Delirium

Since i started my elective, i have realized that what i have learnt in medical school may be a bit too idealistic. Perhaps it is just Potato Land, but i cannot really give an accurate comment since thus far i have only done surgical electives in resource limited hospitals; hence best practice guidelines may not be adhered to.

A few days ago we had a patient on the wards that started behaving a little strangely. He is a very affable elderly man, and all the nurses and doctors really shower him with a lot of attention. I think his vulnerability endears to the healthcare professionals. He always starts tearing whenever we insert a cannula or take his bloods. We asked if he was crying, but he retorted in his gruff manly voice that he wasn’t.

Anyway, that day he was disorientated, a discernible deviation from his usual baseline. He was trying to clamber out of bed, and was accusing the patient in the next bed of stealing his newspapers. Now i must say, that’s clearly off the mark since our patient is almost blind and probably has his papers read out to him by his family.

Since i have just completed my geriatrics rotation, i instantly recognized the first signs of delirium. I would have immediately checked up on this patient’s medications and do a septic workup. But like i mentioned at the beginning of this post, what i learnt in med school may not always translate into practice.

The staff nurse rallied his students and they stood around his bed, ready to whip into action whenever the patient so much as moved. They did not want him falling over. Although i can understand their kind intentions, i also knew that surrounding a delirious patient with unfamiliar faces and having all of them chattering to him, will only make matters worse. I was mortified that the nurses were not more aware of this condition since 90% of the patients under their care are in their early seventies. On the pretext of asking a question, i hinted to the interns that perhaps reducing the amount of stimuli that this patient was being subjected to, would be a good idea. The intern tried to tell the nurses to stay away, but they couldn’t. On the surface, i suppose constantly crowding the patient can look like a sign of affection and care.

And then the intern gave orders that i thought i would never hear. She inquired about the availability of restraints and instructed the nurses to use them if they had to. Physical restraints on a delirious patient when we have yet to investigate fully the underlying causes? Restraints will worsen this man’s delirium and he may go into a downward spiral from that moment on. I was horrified, and really a touch saddened.

I am not quite sure what to think or do anymore. Perhaps it is the system. Perhaps it is the culture. But what i have observed has made me very afraid for myself and for my future patients.

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