George and Martha
Night time briskness slapped me in the face as I climbed in to my car for the familiar trek to work. It was my third scheduled night shift but only the first I had felt half way healthy enough to attend. I had called ahead to prepare myself for the pace of the unit, and was already exhausted at the prospect of a wild night. The evening nurse had sounded breathless and added that she had not yet had one free moment to eat or go to the bathroom.
"That's just wonderful," I mused, as I negotiated the ten miles of rural darkness to the hospital. Busy nights on the maternity unit were not always the happy, baby rocking times that the general public and most other nurses believed. They could be brutal and exhausting. Sometimes they could even be tragic and an inner voice nagged I should probably expect nothing less. As I drove into the parking lot past several ambulances in the emergency bay, I steadied myself for whatever chaos loomed ahead, keeping in mind that however short staffed the evening shift was, our shift would be even more compromised. Such is the stuff of the night shift.
It took a concerted effort simply to walk up the hill and into the hospital. It hadn't escaped my notice that the Emergency room was packed or that there was a blazing harvest moon; two sure hints that my night was going to be crazy. I chuckled at the thought that scientists had actually funded a study to determine that there was no truth to the notion that a full moon impacted upon patient behavior or events. Obviously they weren't out in the trenches with us.
My husband had provided me with some soup so I wouldn't be hungry overnight. I just couldn't to tell him that if by some miracle I was able to arrive at a point that eating became likely, simply eyeballing the mixture sent my poor tummy into a tailspin. I attempted in vain to ignore the aroma.
I wasn't surprised upon arrival. Full moons generally don't lie. At least one night nurse had been called in early to help the evening staff, and looked as though she had put in a full shift. She seemed so pooped that I wondered how she would get through the remainder of the night. Not five minutes into report I was informed that because three night nurses had called in the night before, two evening nurses had been mandated to stay, and were not there for the current shift. All eyes were focused directly on me. I was still ill enough that I didn't care, but didn't tell them that. Nurses are expected to be invincible and available whatever their condition. I apologized on behalf of everyone.
Perusing the patient board, it became readily apparent that it was not going to be the quiet night I had hoped for. Several people were in labor and there were patients in pre term labor as well. I prayed no one would have to be transferred to a specialty facility because there were no nurses to be spared for the ride.
Another nurse took me aside and whispered she had a patient she thought I should take. Apparently my "emotional support" skills were legendary and definitely required in this case, which was an eighteen week fetal demise. The alternative was a drug seeking, needy, fresh c/section patient currently lobbying the staff to take her outside for a smoke. For the first time in quite awhile I wished for a labor to immerse myself.
That said, I informed the charge nurse I would do whatever she wanted. The expression of relief in her fatigued eyes made me glad I had given her the option. I took a deep breath, said a quick prayer, and prepared for battle.
Dragging myself out of the chair, I prepared to meet the unfortunate couple, who were in shock. They had gone to their regular office visit and discovered that there was no heart beat. There had been some spotting previous to their visit but the patient hadn't thought much about it because it was sporifice and had occurred with each of her other two pregnancies.
She didn't want to talk. That was ok by me. She had recently been medicated for the pain. Her husband was snoring on the couch and I noticed both she and I were annoyed by that.
I introduced myself and informed her I was to be her nurse for the night. She grunted something in reply and faced away from me. Her evening nurse had mentioned that this couple didn't want to deal with the staff. They were in a room at the end of the hall to minimize interaction with babies, but we could both hear the cries of the infant in the room next door, and she gave me a penetrating stare that signaled I close the door and get out. I did.
Ten minutes later I spied the husband walk down the hall to the kitchen. A tall grizzly bear type, he breezed past me as though I didn't exist. I was not surprised or offended and quietly introduced myself adding that while I had every intention of respecting their privacy I would be looking in on them from time to time. He nodded, shook my hand and wordlessly, turned back toward their room.
The room light went on signaling a need for my presence. She wanted something else for pain because her cramps were becoming intense. I immediately called the doctor, an old fashioned elderly practitioner who just could not understand why I would bother him barely two hours after her last dose. He refused my suggestion of an epidural and was not impressed with my opinion that the patient should receive more pain medication. Even my argument that people in labor expecting a healthy baby generally receive multiple doses of analgesia at frequent intervals didn't faze him. Eventually he allowed me to offer the patient a sedative but emphatically insisted that she not be given more pain medication until four hours had elapsed from the first dose. No amount of cajoling would sway him, and I did not want to antagonize the doctor in the event I needed him later on. It was my belief that since we were not protecting a live baby and losing her child was already mind numbing, we should medicate the poor woman to the hilt. Every night I realize a moment when I become a patient advocate. This was it.
She wasn't happy with me. Anger blazed across her tear stained face. I told her it was perfectly acceptable to unleash her anger on me. I even encouraged it. Her features softened and she eyed me silently. I promised to bring the pain medication the moment it was due, giving her the option of accepting a heated body massage. I added in the event she chose the massage, I would not expect her to talk to me. To my great surprise and relief, she consented.
Ten minutes into the back massage her first words were directed to me in a t, vulnerable voice. "I just don't want to leave without a baby." Then, "this is the most horrible thing that could ever happen to anyone and I just never imagined it would happen to us." She continued to alternately talk and cry as I wordlessly massaged her back, legs, feet and hands. As she relaxed her wall came down and the tears flowed. Mine joined them. I could tell her husband was no longer sleeping, so made a point to mention that often husbands feel left out or helpless since they can't fix things. Sometimes it can seem that they don't care when I reality they care quite a bit. I noticed that he came over and sat by his wife's bedside as she cried. I finished the massage and encouraged them both to rest, noting that they embraced and there were shared tears between them. I promised I would be close by and readily available, taking time to make sure that the call light was within reach.
Two am was the appointed time for pain medication and I gave it as promised. Not ten minutes later she rang for more and it crushed me not to be able to accommodate her. I sat with her while she cried, screamed and swore. I said nothing but stroked her cheek as she let out some of the pain we couldn't touch with any medicine, all the while thanking God for my four children.
She reached out and grabbed my hand as her poor husband sat helplessly by, pale and silently suffering. I reached over and grasped his hand with mine and with a silent glance that spoke louder than any words I might have said, he acknowledged his gratitude. We three sat there for some time like that, as one.
The older doctor had forbidden the patient to get out of bed and wanted her to use a bedpan. Something about dislodging the medication he had administered to promote cervical dilation and the eventual expulsion of the dead fetus. This was another tidbit left over from the dark ages I would have to figure out how to discuss with him.
When the patient begged to get up to use the bathroom, I told her I certainly wouldn't refuse but stayed close by due to my suspicion that delivery was imminent. I had been told she was five centimeters with bulging membranes just moments before she had received her pain medication. The fetus was small and it would not require much room to be passed. I asked if she felt lady partsl pressure and she angrily yelled that she wasn't sure. She refused to allow me to check her underwear. I think I knew what might happen so parked myself just outside the bathroom door.
"OH MY GOD!"OH MY GOD!" "OH MY GOD!" I heard not three minutes later. I helped her to bed and summoned the troops. I needn't have since, having heard her screams, they quickly assembled.
My heart sank as I peered into the toilet because I knew what I would find; what I would have to retrieve. Suddenly the soup that made my stomach jump seemed totally benign. I inhaled slowly and reached in to gently bring the baby back home, all the while trying to put the heart wrenching wails of grief coming from the bed, out of my mind.
The fetus was intact, enclosed in the amniotic sac with an intact placenta. He was perfectly formed and seemingly suspended in space within the sac. I wrapped the fetus in a towel, and called the doctor to tell him we had a delivery. He didn't want me to rupture membranes so I motioned him aside and told him as a mom I would want to hold my baby and looking at him through amniotic fluid would not be the way I would want to remember things. Crusty, old fashioned with a reputation for eating nurses for lunch, he softened and asked simply that I note the fetus was intact and I was the one to break the water. He walked down the hall a few feet, turned and gestured that I approach. "You are a good nurse and this lady is lucky to have you." Momentarily floored, I no longer felt poorly.
She didn't want to see the baby at first so I quietly suggested she hold him while I stood behind the curtain close by in case she couldn't do it. After several minutes she agreed and as all moms will do, unfolded the blanket and checked to see if he had all his fingers and toes. Behind the drape, my tears flowed as she said to her husband, "look at his long fingers" I wondered if she would take my suggestion that he be named but she refused.
As I was preparing to leave that morning she was already dressed. I gave her a memory box with the tiny footprints I had taken, along with a poem I had composed just for her. Silently she undid the ribbon and more tears flowed between us. No words were needed. She reached up and gave me a long hug. "Thank you for being my nurse." In all the years I have been in nursing these are the words that keep me going back.
I learned early on that palliative care is really all one can do in tragic times, and often it surpasses the importance that clinical intervention provides. Really, it is a marriage of the two that provides optimal support for the patient. In the case of a fetal demise a good OB nurse will learn that while the bond between him or her and a patient is understandably strong, the patient customarily wants to get as far away from the situation as is humanly possible. One of the reminders of her loss is the nurse who cared for her. An OB nurse has to come to understand and not take it personally if the patient does not want her to attend subsequent labors. Taking cues from the patient and family will always lead the nurse into providing the best of physical, psychological and emotional care. I learned a lesson from a patient early in my career who said simply, "you can't save everyone." Well, at least I can try.
My patient walked by the desk and stood there without speaking until I noticed, and looked up.
"George Alexander," she whispered with a hint of a smile, "after my father."
"That will be his name." "Do you think they will find each other in Heaven?"
"It's a strong name," I countered, meeting her sad green eyes. "I am absolutely certain they are together." I asked her to wait while I made a card with his name, and watched as she placed it in the memory box, along with some pictures I had taken of George.
She was gone before my final paperwork was done. Next week I may not even remember her name. Next year I hope if she remembers me it will be because she is back in labor on or near her due date listening to a healthy heart rate on the monitor. If I am lucky, she will request me for her nurse but I will fully understand if she does not.
Until then, she now has an angel in Heaven and however sad I am, I am also grateful and graced that I was appointed to share this experience with them. As I exit the unit, I have to smile as I note that "George" and "Martha" will be irrevocably entwined, always.
Written by: Martha, R.N.
