Errrr....

So life got the best of me, and well....I got busy.

This one wasn't the patient....it was totally the doc.

A woman came in to deliver baby number 10. She was nearly 40, advanced maternal age and probably, while most of us would have been long done having kids she and her husband, who were both very religious were going to let what may happen, happen.

Her OB was out of town, and since she is in practice by herself, another doctor was covering for her. He came in to deliver the baby and after the delivery asked if they were doing her tubal the next day. The woman's husband spoke up and said, "No, we would never do that."

"You're going to have more kids?" the doctor asks.

"God tells us that may be in his plan for us."

"God talks to you?"

From the completely mocking tone I can tell this conversation is going downhill fast.

"Yes"

"You should be evaluated for that."

I try and change the subject to the baby quickly which seems to work but only temporarily. Before the doctor leaves the room he sneaks up behind the dad and bellows out in an ominous voice. "This is God...Get a tubal."

I wanted to die.

Who would believe it?

I have had a string of insanely normal patients lately. My luck has to break soon.

More Vaginal Bleeding.

When someone comes to the hospital complaining of vaginal bleeding there are three possibilities:

A) They have forgotten, didn't hear, or their doctor forgot to tell them that spotting is normal following a cervical exam, stripping membranes or sex.

B) They are crazy.

C) It's not good.

Every time I hold my breath and say prayer that this patient is forgetful, deaf, misinformed, paranoid or crazy.

So, a young (very young) woman is brought in by EMS for vaginal bleeding. She is alone as the father of the baby is (and has been) out of town. She says she wore a pad in and sure enough it is saturated with blood. Crap. I give her a fresh pad, find fetal heart tones, and then call her OB.

Her doctor comes in with the ultrasound to check for placental abruption and placenta previa. Once cleared of both of those she proceeds to a cervical exam. When she spreads the labia the cause of her "vaginal bleeding" is painfully obvious. She has deep puncture wounds from a BITE on her labia that are gushing bright red blood.

"Who bit you?"

"Huh?"

"You have a bite here. Who bit you?"

"I don't know what you are talking about."

The doc pokes at one of the puncture wounds. "Does this hurt?"

The patient yelps that it does in fact hurt but again denies that she has any idea what may have gone wrong down there.

Many stitches later, the "vaginal bleeding" was cured, the baby was thankfully fine and the patient still refused to explain what had happened. I wonder what story the boyfriend will get when he returns to town.

I feel violated.

I was putting a Foley catheter in a woman the other day. Simple, straight forward procedure that isn't particularly comfortable but most people say it wasn't as bad as they thought it would be and if they actually breathe when I tell them to, some say they hardly felt it at all.

I open my kit, put on my sterile gloves, get everything situated where I want it and use one hand to spread the labia so that the urethra will be visible. She lets out a long moan.

I stop. "Are you alright?"

"Yes."

Ok, I start cleaning the area. With each pass of the swab she lets out another long moan. "Are you really, OK? Am I hurting you?" (Sometimes people find the cotton a little scratchy and are very sensitive.)

"No, keep going."

So, with my still sterile hand I grab the catheter, tell her to take a big breath in and try and get it over with for her as quickly as possible.

Instead of taking in a big breath she lets out a series of moans. Then she asks, "Is that supposed to make you have an orgasm?"

"No."

Maybe coffee straw girl knew what she was doing after all.

I know what you're thinking.

Ok, I know some of you must think that when I post about our "frequent flyer program" that I am being insensitive to poor first time mom's that just aren't quite sure about when they are in labor. You same people probably also think that we all laugh at these people as we send them home for being too dumb to know the difference between when they are in labor or they are having Braxton Hicks contractions. We don't. I am not talking about people that come in for a labor check, or two, or three or even four or five.

Last night, as we were reminiscing over some of our recently (and not so recently) delivered patients who were enrolled in our frequent visit rewards program we started to wonder which one actually had the most visits. The winner had a whopping 81 labor checks over a period of 2 1/2 months before she was finally induced at 40 weeks, probably because her doctors were sick of it. You can blame that one on them.

Now, when you come in to the hospital 81 times thinking you are in labor, especially when it isn't your first baby, to me that signifies a fundamental problem in following oral, written and even demonstrated instructions. And, had she have actually called her doctor first (the very first instruction always given) she could have saved herself some gas mileage on what I am going to guess is at least 78 of those visits. Although, that wouldn't be quite so dramatic and she would have missed the 18 phone calls always made to let everyone know that she had to go to the hospital again.

The point of that rant is to never fear, your nurses aren't thinking you are nuts until you have been there so many times that they have your name, address, social security number and the phone number of your seven emergency contacts all memorized, or of course you think your water broke but taste it to see if it was really pee and then admit it.

Stand Up Kind of Guy

A few weeks ago I had a very young patient come in laboring. I really felt for her because in addition to being young she was also alone and probably scared to death. She also had with her a really sweet birth plan that included being able to labor naturally and the father-of-the-baby showing up and being supportive. After talking with her for a little while I found out that the first part was probably going to be a go (IE. her reasons for not wanting an epidural did not include 1) needles hurt or 2) my mom/boyfriend/husband says I am not allowed) but getting a supportive dad to show up when he hadn't been involved for the past 6-7 months might not go so well.

I got her all set up and as soon as a better room opened up I moved her up to a room across from the nurses station so I could keep a better eye on her in addition to giving her access to a jacuzzi tub. I guess she must have taken care of the second part of the plan because a couple of hours into her labor the FOB shows up. To put this VERY mildly, the guy looked rough.

Before long, I am glad I moved her to the room that I did because it allowed me to hear a little better what was going on in the room. My patient was doing a fantastic job but it was obvious that dad was one of those guys that handles crying/screaming and probably any uncomfortable situation by acting like a jack-ass. He is yelling at her to "just get the damn epidural" and it doesn't take too much to realize that he is really agitating my patient. I get her alone and I ask her if she wants him to leave. Big tears appear in her eyes and I can see that she knows that her plan isn't working. I tell her that is it her choice and to just give me the signal and he is out of there.

All it took was two more contractions of him acting a fool and she wanted him gone. So in I go to try and get a guy who can quite obviously pick me up (and probably another nurse too) and run off with us, one under each arm, to get gone. I also call security, stat, for help.

I tell him he has to leave. He doesn't take it well. How dare I take this experience away from him? He loves her so much...blah, blah, blah. You know, all the stuff that being completely absent through the pregnancy clearly indicated. It quickly turns into a shouting match (or at least he was shouting) and we have three nurses and one of out scrub techs in there trying to ease the situation and move him towards the door.

Minutes pass. Where is security? The shouting continues. The four of us start herding the guy in the right direction while he is spewing off threats about how we all better watch ourselves because "I'll be back" Terminator style. We finally manage to get him to the elevator and when the doors open who is standing in there but the security guard?

Nice dude. We call you up here stat and you take the time to get on the elevator with 17 other people.

Now, we get strange calls to L&D all the time of people asking for weird and completely non-L&D related things but about 4 minutes past bar closing time the phone rings. It's A-hole. He is now obviously quite drunk and in tears about how sorry he is and how he is a total fuckup. Plus, he needs a ride home. Ugh. Tell me where you are buddy and I'll call you a cab.

At least my patient got half the delivery that she wanted, at probably a little closure as a bonus.

A Lesson

Lesson for you: Fetal Fibronectin Test (fFN)- a test where a swab is taken of the vaginal secretions at your cervix and looks for a protein (fetal fibronectin) that can predict if you are going to go into preterm labor within the next two weeks. It is usually used in high risk pregnancies or women experiencing signs of preterm labor.

A few nights ago a woman came in 24 weeks pregnant complaining of preterm labor. She had a history of 3 prior deliveries all between 24-30 weeks and also had no prenatal care for her current pregnancy. Obviously, we were all more than a little concerned for her. The midwife on call, who is very sweet and very hands on with her patients orders a fFN, and while this is something that is usually left for the nurses to collect she wanted to do it herself. I went along to assist.

After you collect the sample (on a long q-tip like swab) you place it in a long narrow container and send it to the lab. I hold the container for the midwife and most unfortunately her hand slips and now the sample has been smeared across my bare hand.

While I head to the sink and start scrubbing, she prepares a slide. I figuring she is looking for a "ferning" pattern that would indicate that the patients water is broken. Instead, once we get to the back and look under the microscope it turns out the patient has a raging trich infection.

Lesson for me: wear gloves any time anything with bodily fluids has even the most remote chance of missing its intended target.

Would you like fries with that?

This is an old story but since a coworker brought it up the other night I have been reminded, and thus shall share. I am afraid the nurse who this particular story is about may never live this down but in her defense, she takes it well.

As many of us know, and some have yet to find out, labor can induce nausea and vomiting. Despite that, this does not deter people from stopping through the drive through on the way to the hospital. Anyway, my coworker (who I will call Betty) was taking care of a patient who came in because her water broke. She wasn't contracting at the time, and feeling like it might be her last meal for a while apparently stopped off and Micky D's for a #1 Super sized with cheese.

As labor karma would have it, she soon kicked into active labor, and before long was begging for an epidural. Betty got her bloused, call anesthesia and returned to the room to sit her up. As soon as the patient swung her legs over the edge of the bed, she lost the previously mentioned #1 Super sized with cheese and Betty was the unfortunate target.

I can't really blame her for what happened next as I am a sympathetic puker myself. Betty, feeling the strong urge to vomit that can't be ignored makes a beeline for the patients bathroom, swings open the door and aims for the toilet. No sooner has she let all restraint go than she realizes grandma-to-be is taking some personal time in the loo.

Let this be another advertisement for visitors not using patient bathrooms.

Happy Valentine's Day!

A twenty-something weeker showed up last night, with the very concerned father-of-the-baby, complaining of vaginal bleeding and passing clots. This, never being a good scenario, demanded immediate attention. I put her on the fetal monitor and am able to get a good tracing of the baby, who appears to be quite well. Next come the questions.

"When did the bleeding start?"

"About a couple hours ago."

"Did you wear a pad in?"

"Yes but there was nothing on it"

"Were you having bleeding that's heavy like a period?"
(At this point her doctor has wandered into the room and is standing patiently by the bed.)

"Not really, mostly just some spotting and clots."

When was the last time you had sex?

"Valentine's Day."

Since this was nearly a week prior, I quickly rule it out as the immediate cause of her bleeding. The doc has now poked and prodded his way around assessing her belly and is asking me for a sterile glove.

He goes to examine her and starts pulling out large clots. But wait. Are they clots?

On further inspection, perhaps they are strawberries.

"Honey, did you put strawberries in your vagina?" I ask.

She looks at her companion sheepishly. He answers for her. "I guess we forgot about those."

Needless to say, I am eating my Cheerios plain this morning.

We see normal people too.

I recently had a patient get upset with me that I didn't remember her when I took care of her earlier in her pregnancy when she came in to be monitored for decreased fetal movement. I can understand the natural human inclination to get your feelings hurt when you learn that you aren't "memorable" and the wounded look on her face was a good indicator of that. I tried to explain to her without being too weird or scary that it was a good thing I didn't recall her visit several weeks prior. I have a feeling if I could have pointed her in the direction of this blog the point would have been better made.

Who would you like in the room with you for delivery?

In general we have a three person policy when it comes to deliveries just to make sure that we have plenty of room, aren't knocking people over and are able to move around the room quickly in case of an emergency. For the most part these three people consist of the father and a couple of family members or a good friend.

A couple of weeks ago we had a young lady show up 29 weeks pregnant with no prenantal care and ruptured membranes. She wasn't laboring so she hung out on the floor while we took every precaution possible to make sure she didn't get infected while we waited for the baby to become a little more "ripe".

Now, from the start the family was a complete pain in the ass. It probably didn't help that the father of the baby was also her sister's ex-fiance and they were both there all the time. You can imagine the arguments caused by that situation. There was also some other man that stayed with her nearly 24/7 in the room that we all assumed was her dad. We thought it was a little weird and wondered why the guy never had to go to work but over all, no big deal.

When she kicked into labor, nearly a week after being admitted, she started progressing rather rapidly. Other worried people started showing up at the hospital to visit her and we'll just say that they were a strange bunch. When we asked her who she wanted in the room with her for delivery she chose her sister, the father of the baby and her pimp.

Oh, that's who that guy is! I should have known, it explains a lot.

Wanna guess how that drug screen came back?

You'll look back at that and laugh.

And now, nearly 6 months later I can. I think.

One night I had a patient who was a frequent flyer. Not the kind of frequent flyer that has been coming in for the better part of her second and third trimester for labor checks, but one that was actually in early labor and refusing any intervention.

She would come in screaming in pain. She was actually contracting fairly strongly but refused meds, IV, a cervical exam (at first anyway), membrane rupture to help progress the labor etc. So what exactly she wanted from us was a mystery and out the door she went again only to return a few hours later so we could play the same game over again. This went on for days and finally got to the point where I was the only one who hadn't taken care of her so I was up to bat.

At start of shift I figured she would probably be out the door again but at exam she had actually progressed far enough that she needed to stay. She was also screaming bloody murder and not just with her contractions. Constantly.

She said she wanted to get in the tub so I calmed her down long enough to check her again and make sure she wasn't getting ready to deliver. I drew her a warm bath and let her get in. Not two minutes later she is screaming like a banshee again and out she comes. I help her back into bed. The screaming continues.

She is so loud that I can literally hear her down the hallway, in the back of the nurses lounge, in the restroom with the door closed and the water running. The rest of the staff is working hard to reassure everyone else on the floor (who were all understandably freaked out) that this girl is in fact, going to be OK. I am working hard to calm her down.

When I step out of the room to give her doc a call and an update (which wasn't hard to explain her condition since he could hear her screaming over the phone) the mother steps out and says to me angrily, "I think we need some better labor support in here!"

Um lady, your daughter is a freak.

After hours and hours of constant screaming another cervical exam reveals no change and it would seem her cervix is starting to swell. Miss Priss is still refusing any sort of intervention. Finally, a team of us convince her an epidural would be a good idea and we start an IV so we can get the fluid bolus going.

If you labor nurses out there guessed that she wasn't very patient during this process you are correct. I went ahead and paged anesthesia, extremely worried that she would continue to act a fool and the anesthesiologist would refuse to do the epidural. Luckily for me, while she did continue into her seventh hour of ear piercing screams, I think the doc took pity on me and miraculously placed a beautiful epidural in a moving target.

Silence. At this point, I fully planned to leave her alone for the rest of my shift since I was worn out, was pretty sure she was worn out and most thankfully, she was sleeping soundly. Unfortunately for me, at about 4 AM her doc rolls in and decides we need to check her. Feck.

She is complete but still at a zero station. He wants to rupture her and start pushing. Me, anticipating what kind of a pusher she is going to be, and knowing the baby has looked beautiful all nights suggests we let her labor down some. I lost.

First push: Good. Second push: Good. Third Push: Good. Fourth Push: "Why isn't the baby coming?"

"This takes a little bit of work with first time moms. You are moving the baby well."

She looses her marbles again. We are back to square one screaming bloody murder. The doc comes back in to assess her. She will still push but you can probably figure not very effectively. Her mom starts screaming, "Why can't you push the baby out by pushing on her stomach."

I don't even dignify that with a response. My patient is yelling "Just cut it out, cut it out!!!". The screaming continues. The poor doc is trying to explain her options but she won't stop the damn screaming. She consents to a c-section which has to be done under general anesthesia because she wouldn't quit thrashing and yelling. Mom is pacing outside the OR in tears because her perfect baby is going to have a scar.

The silence in the OR was magical and as I had to push the baby back up this ladies vagina so that it could be extracted from her abdomen I found myself wondering where it all went wrong. Miss "No intervention" inevitably ended up on the operating table.

In a fitting end, as my patient came to, she was still swinging and I got punched square in the jaw. I look at the clock. It is 7:30 AM and in through the door walks my relief. I have never felt so thankful.

A couple of random thoughts.

I am glad I am not working tonight. I really don't want to have to deal with

1) The women that are feeling neglected from all the football hoopla and have suddenly gone into "Labor"

2) The backlash from that article that appeared a couple of days ago on MSN about the woman that delivered her baby in her sweat pants in the driveway after being sent home from a labor check

Kids say the dardnest things.

I am pretty sure we have all heard a story about a couple that thought they weren't able to have any children of their own only to get pregnant shortly after adopting. I was taking care of one of those patients and she and here husband, a middle aged white couple had adopted two black children who were both elementary school age.

Once mom was comfortable with her epidural she started talking to me some about her blended family and how the new baby would fit in. She then told me a story about how she was out with her kids in a location where she was the only white person there. Almost immediately, her older child blurts out loudly, "Look mommie, we are the only white people here!"

Ahhh, to be young.

Thanks for the warning.

A while back I noticed a patient of mine had a cyst on one of the outer lips of her vagina. No big deal. It happens.

Come time for delivery, with the patient up in stir ups and the spotlight on her girl parts I notice the doctor silently but quite attentively inspecting the cyst between contractions. I see her poke at it. Then, with no warning what-so-ever she gives it a firm squeeze and a ridiculous amount of purulent discharge comes squirting out at a speed that I am pretty sure broke the sound barrier. It is heading right at me. I manage to move just enough that it hit me in the shoulder.

I give the doctor a "what the hell was that all about" glare.

She looks at me apologetically.

The whole time the patient remained blissfully unaware.

Things that make you go hmmm.

Sometimes you hear just enough of a conversation to make you desperately curious on and glad you are walking the other way all at the same time. As I was leaving today I caught this tidbit in the hallway.

Two nurses are walking together carrying about every type of restraint imaginable. Another nurse passes and asks "Where are you going with those?"

"The ER. We have a Hannibal Lector down there."

?!?!?!?!?!

What do American Idol and L&D have in common?

As I sat on my couch last night watching that guy explain his collection of “finger nail peelings” on American Idol I was reminded of a girl that showed up in L&D one night with a bag of vomit she had been saving. This led me to ponder what else Simon Cowell and I may have in common.

I decided that like the DMV, American Idol gets a good sampling of the general population. The relatively normal to the over-emotional, to the bipolar and even people that enjoy dressing up in chicken costumes or drag all show up to audition thinking that they may be the next big star. Labor and Delivery is the same way. Pregnancy is non-discriminating and while admittedly when someone shows up in drag as a “patient” we have bigger problems, we too see it all.

Just like rejected auditioners get their 30 seconds in some sort of confessional where they curse Simon and blame their failure on anything other than their lack of singing ability, I too get cursed and yelled at when I send someone home who is not in labor. And like Idol, some do actually take it gracefully.

So, when you find yourself wondering if these stories could possibly be true think of glitter pixie queen (aka Willem Dafoe’s look alike) and Renaldo Lapuz belting out “We’re Brothers Forever” and think of the possibility. For me, I think my lesson is that I need an L&D video confessional out by the elevators.

The Cervical Exam

When I started in L&D one of the nurses who has been working L&D for over 30 years told me that she went to a conference one time and heard someone say that your first 100 cervical exams as an inexperienced practitioner are more like social visits. You are just checking it out but don't really know what you are looking for.

She then proceeds to tell me a story about a doctor from a nearby area that was in a family practice residency, doing his OB rotation. The first time he went in to check a patients cervix he felt around and quickly pronounced her 2-6 centimeters. (Basically meaning "I have no f-ing clue what I am doing.")

Fast forward to a couple of weeks ago while I am sitting in my doctors office for a check up. We were talking about work and he asks me which hospital I work at. When I tell him where I work his eyes light up.

"I did my OB rotation there!" he says. "I came in from (insert area mentioned from above story) and I had no idea what I was doing. The nurses were so nice to me helping me out and teaching me how to check a cervix..."

It was all I could do not to die laughing. He he was, the story of legend that happened over 20 years ago...sitting right in front of me.

Shopping Around

Some women don't deal with not hearing exactly what they want to hear very well. Some cry. Some curse. Some throw things at you. (I have learned to watch my back and am getting better at dodging monitor parts.) Other just leave and try another hospital, hoping that maybe there, the magic of labor will begin.

This of course means that we too get our fair share of women that have previously been seen at another area hospital and now we are their second (or third, or fourth) try. Not surprisingly, they don't like to admit that they have been somewhere else first and were sent home although we almost always find out about the time we start calling other hospitals for their prenatal.

Last week, a young woman came in with an obvious spot on her arm where a band aid had been removed. There was a bruise and it was obvious she had blood work drawn.

"Did they draw your blood somewhere?"

"Yeah."

"What did they draw it for?"

"Oh no, nobody drew any blood."

Upon further inspection it became obvious that she had been stuck in many places and looked like someone had opened an entire box of band aids on the girl. Of course, in an effort to conceal her previous whereabouts they had all been removed so all you could see was the sticky outline of each one.

"So why do you have all these band aids?"

"Oh, those aren't band aids. I fell asleep in a room full of Mexicans and they taped me up with duct tape."

At least she gets points for creativity.

I didn't know this really happens.

I took over an assignment on a patient with the warning that she didn't speak much English. Her husband however was fluent.

I walk into the room and see a beautiful girl (who's admission reveals that she is 22) and her husband, a frumpy looking man who I suspect was wearing a toupee and is a self proclaimed ripe old age of 58. She was from the Ukraine. Yes, I was puzzled.

Before too long, curiosity gets the best of me and I ask how the two of them met.

The husband answers, "We met online."

Me, still showing my true naivety replies, "Gosh, it must have been hard to get to know someone online who is so far away."

"Not really, I just chose the one I wanted and went to pick her up."

Ummmkay.

Happy New Year Weirdo

I was going through the prenatal of one of my patients. It read something like this:

Name: Crystal Chandeleir

Father of Baby: Ronald Muggins (in very neat black in)
Jon Walker (this time in blue pen and a bit messier)
Arnie Fitz (this time in a guys handwriting)

I wounder how that process of elimination went.