Call for Submissions: Change of Shift vol 4 no 3

Just a reminder that Change of Shift, the nursing blog rounds, will be hosted here on Thursday, August 6th! Change of Shift covers the best of the nursing web (the nursosphere?) every two weeks. Posts about nurses or nursing written by students, patients, family members, physicians, and other non-nurses are also welcome.

If you have a good post you'd like to see included, whether it's yours or someone else's, please submit it to mannursediaries AT gmail DOT com with "Change of Shift" in the subject line, or use the handy-dandy submission form. Deadline for submission is Wednesday, August 5th at 5pm. Earlier the better, since I'm working two jobs!

(And don't forget Grand Rounds is being hosted by emergiblog on the 4th.)

Babies After Heart Surgery

Recently in the course of my student nurse internship, I was given the chance to work in the pediatric surgical heart intensive care unit. It's a pretty staggering place. I didn't even know units like this existed. When a baby has an operation for a congenital heart defect, immediately after surgery it goes to a unit like this. The nurses there are extremely specialized in how to take care of these delicate infants. There are something like 32 heart defects, with many variations thereof: hearts that are backwards, hearts with the major arteries and veins reversed, hearts with holes in between the chambers. These nurses have to know how to deal with them all.



The infant I helped recover from surgery (if you can call it help—I mostly just absorbed!) was a hypoplastic left heart, which means he had only one functional ventricle. Most of us, of course, have two; one which pumps blood to the lungs, and one which pumps blood to the body. This baby's pump to the body never grew correctly, as well as the artery which comes from it. He could survive well enough in utero because fetuses have a few arterial detours in place for blood to bypass the lungs, which they're not using, so blood from the lung-pump went to the body instead. After birth, however, these detours begin to close, which means this infant will certainly die within a week to a month after birth. And these infants did die, until 1981, when a convoluted three-step surgical correction was developed to give these people a chance to live on their one (1!) functional ventricle.

This baby, at five days old, had the first surgery, called the Norwood procedure, which involves creating a neo-aorta (yes I said NEO-AORTA!) and attaching it to the right ventricle. The baby arrived in our unit much like adults arrive in the ICU after heart surgery, with what seems like the entire surgical team (surgeon, anesthesiologist, nurses) rushing the patient down the hall and into the room. Except it's not a bed, it's a crib! The baby has a ventilator, multiple IVs, oxygen sensors over their brain and kidneys, three chest tubes to drain fluid from the chest cavity, and an open (!!) sternal incision—the surgical site is left open (covered with a dressing) to allow for swelling. We immediately had to assess lung sounds, heart sounds, and systemic bloodflow. Since these babies have one pump to both the lungs and the body, they can easily shunt all their blood to their lungs (which is a normal response to stress on the body, and a good thing in most people!), causing rapid circulatory collapse and death.

Seriously.

And then, with everything on edge, the parents come in. It's one thing to see any human being in this position. People after heart surgery look like they're dead. They're ashen and limp, they've got big tubes with blood coming out of them and six to eight IV pumps putting things into them. Now image it's a tiny 3 kg baby, but the chest tubes and IV pumps and ventilator are still the same size. Now imagine it's your baby.

I asked the nurse what kind of outcomes these babies have. If they have all these problems with circulation and oxygenation in utero and out, do they suffer any mental or motor problems? I asked half-expecting to hear that they're trached and severely mentally disabled. She said they don't know how things turn out long-term, since nobody who's survived this is older than their 20s, but they're seeing correlations with things like ADHD and behavior disorder. I was astonished. I'd take ADHD over death.

That aside, it is amazing to see some of the stories and images of these kids online. Little Hearts has an impressively large number of patient stories. I can't get over the photos of these kids swimming and being active on one ventricle, or with other heart defects. There's even a section on what do you do when your kid's coach is scared to let your heart kid on the team.

She also said that some hospitals, including some major neonatal centers in this city, still recommend comfort care only for these babies. She met someone two years ago who lost a baby to this condition in a major university hospital because the physician was doubtful about outcomes after surgery. Another nurse on the unit remarked to me that you should probably always get a second opinion.

They want me to work in that unit. My initial reaction was that uncertainty about specializing so much (pediatric heart surgery is like a subspecialty of a subspeciality of a subspeciality!), thinking I should work with regular medical adult patients...but it's an attractive idea. It's an exciting field. There's only a few places like this in the world. And I was fascinated during our congenital heart defects lecture in school last semester; probably one of the few in the class who were.

Of course, the first day I returned to my adult patients, there was a guy yelling and cursing at us, and I thought, Gee, the babies don't treat you like this!

How My Wife Had An 11+ Pound Baby At Home And Didn't Die

Here's a guest post by my wife, about our most recent birth (November '08). I thought it would be interesting to share because, well, I think it was an interesting birth, plus our 'little' baby was 11 pounds and 6 ounces. I'm sure, given the size of the baby and the position my wife had to assume (standing up!) to birth her, in a hospital we would've just ended up with a c-section. As it was, well...you can read on to find out!

Update March 2010: I submitted this to the 5th Science and Sensibility Healthy Birth Blog Carnival, because the topic is avoiding giving birth on your back.

This story begins about 12:30 AM the morning of November 7. I got up to go to the bathroom, and lost a huge chunk of mucous plug. I thought, I'll call the midwife in the morning to report, and I went back to bed. around 2:30 I again woke up to potty, and again lost some plug. this time I held it up to the light and squinted a bit and.. it was streaked with blood! yay! dilation! I went back to bed, assuming I'd be going back to sleep, but I had what I thought was an uncomfortable BH contraction. laid down, had another... and another. after a while I sat up, more comfortable that way. my husband woke and saw me sitting, asked what I was doing. I told him I was trying to figure out if I was in labor or not. by 4 am I was convinced, and I called my midwife, reported the lost plug and the contractions about 12 minutes apart at that time. she said to call back at 5:30, and get some sleep in that time.

sleep didn't happen, and by the time I called back, contractions were 4-5 minutes apart. she said she'd pack her bag and call when she was on her way (she lives just over an hour away). I laid in bed a while longer, breathing through contractions, then decided to take a hot shower. I squatted on the floor of the tub, hot water running over me, breathing through contractions. my plan was to use up all the hot water this way, but it got hard to breath the hot stuffy air, so I turned off the shower, got dressed in between contractions, and curled up into a ball on one corner of the couch. clutching the arm and breathing through contractions. my husband brought me a bagel, but I hardly got in more than 3 or 4 bites.

the midwife showed up after 7, maybe 7:10. her apprentice showed up shortly after. our plan was to have my mom take the other kids for the day, but as I was already contracting hardcore, and the kids were all asleep still, my husband called her and told her not to come get them. the midwife told me to go pee one last time before the birth, and I suggested setting up the floor and couch with plastic and sheets while I was in the bathroom. I knew I would want to come back without my pants on. I knelt before the couch and rested my arms and head on the seat. this was my preferred position. the position I birthed my last son in, and assumed I would push this one out in as well. the contractions began to hurt more and more, and I knew it would be soon. but I didn't know how soon, and I didn't even know what time it was anymore. I completely lost track.

someone suggested using gravity to help things along, so I stood up against my husband and he held me as I bore down with each contraction. three things happened while I was standing: 1) my water broke. the midwife looked at what came out onto the white sheet and said it looked very clear. 2) my kids woke up, and they all came downstairs. the apprentice was very good about telling them before they came into the room that the baby was going to be born that day. my 3-year old son was the most interested, and got right there to watch. the older daughter and younger son hung back a bit, very quiet. and... 3) I puked up everything I ate. my husband held my barf bowl in one hand while holding me in the other,. he's such a great multi-tasker. after I'd puked up everything that would have given me any nutrition for the event, I decided I didn't want to stand anymore. I got into my kneeling position before the couch, and began to push.

of course I couldn't see anything going on, but the midwife said I could touch the head if I wanted. really? already? I reached down and didn't feel it right there. she said I could feel it during a contraction if I wanted, but I couldn't concentrate during the contractions. they hurt. a lot. I won't lie. but I think I was also having flashbacks of my previous birth, which was making it seem like I'd been doing this for longer than I had. it felt like forever.

finally the head began to emerge. I heard everyone else's commentary: my husband, "there's lots of dark hair." my 3-year-old son, "there's the baby's face!" and finally my midwife freaking out and telling me to bear down. like, yelling at me. I knew something must be wrong, but I had nothing else left to push with. I'm not very strong at the moment of birth, I've learned this with all my previous births. I couldn't push any more, so they decided for me that gravity would pick up where I left off. I was literally hoisted up back into my husband's arms, and continued to push with everything I had left, mostly standing, half squatting. finally, out came my daughter. white, then faintly purple, not breathing... and huge. apparently there was cord compression, and since she wasn't breathing either, she wasn't getting any oxygen until she was out and the cord could pulsate again. this was the cause of the yelling at me to push her out faster. the midwife picked her up and patted and rubbed her to get her breathing. the apprentice brought over the oxygen, but it wasn't used. I sat down on the floor next to them. finally, a little gurgle.. I took her into my arms and assured my older daughter that she did indeed get the little sister she wanted.

her breathing was still not great, though, it was very congested sounding, so the midwife bulb-suctioned her out. :P she needed it though. when her breathing sounded good, I attempted to nurse, but she wasn't interested just yet. I birthed the placenta onto the sheet on the floor, then moved up to the couch with my new daughter. we tried and tried again to latch, while my husband tied off and cut the cord, and the midwife and apprentice examined the placenta. there was a tiny spot of calcification, but the MW said it was one of the biggest placentas she'd ever seen, and that the cord was thicker than most she'd seen, too. I had to agree about the cord, my other kids didn't have cords quite so thick. I hadn't seen their placentas very closely, though.

[editor's note: seriously, that placenta was as big as an extra-large pizza!!]

this whole time, I was waiting anxiously for the weigh-in. I knew she'd be bigger than my last (and so far, biggest) baby, 10 pounds even. I expected something like 10 pounds and some ounces... but the midwife said... "eleven pounds and... six ounces." I didn't believe her. she weighed her again. and it was the same. I still didn't believe it. no way. I just pushed out a nearly eleven and a half pound baby!

oh yeah and I don't remember when but someone finally asked what the time of birth was, which the apprentice had apparently noted as 8:33 am. I couldn't believe that either! as I said before, I had lost track of time, but I never would have expected a six hour labor from first contraction to birth. this event was just full of surprises.

and the midwife said if I wanted, she could check for tearing. I'd never torn with any of my previous births, so I figured I hadn't, but then, I never pushed out a baby quite so big before, so I decided, why not? and I didn't have any tearing. not even a little nick. which I could've figured out later when I finally peed for the first time, because it didn't even hurt. normally it stings like crazy after birth, but not this time! I wasn't even raw.

the rest of the day was basically trying to get some sleep, watching my baby sleep, and getting her to nurse. my husband wanted some sleep, too, as he'd been up since about 3:30 as well, so he called my mom to pick up the kids then, and the 3 of us fell asleep together.

8:33 am
11 pounds, 6 ounces
22.75 inches


[My wife doesn't mention this, but the midwife estimated the baby to be at 43 weeks gestation. We weren't really sure of our conception date, but she went to 41/4 with the prior kid, so I guess it's possible!]

Traumatically Injured Kids Are Too Noisy!

Children's Memorial in Chicago is building a new hospital in the downtown area. Naturally, as the highest-volume pediatric hospital in the area, they're building a helicopter pad. Except a neighborhood alliance, the Streeterville Organization of Active Residents (ironically, SOAR), is trying to block it:

"The challenge is what a pilot is going to have to deal with in an urban nighttime environment," [SOAR member] Frost says. "You’ve got the tall buildings, you’ve got all the twinkly lights, which actually impair a pilot’s visible ability."

Pilot: AHHH! Can't see! The lights are so twinkleeeey!" *EXPLOSION*

I can't help but feeling that the issue here is not helicopter crashes but helicopter noise. Streeterville, aka the Gold Coast, is probably one of the wealthiest neighborhoods in the United States. This helipad will be on a level (31st story) with many of the neighborhood's high-rise condos, as the Streeterville association's panicky 'fact sheet' is quick to point out. I have a feeling that this comes down to the fact that, while these condominiums are noise-insulated against the high volume of downtown car traffic below them, they're not insulated against same-altitude helicopter traffic.

Living near a major hospital means you do hear helicopters several times a day. You grow accustomed to it. Maybe the government will help pay for new insulated windows, like they did for the people who live right across the street from Chicago's Midway airport. The neighborhood's alternative is to put a helipad on the ground by Lake Michigan, out of the neighborhood, and have the kids transported by ambulance to the hospital. In city traffic, during rush hour, that could take 30 minutes, and anybody who lives on the Gold Coast knows it.

photo by iirraa

Delivery Room Football

Stand and Deliver has a sweet post about a father (incidentally a physician) fighting to keep staff from taking his baby away after it was born by c-section. It's quite appropriately called Delivery Room Football.

Found it interesting because 1. I'm a dad and I probably would've caved in this situation, and 2. I was a c-section baby whisked away from my mom at birth, leaving her to cry about the fact that I was a boy and not a girl like she wanted. Hey, it's irrational, but it's irrational to give birth and not see your baby. Being left with her to bond might've altered the situation a little, since she decided I might not be so bad when she finally got to hold me. It's just a stupid thing to do to people.
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In other news, I got mentioned all the way down in Argentina!
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Stay tuned for a guest post, a first-person narrative by my wife about our most recent birth: an 11+ pound baby girl (that's 5160 grams for you obstetric nurses and metric system users), born at home. (Update: here's the post.)

Do We Treat Obstetric Patients Worse Than Psychiatric Patients?

Reality Rounds makes a brave point here:

A woman comes to the unit in full labor. Out of control. Screaming. Drug addicted. A repeat offender. She delivers her baby in a chaotic environment of wails, expletives and panic. The baby is brought to the nursery to monitor for drug withdrawal.

“What a bitch. She needs to be sterilized. How can she continue to have so many babies? Lock her up and throw away the key.” Comments from “medical professionals” during their daily routines.

Mom’s with substance abuse issues are the most vulnerable patients we care for. We don’t know their back stories and we really don’t care. We are very good at the dirty looks, the impatience, and the judgment. I am guilty as charged. How ironic. Delivery a baby is often the only time these women enter into the health system. Instead of offering kindness, and empathy, and HOPE, we offer scorn.

It reminded me so much of the crash birth I witnessed. In that case it was assumed she was a drug abuser (why else would she not seek prenatal care?), the baby was swooped away and sent to the NICU, a drug test was performed on it without telling the mother, and it was sort of half-asked, half-presumed that the baby would be put up for adoption. There was so much needless panic and resentment among the staff. Yet the baby was negative for drugs, and she decided to keep it after all. I think in the days that followed she received much better care, social support, and compassion after the horrible treatment she received during her delivery.

But other women who are drug-positive or who will not keep their children probably fare much worse. I don't know if I'd go so far as to ask for empathy from healthcare workers for these kinds of women; but I don't think a normal amount of dignity and respect are too much to ask for. Think of how we in the regular medical community treat psychiatric and addiction patients who knowingly destroy their lives and their families. Dr Edwin Leap just wrote about treating a child abuser with compassion and professionalism. We're instructed to withhold judgment in school, and on the job most of us actually try; but I'm not sure we've extended this to pregnant women as much as we should.

I know, I know, the difference is that these women hold babies inside them. But a woman with problems will not miraculously lose those problems if she gets pregnant. The time she has a baby may be the only time she feels like, and is treated like, a normal human being. This could have a profound impact on a few women. Instead, they're treated like non-citizens in a chaotic and hostile environment, and their entire birth process is taken from them.

Owning your birth, being the one who delivers your baby, is a powerful thing. I think I can safely say it changes you, because it changed me just by witnessing it. Women can be incredibly strong during birth, if you let them. I can't say for sure that letting women with problems have a natural, empowering, woman-centered birth, is going to teach them anything significant about themselves. It probably won't stop that many from abusing drugs or having bad boyfriends or being a bad parent. And not all women would be able to have such a birth. But being treated with respect, accomplishing a feat of such strength and importance, and then being encouraged to bond as a mother, seems more likely to have a positive effect on these women than being yelled at by nurses and physicians while they're lying supine and defenseless, in the throes of a labor nobody is helping them control, and then having their babies taken from them the moment they give birth.

Edible Anatomy

My wife reads Cake Wrecks every single day. Just recently they posted several photos of hysterectomy cakes. What would you like, a slice of Fallopian tube? Myometrium? I have to say the phrase "happy hysterectomy!" has a catchy ring to it, but I'm not sure it's completely appropriate in all cases, or that I'll get to use it very often. The quirky I Heart Guts! blog gave it all the singularly clever title "Totally Ova It".

For those of you who aren't ova it, the blog features plenty of bizarre pregnant belly cakes. The one pictured here, probably the least bizarre-looking actually, had a plastic baby inside intended to be delivered by kitchen tongs. I commented that up-and-coming OBs should practice c-sections on cakes; also that there's some kind of commentary to be made on the fact that regular obstetrics lends itself so well to kitchen cutlery. Also, seems like somebody should make in utero stages-of-gestation baked goods. There's already a fetus-shaped cookie cutter.

I'm not sure how often male anatomy is represented on cakes. Maybe for bachelorette parties? Do they do that? Somehow I don't see men celebrating vasectomies or vasectomy reversals with cakes, though it's certainly possible. If nothing else it seems that we will always be represented by sheer anatomical similarity (accidental, one hopes), as when NASA makes a huge cake which Cake Wrecks considers something special for all the lady astronauts of the world.

Of course, cakes don't always have to revolve around the reproductive system. I really like this brain cake, though I'm not sure why it's sporting a rat-tail haircut. There's also a dour-looking kidney and an impressive complete open abdomen cake. I think a nephron would look nicely elegant, with its convoluted tubules, loop of Henle, and intricate lacework of capillaries. Maybe for a renal doc.

The heart seems well-represented, both anatomically (as pictured) and electrophysiologically, by EKG cakes, usually related to Valentine's Day, though they mostly seem to say "You put my heart into atrial fibrillation."

Of course, Cake Wrecks is not just good for cake ideas for your ob/gyne patients, your EKG technician, or your anatomy professor. If you don't want to eat anatomy, there's always Darth Vader holding a cute little baby, or a life-size Michael Jackson made out of marzipan. You know, something for everyone.