Yes, I Deliver

The circus nurse is now, officially, a (paid) labor and delivery nurse.
Goodbye academia, hello life.
Praise be.

Shift Work

Some of the best moments of the weekend:

Delivering a baby girl to a young mother - one of nine sisters and two brothers - with five sisters and one niece present. The youngest of the 9 sisters, aged 16, cut the cord.

A nurse, about to take a break tells her break-relief, "Don't let that Doc near my patient..." Sticking my head out of a delivery room about twenty minutes later I hear that very nurse singing sweetly and find her sitting side-by-side with that very surgeon while he strums away on his ukulele.

One nurse says to another, "You don't believe in God? Not at all?"
"No. Not at all." The first nurse hugs her tightly and then holds her by the shoulders at arms length and asks very seriously, "Then who do you think made Berkeley?"

Service with a Smile

This week a patient came in, via ambulance, to deliver at our hospital. She was 1cm dilated, (read: not much) huffing and puffing and crying out with every contraction. I met her, along with her Granny, in triage. As we prepared to walk to her room she, naked from the waist down, wrapped herself in a blanket, grabbed her enormous silver purse and said, "Let's get outta here."
Her granny looked a her and remarked, "You better not lose that blanket or you'll be showin' off the goods!"
She replied, "Well, I ain't worried about the goods! I'm worried about my eyeshadow. I ain't goin' nowhere without my eyeshadow. Not even to have a baby!" She turned to me, "I don't wear no make-up... 'cept eyeshadow." Which was true. She had on tons of dark grey and silver eyeshadow.
I just nodded and nodded as this conversation proceeded until we reached her room, at which point she turned to me again and said, "Okay, now I want a hamburger and french fries. I want it medium with pickles and no onions. And a glass of grape juice. And mustard."
Somewhat stunned, I chuckled, turned around, and walked slowly from the room. I was off for some grape juice - thinking that maybe childbirth makes women delusional (she seemed to be mistaking the hospital for McDonalds).... or just really, really hungry.

Storklike

I work in labor and delivery now. Isn't that amazing? No, it's not a paid position. We're in the middle of a recession, so I'm told. But I am now actually a nurse and on the job every Saturday and Sunday. So far, I have been witness to a number of squinty little eyes blinking wildly at the new world. More on that soon, but I thought, for the time being, you might like to know.

On the Fence

Here is a well articulated and fair article about palliative/terminal sedation. This was a genuine and frightening surprise to me during my first clinical rotation and it continues to be one of those ethical dilemmas with which, inside, I can make no headway. It is probably the number one reason why I have shied away from hospice nursing which I originally suspected to be my calling. My hands and heart don't want to carry the weight. Conscience or cowardice? You decide.

Recap

Time for a recap of the past few months:

The winter ends, psych and peds rotations begin... and end, I join Facebook, The Kid graduates to the *fifth* grade, the MEPN year ends (hurrah! hurrah!), I meet new MEPNs with new neuroses, I leave Facebook, The Partner finally visits Montana, I receive my interim permit to practice nursing in the state of California, I register for the NCLEX and I come back to Circus Nurse, fresh and new. Okay. Now we're all squared away.

The Trick of Humanity

I spent the first day of pediatric clinicals in the intensive care unit. My patient was very young, under one year, born with congenital anomalies that included a heart defect, this one specifically, choledochal cysts and biliary atresia, meaning that she needed both open heart surgery and a liver transplant. She received both, preceded by a miriad of other surgies. When I cared for her, she was nine days post-op. I counted eight IV lines going into her body, exclusive of her pacer wires, NG tube, Jackson-Pratt drain, CPAP and ventilator.

I didn't mind the PICU so much as I expected. In fact, pediatrics seems like a place I would be excited to work, a great surprise to me. Maybe it's the timing. The most significant obstacle would be coming to terms with advanced technology out-sizing the patient. Following yesterday's rotation I felt like this was a huge moral dilemma, so I sought out reserach on the subject and found an interesting article that takes on the distress that PICU nurses face in the wake of modern technology that outpaces moral questions about life at any cost. The authors ask how medical and "life-saving technologies are outstripping our human abilities to comprehend and live with the consequences". Certainly a very worthy ethical question and definitley one that represents what I find the most difficult aspect of peds: what it means to be humane. To me, it looks like humanity tricking us again.

No Room at the Inn

I discharged my patient to a shelter yesterday with heparin induced thrombocytopenia recently “resolved” by argatroban (tx stopped 2 hours prior), but with no coumadin. I discharged him with a foley. I did so because I was told to do so by the doctor. I put up a totally meager fight and then sent him packing with Thursday’s copy of the New York Times that I’d brought from home, a bag with handles donated by the gift shop, a pair of flip flops and a sweat suit donated by social services, a walker donated by physical therapy and no clear idea of where he was going or how to care for himself. We just put him in a cab and sent him away.

The Attending

Did I tell you that I inadvertently called the attending physician on Friday for blood pressure parameters for my patient's Cardizem? Learned my lesson about the hierarchy in a hurry. Yes, in fact, it was totally humiliating. And I'm not sure why, except that I didn't live it down in a hurry... And I did not get the damned parameters.

For those who don't know the system it's like this, top down: attending, resident, intern... with, at my institution of practice, multiples thereof under the attending. "Nurse" is somewhere waaayyy down at the bottom of that totem*, falling fast when one phones the attending instead of the intern.

*Oh wait, we're not a kinship group. There I go, mixing up my careers again!

Rites of Passage

In the doorway stands the nurse's aide looking frazzled and tired, rubber gloved, holding wipes in one hand, her pager in the other, towels tucked under each arm. Her nurse is consulting with a family member and a doc about discharge of another patient. “Sarah,” says the aide, “I need your help. Please.” The nurse gives her the, “I’m-busy-with-another-patient-I’ll-be-there-soon” look that means she could be there in ten minutes or two hours. Since I am only charting at the nurse’s station I offer a hand.

I enter the room and approach the patient in her bed. “Just turn her over, please” says Therese. So, I roll the patient toward me and Therese begins to clean her. All the while I’m talking to the patient, “You’re doing a great job, Mrs. L… Here, lean toward me… Just a little longer now…” I adjust her weight, moving my right hand from her torso to her leg and realize suddenly that her extremities are really cold. I place my left hand on her back and get my face down in her face. Not breathing. My ears feel red and hot. I scan the patient from head to toe. I look at the aide. She is madly cleaning the woman, paying me no mind. Suddenly it dawns on me: the aide knows that the patient is dead. In fact, I find out later, the patient had been dead for over an hour.

Why the aide didn’t apprise me of the situation upon my entering the room is totally beyond me. Why she didn’t say anything when she heard me talking, and, more specifically, giving instruction to, a corpse, is also a mystery. My theory is that she either thinks I am deeply spiritual, or she thinks I'm crazy.

It’s a strange world, the hospital. It makes me thankful for my deep and morbid sense of humor, finally serving me well.

The Patient Man

Yesterday I said goodbye to my patient of the past two weeks, a man of great heart.
He took my hand and said, "Goodbye, Dear. I'll see you in the movies."
I smiled, "I hope you fly again someday."
"I will," said he.

Note for Big M.

May the love see you thru,
because we need u.

Written on a plain, white, 3x5 notecard and left at bedside.

Just because

Giantess Nurse

Nurses Unite!

Talking with my clinical group this week about different kinds of hospital nursing (team and primary) I picked up from my colleagues' literature review that there seemed to be no qualitative nor quantitative difference between outcomes for the two -- neither in perceived care nor worker satisfaction. I thought the findings were interesting given the proposed phase-out of LPNs/LVNs in California. The data seemed to reflect that mortality, patient outcomes, satisfaction and nursing burnout were undifferentiated, whether four-year nurses worked on their own or whether they worked with the support of LPNs and CNAs. My clinical instructor weighed it differently, quoting one Linda Aiken who reported in a 2003 study, "hospitals with higher proportion of nurses educated at the baccalaureate level or higher, surgical patients experienced lower mortality and failure-to-rescue rates." The argument was that LPNs had unfavorable outcomes based strictly on their education.

This illustrated for me another great failure of academia. Some quantified outcomes, like this one, contain numerous confounding factors that tend to flub up reported and repeated results. The Aiken study does not illustrate better rates of care by better educated nurses; it illustrates how more resources impact outcomes. Where are the LPNs/LVNs? In poor, rural hospitals. Are there surgical centers in those hospitals? No. Are the baccalaureate educated nurses better able to care for patients? Not necessarily. Do they have more resources -- education being one of those resources? Yes. And what's the relationship of education to labor? The California labor union has systematically displaced two-year educated nurses rather than provide a means to give them the additional year they need for the BSN. So, it's not about the education but the resource -- and to whom that resource is available. It's something to mull over. Especially if you want to argue it away as being strictly about education or strictly about class, as one is wont to do. It's about access and it's about care. Look around the hospital and see who's got it and who's giving it. It's certainly not just the baccalaureate or master's educated nurses that are giving.

It occurred to me in the middle of the night that we are one year educated nurses. An interesting twist.

Substituted Judgment

An interesting article, provided me by The Partner, describes the application of suspended judgment among first-year medical students, wherein patient self-determination is preserved in the face of loss of ability in autonomous decision making via appropriate, designated surrogate. The results are very interesting and an important consideration for all health care providers. It's the conundrum of best interest of the patient, medical judgment or family wishes placed against patient self-determination. As a nurse and 'patient advocate', you think you know what you would do, don't you? It's worth rethinking because it's a very tricky ethical dilemma.

Surgeons are Super

Surgeons have some of the most amazing writing skills I have yet to read. They are keen observers, excellent historians, and duly self-reflective. This observation is based on notes about a patient that I had this week, one Ms. L., suffering from pancreatic pseudocysts, who suddenly and unexpectedly began vomiting copious[1] amounts of bright red blood[2]. She was in absolutely critical condition by the time we got her to the ICU. Because I followed her there and participated in hanging her blood and plasma for transfusion, watched the endotracheal intubation, etc., and since she and I had been chatting and laughing all morning before the incident, I was anxious to follow-up with her the next day. She apparently underwent surgery early Friday morning and the surgery notes represent a unique literary form that I wish would be published as general interest material. I'd quote from it, but that is not HIPAA compliant, so let me just say to you students out there, if you want to learn in amazing detail and narrative about disease and anatomy, read your patient's surgeon's notes. Absolutely the best tool for learning I have been presented with thus far. (It will probably also be somewhat humbling in terms of differentiating the role of nurse from doctor. I'm just being honest.)

[1] 1000mLs* in about 60 minutes * class II blood loss at 1 hour.
[2] blood that would coagulate before we had time to rinse the basin.

Humble Pie

When I was a graduate student, I came to the realization that the more that I learned, the more I could see was out there to learn.
The more you know, the less you know kind of situation.
Now, as a nursing student, I know that I don't know much of anything. How's that for a healthy dose of humility?

Germs, Germs Everywhere!

Note to self: when wounds are being debrided, wear protective gear over the face, because sterile water splashing off of a body covered with decubitus ulcers and positive for MRSA is no longer sterile and does not fall under the "universal precaution" umbrella in any way, shape or form. My mysophobia has multiplied ten-fold since the start of this quarter. Now I follow Nurse J. and take my scrubs home in a plastic bag for laundering. According to this article in the Wall Street Journal, shared with us by Nurse D., you should too.

Sinking Nurse

I know that the hospital is a lot less like television than we would like to think, nurses and docs madly rushing to save lives and falling in love all at the same time (mind you, I haven't had a television since about 1994 so this is all based on first season episodes of ER), but in the *actual* hospital, why can't everyone at least pretend to care what's happening to a 20 year-old patient found unconscious on the floor and desating... and why can't the doctors pretend that they think nurses are competent? We're not doctors, but we're also not dimwits. Seriously.

p.s. if you read this blog with any regularity you know that I defend docs to the hilt; I do so because I recognize that we are not doctors. Personally, I accept that I could never be and would never want to be socialized in that way. Still, experiencing the doctor/nurse dilemma first hand, not as a peer researcher, but as a nurse, was, frankly, a proverbial slap in the face. I'm still trying to understand what it means to follow that path. And that understanding is proving to be difficult.

Sick

I watched this documentary about Bob Flanagan about ten years ago, but The Partner had never seen it, so this afternoon we headed out and got our hands on a copy from Le Video. The whole experience of the film, for me, has been totally recontexualized. What's different now than then? I now believe it should be requisite viewing for all nursing students. Not into S&M? Can't really deal with someone driving a nail through his penis? Tough. Sit through this movie if you want to know what it is like to have a chronic illness and if you want to know what it's like to die. As a nurse or future nurse, it's important. Allied with some of Flanagan's pain journals, it can really provide a window. We just have to be willing to peer through it.

As for my mom, who I think reads this blog from time to time, you definitely don't need to see it.