The path to recovery

25 November 2020

With the lung-protective ventilation used to treat severe cases of Covid-19 associated with an ‘air hunger’ similar to that experienced by victims of waterboarding, and patients suffering from delirium, the pandemic is placing a strain on facilities specifi cally designed to treat post-intensive care syndrome. Will Moffi tt speaks to James Jackson of Vanderbilt University Medical Centre and Richard M Schwartzstein from Beth Israel Deaconess Medical Centre about how critical care teams can protect patients from mental, as well as physical, damage.

In his role as assistant director of the ICU Recovery Centre at Nashville’s Vanderbilt Medical Centre, one of the only clinics in the US devoted to treating survivors of critical illness, it’s not unusual for psychologist James Jackson to receive phone calls out of the blue from people suffering with postintensive care syndrome.

A few years ago, Jackson took an urgent call from a man in Chicago who was struggling with what the medical professional calls “delusional memories”. After a particularly traumatic time in intensive care, during which he was hooked up to a ventilator and pumped with a strong cocktail of opiates, the patient had been struggling with the psychological impact of the ordeal. To try to process what he had gone through, he wrote down 50 ‘memories’ on a legal pad and sent them to Jackson’s office.

“[These delusions] were very vivid, and very graphic,” Jackson says. “Things like a ‘memory’ of the therapist trying to cut his windpipe off; of heads being kept in glass jars; his daughter dragging a dead body down the hall. It really gives you a sense of how macabre these images often are for patients.”

Destabilised by spending long stretches of time with their breathing controlled by ventilators and their minds influenced by strong sedative drugs, patients can experience distressing hallucinations and frightening forms of delirium during critical care.

These episodes can cause what are commonly known in the field of psychology as ‘flashbulb memories’: vivid images or recollections that burn their way into a person’s psyche. Carrying the visceral mind-bending power of an LSD trip, these harrowing delusions can involve patients thinking that their organs are being harvested or that they are being poisoned or abused.

“When something is especially vivid and distinct from the norm, it stays with us, and we couldn’t forget it even if we wanted to,” Jackson explains. “The notion with flashbulb memories is that [because] they are stored in a little bit of a different way to normal memories, they’re harder to override.”

It’s a phenomenon that Jackson and other medical professionals across the globe are now seeing in patients recovering from Covid-19.

As one of the world’s leading authorities on depression, PTSD, and cognitive functioning in survivors of critical illness, Jackson has spent most of his career trying to understand the impact intensive care procedures can have on patients in order to rehabilitate them to normal life. Now, with a steadily building roster of people that have suffered from Covid-19 looking to him for help, he is trying to decipher whether the psychological wounds inflicted by the virus are unique.

“We spend a lot of time trying to figure that out, and I think the jury’s still out. When you look at the Covid-19 patients, in many ways, their symptoms really do resemble those of patients with postintensive care syndrome,” Jackson explains. “They have cognitive problems, [and] they often have mental health problems, including anxiety and posttraumatic stress disorder. They also have physical problems, which are [often] respiratory issues like struggling to exercise.”

A nightmare like no other

Despite these similarities, Jackson has observed some crucial differences within Vanderbilt’s specialist recovery facility between Covid-19 sufferers and other patients in critical care. One of these is primarily social: due to the inability for family members to enter the hospital for fear of contracting the virus, delusional patients often cannot be reassured by their next of kin that these visions and terrors are mostly fictional.

An additional level of anxiety is also being created by the ventilators themselves, which Jackson credits as a vital resource to help recovery, but a clear psychological trigger that fills his patients with a palpable sense of fear when they are asked to talk through their time in hospital.

“That’s often the thing that patients are quite fixated on,” Jackson says. “It’s not uncommon to hear some of them say, ‘if I have to go back into the ICU on a ventilator, I would rather die first’. It’s everything associated with it. It’s the loss of control; the inability to breathe. It’s the altered mental states because you’re sedated; it’s the vivid nightmares that seemed so real.”

A primary cause of this fear is dyspnea, the air hunger patients feel when their breathing is constrained by a ventilator, a sensation similar to drowning or suffocation that causes severe emotional distress in people even months after they have been released from hospital.

Combine these sensations with prolonged isolation, warped sleep cycles and the mental effects of psychotropic drugs, and it’s no surprise that the overall feeling is akin to being in a perpetual medically induced nightmare.

“Studies would suggest that as many as 25% of people put on a ventilator for respiratory failure will have some sort of emotional or behavioral problems afterwards, from depression and anxiety to even post-traumatic stress disorder,” says Richard M Schwartzstein, chief of the Division of Pulmonary, Critical Care and Sleep Medicine at Beth Israel Deaconess Medical Centre in Boston.

Working in clinical care since 1986, Schwartzstein has spent his entire career focusing on patients afflicted with respiratory discomfort, specifically the physiology of dyspnea, and the interactions between chemoreceptors, the upper airway, and pulmonary and chest wall receptors in the generation and modulation of breathlessness. To illustrate just how psychologically harrowing it can be, the physician proposes an intellectual experiment. “Imagine that you have just run up 20 flights of stairs as fast as possible,” he says. “Now you’re breathless, and I say, ‘Breathe as fast as you can, but I only want you to take small breaths’. Just thinking about that makes you uncomfortable, but to some degree that’s what we do with the ventilator to prevent lung damage. We restrain or constrain the size of the breath, but that drive to breathe is still there.”

As rates of Covid-19 continue to surge in Boston, Schwartzstein is concerned about the manner in which patients are being sedated while on ventilators. Despite the perception that drugs used to paralyse patients normally alleviate air hunger, certain studies show that is not always the case.

“When you look at the Covid-19 patients, in many ways, their symptoms really do resemble those of patients with post-intensive care syndrome. They have cognitive problems, [and] they often have mental health problems, including anxiety and post-traumatic stress disorder. They also have physical problems, which are [often] respiratory issues like struggling to exercise.”
James Jackson

In particular, he cites a test conducted on patients under the influence of the commonly used sedative Propofol that demonstrated that certain parts of the brain such as the amygdala were still active while patients were visibly unconscious. Despite this peaceful facade, many people may still experience traumatic bouts of dyspnea and have no memory of it when they wake up, resulting in repressed memories and long-term PTSD further down the line.

Rather than using standard sedatives such as Propofol or anaesthetic, Schwartzstein recommends that opiates are used where possible to relax patients and help them cope with the worst effects of breathlessness.

“We want to actually try to minimise the shortness of breath, within the constraints of what we think is safe for the lungs, but also use a drug that is directed at relieving these unpleasant sensations,” Schwartzstein says. “Right now, the best drugs that we know, or the only ones for which there is much data [on helping control that feeling], are opiates.”

He also stresses the huge importance of postintensive care units during the pandemic and of understanding that, while certain treatments administered to Covid-19 patients can save lives, they are not without their complications. The perception that “now you survived, it’s wonderful – you go home, everything is fine” needs to be altered in favour of a more thoughtful approach to post-ICU care, he concludes.

When it comes to rehabilitating psychologically distressed patients, Jackson draws on his previous experiences treating Iraq war veterans, many of whom came home with a very particular set of symptoms that were quickly dismissed by many medical professionals. Years later, these feelings of chronic fatigue, depression, anxiety and PTSD are now clinically recognised as Gulf War syndrome.

“For years, veterans were complaining about these things and physicians were saying some version of ‘This is all in your head’,” Jackson explains. “If you start interacting with many Covid-19 survivors, many of them will already say that they have interacted with well-meaning physicians who have said some version of ‘Sorry, this is all in your head, you really weren’t sick enough to have these difficulties’.”

While Gulf War syndrome took two decades to be treated as a specific affliction – the term was only granted an official medical classification in 2014 – there are signs that Covid-19 survivors might not have to wait that long, as doctors and psychologists are already investigating ‘long Covid’: a mixture of persistent physical and mental symptoms in patients that have had the virus for eight weeks or more.

Time to talk

Rather than letting history repeat itself, Jackson advocates that medical professionals and those nurses and doctors working in ICUs take a more considered approach to dealing with patients, many of whom are acutely vulnerable when opening up to members of staff.

“Let’s have a little more humility when listening to what these patients say before we impose our very premature notions on them, of what they do and don’t have,” Jackson advises. “Often, these patients really are struggling to create an environment as you interact with them where they feel like they have the space and the safety to talk.”

As the first wave of long Covid patients are forced to deal with the debilitating effects of a disease that is not only physically draining, but, in many instances, psychologically traumatic, the worry is that many feel unable to talk about their subjective experiences in a meaningful, cathartic way. As with other facets of mental health, talking and listening to them would be a good start.

“Let’s lean into questions about mental health issues. Let’s lean into questions about cognitive issues,” Jackson says. “If we can, let’s even move a step beyond just asking. Let’s move towards simple objective assessments to make sure that the person across from me who looks okay, actually is.”


The approximate number of respiratory patients that have some sort of emotional or behavioral problems as a result of being put on a ventilator.
Beth Israel Deaconess Medical Centr

In the rush of the ICU, factors like mental health for patients on ventilators can often go unnoticed.

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