A Difficult Week

It's been a somewhat difficult week. Sunday I felt a cold coming on. Colds, with me, run a predictable course. First I get a bad sore throat, then my nose starts running but the throat feels less tight, and lastly it all goes to my chest, and sits there for up to 10 days.

I doubled my dose of antidepressants for the nonce. I've found the main effect of my particular little blue pill isn't to make me happier, just to make me care less about all the s**t going down, and a cold is one of those things you've just got to last out: "treat it, and it will go away in a week; don't treat it, and it goes away in 7 days". So I faced the next few days, sneezing, sniffling, and coughing, with equanimity.

Of course, I couldn't take any time off work. Right now I work with two other nurses, who work from 8 a.m. to 2-3 p.m. One has 4 children under six years of age at home, which is a commute of over an hour. The other, who can do the occasional evening, has 5 children and is currently attending university in order to upgrade her nursing diploma to a nursing degree. I've created the closest thing to an indispensable position for myself, and while it will be very difficult for the organization to retire me against my will, it means it is also a real problem if I need some time off because either of those nurses will have to put in 11 hour days.

So, with notices plastered everywhere about how vulnerable pregnant women are to both ordinary and H1N1 flu, and how they ought to be inoculated, there I was, pockets filled with tissues, and trying hard not to breathe on anyone. Every medical institution I've ever worked for has made it difficult for nurses to take sick leave; obviously the profession doesn't take its own advice.

For some weeks our completely inadequate facilities ["don't fuss; this clinic is only temporary; no point in doing renovations since in 6 months/a year/2 years/5 years/when the Messiah comes there will be a super-duper new clinic"] have had an additional problem: suddenly both our fetal monitors began to produce static so loud that sometimes the microphones were recording the static rather than the fetal heart rate. When we first complained, we were told it wasn't so bad, and to carry on. When it became obvious that it WAS bad, we were told to "cope somehow". The maintenance folks came around, fiddled with the electrical sockets, said it must be the machines. The technicians from the company that makes the fetal monitors came around, and demonstrated that, when taken to another part of the building and plugged in, there was no noise at all, and told the building maintenance crew it was THEIR problem. Meanwhile we are wrestling with up to 8 women an hour--nearly all with multiple or high risk pregnancies, or who claim not to have felt fetal movements for some time--whose fetal hearts only occasionally can be heard above the static. And at least one of the "emergency walk-in" doctors (we have one doctor specifically for non-scheduled patients all day until midnight) orders an NST on anyone and everyone more than 26 weeks pregnant, no matter what the reason they came ["ran out of prenatal vitamins and need a new prescription"]. He's from the FSU and was so appalled, and terrified, by the stories he heard about doctors in the West being sued for malpractice, he wants to absolutely sure he's missed NOTHING. If a woman wants a prescription for birth control pills he's perfectly capable of sending her to the dentist if he thinks her teeth need cleaning.

[Yesterday one of the medical secretaries plugged in her electric kettle and caused a short circuit. It not only knocked out all the computers in the clinic, it also knocked out all the electronics in the adjoining, very large, pharmacy. I find it immensely fascinating that so much stuff -- nearly one half of an entire floor in the building is on one electrical line. But hey, this is Israel. I wonder if this could be part of our problem...]

But I soldiered on. Old Florence would be proud. I probably only infected a dozen women with my cold, and sent another dozen to the hospital for no good medical reason because I couldn't get a decent FHR tracing. After 42 years I really ought to let this kind of stupidity wash over me; after more than 30 years in Israel I ought to shrug and say "Yiheyeh b'seder" [it'll be all right in the end], or "Hashem yishmor" [God will take care of it]. But my inability to do so is one of the reasons I take little blue pills.

There is a high-risk couple we see on a weekly basis. They are both ex-Americans and extremely ultra-Orthodox, I suspect they are converts, although perhaps the wife is merely a born-again Jew; both are considerably past child-bearing age, and since the husband has a number of fairly severe chronic conditions he may just look like he's in his sixties but might be much younger. I know this is the second marriage for the husband, who speaks freely of his grown children in the US, but it is the first marriage for his wife. She's 40-ish, has gestational diabetes, and only got pregnant after extensive fertility treatment. They came on Thursday for their weekly appointment, and all was well. She's now in her 34th week. An hour later she phoned me to say she was bleeding. I, of course, told her to come back immediately, and our on-call doctor sent her straight into hospital. I hope she can hold the pregnancy for another couple of weeks. While a 34 week premature isn't such a bad situation, it's all relative, and they can still have a rocky course. This is not only a high risk pregnancy, it is a very precious one. She will not be able to try again.

I also give progesterone injections to a woman in her middle thirties who is pregnant, after IVF, with twins. Until the 12th week, progesterone, which maintains the pregnancy, is made by the open wound on the ovary where the egg cell erupted [the corpus luteum]. From the 12th week onwards the placenta produces it. Since several previous pregnancies, also IVF, ended in miscarriage, her doctor has ordered the daily injections this time, and all has seemed to go well. She being now in her 12th week, the dosage is being reduced gradually, and everything was fine until today, when she began bleeding and cramping. The doctor immediately ordered the higher dosage resumed, and we've all got our fingers crossed, but I don't have a good feeling about the outcome. I sat and talked with her and her husband for a while; there really wasn't a lot more I could do. She is highly intelligent -- a psychologist -- who simply left off starting a family early, and then it became apparent that both she and her husband have fertility problems [which is why they had more than one embryo implanted; it seems unlikely that another round of IVF will succeed].

I hate ending the work week like this, with two "cliffhangers". I don't blog often about work, because while it might seem exciting and glamorous to an outsider, most of what I do is really very repetitive and mundane. For every intelligent and knowledgeable patient -- and many of the women in fertility treatment are extremely so -- there is at least one dumb bunny who has, as we nursing professionals are wont to say, an IQ lower than her BUN [blood urea nitrogen, which normally is almost zero]. They ask questions it takes 5 minutes to understand, and since the answer needs to be repeated at least three time for it to sink in, takes 15 minutes of my precious time [the gynecologic equivalent of "Who is buried in Grant's Tomb?" is "My doctor prescribed vaginal suppositories for me. Where do I put them?" This ranks close to "My boyfriend swears he didn't come inside me. How did I get pregnant?"