Dr. John Hagen's Reflections as an ICU Nurse
Physician Reflections as an ICU Nurse
John Hagen MD FRCS(C), Chief of Staff at Humber River Hospital
We are in the middle of a third wave of the COVID-19 pandemic here in Ontario. There is also an acute shortage of ICU nurses. The ICU has a capacity of about 44 beds and currently we have 56 patients. There are at least 10 patients in the PACU that are COVID-19 positive. Our ICU Nurses are overburdened, often being assigned to two patients when in normal circumstances they would only have one.
A program was organized here at Humber River Hospital, by Dr. Sinzi Avramescu, to train physicians to be ICU Nurses. These physicians are assigned a patient and look after them during a 12 hour shift. Almost 50 physicians signed up but there was still a need for ICU nursing relief so I signed up for the program as well.
I was sent reading material and I spent about two hours going through it the night before my half-day course. On Friday May 21, I met my instructor, Maj. I was the only doctor training that day so Maj quickly went through the electronic medical record charting, how to access the medications that I would need to administer, and other technical information I would need to function as an ICU nurse.
The second part of the program was to do a simulation lab. Again, I was one-on-one with Gurmit, who took me through how to run an infusion pump, how to check the blood sugars, how to run the feeding infusion pumps, how to manage the intravenous lines, how to change the dressings, and many other things.
I was assigned to a “buddy nurse” for the first shift and if everything went well, the next day I would have my own patient. They desperately needed some help in the ICU so I signed up to work the Saturday and Sunday of the long weekend.
The Buddy Shift
On my way up to the ICU at 7:30 in the morning, there were two ICU nurses on the elevator with me. I introduced myself and they told me they were happy I was coming up to the ICU. They told me they were both burnt out and it was just so much work and stress in the ICU that the relief was very welcome. I could not help but wonder why they kept on coming into work. Whenever I feel that way as a surgeon, I take off and sail across the lake with my wife. I come back refreshed and rejuvenated. With the continuous lockdowns, there is nowhere for these nurses to go for whatever they do for self-care, to clear their minds of what is weighing on them. They are stuck at home with usual activities of life limited. They can’t be with family or meet with friends, and can’t go to restaurants. I can only imagine how their stress stays bottled up inside.
Ekat, who has been an ICU nurse at Humber River Hospitalfor about two years, was assigned to be my buddy nurse. Together, we were handed over a patient by the night-shift physician - the patient was relatively stable, but ultimately was not expected to survive.
Ekat took me through a head-to-toe examination of the patient which was really quite detailed. It took about half an hour for every inch of their body to be inspected along with all the tubings and intravenous sites. We became familiar with the many pumps that were attached to the intravenous line, learning which pump was for which medication. We spent the following half hour documenting everything we learned into their electronic medical record. Ekat then went over medication-administration and showed me how to get alerts for giving medication within the allotted times. I learned how to go to the medication room, open the door with my fingerprint, obtain the necessary medications, bring all the needed solutions, IV tubings, and dressings to administer the medicine.
The medication administration system is pretty much foolproof. I scanned the medication, entered any other details that were necessary, scanned the patient, and if everything matched, I would hang the medication. The medication pump asked me what the medication was and confirmed it was mixed with the correct solution and would be run at the correct rate. Once it had run through, the primary line would take over and continue the infusion. I see now why the medication error rate is .0001%.
At around 11 am, the ICU doctor came around and there were orders to process, changes to medication doses, and as the patient had not had a bowel movement in two days, extra laxatives administered. We then spent the next hour cleaning up stool that was literally dripping off the bed but I’m sure the patient felt much better.
We were so busy that we did not have our first break until 2 pm.
The patient’s father came in to visit at around 3 pm. They are allowed one visitor per day for one hour. The father had a lot of questions about his son’s condition, whether he was going to survive, whether there was any hope for him and whether he could be given chemotherapy. He had driven four hours that morning to visit his son for one hour and was driving back. He had done the same thing the day before and was going to do the same thing the following day. His daughter passed away from ovarian cancer 10 years ago, after a prolonged and painful period of chemotherapy and surgery. His other daughter lived in Fort McMurray, and last week, her husband had a heart attack and was undergoing stent insertion. He wanted to spend as much time with his son as possible because he knew that he would not be leaving hospital.
Ekat told me that a big part of being an ICU nurse is spending time talking with the families. A lot of time is also spent documenting everything they do with the patient such as changing the arterial line tubing, the dressing changes, any changes to their position that can help to prevent pressure ulcers, are some examples.
Closer to the end of our shift, Ekat realized that she had forgotten something. It turns out that the patient was on propofol drip. Propofol has inter-lipid as a base which has a lot of calories. We had reduced the propofol drip from 40 mL per hour to 35 mL an hour. She suddenly realized that she had not adjusted the nasogastric feedings to account for the reduction in calories from the propofol. She then navigated through the Meditech records and came upon the protocol on how to adjust the calories. It turns out that she had to increase the G.I. feedings by 5 mL per hour. She documented all this and made the necessary changes.
To me, 5 mL per hour is a teaspoon of feeds and it is hard for me to see the relevance of going through that entire exercise. The patient was full of cancer and in no condition for chemotherapy treatment. He was likely not going to survive no matter what we did. For Ekat, it was a matter of professional pride to cover all the necessary patient care intricacies so she could give the best possible nursing care. If you add up all these little details that she looked after throughout the entire day, it is possible that the sum might make a difference to his outcome.
My first shift as an ICU nurse
I arrived Sunday at 7:30 am and was assigned an “easy” patient. I got the handover from a seasoned ICU nurse, Olga. The patient had come from a long-term care facility and has been bedridden for several years. He can’t even swallow his own saliva so he is fed through a feeding gastrostomy tube. He has been having problems with seizures and is likely aspirated. He required intubation, was put on a ventilator, has a lot of secretions, drools continuously and has a reduced level of consciousness but opens his eyes when stimulated. He was full-code status. I wondered why he wasn’t given DNR status and His daughter, understandably, wanted everything done for him and that’s the case for many ICU patients. Our job, as ICU nurses, is to take the best possible care of the patient.
As Ekat taught me, I did the same head-to-toe assessment and examined every square inch of his body. I then familiarized myself with his various tubings, ventilator settings, and the intravenous lines, and then spent the next hour documenting it all. He had medications due at 10 am and so again I went to the medication room and went through the whole fingerprint routine and collection of syringes, tubings, dressings and went about giving the medication.
With the help of other ICU nurses, I learned how to acknowledge the orders, draw blood work, and send it to the lab. I then read a sample of the EKG and saved it to be printed off at the end of the shift. I would run through my to-do list a number of times to ensure I did not miss any of the prompts for any of the assessments.
At around 4:30 pm, I realized I had not spoken with the family so I called his daughter. She had questions about his seizures, how he was doing, and what our plans were for him. I explained that he was on the minimum ventilation settings and if things went well, he could be extubated the following day. She wanted to have another video session with him so she called the bedside computer and I lined it up so that he could see her.
The video session lasted about 10 minutes. She spoke nonstop to her father - explaining where they were going, what they were doing, why they were driving. She asked how he was doing even though he could not respond. He opened his eyes and watched her on the screen – with a ventilator doing the breathing for him and saliva was drooling down the side of his face. She said was excited to see him when he got back to the long-term care facility. His 1 ½ year old grandson could not yet talk but blew kisses to his grandfather on the screen. Every time she put the video back on herself, the child would fuss to see his grandfather again. Then he would start blowing kisses again.
At one point, my patient rolled his eyes towards me as if to thank me. A tear rolled down the side of his cheek. He then rolled his eyes back towards the video screen. His daughter told him how much they miss him, and how much his grandson loves him, and how things were going to be ok. After the video call was over, my patient closed his eyes and went back to sleep.
I made a note of the questions his daughter had about his condition, and that this video conversation happened. What I did not mention in my notes was that it was obvious to me that although he could not communicate outwardly, he clearly recognized his family. In that moment when I felt he was thanking me, I also felt like everything had stopped in time. The noise from the ventilator, the alarms, the endless talking on the screen were all replaced by the power of love. As a surgeon, I rarely get this kind of connection with a family of a patient. I understood then why ICU nurses get on that elevator and come to work each day.
My Reflections as an ICU Nurse
There is a lot more to ICU nursing care then I ever considered. ICU Nurses have a tremendous amount of pride in their work, and every detail, however minor, is important to them. ICU Nurse have great clinical knowledge about their patients and care greatly about them and their families. They see patients suffering terribly and although this weighs heavily on them, they continue to do whatever they can to provide comfort and care for them.
They help each other daily but they also helped me understand how important they are in looking after the sickest of our patients. They are critical.