Drug addicts in ICU
Jan. 25th, 2021 09:13 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
whitewriterTonight I hop on over to bed 28 where there's another D&A with mental health issues type gentleman.
Bed 24 was extubated and he was perfectly lovely thereafter (despite what everyone was saying yesterday: fears he'd abscond, wouldn't keep his arm up and at an angle for healing as per plastics, supposedly tried to deck D with his good hand yesterday - whilst intubated-) and this afternoon asked me if he had been "any trouble overnight". I reassured him he hadn't.
Then he went and pulled out his NGT.
Bed 23 wasn't allowed to be extubated because they sedated him ++++ for the sutures he required for his facial wounds.
They didn't get around to doing them until approx. 15:00 and therefore by the time it was completed, weaning would have meant extubation on nightshift.
No one likes to do anything radical on the night shift.
So he's stuck intubated for another night.
Story goes that he's an ex-cop with PTSD that then became drug addicted, mental health declines and in and out of homelessness (sleeping in his car), motels (getting kicked out for drug affected behavior) and lately, in and out of mental health wards. Apparently he has a partner and a child somewhere but Is currently estranged.
The reason for his injuries aren't clear. Self inflicted? Drug affected? (likely) assault? (possible). With a dodgy GCS and management concerns -- he was intubated.
His PTSD is related to an incident known as the "Redfern riots" or 2004.
What happened in 2004?
Thomas Hickey died
In a nutshell: an Aboriginal boy was riding his bicycle, and he fell off his bicycle- the police saw this and the ambulance was called however he died anyway. However it is disputed as to if he was chased (by police) or if it was an accident. The Indigenous community at Redfern (and at large)-- is very large and some in the community said they saw it differently: that the boy was pursued by police, that his bicycle was clipped by police, causing the accident and therefore someone should pay for what happened.
The day after the boy died, the community gathered on a small street near the train station (crazily enough, I know someone that lives on that street: not indigenous, a nursing friend actually) and a "protest" occurred -- rather, a violent riot. They threw bottles, bricks, live fireworks and molotov cocktails. The train station was even set on fire
Bed 24 was extubated and he was perfectly lovely thereafter (despite what everyone was saying yesterday: fears he'd abscond, wouldn't keep his arm up and at an angle for healing as per plastics, supposedly tried to deck D with his good hand yesterday - whilst intubated-) and this afternoon asked me if he had been "any trouble overnight". I reassured him he hadn't.
Then he went and pulled out his NGT.
Bed 23 wasn't allowed to be extubated because they sedated him ++++ for the sutures he required for his facial wounds.
They didn't get around to doing them until approx. 15:00 and therefore by the time it was completed, weaning would have meant extubation on nightshift.
No one likes to do anything radical on the night shift.
So he's stuck intubated for another night.
Story goes that he's an ex-cop with PTSD that then became drug addicted, mental health declines and in and out of homelessness (sleeping in his car), motels (getting kicked out for drug affected behavior) and lately, in and out of mental health wards. Apparently he has a partner and a child somewhere but Is currently estranged.
The reason for his injuries aren't clear. Self inflicted? Drug affected? (likely) assault? (possible). With a dodgy GCS and management concerns -- he was intubated.
His PTSD is related to an incident known as the "Redfern riots" or 2004.
What happened in 2004?
Thomas Hickey died
In a nutshell: an Aboriginal boy was riding his bicycle, and he fell off his bicycle- the police saw this and the ambulance was called however he died anyway. However it is disputed as to if he was chased (by police) or if it was an accident. The Indigenous community at Redfern (and at large)-- is very large and some in the community said they saw it differently: that the boy was pursued by police, that his bicycle was clipped by police, causing the accident and therefore someone should pay for what happened.
The day after the boy died, the community gathered on a small street near the train station (crazily enough, I know someone that lives on that street: not indigenous, a nursing friend actually) and a "protest" occurred -- rather, a violent riot. They threw bottles, bricks, live fireworks and molotov cocktails. The train station was even set on fire
[Error: Irreparable invalid markup ('<a [...] post</a>') in entry. Owner must fix manually. Raw contents below.]
Tonight I hop on over to bed 28 where there's another D&A with mental health issues type gentleman.
<lj-cut text="The type of pt you don't see in neuro ICU often but is a regular in the general ICU"> Bed 24 was extubated and he was perfectly lovely thereafter (despite what everyone was saying yesterday: fears he'd abscond, wouldn't keep his arm up and at an angle for healing as per plastics, supposedly tried to deck D with his good hand yesterday - whilst intubated-) and this afternoon asked me if he had been "any trouble overnight". I reassured him he hadn't.
Then he went and pulled out his NGT.
Bed 23 wasn't allowed to be extubated because they sedated him ++++ for the sutures he required for his facial wounds.
They didn't get around to doing them until approx. 15:00 and therefore by the time it was completed, weaning would have meant extubation on nightshift.
No one likes to do anything radical on the night shift.
So he's stuck intubated for another night.
Story goes that he's an ex-cop with PTSD that then became drug addicted, mental health declines and in and out of homelessness (sleeping in his car), motels (getting kicked out for drug affected behavior) and lately, in and out of mental health wards. Apparently he has a partner and a child somewhere but Is currently estranged.
The reason for his injuries aren't clear. Self inflicted? Drug affected? (likely) assault? (possible). With a dodgy GCS and management concerns -- he was intubated.
His PTSD is related to an incident known as the "Redfern riots" or 2004.
What happened in 2004?
Thomas Hickey died
In a nutshell: an Aboriginal boy was riding his bicycle, and he fell off his bicycle- the police saw this and the ambulance was called however he died anyway. However it is disputed as to if he was chased (by police) or if it was an accident. The Indigenous community at Redfern (and at large)-- is very large and some in the community said they saw it differently: that the boy was pursued by police, that his bicycle was clipped by police, causing the accident and therefore someone should pay for what happened.
The day after the boy died, the community gathered on a small street near the train station (crazily enough, I know someone that lives on that street: not indigenous, a nursing friend actually) and a "protest" occurred -- rather, a violent riot. They threw bottles, bricks, live fireworks and molotov cocktails. The train station was even set on fire <a href="https://en.wikipedia.org/wiki/2004_Redfern_riots#:~:text=The%202004%20Redfern%20riots%20took%20place%20on%20the,of%20Thomas%20Hickey%2C%20also%20known%20as%20TJ%20Hickey." As was detailed here in this wikipedia post</a>. It's Australia Day today so these issues arise even more so amongst the national conversation.
So now here he was in ICU: PTSD caused his drug addictions; which then caused his crisis; which caused him to be picked up by ambulance and taken to ED where he was intubated until we could "sort out his withdrawals" to an extent.
I think we did a very poor job of the above because at 04:00 on 25 of propofol and after a 10 ml bolus of propofol and 50 mcg bolus of fentanyl (whilst on a 50mcg/hr drip)+ a dexmedetomidine infusion at max rate (supposing his weight was the documented 86 kg, but honestly he felt a lot more like 95kg, in anycase, it was a lot of dexa)+ 300mg of quetiapine (25 is a normal dose... 50 is a lot ... 300 is wtf) he was thrashing about the bed and I couldn't figure out what I was going to do.
I made a fuss calling for help because I was sure he was going to self extubate the moment he had a chance and that would mean me basically sitting on him, on the bed: was the only solution (not workable) He was a GCS 11 so technically, should be extubatable (usually we want a GCS 11 with the propofol and the fentanyl turned though).
You could tell he was withdrawing, he had the sweats, the tremors, he looked like he was hallucinating (hard to tell when your intubated- but he'd stare at the ceiling oddly) - and there was a time when I feared he might deck me (and I don't much like that considering I couldn't leave his bedside- let alone be more than an arms length away for fear he extubate) -
ICU decided to extubate.
Solves one problem, creates another. The extubation is a controlled senario (oh shit I realise as I sit here writing this that I forgot to do a post extubation ABG which occurs 30 mins post usually). Honestly, I could barely leave the bedside to do anything because -- problem number two arose now he was withdrawing and could speak.
5mg of haloperidol and 10mg of diazepam later he was putty in my hands.
For all of 10 minutes.
He'd take his gown off. and his sheets; then say he was cold.
He'd want the bed flat, then say he felt like he lay like that and wanted to sit up. The IV lines were starting to annoy him.
He'd want the IDC out, (I'd explain why not) he wanted to walk around (definitely a bad idea). He wanted to go to the toilet ( and he wanted the IDC out).
I'd try very hard to patiently explain that he was just extubated, had a lot of medications on board, and that if he had a fall; he'd be stuck in ICU for longer than he needed to be if he'd just stay put. There's an IDC and he won't wet the bed.
This went on and on in cycles of about 10 mins. It's surprising that I even got the morning medications done.
The missing ABG is annoying me now though because that's something I forgot to do and it was important. I remember thinking about it ... sighs.
I fought with him about keeping the oxygen mask on post extubation - I compromised with nasal prongs at 4L. Sp02 of 82% really wasn't going to cut it (and it would also have made my theoretical ABG that I should have done look really bad.
I also let him drink water and take tablets (a no-no for the first 4 hours post extubation, but here we are, we extubated someone off 25mls/hr of propofol ... protocol has already walked out the door. and IV diazepam worked for all of 10mins. Perhaps the tablet format would last a little longer and be less "high-giving". You should have seen his face after they injected the diazepam. He was on cloud9.)
The first thing he said post extubation was: "I refuse treatment".
We informed him as he had just been extubated; he remained under duty of care for 4 hours at least (first time I ever heard of the 4 hour rule) --
I'm from neuro ICU: our patients are much calmer. We get confused people all the time, yes. But very rarely, drug addicts. There might have been 1 or 2 with a mycotic aneurysm related to IVDU history, but those had been rather sketchy and not a live: GHB, didn't want to detox, didn't want a bar of treatment type person.
I spoke to his mother on the phone, she went on about his history in the past year, his multiple admissions in various hospitals and institutions- which she'd liked and which she didn't- how the last place (incidentally, MSH btw.) had told her the pt had rights and if they couldn't see a reason to keep him then they'd have to let him go. -- How she'd begged them to keep him but they didn't listen. She wanted him to go to rehab.
I'm not sure he wants to go to rehab. I was slightly itching to ask him, but I figured at 06:00 that was a bad discussion to get into, with a person who was withdrawing and being a general nightmare of a pain to deal with.
My pt's mother also spent about 5 minutes waxing lyrical about nursing staff being amazing and heros and all that jazz. I always feel slightly uncomfortable when that happens (and it seems to happen more recently than before: and a lot more at MISH or MSH compared to SSH - I wonder if that's a community sentiment thing). I have to say though I earned my money that morning working with this gentleman.
</lj-cut>
Yes I can relate this shift to fanfiction (shocker!):
I was recently reading another fanfic I dug out of <a href="http://www.annex-files.com/annex/index.html">The Annex</a> in which <a href="http://www.annex-files.com/annex/annex/stories/kickingthehabit.txt">Mulder gets forced into drug addiction, and Scully is planning to help him out of it.</a> I'm probably about 25% of the way through and whilst the premise is interesting, the writing isn't. The author could have done so much more with that subject.
Funnily enough, bed 29 was sitting there calm as a clam all night long, best patient. A+.
Wished I had him instead. He's a drug addict too. Perhaps I judged his program too harshly because clearly, he's at least functional despite his addiction. Then again it was still Tuesday and not Wednesday/Thursday....
<lj-cut text="The type of pt you don't see in neuro ICU often but is a regular in the general ICU"> Bed 24 was extubated and he was perfectly lovely thereafter (despite what everyone was saying yesterday: fears he'd abscond, wouldn't keep his arm up and at an angle for healing as per plastics, supposedly tried to deck D with his good hand yesterday - whilst intubated-) and this afternoon asked me if he had been "any trouble overnight". I reassured him he hadn't.
Then he went and pulled out his NGT.
Bed 23 wasn't allowed to be extubated because they sedated him ++++ for the sutures he required for his facial wounds.
They didn't get around to doing them until approx. 15:00 and therefore by the time it was completed, weaning would have meant extubation on nightshift.
No one likes to do anything radical on the night shift.
So he's stuck intubated for another night.
Story goes that he's an ex-cop with PTSD that then became drug addicted, mental health declines and in and out of homelessness (sleeping in his car), motels (getting kicked out for drug affected behavior) and lately, in and out of mental health wards. Apparently he has a partner and a child somewhere but Is currently estranged.
The reason for his injuries aren't clear. Self inflicted? Drug affected? (likely) assault? (possible). With a dodgy GCS and management concerns -- he was intubated.
His PTSD is related to an incident known as the "Redfern riots" or 2004.
What happened in 2004?
Thomas Hickey died
In a nutshell: an Aboriginal boy was riding his bicycle, and he fell off his bicycle- the police saw this and the ambulance was called however he died anyway. However it is disputed as to if he was chased (by police) or if it was an accident. The Indigenous community at Redfern (and at large)-- is very large and some in the community said they saw it differently: that the boy was pursued by police, that his bicycle was clipped by police, causing the accident and therefore someone should pay for what happened.
The day after the boy died, the community gathered on a small street near the train station (crazily enough, I know someone that lives on that street: not indigenous, a nursing friend actually) and a "protest" occurred -- rather, a violent riot. They threw bottles, bricks, live fireworks and molotov cocktails. The train station was even set on fire <a href="https://en.wikipedia.org/wiki/2004_Redfern_riots#:~:text=The%202004%20Redfern%20riots%20took%20place%20on%20the,of%20Thomas%20Hickey%2C%20also%20known%20as%20TJ%20Hickey." As was detailed here in this wikipedia post</a>. It's Australia Day today so these issues arise even more so amongst the national conversation.
So now here he was in ICU: PTSD caused his drug addictions; which then caused his crisis; which caused him to be picked up by ambulance and taken to ED where he was intubated until we could "sort out his withdrawals" to an extent.
I think we did a very poor job of the above because at 04:00 on 25 of propofol and after a 10 ml bolus of propofol and 50 mcg bolus of fentanyl (whilst on a 50mcg/hr drip)+ a dexmedetomidine infusion at max rate (supposing his weight was the documented 86 kg, but honestly he felt a lot more like 95kg, in anycase, it was a lot of dexa)+ 300mg of quetiapine (25 is a normal dose... 50 is a lot ... 300 is wtf) he was thrashing about the bed and I couldn't figure out what I was going to do.
I made a fuss calling for help because I was sure he was going to self extubate the moment he had a chance and that would mean me basically sitting on him, on the bed: was the only solution (not workable) He was a GCS 11 so technically, should be extubatable (usually we want a GCS 11 with the propofol and the fentanyl turned though).
You could tell he was withdrawing, he had the sweats, the tremors, he looked like he was hallucinating (hard to tell when your intubated- but he'd stare at the ceiling oddly) - and there was a time when I feared he might deck me (and I don't much like that considering I couldn't leave his bedside- let alone be more than an arms length away for fear he extubate) -
ICU decided to extubate.
Solves one problem, creates another. The extubation is a controlled senario (oh shit I realise as I sit here writing this that I forgot to do a post extubation ABG which occurs 30 mins post usually). Honestly, I could barely leave the bedside to do anything because -- problem number two arose now he was withdrawing and could speak.
5mg of haloperidol and 10mg of diazepam later he was putty in my hands.
For all of 10 minutes.
He'd take his gown off. and his sheets; then say he was cold.
He'd want the bed flat, then say he felt like he lay like that and wanted to sit up. The IV lines were starting to annoy him.
He'd want the IDC out, (I'd explain why not) he wanted to walk around (definitely a bad idea). He wanted to go to the toilet ( and he wanted the IDC out).
I'd try very hard to patiently explain that he was just extubated, had a lot of medications on board, and that if he had a fall; he'd be stuck in ICU for longer than he needed to be if he'd just stay put. There's an IDC and he won't wet the bed.
This went on and on in cycles of about 10 mins. It's surprising that I even got the morning medications done.
The missing ABG is annoying me now though because that's something I forgot to do and it was important. I remember thinking about it ... sighs.
I fought with him about keeping the oxygen mask on post extubation - I compromised with nasal prongs at 4L. Sp02 of 82% really wasn't going to cut it (and it would also have made my theoretical ABG that I should have done look really bad.
I also let him drink water and take tablets (a no-no for the first 4 hours post extubation, but here we are, we extubated someone off 25mls/hr of propofol ... protocol has already walked out the door. and IV diazepam worked for all of 10mins. Perhaps the tablet format would last a little longer and be less "high-giving". You should have seen his face after they injected the diazepam. He was on cloud9.)
The first thing he said post extubation was: "I refuse treatment".
We informed him as he had just been extubated; he remained under duty of care for 4 hours at least (first time I ever heard of the 4 hour rule) --
I'm from neuro ICU: our patients are much calmer. We get confused people all the time, yes. But very rarely, drug addicts. There might have been 1 or 2 with a mycotic aneurysm related to IVDU history, but those had been rather sketchy and not a live: GHB, didn't want to detox, didn't want a bar of treatment type person.
I spoke to his mother on the phone, she went on about his history in the past year, his multiple admissions in various hospitals and institutions- which she'd liked and which she didn't- how the last place (incidentally, MSH btw.) had told her the pt had rights and if they couldn't see a reason to keep him then they'd have to let him go. -- How she'd begged them to keep him but they didn't listen. She wanted him to go to rehab.
I'm not sure he wants to go to rehab. I was slightly itching to ask him, but I figured at 06:00 that was a bad discussion to get into, with a person who was withdrawing and being a general nightmare of a pain to deal with.
My pt's mother also spent about 5 minutes waxing lyrical about nursing staff being amazing and heros and all that jazz. I always feel slightly uncomfortable when that happens (and it seems to happen more recently than before: and a lot more at MISH or MSH compared to SSH - I wonder if that's a community sentiment thing). I have to say though I earned my money that morning working with this gentleman.
</lj-cut>
Yes I can relate this shift to fanfiction (shocker!):
I was recently reading another fanfic I dug out of <a href="http://www.annex-files.com/annex/index.html">The Annex</a> in which <a href="http://www.annex-files.com/annex/annex/stories/kickingthehabit.txt">Mulder gets forced into drug addiction, and Scully is planning to help him out of it.</a> I'm probably about 25% of the way through and whilst the premise is interesting, the writing isn't. The author could have done so much more with that subject.
Funnily enough, bed 29 was sitting there calm as a clam all night long, best patient. A+.
Wished I had him instead. He's a drug addict too. Perhaps I judged his program too harshly because clearly, he's at least functional despite his addiction. Then again it was still Tuesday and not Wednesday/Thursday....
