A Clinical Psychologist Reflects on His Memories (Factual and Delusional) of His ITU Admission
The writer is a clinical psychologist and neuropsychologist of more than 35 years standing, and has in the past conducted research into ICU psychosis. He has a long standing interest in altered states of consciousness particularly in medical settings, and so was in an unusual situation to be able to reflect on his experience from both an academic and subjective standpoint.
Medical History
My problems began in 2007 when my brother died unexpectedly from cardiac arrest in his sleep at the age 49 and my immediate relatives and I were all investigated by the cardiologists. I was found to have paroxysmal atrial fibrillation (no connection with my brother’s death which was due to Brugada syndrome) – although I was unaware of these episodes and they were completely asymptomatic. Eventually the AF became continuous and my cardiologist recommended a routine catheter ablation to avoid problems in later life. I had this procedure on November 11th 2012 and it seemed to go well. However in the lead up to Christmas (2012) I became confused with global amnesia, disorientation, pyrexia and rigour – requiring emergency hospital admission. This was more than four weeks after the ablation. Eventually it was realised that this was a rare complication of the ablation in which a hole had opened between my gullet and the back of my heart, allowing bacteria to enter and infect the heart muscle (atrial-oesophageal fistula) followed by septicaemia. The infection was carried to my brain, creating abscesses. It was a very difficult time for my family because they were told there was a high probability of death, and even with the open heart surgery the chances of survival were only 60%. To make matters worse I was delirious and delusional.
The heart surgery took place on 28th December 2012 and I made a good recovery and was discharged on Thursday 7th February after 6 weeks in hospital. The surgery involved debriding of the left atrium and then patching of the ventral atrial wall.
What nearly killed me was bacterial endocarditis which, following the surgery, was treated with intravenous antibiotics for 14 weeks. A subsequent brain MRI showed that most of the abscesses had disappeared with just two still evident – but even these had shrunk substantially. I am grateful to be alive with no long term disability or significant cognitive impairment. However I have surprisingly good memory for episodes of delirium, hallucination and delusion, especially on ITU, which I recount below.
Memory 1 [approximately 18 hours post-op]
I awoke to find a surgical registrar standing at the bottom of my bed reviewing my case with a nurse. I asked him “where are we?” and he said “Nottingham”. [Some weeks later I checked with this registrar if he had actually said this and he confirmed he did.]. How could I have travelled from Leicester to Nottingham? I asked myself. It then occurred to me that we must be on a hospital ship, perhaps sailing down the river Trent. I looked out of the tall windows and saw trees (silver birch, trunks and branches) moving past “on the river bank”.
I thought to myself “this can’t be right – it must be some kind of hallucination” and began to see if I could make the trees stop moving – but could not. [ I have since visited the location of my bed on the ITU and it is possible to see trees through the windows on the opposite side of the room]. The sound of some patient alarms was like distant ships’ horns in fog, which further reinforced the ship idea.
I began thinking that this “hospital ship” was a means by which medical staff could greatly increase their earnings – offering surgical procedures out of hours during the Christmas holiday, at night.
Memory 2 [approximately 24 hours post-op]
I was feeling very sedated, realised I hadn’t got my glasses so my vision was blurred. It seemed to be night-time [it was probably late afternoon, dark outside]. I was aware of family visiting. I was aware that my communication was limited. The TV was on, showing a programme reviewing the Olympics and medal-winning performances of British athletes. My son helped me to position the screen so I could see it. I recall not being able to see things very well, and remember thinking I would not normally watch such a programme out of choice, but felt hypnotically drawn to the colours and visual effects. I was not really attending to the programme content.
I think I was aware of relatives trying to speak to me, and that I was not communicative (just “mmm”). I don’t recall any pain, but felt sedated, very weak and restricted in movement due to lines. I was not aware of any other patients. The room felt spacious but dark with nurses and visitors just concentrating on me.
Memory 3 [approximately 24 hours post-op]
It was night-time. I could see whole ward – it seemed very spacious. There were islands of light due to monitor displays and perhaps lamps. But it was generally dark with some blue pools of light. My bed was in the dark which allowed me to see the rest of the large ITU area. There were three rows of beds and monitoring equipment and two “corridors” or walkways between them. My bed seemed to be set against one wall with my feet pointing inward towards the middle and outside rows. There were many people walking along the “corridors” and generally on the furthest “corridor” people were walking from left to right, while on the “corridor” nearest me people were walking from right to left. I was fascinated by this movement of people. I was unaware of other patients but could see many staff, some sitting in front of equipment, monitors or desks (nurses seemed to be spending a lot of time writing). I felt sedated and very anergic. Again my experience and perception was shrouded in a hypnotic fog which clouded consciousness. I felt no pain.
Memory 4 [approximately 24 hours post-op]
I saw a “patient” viewing a computer screen in the middle row in front of me, initially assisted by a nurse or doctor. It seemed to me they were reading and learning about an unusual cardiac surgical procedure that the elderly woman was about to undergo. [This was a delusion]
Memory 5 [approximately 36 hours post-op]
My brother, sister and brother-in-law came to visit. Again it seemed to be night time and unlike subsequent visits, I experienced this as being in the ITU in the same bed and bay. I only have fleeting memory of my sister and brother-in-law standing at my bedside and looking very concerned.
Memory 6 [approximately 40 hours post-op]
Night-time (but may not have been). Probably the same ITU environment as in memory 3 but this time much more artificial white light. I was aware of two nurses who were responsible for me. I was taking every opportunity to pull my lines out but as soon as I thought they weren’t watching me they would shout my name and tell me not to pull on my lines. This seemed to go on for a long time until eventually they both came to me and asked me why I was pulling on my lines. I responded flirtatiously “because I like you!” which caused puzzlement and consternation. [I believed the nurses were genuine in their belief that my lines were important and it was dangerous to remove them, but I thought they were deluded or misguided. I was irritated by the apparent hindrance to my movement]
Memory 7 [approximately 40 hours post-op]
Two church friends came to visit. Again I thought I had been taken to another room to see them (but now know I remained in the same bed). This other room was dark but had rolled up carpets (!) and electronic equipment. My visitors found it difficult to fit between the gaps – but my memory is of them sitting in chairs (they have since told me that they could not sit and had to stand up at my bedside). I recall the conversation being difficult and stilted but I could not understand why. There was a nurse sitting on a chair nearby keeping an eye on things, sitting amidst rolled up rugs, equipment and wires.
Memory 8 [approximately 40 hours post-op]
I recall a sense of drifting into sleep but then finding myself in what I thought was a vault underneath the ITU – a sinister Chinese mausoleum (it may be relevant that the writer is of mixed Chinese and White heritage). I had a sense that this was a dream or nightmare, and not reality. There was Chinese furniture (the nurse desk does actually have an oriental appearance); there were dark recesses with “Ginger jars”; there were illuminated yellow Chinese characters [based on the lower row of symbols of the ECG monitors against the far wall]. The same two nurses were still trying to stop me pulling out my lines, and I remember being in the same trolley bed as I was in ITU. They said to me: “we know that you believe this is all part of a conspiracy, but if you pull out your lines you will die”. I did not think they had any malign or sinister intent, but I did not believe their opinion of the need for the lines or what would happen if I succeeded in pulling them out. I did think they were unwittingly part of a conspiracy, but I am unclear what exactly the conspiracy was about.
Memory 9 [approximately 48 hours post-op]
I remember being told I was going to be discharged from ITU and all I had to do was wait. The ITU nurse told me she would come with me and remain with me on HDU. As I was waiting, four patients began to arrive from surgery starting with the elderly woman I had seen looking at the computer screen. They were placed in bays immediately opposite me on the far wall. The bodies were so small, I thought they were children. There was concern about immunological compromise, so these patients were placed inside transparent plastic coverings. I had gained the impression that these patients and their surgeon (who was also present at their arrival on ITU) were all from South Africa or Australia, and that the patients were all from the same family having the same cardiac abnormality or disease. I was moved to HDU just as these 4 patients were arriving on the ITU. [Again, this turned out to be delusional]
Comment
Although from the reader’s point of view these experiences sound quite appalling, horrific and potentially traumatic, for me they were not. Despite the physical trauma of thoracotomy, I had very little pain, probably as a result of effective doses of morphine (which may have been a cause of the hallucinations and delusions). I have little recall of emotion whilst on ITU: even when I thought I was in the Chinese mausoleum, my experience was one of curiosity and perhaps slight bewilderment, but not fear or anxiety. This may be partly due to my familiarity with the ITU environment, and possibly the sedative effect of the opioid analgesics. The only emotion I remember was fearing that if I allowed myself to fall asleep, I might not awaken and would die [a common belief].
I was too physically ill and infirmed to act on any of my delusions, apart from attempting to pull out my lines (including central arterial lines, which could have been catastrophic). It seemed to me that I had made my two ITU nurses’ lives hell and once compos mentis on HDU, sought them out and apologised for my behaviour (although I am aware that trying to prevent patients from pulling out their lines is a common challenge for ITU staff).
It is interesting to note that in Germany and Scandinavia physical restraints such as handcuffs are used on ITUs, reducing staff burden, but perhaps the British public would not tolerate such treatment of ICU patients.
It is noteworthy that there was distortion of perception and absence of my glasses created unfocussed ambiguity in my vision, which was part of the reason for the perception of “illuminated Chinese characters” displayed across the opposite wall in the mausoleum delusion. The hypothesis-generating component of my perception was highly active, often producing misattribution of perceptual ambiguity and consequently feeding into deluded conceptions of reality. This emphasises the importance of ensuring that patients are provided with their normal perceptual aids such as glasses and hearing aids whilst on ITU.
My belief that I was frequently being moved into different rooms was prompted by changes in curtain configurations and changes in lighting during my ITU admission.
The primary delusion of being on a hospital ship cleared quickly, before transfer to HDU. However the belief that there had been a group of patients from South Africa all with the same inherited heart condition requiring specialised surgery and immuno-protection post-op, remained for some weeks. I remember enquiring about this when compos mentis in HDU more than a week post-surgery and my story being received with some amusement.
I cannot be certain about the order or timing of the memories described above, but I am confident that these are reliable accounts of my perceptions during my ITU admission, albeit that several were delusional.
About Professor Michael Wang
Professor Mike Wang, Emeritus Professor of Clinical Psychology, was awarded the Humphry Davy Medal by the Royal College of Anaesthetists for his significant contributions to anaesthesia practice and/or research, in particular to the College’s National Audit Project 5 on Accidental Awareness during General Anaesthesia. He said “It is especially gratifying and humbling that I, as a clinical psychologist (not an anaesthetist), should have been honoured in this way.” He was awarded the Fellowship of the British Psychological Society in 1999 in recognition of his research into psychological aspects of anaesthesia and his contributions to clinical psychology training. He was made a Fellow of the Royal Society of Medicine in 2009.
Professor Wang was appointed Professor of Clinical Psychology, Head of Clinical Section and Course Director at the University of Leicester in May 2005. He retired from his academic post in December 2014.
Full details of the national audit project can be found at: http://www.nationalauditprojects.org.uk/NAP5report