Thursday, July 2, 2015

Traits of a Great Nurse: One Patient's Perspective

This post is dedicated to all the nurses at UWMC Labor and Delivery, especially Mary M, Lori, Ann, Anna, Tammy, Jane, Karen, Lila, Christine, Bekah, Nadine, Sharon, and Laurie.


One good way to understand what makes an effective and empathetic nurse is to rely on their care for multiple days. Without intending to conduct such a study, I recently had an opportunity to do just that. Due to a sudden onset of severe preeclampsia with HELLP syndrome, I was rushed to the University of Washington Medical Center's Labor and Delivery six and a half weeks before my due date. Thanks to the excellent care I received, my son was born safe and sound on Saturday, June 6 at 8:58am.

I am so thankful to each nurse that I met before, during and after delivery (one for day shift and one for night shift with few repeats). I was so impressed with their consistent positivity, skill and good humor that I kept a list of traits to remember. Becoming a mother has already made me more attentive to being the best version of myself possible, starting with the example of my caregivers.

In case you were curious, here's my take on what makes a great nurse.

Bedside Manner

As the days spent in the hospital before delivery added up, I felt increasingly like a helpless and possibly crazy person. The drugs I was given messed with my head, I couldn’t get to the bathroom without help and I needed food and water brought to me in bed. It was uncomfortable to be so needy. But I was treated with nothing but respect and dignity.

All my nurses acted as if it was normal to suddenly require help to use the toilet, not shower for days and have no control over my surroundings or my appearance. Their calm and collected demeanor normalized the whole situation for me. That was comforting. Those that related to me as if everything was in order (bantering, cracking jokes, laughing along with my interactions with Hubbins) were my favorites. It didn't seem impossible to imagine being friends in another context.


All my nurses were down to earth and very easy to talk to. None of them made me feel like an imposition. As far as I knew, I was the only patient in the entire hospital: every shift change, I was the primary focus. It helped me to understand what was going on when I overheard each nurse give their replacement a synopsis of the last 12 hours of my care.

By day two, I was overwhelmed by so many new faces (especially when shift assignments changed mid-day). A new nurse meant another personality to learn and communication style to adapt to. But as time went on I got to know so many fun women. It became a source of entertainment to meet the next nurse! I don't know if their confidence and joie de vivre came as easily as they made it seem, but both were effective methods for putting me at ease.


The nurses who tidied my room throughout their shift made me feel the most cared-for. They took unnecessary items out of the room (empty food containers, used linens, medical equipment that was no longer needed) and cleaned all surfaces of clutter. Then they focused on what I needed without distraction. 

“Can I bring your another cold pack?” Yes, please! 

“Refill your ice water?” Yes, please! 

“Do you need another pillow?” Yes, please!

There are several nurses in my life. I don't know why I didn't make this connection before, between close control of environment and professional necessity. Of COURSE nurses like clean work spaces and carefully monitored surroundings - they are assigned  new patients and rooms constantly, they perform medical procedures that require cleanliness, they are continually picking up where someone else left off and leaving something behind for another nurse (a patient, a room, or a report). I get it now. While extraneous fussing and fidgeting got on my nerves in the past, I can now see those behaviors in a brand new light: occupational efficiency. 

I have a whole new respect and admiration for nurses everywhere. Keep up the good work.

Birth Story: Part III

June 3 - 5
The next three days all run together in my memory. I remember nurses coming and going, ordering meals from Food Services when I wasn't hungry, throwing up all over myself in bed at least once, and calling for nurse's help every time I had to maneuver from bed to bathroom while pushing my IV bag on wheels. In the toilet, the nurses put a hat-shaped container to collect my pee and measure my output. They were keeping track of the fluids I was drinking and peeing. And there was lots of both. Magnesium made me feel hot - like I'd been in the sun too long and was nursing a bad sunburn. I chugged ice water and asked for new ice packs whenever the nurses checked on me. I knew hydration was important, but I was mostly concerned about my dry mouth and internal temperature.

My own personal heatwave

"Do you want apple juice, cranberry juice or Sprite?"
Since there wasn't a rush (yet) to deliver, I was given several methods to induce labor - the idea being that if my body could be coaxed into early labor, we could avoid a cesarean section and get baby away from that crappy placenta sooner rather than later. Here's what I remember about each (not for the squeamish. Feel free to skip this post, Dad).

Misoprostol - the doctors explained I would be given six doses orally every couple of hours, with the intention of getting my cervix to cooperate (words like "dilate, ripen, efface, thin" were all used to describe the desired outcome for my lady parts). The seventh dose was inserted vaginally (the doctor and nurse laughed because the same pill I had been swallowing was simply put into a suppository-shaped capsule. I failed to see the humor).

Cook's Catheter - this was, by far, the most uncomfortable part of the whole experience. The doctors, again, patiently explained the purpose: by inserting small balloons into both my cervix and vagina and inflating them with fluid, the added pressure would create space for baby to lower - in effect, forcing further dilation. I understood the concept, but couldn't picture how this was going to work.

To get my feet up into stirrups, the resident doctor (who looked like she was in her twenties), trainees (in their late teens? Sheesh!) and nurse walked me into a triage room. Hubbins opted to stay behind in the hospital room (for which I am eternally grateful). Had he been in the room, I would have tapped out simply from embarrassment.

The procedure couldn't have taken more than 10 or 15 minutes, but seemed like a torturous lifetime. Knowing it was necessary for the safe delivery of my baby was the only reason I didn't completely wimp out (or melt down in tears). I felt like a needle being threaded. I think it was the first moment I realized what it would take to be a mother: sacrifice I couldn't fathom until it was absolutely necessary. I closed my eyes and gripped my nurse's hand. She commiserated, "I think cervical pressure is the worst discomfort there is." My summary would have included more expletives than that.

When I was sure I couldn't bear another second, I squeaked (in a voice I didn't recognize as my own), "Any progress down there?"

The doctor chuckled sympathetically and said, "Just about done." Thank goodness. She patiently elaborated, "We're working in a curved environment with straight tools." No kidding. She added that my cervix was being "elusive." Add that to the list: Adjectives I hope I never hear used to describe my privates again.

In an attempt to lighten the mood, I said, "Hey, after this my next pap smear will be a breeze!" It was a forced attempt at solidarity. Graciously, my fellow women laughed. As they removed their surgical gloves and left the room, I heard myself say, "Thank you." Touche, Mom. You taught me well. My gratitude wasn't for the harrowing experience, but knowing their efforts were for my benefit and the benefit of my baby.

Pitocen - compared to the catheter, pitocen is hardly worth mentioning. It was added to my growing collection of IV medications and pumped in without me even feeling it. I thought of childbirth class and our discussion on voluntary induction, which is now discouraged in most cases. I was a far cry from laboring at home and waiting until six centimeters dilation before waltzing into Labor and Delivery. By contrast, the whole scene resembled an episode of Star Trek more than natural childbirth.

When a cyborg goes into labor does she get an epidural?
Epidural - Thankfully, I never had my heart set on a drug-free delivery. After three days on magnesium, I knew for sure I wouldn't have the strength to labor au naturale. When the resident anesthesiologist (who looked like Ethan Hawke, only younger and more handsome) visited for the second time to introduce himself and check in with me, I told him Yes, Please.

So, Friday afternoon, he and the MD got me hooked up. This was another procedure that, in real life experience, didn't match up with the textbook description. My childbirth book didn't tell me I would have to sit still and simultaneously arch my back to create space between vertebrae for the local anesthetic injection. It didn't describe the feeling, like an electric shock down one leg or the other, that could easily be felt during the placement of the small catheter in my lower back. It didn't warn me I might bleed, nor of the unnerving sensation of a warm trickle of my own blood down my tail bone.

I sat cross-legged on my hospital bed while the resident and MD anesthesiologists did their thing (thankfully, completely out of my view). Hubbins sat in a chair front of me, beside the bed, and held my hands (actually, he let me hold his hands with all my strength, as if my full body weight was hanging from his grip). I closed my eyes so I couldn't see his reaction as he watched the doctors work over my shoulder. I knew it would distract me to try to interpret what he was observing and the instructions I was hearing between teacher and student. They asked me multiple times how I was doing. I said, "Good" but what I wanted to say was, "This sucks. Are you done yet?"

As they finished, the MD asked, "Are you nervous?" I answered honestly that yes, I was. He quipped, "Don't be nervous, you've got all of us here to help you! You should be nervous about your son turning 16 and getting a drivers' license. 'Cause we won't be there to help you then!" At the time, this attempt at levity was appreciated and seemed appropriate. In retrospect, he's lucky I only responded with a courtesy laugh.

Once everything was in place, I lay back down in my hospital bed. The Ethan-Hawke-Look-Alike handed me a small wand with a single button. "Push this if you feel pain," he said. "It will automatically dispense the analgesic through the epidural." My hero.

When I pushed the button a few hours later, I heard the whirring of machinery behind me. The drugs were locked safely inside a small pain-relief vending machine. I felt a chill down my spine as the dose was released into my back.

Part medical equipment, part Autobot
Because I would lose all feeling in the lower half of my body thanks to the epidural, the nurses also inserted a regular Foley catheter, so I wouldn't have to get up to use the bathroom anymore. That evening, feeling particularly uncomfortable and unable to find a good position to lay in, I realized I was literally tethered to my bed (or at least to all my equipment):
  1. Epidural (line in my back)
  2. Cook's Catheter (connected to nothing, but I was supposed to tug on it periodically to keep the pressure building) 
  3. Foley catheter (pee bag)
  4. Heart rate monitors on my belly to keep tabs on baby
  5. Pulse oximeter on my toe
  6. IV with four bags: magnesium, Lactated Ringer's Solution (regular fluids), pitocin, and penicillin (since I tested positive for Group B strep - common in healthy women but risky for baby) 
On top of all that: tangled up in my hospital gown
Friday morning I was feeling contractions (hence the epidural). By the afternoon I was dilated to 4 centimeters, but baby still wasn't low enough and my cervix wasn't cooperating. An ultrasound technician wheeled her equipment into the room and checked on baby: still tolerating his environment. The nurses adjusted and re-adjusted the sensors on my belly. I asked them to turn the volume down - the racehorse sound of his heartbeat was reassuring, but the scratchy sound quality and highly sensitive mics drove me nuts.

No one had mentioned a C section yet; the waiting continued.

Wednesday, July 1, 2015

Birth Story: Part II

June 2, cont'd
A nurse from the local hospital rode with me in the ambulance to Seattle (bonus: I'd met her before! She is the mother-in-law of a good friend from work - I was so grateful for a familiar face). The driver and assistant were at least a decade younger than me (not the last time I would be startled by the age difference between me and my care givers), both very professional and efficient.

It was a new view of I-5: belted to a collapsible gurney at my ankles, knees and waist and tucked under a couple of lightweight blankets, I faced the rear of the ambulance and saw the familiar route south but in reverse. I wondered if the cars driving behind us could see me inside (if I was a civilian driver, I would be super curious to peer into the lit interior of an ambulance). I thought of my 2 1/2 year old nephew and texted my sister: Clive is going to be so jealous!

We made really good time to the University of Washington Medical Center (kudos to my driver). I was wheeled into Labor and Delivery a little after 9:00 pm. Hubbins was waiting for me at the nurses' station. I could tell he was in "act now, feel later" survival mode because he was joking with the nurses: "Oh here she is! Jeez, what took you guys so long?!" What a relief to see him. I wouldn't know how to direct him to find me if he wasn't there already.

In my hospital room, I got up from the ambulance gurney and into the hospital's bed (a little wobbly on my feet with a couple hours' worth of magnesium in my system plus the bumpy ambulance ride, but I was still mobile). The resident doctor came in to introduce herself (about my age, I'm guessing) and review the facts. "The thing with preeclampsia is that basically you've got a crappy placenta," she explained. She said that because both baby and I were stable, they would monitor us overnight and see if they could keep him in me for as long as possible. She ordered a blood sample around midnight and the lab staff continued to draw blood every six hours for the next four days.

Between the multiple pin pricks, taped cotton over the draw sites, and the constricting blood pressure cuff in the same vicinity, my arm bruised quite impressively. Eventually, I asked the phlebotomists to not use tape and just let me hold the cotton until the bleeding stopped. Still, by the end of the week my right arm looked like an impressionist painter's color palette.


That night, I didn't sleep well at all. Poor Hubbins was on a little bench-bed at my side, probably more uncomfortable than I was. The Magnesium made my mind race, like I was trying to accomplish a long list of things to do but couldn't remember any specific item from the list. My imagination ran wild - my thoughts all had a visual aid to go with them, but they were fleeting and I couldn't keep track of whatever my mind was listing. I got a stiff neck from my position on the hospital bed and dreamt that the light-fixture grid in the ceiling above me was actually my pillow. I felt like my head was inside a gerbil ball: my thinking was foggy and slow. When nurses and doctors talked to me, I tried my darndest to make eye contact, but couldn't focus. Everyone looked like they had four eyes.

The only way I could get any sleep was to specifically visualize a peaceful location or interaction. I thought of my mom. I didn't realize it until later, but I was following her example as a patient: keep in good spirits, give everyone the benefit of the doubt, be grateful (remember first names and say "thank you"), be empathetic to others. Mom lived in a nursing facility for two years. I had lots of material to draw on when I thought of her and the nurses who took care of her in the final stages of Alzheimer's. I wished she was with me then.