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Why is baseline PTSD a risk factor for post-ICU PTSD? What does delirium look and feel like for war veterans? Why should the ICU community understand what veterans have experienced before and during the ICU?

Episode Transcription

Kali Dayton 0:27
Let’s talk about this. We know that a huge risk factor for post ICU PTSD is baseline PTSD. When I first became starkly aware of post ICU PTSD while in grad school, I turned my attention towards developing a post ICU PTSD screening tool to be used during ICU admissions, I wanted to use on a population that would be of most benefit considering this statistic, I felt veterans would be an important population to protect.

Considering the high rates of baseline psychopathologies. When I presented to an ICU team that care for veterans, everyone seemed on board with identifying vulnerable patients. Until the idea of changing sedation practices to remove risk factors came into the discussion. I could almost feel and hear at the slamming of each participant’s mental doors.

When I mentioned avoiding sedation, especially benzodiazepines with veterans that have baseline PTSD. So clearly, we do not know what delirium means to patients, and especially veterans. So I present to you someone that understands all sides of the ICU bed, Paul, thanks for being willing to talk to us. Can you introduce yourself?

Paul McMillan 1:41
Yes, my name is Paul McMillan. I am a critical care nurse. Presently I work in neurocritical care, which I’ve done for I think about four years, maybe a little extra. I’ve been in the most bedside position suffer inpatient, excluding OB for about the last 10 years. And in addition to that, Army Veteran, I have a number of things that I do with that presently, I’m an advocate for veterans like myself who have been exposed to toxic exposures, because there’s just very little knowledge about this in the medical community. But in a nutshell, those are the three big things that I’ve been into for about the last 20 years.

Kali Dayton 2:18
And on top of all that you yourself are an ICU survivor, correct?

Paul McMillan 2:22
That is correct. In 2015, I got to come to my own hospital system and find out what it’s like to have a parent a Monica fusion, that turned to empyema with sepsis. Initially, they tried chest tubes and thrombolytics, but then it came back. So I got to have a thoracotomy with a decortication. A lot of people in my line of work haven’t really who haven’t cared for those patients don’t necessarily know what that is. So just the long and the short of it is they make an incision between your ribs, split them apart and scrape you out from the inside. I like to say it sounds like more fun than it really is.

Kali Dayton 2:56
You have been through a lot. And what happened on top of all of that?

Paul McMillan 3:01
So during my first part of the hospitalization, I had a period where they thought I was fine. They just put me in observation. Then they moved me to med surg for a few days. And at one point, it was getting harder and harder to breathe. I was starting to black out. And I had every fiber of my being of my oh crap alarm was going off saying I was in trouble.

So the nursing staff who was taking care of me figured, “Well, he’s a combat that, you know, he’s probably just stressed out. And so it’s a big thing for anyone to go through.” So they kept trying to leave me alone, close the door, turn off the lights, I wound up making eye contact with them at one point. And basically, I couldn’t say anything I was trying to communicate to my iPhone.

Finally, I wound up throwing my incentive spirometer, which made it a grand total of about two feet. But that got their attention, at which point they put me on larger amounts of oxygen. And suddenly the world came back to me to talk again, from that point, I got transferred into the ICU. And that kind of sets the stage for me because I was in even more of a constant state of apprehension, feeling like, “Oh, they’re just gonna say there’s nothing really wrong with this guy.”

But I’m booksmart at the same time, I know something’s not right here. So from that point, they gave me chest tube and started give me thrombolytics I started showing medical improvement. It was uncomfortable. So I had asked for toradol over the next few days. And I think what happened was they’re saying, yes, we’ll give you toradol but they were giving me Dilaudid.

At that point, I started to go into early delirium and by my third day in the ICU, I was having trouble telling what is reality here. I knew what I was seeing in front of me, but every time I would close my eyes, I would start to have flashbacks. It was weird because some flashbacks were mine. At one point, I remember being out in the middle of the algebra neighborhood in the middle of Mosul where we’ve served that in 2004, to 2005. And I remember very distinctly, “this is a memory of when we were all out sniper hunting.”

For those of you who have never had the fun and pleasure of going sniper hunting with the infantry units, what it basically is, is you’re all moving out to the area where you think the person is, you’re all looking for the most likely places. And if they take a shot at one of you, then you shoot back. Whether this happens in all places, I don’t know, my MOS was more geared towards an intelligence, but I would augment that to these units. And that’s definitely what happened then.

So if you can imagine being in a bed, and all of a sudden, when you close your eyes, you see this red background, and you’re flashing through memories like that. That’s basically what I was going through right there. And it was weird, because sometimes if I close my eyes, I would find out, hey, if I adopt my eyes, the world will come back to me. But the second I will close them, then I will go back into another memory. But the one thing that I managed to figure out quickly was that if I do this a few times, I could kind of change the channel, if you will, and at least go into some other memory or mindset that was a little less disturbing.

Kali Dayton 6:18
And when you were in those memories, were you watching them, or were you living them?

Paul McMillan 6:23
I was living, there was a time, the people who I work with never heard me say this. So kind of bear with me for a second. I try to be a reasonably strong guy. But this is stuff that hits home for me. But we had been out on a mission one morning where we were trying to roll up a particular target. And in the process of moving cars off of the road, I had moved one over to the staging points. And then one of the other strikers was supposed to come back for me, pick me up and then we’re gonna go with everyone rolled, rolled up back into our outpost that striker never showed up.

And I wasn’t really impressed with a particular unit. Isaac, we were tasked out to that day. So I started thinking, is this group going to even come for me or recognize that I’m missing since I’m not one of their normal people. So I quickly wound up weighing my options and realized that the best thing I could come up with was just take the sidewalk, move very quickly and get back to by unit. But believe me when I say that until you’ve tried being alone in mozal, and just running through about half a mile of car after car with people looking at you like, what is this person doing to do this, and he know he’s going to get killed for doing this mix with other people who just look at you with a hatred that I don’t even have an ability to describe. That is when you truly feel isolation. And when I was having these flashbacks and experiences in the ICU, that was the mental place that I was going back to.

Kali Dayton 8:02
Isn’t it like you’re a target- you’re waiting to be shot anytime.

Paul McMillan 8:05
That’s a good way of putting it when. So after this one morning, we’re almost black or one evening, we’re almost blacked out the following morning, the nurse would have me on the med surg unit came up to me to check up on me. Even she had said that she had never been that scared of working as a nurse and for her whole life. And she’d probably been doing that job for about 25 years.

So I appreciate her for checking up on the I was trying to make sense of everything afterwards. And then one of the pulmonary doctors who I’ve worked with for years before that point just came in to check up on me. And the only thing that would have been really more reassuring at that point would be to say, “Oh, hey, there’s Jesus walking through the door and a calming and comforting way.” It just It no longer felt like I had to be on edge. It just felt like I could relax for a minute.

One of the things that wound up happening was like I still remember this conversation verbatim. But it told me that I really outdid myself this time, because he knows I liked the party hard. And he just looked at him at one point and said, “hey, you know those times where sometimes we just seem like we’re trying to keep people motivated, but you know that they’re screwed? Is this one of those times?”

… and I just remember like a single tear running out of my right eye, which is significant, and that there’s been maybe three times I was able to do that since I got back from the service, which was the 2005. And his demeanor once he realized, like, how much of a suck fest if you’ll pardon me, I was going through that he was a little less playful that points and he said something that’s made one of the most impact or the biggest impact at that time. And I’ve started using this line with my patients, which is to say, “No, you know, you’re going to do well. And the big thing is if we think that you can’t get better from this will tell you that.” but I hadn’t realized up until that moment how many people live with that weight around their shoulders that come to our beds, just thinking, “Am I screwed? Or am I not screwed?”

Kali Dayton 10:04
And when you were between worlds, and would come back to the hospital, you were feeling that on top of this feeling like you’re back in combat back at playing bait in the middle of a field, right? And then you come back to the hospital, and then you’re like, “oh, no, I’m just on the verge of death.”

Paul McMillan 10:21
Yeah, it’s so you go through these experiences that are just very intense, and then try to make sense of everything. So then I realize I’m in the hospital bed, the second day that I was there, and my wife was sitting in the corner. She’s a teacher. So she was grading papers.

And I was trying to think, you know, “What’s going on what’s happening to me that I’m having these mental states?” And then I realized, you know, just me being a nurse and thinking through, “it’s okay, I’ve gotten pneumonia, my heart rate’s through the roof. I’ve got fevers. I’m septic.” So I asked her, you know, “Am I septic?” And fortunately for her, she didn’t medically understand that I was. So she said, “No”.

So I’m still sitting there trying to think well, what’s happening to me, and there’s this feeling of uneasiness, uncertainty. On top of that, I think most of us in the medical world realize that we wouldn’t want to, one have it known that we’re medical when we’re in the bed, but then to, when you’re in an environment that you work in, it’s you’re literally down there with your pants down in front of everyone.

So that’s a little bit uncomfortable in and of itself, and just was this constant state of discomfort that would vary from moment to moment, and each experience would be a little bit different. On one hand, I’d be feeling like my ICU staff felt like I wasn’t doing my part, which that may or may not have been true. My wife says that she doesn’t think that was the case. But that was my experience of it. And then the next minutes, you know, moving up the stairwell, realizing that the guy in front of me is about to get shot. And it’s like I mentioned on an interview I did with you. What was really bizarre about that particular memory was that I knew exactly which mission that was, and I wasn’t even on that mission. I was reliving someone else’s memory.

Kali Dayton 12:07
And when you would have been told of that event, did that impact you? I mean, I’m just wondering why that comes out into your delirium. Was that something that you were afraid of happening to you? Or happening to any of your friends while you were out there?

Paul McMillan 12:20
You mean, like as in, why did I relive this particular moment? Yeah, I couldn’t find any rhyme or reason. It just felt like it was almost like channel surfing. And every time I close my eyes, there are a few different channel. It’s kind of like having cable 360 channels, and nothing’s on.

Kali Dayton 12:36
But it felt just as real as real life watching this guy get shot.

Paul McMillan 12:40
Well, in this case, I realized what was about to happen. So I opened my eyes before that moment, however, part of my motivation to open my eyes was that I recognized that I was about to have a significant experience through watching, not that I didn’t want to have. So we didn’t quite get to that point. But I believe that it would have felt that way had we gotten there.

Kali Dayton 12:59
That isn’t some extent you knew that these experiences weren’t real, or you had some sort of controlled, open your eyes and evade them.

Paul McMillan 13:08
Yes, I think it was going into delirium, maybe it was degree of septic encephalopathy as well. But I recognized that it wasn’t real. But I also, if you can kind of think of reality as being something that’s tangible. The harder I tried to hold on to it, the more I was losing it. And I’m very grateful that it didn’t get to the part where I would have had a true psychotic break, where I didn’t recognize what was going on, or where it was truly, completely, not in touch with the world that we live in an all in one that was in my mind.

Kali Dayton 13:43
Did you ever get a CAM score done during that time?

Paul McMillan 13:47
I’m sure on my charting, it said that I had it every day, no one asked me. I even on day three, when they finally sent me out of the ICU, which, incidentally, they kept me the second day just because I’d said look, you know, when I was in this room and blacking out and I felt like no one recognized something big was going on that scared me quite a bit. I just want to be somewhere where I where people are going to recognize if I’m going downhill.

So they kept me there in the third or the second night into the third day as a favor for me. But come that third morning, the nurse she did EOMs with her penlight just to make sure that I could, you know, look into six different directions. And then she went off to the top of the dock. So when she came back, I’d said, “Do you guys have any idea what’s happening?”

And she said, the doctor thinks this delirium, so no one did it. I had responded to that point. It might be I can tell you right now, if you CAM score me, I can pass it. But at the same time, I also know what the test is because I’ve done it enough times to make up essentially muscle memory.

Kali Dayton 14:51
You could have gotten a negative cam score, but you were clearly in delirium.

Paul McMillan 14:56
And this is something I’ve noticed too, just anecdotally working with neuro popular ation, because really there’s no good validated test for the neural population and the line between neurological injury and delirium is such a fine one is frequently difficult to tell if someone is it. But there’ll be times where I’ll say, “look, I think this person is showing some signs of delirium. I don’t think there’s a point of showing it yet.” But fortunately, most of the interventions that can help with that don’t require a doctor’s order. We can just do them if we know what we’re doing and are careful.

Kali Dayton 15:24
Yeah. And if you and if you care about it, right, if you know what to look for and know why you need to intervene. And that makes a huge difference, which we’ll get to in a second. Do you feel like you kind of had some trauma before going into the ICU as far as from your service?

Paul McMillan 15:40
That you could say, Yes, obviously, you know, you look through these experiences one morning, I’ve been a little bit extra mouthy and I got smitten for it or so it feels like we were joyriding and mozal. And we got detached from the rest of our convoy because the officer hadn’t read his maps that morning. So he took us through a road that turned out to be closed because every time people were going down at they’ll get blown up.

So one of the guys in the hatches next to me, were both just staying in there exposed to the world and he looks a little uneasy. I said, “Hey, what’s wrong?” he responded with, “We’re in this place called superwash. Market. This is a bad place and we’re all alone.” So with a little bit of levity, I just responded “So we’re in one of the worst parts of Mosul and we’re alone. What’s the worst that could happen?”

He looks at me like, “Holy crap, you did not just say that.” And then literally less than a minute later, bomb went off next to us IEDs we refer to them it knocked me out cold and I was out for I don’t know what probably felt like a couple of hours will probably was actually a couple seconds. But it felt like a lifetime in which I had this. Again, alternate reality that felt like I floated up to it was kind of like being on a helicopter maybe about 200, 300, 300 feet, looking down and like a newscast or just being aware of what’s in the world, but not really a part of it.

And then I you know, I realized, “Okay, I have to go back down to the world now.” It felt very relaxing. And I actually didn’t want go back. But I wasn’t like given the choice there. So you know, I come to and it’s like this voice going off in the headphones in my ears. It sounds like this off more from Charlie Brown. And then well, “WAHAWAHAHA….f******** IED”. So at that point, I realized IED.

Daisy Chain. Daisy chaining is when you have a series of IEDs wired to go off one after another sequentially. Usually they’re very fast. However, we’re not talking about US military grade explosives. Here, we’re talking about what people can make in their cellars. So I immediately dropped into the vehicle and doing chap just to make sure I’ve got no penetrating injuries the same as the rest of the guys. And afterwards, we’re all minus the officer who was leading us he was he had his own crap face on but the rest of us were laughing and giggling just because we’re writing the adrenaline surge and we’re happy, we’re still alive.

So the reason I get into all this is, that’s kind of the mind space a lot of us live in. I don’t really feel like someone who’s traumatized. I don’t feel like someone who’s got PTSD. I had been told that I had PTSD. But up until these experiences I had in the hospital, it was not really anything that was much more to me than a phrase and something that meant a little bit of work to mess with. But one thing I’ll say too, with being a hospital is, you know, I’ve just heard a couple of stories and has my wife knows they go on, but I never felt like a victim until I was hospitalized.

Kali Dayton 18:33
So even throughout all of your tears and experiences prior to hospitalization, you could bear it you were carrying on okay, and you didn’t feel like you. You were a victim, as you say. And and how is your mental health been since then, in dealing with these memories and flashbacks how has delirium impacted your, I guess, your veteranhood.

Paul McMillan 18:56
It’s definitely added a new challenge on you know, one of the things we talked about mental health when we’re on the provider side of the table, a lot of times we have these preconceived images of what a person with PTSD looks like, you may think that they’re going to come out looking like a veteran from a Five Finger Death Punch video on your table. And they’re going to be out of control and wild.

And the first thing that I really had to learn to appreciate was, that experience taught me that I do have PTSD, but it also taught me I’m functional. And that most of the time, it’s the part of my life. It’s something that I wish in certain ways wasn’t there, but I also accept that it’s just a signature of a portion of who I am. So I have to take care of it. Now as far as the things that have come from there. At one point when they really moved me out of the ICU I was just getting the stutter but I could not get rid of I don’t really know why it was it’s not something I’ve seen any of my other patients do when they get delirious and even this doctor visited me told my wife, I don’t know why he is doing that.

But it got better once I got more into a clear headspace. And when I get really stressed out now that stutter comes back. There’s times where, because of having this lung injury that I have, and when I can’t get when I can’t breathe, it’s almost takes me back at certain times to that room where I could see just the whole picture in front of me fading, fading, threatening to become a little dark that might go away. And I’ve never been as sick as I was then since that time. But there’s always kind of that feeling that goes on, maybe to say, for one of your previous questions, as an ICU nurse that frequently just kind of had that wonder bug going off in my head.

And I’m wondering what it’s like for these folks who sit and just can’t get their last breaths, and how awful that must be. And someone who’s got a lung injury. That’s something that’s a concern to me. But the same time, I don’t have to say that I wonder anymore. I know exactly what it’s like. And it’s just, it’s, it’s unpleasant. So there’s things that when you experience, you walk around, and you take them with you, and that’s become part of my life, that most of the time is something I can just look at and say, “okay, it happened, I accept it.”

But other times, it does feel a little bit more overwhelming. And there’s might even be time to say, you know, I just need to take a break. Or, as an ICU nurse, there’s times where I’ll even say, I’m really sorry, guys, but we’re not slammed right now. And I just need to take a mental health day. I feel bad about doing it. But I’ve got to take care of myself, otherwise, I can’t take care of others.

Kali Dayton 21:37
Absolutely. Do you feel like you’ve relives your combat as far as your PTSD? Do you feel like you’ve experienced those things repeatedly. Whereas before, it was a thing of the past,

Paul McMillan 21:51
Not typically, every now and then there’s something that comes up, but it’s usually just having memories of it. Sometimes the memories are a little bit more intrusive, so they’re harder to keep a bay. And there’s times where I’ve learned, I just have to think about it and let it happen for a little bit and let it go again.

Other times, I have to try and say okay, I’ve tried that, and it’s not working. So myself, I’m an advocate for going getting counseling, my employer has an option for talking to health care professionals. And sometimes I need that, even without being a combat that, as you yourself know, working on the unit, there are some awful things that we see here. You can’t watch a 17 year old female who was healthy 24 hours ago, die right in front of you, with a family sobbing all around and watching providers in front of you break down in tears, and not keep a piece of that with you.

Kali Dayton 22:45
That kind of leads to our next question. How was your own experiences with delirium impacted your care as a nurse?

Paul McMillan 22:54
So I always had been aware of delirium. I remember the lectures when I was first starting out with our system. And then in 2013, 2014, I’d gone to TRANS Conference with ACN, which was talking about the same issue that you talked about here, progressive mobility, they were looking more at the mobility side than the delirium, but it impressed upon me, hey, we need to get these people moving, and try and help them salvage what they have left instead of making it harder for them.

And a lot of times, that would cause some friction amongst my co workers, because they would just be dead set against it, they feel like hey, you know, we have to score them as RASS of negative one, well, we’ll keep them more of a RASS of -12. And we have to say, “We’re not going to get them up. But we have to protect their airway, do all this and that.”

And I didn’t really start to appreciate the kind of mental world that our patients have the potential to go into. And I’ve spoken to some patients who don’t seem to have the types of vivid memories or horrors that some of us experience. But I’ve talked to enough people who did that it caught my attention even more and just felt very affirming. Like, “Hey, even though I feel sometimes, like I’ve got a system that’s that sat against me on what I want to do here, we need to get folks out, we need to move them around. And we need to not drugged them snot out of them.”

Because that whole thing that they do when they look like “oh, they’re just resting,”—– they’re not resting. It’s not the cool illusion. It’s kind of like being in middle desert and you’re looking at that oasis. And that Oasis is what that patient looks like in reality. You know, they could be dealing with their own demons and I’ve seen plenty of other veterans for example, who when they’re reliving these things, and just even saying what they’re thinking they’re talking about. Kids and villages being blown up next to them are talking about family members leaving. Think of any thing that might be the worst you’ve ever been through or even heard of. It seems like a A lot of times, that’s what people tend to fixate and preserve aid on.

Kali Dayton 25:04
So when you see patients that are sedated, what kind of emotion does that evoke in you?

Paul McMillan 25:09
There’s, it’s a combination of frustration, also understanding that it’s not appropriate to go yell at the nurse who’s been doing it. It’s one of those things that, hey, we need to find some common ground that we can both understand and appreciate and talk about this from here. There’s been times like, Well, come on, in, I worked on a shift. So the night shift Adams node and their responses, “well, they had to sleep.”

Like well, okay, have you considered that when you’ve got them snowed on propofol, they’re not going to get to deep REM three and four sleep. So they’re not actually getting sleep, they’re mentally being disconnected from their bodies. And when you do that, for a week, on an end, there’s going to be a price that is going to be paid, it’s going to be paid by the patient, well, but they need to sleep.

So the cycle kind of goes on. And on one hand, it’s frustrating. Some people want to get really aggressive about it to, to which I mean, I’m a veteran. The thing with veterans and service members is if I got stuck in locked in a room of a pacifist convention, I could very easily convinced myself the only way out is to fight. But I recognize that that’s an inclination, not the nature of the world. So it’s like I had one guy recently who got a little bit aggressive with me in front of his Oriente. So I just threw it right back out.

That’s kind of a rarity, because I don’t think that’s really an effective way to affect change. But my hope is that more and more people who listen to podcasts with things like what you’re putting on will listen to this and say, hey, you know, I think I’m coming from a place where I want to take care of my patients, I want to do the right things, and I want them to do well. And can nurses and doctors understand that when you’re just putting them down? They’re not doing well.

Kali Dayton 26:53
And I think your perspective as a veteran is invaluable. I, when I’m setting posts, I see PTSD, I just kept seeing that baseline, PTSD is a huge risk factor. And it’s vastly under diagnosed in the veteran population. And I think it’s so important to be especially sensitive to what veterans have endured on our behalf, right, and not send them right back to it. I my final project for my doctorate was a Post-ICU PTSD screening tool.

And I presented it to a facility that cares for a lot of veterans. And I was trying to advocate for using this as a trigger to avoid benzodiazepines and avoid sedation and improve mobility and try to show that they can recognize if these patients have a baseline psychiatric history or our visit as a peon users, that they’re more at risk of having ICU delirium and post ICU PTSD. But in the end, I was just shut down. They had no interest. The second I said, anything about sedation, they were shut. And so I was really frustrated. And I felt really defensive of all patients, but especially veterans. So what would you have the IC community understand about caring for veterans in critical care?

Paul McMillan 28:15
First and foremost, we’re human beings too, I think because of the culture that there is around veterans, and you can ascribe any number of reasons to this Hollywood portrayals as healthcare workers and mostly people who have been on the unit for a while I’ve seen at least a few veterans who have gone through DTS and other formal withdraws it one, you know, obviously, it’s a challenging situation, you’ve got someone who’s in a psychotic episode in front of you, and to try and keep them out of trouble and keep them calm.

So, you know, that’s hard, but recognize that most of the time, there’s a reason that they’re like that, and that they’re trying to deal a lot of times with the horrors that they have experienced, those horrors might not necessarily be something that is just straight up combat scenario, maybe they didn’t see any action, but they came home. And they had survivor’s guilt, because other people under base or people that they knew did see those things or have experiences that were even worse.

And so then they start self medicating or they withdraw. A lot of times veterans feel like I can’t talk to my family about this, because I love them too much. And I wouldn’t want them to understand what it is that I’ve truly been doing for the last year. Well, we’re humans that need to be able to have a connection in a relationship.

So if you don’t, if you’re the veteran, and you don’t have that relationship with your wife, at some point, it’s probably not with someone else. So that’s not really appropriate either. You’ve just destroyed your marriage. And even if that kind of scenario doesn’t happen, divorce rate is so high. So maybe the veterans having a scenario where they’re losing their family over and over again, and they’re on his broken record that they just can’t do get through a lot of critical care doctors.

I’ve spoken to describe other veterans with my constellation of syndromes or symptoms, which, to me indicates, maybe they need to spend a little bit more time learning about what we’re trying to teach them are these toxic exposure injuries. So you know, recognize that there are people that work equal and that we suffer too, that we do hurt. It’s challenging to appreciate that when you’re dealing with a population in the culture of people that don’t want you to see that aspect of them.

They want you to see them as a strong person who never breaks. But unfortunately, through our life, something’s going to happen, it’s going to get us there. And just, you know, don’t ever forget how hard it is for the person who’s been proud and been able to do these things that everyone else feels like I can’t do. But suddenly, they can’t even get out of bed without assistance. Or maybe they have to use a bedpan like all these little things add up. But then when you start adding things like delirium, where they are having trouble telling what’s real and what’s not real, then that just takes it to a whole new level.

Kali Dayton 31:14
And throughout the whole medical model, we always take a thorough history of patients. And then we refer back to that history when we’re trying to do decision making and deciding what interventions right wane risk versus benefit to the decisions we have in front of us. And I think if we understood what veterans have gone through, and what it’s really like, under sedation, and the impact that it can have for the rest of their lives and the exacerbation of PTSD that they can suffer from the medications that we give? Would it change our conversation? but, how often have you heard anyone during rounds say, “Well, you know what they have, They have PTSD, or they’ve had trauma in their past…. so let’s avoid the propofol?” How often is that discussed?

Paul McMillan 32:01
During rounds? Zero times, I can think of offhand if it has happened. I can probably count on one hand. One thing that I would say and I say this is a shout out to the VTS floor that took care of me when I had the thoracotomy was that I had some really great staff there.

And some that probably could have maybe done better another profession like mortuary sciences or something like that the day out or when I came out of my thoracotomy doctor tried giving me an epidural for pain management and it wasn’t working. It took about 18 hours to recognize that wasn’t working, which was not pleasant. And as you can imagine, that’s a significant understatement.

So, you know, we battle this and finally get under control that night. I was sleeping and they came in for midnight vitals, every time that I would wake up at this point. At that point, I’ve been treated with Seroquel. And you know, it seemed to help me at that point. But when I was coming out of it, I didn’t know what was going on around me. So I kind of quickly learned that if I asked the same orientation questions I asked my patients by the time it took me to figure out what the answers for all those questions were, I usually put enough other pieces together and it could really effectively interact with the people waking me up.

So I just asked, you know, can you give me a second, and this nursing assistance was in one of those mindsets of I’m busy ain’t no one got time for that. So she tries to slap a BP cuff on my arm, she tries to throw a thermometer into my mouth forcefully. And at this point, I can remember like this bubbling up feeling. It’s almost cartoonish where if you can kind of think of the father like cartoon figure getting man but to blow up.

That was me, except that there was nowhere to go. So she recognized that I wasn’t in a good mental place and got out of there. As I put on the call lights, and then she comes back in sweetest pie. Is there anything I can do for you? At which point, you’re not you get out and they could probably hear me on the island before which is about a quarter mile away. So the nurse came in. And she’s like that point. It’s like I was shaking. I had tears streaming down my face.

And I felt like I had no control over anything. So I asked once again, when these moments of what’s happening to me and she said, “Well, you have PTSD.” I said, “Well, people have said I have PTSD. But I don’t really know what to make of that.” And she’s just kind of gently inserted herself and said, “No, I hear what you’re saying. What I’m telling you is, I’m not asking you. I’m telling you, you have PTSD. We see this reaction sometimes with police officers or other veterans service members about your age. You guys are young, proud, you’ve been strong and you’ve probably been the alpha male in your house entire life. You’ve never really been in a place where you’ve had to rely on other people taking care of you.

So for you to suddenly come into this place where you have no control where we you can’t really affect anything and you can’t even go to the bathroom without help. That’s traumatic- it’s psychologically dramatic. And we see this reaction when you and other individuals like you are essentially having sensor patient of it.”

So she got me calm down, if you want blankets around me and helped me settle down, bless this poor lady because she had me the night before when they realized that epidural wasn’t working. So it wasn’t my intent, but I made her earn her money that day and her precept D, and it just, it was one of the following morning came around the day nurse, it said, what the hell that PSA do that for?

She knows that you’re a combat vet. So that floor especially seems to have an understanding of both how traumatic it is to have your chest opened up. But also the significance of what veteran roles can play on it. It just you know, the, as they’re on floor shows that understanding is not universal. But that’s really the only place I’ve done that understood, this is what’s happening. It kind of makes me wonder what would it have been like if that floor had not had that understanding? What it’d be like if I had that inpatient nurse who maybe should have retired, you know, a decade ago, and just decides that the responses to start yelling at me instead.

I’m grateful that I didn’t have that chance. But I’ve seen it happen enough times to know that that’s a real thing. And that that’s just not one that’s not allowed everyone treat my patients. But for any health care provider who’s listening to this, you know, we get into our habits. And we feel like, okay, we’ve grown up, we’ve moved around from nursing school and come up to our own point of view.

But I guess the question I would say is how many people felt like that’s the reason they decided to go to nursing school? How many people decided that’s how I wanted to be or who I wanted to be? And how I wanted to treat people that way? I feel like the answer would almost unequivocally be no one. Yet. That behavior pattern just comes out so many times. It’s disturbing. You know, I don’t know how we as a community recognize that and go back to it. But I suspect that the first area is just to recognize this as a problem and say, how do we face this?

Kali Dayton 37:01
Absolutely so vulnerable to be patient. And I think we can be kind of disconnected when the patient seems disconnected when a patient’s an act of delirium. They’re not themselves, you can tell they don’t know where they’re at and what’s going on. So we just say a few things that maybe are not the most important, because we assume that they won’t be they won’t remember it because they’re too confused. They won’t be impacted. But you’re telling a totally different story. And your patients are blessed to have you as a nurse in their advocate, and to bring in that sense of humanity into the ICU.

Paul McMillan 37:33
Sure, veterans that have good target.

Kali Dayton 37:37
For veterans that have suffered inhalation injuries as well. How can they contact you?

Paul McMillan 37:43
So there’s a couple of things I do, I work with a group called breakfast 360. We were recently at the Washington DC at a press conference at the VFW national headquarters, Jon Stewart, the actor, comedian, as well as John feel from the feelgood foundation with a 911, fire fighters pops to put that on. So if you get curious about any of this, which, if your provider please get curious, we need you guys to start understanding that this is a real problem.

Kali Dayton 38:10
Really quick, sorry, the injuries are coming from the materials that are being burned on the basis, and that veterans or active militants or Alright, inhaling Correct?

Paul McMillan 38:23
That’s one set of injuries. There’s a number of things out there, the stand that we breathe out, they’re toxic, the a lot of soldiers have had exposures to depleted uranium. So really, unfortunately, from what we’re starting to see if you’ve served overseas, your odds of having some sort of exposure and the fact of this is probably greater that you have than not, but the area that we focus on right now is burn pits because it’s the area that’s easiest to study and understand.

And we’ve also seen the same types of problems through the 911 firefighters because there are some groups were the same. They were in a burning building the World Trade Center with jet fuel, which is what we use as an accelerant. And all the particles particulate matter especially which simulates a stand up there, the cancer rates go higher, we’re seeing a lot of cases of constrictive bronchiolitis. But unlike the historical versions, where the median survival might be three years, you could have an indolence period on, you know, 10 years or so before they even start to show symptoms of this. So it’s bizarre and it’s unusual.

But unfortunately, the average physician that I’ve run into their feeling is well, you know, you’re a veteran. So clearly, this must be PTSD. And it’s hard because a lot of the conventional testing does not really show anything that you can appreciate on it. Or we might not give a whole lot of credence to certain values because they’re not always reliable. But unfortunately, the syndromes are real. And that’s part of what got me into all of this year.

Kali Dayton 39:52
So you make so many good points and how important is to consider the full history of veterans, physically psychologically other exposed There’s, that’s I’m so glad that there are specialists in our fields, but especially survivors like you that are advocating for better care for veterans, anything else that you would share with veterans and or the IC community about your your work?

Paul McMillan 40:16
Just, you know, again, recognize as veterans. Part of why I think the civilian world doesn’t understand us, I feel it’s out there, because a lot of veterans I know are upset that the civilian world doesn’t understand us. But at the same time, we don’t tell the civilian world hardly anything about us. So I don’t think it’s really a fair thing to say that I’m mad at the rest of the world because they don’t get what I’ve been through, when I’m the only one who can tell them what I’ve been through.

So maybe just kind of keep that in mind and say, Hey, maybe we need to find the right people to share some of these stories, I preface that because we all know there’s also the wrong people don’t do that. But that’s a big thing. For health care providers just recognize that it seems cliche after a while, but you’re taking care of a human being in that bad. It’s not just the patient with the hot gallbladder or the patient with sepsis.

It’s a real human being with real feelings and our real goals in our life who experiences real pain or real fear. And I think something that we tend to block out, I get that because in the service, there’s a number of things we had to block out in order to effectively do our jobs. But recognize that when you keep blocking these things out, it takes you up a staircase that you necessarily don’t want to go up.

And it also keeps you from being the type of person who’s able to show compassion and your job, which can even affect how well you do your job. I’ve seen so many patients with psych histories, who we kind of shut out. And I had remembered a meeting where a presentation that Suzanna halen who wrote brain on fire put up where she had pointed out all of her providers just kept copying and pasting or health and physical.

So she said, if you take anything from this, do your own issues and peace and, you know, boy learns with psych patients, especially to do that, because things get missed, like, hey, this person with pancreatitis is about to go into surgery, and no one knows they’ve got si ADH, you know, these are all little examples. But they come from a mindset that we let ourselves be in. And at the end of the day, I’m the only one who can decide what kind of nurse I want to be.

And I want to be one who reaches out to my patients, and tries to bring them back from some of those points, because so many of them are in the darkest days of their lives. And they don’t have to do it alone. But especially like with all of our hospital policies for post COVID and visit elimination. You know, if we don’t reach out to them, a lot of them don’t know the questions to ask. So it was really teamwork and trying to say, How can I hold on to these things that led me to want to get health care in first place?

Kali Dayton 42:59
Absolutely. You make so many good points like history is part of the medical history. And if someone has a kidney injury, or they’re at risk of having a hindering kidney injury, we get so upset or concerned about giving them an IV contrast, which we know now is not such a big deal. But we take that into consideration. But when someone has like history, we are just quick to grab the atom and nonetheless, or the verse said the proper fall and just give it to them without considering what that’s going to cause for them later on. Paul, thank you so much for all your contributions, and we’ll put the link to your information on the blog. Thanks so much.

Transcribed by https://otter.ai

 

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