THE NEW YORK TIMES, MONDAY, JUNE 29, 2020 N ATracking an OutbreakThe Infected
similar experiences. Called hospi-
tal 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 Survivor-
ship Center at Vanderbilt Univer-
sity and the Nashville Veterans
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 impair-
ment. Reports from hospitals and
researchers suggest that about
two-thirds to three-quarters of co-
ronavirus patients in I.C.U.’s have
experienced it in various ways.
Some have “hyperactive deliri-
um,” paranoid hallucinations and
agitation; some have “hypoactive
delirium,” internalized visions
and confusion that cause patients
to become withdrawn and incom-
municative; and some have both.
The experiences aren’t just ter-
rifying and disorienting. Delirium
can have detrimental conse-
quences long after it lifts, extend-
ing hospital stays, slowing recov-
ery and increasing people’s risk of
developing depression or post-
traumatic stress.
“There’s increased risk for tem-
porary or even permanent cogni-
tive deficits,” said Dr. Lawrence
Kaplan, director of consultation li-
aison psychiatry at the University
of California, San Francisco Medi-
cal Center. “It is actually more
devastating than people realize.”
The ingredients for delirium are
pervasive during the pandemic.
They include long stints on venti-
lators, heavy sedatives and poor
sleep. Other factors: patients are
mostly immobile, occasionally re-
strained to keep them from acci-
dentally disconnecting tubes, and
receive minimal social interaction
because families can’t visit and
medical providers wear face-ob-
scuring 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 lead-
ing delirium expert who founded
the Hospital Elder Life Program,
guidelines that have helped to sig-
nificantly decrease delirium
among older patients. Both her
program and Dr. Ely’s have de-
vised recommendations for re-
ducing delirium during the pan-
demic.
The virus itself or the body’s re-
sponse to it may also generate
neurological effects, “flipping peo-
ple into more of a delirium state,”
said Dr. Sajan Patel, an assistant
professor at University of Califor-
nia, San Francisco.
The oxygen depletion and in-
flammation that many seriously
ill coronavirus patients experi-
ence can affect the brain and other
organs besides the lungs. Kidney
or liver failure can lead to buildup
of delirium-promoting medica-
tions. Some patients develop
small blood clots that don’t cause
strokes but spur subtle circulation
disruption that might trigger cog-
nitive problems and delirium, Dr.
Inouye said.Nails in a Rotating Head
“AK-47,” Ron Temko wrote in
shaky handwriting from his hospi-
tal bed.
Then he pointed at his neck to
show where the assault rifle
should aim.
Mr. Temko, a 69-year-old mort-
gage 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 Cen-
ter for about three weeks by then.
So, on a Zoom call nurses ar-
ranged 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 deliri-
um,” said Dr. Daniel Burkhardt, an
anesthesiologist and intensivist
who treated him.
But then Mr. Temko’s respira-
tory failure worsened. His blood
pressure plummeted, a conditionpropofol intensifies. To allow the
ventilator to completely breathe
for him, doctors had him chemi-
cally 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 benzodi-
azepine, 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.”
After about two weeks, the sed-
ative-weaning process began, but
other delirium-related quandaries
emerged. Mr. Temko began expe-
riencing pain and anxiety, compel-
ling doctors to balance treating
those conditions with using medi-
cations that can worsen delirium,
they said.
The repeated nursing visits Mr.
Temko needed interrupted hissleep-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 ventila-
tor 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 wrist-
watch (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 Re-
serve chair, and told Mr. Temko
that because he recognized thename, “ ‘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.’ ”
He met with Dr. Kaplan, the psy-
chiatrist, who recognized his
symptoms as delirium
Dr. Kaplan prescribed Seroquel,
which he said helps with percep-
tual 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 de-
velop delirium even after rela-
tively short I.C.U. stints.
Anatolio José Rios, 57, was intu-
bated for just four days at Massa-
chusetts General Hospital and
didn’t receive highly delirium-in-
ducing 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.”
After the ventilator was discon-
nected, Mr. Rios, a normally gre-
garious 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 out-
side 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 bullet-
proof and, to calm him, the doctor
said yes.
Like many delirious patients,
Mr. Rios warped typical hospital
activities into paranoid imagin-
ings. Watching a hospital employ-
ee hanging a piece of paper, he
said, he thought he saw a noose
and feared he would be hanged.
After 10 days of hospitalization,
he spent two months in a rehabili-
tation center because of foot in-
flammation, recently returning to
his East Boston apartment. In
May, his father in Mexico died ofCovid-19, Mr. Rios said. He re-
flected 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 re-
called. “Now I think I know the
price was my father.”‘Down a Rabbit Hole’
Two months after returning home
from her three-week hospitaliza-
tion, Ms. Victory said she’s been
experiencing troubling emotional
and psychological symptoms, in-
cluding depression and insomnia.
She has been noticing the smell of
cigarettes or wood burning, a fig-
ment of her imagination.
“I feel like I’m going down a rab-
bit hole, and I don’t know when I
will be back to myself,” she said.
Dr. Kevin Hageman, one of her
physicians at Vanderbilt Univer-
sity Medical Center, said she “was
pretty profoundly delirious.”
Ms. Victory, a Vietnamese im-
migrant and previously healthy
community college student ma-
joring in biochemistry, said she
didn’t remember yanking out her
breathing tube, which was rein-
serted. But she recalled visions
blending horror with absurdity.
One moment, scientists in Ja-
pan 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 cheese-
burgers.”
Along with this agitated hyper-
active 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 ques-
tions, said Dr. Hageman, adding,
“Nothing was quite processing.”
“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 re-
member what year it was, who the
president was.”
Finally, he said, “something
clicked.”
Now, to help overcome the fall-
out from the experience, she’s
started taking an antidepressant
her doctor prescribed and re-
cently 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?”MENTAL HEALTH COMPLICATIONS
As Body Fights, Virus-Related Delirium Splinters Patients’ Minds
From Page ARon Temko had visions and conspiracy delusions while he wres-
tled with the virus for 60 days in a San Francisco hospital.CAYCE CLIFFORD FOR THE NEW YORK TIMESDabrali Jimenez contributed re-
porting,
MIAMI — John Delgado has
slept in a tent in his backyard for
57 nights and counting.
As the inventory manager of
Farm Share, an immense South
Florida food bank, Mr. Delgado,
51, finds himself holding his
breath under his face-covering as
he speaks to the many clients who
come in without masks, for fear
that coronavirus particles will
seep through the fabric.
Because he interacts with the
public every day, Mr. Delgado
sleeps outdoors to avoid contami-
nating his wife, aging mother-in-
law, three sons and grandson. At
night, he sometimes peeks
through the window to watch his
wife sleep. By day, he does socially
-distanced yard work with his
sons.
“I want to sleep in my house,
sleep in my bed,” he said. “I want
to hug my wife, my children,
grandson, and want to go out to
the community not feeling like I’m
in ‘The Walking Dead,’ where I’m
going to be attacked by a zombie. I
want to live. Right now, I don’t feel
like I’m living.
“How long is this going to be?”
On Saturday, for the second
straight day, Florida crushed its
previous record for new coro-
navirus cases, reporting 9,585 in-
fections. Another 8,530 were re-
ported on Sunday.
The closest hospital to Mr. Del-
gado’s house in Homestead, 40
miles south of Miami, is nearing
capacity as Covid-19 cases soar.
The situation in Miami is equally
serious: One-third of all patients
admitted to the city’s main public
hospital over the past two weeks
after going to the emergency
room for car-crash injuries and
other urgent problems have
tested positive for Covid-19.
Six-hour lines formed in Jack-
sonville over the weekend as thou-
sands of people flocked to get
drive-through tests. Orlando has
seen an explosion of coronavirus:
nearly 60 percent of all cases diag-
nosed in that county came in just
the past two weeks.
Much of Florida’s new surge in
cases appears to follow from the
reopening of beaches, bars,
restaurants and other social activ-
ities. The state’s beaches are full
and throngs of revelers pack its
waterways on boats.
Many people have had enough
of staying inside, feeling trapped
and scared. As fear subsided, co-
ronavirus grew.
Florida now joins South Car-
olina and Nevada among the
states that broke daily records
over the weekend.
“I’m one of the people who con-
tributed to the 9,000-person day,”
said Ian Scott, a 19-year-old col-
lege sophomore in Orlando who
tested positive on Friday. He has
no idea how he got it.
Mr. Scott said that for young
people, getting tested has become
an amusing pastime. They chal-
lenge each other to see who can
get the nasal swab test without
crying. About half of his fraternity
has tested positive.
“We’re seeing positive, positive,
positive, positive,” he said. “My
generation says: ‘Let’s get this
over with. Let’s suck it up for two
weeks, sit in our rooms, play video
games, play with our phones, fin-
ish online classes, and it’s over.”
Mr. Scott barely felt sick, and
was fine by the time the test re-
sults came back. Patients like him
could help account for the fact that
while Florida’s daily case count
has increased fivefold in two
weeks, the rate of deaths has not
increased so far. State records
show that hospitalization rates
have inched up but are not at cri-
sis levels.
Gov. Ron DeSantis said more
Covid-related fatalities in the
state had been people over 90 than
people under 65.
The median age of new coro-
navirus patients is now 36, the De-
partment of Health said.
“Those groups are much less at
risk for very serious conse-
quences,” Governor DeSantis said
of younger patients. But they can
spread the virus to their older rel-
atives and others who are medi-
cally vulnerable without even re-
alizing it, he stressed.
Officials have done little so far
to halt public interactions. The
mayor of one affluent Miami sub-
urb implored residents this weekto stop throwing house parties; on
Friday, state officials prohibited
the sale of alcohol in bars. Miami-
Dade County chose to close its
beaches for the busy Fourth of
July weekend.
Governor DeSantis said the
surge of new cases can be attribut-
ed to the huge numbers of tests re-
sults that are coming in each day.
But he acknowledged that since
the second week of June, the share
of tests coming back positive has
been creeping upward. That trend
coincided with the reopening of
the economy, and also the onset of
recent street protests.
Statewide, about 20 percent of
people aged 25 to 34 are testing
positive, he said at a news confer-
ence Sunday.
He said the risk has also in-
creased as temperatures outside
rise and people seek relief in the
air conditioning.
“As it gets warmer in Florida,
people want to beat the heat,” he
said. “They are more likely to do
that indoors, in closed spaces.
That is going to increase the risk
of transmission of the coro-navirus.”
Florida public health experts
worry that the surging case num-
bers will lead to a crush of hospi-
talizations and, eventually, of
deaths. “We know that there’s a
lag,” said Natalie E. Dean, an as-
sistant professor of biostatistics at
the University of Florida.
Even though young people are
less likely to have severe cases,
the long-term consequences of
Covid-19 infection among the
young are still unknown, she said.
“Some people do get pretty sick,”
she said. “Even what’s classified
as a mild disease, some people re-
ally get the wind knocked out of
them for a week.”
Mariely Ferraro, 40, a heart-
monitor technician who lives in
Orlando, caught Covid-19 seven
weeks ago and has been unable to
shake it.
“I think the situation in Florida
is scary,” she said. “The numbers
are climbing, and the numbers are
scary. I wish there was a way that
it could be explained. If there were
9,000 people in one day, are they
symptomatic? Do they have fe-vers? Are they sick?”
Ms. Ferraro’s entire family
caught the virus last month, but
only she is still ill. Her 13- and 14-
year-old daughters had very mild
symptoms, losing their sense of
taste and smell for a while.
“The whole age thing is — I
don’t want to say offensive, but it’s
untrue,” she said. “Coronavirus is
affecting everyone. People pro-
testing the masks think it’s fake.
It’s not fake. It sucks to wake up
and you can’t catch your breath, or
to have a headache you can’t get
rid of, no matter how much Advil
you take. It sucks to take a shower
and fall down because you got
dizzy.”
Shamarial Roberson, deputy
secretary of the Florida Depart-
ment of Health, said in an inter-
view on Sunday that the state is
monitoring hospital admissions
and intensive care units’ bed ca-
pacity and watching for problem
areas.
“We are working to make sure
that if we are seeing surges, that
we’re in communication with
those hospital systems to ensuretheir capacity,” she said. “I am
keeping my eye on the entire state
of Florida.”
Rose Castanon, 35, who works
on the business side of a hospital
chain in Orlando, tested positive
June 18, after her gym alerted her
to a fellow customer who was in-
fected. “I know almost 10 people
that have tested positive,” she
said. “All of our friends are freak-
ing out, because it’s getting a little
too close to home now.”
Jeanette Matas, a 41-year-old
reading teacher in Coral Gables,
Fla., had been limiting her visits to
her 95-year-old grandmother,
Reina L. Palacios, so as not to put
her at risk. But her grandmother
wound up catching the virus from
her home health care attendant, a
woman in her 40s. Mrs. Palacios
died on June 17.
“You can’t blame them for feel-
ing trapped” Ms. Matas said of the
people who had lost patience with
isolation and had resumed social-
izing in public. “I feel like they’re
stupid. They don’t realize what
they’re doing. They’re only think-
ing of themselves.”FLARE-UP IN FLORIDA
A ‘Scary’ Fivefold Surge
In Cases Over Two Weeks
John Delgado, a manager at a food bank in Homestead, Fla., has been sleeping in a tent in his backyard to avoid infecting his family.MATIAS J. OCNER/MIAMI HERALDBy FRANCES ROBLESAmaris Castillo contributed re-
porting from Tampa, Fla., and Pa-
tricia Mazzei from Miami.