Birthing Baby Burritos

I am in nursing bliss: the happiest place on earth! (Or at least as far as the hospital environment is concerned.) I started my OB rotation yesterday with no real expectations or high standards to meet. I have baby-sat plenty of little munchkins, but none so wee as a newborn. And I have surprisingly little experience with pregnant and laboring mamas-to-be. I walked into this rotation bleary-eyed and lacking my ritual “it’s-too-gosh-darn-early-to-be-awake” pre-hospital caffeine infusion, or even breakfast. I didn’t have these things because I was running late on this particular day, but I expected it to be okay since most first days are mellow and mainly orientation-centered.

Nope, not for me on this day.

I arrived at our prearranged meeting site in the hospital and our preceptor immediately announced that myself and another student would be marching straight up to Labor & Delivery for observation of c-sections and vaginal deliveries! Wednesday was my day for vaginal birth, and Thursday was supposed to be cesarean. Shocked, I completely forgot to even say that I needed to eat something first, and once I realized my error, I just crossed my fingers and swore to myself that I wouldn’t pass out no matter what crazy things I saw. So, up we went, me still trying to surreptitiously rub the sleep from my eyes. The first nurse I was placed with asked me point-blank if I could go get my nursing textbooks or homework and sit in a corner somewhere far away from the laboring mother because she said the mom was anxious about having me there. I must have looked crestfallen, because when I awkwardly mumbled something about this being my only chance to witness a real-live delivery and really wanting to be there, she heaved a sigh and said,

“Oh, well, fine. Let’s see if there’s another nurse that has a mom that’s further along in her labor. You know, my lady’s only 5 cm dilated so far, it could be hours.”

Thank goodness, I thought. That nurse must have woken up on the wrong side of the bed, or quite possibly off the bed entirely, and I was just thrilled to be pawned off on another nurse who, thankfully, turned out to be the complete opposite of Ms. Negative Nelly. This new patient was a mere 18 years old, but there’s something about a huge baby bump that makes one look automatically older. I had to keep reminding myself of how incredibly young she is. As I walked in, she was just receiving an epidural. She was 4-5 cm dilated, but her contractions were already 2 minutes apart.

From the get-go I was enthralled. My nurse showed me the fetal heart and contractions monitors, and she taught me all about monitoring the baby’s heart rate during the contractions, and comparing it to the feed that was being spit out of the machine, to make sure there weren’t an excessive number of variable deceleration, indicating cord compression, and that the baby wasn’t in danger of becoming hypoxic. The fact that this mother-to-be was already having close contractions at 5 cm meant that she certainly didn’t need any other stimulant like Pitocin, and in fact, they really didn’t want the contractions to get much closer together at all. After we gave time for the pain meds to kick in (and boy did they work – she went from writhing and twisting in bed, to a wan smile saying that she couldn’t feel anything below the umbilicus anymore) we took a short break. My nurse told me that she was going to go get some breakfast because it would surely take awhile for the woman to fully dilate. I counted my lucky twinkling stars that I wouldn’t get all hypoglycemic and pass out on her…(how mortifying, even though I am still just waiting for that day to come). 20 minutes and an apricot-studded scone later, I came back up to Labor & Delivery. Immediately I saw that our young mother was quite the overachiever! When I arrived, she was already 10cm dilated, fully effaced, and ready to push. All in a matter of the 20 short minutes that it took me to scarf a scone! I hurried in behind my nurse and we jumped into action. Or rather, I should say she jumped into action. I mainly watched, and pitched in where I could.

It was only a few short minutes until we had the bed revamped into a birthing bed, the resident who would deliver the baby was fully gowned and ready to go, and we had helped usher her family out of the room – saying that only 2 people could be present form her family during the birth due to space constrictions. (I will amend the story at this point to say that by the end of the birth process, I am fairly certain that I counted at least 6 people from the family present and accounted for, surrounding the bed, but who’s really counting anyways?) Anyways, at this point, I was awkwardly peering over my nurse’s shoulders as she and the birthing mother’s own mother helped support her legs outwards while she pushed through her first contractions. The doctor felt for the baby’s head, and found it well-positioned and ready for steady pushing. To maximize each contraction, my nurse told the laboring mother to take a deep breath in and push hard for a count to ten, and then let the breath out and do it again. She did it three times in quick succession for each contraction, and then took a brief respite while waiting for the next wave of contraction to arrive. I was completely mesmerized.

My first glimpse of another life emerging from the mother was a shock of a black hair. My jaw almost dropped and I wanted to pinch myself, it all felt so dreamy. But there was barely time to think. My nurse leaned over to me and verified that I wasn’t about to pass out, to which I quickly shook my head, “No, no, no,” beaming. She smiled back and said, “OK, well would you like to help hold her legs open and count the contractions for her?” Thrilled, I answered in the affirmative and took her spot at the helm, which happened to also be the best viewing spot in this small birthing theater. I didn’t miss the popcorn a bit. My first count was hesitant, but I quickly learned my role and loved it. I encouraged her to take in a deep breath and push. I counted to ten, each number, internally encouraging her to push a little more, to give it her all. After each contraction, I warmly told her how well she was doing, and encouraged her to rest for the brief interlude. During this short period, which still seemed to stretch on for ages, I don’t remember looking at anyone else in the room besides the mother. It could have just been the two of us. I was so alive in this moment, helping a laboring mother was thrilling and intimate and so impossibly surreal, I couldn’t think about anyone or anything else. Watching the baby’s head slowly emerge was thrilling and compelling, while also shocking. Not only the obvious factor that something so big can emerge from somewhere seemingly so small, but because another life was about to appear in the world. And when he did, that first breath was one of the most miraculous things I have ever witnessed. The tiny blue and white body seemed to almost instantaneously swap for a healthy pink tone as the tiny infant drew in his first breath and let out his first lusty cry to the world. So many factors must come together for this breath and subsequent cry to occur and I couldn’t take my eyes of this tiny miracle. Leaning in close, I watched as the doctor clamped down on the umbilical cord, now rendered obsolete, and let the eager medical student do the honors of cutting it. In his eagerness however, and my obtuse baby blissed-out unawareness, as he cut the cord, her sent a smattering of ruby red blood droplets showering down all around, including on my scrubs and forehead. Whoops.

Said medical student also threw out the placenta by accident a few minutes later, in an apparent effort to be helpful and start the clean up process. Double whoops. The nurse and I had to go digging in the biohazard bin for it. Gross.

After the last vestige of physical connection between mom and babe was severed, the nurse and I rushed the baby to the warmer to vigorously rub his tiny body, removing excess vernix and stimulating his nascent blood circulation. I didn’t know about skin-to-skin time with mom and baby at that point; now I wonder whether it’s better to hand the baby right to mommy – disregarding any extraneous fluids, serum or vernix for the moment. Hopefully, I will see many more births in the future and many different methods for doing things. In this case however, without discussing whether this was the best way to do it, we spent about 5 minutes with the baby, taking footprints, extracting cord blood samples from the placenta, and administering the baby’s first medications: prophylactic eye cream and a Vitamin K shot to his miniature thigh muscles. Then I got to watch my first example of baby burrito-ing. The nurse twisted the baby up so fast and expertly in a little bundle that I would have missed it if I blinked. Peeping out of the burrito bundle was a teeny tiny squishy face with a spiky black head of hair. We then passed the little bundle of joy off to mom for their first precious moments together.

I can hardly put words to the beauty and sheer surrealism of this event. These first moments of life really bring it full circle for me. It’s mind-blowing to think that this full-fledged tiny human being emerged into the world from the meeting of just a few specialized cells, designed to do the world’s most magical thing when they met in an event called conception, only 9 months ago. It was miraculous to watch life arrive. It all happens in such a natural way, yet it looks so insanely foreign to a newcomer. I felt so privileged to be present for this birth, so amazed to witness firsthand the miracle of life.  The human body is amazing, and in countless ways I truly cannot believe what a rewarding profession I have entered; I am so excited to be here.

 

Emotions get in the way

This was a saved draft that I started during finals, and never finished:

Last week at the hospital was difficult. Not like, “I got to try a new procedure and I am thrilled but tired” but rather more of an energy zap and I couldn’t really put a finger on what it was that felt so hard until later. I was able to follow-up with my patient from the previous week, which I was very grateful for. Last week, we connected and it’s hard for me to let go of connections gracefully since I grew so accustomed to them while working in Assisted Living. However, it also was a reality check for me. People don’t go to the RICU very often when they are “getting better.” It’s nothing like Labor & Delivery, for example. You may be quite literally breathing life into your patients, not usually a long term solution. My patient from last week had rapidly metastasizing cancer in her lungs. I knew she wasn’t getting better, but it doesn’t make it easier to watch a 60-something year old woman face dying when she isn’t ready for it. I spoke with her son last week who told me that she was non-responsive and nearly obtunded. She couldn’t speak anymore. So much changed in merely a week. The RICU might be her last stop.

My patient for the current week didn’t improve my outlook. She was alert and oriented to person/place/time when we began our care in the morning, although she was also very old and sickly. She had taken a big fall and broken an arm as well as hitting her chin on something hard which caused a lot of swelling and ecchymosis. She was in the RICU for her breathing which was labored and required supplemental oxygen. Just days before, she had been living independently, but the fall had taken a huge toll. Here we were, doing a head-to-toe bed bath, trying to elicit responses and receiving far fewer than we liked. We watched the nurses take blood tests from her delicate veins, covered by a dry and papery-thin layer of skin. They were trying to figure out if her reduced mental status was due to an undiagnosed infection. By the end of the morning, she had gone from awake and alert to lethargic and somnolent. It was hard for me to watch this progression. When we presented on our case in the afternoon, it seemed clear to us as well as to our preceptor that our patient’s prognosis did not look good. I left that day feeling a little bit heavier. I am starting to realize that you don’t always get to help your patients “get better.” As rewarding and obviously satisfying as that might be, it’s only one facet of the job.

Update: The following week, when I went back to the hospital, the aforementioned patient was much better! She had made almost a complete 180. She was awake and alert. She said that she remembered us from the previous week even though it hadn’t seemed like she was at all “with it” to be aware of us. Her bruised chin was less swollen, she was breathing entirely on her own, her skin was cool to the touch and best of all, she could communicate with us. I know this won’t always be the case. Not every patient gets better. But in some cases, the patients that seem the least likely to make a full turnaround, do. You provide the same level of care to everyone and sometimes you get a great outcome. It’s important not to decide for your patient whether they will get better or not, but just adjust your care to the changing conditions, with monitoring mental status being one of the most important indicators. It was so gratifying to see a patient on the road to recovery.

 

Inglorious Bast-turds

Turd is a 4-letter word that I much prefer over test. I promise, I am not talking about wiping bums today, but I do not feel ashamed in at least mentioning it. I would far prefer to clean up after someone who passed their bowels than take a pharmacology/physiology/issues of nursing test…ANY DAY.

I am a bit worn out on exam-taking today. This week. This month.

If there was a pie chart of my life, studying for exams would be disproportionately representative. I know that I need to learn this material in order to be a safe and effective nurse, but this method of tricky multiple choice testing day-in-and-day-out really takes a toll. That’s why going to the hospital this week was such welcome relief. Patience may be a virtue, but I am sadly lacking it when it comes to waiting for competence in nursing practice. Yesterday, however, reminded me why it is worth working for.

Our preceptor placed us with telemetry/cardiac monitor patients this week. In the RICU, this may seem like a step down in terms of hands-on learning since our patients weren’t dealing with tracheostomies and ventilators, but in terms of gleaning knowledge from our patients about their present illness, it was profoundly educational and emotional. This was my first patient that could actually speak to me!  More than speaking to me, she entertained me to no end.* Breathing was difficult, her energy was low, but her wit abounded. She was a total trip. She told a doctor that she was going to kick, ahem, his little “behind” if he didn’t get her off the drug that was causing her anxiety. While she was consulting with a palliative care doctor about possible treatments, her son was telling me all about her career working for the police department and before that, traveling with the army for close to 20 years. In a break from talking with the physician, her son asked, “Hey mom, what’s your favorite gun?” Without missing a beat (quite a feat on a 50%-O2 saturation partial face mask) she responded, “M-16 and M-19,” then she turned back to the doctor and continued conversing about her treatment. I was momentarily shocked that this little tiny lady had not only handled a gun, but that the names of her personal “favorites” had tumbled from her lips as easy as 1,2,3. Previously, we had spoken about salsa dancing and I had pegged her as a dancer in her former life, but that clearly wasn’t all… She is quite a character. Unfortunately, her condition doesn’t promise a quick recovery: sigmoid colon cancer, pancreatic cancer that quickly metastasized to the liver, bones and lungs. For this reason, my day with her was quite bittersweet. I was able to talk to her about her life and illness, take my time in giving a bed bath which she and I both thoroughly enjoyed, and also meet one of her incredible children who moved here from different state barely a week ago to be with her in the hospital. I was able to understand her condition (an achievement in itself) but this also opened my eyes to the possibility (or reality) that she will most likely not be leaving the hospital with her son. This is a hard pill to swallow.

When I left the hospital yesterday, though, I wasn’t sad. Maybe my residents helped me understand death and dying a little better. There was a part of me that was sad for her and her family. But I was able to compartmentalize that sentiment and also recognize another emotion: elation. At 6am that morning, I left the house as a Negative Nelly, feeling down-in-the-dumps over another upcoming test, compounded by a serious sleep deficit. But at 3:30pm, as I left the hospital even more weary, I had a completely different outlook. Again, my patient reminded me why I am here. It made me so excited to learn more, even if it means test-anxiety, some more sleepless nights, and even the monotony of studying on a Friday night. It’s only a few more weeks until August, and then it’s three weeks OFF!

In honor of my impending cooking-fest, I will post a recipe that I found the time to make the other day and ADORED.

Eggs Nesting In Tomatoes On Toast

Adapted slightly from A Cozy Kitchen

Serves 4 (maybe…)

• 4-5 eggs (separated, reserving 2 of the whites for another use)
• 1/8-1/4 cup extra virgin olive oil
• 2 cloves of garlic (minced)
• ½-1 tsp red pepper flakes
• 1/2 tsp of dried oregano
• 1 24-oz can of whole tomatoes (San Marzano highly recommended)
• 1/2 tsp of salt
• 2 Tbsp of chopped fresh basil (I’m growing mine on my fire escape!)
• 4 slices bread–whatever you have on hand, toasted

In a cold medium skillet, combine the oil, garlic, red pepper flakes, and oregano.  Turn on the heat and warm over medium heat until the garlic begins to become fragrant (without browning), about 2 minutes.

Raise the heat to high, then use your hands to “crush” each tomato into the pan. (I used a fork/finger to pierce them because the squirt-factor was out of control. Beware of your cute t-shirt, it is in danger!) Season with salt and pepper.  Fry the tomatoes, continuing to break them up with a fork. Cook until they concentrate and no longer look watery (5-7 minutes).

Lower the heat to medium and stir in the egg whites.  Cook until the whites become opaque and firm, thickening the tomato sauce, about 1 minute.

Turn off the heat. Using the back of a spoon, make 4 indentations in the sauce, allowing a few inches around each.  Nestle an egg yolk into each indent.  Pull the sauce in from the edges of the pan so that it cradles each of the yolks.  Cover the skillet and leave it on the stove, heat off, until the yolks are just warmed through and beginning to set, about 3 minutes for runny yolks.

Gently spoon some sauce and a yolk onto each piece of toast and serve immediately. Use a large spoon, perhaps lightly oiled, to pick up a nestled yolk without breaking it. Enjoy for breakfast, lunch, snack, or dinner. Or another special occasion time (plucking your eyebrows??)

*information changed & withheld to protect patient identity

 

Inserted Co-rectally

A friend's picture: The view from our school

 

The other day, I found myself at the butt of the joke but in a great way. I felt closer to my residents, all the way back home in Seattle. Why? Because I was dealing with feces and bowel movements again! Funny that this can make me feel all warm and fuzzy now. I guess I am a bit kooky. When people curiously inquired about my work as a CNA, they always wrinkled their noses in disgust when we get to the part about helping people pass their bowels. They say they “admire me” for my ability to deal with it without disgust. But really, admire me for wiping poopy butts?? I mean, come on, we all wipe our own don’t we? Nobody has a robot in their bathrooms? Is it really such a stretch to think about helping out someone else who is wiping-impaired? Please, choose something else to admire me for! Listen, I know I write about poo a little more than the average person in this blog, but who doesn’t at least think about poop once every day? At the very least. It’s only natural, folks.   

Which is why what I did the other day really wasn’t such a big deal. Certainly not compared to the catheter insertion last week which felt much more foreign, to say the least. Let’s start by saying that I am amazed that I am where I am. In a hospital, providing care to patients in acute respiratory conditions. Turning a patient over is difficult not because of their weight (usually) but rather because of the sheer number of peripheral and central lines and catheters coming out of every imaginable orifice. Yet, I am not “grossed out.” I am not freaked out. I am learning what each line goes to and I am fascinated by its purpose. My thirst for this knowledge is insatiable because I want to be the most adept at helping my patient. I stare at the medication list (which looks like a grocery list in some alien language) and I feel overwhelmed by my ignorance but willing to look them all up. Mechanism of action, pharmacokinetics and pharmacodynamics…these were all foreign terms to me even 1 month ago and yet I already know the drug indications/interactions/mechanisms for at least 30 classes of drugs. In the hospital now, I am not afraid of my patients, I am afraid of not knowing enough. It’s exciting to be learning so much every day. Every patient confirms or illuminates something I read in a textbook or was told by a instructor. Our patients’ pathologies and co-morbidities helped me understand the renal system, the circulatory system, cardiovascular disease, neurological impairment and so much more. Even about poop! I never knew that nearly everyone in the hospital is on some kind of bowel regimen. But it makes sense: less movement may mean less peristalsis, pooping is never easy lying flat and there are so many medications that have constipation (or diarrhea) as one of their drug interactions. The patient I worked with yesterday had at least 17 meds and I counted at least 5 of them that consisted of her bowel regimen (aka: Poop Plan). Yesterday we found out that our poor lady hadn’t passed her bowels in four days! Talk about discomfort, not to even mention other implications. After providing morning care, I had really grown fond of our patient. She was the sweetest yet most stoic patient I have met so far. She caressed our hands even as we caused her discomfort here and there. Her eyes didn’t show any sign of reproach as we fumbled through only our 2nd bed bath with a patient who has so many indwelling lines and a ventilator.   

After the bed bath, our preceptor enter with a nurse practitioner and announced that we were going to be able to watch and learn from a manual probe to look for fecal impaction, which would then be manually removed if encountered. I looked forward to observing. Then my preceptor quickly changed her mind and said to the NP, “Actually, would you mind if we do it so that I can teach my students?” The NP readily agreed and walked out to help another patient. I happened to end up on the same side of the bed as my preceptor, at the patient’s backside.   

Without missing a beat, my preceptor said, “Okay, Rachel, now I’m not going to do it. You are. We are going to take a rectal temperature, perform the manual rectal exam, remove any impaction and then take two swabs for a culture.” And, to give myself due credit, I also said, without missing a beat, “Okay, sounds good. Should we start with the rectal temperature?”   

Without going into the nitty gritty details, I performed all three tasks with ease. The exam produced no sign of fecal impaction, so we decided to insert a rectal suppository, hopefully to induce a bowel movement. It all went so much more smoothly than the catheter insertion! I thank my residents for the familiarity and comfort I feel at the helm of the behind. Not even an hour later, our resident had her first BM in 4 days. She didn’t say as much (again, the ventilator) but I interpreted her silence as relief. I know I would feel relief. It feels so good to be helping. 

 

Donning Gloves and Gown, Entering Hospital Town

Ten years ago, I squirmed when I saw blood and guts. My best friend loved gory plastic surgery TV shows, but I couldn’t handle them. If someone had told the childhood version of me that I would be a nurse one day,  I would have told them that they had the wrong Rachel. An author, sure. An artist, why not? A TV news anchor, yes for a short time, I’ll admit it. But never, not ever, would I have guessed a nurse. All those personality tests we had to take in high school (Meyers Briggs, career assessments…) none of them correctly predicted my future path. Granted, if they had come back with “Nurse Rachel,” I would have rolled my eyes even longer than your typical high schooler, but little did I know…

In our accelerated summer program, we only have one day/week of clinical time. It is welcome relief from sitting in the lecture hall for hours on end with our bums molded to the weirdly shaped red chairs, hunched over our computers and notebooks, furiously scribbling/typing away. 8-12 hours of classroom time every day is enough to make anyone grateful for an intravenous catheter insertion demonstration (or in my case, hands-on experience). I ended up at a well-known hospital for my first clinical site. Not only did I get lucky with the location, but I was placed on a RICU floor (respiratory ICU) which is like jumping into a freezing lake: much better just to throw yourself in without knowing the temperature of the water. Our patients have acute medical conditions, and the majority are in respiratory failure. The first clinical day, we spent most of the time in the patient lounge with our preceptor teaching us about the floor; essentially a crash course in Respiration & Ventilation 101. We were overwhelmed. At the end of the day, we went in, as a group, to visit one patient. Our preceptor was going to demonstrate how to dress wounds, specifically a pressure ulcer, but it turned out that this woman, Senora Vasquez* had more pressing concerns. She does not have a tracheal intubation (rare for the floor) and just receives oxygen from a nasal cannula. She was able to tell us more about her own disease process that the chart could tell us (with occasional reminders from the preceptor). I noticed that her bed was wet and wondered if he urinary catheter bag was leaking. Our preceptor noticed as well, and quickly determined that no, the bag wasn’t leaking, the catheter itself was leaking and “we” would change it. She asked which of us wanted to do it. Without thinking, I asked in alarm, “Wait, we can do that? We haven’t learned that yet!” She glared at me and said, “Well, I certainly hope you can do it Rachel! You better be able to do that.” I fell silent. She asked again, who wanted to do it. Suddenly, without my permission, a spirit possessed me and I somehow volunteered myself to change the catheter. Who me?? Yes, me. In a dream state, I listened to her instructions and prepared the sterile field. With 10 pairs of eyes (or 11 pairs, counting our patient) watching my every move, I tried to remain calm. I don’t remember much about the process, except that I went through 2 catheters instead of one because my preceptor forgot to tell me when to apply the Betadine the first time, but other than that, it went without a hitch. Luckily for me, this lady was no stranger to catheters and her urethra make an easy target. I was in shock at the end of this, “Oh…wow, that was me! I did that!” But the best part was realizing that in many ways, this wasn’t so different from working in assisted living. I helped someone. As (student) nurses, we made her day better. She had been lying in her own urine, and now she was clean and dry with a new catheter and a freshly dressed pressure sore. I may have felt a little too much sympathy for her condition, but I was also able to walk away feeling like we made a difference. So, that was two weeks ago.

This past week, we were paired in smaller groups with patients. Our patient was an older, emaciated woman, with a trach. When I first saw her, all I could focus on was the plethora of tubes and indwelling lines coming out of her body. Her face was caked with residual sleep, and her mouth needing to be swabbed badly. She looked uncomfortable. I cannot imagine being unable to get out of bed in the morning, stretch deeply, and relieve myself…perhaps splashing water on my face as well. Yet here she was, waiting for the assistance of someone else before she could “do” any of those things. Making matters worse, she didn’t understand that she couldn’t get up and go to bathroom, despite us explaining it to her multiple times. (What do you say? “I am sorry, but here’s a lovely bed pan for you to use instead? Yes, I know you feel like you have energy to walk to the bathroom, but you see, there are all these tubes you are attached to, and they are breathing for you…”) She tried to communicate via lip-reading, but really, she was much better at reading our lips than we were at reading hers. Understandably, this frustrated her immensely. Not knowing what else to do, another student and I started the bed bath. Washing her face, I watched a completely different emotion take over. From consternation and vulnerability her expression melted into total peace and relaxation. Her eyes closed, and her lips spread into a serene smile. It was amazing to watch, and my own body relaxed as well. I swabbed her lips, and suctioned her mouth. We worked our way slowly down her body, warming the water periodically, assessing her skin all the way down. It was a lovely experience, knowing that we were providing palliative care when there really wasn’t much else we could do. The day was draining. Our patient didn’t receive visitors and it was hard to see her all alone, knowing that no one came to see her. Her condition was acute, but not without a fighting chance of survival. Yet, I couldn’t help but wonder to myself whether she felt like she had much to live for. A week later, I was still pondering this conundrum until I realized something quite simple. It is not my place to wonder for her, or to make that decision. My role is to make her day, the moments that I am with her, a little better. I am there to ease her discomfort, ensure that she is not in pain, and fulfill her basic needs. I am there for comfort and healing, which is why I went into this profession. Remembering this, I leave the hospital feeling tired but satiated, as if I have just eaten a big bowl of steaming soup.

*Name changed.