I had one of the most emotionally draining nights. I spent almost my entire shift with a very young, very immature girl who had the most severe needle phobia I have ever encountered. Such a severe phobia that she never had ANY blood work done in her pregnancy. None. Zip.
Blood type? Don't know. Anemic? Could be, but don't know. Gestational diabetes? Your guess is as good as mine.
Preeclamptic? Probably, but don't know how bad. Can only gauge it based on her BP readings (bad), proteinuria (some), edema (yep), hyperreflexia (oh yeah), clonus (yep). Can't give her any good drugs for pain or anxiety, unless it's medications by mouth. Tried antianxiety medication by mouth, didn't touch her. She wanted an epidural eventually, but that wouldn't happen with such a severe needle phobia and no IV site.
I was hand picked by the midwife to admit this young girl, since I would be able to build the best rapport with her. We did build a good rapport and trust. She started out extremely scared and anxious of everything, and developed into having a good understanding of what to expect and what boundaries/privacy/power she had over the whole situation. We worked on building her trust in me, and I was actually very tempted to stay on overnight for the next shift as her nurse, because we did build such a good bond and level of trust.
It had gotten to a point that night, however, that she could potentially be endangering herself and her baby by refusing to get an IV site or labs drawn. She was a very sick cookie, and wasn't going to get any better without (gulp! yes...) medical intervention. She understood all of this, and agreed to it, however her needle phobia took complete control over her physical ability to allow the IV to be placed and labs drawn.
We ran out of options, when the legal department was brought in, and it was deemed that she was not in any immediate harm to herself or her baby, and thus, we could not take legal action to force her to comply.
I hate it when it comes down to that power and control struggle. What makes this unique, is that she is a minor, but yet she controls her own medical decisions. It doesn't matter that her mother wanted her to have things done. It didn't matter that her mother wanted to hold her down for us to do things to her. We cannot physically restrain someone who is of sound mind and able to make her own decisions. It is also NOT my nature to force ANYTHING onto ANYONE. Not to mention, it is assault if I force anything onto anyone. I could lose my nursing license and go to jail. It is just plain WRONG to force anything on anyone.
Yet......she knew it was important to not go home, since she stayed in her L&D room, and didn't threaten or make a move to leave. She knew the importance of the situation, and knew that things could go bad, leaving her or her baby in a serious life threatening situation. She knew. But, she had the mentality of a teenager that was in denial as well. I could see the stubbornness in her eyes, and I could also see the acknowledgment in her eyes that this was serious.
Her situation weighs heavily on my mind. I am seriously worried for her health, her baby's health, and their future outcome.
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Roll out the Red Carpet. NOT!
5 hours ago
28 comments:
I had a pt like this once, took me 90 minutes to get her and IV. she wanted it, but just couldn't do it. I prayed a lot that I wouldn't blow it! I blew the first cause she jumped (even though i was telling her what i was doing) got the 2nd though. tough night. hope it all turns out okay with your gal!
Let us know how this pans out; im very interested as i currenty have a young patient simiar to this athough not as severe!
What a difficult situation. Good that you were there, and able to build a trusting relationship with her, but it sounds very emotionally exhausting.
I was talking to a pregnant woman about her birth plan the other day and she was telling me how she might want pain meds but didn't want an IV...I explained there were no pain meds without an IV. I'm not sure what she'll decide in labor (her needle phobia sounded nowhere near this bad) but it's such a tough situation between medical care and medical phobias. I hope everything goes all right for this young woman and her baby.
Yes, please do update us with her status after you've worked again! Do you have any idea how she develped such a phobia. I suppose that's something that I should work on is the fact that I'm totally the opposite. Wanna practice? I'm your girl! (in other words) I want to be able to be as completely understanding and empathetic as you were!
WOW!
I am sincerely worried for her as well. And being her nurse, I can't imagine how difficult that was for you. *HUGS*
That's a tough one. When I had my wisdom teeth pulled out they sprayed my arm with an anesthetic that they use for athletes and I did not feel a thing. I did not even know that they put the IV in. Does anyone know if something like that would be available for this patient? Please update us on her status.
I am so glad I found your blog. I hope the patient is doing better.
Severe pe cured me of my needle phobia. I was pretty bad back then. After being stuck every hour for labs, you get over it really quick!
IV and labs done about 16 hours after admission. It took brute physical force to hold her down. It was not pretty.
Possible sexual abuse? Not sure that you'd want to go there with a woman/girl in labor, but it's something to think about.
Had a labor support client w/this problem once, and that was the root of it. Actually, her doula was someone else, who wanted me there as *her* back-up, and it did take both of us, plus the CNM plus the MD to get this woman through her labor. Not as bad as what you describe, but it was bad.
It was only after they were home that she said to the other doula, "I guess I should have told you that I was abused...." Well, we figured that part out the first night we talked to her & her husband. And that he knew what had happened--he was too protective of her.
Penny Simkin has a book about sexual abuse & birth. Something like _When Survivors Give Birth_. Haven't read it, but anything that Penny writes is worth reading.
Anne in Memphis
I never was stuck with a single needle during any of my labors, not even my one hospital birth (refused the heplock with no problem) but I didn't want drugs and I was not, as you put it "one sick cookie", so I didn't really NEED it. I would have agreed to an IV if something had been wrong with me or baby (like the BP issues your patient was having). I'm not a huge needlephobe and I did have labwork done during my pregnancies; I just don't like the idea of laboring feeling like there is a thorn stuck in my hand.
Anyways, I digress; I'm just rambling. I've never known ANYONE that was THAT terrified of needles that they did not even get pregnancy labs done, wow.
I have to wonder what this girl would do if she were in a car accident or some other scenario and she HAD to get an IV or a shot of something and she was conscious?
Keep us posted on her.
"Probably, but don't know how bad. Can only gauge it based on her BP readings (bad), proteinuria (some), edema (yep), hyperreflexia (oh yeah), clonus (yep)."
~~~That's not "probably", that's classic pre-eclampsia.
I enjoy reading your blog, and as a CNM for 40 years, I wonder how much of your present attitude will last, once you understand the reasons behind the "interventions" you'd rather avoid. It sounds as if you're currently working in a high-risk unit; you've seen all the potential risks you will face with your own patients. At times I get the feeling that you're too much in love with birth and not enough with medicine -- a balance between both is needed.
Antigonos - can't imagine what you are talking about - atyourcervix regularly posts about births that include all sorts of medical interventions that are beautiful. This post is not about the nurse wanting to avoid interventions - it's about wanting to perform them and a client who refuses!
Regardless of the necessity, it is stressful for a provider to feel they "have" to do something to a refusing client - the one horrible situation I can remember personally is a woman who was basically bleeding to death from a postpartum hemorrhage and was screaming at me to stop bimanual massage, but it was the only thing slowing her bleeding (with IVs running, and multiple meds given, and OB backup rushing to the hospital for possible surgery) It feels terrible to do something to a client who is telling you to stop, even if you feel there is no choice.
I was going to suggest EMLA cream or something similar - I've been able to talk a few people into draws that way. We put EMLA on first at several good sites and give it a good hour. For IVs and lab draws it's pretty effective, not as much for injections where much of the pain is the med going in itself. Add in a substantial dose of something sedating oral, and it might work.
Clients like this are so frightening, when you are so worried that you need to do something and your hands are so tied. I don't think I've ever had someone quite this bad with the needles, but I have had one client who could not in any way tolerate a vaginal exam without anesthesia. So, she's never had a pap, and I've caught both her babies without a single exam prior to an epidural being placed. (Both times she had spontaneous labor, and basically we just started an epidural once she had pain, figuring if she wasn't really in labor we'd augment her after. Both times, she was term and actually in labor luckily!)
-doctorjen
As a homebirth midwife, I do not have clients this phobic. I do have women who do not want VE, but they cope if they are medically necessary. Not happily, but they cope. I haven't ever had a needlephobe to this extent and have only had a couple of women faint because of their fear; of course I always lay these women down to do blood draws.
I would think I'd get more medical-phobic women in a homebirth setting, but either they don't know the option or somewhere inside want the medications but don't know how to overcome the fear. Something to ponder.
Antigonos - a CNM making a statement like "I wonder how much your present attitude will last once you understand the reason behind the Interventions...".
Anyone who's been reading this blog for any length of time would readily realize that this nurse absolutely understands the reasons behind the interventions that she'd rather avoid. She knows the difference between those that are needed and those that are not, and she does not hesitate to employ those that are. Being "in love with birth" does not mean avoiding medical intervention if needed. This nurse, more than most I've come to know is very aware of the balance. Your comment leads me to wonder if you truly do.
I think your criticism was snarky and invalid. And, as a CNM you do not practice Medicine...you practice Nurse Midwifery. If you want to practice Medicine, go to medical school; but you've been doing this for 40 years. Ever thought about the concept of burn-out? Your comment reeks of it.
I hate the way I sound in this response...but your post made me angry...absolutely rubbed me the wrong way. You were very unsupportive of a nurse that was doing (and, as far as I can tell) has always done everything she could, to protect the health of her patient and her patient's baby.
BTW...If you are a CNM, I assume you are aware that, High BPs, hypereflexia, and clonus can result from extreme pain and anxiousness/fear; that edema and "some" proteinuria (although, albeit unlikely here) do not necessarily, in absence of labwork or outright seizure to verify it, indicate severe pre e;
Nor can you definitively tell another nurse that you know what "classic" pre - is from a post on a blog without the lab work to verify it. Get over yourself.
If midwifery is still about being "with woman", you seemed to have drifted more than a little.
RedRN
I was admitted to the hospital a couple weeks ago for severe dehydration and contractions before being term due to a virus. And IV's suck. They really do. And they had to IV me eight different times over my three day stay.
It hurt, and I don't like needles, but it comes down to being mature and understandning that when something is needed, it's needed. I asked one of the nurses to hold my other hand (so I could squeeze down) and I clamped my jaw shut and didn't look while they did it. And yeah, it took them several times, and they don't care if you cry or yelp... so long as you hold still and let them do their job. I don't handle it well, but I let the nurse do what needs to be done. Guess it's a level of maturity and understanding. The nurse felt bad having to poke me so many times, but I told her I understood. It's not HER fault I have terrible veins (and I was dehydrated!)
Gotta buck up and do what's needed, or you could risk yourself AND your child. And imagine how terrible you'd feel if something happened to your baby because you refused to let someone give you an IV?
Wonder what would happen to that girl if she needed a c-section, like I did. THAT would be a nightmare.
Update: she had a vaginal birth!!! Labwork did not support the suspicion of preeclampsia, so she avoided that diagnosis.
Not to be overly dramatic or anything--but this sounds like 90% of my patients! LOL! Gld all went well...
I'm glad to hear that it all ended well. True needle-phobes (NOT "I don't like needles" or "They hurt a lot", I mean real-freaking out-scaling-the-walls-hurling-themselves-at-windows types) are very, very, very draining to deal with when labs & IVs are required. I find phobias like these so sad. I feel like they simply MUST be about something deeper. Something else.
I am so happy for this young woman! I hope now she realizes how strong she really is, and that strength will help her be a good mother.
And, I admit it, I am not above being "snarky" myself when someone has been condescending and so assumptive as to have tried to diagnose someone over the internet...so, take THAT, Antigonos!
RedRn
I love happy endings! I am so happy you were able to follow up in the comments, because I was concerned for her.
Even if I don't agree with the refusal, I am very defensive of people's right to refuse interventions. This was a tough case.
Great case study on ethics! (Share that one with your class mates on Banyan...it's a great teaching moment)
Actually RedRN you are dead wrong regarding preeclampsia and the CNM was right. Yes she was snarky in her post. However, it was a classic case of pe. You just did not know how bad. You can have severe pe in the absence of bad labs. Preeclampsia is defined as 140/90 twice within a 6 hour period or 30/15 over baseline bp and/or protein of 300mg and CNS (central nervous system) involvement. The key is CNS involvement and bp. Protein is not always indicative of pe because some women just dump protein in the absence of bp issues. The fact that this woman had bp issues, hyperreflexia (which indicates seizure risk according to my peri that has 29 years of experience), edema, and protein. The total clinical picture indicates pe. When it hits your labs and it starts going south, then you may have severe pe.
Sorry but that statement pissed me off. My labor nurse with my last baby told me she had personally reviewed my chart and that I was not preeclamptic according to her. Well I didn't give a damn about what she said, but her delivering a medical opinion in which she was NOT qualified to give endangered my care as a patient. I was under the care of a peri with 29 years of experience and an ob with 10 years of experience. I had a history of severe pe where I almost died with my first child. Severe pih with the second (which is JUST as dangerous as pe), and mild pe with the third. It was decided that we needed to take her before it got bad. My clinical picture was baseline of 110/70 bp before getting pregnant on 5 mg ziac. When I was admitted, my uric acid and creatine levels were high. My bp had risen to 150-160/104-110 on strict bedrest and 10mg ziac and 30mg procardia XL. My protein had a baseline of 0 in 1st and 2nd trimesters. However at 34 weeks it rose to 168. At 35 weeks it was 237. At 34 weeks, I got a severe headache that would not go away, severe constant nosebleeds, vision issues where I was losing sight in an eye or seeing squigglies and stars. I was bad hyperreflexive according to the peri, I was swollen. My peri wanted to deliver at 34 weeks 6 days. I refused and my ob agreed I could wait a few more days. At my next ob appt 5 days later, I was given 2 choices. Stay pregnant, get sicker, have labs worsen, have an emergency delivery and have lab work done every two days till I was critical or agreed to delivery OR agree to an amnio in two days at the peri and deliver immediately if lungs were mature. I chose the amnio route. My ob personally called the peri to arrange it. It was nice not being severe. Every nurse that came into contact with me during the hospital stay gave me the same you are preeclamptic stay in bed, labs drawn, etc. EXCEPT the labor nurse. She said nothing was wrong with me. At the very least I was PIH. Had I been a patient that did not know any better. I could have said nope no induction today (I did not want an induction again at 36 weeks)and could have walked out because of her. Good thing I didn't listen to her. My bp spiked after delivery to 160-170/120s. So it was good I got her out when I did.
If your patient has a seizure, that is called ECLAMPSIA not preeclampsia. That requires immediate medical attention, delivery and is an emergency. Not all patients have lab work (blood work) that indicates pe. Remember 140/90 twice in a 6 hour period or 30/15 over baseline bp, and/or protein in urine, and CNS involvement. CNS and bp are more indicative of seizure risk. Medical staff that makes statements that your labs are ok and you are not preeclamptic endanger patients. There are many stories of this on the pe website. Only for those patients babies to die or for them to die themselves. When the lab work goes bad, delivery is imminent because your patient is becoming severe. No one can tell you at what bp or bloodwork level or protein level you will seize at.
If you want more information, please see www.preeclampsia.org. They have free cmes on the website you can take.
Oh and if you check with the leading DOCTORS on pe (check with the pe website again). Women can not cause pe to happen to them. By saying that a woman's anxiousness can cause the hypereflexia, bp issues, swelling, and protein in her urine is crazy. Yes, stress can cause bp to go up. The rest. That is like saying a woman is stressing herself out and caused pe. If you were my nurse, you would be relieved of duty. Nothing pisses off a pe patient more than a nurse telling them that they are too anxious, that anxiety is causing this, etc. The reason is unknown why pe happens. It is thought to have to do with the placenta not implanting correctly and or possibly autoimmune issues. To tell a patient this or to imply they are too anxious is bad medical care. Yes this happens all too often. Most of the time, the baby and mom are ok. Sometimes, they arn't. It was because someone told them they were too anxious or stressed out. I am sure you are a good nurse. Keep those opinions to yourself. Patients don't need to have nurses undermining their provider.
At your cervix nurse, I know you understand the implications and are a good nurse.
I'm not a nurse, so it's hard for me to truly sympathize with this patient. I'm wondering how she's going to give birth and deal with the pain, etc. if she can't tolerate a needle stick. That's just something you do throughout your entire pregnancy - the first of many uncomfortable things you will deal with in pregnancy, childbirth and being a parent in general. I think this poor woman needs help - some form of therapy, perhaps? - to help her get over her fear and maybe realize that it's irrational, and completely necessary sometimes, to have an IV. What would she have done had she been facing death? She should have seen me at my birth, then - they took six tries to get a needle stick (and I don't have a phobia) all while I was completely dilated with a footling breech as they were prepping me for a c-section! Pretty awful!
At any rate, I admire your patience and compassion and dedication to your patients. I know I would have lost my cool and that would have been the end of it.
Thank you for this, really. I'm 34 and have avoided pregnancy (until 12 weeks ago) because of my needle phobia, despite wanting a child for so many years. I still haven't gathered the courage for an office visit, or blood work, but I'm really trying. It's comforting to know that nurses can be compassionate and understanding, and they aren't silently judging needle phobes as 'wimps' or worse, self indulgent brats. Hearing your side makes me feel a little braver. :)
i'm loving all the condescending attitude on this post and comments!!!! :D
obviously yall have never had a phobia so severe that you've seriously considered/attempted SUICIDE just to avoid it. do you think we want to be this way? do you think we can just 'buck up' and get through it? if you had a 'needle phobia' that you just 'sucked it up,' you didn't have a phobia, period. the end. this has nothing to do with maturity. BELIEVE ME, if i didn't have to be this way, I WOULDN'T. there's nothing self-indulgent about it. i WANT to be able to have lab tests done without having day-long panic attacks (HAVE YOU EVER HAD A SERIOUS CANNOT-BREATHE-TOTALLY-WILIN-OUT-IMPOSSIBLE-TO-QUIT-CRYING PANIC ATTACK FOR 24 HOURS? I HAVE). i WANT to be able to have an appointment for a needle prick without researching the most painless ways to kill yourself. OKAY? CHRIST. i am SO SICK of this condescending attitude i've come across AGAIN AND AGAIN AND AGAIN. maybe if you people had SOULS and TRIED TO HELP, it wouldn't be so bad for people with this affliction.
for the next time you have a needle-phobic patient, AND YOU WILL, EDUCATE YOURSELF, and at least try/offer some damn EMLA cream.
info on needlephobia here - Needlephobia
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