Friday, October 30, 2009
Check out Labor Nurse, CNM's post on her blog ReBirth....
I've had these issues as you all know....you can review my trials and tribulations of poor nursing care in this post about Nurse Sucky, and this post about Nurse Crappy.
I'm not alone!
Saturday, October 24, 2009
18-year-old multip who has class B diabetes and hypertension - she was being induced for these reasons at 38 weeks. Trust me, that baby needed to come out...much safer out than in as momma was very non-compliant (I hate that term but appropriate in this case). She had been on insulin prior to getting pregnant. They stopped the insulin when she got pregnant and she was to do diet and exercise. I thought that sounded a little odd but whatever. She came to us late in the pregnancy because she didn't like the care she was getting from her previous doctors. Or perhaps they wanted her to do things like eat right, monitoring, etc. Low and behold, we asked the same thing. She would apparently just not show up for NSTs and things of that nature. She also comes with an overbearing mother. Her mother is very much focused on looking like someone who knows something about everything. When I met her on L&D, she informed me that her daughter has diabetes and htn....uh yeah, I kinda got that from her H&P, from the midwife who scheduled the induction. And that might be why we are checking her blood sugars periodically and told her she could only order certain foods from the menu. How's that for a clue. The mother than proceeds to ask me all kinds of questions such as...
- Shouldn't she have the baby 2 hours after water breaks?
- Won't she have a dry birth?
- I've seen a baby with a rash because the water was broke for 6 hours (huh?)
- They'll start with a low dose for the epidural right?
- It goes in the spine right?
And on and on in that vein. The patron saint of patience must have been by my side as I answered all her questions that had nothing to do with the real concerns (a wbc over 17, baby sky high for even a multip, etc). And it isn't like I broke her water, it was spontaneous.
A patient came in through triage, after being seen in the office by the nurse practitioner. Her first visit with us was at 27 weeks. Then she disappeared. Now she's 36 weeks, contracting, blood pressure is up - lovely. Who needs that silly ole prenatal care - blood pressure issues are no big deal!
Another patient unfortunately had to have a c/s for CPD (this is actually a rare diagnosis - it gets tossed around a lot though). The baby was in the 9-pounder range, momma was a very large lady with a smaller pelvis :( Bad combo and unfortunate for her. We tried everything we could think of to get her dilating better and get some descent of that head, but nothing was working.
I have a momma in the office who stinks of cigarette smoke and has some very strange dreams about chihuahuas.
I have to start taking notes on things I want to blog about. I'll be thinking 'oh, I need to share this, this is good!' But now I can't remember a d*mn thing!
Friday, October 23, 2009
We have some paranormal activity in our house. Sometimes I see figures of little children at my bedside. They usually are whining and wanting to get in the bed. Nothing seems to make them go away...even closing my eyes and trying to go back to sleep. I sometimes am bitten while lying in my bed...even in the daylight! After the cat bites me, she seems to magically fly across the room. I hear voices late at night - in the form of sportscasters. My husband apparently can't hear the voices.
After watching the movie, I told my friend that the first time I found out that my husband was standing over me for two hours watching me sleep...his a$$ would have been gone! Anyone who knows their scary movies, knows that's a set-up for disaster! Course one might deserve what they got for pulling the stupid sh*t that the boyfriend was pulling!
Anyway, go see it!
Monday, October 19, 2009
I found it really interesting to hear from a SAH mom who was very outspoken about her belief that women who have children and work are selfish. She stated that "if you don't have time for children, then maybe you shouldn't be having them". I would actually agree with that statement but not in the context in which she made it. She's implying that any woman who works, couldn't possibly have time to spend with her children. That a woman who works could not contribute to the health and well-being of a child. That a woman who works couldn't possibly raise a wonderful human being.
Yes, this lady was really opinionated. In fact another SAH mom stood up and said that "she does not speak for all of us!".
In general, it seemed that the SAH moms were more likely to be judgemental about working moms. I did not hear any judgements made towards women who choose to stay home. I understand that SAH moms are often undervalued. Working in the home is a career like any other. But I wonder where that defensiveness comes from. Perhaps SAH moms have had to spend so much time justifying their choice, they opt to criticize those who made a different choice.
Dr Phil mentioned some interesting statistics that over a lifetime working moms will spend 80% of the time that SAH moms do with their children. He also mentioned that children who had working moms and were in quality daycare (quality being a key word) were more likely to score higher on school readiness tests, have higher vocab, social skills, etc.
Women raising children are very likely to raise children in their values and traditions. Some women value their children above all else, including themselves. The SAH moms seem to feel that raising their children is the most important thing in their life. I can respect that.
But it's not the most important thing in my life. It's one of the most important things in my life. But my life as a woman and a human being does not begin and end with my children. I had a life before they arrived and I will continue to have a life after they grow up and move on to their own lives. I am not the type of woman who can give up myself for my children. Maybe that does make me selfish in some eyes. I like to think it makes me a better person for my children, my husband, and those around me. Because I could not be a happy person as a SAH mom. I would go insane and might take that out on my family! I love my job and am very passionate about it. Do I feel guilty at times? Sure I do. Being a midwife isn't always an easy career when you have children. But I contribute to society in a very valuable way. I also think that I contribute to my children's health and well-being. I am raising my daughters especially to be strong, beautiful women who can do whatever they want in life.
I also like to think of the women who were working moms who made huge changes throughout our history. What would one say to some of these women? You should have stayed home with your kids instead of fighting for civil rights, for freedom, for healthcare, etc. The world would be a better place had you done that. Yeah, not so much!
I really do have respect for women who choose to stay at home and make child-rearing their top priority. Not all of us can afford or choose that though. We women need to stick together and hold motherhood up, in all its forms, as a tough job and one to be greatly valued.
Saturday, October 17, 2009
- I had to give bad news to an adorable couple, who I was very excited to see pregnant as she is the sister of another of my patients. She was in the process of miscarrying :(
- I saw a patient postpartum, who's baby I caught. She's doing very well with breastfeeding and looks great. The baby is beautiful of course. Her and her husbadn had given me a wonderful thank you card, an announcement, and a gift card - suuuweet! I love cards and gifts - they certainly aren't necessary - but are always very appreciated :p
- I spoke with my favorite nut. She's the sister of a friend of mine. This friend (I sometimes have to question how much a friend she is!) sent her sister to me with the warning that she was a nut. She has mental health issues but manages them pretty well, goes to school full-time as does her partner, has a great dry sense of humor. She can drive me crazy but I admire her for being a pretty tough cookie. Anyhoo, she had been in the hospital with pain issues r/t GI issues (intentionally being vague). We were medicating her, hydrating her, and trying to figure out everything wrong with her....physically anyway. The midwife on call went to see her then came to the office and proceeded to tell me how they did a UDS on her and maybe she's a drug addict and why are we drugging this baby and why aren't the docs managing her blah blah blah. This is Ms. It's-Not-About-Us,-But-About-the-Patients. We could also call her Ms. Holier-Than-Thou. She really was p*ssing me off because of her attitude. This is 'my' patient, quit dogging her out. She may be a nut but she ain't a drug addict just because she has mental health issues. I pointed out that we had been seeing this patient since 5 weeks pregnant and not once had she presented with a complaint or request for pain meds. And she's more than halfway through the pregnancy. Back off B*tch! Anyway, she talked to one of the docs to decide what to do with her as the surgeon said no surgery and apparently the GI doc talked to the surgeon and decided he didn't need to come see her?????!!!!! WTF???? Our doc said send her home for the weekend and then refer her to the perinatologist. WTF??? Why? This is totally non-pregnant related. She needs the GI consult. So guess what I'm gonna do when I see her next week? Off to the GI doc.
- I think I only said drink more water twice on one office day.
- I saw a lady for what was supposed to be a new OB but apparently she had miscarried a couple days prior. She came for her appointment anyway. I sussed out the sitch and it sounded like everything was proceeding appropriately. We discussed grief. We talked about trying again and timing for that. I suggested bringing her back for a WWE in a couple weeks. She declined for religious reasons. She told me that she didn't do paps and would return when she was pregnant. Ok. Whatever. I can respect that as long a woman understands the risks and benefits of testing. I am no longer 'shocked' by out of the ordinary preferences. I'm growing so much :) Not just my a$$ either.
- I saw a doctor patient (because I apparently had a slot open) who was around 29weeks complaining of low pressure, white discharge, peeing frequently, and not feeling the baby move as much for several days. It's her third baby. Um. ok. So I evaluate - lots of fluid in the vaginal vault. Did you have intercourse recently? Yep, the night before. Well, there ya go! No ROM. I explain about common discomforts of pregnancy...i.e. does it feel like the baby is going to fall out when you walk. She looks at me with shock and says yes. As if she is amazed that I know what she is talking about. I explain about pelvic floor muscles and multiple pregnancies. I put her on the monitor. Looks gorgeous. Lots of "contractions" - you know...every 30 seconds, very jagged looking. You labor nurses and midwives know what I'm getting at. Fake contractions! I palpated...not a dayum thing! Go home hun...chill. Come see your doctor next week and drive him crazy..I have enough pain-in-the-a$$es of my own.
- I saw a young patient who had HELLP syndrome with her last pregnancy. She complained about having to stay in the hospital for a week after the birth, being induced, etc. She's really looking forward to doing things her way this time. I said, "If all is well, we do it your way. If all is not well, we do it our way". I hope we get to do it her way!
- I saw a new OB, who is late in the pregnancy and a nut. She has schizo among other issues. I use the term 'nut' affectionately (so don't flame me, I have mentally ill people in my family and I just might be one of em!). This one was hospitalized at the beginning of the pregnancy for trying to kill herself. Her other baby died a couple months out from accidental ayphixia. And she laughed when talking about it. She said she worried that it was her fault for having the blanket in the crib. And laughed. I understand that it was likely r/t her mental status and meds but it was still creepy. It happened last year. Can anyone say social services?
Wednesday, October 14, 2009
I caught a baby for the doc - it was a woman having her third baby. She did an amazing job at pushing out her baby and I got to use my fav spanish saying - "Si, se puerdo (sp)".
Another baby came very fast in a multip who's water I broke at 4-5cms. She delivered just over an hour later and it was so cool. She squatted and pushed the baby out with her arms wrapped around my shoulders, which meant I couldn't see as my face was in her chest....glad she was wearing a bra or I would have been breastfeeding! LOL! I had one hand underneath the baby's head and just felt the baby being born into my hand. I wish more women would birth out of the darn bed! I was so high after that birth...and it was her first natural birth as she had gotten epidurals with her two previous pregnancies then delivered half an hour later.
The third birth was in a patient who had some BP concerns so we were inducing her - second attempt. This would be her second baby, the first weighing at 9-6! I had sent her home a few days previously as cytotec had not worked to ripen her cervix, her labs, were normal, and her BPs weren't too bad. But then she started getting yucky with the BPs again so another midwife put in a foley bulb and had her come in in the morning for pitocin. Her bulb had fallen out during the night so she was 3-4/60/-2. I waited until she had been on the pit for awhile and was starting to feel crampy, then broke her water. She was 4/70/-2 at that point. She got an epidural shortly thereafter (which was her plan from the gitgo). The nurse checked her while I was finishing the previous delivery and she was 10/100/0! She moved along quickly once she got going. What ended up being so surprising about how fast she moved and only fifteen minutes of pushing was that her first baby was 10 years ago, this baby was good-sized at 8-9, and was OP! I was totally caught off guard when I saw this baby's face looking up at me, batting his eyes :)
I went home to sleep but then had to go back as two grand multips came in...neither of which delivered by morning :p
I had a stalker as well....the dayshift postpartum nurse called and paged me a minimum of 12 times in a 12 hour shift. Mostly for stupid sh*t. It was so aggravating as she seems dumber than a box of rocks. I tried to be past but frankly, it was all I could do to not be mean. Example of one conversation...
Me : Stop calling me on my cell phone and at the office, I'm trying to see patients. I don't have my cell phone on me anyway. Page me first.
RN: I did and waited an hour, you didn't call me back.
Me: You didn't page me correctly, my pager never went off. I know it's working because I just got a page from L&D - they seem to manage to get ahold of me the appropriate way.
RN: Oh, sorry.
What was she calling for this particular time? To let me know that the surgical consult wasn't going to happen until tomorrow and the patient needed to be admitted instead of 23 hour obs. That's reasonable right? Well, I had spoke to her an hour and a half previously about the patient's admission - I told her I would come by after office hours to write orders. Seriously, why are you calling me again.....arrrggghh!
Monday, October 12, 2009
I get a call from a patient (#6) who has been harassing us to induce her since 37 weeks. Because she has big babies. That's her reasoning. Oh, and she's dilated 4-5cms and keeps getting sent home from the hospital. She knows she's 4-5cms because she checks herself. And the baby's head is low and the membranes are bulging. I'm amazed and impressed as it takes most labor nurses a minimum of 6 months of practice to get this skill down. wow. In reality, she's 3-4 and the head is -2 per one of the midwives in the office last week. Her biggest babe was 10 lbs. This one isn't that big. But she's now almost 39 weeks and calling me to let me know how uncomfortable she is. I've spent more time on the phone with this patient then I do with my mother! I tell her to come in and I will see what I can do for her. When she arrives, she's actually really 4-5cms so I send her out walking while we wait for a bed to become available for her.
Patient #5 arrives...she's truly a pre-eclamptic. While BPs aren't too bad 140's over 80-90's, her labs have changed significantly in two days' time. Her cervix has also changed a little since the day before to 3-4/60/-3. So I chat with the doc and she agrees that now is the time to have a baby. It's her fourth so ought to go fairly smoothly. I decide to do some cytotec first to get her cervix really really ready....I also wasn't planning on starting an induction this late in the afternoon if it wasn't truly critical.
So I now have one delivered patient and 5 in the works. Oh, I'm lovin' life at this point!
Patient #6 progresses rapidly (it's her 5th kid) after I break her water. She gets one dose of Stadol and pushes out an adorable baby weighing in at 7-10. Not bad, she was very well controlled and did a great job. Had some placenta issues requiring the doc to come in (who was laready in the building at least) - that was the only down side.
It's time to focus on #1. She had gotten an epidural so I broke her water earlier in the afternoon. She was 4/100/-2 at that point, with some caput bulging through the cervix! Naturally, her contractions start to space out. That's about typical for how my weekend is going. So eventually I had started pitocin. When I finally went to see her again almost four hours later, I asked her if her nurse had been changing her position, because she was in the same position I had left her in. This particular nurse, we'll call her Nurse Sucky, spends lots of time charting...at the nurse's station or if she is absolutely required to be in a patient's room...ya know, like, for delivery....she starts through the whole darn delivery. Drives me insane because she pays no attention to what's going on...ya know....like fetal heart tones....shoulder dystocia in progress, etc. Nurse Sucky had not moved the patient a single time! I promptly change the patient's position and mention turning the pit up as if we might want to have a baby *dripping sarcasm here*. It's just about shift change and I have requested one of my fav night shift RNs, Beetus, to take over. I ask Nurse Sucky what the patient's most recent temp was as the baby was a little tachy and the patient had felt a little warm, not to mention her heart rate was a little tachy as well. Nurse Sucky says "I haven't checked recently, let me go do that now". Yes, go do that. I know good and well, that she probably hadn't checked one at all this shift! I look it up and low and behold she had....at 8am, almost 12 hours previously. WTF???
Nurse Sucky comes out and tells me it's 98.5...really? I'm surprised. I decide to go check her (vag exam #3 since breaking water - including the exam when I broke her water) and she's now 8/100/-1 but the caput and molding are lower. This kid is trying to come before she's completely dilated...strange. Plus she's feeling some pressure soon thereafter and is 9cms. Then we get stuck. We have adequate labor (I put in an IUPC at one point) but I know we are running out of time. Baby is looking ok but less and less happy with the process. We spend about 3 hours at 9 then 9 and a half, then a very persistent anterior lip. We change positions frequently, use the peanut, etc. The patient is pushing involuntarily the last hour and a half of that. The lip just would not go away...but the baby wanted to come...the head kept moving down. Finally I call it...call for a section but I put her into one last position - all the way on her right side with the HOB flat. I tell her I will check her one more time before we move to the OR. She's still pushing involunatrily with each contraction, despite repeated boluses on the epidural.
I check her before we get ready to move....the lip is still there but much smaller and a little further back on the head (the caput is just about crowning at this point!) so I have her push while I successfully reduce the lip. I'm so excited - she's gonna do it! I tell everyone to hold on the section and instead she delivers her baby after pushing for fifteen minutes. I did cut a small epis (the equivalent of a first degree perineal lac) due to the heart rate issues and long crowning. Baby came out kicking and screaming with a helluva lopsided molded head! Asyncliticism was the culprit for the cervix not going away. It was all very unusual because if the head is asynclitic then you usually don't get much descent of the head. It also goes to show how inaccurate non-reassuring fetal heart tones are on EFM - as the evidence tells us. But it's still very difficult to wait out a bad strip. This is another prime example of why it's bad to be induced and get epidurals sometimes. Because then you are obligated to use EFM.
Anyway, Beetus and I were very happy that she had a vag delivery. I don't think the patient truly appreciates how close she was to a section. Most OBs would have cut her long before I made the decision to do so.
Patients #2,3, and 5 are all quiet. Patient #2 was on cytotec at this point. I had stopped her pit that morning when I cam in and discovered she was NOT 4cms truly. The foley bulb must not have been all the way through her cervix. Her external os was 4 but the internal os was 1cm! So, I go home to get four hours of sleep...
...when the nurse of patient #2 calls to say she's 9cms and I need you to come. WTF??? Naturally I missed the delivery (it was her third baby). Instead the doc happened to be in house for another delivery so she caught. I was p*ssed. Turns out the nurse had checked her earlier in the night to discover she was 4, then 5 cms. She should have called me at that point. I was so mad. But I know she was just trying to let me sleep. But I told her, it's my job to be there...especially when they are planning natural childbirth!
Patient #3 and 5 are quiet so I round on postpartum and go home to take a nap. Once the pager quieted down anyway! I slept for about 2 and a half hours. I called up to L&D to see what's going on...patient #5 is 5cms but not really feeling them, says Nurse Newbie. Ok, I decide to run to the grocery store then will head to the hospital. Naturally, I get a call from Nurse Newbie an hour later....#5 is 8cms with a bulgy bag and pushy. Greeeaaatttt. I go like a bat out of hell and miss it by 2 minutes. F*ck. Apparently she did a fab job though :)
Patient #3 is all that's left and she continues to do nothing after 4 does of oral cytotec, 2 cervidils. So, cervidil #3 goes in and I leave her for the midwife who left all this for me Friday :p But I'm back on call tomorrow....I bet she's still pregnant.
Friday night I got to stay home even though I had 4 patients admitted at the hospital. I went to the WNBA championship game with Beetus and my older daughter, who really likes basketball. It rocked - we had such a great time, even though the hospital kept calling and paging me. I had told them that I would be unavailable except for emergencies and deliveries until halftime and the end of the game. But naturally, that message didn't make it around to everyone. The game rocked, with our team winning :) I was so exhausted though. I am in the midst of a rough week of call. I had just finished call at 7am Friday morning, only to be back on at 5pm for the weekend. By the end of the game I had such a bad headache, and my neck and shoulders were killing me.
As we leave the game, I get a call that one of the four patients, who is there for an elective induction (grumble - the patient was insistent that she was in labor and apparently refused to leave - her cervix was 1/50/-2??!!), had a foley bulb in but it fell out and she's 4cms now and wanting to get in the tub. I'm thinking "f*ck, there goes any chance of sleep". I lay down and finally drift off to sleep about 45 minutes later when another nurse pages me. Dear God, shoot me now. Another patient who is being induced with PO cytotec for GDM, hypertension, and PUPPS needs some calamine lotion and Benadryl. I'm like "are you serious???? You called me for that????" But just as well, as a hypertensive patient should not get Benadryl as it can raise BPs. I go back to sleep, anticipating that I will get a call soon to go be with the elective chick, who is planning natural childbirth (even though she so badly wanted to be induced - this wasn't her first attempt at being admitted to the hospital, and she's only 40.2). Next thing I know, it's 8am!
This was one of those times when I check my pager to make sure it is working.
I call the hospital to get updates...
-primip (#1) induction due to being 41.3 and wanting to be done - she was getting cytotec through the night...she's now 3/100/-2 and wanting something for pain and asking when she can have an epidural
-elective induction (#2) ended up taking a sleeping pill but is now on pitocin but not feeling them
-Patient #3 with GDM, htn, and PUPPS isn't doing anything yet
-Patient #4 had a foley bulb and was scheduled to come in in the morning for pitocin but actually came in, in labor, around midnight with the foley bulb having fallen out. She was 3/80/-2. She was currently comfortable with an epidural and 6-7cms.
So I get up and head on in. I forgot to mention that I was expecting a fifth patient, someone I had been seeing, to show up for re-evaluation of BP issues.
Enough for now....I want to keep everyone in suspense....will post more later.
Saturday, October 3, 2009
A call at 10pm from a patient who is a G5P3 and 37 weeks. She tells me she's been dilated 5cms for a couple weeks now and they keep sending her home from the hospital. She's tired, not sleeping (3 hours in the past three nights....exaggerate much?), and has big babies and wants to be done. She has an appointment in the morning with another midwife but is tired of being pregnant. The unspoken question? "Can you induce me tonight?". My spoken answer? "No induction until at least 39 weeks (spoken in my head - "especially not at 10pm"). We can do it then as long as your cervix is favorable (who knows if she's really 5cms)". I politely reminded her that I didn't get her pregnant and that her discomfort was not my fault. This was after listening to her complaints for about 15 minutes and trying to be emphathetic. She saw another midwife the next day with the same spiel, who asked me what I thought and I said not until 39 weeks. And she checked her....she was 3-4cms.
4 babies graced me with their prescence (sp) in one 24 hour call shift. All were nice births with no complications.
Had another lady who chatted with her mother the entire time she was pushing and birthing (she had an epidural). I was ready to bang my head against the wall. But she still did good - took 30 minutes to push out her OP baby.
Had a lady who came in because she had been feeling sick for three days. She was something like 30 weeks pregnant. I diagnose her with the flu and she is slightly dehydrated. I give her an Rx for oseltamavir and phenergan since she can't keep anything down. She promptly tells me that she probably won't get those filled because she doesn't have the money for the copays. I ask how much the copays are and she says it varies but the last Rx she filled cost her $4. But you can manage to scrap up money to buy cigs. She tells me that if she gets to feeling worse she'll just call an ambulance. Nice. My tax dollars at work. So why did you bother coming to see me at all and bringing your nice little flu germs with you?????
In other moves....I went and saw the FNP regarding my 'spells'. Because these spells are really getting aggravating...and very persistent. She ran a buttload of tests (some of which I would have declined had I known she was checking them - like syphillis, gonorrhea, chlamydia - really? C'mon I know I don't have STDs). Anyway, here are the significant results....for all you medical people that want to play guess the pathology...Norms are in parentheses.
Med Hx - beta thalassemia, hypothyroidism, spondylarthropathy, IBS, PMDD
Meds - levothyroxine, Yaz, folic acid, rantidine, multivitamin, zyrtec, methotrexate, humira, vicodin prn, skelaxin prn
Symptoms - Low-grade temps (normal is 97.5 area, these run anywhere from 99-100 degrees), fatigue, weakness, muscle and joint pain, shoulders and neck very painful at times especially.
WBC 12.6 (4.0-11.0) This has also been mildly elevated in the last two CBCs I have checked.
RBC 5.58 (3.7-5.4)
Hemoglobin 11.6 (11.5-16)
Hematocrit 37.9 (35-48)
MCV 68 (78-100)
MCH 20.8 (27-34)
MCHC 30.6 (31-37)
Retic count 2.0 (.5-1.5%)
Remainder of CBC WNL.
Serum iron 40 (35-175)
TIBC 412 (250-400)
% Saturation 10 (15-50)
Ferritin 368 (9-120)
CRP 11.7 (<8.0)
Vitamin B12 286 (243-894)
Folate >20 (3.1-17.5)
Rheumatoid Factor <7>
ANA screen positive (negative) This has always been negative in the past
ANA titer 1:160 (<1:40)
HIV, Hep B and C all negative
Transferrin 336 (188-341)
Lyme disease negative
Urine culture negative
Thyroid panel WNL
And there you have it. Feel free to ask any questions and play detective. I have some thoughts in mind but frankly find those ideas a little scary. The FNP wants me to see a hematologist so I have that appointment scheduled for just over a week from now.