Andrea Sikora Newsome, PharmD
"Uh! Uh! Uh! Uh!" The nurse shouts sternly, as she runs over to stop the patient from pulling his IV out of his hand. The patient is a cantankerous man at baseline, had suffered a complicated hospital course and appeared to be floridly positive for ICU delirium. (An evidence-based screening tool for delirium is available at icudelirium.org. Of note, questions like "what is your name?" or "where are you right now?" are not validated as tests for delirium). We had started olanzapine, an atypical antipsychotic. It had shown little effect, but what else could we do?
Sitting at my rounding table, I watched as the physical therapist came into the room. She was a stocky, middle-aged woman with her dark hair pulled back in a tight bun, white streaks showing in some parts. It strikes me that she was the only African American staff in the unit and the patient was the only African American patient in the unit. More importantly, she seemed an equal match for his personality. The patient must have tried some funny business on her, because she immediately says to him in that strict-but-affectionate schoolteacher tone, "Oh honey, I know you didn’t just try that funny business on me." Duly reprimanded, he quiets down, and they get to work. She spends the next hour with him, berating him, albeit in an affectionate tone. "Oh, you’re a strong man, I know it, I can feel it, why are you stopping now? Don’t you slack off now." She does mobility exercises, strength exercises, occupational exercises. She asks him questions about his family. She leaves him with "Bye sugar."
Looking up from my computer, I see him sitting up high in bed, his cheeks flushed, a slight sheen of sweat on his forehead. We make eye contact and we nod at each other in mutual acknowledgment. His nurse comes by, and he politely requests some water. The nurse then tells me she plans to hold the olanzapine because he is so alert and calm, even oriented and pleasant. I agree and recommend this to the resident. The resident is amazed, but why?
We have taken this man from his home, opened his chest, isolated him from his family, and stuck him with at least a half dozen lines and tubes. He finally got an hour of what most every human being crave. We gave him one-on-one attention, a sense of purpose, conversation, and physical touch. We gave him physical activity. We stimulated his mind and his body, and he responded. Who wouldn’t feel better if they had enjoyed a stimulating conversation, an invigorating workout, and a relaxing massage? Sadly, PT positions are limited, while olanzapine is plentiful. Compared to the costs of a full-time staff position, olanzapine is a steal. The only problem is that it doesn’t really work. In comparison to the documented costs of delirium, maybe PT is the real steal here.
Andrea Sikora Newsome, PharmD, is a Critical Care Pharmacy Specialist at Georgia Regents University, North Augusta, South Carolina.