From The Floor
Memories of Caring for Burn Patients in the PICU
What do you do when an airplane crashes onto your small patient?
Unlike graduate nurses of today who have a specialty in mind, nurses from my generation worked in all areas of the hospital before settling into an area of practice. This is how I came to have some touching experiences with burn patients.
Many years ago, my husband who was serving in the Army was stationed at Ft. Sam Houston in San Antonio, Texas. I found employment at our local hospital, Bexar County, and was on duty the day a young boy was admitted to our PICU. Since he presented with burns over 95 percent of his body, his prognosis was grim.The child was simply in the wrong place at the wrong time: He had been sent to the corner market to get cigarettes for his mother when a Navy plane crashed from the sky causing, catastrophic injuries and burns.
We all knew that his stay with us would be short and worked hard to provide him with what palliative care and kindness we could for the time he had remaining. He was placed in our unit’s one-and-only Circo-Electric bed which offered him a modicum of relief, but what really helped was the medically-induced coma we kept him in as we debrided and treated his burns.
The coma was a godsend for the patient and the nurses treating him, but did little to help his grief-stricken mother who was tortured by guilt. She had sent him out on an errand to fetch her a package of cigarettes when tragedy struck.
Of course the irony of the situation wasn’t lost on us. It served as a potent example of the “evils” of smoking. When you’re a nurse you see many horrific examples of life gone awry that become cautionary tales. My children knew at an early age that fireworks would never be used in our household to celebrate either the 4th nor 14th of July — not after I treated my very first pediatric patient who’d lost fingers to an exploding firecracker.
There’d be no flicking of rubber bands at their siblings either, not after I cared for a little boy who lost an eye due to a rubber band that missed its mark. And so forth.
The medical team, many of us parents ourselves, did our best to console this guilt-ridden and grief-stricken mother. We made sure she received counseling from our in-hospital counselor and provided other resources while we made her son as comfortable as possible.
His medically-induced coma allowed us to treat him without him reacting in pain, and I was thankful for that each time I had to change a dressing, apply the Silvadene cream to his entire body, and ensure that the Circo-Electric was turning as required — but little prepared me for the day he woke up.
I’d started my shift that night as I normally did, took report and reviewed the charts. Then, as was my habit, I checked in on each of my patients to make sure all their questions and concerns were addressed at the beginning of my shift. I think that by spending those few moments with them at the beginning of the shift they were left with a sense that their nurse was “on top of everything” and were more confident that I would be proactive rather than reactive to their needs. Thus, my patients and their parents did not feel the need to constantly use the call button to summon me.
It was my practice to save our burn patient for last, in part because of the emotional toll it took on me, and to clear time on my schedule to focus on his care. Due to his complicated treatment regime, we worked in pairs.
My teammate and I found him “asleep” and prepared the trays to debride, gathered medications that needed to be administered and test tubes to draw blood for various physician-ordered tests. Working around the Circo-Electric bed was always a ballet since its huge frame seemed to engulf the room. A normal PICU room with all its essential equipment and a Circo-Electric becomes more of a sardine can than a patient’s room. Nonetheless, masked and gowned we carefully moved around the bed, paying attention to stop and focus when the bed rotated.
I don’t remember which one of us accidentally jostled the bed that night but the results were dramatic. The patient’s trach tube dislodged and quite suddenly, the boy awoke and with a croaking, smoke-damaged voice demanded to know what we’d done to his throat. His question, needless to say, caught us off guard and time seemed to stand still as the magnitude of the event sunk in — a child in a medically-induced coma was speaking! Unfortunately, these would be the first and last words he would utter as he succumbed to his grievous injuries shortly afterwards.
Bracing for the Inevitable
Nurses know that there will be cases where there are not enough heroic measures in the world to save a patient that is in a medical condition that is incompatible with life. We do our best to make their limited time as pain-free as possible, we provide comfort and support to their loved ones, and try to brace ourselves for the inevitable outcome. We know some patients have zero chance of survival, but our hearts still break for the loss of life, especially when the patient is so young.
I’ve never forgotten that boy who went out one evening to pick up a pack of cigarettes for his mother only to be hit by a plane falling from the sky. I also decided that I probably was not suited to work as a burn unit nurse.
Of course, this doesn’t mean that I didn’t treat other burn patients during my long career. I’d often find myself assigned a patient with burns deemed more appropriately cared for in a PICU setting rather than the more high-acuity needs of the specialized burn unit.
Many years later while living in Columbus, Georgia it would be another pediatric burn patient that would teach me an invaluable lesson in personnel management.
It was nearly Christmas when we admitted a six-year-old girl suffering from burns over 60 percent of her body. I was head nurse in the PICU. Poverty left her family without gas or electricity, so the parents had brought a potbelly stove into her room for heat. Her proximity to the stove’s heat caused her pajamas to catch fire. She was just one of many children who was injured or died from pajamas that melted on their bodies. Today there are regulations that require that children’s pajamas be made from non-flammable materials, but this was not the case in the early 1970s.
She was a very cute little girl and everyone on the nursing staff enjoyed caring for her during their shifts. Considering the magnitude of her injuries, she cried and complained very little. There was one area of her care where she did resist: eating. She wasn’t a picky eater but she made it clear she preferred to have me feed her. Since I was the head nurse and had no patient assignment, I could devote extra time. I soon found myself her “dining companion,” a duty that I must admit I enjoyed.
The flaw in this routine revealed itself during the first day I was away from the PICU attending a multi-day conference in Texas. The nursing team thought that they’d be able to convince our patient to eat if they just cajoled her enough. Unfortunately they didn’t count on her stubborn streak, and it wasn’t long before they were embroiled in full-fledged hunger strike, forcing me to come home early so I could feed her. This experience lead me to conclude that we should not allow our patients to become “nurse dependent” rather than “care dependent.” So from that point on, we established a policy in our PICU that no one nurse would become a patient’s sole provider.
She survived the critical first days following the accident, and spent months as a patient in our NICU undergoing multiple surgeries and battling infections, but finally succumbed to her injuries. It wasn’t long thereafter that federal regulations were passed requiring children’s pajamas to be fire-retardant.
I know many nurses who are quick to admit they could never work in the PICU or NICU, and for those of us who are PICU/NICU nurses we can’t imagine any other specialty. However, the same goes for me after the experiences I’ve shared here. I feel that Burn Unit nurses must be answering a very special calling because I can’t even begin to imagine caring for burn patients on a daily basis, knowing how much those two small patients suffered.
We are in a career where the plethora of nursing specialties allows us to practice in an area that suits our temperament. Each individual can find his or her “reason d’être” — the reason for choosing to become a nurse.
Geneviève M. Clavreul RN, Ph.D., is a healthcaremanagement consultant who has experience as a director of nursing and as a lecturer of hospital and nursing management. She can be reached at: Solutions Outside the Box; PO Box 867, Pasadena, CA, 91102-2867; tel (626) 844-7812; email@example.com.
This article is from workingnurse.com.