clinical journal entries
... because it's the end of the semester!
No more clinical till 2010! Yay!
Here is a paper I had to write regarding Ricki Lake's documentary, "The Business of Being Born." At least skim through to see the stats... pretty shocking!
Next week is finals week, and our huge case study is due Friday. If you feel so inclined, you may read it here:
I can't believe I've had it done since yesterday. It's no mystery I'm itching to get out of this semester. I can't wait for break. I need this break. Plus, it's Christmas, and I love, love, love Christmas! I can't wait to just relax with my family, friends, and fiance. :)
There are no headlines
for everyday heroes
there is no tickertape
no standing ovation
sometimes it's all they can do
to set their feet on the floor
in the morning
they go through their days
the best they know how
no rainbow need arch
through the sky
to inspire them
they have a special courage
shining deep inside
they go through their days
the best they know how
Ted Hibbard
This came into my inbox today while I was at clinical.
Today, I could not wake up. My alarm went off, I took a shower, threw on my scrubs, ate a bowl of Cheerios in record time, and left for clinical. We were supposed to be on OB today and next Friday, but our instructor said since everyone has seen births, we had an option of not going to clinical next week and going to campus instead. It's December, and we're all dead. Guess which option we chose. So today was our last day in clinical for obstetrics. We're done. (Well, next Friday we have presentations, course evals, and an "educational" movie, but that doesn't count.)
I begged to go to OB Triage today simply because our instructor was confused and assigned other people to Labor & Delivery and I sure was not going to do Postpartum again. Plus, a lot of births were going on so I figured Triage would be a happening place (Any pregnant patient who comes to the hospital is sent up to OB Triage. They could have the flu, a broken bone, or be in labor - most of them know to come to OB Triage and the ones who go to the ER get sent up anyways.)
Not a single patient came in until probably about 11am. It was all insane from there. December 1st was a full moon, so don't ask why it all happened today, 3 days later, but it did.
We got a woman who had a stomach virus (and was vomiting so loudly that I almost wanted to do so myself) and we loaded her up with a cocktail of phenergan/benadryl/reglan. Then we had a woman who had a scheduled C-section (4th baby, 4th C-section!) who needed prepped. This was my favorite patient because I got to start her IV! Now, rumor has it that no one teaches us IV insertion in nursing school. Apparently it's the orientation responsibility of wherever we get a job. That always sounded stupid to me, and thankfully my instructor isn't into going by all of the program rules. (I love her for it though - she's smart about it, she just has a much more creative, free-spirited approach to nursing) Everyone knows though that one of the meds I'm on make my hands shake. As in a tremor kind of shake. I'm a steller phelebotomist (or I was in my nurse technician days) but sometimes it freaks patients and instructors out. So my instructor felt my hands to see if she wanted to "let" me try the IV. Not even kidding. Then she randomly puts her hand on my stomach and says, "Wow, your entire body tremors." Yeah, welcome to the misery. I told her I was comfortable doing it and thought I could, so after I told her what med I was on and she about attacked me to find out why the doctors make me take it (umm, because I'm allergic to every single aternative?) she finally agreed to let me attempt it. She asked me what I'd need to start an IV and draw some blood (I voted for the 22 gauge, but the RN said I had to do an 18 - scary!), we reviewed the exact steps the process entailed, and I beautifully gathered all of the supplies in a Chux and carried them into the patient's room. (Of course I know exactly what you need to start an IV - I've only had like 100 in my lifetime...)
Oh and let me just insert here that Jen (my bestie) taught me how to do an IV (at my kitchen table - just like the time she taught me how to draw blood!) but I completely blew her vein. She told me to try again, and I was too traumatized by creating a huge blood bruise to accept the offer. I had just asked her this morning to come over this weekend so we could practice again. Too late!
So the patient was African American and didn't have good veins at that. So not only were her veins harder to see, but they just were crooked, deep, or way too "wiggly." I put the tourniquet on and felt around. I finally found a hand vein that curved back and forth but it was the best she had. My instructor liked the site and told me to go for it. I inserted the needle, bevel up, and there was no flash. I was panicking when my instructor said, "Push it in just a little more." Flash!!! I pushed the button to retract the needle and threaded the catheter in. Blood started spurting everywhere (that's a good thing!) so I quickly connected the adaptor and popped a blood vial in. Full. 2nd vial. Full. I removed the adaptor and popped the IV tubing on. Beautiful. I got a warm rag to clean up the blood on her hand, and we covered it with a Tegaderm and taped the tubing securely. I had primed the Lactated Ringers so I opened the line and let it go. (I guess in Triage they just "eye" it and don't put it through a pump.) Drop. Drop. Drop. The LR were infusing perfectly in an IV that I had put in. It was working! Then later I piggybacked 2 bags of antibiotics, and they worked, too! (Why they wouldn't, I have no idea. But I was still on IV-high.) I had an issue with the 2nd bag, but the RN said sometimes it's just the position of their hand, and sure enough, we had the patient place her hand a different way, and the med started infusing. Good to know.
The day I performed my very first blood draw on a real patient (Jen doesn't count) I was teching and I called and texted pretty much everyone I knew (and Twittered!) and about died from excitement and pride and well, it was a little weird how excited I was. Well, that was nothing compared to the IV. The feeling of knowing I could successfully insert an IV made me feel almost like I'm a real nurse now - the IV is always the "big, scary" thing that everyone is petrified to do. Well, I've done it, and I did it well. So I can do it again. And it feels sooooo good! Major high. Other than things involving my fiance like our engagement, first kiss, picking out the ring, blah blah blah, oh and maybe getting accepted into the nursing program, or the birth of my furbaby puppy, it was probably one of the most exciting moments of my life. (And if you're not a nurse or nursing student, you probably don't get it - that's okay.)
Wow, I use a lot of parentheses. So many thoughts!
Anyways...
That was the highlight of my day, and I spent the rest of it helping check in new patients and then wasting time. Not kidding. The story...
We had this huge rush of new patients in Triage, all with what they called "contractions," one who said, "I'm not sure, but I think my water may be leaking. I don't know," and then a couple women who both said their due dates were tomorrow so they were sure they were in labor. Funny because most of the patients were in such early labor we couldn't even admit them. Anyways, I went in with the nurses and helped put on the fetal and contraction monitors, get their urine samples, answer questions, get their data... etc. After awhile, everyone was just chilling because that's what the Triage patients do - they sit there for a couple hours (unless they're obviously in active labor) so we can read a good amount of monitors to see what stage of labor (if any) the patient is in, and how the baby's heartrate is. I think it's more like a "we know you're not in labor, but we need to legally cover our butts" kind of thing. Not sure, but that's my theory because it's kind of monotonous. And yes, most of them end up being sent home. If you're contractions aren't under 5 minutes apart and completely regular, if you are in no obvious distress and have not had your water break, don't come to the hospital. The nurses and doctors don't mind, but you will be very, very bored and miserable waiting and watching and then being sent home.
So Triage got quiet really fast. Everyone just waiting to be sent home to walk around, have sex, do whatever they want to get their labor going faster. Then they'll probably be back tomorrow in active labor. It's crazy.
Our instructor said if we were bored, we could go study in the conference room. A lot of things happened in the morning and early afternoon, so there were a few of us who were bored out of our minds by 2:30/3. We went to the conference room and rested, talked, went to the cafeteria (yes, just because we were bored and hungry), came back, talked some more, and just waited for postconference. We were all completely absent from our brains by that time, one of us had a broken arm, another hurt her back when a patient attacked her this week at her tech job (seriously!), a few were hungover, I was in extreme fibromyalgia pain and had a migraine coming on, and of course we all knew it was the last day on the floor. We were slaphappy and exhausted, and our instructor looked like death (she has fibro too and was having a bad day), so we all agreed to leave a little early.
And now I am typing this as I babysit (which is insane seeing how much pain I am in from this day) and will momentarily take a nap until Mom and Dad come home. I'm with my nanny girls, and L Bug's grandma watched her today and let her talk her out of taking a nap. I literally had to drag L Bug into bed as she's screaming, "I'M (sob) NOT (sob) SLEEPY (sob sob)!!!!!" She's barely 2 so it was kind of cute, but also distressing at the same time. She's never that bad. All I could think was, "I feel like sobbing and yelling I AM SLEEPY!!!!"
This nursing thing - although amazing and fulfulling and perfect- is going to physically take every last bit of me. 3 more semesters + a summer externship. It seems impossible, but I don't know what else to do.
Oh and as a side note, Jen (my best friend, remember?) took her boards yesterday and PASSED! She's an RN! She was going to reschedule her test but failed to do so within 24 hours so either had to take it without studying at all or waste the money and pay to take it again. She told me she knew she'd fail, but she figured she'd already paid for it and it would be good practice, so she went. And passed. Without studying. That is so my best friend. She texted me this AM and said "I know you're in clinical but I need you to call me ASAP." I snuck into a hallway behind a door and called her. We were both almost crying. It was such a great moment. Then she called me tonight. She techs at a hospital and landed a job on her floor, which she loves. Apparently she talked to the nurse recruiter this afternoon, and she's having Jen start orientation on Monday. Tomorrow is her last day teching forever. She's an RN, and she starts making an insane amount of money Monday morning. She will be working on her favorite unit, loving every minute of it, and making the living she's worked so hard for. Snaps for Jen. I'm so proud of my amazing, crazy soul sister. 24 hours ago, she thought she was taking a practice NCLEX and she'd definitely fail it, and right now, she is an RN and starts work on Monday on her dream unit. Absolutely insane. God is pretty awesome. Oh, and she has a new boyfriend too. First "real" boyfriend ever. It's so sweet when life is so good.
Today, her day, almost makes me forget how far away from nursing I feel after remember what I realize at the end of each clinical day - my body cannot do this job for more than a couple hours. My heart can, just not my body. Everything starts aching and throbbing and crushing and burning. My energy dips steeply at about noon, and then I drag. I come home and load up on percocet, a muscle relaxer, a pain patch, sometimes a zofran... and I sleep for 2 solid days. Then during the week, I forget how hard it was and look forward to the next clinical. Then it nearly kills me, and it happens all over again. I think it hurts my soul more than it hurts my body.
One of these days, life will be okay. One of these days...
We all know how much I love alternate experience days were we get to break away from the somewhat monotonous clinical experience and go somewhere new and exciting!
One day during the semester, I shadowed two nurses at the hospital's Women’s Health Clinic. Thursday is the Clinic's High-Risk day where they see patients who are labeled high risk for varying reasons such as seizure disorders, diabetes, thyroid disorders, chronic high blood pressure, previous preterm deliveries, multiples, or even drug use. The patients usually come in every week for the duration of their pregnancies just to ensure things are going smoothly.
The clinic runs with the help of two nurse practitioners, one attending physician, several residents, many medical assistants, and a handful of registered nurses. The NPs see patients for annual exams, contraceptives, and sexually transmitted diseases while the residents primarily see the pregnant moms who come in. The medical assistants accompany the residents for exams, help patients, and assist with tests.
I spent my day observing the roles of two of the RNs, K and C. While I would have thought K would do more of what the medical assistants did, she helped check in patients, obtain vitals, administer vaccines, and perform blood draws. C was a case manager, and her job was making sure all of her patients were progressing well with their plans of care throughout their pregnancies.
Regarding the population, I learned from K that 90% of all of the patients the clinic sees receives healthcare insurance from Medicaid. Additionally, some of the patients who aren’t on Medicaid may have seen the office on a list of insurance-approved clinics and come in “by accident,” and other non-Medicaid patients are often previous patients who are more financially stable now but still want to continue being seen by the same healthcare providers.
Many of the patients were in their teens and early 20s. Many Americans on Medicaid are at a low economic status, and I observed the majority of the patients seemed less educated and even sometimes ill-mannered in comparison to other patients I've observed. Some patients responded to our care with short, one-word answers given with attitudes, while a few were friendly and kind. A few people on the day's list neglected to arrive to their appointments without even the courtesy of a phone call. But like anywhere else, the Clinic sees many different people, and financial status is not always indicative to patients' demeanors or health-seeking behaviors and choices.
A few scenarios of high-risk mothers we saw in the clinic are as follows: a woman in her mid-30s at 12 weeks gestation with a complication of a right ovarian cyst, a 16 year old at 8.5 months gestation with complications from a previous brain aneurism and recurring headaches. Then we had a more typical case of a woman with Type 1 diabetes carrying her second baby. Her first baby was preterm, so she is hoping to have a healthy, term infant. We also saw a 19 year old woman pregnant with her second child, and she produces an antibody causing hydrops fetalis, a serious condition where a fetus becomes edematous in various areas. Overall, it seemed that we saw more diabetic patients than anything else.
After calling a patient in from the waiting room, K would obtain her weight. We'd then go into a room where we'd chat for a few minutes with the patient and - if she came with someone - her partner, children, or mother. We also tested each patient's urine for sugar and protein, and if the patient was diabetic, ketones. Other than the occasional vaccine or blood draw, that's what K's job entailed. It may not seem like much, but since most of the patients come in on a weekly basis, K has the opportunity to form trusting relationships with each of them, and I found it refreshing to observe.
There are two RNs who are case managers at the Clinic, and I spent time with one of them, C. Each patient at the clinic is assigned a case manager who follows her throughout her pregnancy to ensure she's adhering to her plan of care and is taking optimal care of herself and her fetus. C has three formal discussions spread out over each woman's pregnancy where she goes down thorough checklists encouraging the mothers to attend a prenatal or parenting class, maintain an optimal diet, adhere to any prenatal medications, and even obtain a safe car seat and crib. She arms them with support and provides additional resources such as WIC. C also comes in to check on her patients at every visit, and although less formally, she still assesses each patient's progress in preparing for the remainder of her pregnancy, labor and delivery, and living at home with a new baby. She has a great responsibility to teach her patients especially since many of the Clinic's pregnancies are not planned, and many of the mothers are unmarried, unemployed or of a low income. In some cases, the patients may not have any support available to them at home.
Overall, I was surprised at the RN roles in the Clinic. I had been expecting neither, but after spending the day with both K and C, I realized that both of them play vital roles in the lives of their patients. I think seeing the same RNs at each office visit is critical to every patient in all clinical fields as it encourages patient trust and increases the positive image of the professional RN. The more patients trust nurses, the more they will feel comfortable confiding in them and asking them health-seeking questions. I believe nurses can increase patients' image of the healthcare system overall, even in an age where people don't seek care because the system is so complicated, expensive, and downright frightening. Patients often leave a physician's visit feeling disconnected from their doctors for various reasons, while encouraging words from a familiar nurse can only foster a positive relationship and hopefully, a positive outcome.
Today was clinical, but we got off early because my instructor had to go out of town.
Instead of seizing the day and getting things done, I've been thinking.
And I've come up with this.
It's my favorite time of the year, and I don't have a spare second to enjoy a minute of it. I don't have time to enjoy the stress of shopping, make special gifts for my loved ones, or decorate my room insanely early just to enjoy my pink tree a little longer.
I am miserable.
And I know exactly why.
Even worse, I know what will make it better, but I also know the cure comes with an entire set of new problems.
So the original problem is this...
I'm too busy medicating myself to get through each day of this education with a drug that has pretty much taken all but my life. It's a vicious circle - I want to graduate and be a nurse, but with my health like this (and masking it with a drug that I can barely even tolerate), I couldn't even tell you when I'd realistically be done with school. By then, I'd probably be past my strength anyways.
For weeks now, I've been wrestling with a big decision. A decision I don't want to make, a decision I don't want to have to make. And you know what's funny? I thought I finally came to a conclusion today, and then there it was, in my inbox.
These words.
When considering a difficult decision, look ahead in your life toward the day when you will die, and consider: which option would you regret most not doing. In most cases, your answer will be immediately clear.
(m. zetty)
What I would regret most not doing? The very thing that is trying to kill me. The very thing that is stealing my happiness. My drug, the thing I keep coming back to even though I know it's going to be the thing that kills me...
Nursing.
I need it to have a job so I can have health insurance so I can get married, but do I need it for more than that? Do I need it to complete me? Knowing how I could make a difference in the lives of so many people every single day makes me think yes. Seeing the politics of the job and the insane conditions of working out there make me think it might be easier said than done.
Then there's that minor thing - finishing nursing school. It's all a game out there. Seeing how I should have graduated already, I'm in classes with people who act like 12 year olds, and I have professors who act like catty teenage girls among each other and nasty, conniving micromanagers to their students. I'm in a school whose only goal is to raise board passing rates, and they're willing to sacrifice our sanity to make sure they get ahead. Professors give us exams on questions they can't answer themselves and grade our papers using their opinions of us as their rubrics. Then get out there in the work force, and well, I nurse tech'ed so I know how it is. The nurses where I was probably had ulcers and panic attacks and will quit from burnout by the time they're 30. Why would I want a life like that? All to help a few people?
Or is it more than that?
I think it's more, but lately I'm not sure. I just know I'm not as strong or as resilient as I was last time I attempted this, and I know for a fact that my mental state any given day since the last week of August has been a polar opposite of what it was in July. I was finally getting better, things were starting to look up. Then with one fell swoop, I decided to force myself to limits I was sure I'd be strong enough to reach. I decided this was the only way to fight for my future, my happiness, my impending marriage.
So don't ask me what I'm supposed to do now, because I don't know either. Take a semester off? Keep killing myself each day? Decide to settle for that degree in Integrated Health Studies?
All I know is that I have no idea how I'm even going to get through the remaining two weeks of school and then finals, so how could I ever get through three more semesters?
So much is at stake each way, and anyways, if I wasn't doing this, what else would make up the difference? Would it be enough? Would it be the right thing? How would I know for sure?
I am not in the least way superstitous, but it is Friday the 13th, and today’s clinical was insane. Remember I am in Obstetric/Women’s Health clinical, and we spread out among several units - Labor & Delivery, Triage, Post-partum, and Nursery. Today, I decided to go to the nursery since L&D was pretty much empty, and Post-partum is boring.
I went into the nursery, and 3 babies were there. The hospital has 3 nurseries, and there were apparently 8 babies in this one, but hospital policy is huge on mom-baby bonding so they try to keep the babies with their moms as much as possible. A nurse was in the nursery, and I introduced myself and told her I'd be spending the day with her. Her reply was, "You can't be in here. I'm an LPN, not a RN." Technically, each baby has his/her mom's RN, but the LPN (who we will call "L") cares for them, can give certain medications, do certain tests, etc. She told me, "I don't even work in this nursery. I work in the other nursery, and I have no clue where anything is in here." She seemed frustrated, disinterested in her job, and was very crabby, snappy, curt... you get the idea. She would adamantly tell me what I couldn't do (there's a lot of rules on what a student can and cannot do when it comes to infants) and seemed agitated every time I asked a question. I felt so much prejudice like she thought she was about 100 levels above students, when really, we are all part of the team. Then, when we were doing assessments on the babies, our instructor brought a couple other students in, and L about lost it. She was snapping and arguing with everyone as if this was her turf, and we were amateurs invading her space. It was almost like she was happy to be the boss instead of always answering to RNs, etc. She finally had an opportunity to rule in her own lame ways, and she was going to maximize the experience, I guess. I was ultimately shocked a few different times when one of the babies would start to cry, and each time, L would mumble an expletive followed by, "I don't have time for this!" I didn't understand that one bit, but I didn't understand much of what L did or said... of what she didn't do or didn't say. But I can put up with people who have issues. What I refuse to put up with is someone verbally attacking me. And L did just that. By mid-morning, I think she was done being difficult and turned to complete nastiness. To make a long story short, the RN was going to let me pass Tylenol to one of the babies, and as soon as we went into the nursery to do so, L was starting to give it to the baby. I told her that we were going to pass the med, but she snapped back, "Well you're not allowed, so it doesn't even matter." I told her my instructor OK'ed it, the RN agreed to supervise me, and I had passed meds many times before. Her reply was, "You're a student so you can't, and your instructor just has no idea," and after a lot of short answers, I finally got her to tell me that hospital policy was that students could not pass meds to newborns. Okay, now that made sense, and if she would have told me that in the first place, that would have been fine. So she turns her remarks into a speech on why she doesn't like students, it's confusing because all of the schools have different policies, she doesn't think instructors have a clue.... etc. So then she's back on the Tylenol, telling me why I can't pass it, and I should have known better. "It's okay, it's really no big deal," I said nicely, but she's totally in a rant. Finally, frustrated, I said, "It's fine, whatever, it really doesn't matter!" "It's NOT whatever!" she screamed and went into complete craziness again, about students and instructors and rules and well, I honestly can't tell you what else because that's when I walked out the door. She was talking so fast and loudly that I couldn't get a word in, so I just left. I found my instructor, told her what happened, and said I wouldn't put up with being treated like that. (She said I had no reason to ever walk back into the nursery and was mad that at a teaching hospital, someone could be that nasty to anyone.) Instructor discussed the matter with the charge nurse who actually saw L's insane outburst and reassured my instructor that they've had problems with L's attitude before. So that was an interesting experience (I've never seen any kind of nurse be mean to students during any of my clinicals, and I know it happens, but this was definitely an extreme case.) The problem then became where to go since only a couple moms were in labor, the floor was quiet, etc. My instructor told me I could go study until lunch and by then we'd figure something out.
While L was on break and I was still in the nursery, an opportunity arose to see one of our little guys circumcised. Taking place in a simple procedure room, the simple process was pretty hard to watch. The doctor applied local anesthetic which she said ensured the baby didn't feel anything, but I didn't believe it for a second. She said he was only upset because he was restrained, but I don't care if I see a baby dropped on its head - it couldn't possibly cry as ear-piercingly high, loud, and bad as this baby was while the doctor cut into his little newborn skin. The American Academy of Pediatrics is against circumcision, claiming there is no medical benefit whatsoever, and believe it or not, the nurse I was with told me an increasing number of parents are choosing against the procedure. I'm sure if they saw it done, even more would be against it, but as with anything, there are many points to consider on each side of the issue.
After lunch, nothing had picked up, so our instructor had "Pre-conference" where we meet for an hour and talk about what we're seeing, doing, thinking, questioning, etc. We tell about our patients and learn from each other's experiences and how they apply to what we learn in class. I've never seen an instructor hold pre-conferences before, only post-conferences, but with this instructor, we have both, and I think it helps our learning to have extra time discussing. Plus, it makes the day go by extra fast!
So anyways, after lunch and pre-conference, things were still quiet, so I got the OK to walk around until I found something to do. I decided to go with one of the guys to Triage so I could be the first to see some action. Triage is what we call the first step into the obstetric unit which handles all incoming pregnant patients no matter if they're in labor, false labor, experiencing a bug bite, can't stop vomiting... doesn't matter. They go to OB Triage.
We were just standing around hoping for some action when the pager went off. It said: "26 F, wearing stilettos, ready to come back, having contractions, needs you to be fast because she is picking up her wedding dress in 4 hours." We all started laughing, and even a male OBGYN who was there admitted if he was in labor, he would be wearing flats, not stilettos! I went out to get this patient from Check-In, and this was not a joke. Mom and pregnant daughter, in wheelchair, putting lip gloss on and drinking water claiming to be having contractions. She was chipper and chatty the whole ride back to Triage, and she made sure I knew she had to pick up her wedding dress in 4 hours, so according to her, we weren't allowed to keep her longer than that. Obviously she's never been to the hospital before, and we all knew there was no way she'd be picking up her dress in 4 hours.... not because she was having contractions and would stay to deliver, but she actually was just freaking out and being dramatic (fetal monitors don't lie!) which means we had to keep her a certain number of hours just to make sure nothing shows up on the fetal monitor. Some patients... wow. Oh and after we asked if we could help her RN because we were students, her reply was this, "Umm, no it's not okay! But if I don't have a choice then what am I going to do?" (say that in your head with as much attitude as you can think of) We were not offended as she had probably hoped.
We were bored for a little until people started rushing around. My ears perked up, hoping to hear something exciting, and sure enough, I heard the words "C-section." There's a resident we all love who is ALWAYS at the hospital, and she was putting orders into the computer right beside me. I asked her what was going on, and she said it was a crash C-section. She thought there was a patient in L&D whose monitor traced Baby's heart rate down to 30 (Normal is 120-160) so they were doing a crash section. Unsure of what the rules on crash sections were, I asked if I could observe. She told me that would be fine, so I put on a mask, threw my hair into one of those blue puffy surgical hats and rushed to the OR.
I was surprised to see the tiniest woman I've ever seen in my life on the operating table. She was lying there exposed and shivering, and she glanced at me with fearful eyes. She was Chinese, and she did not speak English. Hoping I wasn't violating a cultural taboo, I put my hand around hers and she squeezed it tight. The anesthesiologist told me she still needed an epidural, and he tried to explain it to her husband who knew a small amount of English. It was getting no where so I asked the anesthesiologist to hold up a needle. He saw it, and I pointed to my back. I said, "Tell her it will help her pain. Ask her if it's okay." The husband said something to her, and I asked, "Yes?" "Yes," he told me. Through him, we explained to her that we needed her to sit up. After 3 failed tries at initiating the epidural in her tiny, bony spine, we helped her onto her side where the anesthesiologist finally got the epidural in. I tried to explain the pain, pressure, stinging, and various other sensations, but the language barrier was too large. We waited until she was numb, and I took my place out of the way of the doctors and nurses in the bustling OR. Beside us in another OR was a resuscitation team to take Baby the instant he was born. One of the nurses told me she guessed he'd be around 4 pounds.
The doctor made a straight slice into our patient's lower abdomen. The blood appeared on one side and slowly appeared along the incision line like a curtain opening. The doctor made cut after cut until she got to what looked like muscle tissue. After a tiny cut, the muscles were literally ripped into 2 pieces. I think it was one of the last layers, but eventually all of the cutting gave way to an obvious translucent bubble - the amniotic sac. With a volcano of amniotic fluid, it was ruptured, and the doctor pulled the baby out. There was no cry like you'd see on TV. A nurse was already waiting with her blanket-covered arms outstretched, and she took the baby straight into the adjacent room while the doctors in this room worked to deliver the cord and placenta, suction the uterus, and start slowly, carefully hand-stitching each and every layer back together.
The suturing took the longest part of all, and the entire process lasted until post-conference time. I peeked into the window of the door separating these new parents from their baby, and I could hear tiny little cries. It looked like the little baby boy was going to make it.
Post-conference was normal. Well, it started out that way at least. We were all exhausted and ready to go home, but we talked a little about our patients, reviewed a little for Tuesday's big exam, and changed plans for the next clinical. We have 2 guys in this clinical group, and honestly, I feel bad for them. They have never in their lives had to care about women's health, while we girls have had to our entire lives. Now they're in a class they're forced to pass that's all about things they'd never in any other case even find out about. There was no warning, either, the class started, and bam, they are forced to see this stuff in lecture, in clinical... all while we girls are having a hard enough time trying to remember these things and asking other women questions we know we likely would not want to be asked. So for the guys, it has to be rough. They're adorable though (as in little, innocent puppy kind of adorable) because sometimes they can just be so clueless. There are a lot of awkward silences when they retell the stories of their days because they're uncomfortable using certain words in front of all of us girls. Granted, they try so hard though. Example - one of the guys was visibly proud he was almost done telling about his patient. He had used a few of "the" words, and he hadn't turned red or stuttered or looked stupid. Then came the moment when he was going to finish his recount by talking about a specific test we do postpartum where we check Mom for blood clots in her legs. It's called Homan's Sign, and once he said it, he continued to tell his story probably unaware that he had just called it the "homo test." I felt so bad, but just as everyone else probably did, too, we all erupted into laughter because okay, this was so funny in the moment, and we just couldn't help it. Poor guy... I'm sure that was just the icing on the cake of his day working on a postpartum unit where he was literally doing things like assessing vaginal bleeding and breast consistency.
Until next week...
I never thought OB nursing would be fun.
I had an open mind, but I doubted I'd enjoy checking cervixes, analyzing fetal monitors, teaching breastfeeding, and watching women push watermelons out of tiny little spaces, yet I cannot even begin to tell you what I learned and experienced yesterday.
I'll give you a hint... it revoled around this:
Friday was pretty interesting. Our instructor is great, but she's a little scatterbrained so she sent out an email a few days earlier to ask what time she told us to get to the hospital on Friday. None of us really knew - she said 7:30am, but some of us (okay, myself only) thought the schedule had us there at 7am, so we all got there at different times. I was the first student there, and Instructor told me if I hurried, there were 2 or 3 births happening right then.
On this unit, we wear the hospital-issued scrubs (all of the nurses on the floor do, too, probably because there is a high risk of squirting, splurting, splashing, and umm getting attacked by about 10 kinds of bodily fluids) so I changed really fast, and then she told me where I'd be for the day since originally, I was scheduled to be on postpartum. It turned out one of the births we were "hurrying" for had already happened and the other involved a mom who did not want a student, so Instructor gave me a patient who was thought to deliver soon. Not the case, but it gave me something to do, so it worked out okay.
Mom was 20 years old, a primapara, and had come in late the night before with contractions after losing her mucous plug earlier in the day. She had a relatively healthy pregnancy, and we were planning on a normal vaginal birth. Around 4am, her membranes ruptured and she had an epidural. It slowed her progress a little, but she managed to be dilated to 6-7cm by around 8am, and 9-10cm by around 10 or 11am. There was one little problem though - she had something called an anterior lip where 1-2" of her cervix was holding the baby's head in. The RN I was with had me feel it, and my instructor later told me that she has never had a student who was (what she called) "privileged" enough to do a vaginal exam on a mom. She said it wasn't our job, and most RNs don't trust students with it anyways. Well, I assumed it's what we had to do in the class, so thinking nothing of it, I just felt around as my nurse told me what I was feeling. The weirdest feeling in the world was to feel the baby's head in there - it was so distinct, and when the nurse told me to feel for the baby's fontanels, I felt them so easily. I had never thought about it before but sure enough, I had no problem blindly feeling what I had only felt on a live, visual baby before. I was able to feel the anterior lip, too, which in itself was also distinct. It felt solid and small, yet I could tell it was holding the baby's head in. We made Mom comfortable and helped her get into more of a 90* sitting position (rather than lying down) so gravity could help push the baby onto the cervix. And that was that.
A couple hours later, my RN suggested we see if the baby had moved at all or if the cervical lip had softened to the point of moving.We figured labor was progressing on it's own though when we saw that the baby was starting to go into early decelerations (on the fetal monitor, it shows up as a transient decrease in Baby's heart rate just as Mom's contraction starts, usually because Baby's head is compressed in the later stages of labor) If the cervical lip hadn't improved, the nurse said she would try to maneuver the baby and the cervix a little so we could get the baby out. RN had Mom do a small push just to see if the baby could pass by the cervix she thought had moved out of the way, and sure enough, the baby was on her way out. Since Mom was only a few pushes away from having her baby, we really didn't have time for much of anything. RN had me hit the call light while we all but delivered the baby before anyone else even came in to help. 2 residents barely made it in on time, but they were able to finish up the delivery and remove the placenta. We got a nurse into the room about 5 minutes after the birth, and she took over the baby while my RN worked with Mom. Then there was the OBGYN who came trailing in pretty late, only to find out there was nothing for him to do. I just helped Mom and the 2 nurses, and the residents showed me all the "features" of the placenta. (Which, by the way, is the most disgusting part of birth as far as I'm concerned, and if I never see a placenta for the rest of my life, I will be more than fine.) The umbilical cord was wrapped around the baby's shoulders, and she came out with too much fluid in her lungs, but by 5-10 minutes, she was doing fine. The nurses on the unit are so experienced, and my nurse knew to give Baby her Vitamin K shot early to help initiate her crying. She said typically, the injection is given a little longer after birth, but she knew in this case, the baby needed to cry and get the fluid out of her lungs, so she gave it right away. It worked, and with some O2 and suctioning, we were able to get Baby in healthy respiratory shape by her 10 minute Apgar score. It was an interesting experience how the RNs and myself knew the baby wasn't completely okay, but I followed their cues and didn't let on at all to Mom and family. In the end, I saw how they knew Baby would be okay in a short amount of time, and that's why they were able to help Baby while not freaking Mom out. (If Baby wasn't going to be okay in the end, I doubt they would have covered it up so well.) The nurses on the floor can be kind of snappy to students, but most of them have been on the floor for literally decades and know their stuff inside and out. During labor and delivery, they know what they're going to do, and they do so seamlessly and gracefully without showing any signs of fear, shock, or stress. A few times over the course of the day, my RN would answer a question with, "Not now," and yes, that might sound mean to some, but she would always gladly answer any question I had after we were out of the room or out of that circumstance. She knew the timing of the events and the signs of certain progressions of labor, so I trusted her and saved my questions for later, even when I didn't realize until later why she was having me wait. I can't wait until the day comes where I am happily on a certain floor for that long and can have a routine down pat to that extent. Must be nice to have the skills and intuition only experience can provide.
My patient's birth kept me pretty busy for the rest of the day, but I do want to share another experience I managed to squeeze in. A little something that, like the placenta, I really don't care to see or experience ever again in my life.
We have 2 groups from our school on the labor & delivery, postpartum, nursery, etc. floors every Friday. A student in the other group mentioned to me his patient was going to have an epidural. That sounded pretty interesting to watch, and I was momentarily bored, so we asked the patient if I could observe, too, and she was fine with that. Picture the most freaked-out-Mom TV birth you've ever seen, and that's kind of how this woman was. She was screaming and going crazy at every contraction, and after waiting maybe 20 minutes for an epidural without any signs of an anesthesiologist, she decided she was going to get nasty. (To be fair, I will say that she did apologize later once her epidural had kicked in.) She was screaming obscenities and yelling at the anesthesiologists once they arrived... it really was quite interesting. We have nurse anesthetists on the floor, too, and the whole anesthesia team really does try to make sure the entire floor is medicated to each patient's requests, but it was a very busy day on the unit, so she had to wait maybe a half hour or so. Anyways, the anesthesiologist later told the patient he really didn't think she could sit still enough in the certain position required to get an epidural to actually get an epidural, but surprising us all, she calmed down once he came into the room and began the "procedure." First, he kicked everyone out, including the husband/baby-daddy/whatever he was. I later asked about it, and his reasoning was "too much distraction." Okay, buddy, but if you were having a baby I think you'd want your spouse with you while you got a ginormous needle jabbed into your spine. Just saying. Anyways, once everyone but the patient, anesthesiologist, RN, myself, and the other student were gone, the doctor set up sterile field, went crazy applying Betadine, and numbed the area on the patient's lower spine with an injection. Then he picked up this needle that looked more like a drill and inserted it into the patient's back for what seemed to be about 6 inches, but what I know could not possibly have been that far. Once it was in, he threaded a thin catheter through the needle, pulled the needle out, and secured the catheter into her back with adhesive. Then he cleaned up his mess of wrappers, fluids, and needles, and he was off. And I was extremely disturbed by this poor woman enduring a needle being inserted about 10 feet into her spine (again, exaggeration, but it looked like he was putting it so far in it would come out her stomach!) all alone and without her husband, mother, sister, friend... all the nice people the anesthesiologist kicked out. After my entire day, I will say that my patient having her baby looked much less painful than the epidural, but who knows. I'm really not qualified to make such a statement since I have experienced neither. Just save the epidurals and the placentas for someone else. Both make me want to vomit.
Other than that, I had more fun in my first OB clinical day than I ever thought I'd have! It's messy and kind of eliminates any recollection of the term "personal space," but it's what millions of healthcare professionals deal with every single day, and it's an experience billions of women have gone through since the beginning of time.
Somehow, though, I think what my clinical instructor said on orientation day will always be true. She said that obstetric nursing makes you forget it's medicine and science. It makes you call the same experience you've been through thousands of times, a miracle. When you think of the few life-changing "events" individuals experience throughout the lifespan, having a baby is one of them. OB nurses experience these huge, amazing events with a handful of patients each shift, while most other jobs can't provide anything even close. Kind of crazy...
