Thursday, January 15, 2009
I Hope This Doesn't Discourage You
"You could go another lifetime and not see something like this," said the anesthesiologist while he had one hand squeezing a bulb on the tubing hustling the packed red blood cells to my patient. I hope that I could go six or seven lifetimes and not see something like that.
My patient, baby's heart rate isn't recovering like it should, is taken to the OR for a "double set-up" (they'd try to assist the baby out old school and, failing that, section her) and things went further south and the patient is prepped quick, quick as a bunny. The docs cut into her uterus and a fountain of meconium (fetal poop = not a good thing) -filled fluid fountains up a foot into the air and splashes everywhere. Babe gets a 2 on baby's first test (Apgars: this is out of 10 points. Two= not a good thing.) Everyone slaps the ob on the back: good call, nice work and baby is intubated, but only briefly, and perks right up and gives a hearty cry and, phew.
And then it's time to close and I get the student-worthy job of counting and bagging the bloody gauze ("laps") (remember the Bag-It! I previously mentioned?). The last c-section we filled up maybe four or five Bag-Its, so even I, Student Nurse, started sensing trouble when I was running out of places to hang the bags. There were more and more bloody laps and a doctor came in, "I heard her INR is 3." (and for you lab value fans the d-dimer was over 10,000: what's your diagnosis?) And the c-section turns hysterectomy and there's more blood than you could think was possible. It's spilling out everywhere, there's bloody footprints from blood-soaked shoe coverings. Another doctor is added, more nurses appear. I heard that every stitch opened up a new place for blood to ooze from.
Half of all cases of DIC (disseminated intravascular coagulation) are pregnancy-related. What happens, see, is that via some problem (trauma, infection, auto-immune dysfuntion, etc.) a clotting cascade occurs and teeny clots establish throughout the body and the body is really cool and sends out stuff to break up the clots (d-dimer is a by-product of the break-up of clots) and, phew, there was so much clotting that occurred the body is not able to muster up all that it needs to clot anymore. And, well, you need those clots to stop bleeding and you introduce say, surgery, and you get what happened on my third night out as a preceptee: scared.
I couldn't sleep. I went home and looked up everything I could on DIC. Stupid Wikipedia (yeah, sorry, I did look at my med-surge book first, though) said that DIC is sometimes nicknamed Death Is Coming.
But, the next night I visited the pt in the ICU (so, let you get this straight: I'm precepting in L and D... I had no idea I'd be hanging out in the ICU). She's groggy, but looks pretty good. I hold her hand (I really wanted to hug her I was so glad to see her up and running or at least unbloodied and conscious) and she says to me, "I hope this doesn't discourage you from going in to nursing."
Not at all. It just reminded me that birth is an amazing thing and that you never know what can happen and I was going to say, "So be prepared." But I don't know if any nurse, student or not, could be prepared for what happened. Let's just hope I get at least another lifetime to find out.