#52 Managing Emergencies: Stop & Drop, Vaginal Bleeding & HTN – Triage Part 3

Justine:
Hi, I’m Justine.

Sarah Lavonne:
And I’m Sarah Lavonne.

Justine:
And we are so glad you’re here.

Sarah Lavonne:
We believe that your life has the potential to make a deep, meaningful impact on the world around you. You, as a nurse, have the ability to add value to every single person and patient you touch.

Justine:
We want to inspire you with resources, education, and stories to support you to live your absolute best life, both in and outside of work.

Sarah Lavonne:
But don’t expect perfection over here. We’re just here to have some conversations about anything birth, work, and life, trying to add some happy to your hour as we all grow together.

Justine:
By nurses, for nurses, this is Happy Hour with Bundle Birth Nurses.
I think this might be our first full series we’re wrapping up here. I don’t know if we’ve done a three-part series yet.

Sarah Lavonne:
No, not that I’m aware of.

Justine:
I’m so proud of us. It just took three seasons.

Sarah Lavonne:
I know. We’re so creative.

Justine:
To catch you up, if you haven’t listened to our other two episodes, we started with triage episode one of how to set your patient up, triage episode two, we did normal labor, rule out labor, which is ideally the best and easiest, and today we’re going to try to down-regulate your nervous system on what to do when you have an emergency, because honestly, when Sarah and I talk about it, we’re just like, “It’s fine. It’s not a big deal,” and so it is a big deal in a lot of ways, so I want to say that. It’s a big deal, but if you just know the steps and know what to do, you can just be okay about it.

Sarah Lavonne:
Yeah. Well, and I think there’s an element of taking on emergencies like, “Oh my gosh. It’s my fault,” or if you somehow internalize or personalize the emergency, then it becomes so much harder, whereas like, “Okay. This is what I’m being presented with, and what do I need to do next?” I say all the time, even in business, that I think one of our superpowers as nurses is the skill of prioritization, and now my prioritization isn’t like, “How do I keep a patient alive?” Instead, it’s like, “How do I accomplish 6,000 things all at the exact same time?” But if people are having a hard time prioritizing, they’ll bring me their list, and I’m like, “I can see very clearly where to go next.”
That really is the skill of triage. It’s prioritizing the number of patients that you see, who needs to go first. We talked about that in episode one with MFTI, and then in this case it’s what skills, what next steps do I need to accomplish to get this patient stabilized and ultimately admitted? Whether you take them or not as the patient, that’s another episode for another day, but it’s really getting them to a place where they are safe, obviously, and/or hand it off to the next person.

Justine:
Yeah, because that’s one nice thing about triage. It’s like, “Okay. Well, bye.”

Sarah Lavonne:
Exactly.

Justine:
“You can go.”

Sarah Lavonne:
My favorite part.

Justine:
The first one we want to talk about, because honestly this class could take hours, and there are triage classes out there, and maybe one day we’ll have our own triage class.

Sarah Lavonne:
I love that this just became a class for teaching. No pressure.

Justine:
Oh, here we go. No, but this could be an hour long class, and this is just… We’re trying to do this in a podcast episode on your commute to work. We’re not going to talk all things and all emergencies, but some of the things we brainstormed was, number one, on it’s such a pain point and a panic inducer, especially in DMs, especially with new nurses, is what if they come to the back or come to triage or come to the room and they’re complete. What am I going to do?

Sarah Lavonne:
This is our favorite one.

Justine:
It is our favorite.

Sarah Lavonne:
Step one, panic.

Justine:
It’s their turn.

Sarah Lavonne:
Step two like, “All right, fun.”

Justine:
What is their gestational age? That’s going to be the biggest thing to think about.

Sarah Lavonne:
Most definitely.

Justine:
If you have a patient that is term, 37 weeks are up, it’s like, “Great, let’s have a baby.”

Sarah Lavonne:
Yeah.

Justine:
And so that one is more, listen to the other episode of normal rule out labor, get an IV, get things rolling.

Sarah Lavonne:
You don’t even need an IV.

Justine:
That’s very true.

Sarah Lavonne:
Yeah. Just put some gloves on, call the team, wheel them to a room, and you have gloves on. If the baby comes out, it comes out. Help them breathe. Say, “We got you.” As long as you’ve alerted the team for an imminent birth and it’s term, put gloves on. You’ll be shaking in your boots when your hands are sweaty and you’re like, “I can’t get the stupid glove.”

Justine:
If you can’t get the glove on, it’s also not the end of the world, just wash your hands after. Yeah, just be there. Don’t let the baby fall on the ground.

Sarah Lavonne:
Except for you don’t know their history, and I’m like HIV, some sort of contagious something?

Justine:
I know. I’ve caught a lot of barehanded babies.

Sarah Lavonne:
You have not.

Justine:
Yeah, probably like 15.

Sarah Lavonne:
I have never. All the ones I’ve caught have been with gloves, it might be like a half glove effort in some circumstances.

Justine:
I got a glove on my fingers.
I think, too, as a charge nurse, I’m just rolling into the room. I think it’s different if you’re ready and they’re complete, I’m keeping my gloves on. I don’t know. If they aren’t term, that’s where it gets a little stickier, and I understand the initial panic, so knowing who to call and knowing who to get on board. If you have a NICU team, if you have a special care nursery, if you have a peds, if you have NPs there, your charge, going up your chain, just knowing how to get ahold of people can relieve so much of the stress. I think, too, with travel nurses, that’s one of the first thing I would do I think as a traveler, would be like, “How do I get ahold of people? How do I get people to my room? What do I have to pull or push or yell to get people down here?” That could really help.

Sarah Lavonne:
And/or the charge.

Justine:
Yeah.

Sarah Lavonne:
If I’m in triage and the patient’s 35 and 6, I’ve called the doctor, then they’re huffing and puffing in pain, I feel pushy. They’re like, “Check her,” and again, it’s like do you check a preterm? Depending on your facility, sometimes they may say, “Hands off.” My facilities, I would. And you’re like, “Oh my god, the baby’s right here.” That’s a charge nurse call. I have a 35-weeker that’s, in this case, let’s say 28-weeker, even worse, right? A 28-weeker that’s complete heads in the vagina, I need everyone, then you would expect the charge nurse to call everyone. In that case, it’s like, for me, we’re not so much worried about the patient, we’re worried about the baby for a preterm birth like that. As long as the patient’s stable and they’re not bleeding or something, which is the next one we’ll talk about, but then it’s like I need NICU team present because if this baby comes out, I want all of the tools and supplies for a preterm baby.
Then it’s like that’s when you need them in a room for a warmer. Do they need an IV? Probably not. Is that top priority always? I think we think it is, but in the case of a normal, spontaneous vaginal birth, you can be okay. The key here for a pretermer, I would say, is getting the baby the support that they will need when they are born.

Justine:
Something Sarah and I had mentioned before this call, I initially was like, “You need a warmer in the back of my triage.”

Sarah Lavonne:
In triage?

Justine:
You should have a warmer in triage. She’s like, “Oh, you can just use skin to skin.” I was like, “Oh, that’s so true.” But our triage is PACU triage, so that’s why we have a warmer so it’s just already convenient, but for pretermers, that would be nice to know, do you have abilities… What warmer would you choose if you had a 26 weeker and you wanted to get your resuscitation right away, how would you do that and where you would do that? It’s again talking to your team after you listen to this episode of what would I do, what would the steps be? Because everything is different and your flow is different, so knowledge is power and talking it out is vital and so important. Gestational age, if they are coming in hot and heavy, if they’re doing that wheelchair sign and there’s the wheelchair sign, they roll them back and they can’t sit down, like they’re literally leaning to the side, if they are…

Sarah Lavonne:
And grunting.

Justine:
Grunting.
And they don’t have to be using out of their minds because they don’t like that vocabulary to describe them, but I think we think they have to be screaming or they have to just be so out of control, which again I don’t like that vocabulary, but they can be so calm, collected, and complete, just something to know.

Sarah Lavonne:
But I think just remember if they’re complete and term, throw some gloves on, activate your team, move them to the room, and when the baby comes out, throw them on their skin dry and stimulate, nothing changes. Use whatever linens are right there. If they’re skin to skin and crying, obviously if you need resuscitation, then keep the baby connected to the cord and roll them into a room and you do your best.

Justine:
If they’re eight, you might have time to help the nurse getting the assignment. As a triage nurse, I know it’s nice to be like, “Oh, I started their IV, I sent their labs and we’re trying to get an epidural,” those things will happen too. I think gauging it’s a prime, it’s seven or eight centimeters, you could have time still to do an epidural, and so trying to get that for them could be really the top priority for the patient. If they’re like, “What do you mean?” Especially if they’re like eight, you’re like, “Okay, we have time,” and you know that your anesthesia team is fast and your lab is fast, and just knowing your unit, giving realistic expectations for them.
Okay, so the next one we want to talk about, vaginal bleeding. There’s a lot that can be going on with vaginal bleeding. A lot of people, it’s different, they consider bleeding spotting, which is less blood, but there’s different types of bleeding and our perception of bleeding is very different. I think to give grace to patients because for their whole pregnancy bleeding has been very, very bad, and once they’re term and maybe going into labor, sometimes we’re like, “Oh, blood yay, cervical change.” Or, “Oh, blood, that’s not good.” I think it’s normal for them to come in for any kind of bleeding, so education is huge here. But yeah, let’s talk vaginal bleeding.

Sarah Lavonne:
I want to know gestational age and how much, those are probably the two things off the top of my head that matter the most. If they’re preterm, I’m going to go different story. If they’re term with vaginal bleeding, then I’m like, “How much?” Because again, if it’s spotting, I’m going, “Okay, I’m going to slow everything down.” But if it’s soaking pads, if it’s dripping down their legs, if it’s visible when they walk into triage, that patient needs one-on-one support and activated help. Once I know what’s happening, and let’s say it is profuse vaginal bleeding, right? Is the patient stable? Are they able to talk to me? Are they coherent? How long has it been happening? I want to know their history. Get their vital signs going and ask them what history of pregnancies, previous C-section, scar on the uterus, where’s your placenta? How long has this been happening?
If it happened 30 minutes ago, that’s different than two days ago I’ve been having regular bleeding. How’s their countenance? Are they pale? Are they yellow? How’s their level of consciousness? Are they kind of out of it? All of those things are going to really make a difference. Really what you’re doing is vaginal bleeding is a presenting symptom of many, many problems. In your head, we need to know what are the problems that cause vaginal bleeding? With that, then you’re going, “Okay, let’s say placenta previa.” That’s an easy one. Typically, they know if they have a placenta previa, they’ve been told their placenta is somewhere weird sometimes or it’s on the low part or it’s covering the cervix, or maybe they’ll call it a previa or, yeah, they’re hoping it would move, that kind of thing. If you rule in a placenta previa, you know the source of the bleeding. Obviously there could be something else going on, but that’s going to be the highest chance.
Ask about the placenta. “No, my placenta has been normal.” Cool, cross it off in your head. That’s what triaging is, right? You’re sorting the patient. Then, abruption/uterine rupture are the two other things that I would immediately go to. What are our signs and symptoms of either one of those? What would you ask?

Justine:
Have you had any trauma? Did you fall on your belly? Did you hit your belly? I mean, I think if they got in a car accident, they’d probably be coming from the EF, but in that case you’d be thinking abruption.

Sarah Lavonne:
Yep.

Justine:
Do you have pain? What else could you ask?

Sarah Lavonne:
Did it come on suddenly or has it been more gradual? If it’s suddenly I’d be more concerned of a rupture than I would if they have a history of a C-section or uterine scar. I’d be thinking potentially for uterine rupture, mind you again, that can happen anytime, but if they’re not having contractions and they have a scar, I’d be more likely to think that. Obviously in any case, I want to get the baby on the monitor at the same time while I’m getting vital signs. Hopefully vital signs are good. If they’re not, obviously you’re alerting teams and saying, “Hey, I have a hypotensive vaginal bleeding patient. I need all hands on deck.” In that case, I would prioritize an IV and I’d get anesthesia in the room and I’d see what’s happening with the baby because if there are signs with the baby, then obviously the perfusion has been affected enough that it’s now affecting the placental blood flow.
With their history and then, yeah, if they’ve been in an MBA or they’re like, “Yeah, I fell down.” The trauma, I’d always think abruption, and remember abruption is just when the placenta separates. Ideally it’s nice and stuck and all of the blood vessels are flowy from baby to parent, and if it starts to separate, there’s a decreased blood flow of the baby, so likely you’re going to see that on the fetal monitoring. That assessment’s going to be really important.

Justine:
You might not see it right away, I wanted to throw that there too. It can be a gradual onset. The typical observation for abruption is four hours on minimum. I feel like most of the abruptions I see, it comes on suddenly. You’re irritated, you’re like, “They’re fine,” and then two hours later you’re like, “Whoa,” the baby’s throwing variables, contractions are starting to come, the pain is increasing, so just throwing that out there too.

Sarah Lavonne:
Well, and you’re having a provider in the room. If you have providers outside of the hospital, this is a call in for an assessment, this is a pull the ultrasound machine into the room, get it booted up for them so they can start to look on ultrasound what’s going on, because a lot of times if the abruption is big enough, they can see that on ultrasound and they’ll know no potentially. Now, what’s interesting for me is a lot of my abruptions have delivered vaginally. Depending on where they’re at in labor, are they having contractions, are they not? Do they have acute pain or do they not? If a scar is opening with a rupture, they’re likely going to feel pain at the incision site, meaning where the scar is on.

Justine:
Continuous pain too.

Sarah Lavonne:
Yes. A lot of times, they’re bracing their incision, they’re holding it, it feels like pulling, tugging, stretching, sharp. It happened, I felt this pop, I’ve heard that once, et cetera, et cetera. Once you see the vaginal bleeding, you’ve gotten all the info, you kind of have an idea what’s going on, you’ve already alerted the team, their vital signs are taken, the baby’s on the monitor and you’ve gotten an IV going for vaginal bleeding. By that time, I would expect you to have a whole bunch of people in the room and you’re passing off that patient and saying, “They are either moving directly to the operating room or they’re moving to an LDR to figure out the rest of the clinical picture,” and then you pass them off. Done.

Justine:
Yippee.

Sarah Lavonne:
Hopefully. Unless their charge is like, “No, I’m going to have you take them,” and you’re like, “Really? This is the one?”

Justine:
Right. That’s that one. Easy-peasy. You got it guys. It’s the practicing the ruling out, like you said, figuring out where you are and what this is, and I think that can be anxiety inducing for newer nurses too. I don’t want to diagnose them, you’re not diagnosing, you’re just triaging and you’re giving ideas and you’re making recommendations. I think it could be this, I think it could be that. I think it’s important for us to know those signs, know what it could be so that you can escalate the care too, so you can be like, “No, it’s this much blood, these are the vital signs, this is the baby,” so then it does prompt the provider to come to the bedside, take you seriously because you are the eyes. If you don’t feel like you know that stuff, this is where it comes down to our professional responsibility to keep learning, we got to know stuff. We can’t just rely on what we learned at the hospital or what we’ve learned from preceptors, you got to take classes.

Sarah Lavonne:
For anyone who missed out on Cancun, listen up because I have some very exciting news. For literally one time only, we are offering a two-day physiologic coping workshop as a live online event on February 29th and March 1st, 2024. The class lasts nine hours total and we’ll split it into two days for you to make it super digestible, and it includes everything that we taught in Cancun. That’s a $900 value for just $299 prior to January 15th. This is a crazy deal. We also offer amazing group discounts for groups of 10 or more, so reach out and save even more by getting in with your friends and coworkers. Besides earning you a whopping 9.4 CEs, you’ll also learn everything you need to know about how to promote physiologic coping, physiologic birth, and positively interact with the diverse demographic of birthing people that’s epiduralized and non-epiduralized patients through non-pharmacological coping interventions that help contribute to a vaginal birth. You’ll also know exactly how that’s possible.
Don’t worry if you can’t attend some or all of the live sessions because we’re going to record it for you to view for up to two weeks following the event. This can’t-miss event took me two years of reading more than 300 resources, I traveled the world, I trained with some of the leading minds in physiology and childbirth and other random specialties, and I even became an intermediate MFR practitioner so that I could create and whittle all of that down to one single easy to understand class that’s applicable to your practice tomorrow.
All of those who purchase tickets to the event will be entered for incredible prize giveaways that I will draw about each week leading up to the class as well as a chance at an absolutely unprecedented grand prize that will seriously blow your mind, you will not want to miss it, and I will draw the winner at the class. This is the biggest prize we have ever given away and you don’t want to miss your chance by missing the class. You literally have nothing to lose. We would love to have you. Register now to get in on this amazing one-time opportunity using the link in the show notes below or on the BundleBirthNurses.com website.
If you know those signs and symptoms, it’s like I can see the clinical presentation of an abruption, I can see the clinical presentation of a rupture, and again, sometimes they don’t present exactly perfectly. Knowing those baseline emergencies that are the typical ones that we’re going to see, of course there’s the one-offs. I love when you post those, “What is this syndrome?” There’s so many things on [inaudible 00:17:41] and I’m like, “What? I’ve never heard of that before.” Of course there’s other things going on, but you have to sort of look at the big picture and the heavy hitters in OB to say, “I know what to ask and I know what to assess,” so that when the provider shows up, hopefully five seconds later, you can give that report and say, “She’s been having vaginal bleeding for the last hour, she’s soaked two pads. There’s no known previa, no history of C-section,” sort of rattle off the list of things that you’ve already done because that’s going to expedite the patient’s care rather than slow down, hold on, let me ask all my questions again.
In these emergencies, time is key and speed is everything, so the more you sort of just know what to ask, let me just rattle it off, you’re going to get that big picture and be able to activate whatever teams are necessary. Massive transfusion protocol. There’s profuse vaginal bleeding, the patient is pale and barely able to talk to you, I need anesthesia in that room, I need double IVs, of course I need vital signs, whatever. Again, you’re not doing any of this without a doctor’s order, which is why you’re calling and saying, “I have an emergency in this room and can I start an IV?” Of course. You get that verbal real quick, she needs an IV quick. You’re alerting the other charge nurse if they’re pale and out of it, we’re talking like possibly RRT here.
Rapid Response Team. That came out funny. I was thinking RT. But rapid response, that might even be a rapid response. In that case, you’re thinking this patient could actually code on me if I’m not moving quickly and I’d like to have an IV at least if they’re going to try to die on me.

Justine:
1000%, I would like to.

Sarah Lavonne:
Again, I feel like sometimes when we simplify these things, it’s like, “Well, get them an IV,” get that assessment, alert the team and bye or respond to what comes. I know it’s not that simple. It’s very anxiety producing. You’re shaking, and a lot of times when we have that adrenaline our brains don’t think quite as clearly, which is why you listen to episodes like this and you do your classes and you educate yourself so that it is sort of second knowledge rather than I didn’t know what to ask. You can control that prior.

Justine:
And if you don’t know what to ask, you really are just like, “I don’t know what to ask,” it’s in your charting system. Look at what you have to ask when you do a regular triage, you’d be like, “Oh, I wouldn’t even… That’s why I have to ask that,” and start critically thinking through that.
Okay, the next one and last one we’ll talk about today, hypertension, and I feel like this is a pandemic of hypertensive patients all over our country right now. I’m sure people listening are like, “Oh yeah, every patient you have.” They come in from the office, they had high blood pressures, they come in from home… They can come in different ways. I feel like typical you had a patient check in for high blood pressures in triage, so going back to that MFTE episode, it’s really a nice tool to use to be like, “Well, let me just take these people’s blood pressures before even sending them back to know,” because you don’t want someone sitting in the waiting room with 180 over 110, and so what is that person throwing in the waiting room?

Sarah Lavonne:
Oh my gosh, what about a practice change? I’m like, “Especially in a demographic where you have a lot of triage patients, you have a high volume and you have one triage nurse and you have a lot of preeclamptic patients,” you could have a CNA when they check them in, get them going, take their vital signs, and report back.
Isn’t that so smart?

Justine:
Yeah, I mean that’s why MFTE exists, because MFTE, they literally just take them, take their vital signs, and send them back to the waiting room, and ask a couple questions, but [inaudible 00:20:58].

Sarah Lavonne:
But who’s doing that?

Justine:
A nurse, but the reason why is because you do a doppler, you do doppler tones.

Sarah Lavonne:
But yeah, but what unit is actually doing that? Does your unit do that?

Justine:
They do on day shift.

Sarah Lavonne:
I’ve literally never heard of that.

Justine:
They do do that, but from what I’ve heard from DMs too, here’s the thing that I’m thinking, which isn’t a good thing, but some units would say they don’t want the liability of the high pressure and they don’t have a nurse to take care of them.

Sarah Lavonne:
That’s fair.

Justine:
That’s what sucks.

Sarah Lavonne:
I mean, fair from their perspective. It’s too bad.

Justine:
That’s the reality of a lot of places. Number one is you got to know how to take a blood pressure. We got to stop taking blood pressures laying on their left side. [inaudible 00:21:38]

Sarah Lavonne:
Or immediately when they get into the room.

Justine:
Yeah, wait a couple of minutes.

Sarah Lavonne:
Like “Hey, I’m so-and-so,” and you get the blood pressure cuff connected, you talk to them, and you have them just settle in for a second, and then once they’ve sat, take their blood pressure. Now mind you, if there’s an acute something going on, of course take their blood pressure, but if they’re coming in for my vision has changed or my doctor said my blood pressures were high, it really does only benefit them and if you get an accurate blood pressure. But that initial get to a room, they’re nervous, they’re stressed, it’s a new environment. How many times do you take a blood pressure and the first one is super high and mild range and you’re like, “Dang it,” and then you retake it and it’s like one 110 over 65 and you’re like, “Okay.”

Justine:
[inaudible 00:22:23].

Sarah Lavonne:
Exactly, exactly. Breathe for a second, it’s going to be all right. You’re actually going to get an accurate blood pressure if you settle them in, and we’re talking two, three minutes. Have them take a deep breath.

Justine:
Well, [inaudible 00:22:34] recommends five minutes, wait five minutes.

Sarah Lavonne:
Perfect. There you go.

Justine:
There you go. Do all the strategies we learned from episode one of triage series and then take a blood pressure. What happens? You get a high blood pressure, what are you going to do?

Sarah Lavonne:
It depends on how high.

Justine:
So it’s 180 over 95.

Sarah Lavonne:
I mean, I’m going to plan to repeat it because you do need a verification, but in anticipation of the fact that I’m going to have to push meds, I’m going to call somebody eventually once I get that second reading, but I’d probably pull all the IV supplies, I would get everything else ready, I’d help downregulate their nervous system. I would be anticipating it to still be high on the second read.

Justine:
Yeah, and you can get all their history. How long has it been high? Do you have a family history? Have you had preeclampsia before? Headache, blurry vision, epigastric pain? With those signs, what we’re looking for is end organ involvement. If they have preeclampsia, how severe has it gotten? Yeah, so 15 minutes, you take another one and it’s high, the idea is you start the algorithm. That’s the national recommendation. Do you have that in your hospital flow? Is that a standing order, you get two high pressures, could you start an IV? Then as you’re starting an IV, calling the doctor and being like, “Hey, I have your patient, two severes. Do you want me to start the algorithm?” It depends on what you’re going to do, it’s not set, but some doctors like to start with hydralazine first, some doctors like to start with labetalol first. You would want to start with hydralazine if your patient has a history of asthma instead of labetalol.
Some units like to start with PO nifedipine right away. I actually had a one-on-one mentee, Jen, hi, if you’re listening, they started a practice change because all of their night shift nurses were new and not very good at IVs yet, and so they did a practice change. They started nifedipine first because they were having a delay in trying to get these IVs started, and I was like, “That’s a great idea.”

Sarah Lavonne:
That’s fair.

Justine:
Just get something on board. Knowing when to give the meds, so you give the med and then you wait 10 minutes, and knowing do I go up in dosage? Labetalol, you’re going to start with 20 and then go to 40. On nights especially, and this is just in general with your hypertension patients, when do your doctors want you to call them back? Can you give them 20, 40, then 80, then call? Do you call them after 20? Do you call them after 40? Just knowing preferences because…

Sarah Lavonne:
Well, your policies.

Justine:
Yes, I’ll say that, but then there’s policy set in our place. We have a lot of providers that don’t even go with the algorithm. They’re just like, “This is what I want.”

Sarah Lavonne:
Well then in that case, I’m going to push back about doing the right thing. You still need to call them. This is such a hard thing because, yes, you’re absolutely right, you get yelled at and abused, and they’re upset because why? This is where for us, the ones getting yelled at, it’s like you have to realize that this is not you, you are doing the right thing and you are not responsible for their emotional response. If there’s doctors listening, if there’s hospital administrators listening, please internalize this. This is something that, to me, is such a safety concern because if they’re having severe range blood pressures and they’re having to push meds, one, I just want a doctor at the bedside in general to help navigate this stuff. By the time you give the med, you repeat the thing, you got to pull another huge vial because you’re at how many doses and they’re still there, we need to be talking plan of care, we need to be talking C-section potentially. We need to be starting that.
Again, what does your policy say? When they push back, I am following the policy and procedure, it says to call you, what would you like me to do, doctor? Just keep it super objective. But ultimately, if you’re not following policies and you’re doing it to their preferences, you end up potentially getting in trouble, and it’s not the safest thing for the patient. There’s a reason why we call a doctor because we’re not making the medical order and we have workflows and we may have a policy that says you don’t need a written order, you can get the verbal order, but I would still want the verbal order. What if you do tank them? They said, because they have their crazy protocol that isn’t actually following any algorithm and now we’re hypotensive and creating a mess.

Justine:
[inaudible 00:26:26] It’s just a mess.

Sarah Lavonne:
Right. No, I hear you. But also, why do we have such a crisis in this country for safety, for families? Because of stuff like this. These are the barriers…

Justine:
Bad emotional regulation.

Sarah Lavonne:
Yes, and lack of… It’s laziness. Call a spade a spade. I’m sorry, you got your medical degree and you are sleeping at home and I’m not, so do your job and I will try not to call you if it’s not necessary, but this is a case where it absolutely is necessary and I am concerned. [inaudible 00:26:54].

Justine:
This is a safety issue.

Sarah Lavonne:
Yeah, this is a safety issue. I’m not willing to put the patient at risk by not waking you up.
Again, I wouldn’t necessarily say all of this, but know that we are behind you and for you for doing the right thing, it’s about doing the right thing. If there is a potential emergency, we can all think like, “Oh, it’s fine. We’ll give meds and it’ll bring it down,” it may not. The next step might be a stroke. If you’re having a stroke and you haven’t called a doctor because you didn’t want to wake them, you’re in trouble now. We don’t want to scare you, and we always talk about it’s not about losing your license, it’s not about getting in trouble, but in that case, what was the right thing? We also still have to practice safely. My soapbox, I am stepping down, but again, it’s like all of this comes back to my frustration with looking at the medical system of what aren’t we doing? We’re not prioritizing safety or the patient, we’re prioritizing our own comfort. That’s why we’re not at the bedside all the time, we want to hang out at the nurses station.

Justine:
There might be a protocol that says, “Do the 20, 40 and 80, just do it.”

Sarah Lavonne:
Then if that’s the case, absolutely. Absolutely.

Justine:
That’s all right with me.

Sarah Lavonne:
All I’m advocating for is following your policies and procedures. If you get pushback by the doctor, keep following your policies and procedures.

Justine:
If you have them, because you didn’t even have them.

Sarah Lavonne:
Yeah, but we had protocols, it was in the order set. We could push without the doctor, but we also had residents so if I was in triage, I’d be like, “Hey, resident,” and the residents always wanted to be involved anyway because it was always like, “Ooh, learning opportunity,” so it was different. Anyway.

Justine:
Okay, so you start the algorithm and you have to figure out… Then again, you want to know gestational age, she’s in peds, how are they going to deliver? Are they a 39 and two repeat C-section? Okay, you can anticipate this baby’s going to be another C-section tonight. Knowing how they’re going to deliver, are they a prime and they could be induced? Is mag going to be started and should be started? Are they preterm and they need to start antibiotics? Even if they’re 33 and six and they’re going to do a C-section in the morning and they won’t get a second dose of beta, it’s actually the evidence shows one dose is better than none, and so being mindful of steroids for the baby, remembering baby in this case. This one’s a little more tricky too because you’re trying to protect mom, but then you’re like, oh baby, I also need to put [inaudible 00:29:09] in there.
It is a little bit more complicated of the different systems that are in place about their organs, and you’re thinking about seizure, but like you just said, ultimately you’re thinking about stroke. Going back to seizure, do you know what to do if there is a seizure that happens if the preeclampsia does become eclampsia? We had recently an observation patient that came in for preterm labor and all of a sudden just started seizing and she didn’t have any history of preeclampsia, just all of a sudden went to eclampsia. It was out of nowhere. Everything worked well and she was fine and baby delivered pretty quickly after, but it’s because everyone knew what to do. They were like, “Okay, let’s get labs. Let’s call the team. Let’s push the meds.” I feel like when you have a demographic that has a lot of hypertension, there’s a lot of knowledge and you can pull from a lot of different people of what do we do and how do we do it? This one is literally just learning.
So many people, including CMQCC have created hundreds and hundreds of pages of algorithms and packages. It’s all over your unit. Look for it and you’ll find it of what to do. The same with hemorrhage, we’re not going to go over that with this one, but hemorrhage is the same. There’s so many different people that have put a lot of work into this. To plug mentorship, we have a lot of hypertension stuff and mentorship, and we can make you feel real good about it in our Some Scary Stuff module. Yeah, I think this one, knowing information is power here.

Sarah Lavonne:
Speaking of mentorship, one of the things I remember emphasizing, I can’t remember which of the many classes that’s in there, but was talking about safety checks. Along those lines, it’s sort of like what’s in your triage rooms? That obviously goes for your labor rooms as well, but when you’re specifically thinking triage, and especially when you’re turning around these rooms so quickly, housekeeping’s coming in and they’re jooshing the room and they come back in, what are your safety supplies? Do you know where your ambu bag is? Do you have suction tubing and a Yankeur close by? Yankeur. Some people call it a Yankeur. What do you call it?

Justine:
A Yankeur.

Sarah Lavonne:
Oh, I call it a Yankeur.

Justine:
You call things weird. You call stevia, stevia.

Sarah Lavonne:
Yeah, I do.
Yeah, it’s stevia, it’s not stevia.
Stevia. I think of a man. It’s stevia.
Anyway. Do you have a Yankeur and suction tubing? Where is your blood pressure cuff? Where’s your oxygen tubing, oxygen mask? Then, where are your IV supplies? Many units, sometimes you can just grab the stuff, it’s right there, but do you have a little kit that you can just grab? I would always make those at the beginning of triage to have all of the supplies. Crash cart, where’s your crash cart? How far is it away? What’s the quickest route to out the door? Is there trash cans in the way? Maybe you reorient your room and your trash cans at the end of the bed instead of blocking the exit. That goes with cleanliness of the room, et cetera. I think knowing that you have all of your supplies, eyeball the room before you put a patient in it, and I think it’s easy to sort of get jaded when you triage 6,000 patients all the time, and most of them are ruled out labor that you will eventually get that one where you are needing those emergency supplies.
If you’re like, “Oh, shoot, where’s the ambu bag?” I’ll never forget, I had an AFE and we could not… People were scrambling to find the ambu bag and anesthesia shows up, they grabbed it and all of a sudden we were bagging the patient, but that’s way too much stress. Just eyeball it and go, “Yep, I know I’m good.” In your head, you’ve made that mental note. I know I’m good and now I know that I have what I need in the case of an emergency.

Justine:
It’s such a good point. I think too, ultimately, I was thinking about these emergencies, it’s like they’re going to deliver most of the time in these big emergencies, so what route will they take to deliver? Sometimes it will be a C-section. I was like, “You need to know how to prep a C-section because you’re… You’re going to get them ready and get them back,” and get them ready to deliver vaginally and whatever that means for them. Then, educating them along the way and telling them they’re in good hands.

Sarah Lavonne:
Don’t forget them.

Justine:
Yeah, don’t forget them. Telling them they’re in good hands, especially with the hypertensive patients, I think there’s a lot of anxiety that comes with all of a sudden you had high pressures, now you’re going to get induced for these high pressures. Something I like to say, I’ve said recently, and I don’t even know if it’s a good way to say it, but we have a lot of patients in our community that have preeclampsia and hypertension, and so we really know how to take care of you, it’s going to be okay, you’re in really good hands because we do, myself included.

Sarah Lavonne:
But that might be a connecting point. Look, I had preeclampsia when I had my baby. This is not uncommon. Obviously we’re concerned, but we know exactly what to do to help fix it, and we’ll cross that. We’ll cross each bridge as we get there. We’re here for you. I love that.

Justine:
Yeah.
Yeah, that’s our triage number three episode.

Sarah Lavonne:
Yay. We did it.

Justine:
We did it. You’re welcome. I hope it was helpful and I hope that you were inspired to kind of look at your systems, especially if you’re going to be doing triage soon, when you’re starting to train in triage, what is the system and who do we call? Exactly, do your safety checks and your routes to get out of the room. All of that pre-work would be so helpful.

Sarah Lavonne:
Knowing about everything. It’s back to that education piece of understand what might show up. You’re not diagnosing, you’re assessing. That’s the key here of what questions do I ask, what do I check for to help piece the clinical picture together for the provider to ultimately make a diagnosis, but you want to assist in that process and you need to know when to alert the team.

Justine:
If you’ve been doing triage for a while and you’re going to work tonight and you’re like, “I’m going to do it different,” just blame it on this episode. Be like, “Listen, I listened to a podcast episode. I’m re-inspired. I’m going to do it different.” Your triage buddies like, “What are you doing? Why are you doing safety checks?” Because it’s the right thing to do and let’s keep our anxiety down because I think too, we’re all scared at the… We don’t want something bad to happen, we want to keep everyone safe, and so there’s always this little level of adrenaline and scaredness I feel like in triage. You just never know what’s going to walk in the door.

Sarah Lavonne:
For sure.

Justine:
I think it keeps us alert.

Sarah Lavonne:
Yep, so channel that energy for good. I think too, it’s sort of like what I teach patients is control what you can control and then let go of the rest. What you can control is your education going into it, having the knowledge, knowing where things are, doing your safety checks. Why are you laughing? She’s laughing.

Justine:
Because I was thinking about my colleague at work and she… You know those round balls on the ceiling that help you see people coming in, like the mirrors?

Sarah Lavonne:
Yeah.

Justine:
It’s like two o’clock in the morning and she sees the door open of triage, no one had called her to say someone was coming back and it’s like a big group of people, a lot of people, and her first thought was like, “Am I getting a DAISY Award?” What happened was it was a real emergency, coming from the ED, there was just a lot of people.

Sarah Lavonne:
Oh no. That is such a Debbie Downer.

Justine:
Poor girl. You never know what’s coming, she’s just like…

Sarah Lavonne:
It might be a DAISY Award someday, but it probably more likely is an emergency. No, that’s great.
Prepare yourself for a DAISY Award or for the herd of ED people freaking out at a pregnant person.

Justine:
Yeah, right.

Sarah Lavonne:
Okay. I think ultimately, just remember that when you’re in triage, it’s your job to assess and sort them out, figure out where they’re going, alert the team. Obviously, we’ve heard the same themes over and over again, but I hope you see that as like, “Oh, it’s not that complicated.” You need to know how to start an IV, you need to know what to look for, and remember that first impression is everything. If you haven’t listened to Vanessa’s episode on first impressions, oh my gosh, talk about gold. We’re going to use it in our mentor meeting this week. We have coming up with our mentors for that initial impression can really help not only their nervous system, not only their experience, but also it can help you feel connected and actually get the information that you need to be able to triage better, hone in on those skills, and then pass them off. Send them on their merry little way and then see what’s next, and that’s the adventure of it all.

Justine:
Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to BundleBirthNurses.com or follow us on Instagram.

Sarah Lavonne:
Now it’s your turn to go and do your safety checks. Whether you are in triage or not, anticipate those emergencies, have all of the steps in your brain of what questions you’re going to ask, and make sure you’ve set them up for safety.

Justine:
We’ll see you next time.