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A Mind in Search of Its Moorings

DiMotto, Jean JD, MSN, RN

AJN The American Journal of Nursing: December 2013 - Volume 113 - Issue 12 - p 71
doi: 10.1097/01.NAJ.0000438881.13520.13
Reflections

Postsurgical psychosis in older adults is not uncommon, but that doesn't make it easy.

Jean DiMotto is a judge and a nurse. She lives in Milwaukee, WI. Contact author: jeandimotto@gmail.com. For more information, visit www.jeandimotto.com. Reflections is coordinated by Madeleine Mysko, MA, RN: mmysko@comcast.net. Illustration by Eric Collins / ecol-art.com.

Figure. I

Figure. I

An anesthesiologist was visiting with me three weeks after my surgery for bladder cancer. During that eight-hour operation, my bladder and gallbladder (with its gallstones) were removed, severe scarring and adhesions were lysed, a urostomy was created, and a mesh was sewn into place to repair my abdominal wall hernia. My postoperative course was also complicated.

“There are so many ways to be sick,” the anesthesiologist commented. One of them is mental. After spending 10 of 21 days in a windowless ICU room, suffering the impact of all that was done to me in surgery and the ICU, and experiencing my physiology in tumult, I was mentally injured.

There was a large, round clock in each room that provided the time but not whether it was am or pm. Once, a team of four came into my ICU room. The woman on the team said, “Good morning.” Her greeting caught my attention. I was intubated, so I did my best to look intently at her and then at the clock, back to her, back to the clock. Fortunately, she understood. “Yes, it is morning.” Ah, a simple certainty in a 24/7 environment.

In addition, just the numerical date was written on a whiteboard, but there was no calendar to provide a visual context for the date in the month.

To relieve excruciating postoperative pain, my pain management team put me under conscious sedation for four days. During and subsequent to these days I had phantasmagorical waking dreams. In one, I thought I was at an exclusive birthday party for a wealthy man, and I asked my husband and the respiratory therapist if our being right outside the party room was interfering with the party.

This continued on the step-down unit. Because I was sedated, I didn't experience the transfer between units. So I simply woke up in a new room. But I was dreaming vividly, as well as hallucinating, and thought I was in one of five different rooms.

I dreamt my daytime experiences. Seven days of arm restraints in the ICU because of the endotracheal tube? I dreamt of being restrained in bed for hours in a large room with others who were similarly restrained. Electrocautery in surgery? I dreamt of a man in blue scrubs using some type of electric gun on me.

My experiences were symptomatic of ICU psychosis. My physicians diagnosed delirium and attributed it to the pain medications and an abdominal infection; nonetheless, they also ordered neurology and psychology consults as well as an EEG and a CT scan of my brain. No functional defect was found—just a mind in search of its moorings.

My first conscious awareness that something was amiss was when a nurse began quizzing me about whether I knew where I was. Uh-oh. She repeated the question three or four times, then switched to, “Are you at home?” Phew! A clue. “No.” “Where are you?” she repeated several more times. Finally, I figured out I was in the hospital. “Which one?” Oh no! Right answers are bad; they bring more questions! I gave an incorrect answer based on one of my dreams.

Since my surgery had taken place in early January, I had not yet internalized the change in the year and consistently got that answer wrong, although I finally put together that it was still January, not February, because the Super Bowl had not yet been played. As to the president's name, I just gave a name of any president during whose term I have lived. Where my many birth dates came from I will never know.

My husband and daughter observed these little sessions. While at times amused, they were also worried. I wish someone had reassured them that this was a not-uncommon, temporary occurrence in a 60-year-old after major surgery and its sequelae.

It took longer than my three-week hospitalization to come to terms with the fact that what I thought had been reality was in fact dream based. Even six weeks after discharge I was asking my husband whether something had actually happened. He had been with me in the hospital 21 hours a day, so he was an excellent resource for these reality checks.

Healing of the mind is subtle and takes time. It cannot be focused on—the mind prefers to be left to its own devices as it heals. There are no exercises with 10 reps each, no special foods.

I did notice improvement when I concentrated over the course of two weeks on filling in the blanks (e-mail addresses, etc.) in my cell phone “Contacts” list, adding missing contacts, and proofreading the changes. Twelve weeks after surgery, I was able to journal again. But it took a full four months before my mind had healed enough that I could return to my intellectual work as a judge.

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