Wednesday, January 21, 2009

Name That Tube

There's a large aspect of nursing that deals with tubes. You're either putting in a tube, taking out a tube, putting something into a tube (or, well, yes) taking something out of a tube or you're checking tubes.

So, my preceptor tells me, "We're going in to see the patient and I want you to check her tubes." Got it. Check the tubes. I check out her iv site and all the tubes stemming from it(lactated ringer's, Pitocin. ampicillin) I assess the Foley catheter and, hm, what else. Right. Her IUPC (intrauterine pressure catheter to measure uterine contractions in millimeters of mercury). I brush my hands together in that "I'm done and I'm washing my hands of it" gesture and then my preceptor says, "Don't forget the epidural." *Another* tube (connected to a locked plastic box. Oh what fun it would be for some, I suppose to have that bag o' bupivacaine and fentanyl). And this for a relatively normal delivery. (Yeah. We'll talk about that whole can of monkeys later) Are you keeping count?

One of the fun activities I get to do is to d/c ("discontinue" for you non-nurse-y types) the epidural catheter. You take off all the tape which runs all the way from shoulder to waist and from left to right side. That tape is almost embedded in the poor woman's skin and, after labor, pretty much I want to baby the new mom, but instead I'm removing the hair from her back: ouch. And then taking the epidural catheter itself out is unsettling. I can d/c a nasogastric tube, I can d/c an iv, but something about pulling that thin (thinner than a pencil lead) tube out of someone's back (pull down, not up or out)... It doesn't give easily, there's resistance and it's coming from the spine. Tip: yes, that's it: tip. Check for the tip (it's black) because it could get left behind (I've heard tales of this occurring, "Why just last week..." began one).

So, I'm motoring right along in studying for the NCLEX. I'm on page 228 (almost done: just 1000 + more pages to go!) and I'm about finished with the chapter called Tubes! (It's really called something like Caring For The Patient With Tubes, but I like my title better. It's more festive and jazzy). My favorite tubes are the GI tubes. And by "favorite", I mean that I like the names: Lavocuator (the infamous pump-your-stomach tube), the Salem Sump, and the lovely Sengstaken-Blakemore tube (I think the Sengstaken-Blakemores used to live next door to me) for all your esophageal hemorrhage needs (well, many of those needs, anywho). And you gotta love the respiratory tubes. Cuffed or fenstrated, single or double lumen: you want 'em, I need to know 'em to pass my boards! Do not get me started on chest tubes. Should it bubble? Is it ebbing and neaping like the tides? A possibly deadly leak in the system or normal functioning of the equipment? I remember in our skills lab, the instructor was so confused she said, "Read the manufacturer's instructions."

Another unsettling thing. In Anatomy and Physiology (geez, years ago now) I learned that we're all tubes. The center part of our tube runs from our mouth to our anus. I don't know why being a tube bothers me, but it does so I'm going to move on now.

NCLEX tip number one: If the question asks you which symptom requires a call to the MD and "stridor" is one of the answers you should pick it.

That's one of our inaugural cupcakes. My mom made the cupcakes, I did the frosting and the kids sorted out and sprinkled the red and blue M & M's.

Thursday, January 15, 2009

I Hope This Doesn't Discourage You

"You could go another lifetime and not see something like this," said the anesthesiologist while he had one hand squeezing a bulb on the tubing hustling the packed red blood cells to my patient. I hope that I could go six or seven lifetimes and not see something like that.

My patient, baby's heart rate isn't recovering like it should, is taken to the OR for a "double set-up" (they'd try to assist the baby out old school and, failing that, section her) and things went further south and the patient is prepped quick, quick as a bunny. The docs cut into her uterus and a fountain of meconium (fetal poop = not a good thing) -filled fluid fountains up a foot into the air and splashes everywhere. Babe gets a 2 on baby's first test (Apgars: this is out of 10 points. Two= not a good thing.) Everyone slaps the ob on the back: good call, nice work and baby is intubated, but only briefly, and perks right up and gives a hearty cry and, phew.

And then it's time to close and I get the student-worthy job of counting and bagging the bloody gauze ("laps") (remember the Bag-It! I previously mentioned?). The last c-section we filled up maybe four or five Bag-Its, so even I, Student Nurse, started sensing trouble when I was running out of places to hang the bags. There were more and more bloody laps and a doctor came in, "I heard her INR is 3." (and for you lab value fans the d-dimer was over 10,000: what's your diagnosis?) And the c-section turns hysterectomy and there's more blood than you could think was possible. It's spilling out everywhere, there's bloody footprints from blood-soaked shoe coverings. Another doctor is added, more nurses appear. I heard that every stitch opened up a new place for blood to ooze from.

Half of all cases of DIC (disseminated intravascular coagulation) are pregnancy-related. What happens, see, is that via some problem (trauma, infection, auto-immune dysfuntion, etc.) a clotting cascade occurs and teeny clots establish throughout the body and the body is really cool and sends out stuff to break up the clots (d-dimer is a by-product of the break-up of clots) and, phew, there was so much clotting that occurred the body is not able to muster up all that it needs to clot anymore. And, well, you need those clots to stop bleeding and you introduce say, surgery, and you get what happened on my third night out as a preceptee: scared.

I couldn't sleep. I went home and looked up everything I could on DIC. Stupid Wikipedia (yeah, sorry, I did look at my med-surge book first, though) said that DIC is sometimes nicknamed Death Is Coming.

But, the next night I visited the pt in the ICU (so, let you get this straight: I'm precepting in L and D... I had no idea I'd be hanging out in the ICU). She's groggy, but looks pretty good. I hold her hand (I really wanted to hug her I was so glad to see her up and running or at least unbloodied and conscious) and she says to me, "I hope this doesn't discourage you from going in to nursing."

Not at all. It just reminded me that birth is an amazing thing and that you never know what can happen and I was going to say, "So be prepared." But I don't know if any nurse, student or not, could be prepared for what happened. Let's just hope I get at least another lifetime to find out.

Saturday, January 10, 2009

Happy Birthday

So, on the first day of my preceptorship, I was walking down the hospital hallway with a chilled bottle of champagne and on the second night I was watching my patient's uterus getting stitched up in a chilly OR. My mom always says about nursing: There is never a dull moment.

My first night, my pt had her whole family in the delivery room. Her dad was holding her leg as she pushed out her baby. It was just the sweetest thing in the world and they were the most adorable family and all had tears in their eyes when the baby landed and the mama had had a 48 hour labor and came through it all great. There was some drama at the end when the shoulders were stuck (dystocia is what it's called for my non-nursing pals) but babe squeezed by and mom had virtually intact tissues (and she was a primip - her first birth - too!).

I think my preceptor was dissapointed on my second night when babe 2 got stuck in an unfavorable position and the (heart) decels were too deep and too long. Two obs were in there trying to push the baby into a better position but baby was looking straight up into the sky (well, the bottom of the uterus anyways) and each contraction was bending the back of the head into the babe's back. My precpetor is very prepared and I saw her take out the sodium citrate and I knew that meant c-section. (Sodium citrate can be given before surgery to neutralize stomach acid in case any is aspirated into the lungs. Acidic stomach contents plus lung tissue do not mix well.)

So she's wheeled into to chilly OR and strapped to the table and drapes are draped and her abdomen is prepped and her arms are spread out on the armboards like Christ on the cross (isn't there some sort of crucifix-y name for that position...? Maybe I'm imagining it.) and she's gotten an incredible amount of pain reliever and anesthesia in her epidural AND Versed and Versaid again and she's still feeling it. They cut her open and I'm trying to hold her hand and every time I try (the babe's father is stil out in the hall), my preceptor walks me back around to the other side of the drape to watch which would be fine, but my pt is moaning and obviously terrified. Finally, my preceptor says, "You wanted to watch, you're not a doula, come see the medical side of things." OK. (Here I'm all torn. Wait, haven't I been told that my job is to help patients cope with illness and the treatment of illness? )

My preceptor, though, is my mentor and I'll be working with her for 9 more weeks and - let me say - she rocks in that old-school-tough-as-nails-does-it-right-the- first -time-I'll-take-questions-later kind of way that, frankly, you want your preceptor to rock. And, also, I like the way she introduces me to people sorta proud-like "*This* is my preceptee." And I like that she's as tall as I am short. I feel sometimes less preceptee and more side-kick-y.

So, they get through the skin (which is nicely wrapped in what I'm going to describe as yellow Glad Wrap (just to be funny)), they get through the fascia and they start going through the uterine muscle and I'm sent out to get dad and miss the emergence of the babe. I hear my pt moan/ scream and there's the babe when we come back in. So, pt's uterus is out on her abdomen, yes, out of the abdominal cavity and (reminder: all of my previously participate din surgeries were micro surgeries) it looks like a small, raw thanksgiving turkey (because all products of surgery are described in relation to food items: "It was about the size of a small orange." "It was the color of a blueberry." etc, I'm just upholding the traditions of my profession here).

My preceptor is doing gauze counts and they have this nifty hanging bag thing and - I'm not kidding -it's called Bag-It! (except there is no exclamation point) that looks like one of those cheapy clear plastic things you hang on the back of your closet door to hold your shoes except instead of shoes there's bloody gauze. See, it's a handy way to count the gauze: five pockets per Bag-It! and one or two bloody gauze per pocket (depending on user preference).

And then, bloop, back into the abdominal cavity goes the turkey and all the layers are stitched up and mom is still scared to pieces and babe is whisked away.

Baby is cute as a lil button and fine and mom came out of it all great: a little shakey, a little scared, but snuggling in the recovery room with her little one.

Well, happy birthday. Two ways and two cute-y pie babes and two tired mamas and two bigger families and a very tired student nurse happy to be here.

(That's part of my daughter's cake. I stole the doggy with present idea from somewhere and now I can't find where I found it. oops)

Monday, January 05, 2009

Hi Hat Hell

So, like many cupcake aficionados, I've fallen for the whole Hi Hat Cupcake trend (oh, you too?). For those less into the whole cupcake thing, but still curious, they're those tall 'n' swirly cupcakes w/ a creamy, white frosting dipped into chocolate. They're visually reminiscent of chocolate dipped soft-serve cones.

Like any semi-decent baker out there I did my research and found that many of the reviewers on that Martha Stewart recipe had difficulty dipping their frostinged cupcakes into the chocolate, so I checked out some blogs out there and got a sense of what was working for people. This recipe on The Barmy Baker looked good, but then I blew it in a couple of ways. First, I was making the cupcakes for the kids so I wanted a vanilla cupcake and so used my good tried and true white chocolate cake recipe and I used Martha's dippin' chocolate recipe (which made use of semi-sweet chocolate) instead of Barmy Baker's (essentially I just used the meringue frosting recipe from Barmy Baker).

Big mistake. For one, I think a more lightly-textured cupcake than my white chocolate ones (they're pound-cake-y and dense) would have held onto the meringue better and, secondly, Martha's dip was too thick so when I dipped those things, the meringue came off in the chocolate. It was like a boot stuck in mud. I think I also needed to be less timid and dunk 'em quick and deep so that the top of the cupcake paper was included in the dip and provided more of a sturdy base for pulling out of the heavy chocolate. So, I scooped up the meringue, mostly coated in chocolate and plopped it back on the cupcake. I know, they're ugly. My sister is rolling over in her grave right now and she's not even dead. My sister and I fight about cake and baking all of the time and her big thing is the aesthetics of the stuff. And, (I sense an angry comment here..) I think that is her biggest concern so she is probably UPSET about how ugly the things are. But, they tasted good. The kids wanted the undipped ones, though and it wasn't an aesthetic thing. It was a we-like-vanilla thing.

Do you food bloggers out there usually only post about your successes? See, I want to know where you went wrong. Did you bake it too long? Too much rosemary? It fell off the spatula?

I'm supposed to be starting my preceptorship this week, by the way, but I just got my preceptor's name and number today. The person coordinating that whole thing at Nursing School U is new at it and disorganized anyways and now I look disorganized. I called my preceptor and left a message, "Uh, hi I'm your preceptee and we're starting this week, so, uhhhh, give me a call so we can synchonize our watches." Or something like that. Needless to say she hasn't called back and that watch is ticking and I've heard from those who have gone before me that doubling up on the schedule later on to make up for lost time is like Hi Hat Hell. Zort!