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Musical Morphine?

At my previous job as the Music Therapy Coordinator for a large hospital system, I was required to complete a sequence of leadership courses with all of the new managers system-wide.  I remember sitting next to one of the nursing executives and chatting with her during one of the breaks.  When I told her I was a music therapist, she acted surprised and asked me to explain exactly what I did.  Always eager to educate others about music therapy, I went into the many benefits for hospital patients including decrease anxiety and even decreasing the amount of medication needed to control pain.  The nurse looked at me and said "Hmm.  Very interesting, but no offense, if I'm in pain, I'll take the morphine."

I think about that comment often, especially now that I am a nurse in a hospital that strives to be "pain free."  We have good medications that we know can help to decrease pain. But pain control is complex and often unpredictable.  Take my Dad, for example.  Multiple Myeloma caused him to develop several compression fractures in his spine, a very painful condition.  Because of this, he takes multiple medications that work on different pain receptors to control the pain daily.  And many days, he still has pain.

 While music might not be a substitute for morphine, I do believe that it can be a very effective adjunct therapy for pain management.  I am currently applying to PhD programs in nursing, because I am hoping to study pediatric pain management and effective uses of these non-pharmacological strategies to enhance the effectiveness of medication.

Dance to the Music

While my Dad was coming off sedation in the ICU, I put together several playlists of his favorite tunes to play for him during the day in hopes that providing familiar stimuli would help him begin to wake up more.  In a previous post, I talked about how we were able to see his responses to the music on the Video EEG (while the music was playing, his brain waves became more active, even though he was on lots of sedation that suppresses your brain activity). His nurses always commented on how they loved coming into his room because the upbeat music made their day go by so much faster (his playlist consisted primarily of music from the 60's.  Some of his favorite groups include the Association, the Doors, the Rascals, Sly & the Family Stone.  The playlist also included 2 other of his random favorites: "Margaritaville" by Jimmy Buffet and "Hey, Soul Sister" by Train).  One day, two residents came by to attempt to put another Dobhoff feeding tube in.  Dad's tube had come out, and several nurses had been unable to get another one in, so GI had been sent to try to get the tube.  Otherwise, they were going to have to put in a PEG (a g-tube that comes directly out of the stomach, instead of down through the nose), as he had gone several days without nutrition due to the tube problem.  My mom and I were asked to leave the room during the procedure.  We asked them if it was okay if we kept the music on, as Dad was starting to wake up a bit, and we knew the procedure was uncomfortable for him.  As we left, we quickly noticed that the music also seemed to be helping the residents.  Both doctors appeared more relaxed as they worked on getting the tube in, their toes tapping to the beat and their bodies swaying easily to the music while they worked.  The tube was placed successfully, and I have to believe that part of the success was due to the music helping everyone be a little more at ease.

As a music therapist, I often thought that the organizing CDs and providing recorded music part of my job was a waste of my time and talents, perhaps better suited for a volunteer.  As a nurse and as a family member, I now see how valuable this part of a music therapist's job can be for everyone.  Ambient music helps everyone feel more at ease.  Unfortunately, there are often not enough resources for this service.  The "fish channel" that plays soothing music at my work has been broken for the last few months, and I have to say, I really miss it.  When I am trying to create the right environment for restful sleep, often times I feel that the soothing music is missing.  Our music therapist is great and can make playlists for children with all different types of music, but that is not the main part of her job, nor do we have enough equipment for every single child to have an ipod available to them, not to mention having speakers to play them.  Ideally, I wish that our TV had various music channels available, similiar to those you get through cable.  Maybe at our new hospital.......

This was not part of the plan.

Over the weekend, I randomly ended up admitting a teen who used to be one of my high school music volunteers during my days as the music therapy coordinator at an area hospital system.  I remembered her well as she was planning on being pre-med in college and during that time I had also been completing my pre-med courses at a local community college,  because I had thought that I too was going to apply to med school.  We recognized each other immediately and I am not sure who was more surprised to see the other in this particular situation.  "You're a NURSE now?" she said to me, "This was not part of your plan!"

And she's right.  She's not the only one surprised that I am a nurse.  I actually hear it all the time.  When I was contemplating applying to nursing school, other music therapists said to me "Ugh.  Why would you want to do THAT?"  The other night at work, one of the fellows asked me (after discussing the fact that I had worked as a music therapist for 7 years before becoming a nurse), "Don't you ever wonder what you got yourself into?"

And honestly, as I told her, I LOVE being a nurse.  (She then told me that I'm a good nurse, which I did think was a nice compliment, considering I am only a few months out of orientation and half the time still feel like I'm flying by the seat of my pants).  I noticed right away in nursing school that I feel more at ease as a nurse than I ever did as a music therapist.  I know I was a good music therapist, but there were so many times that I just never quite felt like myself.  Being a nurse feels natural to me.  I get to interact with people, get to know them, spend time with them, and take care of them, all of which feeds my love of being with people.  And I also get to use my brain by problem solving, making suggestions for improvements when things don't seem to be working, and constantly learning about new diagnoses and medications, all of which feeds my inner nerd.  When I was a music therapist, I felt sometimes that I was missing the intimate relationship that the patient had with their nurse.  Sure, my patients liked me, but there is something different about spending one hour with a person versus spending 12 hours with them, sometimes for several days or weeks in a row.  When I used to ask my hospice kids about their experiences in the hospital, very few of them knew or remembered their doctor, but almost every one could tell me the name of their favorite nurse or nurse practitioner.  I realized then that that was who I wanted to be- the favorite nurse.

Over the weekend, I had the pleasure of being paired with two teenage girls.  Other nurses on my unit teased me because they said every time they came past my rooms, I was always in one room or the other, chit-chatting with my patients.  I kept getting behind on my charting because I was spending too much time in the room with the patient.  But that, to me, was exactly what being a nurse is all about.  Encouraging people, making them feel comfortable, helping them learn about their disease and learning a thing or two from them in the process.  There is rarely a night that I think to myself "Ugh.  I just don't want to go to work tonight."  Even when I was a music therapist and for the most part enjoyed my work, there were definitely many days that I dreaded going to work.  Or days that I felt uncomfortable in my job- almost as if I was not able to be myself when I was at work.  As a nurse, I love my job.  It feels like me.  I love that there are clear expectations.  I love that when I go to work every night, there is a set list of "tasks" that need to be completed.  I love the variety of patients that I get to see, and the fact that I never know what I am walking into each night.  And most of all, I love getting to work with such amazing kids!

It makes me sad to already hear some of my nursing classmates and other new nurses already complaining about being a nurse, when we have not even been nurses for a year!  I spent a lot of time and effort thinking about becoming a nurse, exploring my options, talking to other nurses, and looking at different nursing programs, and for me, I think it paid off.  Being a nurse opens so many doors to me that were not options before.  Somehow, I think I might find myself back in management again, but with nursing, there are so many different options for management.  Right now, I love working in the intensive care unit, but should that change, there are other units to explore.  Other types of patients to see.  I can always go back to home care.  I love the opportunity for variety.  And overall, I love the peace that comes with finding a vocation that allows me to reach my full potential.

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?"

Dad's Rehabilitation Plan

Last Friday, my Dad was transferred to the Rehabilitation Institute of Chicago (RIC) for rehab.  His biggest issue right now is the neuropathy that has returned in his feet.  The medication he was taking for the multiple myeloma prior to the transplant (call Velcade) has a known side effect of peripheral neuropathy.  To deal with this, he took a medication called Lyrica.  Lyrica helps relieve the pain from damaged nerves and while he was on this medication, he could barely tell he was having any neuropathy.  However, when he was in the ICU, his Lyrica was stopped, so when he woke up, the neuropathy in his feet was back full force.  Currently, he says it feels like his entire foot from the ankle down is constantly "asleep".  Combine this with the fact that he was sedated in this ICU for 5 weeks and developed severe muscle weakness in his legs and foot drop, and you can see how this becomes a problem.  Dad is determined to be able to walk again, and was very excited to report that he was able to take 12 steps on his own using the parallel bars yesterday!  The therapists at RIC are in the process of making him braces that go from his knees to his ankles to help support his legs as well. 

Where does music therapy fit into this puzzle?  First, I have to say that I am still amazed that the #1 rehab hospital in the country does not employ a music therapist!  I know there is a contracted music therapist that leads groups in some of the areas at RIC, but I still can't believe that do not have music therapy available for 1:1 sessions.  My plan is to help my Dad with his gait training using some modified Rhythmic Auditory Stimulation (RAS) techniques.  This involves using rhythmic cues to help improve the coordination of his movements.  While I personally have never used this method for gait training, I often use rhythmic cues to help coordinate speech patterns and thus improve intelligibility in my music therapy sessions with children with cochlear implants.  I am hoping to be there during his therapy session to get an idea of the rate and rhythm of his gait and provide some rhythmic cues using the guitar.  For the days I am not able to be there and he is practicing on his own, our plan is to review his iTunes list and find songs with a similar tempo and rhythm to his gait (the iTunes gift card Mike and I gave him for his birthday will help with this as well).  This way he can listen to his preferred music, which will not only provide the rhythmic cues needed to help his gait but also provide music for motivation. 

It has been a long time since I completed my Neurologic Music Therapy (NMT) training, so any NMTs out there, feel free to comment with other suggestions!

Congratulations, Elizabeth!!!

I have been amazed at all of the attention that Music Therapy has been receiving ever since it became part of Rep. Giffords rehabilitation plan.  This story was posted today on the Children's Memorial website, and it features a video of our PICU Music Therapist (and a good friend of mine).  Check it out!

http://tinyurl.com/4oc5vo8