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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.

Nurse Megan Quick, above, is one of a select group that makes up the PICU transport team. The team travels by ground, helicopter and sometimes fixed-wing aircraft to regional and community hospitals to bring children to Hopkins for specialized care. There are more than 1,000 transports to the PICU a year, sometimes 100 a month. "Usually, the hospital has a helipad, but I've landed in parking lots," says Quick.

Medical director Ivor Berkowitz, left, says the variety of patients on the PICU-a mixture of cardiac, oncology, transplant, trauma, neurologic and abuse cases-makes his unit unique among Hopkins' intensive care units.

by Anne Bennett Swingle
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.

This infant's heart is fine; it's the lungs that have not been responding to conventional therapy. Now the ECMO will fill in for a ventilator, which, if used for too long, delivers dangerously high levels of oxygen to babies this young. It will turn around a case of life-threatening respiratory failure.

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.

The unit serves 1,000 patients a year, mostly from Maryland but also from across the country. Recently, there has simply not been enough room to care for all the critically ill children. On and off over the past 12 months, the PICU has been on "fly-by," meaning that helicopters ferrying trauma patients cannot land on the helipad. Furthermore, as nurse manager Claire Beers explains, there's been no "surge space" in winter when serious respiratory conditions peak or in summer when kids are particularly prone to accidents.

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."
On this day, nurse Irma Zerbe, a 13-year PICU veteran specially trained in cardiac care, is following a 13-year-old who's just had surgery to repair his heart. There's almost always a cardiac case on the PICU, in part because every child who has had heart surgery is sent here automatically from the operating room.

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."
The scene is typical of what everyone who works on the PICU describes as their "collaborative" culture. For those who love it, the esprit de corps makes the tight quarters more tolerable.

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.



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