Assault on staff and the highest CIWA I've ever documented

It was a Saturday night, and I was told that I was getting an admission from the emergency room. I started looking up the patient's chart and saw that he was there for alcohol withdrawal. The patient was young, in his 30s. Soon after that, the phone rang, and I received the official report from the ED RN. The patient arrived at the ICU about 20 minutes later. He did not have any family with him, which would make completing the admission assessment documentation difficult, given that he was actively hallucinating. I have taken care of many alcohol withdrawal patients, but I had no idea what I was in for with this one.

For the first 20-30 minutes, the patient was cooperative, but still hallucinating. He allowed me to start an IV, answered what questions he could, and most importantly, stayed in bed. After about 30 minutes, something changed, and the withdrawal worsened. He had a sitter from the ED who came to the ICU with him (an aide assigned to sit in the room with him to ensure he stays in bed and doesn't pull out lines and wires). I had left the room momentarily when I heard the sitter yell for help. A few other nurses and I rushed into the room to find the patient standing at the end of the bed, being held there by the sitter, who was struggling to keep him still. The four of us struggled, but we managed to get the patient back into bed. He was still violently fighting us, though. We yelled out for the charge nurse to call a security alert.

The security officers arrived within minutes and took over for some of us. However, the patient was still kicking and attempting to headbutt anyone he could. So, I jumped back in and grabbed a leg. Another nurse hurried to the medication room to retrieve a medication we had ordered, which was supposed to help calm the patient down, or so we thought. We gave the medication with no result. We pulled another medication, but it didn't help either. A nurse who was not holding the patient asked me if I wanted her to call the provider to the bedside. I said, "Yes!" The provider arrived moments later. For the next hour, yes, an hour, security and nurses held this patient down, who was still violently fighting us. We continued to give medication after medication to try to alleviate the withdrawal symptoms of agitation and hallucinations. Still, after an hour, this patient was still wide awake, severely hallucinating, had a heart rate in the 190s, was drenched in sweat, and was still violently kicking and hitting us. The provider stepped out of the room. In that moment, the unthinkable happened. The patient turned his head, got a hold of a security officer's arm with his teeth, clenched down, and locked his jaw. I have never seen skin pulled so far away from bone before. As blood rushed from the patient's mouth and down the security officer's arm, I reached up and dug my thumb into the patient's cheek where his upper and lower jaw meet. It worked; he let the security officer go. Another nurse stepped in for the security officer, and all of us nurses immediately told the security officer to go to the emergency department. The situation with the patient continued.

The provider had come back into the room and announced that anesthesia was on their way to intubate the patient. It was only when the CRNA pushed etomidate that the patient FINALLY went limp. The ETT (breathing tube) was placed, restraints were placed on the patient's wrists, and sedation drips were started. The battle wasn't over, though. Anesthesia left after the patient was successfully intubated, and within about 15-20 minutes, the patient started to wake up again, despite the sedation drips. The provider told me to go ahead and max the drips and get some PRNs, too. I maxed the patient on dexmedetomidine, propofol, and midazolam. It wasn't working. The patient continued to wake up, and we were holding him down, yet again, despite restraints being on the patient at this point. I gave the patient PRN pushes of more medication that would, hopefully, sedate him long enough for the continuous drips to begin acting. Finally, it seemed like all of the medications were working.

The provider told me that the goal is going to be to keep the patient intubated for 3-5 days to allow the worst of the withdrawal to pass, while we give medication to support him. I took care of this patient for the next two days. He remained maxed on sedation and was still requiring PRNs about every 2-3 hours. When I finally got around to charting everything from that first night, I charted the highest CIWA score I have ever seen, 57. Honestly, it was probably higher, but some of the questions in a CIWA assessment are things such as "do you have a headache," "do you have nausea?" Obviously, the patient was unable to answer those questions at the moment, so I marked them as 0.

This patient reported that he drinks a handle of vodka per day, not a fifth, a handle. That's 59.2 ounces. Most people struggle to drink that much water in a day. This patient's liver function panel was the highest that I have ever seen; his electrolytes were abnormal, and his platelet count was 34. He remains very ill, intubated, and in the intensive care unit.

I go back to work tomorrow, and I will see how he is doing then, but, if I'm being honest, I am worried about being there when he is extubated. I am just returning to work after a bad back injury (also caused by a patient), and I was hurting after fighting this patient. Hopefully, my body will allow me to continue working, and this patient will emerge with a new outlook on life.