Girls Just Wanna Have... Babies.

You know her. She's the labor-wannabe. Let's call her Labor Girl.

******

Labor Girl arrives in the ER, breathless, cheeks flushed, anxious but elated. This must be it!

Her husband, let's call him Dear Hubby, parks the car and then joins her in ER triage, arms loaded with suitcases, birthing ball, boppy, radio and fan. He is a little panicky... a trickle of persperation slides from his upper lip. What have I gotten myself into?

But Labor Girl is thrilled. The deck of Uno cards is tucked into the front pocket of her suitcase, and a CD of soothing music resides in the portable stereo. This is going to be fun!

She is quickly retrieved from the ER and wheeled to OB triage, breathing obediently when her belly hardens. The babe inside her kicks in protest. She smiles knowingly.

******

Once she is safely ensconced in her tiny (if not somewhat unsatisfactory) triage room, she slowly strips out of the clothing she had carefully planned as her "going to the hospital" outfit. Dons the threadbare and breezy hospital gown, careful not to displace her perfectly coiffed hair and generously applied makeup. Pushes the call light.

Dear Hubby commences hand-wringing in the corner. Perhaps Labor Girl should share her deep-breathing techniques with him.

******

Soon the monitors are applied, blood pressure and temperature checked. Labor Girl dutifully answers the questions of the triage nurse, alternately smiling and breathing with the periodic tightening.

"Well... I'd rate these contractions about 6 or 7 on the pain scale." Straight face. It's that darn pain scale again.

******

Bad news.

"I'm only dilated to 2 cm?"

Labor Girl is clearly disappointed.
Doubt begins to curl around the edges of her optimism.
"Are you going to send me home?"

******

After a short while, the monitors are removed, and Labor Girl begrudgingly goes for a stroll. This isn't as fun as she had anticipated. Who wants to go for a walk at 2:30 in the morning? Another wave of doubt crests. Maybe if I walk a little faster.

******

Round and round she drags Dear Hubby, whose exhaustion has overtaken his fears.

The nurses smile understandingly each time the determined couple rounds the corner. Does Labor Girl think this is a race that she can win? That if she makes it through the hallways quickly enough or does enough laps, then we'll keep her?

******

It's time to be rechecked.

"Yes," Labor Girl nods to the nurse. "The contractions feel much stronger!"

She holds her breath, awaiting the verdict.

"I'm still 2 cm?!"

******

And now, here it is: the Walk of Shame.

Poor Labor Girl.

She trudges out the doors, pouting, vistaril in hand. How can this NOT be it?

Dear Hubby gathers the belongings and follows her solemnly home. Thank goodness this wasn't it.

******

And so, you see, sometimes no matter how badly you want it, labor it is not.

Maybe next time, Labor Girl.

I'm sure we'll see you soon...

Count Me In

I want to form a committee.

I hereby volunteer to chair the Committee for Outlawing Committees that Accomplish Absolutely Nothing Except Wasting Valuable Time (COCAANEWVT). Anyone care to join me?

Seriously.

As a *lowly* staff nurse, I am subjected daily to the whims and wishes of upper management. Start a new type of charting starting by this deadline, go to this inservice on one of the above days, try to work amicably with nurses from postpartum when they need your help, don't forget your core ideals, have face-to-face conversations when you disagree with coworkers, make sure you pick up your shoes in the locker room... and on and on.

You might hypothesize that a good way to mitigate this problem would be to join one of the numerous committees that are dependent on staff nurse participation in order provide input and encourage change in the workplace.

If only it worked that way.

Despite the best of intentions, committees with which I have been involved rarely accomplish any tangible change. We spend hours brainstorming great ideas that should improve the flow of our work, the effectiveness of our communication, and the professionalism of our practice. But first we must delegate responsibility for each new concept to a subcommittee, survey staff as a whole to guage what kind of reception this change will receive, propose said idea to management for approval, and create posters and inservices so that everyone will know how to alter their practice.

Oh sure, we spend hours on implementation and evaluation of new ideas. We are congratulated by managers for our active participation in these processes. Thank you for all that you do to improve our unit, blah, blah, blah...

Does anything ever really change? No.

The finance committee has been hard at work. There are reams of paper lying around somewhere to prove that the new charging system in triage is more effective than the old one. Or were the papers used to disprove it? Who knows. And I'm sure the new Good Job forms work infinitely better than the outdated ones. Good thing the central values committee spent weeks on that. Now, how can we solve the problem of inadequate staffing during peak scheduled procedure times? Let's send an OB tech to the recovery room to help and make the secretaries do baby baths. But we'd better filter that idea down through the OB tech and secretary committees.

Last item on the agenda: the inconsequential issue of low staff morale and poor RN retention?

Let's pass that one on to the shared leadership committee. I'm sure they'll have that one solved in no time.

Meeting adjourned.

And on a BUSY night...

Finally, a busy night with the pedometer, and I feel somewhat vindicated.

15,367 steps!

That's 7.03 miles!

My dogs are barkin'... time to put them to bed.

Change of Shift is up at Kim's blog.

Cheers!

How Will Nurse Blogging Change You?

Since embarking on this nurse blog journey, I've noticed several changes in myself, both practical and philosophical. Perhaps these are changes that would have occurred in the natural evolution of my nursing career... I'll never know.

I am increasingly aware of issues about which I would never have given a second thought, and I have started to apply what I'm learning at the bedside. I've also found myself becoming more lucid and verbal in work-related situations which I previously would probably have either ignored or gone with the status quo. Lately, I look at nursing issues (and sometimes life as a whole) from a new and wider perspective.

Take some time blog-hopping, described here by the Curmudgeon. Or simply read through a few of the links on my sidebar. You'll see what I mean.

I have to conclude that reading up on the opinions and experiences of the other medical bloggers out there, and responding or at least pondering a response, has changed me. Perhaps not always for the better. I have to admit I've been caught up from time to time, mindlessly lurking from one blog to the next, soaking up useless and sometimes utterly personal information from the multitude of blogs available.

However, if I peruse with a purpose (wink), sometimes I am struck with inspiration. To change my practice, adjust my attitude, or be called to action. All of which, I find, are stretching my limits and my yearning for growth and knowledge anew.

At times, I am also discouraged by what I read. I must confess that I am humbled by the bloggers whom I admire, those who write both prolifically and eloquently on a level to which I aspire. But if I stay silent until I measure up, this blog will lay dormant forever. It is those I seek to emulate who make me both afraid to click the "Publish" button and compelled to do so.

Speaking of my heroes, you can read Kim's ideas for beginning nurse bloggers here. See what I mean? Witty, comprehensive, insightful? Check, check, and check.

I'd love to hear how blogging has changed YOU... for better or worse. After all, this dialogue is what blogging is all about.

Or something.

Day 3

Best yet: 8,415 steps!

And still not THAT busy.

Huh.

Day 2

6,647 steps!

3.04 miles.

92 steps/min.

Not even a busy night. (not complaining about that!)

Pedometer

Day One: 6,805 steps! (at work for 12+ hours last night)

I am such a geek.

Ouch!

I'm thinking of changing the way in which I describe the pain scale to patients before asking them to rate their pain.

As a small part of the volumes of charting we are required to do for every patient, we must enter a digit into the computer, detailing where on the pain scale the patient is rating their pain. Then, we're able to reassess the pain at various intervals, and determine whether or not interventions used to ease the pain have been effective. Great, in theory.

This is how I usually phrase the question: "So tell me, how would you rate the pain, on a scale from zero to 10, zero being no pain, 10 being the worst pain you can imagine?"

Key word, imagine.

Apparently some of my patients suffer from a grave lack of imagination.

Imagining that "worst pain" seems to be a difficult concept to grasp, despite my assurance that this is not about whether you have experienced severe pain in your lifetime and how your current pain feels in comparison. I understand that if you've never been in labor, never had a serious injury, never had major surgery, it can be hard to imagine that kind of intense pain. But seriously, TRY.

Do patients think that I find it amusing that they rate their pain "11" out of 10, when they're conversing with their friends and answering their cell phone, whilst the poor woman across the hall can barely utter "7-8" out of 10 while she sweats and groans and writhes on the bed? And I'm not talking about some ultra-stoic multip. Often, it's the first-timers who like to think that early labor must be as bad as it can possibly get. As I said, key work, imagine. Otherwise, it just defeats the purpose.

The thing is, I really don't intend to judge others on their perception of pain. I frequently elaborate on the fact that we all experience pain differently, and that the pain scale is intended to help us monitor "where we go from here." But it is useful to have a somwhat accurate picture of the current pain level and perceived intensity of pain for each individual patient. Chances are, if you can chat and laugh through a contraction... it's not that bad. Some patients will even go so far as to keep one eye on the monitor so that they will know when they are contracting and can be sure to act accordingly. Believe me, if you're really in labor, you don't need the monitor to tell you when the pain comes!

Apparently, I need to rethink my assessment technique on this one.

How would this work? "So tell me, how would you rate your pain on a scale from zero to 10, zero being no pain, 10 being the pain you would experience while being run over by a steam roller?"

I wonder what kind of a response that will evoke. Probably wouldn't be making too many friends.

Another tactic...

The New-and-Improved Labor Pain Scale:

1. "I think someone just pricked me with a pin, but I can't remember exactly where because I can't feel it anymore."

2. A twinge of pain that's definitely there, but quickly forgotten.

3. Headache pain that is distracting enough, but treatable with a little ibuprofen and a cup of coffee.

4. "Whew, that pain was pretty bad, and made me stop in my tracks and breathe for a minute."

5. Now, c'mon girls... I know not everyone experiences period cramps, but who has never had really bad diarrhea, when you think the cramps are promptly going to expel most of your bowels, along with their contents?

6. When you stub your toe so hard, you're fairly certain it's broken, and probably won't be able to walk on it for a day or so.

7. I have dislocated my shoulder, so I speak from experience when I say that this worth at least a "7" on the scale... that feeling of almost having torn one of your limbs from your body.

8. I've heard really bad back labor described as, "It feels like the baby is trying to come out through my tailbone, like my body is ripping itself in two!"

9. Being dipped in boiling oil... not sure, but this seems like it would be unbelievably painful.

10. Last but not least, the aforementioned steam roller/crushing experience.


Now, some of these are open to interpretation and finesse, but I think perhaps I'd get a more accurate assessment of the patient's pain if she were obligated to take this scale into consideration. Anyone else have fun ideas or suggestions to work into the scale?


***I know... seriously tongue-in-cheek. C'mon, tell me you've never rolled your eyes when your patient rates their pain an "8" out of 10, only to turn around and ask for a sandwich and "How long is this going to take?"

This is So Cool.

Pun intended.

(WARNING: highly educational and seriously UNfunny post to follow.)

In this age of technology and gadgets, it's not often that a revolutionary breakthrough utilizes basic physiology to make a miraculous difference.

Brain cooling is an amazing new (relatively speaking) technique being offered by several NICUs across the nation, and unfortunately, we've had a few babes over the last year that have needed it. Fortunately, it can work.

I was thinking about these kiddos the other day, which led me to do a little surfing in search of further information.

Brain cooling is intended for infants that have undergone hypoxic injury related to labor or delivery, with events such as abruption, ruptured uterus or cord prolapse or occlusion. This article, from Georgetown University Hospital, discusses the pathology of hypoxic-ischemic encephalopathy (HIE) and how brain cooling is used to try to avoid what was described to me as the "second wave" of brain damage that occurs following the hypoxic event.

While specific processes differ slightly, most sources agree that the cooling must be initiated within six hours of birth and bring the infant to a hypothermic state (around 91 degrees Fahrenheit!), slowing down the body's metabolic processes to avoid further chemical and inflammatory damage to the brain tissue. After 72 hours, the infant is then slowly rewarmed.

It is by no means the perfect miracle cure. This article, from the BBC, suggests that it results in significant improvement in outcomes for only one out of every six to eight babies that undergo the treatment and is unlikely to make a difference for those with the most severe brain injuries. However, that is still 12-16% of these deathly ill infants who may now have a chance for recovery.

Here is a short video documenting one such case.

What can I say?

So cool.

When Words Are Not Enough

Sometimes all it takes is one sentence to trigger a flood of memory. Kim's moving recollection about a very sick AIDS patient sent me flying into the past with this sentence: "A family desperately clinging to denial is a painful thing to witness."

*****

She was 22 weeks along, and absolutely convinced that she was out of the danger zone, that there must be something we could do, either to stop her from delivering or to save her baby. If she prayed hard enough, had enough faith... surely everything would be fine.

"I felt him kick again. He's still alive!" she exclaimed brightly. Smiling at her husband, she said, "See honey? He's right here. I can feel him kicking."

Over and over she murmured to herself, "It's going to be okay, you're going to make it. Just keep praying..."

*****

"Do a C-section. Save my baby!" she demanded, once she realized that delivery was unavoidable and the baby's heart rate was slowing. Now, she was scared and angry.

We gently explained that the baby was too early and did not have any hope of survival, whether or not we delivered him quickly. She refused to accept these facts. The tension and terror were palpable in the room, a wall of silence between us.

"It's going to be fine... he's going to make it."

*****

Her denial persisted as we moved her to a delivery room, where the inevitable birth would take place. She insisted that we call the neonatal team to be present, so that they could resuscitate the baby, make him LIVE, as she knew in her heart he could, if only she prayed hard enough. She asked for a chaplain and "anyone that believes in God" to come and pray with her.

*****

And then it came.

The moment of realization, like an invisible bubble bursting. She saw him.

"Oh," she whispered, as he was whisked into the waiting arms of the neonatologist... "He's too small." And she looked into my eyes, and then, she knew.

*****

He was too small. Only 370 grams, 13 ounces.

There is no ET tube small enough... no prayer big enough. I wanted to take her in my arms, shield her from the pain.

But at last, she was able to let go. Now she could see that it was not meant to be. Now she could hold her son, and grieve for him, and love him, as he was.

*****

Denial can be so cruel. So, too, can the onset of reality... and with it, the loss of hope.

MAGNETism

I am ambivalent about my hospital's claim that we are seeking Magnet status. You can find more information about this designation here.

At times, I feel inspired to aid in the effort, certain that if we can find enough like-minded colleagues to work towards positive change, we can make it a better workplace. I am often proud to acknowledge that I am part of such an esteemed institution, that we can provide professional, highly-specialized and complex, but heartfelt, individualized care to a high volume of patients. I assume that my fellow nurses choose to stay because they, too, appreciate the high expectations and abundant opportunities inherent to a large teaching facility.

However, there are also times when I am discouraged by the ridiculous processes and mindless functions of the executives and managers who spend so much time talking in circles and sitting on committees that accomplish nothing. How can we effect change if those in leadership roles care more about the statistics than they do about the people "beneath" them who are daily offering their blood, sweat, and tears at the bedside? I wish I could say that we have a cohesive team from top to bottom, but I am constantly reminded that this is simply not true. There are an abundance of petty battles being waged at any given point, with very few satifactory resolutions made.

To my fellow bloggers: Do you work for a Magnet hospital? I would love to know... how is it?

=======

A few other random thoughts:

-------

It was an incredibly busy weekend. Low staffing didn't help: it would not have seemed quite so out of control with a few more warm bodies present, but we made do (as always) with what we had. Now that all the holiday celebrating has ceased, we have settled back into the normal routine... busyness as usual. Today feels like I'm recovering from a marathon: achy head, sore shoulders, heavy eyelids, sore throat. I still didn't manage to get a pedometer for Christmas, so I'm not sure how many miles it was this weekend. It felt like at least a marathon's worth!

-------

As a charge nurse, I often step into the room for the actual delivery, to make sure that there are enough hands available and that the newborn can receive any extra care if necessary. Sometimes I miss having a close bond with one patient and seeing her through the entire experience, but it is thrilling to be present for so many of those most magical of moments. Within an hour and a half the other night, I witnessed a natural (and naked) birth that was documented by a professional photograper and videographer, the birth of an undiagnosed Downs Syndrome infant, the birth of a first child after days of labor and hours of pushing, and the birth of a sweet babe with a previously diagnosed cleft lip and palate.

Sigh... our bodies are so amazing. And sometimes they betray us, but that's a post for another day.