Just a little delirium‐ A report from the other side

Abstract

An urine tract infection developed in a serious way with shivering and other signs of septicaemia when the author was planning going skiing. After being admitted to his teaching hospital, the condition got worse with mental confusion. The author thought that he was to be executed due to a new law, giving the relatives of patients who have died during his care, a right to demand his assignation in the most cruel way. This is the thoughts and observations made during the illness.

Delirium is a well‐known complication of a variety of medical conditions. It is characterised by a sudden deterioration of the mental process, with symptoms ranging from anxiety, arousal and sympathetic hyperactivity, but can also present with apathy and almost coma (silent delirium).

The development of delirium is associated with a worsened prognosis of the underlying cause. It is very often a complication of infectious diseases and fever. Old age and unmarked cognitive impairment are among the disposing factors, but it can happen to anybody.

I’m a Consultant Anaesthetist and Intensive Care in my late fifties. I’m not active in sports, but do a lot of skiing, hunting and mountain walking. I consider myself to be in reasonably good health, but have experienced 2 episodes of urinary tract infections. Being a man, I have been through the usual examinations afterwards.

The story began on a Wednesday in March. I had some days leave because I work on‐call. My wife and I were planning a weekend skiing at our apartment which is at a skiing destination. I just had to drive alone down to Bergen to collect a bed from my daughter’s apartment. I planned to meet my wife in our apartment on Thursday evening.

After loading the bed into my car I felt very tired and began shivering. I drove up to my mother’s apartment for an overnight stay. During the night, I had an episode of severe shivering, took 1g of paracetomol and 600 mg of ibumetadin and fell asleep, sweating profusely.

In the morning, I had another episode of shivering, and decided to go to a local emergency clinic. The urine sample showed a massive pyuria, C‐reactive protein at 95 and white cell count of 11. Combined with the history of shivering, the doctor wanted to admit me to the University Hospital.

I protested, we were supposed to be going skiing. The doctor consulted an Infections Specialist, and since my white count wasn’t elevated and they considered it safe to treat with trimetoprim‐sulfa.

I started with the antibiotics and drove up to my mother’s apartment for lunch, before I was supposed to drive to the skiing destination. Whilst eating I had another episode of shivering, took 1 g of paracetomol and 600 mg of ibumetanide and waited for the shivering to stop so that I could drive the car. My mother was really anxious. After 15‐20 minutes, I realised that I would have admitted any other patient with the same clinical picture. When reading the note from the doctor, the last line was that the note could be used as a letter of admission if I was to reconsider.

It is not nice to be admitted to your own teaching hospital, but the staff were very friendly. After examination by a junior doctor, they started with intravenous antibiotics. My temperature was 38.6°C.

Once on the ward I began to freeze and shiver violently. An assistant came for me at 18.55 to take me down for an ultrasound examination. I remember thinking that it would be hard to perform an examination with the shivering, and also that I told the young female assistant that this was an attack of shivering. She said that she had never seen it before, and then she pushed me in to the elevator.

Coming out of the elevator I suddenly realised that I was being forced into a trap. We were in an ANTI‐HOSPITAL under the real hospital. The Anti‐hospital was built after the Government passed a new law. The law gave the relatives of patients who had died when I was in charge, the right to ask that I was to be executed in the cruellest way, and that as part of their grief they could watch the process from the auditorium. I started to protest, but the only response was that this was an order from the Government, with no room for parole. I felt very bitter; I had just tried to do my best for the patients. We passed several doors with electronic locks, and it was getting darker and darker. People were passing in the corridor and were then led into the auditorium to watch the execution. I heard that my place was on the right‐hand side.

We came into a big room and I saw the shadows of some technicians surrounding the bed.

I was strapped to the bed and had something up my nose. I was thinking about just giving up at once, but decided that I wanted to fight as long as possible; something could change at the last minute.

I observed that they collected an arterial blood gas, and thought that they were applying the same techniques that I would have used on an unstable patient. I heard somebody say I believe he’s an Anaethesiologist”. Suddenly I felt something in my left ear, and heard “he has a temperature of 41.3°C”. “OK, they’re going to boil me”, I thought. Thereafter I could feel cold blankets applied to my body, and saw that I was given intravenous fluids.

A voice said “he is very unstable, call a doctor”. A consultant came by, and said “I know this guy, we must be careful”. I was thinking “What bad things have I done to make him so eager to execute me”? Then he said that I had to be admitted to ICU. “So they use ICU just like I would have done”.

I was still not very anxious, but felt very unfairly treated. I started to consider if I could decide to end my life, or just had to hang on to the torture.

The consultant asked “Can you hear us”? I started thinking, “Is it wise to answer, should I show them that I still have guts, will they try harder to hurt me”? But after some minutes I said “Yes”. The consultant said “Good”. Some minutes later he asked “What’s your name”? Again I wondered what would be best, to answer or not, but said my name.

Then I must have said something, because the consultant suddenly asked if I was aware of what they were doing. I was able to say something like “You are doing wrong, it’s turned around…”

The consultant sat down on the bed, grasped my hand and said “We found you on the ward, you have been very sick, it’s an infection, we are starting to get it under control and you will be transferred to ICU”.

It started to get lighter; I was able to recognize the blue curtains around the bed. The clock on the wall showed 20.45. I felt that it was difficult to find the words and said “It must be an abscess in the brain”, my first thought after that was “that’s the end of the helicopter EMS duty”. At that moment I started to get very anxious and realised that this could be life‐threatening.

I was then transferred to ICU, and with the correct antibiotics, I was able to leave the hospital 4 days later. The episode is described in the medical report thus, “Soon after he came to the ward his temperature rose to 41.8 °C, he became delirious and had convulsions. He quickly recovered after he was cooled”.

I had an MRI, EEG and neurologic examination with no pathological findings.

After such an experience there are some lessons to be learned. The first is that there is truth in the old saying that hearing is the last sense to disappear. I was aware of a lot, also visually. Much more than I think the team realised. I’m not sure if it would have made any difference, but in hindsight, I think that someone should have tried to reassure me earlier, both verbally and by gently holding my hands.

It was also surprising how much I was thinking. Even if the basic assumption was paranoia, I was doing a lot of rational thinking in the situation. An observer would have said that I showed signs of cerebral latency, while I was just trying to consider the best response.

I am very grateful that I was not given any anxiolytics or sedative medication. To treat delirium by medication could have 2 objectives. The first is to prevent that necessary medical equipment is removed due to arousal and uncoordinated movements. This must be achieved by some sort of sedative. The other could be to modify the course of the delirium. The most widely used medication is different types of antipsychotics. A recent Cochrane review excluding ICU patients concluded that there are no studies favouring any antipsychotics to modify the course. To treat the underlying cause is paramount.1 Another Cochrane review about ICU patients concluded that we do not have any scientific proof for the treatments we give to the delirious ICU patient, and that we need more studies.2 A recent study treating delirious ICU patients with haloperidol concluded that there was no difference compared with the use of a placebo.3

When the hyperpyrexia was corrected, I soon realised the situation. We have all learned that the best way to reverse a delirious episode is to correct the cause. I was not given any symptomatic medication, and I believe that that’s why I haven’t felt any anxiety or nightmares afterwards. The next day I wrote down all that I could remember. I have given a few lectures telling the story to different health providers, with positive feedback. I believe this in fact has been a good debrief.

The most important point is that being a doctor does not turn you into a Superhero. The same risks and dangers that lead us to be cautious with our patients also apply to us.

I was so close to putting myself and others in great danger. If the shivering had started when I was driving along a narrow, slippery road, it could very well have been the end.

Take care.

Larsen RA. Just a little delirium‐ A report from the other side. Acta Anaesthesiol Scand. 2019;63:1095–1096. 10.1111/aas.13416