Ketamine

Somebody tried to tell me today that we aren't allowed to ride around dangling from the elbows on the cardiac walkers, making TIE fighter noises. Fortunately I was on a cardiac walker at the time so I just screeched away with my toes dangling over the linoleum, faster than they could shuffle after me in their Dansko mules.

We’ve had some extra-special pts on the ICU lately. Things seem to come in waves, a month at a time, and this month’s theme seems to be a tie between “exhausting psych” and “heartbreaking pulmonary fibrosis.” April started out with a seemingly straightforward admit: a woman with a fresh spinal fusion, history of chronic pain, and osteoporosis.

Ellen Hamm* was the first pt I took with my latest preceptee, Lizzie, who comes to us fresh from a psych hospital-- sharp and bright and already jaded as hell. “I hope my experience is useful on the ICU,” she said, and sighed when I toppled into chair-spinning gales of laughter.

Hamm had three things working against her. First, she had absolutely spectacular osteoporosis-- the bone mass of an 80yo woman in the body of a 50yo woman. Her vertebrae had the mass-to-space proportion of a bag of potato chips. This was her third attempt at stabilizing her spine, and this time the docs had been forced to open her back and cut through her stomach to reach all the way through.

Part of this bone loss was probably genetic. She had been checked about a dozen times for cancer, due to her severe bone deterioration, but it seemed like she probably just hit the Dr Pepper real hard in her youth, and had a couple bad alleles wrecking her shit to boot. Nothing she could have known about.

I’m not dissin the Doctor, by the way. Coke, Sprite, Pepsi-- they all contain phosphoric acid, which strips calcium from your body, especially while you’re young, starving your bones while they’re trying to grow. And when you’re a tiny kid, you’re literally stashing most of the calcium you’ll use for the rest of your life in your bones, ready to be sucked out whenever you need a little boost, or whenever you shotgun a carbonated drink.

There are a lot of ways to lose calcium. Have a baby? Where do you think its bones come from? Hint: it’s you. It’s your bones. There used to be a saying that a woman would lose a tooth for every baby she bore. Get cancer? It’ll rip the calcium right out of you and spray it all over your blood, where eventually it’ll be excreted instead of stashed back in the bones. Calcium is used for heart function, for blood pressure maintenance, for using your muscles… oh yeah, and also for making your bones hard and strong.

So drinking soda as a child can fuck you over for the rest of your life. Specialists like to say that osteoporosis is a childhood disease with geriatric symptoms-- you fuck up your calcium balance with phosphoric acid as a tiny kid, you end up with half the calcium you need for your lifetime supply, you suck your bones dry and have degenerating bone by the age of fifty. Like Hamm.

Beyond the mere physiological issues, though, Hamm had-- like most people with chronic pain-- built up quite a tolerance to opioids. Enough that we would never, ever be able to sedate her enough with fentanyl to kill the pain. Enough that, after spinal surgery, she would have months of agony no matter what we gave her.

(IV Tylenol might have helped. But a rep was rude to our CT surgeon once, and the pharmacist didn’t like their tone, and it costs like $40/bottle, so we can’t have it. Fear not: I am raging my way through this obstacle course and will get magical IV tylenol or die trying.)

And with the chronic pain and disability, her personality disorder had blossomed into a hothouse flower of fucking crazy ass shit. She raged and wept and begged and flattered; she claimed that we were stealing her meds, even when we started having multiple witnesses to administration; she verbally abused staff and repeatedly called the police on her cellphone to report that we were “torturing” her. Her husband was one of those saintly enablers who longsuffers their partner into an eternal prison of destructive behavior, constantly apologizing for her and placating her and begging us not to think ill of her.

To be fair, she was kinda being tortured. By the time her pain was even slightly controlled, she had such respiratory depression that she nearly coded twice, and her anxiety about pain was so stratospheric that she started screaming any time someone leaned toward her. Literally screaming. Other pts asked in careful tones whether we could do anything for the poor lady, and we replied that we were trying.

We really were, too. We don’t much care for the fine lines between “tolerant,” “dependent,” and “addicted”-- they change too quickly, are too individualized, and do nothing to help us care for our pts. Somebody who uses a lot of opioids, whether it’s IV black tar or cancer-dosed percocet, is at higher risk for withdrawal and will need a higher dose to control pain. Nobody on the ICU gives a shit about your addict status as long as your pain is controlled and you aren’t a complete asshole about it.

So we had Hamm on a 200mcg/hr fentanyl drip, a huge pile of oral opioids and xanax every four hours, IV push dilaudid and ativan every twenty minutes, and a couple tylenol thrown in for good measure. None of it helped. Four hours after she returned from surgery, she cursed out a nurse while screaming so loudly that her larynx started bleeding. All of Lizzie’s psych experience was useless in the face of her terror and pain.

She refused turns and repositioning, but after about six hours the pain of lying still was too great to stand, so we gave her everything we had and gently shifted her weight. More screaming. We felt awful for her, and also we got pretty sick of her, because everyone who went into the room got the same manipulative treatment: first sobbing and pathetic blessings for being “so caring” when “all the other nurses are so cruel and are stealing my meds,” then accusations of killing her, enjoying her pain, getting off on watching her scream, and of course stealing her meds.

Eight hours after her surgery, we thought we’d finally got it under control, because she fell asleep for four hours and her face seemed relaxed. No dice. When she awakened she announced that she’d been lying there paralyzed with agony for “at least a day” and that the nurse had been in the room the whole time grinning at her and shaking her whenever she fell asleep, and also stealing her meds. From that point on, she looked pretty comfortable and frequently dozed off, sometimes even repositioning her legs independently without flinching… but screamed whenever approached, claimed that her pain was too high for our 10/10 scale, and kept on calling the police.

And you know what? We took that seriously. Anxiety plays a huge role in acute-on-chronic pain, and from the way her heart rate and blood pressure leapt when she started screaming, she certainly seemed to be feeling something terrible. We put her on a PCA, patient-controlled analgesia, and let her give herself doses of pain medication-- 1mg dilaudid at a time, up to once every six minutes, up to six mg per hour. The pump reported that she had attempted to dose herself over a thousand times the first hour. We could tell when the previous dose timed out and the next was given, because her eyes would roll back into her head as the medication knocked her out. Clearly, it was hitting her-- she started having periods of apnea and her blood pressure dropped into the 70s systolic-- but even in her stupor she was still pressing the dose button over and over. Opioids just weren’t cutting it for her.

So we went for the big gun: ketamine.

Originally used as a veterinary tranquilizer, ketamine made its way into medical use for humans as an anesthesia drug. You could give it to someone and they would go into a trance state, a waking slumber in which they seemed to feel no pain and form no memories, and from which you could use inhalants to send the pt into complete general anesthesia or just let them hang out in the ketamine state while you did little fiddly work on their body.

Of course, nothing that awesome is without drawback. Sometimes it made people’s larynges spasm shut, choking them to death. Sometimes it made their blood pressure skyrocket. Quite frequently, it caused wild hallucinations and lasting psychological disturbance, and did not mix well with mental diseases. Most of all, it made the operating staff queasy, because it made pts giggle like creepy puppets while the surgeons were cutting on them.

So it’s not a common medication to give on the ICU, and I gather it’s not terribly popular in the OR these days either. But when you have a pt like Hamm who can’t get pain control any other way, well…

We started the ketamine drip and crossed our fingers. We watched her heart rate even out-- a strong indicator that she really had been perceiving tremendous pain, since ketamine doesn’t affect the heart rate. We watched her BP, depressed by all the opioids, rise back to low but stable levels, and her rate of PCA demand dropped to a mere three hundred or so per hour.

Then we watched her trip fucking balls. Hamm saw all kinds of shit while the drip was on her, and her agitation and hallucinations were the limiting factor on how high the rate could go. In her mind’s eye, monsters crawled under the skin of the walls, worms slipped into her bed and devoured her flesh, departed loved ones stood around her bed and discussed how best to cook and eat her, and her endlessly accommodating husband turned into a dog-mutilating Nazi. If we turned the dose down low enough to keep her from freaking out, she bowed up in agony; if we turned the dose up high enough that she forgot to call the police every hour on the hour, she informed us that a huge black bug-man was in the room, but whenever we came in he turned sideways so we couldn’t see him.

But wow, did the ketamine control her pain. Or, more specifically, made her not give a shit that she was in pain. She could turn and move without difficulty, although she still required a high dose of opioids with her Special K, and her husband stressed himself out because she wasn’t depending on him for his constant placation & soothing and had to be sent home to shower because he was starting to smell weird and also yell at the nurses. She still accused us of stealing her meds, and she still called the police occasionally, and she still whined at everyone who came into the room that they were the only "angel" among the "torturers" and would they please get her more dilaudid... but she did all these things with a steady heart rate, between comfortable naps, without screaming at all.

We kept her on the ketamine for the next two weeks, and I’ll tell you more about her departure from the ICU in the next post, because now I’m gonna derail to tell you a story about the last pt I had on a ketamine drip.

When I worked nights at my previous facility, I often ran into small-facility limitations and had no idea what to do with them, because my early ICU training took place in some really big teaching hospitals in Dallas and I consistently clashed with doctors about our nonexistent sepsis protocol. “Sepsis protocols keep people from actually thinking,” one doctor told me, and even though he was one of my favorite doctors there I went full angry possum on him because I had just paged him four times in an hour to beg for steroids for my pt in refractory hypotension.

In this case, however, my big-city book larnin’ hadn’t prepared me for ketamine. My pt in room 312 was a six-foot-two gentleman with red hair, a bodybuilder and personal trainer, in his mid-thirties, and he had been diagnosed with metastatic cancer a few months earlier and was dying. The cancer had gone to his lungs as well as his bones and his liver.

Early in his twenties, Aaron* had been a pretty heavy drug user. Heavier than usual, we suspected, because his red hair definitely came with the redhead gene that made opioids much less effective, and he was so resistant to pain control that he nearly self-extubated just by screaming his breathing tube out on the second night he was admitted. The noc doc and the head of medicine put their heads together and came up with ketamine as a possible solution, and it worked almost immediately when we started it.

Everyone was relieved to see him find a degree of comfort. He had, apparently, managed to get clean from IV heroin at the age of twenty-five, and gone on to really turn his life around, working with at-risk youth and opioid addicts to help them break free and build their new lives around physical fitness instead of drugs. He was the center of a group of people who had turned their individual personal hells into a tight-knit weightlifting community. He was a good person, and his death was a tragedy, and his pain was unacceptable.

But, as with Hamm, the ketamine made him hallucinate. Instead of pain, he felt worry. Between restful sleeping periods, his eyes darted from ceiling to corner, watching dreadful imaginary things. He wrote to us about them sometimes, in his more lucid moments, scrawling with a sharpie on his clipboard. Bugs, of course. Things crawling under the paint on the walls. Tall thing dark things that stepped around the room and cleverly evaded our notice by standing behind the television cables, or by twisting themselves into the curtains. Worms that chewed on his legs.

The hallucinations are bizarrely specific, and distressingly common. Something in ketamine makes us all see the same things, it seems.

Toward the end, he seemed very afraid of something next to his pillow, something that made him crane his neck to the left and gesture frantically for the sharpie. “Mom,” he wrote. “Next me N bed. Shes dying help. Dead.”

We couldn’t reassure him, even by pointing out his mother sitting at the foot of his bed, weeping as she read his writing. His fiancee sat by him too, but he barely recognized her, and for the last 48 hours of his life he only communicated that we should help his mother, who was lying next to him, dead.

When we went to comfort care for him, when his mother and fiancee decided it was time to let him go, we gave him so much fentanyl that it was probably a euthanasia dose. We bombed him with opioids until his blood pressure dropped out the bottom, turned off the ketamine, and pulled out the breathing tube. He died four minutes later, never having taken a full breath on his own since the tube was put in. The opioid dose left his face relaxed, and he seemed to die at peace.

Sad. But, you know, young people die all the time. The funeral home picked him up and we called a stat clean on his room, because there was another pt waiting in the ER for an admit bed.

That was in July.

In February, we admitted his mother.

She had been at home when the symptoms kicked in: shortness of breath, nausea, weakness, lower back pain. She took a couple of tylenol and waited for a few hours, then called for an ambulance when the weakness became so severe that she couldn’t get to the bathroom to pee. She was having a heart attack, of course. The cardiologists tried to place a stent, but the damage was extensive, a huge chunk of her heart had died, and even bypass surgery wouldn’t have helped her. She was adamantly opposed, for reasons we could all understand, to having a breathing tube pushed down her throat, even when her dying heart made it difficult for her to breathe at all.

Fifteen beds of our sixteen-bed unit were full on the night she came in, so Aaron’s mother died in room 312, in the room and the bed where her son had seen her dying the summer before.

Her death was much easier and less painful than his. She was short of breath for a while, complained of indigestion, and then died in her sleep. She knew exactly what room she was in, and seemed to find comfort in it. Aaron’s fiancee came in to see her an hour later, after work, and was able to sit with her body for a few minutes before the funeral home came to carry her away.

Then we called a stat clean, because there was another pt in the ER waiting for the bed.

Anyway, I didn’t really think about Aaron for a long time, until we started Hamm on her ketamine drip and she went totally nuts. Once I thought of him, I remembered his name and the way he’d died, and I looked up his name on the internet hoping to recall when he’d died, maybe spot his obituary. His fiancee had made a blog about his death, which she’d kept for about six months, chronicling her memories and her slow recovery. It ended a month before his mother’s death.

There was nothing on the blog about pain, or even about his hallucinations. She wrote about him sleeping, about the hiss of his breathing on the ventilator, and about the sorrow of losing him. The ketamine we gave him had, in its way, given her a sense of peace.

For Hamm, it gave us all peace. She slept eight hours a night and had some of her first hours entirely without pain in a full decade. The nurses were able to recover and rebuild their sympathy, and her husband finally took an actual shower. Not a bad outcome for the price of a few tall thin black bugs.