June 2, 2008
Walking up those dimly lit corridors, I could see that the patients are being prepared for bed. The main lights for each room have been turned out and almost everyone is in bed – with the occasional exception of the odd patient whom would be seen easing himself with the urine container while forgetting to draw his bedside curtains.
Some patients have mastered the skill of using the urine container in the dark, where as the rest would, of course, be turning the night lights on. This decision is often paired with the fleeting assumption (or total indifference) that ‘it’s bedtime and everyone’s sleeping’ hence proceeding to pee with the curtains wide open. Thank goodness for the night light as they could see for themselves the direction of their pee – being oblivious that so could we.
The thing about working nights is you tend to deal with a greater number of confused elderly patients.
It’s one thing to manage their medical/surgical issues, it’s another thing to manage them as a person altogether. Most of the elderly patients that are on the ward are having dementia – some pleasantly demented (for lack of better description) while some are just difficult to deal with. A number of them would often wake up in the middle of the night appearing all confused. They’d often forget they’re in the hospital and are deluded that they’re being held captive against their will. Half of the time, this strong false belief would turn them into anything from the really aggressive (the worst) to the really clingy and demanding (not too bad, but still very time consuming to deal with).
There is a phenomenon known as ‘sundowning’ where patients with dementia experience extreme unrest and agitation during the night. This is often believed to be due to the lack of their usual daytime cues and prompts (e.g. staff informing them it’s lunch/dinner time, families visiting them, etc) and would often feel insecure (particularly to patients as it’s not their usual home environment). Coupled with impaired memory, these folks completely forgotten the reason they’re in the hospital and start to panic – some to the point of extreme paranoia.
What normally happens then? The patients then can be roughly divided into two categories. As I mentioned before, it’s mainly the paranoid and the aggressive for the purpose that they both stood out in their own way.
Distribution across gender : Majority are female patients.
How to spot them : They are often seen either lying flat on their bed (I meant REALLY FLAT, like commandoes dropping to the ground to dodge bullets) or they have their arms and legs wrapped around their bed rails. Some wrap themselves around you.
The story : I was in my main ward in the middle of stuffs when I got a page from the nursing staff of another ward. I replied the page and the nurse I spoke to sounded a bit distressed. Apparently they’re splitting hairs over two patients whom decided to have a delirium episode on the same night. This is just after the previous night where 4-5 confused patients made the inconvenient decision of pulling out their IV lines. Sometimes it’s hard to believe it’s not a conspiracy.
Anyway there I was, running up the stairs while imagining all sorts (one included the patient holding a nurse hostage armed with the urine bottle). I arrived at the room and saw this elderly grandma being surrounded by half the ward’s staff. She looked up at me and hurriedly questioned, “Are you with THEM?”. I replied, explaining that I’m the doctor on duty tonight and she gestured as me to go closer to her.
The moment I’m within her arm’s length she had me locked into this vise-like grip. It was a bit awkward as she had me kneeling down by the side of her bed (she was gripping me by the wrist) and whispering to me about believing the nursing staff are out to kill her. Each time I tried to reply with an explanation she’d completely forego what I have to say and frantically shook her head and shaking my wrist; basically wanting me to be quiet in the event that the nursing staff would come to know of her delusions. Not sure if she realised that in her haste her whispering became so horrendously audible that I’m pretty sure everyone around her heard everything.
The nurse whom was in charge of the patient decided to wheel the patient’s bed out to the front of the nurses workstation, hoping that some of the paranoia could be alleviated seeing that she’s in a brighter area with more staff to keep an eye on her. Throughout the entire distance of transfer, she wouldn’t let my wrist go and as a result I had to half-stoop (the bed was low) and half-walked alongside as if I am having a debilitating backache.
We had her bed against the corridor in plain view of all the nursing staff. My wrist is still being locked. My pager was beeping like crazy and I really had to be elsewhere.
Me : Okie, you’re here now and you’re safe. The nurses will take care of you, I promise.
Her : But they’re trying to kill me, I know it.
Me : Oh no, I’ve worked with them and they’re your nurses. They’re not here to harm you.
Her : Can you stay here with me?
Me : *Pager beeped again and I mentally groaned* I can’t. I have other patients to attend to.
Her : *squeezing my wrist even harder* No you can’t, they’ll kill me! Stay here Julie!
My name isn’t Julie, and I have no idea where she got that from.
Me : I’m not Julie.
Her : Oh? *lets go of my wrist and seizes my ID tag*
Me : It’s not Julie, see? I’m the doctor and I have other patients to see.
At this point, the nurse that is in charge of her walked past and greeted the patient.
Nurse : Hi darling *with a smile*
Her : *yanks my tag* See! They’re trying to kill me!
If this is a world with no consequences (or no karma cycle), I’d have a loudspeaker in her face hollering “OH GAWD WAKE UP PLEASE, GEEEEEEEEZ!!!”
Me : No they’re not.
Her : *tugs on my ID tag – sheesh* Will you be here?
Me : I will be around a bit to write up some notes in your file, but I’ll sit at the desk closest to you alright? At least you know where I am for now.
She finally let go of me, and I promptly scribbled some notes on her file to document the night’s events. I thought I’d be able to be done in 5 mins and leave but I ended up taking 30 mins because she kept calling out my name in 20 second intervals. She’d be grabbing my wrist or my thigh (sounds funny, I know) and I’d be spending the next 5 minutes clarifying that we’re not hired assassins.
Finally, we decided it would be a good idea to ring up the patient’s daughter so she could reassure her mum (and also to give us all a break). The nurse had the daughter on the cordless phone and passed it to the patient.
Me : It’s your daughter on the phone. It’s alright.
The patient took the phone and suddenly in a weird flash, the paranoia disappeared completely. She ended up happily chatting to the daughter and not flinching anymore at the supposed ‘killer’ nurse whom was standing by her bedside.
I took this chance to make my escape.
I can imagine how fearful it must be if you were to wake up in the middle of the night, not remembering where you were, and to be surrounded by unfamiliar environment. I can understand the panic and the paranoia associated with this as they feel incredibly unsafe and insecure with strangers attending to them.
Having said that, I, on the other hand, could not possibly be sitting there holding her hand (or having her gripping mine) throughout the entire night. Although it is very much part of our responsibility to reassure the patient, there is also a greater responsibility in recognising other patients to whom we owe a greater duty of care to (especially the very ill ones) and that would take precedence over a situation like the one i described.
The Aggresive/Grumpy/Cranky/Last Action Hero.
Distrubution across gender : 90% are male. All that testosterone.
How to spot them : They’re always caught in action. Either in the process of ripping out their lines/tubes, climbing over their bed rails, or knocking a staff out cold. Could potentially look like a scene from ‘Prison Break’ except that the lead is in a half-undone hospital gown.
The story : I got called to see a patient whom had a change in his presenting symptoms. The news was worrisome; patient had developed uneven pupils. This could indicate a change in cerebral perfusion to either one of the brain’s hemispheres – in other words, we’re suspecting a possible stroke.
I arrived at the ward and saw the elderly gentleman sitting by his bedside. The first thing that he said upon seeing me was to look at the nurse questioningly, saying “Your son?”.
Before I could say anything, the nurse replied, “No this is the doctor and it’s a SHE”.
I just had to grin. I introduced myself to the patient and informed him of our concerns. He showed indifference and was reluctant to have me examining him. I attempted to take a history from him at first, trying to elicit if there is any other neurological symptoms that I could pick up. The patient kept saying “no” to each and every symptom that I was questioning for, and I know I couldn’t take for granted that it really is a no to everything as he wasn’t very cooperative to begin with.
I tried to proceed with a quick examination but he became increasingly agitated. At one point he appeared to be tugging at his IV line and that was enough for us to grab his arms. The nurse tried persuading him to have an examination, but the patient kept waving the nurse away reasoning that “we should all go to bed”. He then pointed at me and asked, “How old are you?”
I smirked, and told him this is not about me.
Him : I don’t believe you’re the doctor. You look 16!
Honestly, I was beaming inside. It’s always good to know that I could still pass off looking like a kid, yay!
Anyway, I mentally smacked myself back to the current situation at hand. He asked for proof and I showed him my ID. He then started flicking my ID tag left, right, and center and mumbled something incoherently. Doesn’t appear like he’d take me seriously.
After spending some time haggling with him, I felt that the patient should have a brain scan done regardless of the examination findings so I called up the registrar and reported to him. The registrar also agreed to review the patient; maybe the patient would agree to be examined by a more senior looking doctor, hah.
Registrar came in, and there was a fleeting sign of hope as he allowed the registrar to examine him. Then he bailed out midway and refused once again. Sigh.
We organised a CT scan and felt that there is nothing much more to be done; subsequent management would depend rather heavily on the CT results. I informed the registrar that I’d update him on the scan results and we both parted ways – each of us having our workload dictated by our incessantly beeping pagers.
Half an hour later…
I got a page from the Radiology Department. The female after-hours radiographer was on the phone, sounding harrassed.
“Could you please come down to radiology now, your patient’s being very…uh, aggressive and difficult to manage. Please.”
To me, that effectively translated to :-
“He’s gone bonkers so let’s knock him out”.
So I ran. Cartwheeled through the radiology doors (okie, so maybe ‘walked’ is a more accurate word) to see the patient sitting upright on the CT bed; accompanying nurse was holding him down and negotiating while the radiographer looked just downright frustrated/pissed.
I patted the patient on the shoulder. I told him very clearly that we’re all worried (except for him) about his brain and we really need to do this scan. Like a kid, he kept shaking his head defiantly (almost proud, too) uttering “no” over and over again. Then came the little kicks and shoves.
I looked up to find myself being the target of half-pleading glances from the staff, as if to say “SEDATE him, PLEASE!”.
We can’t all just sit around in the CT room forever, so I wrote up a medication order for sedation. It took the 4 of us to pin him down while the nurse quickly administered the injection into his bum. When we released him, he appeared to be spending the next few seconds in a daze before his cranky self took over again.
He looked at me and said, “You should be very proud of yourself with what you’ve done. Your grandfather would turn in his grave if he knew”.
That remark hit a nerve (and prompted some reflex brow-raising). My grandparents are already deceased and somehow that comment just didn’t go down well with me. My head was swirling with all sorts of verbal comebacks that I could use, including “My grandpa would be so proud if I were to kungfu you right now”.
Hmmph. Anyway I didn’t reply much except for the professional-sounding “It’s in your best interest, Mr Cranky*” – *note : Pseudonym has been used to de-identify crankiness*.
For some weird reason, whenever we saw him fading out (swaying and slurring) he would prove us wrong by suddenly sitting upright and spewing abuse at us once again. In an alternate universe, I wouldn’t hesistate to smack him out cold so we could get it all over and done with (for his own best interest, I say). There is only so much crankiness we could take.
Needless to say, what would usually be a 10 minute visit to the CT room took us approximately 80-90 minutes with him.
The CT scan turned out to be normal. Good then.
Distribution across gender : Half-half, although any bad experience with either would make you more inclined to stereotype them for the rest of your career.
How to spot them : They are pretty good at appearing alright until their next move/speech assures you that they’re anything but that.
I was walking through a room to check on a patient when the lady in the next bed called out to me.
“Where’s my husband??”, she demanded to know. This is at 4 am in the morning.
“Huh? Is he supposed to be here at this time?”, I asked.
“Uh well, it’s 4am and it’s not visiting hours for sure.”, I calmly explained.
“Oh really? I want to get out. Can you lower the bed rails for me? They’re keeping me in!”
Well, that’s exactly what the bed rails are for – to prevent patients falling outta their beds, as well as stopping elderly confused patients from their midnight urges to have walks and subsequently go missing.
I placed my hands on the rails. “Sorry, these rails are up to prevent you from falling off your bed. And I think you’re due for bedrest”.
She started being a bit fidgety. It kinda looked like she’s throwing a mini tantrum; sulking and all.
“It’s all you people’s fault for putting up the rails. Why, last week I broke my hip from hopping over the rails you know!” so she said.
“Then don’t hop, dearie”, I grinned back.
Either she got the hint or her mind was preoccupied with something else, as she went silent and appeared to be deep in thought. I gave her a quick smile and excused myself.
This is more a case of severe short term memory loss than being confused. I have been this situation on a few occasions.
Usually it would start with me giving the patient a brief notice that they’ll be needing an IV cannula in. After obtaining their consent/setting up equipments/preparing the patient/etc, I would be just about to puncture their skin when their amnesia began to play in loops.
Patient : What’s that needle for?
Me : Oh *shows them the needle* this is to put a drip into your arm.
Patient : Oh. *Goes off day-dreaming*
Me : Okie, this is gonna be a sharp sting *The needle’s already on the skin*
Patient : What are you doing? *looks surprised*
Me : Huh? I’m…uh, about to do an IV for you.
Patient : Why?
Me : You need to be on the drip.
Patient : Oh. *Nods and goes off day-dreaming*
Me : Okie. Sharp sting coming through.
Patient : Wait, what’s the needle for? *A slight hint of panic in the voice*
Me : ? This is for your drip, remember? To put the IV cannula in.
Patient : Ah, I get it. Okie.
Me : Okie. Sharp s-t-i..
Patient : What are you doing to me? *Back to square one*
It could feel like your computer’s HD is rebooting itself every 10 seconds. What do you do?
I figured that the best way for me to get the job done as soon as possible would be to do a running commentary on everything I’m about to do. Requires continuous rambling (on top of whatever you need to do) to keep the attention ala ESPN sports commentator. Something like :-
“Okie cold alcohol coming through! Ah now that’s clean…Here look at the needle, this is to go into your veins…like this…Watch it, it’s going in. Oh look, can you see your blood? We’re in the vein, yay! Needle’s out, tape on…fingers crossed and hope it works! Is it or isn’t it? ……Yeeeeeeeeesss sir your IV is all good and ready to go! Thank you very much!”
Sometimes it doesn’t end there. There has been a few times where they’d rip out the freshly inserted IV out of their confusion/amnesia/etc – majority of the time are elderly patients. I’ve had the good fortune to be timely present to see how it happens.
Step 1: Patient busy doing their own thing (memory lapse often happens here).
Step 2 : Suddenly they caught sight of the foreign looking drip+cannula implanted at the back of their hand.
Step 3 : Spends the next 5-10 seconds keenly staring at their hand in a very astonished manner. The expression that you see here varies greatly. Some just appeared to be intently examining it (akin to a kid finding a fancy marble), where as some looked like they’ve just found a Boeing 747 parked in front of their house one morning.
Step 4 : The curious ones (e.g. marble) would attempt to dismantle it. The stunned/shocked ones (e.g. Boeing 747) would violently yank the offending thing out.
Step 5 : Nurse comes to check on the patient and notices that the drip is now on the floor. Promptly pages for the lil’ newbie doc.
Step 6 : Newbie doc receives the not-so-surprising news (which could be up to the 3rd time for that one same patient). Spends the next 3 seconds deciding whether to laugh or cry.
Step 7 : Newbie doc then restarts the task of putting one in.
* * *
Haven’t had the chance to have a quiet shift so far, really.