So, I guess the TBICU probably isn't a picnic?

So I’ve told you that Ed (Dr. Merritt) wants to research the signals in the body which cause seemingly undamaged muscles to atrophy when someone is burned. My goal has been to talk to burn victims about his research and ask them to take part in it. The participation is fairly innocuous—it does involve a muscle biopsy, but this is done when the patient is in the operating room under sedation for a burn related procedure, under very sterile conditions. Taking part in this research doesn’t effect the patients treatment in any way—the goal is to seek information, not to perform any kind of alternative treatment. Given this, why do so few patients agree to take part in this research? I believe there are two main reasons for this, firstly they are already overwhelmed with pain and stress, and aren’t able to risk even a small chance of adding to this, and secondly they have a lot of misconceptions about what research is.

Let’s talk about the experience these patients have in the Trauma Burn Intensive Care Unit (TBICU.) Very often after a burn injury, patients must be placed on a ventilator, a machine that breaths for them. In this situation they are usually heavily sedated, and unable to carry on a significant conversation. At this point, the patient’s spouse or other family member can give permission for the patient to take part in the study—but would you feel 100% comfortable making this decision for someone else, even if you personally thought it seemed like a good idea? Most people aren’t. Not all of the patients are intubated and sedated though, some are able to speak for themselves. I want to share a few observations I have made, so that you can relate to what mindset these patients might be in.

I have observed patient asking for food over a 24 hour period, and not being allowed to eat—his health care providers were considering placing him in surgery and didn’t want any food in his system for this reason. After deciding against the surgery, the patient was able to call room service but they remained unresponsive to his request four hours later. After not eating for over 24 hours, and then feeling ignored by room service, would you want to sign up to do a favor for a scientist?

Burn patients often require specialized bandages which are changed daily by a highly experienced team of nurses. In the middle of this bandage change, the health care provider (HCP) is able to observe the injured area. These bandage changes can be extremely painful to the patient, they often receive extra pain medication for this process, but sometimes this does not occur. On occasion the HCP may not be immediately available to observe the exposed injury, and the patient may be left uncovered in a cold room for an extended period of time. I have observed a patient who was nearly screaming while having her bandages removed, and then left shivering and begging for the thermostat to be turned up while waiting an hour for the HCP. After receiving a warm blower, heated blanket, and additional pain medications she was cooperative and good natured. If you felt that the staff at the hospital didn’t care that you were in pain and freezing, when something could be done about both issues, would you want to do a scientist a favor? You might not.

I am only a student nurse, so I can’t know if it is unreasonable that patient care not be more perfect. But I do know that the stress and pain of a traumatic injury, coupled with frustrations over treatment, can easily lead a potential research participant to not consider taking on another role—no matter how innocuous.

Next time I’ll talk about common misconceptions that people have about research, both it’s methods and goals.

Opportunity Knocks

            Shortly after being accepted into the nursing program at UAB I was offered the opportunity to participate in the Honors in Nursing program, which I gratefully accepted.  A large component of this program involves taking part in a service learning project, which is incorporated into two or three semesters of the program.  Ideally, the project would provide something of value to mankind (at least in some small way!) while also providing me with valuable learning experiences. 

            I had a few ideas for what I might do.  My first thought was to create  a tobacco education program for area middle school kids, complete with lots of creative analogies and shocking props (such as a blackened cadaver lung from a lifelong smoker), in an effort to head off a few possible youth smokers.  I also considered using the dedicated course time to reenlist in Frank Hambly’s “Labs for Kids” program, which teaches anatomy, physiology, chemistry-- well, lots of sciences-- to elementary and middle school kids. I think kids are more likely to stay healthy when they understand exactly how a healthy body is put together and how it can be damaged.  Do you get a sense that I enjoy educating kids?  Well I do, but only in small doses!  I have a lot of respect for professional teachers who can keep that up five days a week for many hours at a time!

            While deciding which of these options best fit my time constraints and interests, life did what it often does—opportunity knocked!  I was riding my bicycle with a group of friends when one buddy, Ed, began asking about enteral feeding (via the intestines) versus parenteral feeding (through an IV directly into the bloodstream) and other healthcare related questions.  I knew he was a postdoc at UAB, but didn’t know much else about his work.  Turns out, he was beginning to do research involving burn victims, and was brand new to using human subjects.  One his queries regarded whether specific training is given to student nurses to enable communication with people during tragic, stressful situations.  I let him know that, boy do we ever receive training in “therapeutic communication!”  Even as students we need to be able to communicate well with distressed patients and families, beginning with first semester clinical experiences at the hospital.  As Ed and I talked, we realized that I could really help him by acting as the face for the research program to the potential candidates and participants. I was kind of excited- here was an actual need for my budding skillset!  Ed began to tell me more about the science behind and the purpose for the research.

            When people are recovering from being badly burned they frequently experience muscle atrophy, which means a loss of muscle tissue.  For instance, a healthy person who receives a burn to the right side of their body will end up losing a large percentage of the muscle mass on the undamaged left side, while recovering over the next many months. This sounds normal right? Lying around in a hospital bed seems like a good way to lose some muscle mass, doesn’t it?  It turns out that when we lose muscle from lying around it is called “disuse atrophy,” and that is a very different thing than the atrophy experienced when recovering from a traumatic injury.

            Being living things, muscles are constantly being built up and taken apart by the body.  Under most conditions these two processes occur at the same rate, and the muscle doesn’t change in size.  In disuse atrophy, the muscle is built up more slowly than it is broken down, hence it shrinks.  However when the body is recovering from a burn, healthy unaffected muscles begin to be broken down more quickly than they are built up, also causing shrinking.  Beyond being a simple inconvenience, this loss of muscle mass can lead to fall hazards and breathing insufficiencies (we don’t think about it, but we need muscles to expand our lungs to breath.)  Health care providers give patients steroids, insulin, and five thousand calorie diets partly in effort to fend off this atrophy, but these measures are usually not very effective. 

            Ed’s goal is to discover the signals within the body which facilitate this process.  What signal might travel from the blood serum to begin speeding up the breaking down process?  What signal might occur inside of those muscles when the breaking down process is caused to speed up? To begin investigating these signals, Ed needs to collect and examine blood serum and muscle biopsy samples from burn victims, both shortly after their injury and about six months later.  If scientists can understand what physical actions are involved at the smallest level, drug companies may be able to create a drug to block those actions.

            As I hadn’t learned much about large burn care in my previous courses,  I felt my first prudent action should be to become familiar with some very basic information in that area before meeting with patients and families of patients undergoing that experience.  Next time I’ll talk about my initial learning experiences, which were simply an introduction to the Trauma Burn ICU.

           

           

What’s this blog all about?

   This blog will describe my adventure as a student nurse entering into the world of scientific research. We’re talking about the alphabet soup world of biochemical physiology, where new discoveries are named the WXYZ-21 pathway, instead of after the last name of the discoverer. These kinds of discoveries are furthering our understanding of how the human body functions. They let us understand how and why the cells we are composed of carry out their minute activities.

   As a junior at the University of Alabama at Birmingham, and a third semester School of Nursing student, I’ve taken two introductory Chemistry courses, one introductory course covering Microbiology, and two introductory Physiology classes—so how can I contribute towards that sort of advanced research? Most of the studies are done by scientists who hold a PhD, or at the very least a Masters degree in a scientific field.

    The answer to this question is found in the fact that research can’t happen only in a laboratory.

At some point when studying the systems and cells of the human body it is necessary to study live people. Often the people researchers need to examine for specific questions suffer from a pathological condition (damage relating to disease or injury) and may be hospitalized under very stressful circumstances. It is under these conditions that a nurse, even a student nurse, may be beneficial to hard-core scientific research.

   Nurses are comfortable communicating with stressed patients, and more importantly are trained to make the patients more comfortable and less stressed. In addition, nurses have a natural role as patient educators—we are practiced at bridging the gap between scientific jargon and layman’s terms. Identifying chemical signals inside of human tissue cells may not be part of our role, but being able to describe the activities and importance of those signals, in layman’s terms, to a patient who may be a potential study participant is.

   In the next blog entry I’ll describe how I got involved in a specific study and what that study is investigating. As a hint- if you want to read ahead, look up "muscle atrophy!"