RAMBLINGS OF A MIND UNTAMED

My tweets

whitewriter — Fri, 17 Jun 2022 02:00:13 GMT

Thu, 16:39: @Valentine702 What shortage? This is the supabarn at Tramsheds Forrest Lodge https://t.co/TsjIx5FJg7

Update

whitewriter — Mon, 24 Jan 2022 03:50:20 GMT

RIP Nexus Well my phone is officially dead. So I have no idea what is going on in the world outside home and work. It fell in the toilet in 2019 right after I had bleeched said toilet, and well now in 2022 it got harder and harder to charge- and yesterday, charged maybe until 20% and then in the morning just turned off.... forever. RIP Nexus 5. You did very well.

So Pete is going to buy a new phone for himself and I'll take his old one (I can't be trusted with new phones - the toilet thing was not the first time...)

Meanwhile I don't know what happened with Dea's IOL. I used my desktop to message a few people on fb - I didn't quite expect Dea to reply, she's probably busy, but the cousin I'm mutually close to uses whatsapp and no phone means no whatsapp which means, I don't know anything.

I had horrible pee again overnight due to what I think is dehydration. So at 340 am I sat up in the kitchen drinking at first 1 cup of water, and then 1 cup of cordial (I find it really hard to drink that much water) and then 1 of hydralyte before I thought I was hydrated enough - to go back to bed at 420am - and have some random sleep until 6:20. I don't have an alarm clock (phone's dead) so at 5am when Pete woke up I was alert enough to tell him to ensure I got up by 6:30 (cause, I still want to attend work -- Lord knows why because I really should have just phoned sick at 3:30am).

I was thinking at 3:40 am, how when women are dehydrated and how that effects the fetal heart rate on the CTG and how they get IVCs and 1 liter of hartmanns and how they all look stunned when we're all surprised that their heart rates are 120 ish. Mine wasn't that high but I was worried. Need to make more of an effort to drink water at work... with these darn masks.

But here I am. At work anyway. Playing hooky (at the bedside of GCS4 SAH grade 5- the not homeless lady).

So what sucks about working is trying to antenatally express is impossible on 12 hr shifts, let alone with sleep deficits.

Today's patient
Was at home, had stomach pain and hypotension on a background of HCC microwave abalation, came to hospital, they did a CT scan, saw a possible cause for the abdominal pain was ischemic bowel. Somehow convinced her to have a laparotomy - opened her up, found nothing, closed her back up, in shock sent her back to ICU where she needed 4 days of ventilation and 1 day of CRRT for an AKI, and 8 days later now she's trying to get up and leave the hospital. Admittedly on the non slip socks the most she can get is to the edge of the bed where she stands up (me trying to explain that I can't let her go/why/and what other options she has) and then sits (almost slides) back down onto the bed.

Every 15 mins she seems to forget what I've said, or decides to ignore it (hard to tell since she thinks she's in a "tower" or a set of townhouses) until after an hour of this back and forth the doctor comes, (male) tells her she can't go home because he makes the decisions about that (he's a registrar so not really but anyways) and it works enough to get her to put herself back to bed. She (like everyone else) hates being manhandled so 20 mins of some bullshit standing up and sitting down and what ever she finally uses the arm rest of the chair that we put next to the bed that she refused to sit in, to shuffle herself halfway up the bed before giving up and letting us use the sheet to OH&S unfriendly method of sliding someone up the bed.

Why am I even at work is the question I've got through my head today. Not because I don't like being here, but just because I really don't have to be.

2 days to go.
So how did this lady end up with the HCC microwave ablation?

Considering she hadn't had a drink for 3.5 years she was asking me every 10 mins for a beer or wine- yes Child Purg B Cirrohosis, EtOh related.

Patients like her do put me off drinking. half a drink in a week or a few sips here and there is fine but really, a taste is enough. I still think a lot of my corporate friends are heavy drinkers. They don't think they are. But then I look at these patients and I wonder how much they drank to get themselves in such a state.

Poor lady just wants to "go home and put the telly on and make some toast and scrambled eggs"

That sounds like a lovely idea.

I can't believe they found nothing was causing the abdominal pain and hypotension ...
That baffles me. That they could just open someone up based on the results of a scan -- that turned out to be a false interpretation of what they saw. I get that she looked really sick (with the norad and all). But I'm sure having surgery didn't help.

Placebo surgery, who knows.

She's only 58. Usually independent at home with cares but uses a 4ww to walk around (Hx stroke) and a wheelchair out of the home.

Hospital sucks. It takes away your autonomy. You can't go home whenever you'd like (albeit one's judgement is clouded with encephalopathy and delirium) -- she had a genuine need to be here, with the hypotension (requiring noradrenaline)and shock like state on admission but them not finding anything in the laparoscopy that would cause all of this is just downright frustrating.

In any case, she's wardable. If they can find a 1:1 special, as for sure without she would land on the floor.

36+4

whitewriter — Sun, 23 Jan 2022 08:22:06 GMT

I have cold feet about having an induction. Actually, I have cold feet about everything to do with birth. How do people do this?
I just read the MSH policy on induction to get a sense of exactly what will happen (I am a naughty pt) and basically it goes like this:

1. you come in, they do a CTG? and a pessary is inserted, You get vitals 4/24 and a fetal heart 4/24 for 12 hours, and then another vaginal exam. Either your cervix is ripe and your not contracting = you are sent home.

2. If your ripe and contracting and or your water broke you can have a baby.

3. If your still not ripe (oddly, this is the correct terminology : cervical ripeness) or your bishop score is less than ideal, then they will keep you overnight and put in a foleys catheter involving a double balloon (we only use single ones at MSH/SSH - and no pessary) to further ripen the cervix.
If your not contracting after the pessary (and your at home asleep) and or not after the baloon foleys(and your on the ward I assume, as it may have become too late in the night to send you home by the time they get it in (it's the responsibility of the night SRMO or trained midwife to do the procedure) - then at 0600 prompt the next morning they start your IOL. With oxytocin. The rates and fluids of which are not in the policy I read, but I know is something like - their oxytocin is in a bag of saline (odd because we use Hartmanns down the road) and the rates are vastly different - but essentially its the same deal.

There's a CTG
A midwife palps your contractions.
They titrate the rate to your contractions.
Vaginal exam every 4 hours.

That bit is essentially the same more or less.

Apparently all this intervention does not increase the rate of cesarian section but rather, decreases the rate.

Furthermore it states in the policy that more monitoring antenatally - does not reduce the risk of still birth or other complications, rather that having the baby prior to being overdue - especially in older ages(such as >40 yrs old) is what actually reduces the still birth rate.

The policy mentions GDM but does not go into detail there.

I think I feel more satisfied that MICH spends so much effort in ensuring my cervix is ripe prior to commencement of induction rather than focusing only on one thing: can I break your waters? (which I feel is the more SSH/MSH approach with the balloon foleys. There's been times when I've done a VE and the cervix is just hard and thick and I wonder - even though it is 2cm or whatever, and the water is broken, how this would ever turn into a vaginal birth given that we need soft and stretchy.

Also this whole process seems unnaturally drawn out and long. You need to stay "on campus" as the policy states during the pessary insertion - which, with covid, probably means confined to your bedspace/ room. Which sounds helluva boring. I want Pete for the company mostly, rather than anything else.

My cousin's cousin is having an IOL today at SSH and just as I was texting "tell me which midwife and room you have" - my phone literally died -- and I tried to charge the damn thing and it's just not having a bar of it. So I wonder how it all went down. The IOL was for decreased fetal movements, subsequent CTG and 1x dip in babys heart rate, - her cervix wasn't open enough to break the waters and so a foleys was placed and IOL booked for today. Yesterday she was like "any tips Rita" and all I could say was rest up! and get to the hospital early, as soon as they call try and leave right away because the earlier you get there the earlier they can start you.

She's approx 40+2

and then I railed about how we phone women at 6 or 7 am and they dont rock up til 11am and that means we don't start them 'til 1300 which really means PM shift 1315 which means who knows when they'll have their baby.

Oh! and go to bed. You'll need your rest.

She was worried about the pain of an IOL - about being delayed re: epidural because maybe the midwife won't "let her have one".

And today I've been 0 support, stuck at work for 12 hours with no mobile phone just like in the dark ages.

I'll find out what happened when I get home I guess.

35+0

whitewriter — Sun, 23 Jan 2022 00:54:02 GMT

35+1
Funnily enough my next appt is endocrine next week Thursday (must be doctors as well) post the U/S scan next Wed.
I've up titrated my insulins and now I'm on protophane 11U at night and novorapid 10 for breakfast only
So far after a week of high fasting's - up titration til 11 allowed for a fasting BGL of 4.7 and an acceptable post-brekky of 6.something.
High readings no longer upset me. Didn't like them but it wouldn't make me feel bad anymore. Poor kid. It's being bathed in high BGLs despite me being really, really good. One high reading was because of pickles that contained sugar, and the others I think was because I needed to go up on the protophane - high fasting leads to highs post breakfast which makes it harder for the lunch to be in range - and by dinner it all shakes out. I did one day with 12 U novorapid trying to mitigate the high fasting, but it only just made the target of 7.4 post breakfast that day.
GDM is actually a really good excuse to avoid sweets and pizza (one of my least favourite foods). I don't what it is about pizza. It tastes nice whilst I eat it but it never excites me and I'd never go seeking the "best" version of it. I'd never suggest it as something to eat as a group unless the other options look cruddy.
Hopefully the 36 week scan will be okay.
I feel like a giant but only around the middle. I could pass for 28 weeks apparently.
I'm particularly tired in the evenings however if you put on an interesting video I'll stay awake.
Baby brain has set in.
Have I set up the "nursery"?
No.
It's just a bit of a mess in there currently.
I'm thinking to get puppy pads to line the bed with, but it'll make things hot - if I can just use a pillow slip to cover the bassinette mattress, then a pillow protector will probably do.

Are children expensive?
I'm in two minds about this. If your looking at it just from an expenses out point of view, I'd have to say no. So far what I've actually spent is:
$200 on an ultrasound because I don't know why. (first timer nerves I think)
$260 on a car seat (and that was on discount, and had high safety ratings for the type of seat it is) - by far not the most expensive on the market -- but safer than others that are more expensive according to the tests.
and $60 on 6 snoopy onesies just because they're so damn cute and I want the kid to wear them ( and they had low stock at uniqlo so I freaked out that perhaps it'll go out of their catalogue).

Course I'll be loosing my $120k annual income, which will likely go down to approx. 36400 pre tax, some of which will still get taxed at high rate due to financial year not coming around until July. and the govt subsidy is something like 4500 so from 120k pre tax I'll go down to 40k income for a whole year. So that's expensive.

Of course the kid needs to get fed, and cooked for and cleaned after and all that will be ongoing expenses.

I'm working until the last moment in an effort to reduce childcare burden, and also because the aircon is so nice (and, I'm not on nightshift due to insulin -- put me back on nights and I'll go on mat leave asap). Plus, there's N95 masks here and a bit of social. What would I do in the community other than stay home and drive myself nuts.

Today, I was talking to a senior (Jane) who was like your taking a year off?? You'll be so bored.

We'll see, I suppose.

35+2
Here's the kicker. I noticed other pregnant girls were working in covid yesterday -
and I was thinking gee, they're brave. And today my manager tells me "it's not a reason to not work in covid"
me- oh.
me- should I start mat leave early?
manager- it's up to you. (but I know they're short, and I'd rather not.) She's like "is it the PPE?" and I'm like .. yeah the PPE. Very hot.
And so now I've been put onto neuro's roster for the last two weeks (woot!)
Thanks boss. I'm good with that. I know Pete is also uncomfortable with me working in covid.

Mr 23

whitewriter — Sun, 23 Jan 2022 00:41:18 GMT

Bed 23 is a 67 year old gentleman from the South West.
Retired.
Hx T2DM (likely leading to) HTN and some CKD.
His wife was also unvaccinated. His children (adult) are vaccinated.
He got covid, strain I don't know.
Here he lays in ICU, his son is allowed to visit for 1 hr per day if he chooses - and this was granted via an exemption from the execs -
and no one else. His wife, is unvaccinated = but also recently had covid. She managed to stay home with it, and got better - but as she still remains with vaccination status "unvaccinated" requires a letter from State health (don't want to say which state) to explain she is exempt from vaccination for 6 months. Meaning, she cannot visit (until this letter is sought).
State health is run off its feet at the moment with an insane number of cases and changes and all sorts - so this could take a while.

If she had been vaccinated prior to getting sick, this wouldn't have been an issue. As she would have been fully vaccinated. Got sick. Got better. and remains vaccinated status, well and symptoms resolved.

Just think. If you choose to remain unvaccinated, and your family member is dying in hospital - you won't be allowed to visit. And it's not like you can just wait until this happens, and then quickly go get your vaccination: you need two doses at least x number of weeks apart. And now, supposedly you can choose whichever vaccination you like. Unlike previous when only under 65s were allowed to have pfiser (should that be one's preferred).

I wonder if anti-vaxxers are okay with this. That if this happens to them they'll feel like they their bad fortune is entirely brought on by the government - and not by their own choosing.

This poor man. His body looks over all well but his lungs are stuffed. He's not for ecmo. We learnt in the last wave there just is no point to putting people on ecmo - because the majority of them died, or had strokes and ended up vegitated and hemiplegic doomed to a life in a nursing home, or - at best, with a lot of care at home.

No one think's it'll happen to them.
I've set up a zoom meeting using the unit's brand new ipad (wonder where that came from) that family members can use to have a zoom call with their loved one. I've proped up the ipad on a Large box of gloves, on a bedside wheely table so they can see his face whilst he lays there, ventilated, heavily sedated and on a mode of ventilation called PC-AC which I'd never seen before and had to look up.

Basically on pressure controlled - assist control, the pt can choose his RR, and at the slightest evidence he is choosing to breathe the machine will deliver a breath - and will not deliver the next breath until the Time inspired has lapsed? It's just a different combination of spontaneous breathing and ventilatory support. It seems to require a lot of fiddling though, with the doctors coming in and rejigging the settings every time I do an ABG - which, I just do... as I feel... I have no rhyme and reason really. Sometimes if they've changed something in response to high RR or tidal volume - and it's been 2 hrs or I'm thinking to roll soon, ill do an ABG ($60 a pop, in house. using our brand spanking easy to use new ABG machine) because post a roll - he will likely desaturate during, and change the dynamics of his chest/water/ventilation - so I try not to take ABG post any events that would effect the result.

Twice today he's done large poops. Watery. Unable to tell me, it's only when I check under the sheets and see a tell tail brown stain that I'll know he's gone.

The zoom call is ongoing. They don't live close by (but not so far) - I reckon with the driving and the parking it would take about 1 hour to get here. stay for the hour or so and then return will take another hour. Totaling the entire morning or afternoon.

I haven't done my notes yet. I'm feeling lazy today. It'll get done though because he's only on a bunch of aperiants (prior to yesterday he hadn't pooped for 8 days), a new diuretic I never heard of until today - via the NGT - along with a bunch of free water to bring down his sodium. No antibiotics. He's not been febrile. Mostly stable. Droping Hb and heparin for PEs is his main concern otherwise but the Hb has stablised at 79 (we accept greater than 70). So onwards we go. Low sodium and low fluid feeds at 40mls/hr + insulin infusion at 1.7mls and hour to keep his BGLs somewhere in the vicinity of 6-10.

PPE rant

We really aren't wearing too much in non-covid ICU: just goggles over the eyes and an N95 mask.
I see pressure injuries all around me on peoples noses and ears. I seem to be ok in terms of pressure injuries but the mask is so darn hot.
I can feel my face sweating beneath it. As my breath is hot its just so moist and wet under my mask. The aircon in here is amazing but its just like having a mini heater on your face.

Today I had an ice pack down the back of my neck for most of the day to take the heat away from the mask. If the ice machine breaks I'm screwed. Or I'm gonna take a walk down to old non-covid ICU (now returned to TPU) and borrow some ice. The other machine is now locked in covid ICU) next door.

In other news
My cousin - the clever one - who, also I suspect is somewhat introverted and totally fine with lockdown - somehow, has tested pos on a RAT. The last time she saw anyone unmasked she says was 2/1/22 but if that wasn't an N95.... Which most people aren't using - I'm not too surprised. her symptoms are mild and she's due for a booster soon but that'll now get delayed.
She works from home anyway in a nice $$$ job. So that's not a worry, and I can't think of any comorbidities she would have (unlike myself, should I end up with covid I have a fair few currently) so I think she'll be fine. Hopefully it's omnicron and it'll go away soon. No fevers yet supposedly.

Pete still has this cough. I asked the doctors at the appt yesterday if he would need some sort of exemption letter considering he's had covid recently, and is fine otherwise except this pesky cough. They aren't asking women and partners to get a 3rd daily PCR test (boy was that a drastic waste of money seriously - prophylactic testing. Who came up with that one. State Health seemed unaware about it until people started calling the media and complaining how were they to get this test considering results are taking 6 days to come through and the lines were hours long ( if you could even find a testing center that was open). So the whole system, including MSH and SSH have moved to RATs for women and partners. I haven't tried a RAT on Pete to see if he'd pass. I sorta don't want to "waste the test" if I can avoid it. Prices are a little high at the moment, and I have some spare from work because there was some miscommunication about how frequently they wanted us to use them.

Pete's working from home again. The whole office is shut. Poor thing is stuck in the living room too (albeit, with a portable air conditioner at the least) because whilst he was in ISO he got off his bottom and moved his work desk and computer from the room with the bed I plan to use when the baby comes - to the only other logically available space. We have too much furniture. I need to get rid of a few things. I haven't set up the room properly though yet. Just been too busy prioritising other things.

Like -- going away this weekend on what will hopefully be, a covidsafe holiday. We booked a holiday home with 6 beds, a deck and a view of the beach which is only a 2k walk down the road. Forecasted to rain however this weekend but I reckon it'll be fine. A bunch of us just wanna chill. Hang. Relax. Maybe go for a walk. I'm planning to make breakfast for tomorrow morning (French toast has been the request) and other suggestions I've thrown out is a BBQ on the deck. A walk on the beach in the morning when hopefully it's not raining. And some crafting. Perhaps, if they have a smart TV we can throw on some netflix and just pretend we don't have covid back in the city. Even Moe plans to come, for one night. Leaving her almost 1 yr old. With covid going on I wonder if she'll have a birthday party for her daughter. Probably a small one with family only. I want to get her a gift anyhow. Covid ruins all gatherings.

34 weeks +1 Day
I feel officially fat.
The linea nigra showed up yesterday as a small 5cm line below my belly button that smiles more so than puckers as it's getting stretched.
Baby rolls a fair bit but I couldn't tell you if it was less or more than previous. Space seems limited in there.
BGLs have been ok, although yesterday and today it's been really up (8 and 9) and really down (4.4 after lunch, but also, I went swimming after lunch and before the reading). Maybe my finger was wet - although I didn't take the first blood.
Sleep, in my own bed at a reasonable time each night has actually been really good. Maybe it's the extra dark room. It's a bit muggy, and we don't have aircon in the bedroom, but tonight I'm planning to put on an extra fan to go along with the fan we already have over head (that I've been staring at for a year now and planning to clean the dust off it) and it should be okay for tonight.
Summer when your third trimester is really shite. Unless you have aircon everywhere you go .... and then how are you supposed to be encouraged to excersize? This is where swimming comes in. Going is a drag but it's the only summer friendly excersize I can think of. At least my bikini fits top and bottom : although, I am a little concerned my boob haven't gotten that much bigger. I've gone up approx one size. Inadequate increase of breast tissue does signal potential issue with milk production. As does insulin resistance and GDM in pregnancy. The key goal here, is to reduce the insulin resistance with excersize. Although insulin resistance increases as pregnancy increases I wonder if this is really due to reduced activity due to just feeling fat and cumbersome, rather than actually increased resistance. Either or. I must have been really nuts thinking it would be okay to go away (although just for 2 nights) to stay in a house 1 hr out of Syd. -- I saw the house has aircon ❤️ Hopefully, it's near where I'm sleeping.

If so, then that's a number 1 reason to go away for two nights. And sleep in delicious aircon.

<lj-cut

100% FiO2 and no where to go

whitewriter — Sun, 23 Jan 2022 00:40:15 GMT

To recap:
67 year old male
from South Western Sydney
T2DM and HTN, CKD
otherwise living independently at home with his wife, retired.
three or so adult children, now with grandchildren.
unvaccinated.
covid positive and is documented to be under the care of public health, trying to care for himself at home. Amn Sp02 was provided.
In his home, lives his younger son and out in the granny flat is the older son and his family.
Slowly, one by one, they all contracted covid.
His wife also scored an admission however, got better and went home shortly before he required admission.
As he was admitted initially to another sister hospital to MICH, which uses powerchart for their notes I've been reading about his stay firstly on the wards, and then ICU.
He was transferred here because when they intubated, they punctured the trachea and thought he would need cardiothoracics input with regards to that. He had subcut emphysema at the time but that's since been resolved. This is likely why on oral care he's always had blood in his oral cavity.
He was heavily sedated to tollerate ventilation and with FiO2 best at 65% he just got worse and worse despite more and more support.
Increasing ventilatory support until there is no more we can change
FiO2 now at 100% his Sp02 is 85%
supine.
Paralysed.

Wasn't febrile but now is becoming so.

His family are lovely so I find this very sad. They say they've read about other people who took 3 months to get better (he's only really been sick since Dec) and that they've had family members on home oxygen living for 10 years.
100% FiO2 via the ETT is a massive mountain away from home O2. Home O2 would be at best 28% low flow, no pressure, natural airway.
I don't think his brain can tolerate CO2 of 68mmHg to 100mmHg ( I kid you not, yesterday it went up to 100, and yes that's an arterial blood gas) - normal btw is 35-45
and not only that his pH is now 7.25 - for maximal therapy he could get put on dialysis to clear the pH but we're still stuck with nowhere to go ventilation wise.
His family inquired about a lung transplant and he's simply too sick to survive.
ECMO has been off the cards since day one.
Last night he deteriorated and they tried to phone his wife but she didn't pick up.
Today, his son phoned. The team was still rounding in the amber/covid section. So I did my best to sort of indicate things were terrible.
The son said he wasn't sure he'd be allowed in today or which.
But as far as I knew the team wants to extubate today - which means, certain heaven in <1 min.
I don't know how the exemptions run and the rules, and what's happening in the unit. It's currently hybrid, half amber, 2 ecmo for I don't know why, 1 covid and my guy.
Likely to become full covid by the end of the week at which point, I have no idea where I will be going. Perhaps Cardiac or neuro ICU. Perhaps elsewhere. Perhaps, I'll take mat leave early. I don't mind I've made it to 35 weeks- it would only be cutting things short by 2 weeks and a bit.
Suppposedly theres a girl whose about 3-4 months working in covid ICU currently. I wouldn't cope with all that PPE - not at 4 months and not now - plus, you can't yawn. the moment you yawn, the mask is breeched. That's probably the hardest think I find about all the PPE (other than the heat) is the inability to yawn. Oh, and drink water.
I know where bed 23 will be going.
It's sad but I know the family don't really understand how bad he is. I don't think they realise that, even if we kept going there is only one ending. The choice is today, or perhaps next week.
How long can your brain and organs tolerate untreatable CO2 and pH of those numbers... I'm not certain.
So at 19:20 I gave the wife and one daughter a 5 min warning that they'd be closing the unit for covid - and at 19:25 I ushered their very polite but teary faces out of ICU. Only to return and the unit be fully covid. I had to wear the cap and face sheild as though I'd worked with covid all day (although I hadn't - but the unit was fast filling up all day bedspace by bedspace 1 at a time 27, 26, 25 etc. Two ex-covids remain in the corner in 28 and 29 and of course, my dude Mr 23.

Update on Mr 23. At 23:00 he had a cardiac arrest and died on the ventilator at 100% FiO2 and no reduction in ventilatory support.
noradrenaline had been weaned to 8ml/hr. Due to covid, his family were not afforded the opportunity to be at his bedside should they have wished to have been. That being said, it seemed via the observation chart to have been rather quick so should they have not been there anyway, he likely would have passed without family there.

Nurses make the worst patients

whitewriter — Sun, 23 Jan 2022 00:39:23 GMT

Today's ethical dilemma: do I play florid Christmas carols at the bedside of an intubated, retired 61 yr old nurse who had an attempted suicide (note left).

Honestly, she looks 70.
I read through the ED notes, someone described her as "lovely"
I google earthed her address and it's local to me, but her address is blurred out so no photo of her residence is available.
She took 10x oxycontin and 10x diazepam.
We extubated her on only 10 min break of propofol and fentanyl
Her friend arrived shortly after
When I extubated her, approx. 30 mins later she became very angry and said something to the effect of "what does it take?" and "I failed"
she asked this later on of the Dr - Did I not take enough?
Her friend said "yes"
Notes say she had become depressed after her partner died 10 years ago and remained unmedicated.
Heavy smoker and EtOh (which I suppose is one type of management strategy).
Lately she'd been suffering from a lot of back pain, and for the past week had hemoptysis.
I think she thought she had lung cancer or something terrible and didn't want to have treatment.
She had positive blood cultures on admission so they wanted to repeat them right before starting the antibiotics - and she refused. She pulled away her hand, and had a small argument with the RMO. Who then asked me to get haloperidol 5mg. She started to pull at the central line when I informed her I would give her "something to settle" so we could "take bloods"= and that if she allowed us to take them, I wouldn't need to give her anything. She pulled more forcefully on the line (which had a connection and I was holding onto the proximal end so no matter how hard she pulled I had real control over the line - and it popped off (wtf that's not supposed to happen) it's just maintenance fluids so I used that fresh lumen to push haloperidol with zero remorse (I thought I'd feel more) and within 1 min 5mg haloperidol was working a treat.

We started precedex preemptively and she slept for the rest of my shift (until 1400 when I was going to take a new admission due to high risk intubation- and the person coming on is the same new grad I dug out of a hole by doing her meds last week)

Friday 29/1/21

whitewriter — Sun, 23 Jan 2022 00:38:29 GMT

36+2
I started antenatally expressing. I was informed to do it for 5-10 mins a day but just like at work, I find it quite addictive. I spent 40 mins yesterday getting approx 0.6 mls out -so close to 1ml! but I ran out of time. This morning, I have an E12 so I managed in 20 mins to get 0.1ml. Maybe I'll find time tonight. I need to take regular breaks or I'll get neck pain from looking down while I do it. I'm getting nervous about pushing something that is approximately 3kg through my vagina, let alone let myself get induced. Women are brave, how do they go through this?

Today I bumped into the old old boss of small ICU (she's returned from a secondment) and gave me some feedback - she said, the acting NUM pushed for me to go to neuro in my last 2 weeks because I'd not complained much this pregnancy (or that I've had a good one). But I then said everyone's been so nice, and I have diabetes with insulin - they've let me not do nights so I can titrate the insulin so. Pregnancy has been easy (but then again, I haven't had it totally easy considering the GDM).
I think a lot of first timers especially get really precocious. Or if they have a small body type, they feel it a lot more gaining 14 kg from say 50 or 60 kg whilst I've gained somewhere between 0-5kg (thanks to GDM diet) and I'm heaps taller so the watermelon in front of me only looks like a small watermelon. It's nice to know people have decided I've not been a winger.
Pick your battles. If you win one, make sure your gracious and a trooper. No nights, is a huge win. Makes me want to stay until 38 weeks but we all know that would be pushing it... (plus I should take a break, even if it feels like I'm always on a holiday when you only work 3 days a week.

She didn't have homeless looking feet. That's what I noticed first on my assessment.
And for 71 that's pretty good.
Plus she's obviously a migrant (Chinese) and they typically are not homeless.
Turns out she's a hoarder that lives in community housing, a 1 bedroom apartment that she pays for out of her pension.
However due to her hoarding, she is unable to use the bathroom (and I assume, quite likely the bedroom also) and so she showers at the swimming pool and train station (thereby giving her a homeless like appearance to those in the community). Her son is somewhat estranged but the way he put it when I finally got the chance to meet him was that she was 'very independent' (and I assume, like most hoarders) - unlikely or unable to take assistance or be dissuaded away from their belongings or their living situation. As much as their family would like for them to cohabitate in clean and peace, the hoarding may inevitably get in the way.
She had a grade 5 SAH in the bathroom at a major train station about 10km away from her home suburb, and was seen to collapse (her saving grace) to which she was then rushed to our sister hospital and then transferred to us. They completed brain surgery to clip and secure the aneurysm, however she remains GCS terrible (4), with likely bad outcome. Best scenario: nursing home with various level of function.

I was talking to the social worker - there is limited ability for her son to go to her apartment and clear it out due to legalities. However when he asked for her house key and belongings (literally 3 bags of junk: some food - apparently she rummages in bins, but to be clear, I've done that in the past under the more acceptable? title bin diving. Almost feel like getting back into it again if the GDM clears nicely... We'll see... -- and one of the bags was wet? There was a pencil case with random papers, a bag of masks, some face sheilds etc. ) I gave them back to him because I know we don't want to keep any belongings in ICU unless they're toiletries or a patient's phone if they're a GCS 15. So he now has the power of the key to open the place up and figure it out. I'm sure the landlord wouldn't take issue with him clearing it out. I'd turn a blind eye if I were them.

That being said, I don't disagree with allowing her to hoard in her apartment. It's a terrible shame but it is her autonomy to pay rent to a place she cannot live in. I guess the problem with her son is that if he allows her to sleep at his place, then technically, she would be considered "moving in" and perhaps she may loose her community housing.

Hoarding is a horrible illness.

names...

whitewriter — Wed, 19 Jan 2022 06:27:32 GMT

I'm supposed to do 20 but I'm stuck on only a handful.

Boys
William
Peter
Douglas
Alfred

Girls
Anna
Elizabeth
Rita
Margaret
Gwendolyn
Maryann
Mary

Ja's stories

whitewriter — Tue, 18 Jan 2022 23:07:18 GMT

On the day of the chest drain debacle - I worked with an old colleague Ja who has 2 kids.
- the same one who had 2x c-section because her midwife at an appt decided she didn't have a body type for NVB (and this was in the last 10 yrs so talk about outdated thinking..) Ja had an ecmo case that was super sick and busy and went to IR for a procedure, and I had... Mr chest drain. So somehow in her crazy busy day, she found time to impart some wisdom on me... (nurses and some cultures can be so superstitious...)--

Story 1
Ja has 2 friends, both were pregnant at the same time. One prepared everything for their baby and the other one, didn't. The one who prepared everything, had a nice kid, all is well, happy ending. The one who prepared nothing- had a stillbirth and didn't have another child again.

-- this one gave me poor sleep 'cause the front room isn't prepared, and I spent a large chunk of time on the weekend cleaning it out and hassling Pete to move the unsafe chest of draws from taking up floor space to taking up cupboard space inside the closet, and then moving the bed around to front of the fireplace to make more space for the cot/change table/set of shelves. In the end I've got a really charming room out the front now with shelves that have little toys (some mine, some new from friends) and I've let Pete keep some of his maths books and random gift statues on there which actually add to the charm of the room. Stocked the baby change table and sprayed some nice smelling room spray and it looks like a guesthouse!

Thanks to Ja's story for making my butt move faster. I now have a nice room for the baby should it decide to come tomorrow. There's a few things that's missing/needs upgrading but nothing essential.

Story 2
Which I think I heard of before at MSH as a student but, put that horrible image out of my mind -
was that, there once was a lady, who had to be taken for an emergency c-section, or emergency birth in theaters - and the baby died, or got stuck, or something (I'm thinking it sounds like an undiagnosed breech birth) and for some reason, the only way they could take it out was to decapitate it. The entire set of OT staff who were present had to attend counselling afterwards because they were distraught with what happened (no shit).

I can see why. If it's a breech birth, and the child died somehow, and you really thought it was unresuscitatable (which, is pretty nuts, cause babies do well with resus - so it must have been really bad, or perhaps it was actually a stillbirth that ended up a breech vaginal) -- doing a cesarian to take out a dead fetus - impacts a woman's ability to have further children vaginally, and if she wants to have, say another 5 children in her plans, cesarean is likely not to be the best option here (considering this one has already died).

However I still can't get the image of a decapitated baby out of my head. Horrible.

I'm not sure what the moral of this story was in the context of me.. Ja, why did you have to tell me this?!

The carer and the Horticulturalist

whitewriter — Tue, 18 Jan 2022 07:43:30 GMT

New Bed 25 is ex-Bed 37
T/F from South West Sydney major Hospital for liver treatment (MISH is a liver Tx center)
The story goes, she was at home the day prior, cleaning the chicken coop and fetilising the yard with dynamic lifter, mowing the lawn.
Had bad abdominal pain and took approx 8 paracetamol in approx 1 hour.
Medical Hx - none
medications - none
Smoking - yes
Drinking - "small nip" of home made macedonean ?wiskey in the morning

Now she's in small ICU, on dialysis, looking as yellow as a member of the Simpsons family. For transplant? Unknown. Plan is to keep going, and hope she gets better.

They did a biopsy of her hip on day 1 in small ICU and she bled and bled and ooozed +++++ (coagulopathy due to poor liver).
Next she had a bleed in her ? rectum that meant blood pooled from her anus - requiring cauterising in IR.

I read as far back as I could in her file. In Juneish of 2021, a friend had phoned police/ambulance as pt was threatening to kill herself, or her father and then herself due to inablity to cope. She was so intoxicated at that time that when the ambulance tried to assess her risk for suicide, they were unable to do a proper assessment.
Supposedly from then on the family rallied support however the Psych who interviewed the family post this new admission is unsure as to the extent of the assistance - and had concerns as to how it got so bad in the first place.

Now she's in small ICU and we are trialing a period of extubation. If she fails, she will be for a tracheostomy.

Psych assessment did a deep dive of the overall picture and interviewed the family(sister and husband) is that she is not a good candidate for Tx due to
-potential low support at home
-alcohol and self harm untreated

I didn't think her sister would accept this answer (and she didn't citing that she had friends who had alcohol dependence who received livers) but Liver Tx explained that the pt would need to be abstinent from alcohol for 6 months prior (damn that's short) which hasn't occured yet - and be off ICU supports (and I assume also, generally well) prior to being on the list.

I wonder where her Dad is now, and who is taking care of him.

I call this a covid related admission to ICU as her family were supportive of putting Dad into a nursing home however, the pt was not.
And I can see why, with limited visitation, family can no longer utilise the nursing home as a "help" - thats what I would do if I ever again put a family member into a nursing home. I would pick one as close to me as possible and then ensure I visited every day, to feed them, to wash their clothes and just generally help out and ensure they got beyond basic care.
But with covid restrictions, this would be all but impossible.

So whilst that may have been the best choice, it was literally unavailable.

Also. BS she isn't an alcoholic. She had at least a 6 months Hx of abdominal pain, bruising etc. and "a small nip" of what is supposedly home made 55% alcohol that is enjoyed by other family members also - her husband admitted she frequently drinks after her father goes to bed, and when she's drunk, phones family members to discuss her anxieties as a carer and the stress she feels with taking care of her father.

The psych seemed concerned that she no longer lived with her husband (no longer co habitating, is how they termed it). From non Western culture, my parents didn't "cohabitate" a bed, or even the same room for a long time prior to my dad going into the nursing home so I don't see that as abnormal.

Then again when Pete wanted to sleep in the other room I did take offence to this (I don't snore. Yes he's a light sleeper. Yes I'm 95kg and pregnant and roll around a lot, but to me it symbols deeper issues). So. Now he starts the night off in the same bed and claims after he pees at midnight has issues falling asleep so goes to sleep in the other room. I don't know if he sneaks off after I've fallen asleep. But it keeps the peace.

The story
Sick from work for last few weeks? months? lives in an apartment in the inner west. Isolated from family due to distance - they live in QLD.
Normally works as a gardener for a council in his area however has become too sick to work in recent weeks. Aged 60s but too young to qualify for a pension.
Was coughing up 1 cup of sputum daily and after a few weeks of feeling unwell, difficulties eating? dihorrea and abdominal pain was on scan found to have a retroperitoneal Ca.
Heavy smoker.
Heavy drinker.

nil other medical Hx, no medications.

They took him to the semi-private across the road to have surgery(his brother told me on the phone on the day of the op, his sister helped him from the car and he was so breathless and could barely walk that they were concerned they would not operate, but no they did it anyway).

When they opened him up, he bled so badly they could not take the tumor, did a liver biopsy instead - as it looked cirrhotic (incidental finding in OT??how did they not see it on scan?)

He was too unstable so they packed him off to ICU, where a few days later - on nightshift, with his very crappy chest (and now fulmittent delirium, albiet, he's the kind that knows he's delirious always asking where he is, and what is going on and why is x y and z, etc.) he coughed so hard he dehissed his wound with large amounts of exudate literally almost spraying out as he coughed. He was an emergency take back to OT the moment the morning list started and he returned 3 hrs later, reintubated.

This was approximately a week ago and now, 1 week + 3 days post my covid leave I'm back and he's still here. Wardable, but did have a peri arrest overnight due to massive nose bleed due to NGT insertion

Never thought I'd say this...

whitewriter — Tue, 18 Jan 2022 07:41:47 GMT

Things I miss about night shift
-It's a pure set and forget shift. You take handover, plan your night, and 90% of the time you just follow the plan.
Obs. Meds. wash. more meds. more obs. handover again.
Stare at someone hopefully sleeping most of the time. Wake them up for a GCS or by accident opening that packet of N/S 100mls (oops)

- No managers around (or limited management staff)
So you can be naughty whilst your patient sleeps (eat snacks)- and if your pt is sedated and/or paralysed, have longer time to chat with other staff members (less so if pt is trying to sleep).

- Few (if any) scans or tests : other than your 0200 bloods, or if shit hits the fan: you don't have to pack up your patient to go anywhere for a scan, and then have the hassle of unpacking them and catching up on things you missed while you were gone. Going for a scan at midnight generally only happens in an emergency, where things have really gone sour and your night is going to be shit anyway, and your pt is probably intubated and sedated to the high heavens so at least you don't need to deal with whining or confusion.

-That the first night shift was like "another day off" as was the day after your night- shift. These were "reasons to chill day". And although it was shitty that you had to work at 08:00 on your day off , you still had the whole day to do whatever you wanted (sleep, mostly). Overall it's a chill time.

Back dated: Bed 30 (again)

whitewriter — Tue, 18 Jan 2022 07:31:19 GMT

I was right! Here I am sitting with bed 30.
So when I last left they were weaning his 0.4mg/hr hydromorphone, 5mg/hr midazolam and 18mls/hr propofol infusions on a nightshift.

My day started with the night staff praying for my baby, that he (she thought the baby was a he) a God-fearing person.

Sounds good to me, I agreed with her that I am praying for the baby every day because it is essential.

(I'm not religious but I by no means deny that prayer is a good thing).

There's some bible verse she's taped to his bed also. He is listed as roman Catholic on his file, and the priest had been around last week.

Night weaning is always terrible, staff always freak out easily and don't give things a chance.

They had 1x raised ICP during a roll (well thats why you don't look at ICP during a roll) and you'd only check after- but nevertheless, he got bolused sedation and that settled, and come day time, they turned off the sedation and low and behold he was fine throughout the day.

He's a GCS 11 E4V1TM6,- will wiggle the thumb and forefinger of the R) hand but nil other fingers, will track eyes to left if you ask, but largely his eyes stay looking towards the right. I'm not sure what that is about.
Apparently, he can move his R) foot toes too but I didn't see that on this morning's assessment.

Overall he looks rather alert. When I arrived the night staff had lullaby from youtube playing in the background (much like you'd have in special care nursery). It's 0800 now so I changed it to 80s rock playlist. No idea what he likes to listen to, but I figured 41 year old male probably wouldn't mind some generic pop rock from the 80s.

I wonder if we'll do any weaning today.

The EVD has been raised from 15 to 20 so that's a sign it might be being weaned.

I was a princess today and driven the barely 2km from home to work despite being a nice sunny (a little chilly due to the wind) day because Pete was going to do groceries and was about to leave right at the same time anyway.

You can see movements externally now. I figured that out on my Tuesday day off whilst I was being lazy at home. It's kinda freaky. I thought I had so much padding down there that it couldn't possibly push through all that subcutaneous fat but there you go.

Last week when I was rolling bed 29 I could tell the baby kicked the patient. I asked the patient if she felt it --and she did. That was pretty funny. She's a long termer ex-covid now covid pneumonitis in bed 29 who, somehow, despite being likely for the ward on my days off. So when I arrived back to work after days off, I was surprised to find bed 30 still in his bed and essentially waiting for me, and that she too was also still here, across the way, in bed 29 still on a ventilator. They were weaning well but her anxiety has set her back to cuff up, and she's back on the ventilator to "give her a break" from the breathless feeling that accompanies being laid flat or moved about.

Sleep is better. I can return to sleep easily after I wake to pee, and I've made it all the way to 0600 a few mornings in a row so that's been nice.

32 +5

whitewriter — Mon, 27 Dec 2021 06:34:27 GMT

Well, I now look like the belly has a baby in it rather than burgers.

Last week my insulin requirements in the morning really spiked - I got started on novorapid from 4U. Which didn't seem to touch the sides, and each day I quickly went up to 6 then 8 then 10 units and at 10 it seems to have plateaued.

It's really easy to forget the added steps to the routine -- and yesterday I forgot to test my fasting somehow, and today I forgot to take the novorapid.

In any case I just keep going and I'll do it better tomorrow.

People say they have trouble sleeping from the baby moving. That hasn't been a problem yet.

I can feel it rolling a lot, and sometimes it's really nuts and you can see the movements externally.

If I'm walking - then I can't feel any moving. It's usually when I'm sitting down to do anything is when it's obvious.

Funnily it likes to push against surfaces. Like, if I'm laying on my left it likes to kick or move against the left side.

If I switch to my right side, then the kicks turn to the right side against the bed.

What's also funny, is that it doesn't seem to ever not be in ROL position.

It's defiantly not engaged. I can palpate the head sitting above my pubic bone on my right side. and I think its back is laying on the right, there's a solid section right there, that's always there and I keep waiting for it to move, but it doesn't seem to change.

I know I should do some yoga and squats and stuff but I have iso malaise and it sucks.

Not to mention, I pee when I sneeze or cough if I hadn't recently gone to pee.

Sighs.

The big question is, can I remain covid free for the next 6-8 weeks? with 5000 + cases testing positive daily? If I wasn't pregnant then I'd just resign myself to getting sick, but I don't like the consequences of getting covid during pregnancy. If I'm sick whilst in labour, I know they do their best but everything will be delayed. They take the placenta for histopathology, I'd be separated from the baby whilst the paed has to check it ... it all round sucks balls.

Honestly I have it good.

whitewriter — Sun, 26 Dec 2021 03:57:26 GMT

I'm bored.

I get to go out for a PCR tomorrow. And if that comes back as quickly as the last one did, I can be out on Tuesday.

So really, its just 1 more day.

How French Kids Eat Everything by Karen Le Billon confirms my own thoughts on parenting.

whitewriter — Sat, 25 Dec 2021 08:36:29 GMT

I may have very few anxieties about passing a ~3kg human through my vagina - but I am concerned about the next 18 years.

I was shopping at the local Vinnies (op shop) prior to Pete's casual contact being upgraded to covid positive, and I found this book I had been meaning to read, titled "French kids eat everything".

One thing I am concerned about, is rearing (yes I do think kids are quite like animals) a child is food and eating. My simple childhood in Western Sydney with migrant from cross cultural backgrounds (Maltese and Indonesian) - Europe and Asia instilled a very open mind toward food, with almost zero fear (was a bit worried about eating fried maggots in Thailand but I ended up really enjoying them as my Burmese friend who was raised in Thailand looked at my sceptically. Her father, knew his Burmese wife liked those snacks wasn't worried and since he didn't seem worried - I ate one, then.. all...). I'm rarely a hassle with food. I eat what I'm given wherever I am- and even if its... not great I'll eat a reasonable portion.

I assumed, this was the case for most people.

Until, I met Pete and his mother (MIL)...

Here's a story. So it was October 25 2019, my fathers funeral and the MIL had driven down from Port Macquarie for the funeral. I'd wished I'd thought to put the MIL with my mum in her house to relieve my own stress of organising the whole thing (which wasn't that hard, I hired a director rather than going things alone or doing anything hippie that my fantastical hippie heart might have desired). She stayed with us.

Post the funeral, I went with a friend who had a costco membership to buy food from costco for everyone to have at the house. The MIL and her son (Pete) went to my mum's in advance. My aunt had made some traditional Indonesian rice in leaves dish (which, Btw. I remember not getting to try as they ran out) - and the MIL being out of her cultural comfort zone in my mother's kitchen surrounded by Indonesian Chinese women of a similar age group -tried the rice thing. To then realise it had anchovies and promptly, basically, threw up in front of them.

I had forgotten to warn my mother about her extreme sensitive pal latte (read:old world country Australian) where a childhood diet of boiled vegetables and plain meat means anything more adventurous was... likely to be a disaster.

There's nothing wrong with traditional old country Australian, except for it's lack of variety which, in today's modern society can become a handicap. I felt sorry for the MIL who clearly also felt sorry for herself. She's never travelled outside Australia (having no Australian passport either) and the idea of going to a foreign restaurant (Thai or Chinese) probably had't crossed her mind ever - let alone, trying traditional, made at home, Indonesian cuisine.

So based on this, Pete has somehow managed to become pretty adventurous despite such a culinary limited childhood. But he has gone on this "snack- lifestyle - keto - I don't eat real meals - whats a meal? what's balance? vegetables come in bags and I don't want to cook" life style along my rigid 6 meals a day GDM balanced counted wholegrain carbs during pregnancy which I actually think is worth keeping post pregnancy, with less counting and rigidity.

Raising a kid amongst all of this... feels like an insurmountable task.

As the book asserts - and I completely agree - children learn from their parents. And conflicting messaging is not going to help matters. I offer Pete some of what I eat for dinner every day and he refuses. And its not on the grounds of Keto; he can skip the rice and make whatever it is I'm eating just as Keto as a peice of meat or cheese (snack).

Hearing nurses in the tearoom say how they cook 3 or 4 different types of meals for dinner (discussed as "short order cooking" in FKEE is also anxiety inducing. I know Pete will always just sort himself out but that's not how I envision family works. Family is eating together, the same thing. Socialising in society: going to people's houses for dinner, this is what you do. Going to a restaurant, you may get to pick, but at the end of the day, its one cuisine, and what do you do with cultures where the food is served to the group to share (Spanish, Chinese and some Italian items).

FKEE gives reassuring tips on not being afraid to hear your child refuse food, and being okay with that - and then the courage to re-offer that food item at a later time. No pandering to picky tastes. They can always say no, but not to be rude about it. No ew or disgusting or some tantrum. its a no thankyou, encouragement to just try a little anyway (no pressure to finish it) and whatever dish is on offer is the dish on offer. No exceptions.

I have no issues with this method. But if Pete won't eat what I make or what my mother gives me to eat (which btw. is amazing) then the kid is not going to be encouraged to try new things. If they see him refuse with not even trying... I can already foresee troubled waters.

In fact, I think training the kid will be easy. Just the same as training a kitten to shake hands for food. What seems like an insurmountable task is easily achieved with patience, and consistency. That took 2 days. I almost got to fetch (Well. best I could get was paw the ball towards me because she never put it in her mouth - she is a cat after all, not a dog) but for lack of patience and consistency didn't get very far. Next year, I won't have a job and the year after that I'll be on reduced hours. The kid is my main concern. And it's human, it'll be way easier.

But. From this book, as I can see Karen Le Billion herself learns she needs to train her own self, change her own habits, to be the model for her children. Unfortunately she starts a little late (when the kids are 2 and 5) but it's not impossible. And luckily for her (or is it unlucky) - her husband required 0 training and completely agreed to the method. It was she, who realised herself was in the wrong - and that her own bad habits (Americanised, sheltered, fast food and even faster everything) drove her children to be picky, annoying, selective eaters that caused nightmareish meals that were stressful. I don't know how her husband (having experienced the eating everything) tollerated that, and actually, it sounds like he hated it too. Karen realised she became her children's slave to their wants, rather than a teacher to them of what is a sensible and balanced way to eat.

Karen found this when she whimsically decided to move the whole family to her husband's home town for 1 year.

Karen then realised that society itself in France was fully geared toward ensuring children had the best food and balance, and was trained to have a diverse a palate as their parents. Wore clothes like their parents (rather than "kid clothes" had table manners and patience that she found lacking in the American children back home.

The most negative thing about my childhood was probably having parents with post WW2 attitudes to food servings. Having come from poverty-ish backgrounds where food was scarce, to the abundance of Australia, both my parents had eyes bigger than their stomaches and whilst my dad was initially larger anyway, my mum followed quickly from probably a size 4, to when I was born, a size 14. She didn't loose the baby weight until I was approx, 20s - and both never really understand "excersize" (a concept I understood after picking up Dragon boat at 23) but my habits, too, are based on theirs. Height hides a lot but BMI doesn't lie.

Reading Karen's book makes me realise that rather than waiting until I have to go through this with the kid, I better first start training Pete to at least try everything. Rather than offering and letting him say no and then eat alongside me his "keto snack" (inevitably un-kidfriendly, and unbalanced food item).

I'll see if I can get him to at least try all the things I eat for dinner (which these days, is cooked by my mum) and to foster a somewhat more ... "traditional" style of family dinner that I think is a very sweet thing to have in one's childhood. It doesn't need to be every day - after all, I'll likely work late shifts some days - and Pete will have to go it alone on some days but most days, this should be achievable.

Why do I think training Pete will be harder than the kid?

Not everything is perfect

I think the culture of France sounds a lot like Japan. Monoculture.

There is literally one way to do things, and only one way that's considered the right way.

Which had its draw backs. Karen writes that neither her nor her husband could remain in France anyway (Despite the 1 year move being a potentially long term thing) because neither could have retained their jobs should they have wanted to stay, and also - looking for a similar level job would have been considered impossible as their qualifications and etc. were from overseas. This is despite her husband being a local until he went to university. He had some reservations about the move, but she convinced him.

At some points she did miss the variety of a multicultural society like Canada's (where they were living before the French experiment) but on returning back she realised that in becoming so diversified, the common goal of families in Canada(and or/North America) is to train a so called 'prodigy' with endless lessons and activities and rushing about (eating snacks as there are no proper times for meals).

When I think of monocultures I also think of Japan. And S, inevitably.

Karen finds solidarity in migrant parents who were also at the same Canadian

Australia/Canada/USA is similar because despite dominant Caucasian - overall this place is becoming more and more multicultural by the millisecond (or was until covid hit). Some parts faster than others (my mum's area - 98% of the kids attending school speak another language besides English at home, whilst in my area, its more like 25%)

I wonder what it'll be like going through another childhood (but through the eyes of the next generation).

It took me approx 2 days to finish reading it and I had trouble putting it down.

Return to work protocol

whitewriter — Fri, 24 Dec 2021 04:22:38 GMT

This all presumes that the covid PCR swab I did today, will come back negative.

Return to work rules

Day 0: Tuesday 21/12
Day 3: Wednesday 24/12 (today)
Day 5: Sunday 26/12 - cannot attend E12 shift due to close contact <1 week from day 0
Day 6: Monday 27/12 - as above but need to attend for PCR covid test
Day 7: Tuesday 28/12 - still cannot attend E12
Day 8: Wednesday 29/12 - go to covid clinic A and pick up a pack of Rapid antigen tests (RATs) to use 2 hrs before work each shift.
Day 10: Friday 31/12 - first shift back, need to do a RAT before work and wear an N95 (instead of a surgical mask) while at work
Day 11: Saturday 1/12 second shift back, RAT and N95 mask
Day 12: Sunday 2/12 - day off- attend for a formal PCR test
Day 13: Monday I'm off anyway
Day 14: Tuesday 4/12 RAT before work and N95
From now on if the Day 12 PCR came back negative I can not use N95 and go back to surgical mask.

The above is subject to change.... but that's the current rule.
And of course it all changes if I have 1 positive test.

Now.
Rules for returning back to society

https://www.health.nsw.gov.au/Infectious/factsheets/Pages/advice-for-contacts.aspx

Iso until day 7
Day 6 take a PCR test and if that comes neg, freedom (to the extent of going back to society).

How did Pete get covid

whitewriter — Thu, 23 Dec 2021 11:07:41 GMT

Friday
Pete had a work Christmas party (for the double vaccinated) on Friday. It was inside the office, and all attendees that day had to take a rapid antigen test (RAT) on the morning prior to entering work- and test negative.

Saturday and Sunday
Pete's unvaccinated (by choice) mother visited us on the weekend - his uncle and sister too (whom I assume are vaccinated).

Monday
On the following Monday, one of the ladies who went to the party, had a positive RAT - went for a PCR and tested positive.

Tuesday
Pete showed up to work on the Tuesday, but by 10am was sent home. Deemed a 'casual contact' he wasn't required to have a PCR Test unless he had symptoms. But around 12 noon when he got home, he did - so he went to get a test.

Meanwhile, I was at RPAH, working a 12 in small ICU - and when I heard this, I decided to go to Mum's after work. Just in-case.

Wednesday: taking the car to get detailed before the baby arrives, then took a train from Yagoona (where the car cleaning place is) to Auburn, did some last minute gift shopping/went to woolies for bread and cheese) then walked back to mums. I had an ultrasound booked at small hospital in the afternoon - and I was wondering- if Pete is deemed casual contact, and I've been away since Tuesday, I suppose that makes me ... nothing at this stage as we don't know the outcome of the PCR test.

Thursday
So I turned to work my 6am shift at SSH and catch a baby by 06:19.
and work with 2 postnates, 2 of which wanted to be discharged--
just as I was leaving at 14:30 I phone Pete to see how he's going (I had issues charging my phone because this phone is old, and cranky and I am too lazy to buy a better cable) - he tells me he's positive.

I was planning to deliver a gift to a cousin's cousin who lives near SSH - this turns into a contactless delivery whilst I contemplate how much of a close contact I was to Pete.

Probably pretty darn close considering we did heaps of family stuff with his mum, uncle and sister on the weekend prior to him testing positive.

I rang small ICU - I'm likely furloughed for the week and I need to do a PCR covid test - so as I was driving home and cancelling all the antenatal appointments with the doctors and endocrine, I was looking for a covid testing site- only to find, as I got back to Auburn that the main one (which is in the center of town) is shut. So I looked up another round the corner -- and it was shut too.

So I gave up. I'd already missed afternoon tea, and I was hungry.

I'll go tomorrow.

Christmas is cancelled. Or at least, postponed.

I hope the tiny 'tickle' in my throat is psychosomatic as Pete says. It goes away when I had dinner so.

In the waiting room again.

whitewriter — Wed, 22 Dec 2021 04:58:49 GMT

So many posts, so little time.

Some are half finished as draft emails so I can't just start them up now without the original draft.

Would feel wasteful.

I'm back in the fetal medicine clinic waiting for my second last scan. It was a bit dicy knowing if they'd scan me or not because when they phoned to do a covid checklist yesterday, I informed them that Pete was at home because he had a sore throat. Earlier yesterday, he had been informed a workmate had covid (test on Monday came back positive) and although he went to work on Tuesday with what he called a "throat tickle" (afebrile) he was shortly thereafter sent home due to the positive case. The sore throat got worse (quickly) and by noon he was down at the testing center behind MICH.

I'd decided to go to mums rather than stay at home with him (even though we have the luxury of separate bedrooms, there is only one bathroom and you need to walk through a long hallway that passes all these rooms to get to the bathroom and kitchen) plus, isn't it nicer for him if I wasn't there. Plus mum's has aircon (or so I thought) turns out she has issue with the electricity so while she has aircon, she won't have hot water or vice versa.. and the fridge is dicy... Anyways. Long story where elderly people don't tell you their problems, you find them out when you get there.

Pete wanted me to go to a hotel. He said maybe I'd risk spreading it (covid or a cold) to my mum.

I'm asymptomatic. I'm more tired than usual which I chalk up to having skipped 3 hrs of sleep having to have moved last min from one house to the other.

Then I also have a scan today, and they weren't sure if I could attend, and didn't answer my phone call either when I called to ask... Yet here I sit. In the clinic. Waiting so I assume, I'll get scanned. I got here at 15:15 and it's 15:45 and I'm still sitting here.

I look obviously pregnant now. Unlike before where I could be there for any number of reasons. I'm staff and just walking in I passed two ppl I know before I got to the ultrasound place. Privacy isn't a thing when you choose to have your baby where you work.

All of a sudden, last Saturday, summer arrived. Much later than usual. It was a mild spring weather until bam! 35 degrees. Mother in law (MIL) decided to visit too. decision made last Tuesday I spent two days furiously cleaning the house to be ready by Friday and she came bearing a portable cot, a pram that looks like it's for a 3mo+ child and a large table that belonged to her late long time boyfriend's mother. Shirleen.

There was an impromptu family BBQ with me, her and Pete on Friday night where her and I spent too much time trying to get the charcoles going.

She doesn't want to get vaccinated and is planning to loose her job as a social worker over it. Yes there is a mortgage but it's basically paid off. She's even considering to change careers, although at 59 I wonder how that'll go and what she can choose in this new world of mandatory vaccination. What if you pick a new profession, train up, and then realise it's vaccination mandated.

I was thinking myself to change or diversify a little. I wanted to add in counciling as a skill I could use in both professions (midwifery and nursing) and perhaps then also become a third job. It could even be done from home potentially. With some caveats. Maybe that would suit her.

I hope rather that she retains her current job with a work from home capacity but... Perhaps that's not feasible (although that's what happened during lock down so I don't understand why not).

GDM

Yesterday, I got started on short acting insulin

Already as a nurse I'm thinking about ways to abuse this.

Like. How many units do I need to have prior to having a slice of pavlova on Christmas day so that I can maintain a reasonable BGL and not have a hyper (or hypo).

I'm only having it before breakfast (not lunch or dinner) and the 4 units I was prescribed barely touched the sides this morning. To be fair, I was at mum's and I had brown rice instead of bread- and I calculated it by eye rather than by weight.

But if a modest portion of brown rice is going to raise my BGLs then I need more insulin...

Thursday at SSH

whitewriter — Sun, 12 Dec 2021 04:30:15 GMT

I had an unremarkable cesarean in the morning. The incharge asked if I felt well enough to go into theater and take on a cesarean by myself, -- as she said, she was concerned if she sent a pregnant midwife to do the case, and they felt dizzy or unwell, or needed to eat or drink; they'd be restricted.

The dizziness was a first trimester issue... which I resolved by working only in ICU where chairs are abundant and u can sneak a snack bag on ur computer. So I took the case.

The elective for previous
The first was an elective cesarian for previous, on a woman who is filipino Catholic but clearly married a muslim man whose name was Mohammed. I asked his name, and when he told me I said I can remember that nice and easy. I wonder what that household does with regards to things like Christmas and Eid. Just have both? Could be fun ... She had no GDM diagnosed in 1st and 2nd pregnancy but in the 3rd there it was. In 1st and 2nd she had LGA babies (well, not strict LGA but for her stature and for Filipino I think it could be classified as LGA: 4.1kg and 4.0 kg -and that being said anything above 4 is considered big (in Australia... but then you hear of women pushing out 5.0 kg babies supposedly just fine and you wonder.. back in the day, they seemed not to be labeled so harshly as LGA.. actually the old cutoff was 4.5kg but still that's 500g bigger than 4kg)and if you didn't have GDM diagnosed then clinicians are sneakily thinking you either had a borderline case or had it but it wasn't picked up.

So this lady had a cesarean for a diagnosed big baby.

And this one, was number 3. So after cesarean number 1, and then number 2, it would be rare for a 35 yr old to then go "I want a vaginal birth" -- plus, this one was thought to be possibly LGA too.

It came out as 3.6kg.

They wanted cord gasses (and I don't know why).

Maybe it was because they thought her diabetes was not well controlled. The HbA1c was a little high I suppose and she did argue with them about taking the metformin - wanting diet controlled instead (but ate custard and other things that were labeled as "dietary excursions"). Her notes sounded really depressing actually.

I thought there was a TOP or a D and C happening in OT prior to this case so I showed up ridiculously late. Usually, I'm supposed to meet the women and her partner prior to the surgery in the wait room, introduce myself, ask about their history face to face, palp their abdomen and do a fetal heart. Write an intro note...

I missed all that -- by the time I got there, they were putting in the spinal and well I can't very well just interrupt an elective cesarean section spinal and say "HOLD IT! MAYBE THE BABY IS DEAD...I NEED TO DO A FETAL HEART JUST TO CHECK" when essentially, in 30 mins, the baby will be out....

Ah well. I figured, if she didn't feel movements she would have said so by now.

I blame baby brain for stuffing up 2x cord gasses by running them as arterial and venous gasses rather than cord arterial and cord venous(yes they're different) -- before all of a sudden on the 3rd test realising my mistake and having to spend time fixing those. Nothing should come of them as the results weren't abnormal but I hate making a mistake like that. Imagine you run a test, but you run it wrong, and say, one number is high - say the lactate is 10 instead of 6. Then based on that one number either the baby has to have more testing (painful heel prick and crying and blood collection) and the test re run only to find its normal. Parents are stressed for no reason... or could go the other way. Something important isn't picked up..

Small mistakes in healthcare can lead to huge (in my opinion) after effects.

The 22 yr old Prinip
so afterwards I had early lunch and was sent to "cover other peoples breaks" which ended up being me, wandering into MAC and taking a phone call-- which led to me helping out instead with a prinip who was 2nd presentation for ?early labour (? because you just don't know until you assess them).

It's always hard assessing a prinip. You don't want to go in too early and declare them 1 cm after they'd been huffing and puffing away in pain for 12 hours- similarly you don't want to decide they're early labour and send them home to then have the baby in the car park either.

But here we were now on the 2nd presentation: which meant, she had early been assessed as "early" and had gone through 12+ hours at home (without sleep, watching law and order SUV to chillax apparently) so clearly, she was here for a reason. I wasn't really keen to send her home without something and we don't give anything and just send people home (anymore) -- we keep them and monitor (incase something bad happens as a consequence of us either missing the fact that they've progressed faster than we thought or; another problem has happened.

I throw on a CTG because we're probably going to give endone, and if the CTG is bad you don't want to give endone and hide a problem. but if the CTG is A+ then you are reassured the baby is fine, all is well, and it's ok for her to ride along the labour journey at her pace.

She had a classic watermelon- stretch mark stripped abdomen, and the hairiest legs (and down there) I'd seen in a long time for a caucasian(?) 22 yr old.

I also had to do a vaginal exam. The 23:00 one the night before, had been traumatising. The midwife had been a bit rough (ok vaginal exams are extremely hard to do on a 1st timer prinip: and worst if its the first one they ever experienced: so here I was to do a procedure I don't like on someone that would rather not have it done -- but it needs to be done. She's here for a reason. We need to know if she's progressed (or not) and how fast or far and so forth. The previous result was closed and posterior.

I considered to offer her gas for the exam but theres no exam in the MAC area, which means moving to another area... and that was too much effort. So I chose not to offer it to her, but instead promised to be extremely gentle (and I know me, I am really gentle-- which can be bad cause sometimes, it means I don't get the answer and I'm up there being too gentle to a fault- but I've learnt now: take your time is the answer if your going to be gentle).

I took my time so hard, I swear, my hand smelt like liquor (but I wasn't convinced the waters had broken even though she felt "like she peed herself" and had moist underwear. firstly, the pad wasn't stained but it was damp and secondly, I could feel the waterbag - and it felt intact) for about 3 hours after the exam.

I literally felt like my hands smelled like vagina (but worse, cause it's labouring vagina... actually I don't know what a non-laboring vagina smells like 'cause who goes up a non labouring vagina for 5 mins?! (no-one). I washed my hands to my elbows about 3 times.

ApparentlY-- shaving cream -- is the answer. I learnt that tip at the lights of christmas duty that night when I then did some volunteer work in the City from 1930-2300 (and drastically wondered what I was doing there to be honest considering my volunteer uniform doesn't fit anymore so I wore my work uniform with a hi-vis on top) Ab from F/F division told me when he worked in a nursing home, shaving cream is what they used when some god awful smell had to be gotten rid of.

I left my shift at SSH listening to the girls in the tea room talk about the 19 yr old girl who had 3 children that was an absolute nightmare to deal with in labour (swearing, carrying on, being nasty, aggressive, even in front of her own other children) whose children still remain in her care. I walked back to the car park with the girl who warned me about Monday and Friday shifts being "the worst" (and she's right. it's like all the shit gets dumped on Mon and Fri due to the abnormal concept of "weekend") -- Neelab. I'm going to miss their Christmas party thing because I'll be on a 12 hr at my other job.

My next shifts will be on Dec 19 and 23rd respectively.

I wonder if the 22 yr old prinip delivered vaginally like she had wanted.

30+0 Dear progeny

whitewriter — Wed, 08 Dec 2021 04:11:51 GMT

The age old question. Where one moment I think of you as tissue (borderline viability rules persist), and of pregnancy up until perhaps this point, as a stage women go through in life that separates them from "single"/child free (I prefer the terminology free on purpose) to "not single" and there being another thing in this world whereby my existence is predicated on another beyond that of my parents or, I suppose my partners/pretty much husband except there's no paper proof.

It's a different relationship whereby, due to your lack of independence and experience the true identity of "dependent" will be borne. Such that you will be wholly dependent for me, for everything - health and education. Probably not forever. But the age at which this link ends is as grey as discussing what type of blue (or green?) the ocean is.

Dear future dependent,
my only wish is that when you grow older you will be useful to society and secure enough in yourself mentally that you can navigate the world as you wish. Aiming for financial dependence is a nice goal, but not at the expense of your health, your values or those around you. Be sensible and don't become a nuisance.

List of people who fall into this category:

drug addicts (that includes alcohol)
anti-vaxxer
body dysmorphic
morbidly obese
perpetually suicidal
someone who complains a lot about their situation (whatever it may be).

Treat those who are on the list above with pity and be mindful of their situation. It's a terrible one - and if your not that list then I'd see that as good fortune. Mental health concerns sit on both side of your genetic tree so the risk for depression/ anxiety/schizophrenia or schizo-affective disorder is defiantly there. As is diabetes, heart disease, hypertension and overweight/obesity.

Average and normal is overrated. As is balance and avoidance of extreemes (extremes of ideas, extremes of lifestyles, extremes of diet... ).

I may be old fashioned and not a creative person - so if you can escape the traps of genetics (whereby both your father and I are pretty similar in that regard)- then I would see that as a good thing. Simple and boring is best and underrated. Freedom to choose is a freedom mostly the rich can afford- and you will always be rich, in resources afforded to you by the hard work of your grandparents- and hence, the hard work of myself in ensuring those can be available to ensure that you face less hardship in that regard.

Push yourself to do the hardest thing first. Even if you think it may be beyond you, try anyways. It is always better to try and fail rather than not have tried and just decide its not for you (except in the situation of drugs... that's just asking for trouble). You may be surprised with what you can achieve, I think, I've managed to surprise myself multiple times over and at the end of the day - it'll bring you confidence that you didn't know existed.

Avoid stagnation. Put yourself first. Work will always push for their agenda - after all, they don't know your needs like you know yourself. No one will be able to put yourself first like you can. So don't expect others to think of you, if you don't stand up and advocate for yourself - then no one will. Money isn't everything and saving for that rainy day - will give you the freedom (and power) to be more flexible. I hope to pass on the frugal skills of your ancestors.

Careful who you are friends with. I'll try to provide you with a sibling but we'll see if that's possible. Family will always help you but friends always have their own families. When your an only child you tend to see friends on equal footing as family and then be hurt when you realise that they don't see it the same way. That's unavoidable. Only only-children understand this hurt and we can all see that it's natural, and unavoidable. If your not on good terms with your sibling then I can't fix that one. That'll be up to you to negotiate that path.

Education is essential and something you can't buy and can only be won with hard work, no matter how "clever" you are. If your smart, use your brains and work harder. And if your average (like me), work harder and you'll see it pay off. If your slower than most, once again. You'll have to work hard. Smart or not - education is hard work. Simple answers and just expecting things to "flow into" your brain- isn't hard work or education. It's propaganda or misinformation - don't fall into those traps. Trust those who have worked tirelessly for years to foster a result that's tried and true. Be one of those and contribute to the answer.

Other than that, if I'm being a pest, put up with that as best as you can. It only means I care enough to make a fuss or advocate on your behalf. Don't be surprised if I take advantage of any benefit you derive from your work or living situation -for example, if you move to xyz country overseas- expect me to be a frequent visitor to your country as an excuse to travel. I grew up with an Asian mother - they have no boundaries when it comes to visiting. I'll probably be no different. Your father has to put up with my mother so you can talk to him about it.

I agree that the relationship you pick up from your father and I will set up your own life long relationships with others of the opposite sex and/or your future mother/father in-law. I promise to make it as simple and easy of one to deal with. Financial stability gives a relationship one less thing to deal with, and is another reason to be careful with your money- and chose a partner who agrees more or less similarly on this point.

There isn't much to add. I hope your clever and easy-going and if your like your father then I'd see that as a good thing. My mother used to say that about me, when it seemed to be a negative attribute but I chose your father for a reason so if I ever tell you your like your father, see it as a positive.

xx

Birthday Musings

whitewriter — Mon, 22 Nov 2021 00:00:21 GMT

Collation spot for other posts nearing B-day period
19/11/21
23/11/21
Written during a sneaky within state trip in-between covid lockdowns.
16/11/14
When you would photograph everyday things on instagram and make them look a lot fancier than they are. I would have been working in neuro ICU then on my last rotation as an IP, being rather naughty having painted nails at work!

20/11/13
Unfortunatly just tweets.
20/11/12
The mind of a 20 yr old new grad...
19/11/11
19/11/10
11 years ago....
23/11/10

23/11/08

20/11/07
Nothing even remotely birthday related! lol on any posts - either side of this date either.

19/11/06
Would have just finished 1st year uni...

I don't actually have time to read through these...
So many posts I'd like to write, so little time.

My brain has draw a blank. I'm blaming the baby for everything even though I don't think it's linked (then again, 1st trimester symptoms can be so vague (bloating, feeling shitty and lightheadedness) that sometimes you do think you're just losing the plot rather than it being pregnancy related)

I'm gonna use prompts this year cause rambling can be hard work.

1. How are you celebrating your birthday
Well on the actual day, I was working - they gave me a lovely ridiculously easy wardable patient 1:1 only for the fact that he had CPE (carbapenem producing enterobacteriaceae - the bacteria itself produces an enzyme that breaks down the antibiotics)which they really really really don't want being spread around so I was extra extra careful with handwashing and wearing those yellow gowns. He could easily be doubled but to reduce spread... My swap buddy, Lisa - had an ex? or current ANU professor who now has quiet severe and violent delirium which tends to swing both hypo and hyper active depending on what time of day it is (hyper at night and hypo during the day) - so that was some "don't go near him Rita just call for help) warnings which I heeded fairly well.

I've never been hit. 9 years. But that's mostly by luck and having forewarning each time I've had such pt-- I've not yet been the first one to discover someone was violently delirious. There's always someone that realises and reaction times will vary.

I informed people to wish me a happy birthday, and reminded them no cake since I can't have any.

Jomaline was really sweet. She remembered, and pre bought a bunch of sugar free treats from the pharmacy which I opened and shared with her cluster (which was opposite mine) with the warning - these are really good but they can give you diarrhea if you have too many ...

There's no such thing as a sweet treat without consequences of some kind.
On the Sunday I threw a BBQ. It's the usual backyard affair with too much food (that tasted surprisingly good) too much smoke (fuck I forgot how much smoke charcoal gives out and actually it poured rain (which is why I changed it from a Beach BBQ to the backyard at home since we have a covered area).

2. When you think about the last 12 months, what immediately comes to mind?
What a whirlwind of a year.
Both going very slowly (when your TTC and wondering when your single life will be over)
and very fast - covid rules literally changing on a daily basis and working in two different districts with different rules and protocols... Covid going all the way from being the WORST thing you can get to - once you and the majority are vaccinated the fear is muchly reduced and hey! let's all have BBQ and go to the shops and go to restaurants....
Vaccine passports (who'd have thunk that ever be a thing).
Friendships broken due to misguided views on vaccination -- large protests in the community against vaccination.

When you think the weirdest thing that can happen is Trump being president of USA-- things can get more interesting still.

3. What are you grateful for?
That I've had a ridiculously easy time conceiving (sure it took a year but come on, if that's the worst thing...) and hopefully despite all the mounting risk factors I get the NVB I'd like to have
(risk factors: age over 30, GDM, prinip) and if I don't get that, it's sorta like having a wedding go a different way to the way you planned. One day of your life. And as long as both parties are alive (and married), then the aftermath can always be dealt with.

4. What surprising change(s) took place in the last year?
Returning to ICU as a senior from casual once a week/once a month/being given only the easy patients -- funnily how fast that can deskill you -- to permanent full time senior -- was harder than I expect. There's been a few lumps and bumps.
When your trying, you never know when it'll work. Could be immediately, could take months... so that was a surprise too.

At least, for the most part, besides covid everything else was stable : financial. Housing. family (no one got sick or died)so that's a real blessing I think. It's nice to have stability amongst this mess (of covid, of changing back jobs out of midwifery) - this should also go in the what are you grateful for section really.

I was surprised with how much money I made despite not doing overtime -- don't get me wrong, I work a lot of extra shifts at SSH but they're mostly all shifts I wouldn't get as overtime anyway (morning shifts, basically, are extremely rarely given out as overtime) so I don't see it as a bad thing but rather a good thing - that I'm working more hours- paid only 10% extra - but they're el primo hours so why complain? Nurses, when they find good jobs, get paid rather well and have a moderate amount of stress in their jobs.

I'm mildly surprised so many people are leaving ICU. Other states pay better and have lower costs of living. If 120k is the top income for a floor nurse (like, not an educator, not a CNS or otherwise) but my living expenses were say, halved (for what we paid for this house you could have a beach side mansion in other parts of the country) then why would you stay in Sydney? People are choosing to retire now rather than say in 1 or 2 more years (or take their long service now and maybe rethink if they want to come back in 1.5 years).

5. What goals have you achieved in the last 12 months? Have you made progress on your Bucket List?
Having a baby was probably on that list that I haven't written down.
Transitioning back to ICU full time in general ICU was definitely something I wanted when I decided I really couldn't do midwifery full time.
Continuing to keep up with my hospital midwifery is another challenge that I think I've been managing well with.
I'm fairly competent at CRRT, which is nice.

6. What goals were you unsuccessful in reaching this year?
I should have put more effort into getting officially signed off for connecting and disconnecting someone onto a variety of CRRT circuit- but to be honest I don't feel completely confident about it as of yet. Troubleshooting could be better also.

Finally learning -- through trial and error -- how to set up those new ventilators we got and I did't get to use whilst I was a barely there casual.

I haven't cut any episiotomies so I haven't improved there either.

Any semblance of repairing old relationships I frequently think about (S) and wonder if it's worth bothering

7. Where have you stepped out of your comfort zone in the last year?
Moving to SSH as a new graduate has certainly been a challenge -- short lived as it was (4 months, 2 1 of which was probably more confusion and trying to give it a chance, 1 month of this is crap and 2 months of figuring out how to get out of there). I've learnt a lot about ... the system, about myself, about the stresses other health professions outside of ICU face... It's been an experience.

8. 8. What was challenging about the last year? There was a fair amount of uncertainty in my professional life (trying to transition back to ICU) which probably didn't help the uncertainty embedded in my personal life (TTC).
Especially after about 5 years of stability in neuro ICU I think it's been really good to get out of the comfort zone - because that's literally where nursing careers go to die.
And fortunately I had a good chunk of time there prior to mat leave: because returning after a whole year is definitely going to be a challenge (will I remember anything?!).

9. What was fun about the last year?
Having the whole house to ourselves. We stopped taking renters after our last - it's good money but the space and freedom is a blessing especially in covid. It's lovely.

10. What difficult problem or challenging situation is top of mind?
Just fears about the third trimester turning me into a monster. It's end of 2nd and I'm luckily not that big at all for 2nd (in comparison to the rest of me I can pass for chubby) - but the backache is already a major pain. I want to work until 38 weeks so...this won't be possible if things get unmanageable.

Sometimes I think about going into other (healthcare related professions) in order to get out of nightshift.

11. If you could speak to yourself 10 years ago, what would Younger You think about the problem above?
This probably reflects more in my work life. Built your pathophysiology knowledge. It'll always come in handy. Anyone can follow policy but it's more rewarding when you understand the details of what is going on. Keep saving. It's always held you in good steed.
Don't forget that you need to look your best - looks are important. (I think I often forget this one even now).

12. If you could speak to yourself 10 years from now, what would Older You say about the situation or problem?
You can always do better, but in general your basically doing fine.

13. What do you want your life to look like this time next year?
Oh geeze.

Health
Hope I can complete Oxfam successfully. That be cool. Maybe be back oc-ing or dragon boating. Don't know how those will go with a baby...

Career
I'd still be on mat leave and not thinking about work. That would be the goal, to not think about work for a whole year.

Business
Honestly.. worst business person ever ... me.

Financial
Hopefully there's even less of the mortgage to pay off. Once that's done... I want Pete to relax a little if he wants to. We could get somewhere bigger. Or not. Or renovate this place. Or not.

Home life and/or family
Hope the kid sleeps well and hasn't got too many issues breastfeeding. I hope to exclusively breastfeed whilst introducing solids into the first year.

Romantic relationships
Hopefully post baby the sex life will be ok...

Friends
This will be a challenge. I have no idea. I hope I have time for my single friends and don't discard them like old books.

Hobbies
I do miss being part of a team sport.

Lifestyle
Could be greener. More gardening.

Spiritual
Not quite sure with this one.

Personal development
I'm sure there will be plenty...

14. What could you do right away to make that vision a reality?
Take a chill pill. Things will be as they be.

Thursday's women

whitewriter — Fri, 12 Nov 2021 02:33:49 GMT

So I came back on Thursday to my second PM shift of the week to find out that Wednesday's woman didn't progress at the midnight VE and so therefore was c-sectioned at 01:00.

What did I think happened? I think the epidural slowed down her labour progress, and as she was not allowed to have an augment in labour, even though the CTG showed good contractions -- a CTG does not really indicate anything more than when uterine tone increases and decreases - so frequency, but not strength etc. -- and the CTG trace was crapola so they weren't gonna allow stressing out the baby with an augment.

Hence she didn't progress (cause contractions were shite) and hence she had a c-section because it was getting long in the tooth at 1am.

Ask a woman who has been labouring for 12 hrs, at 1am, -- with a borderline unhappy baby looking CTG - if they wanna keep going with labour and I'd say considering fetal welfare is at stake your gonna pick the c-section.

anyhow so then on Thursday after a slightly delayed start time (due to the incharge being late, and then the AM incharge being impatient and handing over to someone else, and then the actual incharge shows up, and the boss decides the actual incharge should be the actual incharge - thus meaning handover was REstarted 20 mins late, delaying also- allocation -- staff standing around --- honestly. Anyways)

So I'm allocated to take over from an old classmate of mine in midwifery school (but she trained at SSH whilst I was at MSH):
37+0 (so exactly term baby today)
IOL for IUGR
woman with past medical Hx gastric sleeve.
Hx of depression (medicated for 3 ish years) but is now overcome. I very judgingly thought it was related to the gastric sleeve (being overweight) but on persuing her file properly could see it was related to a TOP she had done. TOP is a very interesting subject-- and its effect on mental health is poorly looked at I think.
Nil other concerns however the gastric sleeve has very much affected this pregnancy.

1. she had to be in doctors clinic. the consultant obstetrician does not allow gastric sleeve women to be in midwives - and I entirely agree.
These women have a very high risk of remaining malnourished during pregnancy.
Nausea and vomiting is much more prevalent with a gastric sleeve - leaving them vulnerable to proper nutrition -- which, in turn can affect fetal growth

2. body habitus changes Palpation of the antenatal abdomen is a fine art. Total art. When you add in variables like the size and shape of different women -this makes it even more of an art form. Add in a Hx of obesity - either current or past - and the palp becomes even more difficult to feel a baby's position, to measure fundal height accurately (a crude but general yardstick utilised to determine fetal and uterine growth without an U/S)

Both of the above means that the doctors will want regular blood tests for iron levels, and other nutritional markers - as well as regular ultrasound scans to measure fetal growth.

My stance on ultrasounds remain the same. They're incredibly inaccurate with 15% swing either side of a weight as to the true weight or size of a baby. They frequently find things (or don't find things) that either should or shouldn't be there --- and essential decisions are made on the basis of the ultrasound which I think should be taken with a grain of salt. This being said, it's very hard to ignore a test result once u have it in front of you - and just say "well its 15% inaccurate either way" when it's a test result that states: your child is not growing properly and is dropping centiles.

Anytime a test is being done, one always needs to know: what is the test for, what will I do with these results and how will it impact my future decisions.

3. body image issues are amplified in pregnancy and considering you had a gastric sleeve done, you were probably someone who struggled with body image (and other health fears) in the past. So mental health implications are heightened further

So here we are at 37 weeks with a prinip, undergoing an induction of labour at the earliest possible time period due to an ultrasound scan at 34 or 36 weeks which guessed the baby's size to be approx 2.2kg (very small) and to have dropped from 80th to 5th centile between 28 and 36 weeks.

A foleys catheter was put in the day before at 36+6 and the woman spent a sleepless night at home, anxious about the events of the following day.

The foleys had been excruciating, she said. Very painful, and freaked her out for what breaking her waters would feel like - and actually it was very different and not painful at all. (Other than the pain of someone's hand in your vagina going up further than you might think to be humanly possible, ARM is essentially painless.

After the hand has broken your waters, the next sensation is one in which you peed yourself but you cannot control- and this happens continuously throughout.

They commenced the oxytocin infusion at 0930 and at approx 11:30 pain actually ramped up. By 1430 when I entered the scene, the anesthetist was putting in an epidural.

Initial VE: 3cm, posterior cervix
subsequent VE at 1:15: 3cm cervix less posterior
oxytocin at first max of 180mls/hr and first bag about to finish.
The plan was once the anesthetist had finished putting in the epidural and the woman was comfortable, for the contractions to be palpated and a decision made to go up on the oxytocin provided the CTG remained beautiful.

It was a beautiful trace. There was very little on it to suggest I should be concerned in any way (unlike Wednesday's trace). Was this little IUGR baby really that robust?

At first the toco started working again - and picked up 5:10 contractions and I was like hang on. Can't ramp up the oxytocin here... but after 20 mins, and a palp later i could tell they were really more like 3:10. so up the synto went at 15:30

to max. rate 240mls/hr
The CTG stays beautiful.

17:20 rolls around faster than I know it and thats 4 hrs post the 1300 VE and we have synto at max rate here so I know I need to do the VE. The epidural is working well, and my VE is,

4cm (generous 4cm), still fairly thick cervix. Easily found - not posterior, but its a bit like feeling a thick rubber tyre inside her pelvis. It wasn't quite soft or stretchy, to be totally honest. O&G come around for a review and grills me on my VE and forces me to admit - that it really doesn't seem that much different from the 13:00 VE (admittedly done by another midwife.

They're happy for another 4 hours at max max rate provided the trace stays perfect.

So I commence on 4 hours of antenatal expressing, discussing breastfeeding, general chit chat where we compared our first trimesters (since I'm 26 weeks currently.. which makes me only 11 weeks behind her.. shit that's less than 3 months away) and agreed 2nd was the best. We talked about tooks like the Haka which I had similarly heard about and wanted to get (to collect the let down) and how she'd purchased it and was keen to try it. She was very easy to talk to and I tried to infuse some midwifery knowledge to her fears about inheriting her mother's concerns with breastfeeding her and her siblings in childhood. Her mother was concerned she could not make a supply, and so they all ended up on formula.

I wondered in some small sense if this is why this girl ended up with a gastric sleeve - and if her other siblings had similar weight issues.

In the tea room - I talked to the receptionist who showed me countless photos of people she knew who were overweight but not morbidly obese, but got gastric sleeves or bands by paying for them.
A lot of them posted on insta or fb thereafter their transformations.

When I was leaving it was 21:20 and the night doctors had just come on, and was reviewing my lady. The progress VE after 4 hours of insane amounts of oxytocin (we were on the 3rd bag and now it's at triple strength to avoid fluid overload) -- I agree the doctor should do it, as I know that this VE is going to make the big decision: To cesarian or to keep going with the induction.

I'm not expecting much - and it ends up being the same as before, a tight 4cm. This cervix is not budging. They discuss the cesarian. and she signs the consent.

Her only comment to me was "it's a bit overwhelming" and I'm sure it was. If I was her i'd be bawling my eyes out.

The incharge kept popping into my room throughout the shift checking the CTG was as good as I thought it was, and she'd always ask how it was going in there and in one of my comments I said "all is well.
I'd like to see more progress in terms of VE and CTG (the CTG can also indicate progress in labour) but I just don't see it) and the incharge just said, well, if at this extreme rate of oxytocin there is no progress then clearly, there is not much else that can be done. And I agreed.;)

At one stage I wondered if they forgot to put the oxytocin into the bag,

I made up the 2nd bag though, and I know I put it in properly - so there's no way it was just hartmanns in there.

I wonder if the baby really was 2.2kg

I was surprised throughout my meandering conversations that no one had mentioned the baby might ned to go to special care nursery post birth. At a weight of 2.2kg - I was under the impression that all babies under 2.5kg were generally admitted to SCN. If only for a short period of monitoring and BGLs.

We briefly discussed this, and how she would go over for feeds if that was the case.

No one had talked to her about antenatal expressing either, in clinic. And I wonder if that was largely because she was in doctors and not midwives clinic. Doctors don't usually talk about those hippy things.

In other topics. Dads.

This one was pretty funny. He was a roofer by trade, and you could tell his nervousness when he started talking a lot (which is what happened after she signed the cesarean section form). I curbed that by giving him something to do -- change into surgical attire.

It's a stressful day, he'd barely slept the night before as well.

He was feilding all sorts of text messages from their family - there's about 4 siblings on his side and 1 on hers - and they all wanted to know the VE results (I think the woman was on the phone to her mother whilst I was doing the 1720 one which I thought was rather funny. Imagine being on the phone whilst another woman's hand was inside your vagina rooting around and feeling your cervix?! Her husband wasn't present and I wanted her to not feel alone so I didn't mind.) or wanted to know what was happening in the room.

Honestly, when it comes to my own IOL (if I do indeed get there) I don't think I'll be telling anyone. Maybe my mum. Maybe. Probably not, she'll have a stressful day thinking about it. They can all just find out when it's all over. Rather than having 50 people in the room (hypothetically in the room) wondering what's going on.

The woman advised me regarding baby names. She said she'd picked some out but once she confided in the options to her family (mother and mother in law) they all had complaints and whines that forced her to find other names and let those ones go. She thought it would be better to just, pick. and tell no one until it was a done deal. I thought that was an interesting interpretation. I gotta get my butt moving on the name picking game. Otherwise I really will just call it Peter if its a boy and Rita if it's a girl.

Three shifts with the one patient in ICU.

whitewriter — Wed, 10 Nov 2021 23:10:08 GMT

Lives the other side of the train station in my suburb.
ex-covid, now battling both sides of the coin: covid pneumonitis and an ICH.
The ICH is hypothesised to be due to either:
the high dose heparin required for the ecmo to get over the covid
or
some clot, also related to the ecmo circut.
It's an ICH, though. Not a hemorrhagic transformation-- although, can you tell on a CT scan the difference, they're both bleeds.
The kicker was that they discovered the bleed sort of late. He was ventilated the whole time( tracheostomyed about 2 weeks prior) and the GCS was persistently crap - it was at best a 5 and went to a 3 and then a week ish later they went for scan, and at the last minute changed it to a pan scan (whole body, not just lungs or abdo ) and hence forth found the ICH
Neurosurgery involvement -
and they did an evac of the clot, put the bone back (craniotomy) and threw in an EVD - and after some discussion decided that further surgical management would not be suitable. (terrible outcome assumed).

Medical management of the ICH ensued. Vent settings for neuroprotection with mandatory mode of ventilation chosen a RR of 32 aiming a normal CO2. I'm trying to remember if it was a pressure or volume controlled mode but I do remember his tidal volumes were 400s which is pretty normal and actually really good for someone with covid pneumonitis - where 100 is bad, 200 is good - and normal volumes is 6-8ml/kg. -

Paralysis + sedation, pupil checks + train of four to ensure adequate paralysis. He was a hard one to paralyse, you could see his thumb twitching with the TOF but the machine would declare 1/4 twitches.

I was unsure which to believe: the hand doing 3/4 (which means, inadequate) or the machine 1/4 (which is adequate). Things to research further. I followed the hand because who wants to be half paralysed and having a forced mode of ventilation at the same time.

EVD outputs hourly were fine and ICP okay.

SATURDAY - they wanted to wean the paralysis and see what his ICPs did. He started shivering (increased metabolic rate is bad for the brain) and his pupils had abnormal movement that I mistakenly classified as similar to dolls eye reflex (which is a feature of brain death testing actually cause I looked it up) but was just deviation. It looked horrid.

His sister was all over it - after being basically not involved for 2 months, due to it being "too hard" for his father to "see him like this" - (he was his father's carer and usually worked in retail however due to lockdowns was out of work for the meantime) - the ICH brought them back to see him.

Perhaps it was the nearing certainty of death rather than disability - as the family had told ICU that the pt would not want to live with a disability.

I wondered if his obesity (he was listed as 95kg for today but .. I'm 95 kg. I stared at him in the bed and wondered if we were actually the same weight and if I was deluding myself about my size) was affecting the paralysis (another thing to research) due to the meds being absorbed into his fat or muscle tissue and having irregular absorption -

anyhow.

So I'm looking at these swinging pupils and semi freaking out and the sister is like "that doesn't look good" and the consultant reviewed then said it's likely seizure like, and he's on anti epileptics anyways and the shivering is bad for the brain so lets just re-paralyse (and mask these terrible symptoms).

SUNDAY.

I'm allocated him again (ex-neuro ICU means everyone in small ICU think's I'm an expert handing the EVD when I haven't actually had a pt with an EVD for 2 years) and I start to realise general ICU is acopic regards the EVD. He remains sedated and paralysed throughout, todays' challenge are his bozo friends from the pub that turn up (I had advanced warning from the sister) who come to the bedside and sorta gently yell over his paralysed and mandatory ventilated body that he will "get better" and "come back and have a beer" and he's doing "Really well" (Cause his ICPs are stable... which we are forcing to be good btw. with that EVD and the paralysis and the sedation: the true test will be when we take these supports away) and here I am trying to explain its still "super early" and we take things almost an hour at a time - and that whilst the scan can say which section the bleed it is in, it won't say things like will he be able to drive or walk (or even drink water, let alone a beer, mind you - but I didn't mention that part).

His bozo friends were like "with all the medical technology you'd reckon they'd know more... "

Yeah buddy, that's why medicare is struggling - because they thought medical technology would fix more stuff (and it can but with more is more cost -- that we didn't budget for... Increased expectation, means you want better care -- these need to be planned for. Life is getting longer but that actually means, more expensive for the tax payer in regards to healthcare).

I didn't go there.

They thanked me for their care and after an hour of that (which delayed my lunch because I didn't quite want to leave him alone with them) - they left.

The day ended quietly.

MONDAY.
It's groundhog day. I'm back with him again.

I question, what if I made an error for the last 2 days. I've been handing over and teaching about the EVD on each handover (admittedly I also re-read the policy since it had been 2 yrs since I had an EVD). Apparently there isn't anyone else they want doing the EVD and he's considered terribly unwell and do you mind? Well no I don't but do you wanna put in someone else in there and I could be in the bedside next to him and I can assist and teach them so then someone else can learn? I thought it but it was too late -

plus I didn't know what the staffing skills mix was like across the floor, there could literally be no one else.

Monday means new consultant. A more experienced one this time who'd been a consultant since before I started and he wants.... to wean the paralysis and the sedation and just "See".

Actually, he wants to wean overnight. As long as the ICP is good, the shivering can continue and the eye deviation isn't an issue.

Weaning overnight is always horrible. You have registrars and residents who don't want to make decisions. They're on the mode of no rocking any boats: just set and sail. The nurses are on that pathway overnight too -- it's one of the things I miss about night shift.

On nightshift your main priorities are meds and obs and the wash. No scans are booked, no visits by allied health. No meals to be had, medications don't get changed. You might be angry cause the day staff forgot to arrange the supply of xyz medication that isn't ward stock, but beyond that: you set your GPS with coordinates and just work the shift.

Keep the pt clean tidy and happy. React to a few changes perhaps and hope nothing changes (like deterioration cause then reset occurs.

So I did the line change.

Because it was going to be due overnight, and I felt sorry for the nightstaff who had to wean the sedation overnight and watch the ICP and who knows how that would go, it could end up with an emergency scan (Actually I thought they wanted to scan him on Monday, but they changed it to Thursday to give him more of a chance which I agree with is a better plan).

Emergency scan AND line change would be too much for anyone.

Plus now I don't do night shifts means that I haven't done a line change in ages. So I did it cause I had time. And I like to do a nice ICU handover.

I left for 4 days off: and I guess I'll find out what happens to Mr bed 30 when I get back on Saturday.

Here's a kicker. I was on my tea break and the junior nurse watching got to talking with the sister and was like "look how bad he is, I wouldn't wish covid on my worst enemy" and the sister said, "Well, he's an anti-vaxxer so he sorta had it coming".

...
What does one say to that?!

We care for them all just the same.

TTC

whitewriter — Mon, 08 Nov 2021 06:51:17 GMT

where if my mum was late to pick me up, or say, I was waiting for someone and they were late - I'd imagine a "worst case senario" for why they were late: car accidents mostly or some other horrible thing. I'd go into pretty graphic detail in my mind, and every time, maybe 10 mins later they would show up and I would think "phew, it's because, I imagined the worst, and because I thought of it, it didn't happen."

So now I'm furiously imagining all the positive things that would be possible if I m/c'd.

Funny isn't it.

It's not great when you've decided not to tell work mates.

I had a girl divulge she was 10 weeks today and was on ondansteron because of morning sickness and I just kept quiet.

She said it works but not 100%, and that it's expensive.

Apparently she's told her boss (she's from neuro) already.

I wanted to ask so many more questions but there's only so much you can ask on the basis "oh I'm a midwife".

I've had so many "how's it going and whats new" and I keep on with the same same...

I feel crappy.

I thought it was related to the worries of maybe having an ectopic instead of a real pregnancy.

But today I feel like I did yesterday- that nauseous feeling where your sorta hungry but not, like your about to have a big exam - but there isn't one. And loads of burping.

Who knew burping was a thing.

Then I'll eat and feel more burpy.

My cousin in Canada was like "dude you didn't need a scan to confirm if your gassy then that's it" but anyway...

I haven't been back to the GP. I'm in no hurry.

I've told Nicole because she has a friend on IVF in Sydney who I was kinda curious about. And Jen because Jen wanted to know why I couldn't eat sashimi... that's going to be a toughie.
And Bel because I tried to sell my oxfam 100km ticket to her and she guessed right off the bat. So she knows.
I even told her and Nicole, see if I M/C I'll be able to do it and they both berrated me for thinking negitively.

Breast tenderness subsided on Tuesday and I was worried that meant something. It's there but it's not as bad as last week.

How long can I keep quiet for...