Sometimes the “Critical” in Critical Care is Actually Pretty Basic

I’ve never been a ward nurse. Theatre, then ICU. Lots of nursing roles within those areas, but never ward nursing.

 

One of my favourite nursing roles is the Outreach Nurse. The Outreach nurse is a member of the Rapid Response Team (in our hospital we have RRT’s instead of MERTs or Code Blue – the idea is the same but the focus is on early intervention not rescue and recovery). The usual duties involve going out of ICU into the hospital and working on a referral/followup basis, reviewing patients and contacting (or chasing up) relevant medical teams. Most importantly, we provide clinical support for nurses using advanced assessment skills and education.


Some nurses I meet have the perception that I’m there to check their work (I’m not) or to devise some previously unknown care strategy based on things that we do in ICU. Mostly the role involves two way learning, I teach the ward nurse something that they might not know and I learn from them. Occasionally I get to give ‘permission’ for the ward nurse to do what they think they should do, in situations where they normally wouldn’t – showers at 2am, bed moves at 3am, making difficult telephone calls to family, reminding care teams of appropriate palliation etc.


And increasingly, I’ve been bringing the ward nursing back to ICU.


We had a long term patient, I’ll call Bob (my go-to anonymous name). We really didn’t expect Bob to survive his admission. A long list of complications from surgery resulted in dialysis (the continuous and gentle ICU version, not the large volume suck that is the dialysis of the renal patient). He had very large dressings, poor skin integrity and malaena. The dressings and malaena resulted in further skin breakdown, blood transfusions, and eventually endoscopies for ischaemic ulceraton of Bob’s bowel.

 

Bob had a few big days. He would have a large GI bleed, dropping his haemoglobin about 30 points, and there would be a large amount of malaena in the bed. He’d required intubation and ventilation for an endoscopy, then extubation overnight. This had happened a few times. It was never clear if he could be successfully extubated after each of these events. It certainly looked like there was less of him left in the bed each time.

 

Bob’s nurse noticed she had an opportunity between everything else going on to cease his dialysis for a bit and get him out to the verandah. (We have a balcony with a view, power, oxygen and suction). I was her ACCESS nurse. I knew it would be difficult to organise, but we felt it would be worth it for him to see the outside for maybe the last time.

 

We disconnected his dialysis machine and set it to recirculate (like hitting pause). Recirculation either goes well or it doesn’t. This one was ok for about 10 minutes, then the machine started alarming and after another five minutes we were going to have to replace the circuit.

 

Oh well. The dialysis was now coming off anyway. We were committed.

 

We moved the required support equipment out to the verandah, moved Bob in his bed out there and after two fun-filled hours with family he returned to the bedspace.

 

His nurse ran an ABG on his return indoors. He’d dropped another 30 points on his haemoglobin. And he had more malaena.

 

Another endoscopy. Another intubation.

 

I fetched the FFP, the platelets and the packed cells. His nurse gathered the items required for the cleanup. His family, who were still present, were obviously disappointed. They had just spent two hours with Bob and could see the cost on his health.

 

We paged for the ICU wardies. Our own wardies do regular turn rounds, and are available between times but have other jobs to do outside the rounds. They are very much part of our team, and we are lucky to have them.

 

Two wardies arrived, and the look of horror at the smell of the malaena was telling. These two had enough experience to recognise the odour, and also what it meant for Bob.

 

We discussed with Bob and his family what we wanted to get done (namely, a big clean up, gown and sheet change) and then we asked them to step out, promising we would be as quick as we could.

 

Three minutes later, we asked them back in, we had finished. Quickest everything change I ever saw.

 

On the way out, one of our wardies asked me if there was much hope for Bob. I replied that I did not think so and that assisting in the clean-up of the malaena was probably the most important thing either of us had done that day. He asked if I was serious and that no-one had ever told him his job was that important before.

 

After the blood and blood products were administered, and the GI people were ready to go, we again ushered Bob’s family outside and, once again, intubated him with no real idea as to how long he would remain intubated.

 

Intubation is usually done by the senior registrar, or, if elective and predictable, by the junior registrar as a learning activity.

 

In Bob’s case, he had been intubated so frequently that most of the senior registrars had at one time or another had a turn.

So I was a little taken aback when the consultant declared there would be no learning (medical or nursing), she and I would intubate Bob, on our own, with his bedside nurse the only other person in the room. This one, she said, would be simple, smooth, and efficient. We would do it this way for Bob’s peace of mind.

Bob got his endoscopy. He also got successfully extubated. He very slowly got better, and out of ICU.

He spent a further 3 months on the ward, and has since gone home to his property a long way from the hospital.

Before he left, he told one of the ward nurses that although he was frequently over the whole admission, he knew he would get better the day of his last endoscopy in ICU. He saw the outside world, and he saw the determined calm effort the staff put in to help put him at ease. And he decided that if we were going to put the effort in, he must be worth it, and he would try as well.

 

Our attitude didn’t really fix Bob or get him home sooner. But keeping the dignity and humanity of the patient in mind is one of the most fundamental aspects of nursing. I’ve seen it in many different circumstances, but most commonly on wards where there are no machines that nurses can rely on to help instill confidence in the patient.

 

I think we really got it right that day. And I have the ward nurses I meet as ICU Outreach to thank for it.

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