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Iatrogenic Delirium and Coma
CHEST
Transparency in Health Care CASE REPORT
Iatrogenic Delirium and Coma* A “Near Miss” William F. Dunn, MD, FCCP; Shirley C. Adams; and Robert W. Adams A 66-year-old woman was cared for at two referral institutions following a witnessed cardiac arrest in a local emergency department. Despite aggressive initial care, she failed to regain consciousness during a 28-day course. Based on an erroneous neurologic diagnosis of anoxic encephalopathy, pessimism regarding likelihood of improvement existed, prompting clinical consideration of withdrawal of care. The correct diagnosis of iatrogenic drug-induced coma alternating with drug-induced delirium only became apparent after the IV administration of repeated doses of a benzodiazepine antagonist. The patient and husband (co-authors) provide insights often unheard within care circles. (CHEST 2008; 133:1217–1220) Key words: antagonist; coma; delirium; iatrogenesis; lorazepam; risk; safety; sedation
Editor’s Note: This submission to the “Transparency in Health Care” series focuses on a case of a “near miss,” actually a near death, imposed by two “systems.” When we view adverse events as “system issues” rather than as opportunities to identify the individual responsible to “blame and shame,” we can more responsibly develop system responses of broadly improved care. As an outgrowth of the case described, amid others, a system solution emerged that created the Division of Critical Care Neurology at the institution described. While the retrospective clarity of the case described serves as an overt example of a number of system failures, the authors caution that this clarity is the tip of an iceberg of similar clinical happenings that may not be so apparent, even in retrospect. Case History 66-year-old woman was transferred O nfromday an1, aout-of-state institution at the insis-
tence of her husband, on postoperative day 27
*From the Mayo Foundation, Rochester, MN. The authors have no financial conflicts of interest to disclose. Manuscript received February 20, 2008; revision accepted March 3, 2008. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: William F. Dunn, MD, FCCP, 200 First St SW, Mayo Foundation, Rochester, MN 55905; e-mail: dunn.william@ mayo.edu DOI: 10.1378/chest.08-0471 www.chestjournal.org
following coronary bypass grafting, for re-evaluation of therapy and prognosis subsequent to home recommendations of withdrawal of life-supportive therapy. She initially presented to her local emergency department with acute chest pain, and acute coronary syndrome in the anterior myocardial distribution was diagnosed. In the emergency department, the patient had a systolic BP of 60 mm Hg and had a ventricular fibrillation arrest. She was resuscitated successfully and sent to emergent coronary catheterization, where she was found to have serial stenoses of the left anterior descending coronary artery, a complete occlusion of the right coronary artery, and an ejection fraction of 35%. At attempted angioplasty, a dissection of the left anterior descending artery occurred, and cardiogenic shock developed. An intraaortic balloon pump was placed. Pressors were begun, and she was transferred to a tertiary care center. She underwent emergent coronary artery bypass grafting. Hospital Course (27 Days) On postoperative day 4, the patient remained intubated and responded only to painful stimuli. Roving eye movements were noted. A feeding tube was placed. On postoperative day 6, a tube thoracostomy was placed for the new radiographic finding of a right-sided pneumothorax. Liver function test results were abnormal, and she became transiently CHEST / 133 / 5 / MAY, 2008
1217
jaundiced. Amylase and lipase were noted to be increased as well in a nonspecific pattern. An EEG was performed and revealed triphasic waves that were interpreted to be consistent with a poor prognosis. During the hospital stay, two CT studies of the head were performed, revealing no focal lesions. A lumbar puncture was normal. A tracheotomy was performed on postoperative day 19. Throughout the course, she never regained consciousness. Continued roving eye movements were noted, and there were intermittent semipurposeful writhing motions, for which wrist restraints and sedation (lorazepam at 1 to 4 mg IV every 1 to 4 h as needed) were prescribed. At times she was fully comatose. Multiple notes in the charting commented on the “doting” nature of the husband, expressing his wife’s seeming visual recognition of him without staff recognition of the same phenomena. “Appropriate” gestures, nods, and feeble hand grasps described by the husband were not witnessed by any ICU staff. The husband had a near-constant presence in the ICU. Within the hospital stay, multiple physicians were consulted, including neurology, gastroenterology, infectious diseases, and ears, nose, and throat. Within the context of the subspecialty consultations, each physician concurred that the patient had anoxic encephalopathy and had a poor prognosis. With passing time, the tone of the hospital charting grew progressively grim. Nonetheless, the husband insisted that the patient continued to intermittently focus on him visually and squeeze his hand, in seeming recognition. A second neurologic opinion was declined after repeated suggestions to withdraw care. On postoperative day 27, the patient was transferred to our institution. The patient’s medical history was unremarkable.
ing movements, and grimaces to painful stimuli. Plantar response was flexion. Laboratory Assessment ECG suggested right atrial enlargement, possible anteroseptal infarct, with nonspecific T-wave abnormalities. Hemoglobin was 9.6 g/dL. Alkaline phosphatase was 729 U/L (normal, 119 to 309 U/L). Aspartate was 54 U/L (normal, 12 to 31 U/L). Bilirubin was 1.3 mg/dL (normal, 0.1 to 1.1 mg/dL). The patient was seen in staff neurology consultation at the request of the house staff the preceding evening (Fig 1). The patient was seen by an ICU team: faculty attending, four interns, four supervisory residents, and three critical care fellows. Findings were as described: the patient was unresponsive to command, with eyes closed, and with slow writhing-like motions of all four extremities. In order to better assess the possibility of drug-induced mental state changes, a decision was made to provide drug sedative antagonists as a diagnostic challenge. No change in status was apparent after two doses of 0.4 mg of naloxone. However, the patient then received flumazenil at 0.2 mg IV for five doses while the team watched. Between the fourth and fifth doses, she regained responsiveness, opened her mouth, and protruded her tongue to command. The 0.7-mm tracheostomy tube was corked, and the cuff was deflated. When asked her name, she responded, “Shirley. My name is Shirley Adams.” When it was requested that she describe her hometown, she said
Consultative neurological summary note: “Asked to see by Dr. _________ for decreased mental status 28 days after cardiorespiratory failure. Reviewed history and examined patient.
Assessments on Arrival At arrival, the patient was assessed by the resident and fellow team in the medical ICU: BP, 120/60 mm Hg; pulse rate, 82 beats/min; and temperature, 38.5°C. The patient was receiving mechanical ventilation via tracheostomy, was receiving pressure support ventilation, was unresponsive to command, was writhing, and had wrists restrained. Head, ear, eye, nose, and throat examinations revealed spontaneous eye opening with roving ocular movements. The chest was clear to auscultation, with a healing sternotomy incision/chest tube site. Heart evaluation revealed regular rhythm, with no murmur or gallops. The abdomen was soft, without organomegaly. The extremities showed a partially healed postoperative saphenous vein graft harvest wound. Neurologic findings were nonfocal, with semipurposeful writh1218
Anterior MI, bypass following PTCA, ARDS, etc
unresponsive.
Exam: Without focal changes. Generalized semi-purposeful limb movements. Appears to want to void. Eye opening. No command following.
Impression: Anoxic encephalopathy —at 28 days potential for full cognitive recovery is low— EEG and MRI should help quantify this.”
Figure 1. Text of neurologic consultation. Although EEG and MRI were recommended, results in similar clinical experiences are often nonspecific. Without accurate diagnosis of druginduced delirium (terminated by iatrogenic drug-induced coma as “chemical restraint”), the true cause of the mental status may have been never identified, with possible further recommendations for withdrawal of care. System changes in response to this and similar experiences have since confined ICU neurologic consultations to neurologists with specialization in critical care neurology. PTCA ⫽ percutaneous transluminal coronary angioplasty; MI ⫽ myocardial infarction. Transparency in Health Care
Figure 2. When performing sedation interruption for a patient receiving mechanical ventilation while in a drug-induced coma, what is often presumed is the clinical course A, with progressing mental clarity. However, what may occur clinically, particularly with longer-acting agents, is the “tail-chasing” phenomenon (B). For 27 days, the patient described received sedation that maintained her cycling between (drug-induced) coma and (druginduced) delirium. Small arrows represent lorazepam redosing for agitation. Sedation interruption does not necessarily prevent this phenomenon because delirium-associated agitation ensues. Options of therapy include the following: (1) observation (impractical); (2) substitution of a shorter-acting agent allowing for metabolism of the offending drug; (3) primary therapy of the delirium with neuroleptic therapy; and (4) selective use of antagonists (diagnostic and/or therapeutic). RASS ⫽ Richmond agitation and sedation scale.1
“I live in Maryville, TN.” She remained subsequently disconnected from the ventilator, and rapidly improved (Fig 2). Subsequent echocardiography revealed normal left ventricular size and function with a normal ejection fraction. She was dismissed from Saint Mary’s Hospital, Rochester, MN, on September 20, 1997, on postoperative day 35 after an 8-day hospitalization. Perspectives From the Husband, Co-author Robert Adams Shirley and I will have been married 54 years in June of 2007. Shirley’s mind is sharp. She remembers me sitting on the lap of Miss Porter, our first-grade teacher in a small town in Western Pennsylvania. We have been blessed with four healthy, loving children. We have a close caring family. Shirley made it so (Fig 3). The case study you read cannot nearly describe the emotional trauma experienced by Shirley’s family: the 911 heart attack in the middle of the night, the local hospital emergency department, watching through an open door, a doctor’s words “we lost her,” the flat line, my knees to the floor, the door is shut, “she’s back” (from a nurse), another ambulance trip to the city hospital, 15 miles distant where a heart www.chestjournal.org
Figure 3. Spring 2007 photo of Shirley and Robert Adams, co-authors.
surgeon is waiting, and a successful quadruple bypass. Shirley’s life is saved by skilled hands. I was with Shirley when she awoke in her room. Her hands and feet were tied to the bed. A breathing tube was in her throat. Her eyes became opened wide and wild looking. She tried to scream and fight to get loose. I tried to reassure her. “Nurse! Nurse!” A shot was administered to calm her down and to keep her from tearing her sutures or worse. And then for 30 days she was in an agitated or comatose state. Several doctors in specialty fields observed and tested Shirley. Cardiology, neurology, internal medicine: kidney, liver, and lungs. All vitals were checked. There was mention of insecurity of a small “gray” area on the brain scan, thus being perhaps the reason for the coma, or maybe not; it is hard to know. I and/or our children were in Shirley’s room when we were allowed or were not chased off. We spent many hours in the waiting room and the hospital chapel also. After approximately 2 weeks, we suspected the drugs, and I mentioned this to doctors and nurses. Shirley can get tipsy on a glass of wine. I told them this also. Once, on my prompt, and during Shirley’s quiet time she gave my hand a gentle squeeze. Another time, son Timothy reminded her of his birthday and she formed a faint smile on her lips. We told doctors of this also. When the neurologist entered her room for his 3- to 5-min visit, Shirley would not respond to his squeeze test. He explained away our observations as an involuntary reaction on Shirley’s part or of our seeing what we hoped to see. There were more times of calm, agitation, and calming shots. Towards the end, one nurse told us Shirley was not in pain, but she was administering morphine. We were frustrated and scared. When we learned that Shirley was going to be transferred from ICU to a “room” we became CHEST / 133 / 5 / MAY, 2008
1219
afraid; she had been dependent on a ventilator to breathe, ever since surgery. I asked the heart surgeon to refer her to the Mayo Clinic. For the transfer, I carried with me written notes of our observations and suspicions of a drug-induced coma. Surely at such an institution doctors would consider her being oversedated. What is the lesson for those reading my thoughts? Stay close to loved ones in a medical emergency. Ask questions of all medical treatments. Find doctors who will listen to those who know the patient best, and get a second opinion if needed. Beware, though, because sometimes doctors make diagnostic mistakes; they did so in this case. Can I offer advice to doctors (who, I am sure are taught the same in medical schools)? Do not let ego and arrogance take hold. Take time to listen to patients and family and share information with other doctors and nurses who are treating your patient. After her release from Mayo Clinic, Shirley wanted to come home instead of being sent to a rehabilitation center. She weighed ⬍ 100 lb and was too weak to hold a newspaper. Over time (approximately 12 months), the milestones were accomplished and she regained her strength and normal weight of 132 lb. Now we are into senior roller skating once a week, and circuit training three times a week at the local health club. Despite the difficulties, Shirley was given her life back through much prayer, the grace of God, the heart surgeon, and the many good doctors and nurses who cared for her. We appreciate the chance to help you learn from our side of the experience. Perspectives From the Patient, Co-author Shirley Adams It was a restless night. I awoke at 1:00 am and went to our deck for a cup of tea. Back in bed for sleep, I awoke nauseous at about 3:00 am. Bob came when I fell on the bathroom floor. He asked where I hurt, and I held my hand to my chest. He called 911, saying a possible heart attack. I thought that maybe it was just an upset stomach. Much is still a blur. As I left home on the stretcher, I wondered if I would ever see my daughter again. We have always been so close . . .
1220
I remember talking to the surgeon prior to surgery, but I have just bits and pieces of what I remember during my coma. Do I remember that it happened or do I remember because I was told it happened? I still wonder today. I like to think I remember hearing my son say it was his birthday. He was so happy that I smiled back at him. After I could breathe on my own, the nurses made sure I could swallow food. I remember the spoon kept turning around and the food kept falling off. I think that was when I realized I was in trouble: 27 days in coma, or something very close to it. My, how weak I became! My husband kept telling me that if I wanted to go home I would have to work hard, but I was too tired and all I wanted to do was sleep. At home I realized what I was facing. I could not walk on my own to the bathroom or sit up in bed without help. I could not hold a small newspaper or a cup of water. Then I became determined to sit at our Thanksgiving table and spend time with our family, downstairs in the den. What I used to take for granted now seemed immense. My big setback was an infection in my leg. The surgeon cut out the bad part, and then it was 7 months before the wound was completely healed. Why so long? Could this be related to the loss of strength from my stay in ICU? My husband dressed it three times daily with saline solution. What a good man . . . we met in first grade. It was almost 2 years before I felt like my old self, as best that a 68 year old could feel. My family told me of their experience in the hospitals and their persistence in not giving in as a few in the medical profession had. I am truly blessed and thankful for my family and the prayers said in five churches in three states, and the pastor and well wishers who came to my bed side. And lastly, I am especially thankful for many in the medical field who healed my body and brought me through recovery. I am 76 years old now and in good health. Yes, I have been truly blessed. Please learn from me. I fear there may be others. Reference 1 Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338 –1344
Transparency in Health Care
Transparency in Health Care CASE REPORT
Iatrogenic Delirium and Coma* A “Near Miss” William F. Dunn, MD, FCCP; Shirley C. Adams; and Robert W. Adams A 66-year-old woman was cared for at two referral institutions following a witnessed cardiac arrest in a local emergency department. Despite aggressive initial care, she failed to regain consciousness during a 28-day course. Based on an erroneous neurologic diagnosis of anoxic encephalopathy, pessimism regarding likelihood of improvement existed, prompting clinical consideration of withdrawal of care. The correct diagnosis of iatrogenic drug-induced coma alternating with drug-induced delirium only became apparent after the IV administration of repeated doses of a benzodiazepine antagonist. The patient and husband (co-authors) provide insights often unheard within care circles. (CHEST 2008; 133:1217–1220) Key words: antagonist; coma; delirium; iatrogenesis; lorazepam; risk; safety; sedation
Editor’s Note: This submission to the “Transparency in Health Care” series focuses on a case of a “near miss,” actually a near death, imposed by two “systems.” When we view adverse events as “system issues” rather than as opportunities to identify the individual responsible to “blame and shame,” we can more responsibly develop system responses of broadly improved care. As an outgrowth of the case described, amid others, a system solution emerged that created the Division of Critical Care Neurology at the institution described. While the retrospective clarity of the case described serves as an overt example of a number of system failures, the authors caution that this clarity is the tip of an iceberg of similar clinical happenings that may not be so apparent, even in retrospect. Case History 66-year-old woman was transferred O nfromday an1, aout-of-state institution at the insis-
tence of her husband, on postoperative day 27
*From the Mayo Foundation, Rochester, MN. The authors have no financial conflicts of interest to disclose. Manuscript received February 20, 2008; revision accepted March 3, 2008. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: William F. Dunn, MD, FCCP, 200 First St SW, Mayo Foundation, Rochester, MN 55905; e-mail: dunn.william@ mayo.edu DOI: 10.1378/chest.08-0471 www.chestjournal.org
following coronary bypass grafting, for re-evaluation of therapy and prognosis subsequent to home recommendations of withdrawal of life-supportive therapy. She initially presented to her local emergency department with acute chest pain, and acute coronary syndrome in the anterior myocardial distribution was diagnosed. In the emergency department, the patient had a systolic BP of 60 mm Hg and had a ventricular fibrillation arrest. She was resuscitated successfully and sent to emergent coronary catheterization, where she was found to have serial stenoses of the left anterior descending coronary artery, a complete occlusion of the right coronary artery, and an ejection fraction of 35%. At attempted angioplasty, a dissection of the left anterior descending artery occurred, and cardiogenic shock developed. An intraaortic balloon pump was placed. Pressors were begun, and she was transferred to a tertiary care center. She underwent emergent coronary artery bypass grafting. Hospital Course (27 Days) On postoperative day 4, the patient remained intubated and responded only to painful stimuli. Roving eye movements were noted. A feeding tube was placed. On postoperative day 6, a tube thoracostomy was placed for the new radiographic finding of a right-sided pneumothorax. Liver function test results were abnormal, and she became transiently CHEST / 133 / 5 / MAY, 2008
1217
jaundiced. Amylase and lipase were noted to be increased as well in a nonspecific pattern. An EEG was performed and revealed triphasic waves that were interpreted to be consistent with a poor prognosis. During the hospital stay, two CT studies of the head were performed, revealing no focal lesions. A lumbar puncture was normal. A tracheotomy was performed on postoperative day 19. Throughout the course, she never regained consciousness. Continued roving eye movements were noted, and there were intermittent semipurposeful writhing motions, for which wrist restraints and sedation (lorazepam at 1 to 4 mg IV every 1 to 4 h as needed) were prescribed. At times she was fully comatose. Multiple notes in the charting commented on the “doting” nature of the husband, expressing his wife’s seeming visual recognition of him without staff recognition of the same phenomena. “Appropriate” gestures, nods, and feeble hand grasps described by the husband were not witnessed by any ICU staff. The husband had a near-constant presence in the ICU. Within the hospital stay, multiple physicians were consulted, including neurology, gastroenterology, infectious diseases, and ears, nose, and throat. Within the context of the subspecialty consultations, each physician concurred that the patient had anoxic encephalopathy and had a poor prognosis. With passing time, the tone of the hospital charting grew progressively grim. Nonetheless, the husband insisted that the patient continued to intermittently focus on him visually and squeeze his hand, in seeming recognition. A second neurologic opinion was declined after repeated suggestions to withdraw care. On postoperative day 27, the patient was transferred to our institution. The patient’s medical history was unremarkable.
ing movements, and grimaces to painful stimuli. Plantar response was flexion. Laboratory Assessment ECG suggested right atrial enlargement, possible anteroseptal infarct, with nonspecific T-wave abnormalities. Hemoglobin was 9.6 g/dL. Alkaline phosphatase was 729 U/L (normal, 119 to 309 U/L). Aspartate was 54 U/L (normal, 12 to 31 U/L). Bilirubin was 1.3 mg/dL (normal, 0.1 to 1.1 mg/dL). The patient was seen in staff neurology consultation at the request of the house staff the preceding evening (Fig 1). The patient was seen by an ICU team: faculty attending, four interns, four supervisory residents, and three critical care fellows. Findings were as described: the patient was unresponsive to command, with eyes closed, and with slow writhing-like motions of all four extremities. In order to better assess the possibility of drug-induced mental state changes, a decision was made to provide drug sedative antagonists as a diagnostic challenge. No change in status was apparent after two doses of 0.4 mg of naloxone. However, the patient then received flumazenil at 0.2 mg IV for five doses while the team watched. Between the fourth and fifth doses, she regained responsiveness, opened her mouth, and protruded her tongue to command. The 0.7-mm tracheostomy tube was corked, and the cuff was deflated. When asked her name, she responded, “Shirley. My name is Shirley Adams.” When it was requested that she describe her hometown, she said
Consultative neurological summary note: “Asked to see by Dr. _________ for decreased mental status 28 days after cardiorespiratory failure. Reviewed history and examined patient.
Assessments on Arrival At arrival, the patient was assessed by the resident and fellow team in the medical ICU: BP, 120/60 mm Hg; pulse rate, 82 beats/min; and temperature, 38.5°C. The patient was receiving mechanical ventilation via tracheostomy, was receiving pressure support ventilation, was unresponsive to command, was writhing, and had wrists restrained. Head, ear, eye, nose, and throat examinations revealed spontaneous eye opening with roving ocular movements. The chest was clear to auscultation, with a healing sternotomy incision/chest tube site. Heart evaluation revealed regular rhythm, with no murmur or gallops. The abdomen was soft, without organomegaly. The extremities showed a partially healed postoperative saphenous vein graft harvest wound. Neurologic findings were nonfocal, with semipurposeful writh1218
Anterior MI, bypass following PTCA, ARDS, etc
unresponsive.
Exam: Without focal changes. Generalized semi-purposeful limb movements. Appears to want to void. Eye opening. No command following.
Impression: Anoxic encephalopathy —at 28 days potential for full cognitive recovery is low— EEG and MRI should help quantify this.”
Figure 1. Text of neurologic consultation. Although EEG and MRI were recommended, results in similar clinical experiences are often nonspecific. Without accurate diagnosis of druginduced delirium (terminated by iatrogenic drug-induced coma as “chemical restraint”), the true cause of the mental status may have been never identified, with possible further recommendations for withdrawal of care. System changes in response to this and similar experiences have since confined ICU neurologic consultations to neurologists with specialization in critical care neurology. PTCA ⫽ percutaneous transluminal coronary angioplasty; MI ⫽ myocardial infarction. Transparency in Health Care
Figure 2. When performing sedation interruption for a patient receiving mechanical ventilation while in a drug-induced coma, what is often presumed is the clinical course A, with progressing mental clarity. However, what may occur clinically, particularly with longer-acting agents, is the “tail-chasing” phenomenon (B). For 27 days, the patient described received sedation that maintained her cycling between (drug-induced) coma and (druginduced) delirium. Small arrows represent lorazepam redosing for agitation. Sedation interruption does not necessarily prevent this phenomenon because delirium-associated agitation ensues. Options of therapy include the following: (1) observation (impractical); (2) substitution of a shorter-acting agent allowing for metabolism of the offending drug; (3) primary therapy of the delirium with neuroleptic therapy; and (4) selective use of antagonists (diagnostic and/or therapeutic). RASS ⫽ Richmond agitation and sedation scale.1
“I live in Maryville, TN.” She remained subsequently disconnected from the ventilator, and rapidly improved (Fig 2). Subsequent echocardiography revealed normal left ventricular size and function with a normal ejection fraction. She was dismissed from Saint Mary’s Hospital, Rochester, MN, on September 20, 1997, on postoperative day 35 after an 8-day hospitalization. Perspectives From the Husband, Co-author Robert Adams Shirley and I will have been married 54 years in June of 2007. Shirley’s mind is sharp. She remembers me sitting on the lap of Miss Porter, our first-grade teacher in a small town in Western Pennsylvania. We have been blessed with four healthy, loving children. We have a close caring family. Shirley made it so (Fig 3). The case study you read cannot nearly describe the emotional trauma experienced by Shirley’s family: the 911 heart attack in the middle of the night, the local hospital emergency department, watching through an open door, a doctor’s words “we lost her,” the flat line, my knees to the floor, the door is shut, “she’s back” (from a nurse), another ambulance trip to the city hospital, 15 miles distant where a heart www.chestjournal.org
Figure 3. Spring 2007 photo of Shirley and Robert Adams, co-authors.
surgeon is waiting, and a successful quadruple bypass. Shirley’s life is saved by skilled hands. I was with Shirley when she awoke in her room. Her hands and feet were tied to the bed. A breathing tube was in her throat. Her eyes became opened wide and wild looking. She tried to scream and fight to get loose. I tried to reassure her. “Nurse! Nurse!” A shot was administered to calm her down and to keep her from tearing her sutures or worse. And then for 30 days she was in an agitated or comatose state. Several doctors in specialty fields observed and tested Shirley. Cardiology, neurology, internal medicine: kidney, liver, and lungs. All vitals were checked. There was mention of insecurity of a small “gray” area on the brain scan, thus being perhaps the reason for the coma, or maybe not; it is hard to know. I and/or our children were in Shirley’s room when we were allowed or were not chased off. We spent many hours in the waiting room and the hospital chapel also. After approximately 2 weeks, we suspected the drugs, and I mentioned this to doctors and nurses. Shirley can get tipsy on a glass of wine. I told them this also. Once, on my prompt, and during Shirley’s quiet time she gave my hand a gentle squeeze. Another time, son Timothy reminded her of his birthday and she formed a faint smile on her lips. We told doctors of this also. When the neurologist entered her room for his 3- to 5-min visit, Shirley would not respond to his squeeze test. He explained away our observations as an involuntary reaction on Shirley’s part or of our seeing what we hoped to see. There were more times of calm, agitation, and calming shots. Towards the end, one nurse told us Shirley was not in pain, but she was administering morphine. We were frustrated and scared. When we learned that Shirley was going to be transferred from ICU to a “room” we became CHEST / 133 / 5 / MAY, 2008
1219
afraid; she had been dependent on a ventilator to breathe, ever since surgery. I asked the heart surgeon to refer her to the Mayo Clinic. For the transfer, I carried with me written notes of our observations and suspicions of a drug-induced coma. Surely at such an institution doctors would consider her being oversedated. What is the lesson for those reading my thoughts? Stay close to loved ones in a medical emergency. Ask questions of all medical treatments. Find doctors who will listen to those who know the patient best, and get a second opinion if needed. Beware, though, because sometimes doctors make diagnostic mistakes; they did so in this case. Can I offer advice to doctors (who, I am sure are taught the same in medical schools)? Do not let ego and arrogance take hold. Take time to listen to patients and family and share information with other doctors and nurses who are treating your patient. After her release from Mayo Clinic, Shirley wanted to come home instead of being sent to a rehabilitation center. She weighed ⬍ 100 lb and was too weak to hold a newspaper. Over time (approximately 12 months), the milestones were accomplished and she regained her strength and normal weight of 132 lb. Now we are into senior roller skating once a week, and circuit training three times a week at the local health club. Despite the difficulties, Shirley was given her life back through much prayer, the grace of God, the heart surgeon, and the many good doctors and nurses who cared for her. We appreciate the chance to help you learn from our side of the experience. Perspectives From the Patient, Co-author Shirley Adams It was a restless night. I awoke at 1:00 am and went to our deck for a cup of tea. Back in bed for sleep, I awoke nauseous at about 3:00 am. Bob came when I fell on the bathroom floor. He asked where I hurt, and I held my hand to my chest. He called 911, saying a possible heart attack. I thought that maybe it was just an upset stomach. Much is still a blur. As I left home on the stretcher, I wondered if I would ever see my daughter again. We have always been so close . . .
1220
I remember talking to the surgeon prior to surgery, but I have just bits and pieces of what I remember during my coma. Do I remember that it happened or do I remember because I was told it happened? I still wonder today. I like to think I remember hearing my son say it was his birthday. He was so happy that I smiled back at him. After I could breathe on my own, the nurses made sure I could swallow food. I remember the spoon kept turning around and the food kept falling off. I think that was when I realized I was in trouble: 27 days in coma, or something very close to it. My, how weak I became! My husband kept telling me that if I wanted to go home I would have to work hard, but I was too tired and all I wanted to do was sleep. At home I realized what I was facing. I could not walk on my own to the bathroom or sit up in bed without help. I could not hold a small newspaper or a cup of water. Then I became determined to sit at our Thanksgiving table and spend time with our family, downstairs in the den. What I used to take for granted now seemed immense. My big setback was an infection in my leg. The surgeon cut out the bad part, and then it was 7 months before the wound was completely healed. Why so long? Could this be related to the loss of strength from my stay in ICU? My husband dressed it three times daily with saline solution. What a good man . . . we met in first grade. It was almost 2 years before I felt like my old self, as best that a 68 year old could feel. My family told me of their experience in the hospitals and their persistence in not giving in as a few in the medical profession had. I am truly blessed and thankful for my family and the prayers said in five churches in three states, and the pastor and well wishers who came to my bed side. And lastly, I am especially thankful for many in the medical field who healed my body and brought me through recovery. I am 76 years old now and in good health. Yes, I have been truly blessed. Please learn from me. I fear there may be others. Reference 1 Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338 –1344
Transparency in Health Care