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The Art of Medicine

Like home

Reed, Harrison MMS, PA-C

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Journal of the American Academy of Physician Assistants: May 2016 - Volume 29 - Issue 5 - p 66
doi: 10.1097/01.JAA.0000482313.09305.73
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Lights on, blinds open, frequent reorientation. The effective treatment of delirium involves no needles or drugs. It requires a militant dedication to normalcy.

Every morning, David's room was dark. I walked in, flipped on the lights, and shouted good morning in the loudest voice I could muster. Maybe the sheer volume would force the outside world through the fog that engulfed him. His eyes rested on the ceiling's fluorescent light fixture and then scanned the room, left to right, not pausing for an instant.

The ventilator hummed a steady rhythm and then fired an extra breath. David's face wrinkled and, as if realizing his unnatural circumstances for the first time, he reached for the endotracheal tube in his mouth. His left wrist snapped to a halt short of its target, held by the taut confines of his restraints. His right wrist lay motionless.

A stroke had robbed David of the strength in his right arm and leg. It had taken his ability to speak and allowed fluids to trickle down his trachea when he swallowed. That tiny malfunction, combined with years of smoke and the inevitable emphysema that followed, led to total respiratory collapse and an admission to the ICU.

A collision of worlds.

“It's OK, David,” I squeezed his still hand, a giant paw thick with the calluses of a lifetime of labor.

His eyes settled back on the fluorescent lights and he stopped struggling against his restraints. I told him he was in the hospital, that a machine was helping him breathe. I told him the time and the date and the plan for his care: wait and see. And then I left him.

But David was rarely alone. An entire camp of family members materialized in the waiting room. They formed an endless parade between the family room and the ICU, two at a time, in strict observation of the unit's policy. Of course, they were familiar with self-discipline.

The family drew stares at first and then just curious glances. Their clothes, homemade in an Amish town or village miles away, clashed with the modern world like the garb of intrepid time travelers. When David struggled and thrashed, they sat at the bedside, relaxed and expressionless, the same tranquility that had insulated an entire culture against the chaos of evolution.

On the third morning, I found David in darkness. This time his wife sat next to him, hands folded in the lap of her long black and white dress. She smiled and greeted me by name and thanked me before I had done anything at all. David shifted in bed, staring into nothingness, still delirious.

“Do you want me to turn on the lights?” I asked.

“No,” David's wife looked at me and smiled. “I think the lights confuse him. He's better without them; it's more like home.”

Realization knocked me over. Of course, the very thing I did every morning to coax David into reality only made this place more alien. The noble pursuit of empathy marred by the arrogance that I could somehow understand his world.

Lights off, surrounded by family, days passed and David's brain forced its way out of the din of delirium. But even though I freed his wrists from the restraints, he remained tethered to the ventilator. His family stood by as the days stretched into weeks. I imagined the far-off place that must miss so many strong arms during this indefinite vigil.

One day a small basket appeared at the nurses' station outside David's room. It was filled with bracelets, handmade with intricate patterns of woven string. A sign read: “Bracelets $1.”

Industrious spirit is hard to repress, even in the worst of times. As I fished through my wallet for a contribution, I pictured the impossible mountain of bracelets it would take to pay for just 1 day in the ICU. Oblivious futility. I didn't understand their world, but it seemed David's family certainly didn't understand mine.

Or maybe they did. Perhaps surrounding David with a family hard at work, forging ahead in spite of the world, was like turning out those fluorescent lights. Maybe, in a tiny way, it felt like home.

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