A neat girl from Heemstede, raised Reformed, but not too Reformed. Mother is a housewife, father works in an engineering firm, one brother. She went to the First Christian Lyceum in Haarlem and got good grades, but it never occurred to her to go to university. And no one gave her the idea. Friends did the in-service nursing training at the Diaconessenhuis and that seemed like something to her: learning and working, a room of her own. She started in 1982, with only girls like her. “Young, white, chosen for the solidity they radiated.”
Now Frederique Paulus (60) is the first ICU nurse to become a professor, professor of intensive care at Amsterdam UMC. She specializes in the ventilation of seriously ill patients. In early April she gave her inaugural speech, If it doesn’t help, it will do harm. She was talking about treatments carried out by ICU nurses that seem self-evident, but which after research turn out not to work. And they do cause damage. She talked about the Covid pandemic and how much has been learned about ventilation from the thousands of patients in the Netherlands with seriously ill and inflamed lungs.
This conversation takes place in her room in Amsterdam UMC, AMC location in Zuidoost, after a tour of the ICU department. Four units with eight beds each, two per room. The patients are almost invisible among the devices that have taken over and monitor some of their bodily functions. Since 2020, everyone knows what that looks like. For every two patients there is an ICU nurse who administers medication, checks IVs and catheters and continuously checks whether ventilation is going well, whether there is any consciousness again, whether a little finger is moving again, whether there is restlessness, pain, fear. , a possible delirium. It was already that way, says Frederique Paulus, when she came here in 1989 to train as an ICU nurse. And it still is that way. “Heavy work, a lot of walking and standing. I couldn’t do it anymore.”
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Critical
Amsterdam was a “culture shock” for her. In Heemstede she had perhaps nursed two or three patients with a non-Dutch background, but here was the whole world. There were patients with AIDS, patients who had been shot in the head, patients who tried to deal drugs from their beds. After six months she got used to it and when she received her diploma after two years, she started to wonder whether all the treatments in the ICU were as effective and safe as everyone thought. “Especially treatments that were done based on feeling and the outcome of which was always different.” She is critical, she says. Always has been.
In her inaugural lecture she explains how nurses tried to make patients on ventilators cough by using balloons. “Patients lie there with a tube in their throat, which irritates the airways and mucous membranes. A lot of mucus is formed, also due to the dry air, and that has to be removed, because it hinders the exchange of oxygen and carbon dioxide in the lungs and the mucus can become contaminated with bacteria. So the people at the bedside are busy all the time trying to get that mucus out. We did this by slowly blowing air into the lungs with a balloon and then having the patient exhale quickly – a kind of cough. And sometimes I saw that happen with a volume and a pressure that made me think: ooh, you’re inflating those lungs. And often it didn’t even help.”
In 2000 – she had two young children – she brushed up on her school mathematics and started a master’s degree in epidemiology: what is good for groups of patients and how do you prove that? For her thesis she did research into ballooning, which she had thought for ten years was not a good treatment. It then became a PhD research – an idea of the ICU doctor and professor Marcus Schultz – and she showed that the air flow, pressure and volume during manual ballooning were never measured in practice, and that they could therefore be unnoticed high and unsafe. become. Cough machines that do everything in a controlled manner – blowing in air, sucking out mucus – seem safer and work well for people with ALS or another neurological disease.
But the question is, she says, whether this is also the case for ICU patients. “That must be thoroughly investigated before we roll a battery of coughing machines into the ICU.” It is a utopia, she says, that you can get all that mucus out. And maybe that isn’t always necessary. “In the Netherlands, we give patients on ventilators preventive antibiotics, directly into the intestines. The growth of harmful bacteria is inhibited and thus limits the risk of pneumonia.”
Nightmares
She says that patients sometimes return to the ICU to see where they have been and then they appear to have no memory of it. But in their nightmares they hear a trash can closing: a bomb. Or alarms going off: a machine gun. They feel tubes being stuffed down their throats and the fear that this evokes, without being able to make a sound. In many ICUs, she says, it is common practice to spray the airways of ventilated patients four times a day with mucus thinners – “dirty and smelly stuff” – and then suck out the mucus with a tube.
After her PhD, she also conducted research into the usefulness of this treatment, which showed that nebulization has no benefits for the patient. There are disadvantages. More frequent complications such as cardiac arrhythmia and that fear, that traumatizing fear. “It was a big study,” she says. “A thousand patients, carried out in no time, with other UMCs. You always do something like that as a team, but the study was in my name and when we had the results, Marcus Schultz said we should see if they could be published in JAMA. I said: ‘JAMA‘? He said, ‘Yes, JAMA.’” That abbreviation stands for Journal of the American Medical Associationone of the most internationally renowned medical journals.
The article was accepted and then suddenly she was in Texas on the stage of the Star at Night Ballroom of the Convention Center San Antonio explaining her results. That was in 2018. “The night before, nurses said to me: as a nurse? Yes, as a nurse. They were flabbergasted. The next day there were fifty of them in the front row. It was one for me tipping point. It has given me wings. I thought: now I am stepping out of that timid role of the nurse who is allowed to participate in the world of doctors and conducts scientific research, a white raven. ‘You are special, you can do that’. No, if I can do it, other nurses can do it too. You just have to train them in it. You have to offer them opportunities.”
Yet spraying with mucus thinners still happens. More than half of ICU nurses and doctors in the Netherlands believe that it can have a beneficial effect and that side effects are rare. This was evident from a survey conducted two years after publication JAMA was taken. “Implementing a treatment is already quite a challenge,” she says. “Abolishing treatment is even more difficult. It took ten years before we stopped taking daily X-rays of all ICU patients.” She is now leading a study into how to do that: de-implement a pointless treatment. In the ICU alone where she works, it saves 4,800 hours of nursing time annually, she says. Almost three full-time nurses.
Corona
And then the Covid pandemic, what has been learned from it for the way patients are ventilated. Ventilation, she says, always causes damage, even in patients who do not have diseased lungs and are in the ICU after an operation or an accident. The pressure at which the air enters quickly causes an inflammatory reaction and that is why the pressure is kept as low as possible. But how low is best? And the breaths, how small can they be? And the frequency? “Everything is connected. With larger gulps, the frequency can be reduced, but the pressure increases, and so you are constantly weighing and weighing. And if you give a patient something for anxiety or pain, you have to think again.”
In 2020, the ICUs were suddenly full of patients, all of whom had seriously ill lungs and no one knew exactly, she says, how ventilation could best be set up for them. She initiated two large studies with more than a thousand patients each, from twenty ICUs. It turned out that everyone used lung-protective ventilation techniques, and yet this still varied considerably. The results have been published The Lancet Respiratory Medicine, also very internationally renowned. Frederique Paulus has already started further studies.
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