ICU doctors and nurses told me that delirious patients may believe their organs are being harvested, or that nurses are torturing them. A spike in fever might feel like being set on fire. An MRI exam might feel like being fed into an oven. Strange figures might appear on the floors, walls, and ceilings of their hospital room.
Delirium is a symptom of a brain strained by the extreme conditions of intensive care. In the ICU, patients often simultaneously experience sensory deprivation (from heavy sedation, immobility, isolation, and day after day spent in a hospital room) and sensory overload (from intense pain, bright lights, extended ventilator use, and constant prodding from a rotating cast of nurses and doctors). In response, they can become confused, paranoid, or completely lose touch with reality.
Read: What life is like after being taken off a ventilator
Doctors and nurses often struggle to spot delirium, but once they do, a proven playbook exists for treating it. Clinicians turn to low-tech methods such as preserving patients’ sleep cycles, allowing them to wear glasses and hearing aids, avoiding medical jargon, sedating minimally, and encouraging visitors—whatever keeps patients oriented in time and space.
But that was before the coronavirus pandemic. As ICUs across the country fill up with COVID-19 patients, doctors told me that the disease itself is undermining their tried-and-tested methods. Allowing visitors and keeping family at the bedside come at too high a risk of spreading infection, as does getting patients up for regular walks around the unit. And because of the severity of some COVID-19 cases, minimizing ventilation and sedation isn’t always possible. Altogether, critical-care specialists tell me, the pandemic has created a perfect storm for delirium.
“We treat critical illness for a living, but this is fairly extraordinary,” Bud O’Neal, a pulmonary and critical-care physician in Baton Rouge, Louisiana, told me. “This disease is going to test us.”
Ask a delirious patient what time or date it is and they’ll likely look around for a clock or calendar as expected. But ask “Does a stone float on water?” or “Can you use a hammer to cut wood?” or “What are the days of the week in reverse order?” and they may falter. “When you start questioning them, you realize they’re hallucinating,” Sharon O’Donoghue, a nurse in Boston, told me. Sometimes, patients’ delusions are downright chilling: whispering voices that won’t let them sleep, or assassins creeping into their rooms. “Delirium survivors fill in the blanks of a reality they can’t make sense of,” O’Donoghue said. “It’s something we take really seriously, and we try everything we can to keep it from happening.”
But in this moment, O’Donoghue and others told me, patients are unusually isolated, immobilized, and terrified. For one, COVID-19 patients are spending day after day on ventilators (typically double or triple the normal duration for ICU patients with lung problems, according to doctors I spoke with), a known risk factor for delirium. Drug shortages are also leaving some hospitals with no choice but to use sedatives linked to delirium. And clinicians are dressed in head-to-toe personal protective equipment, or PPE, a potentially scary image for many patients.