When Music Therapy Doesn't Work

About a week ago I was taking care of an intubated toddler with multiple medical problems who was also having sedation issues.  In report from the outgoing nurse, she told me that sedation had been an issue all day, so she had finally resorted to giving him the Chloral Hydrate that was ordered prn, and finally he seemed more comfortable.  According to her, that usually lasted for a good 4-6 hours, so hopefully he would be able to rest comfortably for the first part of the evening.  No problem, I thought.  During my first assessment everything seemed fine.  However, less than 2 hours later, I noticed that he was waking up, and before I knew it, he was agitated and trying to roll over in bed, pulling on the endotracheal tube.  Of course, my first instinct is always to attempt to soothe with music.  I went in the room and started singing to him, and at first he quieted for a brief moment, but then was right back to crying over the tube, flailing his arms, and attempting to roll over and pull at the tube.  I switched to patting to the rhythm of my singing to help quiet his body, but no luck.  I then decided maybe a little help from some prn meds was in order, so I gave his bolus dose of morphine and versed to help calm him.  Nothing.  Since he had seemed to initially at least alert to the music, I went back to trying every music therapy technique I could think of.  I used the isoprinciple and started with faster, more active songs to see if he would entrain, adding rhythmic patting with his activity level to help calm him.  Nothing.  I tried singing slower, more soothing songs to see if decreasing the amount of stim helped.  Nothing.  I tried humming with gentle massage on his head, hands, and feet to see if that helped.  No change.  I tried familiar kid's songs, improvised songs, humming, singing his name.  Nothing.  By now, it was time for more prn meds so he got another dose of morphine and versed.  Then back to trying non-pharmacological ways to calm him.  I read him a story.  I sang him a story.  His Easter basket was next to his bed with little egg shakers in it (how convenient!) so we did some shaking songs.  He shook the eggs along with me but cried the entire time.  I tried being quiet, and just providing gentle touch.  Nothing helped.  The fellow and resident came and looked at him and had me give another prn medication for sedation, pentobarb.  Didn't touch him.  This basically went on for almost 4 hours until finally, either due to the meds or sheer exhaustion, he finally fell asleep. 

This lasted for about 2 hours, until I went in for my 4am assessment and gas.  During my assessment, he seemed peacefully sedated.  He was arousable when I touched him, but closed his eyes and remained comfortable.  However, 10 minutes later, the resident and fellow were back at my bed space.  "His gas looks terrible.  Wake him up," they told me.  WHAT?!  They had to be kidding right?  They were concerned that he was riding the vent too much, not breathing over enough, and it had caused his CO2 to get dangerously high.  Essentially they were worried that he was so sedated his brain was not telling his body to breath.  After being in there all night, I was fairly certain he was not breathing over the vent when he was awake either, but they had me wake him up anyway.  BIG MISTAKE.  With very little effort, he was wide awake.  And agitated, rolling over, grabbing for the tube, etc, etc, etc.  And guess what?  Still not breathing over the vent.  Great.  "Ok," the doctors told me.  "You can sedate him again.  It's not the medicine.  We'll fix the vent."  Easier said than done.  So, I just started singing, trying to get him to entrain, using the isoprinciple, singing every kids song that popped into my head.  Nothing seemed to be working, and I was tired and just a little bit frustrated.  Mostly frustrated because the music wasn't working, to be honest.  I am not used to music therapy not working.  Music ALWAYS works for me.  What was the problem? 

I was almost to the height of my frustration when the nurse from next door passed by my room.  "Your singing is beautiful," she told me.  I told her thanks, however, it didn't seem to be doing much good.  My patient was still wide awake and agitated despite almost an hour of singing.  "Well, it may not be helping him, but my patient is fast asleep.  She was starting to have another episode but the minute you started singing, she calmed down and fell asleep again." 

The girl next door was a teen with a recent psychotic break.  She was prone to episodes of extreme agitation, screaming and yelling that sometimes lasted for hours and were very difficult to control.  I realized that I had heard her start yelling out again (the walls of our unit are extremely thin) but that shortly after, it had stopped.  I had assumed the nurse had given medication, but apparently, the music had, in fact, worked for her.

I was relieved that it did not appear that all of my music therapy ability was lost.  Sometimes, it just doesn't work.  I gave my little guy all the meds he was able to have (none of which helped- at least on my shift), and stood next to his bed and held his hand and kept him safe until the next nurse arrived to take over. 

Sometimes the music doesn't work.  Sometimes there are so many other things going on with a child in the intensive care unit, that there is more to the root of the problem that can't be solved by giving more sedation or singing a few favorite songs.   A few months ago, I had a similar situation with another pre-school age child who, despite enough sedation to take down a horse, was wide awake the entire night and literally attempting to sit up and climb out of bed while intubated.  When I had started that night, the nurse giving report to me said 'Oh good, I know you're patient.  He needs a patient nurse tonight."  And boy was she right.  Because the music didn't work then either.  Neither did the Precedex drip for sedation that was started on top of his morphine, versed, and ketamine sedation drips.  Nor the high dose pentobarb prns that I gave him.  It was another situation where I sat there, held his hand, and calmed him the best I could.  Later, they figured out that he was actually having a paradoxical reaction to the ketamine.  The minute they stopped the drip, he was a new kid.  That was my first experience in understanding all of the many factors that contribute to the music not working on a complex child in the ICU.

However, both nights I spent singing to my patients, I wished I could have had a real live music therapist with there.  It would have been great to have an extra set of hands, another person to concentrate on just providing the music while I helped calm and keep my patient safe.  And while I know the reality is music therapists can't always be available at the nurse's beck and call during the day shift, I think as a music therapist, every now and then, I would have welcomed a page from the nurse that said something like:
"My patient is freaking out.  Meds aren't helping.  Can you come stat?"