The traumas from intensive care can persist
When Lygia Dunsworth was sedated, intubated and strapped down in the intensive care unit at a Fort Worth, Texas, hospital, she was racked by hallucinations:
Outside her window, she saw helicopters evacuating patients from an impending tornado, leaving her behind. Nurses plotted to toss her into rough lake waters. She hallucinated an escape and ducked into a freezer, surrounded by body parts.
For years after recovering physically from abdominal infections and surgeries, Mrs. Dunsworth was tormented by her stay in intensive care. She had short-term memory loss and difficulty sleeping. She would not go into the ocean or a lake and was terrified to fly or even travel alone.
Nor would she talk about it. “Either people think you’re crazy or you scare them,” said Mrs. Dunsworth, 54, a registered nurse. In fact, she was having symptoms associated with post-traumatic stress disorder.
Annually, about five million patients stay in an intensive care unit in the United States. Studies show that up to 35 percent may have symptoms of PTSD for as long as two years after that experience, particularly if they had a prolonged stay due to a critical illness with severe infection or respiratory failure. Those persistent symptoms include intrusive thoughts, avoidant behaviors, mood swings, emotional numbness and reckless behavior.
Yet when patients leave the I.C.U., said Dr. O. Joseph Bienvenu of the Johns Hopkins University School of Medicine in Maryland, “it’s the exception for them to be screened for psychiatric symptoms like post-traumatic stress or low mood.”
Now critical care specialists are trying to prevent or shorten the duration of the disorders.
Other PTSD sufferers also endure flashbacks, but theirs are grounded in episodes that can often be corroborated. What is unsettling for post-I.C.U. patients is that no one can verify their seemingly real horrors.
“I.C.U. patients have vivid memories of events that objectively didn’t occur,” Dr. Bienvenu said. “They recall being raped and tortured as opposed to what really happened,” such as painful procedures like the insertion of catheters and IV lines.
In Britain, Germany and some Scandinavian countries, nurses in many critical care units keep a diary of the care they give a patient, with additions from the family, which they give to the patient upon discharge. The diaries function as a counterpoint to patients’ hallucinations or amnesia.
The I.C.U. setting itself can feel sinister to patients. The eerie, sleep-indifferent lights. The cacophony of machines and alarms.
Women may be more at risk to PTSD than men, as are patients with a history of depression or other emotional difficulties.
But researchers have begun to identify the treatment that has led to the most harrowing flashbacks: sedation, which is crucial in the I.C.U. to manage pain and compel patients to lie still. They now believe that a class of sedatives known as benzodiazepines, which includes the drug Valium, may intensify the hallucinations that are so disturbing to I.C.U. patients and can return for years.
In January, the Society of Critical Care Medicine released new sedation guidelines, urging I.C.U. doctors to treat pain first and only then to weigh using benzodiazepines for anxiety. Lighter sedation seems tied to better cognitive and physical rehabilitative recovery, as well as fewer and less shattering hallucinations.
A British doctor, Sarah Wake, was a 25-year-old intern when in 2011 she was intubated and sedated following a severe reaction to a medication. She described her hallucinations in the British journal BMJ in May: “Blood seeping through holes and cracks in my skin, forming a puddle of red around me.”
She wrote that the fragmented delusional memories made it difficult for her to understand what had happened. “This prevented my psychological recovery and led to the development of post-traumatic stress disorder.”
For months she could not work in a hospital.
Such avoidant behavior, said James C. Jackson of the division of critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee, is among the most debilitating of PTSD symptoms. “This phenomenon is not uncommon,” he said. “But it makes it hard for individuals who need help to take the necessary steps to get it.”
Even now, after therapy, she is practicing medicine again and yet, Ms. Wake wrote, “I still cannot bear a shower curtain to be drawn as it reminds me of closed hospital curtains and hidden death.”