Friday, November 21, 2008

4 Stories from Night #3

I haven't done 3-in-a-row in a while, but it really wasn't as bad as I thought it was going to be. I'm exhausted and going to bed at 1900 tonight, but I'm really OK with that! We were busy enough last night to keep us all on our toes...

Story #1: Gotta love those shift-change catastrophes. When I walked in right at 1830 last night, the unit looked slightly deserted but everyone who was there was a little high strung. I guess about 1810 a lady had walked in 33wks and said that she had severe right upper quadrant pain. She said it may be contractions, but they just felt funny. The nurse got her on the monitor, got about a 5 minute reactive tracing and then it was the crash. Baby didn't look HORRIBLE, but dropped from 150s to 90's. When I got there she was being rushed to the OR, general anesthesia and the doc was yelling "get the NNP, we're going to have a 33 weeker!" They thought her uterus was rupturing, but when they did the C/S her abdomen was full of blood and her uterus was intact. After they got the baby out, there's a hospital-wide page "Any general surgeon call L&D STAT" Now how fun is that to hear at shift change? Meanwhile, she's still gushing blood and we're activating the Mass Transfusion Protocol. I was standing there debating in my head what exactly I should do at the moment. My preceptor wasn't there yet, there were already about 4 nurses back in our OR and I knew I didn't know enough to really be a help back there. The secretary was on the phone with blood bank trying to get blood stat, and after our MTP drills last week I DID know what to do about that, so I said "I'll go get blood" and sprinted down to blood bank. I didn't feel like quite the idiot that I did during practice last week 1) I knew I wasn't just "pretending" and 2) I didn't have on OR shoe covers and I wasn't skating down the hall! :)
I got down there right behind another nurse who had come down from the OR that I didn't know about it. She took the 2 units they had ready but said "we're gonna need more than this" so I waited for the next 2 units and had just about caught up with her by the time I got back upstairs. When I got back to the OR there were seriously about 20 people in there between all the OB people and the general surgeon and his crew that came over. Our OR's aren't that big to start with, and that was WAY too many people and WAY too many people trying to talk at once. It turned out that one lobe of her liver was a complete hematoma and the other had a huge laceration in it. They had used 45 laps before the general surgeon got there and completely opened her up. She is now residing in ICU and wasn't doing too well the last I heard. Baby was on a vent in the NICU along with the 5 other kids that NICU admitted between 1900 and 2300 last night... THIS ALL BEFORE 1900!

Story #2: By the time we got report on our actual patient for the night it was almost 1930. This poor gal was a cervidil from the night before and after sitting at 30mu of pit for most of the afternoon was still a TIGHT 2. Section time! That's all fine and good except for the fact that liver chick had just been taken up to ICU and the ENTIRE OR was a mess and covered in blood. One S/T for the night, says it will take 1 1/2 - 2 hrs to clean the OR before we can do the next section. My doc wasn't too happy about that. I have my girl all ready to head back to the OR minus her fluid bolus (I wasn't going to bolus her then find out that we were waiting 2hrs for the section). My preceptor (D) was in the back trying to help clean so I really did the whole prep thing on my own. I've decided there's a BIG difference between "knowing what to do" and actually being the one incharge of doing it and making sure it gets done without someone right behind you. I really felt like I was on my own and if something got screwed up, it was all me because I hadn't even really touched base with D! It was a little nerve wracking, I've never REALLY been let on my own before without SOMEONE claiming me.

Anyway, we finally head back to the section, probably sooner than we should have, but we do. I'm in the back with anes, the doc and the S/T while D is trying to finish up cleaning the other OR. Everything's going decently ok until I realize that we keep cutting though layers and nursery still hasn't showed up. I know I'm spoiled, nursery comes to every delivery and I can focus on mom and I never really have to worry about baby. Anyway, we keep cutting, we get to the uterus, then we're to the sac and still no nursery. I've called the nursery to see where they are, no answer. I stick my head out into the OR hallway and don't see nursery, call D and she calls comes out, it's still just me, the docs, anes, no's on the warmer, it's still just me, it's 5min APGAR time and it's still just me...I'm shaking really bad and the only thing running through my head is "warm, dry, stimulate, warm, dry, stimulate, warm, dry, stimulate..." baby's crying, not really lustily, so just for kicks I pull out some blow-by and keep hoping that everything's going good with the docs because I'm a little preoccupied at the time. Finally nursery shows up and I'm still shaking but have a crying baby!

About this time we get the call that some 30-something week twins are coming back for a section and so there goes our scrub tech and now it's just me and the two docs, still no D...I'm still shaking. Another doc comes in and scrubs and plays scrub tech. Thank goodness that these were good docs and they weren't too scary and were laughing about the whole thing. We had to count 3 times to get all the counts correct but everything was there and besides me still shaking everything went down without a hitch. I don't think I really started breathing until that patient was on the bed and in the recovery room!

If I learned anything it's that "hey, I just did my first section totally on my own and I survived!" So while it was a little intense at the time, I think I just jumped a big hurdle. My first section on my own and my first delivery without nursery there...and I'm still breathing and mom and baby are happy!!

Story #3: Not as exciting as the first walks in about 0130 c/o leaking and UC's. We'd just sent her home about 3 hours before, but this time she'd changed her cervix. Long story short she delivered at 0246 about 10 minutes after her epidural and still couldn't move her legs at 0630 thanks to a nice dosing of fentanly by anes to get her comfy quick. She did great though and in my heart of hearts I think she really could have done it without the epidural, but I wasn't going to be the one to tell her that! Did that delivery pretty much on my own too WITH nursery this time!

Story #4: 0530 ( I really think we should lock the doors about this time until after shift change because this is when nasty stuff happens...) lady comes in thinks her water broke. Multip, says she woke up to "wet sheets" about 0430. Didn't wear a pad in, doesn't appear to be in distress about anything and can't amnisure r/t intercourse in the previous 24hrs. I checked her, she's 4 and unchanged since her Tuesday office visit. Fetal head was very ballottable, and I didn't get fluid when I "bounced it" so I sat her on a pad and kept an eye on it. About 0600 there was maybe a quarter size spot of fluid. Got an order for a sterile spec by the laborist, who of course is in the main OR getting ready to start an hist so says she'll be over in about an hour. Patient was denying contractions even though toco was picking them up about very 5-7 minutes. I told her to let me know if she felt a gush or an increase of leakage. I gave report about 0650 and just about then she called and I went in and if her water hadn't broken earlier it had broken then! She got up and went to the bathroom and I changed the chux and let the new nurse know. As I'm walking out the door I was told decisively "she's grossly ruptured and 7-8cm and no IV access." Sorry, she wasn't that an hour ago and she hasn't felt her uc's! I had no reason to start an IV! J texted me and said she delivered about 1100 so I don't feel TOO horrible anymore. By the time I left I was just ready to go to bed. Off for 2 and then back for 3 more!

Babies today: 1m/1f (I haven't had 2 babies in a while!)
Babies total: 27M/21F = 48
Vag:20M/19F = 39
C/S: 7M2F = 9

1 comment:

  1. That was one heck of a shift! You did good girl! With your baby, just remember your basics - airway, breathing, circulation. Dry, stimulate, reposition, bulb if needed. Repeat. If still not pinking up a little by one minute, start some blow by oxygen. If limp and blue, start bagging. You can do it!