Last month I finished a rotation in traumatic brain injury, which is one of the craziest rotations during our residency. Patients who have had brain injuries go through a certain series of stages during their recovery, one of which may include yelling at you, swearing at you, saying sexually inappropriate things, or playing in their feces. Yes, it’s all happened on the locked brain injury unit. When someone’s brain is injured, there are lots of metabolic changes that affect their ability to know who they are, where they are, or why they are even in the hospital in the first place. This phase is called “post-traumatic amnesia” and it’s during this phase that they can be agitated and/or non-compliant with the therapies you are trying to get them to do every day. Luckily the nurses and therapists on the brain injury unit are well trained, have been doing this for some time, and know how to handle even the craziest of patients. And I probably shouldn’t even use the word crazy, because they are not literally crazy, they just act that way until their brains settle down.
It’s surely amazing to see how they progress from amnesia, to agitation, to being oriented, to participating in their therapies, to going home with clear thinking. It’s like they wake up. It’s funny to tell the patients stories about what they were doing in their agitated and confused period: that they were eating off the cast on their arm, pulling out their feeding tubes, yelling at staff, or rocking back and forth in the “cages” or canopy beds we put them into at night to keep them safe from harming themselves. These beds look like large play pens with a top, and after having a brain injured patient jump out of a regular hospital bed in the middle of the night, hit his head and get transferred to the ICU for a fresh bleed inside his head, I can tell you they are in the best interest of the patient. (This patient’s family had refused the canopy bed initially) These patients can also do impulsive things during the daytime. Several years ago a brain injured patient got away from a therapist, ran down the hall, and crashed through a window. Luckily the patient landed on a roof top a story below, and the resident was able to climb down and help him, despite it being one of the biggest snow storms in near history.
One thing that we try to explain to families during this healing period is that it’s important to have a low stimulating environment while the brain heals. Usual rules are no TV, no radio, only 2 people in the room at a time, etc. If the patient starts to get agitated, the nurses know to turn off the noise, turn off the lights, and create a destimulating environment. If all that is done and the patient continues to be agitated, we have to treat them with medications. Twice I have had to order the nurses to give an intramuscular injection of an anti-psychotic medication. Once with a very large male who was getting very aggressive, threatening to hurt others. The other to an old confused man who needed to have some testing for his failing kidneys, but wouldn’t let anyone near him. In both cases it took over an hour for the medication to take affect, and for them to settle down, and sleep.
I was lucky that I didn’t get hit, as I have heard stories from my attendings and the nursing staff of this happening at times. While interviewing my first patient, with the fellow and the attending in the room, I got down in front of a little female patient, eye level as I usually did in order to try to connect with my patients. While testing her upper extremity strength, she jokingly tried to hit me. When we left the room my attending suggested with a smile that next time I don’t get so close to a brain injured patient. Especially when meeting them for the first time. Lesson #1.
As the month flew by, I saw some patients get better, and others not so much, usually because their injuries where so much more severe. By mid month I realized that I was having lots of headaches, and that my stress level was way too high. So I decided to do what I do for my brain injured patients: put myself in a low stimulating environment as much as possible. I stopped listening to the news on NPR on the way to and from work (it’s always depressing news anyway). I stopped listening to the radio while cooking and cleaning. I started trying to meditate for 10 minutes a day. I stopped watching TV. I went to bed early.
Amazingly, my brain responded quite well. Headaches went away, and I found I really liked the silence in my car and in my home. It allowed my own overstimulated and overworked brain to decompress. I felt like I was better able to do my job during the day, and slept great at night. As I transitioned to my next rotation, I continued my “destim” though I have slowly added back some music and TV. When I have a rough day, I know that when I get home I need some silence. I am thankful for all the lessons I learned while on traumatic brain injury, and I look forward to returning there in January for another go at it.