UNMC and its hospital partner, The
Nebraska Medical Center, are the first in the
country to concurrently try every element of
ABCDE to see if it will help patients. And yes,
Dr. Balas said, doing it this way is going to be a
lot more work.

Click to access spring2012_AlienAbduction.pdf

An inexpensive way to reduce ICU delirium: earplugs for nighttime sleep assistance

Anyone who has been a patient in a hospital at night knows that the conditions for sleep are never ideal. Doors slam, gurneys and meal-wagons are moved around and are banged against walls. Restocking teams walk through the hallways laughing and talking as often do nursing staff members. I once awoke in an ICU at 3:00am to hear an in-service training being conducted out in the open with voices at a volume suited to mid-day not past midnight.
In an ordinary hospital ward the door can be shut to this cacaphony of hospital sounds, but room doors in the ICU are typically left open making it easier for nurses to keep tabs on patients who need to be checked more frequently.

Enter the humble set of foam earplugs. Researchers conducted tests comparing patients who were equipped with earplugs with those who were not so equipped. The result was a marked increase in the quality of sleep in those with earplugs and a decrease in the appearance of deadly delirium, particularly in the first 48 hours. If your loved one is in the ICU, there’s no need to convince a doctor to write an order for this ordinary and humble tool. Bring them in yourself and make sure your patient uses them at night. Also, make certain that staff is informed that ear plugs are in use lest staff conclude erroneously that the patient is non-responsive to verbal requests!

Interference with the ability to multi-task – The desktop computer analogy to brain memory and function


To understand multi-attending problems after a concussion, it is key to understand not the specific deficits, but the drain those deficits make upon the brain’s attentional resources. As I have done elsewhere on, I will use a computer analogy to help teach this lesson.

RAM, what is RAM? RAM it stands for Random Access Memory. It’s a computer term which essentially is telling us what is the computer’s capacity to hold things in its electronic storage. By electronic storage I mean held in the active processes of the computer, without actually being saved to a hard drive. What is remembered only in RAM will be lost if not saved before a power loss or crash. RAM is what the computer can actually do in real time. A similarly useful computer concept is “bandwidth”, which is the capacity of a computer to download files from the internet.

Computers have a fixed capacity (which is growing rapidly between generations of computers) to attend or “multitask.” With the computer we use the term multitask. With the brain the term usually used is multi-attend. The two are essentially equivalent. Each program that you have on your computer will require a certain amount of RAM, minimum and maximum. Each deficit or distraction in your mind, will create multi-attending problems.

Some computer programs require a whole lot more RAM than others. At the light end, are old fashioned text based word processing programs. At the other end are programs which process large files, such as movies or high definition photos. If a laptop computer is editing a movie in a high definition program like they would use in Hollywood, all of its RAM will be occupied. The more RAM a task requires on a computer, the longer the task will take. If you are doing something beyond the RAM capacity of your computer, it will either crash, give you the spinning wheel of death, or take an inordinately long time. It can be said in such a situation that your computer had multi-attending problems.

When I first started with sound and movie files on a computer in the mid-1990s, things took forever. You simply could not print and do anything else at the same time. To do what is called “normalize” a sound file would take an hour. We used to work through the night on our earlier versions of our webpages and would take naps while sound files were being saved. It took that long. Now my computer can do that same process in a few seconds, and the RAM capacity of my computer, my current laptop, is a thousand times greater than what the best desktop that Macintosh made in the mid‑90s.
See for a great look back at how far our RAM and bandwidth expectations have changed since 1981.
Now to analogize your multi-attending problems to a computer, we have to assume some completely artificial RAM constraints. But doing so will be helpful.

Attentional Demands of Normal Life
Let’s assume that your brain has 16 gigabytes of RAM capacity. Doing normal things will usually not occupy all of that capacity. For example, let’s assume that participating in and remembering a conversation might require 4 gigabytes of that 16 gigabytes of RAM. So in a normal non-stressful situation, normal people can talk and do other things with their mind.

Attentional Demands of Anxiety
Now, if the person who is participating in the conversation is anxious, the added stress on the brain of the anxiety program running at the same time as the conversation program, might move the RAM meter from 4 to 6 gigabytes. The more anxious the person, the more the brain’s attention capacity will be taken by the anxiety program. While the anxiety program is running in the background without a volitional act to involve it, it is still requiring attentional resources.

Depression Consumes Attentional Resources
Likewise depression, can consume the significant proportions of the brain’s RAM. Depression is a vague term that gets tossed around. Most often it is used as roughly equivalent to “sadness.” But in the context of depression as a RAM occupier within the mind, I define depression as follows:

Depression – A person’s concern about his or her current, past and future well being, and concern about his or her relationships with other people.
Now obviously there is a certain redundancy between saying “well being” and concern about relationships. But relationships are such an important sub-part of emotional health that I think it’s important to separate it out.

Depression in normal day to day life, takes very little RAM. But as soon as something which impacts a person’s concern for his or her well being arises, then the depression program can start to demand RAM. Making it worse is that depression in an anxious person, can start an upward cycle of multi-attending problems.

When things have gone well and the future is bright, attention doesn’t get preoccupied by concerns about well being. When you’re in a happy marriage, when your children are doing well, you don’t spend much time worrying about your relationships. But when things start to go bad, or if you are the kind of person who could loosely be called a “worry wart”, you will spend more and more of your brain’s attentional resources on concerns about well being.

Now some people are just naturally going to be more emotionally volatile. Some people are going to spend more time worrying about their future, worrying about what mistakes they’ve made in their past. Proper frontal lobe development, proper maturation creates a balance between remembering the lessons of life and spending too much time worrying about the bad that could happen. If you don’t learn from experience, you never mature. If you concern yourself too much with those lessons, you haven’t learned them at all. Those who focus too much on the bad, lose some native capacity to do the other things. That is because worrying and anxiety require too much of the brain’s RAM and create multi-attending problems.

With thanks to Gordon Johnson

ICU delirium is America’s most serious and pervasive public health issue that no one seems to have heard of. It needs to be discussed more

ICU delirium is America’s most serious and pervasive public health issue that no one seems to have heard of. It needs to be discussed more

Every day, day in day out, 365 days per year, upwards of 60,000 Americans are admitted to the Intensive Care Unit of a hospital because they have a critical illness that, left untreated and unattended to, could quickly kill them or leave them gravely disabled. And it is a very sad fact that some people will die in the ICU regardless of the amount and quality of care they receive. Most people realize this.

What many people do NOT realize is that once hospitalized in the ICU, a patient’s susceptibility to death in the ICU expands well beyond the dangers posed by the actual illness which necessitated their ICU stay. One of these dangers is delirium and what makes it especially dangerous is that people who should know better – physicians, surgeons, nurses and other hospital providers – fail to advise patients or their loved ones about the realities of ICU delirium – that it’s presence in a critically-ill patient can, independent of the main illness itself, increase the patient’s odds of dying in the hospital by 100%, 200% even 300% and that upwards of half the patients who develop delirium during their stay will likely develop a form of long term cognitive impairment  on a par with the dementia seen in early Alzheimer’s Disease patients.

Worse yet, for decades physicians have been informing concerned family members quite wrongly that ICU delirium (often still referred to inaccurately and archaically as ICU ‘psychosis'[sic])  is a harmless and transient condition, a mere ‘artifact’ of their critical illness that simply goes away on its own.

It is when such misinformation is conveyed either knowingly or self-servingly that great harm to the patient can result because the prevailing belief by leading researchers in this area is that the severity of ICU delirium can be diminished and possibly even eliminated through the simple but time-consuming expedient of ‘titrating’  or adjusting psychoactive medications  given to ICU delirium patients such as tranquilizers and pain medication to the lowest dose consistent with safe care of the patient. The loved ones of ICU patients can continue to urge staff to abide by one of several protocols developed for just this purpose but they can only do so if they are aware that such changes can be made and that they can make a huge difference in the future health and well being of their patient if they do so.

Follow me on Twitter

I tweet as @QuintBy, an awkward but useful shortening of the term ‘quintuple bypass’. While the predominant theme of my Twitter account is ICU delirium and the ICU experience, I have only the one account and thus am more than capable of alienating my followership in all of the many areas I am interested in besides the ICU. I am pleased to assert that at least half of my 600 or so followers are medical professionals, mainly in emergency and critical care specialties.

If you are unfamiliar with Twitter  now is the time to become acquainted with it. Here is my 140 character Bio:

Lawyer in a past life;CABGx5;TBIx4;ABIx3;ICU deliriumX17days; Advocate for improved life/lifespan for ICU delirium survivors via education of & by MDs

The indispensable role of family members to the ICU patient

One of the most important roles you can play as a family member of someone in the ICU is as a medical historian, specifically in terms of assuring that attending physicians are made fully aware of the patient’s overall pre-ICU cognitive state. Without this information, neither RNs nor MDs nor therapists can properly assess the current condition of your loved one.

 No matter how assertive they are in everyday life, the conditions which brings a person to the ICU will utterly disable them from properly advocating for themselves while they are patients there. It is absolutely critical -often literally a matter of life or death – that loved ones be near their patient 24/7 in the ICU.and that they be willing to be aggressive to a degree which most of us would not think of being outside the hospital.

A change in mentation is inevitably more quickly apparent to a family member than to even the most attentive clinician. Such changes can often be stopped in their tracks by a simple medication adjustment. A delayed or absent adjustment can lead to a very rapid decline and often a quick death.