Nursing Narrative
By Eileen McMahon-Bowen, BSN, RN, CNRN, of the Neuroscience ICU
Early one morning following a windy and rainy night, I prepared myself for the first of three consecutive 12-hour shifts in the Neuroscience Intensive Care Unit (ICU), where I have practiced as a bedside nurse for more than 15 years. This particular morning began no differently than any other, but was soon to impact me in ways I had not anticipated.
My personal work ethic is to arrive on the unit early to find out how busy we are, which pod I'm assigned to, who I'm working with that day and, most importantly, who my patients are. I want to be prepared for anything, especially the unexpected. The patient I was assigned to that morning presented an exceptional challenge professionally, physically, emotionally and spiritually. My experience caring for him and his family defined who I am as a person, especially as a mother to a son around the same age, and as a registered nurse.
I will call my patient Joe. At the time, Joe was a 25-year-old male who sustained a massive and severe traumatic brain injury following a motor vehicle accident overnight during the rainstorm. Joe was ejected from his car, and his head was smashed into a pole. He was taken to a local hospital, quickly assessed and then taken by Medflight to BWH. On arrival, he went immediately to the operating room for life-saving neurosurgery. He had such a traumatic brain injury that sections of his right frontal and temporal lobes were outside of his skull with bone embedded in his brain tissue. He had bone fragments and sections of skull bones removed, as well as severely damaged brain tissue that would never recover. His chances of survival were not guaranteed, but should he survive, we could not predict how meaningful recovery would be. Would he ever walk, talk, be able to care for himself? We couldn't know any of those things that morning.
Joe was admitted directly from the operating room to the ICU postoperatively. He was intubated and appropriately medicated to keep him comfortable and sedated, maintain synchronicity with the ventilator, control his metabolism and to rest and relax his injured brain. He also had extensive wounds and injuries to skin and bones in his face, upper arms and legs. A large area of the right side of his skull was removed to allow his injured brain to swell outward to better manage and control intracranial pressure to limit further brain damage as much as possible. This intervention, although beneficial, poses significant risks and required skilled and expert nursing care to protect Joe's unprotected brain tissue from secondary traumatic injury. We had to use great care and caution when turning Joe, and when the time came to get out of bed, he needed to wear a specially fitted helmet to protect his brain where the skull bones were removed. The neurosurgery team was concerned that if Joe recovered, he would be left with significant cognitive, memory and emotional deficits, and that at best, he would have minimal movement of the left side of his body, including his arm, hand, leg and foot.
In this postoperative condition, Joe was barely recognizable and his appearance was very distressing to his large, devoted family. He has many siblings, both parents and a girlfriend with whom he shares a home and two young daughters, ages 3 and 6.
Seeing Joe and hearing about his accident, condition and uncertain chances for a meaningful recovery, both his girlfriend and mother were almost inconsolable. As his nurse and a mother to a son close to his age, I made certain that I gave these two very important women in Joe's life as much honest information and emotional support as I could. I also enlisted both Social Work and Chaplaincy colleagues to meet the family and to offer their talents and support. Joe's condition was very unstable and if he survived, it would be a long, difficult rehabilitation with much uncertainty about his eventual level of recovery. The attending neurosurgeon and care team, including myself and other nurses, met with Joe's family on a regular basis to update them, find out what they needed and offer them support.
Joe's mother sat at his bedside all day literally pleading for me to save Joe, to pray for him. His girlfriend would come in the evenings and stroke his arms and hands, playing home video messages from their two little girls. They both would ask me if he would be okay when he woke up. Will he talk, will he walk? His mother would cry, saying, "He can't die, and you have to keep him safe."
As health care providers, all of us knew that given the type and extent of his injuries, especially to his brain, Joe's prognosis and chance for a meaningful recovery were bleak. But despite that clinical scientific knowledge, we all had seen miraculous recoveries, against all odds, and we silently hoped the same for Joe. I constantly asked myself if we were doing everything we could. I desperately wanted Joe to survive and get back to his life as a son, partner and parent. I thought to myself, how would I cope if I were faced with a similar situation? I know how I panic when I can't reach my son, who is an active soldier in a war zone, when I hear of bombings and plane crashes near where he is stationed.
Joe's mom requested her prayer group be permitted to come into the unit to pray over Joe. Because I had spent a lot of time getting to know his mother, I knew how important her faith was to her. We would regularly make time for her and her friends to pray over Joe. His friends would visit and were encouraged to share with him the news of his buddies.
Joe struggled through clinically high temperatures and an episode of severe Acute Respiratory Distress Syndrome (ARDS). He endured episodes of neurological "storming," when his pulse raced to the 120s and higher, and his respiratory rate climbed as high as the 50s. During these "storms," he thrashed and struggled in bed, and was on the verge of vital sign instability. Seeing Joe like this was absolutely frightening for his family. In addition to all he had endured and was going through, he still had many significant and serious challenges ahead of him, including another surgery to repair his skull. He also sustained two cervical spine fractures in his neck that would likely require a surgery. Because of these spine fractures, Joe was required to wear a cervical collar all day, every day. All of these necessary medical devices were helping Joe, but they also presented barriers to access for his mother and girlfriend. As his nurse, I was sensitive to those barriers and made a point of moving or adjusting devices as much as was clinically safe to do, so that Joe's body and face were accessible to his mother and girlfriend. I hoped there was benefit, even healing, in the touch from loved ones. I also made certain to share this observation and practice with my nursing colleagues to make us all sensitive and aware so that we could provide consistent access to Joe for his family.
Eventually Joe began responding to the care, medications, surgeries, therapies and, I believe, to the presence, touch and love of his family, to the point where, thankfully, he became awake, responsive and even seemed to recognize his family. He even smiled at me sometimes. This was a significant sign of change and improvement for his family to witness, but especially so for his mother and girlfriend. It instilled hope and optimism in them and also gave me a sense of immense satisfaction, since I had my doubts that we would ever see that day.
In Joe's case, and for every patient I have the privilege to care for, a simple smile means more to me than almost anything else I can imagine. I feel a sense of connection and even validation that somehow, some way, I gave this person, my patient, something more, something beyond treatments or medications that made a difference. I gave them something deeply personal that I can't measure, document or define, but I choose to believe that whatever it is, it is powerful and beneficial. These are the moments when I know I made the right decision many years ago to become a registered nurse.
As nurses, we walk a fine line between clinical knowledge and emotional dimensions when caring for any patient, but in my case, especially with the critically ill like Joe. We know the nuances and can measure probability of recovery using numbers and scales. Families have emotional ties, memories of the past, hopes and dreams for the future. As clinical staff, nurses have to be realistic but also find an authentic way to offer families a glimmer of hope, optimism and room for their faith. While trying to help our patients and their families, we all have our own worries that lurk in the back of our minds. Mine is always with my son in harm's way. We also have our own faith. We all believe in something bigger than ourselves.