Kim Victory was paralyzed on a bed and being burned alive.
Just in time, someone rescued her, but suddenly, she was turned into an ice sculpture on a fancy cruise ship buffet. Next, she was a subject of an experiment in a lab in Japan. Then she was being attacked by cats.
Nightmarish visions like these plagued Ms. Victory during her hospitalization this spring for severe respiratory failure caused by the coronavirus. They made her so agitated that one night, she pulled out her ventilator breathing tube; another time, she fell off a chair and landed on the floor of the intensive care unit.
“It was so real, and I was so scared,” said Ms. Victory, 31, now back home in Franklin, Tenn.
To a startling degree, many coronavirus patients are reporting similar experiences. Called hospital delirium, the phenomenon has previously been seen mostly in a subset of older patients, some of whom already had dementia, and in recent years, hospitals adopted measures to reduce it.
“All of that has been erased by Covid,” said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University and the Nashville Veteran’s Administration Hospital, whose team developed guidelines for hospitals to minimize delirium.
Now, the condition is bedeviling coronavirus patients of all ages with no previous cognitive impairment. Reports from hospitals and researchers suggest that about two-thirds to three-quarters of coronavirus patients in I.C.U.’s have experienced it in various ways. Some have “hyperactive delirium,” paranoid hallucinations and agitation; some have “hypoactive delirium,” internalized visions and confusion that cause patients to become withdrawn and incommunicative; and some have both.
The experiences aren’t just terrifying and disorienting. Delirium can have detrimental consequences long after it lifts, extending hospital stays, slowing recovery and increasing people’s risk of developing depression or post-traumatic stress. Previously healthy older patients with delirium can develop dementia sooner than they otherwise would have and can die earlier, researchers have found.
“There’s increased risk for temporary or even permanent cognitive deficits,” said Dr. Lawrence Kaplan, director of consultation liaison psychiatry at the University of California, San Francisco Medical Center. “It is actually more devastating than people realize.”
The ingredients for delirium are pervasive during the pandemic. They include long stints on ventilators, heavy sedatives and poor sleep. Other factors: patients are mostly immobile, occasionally restrained to keep them from accidentally disconnecting tubes, and receive minimal social interaction because families can’t visit and medical providers wear face-obscuring protective gear and spend limited time in patients’ rooms.
“It’s like the perfect storm to generate delirium, it really, really is,” said Dr. Sharon Inouye, a leading delirium expert who founded the Hospital Elder Life Program, guidelines that have helped to significantly decrease delirium among older patients. Both her program and Dr. Ely’s have devised recommendations for reducing delirium during the pandemic.
The virus itself or the body’s response to it may also generate neurological effects, “flipping people into more of a delirium state,” said Dr. Sajan Patel, an assistant professor at University of California, San Francisco.
The oxygen depletion and inflammation that many seriously ill coronavirus patients experience can affect the brain and other organs besides the lungs. Kidney or liver failure can lead to buildup of delirium-promoting medications. Some patients develop small blood clots that don’t cause strokes but spur subtle circulation disruption that might trigger cognitive problems and delirium, Dr. Inouye said.
Nails in a rotating head
“AK-47,” Ron Temko wrote in shaky handwriting from his hospital bed.
Then he pointed at his neck to show where the assault rifle should aim.
Mr. Temko, a 69-year-old mortgage company executive, couldn’t speak because of the breathing tube in his mouth — he’d been on a ventilator at U.C.S.F. Medical Center for about three weeks by then. So, on a Zoom call nurses arranged with his family, he wrote on paper attached to a clipboard.
“He wants us to kill him,’” his son gasped, according to Mr. Temko and his wife, Linda.
“No, honey,” Linda implored, “you’re going to be OK.”
At home now in San Francisco after a 60-day hospitalization, Mr. Temko said his suggestion that his family shoot him stemmed from a delirium-fueled delusion that he’d been abducted.
“I was in a paranoiac phase where I thought there was some sort of conspiracy against me,” he said.
When he was first placed on the ventilator, doctors used a lighter sedative, propofol, and dialed it down for hours so he could be awake and know where he was — a “regimen to try to avoid delirium,” said Dr. Daniel Burkhardt, an anesthesiologist and intensivist who treated him.
But then Mr. Temko’s respiratory failure worsened. His blood pressure plummeted, a condition propofol intensifies. To allow the ventilator to completely breathe for him, doctors had him chemically paralyzed, which required heavier sedatives to prevent the trauma of being conscious while unable to move.
So Mr. Temko’s sedation was switched to midazolam, a benzodiazepine, and fentanyl, an opioid — drugs that exacerbate delirium.
“We had no choice,” Dr. Burkhardt said. “If you’re very sick and very unstable, basically what happens is we conclude you have bigger problems. You know, I have to get you to live through it first.”
After about two weeks, the sedative-weaning process began, but other delirium-related quandaries emerged. Mr. Temko began experiencing pain and anxiety, compelling doctors to balance treating those conditions with using medications that can worsen delirium, they said.
The repeated nursing visits Mr. Temko needed interrupted his sleep-wake cycle, so he’d often take daytime naps and become sleepless and agitated at night, said Jason Bloomer, an I.C.U. nurse.
At home, his wife kept her phone by her pillow so she could hear him via a nurse’s tablet. “He would wake up and was confused and anxious and he’d start getting all worked up to where the ventilator couldn’t work,” said Mrs. Temko, who would reassure him, “It’s OK, breathe.”
His hallucinations included a rotating human head. “Every time it came around, someone put a nail in it, and I could see that the person was still alive,” he said.
He imagined that his wristwatch (which was actually at home) was stolen by a man who turned it into a catheter. The man played a recording of Ben Bernanke, the former Federal Reserve chair, and told Mr. Temko that because he recognized the name, “‘You know too much, you’re not leaving the hospital.’”
When Mr. Bloomer asked “Do you feel safe?,” Mr. Temko shook his head no and mouthed around his breathing tube: “‘Help me.’”
Later, he became despairing. “I did not know if I wanted to live or die,” he said.
He met with Dr. Kaplan, the psychiatrist, who recognized his symptoms as delirium, partly because Mr. Temko bungled tests like naming the months backward and counting down from 100 by sevens. “He could only get from 100 to 93,” Dr. Kaplan said, adding, “The cardinal sin of delirium is always impaired attention.”
Dr. Kaplan prescribed Seroquel, which he said helps with perceptual disturbances and anxiety.
Mr. Temko said another turning point came when Mr. Bloomer said that with months of hard work, recovery was likely.
An optimistic cognitive sign, said Dr. Kaplan, is that Mr. Temko can now describe his delirium in much more detail than he could several weeks ago.
‘I saw the devil’
Some coronavirus patients develop delirium even after relatively short I.C.U. stints.
Anatolio José Rios, 57, was intubated for just four days at Massachusetts General Hospital and didn’t receive highly delirium-inducing sedatives. Still, as sedation was lifted, he heard booms, and saw flashes of light and people praying for him.
“Oh my God, that was scary,” he said. “And when I opened my eyes, I saw the same doctors, the same nurses who were praying for me in my dream.”
Frequently Asked Questions and Advice
Updated June 24, 2020
What’s the best material for a mask?
Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.
Is it harder to exercise while wearing a mask?
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
I’ve heard about a treatment called dexamethasone. Does it work?
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
What is pandemic paid leave?
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
Does asymptomatic transmission of Covid-19 happen?
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
What’s the risk of catching coronavirus from a surface?
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
How does blood type influence coronavirus?
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
How many people have lost their jobs due to coronavirus in the U.S.?
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
What are the symptoms of coronavirus?
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
How can I protect myself while flying?
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
What should I do if I feel sick?
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
After the ventilator was disconnected, Mr. Rios, a normally gregarious man who hosts a radio show, only responded with one- or two-word answers, said Dr. Peggy Lai, who treated him.
“I saw people lying on the floor like they were dead in the I.C.U.,” he said. He imagined a vampire-like woman in his room. He was convinced people in the hall outside were armed with guns, threatening him.
“’Doctor, do you see that?’” he recalled saying. “’They want to kill me.”
He asked if the door was bulletproof and, to calm him, the doctor said yes.
Like many delirious patients, Mr. Rios warped typical hospital activities into paranoid imaginings. Watching a hospital employee hanging a piece of paper, he said, he thought he saw a noose and feared he would be hanged. His delusions were not helped by one of many seemingly small delirium-fueling factors: his eyeglasses had not yet been returned to him.
After 10 days of hospitalization, he spent two months in a rehabilitation center because of foot inflammation, recently returning to his East Boston apartment. In May, his father in Mexico died of Covid-19, Mr. Rios said. He reflected on another hallucination in the hospital.
“I saw the devil and I asked him, ‘Can you give me another chance?’ and he said, ‘Yes, but you know the price,’” Mr. Rios recalled. “Now I think I know the price was my father.”
‘Down a rabbit hole’
Two months after returning home from her three-week hospitalization, Ms. Victory said she’s been experiencing troubling emotional and psychological symptoms, including depression and insomnia. She has been noticing the smell of cigarettes or wood burning, a figment of her imagination.
“I feel like I’m going down a rabbit hole, and I don’t know when I will be back to myself,” she said.
Dr. Kevin Hageman, one of her physicians at Vanderbilt University Medical Center, said she “was pretty profoundly delirious.”
Ms. Victory, a Vietnamese immigrant and previously healthy community college student majoring in biochemistry, said she didn’t remember yanking out her breathing tube, which was reinserted. But she recalled visions blending horror with absurdity.
One moment, scientists in Japan were testing chemicals on her; the next she was telling them, “‘I am an American and I have a right to eat a cheeseburger and drink Coca-Cola,’” she recalled, adding: “I don’t even like cheeseburgers.”
Along with this agitated hyperactive delirium, she experienced internalized hypoactive delirium. In a recovery room after leaving the I.C.U., she’d stare for 10 to 20 seconds when asked basic questions, said Dr. Hageman, adding, “Nothing was quite processing.”
Ms. Victory managed to take a picture of herself with nasal oxygen tubes and a forehead scar, post it on Facebook and write “I’m alive” in Vietnamese so her parents in Vietnam would know she’d survived. But another day, she called her husband, Wess Victory, 15 or 20 times, repeatedly saying, “I give you two hours to come pick me up.”
“It was heartbreaking,” said Mr. Victory, who patiently told her she couldn’t be released yet. “For four or five days, she still couldn’t remember what year it was, who the president was.”
Finally, he said, “something clicked.”
Now, to help overcome the fallout from the experience, she’s started taking an antidepressant her doctor prescribed and recently saw a psychologist.
“People think when the patient got well and out of the hospital, it will be OK, it’s over,” Ms. Victory said. “I worry if the virus didn’t kill me back then, would that have affected my body enough to kill me now?”
Dabrali Jimenez contributed reporting,