“Surviving” the ICU: A Perspective from Both Sides of the Bed

Alison S. Clay, MD, FCCP Assistant Dean for Clinical Education

Duke University of School of Medicine

Departments of Surgery and Medicine

https://www.recordnations.com/wp-content/uploads/2015/04/two-viewpoints.jpg (accessed 4/8/2017)

Disclosures

• I have no conflicts of interest to report • I speak as a patient with chronic illness, not as faculty from Duke • I have used, with citation, photographs or pictures from many

webpages, including photos from some medical company websites. • I do not endorse any of the products pictured in these photos.

http://genelu.com/2010/11/word-up-thesis-concept-no-2/ (Gene Lu, 12/18/2013)

Context: About Me

Curiosity

http://www.cannockchasedc.gov.uk/site/custom_scripts/HeritageTrail/images/museum_cannock/scott.jpg

Context: About Me

Patients with Chronic Illness

Detailed View of Oxidative Phosphorylation (reprinted with permission from Kanehisa Laboratories and the KEGG project: www.kegg.org ); http://employees.csbsju.edu/hjakubowski/classes/ch331/oxphos/olcouplingoxphos.html (12/18/2013)

Context: About Me

Biochemical Basis of my Illness

LACTATE

http://www.bioinfo.org.cn/book/biochemistry/chapt15/bio4.htm (12/18/2013)

Context: About Me

Biochemical Basis of my Illness

http://en.wikipedia.org/wiki/Tracheal_intubation (Philipp, N, accessed 12/18/2013)

Context: About Me

Consequences of Biochemistry

• >50 Intubations • A tracheostomy • CLABSI:

• Staph Epi • MRSA • Candida

• VAP with Septic Shock/ARDS

• DVT

https://miscetceteradotcom.files.wordpress.com/2014/04/invisible_disability_stickers-r449f8209b2e24f9e99cbbfda6d03ece2_v9i40_8byvr_324.jpg

Mistrust

Context: About Me

Consequences of Biochemistry

http://www.kstoolkit.org/file/view/storytelling.gif/33222395/363x262/storytelling.gif (accessed 4/1/17)

Problems with Care in the ICU

Storytelling

Problems with Care in the ICU

One ICU Admission: A Journey

http://www.aime.com/flashbpic/201401/201401200034252066.jpg(accessed 4/2/2017)

http://saplingstories.blogspot.com/2013/12/my-new-dragonfly-friend-aka-port-huber.html (accessed 4/2/2017)

http://commons.wikimedia.org/wiki/File:Bag_Valve_Mask_(AMBU_-_bag).jpg (Creative Commons Usage, accessed 12/18/2013)

Problems with Care in the ICU

Readmission with Intubation

http://www.tracheostomy.com/care/suction.htm (Bard Medical Division, accessed2/18/2013)

Problems with Care in the ICU

Mechanical Ventilation

Reprinted with Permission Cartoon Stock

Problems with Care in the ICU

Restraints

http://www.rehabmart.com/imagesfromrd/PO-2528%20Posey%20Double%20Strap%20Foam%20Limb%20Holder_Patient%20Restraints.jpg (accessed 4/1/2017)

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Problems with Care in the ICU

My Restraints

Intensive Care Medicine 2013; 39:31-37

0

20

40

60

80

100

% of Patients Duration of Use

>75%50-75%25-50%<25%

% of French ICUs Reporting Restraint Use

Problems with Care in the ICU

Restraint Prevalence

http://www.listerhospital.com.gh/images/visiting_hours.jpg (accessed 8/14/2014)

Problems with Care in the ICU

Isolation

0102030405060708090

Visiting Hours VisitationDuration

VisitorNumber

ImmediateFamily

Members

Age limitations

Critical Care 2013; 17: R71

Problems with Care in the ICU

Isolation: Visiting Hour Restrictions

http://www.atitesting.com/ati_next_gen/skillsmodules/content/nasogastric-intubation/images/NG_salem_sump.jpg (accessed 3/31/2015)

Problems with Care in the ICU

Painful Procedures

http://img15.deviantart.net/b83a/i/2004/145/9/e/bloody_nose.jpg (Accessed 3/31/2015)

Problems with Care in the ICU

Painful Procedures while Restrained

https://loretob1group2.files.wordpress.com/2012/09/paranoia1.png (accessed 9/2/2014)

Problems with Care in the ICU

Paranoia

http://www.faecdn.com/bex/manual/i/CAD_4I-fixed.gif (accessed 4/2/2017)

Problems with Care in the ICU

Paranoia

1Heart & Lung: The Journal of Acute and Critical Care, 2014; 43(5): 427-431 2Johns Hopkins Medicine, February 26, 2013 http://www.hopkinsmedicine.org/news/media/releases/ptsd_symptoms_common_among_icu_survivors

Held as a Prisoner1

“I’d wake up…well like somebody is holding your head underwater or strangulating [you]”

“I was locked up…and every time I tried to get out, that person would try and stick me with a pitchfork”

Being Drowned1

Rape/Assault2

Problems with Care in the ICU

Themes of Paranoia experience by Patients

50 dB 75 dB 104 dB

Critical Care 2009; 13 (2): 208

http://www.clker.com/cliparts/z/U/G/l/B/3/blow-dryer-hi.png (Creative Commons Usage, 12/18/2013)

http://www.clker.com/cliparts/5/b/b/7/11954217391761912368Machovka_Power-saw.svg.hi.png (Creative Commons Usage, 12/18/2013)

Problems with Care in the ICU

Noise

http://livelovefruit.com/wp-content/uploads/2014/11/AR-403130303.jpg (accessed 4/1/2017)

Problems with Care in the ICU

Sleep Deprivation: Delirium, Drugs

1. Common Complaints of Patients in ICU 2. Sleep fragmentation occurs, even when appear to

be sleeping 3. Sleep Deprivation and Delirium look similar in the

Brain (neurohormonal/chemical) 4. Sleep Deprivation and Delirium provoke each other

Critical Care 2009 13:234 http://www.ccforum.com/content/13/6/234

Problems with Care in the ICU

Consequences of Sleep Deprivation

http://www.thisoldhouse.com/toh/how-to/intro/0,,20562442,00.htm (Kolin Smith, This Old House Magazine, Accessed 12/18/2013)

Problems with Care in the ICU

Transitions to Home

http://well.blogs.nytimes.com/2009/12/01/why-loneliness-can-be-contagious/?_r=0 (Vetta Collection, New York Times Magazine, December 1, 2009, Accessed 12/18/2013)

Problems with Care in the ICU

Transitions to Home: Loneliness

http://blackburnnews.com/wp-content/uploads/2012/08/thunderstorm.jpg (Josh Boyce, Blackburn News, Accessed 12/18/2013)

Problems with Care in the ICU

Transitions to Home: PTSD

“ICU stays lead to Alzheimer’s like

problems in one-third of patients s”- CBS

News

“Extended ICU Stays cause brain damage”-

USA Today

“Delirium in the ICU was independently associated with a

longer post-ICU stay, fewer median days alive and without mechanical ventilation and a higher incidence

of cognitive impairment at hospital discharge.”-Ely et al, JAMA 2004

Problems with Care in the ICU

Transitions to Home: Cognitive Dysfunction