Sunday, February 22, 2009

Good And Bad

The ob used the amnio-hook (looks like a thin knitting needle) to break the pt's water. Sometimes when this happens the cord can suddenly get squished in the wrong way. No one said the word "prolapse", but one minute later that babe's heart rate plunged to 60 and stayed there one minute, two minutes, OB says, "I can only take one more minute of this," three minutes and suddenly there's a crowd in the room, the sodium citrate is in my preceptor's hands and being downed by the pt who is already wheeled out the door in her bed and to the OR for the emergency c-section. Babe's heart rate comes up a bit in the OR so the pt lucked out and got a spinal rather than being put under.

Babe comes out and the cord is around the neck, under the arm, around the abdomen, around the leg. It looks like this little one had been tied up in umbilical cord and the wee one was big and green-tinted from the mec but cries the instant s/he hits mama's tummy and then doesn't stop crying, thank goodness.

There are times when a c-section is the best of western medicine. It's amazing how quickly a baby can be removed via surgery and, when the baby crashes like this one did (we'll talk about induction in a sec here) then we can all sing the praises of technology and advances in medicine. But that's the tough thing, too. C-sections represent the worst in western medicine, too. "Failure to progress"? What does that mean? Clocks are ticking. Women are supposed to open their cervices in labor at the rate of 1 cm/ hour. Are you kidding?

And even at the groovy, pro-women and birth-is-a-positive thing hospital I'm precepting at, induced labors happen for some questionable reasons. "Cervidil was placed." I see that up on the board and sometimes it's just because the ob wants all of his/her pts to deliver when the ob is going to be on for the night. Or they are 40 weeks and a day and, hence, "post-dates". So, they get cervidil or cytotec in hopes of forcing the cervix to "ripen" and then we "pit" 'em (give them pitocin via IV at gradually increasing rates). Then clocks are really ticking, especially with ruptured membranes (broken bag of waters). Sometimes things don't go well when you try to force the body to do what it is not ready to do. Pitocin makes labor much more intense and painful, so then the pt gets an epidural and a foley catheter and a blood pressure cuff constantly inflating on the arm. And lots of obs pit all of their pts just to move things along.

But, with my pt with the nuchal cord and the green babe, that c-section was going to happen at some point by the looks of things. It was good that the ob was in the room and ready to go even if it was stupid to AROM (artificial rupture of membranes) the pt in very early labor.

So, I'm graduating in three weeks and there are no jobs for new nurses in my neck of the woods. We're all being told to move out of state or at least to places no one wants to live to get a job. So, I'll go from being Student Nurse to Nurse in Limbo. It's frustrating and discouraging and I've stopped studing for the NCLEX because I feel...defeated, exhausted, and, well, what's the point?

The cupcakes! You've got to try these. Use my usual recipe for chocolate cupcakes and then this here recipe for cinnamon-chocolate frosting and yum! I left out a tsp of the cinnamon and dusted the cupcakes wih it and added red hots. Next time I'll add more chocolate to the frosting.

NCLEX tip #3: Memorize your fundal heights. Geez, I ALWAYS get this wrong and it shows up in so many px (practice) tests: "click on the image at the spot the fundus should be at 23 weeks gestation/ 2 days postpartum" (whichever) and I could tell ya, I could feel it on a pt, but on paper/ a computer screen I never click the right spot.

Wednesday, February 11, 2009

IV Starts L and D Style

I've failed at two of my two attempted IV starts in the past week. My preceptor said to me, "It doesn't get any better than this. In labor and delivery women have big, fat juicy veins." That made me think of what my son calls blood vessels: blood pipes. That's a much more accurate word for 'em, I think. When I think "vessel" I think earthenware, handles, a spout. Maybe a gravy boat. A vase, but one with useless little ear-like handles up at the neck, you know the style. Maybe blood tubes, but Tube Week has come and gone here on StudentNurse. Yes, I was sad you missed it, too.

But I think it *does* get better than this. First, I have to use lidocaine. Have you done that yet? You use an insulin syringe and make a little lidocainy bleb just under the skin and then wheeeeee! that vein in obscured or pushed to the side and suddenly you're going nowhere fast with that next fat needle. My precpeptor allowed me to go without the lidocaine, but I decided I would give my patient a choice (so, you'll be poked TWICE with TWO needles, but it might make the second stick hurt a wee bit less. What's it going to be gov'nor?) And, good afternoon, we're going 18 gauge here people. "What if they need blood products?" It's not like the needle is as fat as my pinky, but that monster obliterates those fragile hand veins. Gotta go for the forearm. You can't see 'em, you may not be able to feel 'em (especially with that bleb), but you know they're there.

So, I've gotten into the vein (check out the flashback in that hub!) and I've gotten the needle into the right spot, but then chickened out on the digging around for the vein because my patients were squirming so much (yeah, so much for that lidocaine). My precpetor was able to get it in with my start by pulling back a little and going a little deeper. And then blood comes kasplorching out on the chux ('cause remember it's that big fat needle in a big fat pregnant vein in that blood pipe-y forearm neighborhood...) and then, the final L and D challenge, you have to risk the whole IV start to draw blood because we don't want to stick these laboring women more than is necessary. So, I apply the Vac-U-Tainer (JC, how about some logo artwork?) and (with the first gal) popped four tubes in and wiggled four tubes out.

Oh yeah, L and D IV starts are a dream. Next time: no lidocaine for you!

So, I go to "work" and I'm all preening in the mirror beforehand. How do I look? And why do I care? Have you ever been in the nurses lounge on an L and D floor? Take a look around. Hair is neat, earrings and necklaces are worn, jaunty sweaters are thrown over festive scrubs. What's up? I have been in several photos now: Here's baby's first bath. Look at baby getting his first little beanie. Baby's first hepatitis B vaccine: aw, cute! And some of the posed ones: Here's our whole birth team.

But don't look at the shoes in L and D. My preceptor has some tennies with mesh and there's a blood stain on them. One of the midwives has a pair of dark blue Danskos that are really nasty looking. I notice lately she's been wearing shoe covers. I have my bright-white-from-last-year's-dark-days -of -all -white shoes just waiting to be oozed or kasplorched on. On average, a woman loses 500 ml of blood during delivery. That's two cups. And, name that bodily fluid, many of them make an appearance during labor and delivery.

NCLEX tip #2: When in doubt, assess.

Sunday, February 01, 2009

PM Shift

Working the PM shift...wait, I can't call it "working" can I? I don't know what else to call what I'm doing (precepting the PM shift, doing the PM shift, riding the PM shift, studenting the PM shift?), so, let's just say "working" until someone comes up with a better word...

Working the PM shift is making me a somewhat lonely person. I can't call most of my friends when I get home (most are doing days, some are doing nights so one is reluctant to call those night-shifters at all because they're probably sleeping at noon in a room with tinfoil taped to the windows or something). The kids are asleep and Mr StudentNurse is grouchy waiting up for me. I drop the kids off at school in the morning and say, "See you tomorrow." Ouch. Have I mentioned that one of the reasons I went into nursing is that it's a good Mom Job? Have I mentioned that nusing student is not at all a good Mom Job? I do like working the weekends, though, I get to hang out with the kids in the morning (Well, I'm sleeping past 10 AM on the weekends. Can you blame me?) and afternoon and I get to kiss them goodnight at 2:30 (oops, sorry at 1430. That was a potential med error..) instead of at 0800. Sure, the hubby is grumpy when I get home, but it's a Saturday night, right? He can take it.

Did I already tell you how much I LOVE labor and delivery? I am going to cry and cry (and cry) when my preceptorship is over. My second patient tonight was in there with her family. She had on pajama bottoms and wanted "female providers only" (she's Muslim) and her mom was in there rolling on her back with a wooden rolling pin. She was a tiny little thing with an out-sized tummy and even at 8 cm and with no pain meds on board would politely say, "I'm having a contraction now," and breathe quietly. My preceptor let me take care of her with minimal help and, at first (with intermittent monitoring) it took me FOREVER to find that babe's heartrate, but by the end of the night I knew EXACTLY in what neighborhood I could pick up that hummingbird-fast heartbeat. I actually felt...competent.

Doesn't that picture look like it was taken with an electron microscrope? It's actually a close-up of that funky, swirly cauliflower that probably has a name but it's 0130 and I can't come up with anything anymore.