At 11 p.m., I heard the familiar whine of my ICU coverage pager. Let’s get this over with, I groaned internally as I called the charge nurse back. After a click on the other line, a voice said, “Don’t worry; this one is a soft ball. ED cart 53.”
I pulled up the patient’s chart on my computer and read about his case: 43-year-old male, found wandering in the middle of the street by the police, acutely intoxicated, known history of alcohol and opioid use disorder. In the ED, he was acutely agitated and yelling at staff. An extensive catalog of ED notes gave me the detailed play-by-play.
9:32 p.m: Patient jumps out of his bed and runs down the hall. Security is called. Lorazepam 2mg IV administered
9:37 p.m.: Patient placed in four-point soft restraints. Patient placed on a propofol drip. Intubated by Dr. XYZ
9:57 p.m.: Patient is lying in bed sleeping
10:15 p.m.: Patient still sleeping. Report given to next shift
When he arrived at the ICU, I dutifully wheeled my workstation computer to meet the patient in his room. He lay on the bed, still in soft restraints with an oropharyngeal tube and respiratory plumbing connecting his lungs to a ventilator. Wow, I thought, a true “soft ball,” indeed — I was not going to get any words out of a “snowed” patient. But as I approached him, he let out a muffled groan and opened his eyes. Throughout my attempted interview, he nodded and shook his head whenever he was able to break free from his involuntary slumber. He looked uncomfortable. When he finally gave in to the sedation’s full effects, I completed my evaluation. I had barely wrapped my head around his story and all of his numbers before the attending knocked on the glass door of his room and motioned for me to meet him outside.
“Assessment and plan, only,” he commanded. I had heard earlier that the ICU floor above us was a zoo of despairing nurses and wailing patients. There was only one critical care specialist on call, and he was pouring from an empty cup. Only two months into intern year and not yet adept at the life-or-death pace of the critical care world, I could feel myself falling short of his standards while I fumbled through my plan.
“Uhhh, I guess he is in acute alcohol withdrawal, I think that would be his biggest issue. And …. he has alcohol use disorder? There could be a component of opioid withdrawal, as well, which could confound his presen —”
“Are we going to address the fact that he’s on a ventilator? Why is he in the ICU?”
“Well, I guess that’s part of the whole treatment for alcohol withdrawal, or maybe he is acutely intoxicated, it’s not yet withdrawal …. ”
My attending cut me off again. “I want a clear, numbered problem list. First: he has acute toxic encephalopathy because he isn’t alert, oriented, or doing any of the things you and I are doing right now. The things that could be causing encephalopathy are propofol, drug and alcohol intoxication or withdrawal, and pain medications. Next, he has acute hypoxic respiratory failure because he is on a ventilator, and we have to breathe for him. Now, you do problems three, four, and so on in that fashion. Maybe problem three could be alcohol use disorder, maybe problem four could be opioid use disorder.”
My confusion surfaced.
“What? Why would encephalopathy and respiratory failure be problems at all?” I paused, “He didn’t come in with any breathing issues. Essentially, we put him on a drip and intubated him because we didn’t want to deal with him in the ED. We gave him those issues.”
With the sigh of an overworked, burned-out physician, my attending said, “OK, just put in the orders and talk to your senior about it.”
In evaluating a patient, a physician first must ensure that their ABCs (airway, breathing, circulation) are stable, as these are the most basic indicators that the patient is alive. To safeguard even these basic needs, clinicians often have to make aggressive interventions in care. In my patient’s case, to prevent him from going into life-threatening delirium tremens, he had needed a propofol drip. Then, as an unfortunate side effect of the propofol, he could not maintain his airway’s patency, necessitating intubation and a pricey ICU stay. All of this — the lines, tubes, upgraded nursing — was a result of what, from the patient’s perspective, might’ve seemed a small infraction: heavy imbibement. For the layman, it’s difficult to envision the barrage of medical care that is required after one bad decision. The patient requiring an external respiratory device and its associated “acute hypoxic respiratory failure” were just small pieces of increasingly complicated care.
Given my own feeling of surprise at what we had done to an intoxicated patient, I can only imagine the level of confusion the patient must have experienced, assuming he had any recollection of the intubation. Notably, many patients can have vivid and accurate memories of traumatizing interventions that they did not explicitly consent to, even if those interventions occurred during moments where the patients lacked capacity. Some patients even develop PTSD symptoms after experiencing delusions while in the ICU. In fact, patients with delusional memories and no factual recall of ICU events are more likely to develop PTSD symptoms than those with factual memories. Even when a patient is in a reduced cognitive or delirious state, their mental faculties are still intact enough to experience primal intuition. When medical professionals must pursue an intervention for patients in these states — often, to protect staff and/or the patient — the patient may only remember how forceful or gentle someone’s touch was, rather than the benefits, risks, and justifications associated with the intervention. These events are often misunderstood by patients, especially if they are not thoroughly explained by clinicians. Symptoms may be misattributed, and intentions may be misinterpreted. The inability of the health care system to prepare patients and families after critical care discharge can lead to prolonged recovery and lost quality of life.
As swarms of patients have required hospital care during the COVID-19 pandemic, greater attention has been directed toward post-COVID clinics, which provide a “multidisciplinary assessment service,” including specialties such as pulmonology, psychiatry, neuropsychology, geriatrics, and rehabilitation and occupational therapy services in order to monitor post-acute sequelae of SARS-CoV-2 infection. But even beyond a COVID-crazed world, this clinical infrastructure has value; these multidisciplinary services can be utilized in the treatment of post-intensive care syndrome (PICS), a phrase used to describe the “physical, cognitive, and mental impairments that occur during ICU stay, after ICU discharge or hospital discharge, as well as the long-term prognosis of ICU patients.” (Patients suffering from PICS can have COVID-related or non-COVID-related diagnoses.)
Similar specialized post-ICU care has been popular in Europe for at least 20 years, and is now gaining favor in the United States. The existing research regarding whether post-intensive care clinics improve patient-centered outcomes — quality-adjusted life years, cost efficiency, and physical and cognitive function, for example — has been limited and unimpressive. Protocols for evaluating and treating patients remain unstandardized and are largely conducted outside of the U.S. Despite the infancy of PICS research, there is a small chunk of data supporting the notion that post-ICU follow up has improved PTSD-related outcomes. Clinics are equipped with support groups and mental health professionals who use ICU diaries (which document the patient’s experiences in critical care from the clinician’s, family’s, and patient’s perspectives) to bridge the gap between what the patient thinks “should” happen in the context of a medical encounter and the actual, seemingly preternatural events that occurred in the ICU.
On my first ICU night float, I had an outsider’s perspective to critical care, more akin to the layman’s understanding than an attending’s, except that, unlike my patient, I was eventually able to process the care events as they unfolded. For my patient, something like an ICU diary, in which health care professionals could write to him personally about his care, might serve not only as a powerful motivator for sobriety, but also act as a tool for rebuilding his trust in the health care system as he pieces together the rationale behind our care decisions and the unfortunate, inevitable consequences. Post-intensive care clinics are uniquely equipped to bridge knowledge gaps and have the potential to help restore patients to their physical, cognitive, and mental baseline. As such, they ought to be a permanent fixture, rather than a transient response to a pandemic.
Has a medical intervention you initiated ever caused harm beyond the scope of the patient’s original complaint? Share what happened — and how you felt — in the comments.
Katherine Wu, MD, MA, is a preliminary medicine resident who is interested in applying to psychiatry next year. She is passionate about women's mental health, cultural humility in health care, and addiction medicine. In her free time, she likes to tend to her plants, read books, learn about Chinese culture, and stay physically active. Dr. Wu is a 2021–2022 Doximity Op-Med Fellow.
Illustration by Jennifer Bogartz