BackRebuilding life after the ICU
Why even a short stay in the intensive care unit can leave behind scars, and how to overcome PTSD, a common disorder among survivors
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A lone gulmohar tree ablaze with fiery orange flowers outside the window was the sentinel of my sanity as I lay in bed in the medical intensive care unit (ICU), surrounded by heavily sedated patients, each cocooned in a host of tubes, bandages and ventilators.
Isolated from the outside world, with no familiar faces, no TV, no music or books, and no one to talk to, the days spent in the ICU were a harrowing and unnerving experience. Diagnosed with dengue and with a very low platelet count, I had to undergo several platelet transfusions. I was pricked twice a day to check for blood counts and had to be confined to bed for fear of internal haemorrhages (caused by the low platelet count). In addition to the physical stress of the illness and the treatment, paranoia about the oft-heard medical negligence ended up causing sleep deprivation.
Fortunately, my stay there was short. And after all the stress and anxiety, I was glad to leave the ICU after three days, and the hospital within a week.
A study published in May 2015 found that leaving the ICU can be just the beginning of a long and distressing journey. Conducted by the US’ Johns Hopkins University and published in the journal Critical Care Medicine, the study found that one in five patients was suffering from post traumatic stress disorder (PTSD) within one-six months of leaving the ICU.
Symptoms of PTSD include acute anxiety, panic attacks and nightmares that affect a person’s ability to communicate and connect with emotions, affecting interpersonal relationships—these symptoms can also become chronic.
“ICU-related PTSD is very real," says Justin Aryabhat Gopaldas, consultant, critical care medicine, at Manipal Hospital, Bengaluru. He was part of a medical group in Adelaide, Australia, which evaluated psychological impact in a study that involved not only patients but also the family/next of kin/caretakers of patients who had stayed in the ICU. “The ICU period leads to a lot of psychological load on an individual. PTSD is one of the diagnoses that was evaluated in those studies. We found that a quarter of patients develop anxiety as part of the PTSD spectrum, but, more importantly, one in five family members too had symptoms," says Dr Gopaldas. The study was published in the Australian Critical Care journal in 2014. Another study, published in Intensive Care Medicine in 2009, found that ICU survivors often suffer from delusions, including hallucinations and nightmares.
Mahesh Natarajan, counsellor at the Inner Sight counselling centre in Bengaluru, who has dealt with patients who have been in the ICU, says the experience can be quite traumatizing, with the pain and illness being compounded by fear, loss of control and insecurity.
Preventing PTSD
In the Johns Hopkins study, scientists recommend keeping an “ICU diary", a book in which clinicians and family members can write daily notes as a narrative about what is happening to the patient.
Natarajan says, “Keeping daily records is important not only from the medical perspective, but also as a place holder for helping patients engage with their stay, especially as a memory bank—adding to it little scrapbook-type entries (pictures, receipts, dried flowers) can be a start." Also, the caregivers could spend time listening to any experiences that the patient may have had, including heightened sensory experiences or seemingly unreal experiences arising out of hallucination. Natarajan suggests that in such situations, caregivers should explain the real events in lieu of a patient’s unreal memories, but in a way that does not make the patient feel s/he could be wrong.
False memories, or the lack of factual memories, play a crucial role in ICU-related PTSD. Our memories are created during our wake and sleep states, says Dr Gopaldas. This process could be abnormal in patients with ICU-related PTSD. Diaries can help fill in the memory gaps, which can cause an individual to become anxious, he adds.
Ideally, ICU diaries should be written by the primary caregiver, such as the ICU nurse. But since this is not a common practice either in India or abroad, the patient himself/herself can later attempt to chronicle events in the ICU. During the recovery period, the patients can try to recollect events/episodes during follow-up sessions with the help of doctors.
Natarajan says: “If the patient is able to do so, it will increase their sense of control over their thoughts or behaviour in that situation. Engaging with their stay in the ICU, and actively remembering and processing it by oneself, helps to normalize the experience."
But just filling in the memory gaps may not work every time. In such cases, counselling and psychotherapy can help. In severe cases, a psychiatrist may prescribe medication.
During my stay in the ICU, I tried to make a mental note of all that happened. In the week after, I chronicled the sequence of those events, going back to add bits and pieces of incidents as and when the memories came to me. It not only helped me process the episode and look at it objectively, it proved to be a cathartic experience.
Help is at hand
Some strategies that can aid quick recovery
u During the stay, it helps if the patient is noticed by the caregiver, who listens to the patient and assuage any feeling of anxiety. The quality of care in reducing fear and worry is important.
u The primary caregivers should take care not to ignore the patient, if s/he is conscious, while having conversations about the patient’s state. It’s important too for caregivers to take care of themselves.
u Trauma-focused cognitive behavioural therapy is recommended for patients with severe post-traumatic symptoms in the first month, such as nightmares and severe panic attacks, which can include sweating, a pounding heart and nausea.
u Early counselling by a qualified psychiatrist or counsellor has been shown to help reduce a patient’s psychological load.
—Justin A. Gopaldas, consultant, critical care medicine, at Manipal Hospital, Bengaluru.
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