Like everyone else, due to budget cuts we've been a lot stingier with staffing lately which means we're putting nurses and scrub techs on standby a lot lately. I enjoyed it by being put on Friday night, which was great since I hadn't gotten but about 2 hours of sleep overnight with Ben and didn't get to catch a nap during the day either. So when they called and offered it to me I didn't miss a beat.

Last night was a good night. We were again furloughed down to minimum staffing (4 RNs) but it was fine. We only had one pretermer on Mag, a spontaneous laborer, a R/O SROM and a R/O Flu. The last one was found to be positive for Flu A pretty quick after our shift started so I stayed the hell away from her room since Ben's surgery is this week. Even though I had the flu shot I still didn't want to take any chances. We had a nurse orienting last night and her preceptor had called in sick so I was in charge of her as well as the unit. We took the labor patient for the experience and it worked out wonderfully!

Since I took the charge position last July I'm now in charge EVERY time I go to work. Most of the time I like it because my personality meshes well with wanting to call the shots, decision making and critical thinking skills. I think I do a good job, and many nurses tell me they like working when I'm in charge because I'm confident, fair and don't hesitate to stand up to the docs or the nurses if need be. The main drawback to this job assignment is that I rarely "get" laborers anymore because in an ideal world I'd never take a patient assignment when I was "stuck" in a patient room for longer than 30 minutes at a time, in order to know what else is going on in the unit. So, unless its a crazy night where we all have labor patients, I tend to take the pretermers, or other lower acuity patients. I miss the laborers sometimes. I still get to "help" with them, by relieving someone so they can grab a break, or still be in the delivery since we send in another RN to receive the baby, but it's not the same.

Last night our patient was in spontaneous early labor, a multip. She was married and spouse was very nice and very supportive. She didn't want anything for pain control and was in total control, most of the time. I love taking care of these patients. It was fun teaching the new RN how to marry our two needs, her need to be free to move and our need to monitor baby. We got her up to walk the halls with periodic returns to the room for monitoring until she got into transition and then we put her on telemetry monitors in the room and used the straddle chair, jacuzzi, etc. We advocated for the patient when she wanted to be free of the IV (her provider was a doc rather than a midwive, which would have been more in line with her wants but a little late for that!) and when she wanted to wait for SROM rather than be ruptured artificially. She had her delivery, the way she wanted it and we were lucky enough to be invited along. It was a surprise what they were having and when Dad announced it they burst into tears because the little girl made their family two boys and now two girls which their other daughter had been praying for fervently all pregnancy!

What a great night! I'm back again tomorrow night and then off for Ben's hernia repair this week so I'm off until Sunday when hopefully they'll put me on standby again because I wanted to take the night off but couldn't find coverage.

IUD and other updates

Since I quit pumping about a month ago my doctor said I could go ahead and get the Mir.ena IUD. (He won't place it in a postpartum woman who's breastfeeding until 6 months due to increase chance of migration.) Before he inserted the Mir.ena he "tested" my cervix with a device using sound waves to make sure they would "go through." This was by far the worst part for me because it immediately caused my uterus to go into one huge cramp that persisted then while he placed the Mir.ena. It only took about 20 seconds or so to place it but man was I cramping horribly. The urgency of it reminded me of diarrhea cramps because it just came out of nowhere and became so debilitating. I took some Ibu.profen and checked out of the office. I wish now that I would have taken some before my appointment; I think that would have really helped. I'm thrilled about the low-maintenance birth control though! I had been taking the Progest.in only pills and HATED them. If you take them more than 2 hours off from your set time each day they are inneffective and you need to use backup for 48 hours! If I got more than 4 hours off I started spotting and it would take at least 10 days of immaculate pill-taking to get it to stop so I pretty much had a light period the entire time I was on them. I wish now I just wouldn't have even bothered with them. Oh well though!

Ben is doing great. We have been home for 2 months tomorrow! He's been off the oxygen for a month and rarely sets off the alarms on his apnea monitor. His alarms are always of the bradycardia type as a result of reflux. All but about 2-3 of them since we've been home have been while he's eating so we could have seen that he needed help without the aid of the monitor but a few times he's choked up on reflux about an hour or two after he's eaten at night while sleeping so those are a little scary. I'm not sure how long they'll leave us on the monitor. At one point someone threw out "a month with no alarms" as how to know when we're ready to graduate.

He is scheduled for surgery to repair his bilateral inguinal hernias next week. They will be done at the hospital I work at, the same one he spent his 86 days in the NICU. He will be readmitted under NICU care so they will do all his pre-op (IV, intubation, etc) and then the RN, Dr. and RT will attend surgery so that's a big relief to me! He will most likely stay at least one night and then we'll be back home. Hopefully he will be able to be extubated quickly and not need supplemental oxygen again. We are hoping this makes his belly feel better to get his intestines back where they belong and his gas issues will improve and his pediatrician says that a lot of times reflux is improved post surgery as well so that would be fabulous! He is on Preva.cid twice daily for that and we are using the formula thickened with rice cereal. We tried adding the cereal to my pumped milk but we couldn't get the consistency right. It was either hanging up in the nipple and frustrating him endlessly or coming out too quickly and choking him up leading to more bradycardic episodes. So, we're doing the formula for a month or two until he can tolerate the thinner liquids again.

He's a wonderful baby, loves to be snuggled, and a pretty good sleeper, all subject to change at a moments notice I know. He's up to 7 pounds finally! We are still home-bound which I've discovered is a great way to make me look forward to going to work since it's my only socialization. We hope to be able to go out and about in the next month or so.

I hope to get back into this. I have a lot of time at home right now and I just typed this whole entry with one hand so...no excuses, right?

Delivered

I had Ben on Saturday October 18 at 2034 for severe pre-eclampsia/HELLP. The epigastric pain came back on Saturday morning and no amount of pain medication could relieve it or even touch it actually. My enzymes shot through the roof and my platelets started dropping about 40K every 4 hours so we proceeded with delivery before it became a crash. He cried at delivery, apgared 5/9, weighed 1# 5.2 oz and was 12 inches long. He is doing as well as can be expected. For further updates visit http://www.carepages.com/carepages/benball

Bedrest

I'm 25 5/7 weeks pregnant and in the hospital on bedrest with pre-eclampsia. :( Developed severe epigastric pain, thought it was gas or heartburn or somesuch but alas my uric acid was 7.8, SGOT/SGPT were both around 100, and 24 hour urine was 6600 or so. :( Demerol relieved the pain and it hasn't come back yet. My doppler studies on baby were good but my uterine artery was restricted (but didn't have reverse flows) My BP is high but not too high so I'm just hanging out for right now, getting blood draws every 12 to check platelets (hanging around 170) and liver enzymes (down to almost normal ranges). We recheck dopplers Monday.

Blast from the Past

I recently took care of a young woman who was a Cervidil induction on the night shift for "postdates." When I first entered the room she looked familiar and I commented on that and she smiled and told me that I had taken care of a family member of hers and she translated for us. I told her thank you again for translating! Even though we have to use a hospital translator for the official business it sure is nice when non-English speaking patients have a translator with them. Anyway, I'm getting off topic. I went on with my assessment, putting in her INT, etc without a second thought...

A few hours later on one of my visits to her room her family was there visiting. They had an infant with them that smiled at me and several of them said things along the lines of "do you remember her?" Right. Like I'm going to recognize a baby 3 or 6 or 9 months or more after I circulate the delivery. They must think I'm amazing! :) I smiled at all of them, cooed at the baby and went to my other patient's room, again without a second thought.

About 10 minutes later it hits me. This family member was not just "any patient." I SHOULD remember the situation. The mother of that infant was not one of the several young women in there but the older woman sitting in the chair, the one with chronic hypertension among other risk factors. The one who PPROM-ed and hung out with us for a week or two. The one I was taking care of when she suddenly complained of being blind. The one who's pressures were fine for her at that time without headache, brisk reflexes or other symptoms. The one who's eyes tracked a pen light. The one who went into preterm labor and delivered a few hours later. The one who convinced her nurse that she truly was blind but we could not convince the doctor that night. The one who ended up with a postpartum hemorrhage and went to ICU where she spent several days on all kinds of medication trying to figure out why the frig she was blind??? She can see now thank God. I went back down there and gave her a hug and told her that YES, I did remember that little girl after all.

Doctor's Orders

Many of our scheduled inductions come in at 0500. We change shifts at 0600 so I barely get a chance to know these women before handing them off. On a good day I can get her in and out of the bathroom, to bed, monitors on, vitals taken, consents signed, IV in and complete physical assessment complete before 0545 when report starts. If I don't then she ends up not getting her pitocin started until at least 0700 for one reason or another. (This is a whole other post that I'll address sometime.) So, I tend to try to be as efficient as possible. Everyone once in a while we'll get a real kink thrown in like someone wanting an enema, an extremely complicated medical history, tough IV start, etc. I do my best to get them going as quickly as possible without them knowing that I'm busting my ass to get their crap done!

I was starting an induction the other day and she asked me if she could have something to drink. I told her that her doctor usually preferred that patients just have ice chips but that I could probably get her a glass of water if she needed one.

Now, there are a couple reasons that I would go "against" doctor's orders in this case.
#1 One small glass of water is no different than ice chips; I wasn't offering her a Big Gulp :)
#2 She was having her third baby in 5 years, one of which was almost 9 pounds so she had a fairly significant proven pelvis as opposed to a first timer.
Now, if a mom is trying to VBAC, has a known risk factor such as history of shoulder dystocia, IUGR or diabetes, I would have refused her the water and just given her the ice chips. I promise I have a point. :)

A few minutes later I'm signing consents with them and we go to have her husband sign one of them and I find out they are under our hospital's insurance...so I dumbly say "so where do you work?" And he tells me he is one of our hospital's physicians...in a specialty we rarely if ever even consult with. Oops.

No doctor, we nurses don't ever offer your patients something against your orders. :)

One for the record books

I just worked 6p-6a three nights in a row and I am dragging ass. About an hour before shift change a few nights ago we had a nurse on Postpartum call us and ask us to come help her out. She was taking care of a 38 weeker with pneumonia who's O2 sats were getting progressively worse through the night. She was trying to get fetal heart tones and having trouble. I go out there and RT is there ready to set her up on BiPap, I get heart tones in the 80's with maternal in the 140's, call back to my girls, tell them to get a room ready and call the doc on call and start unplugging crap. We get her back to the birthing center and RT is setting her up on the BiPap and her sats were running 78-80. When the BiPap got tweaked her sats went up to low 90s and baby recovered nicely. When the pulmonologist got there he decided she needed to be on a vent in ICU so we did rapid sequence intubation and moved her upstairs. We had two L&D nurses, an OB doc, the pulmonologist, three RT's, two PP nurses, an ER nurse, the ICU charge nurse and the house supervisor helping out. Once we got upstairs and set up the fetal monitor baby was having some lates and then resolved, she was determined to have pulmonary edema, cardiomyopathy with an ejection fraction less than 50%, and pneumonia. They decided to induce the baby with pitocin so they could treat her problems without the worry of influence on baby. We delivered a baby vaginally in ICU with mom on a vent, how freaking crazy is that?