Spring 08
Vol. 15/ No. 1

Katie Merrill
RN-BSN student and MU staff nurse

In the week after the attacks on the World Trade Centers in New York City, a call was put out to burn centers across the country for experienced burn nurses to care for the injured admitted to the Hearst Burn Center at New York Presbyterian Hospital in Manhattan. This exemplar is a recollection of the care I provided to one particular patient and her family.

Mary was a 40ish Catholic lady of Italian ancestry. She had a short little mama who was not quite as wide as she was tall and an aunt who was very similar. An uncle, a sister, and a brother were all at her bedside every day that I was there and no doubt, every day she was at the burn center.

Her life story was told to me by her devoted sister who talked kindly to her, urging her to fight on and get well even though she was not conscious any time that I was there. I encouraged her to do so.

I talked to Mary also; as I turned her, when I dressed her wounds, and when I suctioned her. She liked to listen to Barry Manilow and Bette Midler I was told, and so, in the middle of the night, we would put on the CD player, and I would belt out Manilow and Midler tunes as I titrated her vasopressors, changed her soaked linens, and hung her many medications.

I don't know that she ever heard me, but I don't know that she didn't and if there was indeed some part of Mary in that very ill body, I wanted her to know that someone was there all the time.

Mary was waiting for a bus outside WTC Tower 1 when the first plane hit the building. She was covered with jet fuel falling from above, so her approximately 95 percent burn was both chemical and thermal.

The nurses at Cornell told me initially, they took turns taking care of her, because the jet fuel odor was so strong in the first few days that they were becoming ill.

A nearby man helped her into the second tower. She asked to pray with him because she told him she thought she was going to die. They prayed together and then the second plane hit the second tower. The man helped her out of Tower 2 and onto the street which, of course, was full of chaos.

He helped Mary into an ambulance and with a presence of mind, was able to get her name and relate her allergies to the emergency medical staff. Mary's family didn't find out where she was until later that night. They were relieved to find her on the same day, and it was a blessing that they did, because she was quickly unrecognizable and unconscious.

The man who helped Mary located her several days later. He visited with her family and assured them that he thought she would live. He believed that, because on one of the planes that had crashed into the towers were his sister and nephew. It was a cruel coincidence. They had died and she had to live. Her family grasped that hope and so did I.

I took care of Mary in the sixth week after her injury, the last week of October 2001. It was surprising to me that she had survived that long. Her injuries covered over 95 percent of her body, sparing only part of her scalp and the soles of her feet. She had had a number of operations to excise necrotic tissue and cover with a variety of skin substitutes. Her remaining body was nearly skinless, purple, and bloated.

She had a large dressing change daily and frequent linen changes due to the body fluids and silver nitrate solution that kept her bed saturated. She was fed intravenously as her GI tract had shut down, given lots of fluids to replace the massive amount she continued to lose through her non existent skin, and ventilated with a machine.

She was supported with vasopressors to help keep a semi-normal blood pressure. She had many antibiotics and various other medications administered around the clock. She was kept sedated and comfortable with fentanyl and ativan continuous infusions. She was an overwhelming medical and surgical challenge.

Each night before Mary's family left for the evening, her sister prayed with her. Mary had countless prayer cards, get well wishes and other messages all over her walls from people she knew and many she didn't from all over the country. Her sister had a ritual of pulling certain prayer cards off the wall in a certain order, praying, and then anointing her with holy water from Lourdes and Fatima.

I got in the habit of pulling the cards and handing them to her to help. Then I would find a small area of unharmed skin to uncover for her to touch with her own hands, sister to sister. I think they appreciated me participating in their prayer, but I was honored that they included me. I felt I was a part of their family for just a short time.

The last night I was there, I arrived to find that Mary had had a particularly bad day. She had coded several times through the day and was very, very ill, although still alive. I received report from the off-going nurse and assessed the situation. From all the obvious and less obvious signs, Mary was dying and would die for the last time on my shift that evening. I would do my best for her and her family, but her time on this planet was coming to an end.

I met with her family and discussed the situation. Through their faith, they still had hope and wanted us to proceed as best we could. I asked the attending and the resident to be available quickly should we need their assistance at short notice.

Although the attending did not know me personally, he knew I had come from the University of Missouri Burn Center and had worked with Dr. Terry for more than 10 years. He knew Dr. Terry well and this information gave him enough confidence in me that he directed the resident to listen closely and respond promptly to my requests.

Shortly after that, Mary coded again. She had no heart beat, no blood pressure, and no spontaneous breathing. We immediately initiated ACLS protocols and did everything we possibly could to preserve her life. Her family was at her bedside and they begged us to try to bring her back. They were on their knees, begging God to save their Mary, and crying out to Mary to “stay with us”, “fight Mary, we need you."

We administered medications and shocked her wounded heart through tears and she came back, but only briefly. Shortly after that, Mary died for the last time. Her family sobbed and so did I. After awhile, I think they were comforting me more than I was comforting them. They thanked me for my care of her and her little Italian mama gave me the holy water from Lourdes to take home with me to Missouri.

Reflecting back upon this experience, I would characterize myself as an expert on the novice to expert continuum (Benner, 1984). I used more than 10 years of critical care and burn experience to coordinate the care of a patient with burns over 95 percent of her body.

I was required to balance the intake and output of a patient who had lost her natural ability to conserve her own body fluids using my expertise to titrate and bolus liter after liter of intravenous solutions. I titrated vasopressors up and down to maintain an adequate blood pressure, and in the end, I initiated ACLS protocols to follow the family's wishes to give my patient every opportunity to survive.

Daily, I had long discussions with the family and explained every interaction and every intervention related to Mary's care. I tried not to give false hope, but I did promise that I would do everything in my power to give the best possible care to their loved one.

Caring for this patient required practice in every nursing domain described in “From Novice to Expert: Excellence and Power in Clinical Nursing Practice” (Benner, 1984). The two domains most represented were “The Helping Role” and “Effective Management of Rapidly Changing Situations” (Benner, 1984).

This patient was essentially a constant code. She was on complete ventilatory and vasopressor support. If either measure were interrupted, she would expire within minutes. It was my responsibility to maintain her life support and maximize it. The plan was to sustain her until skin coverage could be completed and Mary's body could start to heal itself. She was constantly in a “life threatening emergency” (Benner, 1984) requiring continuous monitoring of minute changes and skilled interventions at the appropriate times. This was practice in the “Effective Management of Rapidly Changing Situations” nursing domain (Benner, 1984).

Caring for this patient also required practice in “The Helping Role” nursing domain (Benner, 1984) . This is evidenced by the level of personal interactions experienced with Mary and her family.

Since she was so critically ill, Mary was my only patient. I was able to spend nearly every minute of my shift in the room at her bedside in support of her and her family. I spoke to her as if she could hear me before, during and after each and every intervention. I wanted her to know she was not alone. S

he had burn dressings from head to toe, so we found small areas of uninjured skin to touch so she might feel the presence of those who cared around her. My communication with her family was continuous. Every intervention, every change in her condition, and every alteration in her plan of care was discussed at length. Questions were answered and support offered.

In reviewing the care of this patient, decisions were made minute by minute. The greatest decision was made by the family prior to my introduction to the situation. They decided to pursue full care despite overwhelming evidence of futility. They chose this course because of their love for Mary and their faith in God.

The decision I made as I first was assigned to Mary's care was to be fully committed to following the wishes of the family to the fullest and support them in every way possible. This was an optimizing decision in that there were other options available. I could have declined this assignment. I could have encouraged the family to withdraw care in light of the futility of our actions, or I could have participated in the care of this patient without any personal or emotional involvement. Weighing the options after reviewing the situation at hand, and evaluating my own values and mores, my decision was not difficult.

I believe the decision made by the family and my own were both high quality and acceptable (Bernhard & Walsh, 1995). The family was advised of the extent of Mary's injuries and the probability of her demise. They were given several different avenues of care and made a difficult, but informed choice. Despite our inevitable outcome, everyone involved was satisfied that every effort was made to give Mary the best possible chance for recovery.

In applying a decision making model to the decision I made in providing care for this patient, I chose the Claus-Bailey Model for Problem Solving (Bernhard & Walsh, 1995). I prefer this model because it is logical and linear in its process. Rarely in critical care does a nurse have the time to construct a matrix or poll for opinions let alone think through a 10 step course of action as in this model. However, this method can be streamlined to assist in making good decisions in a meaningful and efficient mer.

In the first two steps of the Claus-Bailey model, the goals and then the problem are defined (Bernhard & Walsh, 1995). My goal was to provide the best possible care for this patient and her family. The problem was, despite ongoing critical and intensive care, the prognosis for recovery was nearly non-existent. The family had chosen to fight on, and I had to decide how I was going to approach their decision.

The third stage of the model compares the positive and negative factors that influence the decision. I weighed the spiritual and emotional investment the family had made against the medical evidence of the prognosis for this patient. The persons affected by my decision were Mary's family and they spoke for her.

In the fourth step of this process, I assessed the factors of step three and came to the conclusion that the family's wishes, beliefs, and conviction were more important than the medical evidence despite its overwhelming presence.

Identifying objectives is the purpose of step five and the most important objective identified in this case was to absolutely spare nothing to give the best possible care to this patient. This was a critical objective not to be compromised even if the situation changed and the family altered their choices for care. With this objective in place, any decision made by family or staff would be of very high quality and acceptability for all those involved.

Steps 6, 7, and 8 are often grouped together to streamline the decision making process (Bernhard & Walsh, 1995). This involves searching for solutions, examining them and making a decision as to what avenue to follow. In this situation, as stated previously, the decision to pursue full care was already made. The decision I needed to make was how to approach the family's decision. I narrowed my options to three choices: decline the assignment, participate in the care of this patient without personal or emotional involvement, or fully immerse myself in the care of this patient and her family fully supporting their decision to continue care. I used my personal beliefs, my new grief for the other victims of the World Trade Center attacks, and my sense of duty to decide, quite easily, to support the family's decisions with every resource available to me.

In steps 9 and 10, my decision to completely participate in the physical, emotional and spiritual care of this patient and her family is implemented and evaluated (Bernhard & Walsh, 1995) . My exemplar is evidence of these steps. I became fully involved with this patient and her family in every aspect of the last days of her life and ultimate death. Despite an unhappy and unsatisfactory outcome, this family and I were satisfied with the decisions we made.

The Claus-Bailey model is not likely to be used precisely, step by step in everyday nursing practice. Bedside nursing requires quick thinking and definitive decisions in appropriate situations. However, this model may be the closest of any to the logical thinking process that occurs at the bedside daily.

The decision on what problem solving model to use for this paper was more difficult than the decisions I made caring for Mary in New York City after the World Trade Center attacks. I became a part of a stranger's family during their greatest personal crisis during one of America's greatest personal crises. It was a life changing experience.

References

Benner, P. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Addison Wesley Publishing Co , Inc.

Bernhard, L. A., & Walsh, M. (1995). Leadership: The Key to the Professionalization of Nursing (3 rd ed.) . Mosby-Year Book, Inc.

Correct Citations

Benner, P., (2001). From novice to expert: Excellence and power in clinical nursing practice.

Upper Saddle River, New Jersey: Prentice-Hall.

Bernard, L.A. & Walsh, M. (1995). The nurse-leader and the decision-making process. In

Leadership: The key to professionalization of nursing. (3 rd ed.). St. Louis, MO: Mosby.