A year at U of R

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Thursday, September 14, 2006

First time in an OR

The labor and delivery portion of the clinical is supposed to be primarily observation for the nursing students. It has turned out to be fairly hands on, though. This week I was in the triage area, observing at the doctors and nurses as they prepared several patients for cesarean sections. I asked how long it would take. The nurse said it would be a while, since they had to give them anesthesia, insert catheters, and prep them. "Catheter?" I thought. "Bingo!"

"Would it be possible for me help do the Foley catheter?" I asked. Before I knew what I'd gotten into, I was in.

I had done one Foley insertion, the week before. However, as I'm learning, every single situation is unique.

This time, I was in an operating room. I was wearing ridiculously large surgical scrubs, since they didn't have size extra-small. I had a flowery paper bonnet over my hair, and a surgical mask tied over my face. I was absolutely freezing, since the operating rooms are kept at arctic temperatures. And I was listening to Faith Hill wafting out from the boombox in the corner. That was my first experience in an O.R.

The while the anesthesiologist gave an epidural, I helped hold the Mom's arm, so she wouldn't fall forward if she got dizzy. Then it was time for the Foley.

I don't think I would have felt nervous this time, if it hadn't been for the situation. The nurse whispered to me a last piece of advice, "You have to do it quickly! This doctor hates to wait."

OK, now I was nervous. The room was full of people ... the anesthetist, the M.D., a Resident, assistants, and a classmate. This time, though, bunny-suit or not, I knew what I was doing. I donned my gloves aseptically and with lightening speed. I tested the balloon at the catheter tip, following correct procedures. I swabbed the area, lubricated and coiled my catheter, and in it went! Success!

Crying over deliveries

Last week during clinicals, some of my classmates got to witness deliveries. I saw an awful lot of labor and interventions, but no actual births. In the post-clinical conference where we debrief, I listened to them exultantly describe the experience. They all said they'd cried when the babies were born.

"Isn't that a little overboard?" I thought. "After all, it happens every day. Why all the sentimental touchy-feely-ness? Come on!"

Little did I suspect that I'd spend much of my clinicals the next week holding back tears and telling myself, "Come on, don't go overboard!" But the battle was futile. A birth is truly a Bambi moment.

The first one that got me was a mom in labor. She had been laboring for hours, sucking ice chips, shifting positions, trying to endure the pain with fortitude. It was exhausting just being in the room with her, and watchiing one contraction and waiting until the next one, on and on for hours.

When she reached the final stage of labor, the head of the baby began to crown. But by then the mother was spent. Each time there was a contraction, the nurse and doctor coached her to bare down. “Push a little harder, keep going, push!” they urged. I was standing at the foot of the bed. Each time she pushed, I could see a larger silver dollar of the baby’s mucous covered hair showing through the slit of the vagina. Then the contraction would end, and the little tuft of hair would slip back inside and disappear.

“Push!” the nurses urged. They watched intently as the tuft of hair came and went.

But the mother’s endurance had been pushed far enough. She had been in labor for hours. She hadn’t slept. She hadn’t eaten. She took a gasp, and began to cry with exhaustion. “I can’t do it anymore.”

The nurses stopped paying attention to the labor, and looked at her. “The baby's almost there, we can see the head,” they encouraged. She continued cry.

“Would you like to see the baby? We’ll get a mirror,” the nurse said, and dispatched me off to find a mirror.

Once outside the room, I realized I had no idea where to find a mirror. “The supply closet is over there,” the secretary told me. I found the supply closet, and opened the door. It was immense. It was a vast supply room, packed with row after row of instruments, supplies, birthing balls, and sterile kits. I had no idea of what kind of mirror I was looking for. I imagined the humiliation of having to go back to the room without a mirror, and ask one of the nurses to show me. I’d better find it, and quick.

I turned around, and lucky for me, there it was! Not the little mirror that they use in barber shops to show you what the back of your haircut looks like. This was a huge mirror on wheels. I think I broke the speed limit wheeling it back to the room.

Once in the room, I negotiated it around the tubes and IV’s, and positioned it at the foot of the bed, asking the mom if she could see. Just then, she had another contraction. “Push harder!” the doctor urged. “Keep going a little longer!” said the nurse. The mother pushed, but she was no longer paying attention to the doctor or nurse, or to the pain or exhaustion of her body. I could see from my station at the end of the bed, the only thing that the mom was seeing in the world was that tiny silver dollar of hair in the mirror.

Thursday, September 07, 2006

Labor & Delivery clinical

I walked out of the first day of the new clinical rotation thinking, "Everyone on the planet should be a nurse." They told us that the labor and delivery rotation is a one chance in a lifetime type of experience. I wish everyone could experience it.

All of the seminal events of life; birth, death, health, illness, families, emotion, used to be commonplace at home. A hundred years ago, births seemed a more integrated part of daily life. Now they are all hidden away in six story, billion dollar buildings with parking garages that charge by the hour.

The difference between the nurses role and the MD's role in labor and delivery is marked. The nurses are there non-stop with the patients, as long as it takes. They know the patient, the meds, and all the details. They take the mother all the way up to the birth. A doctor or midwife just comes in at the last minute to "catch" the baby. Which job would you prefer?

This clinical is supposed to be more observation, but today was definitely hands on. In addition to inserting my first foley catheter, I took the mother's temperature several times, helped change linens, wiped her forehead with cool washcloths, and assessed the average fetal heartrate and spacing of contractions based on telemetry data. I got to talk with the family members, and I even did a little teaching. I explained to them what pitocin is, and the effect it would have. I could follow the medical jargon of the nurses and doctors better than the family, so although I knew very little about the birthing process, I could occasionally translate a little for the family.

In one day, I observed an epidural injection, deaccelerations of a fetal heartrate, insertion of an IUPC, amnio infusions, administration of pitocin, and bolus infusions. Wow. Although I didn't actually get to see a birth, I saw plenty of life for one day.

Foley catheters

Today, I feel like I summited Everest. In fact, all I did was insert my first foley catheter. It doesn't sound like a big deal, and it actually was very easy once I did it. But it was like the plunge a skydiver makes from an airplane at 14,000 feet. You have to get out the door before you can float.

I was in labor and delivery today. The clinical rotation in women's health is divided up, so I'll spend a few days in labor and delivery, a few days in triage and a few days in postpartem care. I started with the labor and delivery at 6:45 this morning. The nurses work one-on-one with the laboring moms in delivery, so I was shadowing the same nurse and the same mother-to-be the whole day.

The mother was very dilated when the day started, and in a lot of pain. To add to the pain, she was scared. I had never considered that anxiety could be such a factor in labor. It seems obvious to me now that the combination of pain, exhaustion, and fear of the process could make an expectant mom break down and cry. It is a lot to go through. I tried to praise her, and tell her how brave she was. Meanwhile, I was quaking myself, feeling totally out of my league with no knowledge of this whole new branch of medicine.

Labor and delivery is so different than the acute care I became used to. The nurses spend inordinate amounts of time recording notes on the tracking of the fetal heart rate every time the mother changes position. They also monitor the mother's blood pressure and vitals constantly. All of the vocabulary was new to me; "IUPC, Terbutaline, variable deacceleration" to name a few. But like anyone thrown into a a country where they speak a foreign language, you sink or swim. I just tried to pick up as much as I could.

I watched the mom get an epidural, and grilled the anesthesiologist for a while with questions about the procedure. He laughed, and joked that he felt like I was giving him his board exams. I learned to assess the level of the epidural by touching a wet alcohol pad to the mom's trunk, and asking at what point she felt it. If the level was too high on her trunk, the bed had to be raised to make sure the anesthesia didn't rise any higher.

An lucky for me, the epidural also meant that the mother could no longer sense a full bladder. She needed a foley catheter inserted to drain the bladder for her. When the nurse asked if I wanted to do it, I was inches from chickening out. I had just returned from a two week break. I learned how to do a catheterization how many weeks ago? Five weeks? Ten? Was I prepared? No way! But something in the back of my head said, "Jump!"

I ran to the other end of the unit searching for my instructor, to get permission to do the insertion.

"Go ahead," she said. She may as well have just said "cleared for takeoff" to a flying elephant.

"I'm a little nervous," I told her. Understatement of the century.

"Go through the steps," the instructor said. I told her exactly what I was going to do, and verbalizing it helped.

I dashed back into the delivery room, praising fate that because of the epidural, my first urinary catheterization patient wouldn't feel anything. But there was still her whole family in the room, watching me perform. Thankfully, the nurse was fantastic, and she walked me through it. I was so focused on the procedure that I didn't notice the family at all. I opened up a kit, and set up a sterile field. Once my gloves were on, and I'd swabbed the whole area, I inserted the catheter. Just like they told us in lab, urine started to come out through it. One more first out of the way. I wiped up the betadyne stains and hung the urine bag on the bed frame, thinking "Now I can float for a while."

Wednesday, September 06, 2006

Fall semester

A quick note back after two weeks off on break...

Just two weeks ago, I was working with patients over the age of 60 with major organ failure. Today, my first new client of the semester was a 7 pound, 6 oz. smiley little guy with curly hair. What a change. Maternal health nursing seems like a different profession entirely. It is so calm and quiet compared to acute care. I must say, though, that I'm a little nostalgic for my old unit. I miss the nurses and staff there, and the familiarity. It's hard to jump around to a new rotation every 5 weeks.

This coming fall semester, I'm doing rotations in women's health, pediatrics, and psych mental health. For the women's health rotation, I'll spend 3 days observing labor and delivery, a few days assisting in a triage care area, and the rest of the time caring for moms and babies in the post-delivery area. I'll also get to watch the lactation consultant at work, and attend some of the parenting classes they have.

I can't believe I've been back from break for 2 days, and tomorrow I may be helping deliver a baby. I'm very excited and nervous. Check in tomorrow and see if I lucked out and got to observe a delivery.

I'm off to read more about the amazing birthing process. Five hours of reading down, another three to go...