Post-operative behavioural changes are a well-known phenomena—in one such case, a gentle god-fearing soul turned into a violent person
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You need an operation on your neck, Mrs Smith,” I told the god-fearing 66-year-old lady after conducting a detailed evaluation in her hospital room. The medicine cabinet next to her bed had three different-sized photo frames of Christ, two rosaries, and the Bible. The window sill was lined with a picture of The Last Supper, and next to it were a couple of wooden crosses. There was gentle ‘Praise the Lord’ music playing on her husband’s phone. I felt as though I had just walked into the kingdom of heaven.
Over the past year Joanne Smith had started to complain of a difficulty walking on uneven surfaces. She had tripped over and fallen a few times. She found it hard to cook, as vegetables and utensils kept slipping out of her hands. As a well-built lady, she was used to a large amount of physical labour, but most of her activities had been curbed owing to her ailment.
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“I feel like I’m walking on fluffy clouds all the time,” she said in a reticent voice, describing the sensory impairment in her feet. I really was in the kingdom of heaven. “Squeeze my fingers tight,” I instructed as I put them on her palm for her to grasp. Her hand slipped off easily, and her husband, who was standing stoically next to me, nodded his head, expecting this outcome.
I prophetically held the MRI films against the light streaming in from the window to show them where her cervical spine was being compressed by her thickened bone and ligaments. “We will remove whatever is pinching on the cord, and over the next few months, you’ll regain most of your function back,” I explained, advising them of the usual complications that could arise with an operation like this. “God has chosen you as an instrument for her healing,” her silver-haired, dark-skinned husband proclaimed. “I will do my best,” I said, with my hand on my heart, albeit a little nervous of their proximity to God.
The next morning, we flipped her on her belly, fixed her head on pins, and sliced down the back of her neck. I went ahead and meticulously drilled off the bone, punching out the thickened ligament to allow for her spinal cord to breathe again. “I don’t want anything to go wrong with this lady,” I said, which is what I assert loudly when my subconscious tinkles that something might. The surgery had gone off well, and I sounded off the post-operative instructions as we closed. We shifted her to the ICU for overnight observation.
I saw her again in the evening before I left for the day. As I placed my hand over her forehead, she softly smiled at me and said, “Thank you,” still groggy from the anaesthesia. She was moving her arms and legs well, which was an excellent sign. “Thank you, Jesus!” I said to myself for a change, a variation from the oft-used “Thank you, Khodaiji,” hoping my Parsi God wouldn’t mind. I drove back recalling the Smiths’ belief in God and I wondered if atheists or agnostics recover just as well as devotees of the divine. It might be a study worth conducting one day, although I am convinced that providence plays a big role in successful outcomes, especially in the kinds of cases I do.
The next morning, I walked into the ICU with a bounce in my step and a freshness that comes from having slept deeply. After the previous day’s successful operation, I was hoping to see Joanne sitting up in a chair and eating breakfast. But when I walked over to her, I was aghast to see her lying flat with all four limbs restrained to the bed. She was thrashing around violently with a strength I never knew could exist in someone who was so weak before surgery. Her heart was thumping at 200 beats a minute and her blood pressure had the same numerical value. I looked urgently over at the ICU registrar and a couple of nurses who were around, my eyes wide open and arms up in the air, questioningly. “She’s become violent and aggressive over the past hour,” the nurse explained, showing me her own arm that had been clawed into by Joanne. “She almost bit the ward boy who tried to help her,” another continued.
“Everyone here is trying to kill me!” Joanne yelled at the top of her voice. I thought that looking at me—a familiar face—might ease things a little, but I was wrong; the screams continued. “You are the devil and my murderer,” she growled at me with fiery eyes. The way she was moving her neck while chained to the bed made me worry if she would suffer a whiplash injury. The junior doctor in the ICU came over to confer with me. “We gave her something to calm her down, but it hasn’t worked so far,” he said, pointing to her chart.
“We should shift her out of the ICU now, she’ll be fine,” I said, announcing it with the panache of James Bond, who knew exactly what might be going on. “But her blood pressure and heart rate are uncontrollable; it might not be safe,” the doctor responded, reasoning for the well-being of the patient. I put my arm around him and said, “Please shift her out. Being in the ICU is part of the problem.”
Post-operative psychosis is a rare, but known phenomenon. A wide range of behavioural symptoms may occur after any kind of surgery, not necessarily those performed on the brain or spine. Patients have been reported to develop depression, mania, hallucinations, and impulsivity. In an ICU setting, however, listening to the constant beeping of various machines, hushed voices of the nurses, and the wails of some who are gravely ill, patients may experience disturbed sleep and start hearing voices, feel severe anxiety, and see things that aren’t there. This might result in them being severely disoriented, agitated, and even violent. We call this ICU psychosis and it shows up acutely. It is best treated by transferring the patient out of the ICU and into the comfort of their loved ones. If lifesaving treatment is being administered and that might not be possible, appropriate medication is administered instead.
The next morning, Joanne greeted me with a cheery “How are you, Dr Turel?” exhibiting an effusive warmth that was oblivious of the apocalypse of the previous day. I tested her hand grip and it was as strong as a beast. My operation was a hit, but I wanted to get to the bottom of all the drama. “Do you have any recollection of what happened in the ICU yesterday?” She shook her head sideways, unaware. “You were not a good girl in there!” I reprimanded her in jest, knowing fully well that what she had gone through was beyond her control. “Jesus died for our sins,” she said apologetically. “And it would be a complete waste of his time and effort if you didn’t commit them!” I concluded in agreement.
The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.
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