Wednesday, April 28, 2010
Even one of the docs I was doing a section with (their patient, not mine) was ready to bang her head against the wall. This doc is one of the nicest most patient docs ever. But Nurse Crappy can do that to you.
My BFF joked that she ran into Nurse Crappy in the cafeteria and asked her to not kill my patient today. That had me laughing at least.
But I have to be nice. There's been a b*tchfest recently about us midwives on the part of some of the nursing staff. I can't bark orders at intellectually challenged nurses anymore. I have to mentor them instead. F*cking p*sses me off. I don't see my job as being about educating and mentoring the nursing staff - don't get me wrong, will do this with those I like and those that are interested in that from us - but it's not my job to focus on nursing staff development. Seriously - that's what the nursing educator is for. Not really sure what she does. But theoretically that's her job. I see my job as protecting my patients from those who are lazy or incompetent. It gets old....hence the 'barking' of orders.
This particular patient was a really nice lady that showed up wanting to VBAC. Unfortunately she was barely dilated and her water had broke. I always hate it when that happens because even though we can be pretty liberal with time constraints, it still creates a sensation of pressure for everyone involved - the midwife, the patient and her family, the nursing staff, etc. This lady was very much wanting not only a successful VBAC but a very natural experience as well. I was able to accomodate this up to a certain point. The plan was to leave her be to ambulate, do nipple stim, etc in the hopes of increasing the little bit of labor she was having. Her labor appeared very prodromalish (is this a word?) to me. I was a little concerned but kept that to myself. I gave her a peptalk (inlcuding a discussion about previous c/s baggage and letting it go) and everyone was on board with the POC (plan of care). Under no circumstances did she want an epidural. I've heard that before and usually dread hearing it. It inevitably sets a woman up for guilt IMO, if she decides, once she's in the heat of the moment, to get an epidural.
Fastforward several hours later.
The patient and myself are both ready to move to the next step as labor hasn't seemed to progress. The POC is a nap with a narcotic to help her sleep for a bit then on to pitocin. I head off to get some dinner and chill for a bit. I get a call from the nurse who says the patient woke up from the nap feeling like things were different and that she felt herself dilating. She doesn't want pitocin and thinks that the birth will be sooner rather than later. Ok. Stranger things have happened so I head back to the hospital.
She feels like she needs to push. I check her - *sigh* disappointment for all, she's progressed a little but still in the latent phase of labor in terms of dilation. She falls back to sleep. I head out to try and get some sleep myself - feeling really tired as all the husband health stuff is taking its toll on my autoimmune issues.
Once we hit the 18 hour mark, the patient and everyone are in agreement with re-evaluating her cervix. Nothing has changed, so now we start pitocin. I tell the nurse to call me when she gets active and I will come back.
2 hours later...
The nurse calls to let me know the patient is demanding my presence at her bedside...WTF? She also wants more narcotics. I, being a little irritated with this demand for me to be at her bedside, fall back asleep. I know, not very nice or mature of me....was also really feeling tired. A little more time goes by and the nurse calls again to let me know the patient wants to know where I am at. Has she called her doula to come? Nope. But I better get my a$$ up there ASAP. Apparently she called out on the call light screaming. Now she wants an epidural. She's now 4cms. And the pit was shut off at the patient's demand. I head in and arrive as she is signing the consent for the epidural. She looks so exhausted but not really seeing the behavior from her that the nurse was describing to me. Of course, the relationship between the provider and patient is different from the patient and nurse relationship frequently. She absolutely wants the epidural so we go with it.
Once the epidural is in, mom is sound asleep, pit re-started, and baby looks good, I go home to bed with 4 hours of call left. The oncoming midwife caught her baby just over 4 hours later. I'm very happy that she was successful in VBACing....but I feel worried that she may not be happy with her birth experience. *sigh*
Monday, April 26, 2010
I brought him home (yep, he's still surviving on that 5%!) after 8 days in the hospital. He and I were both getting a little stir crazy. It was finally decided that he didn't meet the requirements for the three lead pacemaker. Both the nephrologist and the internal med doc said "He needs a heart". Well, thanks for that newsflash :P The cardiologist who really wanted the pacemaker pretty much bowed out once it was decided that the pacemaker wasn't gonna help. The 'winning' cardiologist ended up discharging him home after putting him on a new beta-blocker (sotolol - go ahead look it up.....it'll scare the crap out of ya). He had been having lots of PVCs and had 2-3 runs of V-tach (non-sustained). He didn't have any awareness of the V-tach episodes as they weren't fast enought to trigger his AICD nor did they last more than 24 seconds. Nice. As if anxiety levels weren't slightly elevated already. He was to follow up the following week and the transplant route is now under way. We got an information packet from the transplant program and the newest leg of the adventure begins. Currently waiting on insurance authorization to proceed with scheduling the appointment for the consult. He's been in much better spirits since coming home. No coughing and down about 34 pounds total. I'm still not used to his new look - skinny :p
I have been on call a lot due to another midwife being out of town. I have caught so many babies in such a short time that some of the labors and births have blended together a little :( I was on call for my weekend and broke my previous record of 7 babies in a weekend! I got about 3 hours of sleep in a 41 hour period of time...and not all in a row! Everyone that came in wanted to have natural childbirth. I was so exhausted that I started hoping women would get epidurals so I could sleep. But then of course, I felt guilty for thinking that. But it was really the sleep-deprivation speaking. If I recall correctly, I had something like 4 epidurals, 1 IV pain med labor, and 4 natural childbirths.
Two of the women were ladies I had seen a lot of in the office so it was extra special to get to catch their babies. One lady had a history of vacuum assisted birth with her first child and very much wanted to avoid it this time. She did! But it was getting to be a close call. In fact I had called the doc on call to come in to stand by vacuum. In the meantime, she got riled up and pushed her baby out about the time he arrived. I was very happy for her...and the baby was almost half a pound bigger than her first! I don't know if she just reached a point where she had a psychological block and couldn't get past it initially or what.
The other lady was having her first baby and had a beautiful natural childbirth - one of those ones where everything goes smoothly and damn near perfectly. Love it!
I've had some more births since that weekend...lots of fun and interesting births but can't remember much right now :p I think I have a touch of stress, busyness, and maybe some fibro fog going on :p I need to try and blog more often before i forget details I guess. We'll see what I can do.
Sunday, April 11, 2010
Events preceding admission - he was feeling worse and insurance was dragging feet about pre-authorizing a heart cath. Cardio people were very uncomfy about the delay so advised us to go to the ER. He could get the cath done as an emergency procedure. Direct admit wasn't an option due to the insurance not being contracted with the hospital. But emergency admission would be covered.
Day 1 - arrive at the ER, things move promptly. Three hours after arrival he's off for the heart cath. Then admission afterwards. He vaguely remembers the doctor exclaiming "How old is this guy? His heart is very bad!" and that the ejection fraction was 5%. No one comes to see us afterwards. My husband is stable at this point but has pulmonary edema still.
Day 2 - labs are mostly ok except creatinine is a little elevated, BNP is horribly high (13,000). More waiting. The doc finally comes by and discusses the cath and results. Yes indeed, the ejection fraction is now 5%. He's amazed that someone my husband's size is still alive. Well, I guess that's reassuring....or not. He wants to put in a BiV pacemaker but after further reviewing the chart determines he is not a candidate. Insurance will not pay for the pacemaker so he has to meet the criteria for a research program to get it. So next plan is to recheck labs and chest x-ray in the morning and send him home if all is well. The following week, the doc will get him set up for a transplant consult. Traumatic afternoon involving som crying and statements such as "I don't want to die!"
Later that night - another cardiac doc comes strolling in. He wants him to have the pacemaker. This particular doc is actually my husband's doc (even though we have never met him - we had been seeing the PA the past couple months) while the first doc is on call for the weekend and did the heart cath. He says he's gonna get my husband fixed up and it's too soon for a transplant.
30 minutes later - my husband has a very scary bout of chest pain treated with MONA (morphine, oxygen, nitro x 2, aspirin). I was ready for him to code. No ecg changes though. Uneventful remainder of the night.
It's gotten around the staff by this time that I am a nurse . Most are receptive to that. Which is good cuz I sure would hate to have to be a b*tch. But as anyone knows that's been ill in the hospital - he's not just another patient....he's my husband and father of my children - I'll guard dog him more than I have ever guarded a laboring women. And that's saying a lot!
Day 3 - first doctor comes in and says we can go home and to call his office in a couple days and he will get a transplant consult. Other doc comes in and says he has a research person coming to take a look at my husband.
The doctors argue. The second doctor wins. They will go for the pacmaker. No one consults us as to what we would like to do. The second doc never comes to see us after winning my husband.
Day 4 - we spend a lot of time waiting. First doc stops by and says my husband's care was taken over by the second doc. The plan is to have an electrophysiology eval for the pacemaker. But it's the weekend so probably not until Monday. Still haven't seen second doc although he is apparently a bit of an nightowl.
And before you ask....the docs are from the same practice (but different offices) and have worked together for 20+ years. I plan to push for both plans - the pacemaker and the transplant consult.
I'll keep you posted.
Saturday, April 3, 2010
I'm breathless at times from anxiety. I feel this intense fear because I know 'it' could happen any moment now. What's 'it'?
'It' is death, heart attack, chest pain, etc. All the bad things that might happen due to his condition.
I try not to focus on 'it' too much but it's damn hard to avoid. I don't know if I should be talking to the children now about what's happening with him. That would be a painful conversation. And what exactly do you say? Without scaring the crap out of them? My daughters understand that daddy has a bad heart but I think only my older daughter has a realistic idea of what that means. To some extent anyway. My son is mentally disabled and has no clue. So I rely a lot on my older daughter to help keep an eye on him. She knows to call 911 if something happens to daddy while mom is away at work or out of the house. She knows what to tell them. I worry that I am burdening her too much though so I try to really watch what I say.
I hate when people ask me "How's your husband?". I know they are just being courteous or well-meaning. But what do you say to answer that? He's great? He's fine? He's dying?
Friday, April 2, 2010
While he has since recovered from the pneumonia, he continues to be tired and run-down. He had the CT angiogram of his chest, however the tech didn't put down any pulmonary pressures - which was the point of doing this test! I was aggravated to say the least. He's now having ECG changes which indicate that his non-ischemic dilated cardiomyopathy is becoming ischemic dilated cadriomyopathy. What does that mean you ask? It means that his heart muscle may now be deprived of enough oxygenation whereas it wasn't before. Not good. We have decided to proceed with left and right-sided heart cath to get more exact numbers and hopefully clear him to have a third lead put in his heart (currently has two - one to shock and the other to pace). We were told that the third lead might increase his function and might help him to feel better. Ok, sign him up! The cath will probably be sometime in the upcoming week.
The next day, he has an hour of chest/arm pain in the wee hours of the morning. He's up out of bed, can't get comfortable. I find out about this 6 hours later when i call from work to check on him. Naturally we had a little discussion about signs of bad shit happening! If it happens again, we were instructed to bring him to the ER and they will do the cath as an emergency. Fortunately it hasn't happened again.
So I watch, and we both wait. It's stressful. I think he's getting depressed. He spends all his time sleeping or watching TV. I told him today - you can't just give up and grow roots into the sofa. You should do what you can do. Stay active to whatever extent possible. Spend time with the kids, with me.
My best friend and I have had a fight. It's pretty bad. I said some things that weren't very tactful or came out quite like I meant them to. She said some things that I don't know if I can get over. Not sure what will happen with this situation.