Tie Me Up, Tie Me Down

One of the surprises of the job of being an ICU nurse for me was how often I had to restrain my patients. Almost every patient that is on a ventilator has both arms tied. The exceptions are those that are not physically able to move (organic restraints) and those who have been intubated for some time and have demonstrated trustworthiness. The second group are often subjected to the nurses whims. If the night nurse for instance sees such a patient scratch his nose at the beginning of the shift, she may decide that it is not worth the risk and she may tie the patient up for the night and be done with it. There are also quite a few patients who sundown. They may be okay during the day and then become erratic at night.

Then there are the so-called ‘social’ intubations. These are usually large men who come into the ER intoxicated and in need of treatment. Their belligerence interferes with their treatment and more and more sedatives are prescribed. At a certain point the doctors begin to worry that when they do finally fall asleep they will stop breathing because of all the sedation. A-bing’n-a-bang’na and they are smoking plastic.

Patients who have recently had feeding tubes inserted through their noses also usually need to be restrained. It takes a fair amount of self control for a patient to not pull them out. I once watched as my large male patient wiggled down in bed to try to get enough slack on his restraints to get his hand around his NG (naso-gastric tube). “Sir, please do not do that,” I said. “I got to!” he replied.

What about self determination?

What about it? It is not that patients get to dictate their care. If they are in the hospital, they need certain things. A patient cannot be allowed to starve to death simply because they pulled out their NG. Generally speaking, they do not want to be starved; they are just annoyed by the plastic tube in their nose. In the end, it is usually an all or nothing scenario – you get it all (by force if necessary) or you go home. If you cannot go home (if you could you probably would not be in the ICU in the first place) then you just sort of have to get it all. No one really has much choice in this regard. The patients do not, but the nurses and doctors do not really have much leeway either. Protocols have to be followed. In this way I have seen many a patient suddenly find themselves with a sterile drape over their heads and a large needle plunging into their neck (central line insertion) without so much as a “do you mind?” And the docs do not always get it on the first try. Sometimes it takes three different doctors and three different sites. Sometimes they cannot get it at all.

Then there are chemical restraints. Ativan tends to put patients to sleep. Particularly needy patients tend to get a lot of it because the nurses get fed up with them. What else can you really do for them anyways? When a patient makes an angry disturbance (banging on the bed for attention for instance), the nursing joke is to say “I think he is saying ‘give me ativan.’”

The hands down favorite drug of ICU nurses is Propofol. This milky white IV infusion induces a coma like state and can only be used on intubated patients. Propofol turns the nightmare patient into a turn-water’n-feed patient. I have heard one nurse refer to it as ‘the milk of the gods.’ Doctors also like propofol because the effect of it wears off in about ten minutes once it is turned off. A patient’s neurological status can thus be assessed briefly periodically whereas the patient who has received large doses of ativan may take days to wake up. There is a hitch though. Propofol is fat soluble, so if the patient is on it for more than a few days it absorbs into the tissues and may take weeks to clear after it is turned off.

One day I heard a commotion and went to the room of a newly arriving patient. Two teams of doctors and a large handful of nurses were settling the patient into his room. It was sort of an ad-hoc gathering. The patient did not really need much attention; people had just happened by and ended up in the room. The patient was tied at both wrists and both ankles. Four point restraints are illegal, but not uncommon. The patient was yelling, begging and pleading, “Please! Please! I do not want to die tied down like a dog! Please untie me! Please!” With the exception of me, everyone in the room was laughing at him. It was not malicious laughter it was more of the way people laugh at a child who is asking for the moon. Such a ridiculous suggestion! How could we possibly? The man was obviously crazy.