2

Back to Bay 2 again today, with different patients this time. This is usually the case. It is still amazing to me the impacts of new traumatic brain injuries. It is difficult to parse out the new symptoms from the patients’ baseline, especially with newly extubated patients, who when intubated are really incapable of expressing themselves. One of my patients today when from calm and cooperative to agitated and  persevering within a blink of an eye. Persevering. This is a fancy term for an irrational or unusual focus on a single behavior, idea, or expression. It can show itself in many different forms. Repetitive motions, or sentences, usually coupled with a high anxiety.

The hard part about brain injuries is that the physical manifestations in the brain do not always correspond to anticipated psychological or physical expression in interactions. Small injuries can lead to major changes in personality; without knowledge of what the person was like before the accident, I have no idea if the patient’s current personality has changed. Man, neuro injuries are tough. Often I find myself reacting to new, volatile situations, which makes it very difficult to look at the big picture to try to figure out what is actually going on. The best approach, it seems, is to manage symptoms first, ensure patient safety, and then try to connect the dots afterwards.

I am sure that this will come with added experience. But now sometimes it feels that the patients are controlling the environment and I am purely reactionary. I think it would be beneficial for me to incorporate a ‘medical timeout’ into my daily routine. Somewhere within my shift, and in particular after change prompted by patient change in care (drugs, mechanical ventilation, etc) take a couple of moments away from daily task-oriented duties and paint a revised picture of the patient. This may help me sort out and make better sense of patient actions.

As in the case with one of my patients today, who, after now thinking about it, clearly is suffering from some frontal or prefrontal injury. This injury is not present nor described in scans, yet is clearly there. Personality changes, impulsiveness, persevering. The fact that I did not recognize this in the moment makes me want to slap myself in the forehead. Not that her plan of care would have changed clinically, though. But it somehow makes the nursing shift easier when I understand that what the patient is going through and externally expressing is a logical result of some type of brain injury that I can name. Once I understand the language of neurology (as with any sort of understanding), I feel more empowered to deal with its after-effects and consequences.

Language informs meaning. That is its power.