Splenectomy, ICU Psychosis

Surgery was quite tough at the beginning, as I mentioned in my last post. Several days in a row, I truly was trying to figure out how I could make a living by sailing so I could drop out of med school because I didn't think I could finish this rotation, let alone five years of residency. Thankfully, I was too tired and worn down to figure out how, because I think I would have gone through with it if I had thought of a way. I have, however, risen to the challenge of this rotation, and am again excited to be on my first surgery month. Yet another example of both the roller coaster that is med school and the wisdom behind "Illegitimi non carborundum."
The first big thrill I got was when I was on call with my attending this past weekend, was going home after having worked a straight 13 ¹/₂ hour stretch, and realized I wanted to stay to do more! Since deciding to be a doctor, I have never wavered in my desire to be a surgeon, but it is so encouraging to get reassurances that I've made the right choice. Unfortunately, my top two choices are Orthopedic Surgery and General Surgery, which are among the most competitive specialties to get into, and my grades and test scores are not competitive. That means I have to rely more heavily on my rec letters and audition rotations, when you rotate at the place you want to do residency with the hope of getting your name/face known and impressing everyone there. I mention this because we recently had a presentation on residency application considerations. That's a worry for another day, though.

One of the cases we saw over the weekend was a lady who had slight pallor, poikilothermia of the extremities, and abdominal distension. CT scan showed hemoperitoneum and lesions in the spleen. History was positive for metastatic lung cancer. The radiologist's report indicated spontaneous splenic rupture as the cause of the bleed (odd, since spontaneous rupture is rare), so she was prepped for emergent splenectomy. As a side note, she reported to us at the time that she drank a beer per day. When she was opened up, almost 4L of blood was removed from her peritoneal cavity. The average adult has 5L of blood, so she was holding 75% of her blood in her belly. The spleen came out well, she received several units of blood during the process, and was admitted to the ICU, where she was alert and doing well.

Sunday, I walked into her room and she was on a CPAP machine and only oriented to person and time (in a normal mental state, you know who you and those around you are, the day/date/season/year/etc., and where you are). She had become acidotic the previous night, which can normally be compensated for by increasing breathing rate* if the kidneys are failing or by flushing more acid out with the urine if the lungs are failing. In her case, the hypovolemic hypotension decreased her renal perfusion, keeping the kidneys from working well; the lung issues and opiate-induced decrease in respiratory drive prevented good lung function, so her two acid-handling methods were crippled. A nephrologist and pulmonologist were called to consult and they removed her from opiates and corrected some electrolyte imbalances. Another aside: the patient told one of these consultants that she drinks three beers per day.

Her blood work was better Monday morning and she was off CPAP. She was fully oriented, but was complaining of feeling neglected by the nursing staff. I asked the nurses about this (non-accusatorily; remember, nurses are your friends and can make or break you as they see fit) and they said she had been difficult and complaining all night and morning. I attributed her mood to homesickness and feeling cooped up. Her medical condition was improved enough for her to be transferred off ICU to the floor, so they moved her later that day.

On Tuesday, I first thought she was simply a little sleepy. Her attention was poor, she would nod off, and she had her dentures in loosely and was enunciating poorly, making communication difficult. When I started talking with her, she seemed fully oriented, but as I continued, she started saying odd things and trying to get out of bed to "go home." I reevaluated her orientation and she was only oriented to person. Then it became clear that she was having persecutory delusions, possibly illusions, and maybe even hallucinations**. The nurses relayed that she had been agitated and combative since the previous night. My attending said she likely had ICU psychosis, common in the elderly, with the constant light, strange environment, and altered physiologic functioning. I asked if she could be undergoing alcohol withdrawal, which my attending said was a possibility.

Today, Wednesday, she was much calmer. She was sitting in the bedside chair and was apologetic about the disturbance she caused yesterday. Interestingly, she still held the veracity of her illusions/delusions. From her point of view, people had put away "the brass knuckles," so she was friends with everyone again. I'm not sure if she'll ever realize that her experiences were not actual, but I think the prognosis is fairly good that she will stop being delirious. The internist on the case also seems to have suspected alcohol withdrawal as a contributing factor, so he started a benzodiazepine (first line treatment for alcohol withdrawal) late yesterday. According to the internist's note, the patient told him she drinks a six pack per day. There is a slightly tongue-in-cheek rule of thumb that you can double the reported amount of alcohol a patient drinks***. I'm sure not everyone reports only half their alcohol use, but let's put it this way: it's a very rare patient who overestimates his alcohol consumption. Anyway, I wanted to blog about this case since it has such a diversity of info in it. There are other, more straightforward cases to blog about and I'll try to do that regularly.

Scott

*The the mechanism behind increased respiratory rate reducing acidity is due to Le Chatelier's Principle as it pertains to this formula:
CO₂ + H₂O <--> H₂CO₃ <--> H⁺ + HCO₃^-
Atmospheric air has minimal amounts of CO₂, so each breath "blows off" CO₂, shifting the above equation to the left, decreasing H⁺.

**Delusions: fixed beliefs that are incongruous with rational though or truths held by society; e.g. the patient somehow knows Brad Pitt sleeps in their attic, but has never seen or heard him up there. Illusions: misinterpreted sensory perceptions; e.g. seeing a car and thinking it's a hedgehog. Hallucinations: sensory perceptions without any stimuli; e.g. hearing a voice narrate your actions and thoughts.

***I've also been told that you can safely add five pounds to a woman's self-reported weight, but that's another matter...