A neurosurgeon experiences PTSD after being intubated in his own ICU. His journey through that one long night holds lessons for us all.
As a neurosurgeon, the Intensive Care Unit used to be my safe place. Over the past few decades, I have consigned thousands of individuals to be intubated and placed on ventilators. As a veteran of Desert Storm, I have participated in research studies to evaluate brain function among my fellow veterans afflicted with PTSD. It never crossed my mind that I might experience PTSD myself as a result of being intubated inside my own ICU.
I had to undergo surgery for an abscess that had ruptured in one of my lungs. It is perfectly normal after such a surgery to keep a patient intubated and on a ventilator. This maneuver allows the patient to rest the lung and recover respiratory function while the ventilator does the work of breathing. I fully understood what to expect after surgery. I know the ins and outs of intubation and figured I could deal with it as well as anybody.
When intubated, individuals have a wide-bore, flexible plastic hose inserted into their windpipes. Remember the last time you accidentally had a drop of water head down the “wrong pipe?” Remember how you sputtered, coughed, and choked half to death on that one swallow? Over millions of years, humans have evolved an exquisite “gag reflex,” meaning that anything that threatens our airways can be counted on to produce a violent physical response. Your heart can race up to nearly two hundred beats a minute. Your blood pressure can soar to dizzying heights. I have had several patients who were undermedicated for intubation and their blood pressure took off like a rocket, and they developed an intracerebral hemorrhage. I met those patients because I had to remove the blood clot from their brain.
There is almost nothing you can do that will unleash as powerful a fight-or-flight response as intubation. For this reason, we go to great lengths to heavily sedate patients and blunt their sensorium. Basically, you want to zonk them out so thoroughly that their bodies will not react to the endotracheal tube. The overwhelming majority of patients never recall being in the ICU, let alone on a ventilator, because we have them snockered on medication. That is how it is supposed to work.
So, imagine my surprise when I found myself bobbing up to consciousness—like a submarine speeding to the surface—only to find a garden hose stuck in my windpipe. It felt like someone was choking me to death. So, I did what Mother Nature taught me to do: I couldn’t flee, so I fought. I reached to pull out the offending tube, and as I reached for it, someone grabbed my hands. So, again, I resorted to instinct. I fought harder. By God, I’m not going to go down without a fight. I start trying to see if I can land a punch or shove the person off of me.
“Help!” I hear a nurse’s voice ring out. “We need help in bed eight!”
Suddenly, I was surrounded by a team of hefty guys: One is pinning my shoulders back, and there’s one on each of my legs. I am fighting with every ounce of strength I can muster. I want to scream, but not even a squeak can come out because the tube is blocking air from passing over my vocal cords. I can’t make a sound. Meanwhile, this endotracheal hose has become a living creature burrowed in my windpipe, and I’m fighting these goons so I can snatch it out.
“Geez! Someone watch his blood pressure!” It’s a male voice. “He’s over two hundred systolic. He keeps this up and he’ll have an MI.” Then the orders really start flying. ”Pull up 40 of Propofol and give it to him. IV push to knock him down. And let’s get this guy in four-point restraint!”
Other orders are barked, but the “four-point restraint” got my attention because it meant they intended to tie down my arms and legs to the bed. Then I’d have even less chance to get the endotracheal monster out of my airway.
“Forty of Propofol. IV push. Going in.” It’s a female voice. And, suddenly, I no longer wanted to struggle. I felt like I’m just drifting to the bottom of the ocean. The last words I heard were, “Now, someone get me those restraints before this guy extubates himself.” And I think to myself, Who cares?
But I do care shortly, because I don’t even touch the bottom before surfacing again. This time I become aware that I am lashed down at all four extremities, and I have even less opportunity to get to the tube. I thrashed around, twisting from side to side and picking my chest off the bed. It hurt like hell, as I have just had surgery on my chest.
“Are you in pain?” asked the nurse.
On the surface, a reasonably straightforward question. No, my chest was okay. I figured that would be the subject of a typical nurse’s query. You know: does it hurt where I think it would hurt? So, no, I was not in pain. But I felt like I was being suffocated after someone had shoved a garden hose down my windpipe. Is that pain?
“Nod your head yes if you are in pain,” she admonishes me.
I wanted to yell, “I’m thinking!” but obviously couldn’t. Why don’t you ask me: “Do you feel like you are being smothered to death?” Then I could nod my head most emphatically. Instead, I did what I could: I pointed to my throat with my index finger repeatedly. I felt like the human equivalent of a turn signal.
“Oh,” the nurse said. “Your hands are tied down. Is that what is bothering you?” Again, a tough question. Yes, it bothered me that my hands were tied down because I wanted to reach for the endotracheal tube and yank it out by the roots. So, it did trouble me that my hands were tied down because it was indicative of a much larger problem. I thought I would trigger further inquiries if I nodded affirmatively.
“That’s simply so you don’t extubate yourself,” she explained to me dutifully.
I nodded. Index finger still blinking.
I arch my eyebrows as if to say: “Ah, ha!” Then I thought to myself: Why the hell are we even having this conversation? Aren’t you supposed to put me under so I am unresponsive; i.e., so we are not having the ICU-equivalent of 20 questions because I am supposed to be unconscious!
I started to jab in the air. I wanted to jab her in the chest, as if to say: “You get this friggin’ tube out of me right now or I’m going to find your family and slaughter them all.” Then a light bulb went off. I made a writing motion with my hand.
“Oh,” the nurse yelped with delight.
“You want to write something down? I’ll find you a pad of paper and a pencil.”
Tales of Two Friends
Two of my closest friends saw combat in Vietnam. The first, whom I will call Bob, was a member of a team that manned a howitzer. One day, while Bob and his unit were driving in an open truck to move their artillery piece from one firebase to another, they hit a land mine and were then raked with machine gun fire and grenades. Bob lost three in his team that day. Two of them died in his arms. For the rest of his life, he waited to be ambushed again. He could never sit by the open window of a restaurant. He always needed his back against the wall. And he always spent the night of the Fourth of July in a cold sweat, working through a bottle of Jack Daniels. As he grew deaf—a secondary effect of being so close to artillery fire—he refused a hearing aid so he would no longer live in terror of loud noises.
The second friend, whom I’ll call Jack, was a Special Forces Medical Sergeant, and what he saw may have been worse. Twice he ran into a burning helicopter to pull men out of the flames. Once, his own helicopter was shot down and half of his team was killed. Not only did he never have PTSD, he reupped for two more tours in Vietnam. He once admitted to me, “The closest I ever felt to being home somewhere was in the jungles of Vietnam. I wish I could go back.”
“Well, you can,” I said. “Vietnam is now a big tourist destination.”
“No,” he said. “I wish I could go back to 1968.”
Great! I thought. Then you’ll have to untie my right hand so I can write. And I’ll be able to make a break for the tube!
Mistake number one. Nurses have been down this road with patients many times before.
“Now, I’m going to slip this restraint a little higher on your wrist. We don’t want you to get your hand loose, so I’ll hold the pad and you can write on it.”
Have you ever tried to write on a pad that is being held alongside your hip? Not easy. But I managed to scrawl, in crazed letters, my unvarnished truth at that moment: “I want to kill you.”
I guess my “K” was a little shaky because the nurse took the pad, read it, and then asked: “You want to bill me? Bill me for what?”
I signaled with my index finger to bring the pad around again because I had more to add. I wrote down my capital “K” very clearly this time: “KILL not Bill.” The truth of the matter is that the sedation was getting lighter and lighter and I was trying to hold back a terrible sense of dread and panic that seemed intent of devouring me.
“You want to kill me?” the nurse asked. “Why would you say—write—such a thing?” She stormed out of the room, leaving me with CNN on the TV. So, I got to watch Donald Trump descending from Heaven on an escalator to announce his improbable candidacy for President. I wondered that maybe I was beginning to hallucinate, but then a very big, broad-shouldered resident walked in and announced, “We won’t have you threatening our nursing staff!”
No, no, I thought to myself. You are looking at this all wrong! The question is: Why? Why would I want to kill my nurse? What is my motivation? You should be asking: Why would one of your own brain surgeons want to kill an ICU nurse he had never met before? The next words out of his mouth were like a dagger straight through the heart: “Give him four milligrams of Haldol.”
Haldol? My God, not Haldol! I screamed inside my head. Haldol is the trade name for haloperidol, and it is for people suffering with psychosis. So now I have them convinced I’m a crazed lunatic.
I did feel like a crazed lunatic. Someone or something seemed intent on suffocating me, and my terror was incredibly real. I remember being overwhelmed by a great sadness when I realized that if they killed me, I would never have a chance to see my family again. I remember feeling tears streaming down my face. I hatched a plan.
I would let the creature choke me. I would let it think it was winning. That I was giving up, succumbing to its greater strength. I would pretend to fall into a coma—and resist all urge to move. My friend Jack had told me about one occasion when he had to hide in a swamp as scores of North Vietnamese troops and trucks rolled past him in long columns for almost a full day. He had covered himself in mud and, on two occasions, had used a wide hollow reed to breathe while he had remained submerged. So I stopped struggling and locked onto the news ticker across the bottom of CNN to stay focused while The Beast remained lodged in my throat. I knew I had to lull them all into a false sense of security. The Haldol didn’t touch me, but the fear of dying did.
Finally, the nurse on the day shift signed out to the incoming nurse on the night shift, and I heard her say: “He’s been quiet all evening. Quiet as a mouse.” Good, I thought. Let them think I’m all quiet in here. But the whole time I could feel that endotracheal tube like a fist down my throat. Stay focused on the ticker! I barked at myself. I would start spelling words backwards—anything to distract me. Finally, one of the nurses began playing around with the arterial line in my right wrist. That was good: my dominant hand. More strength and speed. She undid the restraint.
I laid limply in bed, as if paralyzed. She was getting some heparin ready on the nightstand and preparing to change the dressing. Her back was to me. Now it was time to seize my chance. Strike like a snake. But I miscalculated and grabbed the tubing to the ventilator and only managed to disconnect the system. Now, an alarm started blaring—a back-up system to warn nurses if a patient lost that vital connection to the ventilator.
I finally got my hand around the creature, but I forgot the most basic precautions that were taken: the tube was taped in place. I pulled hard but the tape stuck fast. People started flooding in as the nurse dove on my one free hand and hung on with all her might.
“Give him the full slug of propofol!” I heard my nurse yell out. I felt like The Beast must be chuckling, wiggling the end of the endotracheal tube to create overwhelming fear and anxiety. I looked at the ticker. Almost midnight. Then I started sinking to the bottom.
What We Know About PTSD
We all suffer traumas, and the overwhelming majority of traumas we encounter make us stronger, more resilient, and more resolute. We often emerge wiser and more thoughtful. An extreme example is Victor Frankl, who experienced the horrors of Auschwitz and concluded, “Man does not simply exist but always decides what his exis-tence will be, what he will become the next moment.” Out of that profound realization grew Frankl’s whole psy-choanalytic notion of “the freedom to choose one’s attitude.” But for those of us who suffer from PTSD, certain triggers hijack the brain and cause victims to essentially reexperience the original trauma—often taking away that freedom.
PTSD is an elusive beast, but here’s what we know so far:
As the name implies, PTSD occurs in the aftermath of experienced traumas, such as combat, terrorism, domestic violence, sexual abuse, assault, and severe traffic accidents. Symptoms of PTSD follow anywhere from weeks to months to years after the inciting event. In any given year, three and a half percent of the American population is overcome with PTSD. That’s roughly equivalent to the whole city of Los Angeles. And about 10 percent of us will experience PTSD at some point in our lives.
Children seem somewhat more resistant to developing PTSD than adults because they have less developed brain substrates for making memories. But children caught up in the horrors of war are 16 times more likely to develop PTSD than the population at large. Places like Ukraine, Ethiopia, Yemen, Myanmar, and Afghanistan are incubators for individuals who will be conscripted into an ever-growing global pandemic of PTSD.
From studying identical twins, we know that about 30 percent of our susceptibility to PTSD appears to have a genetic component, and identical twins have a much higher rate of concordance in developing the disorder than fraternal twins. By looking at studies that image brain activity, we can see that individuals who develop PTSD have exaggerated “startle reactions,” meaning their brains are primed to respond to a threat in an exaggerated fashion. When we look at the blood sample of individuals with PTSD, we see that their white blood cells also seem to be on high alert. They swarm in large numbers in the circulation, bristling with inflammatory markers.
But it takes more than stress to develop PTSD. It also takes memory. People born with excellent memories are more susceptible. Animal studies have also now clearly implicated sleep as an additional vital factor in developing PTSD. During sleep, the brain appears to replay the potential PTSD-inciting episode while preparing the experience to be stored in the brain’s memory banks. Although studies haven’t been done, getting really drunk after a traumatic event might be protective.
Lastly, we know that activating the brain’s fight-or-flight mechanism is also a critical component in forming PTSD. The usual progression of a memory is that we take our experiences and process them consciously using our frontal lobes to add cognitive assessment and judgment. So, for example, let’s say we had fun surfing on vacation in Maui. In our frontal lobes, we might compare the Maui surfing to other times we surfed or other vacations, and then we file it away in our memory banks in our hippocampus. But, if we add the fight-or-flight component—say, we were attacked by a shark this time—the experience may bypass all conscious processing in the frontal lobes and get stored directly in the hippocampus without being cognitively analyzed. And therein lies one of the critical features of PTSD: We don’t recollect the terrifying incident as much as we reexperience it—and thus what we do next may be beyond our rational judgment or control.
I came back to my wife’s voice explaining to the nurses, “It always takes a lot of medication to knock him out—and keep him knocked out!” She was right, and they should have listened to her, because no sooner would they knock me down than I would pop up struggling like a hooked tuna. But in my paranoia, I blamed my wife for letting them do this to me. It felt like I was being waterboarded. I would have said anything and done anything to get that tube out. Halfway through the night, my wife put the pen in my hand and held the notepad, and I scrawled across it, “I’m going to divorce you for doing this to me!” She just kept stroking my hair and telling me, “The doctors say the tube may come out in the morning.”
Morning came, and eventually the team agreed I could be extubated. The most frightful night of my life was over.
In the weeks that followed, I had a series of violent nightmares about being held down and intubated. I would wake up in a cold sweat but still had no idea what was going on. When I went back to work and walked into the ICU with a team of residents and medical students, I heard the alarms go off and saw the ventilators and felt that someone was going to grab me and shove a tube down my throat again. I could barely control my panic as I insisted my team leave the ICU. In my medical simulation lab, where we train medical students to intubate patients, I could not even look at the instruments. They scared me to death. I finally asked for one of the other faculty members to take over the training because just seeing an endotracheal tube brought back the panic. I could barely stand looking in on patients in the ICU because it would make me feel so trapped. It was my wife (a psychologist) who recognized that I had developed PTSD.
When covid arrived on the scene, we realized that my lung operation had put me at much higher risk for developing complications of covid than the normal population. Suddenly, all I could think of were the covid patients on vents. I just looked at her. “No matter what happens, don’t let them intubate me again.”
“A lot of patients need to be on the vent for a short time to recover,” my wife said.
“Some of those patients are on ventilators for weeks! I barely made it through one night.”
“But you made it.”
“Barely,” I said again. “I think I would lose my mind.”
Now I understand the compelling “logic” of those who suffer with PTSD: that one will go to almost any lengths to avoid confronting The Beast again. The triggers can lie all around you. They’re clues that others can’t see. The sound of the vent. The disconnect alarms. The laryngoscope on a table. And the endotracheal tubes themselves, of course.
The truth is, the intubation incident broke something inside me. It left behind a permanent hole, filled to the brim with terror. I’m not sure it can be fixed. I still can’t look at a patient on a ventilator without wanting to sprint out of the building or hide in a closet. My triggers seem almost silly and trivial to almost any doctor but me. They may make no sense to anyone but me.
I recently heard that a friend of mine—a fine surgeon I practiced with years ago—had passed away. His widow was telling me about his last days. “Sadly,” she said, “the final days were miserable. He spent 11 days on a ventilator and then became unresponsive and we withdrew support.”
“Did they take out the endotracheal tube before he died?” I asked.
“I think so,” she said. “Why do you ask?”
25 Years of Total Aliveness
Over the years with S+H, Allan Hamilton has located “The Source of Flow” in the brain and how to best connect with horses in “Zen Mind, Zen Horse” and even how to make people more peaceful in “Peace Lessons from a War Horse.”