ICU Psycho

When I came in for my much heralded first solo shift it turned out I was assigned two patients that'd had floor orders since that morning, but no rooms available upstairs. So much for saving the world all on my own.

Pt #1 is a post-op day 1 CABG patient who, aside from being overtly particular, seems pretty chill. He's sitting up in the bedside chair, reading a book and just hanging out. I introduce myself, get report, grab vitals, and head off to meet patient #2.

Pt #2 is a post-op perf'd bowel resection. Brand new colostomy and ileostomy. The only reason he's on our unit at all is he's an old double lung transplant from 2007. He's the picture perfect double lung--10/10 anxiety, twitchy, constant guppy breathing--basically crawling the walls. He has a Dilaudid PCA and knows exactly when he got his last nurse bolus, and when the next one is due. And the last and next Ativan.

From the above brief description, can you pick which patient is going to be the troublemaker?

If you picked like I did, you'd be wrong.

I get Pt #1 assessed and charted, just in time for Pt. #2 to have an anxiety attack, (right on the scheduled Ativan dose time coincidentally), and head to his bedside. I get him settled down, drugs admin'd, assessed and charted. He slowly starts dragging his sats--was at 95% most of the day now consistently at 93-94% on 5L NC. (Cue ominous music.)

By 2100, I've assessed and charted both patients, given 2100 meds, hung about 4 different antibiotic IVPB's on Lung Boy (Hmmm immuno-suppressed and septic much?), and I've gotten Pt #1 into bed (in his Dean & Deluca bathrobe, no less). Lights out; Pt #1 drifts off to sleep and Pt #2...doesn't.

About 2230 Pt #1 awakes suddenly and starts yelling my name, completely freaked out. I dash to his bedside, only to discover...the bedside computer monitor has him freaked out. It's not on, it's just sitting there.

Pt #1 doesn't like this.

Now you're starting to see how this is going to go...

At this point he sits up on the side of the bed and tries to leave the unit. (Post op day 1, mind you.) Through some fancy wordwork I talk him down and avoid having to physically intervene. After 90 minutes of constant reorientation and reassurance, I manage to get him settled back in the chair and reading his book. Where he stays. The. Entire. Night. Hypervigilant. Refuses to sleep. Won't take his antibiotic because he's convinced it's spiked with something to put him to sleep (hmmm...not a bad idea thinking back...).

As the night rolls on, Pt #2 is getting weaker and weaker, it's clear that his physiological reserve is just spent. But he's hanging in.

Meanwhile about 0430 Pt #1 starts nodding off in the chair. He starts complaining how uncomfortable he is so I suggest getting back into bed and surprisingly he agrees. For the briefest of moments he appears to be going to sleep. But alas, the light comes back on and he continues reading.

By 0600, Pt #2 drops his sats to 88-89% and I start him on a non-rebreather, which perks him up to 98% or so. I figure I better notify the pulmonologist since that's a pretty big status change, not to mention it's after 0600 anyway--pager fair game.

It's while I'm on the phone with the pulmonologist getting a lecture about not trying a simple mask first before the non-rebreather (WTF?) that Pt #1's monitor starts alarming. After hanging up on politely excusing myself from the doc on the phone, I dash to Pt #1's bedside to discover he's in V-tach or SVT, and all hell breaks loose. My pod partner runs for some lidocaine, my charge nurse starts paging the on call CT surgeon, and I try and get Pt #1 to valsalva just to see if he's possible in SVT that we can convert.

And he flips out.

Gone.

Bonkers.

Looney.

ICU Psycho.

He's screaming obscenities, misogynistic slurs, anything he can think of. I'm physically holding him in bed after he assaults the RT trying to get an ABG. He tries to attack me, but he's 72, just had major surgery, and I'm probably 6" taller and 100 lbs heavier. He ends up in 4 point restraints struggling with all his might, which although puts him at danger of dehiscing his sternal incision, it's actually bringing his heart rate down because he's in one constant valsalva. Amio bolus on board, Haldol x10 mg, and that's where he was when I left after giving report.

Oh, and Pt #2? During report I coax him into coughing, and he coughs up a nasty black mucus plug and immediately starts satting better. (Guess who's a closet smoker with a double lung transplant.)

When I called in after I got up to check on the two of them, Pt #1 was in 4 point restraints, a posey vest, and mittens after scratching a nurse. Pt #2 had transferred upstairs.

It makes me wonder if Pt #1 would have been alright if he'd made it upstairs to a private room. Kind of sad really.