On one of the most extraordinary nights of my first year as a doctor, I admitted a young woman to the intensive care unit who was coughing up blood and barely able to breathe. Just days before, she’d traveled to a hotel somewhere outside of New York City, where she’d received cosmetic injections of liquid silicone into her buttocks. She was 28 years old. Now, the silicone had traveled through her body, showering her lungs.
I’d never been so close to acuity, and there in those moments—as the bleeding in her lungs threatened to suffocate her, as her heart stopped and we started it again—I found myself terrified, but excited, too.
She didn't die that day, nor in the days and weeks that followed. Slowly, her lungs healed. We decreased the doses of the medications that kept her paralyzed and sedated; she started to wake up, nod, and squeeze our hands when we asked. It was awesome. She was going to be okay, I told her parents and husband. We’d saved her.
I've carried that victorious narrative with me for years. I told it again while interviewing for training to become a critical care specialist. But now, working as a physician in the medical intensive care unit myself, I've started to wonder if this is not only a story about the best of medicine today, but the worst of it, too.
As more adults survive intensive care, we've inadvertently created a new world populated by the walking wounded. Some return to work, bodies healed, but find their minds are different, slower than before. Others are depressed, anxious, tortured by flashbacks to horrific events that never occurred. As a critical care doctor, it’s entirely possible for me never to see any of these outcomes. But I've come to fear that our best interventions are less meaningful, and our counsel to families shallow, if we don’t fully understand what happens to our patients after they leave our units’ doors.
Nancy Andrews is a Maine art professor who had spent weeks in the intensive care unit at a Boston hospital back in 2006, when a tear in the wall of her aorta nearly killed her. After she left the ICU, she told me, she found that she’d start to cry at random moments. The sound of helicopters scared her. No one had prepared her for this.
“If I had one word to sum up my ICU experience,” Andrews writes on a website she’s put together as a resource for other survivors of critical illness, “It would be ‘horror.’ In addition to my paranoid delusions of people trying to kill me were hallucinations of ants on peoples’ faces; weird things in my IV fluid bags; nightmare-like hallucinations where I was variously stuck in the bottom of a boat … stuck in a well … being tethered by rubber tubes attached to my genitals to the ground … ”
Finally, her primary doctor recognized that she seemed to have post-traumatic stress disorder. She slowly recovered, but what about those who weren't lucky enough to be properly diagnosed?
About one in three ICU survivors who are sick enough to require intubation might develop post-traumatic stress disorder. Recent studies have also described that those who leave the ICU also suffer high rates of impaired brain functioning, on the level of mild or moderate dementia. The individuals might have a hard time concentrating, planning, or remembering simple tasks. They might have trouble returning to work or paying bills. Other studies have shown that, of patients who are admitted to the ICU, more than a quarter have significant depressive symptoms, which negatively impact their quality of life.
None of this is regularly part of what doctors tell patients or families. Who would care about a little weakness or anxiety or difficulty balancing a checkbook, our silence seems to suggest. Isn't being alive—walking, breathing—good enough?