by Tilda Shalof
For me, this experience is a prime example of what nursing is all about. Like air traffic controllers, we watch over our patients, making sure they remain safe and don’t crash. We coordinate a multitude of activities, personnel, and traffic related to our patients. We are our patients’ surveillance system. As a nurse I not only monitor my patient’s condition, but also act as the pilot, delivering complex technological care on a minute-by-minute basis. I am the one person responsible for the patient’s survival from the moment he or she comes into my care and for making sure that care is continuously adapted to the patient’s needs.
I love being a nurse, and I love using my years of experience and skill to care for patients and their families at perhaps the most difficult time of their lives. But the expectations placed on nurses have become unrealistic. At times, the workloads are overwhelming—and worse, unsafe. I cannot be in two places at once—and as a patient’s medical needs become more complex and urgent, I worry that I will not be there at a critical moment to meet a person’s needs. For the last 28 years I have been my patient’s last line of defense; I will continue to be that until I can no longer provide safe care.
That Deep Place Within
Elizabeth DiLuciano, RN
I’M A REGISTERED NURSE. For the past 19 years I’ve worked 12-hour night shifts (from 7:00 P.M. to 7:00 A.M.) in a neurosurgical ICU at a major hospital in a large city, and for the past few years, as team leader. Many of our patients have suffered severe trauma to the brain after a serious accident or injury. They’re in extremely unstable condition when they arrive in our unit and they’re usually unconscious.
Working with seriously ill patients, who have startlingly landed, with massive trauma, in the ICU, can be quite upsetting, but we have so many duties and responsibilities that we need to fulfill for our patient that emotions are usually a distraction. Nevertheless, the feelings remain. When I’m not at work I sometimes wonder where those emotions go while I’m actually on the job. The answer I’ve come up with is that they go underground to a deep place within myself, so that I can function professionally and stay focused on my critically ill patients’ pressing needs.
In a trauma case, I work with a team that includes doctors, other nurses, the blood bank, lab technicians, waiting room attendants, security, the chaplain, and other hospital employees. The family is usually around, looking to me for answers to their many questions. Sometimes I don’t have the answer to the question they really want to know: Will my loved one make it? As frenetic and complex as a patient’s clinical situation is, nothing is as challenging, as demanding, and as sensitive as interacting with patients’ immediate family. “Family” can mean parents, grandparents, brothers, sisters, boyfriends, girlfriends, aunts, uncles, cousins, neighbors, friends and just about anyone else who the patient wants to be included in that group.
These visitors are also frightened—even traumatized—by what has happened, and they look to me for information and emotional support. Processing information during a crisis, along with the pressure of split-second decision-making, is typically overwhelming for family members. In addition to questions involving immediate care, on my shift one of the most sensitive topics the patient’s family faces is that of organ donation. As the patient’s nurse, I play a crucial role in conveying information on the procedures involved. Rarely is the family prepared to have this conversation with me in the dark of night, in what may be, quite literally, their most anguished hour. Yet what I describe here is nothing more than my average night at work.
In the ICU, patients are just as critically ill at night as they are during the day. Situations are rarely stable. Patients’ conditions can change dramatically in the space of a moment. I might be caring for an unstable patient, trying to titrate an inotrope to boost his blood pressure, and seconds later, be called to help with an incoming case. After entrusting care of the first patient to another nurse and delegating certain responsibilities to her or him, I’ll focus on the next patient, a critical trauma from the emergency room. After a report from the ER, the new patient is placed in my care. At first, while we get everything under control (if that is even possible), my mind and body are exclusively task-oriented and I perform under strict emotional control. I don’t allow my emotions to interfere with the skills I’m performing. A human being’s life is in my hands. I’ll remain in this state for the rest of my shift, if I have to; I have to keep my mind rational and clear.
Fortunately, there is lots of help when a fresh trauma patient arrives. Everyone arrives to lend a hand and those hands swarm over the patient, connecting monitors, changing drips, inserting new IVs and central lines, perhaps working as many as six or more IV pumps, adjusting potent medications, and taking minute-by-minute vital signs, to name but a few of the activities that are taking place. When there’s a brief interlude in this flurry of activity, I do my best to bathe or at least quickly wash the patient before the arrival of the family. This entails cleaning off blood, wrapping the wounds, discarding all soiled or bloody clothing and linen, disposing of any trash or other detritus, turning down the lights, covering or closing the patient’s eyes, and standing nearby to greet and comfort the arriving visitors. Sometimes I even have to catch them when they collapse in shock at the sight of their loved one’s battered, swollen body connected to tubes, monitors, and machines.
Although I receive a detailed report on the patient’s condition, along with a provisional prognosis before seeing the patient, nothing really prepares me for what I encounter when the patient is rolled into the room. I have cared for a 32-year-old motor vehicle accident victim who was a single parent of two children, aged two and six, whose injuries were so massive she was hardly recognizable to her family. Another patient was a 14-year-old boy with a gunshot wound to the head. He had been an honor roll student, never in trouble. For kicks one day after school, he played Russian roulette at a friend’s house. His mother was out of town and unreachable, so I had the boy’s older brother and sister, and an aunt, to call. Another gunshot wound patient was a 68-year-old male with a self-inflicted wound to the head. His wife waited in the company of a young couple from their neighborhood. The pair approached me to tell me that these older folks were like parents to them. I will never forget a newlywed 25-year-old man who must have stopped for a few beers on his way to meet his wife after work. Those drinks cost him his life: on his way home, he lost control of his vehicle in a tragic accident.
The initial tasks involved in settling a patient after a trauma are ideally accomplished within an hour or so, especially when I have the professional assistance of the rest of the team. When we’re finally ready for the family to enter the unit, the rest of the staff clears away to give the family space to visit with the patient. The only people remaining are the patient, the family, and me. It is up to me to present and explain the situation, to counsel, teach, and comfort the family as they stand at the patient’s bedside and do their best to take in this overwhelming, frightening situation—and do their best to hold themselves together.
AT SOME POINT, a doctor will apprise the family of the patient’s situation. Although the family members are anxious to visit the patient, they are usually overcome with emotion when they do. Though I’ve established my emotional reserve for the duration, I immediately form a protective bond with my new patient. This instinct soon extends to the patient’s loved ones as I prepare to meet them. I don’t wish to make them wait needlessly or keep them from the room. This emotional bond will not break down throughout the patient’s and family’s ordeal. They look to me for answers, for calm and reassurance, so I need to be strong and steady for the family, guiding them through their grief and encouraging them in their decisions. This does not mean that my eyes won’t suddenly fill with tears, or that my voice won’t crack when speaking, but if I can’t put my emotions aside, it becomes almost impossible for me to both care for my patient and serve the family’s needs. I try to truthfully and succinctly prepare them for what they’re about to see. This
will be hard for them, and it’s hard for me. I take them into the patient’s room, and after making sure they are comfortable, I pull the bedside curtains and leave them alone with their loved one for a moment. Yet not too long—there are many tasks that can’t wait.
I’ve now become a source of strength for this family. My support has built a trust. It’s so hard to answer their questions. My honesty can seem blunt: “No, he cannot survive this injury.” I say it gently, but the meaning is, of course, so harsh.
“Can I do anything for you?” I ask one teenaged girl who is weeping.
“Yes, can you just put a smile back on my brother’s face?” she answers, and I have no choice but to reply, “I wish I could, more than anything else.”
In such moments, I almost hate this job. But I’m needed, and that carries me through the painful times.
I’m also preoccupied with another dilemma. How will the family handle the news of their loved one being pronounced brain dead? Will organ donation be an option? The two questions must be addressed immediately. At the same time, I must allow the family time to process the news, to let it sink in, to accept their new reality, and to grieve. Each of us is different and each tragedy is unique; some people accept the reality quickly, while others take longer.
As I look out of the unit and into the waiting area, I may see many family members, but sometimes it’s only a wife or a solitary friend. I consider how to broach the organ donation topic; sometimes my role is made easier, when a member of the extended family approaches me with this final gift in mind. If the family members wish to donate, or think they do (which is often the case), they turn to me for reassurance about their decision. I gladly provide it. I’m the nexus, the point of contact with their loved one and with the hospital; the family looks to me for not only answers, but for my continued honesty and support.
I bring the organ donation nurse to them. She discusses options and explains the process in detail. Whether they move forward with donation or not, she helps them arrive at the decision that’s right for them. Many times, the nurse stays with the family through the duration of the patient’s care. The sadness that donation brings breaks my heart, but the family’s acceptance of me and their faith in the goodness of their decision strengthens my resolve. I “take care of” the brother, the sister, the parent, the friend. The joy of the organ recipients, their families, and loved ones is not something I’m there to experience. It simply isn’t part of my role. I perform the tasks ahead of me as we prepare for donation.
My shift ends. I’ve talked with my coworkers, the patient’s team of care providers; they are very supportive. I get in my truck—a big black truck, with big bumpers and big tires, plenty of air bags, and extra-snug seat-belts—and on the drive home my thoughts and emotions become only mine. In my internal file, I’ve added another case. Each one helps me learn, enables me to go on, and get ready to be there again tomorrow. Sometimes, I receive a letter from the organ donation staff, thanking me for my work and our support of the program, regardless of whether the family ultimately donated. If it did, the letter lets me know the outcome, which will help me cope with the next tough cases, where presenting the opportunity for organ donation to the family is an all-too-familiar occurrence. I’m reminded that the need that offers the greatest potential for joy also carries the greatest potential for pain: the need to share our life with someone we love.
Rescue Work
Tilda Shalof, RN, BScN, CNCC(C)
AT TIMES, we worry about the fate of some of our patients after they leave the ICU. We want them all to continue to receive the same close attention that we are able to offer in the ICU, but that isn’t possible on the floors. The problem is, certain patients still need it.
Transferring a patient to the floor is a sign of progress: it means the patient has recovered from a crisis and is no longer in a life-threatening situation. It means the patient has stabilized and is now able to do more for him- or herself. At least, that’s what it means in theory. In reality, though, many of our ICU “graduates” are still fragile. Many need a lot of complex, ongoing nursing care. The average floor patient these days is acutely ill. Medical advances have brought about a shift: conditions that once necessitated caring for a patient in the ICU now are typically handled on the floor; in turn, a patient who used to be on the floor has likely been discharged home, to be cared for by family members or, intermittently, by a visiting nurse.
A recent innovation in some hospitals is the Critical Care Rapid Response Team. Its purpose is to follow ICU patients and make sure they are progressing on the floor. But the CCRT is a relatively new development. For many years, and in many hospitals still, some floor patients have experienced complications and have had to return to the ICU. Before the CCRRT, we frequently would transfer a patient from the ICU, give our report to the floor nurse, wish the patient and family well, say our goodbyes, and walk away, trying to brush aside our lingering concerns. We had faith in our colleagues on the floor, but we also knew of their onerous patient workloads and their burdensome administrative tasks and non-nursing chores they were also expected to perform. Moreover, the floor nurses often weren’t as experienced as ICU nurses and usually didn’t feel as empowered as we felt.
Ironically, Mr. Abruzzi was not one of the patients who we were worried about. He had made extraordinary progress after a long and complicated stay in the ICU. When we sent him to the floor, we had every reason to believe he would do well. He had been critically ill but after a few weeks in our care, he was in excellent shape, joking and chatting with the nurses, taking ice chips and then enjoying the clear, homemade chicken broda his wife brought for him. During the six weeks he spent in the ICU almost every nurse had taken care of him. He was one of our “success stories.”
His illness had started with a simple paper cut on his finger that he’d got at home. From that tiny injury, Mr. Abruzzi had developed an infection that raced through his body. It was necrotizing fascitis, also known as flesh-eating disease. Within hours the infection spread to the rest of his hand. Less than a day later, the infection—evidenced by swelling, redness, pain—had traveled right up his arm. He lost consciousness and went into septic shock. In the ICU we intubated and ventilated him, and gave him antibiotics and a then-experimental drug that has since proven very helpful in such cases of massive inflammation. He was taken to the operating room, where his now-necrotic fingers were amputated, along with part of his hand. His entire arm, neck, and part of his back were opened up, the dead tissue cut away, and the entire area flushed and cleaned of all visible infection.
I was his nurse that first night, when he returned to the ICU from the operating room. He was hypotensive; I gave him boluses of normal saline and Lactated Ringer’s solution to replace not only fluid volume but also electrolytes. Later that night, as I was in the midst of titrating his inotropes to boost his blood pressure, the surgeon who had performed the debridement of the infected tissues came in to see how our patient was doing. Specifically, he was eager to have a look at his handiwork. I opened up the bandages that covered more than half of Mr. Abruzzi’s body. The sight was shocking. It made me think of a slab of meat hanging in a butcher’s shop window. However, it was fascinating, too: it’s not often that you get to see right into a living person’s body. The muscles, bones, tendons, veins, and adipose tissue were all exposed: red, pink, and yellow-marbled fat. I recoiled. It was an involuntary reaction, and I didn’t take long to compose myself again—but the surgeon had a much different perspective.
“What a wound! It was bad,” he said, with a gleeful expression that told me that “bad” meant “wicked good,” which meant, to him, fascinating. “It was beautiful,” he crowed. “Man, I tell you—work of art! We were doing sculpture in the OR.”
He may well have been a budding Michelangelo, but the nurses were the Master’s protégés. Every day, for the next several weeks, we each took our turn, three times a day changing the massive dressings. Each time we had to push our hands deeply
into the huge cavities along his arms and into his back where the bacteria had devoured all of the flesh along the way. Each time we packed it with saline-soaked sterile gauze. During each dressing change, we could see deep into his body all the exposed tendons, veins, and arteries, the muscles and bones that had been salvageable. Within a week, the tissue surrounding those internal parts started looking pinked-up and plump. We began to have hope: if we could keep that wound perfectly clean and under the right conditions, it just might heal. For a time, we were even pouring honey into the wound, after one of our staff surgeons read a scientific report touting the healing properties of honey. (Even those nurses who were known to be uptight about tidiness and order didn’t mind that the bed had become a sticky mess.) There was every indication that the infection was receding. Mr. Abruzzi’s vital signs stabilized. His white count returned to normal. He was weaning off the ventilator. He was awake and aware. All signs of healing.
We got to know him. His wife came in each day and read to him from Oggi, an Italian newspaper, and played his favorite Caruso recordings and Italian polkas on a cassette player beside his bed, over and over again. He was still on the ventilator, but he was now trached. He was engaged in active physiotherapy to mobilize his limbs and had even started walking around the ICU.