“Hi, Dr. Heart, I’m calling you about Mr. I’ve-gone-crazy who your partner did a pacer generator change on today. He’s become very agitated and combative since the start of our shift. I need something now to calm him down as nothing else has worked. Would something like Depakote sprinkles or Zyprexa, maybe even Haldol be OK with you? said the nurse into the phone.
Seriously, the guy was freaking out. Every non-pharmacological method we have in the arsenal had been thrown at him. He was confused and rightfully so. It’s not nice to put folks with dementia through surgery, it leads to some very funky things. He went from perseverating over his pants to perseverating over his wheel chair, then he wanted to be in bed, now in the chair and wherever you put him he wanted out of it. Did I mention he could not stand and bear his own weight?
The other nurses looked at me imploringly to help his nurse out. “You’ve got to do something!” they said to me.
“She’s his nurse, and yes, we’re doing all of her work for her, but I cannot call the doc for her. I don’t know the details, I don’t know enough about his history to state my case for what I think is needed. But I will talk with her.” I said.
The nurse came up to me minutes later and asked what to do. I reeled off the things that might help, meds that we have used time and time again in these situations. She agreed and went to call the doc. Above is how I pictured the conversation (she likes to hide in the med room or pharmacy office to call).
I can surmise how the rest of the above conversation went. “You want what? I have no idea about any of those meds. He’s agitated? Um, not really used to dealing with this, is he covered by Medicine? No? Really? I don’t even know what the doses would be for those meds in this situation. Uhhh…how about some Ativan?”
To which the nurse readily agreed. Really we would have taken anything at that point. This is not to say that our cardiologists don’t know what they are doing, they’re just not as adept at helping us handle the agitated and combative elder as say our medicine interns or geriatrics service. It’s a level of comfort. Our geri docs would readily agree to something like Depakote far faster than Ativan, but it’s their milieu. Would not want one of them dropping a stent in my patient. It’s what you know.
And the Ativan? It worked for a while but he ended up with a sitter by daybreak, still confused and combative, but staying safely in bed. Lesson? Avoid general anesthesia and things like Versed and Fentanyl on demented elders: it makes them worse.