Shadows In The Hall

Chapter two

Shadow of Responsibility; Nursery Charge Nurse

I enjoyed working in the Nursery with the babies. However, in those days we only had one Nursery for all the babies. Today there is the Critical Care Nursery, the intermediate Nursery, and the Newborn Nursery. In our Nursery, however, we had them all. Healthy babies, premature babies AND physically challenged babies like the one born with a Myelomeningocele on her low back.

It looks like someone laid a loaf of hamburger there. She also had Spina bifida causing her to be paralyzed from the waist down, with no kneecaps and bilateral club feet. What causes it? During the first month of pregnancy, the two sides of the backbone join to cover the spinal cord, spinal nerves, and meninges (tissues covering the spinal cord). Spina bifida is a birth defect due to incomplete closure of the spine.

It's caused when the bones of the spine don’t form completely, causing an incomplete spinal canal. The spinal cord and meninges to stick out of the child's back. 1 out of every 4000 babies is born with this disease. In most cases, the bones still don’t close but the meninges stay in place with the skin covering the defect. Other disorders may also be present such as Hydrocephalus (water on the brain) in 90% of the children with this disorder.

The cause of this birth defect is unknown. Low levels of folic acid, which is responsible for brain and spine development, in a woman's body before and during early pregnancy are considered to play a part in this type of birth defect. Future children in that family are at higher risk for the same defect. Some have said that a virus may play a role as well as radiation exposure. It can also cause loss of bladder or bowel control, partial or complete lack of sensation, partial or complete paralysis of the legs, weakness of the hips, legs, or feet of a newborn and Club Foot.

Prenatal screening can help diagnose this condition. During the second trimester, pregnant women can have a blood test called the quadruple screen, testing for myelomeningocele, Down syndrome, and other congenital diseases in the baby. Most women carrying a baby with spina bifida will have a higher-than-normal level of a protein called Maternal Alpha Fetoprotein (AFP). If the quadruple screen test is positive, further testing is needed to confirm the diagnosis, such as pregnancy ultrasound and amniocentesis (checking he fluids in the uterus, etc.)

After the child is born, it is also diagnosed during a neurologic examination due to the loss of nerve-related functions noted. For example, watching how the infant responds to pinpricks at various locations may reveal where the baby can feel the sensations. Further tests such as x-rays, ultrasound, CT, or MRI are used as well.

Genetic counseling may be a recommendation. In some cases, where a severe defect has been detected early in the pregnancy, abortion may be considered. However, intrauterine surgery to close the defect (before the baby is born) is offered in some centers and appears to reduce the risk of some later complications.

After the baby is born, surgery to repair the defect is usually recommended within the first few days of life. Before surgery, the infant must be handled carefully to reduce damage to the exposed spinal cord. This includes special care and positioning, protective devices, and changes in the methods of handling, feeding, and bathing.

Children who also have hydrocephalus may need a ventricular-peritoneal shunt placed. It helps drain the extra fluid from the ventricles (in the brain) to the peritoneal cavity (in the abdomen).

Antibiotics may be used to treat or prevent infections such as meningitis or urinary tract infections. Most children will require lifelong treatment for problems that result from damage to the spinal cord and spinal nerves. They may need bowel and bladder care, physical therapy, wheelchair or braces.

Visiting nurses, social services, support groups, and local agencies can provide emotional support and assist with the care of a child with a myelomeningocele who has significant problems or limitations.

Then I remember the child born with Collodion Skin. She looked like someone had shrink-wrapped her whole body with plastic. We had to give her oil baths to help loosen the tight skin. It worked she began to peel nicely. We nick-named her our “Butterfly” because she seemed to be coming out of her cocoon. These conditions are rare. Here is a picture I found on Medscape.com. Below is what they had to say about it

“Lamellar ichthyosis (LI), (the medical term for Collodion Skin) is an autosomal recessive disorder that is apparent at birth and is present throughout life. The newborn is born encased in a collodion membrane that sheds within 10-14 days. The shedding of the membrane reveals generalized scaling with variable redness of the skin. The scaling may be fine or plate-like, resembling fish skin. Although the disorder is not life-threatening, it is quite disfiguring and causes considerable psychological stress to affected patients.

In adults, the disease is characterized by generalized scales, which range from fine and white to thick, dark, and plate-like. The scales form a mosaic pattern resembling fish skin. The lesions involve the entire body; increased in flexural surfaces such as the axilla, groin, antecubital fossa, and neck. The individual scales tend to be larger over the legs and, in some areas, are centrally attached and raised at the edges.” Medscape.com.

Other abnormalities:

“The nails may grow 2-3 times the normal rate. Scalp scarring can result from the overall tightness of skin and the thick stratum corneum entrapping hairs. The hair may be thin and fine but like the nails, can grow at 2-3 times the normal rate. The lips and mucous membranes are spared. Other associated features are ectropion, eclabium, bilateral conjunctivitis, small and deformed ears, and inflexible digits due to the tight skin.

This disorder has no cure; therefore, treatment is directed at decreasing symptoms. This condition, along with the other congenital ichthyoses, is one of the targets in gene therapy research.

Emollients are applied after showering or bathing. The stratum corneum will absorb 6 times its weight in water, and a heavy emollient, such as petrolatum jelly (Vaseline) or water-in-oil preparations (e.g., Eucerin) is applied while the skin is still wet. Alpha-hydroxy acids, such as lactic acid (e.g., Lac-Hydrin), help reduce coenocyte adhesion and decrease the thickness of the epidermis. Urea creams can help soften scales. Salicylic acids in combination with propylene glycol help to remove dark scaling. Care is taken when using topical salicylates over large areas, especially in children, because of reports of systemic salicylate intoxication. Topical retinoic acids (e.g., Retin-A) decrease thickened scaling. Antiseptics and antimicrobials can be used topically to control odor. Because of the significant long-term adverse effects, reserve systemic retinoids for severe disease that is refractory to conventional therapy.” Medscape.com

The children born with a cleft palate and hair lip were fed with a special nipple: one that had a flap on one side. It was put in the child’s mouth to cover the palate to prevent choking. The baby was held in the sitting position also to prevent choking. These children didn’t stay in our Nursery long; soon they were being transferred to the nearest Medical Center. Nowadays, these babies would be transferred right from the labor room. In fact, with all the equipment we have today, they would not have had any surprises. This knowledge allows the mother to deliver at the Hospital able to take care of her child as well as herself as soon as the child is born.

There were shades of humor in the Nursery as well such as the time Pat, a Nursing Assistant came into the Nursery while I gavage a baby. That is where you put a tube in the baby’s mouth or nose down into the stomach to feed them. This feeding in done for Premature Babies unable to take the nipple yet.

Pat stood next to me, watching me intently, as I swaddled the infant, measured the tube from the mouth to the stomach and proceeded to put in the tube. Just as I started the procedure, she asked seriously, “How do you know if you are putting the tub in too far?”

With a flat affect, I returned, “That’s easy Pat! You just pull the diaper down, if you see it coming out, you just pull it up a little bit!” I could no longer contain my smile.

With mouth gaped open she exclaimed, “Oh you! I should have known better than to ask!” With that, she turned on her heel and left.

Another humorous time was when I decided to try to learn labor and delivery procedures. Being assigned to the labor rooms, I was told to prep the woman for delivery. In those days, we shaved ALL the pubic hair and gave them an enema.

I had gotten my supplies, put her in position to shave her pubic area when what did I see? The thickest mound of pubic hair I had ever seen. I began to shave her, only removing exceedingly small amounts at a time due to the frequent need for rinsing my razor. Being young and stupid, I blurted out, before I could stop myself, “With all this hair, how did you get pregnant?”

She calmly retorted, “Immaculate Conception!”

Laughing together, I apologized for my comment.

Understanding, she said, “You’re young, and it’s OK.”

My next training session in Labor and Delivery didn’t fare as well. I was trying to care for the woman, help her relax, breathe etc., when she blurted out, “You’ve never had a baby have you?”

Sheepishly I answered, “No, but I am a Licensed Nurse!”

She hollered, “Get out! You shouldn’t work in this area until you’ve had a baby!”

Leaving, I went to my Charge Nurse, telling her the story. Thankfully, she sent me back to the Nursery. The kids don’t care, just feed them and change their diapers! Little do they know it’s much more involved than that. I never worked in Labor and Delivery again until many years later after my own three children were born.

I gave birth to both my two youngest children there at my Hospital. It was my son’s delivery that was the most interesting. The Charge Nurse on duty was my old Charge Nurse. She was a southerner all the way to her southern accent. With my oldest daughter, I didn’t have the pushing urges but that was NOT TRUE with my son!

We were in the delivery room, my feet up in stirrups and the doctor outside scrubbing up. When those puppies hit, I had no control. In a director’s voice, I exclaimed, “Pannell get that Doctor in here, or it’s gonna be you and me!” Words no Nurse in her right mind wants to hear.

Pushing the Delivery doors open wide with both hands she screamed, in her southern drawl, “Doc-ta, Doc-ta hur-ray!”

To her delight and mine, he arrived in time.

In another incident, Pat came to the Nursery door exclaiming, “Linda, I want to weight and measure the next baby OK? I want to follow it from the Delivery room to the Nursery, do everything!”

In agreement with the plan, I nodded. Pat was a Nursing Student as well at the time, seeking all the experience she could get.

A few minutes later, Pat returned to the Nursery, shoved the bundle of joy at me, huffing, “Take this baby! I don’t want to do it now! She (the mom) didn’t give me a chance to do anything. She spit it out in the bed!”

We did not like to deliver in the bed. First of all, it didn’t break down into a delivery table the way they do today. That’s really important because it makes the delivery easier, your right at the door so to speak. Also, if they woman tears during delivery, she can be sewn up easier, not so easy in the bed. The equipment such as clamps are kept on a table in the delivery room, opened in anticipation of a pending delivery. It’s not a great idea to have to rush to get the table and have packs already open. Sterile instruments could drop on the floor. When delivering in the room these days, the table is brought into the room with all equipment in their packaging and then opened, thus preventing contamination.

The Hospital had the county contract to deliver what would be Medicaid patients today. Unfortunately, we had many Hispanic patients coming to our hospital, waiting until they are about to deliver to come in. At the time, I didn’t even think about it, but they were probably illegals trying to get their anchor babies born before someone from the Immigration Department found them. There were a lot of them coming to that hospital.

There were sad shadows too. One evening, when our census was low, I was sent to the Medical floor to work. The LVN’s gave medications; the RN’s were charge nurses and the Nursing Assistants worked the floor doing direct patient care. It was later in the evening; while we were sitting at the desk, charting, when an announcement sounded overhead, “Code Blue, ICU! Code Blue, ICU!”

In this event, any Doctor in the house and all the RN’s went to the Code. LVN’s were left in charge. It seemed like forever before our Charge Nurse returned. She had been crying. We asked what happened. Here is the story she told us:

“When we arrived at the ICU, we found a man on the floor, covered with a sheet to his neck. The Unit staff had already started the compressions and were trying to ventilate him with a mask that covered his face. Dr. Delmar Tonge was the MD relived the staff with fresh members of the team and started giving orders for an IV, medications to start the heart but nothing worked. Then they used the paddles to shock him. Finally, when they couldn’t bring him back, Dr. Tonge called the code sighting time of death. The oxygen mask was removed. Dr. Tonge looked at the patient, suddenly realizing it was his brother, Dr. Burnett Tonge they had coded. He fainted.”

When I was back in the Nursery the next day, I mentioned to my Nursing Supervisor, about the code and how sad I thought it was. She growled, “He wanted to have wall to wall Persian Carpets in his house, that’s why he was doing so many abortions. He should have wall to wall babies!”

A few days later, the funeral for Dr. Burnett Tonge was held in the Seventh Day Adventist Church of which his whole family were members. The SDA church owned the hospital at that time. His family owned it before when his father was a young Doctor. His father was still alive and practicing medicine currently. He did the physicals on all the new employees. I will never forget what he said to me on that day, “Linda remember, to be a good Nurse you should have surgery once a year, but Doctors should have it every six months!”

That church was packed to the hilt. They had the Nurses all set together in a special area wearing our white uniforms as a show of respect. A day I will never forget.