by Tilda Shalof
Suddenly I realized my hands were wet. I could feel a soggy wetness through my gloves. I looked down and saw in horror that my patient’s large intestine had been expelled from the wound over his abdominal cavity, by the force of my compressions. Dehiscence—a splitting open of the wound. I’d read about this in a textbook somewhere. Fluid was pouring out and along with each gush, long loops of large bowel. It seemed like I paused for only a moment to take in that shocking sight, but it must have been longer.
“Keep going,” everyone shouted out, and I did.
That was the first time I participated in a cardiac arrest. Despite all my fears of doing something wrong, my patient actually made it, thanks to my efforts in this episode and the rest of his stay in the ICU.
I was still a nursing student when I helped save this patient’s life. I was doing my final clinical placement in the ICU because I wanted to see whether, when I graduated from nursing school, critical care might be for me.
As a child I didn’t plan on being a nurse. No young boy growing up in the 1970s would tell his grade school teacher that he wanted to be a nurse when he grew up. I hope that times have changed since then, but I suspect that they haven’t.
In high school, I was a geek, and most of my teachers thought I would go into some aspect of the then-new and promising field of computers. However, I saw those machines only as tools. I wanted to stay with something more real and connected to people. I thought that forensics was my calling but after half a year in college, I learned that a lab bench was not where I wanted to be. I toyed with the idea of pharmacy or medicine but after talking with many people, especially family members who were nurses, I decided nursing made more sense.
When I entered nursing, my intention was to go into rural or outpost nursing. I had grown up on a farm and looked forward to returning to a more rural lifestyle after finishing school. After my first year of nursing school, however, I failed to find a summer job in the city, so I volunteered at the local hospital in the intensive care unit. My volunteer work quickly became a paying job as a ward clerk. I had the opportunity to view the expertise and compassion of the ICU nurses, doctors, respiratory therapists, and a host of other professionals. I quickly discovered that critical care nursing was what I wanted to eventually do. I continued to work in the ICU, first as a ward clerk and later as hospital assistant, actually getting involved with patient care. Each experience seemed to further show me that critical care was where I needed to be.
Working in the ICU has opened up many opportunities for me. It has presented me with some of the most challenging and amazing experiences of my life. I had an excellent preceptor in Rob Fuerté and the further luck of having a nurse manager, Maude Foss, who was open to the idea of having a student in the ICU, which was then a rarity (the prevailing belief at that time was that one should first acquire years of regular floor experience before graduating to the ICU). However, I knew exactly what I wanted. I was elated when, once I had graduated and become a nurse, Maude, who managed the ICU where I wanted to work, agreed to sponsor me to attend a critical care course and then to hire me, straight out of school.
I never expected the transition from student to nurse to be easy. There was an overwhelming amount to learn. During my first year, I was always lugging around at least three textbooks. I read most of them cover to cover, some a few times over. Surprisingly, the most challenging aspect of the transition was not my needing to acquire a tremendous amount of new knowledge or skill sets: rather, I encountered unexpected social pressures.
My being a new graduate caused quite a stir in my ICU. I didn’t understand my coworkers’ resistance to having a new grad working in the ICU. I heard whispers from coworkers whom I had grown to know and trust, now questioning the appropriateness of hiring me, a new graduate, straight out of school. There was this sense that you had to “do your time” in the trenches, aka the floors, before becoming part of the elite team in the ICU. I think some people were waiting for me to make a major error—and I knew they’d be ready to show me up when I did. I give great credit however to the many colleagues who did support me. This was especially true of my preceptor, Rob, and my manager, Maude. They defended me and at the same time found clinical experiences appropriate for me at every stage of my learning curve. They helped me succeed in a sometimes hostile environment. In time, the whispers of doubt, which had sometimes seemed to me a muted roar that would never go away, faded. The fatal error that some were expecting, thankfully, never happened. I moved into a full-time position. I started the standard line of 12-hour shifts, alternating between days and nights every two weeks. Eventually, I gained the trust and respect of my coworkers, and they won mine.
As the years went by. I was able to shift my focus from acquiring the practical knowledge and many technical skills of the ICU, to learning about my patients’ emotional and spiritual needs, and to those of their families.
In the ICU, we see patients and families at some of the worst times of their lives. We help them understand what is going on and support them as they make some complex decisions and deal with some difficult outcomes.
Today, I am at a point in my career where I split my time between bedside practice and my medical/nursing informatics business. Many people told me that I would not be able to do both—each requires such a different skill set. I’ve managed to do both for over five years now. Being both clinical and technical is an ideal work arrangement for me. It allows me to identify problems in the workplace and to come up with solutions that others may not see. To my mind, I’ve got the best of both worlds.
Stranger in a Strange Land
Rosemary Kohr, RN, BScN, MScN, ACNP, PhD
THE ICU IS NOT MY “HOME”—it’s not the place where I work—but I’m called there frequently in my role as a wound care specialist. The ICU is a world apart from the rest of the hospital. It’s closed off by doors marked “Hospital Personnel Only” on one end, and at the other, a long counter where the receptionist sits like a gatekeeper, controlling the flow of family and other visitors. I use my identity badge to swipe the lock and walk through to the back entrance of the ICU, away from the waiting room with its televisions, aquarium, and anxious families who look up each time a staff member walks past. I rarely get more than a glance because I’m clearly not an ICU staff member—I’m not dressed in OR greens or even in a uniform, just my ordinary clothes.
But I am there when a patient needs my services. I don’t like to say “Doctor” because then some people think I’m a physician; I’m not, but I do have a PhD, as a nurse who specializes in the care and management of wounds.
The ICU is both noisy and quiet. When you walk in, the sounds of the machines coming from each of the bays where there are patients is very loud, almost an assault on the ears. However, the voices of the patients are noticeably absent: most are unconscious or much too sick even to be fully aware of their surroundings, much less to speak. In the ICU, each patient is in a large room, with curtained, sliding glass doors. Outside the room, nurses can sit and observe the patient while also keeping an eye on the monitors in the room. The ICU beds are high-tech. They can be raised or lowered, can pulsate or float the patient, and even transform into a chair. The machines whirl and beep and the monitors have colored screens covered with numbers, lines, graphs, and words. Attached to each patient are tubing and lines connected from the machines to the patient’s fingers, toes, throat, chest, urethra, rectum, nose, mouth, and head. The patients lie in the beds, at the center of this little universe of busyness, often sedated, sometimes partially awake. Their eyes are closed or flutter open. They look around sometimes as a voice speaks to them, or when a hand touches them, or when a machine beeps, all in response to the ever-changing stimuli around them.
Each nurse cares for one patient, or sometimes two, depending on the complexity of the patient’s needs or staffing conditions. The charts are outside the room and the nurses, when not dealing with the countless demands of the machines, or attending to their patients
, often sit to record their observations, all the while keeping a close eye on their patient and the ones in the surrounding rooms. This vantage point, outside the patient’s room, allows them to observe and respond quickly if a patient develops problems, or if one of the other nurses, doctors, or respiratory therapists needs another pair of hands, another set of eyes, or their expertise.
This is not my usual world and it is way outside of my comfort zone. It is far more machine-oriented and more spacious than where I usually spend my time, in the general medical and surgical floors in the rest of the hospital. To me, the ICU seems overwhelming, with its machines and technology. It is a much more sterile environment than the wards where I usually work. It is scrubbed clean. The tile floors are shiny, the walls a soft yellow, and the lights bright; it seems like an alert, active place.
I come to the ICU as a visitor, a consultant, to offer something specific, something they need. Many critically ill patients have wounds, either due to trauma, infectious disease processes, or skin breakdown related to a multitude of causes. The staff needs my assistance and my skill in treating these complicated cases.
“Oh, thank God you’re here,” says the nurse who paged me. She’s enfolded in a yellow isolation gown that looks far too big on her. “We have no idea how to handle this wound …”
She sighs, and waits while I leaf through the patient’s chart, wash my hands, gown, and glove. MRSA, or methicillin-resistant Staphylococcus aureus, is a common organism in most hospitals these days. It is one of the new superbugs that is easily transmitted and very difficult to treat. We do everything we can to fight its spread and I am careful to maintain the protocols to decrease its spread. Patients have died from MRSA and wounds are often MRSA’s point of entry. As nurses, we seem to be in a perpetual state of hand-washing. Whenever I see a hand-wash dispenser, I automatically wash my hands—it’s a reflex. I change my gloves almost as often. I wear no jewelry on my hands, not even my wedding ring, as the cracks and crevices are potential hiding places for infectious material.
Mr. Mountain, the patient I’ve been called to consult upon, is indeed a mountain of a man. At least, that’s what I see from the doorway. The bedclothes are in a huge pile over his prone body. Tubes are everywhere; machines beep and whirl. I’m eager to get closer, to touch his skin, to see the flesh, especially the wounded parts, and try to fix them. As I approach, I see that the exposed skin on his face and hands is pale and puffy, soft and squishy like marshmallows. His eyes are closed; he has a tube in his nose and more tubes coming out from under the bed covers. The bed whirls and the mattress seems to be breathing along with him as it automatically adjusts to his body’s position. I look closely and see that he is breathing little shallow breaths that move the blankets slightly across the vast expanse of his belly and chest.
I am never certain what to expect with wounds. Even when I’m given information ahead of time, it’s never enough: I have to see it with my own eyes. Often, when I take off the dressing, roll the patient over if necessary, and expose the wound, it is very different from what I’ve been told to expect. I have seen some wounds that are truly horrific and would be beyond most people’s ability to describe. But I need to put my hand in them; see down to bone if it is deep; touch, and see fluid moving, rivulets of pus when I press. I even need to smell the wound: that helps me know what kind of infectious organism is lurking. I know for many people, even nurses who are accustomed to dealing with the most intimate of body parts, some wounds are difficult to face and elicit a visceral repulsion. I think my own neutral, or even fascinated, response to wounds comes from my lifelong interest in art. When I was taking drawing lessons and learning to see as an artist, my “eye” was trained to see what was before me; I learned to record what I observed without attributing an emotional response to it.
There’s another way I look at wounds. To me, wounds are like enticing presents: there’s always a sense of excitement when you receive one, they are always wrapped up (in gauze and tape), and you never know what you’ll find inside! For example, the dressing might be huge and the wound very small and insignificant. Sometimes it is deep and dark like a cave, the end point disappearing out of sight. There are often surprises contained within those packages….
So, Mr. Mountain, where is your wound?
I ask Donna, the nurse who is his primary caregiver today, to show me. He was admitted to the ICU from home. He’d had a sudden decrease in his level of consciousness at home and hypotension—a severe drop in his blood pressure. The diagnosis of urosepsis, a blood-borne infection from urinary tract bacteria, was made. He is now critically ill and on full life support. Due to his overwhelming infection, the medications he’s received, and his poor cardiovascular condition, his body has reacted by pushing fluids out into the tissues.
Donna points out some of the relevant lab work that helps to explain the leaky condition of his skin. His infection, despite IV antibiotics for the past several days, has not yet resolved. Donna fills me in on his baseline health, other co-morbidities, and his family’s concerns.
Some consultants come in to see patients, never speak to the nurses or anyone else, write their notes and orders, and leave. However, I always see these consults as an opportunity to teach and learn. I like to discuss the situation with the nurse, include the patient and family if they’re able, and also include the physiotherapist, the occupational therapist, dietitian, and attending physician, when they are available. ICU patients are usually in such complex situations that it takes a team to care for them. I enjoy this collaborative aspect of the ICU. It’s a great time to share information, thoughts, learn something new. We develop a plan of care that addresses all the components of the patient’s world—what it takes to nurture and heal, when possible, and when not, to care and comfort. This collegial, caring approach makes me think of Johnny Appleseed (one of my heroes, I must admit), who traveled across the midwestern United States in the early 1800s. His real name was John Chapman; he got people to plant apple trees, and he showed them how to grow and nurture those trees in orchards. Perhaps his story speaks to me so much, even today, because I grew up on a piece of land that had 36 apple trees, vestiges of an ancient orchard in my backyard, that my parents cherished.
We pull back the covers. Mr. Mountain has had a reaction to the drugs he’s received that has caused further swelling with fluid. His body is covered in huge blisters, some still filled with fluid, some flat and crumpled with dead skin across his back, shoulders, and thighs. The skin, where the tissue has died and rolled off, glistens. There is bloody drainage on the sheets and he’s oozing pink-tinged fluid as we gently move him onto his side. He groans, and his eyelids open and close.
My heart sinks. Even with all my experience, the sight of wounds this massive still stops me in my tracks. I will have to call on all that I have learned and experienced as a wound care specialist. What to do? This is not just one wound: it’s many, covering huge parts of his massive body. He’s not a small person to begin with, and now, he’s puffed up like the Michelin man. My mind goes into a clicking, autopilot checklist as I scan his body with my eyes, touch his skin, and assess the edema and the circulation. Pain? Under control, thank goodness. Pressure relief? Appropriate bed surface: yes, that’s standard for the ICU, which is a huge advantage here.
I think about what to do, what to do now. There is no simple solution. We can’t wrap all of his wounds because too many parts of him need dressings, but if we can protect the newly exposed tissues, deal with the drainage and the blisters sloshing with fluid, maybe we can promote the healing process….
As I think through my plan, I’m talking with Donna. We are standing close together, our long yellow gowns flowing into each other. Our purple latex-free gloves are tight, to maximize the intentionality of our touch. We follow the research-based, best-practice guidelines on treating these types of wounds and talk about the current research. For example, there are two sides to the argument “to pop or not to pop” water blisters. I am in fa
vor of controlled removal of fluid in blisters—if there is a lot of fluid and, for example, if the blister is on a pressure point (e.g., the heel), preventing the person from walking. I ask Donna what she thinks; at first she is skeptical about my position, but she agrees once I tell her of the scientific evidence.
“As long as I can see why it’s being done, that there’s a good reason,” she says to me as we gather our supplies.
Donna is right. As nurses, we have to be able to know the rationale for our actions, to be sure we are in fact “doing the right thing.” I’m glad she understands the reasoning for this procedure; she can answer questions from other members of the team who might ask why we’re opening these blisters. Knowledge is a powerful tool that not only strengthens us as nurses but also enables us to advocate for our patients and their families.
We gather the supplies we need—sterile drapes, a sterile scalpel, surgical gloves, and lots of gauze and pads—and set about treating Mr. Mountain’s huge blisters. While this is not within everyone’s scope of practice, I have the knowledge, experience, and judgment to do this procedure. I know I can do it properly and safely.
Donna and I work side by side, carefully and quietly. She holds the gauze 4 × 4s to catch the drainage as I create the incisions in the devitalized tissue. As we’re doing this, I’m thinking about what to put over these, to protect the skin. In the end, we decide to lay soft, silicone mesh over the worst parts and cover them with big abdominal pads. The contact layer can stay on for up to a week, and we can just replace the abdominal pads as they become saturated. Mr. Mountain isn’t moving much, so we don’t need to use tape. We wrap his arms and legs with a soft, non-woven wrap and then put stockinette over them to keep the coverings from riding up or falling off.
