Intensive care unit (ICU) nurses manage the most fragile, critically ill patients. They're often described in the nursing profession as meticulous, organized planners who love detailed levels of care, and who can simultaneously "orchestrate 10 pumps, 6 drips, 4 beeps, and 1 crashing patient without blinking an eye". The pressure of the intensive care unit demands split-second, life-or-death clinical decisions-making. ICU nurses need to be able to preemptively recognize signs of decompensation and act swiftly on them. They're advocates for their patients and members of an intensive care team working in an environment that is structured, full of high acuity, and multifaceted treatment modalities.
PH is a 17-year-old female who presents as a Level 1 Trauma following a motor vehicle crash in which her SUV was t-boned by a logging truck. She was originally taken to another facility where she presented with extensive trauma from the motor vehicle collision resulting in significant brain injury including subarachnoid hemorrhage, subdural hemorrhage, epidural hematoma, multiple skull, and facial fractures.
She was emergently transferred to Maine Medical Center by Lifeflight, immediately went to CT Scan, and assessed by the Trauma and Neurosurgery teams. After collaborating as a team it was determined her best chance was to be taken to the OR where she underwent decompressive craniectomy and EVD placement.
A craniectomy was performed to physically change space and would allow the brain room to swell rather than herniate. Traumatic brain injury commonly leads to elevated intracranial pressure (ICP), which can have catastrophic consequences. The cranial vault is a fixed structure, so it can't enlarge when its contents expand. Post-surgery the patient came to the Neuro Intensive Care Unit of Maine Medical Center, Special Care Unit 3. PH had been stabilized from the initial insult, but now expert care from the team to treat her (TBI) would be needed for her to recover.
Over the next 8 days, the team managed the patient's brain injuries, surprisingly these were her only injuries from the crash. They were often challenged with managing evolving injury and associated swelling. The team followed a clear plan while delivering normal ICU care and supporting the family while they dealt with grief.
Frequent Neuro checks and repeat CT Scans
Managing Blood pressure for optimal perfusion
Analgesia and Sedation
Seizure prophylaxis
Osmotic therapy and Hyperventilation as needed
A week in the ICU and PH made some progress. It was determined the endotracheal tube should be removed and transitioned to a tracheostomy. She would have this done along with a feeding tube in the OR. On this day, Lindsay Rosario teamed up with Dawn Meadows RN, a bridge RN from R6IMC to care for PH R6 and SCU 3 have been building a program of cross-training nurses in order to share knowledge, improve flow and ultimately provide excellent patient care. Dawn was completing her orientation experience by taking more intense patients and specifically those who were intubated requiring ventilator support. This seemed like a routine assignment that Dawn would benefit from. Lindsay is one of the more experienced nurses in SCU 3 and was guiding Dawn through this patient population.
After the patient's trip to the OR, Dawn was quite concerned after she performed her neuro exam and found it changed form prior to leaving. She quickly conferred with Lindsay who identified there was a major problem happening.
There are a few emergent neuro situations in SCU 3. However, the most important is brain herniation. When the pressure inside the head exceeds the space available the brain starts to shift, the stretching which ensues is life-threatening. Herniation is a big deal. When brain cells die, they're gone.
Late herniation warning signs prompting immediate action are:
Pupil size, reaction.
Vital sign changes
Respiratory pattern/ not protecting airway
These are late signs, but this doesn't mean Lindsay and Dawn were sitting on their laurels. It's not uncommon in SCU 3 for the neuro nurses to be able to identify if a patient is in vasospasm just by detecting the subtle changes in personality. Dawn and Lindsay immediately noted PH had some of the classic late signs of brain herniation and began to act. She had developed pupillary changes and her heart rate and blood pressure had changed dramatically. Some would have attributed this to post-op analgesia/sedation, but these two savvy neuro nurses knew better.
Dawn and Lindsay knew they had to be proactive with this situation. In addition to knowing specific neuro changes, neuro nurses like Lindsay and Dawn also know what other information to anticipate that the provider team will need.
When was their last head CT or MRI was - what did it show?
What are the patient's lab values (neurologists/neurosurgeons care about a patient's sodium like cardiologists/cardiothoracic surgeons care about potassium)?
What meds they have received that could have affected your neuro exam? They called the provider team and reported their observations.
The mark of a good neuro nurse is not only solid assessment skills but also being able to articulate it to the rest of the team. It's really hard for them to decide what orders to put in if the nurse calls them with vague changes. Knowing specifically what they are doing before, what change occurred, and how to communicate it to the provider is crucial to good patient outcomes. Along with this is knowing what the next steps to anticipate in the plan will be. Lindsay has much experience with this patient population and given the plan of care knew one of the next steps had to be another craniectomy to physically relieve the pressure on PH's brain.
She not only informed the trauma team of the patient's changing condition but also knowing the trauma team was inundated with the recent burn patients from the code triage, she contacted the neurosurgery team to start the consult process for surgery. This is typically a physician to physician consult.
Many nursing professionals share a relationship of increased trust with their physician colleagues. This trust often results from close-knit realities of a tight ICU working team. This interaction represents the key component in the delivery of treatment for patients in the ICU.
The patient care environment sees the status of each patient fluctuate with the circumstances regarding their medical condition. The registered nurse performs a key role in responding to an acute or emergency development by administering medications or performing the accepted techniques in response to the emergency and sometimes they go beyond this by acting on their instincts and intuition.
Managing increased ICP in patients with TBI calls for a team approach to optimize outcomes. Bedside nurses are better positioned than other clinicians to identify rising ICP early to ensure appropriate interventions.
After Neurosurgery consulted on the patient and a CT Scan was reviewed, it was determined again the best chance for her survival would be a decompressive craniectomy on the opposite side to relieve the pressure.
In the OR the neurosurgeon found that the patient had re-bled and after removing the skull he was able to remove the clot, decompress the brain and restore vital perfusion to the brain. The patient was transferred back to SCU in stable critical condition
It was the quick and proactive action that kept PH from having a devastating setback and possible death. These nurses are highly vigilant, meticulously detailed, skilled clinicians. They're patient advocates and tireless watchdogs who are prime examples of the professional nurses in the Intensive Care Units of Maine Medical Center.
Note: This is Lindsay's 2nd DAISY Award!