Day In the Life of a Proton Therapy Nurse (Part II)

There are usually two nurses who arrive between 7 and 8 am, depending on the number of sedated cases we have that day. We start by setting up for the day: making sure we have our dosimeters on and our mobile work phones charged, getting out supplies for anesthesia/LMA (laryngeal mask airway) placement, taking out emergency and sedative medications from the OmniCell, reviewing patient charts, and setting up monitors and IV pumps. Most of the patients have their ports accessed and dressed each Monday and will leave it in until Friday after treatment - we check for blood return, saline flush and hep-lock in between. Treatment is five days a week and usually lasts about five to six weeks, depending on their individual plan. The demand of the schedule alone must have such a huge impact on their day to day lives.

When the patient arrives we try to not have them wait around very long before treatment - the kids begin to get wise to the whole process and some get stressed about the impending "white sleepy medicine". Myself and another nurse quickly rotate around the patient; doing a quick assessment, checking their line, putting on an ID band, checking vitals, and helping the anesthesiologist prepare for sedation - all while chatting with the family. The parents are able to stay while the child is put to sleep but are quickly ushered out before our trip to the gantry where most MDs like to manage the airway by inserting the LMA (some prefer to do it at the bedside before transport). The patient is attached to an O2 sat monitor the whole time and they breathe on their own. It's important to note that sedation is certainly not required for proton therapy - older patients report feeling nothing during treatment. It is imperative to remain perfectly still though, as to deliver the most effective dose to the specific tumor site - so the younger pediatric patients all need sedation to be able to receive their treatment accurately.

Driving the hospital bed through the long windy halls with multiple narrow single doors requires nearly as much precision as the proton beam (not quite, but you get my point - they are hard to steer!). The anesthesiologist remains at the head of the bed and uses the bag mask to deliver oxygen while we're driving to the gantry. Once inside, we're greeted by two or three RTs (radiation therapists) and another whirlwind occurs around the patient. Within seconds the patient is transferred to the treatment bed (or the "couch"), any obstructions are removed (can be anything from earrings to clothing - depending on where the proton beam needs to go), the EKG leads are placed, O2 is switched from portable to wall mounted, LMA is placed by MD, molded mask is placed (to hold head in exact position needed for proton beam), IV propofol drip is started, the CO2 monitor is connected and BP cuff is set to q5 minutes and the safety strap is applied to the patient's waist. I run a quick "time-out", ensuring we have the right patient, right treatment, right propofol dose running, the safety belt is intact, and check allergies.

The RN is in charge maintaining the IV lines, monitor lines and O2 line while the RT moves the couch with a remote to a precise angle. Sometimes it's a basic motion, other times there's a "couch kick" where the whole table can swing in any direction needed. These are a little stressful - but the RTs are great at giving me a heads up so I can anticipate where I need to move my monitors and lines. When all is a go - we step behind a barrier (with a window to monitor patient) and x rays are taken to check body placement for proton delivery. It's amazing to watch the RTs do this part - the precision required is way over my head. One last quick overview of the patient and we all head out of the room quickly.

We go to a room outside the gantry (separated by feet of concrete walls to reduce radiation exposure). We monitor the patient by remote VS monitors and multiple video cameras. There are usually two or three rounds of proton beam delivery. Myself and one RT go in and out of the gantry in between each dose to monitor the patient, move the couch and move the equipment, eyeball the patient. The delivery of the actual therapy doesn't take very long at all. It's rare but the beam does occasionally go down due to technical issues - we continue to monitor the patient (and the dwindling propofol drip), hold our breath... and wait for it's return.

When treatment is complete we reverse all our previous work - undoing the set up and getting the patient ready for transport back to the recovery area. Transfer back to gurney. Propofol drip off. Bag mask, check. Weaving through the narrow halls again - this time with the monitor and IV pump added to the mix. (Someone should tell my husband the news - I'm an excellent driver!)

We return to the bedside and continue to monitor closely. The LMA is removed by the MD. The propofol is drawn out of the IV line, flushed and hep-locked. This is the time to tend to any radiation dermatitis (burns caused by the cumulative treatment). I try to put back anything we moved during treatment, jewelry, stuffed animals, blankets, etc. We continue with vitals q5 minutes and wait for the patient to wake up. Ever seen a cranky toddler? I assure you they are nothing compared to a cranky toddler post Propofol. I have had my eardrums blown out on several occasions (Huh? What? Did you say something? Can you speak up please?!). Hitting 20% of their baseline blood pressure to complete recovery is usually a non-issue. Most just wake up groggy - wanting their parents and snacks. The families I've encountered have all been so sweet, trusting and grateful. We chat a bit, say our goodbyes for now and will see them again in less than 24 hours.

Proton therapy is truly an art form - an amazing symphony of science, modern medicine, and compassion. It provides a new possibility for treatment. One that didn't exist not too long ago. I hope this article does it all a bit of justice. I continue to be fascinated by it each shift and couldn't be more grateful to have experienced it so closely.

For Part I in this series, please read Part I - Nursing and Precision Proton Therapy.