Friday, October 7, 2011

Thirteenth Chapter


Thirteenth Chapter
Nancy
A widow’s progress is traced and she endures a blamestorm
   It has been seven months now since Nancy lost her husband Steve, a policeman, to a tragic accident. There have been many adjustments, some more successful than others. She still sleeps on her side of the bed, often waking in response to the empty space next to her. She still keeps Steve’s pajamas under the pillow on his side of the bed, his scent now only very faint on them, but she can’t bring herself to remove them. Her loss was at first a numbing blow, which soon became a burning of the soul. With time it has scarred a bit and become an ache that waxes and wanes, but is always present. There are things Nancy can expect to trigger the pain, and she tends to avoid these whenever possible. But there are also the unexpected, surprising things that bring on the ache.
   This night Nancy is on call, she is sleeping in the on-call room at the hospital, her children staying with her sister.  Not many hospitals have on-call rooms for nurses, but University Hospital does. Being located in center city, most of the nurses live in the suburbs, and could not be to the hospital in the required response time. On-call rooms for nurses, residents and doctors are located on a former patient care floor of the old building. The rooms are still in unrenovated nineteen fifties décor, somewhat on the worn and shabby side but clean and comfortable. The nurse’s room features a television, microwave and lazy-boy recliner donated by the nurses, as well as a standard hospital bed and bedside table. There is also a bookshelf stocked with magazines and dog eared paperback books. The phone on the bedside table rings in chorus with the on-call pager going off. Nancy answers the phone, hears the brief message and heads out of the on-call room for the OR, already attired in surgical scrubs which also function as PJs. The case at hand is an emergency Caesarian Section, in this instance the result of a placenta prematurely detaching from the uterus, a condition called placenta previa, which would result in loss of blood supply to the baby. As emergency C-sections go, they do not get any more urgent than this.
   Arriving in the OR, Nancy finds that Debs has already set up the room, with all the sterile packages and cases ready to open. “You go and scrub, I’ll open up” Nancy tells Debs. Nancy begins opening all the packages in that careful, deliberate manner that creates the sterile fields, and exposes all the instruments so that Debs can unpack and prepare the items that will be needed, laying them out in order of use. Debs reenters the OR from the scrub sinks, arms dripping, but held with the hands up so that water will not run down from the upper arms carrying bacteria to the hands. Debs reaches and picks up a sterile towel from the gown pack set on a small stand apart from all the other sterile fields so that if she slips or drops something, nothing but the gown pack will be contaminated. After drying her hands, the forearms, still keeping her hands up, she drops the towel in the dirty linen bag, picks up the gown by what will be the inside, never touching what will be the outside, and puts her hands through the sleeves, but not through the cuffs. Keeping her hands inside the cuffs, Debs picks up a sterile glove by the cuff which has been folded down over half the glove, so that once again, she is touching only the inside of the glove. Deftly, she pulls it over her cuff enclosed hand, and then pushes her hand through the cuff into the glove. Now she picks up the other glove with her gloved hand, repeating the process so that she now hands both gloves on and the outside of the gown and gloves has not contacted her skin. Nancy fastens the gown at the neck, ties the ties that are inside the gown in back. Debs detaches another tie at her waist, handing the end with a cardboard card at the end to Nancy. When Nancy has the card in hand, Debs turns herself around, grasps the tie and pulls it free from the card, and ties the gown in front. The whole process has left Debs with her exterior surface completely untouched by anything unsterile. Debs completes the set up again maintaining a strict isolation of sterile items from the unsterile. Completing the set up, Debs looks around and sees that she has time for one last special thing she likes to do for C-sections. She unfolds one of the square multi layered gauze sponges called a 4x4 for its size (4 inches by 4 inches) until it is a square 12 inches on a side, and just a single layer thick. She then pokes the snout of a rubber bulb syringe through the center, and gathers the corners at the rear of the bulb, tying them in a knot. The result is the bulb syringe with a non slip grip. When covered in blood, as it will surely be, the bulb syringe can become quite slippery. The bulb syringe is essential for removing blood and mucous from the baby’s nose and mouth, the first thing that will be done when it is free from the uterus.
   Nancy and Debs count their sponges, instruments and sharps. Just then Archie, the anesthesiologist, enters the OR pushing the gurney with the patient. With him is Dr. Bensalem, OB-Gyn surgeon, and Linda, a nurse from the Labor and Delivery (L&D) unit. Dr. Petersen, a pediatrician rounds out the team. The anesthesia for emergency C-sections is very tricky. In non emergent C-sections, a spinal anesthetic can be used, posing no risk to the baby. But putting a spinal into a pregnant woman is not easy, and it is time consuming. A general anesthetic is quick, especially using a rapid sequence induction, but you only have about two minutes before it begins to adversely affect the baby. In the situation of a placenta previa, there is no time for a spinal.
   Quickly, the gurney was pushed up against the OR table, the patient lifted over, the gurney removed. Nancy moved to the head of the table to assist Archie with the rapid sequence induction, while Linda exposed the patient’s abdomen and began to paint it with an iodine solution. Nancy held an oxygen mask to the patients face, explaining that it was just oxygen to get her blood level of oxygen as high as possible. Archie attached his drug syringes to the lines. Dr. Bensalem, who went by Bea, came in dripping from the scrub sink. Debs got Bea gowned and gloved. Linda set up the incubator that would receive the baby, and opened the pack of supplies for caring for the baby. Debs and Bea draped the patient’s abdomen, handed off the suction line and the cord for the Bovie, also called the electro cautery, and Linda plugged them in. Debs handed Bea a scalpel and sponges and picked up a Richardson retractor. Everybody looked to Archie, who asked if everyone was ready. Getting the affirmative, Nancy placed two fingers on the patient’s throat, feeling for the cricoid cartilage just below the Adams apple. She nodded to Archie who injected his drugs. Nancy pressed down on the cartilage with two fingers of one hand while picking up the ET tube with the other. Archie tilted the head back, placed the blade of his laryngoscope in the patient’s mouth, slid it down the throat, and raised his open hand, not taking his eyes away from the patient’s vocal cords, exposed by the laryngoscope. Nancy placed the ET tube in his hand, and Archie slid it into place. He gave a squeeze on the ventilator bag, and when Nancy saw the condensation form on the inside of the ET tube, she inflated the cuff of the tube. Archie called out GO! And Bea made her incision.
   There are two incisions used for C-sections, the Midline and the Pfanstiel. The Midline starts just below the umbilicus and goes downward. It has the advantage of being fast, as there is only the skin, subcutaneous fat, fascia and peritoneum to go through before you are in the abdominal cavity. It is also easier to close because there are fewer layers to sew.  Its disadvantage is its lesser strength, and the fact that most bodily movements put stress on the closed incision, pushing it apart. The Pfanstiel incision goes from side to side, across the bottom of the belly, and is sometimes called the bikini line incision as it will be concealed even by a small bikini. It is a more difficult incision because going out from the center line the fascia divides into anterior and posterior layers with a layer of muscle in-between. So there are more layers to deal with. Its advantages are its cosmetic value and the curious fact that it is a stronger incision as all the bodily movements cause it to push together. Bea goes for the midline incision. As she cuts with the scalpel, Debs sponges the bleeders and places the retractor to expose what Bea needs to see. When they reach the peritoneum, Bea makes a small nick with the scalpel, and then Debs places a pair of Metzenbaum scissors in her hand. Debs tents the peritoneum with a pair of forceps and Bea quickly cuts t from the center to the left where Debs has held the incision open with the retractor. As Bea gets to the end, Debs shifts the retractor to the right, and Bea cuts from the center to the right. The swollen and muscular Uterus is now exposed. Debs has the Balfour retractor in hand and Bea places it in the incision, each of them pulls on an end, extending the ratcheting mechanism so that the uterus is fully exposed. Bea must now peel the bladder off of the lower front side of the uterus to avoid damaging it while incising the uterus and removing the baby. And this is where it starts to go wrong.
   “Shit!” Bea exclaims “the bladder is still full! Is the Foley draining?” Linda speaks up: “Remember? You had the Foley removed….” “Get a Foley in her now!” Bea shouts. Nancy grabs the emergency flashlight from the desk, and a Foley kit. “Hurry!” Bea exclaims. Debs moves her sterile table away from the foot of the bed; Nancy lifts the sterile sheets up exposing the patient’s legs which she puts in a frog leg position. Diving under the drapes she puts the flashlight in her mouth, opens the Foley kit, grabs the catheter, and attaches a syringe of saline and plunges further under the drapes. “Get that Foley in, can’t you move any faster?” All she can see of the patient’s perineum is blood. Nancy grasps the sponges in the kit and she wipes furiously, seeking the small target of the patients urethra. Bea is pounding her fists together in a fury. “Can’t you insert a simple damn Foley? We’re going t6o loose this baby!” The patient’s genitals are swollen and distorted as well as blood covered, and Nancy struggles to find the urethra. “I am going to see you in hell if you don’t get that Foley in!” Nancy sees the small hole and stabs with the Foley. Urine starts to flow down the tube and Nancy inflates the balloon of the catheter. At the same moment Bea gasps as a tear forms in the bladder, and the field floods with urine. Debs suctions madly, clearing the field. Bea continues to peel the bladder away from the uterus. She is now too busy to talk. The bladder retracting blade of the Balfour is inserted, retracting the bladder. Nancy puts the legs straight and replaces the drapes as best she can.
  “Scalpel” Bea calls out, and Debs places it in her hand. She makes a small cut carefully in the uterus, working down until the baby’s head is seen. Debs gives her the Mayo scissors, heavier than the Metzenbaum. Bea cut from side to side and more of the baby’s head is exposed. Debs supports the uterus, as Bea works her fingers in and gets a grip around the baby’s head, pulling it out of the uterus in one smooth, fluid motion. Debs hands her the bulb syringe, and Bea clears the baby’s nose and mouth, she is rewarded with a feeble cry. The baby is a blue color instead of a healthy pink, a bad sign called cyanosis. While Bea has been doing this, Debs has placed two Kelly clamps on the umbilical cord and cut it with the scissors. Bea hands the baby off to Linda. Bea reaches into the uterus and scoops out the placenta, placing it in the basin Debs holds out. Debs starts handing Pennington clamps to Bea, which she places all along the edges of the incision in the uterus. This stops the copious flow of blood from the engorged womb. Debs suctions as Bea mops blood with sponges. When the field is clear, Debs puts a loaded needle holder and forceps in Beas hands, and Bea begins to sew the cut in the uterus. She uses a locking running suture, like a blanket stitch. Deb and Nancy start counting the sponges, sharps and instruments, the count needing to be checked before the uterus is closed to avoid leaving anything behind. Retained objects have occurred in controlled, calm situations, and in an emergency like this the risk is much higher. The count is short one 4x4 sponge.”Remember the bulb syringe!” Deb says. “That’s the one we are missing. Counts correct!” Nancy states loudly.



“How is the baby doing?” Bea asks. Linda replies “APGAR is 3”. The APGAR is a score based on heart rate, respiratory effort, muscle tone reflexes and color. 0, 1 or 2 points are assigned for each criterion, so 10 would be a perfect score. Three represents a severely depressed infant. Bea reaches the end of her line of suture, Debs hands her scissors, the suture is tied and cut, Debs gives her another loaded needle holder, and uses forceps to pick up the bladder, grasping either end of the tear so that the edges are brought together, and Bea begins to sew. “How is the APGAR now?” “Four” is the reply from Linda. Dr. Petersen has used a laryngoscope to suction out the baby’s airway and place an ET tube. Now he is working fast to place an IV catheter into the large vein in the baby’s umbilical cord. Bea refocuses on repairing the bladder. When the sure line is complete, Debs cuts the suture. Bea takes another loaded needle holder and Debakey forceps from Debs and begins closing the peritoneum. “How is the baby now?” asks Bea. “APGAR 5, everything is looking better” Dr. Petersen replies. He has given Sodium Bicarbonate to raise the baby’s blood pH; Narcan to reverse the effect of narcotics picked up from the general anesthesia, and started an IV solution of glucose and calcium glucconate. “It’s your fault that the bladder got torn. I will see that this is addressed by your superiors” Bea directs at Nancy. Bea is obviously very upset and angry. Nancy is now in the classic bad place for OR Nurses. If she says anything, she risks getting the surgeon more upset, and the patient may suffer as a result. Best to let Bea calm down. Usually the surgeons recover from these sorts of tantrums, and usually apologize after the dust settles.  Debs gives Nancy a look and rolls her eyes. Nancy begins to mentally compose what she will write in an incident report, something a nurse must complete whenever something does not go as it should, be it an equipment failure, an injury or near injury to a patient, or just about any break I technique or error.
   Nancy and Debs count all the sponges, sharps and instruments again, to be sure nothing is left behind in the abdomen. Again, Nancy announces loudly that all is correct.  Bea should verbally acknowledge the count, but she is still stewing, so Nancy decides not to make any comment. Bea finishes sewing the peritoneum, a sort of sack of tissue that encloses the abdominal contents. Debs place another loaded needle holder and some Russian, or as they are sometimes called, bear paw forceps in Beas hands. The bear paws are more suited for tough thick tissue like the fascia than the Debakeys which are for delicate tissues. Nancy prepares the dressing materials for the wound. When the line of interrupted sutures in the fascia is complete, Debs give Bea the skin stapler and Adson forceps. Nancy and Debs do a final count of the sponges sharps and instruments, and this time Bea does give a sign that she heard the counts correct announcement. Nancy opens all the dressing materials to the sterile back table.
   Linda and Dr. Petersen begin to wheel the incubator to the door, announcing that they are headed for the NICU (Newborn Intensive Care Unit), and exit the OR, pointedly not saying more. Nancy wishes that she could have gotten Linda aside to find out more about her comment “Remember, you had the Foley removed….”. She makes a note to herself to have a look at the L&D records. If Bea had ordered the Foley removed, the L&D nurse who removed it should have charted the order and removal of the catheter. It is also something that should have been reported to Nancy by Linda on arrival in the OR, as a report of all the salient facts about a patient’s condition is supposed to be given when care is transferred from one nursing unit to another. In practice, the OR nurses almost never get such a report, despite the fact that the nurses on the floors howl if they do not get such a report when patients are transferred to them from the OR. It is also standard protocol for C-section patients to have a Foley in place before they leave for the OR. Of course if Bea calms down there may be no problem, but if Bea goes to the supervisors it could get ugly, as when things go wrong the crap tends to flow downhill. Nancy resolves to be prepared and write a good description of the whole incident in the report.

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