Encroaching Madness
The clinical significance of touching grass
Yesterday morning, around 0800—just as I was finishing up first rounds—the ICU charge nurse1 came blundering past our usual ICU RT hangout, sobbing. Naturally we asked her what was wrong, and she explained that she had been “fired” from Bed 18 and didn’t know what she’d done wrong. Firing is an occasional hazard of hospital work; every now and then a patient or their family member will decide that you are too incompetent or malicious to be trusted and they don’t want to deal with you anymore. It happens to nurses, to RTs, and sometimes even to doctors. Sometimes especially to doctors. This charge nurse, “Alison,”2 naturally wondered how she’d screwed up so badly. She felt sure she was a terrible nurse.
Gradually my shift lead and I helped Alison pull herself together. I noted that, were she the sort of lazy useless nurse she felt like, her reaction would be “joke’s on you, fool; that’s less work for me.” This, she had to acknowledge, was a fair point. We’ve all known healthcare workers like that. But that was secondary, because given how long Bed 18 had been sitting there failing to improve, a firing was inevitable. Alison only happened to be the one nurse in the line of fire when the patient’s family member went over the tipping point.
Firing is, at its most basic level, a reaction to stress and disorientation. The stress part is obvious. The disorientation … well, there’s a thing called “ICU psychosis.”3 It’s a real thing, and it can have many causes, but all of them are rooted in the fact that a hospital is a lousy place to live4. Human beings were not made to stay in bed in a place that isn’t home, not meaningfully exercising, not participating in any part of their daily routine, meeting a steady stream of strangers, sleeping inadequately at weird hours, taking drugs with weird effects, maybe almost dying once or twice, and when none of that is happening trying not go mad from boredom by gorging on basic cable for hours on end. When all that gets to be too much, a patient just might go raving batshit bonkers, start babbling incoherently or seeing stuff that isn’t there.
It doesn’t usually happen to visitors or family members, because they don’t live there. But they can get a whiff of it if they decide, against all gentle suggestions by staff, that they owe it to their loved one to stay by their side until they are better5. Some people try this for a bit, then quit when they realize it’s stupid and useless; they don’t actually serve any purpose by being there all the time, since there’s a staff member there to answer to all routine needs. They can bring in a few creature comforts, they can talk for a bit if the family member isn’t too sick to understand, and then they have nothing to do but bask in the shitty daytime TV while getting in the nurses’ way6. After maybe the fifth bad show7 they remember that they have lives and responsibilities, and go back to them after a securing a promise from the nurses to call if anything significant happens. Those people, I think, generally come out okay.
But then there are those who don’t quit. I’ve never been in such a position, but I think for these people there’s always something other than affection involved; they’re proud, terrified, burdened by others’ expectations, or otherwise feel they have something to prove. It’s not always their fault, but it eventually becomes our problem.
I don’t recall where, but in some C.S. Lewis work he notes that it is, in a way, easier to be ill than to love an ill person. A suffering person doesn’t need to be instructed on how to suffer. That part happens automatically and is impossible to screw up and all you have to do is endure it as best you can. A suffering person’s father, wife, or cousin, on the other hand, can sit there perfectly healthy and want to help, only to be stymied by their obvious uselessness. If you happen to be, say, an oncologist, you might be the exception to that general rule; the rest of the time, you can only hang about feeling inadequate.
More than that, human beings like for stories to have a point to them; that’s why we tend to like religion so much. But your sick brother is just there. This might have happened for a clear reason, such as occupational hazmat exposure or substance abuse, but all that was in the past and neither the Gulf War nor the 1,300 bottles of Jim Beam are present in the room for you to yell at.
You could be mad at your brother; this is a somewhat popular choice, but doesn’t work well for long. He’s already sick so yelling at him mostly makes you feel mean. If you actually, in your heart of hearts, hold him to blame, you’re probably not there in the first place, and all communication with hospital staff will be by phone after a brief visit or two8. If you’re just mad because you need something to be mad at because mad feels better than helpless, your brother himself will make a very unsatisfying target.
You can be mad at yourself instead, but this isn’t much better than the helplessness, and finding a reason to blame yourself may prove challenging. Blaming some other family member is a thing that happens, but I imagine it mostly doesn’t happen at bedside9 so I don’t see it much. And if they aren’t at bedside with you they can always hang up or block you.
That leaves hospital staff. We make an excellent scapegoat. Unless you work in healthcare yourself or are fairly well-educated, you have no idea what the hell any of this stuff we’re doing is for. You have to take our word for it. After years at work, we may discharge our duties in a lazy, callous, or apathetic manner. Our personalities may clash with yours, we may have disagreements or tense moments when you get in the way or misinterpret a situation, and we may even try to hint that we disagree with what you are doing.
Incident feeds on incident. Initial suspicions harden with apparent confirmation because the one nurse said X was very important while the next one said Y. You’ve been sleeping on an institutional couch, its fabric selected for washability over comfort, for the last two weeks running10. The monitors never stopped beeping and blinking, and alarms went off at all hours. You long ago learned how that guy met their mother, and you have decided you are the exception when it comes to loving Raymond. The hospital cafeteria sucks and/or is overpriced. The gift shop is boring. That one doctor has an annoying habit of speech and that one nurse is an infuriating bimbo airhead.
One time the IV pump started alarming11 and it took a while for anyone to come in and silence it. When it happened again, you snapped at someone about it. Now they don’t really want to come in, because that entails dealing with bitchy family. They will find reasons to do something else first. The more avoidant they get, the pissier you feel, and the more certain you are that some kind of neglect is going on12. The final result of all this may be easily foreseen.
In the end, we persuaded Alison that no, really, the most probable explanation lay in the fact that the patient in Bed 18 had been there for well over a month and showed no signs of improvement. She knew as well as we did that this is a common problem, and that a sufficiently hostile family will have nearly the same apophenic suggestibility as a full-blown paranoid schizophrenic. It’s easy for indignation to cascade; occasionally they’ll fire so many doctors that we have no choice but to tell them, with a very straight face, that they can’t fire this one for lack of a suitable replacement.
Alison calmed down and went about her day. The family perhaps did not. If you ever find yourself in their situation, and wonder how you can help, the answer is almost certainly to go home and pay attention to their dogs and/or kids. We’ve got this. Honest. And if we don’t, you probably don’t know enough to tell.
If you didn’t know, a charge nurse is sort of the sergeant for a given floor, roughly equivalent to a shift manager in a restaurant but vastly more skilled. She will invariably be one of the most experienced nurses on the floor.
Like the bed number, this is fake.
I just looked it up to see how official it is, and evidently the preferred sensitive modern term is “ICU delirium.” Psychosis is less accurate and more offensive but also more colorful so psychosis it is.
Also, I will never not find the phrase “incompetent fundus” hilarious. I hear it and picture a beady-eyed gynecologist inspector-general with a swagger stick and a monocle tut-tutting in a posh accent that this sort of thing simply will not do. Bad form. We expect better from a modern uterus.
It’s not even a nice place to visit!
THIS IS A TERRIBLE IDEA. DO NOT DO IT.
They may tell you that you are not in the way. This is of course a polite lie. The room’s not that big and an ICU patient spontaneously generates bulky equipment in the same way we used to believe rotting meat magically gives birth to maggots. Case management is racing against time to find placement for them before the combined waste heat of all those machines simply cooks the patient alive.
For example, one of those HGTV shows (they’re basically all the same) where they take a house with dowdy furnishings and a few broken bits, suitable for sale as a fixer-upper to a yucky poor person, and dump cash on it until it turns into a giant Barbie dream house which might barely be affordable for the sort of person who produces bad shows on HGTV. Basically Marie Antoinette Presents: Holy Shit, This Cake Is Good! When the revolution comes, HGTV show hosts will be first against the wall. They will use their last words to note, with barely concealed snickers of contempt, that its wallpaper is faded and shows bloodstains much too easily.
With perhaps one more visit at the very end, from which you will walk away while shaking your head in a resigned fashion because you saw this day coming twenty years ago.
Until you disagree over end-of-life decisions.
I’m pretty sure most hospitals have visiting hours and formal limits to how many visitors can come at a time. These are often overridden by pushy families.
IV pumps will only alarm if they run out of fluid, if they finish delivering a set amount of medicine, if the line goes bad, or if the patient slightly moves their elbow and crimps it. Or if they’re busted. Or for no apparent reason whatever. If you think the pump is bad, just be glad the patient doesn’t have a vent, or worst of all a bipap. The latter is noisy as hell even when it’s not alarming, and it’s almost impossible to configure a bipap such that it’s not going to false-alarm pretty regularly, and most nurses don’t like to touch our stuff even to silence it.
I once heard of a family who accused the nurse of giving the patient sepsis on purpose. This is an interestingly wacky claim, as it implies motivation by pure spite; septic patients are a lot of extra work for a nurse.