18 February 2013

I do believe I found the problem with my Ensign.  Anyone who knows me knows I like unmedicated labors or I like patient's who are almost circling the drain; give me a patient on Mag, Insulin, and Pit with a side order of pressor drugs and I'm one happy camper. I love me some adrenaline!  Don't get me wrong; normal, uncomplicated labors with epidurals and c-sections have the effect on me to a degree.  Seeing a family made complete, a new mom and dad enjoying this little person they've been wanting to meet for so long is amazing and humbling no matter how the kiddo comes out, or the circumstances surrounding the birth.  But day after day of induction, epidural, induction, epidural has a Groundhog Day effect and can leave me wondering if I need to change jobs for a little while.  Add in to this stew of ennui, a clueless Ensign who can't seem to grasp what the hell is going on no matter how many times I tell her, and I'm about to pull her hair out, along with my own, and weave a raft to paddle my happy little ass away from this Island of Frustration.

The other day I had her running triage with the understanding that the first patient through the door, in labor, was ours for delivery.  She needs to get the hang of the rapid changes that can occur during delivery and the need to multi-task with, sometimes, three different people asking you for something at once.  She's a very concrete thinker, and in high stress situations, tends to get ye olde "deer in the headlights" look about her.  Anyway, this young lady comes in to triage, it's her second baby, she is found to be 5 centimeters and she is adamant about not having an epidural.  Fine.  She "caved" (her words) during her last delivery and wanedt to avoid the word even being mentioned in her presence this time.  I told Ens. Getaclue that the patient and her husband needed to come up with a code word, known only to them, that, if she changed her mind and said it, would allow us to get her whatever pain management she wanted,  Otherwise, we would comply with her wishes and not talk to her about epidural even if she requested one.  (Some mamas, in the throes of transition, have been know to promise to give out the launch codes if they can just have an epidural.  This is transition speaking, not the mother's desire.  Unless she throws out the code word, like, say "chimichanga" and then her support person lets us know the patient is indeed serious about her desire to make this madness stop,)  We had been busier than a one legged man in an ass kicking contest lately, so we only had one room available and it had recently been cleaned.  The corpsmen were in the process of putting it back together and stocking it, so the patient was going to ambulate in the halls for a little while, unil the room was ready and then we would finish the admission process.  Which in this hospital meas at least IV access and labs for all laboring patients. As I am very territorial and have a definite "see a need, fill a need" mentality, I have not allowed myself to be in the room with Ens. Getaclue, unless she specifically asks for me.  So, I'm in the nurse's station, pacing back and forth (I hate not having anything to do) when I see this patient ambulating in the halls.  Then stop.  Get a death grip on the railing, bend her knees and breathe through a contraction.  "Shit, oh dear, " I think to myself.  I go to the room designated for her use and ask one of the minions if the room was about ready.  They only had linen left to stock in the room, so I said, "That can be done while she's in the room."  I urged the patient into the room and asked if she was interested in the tub.  She said, definitely, and since it takes roughly a millenium to fill, I started the water then went to tell the corpsman to set up a table.  The Ensign went in to start her IV, missed and asked me to come try.  I go in the room and wait while the patient signs her consents.  As I'm putting on the tourniquet she asks when she can get in the tub, and I told her if she wanted she could go right now and I could start her IV in there.  She jumps up, speed walks to the bathroom, and starts disrobing faster than a sophmore on prom night.  As she gets in the tub, she visibly relaxes and I say, "Awesome, right?" to which she replies, "Ten times better."  She has a contraction that she deals well with, kneeling in the tub surrounded by lovely water.  I
 put on the tourniquet to finally get this IV in, and she says, "You might want to wait...." So I release the tourniquet and she starts moaning, her eyes get the size of hubcaps, and she moves to where she is now sitting in the tub. I ask, "What are you feeling? knowing damn well what the answer is going to be, and she wails, "Lots of pressure!" with "pressure" being said on a gutteral growl that pretty much means "tape the windows, baby here comes the hurricane."  I, being much experienced and knowing that if I have a baby in this tub, the psycho doctor that's on the deck will make damn sure it's a blazing day in the ol' PacNW before a laboring patient gets in the tub if she's more than 2 centimeters, so I did the only thing I could; I shoved my arm into the water and stuck my left (and only gloved) hand onto her vulva, told her to blow and not push as I feel her perineum, and therefore the baby 's head, bulging into my hand.
I asked the Ensign to drain the tub and go get the doctor.  Then, as I felt her standing there looking at me, I looked her dead in the eyes and clearly stated, "Drain.  This.  Tub.  Go.  Get.  The.  Doctor."  This made some impact on her psyche, as she left the bathroom and returned with a physician.  By this time, the patient had enough clarity to say, "I'm ready, " flung her arms around my neck, I pulled her from the tub and she sprinted, literally sprinted, to the bed.  She crawled on it, about four seconds later her water broke, she looked at me and said, "What do I do???"  I told her to push her baby out, and voila!  Undmedicated birth, just like she wanted.  I was so stoked, you could have powered a small country with the energy I was feeling!  I was dancing around saying, "Oh my god, I DO love my job!"  And after this beautiful, natural, wonderful delivery, my Ensign came up to me and said, "I did NOT like that.  That scared the shit out of me."  And therein lies our problem.  Perhaps this is not the specialty for you, sister.  

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