24 Hours on Cardiac Critical Care:

24 Hours on Cardiac Critical Care:

There is no real typical day when working on critical care. Each one has the potential to be heartbreaking or heartwarming, exhilarating or exhausting, inspiring or soul-destroying, or even all of the above. But as the future MDT, upon setting foot on intensive care, it is important that we are prepared to deal with whatever that day throws us; demonstrating our most important skills and qualities, whether that be emotional resilience in the face of some of life’s most cruel acts, or communication as we work as a team to ensure optimum patient care.  

Having spent 6 weeks working as part of the cardiac critical care team at the Queen Elizabeth Hospital in Birmingham, I have not only learnt the importance of the work that we do in this particular area, but also grown to love it. 

Each MDT members day will be different, but below is an example of one that I, as a student physio, experienced and the lessons it taught me. 

On this particular day I got in early to do the morning intensive care area handover. In short, I was required to go round each bed space and speak to the nurse, getting an update on how their patient was doing, if there were any changes, and what the plan was for the day ahead. 

TIP 1: Use the nurses to your advantage! On critical care patients have 1-1 care and that nurse knows it all - the medication that patient is on, how that patient is feeling, the list goes on.

Having done this, I would head back to our staff base and feed this back to the rest of the physiotherapy team. This would also help with patient allocation and prioritisation. Being a Tuesday, it was also the day of transplant meeting (the QE has a large transplantation service) whereby each patient who is either on the transplant list, or post-transplant is discussed, with members of the MDT feeding back and a plan of action being put in place. The designated physio then reported back to us at our handover. 

TIP 2: Take advantage of opportunities! I was fortunate enough to observe and take part in a transplant meeting. It allows you to practice communication and to be involved in the whole of your patients’ treatment. Wherever your placement is, it is likely to have a specialty, make the most of this whilst you can as you may not have the opportunity again. 

And then the day would begin properly. I would be split across three wards; intensive care, the cardiothoracic ward and cardiology ward. Firstly, would be to prioritise my list. Which patients are new? Which require chest physio? Who are the transplant patients? On this day, I had a new patient on intensive care. As an AVR they were a screen (we had a screening tool whereby you would check the risk factors and decide whether they were appropriate for physiotherapy). As a current smoker this patient screened in. 

Next, up to the wards. First up was one of my long-stay patients who was a post-bilateral lung transplant. She had been told that she would be ready for discharge by the end of the week. We went for our daily walk down to the atrium to buy her a paper, stopping on the way back due to some shortness of breath, and to have a chat. 

TIP 3: Remember that patient care is holistic! When working on ITU it is crucial to consider the patient as a whole. Having someone with so many attachments and tubes, hooked up to a ventilator, unable to communicate can sometimes take the humanity away from a person. Although this patient was now very much clear from all of that, combining her treatment with something more functional for her was much more successful than merely putting her on an exercise bike.

11am = morning coffee break! Heading back to the staff room to have a welcome coffee and to catch up with the rest of the team was always a highlight in the day. It was a chance to hear about how other patients were getting on and to discuss any theories or problems you had. 

TIP 4: Use others’ experience. Whatever team you find yourself working in, there will be wealth of experience. Ask the questions, discuss your knowledge and show an interest. It can be really inspiring hearing some of the more senior professionals’ stories and life experiences.

Back to critical care where myself and my educator had an LVAD patient to treat. This patient had a tracheostomy and required some extensive treatment. I was able to put some theoretical skills into practice, being guided through manual hyperinflation for the first time. This patient did not respond well to physiotherapy; he was despondent and refused some parts of treatment. Intensive care can be frustrating; patients conditions can change in a second and the psychological impact can have huge effects on the care they require and are willing to partake in. 

TIP 5: Be flexible! You cannot expect your exact treatment plan to be suitable every time. Whether a patient refuses treatment, or their condition not allow for it, it is vital that you are able to consider alternatives. 

With one of the other critical care units being short-staffed, my educator was asked to go and assist with a patient. As it was a burns patient, we agreed it would be good experience for me to go with her. I mainly observed this session, but it was interesting to witness treatment in a different environment and a patient with different needs to those I had become accustomed to treating. 

TIP 6: Don’t be afraid to step outside of your comfort zone! Intensive care will offer a variety of patients; even if you are on a specialist area, patients with multiple conditions may be admitted, or, as I was, you may be required to display new skills. We would often have patients with cardiothoracic needs who also required some neurological physiotherapy, for example. Ultimately, critical care is never straightforward!

1pm = lunchtime! Today I went down to the canteen with two of the other physios and we took our lunch outside to enjoy the nice weather. 

TIP 7: Get to know your colleagues! Critical care can be a daunting and overwhelming place, especially for a student new to clinical work. Having a good rapport with those around you can help you to not only feel supported should you need it, but also to have fun and distract from the intensity of the work you are doing. 

I had two last patients to see. The first was another of the long-stay patients, a patient with a life-limiting condition. In our session she opened up to me about her low mood and worries about life, and her desire to self-discharge. This was my first experience of having to have one of these conversations autonomously. I talked to the patient about what she was thinking and used my empathy and compassion to ensure that she felt listened to and understood. Leaving her room, she was a lot happier and it seemed to have been a successful interaction.

TIP 8: Your emotional resilience will be tested. Patients on critical care have been through a lot. They have become completely dependent on complete strangers and the impact is not only physical, but also mental. The time you take to treat a patient can build a trusting relationship and so there is the potential for them to choose you to open up to. You can only do your best. Don’t worry about your lack of experience. What that person wants in that moment is for someone to listen to them. Use your empathy, compassion and innate sense of care to help them. As Maya Angelou said ‘Someone might not remember exactly what you did, or what you said, but they will remember how you made them feel’. And remember to speak to someone afterwards should you need to; it can be an overwhelming experience.

My final patient was my dementia patient. A patient where the stigma of dementia was incredibly obvious. Myself and my educator had worked hard to get him out of bed and progressing with physio, but we were faced with boundaries and a reluctancy from others to assist. Today I made sure I at least went and spoke to him and advised his family members to bring in some photos from home. I also spoke to the nursing staff about his progression and status. 

TIP 9: Don’t be afraid to speak up. As students it can be natural to assume that we don’t have a voice. If you feel that something is wrong or that something can be done, make the effort. Sometimes we spot things that others don’t, or have a passion for something that may indeed bring about change. We have the right to be a part of a patients journey. 

With the day almost done, it was just a case of getting any outstanding notes counter-signed before clocking out, and heading home. I had a long commute back, and it was during this that I found the time to reflect on the day. Sometimes it can only be upon leaving the unit that the enormity of what you have witnessed or been a part of can hit you. I found it important to make sure that I had a good work-home balance that ensured I did not overthink the day. By reflecting before I arrived home, it helped to prevent too much attachment. With a new list of conditions and treatment plans to research and learn about that evening, my day on critical care was never really over. But even after such a long, and challenging day, I can say hand on heart that I couldn’t wait for the next! 

TIP 10: Make the most of it. To many the idea of working on intensive care can be daunting, perhaps even terrifying. We are well aware that the majority of patients are critically unwell, and as students the fear of doing something wrong or not being good enough is not unknown. But it can also be the most rewarding area; you get to see procedures that are pioneering and ground-breaking, and see the true meaning of human life. You get to work amongst a team of people who give all of themselves to the work that they do and put their all into being there for others.

Remember, you can only do your best; it might not be easy, but it will most certainly be worth it. 

Naomi Spencer, Student Physiotherapist