Wound healing has taken on a broader meaning to me as an ICU nurse at the Tampa (Fla.) General Hospital Regional Burn Center. The healing our patients strive to achieve means not only the physiologic process of wound healing, but also integrates the holistic concept of the interconnectedness of the body, mind, environment and spirit. This concept also extends to our patients families.
Some patients conditions are so critical and unstable that you become immersed in their care as soon as you cross the threshold into the ICU. This was the case in caring for a gentleman named R.L., who was in his early 70s. He suffered deep burns to over 80% of his body when superheated gasses seared his lungs as he attempted to re-enter his house to rescue his wife from a fire. As I took over R.L.s care, a breathing tube was in place and he was on full ventilator support. Two medications along with intravenous fluids were infusing to support his blood pressure. Long, shallow incisions to his arms, legs, chest and abdomen had been made to restore circulation and alleviate the tourniquet-like effect of the deep, circumferential burns.
In response to a burn injury, blood vessels lose their patency and allow fluid to leak into the surrounding tissue causing a fluid shift. R.L.s skin was so compromised by the burn injuries and incisions that it was unable to support one of its vital functions to prevent fluid loss. His dressings and bed were so saturated with fluid that it dripped from the bed sheets and pooled on the floor. I set up a bed drainage system and inserted two suction catheters under the patient. Within minutes, more than two liters of drainage filled the canisters. The greatest initial threat to anyone suffering a major burn is hypovolemic shock, so it is crucial to evaluate and respond to all forms of fluid loss. I responded by increasing his intravenous fluids to account for the additional drainage.
R.L. continued to have difficulty maintaining his blood pressure despite my adjusting his vasoactive medications and infusing substantial intravenous fluid boluses to counteract the fluid loss. A third blood pressure medication was started, but it was not long before it also reached its maximum dose and the first of four codes was called by mid-morning.
R.L.s family arrived at the hospital shortly after the first code and received an update on his prognosis and treatment options. The family continued to want everything done despite R.L.s extremely poor prognosis. The chaplain, whose presence was invaluable, brought the family to the patients bedside. The family chose not to come into the room, but congregated at the doorway, silent. Lying in the bed was someone they hardly recognized and, conversely, someone I did not recognize when shown a picture of R.L. and his wife by his family. I explained to the family that R.L.s extremely swollen appearance was a result of the burn injury and the intravenous fluids he was receiving to sustain his blood pressure. It was obvious that the moment was visually and emotionally overwhelming for the family, but the explanation seemed to reassure them. They watched as I feverishly replaced bags of fluids, emptied canisters and titrated analgesic and sedative medications to keep R.L. as comfortable as possible.
As the day progressed, R.L.s condition deteriorated even further. Late in my shift the fourth code was initiated. R.L.s family members returned to his doorway as they had the two previous codes. However, he failed to respond to the resuscitative efforts and passed away. R.L.s family members lingered at his doorway for a few moments then left after thanking the staff for the care they provided to R.L.
Many of our burn patients are with us for weeks or months, which enables us to engage with our patients and families in a personal relationship. We understand the context of the patients life, recognize his or her uniqueness and assist the family to become participants in the patients care. As nurses, we not only care for the patient, but also the patients family. At the end of a physically, mentally and emotionally exhausting day, I knew I had done all I could to respect and fulfill the familys wishes that, in spite of his clinical picture, everything be done for R.L. Even though R.L. endured a difficult death, I could only hope he knew how relentlessly I fought for him and that he was cared for with respect and compassion. I was also hopeful the familys presence at the bedside allowed them to comprehend the seriousness of R.L.s condition and, knowing that everything possible had been done, eased their grieving and started to heal their wounds.