Last night we transferred a guy recovering from a stroke, with a history of alcohol abuse, out of the ICU stepdown unit and onto the regular medical floor. He was fine, roughly aware of where he was and what the plan was, when I took him up. We had several other patients transfered to the same floor that night, so I saw him later—getting out of bed. He's a really big guy, so I called the nurse and some aides and we got him back into bed. About an hour later I take the next transfer up, and I see the same guy hanging half over the siderail trying to reach the siderail release. So once again we go in (this time it was another ICU tech, me, and the nurse) and we are physically holding him in the bed. Eventually more nurses come, so I and the other ICU tech slip out. I told my colleague that given his mental status changes, he'd probably be coming back to our stepdown unit, maybe after a stat CT of the head to reevaluate his stroke. I also said I never want to be in a hospital if I have a severe neuro diagnosis, because if you have a mental status change, say from a new stroke, right after being transfered to a new room, nobody will ever know it—the nurses will just think that's how you are. You'll just be put in a Posey vest restraint and rant and rave all night. Unfortunately, because of high patient loads and high turnovers and transfer rates, nurses and nurse's aides have to make snap judgements about patients.
Sure enough, I come into the ICU this afternoon (not the stepdown unit) to hear a man's bloodcurdling screams, like he's being tortured. It was my friend from the night prior. He was screaming because they were holding him down and trying to start an IV. He's thrashing around in full DTs in restraints and hollering at them. With no IV access, they couldn't sedate him. And sure enough, he had spent the night in four-point restraints before the doctors came in the morning to see that he was in severe withdrawal and needed to be treated in the ICU.
We finally got an order for intramuscular shot of Ativan, which calmed him down a little...for an hour. Three ICU nurses still couldn't get a line in him; then we tried an IR nurse, and an anesthesiologist, to no avail. Finally a surgeon came and put a subclavian central line in like it was nobody's business. I was laying across his legs and holding an arm. I think I smell like him now.
DTs are scary—an alcoholic can be in the hospital for two days without a drink and be fine, and then one day they're a complete animal.
Thursday, April 30, 2009
Wednesday, April 29, 2009
Shaken baby...and the Baby Cage
We had a shaken baby the other day. She was so cute. She was admitted two or three weeks ago for seizures, and now came in again with a right eye deviation. She had the retinal microhemorrhages (bleeding of the retina) and subdural hemorrhages (little bleeds in the covering of the brain) which characterize shaken baby syndrome. Her mother and father do not have custody (the dad's sister does), but the thinking is that the mother's boyfriend is doing this.
I ate lunch with her and sat with her a while. She was so clingy and happy to be with people, I didn't want to put her down. She finally fell asleep so we put her in the pediatric crib (the baby cage), which if you've never seen one looks like this:
When she woke up she stood up in the crib and waved and smile and laughed at us as we passed by, but then started crying. There is nothing worse than a kid alone in her hospital room in a baby cage. I don't get it—I could never ever ever leave my child alone in a hospital, in general, and especially if I saw that they'd have to be in a baby cage by themselves.
The girl will probably have permanent neurological damage, but at least she's alive, unlike many SBS babies.
The grandparents came in and seemed so normal. Which they have every right to be...but it still seems weird. I guess you unfairly expect them to be dysfunctional. I can't imagine how they must feel. I'd be convicted of murder.
I ate lunch with her and sat with her a while. She was so clingy and happy to be with people, I didn't want to put her down. She finally fell asleep so we put her in the pediatric crib (the baby cage), which if you've never seen one looks like this:
When she woke up she stood up in the crib and waved and smile and laughed at us as we passed by, but then started crying. There is nothing worse than a kid alone in her hospital room in a baby cage. I don't get it—I could never ever ever leave my child alone in a hospital, in general, and especially if I saw that they'd have to be in a baby cage by themselves.
The girl will probably have permanent neurological damage, but at least she's alive, unlike many SBS babies.
The grandparents came in and seemed so normal. Which they have every right to be...but it still seems weird. I guess you unfairly expect them to be dysfunctional. I can't imagine how they must feel. I'd be convicted of murder.
Tuesday, April 28, 2009
ALTE: Apparent life-threatening event
I took care of a kid for something I had never heard of: ALTE, an apparent life-threatening event. Essentially it's an episode of coughing, gagging, not breathing, or turning blue, in an infant, which scares the caregiver. The "scared caregiver" seems important because it's usually benign, but the pediatrician or ER has to try to figure it out, and ALTE is the diagnosis-in-the-meantime.
My ALTE infant (15 days old) had a choking episode and couldn't get his breath back for a minute or so, so the parents brought him to the ER. The ER thought it was a simple case of overfeeding (the mother was breastfeeding and then giving formula). However, he spiked a temp, and his urine culture was positive for ampicillin-resistant E. coli. UTIs are also a possible cause of ALTEs, but the amp-resistant variation is sort of a hospital thing, which might mean he acquired it here or it was a contaminated sample. (Truly clean urine samples are not easy to get on infants!) And he's a boy—UTIs are a little rare in boys, right? So he was worked up for the UTI and had to stay a week, but it still sounds like it was might have been a benign episode of overfeeding/choking and a coincidental fever, maybe from mild dehydration or stress of hospitalization. This is why I'm reluctant to bring my kids to the hospital: you have to be so cautious with children (is it a bad sample? or is it a UTI which will travel up to his kidneys and destroy them within a day?) that the residents will keep you there forever.
ALTE is not to be confused with SIDS. It is commonly called a "missed SIDS" or an "aborted crib death" by some nurses and doctors—the presumption is that it's a case of SIDS that was interupted by a watchful caregiver. However, ALTE has different causes than SIDS, i.e. digestive problems or stress rather than respiratory problems or deep sleep and being left alone. My textbook claims that less than 6-7% of SIDS cases had a previous ALTE.
My ALTE infant (15 days old) had a choking episode and couldn't get his breath back for a minute or so, so the parents brought him to the ER. The ER thought it was a simple case of overfeeding (the mother was breastfeeding and then giving formula). However, he spiked a temp, and his urine culture was positive for ampicillin-resistant E. coli. UTIs are also a possible cause of ALTEs, but the amp-resistant variation is sort of a hospital thing, which might mean he acquired it here or it was a contaminated sample. (Truly clean urine samples are not easy to get on infants!) And he's a boy—UTIs are a little rare in boys, right? So he was worked up for the UTI and had to stay a week, but it still sounds like it was might have been a benign episode of overfeeding/choking and a coincidental fever, maybe from mild dehydration or stress of hospitalization. This is why I'm reluctant to bring my kids to the hospital: you have to be so cautious with children (is it a bad sample? or is it a UTI which will travel up to his kidneys and destroy them within a day?) that the residents will keep you there forever.
ALTE is not to be confused with SIDS. It is commonly called a "missed SIDS" or an "aborted crib death" by some nurses and doctors—the presumption is that it's a case of SIDS that was interupted by a watchful caregiver. However, ALTE has different causes than SIDS, i.e. digestive problems or stress rather than respiratory problems or deep sleep and being left alone. My textbook claims that less than 6-7% of SIDS cases had a previous ALTE.
Monday, April 27, 2009
Echolalia
Tonight we admitted a lady in diabetic ketoacidosis (DKA), and the nurses pointed out to me all the classic symptoms: a blood sugar of 900+, fruity breath (ketone breath or acetone breath), loss of consciousness, tongue dry and shriveled from severe dehydration, etc. One of the not-so-typical symptoms she had, when she started coming around (though very confused), was echolalia. She repeated everything we said, and when she started getting agitated and combative, she would scream everything we said to her, or anything said in her presence. She yelled "My name is Chris!", "You have to stay here!", and "You're in the hospital!" When a nurse (call her Nurse X) walked in, somebody said "Nurse X is the most beautiful nurse in the world." She started saying "Nur-...Nurse X is..." and then, really loud, "HA! HA! HA!" I guess she was a little with it after all.
Incidentally, we're always taught that DKA is a complication of type 1 diabetes who don't take enough insulin, but I seem to see it more often with elderly type 2 diabetics after a sickness or dehydration. Maybe there's just more type 2 diabetics now than there where when DKA was first defined.
Incidentally, we're always taught that DKA is a complication of type 1 diabetes who don't take enough insulin, but I seem to see it more often with elderly type 2 diabetics after a sickness or dehydration. Maybe there's just more type 2 diabetics now than there where when DKA was first defined.
Breech babies
One day in my obstetric rotation, the nurses were all irate. One of their cases was found to be breech three days ago - mom came in for scheduled C-section, and when she was opened up the baby was head down. Did no one even look at her? Palpate the baby? Leopold's manuevers, anyone? Geez.
It's utter negligence that they didn't know the baby had turned—but had they known, and I think they probably did know, I wouldn't be surprised if they would do the section anyway. A c-section is a procedure in its own right, not always needing hard justification—and it's easy. Practitioners know it has risks, including the biggies, blood clots, pulmonary emboli, and intraabdominal infections, but they almost uniformly minimize or neglect to mention those risks to moms. It's a c-section. It's normal.
This is on top of the shady justification for sectioning a breech baby anyway. See this ICAN fact sheet on breech babies, including statistics by country on safe vaginal deliveries of breech babies.
Other breech related posts:
Nearly Bleeding to Death from a Cesarean Section
It's utter negligence that they didn't know the baby had turned—but had they known, and I think they probably did know, I wouldn't be surprised if they would do the section anyway. A c-section is a procedure in its own right, not always needing hard justification—and it's easy. Practitioners know it has risks, including the biggies, blood clots, pulmonary emboli, and intraabdominal infections, but they almost uniformly minimize or neglect to mention those risks to moms. It's a c-section. It's normal.
This is on top of the shady justification for sectioning a breech baby anyway. See this ICAN fact sheet on breech babies, including statistics by country on safe vaginal deliveries of breech babies.
Other breech related posts:
Nearly Bleeding to Death from a Cesarean Section
Sunday, April 26, 2009
Crash birth
Originally posted February 09, 2009
Got to see and participate in a crash birth today. This is my first labor and delivery in a hospital.
22yo woman comes in with significant other at 0730 saying she's been in labor since 3am. She pissed off the L&D triage nurse (who I was assigned to) by yelling that she didn't know her history or her allergies - we should know that since she was here 3 years ago. (People say this all the time on the medical floor, so I didn't think it was a big deal.) She doesn't know her due date; no prenatal care. The OB comes in already somewhat crabby and re-questions her in a ridiculous tone about who her doctor is. "Well who was your doctor last time?!" She yells "I don't know!" and starts sobbing. I went to the bathroom at this point, and as I'm leaving boyfriend comes in and starts puking. After a while they do a vaginal exam and find she's 7 cm and rush her off to a delivery room. I realized the boyfriend is still in the bathroom, so I brought him a drink of water and took him to the new room.
The room fills up with staff and there's many exclamations of "No prenatal care!" "7cm and 80%!" (that's cervical effacement) and "Get the delivery kit!" The nurse I'm following says "Why don't we just deliver her now?!" Whatever that means - Pitocin I guess? The doc asks her how much her last baby weighed. She gasps "8 pounds" and the doctor mutters something like "My lord" and then starts yelling "Listen to me! Do you think this baby is the same size as your last one? Or bigger?" (If I ever take my wife to the hospital and they ask her that and she says "11 pounds", the doc'll have a heart attack right there.) The woman is screaming that she wants pain medicine, but they can't give her narcotics because the birth is imminent (it will depress the baby's respiratory drive), and they can't sit her up for an epidural insertion because with gravity "you'll give birth right now." (So why is that a problem?) So she's made to lay flat, legs out on stirrups, and they kept having to pull her down to get her bottom to the edge of the bed - so she ends up completely flat. They rupture her membranes, meconium-stained fluid comes out, and they insert a fetal monitor electrode into the baby's scalp and an intra-uterine pressure monitor into the amniotic cavity.
Baby's heartrate rapidly decelerates to the 50's, so they push her onto her side and put O2 on her - and the rate quickly climbs back up to 150's-160's. Which was neat to see that what they told us in class actually works in real life - but also irritating and stupid because if she wasn't on her back it would've never happened in the first place. Incidentally they thought she might be decel'ing in the exam room, but the baby was doing fine other than this one instance in the delivery room. The heart rate was beeping quickly this whole time.
They start lactated Ringer's in the IV, no Pitocin, and an amnioinfusion - fluid into the uterus to flush out the meconium.
Meantime the woman is screaming that she's not pushing, she wants meds, if she doesn't get meds she demands a C-section. The doctor says "You're not getting a section. You have no choice." She argues with the nurses (all four or five of them) and the doc, and they finally say "Fine, don't push - we'll just wait here until the baby comes out." The woman calms down, and then with the next contraction she starts to push and seems to actually feel better. In fact, she seemed okay in between contractions, and even with contractions managed to hold herself together, so I think her screaming for pain meds and c-sections was more from being frightened than anything. Having already had hostile encounters with all the staff probably didn't help.
The staff is telling her she needs to push the baby out soon to save it, and they ask what the baby's name will be and she yells it's for adoption. They take this seriously, and don't really encourage the mom or dad to look at the baby, but I thought it sounded more antagonistic than serious. (Since they were trying to use the name to persuade her to cooperate.)
So the baby crowns and EVERYONE - four nurses, two residents, and the OB - is screaming at her to push. Not in unison - just a cacophony of people yelling at her. Then the doc says "Fine! We'll wait for the next contraction." WTF? I couldn't believe they wanted her to push without even contracting, but they were panicking. So with the next contraction and everyone taking up the hollering again, she blows the baby out in one push, head & shoulders & body. It's a girl. Cord was wrapped three times around her neck, and I will always remember everyone counting in bewildered unison "1...2...3" as the OB unwrapped it. The baby is gently handed to the NICU nurse at the radiant warmer and they suction her and laryngoscope her to look for meconium. She didn't aspirate any that they could tell. Triple vessel umbilical, good color, Apgars were 8 and 8, weighed over 6 pounds. Born at 8:38 (one hour post admission).
Mother in the meantime passed the placenta in about 20 minutes without anyone tugging on the cord and without Pitocin (I was surprised). She then got Pit and methergine for some bleeding (not hemorrhaging, though). Oh, and she had a 2-degree laceration (for a 6 lb baby!). The OB kind of yelled at the resident for not knowing the signs of imminent placental expulsion (bleeding, cord lengthening) and what methergine was. We nursing students, of course, did.
In the end the baby seems okay, put on supplemental oxygen in the NICU but in kind of a 'just because' manner (for mec-stained fluid, probably), and the mom changed her mind and decided to keep the baby.
Got to see and participate in a crash birth today. This is my first labor and delivery in a hospital.
22yo woman comes in with significant other at 0730 saying she's been in labor since 3am. She pissed off the L&D triage nurse (who I was assigned to) by yelling that she didn't know her history or her allergies - we should know that since she was here 3 years ago. (People say this all the time on the medical floor, so I didn't think it was a big deal.) She doesn't know her due date; no prenatal care. The OB comes in already somewhat crabby and re-questions her in a ridiculous tone about who her doctor is. "Well who was your doctor last time?!" She yells "I don't know!" and starts sobbing. I went to the bathroom at this point, and as I'm leaving boyfriend comes in and starts puking. After a while they do a vaginal exam and find she's 7 cm and rush her off to a delivery room. I realized the boyfriend is still in the bathroom, so I brought him a drink of water and took him to the new room.
The room fills up with staff and there's many exclamations of "No prenatal care!" "7cm and 80%!" (that's cervical effacement) and "Get the delivery kit!" The nurse I'm following says "Why don't we just deliver her now?!" Whatever that means - Pitocin I guess? The doc asks her how much her last baby weighed. She gasps "8 pounds" and the doctor mutters something like "My lord" and then starts yelling "Listen to me! Do you think this baby is the same size as your last one? Or bigger?" (If I ever take my wife to the hospital and they ask her that and she says "11 pounds", the doc'll have a heart attack right there.) The woman is screaming that she wants pain medicine, but they can't give her narcotics because the birth is imminent (it will depress the baby's respiratory drive), and they can't sit her up for an epidural insertion because with gravity "you'll give birth right now." (So why is that a problem?) So she's made to lay flat, legs out on stirrups, and they kept having to pull her down to get her bottom to the edge of the bed - so she ends up completely flat. They rupture her membranes, meconium-stained fluid comes out, and they insert a fetal monitor electrode into the baby's scalp and an intra-uterine pressure monitor into the amniotic cavity.
Baby's heartrate rapidly decelerates to the 50's, so they push her onto her side and put O2 on her - and the rate quickly climbs back up to 150's-160's. Which was neat to see that what they told us in class actually works in real life - but also irritating and stupid because if she wasn't on her back it would've never happened in the first place. Incidentally they thought she might be decel'ing in the exam room, but the baby was doing fine other than this one instance in the delivery room. The heart rate was beeping quickly this whole time.
They start lactated Ringer's in the IV, no Pitocin, and an amnioinfusion - fluid into the uterus to flush out the meconium.
Meantime the woman is screaming that she's not pushing, she wants meds, if she doesn't get meds she demands a C-section. The doctor says "You're not getting a section. You have no choice." She argues with the nurses (all four or five of them) and the doc, and they finally say "Fine, don't push - we'll just wait here until the baby comes out." The woman calms down, and then with the next contraction she starts to push and seems to actually feel better. In fact, she seemed okay in between contractions, and even with contractions managed to hold herself together, so I think her screaming for pain meds and c-sections was more from being frightened than anything. Having already had hostile encounters with all the staff probably didn't help.
The staff is telling her she needs to push the baby out soon to save it, and they ask what the baby's name will be and she yells it's for adoption. They take this seriously, and don't really encourage the mom or dad to look at the baby, but I thought it sounded more antagonistic than serious. (Since they were trying to use the name to persuade her to cooperate.)
So the baby crowns and EVERYONE - four nurses, two residents, and the OB - is screaming at her to push. Not in unison - just a cacophony of people yelling at her. Then the doc says "Fine! We'll wait for the next contraction." WTF? I couldn't believe they wanted her to push without even contracting, but they were panicking. So with the next contraction and everyone taking up the hollering again, she blows the baby out in one push, head & shoulders & body. It's a girl. Cord was wrapped three times around her neck, and I will always remember everyone counting in bewildered unison "1...2...3" as the OB unwrapped it. The baby is gently handed to the NICU nurse at the radiant warmer and they suction her and laryngoscope her to look for meconium. She didn't aspirate any that they could tell. Triple vessel umbilical, good color, Apgars were 8 and 8, weighed over 6 pounds. Born at 8:38 (one hour post admission).
Mother in the meantime passed the placenta in about 20 minutes without anyone tugging on the cord and without Pitocin (I was surprised). She then got Pit and methergine for some bleeding (not hemorrhaging, though). Oh, and she had a 2-degree laceration (for a 6 lb baby!). The OB kind of yelled at the resident for not knowing the signs of imminent placental expulsion (bleeding, cord lengthening) and what methergine was. We nursing students, of course, did.
In the end the baby seems okay, put on supplemental oxygen in the NICU but in kind of a 'just because' manner (for mec-stained fluid, probably), and the mom changed her mind and decided to keep the baby.
Friday, April 24, 2009
Needlestuck
On April 13th I became blood brothers with a 56 year old alcoholic via a contaminated needle. The nurses were urgently trying to insert a new IV because he needed to be intubated. One of them dropped a 20 gauge angiocath with the safety chamber half closed onto some towels on the bed. I came along and picked up the towels, and was stuck in the left ringfinger right above my wedding ring. I looked and saw the needle sticking through a towel, and uncovered it to see an angiocath with blood in the chamber. I didn't bleed at first, however, so I almost felt like I was off the hook. Probably not really, but it didn't matter: I bled a drop, and then another. Not enough to do a blood sugar check! But enough. I would now be referred to, in lab and employee health records, as the Exposed.
The guy (the Source) was a hefty 300-pound fellow in full-blown delirium tremens—confused, angry, demanding to leave, too weak to get up, but strong enough to get a little combative. I had been wrestling him all day, trying to keep him in bed and out of leather restraints, which are not nice for him and not nice for the nurses (leathers require documented assessments every 15 minutes). I already felt well-acquainted with him. I didn't think we'd get this close.
The charge nurse said to let it bleed to wash out contaminants, and I went down to employee health. Had my blood drawn for a baseline HIV and hepatitis B and C screens—not to tell if I'm infected by this stick, but to verify I wasn't already infected if I happen to turn up positive later. His blood was also drawn for a rapid HIV screen and hepatitis. If he was reactive (a potential positive), I would go to the ER to initiate antiretroviral treatment, which can cause nausea, vomiting, and nuke your liver. Luckily he was negative, and blood cultures showed no growth.
Frustrating describes the whole situation. Since HIV and the various hepatitis virii can seroconvert up to six months after an initial exposure. This means that I have to go back in six weeks, three months, and six months for further testing. I have to do this even though he was negative because he might be pre-seroconversion. It also means I have six months to think about not exposing my kids in whatever way; and not exposing my wife, which has pretty significant ramifications for our sex life, to say the least. And everyone wants to know: who the f*&% the nurse was! Well, I know who it was. But I like working with her. She's a good nurse; but it was a fast and stressful situation and she was careless.
I think I'll be fine. HIV has a 0.3% infection rate after a needlestick; HBV has up to a 30% rate but only if you're not immunized (which I am). So we'll see.
The guy (the Source) was a hefty 300-pound fellow in full-blown delirium tremens—confused, angry, demanding to leave, too weak to get up, but strong enough to get a little combative. I had been wrestling him all day, trying to keep him in bed and out of leather restraints, which are not nice for him and not nice for the nurses (leathers require documented assessments every 15 minutes). I already felt well-acquainted with him. I didn't think we'd get this close.
The charge nurse said to let it bleed to wash out contaminants, and I went down to employee health. Had my blood drawn for a baseline HIV and hepatitis B and C screens—not to tell if I'm infected by this stick, but to verify I wasn't already infected if I happen to turn up positive later. His blood was also drawn for a rapid HIV screen and hepatitis. If he was reactive (a potential positive), I would go to the ER to initiate antiretroviral treatment, which can cause nausea, vomiting, and nuke your liver. Luckily he was negative, and blood cultures showed no growth.
Frustrating describes the whole situation. Since HIV and the various hepatitis virii can seroconvert up to six months after an initial exposure. This means that I have to go back in six weeks, three months, and six months for further testing. I have to do this even though he was negative because he might be pre-seroconversion. It also means I have six months to think about not exposing my kids in whatever way; and not exposing my wife, which has pretty significant ramifications for our sex life, to say the least. And everyone wants to know: who the f*&% the nurse was! Well, I know who it was. But I like working with her. She's a good nurse; but it was a fast and stressful situation and she was careless.
I think I'll be fine. HIV has a 0.3% infection rate after a needlestick; HBV has up to a 30% rate but only if you're not immunized (which I am). So we'll see.
Wednesday, April 22, 2009
The Extent of my Critical Care Duties
Today, literally within one hour, I helped admit a patient from the cardiac cath lab, set up two lung taps for the pulmonologist, took the two liters and several vials of reddish-yellow fluid from the two taps down to the lab without mixing them up, ordered stat cardiac biomarkers on one patient and a stat potassium level on another, did a stat EKG, discharged a patient to the front door and prepared another for transfer out of the unit, and in the middle of all this I managed to write down, collect cash for, call in, pick up, and sort SEVENTEEN orders from nurses for Chinese food.
Friday, April 17, 2009
Obstetrics: causing a problem and then fixing it
Originally posted Jan 26, 2009, at the start of my maternity classes.
My maternity nursing classes have been interesting. I've never talked so much in class! I'm the only person in the class with any home birth experience, and I'm also the only male student (out of 3) with any recent birth experience. I think there's 37 women in the class. So I have a weird perspective on things.
For instance, we went over the different positions a woman may labor in - but the teacher said "I have to teach you this, but I also have to tell you you'll never see any of these. As soon as the water breaks, they're in bed until that baby is born." She asked if anyone has seen a woman laboring standing up - I raised my hand, and she said "Well, sure, you have. Your wife had home births, which was great because she could do whatever she wanted." :) She also asked if we felt more empowered giving birth at home. She's repeatedly said that lithotomy is the worst position from which to push a baby out.
She's also thinking of showing The Business of Being Born.
9 out of 10 complications we're being taught about are caused solely by the obstetric process - maternal fever from anesthetics, constricted placental bloodflow from Pitocin, urine retention from spinal blocks, babies with poor respiratory drive and suckling reflexes from opiate use. The most common problem is called supine hypotension syndrome - if a woman labors on her back, her uterus squishes the blood vessels supplying the lower body. This causes a reaction where her blood pressure and heart rate drops, which drops blood supply to the fetus. This shows up as heart decelerations on the monitor. Nursing response? Turn the woman on her side, slap some oxygen on her, start IV fluids to increase her blood volume. If that doesn't work, try the other side - if that doesn't work, prepare for a c-section. The cause? Laboring on her back - so she can be hooked up to an electronic fetal monitor. And the only reason she's on the EFM, as they've repeatedly told us in class: lawsuits.
There's not much emphasis on real pregnancy problems - placental abruption, placenta previa, eclampsia, etc. I have a feeling that OB nursing is all about complications of treatment, not complications of labor. A midwife or an obstetrician has to think about physiological complications, while an OB nurse has to think about treatment complications.
My maternity nursing classes have been interesting. I've never talked so much in class! I'm the only person in the class with any home birth experience, and I'm also the only male student (out of 3) with any recent birth experience. I think there's 37 women in the class. So I have a weird perspective on things.
For instance, we went over the different positions a woman may labor in - but the teacher said "I have to teach you this, but I also have to tell you you'll never see any of these. As soon as the water breaks, they're in bed until that baby is born." She asked if anyone has seen a woman laboring standing up - I raised my hand, and she said "Well, sure, you have. Your wife had home births, which was great because she could do whatever she wanted." :) She also asked if we felt more empowered giving birth at home. She's repeatedly said that lithotomy is the worst position from which to push a baby out.
She's also thinking of showing The Business of Being Born.
9 out of 10 complications we're being taught about are caused solely by the obstetric process - maternal fever from anesthetics, constricted placental bloodflow from Pitocin, urine retention from spinal blocks, babies with poor respiratory drive and suckling reflexes from opiate use. The most common problem is called supine hypotension syndrome - if a woman labors on her back, her uterus squishes the blood vessels supplying the lower body. This causes a reaction where her blood pressure and heart rate drops, which drops blood supply to the fetus. This shows up as heart decelerations on the monitor. Nursing response? Turn the woman on her side, slap some oxygen on her, start IV fluids to increase her blood volume. If that doesn't work, try the other side - if that doesn't work, prepare for a c-section. The cause? Laboring on her back - so she can be hooked up to an electronic fetal monitor. And the only reason she's on the EFM, as they've repeatedly told us in class: lawsuits.
There's not much emphasis on real pregnancy problems - placental abruption, placenta previa, eclampsia, etc. I have a feeling that OB nursing is all about complications of treatment, not complications of labor. A midwife or an obstetrician has to think about physiological complications, while an OB nurse has to think about treatment complications.
Thursday, April 16, 2009
AWHONN vs ACOG
Originally published February 13, 2009
I'm happy and surprised because AWHONN, the Association of Women's Health, Obstetric, and Neonatal Nurses, published an editorial against ACOG (the American College of Obstetricians and Gynecologists) and the American Medical Association regarding their 2008 resolution against home birth.
The idea that a normal spontaneous birth is by design the best outcome for a healthy woman and her infant is neither believed nor entertained as a basic concept. Most U.S.-trained physicians and sadly most U.S.-trained nurses have minimal experience with normal labor and birth. Without fetal monitors, intravenous lines, infusion pumps, epidurals, pitocin, endless charting, and rules theses individuals are helpless and unskilled to provide the kind of informed human support and wise guidance that a laboring woman needs while the normal process of labor and birth unfolds.
In fact, knowledgeable women often must fight to defend the normalcy of the process and their desire to labor and birth spontaneously without medical technology or intervention. In many ways it is reminiscent of the 1960s when many of us who were young women at the time fought for our right to natural childbirth without general anesthesia and to have our husbands accompany us into the delivery room.
To pretend that a normal healthy woman cannot give birth safely without the trappings of a U.S. hospital is not only audacious but also uninformed.
I'm happy and surprised because AWHONN, the Association of Women's Health, Obstetric, and Neonatal Nurses, published an editorial against ACOG (the American College of Obstetricians and Gynecologists) and the American Medical Association regarding their 2008 resolution against home birth.
The idea that a normal spontaneous birth is by design the best outcome for a healthy woman and her infant is neither believed nor entertained as a basic concept. Most U.S.-trained physicians and sadly most U.S.-trained nurses have minimal experience with normal labor and birth. Without fetal monitors, intravenous lines, infusion pumps, epidurals, pitocin, endless charting, and rules theses individuals are helpless and unskilled to provide the kind of informed human support and wise guidance that a laboring woman needs while the normal process of labor and birth unfolds.
In fact, knowledgeable women often must fight to defend the normalcy of the process and their desire to labor and birth spontaneously without medical technology or intervention. In many ways it is reminiscent of the 1960s when many of us who were young women at the time fought for our right to natural childbirth without general anesthesia and to have our husbands accompany us into the delivery room.
To pretend that a normal healthy woman cannot give birth safely without the trappings of a U.S. hospital is not only audacious but also uninformed.
Tuesday, April 14, 2009
NICU
Originally posted February 02, 2009.
I was in the NICU today. It was a little slow, but we had a 2 pound 30 week old baby there. He was really little but doing very well. His mom's maternal hypertension depressed his placental bloodflow, which ironically (or fortunately) matured his lungs faster. The nurses said normally a baby his age would be intubated and on a ventilator, but he was off oxygen and breathing room air on his own when I took care of him. He'll probably be there a month, just to gain enough weight to leave.
The meds! Such tiny doses. He received 15 ml of blood last night - a sip! Crazy. And everything, down to the saline flushes for the IV lines, has to be double-verified by another NICU nurse. Oh, and they give the premies caffiene - little bottles by IV to stimulate their heartrate, breathing, and alertness. Hopefully it doesn't give them ADD.
I could see myself working there. It's like ICU, except simultaneously quieter AND more intense. It makes you realize how much adults can handle. Adults even in the ICU can usually withstand receiving the wrong doses and wrong meds, and they can sit around with low blood pressure and dropping oxygen saturations and give you plenty of time (and notice) before they code on you...but apparently not babies. At least not premies.
I still plan on working ICU as a nurse, of course. But PICU and NICU might be neat.
The NICU also needs a sign on the door saying "COLOSTRUM PLEASE!"
I was in the NICU today. It was a little slow, but we had a 2 pound 30 week old baby there. He was really little but doing very well. His mom's maternal hypertension depressed his placental bloodflow, which ironically (or fortunately) matured his lungs faster. The nurses said normally a baby his age would be intubated and on a ventilator, but he was off oxygen and breathing room air on his own when I took care of him. He'll probably be there a month, just to gain enough weight to leave.
The meds! Such tiny doses. He received 15 ml of blood last night - a sip! Crazy. And everything, down to the saline flushes for the IV lines, has to be double-verified by another NICU nurse. Oh, and they give the premies caffiene - little bottles by IV to stimulate their heartrate, breathing, and alertness. Hopefully it doesn't give them ADD.
I could see myself working there. It's like ICU, except simultaneously quieter AND more intense. It makes you realize how much adults can handle. Adults even in the ICU can usually withstand receiving the wrong doses and wrong meds, and they can sit around with low blood pressure and dropping oxygen saturations and give you plenty of time (and notice) before they code on you...but apparently not babies. At least not premies.
I still plan on working ICU as a nurse, of course. But PICU and NICU might be neat.
The NICU also needs a sign on the door saying "COLOSTRUM PLEASE!"
Wednesday, April 8, 2009
DNI, DNR, and lack of communication
The other night at work in the intermediate care unit (sort of an ICU stepdown unit) we had a code blue and a rapid response on two patients at once. Both represented a breakdown in communication - that's not what caused the codes, per se, but the communication breakdown was clinically significant.
The first was a new pneumonia admit from the ER who had a DNI order - do not intubate. She was in respiratory distress and her blood gasses were terrible. Normally she would have been intubated and admitted to the ICU, but since she was a DNI she was instead admitted to the intermediate care unit on a positive pressure BiPAP mask. I think the ER physicians and the residents assumed she would be comfort care from that point on, but when the nurse brought this up to the family (basically saying it's either intubate or she will not live very long), the family said that they had only meant she didn't want to be on a breathing machine long-term—it was okay to intubate her just to try to treat the pneumonia. Anyway, during the course of her intubation her sats and pulse dropped and she became a silent code blue - never called overhead because the physicians and nurses are already there.
In the meantime, on the other end of the unit, a pleasantly ornery and opinionated little old guy wearing a little US Marine cap suddenly stopped talking to his family, picked up his IV tubing and started chewing on it. The family was completely frightened and started calling for help. Now, on the medical floor, an acute change in mental status is enough to call in the rapid response team, which is basically what the family wanted. But in the ICU and IMCU, you have an experienced nurse with only a couple patients and you probably already have a neuro consult, so you would page neuro stat and see what to do. The family in the meantime is very upset that we don't seem to be doing anything and there are no doctors around, and they keep asking why we aren't giving him aspirin. The daughter tried to remember some stroke assessment thing she said was SMILE - have them Smile, Make a face, etc. She's in there yelling at him to smile while I'm calling the neurologist, and finally I said to the nurse that on the floor we'd call a rapid response, so she agreed and I had them call it overhead.
Incidentally this man was a DNR in another state, and the chaplain tried to ask him what his wishes were to establish a DNR in this state. He was completely confused and irritated by the questions and kept saying negative things, which the chaplain assumed meant No to the DNR, but half the time the patient said things that sounded like he assumed the chaplain wanted to be a DNR and wanted him, the patient, to do something about it.
Meanwhile the residents at the silent code assume that the RRT being called overhead is for their lady, so I had to go get them and tell them there was another event happening at the other end of the hall. When I get back to the gentlemen munching on the IV tube and ignoring his family, other nurses have arrived and are trying to calm the family down by explaining that the man does have a history of senile dementia. Which he does—the family knows that better than we do!—but that doesn't explain a sudden change from freely talkative and downright irrited at being hospitalized, to completely nonverbal and eating random things. Meanwhile the family rushed upon the night shift SCT who had come in to relieve me—asking if he was a doctor!
And while the residents start handling their second code in the space of minutes, the first patient was being bagged and rushed to the ICU. The gentleman (who I deprived of his tubing) was being scheduled for a stat CT of the head.
So we had a few communication errors, including:
1. The wishes of the pneumonia lady and her family should've been appraised better in the ER, and it should have been made clear that she needed to be intubated emergently if she was going to survive - in other words (to be blunt) that a DNI order meant death; this would've at least saved the rush from ER to IMCU to ICU and might've slightly improved her chances (by being intubated hours earlier).
2. The family of said Marine should've been quickly informed that we don't treat strokes the second they happen. As far as I know, there is not much you can do, because the first order of business is to see if it's due to a clot or a bleed. That's pretty crucial, because if it's a bleed you can't give him anti-clotting agents! I should've thought to say that at the time. Instead, the family now has the impression that we did nothing.
3. It's a minor point, but the wishes of the ex-Marine should have been carried over from state to state, or his wife, who has his power of attorney for healthcare, should have been consulted. That would not have prevented a rapid response due to his acute change in mental status—that should be treated, since it's not a resuscitative measure (in other words, he's not dying)—but it was a waste of time and resources for the chaplain to sit there for an hour trying to get a coherent yes or not out of someone who doesn't even know why you're keeping him in the room.
4. Come to think of it, the pneumonia lady shows why a simple order like DNI doesn't really work in the real world. Maybe DNI based on prognosis? I've seen more than a few cases where someone is DNI/DNR because they or their family want to allow natural death versus long-term technological life support—and don't realize they're ruling out resuscitative measures for immediate life-threatening problems that might (or might not) have a fair prognosis.
The first was a new pneumonia admit from the ER who had a DNI order - do not intubate. She was in respiratory distress and her blood gasses were terrible. Normally she would have been intubated and admitted to the ICU, but since she was a DNI she was instead admitted to the intermediate care unit on a positive pressure BiPAP mask. I think the ER physicians and the residents assumed she would be comfort care from that point on, but when the nurse brought this up to the family (basically saying it's either intubate or she will not live very long), the family said that they had only meant she didn't want to be on a breathing machine long-term—it was okay to intubate her just to try to treat the pneumonia. Anyway, during the course of her intubation her sats and pulse dropped and she became a silent code blue - never called overhead because the physicians and nurses are already there.
In the meantime, on the other end of the unit, a pleasantly ornery and opinionated little old guy wearing a little US Marine cap suddenly stopped talking to his family, picked up his IV tubing and started chewing on it. The family was completely frightened and started calling for help. Now, on the medical floor, an acute change in mental status is enough to call in the rapid response team, which is basically what the family wanted. But in the ICU and IMCU, you have an experienced nurse with only a couple patients and you probably already have a neuro consult, so you would page neuro stat and see what to do. The family in the meantime is very upset that we don't seem to be doing anything and there are no doctors around, and they keep asking why we aren't giving him aspirin. The daughter tried to remember some stroke assessment thing she said was SMILE - have them Smile, Make a face, etc. She's in there yelling at him to smile while I'm calling the neurologist, and finally I said to the nurse that on the floor we'd call a rapid response, so she agreed and I had them call it overhead.
Incidentally this man was a DNR in another state, and the chaplain tried to ask him what his wishes were to establish a DNR in this state. He was completely confused and irritated by the questions and kept saying negative things, which the chaplain assumed meant No to the DNR, but half the time the patient said things that sounded like he assumed the chaplain wanted to be a DNR and wanted him, the patient, to do something about it.
Meanwhile the residents at the silent code assume that the RRT being called overhead is for their lady, so I had to go get them and tell them there was another event happening at the other end of the hall. When I get back to the gentlemen munching on the IV tube and ignoring his family, other nurses have arrived and are trying to calm the family down by explaining that the man does have a history of senile dementia. Which he does—the family knows that better than we do!—but that doesn't explain a sudden change from freely talkative and downright irrited at being hospitalized, to completely nonverbal and eating random things. Meanwhile the family rushed upon the night shift SCT who had come in to relieve me—asking if he was a doctor!
And while the residents start handling their second code in the space of minutes, the first patient was being bagged and rushed to the ICU. The gentleman (who I deprived of his tubing) was being scheduled for a stat CT of the head.
So we had a few communication errors, including:
1. The wishes of the pneumonia lady and her family should've been appraised better in the ER, and it should have been made clear that she needed to be intubated emergently if she was going to survive - in other words (to be blunt) that a DNI order meant death; this would've at least saved the rush from ER to IMCU to ICU and might've slightly improved her chances (by being intubated hours earlier).
2. The family of said Marine should've been quickly informed that we don't treat strokes the second they happen. As far as I know, there is not much you can do, because the first order of business is to see if it's due to a clot or a bleed. That's pretty crucial, because if it's a bleed you can't give him anti-clotting agents! I should've thought to say that at the time. Instead, the family now has the impression that we did nothing.
3. It's a minor point, but the wishes of the ex-Marine should have been carried over from state to state, or his wife, who has his power of attorney for healthcare, should have been consulted. That would not have prevented a rapid response due to his acute change in mental status—that should be treated, since it's not a resuscitative measure (in other words, he's not dying)—but it was a waste of time and resources for the chaplain to sit there for an hour trying to get a coherent yes or not out of someone who doesn't even know why you're keeping him in the room.
4. Come to think of it, the pneumonia lady shows why a simple order like DNI doesn't really work in the real world. Maybe DNI based on prognosis? I've seen more than a few cases where someone is DNI/DNR because they or their family want to allow natural death versus long-term technological life support—and don't realize they're ruling out resuscitative measures for immediate life-threatening problems that might (or might not) have a fair prognosis.
Wednesday, April 1, 2009
Hospitalized infants and breastmilk
The other weekend in my pediatric clinical (which is at an excellent children's hospital) I took care of a poor little 5 month old with RSV bronchiolitis. It's the common cold virus, but an infant's upper respiratory tract is so relatively close to their bronchial tree, which means what would be the common cold for you or I might travel down to their lungs very quickly. This poor girl was completely clogged from nostrils to lungs with the thick, tenacious mucus characteristic of RSV. I spent all of Sunday suctioning her and sitting her upright with her mom, but it helped keep her out of the PICU which is where the respiratory therapist and nurse thought she might be headed. One of our lecturers said that RSV infections before one year of age is correlated with a much greater incidence of asthma. She thought it has to do with oversensitizing the respiratory immune system.
I can't help feeling like breastfeeding would've prevented this. She was formula-fed. I mean, I don't know what the mom's situation is, so I didn't really say anything to her. Maybe I should've. But think about it: we are all exposed to RSV. I think I can safely assume the mom is actively immune to many forms of the common cold virus. And the antibodies which are produced in breastmilk——immunoglobulin type A—are chiefly antibodies of the mucus membranes, including the respiratory tract. (They also heavily protect the gut from unpleasant visitors like E. coli and rotovirus.)
So why would we not recommend the mother begin breastfeeding? Why aren't there breastmilk donor banks to help treat these children? Except there are, but I don't know if they're equipped for treating every RSV and gastroenteritis case that comes along. Why doesn't the government offer financial incentives for breastmilk donation?
Another of my instructors told us about the time her entire family came down with salmonella diarrhea—except her infant who she was breastfeeding. Apparently while she battled salmonellosis herself she had developed enough antibodies not only to fight her own enteric infection but to protect her infant. She said the day after she stopped breastfeeding, her infant spiked a 103 temp and began diarrhea. I don't know why she didn't resume—instead she went to Pedialyte mixed with formula—but the lesson seems clear.
I have a four month old. I was afraid of bringing RSV home to her after taking care of this poor infant. RSV is extremely communicable—it transmits easily from hand to mucus membranes, and can live for days on dry surfaces. I scrubbed my hands & arms within an inch of their life and used alcohol foam. Even thought about using chlorhexidine wipes like they use presurgically! But on the other hand, she is breastfed. I wouldn't play games with that, but I don't think it was as great a risk as I felt it was at the time.
I can't help feeling like breastfeeding would've prevented this. She was formula-fed. I mean, I don't know what the mom's situation is, so I didn't really say anything to her. Maybe I should've. But think about it: we are all exposed to RSV. I think I can safely assume the mom is actively immune to many forms of the common cold virus. And the antibodies which are produced in breastmilk——immunoglobulin type A—are chiefly antibodies of the mucus membranes, including the respiratory tract. (They also heavily protect the gut from unpleasant visitors like E. coli and rotovirus.)
So why would we not recommend the mother begin breastfeeding? Why aren't there breastmilk donor banks to help treat these children? Except there are, but I don't know if they're equipped for treating every RSV and gastroenteritis case that comes along. Why doesn't the government offer financial incentives for breastmilk donation?
Another of my instructors told us about the time her entire family came down with salmonella diarrhea—except her infant who she was breastfeeding. Apparently while she battled salmonellosis herself she had developed enough antibodies not only to fight her own enteric infection but to protect her infant. She said the day after she stopped breastfeeding, her infant spiked a 103 temp and began diarrhea. I don't know why she didn't resume—instead she went to Pedialyte mixed with formula—but the lesson seems clear.
I have a four month old. I was afraid of bringing RSV home to her after taking care of this poor infant. RSV is extremely communicable—it transmits easily from hand to mucus membranes, and can live for days on dry surfaces. I scrubbed my hands & arms within an inch of their life and used alcohol foam. Even thought about using chlorhexidine wipes like they use presurgically! But on the other hand, she is breastfed. I wouldn't play games with that, but I don't think it was as great a risk as I felt it was at the time.
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