Before I begin I just want to state that there are many different opinions about electroconvulsive therapy (ECT). This post is not about weighing up the pros and cons or discussing the side effects. It’s certainly not meant to offend any sensibilities. I believe if someone is in the situation of considering this treatment then they can find much better sources of information for making up their own mind. (And I haven’t used any names or places to protect any identities I might have come across)
This post is about a student nurse’s experience of observing ECT during a placement, and what the procedure involves from my understanding (which may be limited, but it was my first placement!).
For my first six weeks placement as a student mental health nurse I was based on a male psychiatric ward. Before we went out I had a long chat with my personal tutor about what to expect – fear of the unknown and lack of knowledge is always rather intimidating! One of the things we discussed at length was what would happen if the possibility of observing electroconvulsive therapy came up.
Having a psychology degree already I had a little awareness of the procedure, but we had always been taught that the only reason ECT was used in the first place was because of the rationale that people with epilepsy did not experience symptoms of schizophrenia. This always made me quite skeptical of it’s use, and films like one flew over the cuckoos nest didn’t do much to promote me to it either.
Studies have found a link between lack of knowledge and negative attitudes towards ECT, among nurses as well as student nurses (Byrne, Cassidy and Higgins, 2006), so I was glad that I had chance to discuss it at length before seeing the procedure first hand. A couple of the patients told me on the ward that one of the most important things we could be as mental health nurses is non-judgmental, so I would have hated to come across as biased at such an important time.
I was also lucky that I had seen a documentary called Bedlam on the modern day patients of the South London and Maudsley trust, where a patient had been through the treatment with, for me, rather astonishing results.
For anyone that needs a little background on what ECT (or electroshock therapy as it used to be known) is, it is usually a last line of intervention for psychological disorders like depression. That means other methods, like talking therapy or medication, will have been tried first. It consists of passing an electric current into the brain to create a short seizure.
It wasn’t until the final week of my first 6 weeks nursing placement that we got chance to observe the procedure. Prior to this I had also had chance to talk in depth with a patient on the ward who had been through the procedure, which was very helpful. The reason we couldn’t observe until week 6 was partly down to the fact that no one from our ward was undergoing the procedure at the time (it being about 70% more common to be undertaken by females). It also made it difficult to follow a patients journey through the procedure – I was just there during and post treatment so had to research the pre-treatment myself.
According to guidelines a nurse has the following four issue to consider when they are taking a patient through ECT:
(1) providing emotional and educational support to the patient and family/carer before treatment
(2) assessing the pre-treatment plan and the patient’s behaviour, memory, and functional ability prior to ECT
(3) preparing and monitoring the patient during the actual procedure
(4) recovering patient, observing and interpreting patient responses to ECT with recommendations for changes in the treatment plan as appropriate
If a patient is being prepared for ECT, besides giving them knowledge on the procedure and answering any questions they or their family may have, there are a few things that have to happen beforehand. A thorough physical assessment has to take place, making sure the patients heart, bones, lungs and teeth are healthy enough with ECG, x-ray and blood tests. This also rules out the possibility of the symptoms having an organic cause. The spine is checked as well as familial history of spinal problems. They also have to have their medication assessed for contraindications, which could mean not taking it for a time prior to the treatment.
The patient will be required to be nil by mouth (not eat or drink anything) for usually about 8 hours before treatment, to prevent asphyxiation under anesthetic. You would also discourage smoking before a treatment.
If you are on a ward with a patient you would encourage them to shower before they go for treatment (having clean dry hair encourages good contact for the electrodes). The patient should also be asked to remove any hairspray, creams, make-up or nail polish, or metal slides or grips pre-treatment for the same reason. You would also encourage a patient to go to the bathroom before the procedure to empty the bladder to avoid incontinence and minimise the risk of bladder damage or distention.
The named nurse (or equivalent) would then escort the patient to the procedure room, usually in a day procedure or out patient unit. The room I was in looked a lot like this:
Before the patient gets into the procedure room the nurses, and doctors set up the necessary equipment (cannulae, varying grades of syringe and needle, bag and mask to breath for the patient under anesthetic, etc.). The nurses do a check of the equipment as well.
I was there with a fellow student nurse and they asked us to check the electrodes were working. We were supervised doing the checks which involves pressing the electrodes onto a plate and pressing the button on top until you hear a clear beep. I know I was extremely nervous about this (what would happen if I let the electrode slip and zapped myself with it?!) so it took me a couple of goes to get the technique.
When the patient comes in to the room they are introduced to the members of staff – usually a couple of nurses, an anesthetist and one or two psychiatrists. The patients identity would be double checked. Wires are then applied for ECG (electrocardiogram – measures heart activity) monitoring and EEG (electroencephalogram – measures brain activity) monitoring and an IV cannula is inserted at the hand – to make giving anesthetic and muscle relaxant easier. Your blood pressure and oxygen saturation will be measured and the blood pressure cuff and pulse oximeter will be left on during the procedure to monitor you, like this:
The nurse ensures that the patients shoes are removed (to help understand when the patient is in seizure) and any dentures, hearing aids, prosthesis, glasses, contact lenses, etc. are removed just prior to the intervention (to allow good communication up to that point, and then to protect the patient).
The patient will then be anesthetised, with a short acting anesthetic (about 5 to 15 minutes) and given a muscle relaxant. In my case the anesthetist then ‘breathed’ for the patient using the mask and oxygen. She was aiming to hyper oxygenate the blood before the procedure as you do not give oxygen during the seizure. Once the mask comes off a guard goes into the mouth to stop damage occurring.
The psychiatrist will then clean the patients temples and apply conductive gel to the electrodes. These are then placed on the temples and the sock is administered. The psychiatrist is watching for slight movement of the feet, and the reading of the EEG to see if the shock has created a seizure. A seizure of 20 to 50 seconds is seen as therapeutic. In our case it was the nurse that counted this out. In new cases the doctor would always try and use the lowest voltage to induce this seizure, known as the seizure threshold.
During this stage we, as student nurses, were standing back and observing. To me it was very interesting to see just how surgical the whole procedure is – I never realised that you would need to breathe for the patient when they are under muscle relaxant (even though it makes sense!). There is also so much monitoring going on.
The seizure itself was often hardly visible, which surprised me. It was so interesting to watch the whole procedure I didn’t have an emotional reaction which I thought I would. Yes we felt awkward just watching rather than being involved, but this is becoming a normal part of being a student nurse – there is rarely a week goes by on placement when I am not feeling awkward or lacking knowledge at some point!
What made the procedure for me was being able to talk to some of the patients before they went under. A few ladies were there for refresher treatments – which means they had their original course and this was just to keep them well anywhere from 6 months to 1 year on from their original course. There’s nothing like hearing it from the horses mouth how much they were happy with the treatment, and how it has worked for them.
We were also able to assist with some patients at the start of their ECT course of treatment (some who were detained for treatment), which meant reassuring them and trying to calm them to enable them to go through the procedure as easily as possible for them.
After the quick intervention oxygen is administered again, until the anesthetist is confident the patient is breathing on their own again and the patient is taken round to recovery, which looked like this:
We followed a couple of patients round to recovery, which involved care of an unconscious patient. There has to be at least one staff member per patient during this phase. We were able to monitor and record vital signs every few minutes to monitor their condition and talk to them as they came round. I also removed a cannula from a patients arm, which was a first for me.
Patients can often feel a bit nauseous after the treatment and it’s a matter of trying to make them feel comfortable until they feel able to have some refreshment, or be moved round to a waiting area.
What did I get out of observing this treatment?
A greater understanding of what ECT is, what it does, what it involves and why patients would choose to undertake it. Care of an unconscious patient. Various ways of monitoring vital signs and why they are important. Importance of reassurance to patients, and explaining the procedure. Aspects of surgical technique. Multidisciplinary team working together.
And probably much more should I go back another time and see what I missed on this first opportunity!
What would I do differently in my practice reflecting on this?
Always introduce myself to patients as well as try and put them at ease – often I assume as a student nurse I’m so insignificant no one needs to know my name! Always ask if you can get involved – even as a first years there’s usually something you can do. Don’t be afraid of looking stupid – it’s going to happen a lot while I’m learning!