Driving to Work in the Dark

Snow drifts on the ground.

My breath hangs uncertainly in the frigid air.

Winter still. Stubborn.

But as I drove to work in the warm cocoon of my car, I was transformed by a vision of bright rows of lights, shining festively through the transparent walls of a greenhouse at one of the nurseries I pass by.

Instantly invigorated!

I imagine the vibrant lights perched above tiny seedlings, coaxing them to grow despite the lingering reality of winter outside their sheltered walls.

And as the birdsongs further testify this morning, spring is coming.

They know it.

And I am hopeful again.

******

I enjoy working at a teaching hospital. Really.

However.

It can be extremely, astoundingly, incomprehensibly frustrating when the team of residents on call are a bunch of indecisive know-it-alls. Sounds contradictory, right? Maybe that's why the plan of care for my clinic patient (whose care is overseen by the residents) changed every 5 minutes or so last night. They all know it ALL and are ALL making the decision.

Draw labs at 0500.

(talk to senior resident)

Cancel that, let's recheck them stat.

Straight cath her.

(discuss with attending)

Actually, now that you just cath'd her, I think we're gonna need a foley.

Let's hold off on the Mag.

(enter senior resident)

Pressure's up but we'll just keep a close eye on it. And better draw those labs again.

(update chief again)

Now we are starting Mag. And antibiotics.

And some rectal Tylenol.

And I think she's gonna need a section.

(review with attending)

Yeah, let's just do the C-section now.

Hold that thought, the other clinic patient needs a section, too. This one can wait an hour.

*** hour goes by while I furiously try to catch up with meds and charting and explain to family why, despite the fact that the decision has been made, we can't do the C-section right now***

(re-enter senior resident)

Let's go, we're ready NOW!

Intersperse numerous cervical exams by whichever resident is around at the time, and you may have a potential cause for the chorio.

Argh.

Baby did great, and the patient came through it all okay.

The nurse, on the other hand, feels defeated and sad. For the patient, for herself, and for a system that could clearly be better.

On the Other Hand.

And in sharp contrast to Labor Girl:

******

She rolled in by ambulance. Well, ok, the roads were a bit treacherous.

EMT: "23 year old female, fourth baby, term, her water broke about 20 minutes ago, she usually delivers an hour after her water breaks."

Ok.

I'm getting her hooked up to the monitors, asking the usual questions...

Any health problems? No.
Any problems during the pregnancy? No.
Clear fluid? Yes.
Any bleeding? No.
Feeling the baby move? Yes.
Who is your doctor? I don't have one.

What?

I don't have one.

You didn't see anyone during the pregnancy? No.
Not even one time? No.

Okie doke.

How do you know how far along you are? I'm about 9 months.

Uh-huh.

Is there anyone on the way to be with you? No, my husband is home with our other children.

Oh my.

I said, "It's ok, honey. We're here with you." And I held her hand.

******

She did deliver a term infant about an hour after her water broke. Doesn't like doctors. Doesn't like hospitals. But my baby will be just fine.

And she's probably right.

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...

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?"

Sweet and Bitter

Today it's not so much bone tired as totally wired.

There's nothing quite like the feeling of helping a patient who is completely out of control because her labor is barreling like a runaway train towards delivery. A very anxious first-time mom who delivers a couple of hours after feeling the first contraction is going to be understandably agitated by the fact that her uterus chooses to contract every one minute in order to expel the baby, wham-bam-thank-you-ma'am! However, screaming at the top of your lungs for your mommy does not (contrary to the popular belief of many patients whose labors progress this quickly), NOT help to get your baby out.

While a delivery like that can be completely draining, it is also exquisitely intense... working and coaching with the patient to breathe and to push, allowing her body to do its work, forcing her to look into my eyes so that she can stay focused and not let the fear take over. I certainly cannot take credit for what these patients accomplish... it is awe-inspiring.

Unfortunately, the babe was not at all impressed with the process of slamming through the pelvis and into a cold, bright and, according to this babe, rather tiresome world. After working with babe for a few minutes, we got pinkness and a few squawks, but the dusky color quickly returned as babe decided breathing isn't all it's cracked up to be, and after working with babe for almost an hour... got tranferred to Neo. Disheartening. Hopefully babe will turn around after basking in the O's for a while, but it was sad to separate mom from her sweet child after all that.

That's the Sweet and the Bitter in my world this morning.

Nighty-night.