Where, oh where would we be without our computers and technology. Back in the dark ages, I suppose.
The computer system for the fetal monitors was out - back on for 5 minutes - out again - lather, rinse, repeat.
All. Day. Long.
All evening. Then again on nights.
And wouldn't you know it, but the unit was busy as all heck. Every bed full. Short staffed. Well, actually we were fully staffed, but we needed at least 3 or 4 more nurses to make up for the fact that our centralized monitoring was on/off/on/off. Of course, almost every c-section (of which there were far too many to count) had some kind of complication/hemorrhage. All uteri were still present and accountable when surgery was complete, thank goodness. AKA, no c-hysters. And we got unexpected transfers from other units. And the laboring women (in active labor no less, no false labor) came in 2x2.
The charge nurse was all frazzled. I don't blame her.
At one point, there were two people doing charge, but neither could be found. Taking care of patients, yo. And the secretary wanted to know where to put the several pregnant ladies who arrived unannounced, that are standing right in front her. And the phones kept ringing.......
No nurse got to sit down, much less pee or eat. Some of us (ahem, moi) scarfed down food while multi-tasking with patient care. Why yes, my mouth is full, can I refill your water pitcher for you?
My automatic BP cuff in one room stopped working. The wall unit was so outdated that the latex was dry rotted and that didn't work. Had to find the lone portable vital signs/EKG machine -- of course, it doesn't cross over into the computerized charting, so all vital signs on my client needed to be manually entered. Did I mention she was sick, sick, sick? I need to keep a super close eye on her vital signs........hello! I need equipment that works!!!
Jump back to my laboring woman's room, because I can't view her fetal monitor strip because the system is down again.......fresh epidural.....have to keep a close eye on baby and on mom's BP readings (which need transcribed over by hand.......grrrrrrrrrrrrrr)..........and find that I don't have a pulse oximeter. The one that is brought to me doesn't fit in the plug/outlet. Oh technology.......you really, really suck.
Jam the fax machine multiple times trying to fax orders to the pharmacy. ::sigh:: REALLY!!??
Night shift comes on and has a freak because the system is on the fritz still. Seriously guys??? You think we didn't try to fix it before you came on? Oh wait, that's right, we were scrambling around trying to safely take care of all of the patients!!
I was so, so, so grateful to be done by then.
Peace. out.
Showing posts with label a day in LandD. Show all posts
Showing posts with label a day in LandD. Show all posts
Friday, May 17, 2013
Friday, April 06, 2012
Stop the presses!!
I absolutely, cannot believe it. It was a "nice" Thursday shift last evening. No crazy families, no one came in drunk or high (patients or family), and there were no fist fights in the hallway (family members). Nurses got to go home early from their shift, and there were no crazy stat-OH-MY-GOD c-sections for the entire shift. How can this be? It was a full moon too!
Oh man, we are so screwed tonight. The Karma Gods and Goddesses will be paying us back in full for having a normal Thursday. Time to pull out the TED hose, prepare to not pee for 8+ hrs straight, and forget about a dinner break. Oh, and coffee? Yeah, forget about that.
Oh man, we are so screwed tonight. The Karma Gods and Goddesses will be paying us back in full for having a normal Thursday. Time to pull out the TED hose, prepare to not pee for 8+ hrs straight, and forget about a dinner break. Oh, and coffee? Yeah, forget about that.
Sunday, December 04, 2011
Reposting: Things overheard on L&D
Ok, so my brain is not working so well on coming up with witty and new posts lately. So, here's an oldie by goodie, a blast from the past.
"This is not a freaking hotel!" ~~ midwife, referring to a woman we were sending home, after a failed elective induction. The woman wasn't happy with the idea of staying overnight to try again in the morning. Then she wasn't happy about going home instead. (Can't make everyone happy, can we now?)
"I just want to be a good mom." ~~ developmentally delayed new post op c/s mom, when asking about pacifiers for her newborn baby who was in the NICU. (This woman broke my heart. I hope she does well with being a mom! She's going to need a lot of extra support and services.)
"Make two fists with your hands and sit on them." ~~ midwife to woman in early labor, who obviously has a very posterior cervix. (Sitting on her fists helps tilt her cervix and pelvis forward, for the midwife to be able to reach her cervix better.)
"I wish I had some roller skates." ~~ one nurse to another nurse, as they pass each other in the long hallway between the labor rooms and triage rooms.
"I didn't know you were working tonight!" ~~ one nurse to another when they finally cross paths, more than halfway into the shift. (Yeah, that's how busy it's been!)
"Is it time for more pain medication yet?" ~~ patient to nurse, several times during the shift. (Patient was not in labor, and had a strong history of drug abuse. Questionable back pain with no apparent cause.)
"Give a good cough for me." ~~ doctor during a speculum exam to check for pooling.
"I'm here to see my sister. No, I don't know her last name." ~~ visitor to secretary. (Ooops, sorry! If you don't know her first AND last name, then we can't help you. No, we can't violate HIPPA by suggesting different last names that match the first name you have provided either.)
Tuesday, January 12, 2010
Things overheard on L&D
"I just want to be a good mom." ~~ developmentally delayed new post op c/s mom, when asking about pacifiers for her newborn baby who was in the NICU. (This woman broke my heart. I hope she does well with being a mom! She's going to need a lot of extra support and services.)
"Make two fists with your hands and sit on them." ~~ midwife to woman in early labor, who obviously has a very posterior cervix. (Sitting on her fists helps tilt her cervix and pelvis forward, for the midwife to be able to reach her cervix better.)
"I wish I had some roller skates." ~~ one nurse to another nurse, as they pass each other in the long hallway between the labor rooms and triage rooms.
"I didn't know you were working tonight!" ~~ one nurse to another when they finally cross paths, more than halfway into the shift. (Yeah, that's how busy it's been!)
"Is it time for more pain medication yet?" ~~ patient to nurse, several times during the shift. (Patient was not in labor, and had a strong history of drug abuse. Questionable back pain with no apparent cause.)
"Give a good cough for me." ~~ doctor during a speculum exam to check for pooling.
"I'm here to see my sister. No, I don't know her last name." ~~ visitor to secretary. (Ooops, sorry! If you don't know her first AND last name, then we can't help you. No, we can't violate HIPPA by suggesting different last names that match the first name you have provided either.)
Tuesday, November 29, 2011
Receiving compliments
I really feel good and proud to be a nurse when I receive feedback and positive comments from the people that I take care of.
Just a few days ago, I had a muslim couple that I was caring for after the birth of their baby. The baby had to go to the NICU for some transitioning, but then I was able to bring him into the parent's room. Immediately (after checking ID bands), I asked the dad if he would like to say his prayers to the baby. He was shocked that I knew about that cultural aspect of muslims. I am always in awe of the different beliefs and customs that surround me every day at my job. The muslim prayers always have been one of my favorites, and they bring tears to my eyes.
Later in the evening, after the father of the baby had left, my patient told me how surprised and happy she and her husband were that I was knowledgeable and open to muslim beliefs after the birth of a baby. To me, it was part of my job. (Making sure that the father said the prayers in the baby's ears before the mother held the baby.) To them, it must have made a huge impression, I suppose, to be treated as individuals, and respected for their beliefs.
Another time, a few weeks ago, one of my co-workers (who is also a midwife student) said that she saw a patient in the office that raved about how wonderful I was during their birth experience. The patient said that she didn't like the doctor, nor the midwife who was on that night when she gave birth --- but absolutely LOVED the nurse (who she described as me, to a "T"). Talk about making *me* feel good!
I know that I do my absolute best to give 110% to the families that I care for, but it is so heartwarming to hear feedback after the birth experience. Unfortunately, as an L&D nurse, I don't see my patients/families again unless they come back to the hospital having another baby.
And this reason (last paragraph) is one of the big reasons why I am becoming a nurse-midwife. I want to be able to see, care for, and interact more with the families than just on the L&D unit. I crave those long term, therapeutic relationships with these wonderful families.
On another note, I ran into the mom of a former patient from L&D, and she gave me an updated picture of the "little" man I helped come into this world. What a big boy he is now! I keep his pictures on my "inspiration board" near my desk at home.
I LOVE WHAT I DO!!!
Just a few days ago, I had a muslim couple that I was caring for after the birth of their baby. The baby had to go to the NICU for some transitioning, but then I was able to bring him into the parent's room. Immediately (after checking ID bands), I asked the dad if he would like to say his prayers to the baby. He was shocked that I knew about that cultural aspect of muslims. I am always in awe of the different beliefs and customs that surround me every day at my job. The muslim prayers always have been one of my favorites, and they bring tears to my eyes.
Later in the evening, after the father of the baby had left, my patient told me how surprised and happy she and her husband were that I was knowledgeable and open to muslim beliefs after the birth of a baby. To me, it was part of my job. (Making sure that the father said the prayers in the baby's ears before the mother held the baby.) To them, it must have made a huge impression, I suppose, to be treated as individuals, and respected for their beliefs.
Another time, a few weeks ago, one of my co-workers (who is also a midwife student) said that she saw a patient in the office that raved about how wonderful I was during their birth experience. The patient said that she didn't like the doctor, nor the midwife who was on that night when she gave birth --- but absolutely LOVED the nurse (who she described as me, to a "T"). Talk about making *me* feel good!
I know that I do my absolute best to give 110% to the families that I care for, but it is so heartwarming to hear feedback after the birth experience. Unfortunately, as an L&D nurse, I don't see my patients/families again unless they come back to the hospital having another baby.
And this reason (last paragraph) is one of the big reasons why I am becoming a nurse-midwife. I want to be able to see, care for, and interact more with the families than just on the L&D unit. I crave those long term, therapeutic relationships with these wonderful families.
On another note, I ran into the mom of a former patient from L&D, and she gave me an updated picture of the "little" man I helped come into this world. What a big boy he is now! I keep his pictures on my "inspiration board" near my desk at home.
I LOVE WHAT I DO!!!
Friday, November 18, 2011
Week 8: winding down
Week 8 of the school term is winding down. Soon to start week #9.
I had an interesting phone conference with several other students and our instructor this week. It was a breastfeeding discussion type of "class". We all had areas regarding breastfeeding that we needed to research and be prepared to answer/discuss. It was interesting to hold a class that way. Except for that "one person" (not me) who kept dominating the conversation. I really hate that. Please be quiet - you don't have to answer or relate a story to each question/topic. Thank you. (Although, I do get your enthusiasm.)
Women's health is moving along swimmingly. Working this week on abnormal uterine bleeding and the sundry of medical diagnoses that are related to that topic. Next week, I'll be continuing with this topic, because it is such a broad area of women's health. Next week: test for this material, and submit a written case study. Fun fun! Believe it or not, I am really loving this women's health class. I didn't think I would enjoy it as much, but I know I have definitely found my calling when I can enjoy the variety of gyn related topics.
On the work front --- I've been the triage queen again. I actually don't mind working triage. It's a pretty hopping, busy place to be! Keeps my assessment skills fine-tuned. I also notice that so many women in their 2nd trimester have bladder infections. Of course, we have to work them up for preterm labor, and rule that out as well. But, more often than not, many (if not all) of these women lately have been discharged with a diagnosis of a UTI.
I also like triage because, quite simply, it keeps me busy. It makes the whole shift go so fast. Here is my issue: if things get s-l-o-w, I get b-o-r-e-d. Keep it busy, keep me moving, and I am a happy girl.
One more shift this week, then 2 lovely days off to get caught up on my studying!
I had an interesting phone conference with several other students and our instructor this week. It was a breastfeeding discussion type of "class". We all had areas regarding breastfeeding that we needed to research and be prepared to answer/discuss. It was interesting to hold a class that way. Except for that "one person" (not me) who kept dominating the conversation. I really hate that. Please be quiet - you don't have to answer or relate a story to each question/topic. Thank you. (Although, I do get your enthusiasm.)
Women's health is moving along swimmingly. Working this week on abnormal uterine bleeding and the sundry of medical diagnoses that are related to that topic. Next week, I'll be continuing with this topic, because it is such a broad area of women's health. Next week: test for this material, and submit a written case study. Fun fun! Believe it or not, I am really loving this women's health class. I didn't think I would enjoy it as much, but I know I have definitely found my calling when I can enjoy the variety of gyn related topics.
On the work front --- I've been the triage queen again. I actually don't mind working triage. It's a pretty hopping, busy place to be! Keeps my assessment skills fine-tuned. I also notice that so many women in their 2nd trimester have bladder infections. Of course, we have to work them up for preterm labor, and rule that out as well. But, more often than not, many (if not all) of these women lately have been discharged with a diagnosis of a UTI.
I also like triage because, quite simply, it keeps me busy. It makes the whole shift go so fast. Here is my issue: if things get s-l-o-w, I get b-o-r-e-d. Keep it busy, keep me moving, and I am a happy girl.
One more shift this week, then 2 lovely days off to get caught up on my studying!
Monday, September 05, 2011
Pushing and pushing - oh yeah! It's a BABY!
I haven't had many births on my shifts for the past week or so. A few, but not many. I've taken care of quite a few laboring women though! I seem to be having a run of getting them through their labor, and towards the 2nd stage, but not quite at the pushing part yet. Which is my favorite part - unless it's lasting fooorrrevvvverrrr.
One thing that is tiring for everyone involved: pushing with a first time mother who has a dense epidural, and it takes her 2-3 hours to finally push her baby out. Sometimes that is WITH laboring down (passive descent), and WITH various position changes to help ensure the most optimal fetal position and rotation into that position for birth. Women in this situation get tired, they get discourage, and they often tell me that they just can't do it anymore. I try and try and try to be the best cheerleader, being encouraging, and describing what type of progress I'm able to see. What usually helps a woman connect to her baby is when I have the father look and tell her how much hair the baby has & what color it looks to be! That usually gives a woman that extra ummph and energy to push her baby down some more. It's almost like - oh yeah - we're having a BABY!!!
One thing that is tiring for everyone involved: pushing with a first time mother who has a dense epidural, and it takes her 2-3 hours to finally push her baby out. Sometimes that is WITH laboring down (passive descent), and WITH various position changes to help ensure the most optimal fetal position and rotation into that position for birth. Women in this situation get tired, they get discourage, and they often tell me that they just can't do it anymore. I try and try and try to be the best cheerleader, being encouraging, and describing what type of progress I'm able to see. What usually helps a woman connect to her baby is when I have the father look and tell her how much hair the baby has & what color it looks to be! That usually gives a woman that extra ummph and energy to push her baby down some more. It's almost like - oh yeah - we're having a BABY!!!
Saturday, July 16, 2011
I am beat!
How can I say that I am totally beat, when I *only* worked three evenings in a row? Well, I can say that I'm totally beat, because those three shifts kicked me in the patooty!! And they kicked me hard and repeatedly.
I hate to say it, but I cannot remember many of the women I took care of on those three shifts. There were a couple of c-sections in there (I circulated) with a doc that must have a 100% c-section rate when he's on call. (Sigh.)
I worked in triage for part of some of the shifts (how's that for vague, I can't even recall if it was a whole shift, or several partials......I think it was several partials). Yeah, sometimes they run us ragged -- do this birth, then go to triage, oh wait -- now I have this lady who is 5cm and needs a labor nurse to admit her.
You kind of get the idea, right?
Oh wait, I did have two first time mothers who pushed for less than 10 minutes each. Over relatively intact perineums too! (Just some minor skid marks.) That was totally awesome to have not one, but TWO first time moms who were able to push so quickly and effectively!
I swear to you, if it wasn't for the awesome times on L&D and my passion for birth, I would leave this unit in a heartbeat. It has just drained me this week.
I hate to say it, but I cannot remember many of the women I took care of on those three shifts. There were a couple of c-sections in there (I circulated) with a doc that must have a 100% c-section rate when he's on call. (Sigh.)
I worked in triage for part of some of the shifts (how's that for vague, I can't even recall if it was a whole shift, or several partials......I think it was several partials). Yeah, sometimes they run us ragged -- do this birth, then go to triage, oh wait -- now I have this lady who is 5cm and needs a labor nurse to admit her.
You kind of get the idea, right?
Oh wait, I did have two first time mothers who pushed for less than 10 minutes each. Over relatively intact perineums too! (Just some minor skid marks.) That was totally awesome to have not one, but TWO first time moms who were able to push so quickly and effectively!
I swear to you, if it wasn't for the awesome times on L&D and my passion for birth, I would leave this unit in a heartbeat. It has just drained me this week.
Thursday, June 16, 2011
Things you won't hear your L and D nurse say (but she's thinking them)
What I'm thinking versus what I really say
I have never seen something like that before!
Well, that's interesting.
What IS that?!?
I'm not quite sure. Let me get your doctor or midwife.
All 20 of your visitors are your labor support? Sure.
That's wonderful that you have so many supportive people to help you through labor.
Grandma is drunk. I can smell it from 10 feet away.
Grandma, you look a little tired. Can I show you to our waiting room so you can rest your feet for a bit.
Oh crap! A cord prolapse!
Apparently, the cord is coming out first. This is urgent, and we need to go for a c-section right now. A lot of people are going to be coming in to get you ready, so don't panic. I'll be right here with you.
Oh crap! SHOULDER DYSTOCIA!
We need to get your legs far back and you need to push really hard now, alright?
Oh crap! This is a LOT of bleeding! Why won't it stop???
It appears that you're having some extra bleeding.
Where is the doc when I really need him/her??
The doctor is on his way.
Of course your doctor will be with you all throughout your labor - NOT.
Your nurse is with you for the majority of your labor. The doctor comes in when you're close to the birth.
I have no clue what I'm feeling (during a cervical check).
I can't quite reach your cervix. Do you mind if I have another nurse check?
I hope I never see that again.
Well, that was interesting.
This is the first time I'm doing this.
I've done this lots of times.
What a funny looking kid!
Oh look, he has your eyes!
The call bell needs to be taken away from you. You're on it every 2 minutes!
Is there anything I can get for you?
Your pain is 10/10? Seriously? I don't believe you when you're on the phone and laughing with your "guests".
.....blink blink....... What have you done to help ease your pain?
History of rapid births. Better have everything set up 20 minutes ago!
Tell me when you feel like the baby is coming, I trust you 110%!
She has five kids already, working on #6. And she's not old enough to drink. Hip hip hurray for welfare!
What method of birth control do you plan on using after the baby is born? (Not a normal question when admitting a laboring woman. But very pertinent.) Oh, you haven't thought about that? Let's review your options.........
Aw crap! Another laboring patient. We are packed to the gills with no spare labor rooms. WTF are we doing to do??
Hi there! How can I help you?
Ahhhh, the wheelchair sign. She's either 10 cm or has a closed cervix. I'm betting on the closed cervix.
Hi there! How can I help you?
Ahhhh, the positive towel test. She's definitely ruptured her membranes!
Let's get you into a room right away.
Your doctor is an ass. I wouldn't let him touch me, even if I was dying.
All of his patients seem to really like him.
A multip who is breech, and in active labor at 6 cm, and is sectioned. WTF didn't he deliver her vaginally?!
You should be able to have a VBAC next time, if you choose.
Friday, February 11, 2011
Day 2 of "orientation" to charge/Day 3
Well, day 2 of orientation was just like day 1. In other words: no orientation, just thrown to the wolves.
Day 3 (officially off orientation, even though I technically never was oriented), and I was in tears and ready to totally quit nursing one hour into the shift. Seriously. I threw my badge down and everything.
I asked another (much more experienced) nurse to please, please, take over charge and she did. She even admitted that the unit was absolutely dangerous. Too many patients, and not nearly enough nurses. So, at least I know it wasn't me!!!
What was my final straw that said "enough, I quit"? One bed left, and in rolls a preterm patient who was completely dilated. And we're supposed to be staffing for a c-section (not emergent), and we didn't have nurses available for either the fully dilated pretermer or the c-section. Oh, and a day shift nurse tells me that the patient assignment that she had, that I gave to the oncoming evening nurse, was not possible for the evening nurse to do. Really? You did it. Why can't she? (Yes, I know, that is almost a "nurse eating their young" type of attitude, but what more could I do at that point?)
I also had just received report on one of my two patients (she needed to be weaned off of magnesium sulfate and a terbutaline pump started), and my 2nd patient hadn't even been put on the monitor yet, and she had admission labs and an IV (as well as the full admission) to be started.
And in rolls the completely dilated pretermer. The doc chomping at the bit to go examine her. I actually told the doc to hold her horses. I can't pull a nurse out of my ass to assist you right now. I ended up going in with her, then pulling another nurse from her own lesser acuity assignment to go in and have the birth with the preterm mother.
Then I cried. Threw down my badge and said that I quit. Get the managers to come back in, get them to take care of it all, I CANNOT DO IT!!!
I cried, explained to the manager and nursing supervisor that I absolutely refuse to do charge nurse duties. It's unsafe and I was never properly oriented. I should have refused to be "oriented" the way I was (not) in the two previous days. The other, more experienced nurse took over charge duties, while I finished crying. Then I went about my day and took care of my two assigned patients.
I also wrote an email to the unit manager, clinical manager, and unit educator telling them what happened, and that until I am actually TRULY oriented to charge duties, I REFUSE to accept charge nurse assignment. I reiterated that the staffing is chronically short staffed, and the patient acuity level remains too high for the unit to be run safely. I emphasized UNSAFE and SHORT STAFFED several times. I know it's like talking to a deaf ear, but I at least started a paper trail.
Next: writing to the chief nursing officer and the CEO of the hospital.
Running an acute care unit with fluctuating patient acuity levels with a chronically short staffed nursing staff is WRONG. It is DANGEROUS. We cannot keep running this unit like this.
Day 3 (officially off orientation, even though I technically never was oriented), and I was in tears and ready to totally quit nursing one hour into the shift. Seriously. I threw my badge down and everything.
I asked another (much more experienced) nurse to please, please, take over charge and she did. She even admitted that the unit was absolutely dangerous. Too many patients, and not nearly enough nurses. So, at least I know it wasn't me!!!
What was my final straw that said "enough, I quit"? One bed left, and in rolls a preterm patient who was completely dilated. And we're supposed to be staffing for a c-section (not emergent), and we didn't have nurses available for either the fully dilated pretermer or the c-section. Oh, and a day shift nurse tells me that the patient assignment that she had, that I gave to the oncoming evening nurse, was not possible for the evening nurse to do. Really? You did it. Why can't she? (Yes, I know, that is almost a "nurse eating their young" type of attitude, but what more could I do at that point?)
I also had just received report on one of my two patients (she needed to be weaned off of magnesium sulfate and a terbutaline pump started), and my 2nd patient hadn't even been put on the monitor yet, and she had admission labs and an IV (as well as the full admission) to be started.
And in rolls the completely dilated pretermer. The doc chomping at the bit to go examine her. I actually told the doc to hold her horses. I can't pull a nurse out of my ass to assist you right now. I ended up going in with her, then pulling another nurse from her own lesser acuity assignment to go in and have the birth with the preterm mother.
Then I cried. Threw down my badge and said that I quit. Get the managers to come back in, get them to take care of it all, I CANNOT DO IT!!!
I cried, explained to the manager and nursing supervisor that I absolutely refuse to do charge nurse duties. It's unsafe and I was never properly oriented. I should have refused to be "oriented" the way I was (not) in the two previous days. The other, more experienced nurse took over charge duties, while I finished crying. Then I went about my day and took care of my two assigned patients.
I also wrote an email to the unit manager, clinical manager, and unit educator telling them what happened, and that until I am actually TRULY oriented to charge duties, I REFUSE to accept charge nurse assignment. I reiterated that the staffing is chronically short staffed, and the patient acuity level remains too high for the unit to be run safely. I emphasized UNSAFE and SHORT STAFFED several times. I know it's like talking to a deaf ear, but I at least started a paper trail.
Next: writing to the chief nursing officer and the CEO of the hospital.
Running an acute care unit with fluctuating patient acuity levels with a chronically short staffed nursing staff is WRONG. It is DANGEROUS. We cannot keep running this unit like this.
Thursday, January 27, 2011
Woe is me
I'm really not so sure about this charge nurse thing. I was told when I arrived on a recent shift that I was to be in charge. I think I've done charge (maybe?) three times. Those times were only because there was no one available who did charge, and I was the most likely choice to do it. I haven't been trained or oriented to do charge. It was kind of a "toss her in there and do it" situation.
So, I did it again. Tossed in to be in charge. I need to be paired up with an experienced charge nurse for several shifts, before I can feel like I'm really doing things right. It's like I'm putting out fires left and right for the entire 8 hours.
Initial patient assignments........planning for emergencies (like a c-section, which takes 2-3 nurses off the floor).....readjusting those assignments and emergency contingencies when the patient population and acuity levels change yet again. Getting everyone dinner coverage. Making physicians happy about if they can do a non-urgent c-section now or later. Stat c-section on another patient (we actually did REALLY well on this one!). Walk-in patients who we had no idea were coming now need a nurse, and I have none left to spare.
Oh, and to top it all off? A call off for night shift. I try to call the on call manager to come in for nights, and she refuses. I call the nursing supervisor, and between the two of us, we make some last minute phone calls to try to get ANY nurse to cover ANY part of nights. No go. Argue back and forth with the on call manager, who really needs to come in, and she still refuses. Too bad, so sad. You're on call, and we can't get any other nurse to come in and we are poorly staffed as it is for nights, and now with a call off? You have to come in!
When I left, the night shift charge nurse was still arguing with the on call manager about her having to come in. How can a manager get away with refusing to come in, when she's on call? I just don't get it!! If it was a "regular" nurse on call, who refused to come in, she would be written up and reprimanded, possibly even put on suspension.
All of the above, plus the charge nurse taking care of patients too? Totally NOT worth the extra $1/hr. Not one bit.
So, I did it again. Tossed in to be in charge. I need to be paired up with an experienced charge nurse for several shifts, before I can feel like I'm really doing things right. It's like I'm putting out fires left and right for the entire 8 hours.
Initial patient assignments........planning for emergencies (like a c-section, which takes 2-3 nurses off the floor).....readjusting those assignments and emergency contingencies when the patient population and acuity levels change yet again. Getting everyone dinner coverage. Making physicians happy about if they can do a non-urgent c-section now or later. Stat c-section on another patient (we actually did REALLY well on this one!). Walk-in patients who we had no idea were coming now need a nurse, and I have none left to spare.
Oh, and to top it all off? A call off for night shift. I try to call the on call manager to come in for nights, and she refuses. I call the nursing supervisor, and between the two of us, we make some last minute phone calls to try to get ANY nurse to cover ANY part of nights. No go. Argue back and forth with the on call manager, who really needs to come in, and she still refuses. Too bad, so sad. You're on call, and we can't get any other nurse to come in and we are poorly staffed as it is for nights, and now with a call off? You have to come in!
When I left, the night shift charge nurse was still arguing with the on call manager about her having to come in. How can a manager get away with refusing to come in, when she's on call? I just don't get it!! If it was a "regular" nurse on call, who refused to come in, she would be written up and reprimanded, possibly even put on suspension.
All of the above, plus the charge nurse taking care of patients too? Totally NOT worth the extra $1/hr. Not one bit.
Monday, January 24, 2011
Placental abruption, from the nurse's point of view
It was change of shift, and I was just starting out my shift on L&D. *Annie and her husband *Frank (*names changed*) had also just arrived on L&D. Annie had noticed some vaginal bleeding, and she and her husband were concerned about this, so they decided to come in to be evaluated.
Annie had a known history of a partial, but stable, placental abruption. I walk in the room to find two nurses valiantly trying to establish an IV site and maintain fetal heart tones.
**thump...thump...thump**
The fetal heart monitor is kicking out a too slow rate ~ about 80-90 beats per minute. Oxygen is on and one of the nurses turns Annie on to her side.
**thump.........thump..............thump**
Even slower.
I jump in and deftly insert an 18 g IV site, pulling various tubes of blood off of the line, then hook up IV fluids.
**thump..................thump............................thump**
Slower and slower.
We race Annie back to the OR. Her poor husband Frank, bless him, understood the implications of what was happening.
Everyone is rushing around in the OR, working to get Annie transferred to the OR table, catheter placed, instruments at the ready. Annie looks around, about ready to burst into tears. I'm on the phone with the NICU, telling them we have a STAT c/s for an abruption, hearts are down.
I walk over to Annie, get down close to her ear, gently touch her arm and hand, and whisper to her:
"My name is ____. I know it's very scary right now, but we're doing many different things at one time to help get your baby out. You're going to feel the catheter go into your bladder in just a second here - it's going to burn and hurt for a minute. Cold gel on your belly as we listen to your baby's heartbeat - listen to that! It's up again at 120 beats per minute. That's very good!"
Annie nods her head, tears welling in her eyes. "His name is Matthew."
"The baby?" I ask her.
"Yes, his name is Matthew."
"Annie, we're going to work very quickly now to get Matthew out, and we will take very good care of him and you. You're going to go to sleep in a just a few seconds here, but I will be with you and Matthew the whole time."
"Save my baby," she says, as we tightly grip each others hands.
Cold antiseptic solution is splashed on her belly as Annie is quickly put under general anesthesia.
**incision!**
**membranes ruptured - bloody fluid!**
**baby!**
An immediate lusty cry is heard as baby Matthew is born.
Audible sighs of relief can be heard throughout the room as Matthew is dried off and assessed by the NICU team.
Frank, now a proud new papa, is escorted into the OR to greet his new son.
**smiles**
A very positive outcome for a situation that could have been much more dire.
Times like these make me feel very honored to be present at the amazing miracle of birth.
Happy birthday Matthew!
Annie had a known history of a partial, but stable, placental abruption. I walk in the room to find two nurses valiantly trying to establish an IV site and maintain fetal heart tones.
**thump...thump...thump**
The fetal heart monitor is kicking out a too slow rate ~ about 80-90 beats per minute. Oxygen is on and one of the nurses turns Annie on to her side.
**thump.........thump..............thump**
Even slower.
I jump in and deftly insert an 18 g IV site, pulling various tubes of blood off of the line, then hook up IV fluids.
**thump..................thump............................thump**
Slower and slower.
We race Annie back to the OR. Her poor husband Frank, bless him, understood the implications of what was happening.
Everyone is rushing around in the OR, working to get Annie transferred to the OR table, catheter placed, instruments at the ready. Annie looks around, about ready to burst into tears. I'm on the phone with the NICU, telling them we have a STAT c/s for an abruption, hearts are down.
I walk over to Annie, get down close to her ear, gently touch her arm and hand, and whisper to her:
"My name is ____. I know it's very scary right now, but we're doing many different things at one time to help get your baby out. You're going to feel the catheter go into your bladder in just a second here - it's going to burn and hurt for a minute. Cold gel on your belly as we listen to your baby's heartbeat - listen to that! It's up again at 120 beats per minute. That's very good!"
Annie nods her head, tears welling in her eyes. "His name is Matthew."
"The baby?" I ask her.
"Yes, his name is Matthew."
"Annie, we're going to work very quickly now to get Matthew out, and we will take very good care of him and you. You're going to go to sleep in a just a few seconds here, but I will be with you and Matthew the whole time."
"Save my baby," she says, as we tightly grip each others hands.
Cold antiseptic solution is splashed on her belly as Annie is quickly put under general anesthesia.
**incision!**
**membranes ruptured - bloody fluid!**
**baby!**
An immediate lusty cry is heard as baby Matthew is born.
Audible sighs of relief can be heard throughout the room as Matthew is dried off and assessed by the NICU team.
Frank, now a proud new papa, is escorted into the OR to greet his new son.
**smiles**
A very positive outcome for a situation that could have been much more dire.
Times like these make me feel very honored to be present at the amazing miracle of birth.
Happy birthday Matthew!
Tuesday, December 14, 2010
Updates on work and school
Have I really not written a post since last Thursday? Oh my goodness - no, I haven't! I've been so crazy busy with being back at work plus working on finishing up my assignments for this term.
L&D: super duper busy! We have been seeing a whole lot of preterm labor and premature rupture of membranes. I recently had a pre-viable birth, where the baby was not expected to survive the birth. Little one held on and on for almost two hours after she was born. So sad.
I'm pursuing further training at work to become a grief counselor for women who have any type of infant death (IUFD, stillborn, pre-viable babes who die after birth, neonatal deaths). It's going to be two full days of education next month, and then I'll be an official grief counselor. There are several nurses on L&D with this distinction already. I am actually looking forward to learning more about the grief process, and how I can support women and families in their time of need.
School: also super duper busy! I finished up my pharmacology course. WHEW! It was a lot of reading, studying and testing for this course. I learned so, so, so much! As for my midwifery community assessment course ~~ I worked for 10 hours yesterday on writing up my final paper for that class. This paper goes in depth into the Healthy People 2010 maternal child health indicators, and all of the statistics and data analysis of the results. Plus, we had to come up with a plan of how midwifery could help with one of the MCH indicators. I chose reduction of preterm births for my topic. Eh. I have to edit the paper a bit, and fine tune the conclusion before I submit it. 29 pages, including title page and four pages of references. Talk about a big headache.
Next term starts in about 4 weeks. I'm only taking one course, but it's a biggie: Antepartum Care. YEAH!!! Just got my Varney's Midwifery book in the mail yesterday too. I am so ready to dive into the meat and potatoes of my education: the midwifery content.
Bring it on!!!
Monday, October 04, 2010
Birthin' them babies
Was it a full moon last night? It sure felt like it! It was the night of precipitous births. I literally caught one baby, then went in to hook another mom up to the monitor when she also precipitously delivered! There were several more moms who walked in/wheeled in and quickly gave birth to their babies as well. There were so many that I lost count of the total in the unit. At least 5 or 6 within an hour or so. We were slammed.
Lots of babies keep the nurses in business!
Oh, and can I say, "high five" to the mom who was told she needed a repeat c/s, but instead VBAC'd successfully. Your body was made for birthin'!!!!
Thursday, August 26, 2010
A premonition or just being prepared?
Something told me to be prepared for a shoulder dystocia. I honestly can't say what exactly told me to be ready. The pushing was going good, albeit slow. The baby was thought to be LGA (large for gestational age), but shoulder dystocia can happen with even the smallest of babies.
But nevertheless, I pulled the step stool next to the bed, and visually located the emergency button. I also made sure the regular call bell was within my arm's reach.
I had a family member holding each of the mom's legs with pushing, leaving me free to be able to call for help and perform suprapubic pressure if needed.
I had the attending in the room, watching over the resident who was catching the baby.
Then.......*the sign*.
The turtle sign: when the head slowly emerges, but then seems to be partially sucked back in to the vaginal opening. In other words, the anterior (top) shoulder of the baby is stuck and the baby cannot fit through and finish being born.
Shoulder dystocia.
I jump up on the step stool, tell the family members to pull mom's legs back even more (McRobert's), and look at the resident, who nods his head for me to do suprapubic pressure. I hit the call bell (can't reach the emergency one - it's on the wall) and yell out "SHOULDERS!!!!". This is the key point where additional staff come in to assist.
No one comes.
McRobert's continues, I apply suprapubic pressure, and the resident does his thing with maneuvering the shoulders. Time from head delivery to complete delivery is about a minute. It feels like time moves so slow when it's happening though.
Baby's out! Clamp and cut (ugh, how do we convince docs to leave it intact for the extra blood, especially with a compromised baby?!?), and I work on resuscitation of the baby under a warmer.
Wipe off the baby (tactile stimulation).
Bulb syringe (clear airway of mucous).
Rub baby some more (tactile stimulation).
(Where are my helpers? Hello? Anyone coming??)
Baby cries a lusty cry and pinks up.
Whew!!
Excellent Apgar scores. Physical assessment of baby shows equal strength and movement to both arms. Clavicles feel intact. Quickly weigh and measure baby, then wrap her up and give her back to her mother.
All in a day's work folks. All in a day's work.
But nevertheless, I pulled the step stool next to the bed, and visually located the emergency button. I also made sure the regular call bell was within my arm's reach.
I had a family member holding each of the mom's legs with pushing, leaving me free to be able to call for help and perform suprapubic pressure if needed.
I had the attending in the room, watching over the resident who was catching the baby.
Then.......*the sign*.
The turtle sign: when the head slowly emerges, but then seems to be partially sucked back in to the vaginal opening. In other words, the anterior (top) shoulder of the baby is stuck and the baby cannot fit through and finish being born.
Shoulder dystocia.
I jump up on the step stool, tell the family members to pull mom's legs back even more (McRobert's), and look at the resident, who nods his head for me to do suprapubic pressure. I hit the call bell (can't reach the emergency one - it's on the wall) and yell out "SHOULDERS!!!!". This is the key point where additional staff come in to assist.
No one comes.
McRobert's continues, I apply suprapubic pressure, and the resident does his thing with maneuvering the shoulders. Time from head delivery to complete delivery is about a minute. It feels like time moves so slow when it's happening though.
Baby's out! Clamp and cut (ugh, how do we convince docs to leave it intact for the extra blood, especially with a compromised baby?!?), and I work on resuscitation of the baby under a warmer.
Wipe off the baby (tactile stimulation).
Bulb syringe (clear airway of mucous).
Rub baby some more (tactile stimulation).
(Where are my helpers? Hello? Anyone coming??)
Baby cries a lusty cry and pinks up.
Whew!!
Excellent Apgar scores. Physical assessment of baby shows equal strength and movement to both arms. Clavicles feel intact. Quickly weigh and measure baby, then wrap her up and give her back to her mother.
All in a day's work folks. All in a day's work.
Wednesday, August 18, 2010
Sometimes, you just can't predict what will happen
What are the odds that two different potentially catastrophic obstetrical emergencies could happen within just a few days?
It makes me wonder.........
One cord prolapse after SROM, and one spontaneous uterine rupture (no labor), all in a span of just a few days. Seriously! No precipitating factors, and not caused by medical interventions. Just....BOOM!
Wow, wow, wow. I'm constantly amazed at how normal things can turn bad in a moment.
I have honestly only ever seen two uterine ruptures in my 9+ years in OB. Just two! One with no prior uterine incision, one with a prior incision.
Cord prolapse? I can count on one hand how many of those I have witnessed in my years as a nurse.
That's how rare these two events can be. Some nurses never see either event in their career. I'm just so grateful for such fantastic co-workers who pull together in emergencies like these. We can get a baby out in less then 10 minutes, from the time a cord prolapse is discovered. Everyone does their role beautifully.
Best of all? We have some of the most amazing maternal and neonatal outcomes!
I'm so glad to experience not only the good in my job, but also these dire medical and obstetrical emergencies. I believe that these experiences will help me to be the absolute best nurse-midwife I can be in the future.
It makes me wonder.........
One cord prolapse after SROM, and one spontaneous uterine rupture (no labor), all in a span of just a few days. Seriously! No precipitating factors, and not caused by medical interventions. Just....BOOM!
Wow, wow, wow. I'm constantly amazed at how normal things can turn bad in a moment.
I have honestly only ever seen two uterine ruptures in my 9+ years in OB. Just two! One with no prior uterine incision, one with a prior incision.
Cord prolapse? I can count on one hand how many of those I have witnessed in my years as a nurse.
That's how rare these two events can be. Some nurses never see either event in their career. I'm just so grateful for such fantastic co-workers who pull together in emergencies like these. We can get a baby out in less then 10 minutes, from the time a cord prolapse is discovered. Everyone does their role beautifully.
Best of all? We have some of the most amazing maternal and neonatal outcomes!
I'm so glad to experience not only the good in my job, but also these dire medical and obstetrical emergencies. I believe that these experiences will help me to be the absolute best nurse-midwife I can be in the future.
Tuesday, August 17, 2010
Working well as a team - KUDOS!!
I love when we work together as such a cohesive team when the crap hits the ceiling on L&D.
Case in point: a recent "hypothetical scenario" of a potentially very catastrophic event. Each and every person on my L&D unit pulled together and turned what could have been certain death for a mother and baby into a much happier ending. One nurse worked on fetal heart tones and maternal interventions, another nurse got the IV in place, another was on the phone with the doctor to update and get him to the bedside, 2-3 more got the OR ready.
We worked WELL as a TEAM. Each person doing what needed done to help save not one, but two lives.
WELL DONE LADIES!!!
Case in point: a recent "hypothetical scenario" of a potentially very catastrophic event. Each and every person on my L&D unit pulled together and turned what could have been certain death for a mother and baby into a much happier ending. One nurse worked on fetal heart tones and maternal interventions, another nurse got the IV in place, another was on the phone with the doctor to update and get him to the bedside, 2-3 more got the OR ready.
We worked WELL as a TEAM. Each person doing what needed done to help save not one, but two lives.
WELL DONE LADIES!!!
Tuesday, August 10, 2010
Things that make me happy
When a baby latches on to the breast easily with no assistance.
When I work hard with a mom to breastfeed for the first time, and with lots of support, the baby latches on.
When educating a mom about pros and cons of breast vs bottle feeding, and she decides to give breastfeeding a try.
Mom and baby have extended skin-to-skin time after birth.
A posterior lying baby spins and is born OA - vaginally.
Pushing phase in a primip that is less than one hour.
Laboring down!
Helping a woman achieve birth goals that she has set, no matter what those goals are.
Making a difference to a new family.
Turning a negative experience into a positive one.
Teaching labor support to family members at a birth & seeing them apply those learned techniques.
Purple - cause it's my favorite color. Just not in newborn babies.
Taking the "difficult patient", finding out what she needs, and being able to give that to her.
Being able to provide some semblance of normalcy in a big hospital setting.
When my favorite CNM tells me how much she loves it when I am caring for her patients - and she tells me this in front of the patient.
Oh heck, just working with my favorite CNM makes me happy!
Being a silent witness to miracles.
When I work hard with a mom to breastfeed for the first time, and with lots of support, the baby latches on.
When educating a mom about pros and cons of breast vs bottle feeding, and she decides to give breastfeeding a try.
Mom and baby have extended skin-to-skin time after birth.
A posterior lying baby spins and is born OA - vaginally.
Pushing phase in a primip that is less than one hour.
Laboring down!
Helping a woman achieve birth goals that she has set, no matter what those goals are.
Making a difference to a new family.
Turning a negative experience into a positive one.
Teaching labor support to family members at a birth & seeing them apply those learned techniques.
Purple - cause it's my favorite color. Just not in newborn babies.
Taking the "difficult patient", finding out what she needs, and being able to give that to her.
Being able to provide some semblance of normalcy in a big hospital setting.
When my favorite CNM tells me how much she loves it when I am caring for her patients - and she tells me this in front of the patient.
Oh heck, just working with my favorite CNM makes me happy!
Being a silent witness to miracles.
Monday, July 26, 2010
Triage: tales of woe and suffering
It's amazing how much we can fluctuate in our census on L&D from one day to the next.
For days, we were jam packed, constantly busy with rule out labors that were admitted, babies born left and right, etc. I know I've said that I enjoy doing OB triage, but it was just ridiculous when we were admitting EVERYONE, and there were no beds to admit them to on the L&D unit. And yet, there were more waiting in the waiting room, or standing at the main desk on L&D.
Note to the charge nurse: I really don't care if the patient is a high ranking official/has such-and-such of a profession. If she is not actively laboring or delivering right NOW, she will wait in the waiting room until I have a bed available! Seriously! I cannot discharge anyone until their MD/CNM has determined that they can go home! Without someone being discharged first, if I don't have an empty bed/stretcher for someone to be assessed, that means they have to wait.
Note to patients: unless you are actively bleeding, or the pain is severe, it's more than likely NOT an emergency, and you really should listen to your MD/CNM when he/she tells you not to come in to L&D. Oh heck, let's get to basics: CALL YOUR PROVIDER FIRST. It's their job to determine on the phone if you should come in to the hospital to be seen.
Note to the other triage nurse: if I can fully admit several patients at one time, then surely you can too. If you have time to gripe about not getting your admissions completed from 4 hours ago, then you have time to admit them, do you not?
Baby coming out right now? Yep, I will find a space for you, I will CREATE a space for you where none should physically exist.
Contractions started 10 minutes ago? HA! Girl, you're waiting in the waiting room. That woman over there with the baby coming out of her vagina? She comes first, thankyouverymuch.
For days, we were jam packed, constantly busy with rule out labors that were admitted, babies born left and right, etc. I know I've said that I enjoy doing OB triage, but it was just ridiculous when we were admitting EVERYONE, and there were no beds to admit them to on the L&D unit. And yet, there were more waiting in the waiting room, or standing at the main desk on L&D.
Note to the charge nurse: I really don't care if the patient is a high ranking official/has such-and-such of a profession. If she is not actively laboring or delivering right NOW, she will wait in the waiting room until I have a bed available! Seriously! I cannot discharge anyone until their MD/CNM has determined that they can go home! Without someone being discharged first, if I don't have an empty bed/stretcher for someone to be assessed, that means they have to wait.
Note to patients: unless you are actively bleeding, or the pain is severe, it's more than likely NOT an emergency, and you really should listen to your MD/CNM when he/she tells you not to come in to L&D. Oh heck, let's get to basics: CALL YOUR PROVIDER FIRST. It's their job to determine on the phone if you should come in to the hospital to be seen.
Note to the other triage nurse: if I can fully admit several patients at one time, then surely you can too. If you have time to gripe about not getting your admissions completed from 4 hours ago, then you have time to admit them, do you not?
Baby coming out right now? Yep, I will find a space for you, I will CREATE a space for you where none should physically exist.
Contractions started 10 minutes ago? HA! Girl, you're waiting in the waiting room. That woman over there with the baby coming out of her vagina? She comes first, thankyouverymuch.
Thursday, June 24, 2010
Getting report/change of shift
Welcome to my little world of getting report. I wanted to share with you an example of how I take notes (also known as "my brain") on little cheat sheets when I get an assignment at work.
I like to write down a lot of little odds and ends, otherwise - I will forget those finer details! Especially when things are due (medications, etc). A big no-no to forget something like that. (I create little lines or boxes to check off things on my "to do" list for the shift.)
Here is an example "brain" sheet I write up at the beginning of the shift:
Room 2 -- Mary Smith
OB: ABC Group Peds: XYZ Group - Breast, Boy "Luke"
Allergies: NKDA Diet: Clears
Reason for admission: Ind for PD/pitocin
G2P1001 EDC 6/17/10 (41 0/7)
Blood type O+, GBS+
Membranes: intact
Pit up at 0900, now at 14 mu/min
UCs Q 2-3, pain 3/10
Plans epidural
1st L LR up @ 125, IV in RFA
SVE @ 1400: 2/80/-2 (no chg from 0900)
PCN:
16__
20__
24__
PMH: depression (on zoloft), hx PPD, PPH after 1st baby (2007)
Current OB: VB 1st trimester (?)
Social: husb John, mom Sue, dtr 3yrs Alice
? pit off at 1700/dinner? __
__table set
__lidocaine
__baby papers
**************************************
There. A sneak peek into my nursing brain. This was a (made up) rather plain Jane report sheet. HIPPA and all that, you know.
I like to write down a lot of little odds and ends, otherwise - I will forget those finer details! Especially when things are due (medications, etc). A big no-no to forget something like that. (I create little lines or boxes to check off things on my "to do" list for the shift.)
Here is an example "brain" sheet I write up at the beginning of the shift:
Room 2 -- Mary Smith
OB: ABC Group Peds: XYZ Group - Breast, Boy "Luke"
Allergies: NKDA Diet: Clears
Reason for admission: Ind for PD/pitocin
G2P1001 EDC 6/17/10 (41 0/7)
Blood type O+, GBS+
Membranes: intact
Pit up at 0900, now at 14 mu/min
UCs Q 2-3, pain 3/10
Plans epidural
1st L LR up @ 125, IV in RFA
SVE @ 1400: 2/80/-2 (no chg from 0900)
PCN:
16__
20__
24__
PMH: depression (on zoloft), hx PPD, PPH after 1st baby (2007)
Current OB: VB 1st trimester (?)
Social: husb John, mom Sue, dtr 3yrs Alice
? pit off at 1700/dinner? __
__table set
__lidocaine
__baby papers
**************************************
There. A sneak peek into my nursing brain. This was a (made up) rather plain Jane report sheet. HIPPA and all that, you know.
Tuesday, June 08, 2010
Hurry up and wait
That was the name of the game. I was assigned to a preop c/section patient, who was scheduled for the day, but was bumped several times due to emergent c/sections. When I arrived, she was pretty much all prepped and ready to go, except for the few things we do within 30 minutes of the surgery (fluid bolus, sodium bicitrate, shave prep).
I'm telling you, to go from being able to prep a patient for a c/section in 5-10 minutes for a stat/urgent case (which I am exposed to more so by working the late night shift), to being able to have all of this time in the world to prep her........I was literally twiddling my thumbs BORED. I helped out with some transfers via wheelchairs and stretchers in the meanwhile. I even was able to take a dinner break! WOW! Something that rarely happens on my shift!
We finally get her back for her scheduled c/section, and the poor girl has a panic attack on the OR table. I think all of the waiting, then finally going to the OR really did a number on her mental status at that time. Baby was born, went off to the NICU (something we expected for this baby), and I recovered the mom in the PACU.
That day, it certainly felt like a "hurry up and wait" kind of shift.
I'm telling you, to go from being able to prep a patient for a c/section in 5-10 minutes for a stat/urgent case (which I am exposed to more so by working the late night shift), to being able to have all of this time in the world to prep her........I was literally twiddling my thumbs BORED. I helped out with some transfers via wheelchairs and stretchers in the meanwhile. I even was able to take a dinner break! WOW! Something that rarely happens on my shift!
We finally get her back for her scheduled c/section, and the poor girl has a panic attack on the OR table. I think all of the waiting, then finally going to the OR really did a number on her mental status at that time. Baby was born, went off to the NICU (something we expected for this baby), and I recovered the mom in the PACU.
That day, it certainly felt like a "hurry up and wait" kind of shift.
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