While you were sleeping...

Darkness has enveloped the city of Denver, and for most people that indicates time to prepare for sleep.  Well… my body isn’t quite sure what to make of ‘time’ anymore, especially the meaning of daylight hours.  I worked last night, and I remember watching the sun rise and light up the unit, which was the signal that our shift was nearing its end and I was almost free to go home.  Rather than preparing for a new day to begin, I was reflecting on the night’s adventures and processing all that had happened – I still cannot believe all the chaos we dealt with!  Although I’ve had some crazy nights over the past couple weeks (I’ll share some highlights later), nothing quite compared to the madness of last night.  And I feel it’s only fair to share my experience with you…

07/12/10 @ 1715 (5:15 pm for those not familiar with the 24-hour clock): I roll out of bed after a 3-hour nap hoping that I’ve had enough rest to carry me through the night (my FRS natural energy drink helps a bit too).  I throw on my work attire - navy blue scrubs - and gather my supplies (and my brain) for one of the few remaining shifts I have on the WCC unit here in Denver...

1750: Driving on the freeway to the hospital, I get caught in rush hour traffic – people heading HOME after a long day at work.  To think that my night had only just begun…

1820: Walking on to the unit, I take one look at the board to find 4 out of our 5 birthing rooms occupied, with 2 patients in active labor (meaning they are past 4 cm dilation).  The rest of our inpatient rooms (14 antepartum/postpartum and 1 PACU) were nearly full, and we had 2 patients in triage (with 5 triage rooms available).  I knew then it was going to be busy, but I had no idea what the night would turn into…

1845: I get my patient assignment, and find out that we are slightly short-staffed, so I will be managing this labor patient mostly on my own (!!) with Miriam, checking in occasionally to see if I am managing okay.  I learned that my patient was G3/P2, meaning this was her third pregnancy and that she had 2 additional children (one who wanted to be at the hospital with her mom and dad).  I was not too worried – ‘multips’ (as we call those women who have had 2 or more pregnancies/deliveries) usually know their bodies well enough to tell us when they are ready, and know how to push (one of the primary factors that affects the delivery process, and usually the most difficult thing for women to figure out how to do).  We anticipate that once these patients 'go', they are able to deliver a baby smoothly and quickly.  Yes, we were treating my patient for severe pre-eclampsia, but nothing else stood out as being a major factor for a complicated delivery (we deal with pre-eclamptics quite often, and it is serious, but we are well-equipped to manage these patients).  The best treatment for these patients is delivery, so it’s common to induce/augment the labor process if the contraction pattern is not regular enough to cause any change in the cervix.  We received the order from the doctor to start Pitocin (the synthetic form of the natural labor-inducing hormone) and turned the IV drip on at 1 mU/hour (the smallest dose possible).  I will say, I am NOT a fan of Pit… yes, there are situations that it is more-or-less necessary (as with my patient) but many physicians/hospitals exploit the ‘benefits’ of Pit – namely, that they can schedule deliveries.  If a doctor wants to deliver a baby faster, they’ll turn up the Pit.  Well, that’s all fine and dandy – unless you consider the stress it puts on the baby.  Every time the uterus contracts, pressure is put on both the baby and the placenta, which decreases the amount of blood/oxygen flowing to the baby.  If the contractions occur too frequently (hypertonicity) and baby isn’t getting enough oxygen, the fetal heart rate (FHR) drops… and when the monotonous sound of the rapid heartbeat emitted from the monitor slows from 130 to 80, it sets off alarms in our heads to react.  This doesn’t always happen with Pit, but it is definitely a ‘common’ adverse effect that we must be prepared to deal with.  So, we started my patient on Pit, and watched her progress from the central monitors in the nurses’ station.   

1950: A nurse calls an L&D ‘code’ for an antepartum patient, who was pregnant with twins at only 30 weeks.  Her twins had been diagnosed with “Twin-to-Twin Transfusion,” meaning one infant was receiving more of the placenta’s blood supply than the other (a high risk for infant mortality).  She was also a Jehovah’s Witness, so refused any transfusions during her pregnancy to promote development in the smaller twin.  The ‘code’ was called for the smaller baby, when the FHR dropped to the 60s – and stayed there.  The doctors rushed in, checked the ultrasound tracing, and confirmed that the baby was not getting enough oxygen = CRASH C/S.  The team raced back to the OR for delivery, and en route, our charge nurse nearly ruptures her Achilles’ tendon – no joke.  I guess in her efforts to push the bed back to the OR, she turned too quickly around a corner and heard a dreaded ‘POP’ and then found herself in the ER for the next couple hours (after the C/S of course).  What a trooper… especially when she came back up and wheeled around in her classy hospital wheelchair in order to manage the floor. 

2000: I return to my patient’s room to do her hourly ‘Mag check’ (an IV med she’s on for the pre-eclampsia) and my preceptor insists that I turn up the Pitocin.  “We want to deliver this baby!” she says… and I understand that delivery is important for women with Pre-E, but she’s not showing any major concerning signs of the diagnosis. I know my preceptor is slightly more aggressive with Pitocin titration, so I expressed my desire to hold off a little while longer, but I work under her license… so we turned up the Pit by 2 mU/hr. 

2115: One of the laboring patients feels the urge to push… some of the staff returning from the OR dash into the room to deliver baby #3 for the evening, leaving the nursing station virtually empty.  I wandered into the room to see if any help was needed, and one of the nurses asks me to check in on a patient next door who is paging.  I walk in to deal with Cinderella’s stepmother and two stepsisters – a teenage ‘primip’ (1^st pregnancy) lounging on the labor bed, expecting to be waited on hand-and-foot while she is in ‘labor’ – I’m sorry darling, a cervix that is “cl/thk/H” (closed – thick – high) is NOT considered labor, regardless of your seemingly-regular contractions – asks me to clean up a spot of blood on the base of the bed.  Okay, I understand in normal circumstances this would be something I would take slightly more seriously (it should have been cleaned better) but in comparison to the events taking place just 30 feet away, I almost wanted to hand her a paper towel to clean it up herself.  But of course the Cinderella inside me smiled, grabbed a Cavi-Wipe (hospital-grade Clorox wipe) and cleaned up the small reminder of a previous delivery.  Apparently, the rest of the night she paged every 5 minutes because she felt as though HER needs (including ice water, which is accessible to family members) were priority #1. 

2130: I return to my patient’s room to check in on her progress (our new intern, now in her 3^rd week of her residency program) comes with me to do another cervical exam.  “Great news – she’s complete!  Her bag is bulging, and we should probably AROM her so we can have this baby.”  Artificially rupture her membranes?  I understand this does speed up the process, in most situations… but is it really necessary?  My preceptor and I are both on the same page.  But in this hierarchical chain of command, the doctor’s decision trumps our intuition, even if she is only in her 3^rd week of her residency (meaning that she just graduated to receive her MD less than a couple months ago).  The attending physician approves, and soon enough, the patient is one step closer to having her baby.  Miriam and I stay close to monitor baby, and the pushing begins.   Because the patient has her epidural, she can’t feel her contractions, so we have to ‘coach’ her as she pushes to ensure that she pushes with the contractions, and that she’s focusing her efforts on the right area (which she can’t feel).  I understand that comfort is ideal, but this is LABOR! It is not meant to be cushy and relaxing… even if the anesthesiologists market their services to offer that experience.

2220: After nearly 30 minutes of pushing with little progress, unusual for a gravida 3 patient, the repetitive sound of baby’s heart beat disappears from the monitor.  I jump in to move the monitor and throw a pulse-ox on the patient’s finger to distinguish mom’s heart rate from baby’s, and find that the situation is much worse than we expected – mom’s heart rate has jumped to 120, and baby’s has dropped to the mid 80s-low 90s.  NO BUENO.  Delivery needs to happen, and it needs to happen NOW.  Lucky for us, the chief is close by – even though this is his FIRST NIGHT working at our hospital (he had just completed his residency in Ohio) he scrubs in to help our attending and intern.  “FORCEPS!” He yells.  One of the nurses races down the hall to grab the sterile ‘birthing spoons’ used to help deliver baby’s head in such emergent situations.  Just 20 minutes later, a healthy baby girl is born screaming her little head off – it was almost as if she was laughing, like she had played some practical joke on us to scare us all into thinking she was tanking.  Her APGARs of 9 and 9 are indicative of a healthy baby, and the NICU team (who are always present for forceps-assisted deliveries) chuckle as they swaddle this ‘perfect’ little infant.

0015: We get a call that a patient is being flown in from Boulder, with complaints of regular contractions and bleeding – and she’s only at 27 weeks.  We prepare the room, alert NICU, and wait for her arrival.

0045: A patient checks in, and we look at her numbers – G10/P0905.  Yes, she’s on her 10^th pregnancy, but all 9 previous babies were born pre-term (before 34 weeks) and only 5 survived.  Patients with 6+ pregnancies are considered ‘grand multips’ and we definitely worry about precipitate delivery (labor onset à delivery less than 3 hours) with these unique patients.  She’s at 28 weeks, however, and that means yet ANOTHER preterm infant.  She rattles off her complex OB history (including 6 cesareans), and we all look at each other stunned that our shift is only ½ over… and wonder if this is the rain starting to pour…

0100: I return to my patient’s room for her routine Mag check, and notice that her blood pressures are spiking upwards of 170s/100s – a BAD sign for any patient, but especially for those with the diagnosis of pre-eclampsia.  I get the information to the doctor, and she orders a stat dose of Labetelol to be given IV.  My preceptor returns with me and we administer the med, and I complete my assessment.  Thankfully, she doesn’t have any other complaints or worrisome signs/symptoms, so we watch the monitors closely and see her BP return to her baseline, offering reassurance that we avoided a possible eclamptic seizure. 

0130: A patient returns from a 2-hour ‘walk’ (we send patients to walk through the hospital if they are in earlier stages of labor and don’t want to admit them just yet) and is vomiting at the front desk.  The triage nurse brings her back to one of the rooms, and has her lie down… just a few minutes later, we hear her shout “I can see baby’s head!  We are delivering in Triage C!”  As if we haven’t had enough exercise running through the halls of our unit this evening, we rush to help.  The triage rooms are quite small, so only a handful of people can actually fit, so we wait outside for instruction.  Shortly thereafter, screams are heard (not from baby) indicating that the patient is very close to delivery.  I can only imagine what the other triage patients were thinking… but it’s the reality of the situation they’re all in, and I’m sure many of them contemplated the idea of an epidural at that moment. 

0220:  Triage C baby is doing well, and we look to the board to see all of our triage rooms full, with 2 patients in very active stages of labor.  Our crippled charge nurse calls upstairs to the ‘Birth Center’ (the low-risk labor & delivery unit) to see if they can take some of our less-complicated patients.  They are short-staffed as well, but we are able to send 2 of our patients up for their deliveries. 

0245:  We learn that the transfer patient from Boulder is not going to deliver… yes, she did rupture, and yes, she is at risk for pre-term delivery, but thankfully her baby has decided to stay inside for a little while longer.  Despite all the medical interventions we can implement, in the end, nature does take over – mom’s body is the best (and only) determining factor that can predict what will happen.

0400: I return to check on my patient, finally resting comfortably in the peace and quiet of her postpartum room with her 5-hour-old infant in the basonette at her bedside, and her husband and 7-year-old daughter asleep on the couch, and offer a small prayer of thanks that this little Hispanic family was so patient with me as I did my best to care for them throughout the frenzy of the night.

0430: The chaos finally subsided (I didn’t even mention the incidents with a couple of the postpartum patients who were being managed for hemorrhages they had suffered during their deliveries the day before).  We gathered together in the nurse’s station to process and debrief the events of the previous 10 hours.  We finally found time to laugh at our charge nurse, who had attempted to hobble in to Triage C on crutches to help with the delivery, and listened as the nurse caring for stepsister A joked about some of her ridiculous demands throughout shift.  With another 2 hours to go, we all PRAYED that nothing else would disturb this rare silence… (thankfully for us, our prayers were answered)

0630: I returned to my patient’s room before I left the floor to offer my ‘best wishes’ and ‘congratulations’, and her sincere response of “Gracias” made (most) memories of the night dissolve… oh, wait, did I mention she only spoke Spanish? HA. But in all seriousness, despite crazy nights like these, I am SO grateful for this position that I have been called to – I have the unique opportunity to be a part of this momentous occasion in each of these patients’ lives.  It might be just another night of work to me… but I constantly remind myself of one of my favorite quotes:

“To the world you may be just one person, but to one person, you just may be the world.”