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Thread: Critical Care: The making of an ICU nurse

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    Critical Care: The making of an ICU nurse

    I thought this would be an interesting article for all of you: http://www.boston.com/news/specials/.../whole_series/

    Julia Zelixon pulled back the crisp green blanket covering Helen, her patient, and suppressed a gasp.

    “I’ve never seen anything like this,” she whispered to another nurse, standing nearby. “Never.”

    Julia had read about necrotizing fasciitis — better known as flesh-eating bacteria — in nursing school, but this ravaged abdomen was beyond any textbook description. From just below the ribs down to the left hip, an enormous patch of Helen’s flesh had been surgically removed to block the fast-moving infection. Only a white layer of gauze covered her crimson muscles, and black magic marker lines, drawn by nurses across Helen’s thighs, mapped the bacteria’s continued spread.

    Julia, a first-year nurse, carefully cut the sutures that held one of Helen’s monitoring lines in place. She revealed nothing of the thoughts racing through her mind to the 55-year-old patient, who was staring straight up and trembling slightly.

    “I’m sorry dear,” Julia said softly, her accent redolent of her native Russia. “Does it hurt?”

    The other nurse in the room, Michele Jerard Pender, had seen too much in 20 years of nursing at Massachusetts General Hospital to be unnerved by Helen’s wounds. She didn’t miss a beat in her stream of advice about removing the monitoring line from a major artery: Be sure to block the opening with gauze and “hold it real solid for five minutes” to prevent a gusher of blood. It was a lesson M.J., as she is universally known, had learned the hard way, long ago.

    M.J. and Julia had been thrown together for an extraordinary crash course in the ways of the Intensive Care Unit — Mass. General’s answer to the national shortage of veteran nurses. M.J. had just eight months to turn a trainee fresh out of school into a nurse ready to care for the most gravely ill patients at one of the nation’s leading hospitals.

    Eager and ambitious and, at 35, more tested by life than most of her peers, Julia was, from the start, utterly sure she would succeed.

    M.J. believed in her, too, but also knew how hard the road ahead would be.

    M.J. watched carefully as Julia continued preparing Helen to “travel,” an oddly cheery nursing term, considering where the patient was about to go: Doctors wanted a CT scan of the advanced ovarian cancer that surgeons had discovered as they battled the infection. Helen hadn’t been told yet, but she was in danger of dying from two diseases at once.

    As with many intensive care patients, Helen’s problems were a devastating mix of bad luck and bad choices. The reclusive woman had noticed a lump in her groin months earlier, but had not sought medical help until the infection was rampant. She also had stopped chemotherapy for ovarian cancer against her oncologist’s advice. Surgeons at a suburban hospital discovered the consequences of both decisions, and promptly put her in an ambulance bound for Boston.

    Now she was in the hands of Julia and M.J. in the surgical intensive care unit, or SICU. Nurses in the cluster of 20 small, starkly lit rooms on the fourth floor of Mass. General’s Ellison Building jokingly call the ambience “cavelike,” because most of the windows look out on a brick wall a few feet away. But they pride themselves on caring for the most difficult caseload among the six intensive care units in this 875-bed teaching hospital of Harvard Medical School. Its patients run the gamut from gunshot victims to some of the most severely burned patients from the 2003 fire at the Station night club in Rhode Island.

    The SICU is a place of inescapable intensity, where staff members converse in a clipped shorthand that is both urgent and sometimes vulgar; where the loudspeaker can summon a stampede of white coats and blue scrubs to the bedside of a “crashing” patient; and where, lest anyone for a moment forget how fragile their patients are, electronic bulletin boards in the halls flash a stream of warnings in red — 434 APNEA ..... 406 TACHY ..... 428 VNT ALARM — whenever a patient’s vital signs drift beyond safe levels.

    “You’re at Mass. General now; do you know that?” M.J. loudly asked Helen about an hour after she arrived on a frigid January afternoon, nervous and disoriented. The patient shook her head. M.J. told Helen that she had taken care of her two years earlier, when she was in for cancer surgery, but Helen didn’t seem to comprehend that, either.

    “You might want to see if she’s anxious,” M.J. said, turning to Julia. “You’ve got that order for Ativan.” Minutes later, Julia injected a clear syringe of the fast-acting sedative into a tube that drained into Helen’s central vein. Soon, the patient closed her eyes, looking almost serene.

    For Julia, who only a few months earlier had been a nursing student at the University of Massachusetts at Lowell, Helen would be the first highly unstable patient she would transport out of her room, a carefully orchestrated undertaking that requires a nurse to leave behind the built-in monitors, breathing equipment, and racks of medicine in a patient’s room for portable versions of the same. Every ICU nurse has a healthy respect for the challenge of what sounds like a simple chore — pushing a very sick patient’s bed down the hall. “You don’t want to be stuck in the elevator with a dead [oxygen] tank,” M.J. said.

    Julia set about moving Helen with single-minded zeal, stretching on tiptoes to the farthest corner of the bed to disconnect tubes and unplug wires, laughing when M.J. compared her to an octopus. She got the monitoring line out of Helen’s artery and held gauze over the wound, just the way M.J. had suggested. She attached Helen’s IV medicines and fluids to a “tram,” a rack that hooks to the bed. She put a green canister of oxygen on the bed and connected it to a purple “ambu bag” with a facemask to manually inflate and deflate Helen’s lungs. She placed a portable vital-sign monitor in its rack at the foot of the bed, plugged Helen in, and headed off for the scan.

    “You’re remembering everything today. You’re getting an A-plus,” exclaimed M.J.

    Julia’s very presence in an ICU at New England’s largest hospital is a measure of the upheaval in nursing, one of the most demanding but least glamorized professions in medicine. Although television shows such as “ER” make it seem as if doctors do just about everything in hospitals, nurses actually provide nearly 90 percent of intensive care, usually with no doctors in sight. Nurses sometimes feel like second-class citizens, but they are the backbone of the ICU, and hospitals struggle to recruit and train enough of them.

    Until four years ago, Mass. General required nurses to have one to three years of hospital experience before they could work in the ICU, giving them more on-the-job training than most residents, the recent medical school graduates who are the frontline doctors in teaching hospitals. As residents rotate through, seasoned nurses provide continuity of care and a practiced eye for the telltale blood pressure drop, raspy breathing, or other signs that a patient is failing.

    But the nationwide shortage of nurses — 6.7 percent of nursing positions in Massachusetts are vacant — has forced even prestigious hospitals to take once unthinkable steps to recruit the next generation, including signing bonuses of up to $5,000.

    In 2001, Mass. General began its intensive care program for new nurses willing and able to work under near-constant stress. A patient in the SICU typically requires 20 hours of nursing care daily, 13 percent more than in 1999, as medicine gets better at keeping the sickest of the sick alive. Patients here routinely require a dozen or more intravenous medicines and up to six feeding and monitoring tubes.

    “The patients that ICU nurses are taking care of would have died 30 years ago,” said Jeanette Ives Erickson, Mass. General’s nursing chief.

    Some senior nurses are uneasy about the growing number of first-year nurses in the ICU, believing they lack the judgment to make life-and-death decisions. But the idea is catching on: Nearly one-fifth of Julia’s graduating class went directly into intensive care or emergency room positions.

    For Julia and the other fledgling nurses, the months of training would be exhausting. In short order they had to master how to administer scores of drugs; carry out complex procedures; help families cope in their darkest hour; and, most important, head off crises that can take a patient swiftly from critical care to the morgue. “There were times when I would come home and couldn’t keep my eyes open past 8 p.m.,” recalled one former ICU trainee less than fondly. Senior nurses like M.J. decide whether trainees have the aptitude and grit for this work. And while the teachers are supportive, they pounce quickly on mistakes, especially those that may jeopardize patient safety.

    “Some days you’re going to get hammered,” M.J. said one day, summarizing what she expects of trainees. “But you know what? Take it to heart, learn from it, and tomorrow’s another day.”

    Not everyone makes it: Four of the 17 nurses in Julia’s class would not graduate, a higher dropout rate than basic training for the Marines. For those who survive, the prize is considerable: a job with lots of autonomy at a world-famous teaching hospital, where senior nurses make more than $100,000 a year. For Julia, whose training was observed firsthand by a Globe reporter and photographer, graduating from the ICU program would mean something more: regaining her sense of direction after tragedy knocked her life off course.

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    A striking, red-haired woman whose square shoulders and firm jaw add to her aura of confidence, Julia arrived at Mass. General in August 2004, certain she would be a good nurse. Sure, she was a little intimidated by the place, and the fact that its ICUs take the patients too sick or badly injured for smaller hospitals to manage. But Julia was no kid — she had lived in three countries and had two children — and she had prepared well, getting excellent grades in nursing school and doing an internship in a community hospital ICU.

    In fact, if not for the twists and turns of family life, Julia would be a doctor herself by now. Growing up in Omsk, a river city in West Siberia, it was her dream. “I knew I was going to be a doctor,” she remembered, her pale-blue eyes wide at the memory. “I had no doubt.”

    Her vision was matched by drive. Julia’s parents, a scientist and a voice instructor, had long stressed that she and her brother needed to outdo other students if they were to overcome the anti-Jewish bias in Russian society. “If there were 10 Russians all with the same [test scores], you would be the last chosen,” she recalled them saying. A voracious student who loved Russian translations of novels by William Faulkner, Julia won acceptance to the Omsk State Medical Academy, a six-year program that combines undergraduate and graduate education.

    But three years into her training, in 1990, Julia’s family got long-awaited permission to immigrate to Israel. Newly married and pregnant with her son Michael, Julia moved to Haifa, and began learning a new language and culture. She tried, and failed, to get into Israeli medical schools, which were awash in applications from Soviet emigres. “It was the most frustrating experience of my life,” she recalled.

    Still, she gamely shifted gears, getting a business degree and taking a job at an electronics plant, where she eventually supervised 10 employees. By 1998 the family had moved into a big new house and she had given birth to a second son. “I had a really good life,” she recalled. Medicine, it seemed, was part of her past.

    Then everything changed. Her husband, Valery, was offered a job in Massachusetts, and Julia reluctantly agreed to go along, believing the relocation would be temporary. The family settled into a smaller home in a country where Julia didn’t yet speak the language fluently and knew only two Israeli families. The brilliant foliage was the saving grace that fall.

    Loneliness was soon the least of her concerns. Two months after she arrived in the United States, her toddler, Daniel, started to become apathetic and unresponsive, even to his parents. Doctors diagnosed him with a rare — and fatal — genetic disorder.

    For two years, as Dan became progressively sicker, Julia cared for him round the clock. Finally, in the spring of 2001, she bought Dan a one-way ticket to Israel and the family returned to the country she loved so that her son could spend his final days surrounded by his extended family.

    Until Dan’s illness, Julia had assumed she would eventually resume her business career. But now that seemed an empty prospect. The hours she had spent at her child’s side, at home and in hospitals, “sort of captured me and brought me back to what was mine when I was growing up.” She began talking to one of the visiting nurses about the possibility of becoming a nurse, a family-friendly alternative to getting an MD. “Medical school is OK when you’re 25,” she said, “but I wanted to enjoy my life.” Just before she left for Israel with Dan, Julia applied to the UMass-Lowell program.

    She would have a new baby, Eran, to look after by the time she began her studies in the fall of 2001. Nonetheless, she completed the four-year program in three years while still finding time to take English courses. Finally, she could read her beloved Faulkner in the original.

    “She’s an amazingly committed woman,” said Stephanie Chalupka, director of the nursing program in Lowell. “She knew what she wanted, and she knew what she needed to do to get there.”

    From the beginning of nursing school, Julia had known she wanted to work in intensive care. After graduation, Julia was accepted to ICU training programs at two Boston teaching hospitals. She chose Mass. General, believing that at such a busy, prestigious place she would have more freedom to make decisions. By the time she arrived one of the oldest “new” graduates in the ICU, Julia recalled, “I felt I was ready to go to work.”

    M.J. wasn’t so sure. Julia had much less bedside experience than the three other intensive care nurses M.J. had trained, and she knew from the day the two met that she would have to work a little harder to prepare Julia.

    And M.J. worried that Julia might be slow to accept a fact of nursing life: Though a nurse can influence doctors’ decisions, ultimately she must defer to them in diagnosis and treatment. M.J. suspected that Julia might approach her job like the doctor she once planned to be.

    “Sometimes it’s hard for her,” M.J. said one day early in Julia’s training. “She’s used to telling other people what to do.”

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    Michael Hill, a muscular X-ray technician, braced his feet against the wall and pushed until he was almost horizontal, trying to slide an X-ray film under the abdomen of a semiconscious 420-pound man as Julia and M.J. lifted his left side. But it wasn’t enough. “Turn help in 32, please,” announced M.J. over the intercom, and two critical-care technicians joined the crew at the patient’s bedside.

    “These heavy patients,” said one of the technicians, Diamond Ambrosh, “they’re murder on the human body.”

    Such patients are increasingly common at Mass. General, where, on this winter day alone, 15 patients required “big boy beds” designed for people who weigh more than 350 pounds.

    But for Julia, M.J., and the ICU staff, the real problem with the 54-year-old wasn’t how to make him comfortable, but the chain of health disasters his obesity had engendered. The man had come to Mass. General for replacement of two bad knees, and doctors gave him post-operative blood-thinning medications to prevent the blood clots that are common in gravely overweight patients. He was soon complaining of severe stomach pain that turned out to be internal bleeding, likely exacerbated by the blood thinners. Surgeons struggled to stop the bleeding, but by the time they succeeded, the blood loss had triggered both a heart attack and sepsis, a dangerous systemic infection. Now he was lying in the ICU with a fever of 103 and a breathing tube in his mouth, and the nurses were anxious that he might abruptly “bleed out” and die.

    When she was a medical student in the former Soviet Union, Julia had seen lives ruined by rampant alcoholism and other lifestyle-related sicknesses. But it surprised her to see so much self-destructive behavior in a prosperous country like the United States, where popular culture celebrates the slender and the fit. Julia would care for 25 patients during the days and nights that a reporter was present to observe her training. Half of them had significantly contributed to their sickness through smoking, alcohol abuse, extreme obesity, or, in one case, failing for years to get treatment for diabetes.

    Doctors at morning rounds said they hoped to break the obese patient’s fever, ease his breathing, and get his heart rate down, but his weight complicated all three goals. Julia and M.J. couldn’t get an electric chilling blanket underneath him, where it would be most effective, so they spread it over him. Then, Julia prepared a medication pump to give the man Lasix, a medicine that would help him urinate away the fluids that had swollen his belly and were hindering his breathing. But the man’s heart rate rose to 129 beats per minute, setting off a flashing red light on the vital-sign monitor.

    M.J., who had stepped back to let Julia make decisions, couldn’t remain silent.

    “What are you most worried about?” she asked, and then answered her own question. “Getting that heart rate down. ..... The name of the game is prevention. You don’t want him to have an MI [heart attack]. That will make your life very difficult today.”

    For M.J., such on-the-spot decision making has become second nature. She is a big believer in seeking the advice of doctors whenever she has doubts, but the 42-year-old nurse has vastly more bedside experience than the young residents who pass through.

    Within weeks of her arrival, Julia had already seen how independent-minded and forceful her teacher could be. A petite but sturdy Armenian grandmother, admitted to the ICU after hernia surgery, suddenly became delusional, insisting that her daughters were “ringing the doorbell,” and that Japanese dinner guests would arrive soon. M.J. recognized her confusion as a symptom of oxygen deprivation and stuck a suction tube down the patient’s throat to clear her congested airway. “I don’t want it! I don’t want it,” the woman hollered, but moments later, she was talking normally about her houseplants again.

    M.J. has far more autonomy than nurses at most hospitals, in part because the lines of authority between nurses and doctors in Mass. General’s ICUs are sometimes blurry and often crossed. M.J., for instance, will order X-rays or change drug doses in an emergency, then get a doctor’s approval after the fact.

    “A lot of times, I feel we’re here more as consultants to the nurses,” said Dr. Bill Benedetto, an anesthesiologist, who notes that doctors can have up to 10 patients at a time while ICU nurses typically focus on no more than two. The relationship relies heavily on trust and communication, he said.

    Still, M.J. and other ICU nurses know the public views them as less important than doctors, and they chafed when Abby, the only nurse among the main characters on “ER,” went off to medical school a few years ago. As ICU nurse Jen Matthiesen put it, “Doctors say, ‘Oh, you’re so smart; why aren’t you a doctor?’ I say, ‘I don’t want to sleep on a cot.’.”

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    The mother of 5-year-old Haley and 7-year-old Colin, M.J. seldom completely leaves her family life behind during her 12-hour shifts, fielding calls from the sitter, her husband Greg, and the children, and carrying an oversize calendar to track their first communions, swim meets, school barbecues, and other activities. During one lull in the ICU last winter, M.J. grabbed a few minutes to read a magazine article on how to get children to pick up their toys and coached her husband by phone on where to find one of Haley’s favorite outfits.

    At work, as at home, M.J. is accustomed to making decisions. Residents often glance in her direction during morning rounds and ask, “Isn’t that right, M.J.?” Everything about her seems practical and purposeful — from her choice of words to the clogs she wears for the extra inch of height she needs to reach IV bags.

    M.J. knew from the age of 5 that she wanted to be a nurse. “My dolls always had broken arms, and I had to fix them,” she recalled. “I just never wanted to be a doctor. I saw them as being really busy and spending a lot of time on the bookwork of medicine and not really spending a whole lot of time with the patient.”

    As a teenager she worked as a candy striper at the local hospital, then went to nursing school at the University of Vermont, landing at Mass. General right after graduation in 1984. Unlike Julia, however, M.J. spent three years on regular wards before she switched to intensive care.

    “I would never even have considered going into an ICU right out of nursing school,” M.J. said. “It was something, stresswise, I wasn’t going to put myself through.”

    As Julia’s ICU training began to involve more nights, longer hours, and sicker patients, she began to see the wisdom in M.J.’s words — though she never doubted her decision to go straight from school to the ICU.

    “When I came there, I had a lot of confidence because of my life experiences,” Julia said over tea one February morning. “It surprised me that there were a lot of things I wasn’t ready for.”

    Julia held her patient’s right index finger reassuringly and leaned in close to his pillow while a resident peeled back the large bandage above Frank’s left knee. Gray foam concealed a deep, six-inch-long opening where surgeons had inserted steel pins to hold his thigh together.

    “Are you all right?” Julia whispered sweetly, and Frank squeezed his eyes shut so tightly she knew the answer was no.

    A generation ago, Frank probably would have died in the crash that landed him at Mass. General. Another driver, allegedly high on marijuana and painkillers, had smashed head-on into his car as Frank drove home from a birthday party. The impact nearly split Frank’s pelvis and shattered his left leg, so that he practically bled to death before firefighters could get him on the med-evac helicopter. Little more than an hour after the accident on a rural highway, the helicopter delivered Frank to Mass. General, where high-speed pumps kept him alive with transfusions equal to the entire blood supply of 10 adults.

    Now, five weeks later, Frank was alive, but a challenging patient for a new nurse to manage. He was conscious enough to notice the picture of his nephew taped to the wall, but also to suffer as an orthopedist examined the gash in his leg for signs of infection. His heart was so fragile, it had stopped twice the previous weekend. And he had to be fitted with a device with five attachments running into his chest to monitor the strength of each beat and to stimulate his heart if it slowed. Julia had never cared for a patient with what’s called a pulmonary artery line, but she had a mantra for moments like these: “If it’s easy for you at this point, it should be scary.”

    M.J. tried to make it sound simple: Just inflate the tiny balloon at the tip and slide the line along the blood vessel near his heart until it can’t advance any more. Of course, she had to warn that Julia could kill her patient if she moved the line beyond the vessel and into Frank’s heart. “You can put the patient into v-tac or v-fib,” M.J. said, using shorthand for rapid and irregular heartbeats. “It can be lethal.”

    As she spoke, M.J. realized that Frank was watching them. A doctor himself, Frank couldn’t speak because of the breathing tube in his trachea, though he moved his lips wordlessly. Still, the nurses knew Frank understood much more about what was happening to him than the average patient. He knew, certainly, that his life was, up to a point, in the hands of an ICU rookie.

    “He knows everything,” M.J. said. “He’s listening to me teach Julia and thinking, ‘Oh, my God.’.”

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