Lives in the Balance: Nurses' Stories from the ICU

by Tilda Shalof

  Yes, we had saved this woman’s life—an entire team had worked together so efficiently and professionally to act swiftly and aggressively. Yes, we had saved this woman’s life—and there’s no better feeling in the world than that.

  Bridge to Transplant

  Linda McCaughey, RN, BScN, CNCC(c)

  TWENTY-FIVE YEARS a nurse. I’ve never been able to come up with an adequate answer when someone asks why I chose nursing. It just drew me in. Now I believe it was my destiny, because it suits me so much. One thing I know for sure is the time has flown by. I never expected to stay so long, but here I am today, 25 years later, with not one regret.

  I started nursing on a general medicine floor. After a year, although the nurse manager was very happy with my work and wanted to keep me on the floor to develop my skills there, she suggested I take the critical care course so that I could qualify to work in the ICU. I felt flattered because it was a real compliment: she saw my potential to take on even greater responsibilities and develop my career. So I applied to the ICU, and I’ve worked there ever since. There have been many changes over the years and lots of new things to learn—a day at work is never boring.

  In the last year or so, I have been helping to bring an exciting new technology called Novalung to the ICU. It holds a great deal of promise for some of our sickest patients with lung diseases, though ICU nurses need a great deal of additional education and preparation in order to implement the new technology safely.

  My first patient to benefit from Novalung was a young woman with pulmonary hypertension, a rare, very serious lung disease. Francesca was in her mid-thirties but looked far older. She was frail, malnourished, cyanotic, and gasping when she was brought to our ICU by two burly paramedics. The intense, high-pitched whistling sound of the oxygen flowing from her face mask told me that it was set at maximum flow. She was fighting for her every breath.

  I took care of Francesca for a few consecutive shifts. Many patients in her situation would be angry, impatient, demanding, and difficult to deal with in some way. It’s understandable. But Francesca, in her grave illness, was so soft spoken, so appreciative, so thankful just to be alive.

  For the next few days she was on a high percentage and rate of oxygen, as well as FLOLAN (its generic name is epoprostenol sodium), a medication used specifically for patients with pulmonary hypertension. It helps to vaso-dilate the pulmonary veins, to improve oxygenation. We administered this powerful medication through a permanent IV catheter in her chest; she also had oral medications to help her maintain a decent gas exchange and stay alive. But time was running out and her condition was worsening.

  The intensive care team and the lung transplant team came to talk with her and her family, and outline her limited options. The treatments that we were presently using were no longer effective. The carbon dioxide level in her arterial blood was rapidly increasing and her oxygen level was decreasing. She couldn’t survive like this for much longer. She, her family, and the teams decided to intubate her and put her on a ventilator while she waited for the call, which hopefully would come, announcing that a set of lungs was available.

  After a few days of being intubated, however, Francesca’s pulmonary function had worsened so severely that the conventional ventilator was no longer able to support her lung function, so we had to change to a jet ventilator, which delivers many more breaths per minute and is usually effective in keeping the lung’s alveoli open so that gas exchange can occur. But even the jet ventilator wouldn’t be able to sustain Francesca for long. The jet ventilator would have been the last option for Francesca if she had come to us a year earlier, but now we had something new to offer her that just might work and buy us some more time until, hopefully, a pair of lungs would come available for transplant.

  It was the mechanical device, called Novalung, that acts as a bridging device until transplant can occur. A few months earlier the lung transplant team and the ICU had started to conduct trials of this new device. The Novalung, or “iLA Membrane Ventilator,” is to be used only when all other treatment modalities have failed for the patient awaiting lung transplantation. The only real solution is transplant, but this device might be able to buy her some time until a lung transplant was possible.

  The Novalung is a small, white structure that is positioned outside the patient’s body and takes over some of the functions of lungs. Francesca’s blood would circulate through the device and then back into her body. Her own blood pressure would act as the pump. The machine is able, through the integrated membrane, to help eliminate carbon dioxide and to a small degree, improve oxygenation. It then returns the blood to the patient with the force of contractions of the patient’s own blood pressure. The device not only helps the patient with carbon dioxide removal and oxygenation but also alleviates some of the stress that pulmonary hypertension was placing on Francesca’s heart.

  Initiating the device is no easy task. It takes a lot of coordination and a lot of medical staff and nurses. For a couple of hours, Francesca’s small ICU room became a makeshift operating room. There were OR nurses, lung transplant surgeons, respirologists (also called pulmonologists), intensivists, ICU doctors, perfusionists, respiratory therapists, a hospital assistant, and a ward clerk at the desk, ready to direct and call whomever might be required. Last, but not least, I was there, right beside Francesca, monitoring her vital signs, drawing blood, giving medications, and doing everything that needs to be done. Strangely, the crowded room is always calm during this process. Everyone knows their roles; everyone has an important job today. We are united in our mission to save this patient’s life.

  We all congratulated one another when Francesca’s artery was cannulated and the Novalung device was initiated.

  Francesca stayed on this device, heavily sedated and unconscious, for six weeks—and finally the good news came that a set of lungs was available for her. The six weeks that she was on the Novalung was a very trying time for Francesca, her family, her friends, and also for the numerous team members from lung transplantation and the ICU.

  Perhaps because I saw firsthand how the Novalung worked to save the life of someone who would surely have died without it, I have taken a keen interest in learning to run it and in acquiring as much knowledge as I can about this new technology. I am very enthusiastic about teaching other nurses to care for patients who are on the Novalung as a bridge to lung transplant. To an untrained eye, the Novalung appears to be a simple thing, but most of the general public, and even many within the profession, do not realize the tremendous skill, attention to detail, and knowledge that an ICU nurse must possess in order to monitor and run this device while at the same time being responsible for all other aspects of a patient’s care. Because all this work has the purpose of keeping patients alive so that they can reach the goal of receiving a lung transplantation, it is a very worthwhile device indeed.

  My role in taking care of Francesca included not just her medical needs. She had a family, a husband, children, a sister, and parents. They all had endless questions and needed immediate answers, constant updates, and gentle reassurance. Above all, they wanted to hear the nurse say that Francesca was going to make it. We can’t always promise this, but we do our best to hold out hope.

  Even when Francesca finally received a set of lungs and underwent transplantation, her battle was not over. She did not make a speedy recovery: Francesca experienced complications such as infection, bleeding, coagulation issues, kidney failure, and later, when she woke up, severe depression. Weeks were spent on her recovery, and her recovery required help from every member of the team.

  Eventually Francesca went home and began to live her life again.

  I actually happened to see Francesca a few months after her transplant, when she came to one of the outpatient clinics for a follow-up. It really was only when I saw her husband that I realized, to my delight and shock, the identity of the beautiful, vibrant woman standing next to him. She had such a huge smile. And then it hit me: Oh my goodness, that
’s Francesca!

  Open Heart

  Meera Rampersad Kissondath, RN, BA, BScN, MN

  MY NAME IS Meera Rampersad Kissondath and for as long as I can remember I have wanted to be a nurse. My parents immigrated to Canada from Trinidad the summer I turned 16. I had already finished my Form 5 level of education and had sat my exams for Form 6 after only one year of additional studies, so I thought there was nothing to hold me back from entering nursing school in Canada. I was adamant that I would be going to college in the fall. I dragged my mother and my aunt, who was a nurse, to St. Joseph’s Hospital in Toronto and actually spoke to the Mother Superior there. She told me in no uncertain terms that I was too young to be admitted to the nursing program; I would have to apply again when I was 18. She tried to impress upon me the fact that nursing is not a glamorous vocation (she actually used that word), that it was difficult and physically demanding work, and that it took a strong and dedicated person to look after the sick. She said if I felt strongly enough about being a nurse I should try again when I turned 18.

  Well, I was mad at the world. I was mad that I had been uprooted from my home, mad that I’d been forced to leave my friends, mad that I’d been brought to this foreign country that would not even allow me to be a nurse. I was so mad that when I was forced to go back to high school, I deliberately failed science, my best subject, that fall term. I may have felt that I was prepared to be a nurse, but I was still young enough for teenage angst to get the better of me.

  So, it took a little longer than I expected—but I did become a student nurse. It wasn’t long into my studies that I realized I wanted to be an ICU nurse. I have now worked as a critical care nurse for the past 23 years, and I’m still going strong. Most of my experience is in cardiovascular ICU nursing.

  A NUMBER OF YEARS AGO, I went back to school to get my Bachelor of Science in Nursing degree. At that time, there were some colleagues who questioned the need for nurses to have a university degree. But I believe that education is the most important criterion to finally establish nursing as a profession, not merely a “calling.” These days there are numerous programs in nursing at the master’s and doctoral levels, nursing chairs for research and health policy, and new roles emerging for nursing at the clinical and administrative levels. More recently, I went back to school again, to complete a master’s degree in the Nurse Practitioner program at the University of Toronto. But for me, bedside nursing is the role that continues to bring me the most satisfaction. As a nurse practitioner, I plan to sustain my deep commitment to bedside nursing. Wherever this takes me, my true love remains cardiovascular nursing.

  My shift starts at 7:15 A.M. at the Toronto General Hospital; by 7:30, rounds start on all the patients. Nurses are expected to present their patient; this presentation includes a short summary of the past medical history; the type of surgery and the salient highlights of the surgery; the post-operative course in the ICU, with a final plan for discharge to the floor, whether in the morning or the afternoon; and a head-to-toe assessment of the patient. The prudent nurse will use this opportunity to develop a plan for managing the post-operative course more efficiently.

  At no other time is the nurse’s role as patient advocate more apparent than at rounds. Let’s face it, there is always a crunch for surgical beds, and the push is always on to free up those beds—but if, as a nurse, you feel your patient is not ready to be transferred to the floor, you have to say so and give your proof or rationale. No surgeon wants to put a patient at risk by transferring early, but all surgeons are aware that ICU beds are precious. As nurses, we have to support our position with information and knowledge. For a typical stable patient, my presentation may sound something like this:

  Mr. John Doe is 37 years old. He had a STEMI [ST wave myocardial infarction] one month ago and now has an LV [left ventricular] function of two out of four. His past medical history includes high cholesterol, smoking, and a positive family history of heart disease. Yesterday afternoon he had a CABG [coronary artery bypass graft]…. Surgery was uneventful and he was admitted to the ICU at 1600 hours and extubated at 1900 hrs. He’s in a positive six liter balance; his K+ [potassium] and Mg+ [magnesium] have been replaced. All other chemistries are normal. Hemoglobin is 89 and INR is 1.0—all within normal post-op range. Blood pressure is 110 on 80, but filling pressures were low, so he received 500 cc of Pentaspan. Cardiac output has improved and is now 4.5 liters per minute. CVP [central venous pressure] is 10 mmgHg. He’s in sinus rhythm with a rate of 90 beats per minute with no ectopics. Overnight he had a few runs of SVT [superventricular tachycardiac] at a rate of 120 per minute. May need to be restarted on a small dose of beta blocker. Chest tube drainage is minimal. Plan to pull them out once he is mobilized, if all goes well. Neurologically, he is fully awake with no deficits. Respiratory condition is stable, now on nasal prongs at 4 liters per minute, O2 saturation is 95 percent. Air entry is decreased to bases with bilateral crackles; will need Lasix. He’s tolerating clear fluids and his urine output is between 40 and 60 cc per hour. The plan is for him to be transferred to the floor this afternoon.

  An ICU nurse is expected to present the patient and a plan of care for the shift ahead. The ICU’s ability to fulfill the expected surgical caseload for that day depends, in part, on the ability of the nurse to present a realistic plan for the patient. At the end of rounds, it can be estimated how many surgeries can safely be performed that day. Therefore, the purpose of rounds is twofold: to assess and manage patients’ post-operative course, and to control patient flow.

  At first, I found it challenging to organize my thoughts and communicate them precisely during rounds, but I worked hard on that skill. I didn’t want, on rounds, to be fumbling around, hesitating, or flipping back and forth in the patient’s flowchart to find the information I needed to present. I started out by simply memorizing the information, because I did not want to look foolish, but later I realized that for me it was a matter of professional pride that my presentation be informative and succinct. A recent experience has confirmed again for me why I love working in the CV-ICU. My patient was a woman in her late fifties who had had a CABG and had been extubated during the night, about six hours after her admission to the ICU. She had been nauseated so was given Gravol and was now a bit sleepy—a common side effect of the drug. After I received the night nurse’s report, I delayed performing my initial assessment, in order to let my patient sleep. It’s amazing how much a nurse is able to assess before laying a hand on a patient. I was able to measure her cardiac output, analyze her heart rhythm, and take her vital signs. I checked that the medications that she was on were the exact medications she was actually receiving, and I reviewed what IVs she had and checked that they were patent. After noting that her urine output was adequate, I reviewed her laboratory results from the blood sample taken during the night. I observed that her breathing was shallow, but that is common after cardiac surgery with four chest tubes in the mediastinum and surrounding the lungs.

  One thing that did concern me was that the chest tube drainage for the previous hour was more than normal. Sometimes chest tubes will dump a large amount of blood when the patient is mobilized, and they may continue to dump larger-than-expected volumes for up to an hour or so later, but this patient had not yet ambulated. Also, the chest tubes draining the blood felt heavy in my hands and the blood in the chest tube drainage system had a certain thick look that concerned me. I decided to run some tests on the patient’s hematological profile (such as a complete blood count, or CBC) and her coagulation function (such as PT/PTT and INR) so that I could get a more accurate picture of the clotting status and hemoglobin level. I also sent a sample of arterial blood for blood gas analysis.

  By this time, my patient was awake, so I introduced myself and explained that I was going to be her nurse for the day. I told her she was doing really well and that her surgery had gone well. I continued with my initial assessment and moved on to listening to her heart and chest sounds. Since her nausea had still not a
bated, I decided to give her something stronger. She held my hand and tried to smile at me while the drug took effect. By then the team had arrived on rounds. I presented my patient and my concerns about the chest tube losses and told them that I had repeated the blood work. My plan was to mobilize the patient after her nausea had subsided, just in case there was a stubborn pocket of blood sitting there in the mediastinum.

  She had a good sense of humor: she asked if we’d talked about her during rounds. I said, yes, that we’d been planning her care. “Well, I should feel like a star, then!” I told her she was indeed a star, that I was sorry she was feeling so poorly from the nausea, but soon the medication would take effect. Abruptly, she sat up in bed, clutched my hand, and coughed. Then all hell broke loose.

  Her eyes rolled back and she fell back onto the bed. Her momentum took me forward with her. I whipped back the bed linen to see bright red blood pouring out of her bilateral chest tubes, filling the collection canister at an alarming rate. I called for help. I reached over and opened up her peripheral IV, which, luckily, had a large bore—18 gauge. I opened up her central venous line too, the one that is situated in the large neck vein. I was trying desperately to get fluids into her before she went into hypovolemic shock from the massive blood loss. I looked at the cardiac monitor and saw a rhythm, but I could feel no pulse, so I climbed up on her bed and started CPR. By then, people were barreling into the room, pushing the crash cart in and yelling out orders, asking for explanations of what happened.

  “Who’s the surgeon?”