To be fair....

To be fair...I only have one child. I've only given birth once. However...I was pretty good at discerning rectal pressure from the head as opposed to rectal pressure from stool or gas. I just don't understand how so many people make the mistake of thinking one is the other...I especially don't understand how you do it on your third baby. However, it happened twice last night.

During a particularly stressful situation involving bedbugs, bleeding, chorio at 17weeks, and b/p's in the 60s/20s I was notified by registration that there was a very uncomfortable patient at the desk. Yeah, Sure, I thought...how about letting the triage nurse triage? So, I sent the triage nurse to pick her up and was greeted at the desk by a swiftly-moving triage nurse and a preterm patient who was doing the cheek-to-cheek dance...no, not like in high school...the one that we all have come to know and trust as a great indicator of fetal station/dilitation(meaning...fully or 1cm...i've never seen it be, like, 5, just 10 or almost nothing). We wheel her in to the room, set up a table, page MDs, get meds, and I call the NICU...a perfect symphony...the doctor comes in and checks her and tells us she's 1cm. Okay, but she's on her 3rd baby, so this abdominal pain is still scary...is she abrupting? Why is a woman who is so clearly used to labor pains in so much pain at 34 weeks? And then it happened. After one particularly flatulant moment...the patient began to have less and less pain. Eventually, after two hours on the monitor, the patient was discharged to home (at your cervix...she's headed your way! She's from your state...)...with a diagnosis of gas.

Okay, funny as that was, what are the odds that two hours later I had another patient who was triaged and sent to a room because she was soo uncomfortable and it was her third baby. After finally tracking down the family practice MD to check her, he reported to me that she had so much stool in her rectum that the vaginal exam was difficult...

For the love of God...here we go again!

That didn't take long...

So, I recieved my acceptance letter in the mail today. I feel so alive it's scary. I cannot wait to get back into school. In fact, I'm not sure if I have decided to take the position yet, because I think that school was really what I needed to renew my love of nursing.

Someone asked me the other day if I don't think I was meant for clinical...like maybe I'm better at the books than the bedside. A rather pointed question, if you ask me...

I would like to think of myself as "supernurse" well rounded in all aspects. I cannot, for the life of me, figure out why nurses continue to believe that they must be "bedside" people or "book" people. There is so much negativity about me going back to school (i.e. "you know you'll get the degree and end up back here with us")...I cannot figure it out. I will be entirely honest with you. When I went to college (before switching to nursing 3 years later), I thought nursing was for the dumb girls in my class. The students who went into nursing were not the stellar students, and all were female. The only nurse I knew was flighty, and not someone I would trust to make healthcare decisions.

I ended up in nursing by accident. I needed a change, and I thought...why not nursing? It's the best accident to ever happen to me. I wouldn't change a thing. Here's the thing...I've met some extraordinarily intelligent nurses...and I want to include myself in that group someday. What I can't figure out is why when someone wants to advance their practice, expanding their role, other nurses see that as a threat and must kill the buzz. Nursing has made great strides toward being recognized as a profession, and not a vocation. Why do we always fall short?

Someone else asked "so, you don't really love what you do here"...au contraire, mon ami...I love what I do so much that I want to share it with others. I love teaching so much that I'm going to focus all of my nursing career on it. I want to make others love it as much as I do. I want all of my co-workers to feel as empowered to defend a woman's right to choose her birth experience as I do. I want them to use their knowledge to form reasonable, well thought-out arguments why they don't want to turn up the pitocin, why they don't think it's quite time for AROM, why they think that intermittent monitoring is okay with this patient.

Just to clarify...

rant...

I just wanted to share my wonderful night...but also rant about an issue that bothers me...

I picked up a patient from triage who was a g3p2 at 7cm, intact...she was laboring hard and very uncomfortable, but used the breathing techniques she had used for her previous deliveries and was going to deliver without pain meds. She made change to an anterior lip, and the MDs stayed in the room with the patient for a bit, AROM'd her and then she preciped (duh, guys...you AROM'd a multip with an anterior lip in natural childbirth and I'm the only one with gloves on when she delivers? Two docs in the room and I'm the one with gloves on!)...beautiful delivery...

Then, after a break, I took over a very nice primip who was also going natural. she had a birth plan...a lot of stuff I'd seen before, completely reasonable and within the limits of policy. She was 5-6cm and intact. However, the experience was very different. She told her attending about her birthplan, who seemed flustered that she hadn't mentioned it at earlier office visits, and basically said that she would follow the plan until she wouldn't. SO....we'll do what you want for a bit until I decide it's not going fast enough and then we'll do what I want.

So...she had labored for a while, but was still using the shower, breathing well with the ctx, and was changing positions frequently. she was doing so well...then the family practice resident came in with the intention of performing a vag exam (which was in the birth plan as a no-no unless there was a medical reason or the pt requested it...not sheer curiosity or a complete report at signout) and if no change AROM (another no-no)...I was frustrated because she was completely ignoring the plan. I requested that she page her attending and make sure that was the plan...she did and, lo and behold, the plan of the attending was to examine and ROM...boy, that didn't take long to change from the patient's request to the MDs desires...how frustrating.

I was fighting for the pt, informing her of her choices, and answering her questions, and the doc had an agenda. It wasn't an unreasonable plan...if it were her choice...but I was frustrated. I often hear tones of "beware the nurse...she'll push you to the epi because it's easier for her when you're comfortable" on blogs...and I'm here to tell you that while some people feel that way, it's not everyone and it's not just nurses...Many docs like to control labor even when it doesn't need controlling...My urge was to tell the patient to go home and labor there because I saw the train coming down the tracks way before it ran her over, but instead I supporte her, running interference from "well-meaning" anesthesiologists who wanted to talk to her and obtain consent "in case" she changed her mind and while she was comfortable, from residents who couldn't wait to stick their fingers up to check her, from visitors who said she should just take the pain meds, and from her own attending who wanted to break all the "no-no" rules...

I checked in after I left, and found out that they did, in fact, AROM her at 0730...my gut was that she wasn't in full-blown labor yet and that if they ruptured her it would make her more uncomfortable, she would be open to the barrage of people asking her if she wanted an epidural, and she'd end up strapped to the bed, which she had expressed was her worst fear...worse yet, she might end up with a c-section...and so after her arom...she's in bed, stalled at 7 with an epi...I see the vision coming true.

I hope she has no regret...I hope she gets some sleep and wakes up fully and pushes and thinks it's the best decision she made. Many do...I want that for her. However, I'm nervous things may go differently and I'm sad for that. Labor is not a time for patients, primips who are easily dissuaded, to have to argue that they took hypnobirthing for a reason and that natural childbirth is not just a phenomenon but rather the way it was intended. If a patient wants an epi at 2...so be it, but if a patient doesn't want it...what is the deal with people thinking she should just get it?

As a nurse, it's not easier, really...patients with an epi don't have the natural instinct to change positions as frequently, and they don't move as well, so often we're moving them and positioning them...the bladder needs to be emptied in most cases, and directed pushing is fairly common, as is increased duration of second stage (so the "tricks" we use are much more physical-tug of war, etc)...part of a day's work, but certainly not "easier" than a patient who changes position frequently, enjoys sitting on the toilet because it feels better, and pushes without direction...

just know it's not always the nurse...we're often behind the scenese irritating your attending to support your wishes (just try and make them known in the office...it may save you a fight!)

In my absence....

Sorry for being negligent in my posting. I wish I could say that I haven't had any complicate/crazy/funny patients lately...it's not true. However, I've been busy with my application to an MSN program (we'll know soon!) and the interview process for a management position on my unit (wish me luck even though i'm moving to the dark side...), so I haven't been as focused on the craziness recently.

I've been reading, though!!!!

Triage is always an experience...

So,
I had a fun night in triage the other night. Not terribly busy, but always amusing. My favorite patient was also my most amusing one. I picked her up (in a wheelchair...never a really good sign when you pick up a labor patient in a wheelchair...you all know what I mean) and asked her if she could walk and she said she didn't want to because she had bled at home and was concerned that she had a placenta previa. Her accent was thick and it was like a bad rendition of "who's on first" trying to get to the botton of what really happened. Here's what I got out of our first few words...she was g2p1 and a trial of labor, prev c/s for failure to progress, and she hadn't felt the baby move in a while. So, we got to triage and I first obtained a FHR by doptone to set her mind at ease. Baby was great. Then I asked if she had a pad on. She did...no bleeding. Okay...off to get dressed. I called the resident and let her know that the patient had arrived. While we waited for her, I talked to the patient more about the previa. She said she needed an ultrasound, and I questioned if it was because she had a previa that was being followed in the office...like was it marginal and they wanted to see if it was moving up? She said she didn't have a previa at her last ultrasound, but was concerned that the amount of bleeding made her think that she might have one now (huh? I would be thinking abruption at this gestation...I mean if we're getting our info off of the internet...at least get a diagnosis that is possible...). Further discussion revealed that she had some bleeding when wiping and that it was fairly mucus-filled (bloody show anyone?) and now she was having contractions. Good story for labor if you ask me.

She meets the resident who is equally stymied by the patients diagnosis of previa (is the placenta now sliding down the uterus...i'm very confused...it's harder to explain things to people who have SOME knowledge and think they know it all then to explain it to a person with NO knowledge). The resident does an SVE and the patient is so uncomfortable she's unable to continue with the exam. She decides to go for a walk to help with labor pains and maybe stir something up and then we'll re-check (is it really re-checking when you didn't get an exam?) in an hour. The patient is very concerned that the resident didn't do an ultrasound and is now questioning her abilities. I reassured the patient that it wasn't really indicated in this situation and then the patient says to me "They did a transvaginal ultrasound in the office to check dilitation. You know, I'm a physician"..you could have knocked me over with a feather. I reassured her again that this wasn't standard practice and that when she was further dilated the cervix wouldn't be so posterior and would be an easier exam. She said "well, I didn't know that. I'm in Family Practice. I'm not an obstetrician, you know"

No Sh**. I was thinking maybe you were.

Oh those residents....

So,
I spent one entire night with a gut feeling about the strip I was watching. The resident changed her to antepartum status and told me to take her off the monitor. I hadn't seen any accelerations all night and none since her arrival. So, in about 15 hours no reactive strip. I refused to take her off, offering instead to get an NST. The resident agreed, but was irritated when it had been a couple of hours and I was still bugging him about the strip. Finally, after 3 hours I requested a BPP. This was not an NST anymore. I was not reassured (surprisingly he kept telling me that it was reassuring). He blew me off. I asked again 30 min later. Then the attending came by, headed to a delivery. Before I had a chance, the charge nurse told her what was going on. She responded appropriately and took the paper strip and reviewed the entire day with him. Ultimately they decided that it was better to induce her at 32.3 weeks than it was to wait for the second celestone because the strip had been so minimally reactive and there was nothing reassuring about it, rather than wait for another 30 hours and stress the kid out further.

Why don't they realize that when I suggest something that is per our protocol it's to protect the patient first, and then the MD and RN equally. When he chose to ignore me I charted it (appropriately) because you're not taking me down with you, but why can't he see that I am trying to let him learn while helping him cover his ass? Again, it's very us vs. them. It's very silly.

I then was in charge sat night...and we ended up keeping 3 patients who should have been discharged, just because it was snowing. We do live in New England. It does snow. I pointed out that they managed to drive in to the hospital in the snow...why was sending them home any different. They decided that it was safe enough to drive in when they were having mild cramping and one had nausea with no vomiting. We had the staffing to support it so we just made it work. Still...I hate setting that precendent.

I wish I had a funny story...it's just been a lot of pretermers and high risk lately, not a lot of funny!

Why, people? Why?

So,
Again I'm finding this week to be one of those weeks where I'm so frustrated that talking about it may not help me, but I'll share. So, I had the pleasure of a lovely couple the other night...primip who made it to 8cm on one dose of miso and without an epi. She knew she wanted her epi, but, get this, waited until she was really in pain to get it! Not just 4cm...but actually needing it. It was a great labor, I didn't get to see the resolution of it, however.

At the end of the shift we recieved our least favorite call...CODE WHITE ER....CODE WHITE ER. Usually we hate these calls because it's a pink,healthy, screaming patient who delivers prior to crossing the threshold of the ER and while the ER usually cannot get a pregnant patient up to us fast enough, when the baby's our they like to stall and hang out and take up an insane amount of our time in the ER.
This time, the call was really not good. We went down thinking it was like normal, but then when they called in again to clarify we learned that it was a 24 weeker who delivered at home. As more info emerged, we learned that it was the same woman with no PNC who went home the day before AMA from CCU with pneumonia and a positive utox from the day before (on admission). She was estimated at 26 weeks, actually, but delivering on the bathroom floor isn't usually good for the little ones due to the time from home to the hospital and the fact that cold stress is so dangerous to pretermers (any baby, actually, but especially pretermers).

We know that she ignored preterm labor signs all day. We know that her infection likely caused her preterm labor. We suspect that she went home AMA to get a fix, and one can wonder what would have happened if someone else at her friend's house hadn't called 911, so she's not up for mother of the year, but I couldn't help but feel bad for her.

I have found that even the lowest of the low on the food chain don't tend to want to harm their babies. Even those patients who seem to care nothing about themselves or how the things they do affect their unborn children still cry when they see a severely compromised baby. Not all, but I feel comfortable saying that a lot of them do.

When I left the patient was getting section 12 (hospitalization against her will)...we NEVER do that. NEVER. so I know she was really not doing well...but I just don't understand how people get to that point?

sorry....boring rant, rambling, but I have no heat right now and haven't slept in a while...i'm in a rambling mood. Hopefully this weekend will be better.