Friday, January 28, 2011

We Do This To Ourselves

So with New Cathy gone, I have had a few days of working with SIC (Second in Command). She's not too bad to work with as long as we are busy. I have figured out that I am somehow threatening to her, or that my experience makes her feel inadequate. The sum total of her ER experience lies within our small 6 room facility. That doesn't make her a bad ER nurse, she is actually a very good nurse and I have never knowingly said or done anything to make her think that I felt she was incompetent, but people can be so weird. Having worked in larger, busier ER's where nurses have more autonomy and/or standing orders, (and flow rather depends on it) I sometimes chafe at waiting to get things started when I know that they are going to be required anyway. I appreciate that we all come from different backgrounds, so maybe she is finally getting comfortable enough to let her guard down instead of always being on the attack. Anyway, we were working with Bobo, who is still, apparently on his meds and willing to have a laugh or two.

Bobo had the misfortune of having to deliver (for the first time since his residency) a baby several months ago at our treat 'n transfer station and Taco stand. Luckily, he was working with Mikki who has some OB experience and the midwife showed up to "coach" over his shoulder. Mom and baby did fine, but Sherry and Bobo were shaken up since nothing strikes fear into the hearts of ER personnel like the sight of a gravid female in active labor. At Your Cervix, I know this is your thing so hats off to you.

You can maybe understand why the 39 week pregnant female who "just wanted a labor check" (we don't do this) was not an especially welcome patient, especially since she didn't want to have to drive to the Big House downtown. You should know that, especially anxiety provoking for us, she was Gravida 10, Para 7.*

And no ma'am, she didn't call her OB. WTF.

Some creaky, squeaky memory deep in my brain from about 40 years ago whispered that with that number of pregnancies and deliveries, she was the most fearsome and feared of all OB patients, the Grand Multip

She was having inconsistent contractions; or maybe they were Braxton Hicks. No rupture of membranes. No history of precipitous delivery. She just "didn't want to go all the way downtown to be told just go home, you're not in labor".

As if.

As she was using the toilet she remarked, "Gee, I almost feel like I have to push".

"No you don't!", I shot back. Saying it makes it true, right?

Finding a fetal heart rate is not my strongest skill set, but I managed. This was followed by quick check by Bobo who insisted on sending her downtown in an amb'lance even though she was only 2-3 cm.

I know, I know. Why?

L.I.A.B.I.L.I.T.Y. The bottom-most rung of the bottom line.

Rather irksome in an otherwise successful turf was the bored and superior-sounding L&D nurse to whom I gave report. She had no idea that we are in the sticks without so much as a baby warmer which is why the hot-potato treatment.

When I was younger and inexperienced, I might have been made to feel badly. Now, I just recognize this kind of behavior for what it is; the "Eat your young" mentality rears its ugly head. We all have our strengths and weaknesses, comfort levels, and skills; it is important to remember that. Different specialty and critical care areas require different knowledge and education. In the ER, we have lots of knowledge and a variety of skills; we know a little bit about some things and cover every age from cradle to grave. That doesn't make me an expert on everything, but it does give me enough knowledge to have a healthy respect for what is most dangerous, and, most importantly, what I don't know.

In fact, that is kind of the point, isn't it? Every patient we see in the ER, every patient we triage we think, "What is the worst case scenario here?". Then we go about ruling it out, right?

Chest pain: having a big MI, or costochondritis?

Shortness of breath: pneumonia, PE, or anxiety?

Rectal bleeding: a big GI bleed, or hemmorhoids?

Rash: poison ivy or necrotizing fasciits (flesh eating disease, so called)

This is why most people go to the ER in the first place, they think of the worst thing it could be(or have determined that they have it, thanks to the magic of the internet) and count on us to rule it out. We often don't have to hunt Zebra,** the patient has conveniently done it for us.
But it's nice when we can help minimize their fears and allay their anxiety.

We certainly would never tolerate anyone who made the patients feel stupid, no matter how trivial the complaint may seem at first glance. That is one reason why it is sometimes so difficult to calm people with non-urgent complaints who can't understand why they are being made to wait. We don't make them feel stupid. It would be really nice if the culture of nursing was such that we go out of our way to extend the same courtesy to our colleagues.

*10 pregnancies, 7 births. This would be her 8th child.
**Zebra hunt: "If you hear hoof beats think horses and not zebras". A rephrase of Occam's Razor: All other things being equal, the simplest answer is usually the best.