Baby!

Just one this time. After two weeks of listening to everyone else in my group talk about the deliveries they've seen and how awesome a c-section is and all that cool stuff that I hadn't had the chance to see, I finally got assigned to a laboring mom.

First the history: This was her first baby and she had been in the hopsital for a very long time for a variety of reasons. Details withheld because of HIPAA, take it up with the government. She was supposed to be induced the following day, but her body decided induction didn't sound like much fun so it went into labor all by itself around 9am. When I showed up and got report she was at 3cm and had not received an pain medication. She had said that she did not want an epidural.

Shortly after I arrived, around 3pm, they did another internal check (that means the doc lubes up their fingers and sticks them in the patient's vagina to feel the cervix and the baby's head) and she was 4.5cm dilated, 90& effaced, and the baby was starting to descend into the pelvis. All good progress. Patient requested some pain meds, got an IV dose, felt much better. You could tell when the pain meds started to wear off again because the moaning got progressively louder and her grip got progressively tighter on the hand of whoever happened to be at the bedside when the contraction started.

The baby was in a posterior position, which means that its back was against the mom's back. Normally, the baby should be in an anterior position, facing mom's back, because that allows for the smallest part of the head to go through the pelvis first. When the baby is posterior, the labor pains tend to be concentrated in the lower back, all the way down to the tailbone. That's exactly what this mom was experiencing, and it didn't look like any fun. She did a really amazing job of concentrating on the breathing and rocking her hips and changing positions to try to keep the pain managable. We also tried a birthing ball, which I though looked great. It's just a regular exercise ball, but they put it in a chair-like frame, so there's a backrest. This mom didn't particularly like it , but I kinda want one for myself.

The nurse and I kept checking on her throughout the afternoon. At one point she and her husband kicked the rest of the family out of the room. Around 6pm they did another internal check and she'd progressed to 7cm dilated, 100% effaced. Fully dilated is 10cm. This was when my nurse told me that if I wanted to eat dinner I should do it now. So I did. Then came more monitoring and encouraging and checking vitals. Lots of encouragement for both the mom and the dad. She was still smiling between contractions, so that was a good sign.

Anoher internal check in a couple of hours showed her still at 7cm. The baby was starting to turn around to a more anterior position though, so something was happening. The mom was feeling more of the contraction toward the front and less in her tailbone. The contractions were also getting stronger and more frequent. Sometime around now the husband asked me if I was going to stay through the end. I told him I would if they were okay with that, and they both said, "Yes, please!" I was very happy to hear that they wanted me there. It was the first time for all of us.

Contractions continued, and the mom was obviously starting to get tired. The nurse mentioned that it was not too late to get an epidural, and discovered that the mom's reason for not wanting one was fear of a needle being put into her spine. But she was tired, and in a lot of pain, and said the anesthesiologist could come talk to her about it. So he did, and she decided that she wanted to go ahead with it. Now, having an epidural put in normally is not a whole lot of fun. Having an epidural put in when you're in labor with contractions every 3-4 minutes is downright miserable. We had her sitting on the edge of the bed propped up on both me and the nurse. The husband had to leave the room because he has a problem with needles. It took them four tries and nearly an hour to get the epidural in place and I think that was by far the worst hour of her entire labor.

When the placed the epidural the also gave her a spinal block for immediate relief. Unfortunately that also completely numbed her from the waist down. So we stuck her back into bed, covered her in warm blankets and left her alone to try to rest. She couldn't feel her contractions at all any more. They were happening, because we could see them with an external monitor, but she felt nothing.

More time passed, she was still numb, but the contractions were still going. Around 10pm, the doc did another internal check. This time she was fully dilated and there was already a head in the birth canal. We asked her if she felt like pushing and she said no, so we just left her alone. Contractions were still coming and we checked on her every 5 minutes or so. In about a half hour she said that she could feel some pressure, although no urge to push. So we had her push anyway. That nurses description of it was to, "Push like you're trying to poop out a watermelon." So she did, and it worked, even though she couldn't feel a thing.

After about 3 contractions worth of pushing I could see the baby's head. That's when we called for the docs to come in. They did, and set up all the stuff for delivery. I pulled out her foley, the docs got themselves ready, the husband was trying not to look, and the nurses were preparing the crib for the baby. It took less than a half hour of pushing for the head to come out and then one more push and the whole body followed. The baby was an adorable little girl (parents didn't know ahead of time), wrinkly and blue until she cried and magically turned bright pink. She was small, only about 5lbs, but she was a few weeks preterm, so it was to be expected.

As soon as she came out there was a flurry of activity. They cut the cord, handed the baby off to the NICU nurses, who did a quick assessment, Apgars, and got her warmed up. In the meantime the docs were massaging the mom's uterus to get the placenta out. It came out in about 5 minutes after the baby. The docs also saved the cord blood and the cord itself for research and the placenta looked a little funky so they saved it to be sent to pathology. It was about 15 minutes from the time of delivery until the mom actually got to see and hold her little girl. Then she got to hold her for only a few minutes before the baby got whisked off to the NICU. There wasn't anything wrong with her, she was just a little bit preterm so she had to go for observation for at least 6 hours. Mom couldn't go with her because she still couldn't move from the epidural.

There were many rounds of congratulations and hugs and then the docs left as quickly as they had arrived (I think they were in the room for less than an hour). I then helped get the mom more comfortable in bed and cleaned up. Both mom and dad thanked me again for staying, and I thanked them for letting me stay. It was quite an amazing experience. I got home about 2 hours later than usual from clinical, but it was well worth staying late.

I'm back

School started again on Tuesday. I'm taking only two classes at the moment: Women's Health and Management of Care. Management of Care is going to be boring and you probably won't hear me talk abou it much. Women's health, on the other hand, means I get to play with babies. Oh, and women, most of them pregnant. You'll hear about that a lot (disclaimer for the parents: Yes, I adore the little babies, and no, I do not plan on getting pregnant any time in the near future.)

I've had two clinical days so far on the OB floor. The first day we were jsut there to observe for a couple of hours, but I still got to hold a couple of newborns and see a bunch more. And their moms. Can you tell which I'm more interested in? The second day I go to use a doppler to find fetal heart beats in pregnant moms and watch two circumcisions. (Disclaimer #2: I'm going to go into detail about the circumcision procedure. Skip the next paragraph if you don't want to know.)

Before I start, I should say that I don't really like circumcision, because there is no proof that it has any benefit whatsoever. Recently a study came out about how circumcised men have a lower chance of contracting HIV during heterosexual sex, but the most current literature reviews say that there is no significant benefit (trust me, I just checked). That's how I felt about circumcision before I'd ever seen one. Now, what does an actual circumcision look like? First they give the baby some sugar water (which somehow calms them down) and then inject lidocaine into the nerves that run along the top of the penis. Then they let the lidocaine do it's thing for about 5 minutes so the area is numb. The baby is then put on a little tray thing with slots for his legs, which are held in place with velcro. A kicking baby would be a very bad thing during this procedure. One nurse holds down the baby's top end while the doctor takes some forceps and separates the foreskin from the glans of the penis. Naturally, the foreskin may not separate from the glans until he is 5 years old. Once the foreskin is separated, a cut is made so that it can be pulled back exposing the glans. Then they put a little plastic bell shaped thingy (called a plastibell, shockingly) over the glans to protect it. The doctor then ties a piece of string as tightly as possible around the base of the glans to cut off circulation to the foreskin. The foreskin is then cut off close to the string and the plastibell is removed, leaving a little plastic ring between the remaining bit of foreskin and the glans. Over the next 7-10 days the foreskin will become necrotic, turn black, and fall off, along with the string and plastic ring. For the most part, the baby doesn't feel anything during the procedure except for the initial lidocaine injection. The painful part is urination and diaper changes for the next week or so while he heals up.

Okay, so that's how it's done. Why is it done? We got a little history lesson from the doctor who did the ones we watched. She was Norwegian, where almost no one gets circumcised, so she went and looked up the history of it when she arrived here. Apparently it gained popularity in America after WW1 when many men developed infections because they were unable to clean themselves properly underneath their foreskin while in the trenches. I don't know if that's true or not, but that's definitely the time period when circumcision took off in the US. Now 80% of American men are circumcised. In the rest of the world, the cultures that circumcise are mainly Muslims and Jews and only 30% of the total male population is circumcised. None of the national medical associations in the US recommend circumcision and most families say that they do it because they, "want him to look like his father." Anyway, I'll get off my soapbox now and go back to my usual blogging.

I haven't really been doing anything since I got back except school and sleep. It's been freezing cold here for the past couple of days, about -10 and frequently snowing. I'm mostly hiding out inside and trying to stay warm. I did manage to get to a blood drive yesterday, which was good. My hemoglobin is still nice and high (12.9!), which I love to see, and they only had to poke me once. I even got a free movie ticket and coupon for coffee. Also, I discovered that hospitals that use blood from the red cross get charged based on how much blood is donated at their facilities, so support your local hospitals by going to their blood drives! I may be going with a couple of other students to donate platelets sometime in the near future too. I haven't done that yet, but I've been wanting to give it a try.

That's about all for now. I'm sure there will be more to write about soon. A lot of the next 5 weeks is going to be OMG BABIES!!!!! so consider yourself warned.

A sorta, maybe good day

I think today was a good day in clinical. Why? Because I was busy pretty much the entire time and I felt like I really did something good for my patient. Unfortunately, the situation that allowed me to be busy and contribute was my patient having a stroke. Does that make today a bad day? It was definitely bad for him, and it was very stressful for me, but I got to learn a lot and while we were rushing down to get a CT scan, I was the one providing the neurology docs with his pertinent history and current medications. I was capable of answering all of their questions, I explained what was going on to my patient, I worked with the team of nurses and docs to get him where he needed to be as quickly as possible. In that sense it was a very good day.

I guess I'm feeling a little bit guilty for being happy with what happened today. I'm glad I got the chance to help with an emergency situation, but I shouldn't be too glad because it means that my patient's health is declining. On top of that, today was my last day on 7-14 and I will probably never find out what happens with him. That part of school bothers me a lot. I want to see my patients' outcomes, I want to know whether they will be okay. Sadly, there is nothing I can do to change that part of the system.

My major frustration today was with the neurology resident. After forcing my patient to get up out of bed, despite being warned that he was very unsteady and barely able to walk, he left me there with a medical student and my patient sort of half sitting on the edge of the bed. This was incredibly unsafe for several reasons. First, my patient weighs about 350lbs. If he falls on the floor (which has happened) it takes about 6 people to lift him back up. Second, he is very weak at the best of times and understandably exhausted from everything he was put through that afternoon, he barely had the strength to help us move him back to bed. So, this doctor finished his exam and just walked away, leaving me and a med student with an incredibly large, exhausted, and weak man who we can barely keep from falling onto the floor. Thank god my clinical instructor was walking by the room and grabbed a few people to help us. I understand that docs are busy and very focused on their specialty and figuring out what's wrong, but the primary focus of every health care worker in the hospital should be patient safety. There is no excuse for what he did.

I have had other bad experiences with providers (doctors and nurse practitioners) lately. They get too focused on diagnoses and orders and forget about the basics, like safety and comfort. I do not expect to ever see a doc giving a patient a bath, but I do expect them to make sure that if they cause a huge mess (such as a patient vomiting all over himself during an NG tube insertion) that the nurses and techs cleaning up that patient are okay and have all the resources and information they need before the doc leaves the room. That way we don't have to go harass the doc while he's writing his orders or seeing another patient.

All of that being said, I am going to miss 7-14. It was a good floor with (mostly) good staff. I've heard very contrasting reports of what my next floor will be like, so I'm keeping my fingers crossed.

Clinicals

I started my adult health rotation last week. I'll spend 5 weeks on a cardiovascular surgery floor, then 5 weeks on a short stay medical floor. Here's a quick rundown on what my weeks are going to look like from now until Christmas:

Mon: Lecture noon-8pm

Tues: Lecture 8am-3pm, go to clinical unit and copy patient information, write up a report on patient including primary diagnosis with pathophysiology, up to 6 comorbid diagnoses, explain their pathophysiology and effect on primary diagnosis, past medical history, drug cards for medications (up to 12), and a priority nursing diagnosis.

Wed: Clinical 7am-4pm, write up a report that includes assessment of patient, and nursing care plan with daignoses, interventions, expected outcomes, and method of evaluation.

Thurs: Clinical 7am-4pm, implement the care plan, write up an evaluation of whether it worked.

Fri: Simulation or Community Health (alternating Fridays). For simulation days, write SBAR report, critique partner's SBAR, blog, and comment on blog.

That's the summary for this class alone. I guess that's what happens when you take a single class worth 8 credits.

Other than the crazy workload, I think I'll really enjoy this clinical rotation. My instructor is great, gets really involved while we're on the floor. And the patient population is mostly interesting. I say mostly because I'm interested in cardiac surgery patients, but not vascular surgery patients. Vascular surgery is a lot of, "Oh, you had uncontrolled diabetes for your entire life, we're going to cut your gangrenous leg off now." I'm hoping to be assigned a cardiac patient for this week.

Also, our nurse manager had breakfast there for us on the first day. How cool is that?

I'll write more about clinicals when I start to get interesting stories to tell.

Life, clinicals, and almost done...

Two more days before I'm finished with one third of my nursing program. I'm almost one third of a nurse. That's a little scary.

Life outside of school has been going extremely well lately. First and foremost, the bat guys came today and did their work on the house. So, there should be no more bat invasions, and no unpleasant surprises for my incoming sublettor (sublessor? sublessee? I have no idea...)

Secondly, I had dinner with my soon-to-be housemates last night. They are wonderful! And they love to cook, and are very good at it. Jordan is a second year medical student and Jessica is a music teacher who is going back to school for a Master's in counseling. They invited me over for a "simple dinner" which included panini (on their shiny new panini maker!) salad, pasta, chips and hummus, wine, and peach cobbler. And it was all fabulous. I'm going to like living with these people. One of their friends was there too, a blind pianist from Eastman School of Music who had just returned from an international piano competition in Moscow. A really amazing guy, with a lot of good stories. The four of us got along great right from the start, lots of laughing and making plans for the house, and going on outings together, and all sorts of hilarity. I had a blast, and stayed way past my bed time on a clinical night, but it was completely worthwhile. I'll be moving into the house as soon as I can after I return from Portland.

The whole Paul thing is going rather well right now too. There was a day of canoing on the Genessee River, and some cuddling, and the purchase of a webcam for me so that we can chat to each other while gallivanting around the west coast. He's currently in San Diego at a conference, and won't get back until Friday, the day before I leave for Portland. Bad timing, but the webcam/Skype thing is pretty cool. Sarah seems to be incredibly proud of herself for managing to set us up.

Lastly, school stuff. Like I said, I'm almost done with this semester. I've determined through this clinical rotation that I have no interest in working on an ENT floor. I prefer patients that can talk to me, and so far I haven't had a single one of those on this floor. A lot of them have trachs and that makes talking very difficult unless they use a speaking valve, which can make breathing difficult. Usually they choose breathing. Also, I don't enjoy phlegm and sputum. I'd honestly rather deal with vomit and diarrhea. The whole suctioning out a trach thing is quite gross to see, but even worse to listen to. My next rotation will be Psych, on the Mentally Ill/Clinically Addicted floor. That will be very different and probably really cool. I bet I'll be longing for the patients that don't talk after five weeks of patients in withdrawal, though. And then I'm on the Cardiac Surgery floor, which I'm looking forward to a lot. Oh, and there will be a ton of classes mixed in with that stuff too. Fall is supposed to be the hardest semester of this course. Can't wait.

I think that's about it for now. I don't know how much I'll be posting from Portland, but I'll definitely be getting photos of my new place up here as soon as I can after moving in. So exciting!

Clearly Monday was too optimistic

This one is going to be another quick and dirty list.

1. The wedding was beautiful and I had a lot of fun with all my Oregon (and other) friends.
2. I made it back to Rochester without a problem and even got a 3 hour nap on the floor of the Philadelphia airport.
3. Sarah kidnapped me for hanging out on Monday and I fell asleep on her couch after dinner. Ronen was kind enough to drive me home.
4. I've started my Acute Care clinical. It's a lot more exciting than Long Term Care was. I'll elaborate more about clinicals when I'm less busy (read: after August 15th).
5. I emailed my landlord and there will be bat-proofers coming to check out the house either Saturday or Monday. Apparently after the initial bullying attempt he becomes a reasonable person.
6. I have an RIT student coming tomorrow night to check out my room and the house to see if he would like to sublet. Therefore the rest of the night will be spent cleaning and then collapsing in bed.

And finally, a plea for help. My suitcases were stored in the basement and apparently that was a poor choice, because they are now filled with bugs and spiders and various creatures that I don't want in my stuff (not sure about bats). Any ideas on how to rid said suitcases of said critters?

Feeling better

I'm back home now, having spent a really nice day hanging out with Sarah and the little ones. I had gone over to her house to do that online exam, because if I went home I was pretty sure I would forget about it, and ended up staying until after dinner. She gave me lots of hugs, fed me, chatted with me, let me play with her adorable children, and generally did a fabulous job of cheering me up. I think Maya is starting to get to know me, and Yasmine will usually give me random flying hug attacks throughout the day and won't let me leave without saying goodbye. It's very sweet and cute and a perfect way to forget about stressful life stuff. We even went for a walk to the park after Ronen got home and I got to play with more adorable small children, including a set of 2 year old twins named Henry and Calvin who insisted on repeatedly filling my hands with woodchips.

Tomorrow is my first day of clinicals. I'm going to a long term care facility close-ish to the hospital, but far enough that I'll be carpooling with my friend Laura. I offered to buy the coffee if she'd drive, which I think is a good deal. We have to be there at 7:00am, so I'm meeting her at her house by 6:30, just to be sure that we're not late on our first day. I have a few final things to do before I'm ready to go, but otherwise I should be all set. I'm sure I will have a lot to talk about after this first day, but I may not get to blogging about it until later, depending on how long I need to recover.