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Monthly Archives: November 2010

Progress Report

Brief news:

Small bowel transplant went without a hitch according to the surgeons. They called it a “perfect fit.” For some reason I had a terrible feeling in the pit of my stomach all throughout it… But, for once, I know I was wrong to trust my gut. This young woman is one of the strongest people I know. Today, barely 24 hours later, from the ICU I actually spoke to her on the phone. She is awake, and sounds amazing. Her physical therapist helped her get OUT OF BED. I haven’t ever heard of anyone sitting up in an ICU, much less moving to a chair! Her strength is phenomenal; I have goosebumps as I write this. I will be next to her Friday evening, and I am so grateful that I can be there.

Other news: I helped a woman breastfeed for the first time today. It was the most amazing, beautiful and healing experience ever. OB is like respite care for nursing students. I wish I could take it like ibuprofen for headaches.

 

 
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Posted by on November 17, 2010 in Babies, Healing Spoonful

 

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Tumult

I don’t even know where to begin. I feel like my brain has been rolled through a paper shredder on high speed with a magazine mixed in for confusion.

Last night I got the news that one of my close friends got the phone call she has been waiting for. However, this is not the type of call that any healthy 23-year young woman should be waiting for. She has been waiting for a small bowel transplant after having gastric bypass surgery just over a year ago, losing well over a hundred pounds and nearly reaching her ideal body weight through a combination of healthier living and exercise. Then, severe and sharp pains to her abdominal region complicated her course. Her gallbladder and 26 gallstones were removed, which unfortunately didn’t go far to solve any problems. Without writing a novel, or giving away any personal information, it was soon discovered that nearly her entire intestinal tract was rotten.

Suffice to say, her outcome was poor to dreadful. But through a combination of incredible strength, excellent medical care and a whole lot of love, support and luck, she somehow stabilized after having her entire bowel removed, save a few inches on either end. She was stable, but certainly not out of the woods. To say nothing of the struggle with insurance or malpractice suits, her life has been blown to smithereens for the past 5 months, and it is only recently that she was finally cleared for transplant. And yesterday she got the call.

The organ was in the Midwest, so at 3am, a team went out to harvest it. I was in contact with her via a few brief phone calls and a piddling of texts. She is on edge, and I am on pins and needles – I can only imagine how much more difficult it is for her. She is so incredibly strong, yet how much can a person really take? While in my afternoon classes, I got news that she was being taken in. The transplant would go forward: the organ was viable. After clinic this evening, I got a text from her mom. About an hour ago, the bowel had been successfully placed and she was stable. She would still be in the OR for a few more hours. So that’s one piece, the most important piece, of this whirlwind that is stealing my breath and messing with my mind. But it’s not all.

I have recently started volunteering with a Harm Reduction Clinic and needle exchange. Initially, the idea was to participate with the student-run clinic, which operates every other week, on one weekday evening. But more recently we have been working closely with the program coordinator and toying with the idea of starting a program that offers services strictly to their female participants. These participants are sex workers, IV drug users, or both. The idea is to offer a support group, maybe some case management, definitely health education, and hopefully women’s health services and point-of-care testing. This is all still a nascent dream, but it has already gotten minimally underway with a survey tool that we have developed to use in conjunction with a focus group. More on that to come.

Today we spent time at the needle exchange in the morning and the evening just to start getting to know a few of the participants and the general “flow.” The morning was mellow and this evening we were able to watch and observe the clinic in action. I shadowed a medical student with a patient who we’ll call Arnie.* Obviously it would be crazy to claim that I didn’t have a single stereotype or preconceived notion of what a (past) drug user, current panhandler and intermittently homeless man would be like. And being myself, I at least give myself credit for expecting and seeing these incorrect assumptions disproved within seconds.

This was a fairly well educated man with typical but exacerbated health problems: many of which that he understood far better than your typical layperson. Better than me, in fact, in some cases. He was agitated when he sat down, and rightly so. He felt like he was being seen by a medical student and a nursing student and he wanted to see the real doctor right away. He asked smart questions and he made a lucid point about unequal medical care, comparing his own care to that of former Mayor Giuliani’s daughter’s care. I had to agree that they didn’t quite match up. Then we got down to business. I was at once impressed by the second year med student’s knowledge and overwhelmed by my vast lack of knowledge. But I have to remind myself that knowledge isn’t a secret elixir-I will attain it too, someday, and at least my social skills are intact.

Arnie and I made a connection. I recognized it, and I think he did too. In trying to compliment me at the end of the history-taking, he told me that I should really go to med school too because I would make a better doctor. I could have hotly informed him all about nursing and why I chose it as my profession instead but….Argh, sigh. We’ll tackle that topic another day.

(Reflecting on how astute and intelligent I found him to be, I do want to mention that in one of his many rants, he speculated on how silly it was that doctors didn’t have to become nurses first. He said that nurses do all the work, they provide the majority of the hands on care, and they are the most well informed individuals in firsthand experience and that they should be the ones to go onto med school and become the best doctors one day. His words, not mine. I swear.)

His problems aren’t insurmountable, but they did seem enormous to me tonight. It wasn’t the diabetes, the infection, the mysterious skin condition, or even the coronary artery disease. It wasn’t the arthritis or the peripheral neuropathy. It was more the fact that he was in a downward spiral and unlikely to climb his way out, despite our best effort. This really put a story to the faces that I see in the subway. The panhandlers, the singers, the dancers, the vendors. They all work in this gray market – one that isn’t very visible but very much exists. Arnie is an a cappella singer. I heard his baritone when he opened his mouth for us to examine his throat. I got a vivid image of one day seeing him on the subway in my daily commute. It’s not unlikely. It made me squirm and feel desperately sad for a moment.

When I left that evening, late, well past 10pm, I sighed when I looked  outside and saw pouring rain. I turned back inside and mentioned to one of the clinic’s participants that it was raining. “Bummer,” I said. And she looked at me and said, “Yeah, that really is. That just about ruins my night.” I sucked in a breath. It was too true. And it hit me hard. Our program coordinator told me that volunteers here hope to get their “feet wet” in the complex world of harm reduction. But she said she always laughs a little bit inside, because the reality is, that if you really want to help, you’re not going to just get wet. You’ll get soaked.

So, saying goodnight, I jogged out into the rain without another self-pitying thought. I took the subway. And then I biked home from the train station, barely even glancing at the tempting taxis. I got soaked, and as melodramatic as it might sound, it felt right.

* Name changed

 

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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.

 
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Posted by on November 12, 2010 in Babies, Healing Spoonful, Hospital

 

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Life is fragile, handle with care

I wrote this on the subway home from last week’s clinical but didn’t post it.

How quickly I forget. I know I am not alone in this matter, but I can only speak for myself. I am in a hurry so I cross the street without looking left, right, and then left again. I speed through a yellow light; God forbid I have to sit at a red for 2 minutes. I don’t wear a seat belt in the back seat of cabs.  I have no idea if our smoke detector even works.

Riding my bike every morning, I have become so careless in being a defensive cyclist. I am impatient and even borderline aggressive when cars don’t give me the right of way.

I am so lucky to have periodic reminders to be more careful with the precious life that I temporarily own. I am reminded to heed these more gentle warnings, minding the fragility of life. And you should, too, because there is a more than likely chance that if you are taking the time to read my blog, you love me and I love you.

This morning, I got off a stop early on the subway and walked through Central Park. I woke up smiling, literally, because this is my favorite day of the week. On Thursdays I get to be with my mentor, a stellar DNP (Doctor of Nursing Practice, semi-new terminology for a nurse practitioner holding a doctorate). My step had a bounce to it, and I beamed at all the passersby even if they didn’t smile back. I even thought about telling a cyclist waiting with me at a stoplight that he should buy a helmet. But, I didn’t because that would be an unsolicited intrusion in a complete stranger’s life, right? Wrong. I wish I had said something.

My day was good, great even. I arrived and my instructor informed me that I would do my normal tasks, and in addition, perform part of a physical and take a partial patient history. I got an amazing, hands-on, taste of my future life as a nurse practitioner. And I got more nimble and confident with my fingers, administering a whopping 6 vaccines. That makes probably more than 20 shots total! Heaps of practice.

The day was wonderful until the last patient. My instructor prepped me for her, but the reality didn’t truly hit home until I put a face to the tragic story. She is a nursing student, I won’t say where or what program, but mention that fact only because it eerily parallels my own life. She is young and recently married, but her spouse and her have a long history together as they grew up together. Three days ago, her husband was riding his bike, in a bike lane in Manhattan. Cars were parked to the right of the bike lane, as is common. A driver opened his door without peeking behind to look for oncoming traffic, bike or otherwise, and “doored” the cyclist, which happened to be our patient’s husband. He flew forward, cartwheeling off the bicycle and landing in the middle of the road, where he was run over by an oncoming vehicle. He died.

When our patient walked in, emotions flooded me. She was ashen, her face a mask. Clinically speaking, her features lacked any affect whatsoever. It was clear that she was grieving tremendously. She came in for Xanax and I felt completely helpless, sitting on the rolling stool because I, no actually, “we,” couldn’t do anything for her. It wasn’t just me, the provider couldn’t say anything to assuage her pain either. That was a terribly painful realization. The least I could do, and somehow managed though I know not how, was contain my own tears until she left. When the door finally closed, I was berating myself internally for the tears that had already overflown. But when I looked at my clinical instructor, I saw that she was crying openly as well. We took tissues and simply sat for a few moments in silence. It was cathartic to realize that I can feel pain. I am supposed to feel pain occasionally, but I have to work on letting it wash over me, without internalizing it.
I did my best. But when I left, I still dialed my most loved companion and asked him slightly desperately to please not ride his bike that day. Or ever again until we could talk more about it. We both ride our bicycles all the time. We are young and in love. It so easily could have been one of us. This is one of those tragic accidents that makes you feel so helpless and grief-stricken. So many of us have false perceptions of how protected we are, but everything can change in a second without changing a single thing about how you live. I feel distraught for that young woman I met. She so easily could have been me instead of my patient.
 

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Homemade Applesauce Oatmeal: A cozy fall treat

Drowning in apples, swimming in sauce. Not for long, though. While I ambitiously put a few jars of my applesauce in the freezer 2 weeks ago, imagining I would find them in the middle of the winter when I was severely apple-anemic, I have already tapped into my stores. In a post-Halloween and birthday weekend funk, this is the perfect antidote and best way to start an unwelcome Monday. This warm combo tastes like breakfast apple crumble. It makes me happy, cozy and warm to my toes. It also helps me face the day, which is 32 degrees too cold, in my opinion. This recipe is simple and sweet, and tastes even better when you pick the apples yourself, or at least from a bin at a local farmers market. 🙂

Simply Applesauce

  • 3 to 4 lbs of peeled, cored, and chopped apples
  • Juice of one lemon, plus some zest
  • 2-3 tsp cinnamon
  • 2 tsp vanilla
  • ¼ dark brown sugar, or to taste
  • 1 cup water
  • ½ tsp salt
  • A dollop of brandy or rum if you feel like a little mischief

1 Put all ingredients into a large pot and cover. Bring the mixture to a boil, then lower the heat and simmer covered for 20-30 minutes. Test for softness with a fork, it should pierce the apples with no resistance.

2 Remove cooked mixture from heat. Mash with potato masher, and you may also blend half of it, depending on the consistency you desire.

Ready to serve, either hot or refrigerated. Delicious with an array of partners: such as oatmeal, steel cut oats, vanilla yogurt, or even ice cream.

Freezes well, use within a year!


 
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Posted by on November 1, 2010 in Breakfast, Snacks

 

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