I first started working as a paediatric nurse in intensive care (ICU) in 2003. I was pleased to see, when moving throughout every NHS paediatric ICU in London, bar one, and into a private hospital as well as across the ocean to Melbourne and Sydney, that there is little difference between them.
As a nurse there may be different equipment to test blood, or different policies on the best way to draw up medicines, or on how to record patient details. But you often follow around the same make of ventilators and feeding machines and even colleagues.
This means that whatever unit your child, unfortunately, needs to go to you can feel assured that the information given here will be helpful.
It should be noted that not every hospital has these specialist units, so you may find you and your child being transferred some way away from home. But rest assured it is so that your child can get the best possible care and hopefully then recover back to their usual entertaining self!
Which unit will me child go to?
Neonatal intensive care is usually reserved for premature babies, or those that struggled at birth for one reason or another. It is different from a special care baby unit (SCBU) which are found in more hospitals. SCBU is where babies go to after they have graduated from NICU, or if they are not delicate enough to require NICU. These units do a fantastic job, but unlike NICU they are NOT the topic of this article.
Once your baby has gone home and into the bugs of the outside world then even at a few days old they will be admitted to the Paediartic (PICU) Intensive care unit. This often surprises families as paediatric tends to make people think of children rather than babies. But, staff are trained to care for any child requiring intensive care from birth to 16 years old.
In Cardiac paediatric Intensive Care (CICU) or Cardiac Critical Care (CCC) where children come post congenital heart surgery, or for complex medical management of a heart condition, the age range is again birth to 16 years old. But here, with the moving forward of technology and children living to adult hood with certain congenital conditions not seen by adult clinicians, I have cared for a patient as old as 24 years old. This is unusual though and it is usual for transition to adult services to start at 16 years old and definitely be completed by 18 years old.
Arriving on the unit
Which ever intensive care your child is admitted to, and whether they go there post theatre (after an operation), or from the ward, or local hospital as an emergency transfer there will always be a ‘settling in period’. This is a very stressful time for families.
Every unit has a ‘parents room’ which usually has toys for other children, a television, some useful information about the hospital, unit or people who are there to support you and usually a kitchen for making tea or coffee or warming foods. There may even be a fridge. It is in this room that family members are asked to wait during the ‘settling in period’. The time frame of this is hard to judge and rarely has any bearing on how sick your child is on arrival. Usually about half an hour I have known it to last any thing up to two hours, however, it is usual that a nurse will pop in regularly to reassure you that your child is fine. If you find yourself overwhelmed with emotion in the parents room and unable to talk, or to stop crying feel comforted in the knowledge that everyone to enter the parents room understands as they are in, or have been in the same ‘waiting’ situation.
What happens during the ‘settling in period?’
Nothing is usually being done to your child directly. The emergency team, theatre team or transfer team that was just with you have ensured that your child is stable. If alert and awake when you left them then your little one would have already been given painkillers at the minimum, but the usual picture would be that they are asleep (as they were when you left them) and have an infusion of sedation running.
Infusions travel pain free into a plastic tap (cannula) or line in their arm, foot, neck or groin and this would have been put in using a needle (that is immediately removed) before the transfer. Having had this myself I can assure you that a cannula (plastic tap) can be annoying especially if it is banged on something, or if antibiotics are given through it, but it otherwise doesn’t really hurt more than a slight bruise would if you stuck tape over it. Unlike fluid infusions which keep your child hydrated the morphine (usual sedation of choice) doesn’t even feel cold at first travelling into the vein because it is travelling so slowly.
It is highly likely that your child has also already been given a breathing tube or ETT already. This allows your child to rest fully while a ventilator does the work of breathing so that they can concentrate on getting themselves better. In order to insert one of these they would have had an extra dose of strong painkiller and a muscle relaxant which would leave their whole body floppy for some minutes afterwards. Some children are even transferred with these muscle relaxants being given continuously. This is for a number of different reasons, but also so that there is no risk of anything being pulled out accidentally by a wriggling child.
So if the clinical team are not hurting your child. What are they doing?
Firstly there will be the handover…
At arrival on the unit there will be a lot of people round the bed..
The transfer team
~ the doctor/anaethatist who has been in charge of the transfer
~ possibly a more junior doctor, or ODP (anaethatist assistant) depending on where your child is coming from
~ a theatre nurse or senior nurse, perhaps a member of the emergency team for the hospital, or transfer team for the area. They not usually attached with the ICU your child is now at, but usually known to them.
The arrival team
~ the bedside nurse: the nurse who will be looking after your baby (usually one to one, but at least one nurse to two patients) for the rest of the day or night.
~ another nurse to assist: this is a colleague who is either usually caring for the patient in the next bed, or that is working as a ‘runner’ and helping to cover breaks and check medication etc. The aim is that he or she helps speed up the whole ‘settling in’ process.
~ the ‘nurse in charge’: this is one of the senior nurses on shift who is responsible for the running of the unit for that 12 hour period. They will come and introduce themselvs to you soon after your arrival.
~ a registrar: this is a type of doctor. When first trained medical students become doctors and are called house officers (HO), then senior house officers (SHO) and then registrars before becoming senior registrars and consultants. In intensive care your child will be looked after by a registrar; a senior doctor. There are no HO or SHO in intensive care. If you ever over hear them asking nurses where things are, or what certain policies are this is not because they don’t know what they are doing. Registrars rotate around many different units in many different specialities to gain experience and knowledge every few months. When they first start nurses can unprofessionally voice frustration at their questions, but they too know that within weeks it will be as if they have been there forever! There will always be at least two registrars on the unit at all times day or night.
~ a consultant. Each week the unit is overseen by a different consultant, and there is usually about four permanently linked to each unit with one being the overall director. They are not on the unit at all times, but are in constant contact day or night with the registrars or nurse in charge. They usually have years of experience working in the same place. As parents you will find them very approachable and it is very easy to organise a meeting with them to discuss your child’s progress. A nurse will also usually sit in on these meetings in case you need extra support or reminding of what was discussed at a later date.
Transferring onto an intensive care bed
After all the staff mentioned hear about your child’s care so far, which can take some minutes. Your child is moved from one bed to another gently. In moving from one unit to another as stated your child is not hurt and the lines in your child wont be changed, but the infusions and pumps and ventilator and monitor all do need to be changed. This looks like a buzz of activity around the bed.
There is also almost always a mess of spaghetti of plastic lines and cables on the bed that need threading through one another. The bed needs to be adjusted to the right height and lines need to be measured with a spirit level to ensure that they are at the right height to record the correct information. Handover sheets need to be signed. Reports need to be finished. Drains or urine bags need to be emptied and hung. Wounds need to be looked at to get a baseline for further observations and observations need to be done to monitor your child’s breathing and heart rate, so again the nurse knows what is usual for your child. If any one of these things is not done straight away then your child will be at risk, and for no good reason.
Imagine your child is sedated and something as simple as a urine bag is not emptied. This means it wont be able to drain probably causing backflow up to the kidney which could lead to an infection. Also urine levels are measured each hour to ensure your child stays hydrated and that their body is working probably. A small change in urine output can be picked up quickly and action can be taken to stop stress on organs.
So what seems like ignoring you is not because we don’t know how important you are. Or because we are not parents who may have been in a similar situation. I for one have been. It is because we have to do a lot of tasks to ensure your child can remain stable for the rest of the day.
At the end of the settling period, when you are invited back onto the ward you will probably just find your child’s bedside nurse waiting to greet you. It is usual though that the transfer team may have popped their head in to you in the parents room to say goodbye.
This is the second reason for the ‘settling in period’. When you arrive on the ward the ‘handover’ will have been completed. The doctors will have moved away and stopped ‘teaching each other’ or contemplating out loud things that they would probably not have to do and things that if they do decide to do they will discuss with you first in a much clearer manner. There will be space free from people for you to get to your child and to hold or kiss them. There will be space for you to feel overwhelmed and time for the bedside nurse to go through every line you can see and every beeb you can hear.
As a bedside nurse it is important to know that we can give you the majority of our attention as we already have a good idea of your child’s current condition and needs. It happens that a parent can faint or becomes ill at the bedside the first time and if not then to get upset. This is not the result of weakness or horror, but often of tiredness and shock at the situation, so please do not worry if this happens to you. Parents are often surprised at how quickly they adapt to life in intensive care and although usually, though not always, pleased to leave they keep warm sentiment towards many staff met and at the high level of care they received. You will never have to go looking for help on intensive care.
I hope you have found part one of this article informative. In part two and three I introduce the different pieces of equipment you will meet at the bedside and talk through the bare bones of a typical day on intensive care. Please feel free to share your experiences or ask any questions as a comment below. I as always welcome debate.
- What to expect from intesive care (paed, neonatal and cardiac) : Part two (niccilouise.wordpress.com)
- What to expect from intensive care (paed, neonatal and cardiac): Part three (niccilouise.wordpress.com)
- Intensive care … is intense (kaowenblog.com)
- Music Therapy Helps Premature Babies At Beth Israel NICU (newyork.cbslocal.com)
- Neonatal Song Lowers Heart Rate, Improves Suckling (medicaldaily.com)
- The miracle of love, true story (danodongo.wordpress.com)
- The Neonatal Intensive Care Unit (NICU) (nicunursing.wordpress.com)