Room Enough for the Sickest Children
A recent expansion in the pediatric intensive care unit is only a stop-gap solution. But not even an ongoing space crunch can stifle the remarkable spirit on teh PICU.
Photos by Keith Weller
It's been a rough morning on the pediatric intensive care unit. Word has it that a patient is "going on ECMO." Short for extracorporeal membrane oxygenation, ECMO is an elaborate though smaller version of the heart-lung machine that's used in surgery.
Getting a patient on this high-tech, high-intensity therapy is not an everyday occurrence. This is only the 21st patient to go on this year at Hopkins Hospital, the only children's hospital in Maryland that has ECMO. It's always a time-consuming procedure, but today has been particularly protracted because the circuits aren't cooperating. Now, a dozen practitioners, all gowned, backs to the door, hover at the far corner of the back room. Because ECMO involves an invasive surgical procedure, among them are two pediatric surgeons and nurses from the operating room. There's also a specially trained respiratory therapist, perfusionist and radiologist. If the PICU were a ship, it would be listing to starboard, sharply.
It takes all morning, but finally the job is done, the waters part,
and there is the patient, a tiny baby, just days old. There, too, is
the ECMO apparatus, an impossibly complicated arrangement of monitors,
pumps and sinuous tubing.
All morning long, the child's parents have been sitting in the cramped waiting room adjacent to the elevator bank. Soon they'll be summoned to the bedside. A social worker and Child Life specialist are on hand to ease the way, because nothing these parents could have learned about bringing up baby-not anything their obstetrician could have told them, not any child-rearing book they might have read-could have prepared them for the measures that would be required to save their child's life.
The PICU is the kind of place no parent ever wants to go to, unless
the unimaginable happens, and then it is the only place a parent wants
to go to. There is no other place like it.
To ease the pressure, the PICU opened six new beds in November, bringing its total to 22. What's more, two new monitored beds on CMSC 4 and three others on CMSC 9 now are reserved for patients transferred off the intensive care unit. In addition, PICU nurses no longer have to staff a patch of intermediate care beds set up on CMSC 6. Now, the 6th floor nursing staff attends to them.
Still, the jockeying is a Band-Aid approach until the new children's
center opens in 2007. Even the PICU's six new beds were squeezed into
a less-than-perfect space; they are separated from the main unit by
a hallway and an elevator shaft. Thus, nurses here have to be able to
practice with a fair amount of independence on their patients, who are
typically slightly less critical.
Because of its mix of occupants, the PICU is unlike any other unit in the Hospital. Patients range from tiny infants, just days old, to hulking, 18-year-old college students. Half are medical cases; half, surgical. They might have cardiac disease or cancer, kidney disease or neurologic problems. Some have serious infections, are awaiting transplants or-considering that the Children's Center is the regional pediatric trauma center-have life-threatening injuries. Some patients have suffered terrible abuse; the older ones may have attempted suicide.
Unlike the hospital's other intensive care units-the surgical, medical or cardiac intensive care units, for example-the PICU is not "specialty-narrow."
"We have a mixture of different kinds of patients," explains
Ivor Berkowitz, PICU medical director, "and that's what makes it
challenging and satisfying."
Three other cardiac cases also are on the unit, among them a 1-year-old who's rapidly deteriorating. Zerbe senses the level of anxiety rising. "When the acuity is high, it sets the tone for the day," she says. "We know what we're doing, but we can't predict what the child is going to do. And that not knowing is what steps up the pace."
This child is from another state. Arriving at Hopkins, the parents had a hunch he would be admitted to the hospital. But the PICU? They'd never seen anything like it. Like many parents, they'd been accustomed to the private rooms and comfortable surroundings of a community hospital. The PICU is an open unit with little if any privacy. Plush it is not. Day and night, the lights are on, the call system squawks, an endless phalanx of doctors comes through.
But the PICU has a luxury few other hospitals enjoy. The staff can
call on highly trained people in a host of different medical specialties.
A cardiologist is following this 1-year-old, but the minute-to-minute
care is provided by the PICU team, which consists of the attending (a
responsibility shared by six full-time faculty, all in the division
of pediatric critical care and anesthesia), the child's nurse, two fellows,
four residents, two respiratory therapists, a pharmacist, a nutritionist,
a social worker and a Child Life specialist.
Pharmacist Mike Veltri, a clinical specialist, tells himself that the child's problem is drug-related until proven otherwise. It's a mantra that makes sense, considering that the average PICU patient is on 10 different drugs. Veltri taps out a prescription on his new wireless computer, and seconds later, down in the pharmacy, the label prints out and the medicine soon is on its way.
Meanwhile, to aid the parents, the social worker has found a temporary
apartment and ironed out byzantine insurance matters. The Child Life
specialist will help them find the words to explain to siblings at home
what's meant by "getting on the transplant list."
Certainly it would be nice if the unit's sole meeting room, hard by the nurses' station, was bigger and better appointed. Inside this tiny space-one that's often used when doctors call family meetings to discuss a change in prognosis or in the care plan-are three chairs, a table, a lamp, a Bible and a breast pump. People who work here fantasize about the most basic amenities: a conference room, a spacious waiting room, an up-to-date nurses' station, ample storage space. The new children's center will solve these problems (for the PICU, 40 beds have been requested). For now, as the PICU resolutely goes about its work-marshaling all its dazzling expertise to save young lives and bring solace to families-amenities will have to wait.