The Symphonic Soul of Critical Care
Monday January 8, 2001
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Like a maestro, the critical care nurse transforms the cacophony of bells and whistles into life-giving music for the patient. Sometimes, it's a quick little number before the patient is ready to solo. But oftentimes, the band plays on and on.
The Human Side of Critical Care Nursing
Sandy* had a song in her heart. With the addition of a new granddaughter, life was good. Then the chest pain started. With staccato succession came the tissue plasminogen activator (TPA), the cath lab, the balloon pump, the bleeding into her lungs, and the adult respiratory distress syndrome (ARDS).
Sandy soon found herself center stage on a critical care unit at Georgetown University Hospital, Washington, DC. The hours turned into days; days into weeks. And all the while, the constant audience of her devoted husband and the staff of the unit stayed at her side.
Although many patients pass briefly through critical care areas on their way to less intense nursing units, some, like Sandy, are in for the long haul. The care that long term ICU patients need often goes beyond trying to maintain physiological balance through technical prowess.
The surreal experience of living among machines, frequent monitoring, and treatment by caregivers, and ever-changing prognoses, for a prolonged period of time, creates enormous pressure on the patient and family. This pressure translates to emotional and spiritual needs in addition to the intensive physical needs that must be addressed by the nurse. And critical care nurses must address their own needs as they deal with the often discouraging reality of the patient who stays on and on in the Georgetown unit.
Joan Kearney, RN, CCRN, a staff nurse on the unit has seen her share of both miracles and sad endings in her 17-year nursing career. "When you start seeing progress, that's what keeps you going," she says of her long-term, critically ill patients. However, progress can be hard to come by in critical care. "It's a constant two steps forward, and three steps back," says Kearney.
Nancy Frongello, RN, CCRN, also a critical care nurse at Georgetown, describes the challenge of trying to wean the patient on a ventilator as being a "ping-pong game" of sorts. "We're trying to wake people up to get them off the vent," she says. The agitation that can come from the weaning can result in the need for sedation which in turn can result in continued ventilation.
One key to coping with the endless cascade of potential complications is to head them off at the pass. "Catch it before it happens," says Kearney. "It takes a lot of prior planning," when it comes to preventing the dreaded sour notes such as pressure ulcers, she says. A specialty mattress may provide only a brief intermission from the inevitable for the patient whose systems are all in a prolonged state of overdrive and in various degrees of dysfunction or failure.
One complication often serves as a bridge to the next. Necessary invasive procedures can lead to nosocomial infections, causing further compromise, and a long-term situation that may or may not improve. Add a preexisting illness and the situation can further deteriorate. Despite this, Frongello wouldn't want to work anywhere else, even after 18 years. "I'm not anywhere near being burned out," she says.
Beyond the Cacophony
Frongello and Kearney see the person beneath all of the clamoring equipment andshare a connection with patients' families. "Your energies are not just spent on your patients," says Kearney. "There is family interaction on a daily basis. We share the subtle changes we see. They [the families] need somebody to help them assimilate all of the information." Frongello adds, "We try to meet their needs, whether it's information, or comfort, or just someone to talk to." Sharing of information not only helps the family, but also helps the nurse gain a different perspective on the patient's needs.
Sometimes, the information that needs to be conveyed is not easy to impart. "The most important thing is to (not) be afraid to communicate with families," says Carolyn Thomas, RN, a critical care nurse at Reston Hospital, Reston, VA on the subject of advance directives. "You get very close to the families and it's sometimes easier for us [nurses] to approach families and start the conversation." Thomas finds that family members are often looking for tactful honesty. Nurses need to be comfortable exploring such sensitive issues. "Some of this (comfort level) comes with time and experience," says Thomas. As a 26-year veteran nurse, she has plenty of both. For the nurse who is less comfortable with discussing sensitive issues, she advises, "You need to come to grips with how you feel about (these) things."Usually nurses who have come to terms with issues like advance directives themselves, are more comfortable discussing them with others.
Meaningful Resources for Nurses and Patients
A crisis can rattle the core of even the most harmonious of families, and family discord can be amplified by the presence of a long-term critically ill patient. Therefore, nurses should observe how family members interact and how it may affect the patient's well-being and recovery. "Nurses have to be patient and let (the family) work through it," says Thomas. She stresses the importance of seeking additional resources when needed such as spiritual counselors or even another colleague who may have a different relationship with the family.
At times there is no family to share even the two steps forward with. There were no family members to inform when Marvin* started to smile again and held up two fingers to indicate he wanted two dollars for bus fare to get home. And there was no one to tell when he swatted at the donut cushion suspended from the ceiling like a punching bag to get him moving his arms again.
But Sandy had her husband. Right up until the end. Even when the symphony of life was sounding more like a mournful dirge, she had her husband. Her neurological status was not improving. But then Sandy woke up. "She opened her eyes and she was there," says Frongello. Sandy was discharged two weeks later on New Years' Day. That was several years ago. Her picture and a letter from Sandy and her husband still hangs on the bulletin board on the unit. "Other patients can use that as a little bit of hope," says Frongello.
And, a few Christmases ago, Sandy returned to the unit, bearing angels as gifts for all of the staff. For the nurses on the unit, it is always an inspiration when a former patient visits. "We thank them profusely, because that's what keeps us going, seeing them walk through that door," says Kearney.
The symphony that is critical care sometimes plays on longer than expected. It leaves an indelible mark on the hearts of all who play a part in it. High notes, low notes, loud and soft notes form a unique concert of profound experience. For sure, whatever the outcome, there is great meaning in the song.
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