By Elizabeth Cloutman

Extensive medical knowledge, empathy and inner strength are essential

Nursing has always been a challenging profession. Nurses spend long hours tending to the urgent and most intimate needs of patients who are ill, incapacitated or reaching the end of life.

In today’s modern hospital, nurses face even greater challenges. They must learn about increasingly sophisticated medical equipment and an ever-growing array of new medications, coordinate patient care with physicians and specialists, while they continue to administer to the emotional needs of their patients and their families. In the critical care unit of El Camino Hospital, nurses also need to be conscious of cultural differences.

“It’s a job for someone that’s assertive and compassionate - and a sense of humor is essential,” said Pat Reardon-Pagano, the clinical manager of the El Camino critical care unit. “We’re on the firing line for medical ethics, the patient, the family, technology. When we lose patients, there can be a tremendous amount of sadness and guilt, feelings of failure. We feel very responsible for patient outcome.”

Reardon-Pagano said that nurses also put their own health at risk, from the constant exposure to patients. “We’re working with AIDS, hepatitis, sexually transmitted diseases, infections and resistant bacteria.”

Patients in the 16-bed critical care unit at El Camino are most often those with respiratory or cardiovascular problems, as well as some with critical neurological conditions. They are monitored for blood pressure and blood oxygenation, heart and respiration rate. They may have intravenous medications or special feeding tubes.

Some may also need special equipment such as respirators, pacemakers or a new kind of kidney dialysis - continuous hemofiltration - for patients with acute renal failure who have unstable blood pressure. The intra-aortic balloon pump is a new device for patients with severely blocked arteries or heart failure, which is inserted into the aorta through a catheter. Intra-aortic balloon pump therapy helps restore the balance between the supply of oxygen-rich blood the heart receives from the coronary arteries, and the amount of oxygen the heart needs to pump.

Nurses need to have an understanding of how all this equipment works. “If something goes wrong with this equipment, we have to know how to deal with it,” Reardon-Pagano said.

Nurses must also coordinate patient care with physicians - one patient may have a general practitioner and one or more medical specialists. Nurses must also work with pharmacists and ancillary caregivers, such as nurses’ assistants; respiratory, dialysis and skin specialists; X-ray, cardiac and lab technicians and dietitians to meet the patient’s needs.

Pharmaceutical companies issue a constant stream of new medications that nurses need to know about. “You don’t ever feel you’re on top of drugs,” said critical care nurse Barbara Callens.

Callens said chronically ill patients often return to the critical care unit. “Even though the patient eventually moves out, many of us know they’ll be back … They’re tenuous.”

Patients - and their families - often have to make decisions about the end of life. Nurses, as well as physicians, may offer advice. “When the body says it’s time to go, not even high-tech can keep them going,” said critical care nurse Ilana Shafir. Unless there is an advance care directive, end-of life decisions can frequently involve a patient’s extended family. “There’s a whole community that comes with a patient,” Callens said. “Families are not all necessarily in the same town. Trying to get everyone in touch is difficult.”

In addition, cultures can view Western medicine and death in varying ways, Shafir said.

Stress can take its toll. “While we have to face it with our patients, we don’t have time to deal with our own grief,” Callens said. “That has to be tucked away in a little box to deal with later. It doesn’t seem like there’s really a closure - and then a sicker patient moves along.”

Fortunately, El Camino has critical care debriefings for the nursing staff, led by Maryellen Garnier, the hospital chaplain, and social worker Marilyn Reagan. “With nurses, it’s a new thing. It used to be, you were expected to ‘buck up,’” said Reardon-Pagano. “Now, we understand it’s okay to be devastated.”