Life in the Cardiac Surgery ICU
I started my first shift in the prestigious and prominent London hospital on the river. I was stationed on the 8th floor with panoramic views over the capital. As you walked the perimeter of the floor, the views of Big Ben, London Eye and St Paul’s Cathedral soared imposingly towards you, reaching but not quite meeting the height you were at. Even the usually murky Thames glittered in the sunlight, and you could see the tourist citycruises and police speedboats meandered up and down the river.
It should have been picture perfect, a dream viewpoint for tourists and locals alike. It’s the sort of place you’re expect to grab a drink or a meal, wind down and just live in the moment. I, however, was in the Cardiac Surgery ICU at St Thomas’s Hospital.
My first day was a bunch of funny feelings I don’t think we would get working anywhere else. ICU is where I expect the sickest patients, those who may even be on the brink of life and death and the emotional challenges which come with it. This was different. Very different. This was happy.
Let me try my best to explain this…
Imagine a little old lady with her shopping trolley trying to balance standing as she walks towards her bus seat? Or do you remember your once active grandad now hunched over a zimmer frame, making the slowest progress around the park you took them out to. It’s a sad picture. You find it difficult to watch and you feel a pain for what once was, now lost.
Now imagine Usain Bolt, or any a professional athlete sprinting down the 100m. The activity they have just done is a million times more strenuous than walking to your seat on the bus. But you were upset it watching your frail granny doing something something simple like walking, but had joy watching an athlete sprinting.
To a doctor, Cardiac ICU is a bit like the Usain bolt doing a sprint analogy. The patients who undergo a major cardiac surgery are fit. They were selected so that the odds were in the favour, they were selected because they would survive and recover and come out stronger even if the aftermath of the surgery may be tremulous.
Every shift I come one, my heart fills a little bit more. I know how the trajectory is likely to go.
The first day post cardiac surgery after extubation (the time when the tube they use to artificially ventilate the lungs during surgery is taken out), they may be a few blips. They may need some high-flow oxygens to help re-expand their collapsed lung after a general anaesthesia. They will naturally by in pain, but that can be helped with a good going “pain pump.” This is a little syringe which delivers morphine to the patient, and they can press a button if they need more pain control and titrate their pain needs until they are comfortable.
But the most striking of all is that on day 1, they don’t look like themselves.
They have lines, wires and drains poking poking out of them. They have a line in their neck, it’s like a large cannula with multiple ports (“the central venous catheter”) to have medicine delivered and blood tests taken. They have a line in their artery on the wrist to constantly monitor their blood pressure. They also have electrical wires sticking out of their chests which are used to pace the heart rhythm in case it goes into an abnormal beat. They have ECG leads monitoring their beat, a blood pressure cuff and a little finger probe to measure their saturations. They have chest drains to collect any excess post-surgical fluid. They have catheter to monitor their urine output to make sure their kidney are happy and also because with all that is going, there is no chance they will be able to walk to the bathroom at this stage.
With so much going on, it’s hardly surprising that all the medical accessories – the tubes, the drains, the wires – which help keep them alive after the heart surgery, also imprison and confines of their hospital bed. There is a lot of raucousness and clatter, the constant beeping of the monitors. They look small and drowned in all the medical paraphernalia around them.
But then comes a new day, the second and the third, the sun begins to shine a bit more
Their breathing settles, their pain improves. They edge out of the “danger zone” post-surgery and their heart rhythm begins to stabilise. Their pacing wires and neck lines and drains are removed. It’s a breakaway from the tubes. The unit in which they exist becomes more of them and less of the hospital. Their smile comes out of the wires previously restraining them and their strength begins to build.
They beam as they sit in their chairs, a position and luxury which they couldn’t manage just 2 days back. Just last a week patient stopped me as I walked past her bedside on my way to the doctor’s desk. I thought she needed something – painkillers or an extra blanket. But she had smile pasted on her face and she said, “We both feel so goooood”. I didn’t know who she was referring to with the “we” and so I replied asking “I am so glad you’re feeling well but who else is?” She nodded to the patient right opposite her who was also waving back at me, her eyes twinkling. “We both started together downstairs, in theatres and recovery, and we both now feel so good.”
Stories like these makes your day worth more. The rise to greatness, the rise to strength of your patients inspired and motivates you to do more. The Intensive Care Unit is exactly that – Intense. The ward round which normally takes place once a day happens three times a day. The constant tweaking and shuffling of treatment plans, monitoring of patient’s physiology requires that level of care. But instead of bracing ourselves for new deterioration, or a confirmation of a losing battle we very desperately hoped we could overcome, in a Cardiac Surgery ICU we came to expect good news.
An improvement, a rally, an upswing.
Of course, to our cardiac surgery patient is must feel overwhelming, like there is no light at the end of the tunnel. It must be a huge emotional dip on day 1. But with that, comes an equally remarkable elation when they feel like a whole different person, or a lot like their “old self” rather in a short space of time. And it feels magical to experience this road to recover with them, over and over again.
However, complications post-operatively are a part of the process and each patient’s journey is unique. In the odd occasion when things go south, it can go really bad. If these patients have a cardiac arrest, the resuscitation algorithm that have been ingrained in our muscle memory, the action plan that we as doctors and nurses find second nature does not apply. You simply cannot do chest compressions on a patient who has had a heart operation in the last few days. The surgeons use metal sutures to hold the sternum (breastbone) back together following cardiac surgery. Pressing on the chest means these sharp metal sutures dig into the heart and lacerate the heart muscle and you ABSOLUTELY do not want a torn heart – I mean this literally, not metaphorically. For this reason, the “Chest Opening Trolley” is always stocked and on standby. If a post cardiac surgery patient arrests, you physically have to re-open the chest, undo the sutures and pull back the breastbone, as soon as it deemed necessary to explore, control and reverse what may have gone wrong. This is scary stuff, and thankfully in my time here we have never had to do this on the unit, so for me it had largely been happy success stories.
So, you know maybe you can say my days in Cardiac ICU were not the depressing you would expect from an ICU. I could enjoy the london city vistas, sip back on my daily dose of caffeine and watch my patients recover and get brighter, day after day.
I have wondered if a good view can shape your experience of one’s monotone routine, so that your daily life feels colourful, more alive!
When it comes to vacations and weekends, I am an absolute stickler for a good view. I scrounge for the best restaurants on rooftops with city’s skyline rocketing in the distant, or a café on the waterside promenade where a quiet tranquil river stretches for all the miles your eye can see. I love to sit by the edge of the cliff and hear the waves gently embrace the sand. Nothing beats the feeling of warming my hands on a hot cuppa and watch the sun set over snow-capped mountains. It is as if the natures grace and beauty tumbles through the eyes to restore the soul, calm the mind, swell the heart. I would willingly pay a premium for it, and I bet so will most of the rest of the world – after all isn’t that why people go on holidays. This quest for searching a picturesque scenery is universal.
But as a scenic cityscape was thrown into my usual mix of whitewashed hospital and blue curtains, I wondered if the power of a good view is healing beyond just the time-out periods. Granted I was lucky, my ICU patients have so far always recovered, my team members are fabulous, we aren’t usually pressured or short-staffed. Most importantly, there is always a box of M&S shortbread, Belgian collection, or Percy pigs for us to share on the table. However, work is work. It’s not your Friday evening, or a Sunday lunch and it is definitely not a holiday.
So, I got digging to try and answer can your environment’s beauty have a therapeutic impact in the most unusual scenarios?
The answer is, yes to absolutely. Whether you are a staff member working in ICU or a patient recovering from a major surgery the healing power of nature is all encompassing.
Stay tuned for my next post where I explore the scientific basis of the healing ability of nature!