1 in 275

Traitor.

Traitorous awful wench.

I'm afraid of you, of your power, of your thousand million ways to change.

Changes that spell a disaster for me.

You know, you've made me money.  I am something famous because of you.

We should be working together, you and I,

For the benefit of many.

They all appreciate you, call you perfect, sing your praises.

And here you are.

Knocking at my door, singing your own deadly song.

Low-risk, awareness, modified, sparing, aspiration.

The meaning in those words that you can evoke weighs heavy on my mind today.

I have aspirations, you know.  Plans for you.

It seems you might take us down a different path.

I'm sure it will be fine, I tell myself, try not to feel betrayed.

1 in 275 is pretty slim odds, right?

No air.

"Code Blue, Post Partum, 3rd floor" the page repeated overhead.
We all looked at eachother, disbelieving. We were used to the pages for the code team to the ICU, CCU, Tele floor... But our own?
Should we go? Help out? Postpartum nurses aren't much for adrenaline rushes, our patients have specific reasons for coding and the team doesn't want to touch a pregnant lady or someone who has been recently pregnant with anything less than a 10-foot pole.
Alright, we go.
I wish I hadn't.
We took the elevator, expecting the best.
Should have taken the stairs.
We bolted down the dark hall, turned the corner and found the worst, the very worst.
Wish I had expected it.
We came upon a nurse fluttering around a crib with an oxygen mask. My ears roared. I ran through a checklist in my head.
Fumbled with a stethoscope. Wish she'd stop bagging so I could listen, I can't hear a heartbeat with her bagging.
I can't hear a heartbeat.
Babies frequently need a kickstart. They need a little oxygen, a little pressure to start the gradient shift that will mark the transition out of their previously watery existence.
They finally gasp, turn pink and cry a bit and we walk away.
They all finally gasp, eventually.
All of them.
Where's that heartbeat? I pause compressions, shifting my hands. Am I doing this right? Compress to 1/3 the diameter of the chest. 90 per minute or 120? Bagging too fast. Something about counting, but I can't remember, so I keep counting. I lose it at 100 and start again.
The NICU team arrives. Good someone else to do compressions.
Someone else want to do this? Because so far I'm failing.
Fumble with a stethoscope again. There's a cartoon that I remind myself of but I can't remember which one.
Can't think, keep compressing.
"Do you want to call this?"
What?
Call it?
You've only done two doses of epi. It's only been like 5 minutes.
12 minutes? It's been 12? I've been compressing the whole time. Bagging, compressing, keeping going...
He was a little cold, I guess.
Livido, already, mottled when I got there.
No heartbeat for at least 12 minutes.
"3:56am."
Gone. Long, long gone.
Isn't there more we can do? Other drugs? I took ACLS, can we give lidocaine? Atropine? ECG? I blinked and stopped. They extubated.
I blinked and thought of his parents. Who would tell them?
Who would say "I'm sorry, there was nothing we could do."?
He was dead when I got there. Tiny soul only 28 hours old, already gone. Long gone.
I'm sure they thought they were home free. Having negotiated the treacherous pregnancy and birth process, they were relieved and waiting to go home. Waiting to take their new son home to meet his brothers and sisters, his aunts and grandparents.
But now, they'd just have an empty crib. Empty booties, shirts carefully folded away.

"Do you want to call it?"
There is nothing in the world more tragic.
But sometimes, babies die.

I wandered slowly back downstairs. Thanked the ICU nurses for coming and sat, deer-in-the-headlights. I looked up the NRP guidelines, I'd done it right, it just didn't work.
I heard the story later that the baby had been tucked in the fluffy sheets with his dad. So proud, so happy to have his new son. Fell asleep with the new babe next to him and awoke to find no breaths, no heartbeat. We educate families on bed safety - no babies in the bed because they can get wrapped up in the soft sheets. Sleeping parents have rolled onto their children, unknowing. We educate for precisely this reason. I cannot imagine that father's horror.
The autopsy showed he'd died of suffocation.

Something?

I still see them, here and there. Perfect tiny dolls with heads that were too big and hearts that were too big but voices too small.
One tried to tell me his name. Tried to tell me his story but was interrupted by his destiny.
I wish I knew what his small purpose was. Maybe I'd sleep a little easier.
I watched a birth too soon into a world that just wasn't ready for it yet.
And, to add insult to injury, 15 minutes passed and his brother came toddling behind.
I can imagine that's how it would have been - one always following the other into adventure and trouble. Dirty knees and dripping noses, they might have fought and cried together.
Loved together. Always joined in that secret knowledge that only twins have.

She, in shock, couldn't bear to face the fact. Couldn't bear to look into their little faces so soon so I took them away.
Couldn't take them to the demise room, there would be time for that later. Couldn't leave them alone but I couldn't be far away so I took them to 218 and held them close. The strong one gasped every now and then, surprising me. His chest didn't move but with each heartbeat.
For lack of anything else to do but wait, I sang them lullabies. I sang them to sleep, to death, to heaven or limbo. I sang quietly and tried to keep the notes from catching in my throat.
"Hush, little baby, don't say a word..."
I sang and waited. Checked the clock and their tiny chests over and over again. Kept them warm and tried not to move too much.
Replayed that first moment in my mind, seeing that pink translucent skin and heaving ribs, hearing that first gasping breath, too short.
All too short.
I wondered, "isn't there something we can do?"
Anything? We have to do something, what if? What if this is the one-in-a-million? I'm a gambling person, can't we intubate? Umbi-lines? Do we really have to just let go?
Misplaced hope tumbled over me like so many hard, cold rocks. I know the truth, I've seen the consequences of 'doing something'. The pokes and stabs and exams and X-rays. The infections and head bleeds and pain and pain and more pain that their little lives would hold. That their chances for living a quality life approached their chances of becoming President. Close, but not quite.
23-week twin boys just don't make it. I know this.
So I shift my hope to something new. I hope that they were comforted by my songs. That they heard their father's wracking sobs and felt some sadness and some understanding. I hope that they were relieved to be out from the squeezing pressure and stress of their shared apartment. I hope we were able to make a horrible and tragic day the best it could be for a woman losing her dreams, her heart, for the 6th time.

I hope that those little souls hang around for a while and maybe make it through her body again, this time to sing their own songs to their own children someday.

It's been a while.

How do you say it?
How do you look a woman in the eye?
I wanted to run, run fast and far.
I kept pushing the volume button, searching and searching. Didn't know I was turning up silence.
I could live a long, happy life if I never had to see that telltale black and white smudge that shouldn't be so still.
Little telltale heart, your stillness rushing through my ears, betraying every laugh, every smile and little dimple that just would never be.
Betraying that raucous announcement that just would never be.
Winged joy just ran away, why can't I?
Mottled purple, green and red, like a child's colorful drawing of what a baby might look like.
Those lipstick-red lips, gaping open to join everyone else in surprise.
Surprise, nothing.
I cried later, where you couldn't see me. We keep it all together in some feigned show of strength and professionalism.
Professionals don't show that much emotion, apparently.
Although, secretly I think that my stoicism in the face of such open heartbreak, wailing weeping and abject sorrow is something that I'll be judged for, in the end.
Maybe I'd feel better now if I had cried with you.
How do you dash someone's dreams in a sentence?
"I'm sorry, ma'am. I'm so sorry."
I was just thinking it had been a while, I even looked back to see when the last time was that that room was used. The one with all the sweetly painted boxes, the play-doh and plaster of paris, the cards and stamp ink, the scale that's used for weighing only one thing. There's a sink in there, and a chair. A little photo printer... A macabre little art room.
It had been a while, thankfully. If it was more often, this job might not be worth it.
I hope you recover, I hope your other beautiful children and your multitude of family members are a comfort to you. I hope you don't blame yourself and most of all, I hope you always remember with love, not bitterness.
I hope I do, too.

Placenta Lasagna

So, I get an uneventful report from Dayshift Nurse. She then pulls me around the corner and half whispers "I have to tell you what's going on."
Ok.
So, it seems FOB (Father of Baby, not to be confused with SOB) wants to keep the placenta.
Fine, I say, some cultural thing? Expecting to hear he's southeast asian, or some sort of uber-hippie who's trying to complete the cycle of life by planting a tree over the discarded organ.
But no.
"He's white. He just wants to eat it."
She wasn't kidding.
She goes on to say how she asked further "is this some cultural thing?" and was totally unprepared for his response:
"No, you see, I have this fetish..."
He says he has always wanted to eat another human being, and figures this is his only chance to do it legally. He's actually done the research, and there are no laws that say you can't eat your kid's placenta.
"Like, Hannibal Lecter-style?" Dayshift Nurse asks, half bemused, half bewildered.
"No, I don't want to hurt anyone..." replies FOB.
She really wasn't kidding.
So, I went about the patient's care and delivery - apparently patient and her family know about the placenta eating and are just as grossed out as the rest of us. But he persists, willing to buy a new pot so he can cook it because his wife doesn't want him using her pots to cook up a placenta omelet. Or lasagna. He calls a friend after the baby is born "wanna eat some placenta?"
I suppose that a placenta is actually very nourishing tissue, being full of blood and vascular tissue. I'm sure there are nutritional benefits out there, and really, we eat chicken placenta, why not human placenta?
Because it's gross, that's why. Can you imagine forking off a mouthful of mushy lobe? Would the calcifications make it chewy? Would you save the cord for dessert or snack on it first for an appetizer? Would you dry it like jerky? Soy sauce? White wine, or red? Amnion soup? Salad with pecan-encrusted artery? Do you like your placenta broiled or fried?
Gross.
I dutifully packed up the placenta in its yellow-and-white pathology bucket and bagged it for him to take home. I got the impression he wasn't so sure about the whole thing, after seeing and smelling it, but he took it home, despite loud protests from his wife.
I have no idea whether or not he actually ate it, but I hope he did, and I hope it tasted like chicken.

TMI

My poor, darling husband.
He is a wonderful man, we'll call him Perfect Husband, and a really good Family M.D. Other nurses who take care of his patients go out of their way to tell me how wonderful he is. How caring of his patients, how respectful and kind to the nurses and how pleasant he always is. (And how disappointed they all are when they learn he's married... He's a hottie!) When I worked in the local carcass dump (read: medical floor), I took care of his patients occasionally, and was frequently curbsided by other RNs to decipher his hurried handwriting. When we shared patients, they sang his praises to the heavens. They stop us in the grocery store to tell me how much they love him. I think he's great, and it's really nice to hear other people think so, too.
So, when I went into nursing, and was thinking about my life and my career and my future plans, I decided I didn't want to talk about medicine all day, and so didn't want another medical professional as my partner. I met Perfect Husband outside of work, and it took me months to figure out he was a medical professional. You see, he's an excellent chameleon and takes care to leave work at work. He's an M.D. from 8am-6pm Monday-Friday and that's it. So I made an exception because he's a catch I just couldn't throw back.
I know a lot of docs and nurses that embody their profession in all that they do, carrying that identity throughout their life. That's fine, I'm guilty of it and not rendering criticism, but I admire terribly his ability to turn the M.D. off, and turn on the hippie, artistic, creative car mechanic/circus artist. Anyone who meets him outside work and then learns his day job says something to the effect of "I never would have guessed..." that the greasy t-shirt, longish hair, humble smile and quiet-and-shy exterior contained a highly trained, highly respected professional.
And then the questioning ensues.
Every M.D., R.N., R.T., C.N.A., or anyone else with any remotely medically-related letters after their name has been cornered at one point or twenty by a friend, family member, or recent acquaintance and presented with Too Much Information, in the hopes that said healthcare worker will shed some light in their darkness. I really don't mind it, personally, but Perfect Husband spends his days listening to madness and maladies galore. He cares for the poor and uninsured; those who place many things above preventive care in their hierarchy of needs, and so are usually highly complex when they finally reach him. It's really difficult work, much harder than mine, and I'd say I don't know how he does it, but I do: he goes out of his way to retain some ounce of passion for his work by fully removing himself from it at any opportunity. He tries not to be an M.D. from 6:01pm to 7:59am so that from 8-6 he won't feel quite so much like quitting his job to be a surf bum in the Bahamas.
So when a slightly inebriated woman we met 10 minutes ago hears he's a doc and starts giving him a painfully detailed family history, he all but vomits on the spot. He's such a kind, gentle soul, though, that he smiles and tries to keep from squirming while she rails on about her sister's breast cancer and how she died and was brought back to life three times in the ER... He politely listens, rather than saying "Hey, how about the weather, huh? And by that I mean: Look, Cuckoloma Extraordinaire, I'm off the clock, ok? Do you see a stethoscope or a white coat in sight? No. Yes I am a doctor, but everyone else I give medical advice to has to pay for it, and so should you. I'd be happy to see you in the office."
I'm sure he wasn't thinking that, sweet man. He just turned to me sometime later and whispered "I'm getting asked Questions. Can we go home soon?"
Perfect Husband, I am sorry you were uncomfortable, but you're just so darned cute and personable...

Benzo Salvation.

I spent the better part of 6 hours last night with a friend who took too much. She had been told: "Here, take this, it's old and probably not so good anymore, so you'll have to take a couple..."

Half an hour later, she was curled up in her car, headed for the worst trip of her life.

Pupils the size of dinner plates, tachypneic, anxious, having visual and auditory disturbances, and begging to go home, my poor friend took little comfort from her boyfriend who was "...not feeling anything."

I heard she was sick, and stepped in with my labor & delivery skills to help calm her. My experiential toolkit is stocked with coping strategies and support techniques for anxious, pain-full laboring women - this situation wasn't all that dissimilar.

She started complaining about muscle cramps, and as observed her contorted lips and hands, the possiblity of malignant hyperthermia or some serotonergic syndrome popped into my head. She didn't feel particularly hot, and wasn't overly tachycardic, but was only 45 minutes into this ride, and who knew how long, or how deep this rabbit hole went. I talked her through some slower breathing, helping ground herself, focusing on not adding to the anxiety. It helped for a little while.

Two other medical professionals assessed her, one experienced in primary care, one in operating room protocol. I suggested a benzodiazepine that I had at home. That we should offer her an oral sedative, take her home and watch her closely until one drug or the other wore off. One agreed with me, the other thought she looked cyanotic, needed 100% O2 and an ER bed.

Here lies my dilemma.

Do I continue to support her, decrease stimuli, attend to her basic needs, assess her ABC's frequently, and keep feeling for rising temperature, or any other signs she might be decompensating? Do I take this responsibility for her healthcare, knowingly blur the lines between friend and nurse and give her an oral sedative? What about injectable? Can I rely on my experience and my 5 senses to tell me when something is wrong and she needs more help than I can give her?

Or do I withhold my skills as a nurse, protect myself, and deliver her to the ER, where she will be in a bright, loud, scary place; get an IV and a slot in the locked Psych room for the next 8 hours while she wrestles with a universe of demons. Would she be even further traumatized by that experience? What defines a safe place? A place where your vital signs can be monitored, or a place where your friend can help you fight your way back to reality.

Could I recognize the signs of MH, stroke, or cardiac arrest fast enough to save her from permanent damage?

Did my own experience with the very same drug color my assessment of the danger she might be in? (Neither of the other two professionals had had any experience with this particular recreational pharmaceutical)

In the absence of clear threats to her health, would an ER trip be a threat to her mental health in the long run?

When I worked in the ER, we did not sedate people on bad trips - the rationale being some possibility of adverse interaction between the recreational drug and the sedative, causing more harm than good. People on bad trips are very unhappy, but as long as they do not present a threat to themselves and the people around them, let 'em be uncomfortable.

I couldn't do that to my friend. I knew that if I stayed by her side, I could minimize her fear and anxiety. I could assess her constantly and recognize danger that was beyond my capability to manage. I could safely give her a medication to help calm her and trust that it would overtake the beast inside her and give her some peace. Lastly (least importantly, but still deserving of consideration) I could save this artist/student from the ER bills that could quickly mount into the thousands of dollars.

And so I did.

My partner in crime and healthcare professional extraordinaire helped me to give her sips of water, hold her hands from thrashing, keep a blanket under her head when she fell to the floor screaming. She became an animal, totally disconnected from reality, floridly psychotic.

But she was breathing. She was not hot, alarmingly tachycardic, or developing any focal deficits. The muscle spasms went away, and after a second dose of said benzodiazepine, she finally fell asleep.

She is well this morning. Still suffering the bruises of her thrashing, and echoes of visions still dance in her head, but my friend has returned; the beast within her gone.

Was I right? Was I wrong? What more could I have done? How do you draw the line between your job and your life? In your own conscience, which is the ethical decision - sterile Professional overkill where her health is more guaranteed, or the love of friends who watch over her with professional eyes? The outcome was good, but would it be next time? What if it had been different?

What if I had been wrong?