Annals of Nurse-Midwifery

A big pot hole for my confidence

2009-11-04T09:43:00.004-05:00

Many times throughout my days at the hospital I pause, and think to myself "I should really write about this on the annals..." but alas, the transition from brain to post has been a challenge I have not, until this morning, overcome.

Let's see - in short - since August 20th I have caught a bunch of slippery babies, transitioned from watching to being watched and now, to flying solo at the hospital, and (last, but most certainly not least) have gotten married. It has been a blur of a past few months, which have left me curled up in the fetal position in the late evenings sipping on a glass of wine, watching Mad Men if I am lucky, or, as has been happening as of late, baseball with my now husband. Doing anything remotely taxing on my brain has seemed, quite honestly, out of the question.

In general, orientation has gone well. I have done tons and tons of admissions, and have caught less babies than I had hoped, but enough to keep my adrenaline up and my love of midwifery current. I have been feeling rather confident, and ready to take on the challenge of being the sole provider in the room at the always-different moment of birth.

Until yesterday, I suppose, when my confidence took a bit of a nose dive, and reality of being the new provider that I am set in with the steely cold vengeance. The day started out quiet- and from 8:30-9:30 I even broke out my knitting project for a lovely secluded moment in our cozy call room. Then, as most days do, the pace picked up as woman after woman presented to L and D triage with contractions, pain, bleeding, and the like. There was even a woman who came in after having fallen on her belly after being chased by a pit-bull. Somehow, during report, the type of dog was always mentioned, as if it gave the gravity of her case more umph to say pit-bull, as opposed to, let's say, a poodle (she was fine in the end, with a bruised hip only, pit-bull be damned).

Two of the admissions were mine. One, an 18 year old girl from Puerto Rico with a far away look in her eyes throughout labor, turned my confidence around and spun it on it's wobbly head. After admission for spontaneous labor, she progressed without any pitocin or epidural (yes, a rarity where I practice, and something to be stangely proud of, I suppose) to full dilation around 6pm - right before my change of shift. I decided to stay for the birth, my numbers have been rather low and had been with her all day. Her pushing was somewhat disorganized - but, without ever getting the hang of it externally, she managed to move the baby down to almost crowning... which is when the baby began to poo and poo and poo (meconium, thought of as a sign of fetal stress). Pediatrics was called to the delivery as is protocol after meconium, and the nurses changed shift as she was about to crown.

The new nurse in the room was a woman I had never worked with before, and she seemed to be against what was going on from the moment she walked into the room. She was exasperated with the disorganized pushing, with the fact that our sweaty 18 year old was pushing into her face, not into her bottom, and with me trying (usucessfully) to get her up and squatting. The girl resisted, the nurse resisted, and, after two ungraceful attempts, I let her back on her back with her legs supported back, to the position everyone seemed to want but me. Somehow, through my failed squatting attempts, the frustrated nurses coaching, or the tenacity of the pushing mom, the baby crowned. And crowned. And crowned.

It was one of those moments when I wished it was the 1970s and I could just cut an episiotomy and free this child from the tight skin of her mother. But I didn't, knowing the research that perineum's torn naturally heal better than those cut by our scissors - so we waited. And the impatience and frustration in the room seemed to grow as did the beads of sweat on my chest. Just as I looked up to see the fetal heart monitor and get a sense of the heart rate, the head popped through the perineum, restituted, and the baby was born (Mistake #1 - never look up from a crowning baby). I placed her into the birth soup - unslickly- while I clamped and cut the cord... I felt like my hands were adorned with lead gloves rather than latex - and they seemed to move slowly. As I brought the baby over to the warmer to meet the team of pediatric residents waiting to greet this child - I placed the baby backwards on the warmer for their liking (Mistake #2 - head should always face the room). Moments later, there was a low hum of griping that I had clamped the cord too close to the umbilicus for their liking. Mistake #3. So far, without anything bad actually happening, I had annoyed all providers in the room - and was feeling like crawling under the sheet with our 18 yr old patient to hide.

I couldn't do that - but instead delivered her placenta - and she hemorrhaged. She was low risk. First baby. Not a prolonged labor. Got pit after delivery of the baby. And voila. A gush of blood that wouldn't cease. Pit IV. Cytotec in her bottom. Pit IM. Still bleeding. Then I called in the attending and she started to slow down... It wasn't a mistake, but it didn't go well. And I felt like it was bad thing #4.

On inspection she had a 2nd degree tear - like a natural episiotomy - that I sewed up slowly. The nurse that had been so frustrated in the beginning continued to remind me, through snide comments and remarks, that I was horribly inexperienced. I couldn't wait for the moment that, 2 hours after my shift was over, I could leave the room, write my note, and say goodbye. Before I left I hugged and kissed my smiling patient, and told her that I was proud of her. She said thank you. And I thanked the nurse for bearing with me and my newness. She didn't even smile. She just reminded me to take the cart out with me as I left the room. While I know it was the patient who was most important in this case, I couldn't help but focus on the nurse. I walked out of the room feeling ashamed. I was proud of my patient, but was not proud of myself.

Today I feel a bit better about it - it was my first unsupervised delivery ever. In my life. And while it wasn't slick or beautiful - it was safe - and the baby was born. And her bottom will heal. And her iron will replete, and all will be well. I will try to remain proud of myself for what I did right in that room - and not the little things that I did wrong. And so I will move forward to the next birth, and hopefully my list of mistakes will begin to grow less with each birth, and the number of smiles will grow more... both mine, the nurses, and the patient.

Off to clinic. No more time to reflect. I just need to jump back on the horse and continue riding on.

Hospital Hangover

2009-08-20T08:43:00.003-04:00

It's amazing how much energy the hospital can suck out of me. Even though I'm still under a strict 'no touch' order until I get properly credentialed in the hospital, I felt like I worked for my money yesterday. And woke up today, feeling the worse for the wear, struggling to open my eyes and leave my cozy bed.

I spent the day battling our terrible computer system and filling out admission paper work in triage. I think I broke the record for the longest time ever taken to fill out an h and p (history and physical) - 5 hours. Perhaps I cheated in the breaking of this record, because the computer froze and my first version was lost entirely... By the end of the day, however, I felt like I had some sort of grasp on the many quirks and minimal perks of this system. The system has the ironic name of 'Sunrise' - which it is anything but. I would more appropriately title it "Darkness."

As the evening progressed into the later hours of night - the hospital got stranger and the cases got more interesting. I saw things that I had only read about in school. (Side note: this attitude always makes me feel conflicted, as it is a direct using of someone else's misfortune. I always want to preface stories like this with the fact that even though I learned from it it would obviously be better if it had never happened in the first place. The women I will write about probably had one of the worst days of their lives yesterday and I am happy only that I could be of minimal comfort). The interesting first case to walk through the triage door was a woman at 39 weeks pregnant who had been assaulted by her husband. I had presented on domestic violence during school and what to do - but in all honesty - a case like this had never confrunted me so directly. As I was leaving last night the husband showed up, started screeming, and created a mini-Maurie Pauvich episode on the floor. It was scary and sad and eye opening.

The second moments of chaos came slightly after. A woman who was 10 days post partum after a c-section came in complaining of "I don't feel well." Then she seized. And seized. And seized. My non-touching order allowed me to take her sobbing friend out of the triage room and explain to her everything that was going on - from afar - then chat her up about her own new baby, and how good of a friend she was for taking her bestie here. After the hanging of mag, and the giving of oxygen and the overhead paging of anesthesia and more chaos on the floor - she seized again. While no longer pregnant, this woman had an obstetrical emmergency that we all fear most.

I biked home late last night, images running through my mind, thinking "Wow. it's not just stuff you read about. Shit like that really can hit the fan." My experience in this job will inevitabley teach me so much about my field. It already has. I wonder what I will learn about tomorrow...

That's more like it...

2009-08-15T16:41:00.002-04:00

I almost cried during a birth today - which I haven't done in a long time. It wasn't actually during the birth itself, but during the labor.

The patient was a young woman, in labor with her first baby, and accompanied by her boyfriend and her boyfriends family (mom, and two sisters). Her family was - well, we didn't know - the mom-in-almost-law gave the universal sign for "I have no idea - and don't ask..." with a shrug of her shoulders, a shake of her head, and a gentle roll of her eyes. She had dilated rather quickly, but things had slowed way down while pushing. She had been pushing for almost three hours - which- by any standards, especially my new medical institution, is a rather long time. We didn't think the baby was very big, the position seemed fine, and she was pushing with strength. Her family-in-almost-law was lovely and doting, and things should have been moving more quickly than they were. The docs were knocking on the door - both literally and figuratively - wanting to know what was going on - and starting to use the evil c-word when talking about the plan.

I was at a loss for what to do - we had changed positions, and used all the tricks up my fledgling sleeves. However, the midwife whom I'm shadowing today was almost eerily tuned into the woman's feelings. After a long hard push, the patient started weeping. Not a frantic 'this hurts like hell' feeling - but a deep, mournful cry or sadness. The midwife put her face close to the patients and stroked her hair. "I know this is hard," she said. "You want your own mom to be here with you. His family is wonderful - but you want your own mama now." The laboring woman's tears increased, and we encouraged her to cry as she needed to. She held her boyfriend's head, and cried, and grabbed the hand of her future mother-in-law - and cried. And they cried. And that's when I almost cried.

Voila. In about 30 minutes, she pushed out a screaming baby boy. It wasn't a shoulder or a body part dystocia. It was emotional dystocia. And she let it out. And it worked.

And.... we're back

2009-08-13T08:08:00.002-04:00

After a year long-hiatus, I'm back to the bloggesphere. Perhaps inspired by a huge transition and a new job, or requests from disappointed family and friends to start writing again, or perhaps because I missed public reflection on my career choice.

In short... since I posted last - I've graduated from a master's program in nurse-midwifery, passed my boards, applied for and accepted a job as a midwife at a large public teaching hospital in an inner city, visited Costa Rica and Israel, eaten lots of felafel balls and musli, and settled into an apartment with my fiance which feels like home.

Yesterday was my first true-day at work. I am only allowed to observe, as I am not yet privileged at the hospital. What a different place from the small, touchy-feely hospital where I did my training. There are no tubs, and only one doppler for intermittent auscultation (vs. continuous monitoring... the not-evidence-based-standard), which certainly speaks to the lack of it's use and there are no tubs in any of the rooms. There is a contraption, hidden in a closet, called an aqua doula - a portable tub which requires about 10 different small metal pieces to hook it up to be filled in by a sink (!!). Um, yeah, you guessed it. No one uses it.

Perhaps auspiciously, however, the first birth I witnessed there was a precipitous totally unmediated birth by a 19 year old woman. She was in control, in rip-roaring labor, and ready to give birth when she arrived. I learned, in watching her birth, that as new as I am, I have my own style, and was surprised by some of the hand techniques of those around me. I found myself, although rendered to the side of the bed to observe only, desperately wanting to touch and jump in hands first. It was not the birth that I would have conducted exactly, but it didn't matter. I was reminded, that even with 1 clueless but curious male medical student, one nervous ER intern catching, one experienced midwife, one inexperienced observing midwife, one nervous boyfriend, and two nurses at change-of-shift, birth is beautiful.

fits and spurts

2008-09-17T08:15:00.002-04:00

This school year is starting out with a squeak and a jolt - in some need of oil to make it run more smoothly. It has been moving in fits and spurts - long 14 hr days to New Haven and back for class, 12 hour call shifts with a beautiful birth, job applications and no success, and lots of down time in between. I have been trying to get ahead on school work - I know that when the wheels are greased this year will fly by - but at the end of some days, it's hard to point to what I really accomplished. Putting together some Ikea furniture, writing a short paper, starting to flush out a lit review for my thesis? Sometimes it doesn't amount to much - and I miss the feeling of being a nurse or midwife when someone says thank you at the end of the day because you worked your butt of for them...

In due time - it will run smoothly. I must seem like a real schmuck for complaining about free time.

Here are a few photos I took on my last day in Lusaka. Things I had been meaning to photograph for a long time.

I jogged by this bike repair/car hub stand often - and always wanted to photograph this guy and his wheels. My last day there I finally was able to meet him. He was piss drunk falling all over himself to allow me to photograph him - happily doing a modeling shoot. Fall from grace?

Perhaps the opening photo for a future power point. The sign from the labor ward outside Chilenje Clinic what I took when going to drop off thank you notes and eye glasses.

A tuck shop in Chilenje.

The drunken friends of the bike repair man, offerin my Shima to eat. I gracefully said no.

Luckily, my PPD test came back negative. But what a scary sign! This was all over the University Teaching Hospital.

Nurse writes in the Times

2008-09-09T07:29:00.003-04:00

A nurse after my own heart - writing about her experiences. Trying to gain something new. It shouldn't be unusual to hear from a nurses prospective, but it is. Kudos for the Times.

School has started - but is certainly not in swing.

My new apartment is wonderful here in Cambridge.

Life is trucking again. This article reminds me to take advantage of every moment. Important to remember, especially when things get busy.

http://www.nytimes.com/2008/09/09/health/09case.html?8dpc

Ina Mae in Zambia

2008-08-15T02:17:00.002-04:00

A Zambian Midwife and the baby bundle in Chipata.

In my last week here I have been reading Donna’s (my host) copy of Ina Mae Gaskins Spiritual Midwifery from 1977. This book is groovy in the true Simon and Garfunkle late1960’s sort of way. Besides being an integral component of the midwifery cannon of literature, it is a fierce, if not dated, reminder of the potential pleasures of having a baby – and the essential role that trust, sensuality, surrender has in birthing [this is an Ina Mae term as is Puss, Rush, groovy, heavy, loving, tantric, psychedelic, telepathic, get high with each rush, smooching….]

I have really been enjoying it. The first half of the book is birthing stories, each about 2-3 pages, written by women and their partners about their birth experience with the midwives on The Farm – and before the farm existed when they all lived and traveled in a caravan of school buses. (Yes, I’m telling you, those were the groovy days.) While the stories are full of breech deliveries, premature births, tight cords around necks, and even a stillbirth, the excerpts by the women convey such a sense of satisfaction with their birth experience – even when there are episiotomies and hospital deliveries involved. They talk about loving the midwives, loving their partners, and feeling blessed no matter what the outcome.

The farm midwives placed a lot of importance on working through psychological blocks and interpersonal dynamics between partners on the ability of the woman to both safely and fulfilling deliver the baby. They tell the women often that ‘tight lips equals a tight bottom’ and encourage the mothers to ‘smooch’ their partners, and get out all of the psychological crap between them. The men play an integral role in the process – and many women write about how they relied heavily on the energy given to them by the presence of their partner. They create an environment of love and trust and sensuality – as they say, “a baby should come out in the same way that it was created…”

And then I sit up. And I’m in Zambia. And birthing in the clinics here could not be any more different than the loving, groovy rooms of Ina Mae’s farm (indeed – they are all home births – the rooms designed and created by the mothers themselves). And I wonder – should this privilege of a fulfilling birth experience come only after basic sets of safety standards have been met? Is this the equivalent of Maslow’s hierarchy of needs? That only after the basics have been met (shelter, food, safety) can one actualize one’s self and experience true fulfillment? Or is birthing opposite? Is it especially important to create a kind, loving, mother-friendly environment in low resource settings? Or is the question a completely mute point? Is it important for ALL women, regardless of financial status or geographical location or health status to have that kind of experience?

Yes. To both.

Here is why I think this kind of experience is especially important in a place like Zambia – besides the fact that (I believe) it is a human right to have a humanizing birth experience.

1) One of the reasons that maternal mortality is thought to be so high here is the low rate of facility births. Many women deliver at home – with traditional birth attendants – and not in the hospital. The government has made a big push for facility births because the staff is trained to handle complications and there are more resources than at home. However, after describing the birthing practices here – including the occasional hitting of women, yelling at them that they are ‘uncooperative’ – and leaving them virtually alone until they grunt and push – my mom said it best: “Why would the women come to the facilities to have their babies?” Even if it is ‘safer’ – it is less pleasant – more isolating- less fulfilling – and therefore less chosen. If more emphasis was placed on creating a pleasant birthing experience for the women – perhaps that would reduce the maternal mortality just by getting the complicated cases near the interventions that could save lives.

2) There is physiologic and anecdotal evidence that decreased stress leads to fewer complications in birth. Separating a woman from her family, her partner, her loved ones, and placing her with a care provider who she perhaps less than trusts increases her adrenaline, which blocks the oxytocin (the contraction, orgasm and breastfeeding hormone), which slows down labor and increases risk of complications. So make her happy and decrease complications. Sounds easy, no?

But the other parts of me thinks- do all these niceties really matter? Or are they just that? Is it basic skills in safety that are at the crux of decreasing the number of women who die in or after childbirth?

During my presentation to HSSP to update them on the preliminary results of the project – I talked about the ubiquitous ‘baby bundle’ – as I call it. After the baby is born, it is whisked away and wrapped in a cloth diaper, then a towel, then a crocheted blanket, then a huge fuzzy adult size blanket – so it looks like an overstuffed burrito baby – which is so large in diameter that it is tough for two adult arms to completely wrap around it. I talked about how that baby bundle reduces any skin-to-skin contact that the mother-baby pair gets, and I included in my list of recommendations that more emphasis be put on the importance of skin-to-skin contact in the hours following birth.

After the presentation, the deputy director, an American woman, expressed her dismay in this reduced skin-to-skin time due to the baby-bundle, to which her Zambian colleague responded "everyone in this room was born into a baby bundle. We all survived." Which is true. It’s a good point. And it calls into question that, which I think, from my midwifery background, is ‘essential.’

So what is the answer? Should each clinic around the world strive to create the groovy experiences as Ina Mae and her team does? Or should it be a strictly safely first approach? Or is it an obvious combination of the two that is important?

It is this question of mother-friendly services that brought me into midwifery in the first place, back in 2002 in Tanzaniza, inspired by Mary Kroeger. I think it is this question that will keep me active and passionate about this profession. I think one thing is clear – there is no harm in providing mother-friendly-fulfilling birth experiences. So why not include it? We could all use a bit more Ina Mae.

[There is an international effort to improve the friendliness of birthing practices. It came out of the work done by Mary Kroeger and her wonderful colleagues: International MotherBaby Childbirth Initiative - www.imbci.org]

land of plenty

2008-08-13T06:37:00.004-04:00

The past few days I have been feeling really ready to go home. However, after a day of feeling sorry for myself on Monday, I decided to make the most of this last week: to get as much work done as possible, to continue explore Lusaka, and to continue to learn about what it means to be Zambian.

Today I decided to my walk back to the HSSP office (my hosting organization) from the hospital instead of hopping on a ubiquitous minibus or jumping in a cab. I wasn't in a hurry to get back in front of my computer, and have started to relish each moment

here (a self monologue "why not walk back? when will be the next time you have the luxury of walking down a red-dusty street in africa?"). While I moseyed down Nationalist Avenue, a large wide street past some embassies but without many pedestrians, I found myself walking almost in tandem with a thin Zambian man in a dirty white baseball cap, dirty white pants and a dark green sweater. He was walking at almost the same pace as me, and after a while like this, I realized that we were alone. My inner monologue, as ashamed of it as I am, started something like this "I have a computer and digital SLR

camera in my bag. We're alone on this street... it's broad daylight, and I've never heard of anything like this in Zambia.. but should I switch to the other side of the street?" It didn't take long before he interrupted my monologue with his voice. It was obvious that his inner-monologue was very different from my own: "Madame. I am looking for employment," he said. "Do you have any employment for me?"

He looked in my eyes. His were sad. His clothes hung on his bony frame and the baseball cap was shading a wasting face. "I am sorry," I said. "I am leaving on Saturday to go home to America." The minute that came out of my mouth I regretted it: what kind of answer was this? What was I saying? "I am sorry you are desperately poor. I am rich. I am getting on an airplane that cost close to 2000 dollars to buy and heading home to the land of plenty." I don't think he took it like that - instead he feigned a smile and walked ahead of me.

I welled up with tears. I have been asked for employment here before - women have shoved their numbers at me, asking if I know of anyone who needs a housekeeper. Men constantly ask me if I want a cab - cars drive by honking as if to say "need a ride?" I don't know why this man caught me so off guard. I know life here is hard.

Even I complain that the grocery store is more expensive than at home - gas is almost at $12 a gallon - and even a small beaded key chain runs about $2-3 dollars. But the statistics say that people here live on $1 a day. How can that be? It is true however. The manager of the compound where I live, Vin, makes 200,000 kwacha a month. That's about $75. He supports a family of five. And there you are, less than a dollar a day per person. He struggles every day and lives literally hand to mouth.

(Vin's family in front of my house here)

His wife is pregnant with their fourth child - and has been having unusual pains that prompted him to bring her to a clinic. The cost of an ultra-sound was about $20 - more than a quarter of his monthly salary- and figuring out what was going wrong was nearly impossible. When he told me his story, I gave him the money - but it is only a small band aid for a huge problem. The next week her tooth was aching so badly she couldn't eat. Another $20 needed. Last night, while we were talking, he said "I hate it. I hate only working for millie meal. Life is worth more than that." His words rang so true. The struggle for the poor here is truly heart breaking.

And so my heart I ached for this man who was honestly asking me for employment. And for the cab drivers who sleep in their cabs, and drive me to the hospital at the wee hours in the morning with dust still in their eyes. And for the women who leave their own children alone to care for someone else's for less than $100 a month. While here the roads are often good, and on the surface this country sometimes looks together, there is true hardship when you just lightly scratch the surface.... I don't know that I've done a darn thing to help this summer. I don't even know what I could do.

So I will leave Zambia with love for this country - but with sadness too. Knowing that as I board my plane to the land of plenty, the people who have touched me will be here. Every day. Hungry. Struggling. Asking the next white girl who walks down the street if she can give them job.

Lusaka again

2008-08-09T06:20:00.004-04:00

Midwife in Kanyama with her thank you eye glasses

Looking through the window of the train...

Toasting our big night

Adorableness in Zanzibar

Two weeks with no blogging translates into the fact that I was having too much fun...

Where to begin?

Caleb and I took a canoe safari for 4 days on the Zambezi river.... paddling and floating our way down the river with Zimbabwe on our right and Zambia to our left. We camped on 'neutral territory' islands in between - so as to not have to avoid elephants on our camp site (hippos and crocodiles do travel to the islands, so swimming was sadly prohibited...) Our guide, Kambol (he said his parents tried to name him after the soup brand, but that the person who wrote out the birth certificate misspelled it and the name stuck) was fantastic. He was a one man show, as neither Caleb nor I are particularly expert at canoeing and camping 4 course dinners over a fire) and knew so much about the land and the foliage and the animals that surrounded us.

To the midwives among you - we learned about a type of antelope that can retain their fetus and stop themselves from giving birth for months and months during a drought - and that when born, the baby is not any worse for the extra months inside.... He told me the name, but I've forgotten now.

After we returned from the trip, we spent a few days in Lusaka, and I handed out my thank you gifts to the midwives that participated in my study - safety eye glasses to prevent against transmission of HIV if there are any 'splashes' of bodily fluids. I spent a fun and santa-clause-esque day driving around to all of the compounds in which I worked, dropping off three pairs per clinic. The midwives were very appreciative, and it felt like great closure. I will try to post a picture if the internet cooperates.

Then we left on a trip into Tanzania with some friends. As a train lover, and an over-night-train-lover especially, I had planned for us all to take the train from an industrial town about 4 hrs north of Lusaka (Kapiri Mposhi) to Dar es Saalam. It was supposed to be 44 hours (2 nights)- but ended up being 52 - and the ride became VERY long and greuling. It perhaps was my fault, as somehow I thought that Africa would magically transform into India, and we would be served hot chai by the chai-wallas in the morning and indian food for lunch. Instead, it was chips (french fries) and pink sausage on the menue. Yuck. Ok, sometimes chips are delicious.... but enough was enough after 3 days of fries.

Dar captured my heart in a surprising way in an India-meets-Africa sort of experience. We did get chai there from a local shop, and Caleb managed to put down a whole plate of curry and chapati before 9am, which impressed me. I was content eating a half of a papaya drizzled with lime juice with a spoon - trying to recover from french-fry-overload. The markets were full of colors and energy and men on bikes and mosques and cows and - well - it made my heart soar. If I can say this only once without getting in trouble - it made me wish I had picked a different city to base this study. Ok. That's out. Moving on...

Zanzibar was just pure love. And our lodging for a few days was called "Paradise beach bungalows" - a name that could not have been more fitting. I could go on an on about the turquoise water, the Swahili culture and food, and the joy of relaxing, but I'll spare you.

I'm back in Lusaka now. I have a week to tie things up here: present preliminary results of my project to my hosting organization, finish handing out eye glasses, buy last minute gifts, and say my goodbyes.

People keep asking if I'm ready to go home - and I think I am. I am sad to leave Africa. But at this point I feel like if I was to stay longer without another project or mandate I would be spinning wheels.

And, to continue with the food theme, I can't WAIT for a huge salad.

"My Dear - this is Africa!"

2008-07-21T08:48:00.003-04:00

It's amazing how much can happen in a week. I feel like I'm standing in a very different pair of shoes than I was during my last post - although in reality it's the same warn pair of Dansko clogs.

1) Caleb arrived on Thursday night. It is wonderful to have him share this place with me. We had a lovely and relaxing weekend jumping on and off mini buses, going to the market-in-the mall, and reading at home.

2) I returned from Ndola - on a bus - after waiting 4 hrs for the bus to fill to capacity and FINALLY leave the station. No sooner was I done thanking god for the departure than on came the terrible Nigerian soap operas played at unimaginable decibels. After covering my ears and whimpering for a while - the man behind me laughed. "My dear - this is Africa!"

Ndola was a beautiful little city - with wide tree-lined streets, a 'Shop Right' super market, and a nice woman selling hard-boiled eggs and delicious oranges on the corner between my guest house and the hospital. I spent a full three days there - and in total - only observed 7 births. I decided, as most babies are born in the wee hours of the morning - to switch my day shifts into evening/night shifts. My plan all but failed there - as in 11 hours - I only saw one normal delivery. Although my eyes were tired, my confidential envelope was all but empty. Ndola hospital was very well equipped however, and did not buck the trend that I have been seeing: Active Management is used and loved by the midwives.

The last morning of my trip, acknowledging my bad luck at the hospital, I hopped a cab to see the busiest clinic in one of the surrounding compounds. What luck! I saw two beautiful deliveries in one morning. Both done by students- with the midwife looking over her shoulder.

So - my total number of birth observations is at 58 (6 higher than expected). I am now heading into the next phase of my project - the analysis and the closure of sites. I have spent the day coding - and making thank you cards. As a gift I am giving protective eye glasses - as all the midwives wanted mine. In my interviews, when asked about what was needed, many said "protective clothing." While 30 pairs of goggles won't save anyone necessarily, hopefully it can prevent one splash from getting in a midwifes eyes.

Wednesday I leave on a canoe trip for a few days. Time to see some hephalumps and woozels.

Warning – this is sad. Don’t read if you’re already not having a good day.

2008-07-15T05:09:00.002-04:00

[note: this is posted from Ndola - since I didn't get to an internet cafe in Lusaka. More on Ndola soon...]

I am back in Lusaka for a day before heading off again – this time to Ndola, the site I proposed in the very beginning. Ndola does not have a rural catchement area. Instead, it is smack in the middle of the Copperbelt province, one of the richest, I hear, due to the copper industry that funds most of Zambia. With the advent of wi-fi and silicone cables - and the reduction of copper cables being used – this province in Zambia has apparently been through some major economic shifts and down turns in the past decade or so – and is now just starting to rebuild. There is an anthropological look at the social ramifications of this down turn by James Furgeson called Expectations of Modernity. As a non-academic-anthropologist, it is a bit hard to get through, but the parts I’ve read have certainly been interesting – and I’m curious to see the capital city tomorrow.

My last 2 days in Choma had a strange air to them – there was more death than there should have been, that is for sure. There was a maternal death on Thursday night. Her baby died as well – both from a ruptured uterus diagnosed too late. I met the woman during my evening – when I had said I was returning to the hospital. When we arrived, she was 8cm and screaming. Then she got really really quite. Unsettlingly so – and curled up into a ball except when she sat up to vomit. With the weak stomach that I am known for, I often left the room when she was vomiting – having a bad feeling about the whole situation. This was not the typical transition vomiting that women are want to do before finally pushing out their baby. The midwives were aware that her condition had changed. In my field notes that I try to keep during each day of observation – I wrote “The midwife just came in to call the doctor – she said ‘her skin is cold and clammy.’” Her BP was stable, but something was obviously wrong. I did not know HOW wrong it is – but will NEVER again miss the obvious signs of a uterine rupture. I never put my hands on her. I never felt her fundus. I asked for her consent when we arrived so that I could observe her delivery – which she sweetly gave and signed the paper herself. I don’t know what to do with that paper now. Realizing that she was more sick than about to have a baby – the RA and I left, as it was late. When we arrived the next morning – and asked how she was – we were told she had died on the OR table (in theatre) – at about 12:30. She had ruptured. The baby was dead and high in her abdomen. She was in shock. I almost threw up.

That day, a premature baby was born. I think it was about 28-30 weeks gestation, but the young mom did not know her LMP(last menstral period) and came in at 7-8cm dilated. Anyway, there are no tocolytics, so if she’s in labor, she is going to deliver here. The baby was born – Apgars about 4 and 6 – meaning the baby was limp, but breathing. It was weighed immediately (yes, that usually happens here before the placenta is out or the oxytocin is given) and was 1.3 kg – which is 2.9lbs. After an hour, an oxygen tank and adult size nasal canula was brought in, and put on the now blue baby – that the midwife had tried to resuscitate with the resources available. The oxygen was taped on to the tiny face as best as it could – and I watched the baby throughout the day – continue breathing. Knowing the value of kangaroo care for premature infants – in both low and high resource settings (where the baby is kept next to the mother for warmth – instead of on the artificial warmer wrapped in blankets, as all neonates are here – I asked if the baby was ready to go with it’s mom for Kangaroo care. The midwife told me that no, this baby (whose oxygen had just been removed) needed to stay on the warmer for ‘observation.’ The only trouble was that it was all alone, and rarely observed, because the midwives were busy doing something else [side note- usually 2 or 3 midwives and no nurses are responsible for all admissions, discharges, complicated antenatal cases, post partum mothers, laboring mothers, and referrals including pre eclampsia, eclampsia patients, and any one else who is pregnant and walks through the door]. I tried to keep watch as best I could, but left around 5.

In the morning, I returned, and saw the mom. “How is your baby?” I asked her as she was walking to the bathroom to bathe. “My baby is dead.” She said. Her eyes welled up with tears and she turned away. Again. I went to an empty bathroom and cried. I do not know if I could be a midwife here. There were other stories, but I won’t go on.

So – 6 deliveries were observed in total during the 3 days in Choma – but I have to say, I was ready to leave when I was picked up on Saturday afternoon. I feel guilty walking away – without having done anything really to help. I put on a pair of gloves sometimes to help a midwife hold something, or pass her something – or adjust the oxygen on a baby – but I have not really helped. I don’t even know what I would do. Make recommendations? As if that’s enough.

I hope Ndola will not bring with it the witness of so much sadness. But this project trecks slowly on – and I have almost reached my target for numbers in both interviews and in observations. I am ready to see some elephants, giraffes, and stare at the wide open and star filled sky for a bit.

Kafue river with no fish

2008-07-11T10:41:00.001-04:00

Outside Chipata General Hospital with the sun setting

Labor ward of Chipata General Hospital

Partograph and nurses hats in Chipata

The lovely Midwives at Kapata Clinic

I am sitting in one of the tackiest rooms I’ve ever stayed in. Brick-a-brack doesn’t begin to cover it. The under curtain is lace – the outer curtain is a fake patchwork of animal prints and bad drawings of the big 5 safari animals. The floor is tiled in a pink and gray tile that could be confused for dirty if you don’t look carefully and realize the gray splotches are part of the design. The over-stuffed love seat in the middle of the room is mauve and velvet and hard when you sit on it. There is a TV, a lamp and a dresser pushed up against one wall and a fridge pushed up against the other with bad painting of a lion hung 2 inches from the ceiling molding.

But – I love that I’m on the road. I’m sharing the room with one of the research assistants working on a complimentary project. She’s wonderful – an experienced midwife and trainer, who has been hired to help out with data collection. It is 7:30pm – and we are taking a break before we head back to the hospital to see if there are any deliveries. Apparently, July 10 is not a popular day to go into labor in Choma, Zambia.

I did watch one delivery today- the 18 year old girl – in my opinion – did wonderfully. But the midwives didn’t happen to agree. I watched, clutching my binder with data collection tools, as they yelled at her, and hit her legs and once her face when she was screaming, as she pushed. “she’s an un-cooperative gul.” One midwife said to me. I had to bite my tongue. Active management was used in that delivery – but I can’t say that I cared much. In just standing there and observing, I felt complicit in her meanness. I suppose these are the ethical dilemmas that the Downs committee encouraged me to think about – but meanness wasn’t on my mind then and I’m not sure I handled it well. I tried to compensate by telling her over and over what a good job she’d done – but I don’t speak Tonga – and I’m not sure she understood.

While that is the delivery experience fresh in my mind - I don’t want to paint that picture at all of the practices here. I have watched and interviewed some wonderful, skilled and kind midwives that put the lives of their patients (clients – as they call them here) ahead of everything else. They love active management, not because it cuts down on their work, but because they have said over and over that it truly cuts down on the rates of hemorrhage. They are upset when oxytocin is out of stock, and they reserve it for the clients at increased risk of hemorrhage when they are low. This has been the theme in all the clinics I’ve spent time in Lusaka, and in the clinic and hospital I visited in Lusaka.

Along wit the good – of course, I’ve seen the bad. After the discovery of a lack of fetal heart in a woman with polyhydramnios (too much amniotic fluid)– the doctor said “this is like the Kafue river – but with no fish.” People laughed. I did not. I also saw a footling breach (baby is born 1 foot first) that was ignored for a while. Unbeknownst to me, the mom was just laying on the bed with a half delivered baby….

There is very little labor management. Women are lucky to have the fetal heart checked every 4 hrs – as they are supposed to. There is NO Doppler, no sound of fetal heart in the room, and very little attention paid to the fetus. I have seen a few patients go to c-section (Cesar – as they call it hear) for fetal distress – but I’m not sure how they discover that.

As for the rest of Zambia – it continues to grow on me. It is a no-frills place in the most honest sense of the word (except the frilly curtains in my room). Life here is just life. Unadorned by crazy fashion, fancy food, and lots of hobbies. People are surrounded by death – and life – more than I am used to at home. There is always a funeral or a funeral procession – or talk of someone dying – and living – and life.

I have 1 more week of traveling and data collection – then the project slows down a bit when Caleb arrives. I feel that – while I have not analyzed the numbers – I have a good sense of what is happening in the urban and peri-urban clinics here.

I may just have found the answer to my question though...

from the road

2008-07-10T11:19:00.002-04:00

Since I've last written - I've FIANLLY ventured out of Lusaka. I drove to Chipata - on the boarder of Malawi - with some friends here to do some work and play a bit as well. It was so refreshing to leave the capital city - and I feel like I've finally seen some of Zambia.

I'm on the road again - this time in Choma - which is half way to Livingstone. I've decided to change the structure of my research a bit - spending only a few days at each clinic or hospital. Each place has a culture of it's own - so many days seems redundant. Thus - I've seen 7 or 8 clinics - in stead of 2 - and feel like I'm painting a more cohesive picture of what's going on.

I have many thoughts - which I will write up on my laptop and post tomorrow.

Cheers from Choma.

A week under my belt

2008-06-29T06:06:00.002-04:00

Each day this past week I visited a clinic here in Lusaka and hung out with the midwives in the Labor Wards. It has been the best week so far - and it feels all warm and tingly to be doing that which I set out to do.

My initial sense? The midwives here are overworked and under paid. They are passionate like midwives around the world about what they do. They are skillful and are hungry for more techniques to save lives and reduce morbidity. They LOVE oxytocin and active management. The only reason they are not using it is if there is not oxytocin available. In some of my interviews, which I expected to be a careful unpacking of attitudes and barriers, I have been getting answers like "I love it" and "It works." The interviews that I expected to last an hour are barely 15 minutes. One midwife actually said "Why do you keep asking me about the same thing?" Hmmm...

But not all is well in the clinics. Mothers are separated from their babies almost immediately and are asked to get up, clean themselves off, and wash their own linens about 10 minutes after delivery. The babies stay stacked on an empty bed, wrapped in a HUGE bundle of blankets and towels, waiting for their mother to nap and rest before they come together. There is very little attention paid to the post partum period. Women are discharged 6 hours after delivery. When I explained that in the US they stay for 2 days post partum there were gasps. "What do you do with them for two days??" Ah, America.

I will spend a few more days observing in Lusaka this week - and then will take off for a series of trips to observe further out. Thursday I'm leaving for the Eastern Province, bordering Malawi... then will return Tuesday to head South to Choma and Mumbwa... then North to Ndola. I have expanded my sites because a) why not? and b) a few days in one place seems like enough time to become acquainted with the culture and the practices of a place.

So, 25 births later, I'm feeling like a researcher in Lusaka at last. Time is moving fast now and I just hope I can finish that which I set out to do.

More soon.

Back on track

2008-06-23T10:56:00.002-04:00

Only a week later than promised - we have IRB approval, sanction from the Ministry of Health, and have officially begun data collection. Today I traveled to a health center in the middle of one of the largest compounds in Lusaka. THAT was the 'Africa' I was expecting, strangely. Kids with swollen bellies and no pants running around little concrete shacks. Smiling women behinds stalls of fruits and veggies - right next to the chickens and the goats. Women with precariously balanced watermelon slices on a platter on their heads - that somehow never falls amidst the bumpy roads.

I saw only two deliveries. Five delivered before our arrival (a research assistant and myself) and two were in active labor when our ride came. Tomorrow I will return and hopefully see many more. This week in Lusaka - and next week I'm (finally) on the road.

Initial impressions: 1. Although (or because) there were many less resources (no surgery, no pain meds, not even oxygen for the mom in case), the clinic is a much kinder environment in which to give birth than the big hospital. The windows were open. The midwives were kind and skilled. And women labored naturally, vocally, physically - without any yelling at all. Birth there felt as normal as grocery shopping. Something you do. Sometimes it's a pain. You get something yummy when you're done.

After delivering, one woman got up and WASHED her own chitenge in the sink (big piece of printed fabric... kanga, panya... etc) within 15 minutes.

God damn. Women are amazing.

Kindness

2008-06-19T12:13:00.002-04:00

I had written a whole entry in my head after a long day of observing at the Hospital on Tuesday - but when I got to the office today - my Macintosh died. Now computerless, and feeling disoriented, I write at the end of the day from an internet cafe.

Tuesday I piloted my new and beautiful data-collection tools. I observed a hand full of births - and interviewed the midwives briefly. The births were mind-boggling in their routine-ness. The women delivering at the hospital were not treated at all as if this was a special day. On the contrary, they were treated as if they were doing something rather gross and animalistic. The woman deliver on flat beds (all on their backs - they are lucky to have a metal bar on which they can rest their head while they push. There are no sheets. women bring their own fabric - and if there is none, well, it's black-garbage-bag plastic to lay on.

But the surprise - or the noticeable component - was not the lack of resources. I expected that. It was the unkindness with which some of the midwives treated their patients. One, when seeing his patient grunting to push, scolded her and made her cross her legs until he had time to catch the baby. When he did come back, about 10 minutes later, he started waving his scissors about - near her perineum saying "If you do not push this baby out in 10 minutes I will CUT you (snip snip with the scissors) - or you baby will die...."

Luckily, she did. While she was pushing, however, he didn't like the effectiveness of each push and grabbed her lips and held them tight - in a mix of Nyanja (the local dialect here) and English- he said something all to easy to understand "Enough with the drama, drama, drama! Push with your mouth closed."

I used my new learned midwifery skill of biting my tongue and sitting on my hands or I think I would have jumped on him. She was also HIV positive - and on PMTCT. And I really hoped that he was not treating her badly because of that. Who knows. Stigma runs deeply.

They were not all so dramatic. However, it made me wish that my first idea for a project - looking at what happened to a mother-friendly-organization - had worked out. At the end of the day, I didn't care if they used active management - I just cared that they treated these women like the goddesses - or even the humans - that they are.

On another note- the 'expidited' IRB process still hasn't given birth to a letter of approval. Thus, full data collection is still on hold. We are INCHING closer by the day.

So, another day, another story. I'll keep you posted. On the flip side - Zambia is growing on me. It is the perfect weather to run - and the roads are long and dusty.

in conclusion?`

2008-06-16T09:33:00.003-04:00

Many things have happened since my tearful post last week - and besides my sore throat today, I'm feeling much better.

1. The organization paid the fee. I had nothing to do with the decision. They will meet today - so my fingers are crossed that it's a yes, and I will have to spend more time ruminating on the meaning of the on the un-ethical behavior of the Ethics committee.

2. I spent a night dancing to Congolese Rhumba at one of the few dance clubs here in Lusaka. One of the people who came dancing with us is a new friend Nathan - who happens to be a Zambian wedding choreographer. He tried his best to teach me his moves (picture a slowed down and more controlled version of west-Africa dance). It was a great evening - better still because of the un-sexuality of the dance floor. It was mostly young men - showing of their moves for each other - completely un-self-conscious and ready to bust a move at every song. Quite a refreshing change from the bop-your-head-to-the-beat style of may American men.

3. We conducted a training for our two fantastic research assistants. They are both experienced Zambian midwives who had great advice on the phrasing of questions. We met outside, and ate insheema (a local maize mush) with a delicious vegetable called "rape" (not kidding) - which is like, if not exactly, Swiss Chard. Once this project gets rolling, they will be a joy to work with.

4. I got a letter of permission from the Ministry of Health to pilot the data collection tools. Yeah. One accomplishment. This morning I took the tool to the director of the hospital, who was at another meeting and will not be around until tomorrow. Argh. Stymied again. "Don't worry," my friend Masuka said. "You'll get used to the Zambian slowness. You people always do."

Hopefully tomorrow.....

2008-06-12T10:22:00.002-04:00

It's rare that I feel angry. But today I feel furious.

We have been promised almost daily since my arrival that "tomorrow" we will have word from the ethics committee here to get approval for this study to proceed. I've gotten a lot of "don't call us, we'll call you" - when I keep bothering the poor secretary. So today I called again, a bit more desperate, and asked to speak to the head of the committee. She explained that we wouldn't be reviewed until the end of the month?

WHAT??

JUNE 30?

That will add up to a month of waiting.

She has to be kidding.

There was one caveat. We could pay 2.5 million Kwatcha (about $800) to organize an expedited meeting that could be called in a day.

Here, I have found out, officials are paid a "sitting fee" for each meeting that they attend. People in lots of health organizations are impossible to get in touch with because they are always in meetings. And now I see why - what a supplemental income strategy.

So my project has been sucked into this fiasco. It is possibly a combination of a miss-communication (the secretary hoping it would be passed, so she led me on in a way), the huge wall of bureaucracy with a hint of corruption peering through the silver walls...

I am trying to spin this in my head as a cross cultural experience (yes, thanks mom). Perhaps it is a different sense of time, a lack of a sense of urgency. I joke with people here that there is "Zambian time" and "America Time" when we call a meeting. A 9am meeting in Zambian time means between 10 and 10:30. In general, people here have been nothing but generous. However, in this situation, I feel like I want to pull out my hair.

In the end it leaves me feeling like I want to cry. I am here. Now. I would love to get this thing off the ground. We are trying to circumvent this by talking to people with power. At this point, my fingers can only be crossed - that, or I (or the organization I'm working with) can cough up $800. Or, I could think of a fun plan to do for the next few weeks and take off for greener pastures.

Oy.

Cloudy day

2008-06-11T03:24:00.004-04:00

Two unusual things happened yesterday.

1. It was cloudy here.

Strange to say - but every other day has been cloudless and getting into the 70's. Yesterday it was windy, cloudy, and cool. It feels like fall here. The clouds weren't ominous - or threatening of rain - just grey - and pervasive - and preventing sun. Today is the same. I hope we see sun again soon.

2. I finished two novels in the span of a week.

I don't remember the last time I've done that. After six here it's pitch black out - and there isn't much of a night life - so I've been staying in most evenings. I guess that's how one finishes two novels in a week. I'm only on week 2 - and I am already half done with the books I brought. Hmmm...

I'm anxious to get this project started. It's been a week and a half of prep work - paper work - office time. We still don't have local ethics committee approval - which means I can't even go into the hospital to pilot tools. I've been talking to lots of people working in this field - and I am starting to get the impression that Active management - what I'm looking at - is being done pretty routinely in Lusaka. Yesterday I went to a grand rounds at the hospital here - on the topic of a garment they are piloting to reduce death from hemorrhage - in their presentation they mentioned that they've seen lots of preventative measures being taken (ie: active management) and sort of brushed it off. I have this fear that I won't find much of anything interesting at all. I guess, stepping back, that 100% compliance is interesting - it means that the trainings worked. That there is a shift in culture.

Oh well, hopefully with more prodding and nudging and bugging this IRB thing will go through and I will be able to get started. Data collection is scheduled to begin on Monday. We'll just see about that...

Population

2008-06-09T01:57:00.003-04:00

Zambia is not a very densely populated country. Indeed, the whole population (roughly 11 million) is smaller that that of the city of Lahore in Pakistan (almost 15 million). There is not the hustle-bustle here of urban or rural life. In the rural areas, although I have not yet visited them, the towns are said to be miles away from each other, and each one sparsely populated with only 20-100 people living within the town walls.

Not only does this make for a non-hectic (almost suburban) experience when walking around the streets of Lusaka (indeed: after a week here I can count the number of times someone has asked me for money on one hand: 2), but it poses interesting challenges when developing health care interventions for the rural areas.

On Friday I sat in on a professional meeting for people working on pediatric health in Zambia. New research was presented and discussions were had regarding how to decrease the extremely high neonatal mortality rate. One pediatrician shared her research regarding the intervention of barefoot neonatologists - that is, lay people trained in basic neonatal health and newborn resuscitation to accompany traditional birth attendants or to visit new moms shortly after birth. This intervention has been rolled out in India, and in some areas, has reduced neonatal mortality by 30-40%. However, an interesting concern was brought up: with such a small population, and such sparsely populated rural areas, would a trained lay-person have too little to do to maintain upkeep of their skills? If they only had three or four babies per year in a small town of 20 - would that be enough? Until you are REALLY comfortable - clinical skills certainly fall under the category of 'use it or lose it' - and they are afraid it is a 'lose it' scenario. But, with such a small population - it is not worth putting one of the rare doctors in these towns. So that is the challenge of Zambia (ok, one of the many). One solution is to have a system set up where doctors literally fly into rural towns when there is an emergency - but this, too, poses challenges.

The sparse population has affected me as well. The entire time I've been here - I have kept waiting to feel like I am in "Africa." This has begged lots of reflection on my part around the questions of my biases, my expectations, my sterotypes of "Africa." What was I looking for? What was I expecting? Why, when Zambia is almost smack-dab in the middle of this continent, can it not feel like Africa? And I think it comes down to that feeling of being overwhelmed that I am used to - or that I experienced in Mali and Kenya long ago. I am not really overwhelmed at all. Perhaps this is due to my cush-living situation in ex-pat ville, and perhaps it is due to Zambian culture. It is not a pushy culture. People so far that I have meet have been nothing but lovely, and rarely pushy at all. Even at the markets. Perhaps it is because English is used widely here - so I have been able to communicate rather freely. Perhaps it is in part simply due to my incorrect expectations and assumptions about what this country would feel like on the outside.

Saturday, in a quest for hustle-bustle, my new friend and I ventured into the down-town area on Cairo-road. I had been warned to 'not get excited' - that it is little more than a row of Banks.

It was more than banks, and my friend and I found a big (ish) Zambian market with local food (ensheema - sp?) which is corn paste - similar to ugali - and fried fish, chicken, and dark greens. We found pirated DVDs, lots of car parts, sink parts, and the nuts and bolts (literally) of life. Hair salons teeming with women getting new-do's, extensions, un-extensions, braids... and some tailors with black singer sewing machines and foot-pedals.

I brought my camera - but was too nervous to take lots of photos for some reason. A few people said 'NO' with their hands when I lifted it out of my bag, and one woman asked for money.

The photos aren't great - and I tried over and over to upload them - but the connection must not like it.... I'll try again later.

Today I'm going to visit a midwifery class to get a 'feel' for education here. It will be my second observation, the first of which led to many insights indeed.

Drastic Drop

2008-06-04T03:17:00.002-04:00

The preliminary report of the Demographic Health Survey (DHS) for Zambia came out this week. This report gives statistics from the last 6 years on all of the key health and education indicators: neonatal mortality, infant mortality, under 5yo mortality, and maternal mortality are the statistics that affect the organization with whom I’m working.

The maternal mortality rate for Zambia in 2002 was estimated to be 729 for 100,000 births. That’s huge. 1 in 19 – and compares to places like Sierra Leone and Afghanistan (who have the highest, I think - close to 2000/100,000). Lots of money has been poured into Zambia - lots of programs – lots of trainings – and guess what? This Monday – preliminary findings say it is now 442 per 100,000. That’s almost a 300 point drop! Huge! Huge mongus. Amazing if it’s true. The question it begs – if it’s true – is what happened here? And how can it be replicated?

There is disbelief amongst the NGO community from what I gather. “That can’t be!” One well known (un-named) organization has already heard threats that they will lose major funding because of the less dire straights of Zambia. “They need to check those numbers before they release the report. That’s CRAZY!”

So, is it true? It’s statistics only. But has something changed? I asked a Zambian doctor who works with the organization and she gave me a long and thoughtful answer in her lilting and lovely Zambian accent (A fairly geographical accent, I think – sort of a East Africa meets South Africa mix). I would have killed to have gotten her explanation on tape.

“I think it is” – she said. I don’t know about numbers – but something drastic has changed here in the past five years. She told me that five years ago, after graduating from medical school and working in the crappy Zambian facilities for a few years – she and her husband up and moved to Botswana – where they have more resources and better facilities. “It was awful here.” She said. “The hospitals were terrible – the clinics were terrible. When you went into the field – all of the kids looked malnourished – with swollen bellies and light hair. But now? Only a few. We used to have admissions all the time for malnourishment – but now it’s rare. Things are a lot better.”

She paused.

“I think it has to do – in a strange way - with AIDS. When the AIDS epidemic came here many people rushed here with lots of money, lots of programs, and lots of help for our Ministry. In order to get out ARVs and do health education programs, they made the clinics better and taught the people that they needed a basic level of care. The people now think that they deserve better – there is more of a demand. People now think about ‘good health’ in way that they didn’t used to talk about before. And with ARVs, the people are stronger. Women are stronger and can give birth when they are not so weak.”

“When I returned last year from Botswana – it felt different. It is getting better. But sometimes I wonder – if South East Asia – and Latin America – and South Asia - who are all in a similar economic position as Africa can get their mortality rates so low (Indeed – they hover around 50-100/100,000 women – about an eighth of Zambia) – why can’t Africa? Why can’t we?”

She concluded – “If we keep going at this pace, we will do it I think. We have far still to go – but I think we will make it.”

Wow-ee. What an exciting time to arrive. What a way to start a project in reducing maternal health. How positive. What a sense of promise. The facilities really are changing here – there is a sense of possibility in the air – and it makes me excited to be here – and take this leap…

*Please note - the statistics on this page are a rough estimate. Exact numbers differ between sites. Luckily for me, I'm not writing a publishable paper right now - so I can be duly liberal with my numbers. Also, the theories posted in this are only that. Theories. Thoughts. Some interesting ideas.

Lion on the bed

2008-06-04T03:00:00.001-04:00

I am sitting on my big bed with a Lion print blanket (it does get cool here at night) – not a lion print as in leopard print – but an enormous picture of the head of a lion printed onto the blanket. Yeah, a bit scary. But then again, it’s Africa, right? Even in ex-pat style. will post this tomorrow morning from the office.

The electricity has just come back on. It was out during the dinner hour – about 6pm to 8:30pm – “rashioning” it’s called. Fairly smart if you ask me. Apparently there is a schedule, although the electric company doesn’t keep it, so every few nights or days – or both – the power goes off in different neighborhoods for a few prime hours just to save. It was fairly incredible – within seconds, literally, of the electricity suddenly shutting off – the surrounding houses looked like they started turning on lights. Folks around here have the flash-light-mixed-with-candles lighting down to a science.

I am feeling less resistant to the expatriate style. I even wore heels to work today – ha! I never once wore them to my clinical site this year- but today we had a meeting with the ministry of health so, what better a time?

It was refreshing in some way to visit the ministry. A rather drab building – about 7 stories in the middle of nowhere in Lusaka – jutting upwards like a big box built with legos in the middle of a living room floor. It had decent landscaping dozens of white 4x4s in the parking lot, and a fountain with dolphins (hmmmm? It’s land locked country. Not exactly their mascot). The building was rather dark inside – and the offices had little to no decoration – a small fridge jammed up against a standing fan- jammed next to a built in shelf made of peeling and old formica with big binders labeled “Action Plan” and “WHO recommendations” and “Child Mortality.” Some of the ceiling tiles were falling out, I noticed, as I waited for the meeting. One of the few decorations in the Hall was a World Breastfeeding Week poster (shout out to WABA – my old job). But the minister we met with was really sharp – really smart – gave great feedback and supportive advice for the study.

That was the Zambia I was expecting. And in some really selfish way – I was glad to see it. Some how the peeling formica and pictures hung-too-high on the walls made me feel at home.

Thursday and Friday I’m scheduled to visit some midwifery school clinical rotations – that should be another big step towards opening my eyes to what this country is – and how it functions. I don’t think I’ll wear heels for that day.

Africa-light

2008-06-01T05:18:00.002-04:00

We'll, I've arrived in Lusaka after 27 hrs of flying - but oddly feel like my trip has yet to start. While the flying is behind me, I still feel swept up in American ex-pat life - and have not experienced the challenges that I had expected. I am staying with my professional contact, Donna, who lives in a beautiful house in the Kabolunga neighborhood in Lusaka- which might as well be called ex-patriot-ville. The houses are all surrounded by walls - and the only way to recognize one house from another is to recognize the gate that the gate-boy opens.

Tomorrow the project officially begins - I have meetings with a member of the ministry of health and will start my project arrangements. For now, I am left to wonder about this place -to wonder what it is like beyond protected walls.

Yesterday I ventured out to a tame market with everything from knit plastic tote bags made from recycled plastic, to traditional African print fabrics, to gem-stone rings worth hundreds of dollars. Very few people hassled me. Only one street kid followed me to ask for money. What an interesting place...

My challenge will certainly be to strike a balance between who I am (American, student, midwife) and where I am. I am excited nonetheless to be here, and look forward to what the next 10 weeks has to offer.

On the eve of my departure

2008-05-28T23:14:00.002-04:00

I'm posting the abstract of the study that I'm about to try and accomplish. It's in rather boring and scientific terminology - but enjoy if you're interested.

Post partum hemorrhage (PPH) is the leading cause of maternal mortality in Zambia and around the world. Active management of third stage labor (AMTSL) can reduce PPH by 60%. The Zambian government supports this practice and has invested in nursing and midwifery training programs. Prior research and anecdotal reports from the field, however, suggest that AMTSL may be practiced in less than 30% of births attended by SBA. The proposed triangulated study uses quantitative and qualitative methodologies to answer these questions: (1) Are skilled birth attendants (SBAs) in Zambia practicing AMTSL? (2) What is the lived practice experience of a skilled birth attendant with the third stage of labor? Data will be collected in two Zambian sites, the Central Ndola Hospital (Copperbelt Province) and the Chilenge Health Center in Lusaka. The quantitative component involves observation of 52 births (26 births at each site) conducted by SBAs and completion of a standardized tool to record utilization of the components of AMTSL. The qualitative component involves interviewing eight SBAs (four from each site) about their knowledge, attitudes, practices, and perceived barriers encountered when managing the third stage of labor. This study aims to describe current adherence to AMTSL guidelines, and will generate hypothesis regarding barriers to routine use of AMTSL. Knowledge of current practices and information regarding the experiences of SBAs will be useful in the development of future programs to promote AMTSL and other safe motherhood interventions. This study will add to the growing body of literature on the pragmatic implementation of routine use of AMTSL.

my new haven

2008-05-17T10:36:00.005-04:00

A pile of discarded childrens clothes on the bridge. They've been there for weeks. There is a story behind that pile that has not yet been told. Did something happen to the person carrying theme home from the laundry matt? Did they never make it? Did they get to lazy to make it to the salvation army? How did they get there?

No dumping at the dump. Figures.

Green water beneath the boardwalk. Today they we re selling lobsters from the water below. $7.99 for any lobster. Any size. Delicious.

The walking path of the bridge.

I have been meaning to photograph some of the sights I see each day on my bike to school from my house in Fair Haven. Now that finals are done, I finally brought my camera as I walked to school.

The juxtaposition of wealth and poverty in New Haven is it's most interesting feature - in my humble opinion. It's also what makes living here hard. There is no way to forget the stark fact that in this world - there are 'haves' and 'have-nots'. The recent earth quake and cyclone remind us that we 'haves' can soon have not as well. Those labels are not with us for a life time - and can shift and change with the economy, our emotions, and what life serves up on a plate.

New Haven serves up some interesting city scapes at least - here is a fraction of what I pass each morning near the bridge into New Haven.

On my ride this morning I wanted to bottle up the pungent smells that accompany the photos above - rotting fish, a dusty texture from recent construction, and a sweet toxic odor from the scrap metal yard.

Strawberry Cervix

2008-05-07T10:25:00.006-04:00

Trich - see the ovid shaped protozoa in the center of the slide? That's the bugger trich.... what we see under the microscope.

I saw one last Friday at clinical. It was so obviously infected, and it's owner, a teenage girl, had been suffering with it for weeks. It was one of my first experiences in this new skill set that I'm developing where I just KNEW something major was up with her. I followed my instinct, and the advice and assurance of my preceptor, and treated her for a whole gamut of STIs even without the return of test results.

Results came back yesterday. Trich and chlamydia indeed. She took her medication, and is feeling much better... it's nice to know that sometimes, I have a small semblance of confidence and actually know what I'm looking at.

Then, to remind me that I'm really still quite clueless, my professor asked me yesterday during a skill-set check off: "Is English your second language?" My mushy brain forgot the word laryngiscope and instead said "The tube that we intubate with." Yikes - at least I could have said "With which we intubate!" I passed, thank goodness.

I am ready for finals to be finally done and move on to the next big adventure in Zambia, where things more exciting than a strawberry cervix will certainly occur.

uterine rejection

2008-04-19T09:27:00.002-04:00

Midwifery is not always a happy field. Perhaps what we dread most is birthing an unexpected still born baby. Or a late term fetal demise - one in which labor needs to be induced to birth the now-still child.

Yesterday, while not so dramatic, reminded me of the sad components of both life - and reproduction.

Our first patient was a 30 year old woman, there for her first prenatal visit. She was 13 weeks and 1 day pregnant - and was coming to us for her labs, her physical work up, and a long discussion about the signs and symptoms of pregnancy. Before I geared up for my shpiel, I asked her the standard questions. "Do you have any vaginal bleeding, any loss or leak of fluid? Can you feel the baby move?" Now, 13 weeks is too early for fetal movement, but not, in her case, too early for bleeding.

When I did her exam, I felt she was 1 cm dilated, and I saw blood in the hole (os) of her cervix. I knew in my heart that she was having a misscarrage. She had been trying to get pregnant for 5 years (since the birth of her now 6 year old boy). She was a recent immigrant from Mexico - and had no insurance what-so-ever. She had already had one miscarriage at 12 weeks (3 months) and now, I was going to have to tell her she was having another. Her husband was in the room, excited to hear the heart beat for the first time. But, of course, we found none.

She cried and cried when we told her. She kept asking "why?" Was it something she did? or ate? or a problem with her? We had no answers. Expensive genetic tests and infirtility work ups are the only possible way to find these answers. But for an undocumented worker with no insurance and minimum wage - well, the explination that "we don't know." Will have to suffice.

Our next patient was HIV positive. She was staying in a half way house, and admitted to me early on that she was coming for an annual exam just cause a doctors appointment was the only way to get out of the house. She told me - when offered condoms - that she didn't want to have sex ever again. "I have the virus, and I have my toy. No condoms, thank's any way."

Our next patient was a 16 year old girl - who had a baby about 2 months ago. Two weeks ago, I had put in an IUD. THis week? It was falling out. Her uterus expelled it. This girl made me sad - her BMI was 38 (ie: She weighed 274 lbs on a 5'5 frame), her teeth were chipped and grey, and in the 3 times that I'd seen her since the birth of the baby, never once had I met the little tyke.

The day continued, in a more normal patter of pre-natal checks and acute complaints. But the start of the day sobered me up a bit. Sometimes the uterus rejects. And our system is not ready, willing, or able, to be there.

Bienbenido bebe

2008-02-27T21:33:00.004-05:00

The hazy blue of this poor quality cell phone photo represents the day. This message was scribbled on the white board by the 21 year old husband of the 17 year old girl who was in labor when they first came in. She, then, was dressed, walking slowly, but barley breathing heavily.

Over the course of the next 4 hrs, she transformed from a young Mexican, looking girlish in jeans and a sweater, with gorgeous long black shiny hair in a braid swinging behind her, to a powerful woman - pushing out a baby with a grunt and a moan with no pitocin, no pain meds, clutching the arms of her husband on one side and her cousin on the other, and me at her perineum, grinning behind my plastic mask. In the interim, she learned to be intimate with strangers, to try rolling on the birthing ball, and to listen to and trust her body.

The baby, Shanelle (pronounced like the perfume), came out spinning, with her fist raised up and held high, yelling her way into this big beautiful world. I did nothing more graceful than just hold on and slip the slippery wet cord around her slippery wet head and - oops - that hand. We laid her on her mama's belly and reveled in her wales.

Who knows what her life will grow into, if she will have her first baby at 15 like her strong mama, or if she will be the first in her family to speak English, go to college, and keep her fist raised high in the fight for immigrant rights, for human rights, and for being fully human.

Life is precious indeed.

babe in toy land!

2008-02-15T20:05:00.003-05:00

I caught my first kid today..... she was slip sliding right out of her 21 year old mom. It was stressful - I did not cry, but instead sweat up the inside of my gown and fogged up my shield mask so I could barely see. It's the little things.

She came in at 7am for an induction (induction: beginning labor with medication, not time...). The bag of pitocin was hung at 8am. By 10:58 she had a broken bag of water, and by 11:19am a screaming baby and a sweating nurse midwifery student staring at her perineum with wide eyes.

We sewed her back up a bit, the other student did breastfeeding counseling while I filled out paper after paper after paper. It was a great event. At 5pm the midwife and I went upstairs to visit her. She was sitting in bed, surrounded by family and friends, breastfeeding like a champ.

It warms a fledgling midwife's heart. I feel inducted into this tribe. I have caught my first baby. It was not magical, but very very real. Very stretchy. Very stressful. Very wet and messy and beautiful.

No babes in toy land

2008-02-13T09:24:00.001-05:00

Although I awoke each hour almost on the hour last night to check my phone for a dreaded missed call, there was none. No call. No labors. No births. No snowy adventures. Perhaps next time.

Ring ring

2008-02-12T20:20:00.000-05:00

I have my first overnight call shift right now. And it's snowing. And my car was stolen this week. So I'm experiencing a moment of self pity.

This is our third week of clinical - and thus far, I haven't used my fingers as measuring tapes once. Nor have I seen a little head crowning. Nor have I helped guide a screaming, milky newborn into this snowy world.

So, as I sit at my desk to study, with fingers un-decidedly crossed, I await my first birth. I am trepidatous about the snow, my car-less situation, and how this whole thing will unfold. The thing about normal, natural birth is that it doesn't go by my clock. Silly birth.

I'll keep you all posted.

Before it was Varanasi

2008-02-04T21:22:00.001-05:00

It was Banares. This photo was taken circa 1982. Can you spot me?

My mom found this photo recently and shared it. She suggested we put it to music.... "One of these things is not like the other, one of these things is not quite the same."

Cheers to adventures, bicycles, and chupples.

not just hands

2008-01-24T22:19:00.000-05:00

A midwife's hands do so much more than hold and support. Indeed, it is not cheesy when people talk about their power. Much of what they do is to feel the invisible - and 'see' what is under the skin, just out of reach, and up and back behind what we can image. A good (and practiced) midwife can tell the estimated weight of a fetus in utero, it's position, if it's head is flexed or extended, if it is facing a bit to the left or right inside the mother's uterus, if the head is down or up or (lord forbid) sideways.

Hands become measuring tools as well - how much is she dilated? how big is her pelvis? how far down has the baby dropped? there is no scientific measurement - just very educated guesses - placing one or two fingers in the cervix and thinking - if two tips of my fingers are 3cm - she must be just under three cm dilated. Yes, sobering how un-exact it is - but excited how precise it can become. We have all measured every length and width of our hands, fingers, and fingertips. I have really never paid so much attention to any part of my body. The length from my pointer finger to the base of the thumb is 13cm.

To practice estimating dilation - we have been instructed to measure every round thing with our fingers - then check the diameter with a tape to get a sense of truth. For example, the middle and pointer fingers of my left hand stretched to their maximum is about 10cm from edge to edge. And so, voila - if I can fully stretch them - she's ready to have that baby.

So, there goes distancing my self from just about anything - a water glass, a water bottle (mine is about 3cm in diameter at the opening, a door knob, a shampoo bottle.

It's all a cervix. And my hands are my tape measure.

Hmmm.... I think I deserve a manicure.

boot camp

2008-01-23T21:29:00.000-05:00

I fondly call the last two weeks "midwifery boot camp." Each day from 9-5 (or beyond), our class of 16 has sat through lectures, demonstrations, skits, pretend-you're friend-is-birthing-a-plastic-baby-in-the-squat-position sessions, chicken-thigh suturing lesions, and other creative means to determinate the how-tos of being a midwife. Today we ended with a two hour tour of the labor and birth unit where we will be taking call starting next Tuesday.

Honestly, how fun, and what a whirl wind. Two weeks ago I really didn't know much about being a midwife, and wasn't really sure that this whole labor and birth thing is what I really wanted to do - and now I am undeniably excited about the years to come - and could probably even bumble and fumble my way through explanations about latent, active, second and third stage labor, and a myriad of genetic tests that we offer during prenatal care, and why.

There is certainly a HUGE amount still to cover, and lots of practice to obtain, but what a way to start the new year.

Perhaps one day I'll sneak my camera into the lab while my friend Amber is butt up in the air, grasping a plastic head while the rest of the class coaches her and rubs her back, and one of us take the seat as the catcher...and she huffs and puffs and pushes out that plastic head and soft little body right through her legs to the applause of 15 other midwifery students.

the goings and comings

2008-01-13T22:31:00.000-05:00

While in Kentucky, visiting Jo, I quit my job. What a relieving, freeing, scary, odd, sentimental feeling. I did it in the respectful way, with lots of notice and an explaination.

I worked my last shift on Saturday - complete with a 28 year old drug addicted man who fell while jumping down some stairs and broke his ankle in 2 places - and nothing could 'touch' his pain - a 25 year old law student who was scared and brave, admitted with a small bowel obstruction, young, blond, shivering in the bed, wishing she was anywhere but here - a 51 year old guy who looked 72 with no teeth, grey hair and recovering from a hip replacement with a crit that, even with 3 units of blood - wouldn't creep above 28 - and a handful of others, in and out, in pain and out of it- admitted and discharged.

It was such a strange feeling to walk out at 7:30, running to meet caleb for a delicious dinner and movie. Everything seemed so normal - but also so disorienting, knowing that I would never work there again. I finished a chapter after I had started the next book, reminding me of the multiple stories that weave throughout a life, and how new doors open and close continuously, and nothing is ever done really, but just is added into the ever expanding record - our own sort of chart.

So too do I go and come. I just drove back from Cambridge to New Haven after a wonderful three weeks away. A new chapter is starting tomorrow. Second semester. Monday starts at 9 and goes 'till 7:30. A brutal amount of sitting and listening, in my opinion. And while last semester was in a midwifery program, tomorrow is the start of learning to be a midwife. We will be focusing on IP (intrapartum - labor and delivery) and AP (antepartum - pre-natal care) throught out the next 4 months. Clinical will start in a few weeks, and I will finally catch babies, assist with breastfeeding, hold hands, wipe sweat, and memorize, memorize, memorize. This is a chapter, that while seemingly is beginning tomorrow, actually began years ago - perhaps even 28.

A funny moment from today, below. A flat. As if I needed another excuse not to leave Cambridge.

Not in order of importance

2008-01-07T12:35:00.001-05:00

Ok - an update since my last post (no promises regarding order and significance)

1. I am currently eating ice cream for lunch in Charlotte Airport on my way to Lexington to visit a dear friend

2. 3 out of 16 women in my midwifery class got engaged over break. odd. amazing

3. Obama won the Iowa caucus and is well on his way in New Hampshire tomorrow - a fact that is hard not to get excited about... regardless of how undecided I was before

4. I had a very relaxing and computer free vacation - a lovely Christmas at home with Caleb and my family complete with a plastic talking Jesus - a quick trip to Virginia to see my whole entire quasi-Mennonite crew and some historical houses and (out) houses - a visit to Frank Loyd Wright's Falling Water - and a snow filled fabulous few days for new years in New Hampshire.

5. I haven't worked a day at the hospital while on vacation - but did send a huge check to my union, as I'm still technically a member of my bargaining unit. Argh. Union dues. Good in theory. Making me broke in practice at the moment. I think I may have forgotten how to be a nurse.

6. Luckily for me, I'm working on other things - and am knee deep in information on maternal mortality and post partum hemorrhage for a research proposal I'm writing for the summer (fingers crossed).

7. My ice cream (it had fresh blueberries and raspberries - the best thing I could find in this airport - snobby me) is all gone now.

here are some pics to share from my vacation.

Don's John, Virginia, 2007

Frisbee on the frozen lake, New Hampshire, 2007

UNO! New Hampshire, 2007

Bob's famous Christmas Stolen, Hastings, 2007

My cousin Hillman and his mock apple, VA, 2007

And finally, finals

2007-12-18T07:42:00.000-05:00

In a strange way, I'm glad finals are upon us. I feel as if I have been studying for weeks - ok, semesters. It's good just to push it and knock down these tests. Ok, the one yesterday was gently pushed over, or perhaps it pushed me. However, 1 down, 1 today - and then 2 more.

Thursday evening will be sweet, sweet joy.

More soon, when it is all wrapped up.

me, a quarter, and a spinning brain

2007-12-11T20:54:00.000-05:00

Today was my last day of Gyn clinical and I am making a big pot of soup, preparing to hibernate until December 20th when exams are over.

The semester simultaneously feels like it is winding down - and gearing up. We have 4 exams next week - one each day - and the preparation feels both overwheming and underwheming. Underwhelming in the sense that I am not excited about it - and overwhelming in the typical, I'm about to take four big tests, kind of way. My brain is spinning, and not so articulate, but I will try to eek out a bit before hitting the books.

I put in my first IUD today. To those of you not in midwifery school(which means everyone who reads this as I have not gone public yet) and are not doctors (who put central lines in on the regular, and other fun things) putting in an IUD is a pretty big deal. Perhaps it won't be on the 4th or 5th - but the first time is a make-the-palms-sweaty kind of moment. It entails tenaculums (think: big huge pinchers. ouch), betadine, some pulling, some ouchieness, some measuring of the uterus, and some chutzpa. (wow, that didn't get a red underline, I can't believe I spelled chutzpa correctly on the first try). My victim, er-um, patient, was an adorable 19 year old girl who just delivered her first baby 6 weeks ago. She prepped correctly with a bunch of ibuprofen, and seemed to do well. If she had been yelling, I would have been yelling, and then it might not have been so smooth...

That was my first patient of the day - and the rest, as if a gift, were all happy cases as well. No "I slept with 6 men and have some nasty critters and huge heap of medical problems" kind of patients. I saw a grinning 18 year old with a doting boyfriend at one of their last prenatal exams, I saw a 62 year old woman with no real complaints except constipation (yeah! I know what to say about that), and some other benign cases that all blend into one...

So the first semester, 1/4, of my clinical experience is now finished. I do not feel like 1/4 midwife yet - or, well, perhaps I do.

Yes, 1/4 done is exactly where I am - and when exams are over, being 1/3 done with coursework will feel just fantastic.

eating is healing

2007-12-04T09:00:00.001-05:00

Sometimes healing involves eating, hiking, cooking, and more eating... which is just what we did for 4 days in New Paltz over thanksgiving. I have been let in on a fun and long lasting tradition of Caleb's family and have been taking full advantage.... (the whole 2007 crew above)

The making of Lumpias (it doesn't decrease the deliciousness to see this pot of oil)

Turkey Trotters pre race.

Liz by her electric stove - The joy of kitchen duty

balance

2007-12-01T13:39:00.000-05:00

There is a sad difference, while training to be a nurse-midwife, or any health care provider, I suppose, between what is practiced and what is preached - or taught - in the classroom.

In our primary care class, we are taught to always look at the whole person - a theory to which I subscribe fully - if a woman comes in for a specific complaint: an itch, an earache, a pregnancy test, some pain - we should deal with the complaint... and then pay attention to her picture as a whole. Is she obese? Is she depressed? or does she have a history of mental illness? which co-morbidities does she have? can we manage them today as well? How are her relationships? Is she at risk for abuse? We have learned tricks and tools and resources for dealing with all of those things - wonderful, great, I'm ready to go...

But then, in my clinical site, I have barely enough time to diagnose and manage the one complaint- let alone target anything else about her history. When I launched into weight management discussions with a 342lb woman who came in to use for an STD check because the was 'trying' three men currently... I was told to hurry - we had 3 folks waiting. But how can I feel comfortable sending her out with an antibiotic prescription (indeed, she did have some critters) and not addressing this 28 year old woman's diabetes, high blood pressure, and obesity. The STD check, while important, seemed almost to be the least of her problems. My preceptor, when I pushed it, told her to make another appointment with the medical clinic and another one to go get labs drawn. With a full time job, and 2 kids with no father figure, I don't hedge my bets that she will keep them. She was in our clinic, here, now, with an acute complaint, and I just wanted to start her process...

I gave her my 30 second schtick, a pack of condoms and a rx for flagyl 2g POx 1 - and sent her on her way. Lamenting the gross difference between practice and ideal, and the way in which to pressures of low income health care surely does necessitate less than optimal care.

X rated

2007-11-18T21:57:00.000-05:00

It's going to be hard to write this year without using culturally racy words... and I say culturally, because in the didactic portion of nurse-midwifery school (and the clinical) they are our every day language. We put the Vagina monologues to shame on the regular.

So, with that preface, I will recount a touching and and amusing story that happened on Thursday at my clinical site (a public Gyn clinic in a hard-knock city in Connecticut where the average age of first pregnancy can't be much over 17....)

A twenty year old hispanic girl came in to get an IUD placed. She brought her adorable 6 week old baby girl clad in pink and swimming in the biggest ensemble of carriage, blankets, stuffed animals, diaper bags that I had seen that day. She also brought her partner, who sheepishly wiped the long dark hair out of his eyes as we asked him to take a seat next to the exam table where his nervous girlfriend lay. He spoke very little English, and his girlfriend, by now wearing a hospital gown and draped in a sheet, translated each word we said.

As my preceptor gave the instructions, they both nodded in agreement "Take 2 ibuprophen when you get home, feel the strings to see if they have moved, you may have some cramping and spotting for a month... and nothing in the vagina for 2 weeks." The long haired partner sat up a little straighter - obviously understanding.

"And that includes penis." The midwife mater-of-factly said.

Her partner smiled an embarrassed smile, laughed, and looked between us and his girlfriend - his eyes saying "Are you suggesting we have sex? How could you think such a thing?" She giggled, he giggled, and the procedure began.

While grimacing during the IUD placement, her partner started laughing again. "No penis!" He blurted out. She couldn't help herself in her nerves and pain and laughed too.

As I drove away from the clinic at the end of the day, I saw the two of them walking, pushing their baby entourage, and holding hands.

It is nice to feel good about the dynamic of the young couples once in a while. And I was sure they would follow the instructions and advice they had gotten that day.

Was there life before pap-smears?

2007-11-15T10:51:00.001-05:00

Ok, ok. A blog is no good if you don't write on it.... no one will read it, check it, and friends will give up on you and your determination to share the joys and pains of life on a regular basis.

I appologize, life moved out from under me and updating this blog fell through the missing spaces of free time.

I am back in school - studying to be a nurse-midwife - and it is, cliched as it may be - all that I dreamed it would be. And this dream has certainly been a long time coming... I have been talking about this since 2003 - so with two years of pre-reqs, a year of nursing school, a year of nursing, and more debt than I care to admit, I am here.

In the past 3 months I have become adept at pap-smears, staring at body fluids under the microscope, talking to young girls about the evils of douching and the joys of birth control, and more than anything, sitting at my desk reading, reading, memorizing... It is certainly not everyone's cup of tea. But it is mine - and with a little sleep under my belt and a newly vacuumed floor - I feel positive about the direction this is heading.

In the mean time, here are some pictures of Caleb and my vacation to Italy and Croatia this summer - which seems like longer ago than 4 months. Was there life before pap-smears?

Yes....

Montreal

2007-04-24T22:24:00.000-04:00

Caleb and I had a fantastic road-tripping vacation this past week from New Haven, to Burlington, and onto Montreal. It was so easy to leave the working world behind and join the land of the living and relaxing and not going to work all the time. Here are some pictures.

Emeleia - Zoe's baby. Loving her spoon while the rest of us enjoy Pepe's Pizza and some beers.

Helen and Nick. Two great New Havenites.

Sahir and Justin - narcissistic and wonderful as ever.

Caleb - yes, the sad truth of road trips. But look how beautifully blue the sky became.

Grafitti. Montreal integrates it so well into the urban landscape. It was everywhere. We decided to celebrate....

And kiss.....

And eat....

And frolic...

How fun.

And the winner is... (better late than never)

2007-03-25T13:42:00.000-04:00

CCSC. They won the whole darn thing. Here are some pics. Check out CCSC Hoops for more.

http://www.ccschoops.blogspot.com/

Day off

2007-03-18T10:48:00.000-04:00

It is Sunday morning. I am supposed to be slogging it out at the hospital, but no. I have requested time off today. The CCSC varsity team, who has no one over grade 10 and is only 2 years old, is playing the championship game today at UMASS Boston. Ranked 7th out of 8, they won against the 2nd and 4th seated teams in two incredible games and now face HCa (Health Careers) for the championship .They will be up against more years, more muscle mass, more inches, but I think they have a shot.

The kids are thrilled to have made it. I can't wait to experience the energy, the excitement, and the crowd. I will be taking lots of pictures, trying to capture the win.

Stay tuned.

Ode to taking a crap

2007-03-07T18:38:00.000-05:00

Let's call him Brian. He is 66 years old - and was born with cerebral palsy. He has been admitted to our hospital twice in the past two weeks - both times for abdominal pain. He is no more than 4'11 when stretched out, but probably about three feet in length as he lays in the bed, his legs contracted and bent perminently towards his head and his hands unable to strighten, perminently bent at the first knuckles. He is unable to bend and maneuver his thumb, which renders him unable to push our non-handicap-friendly call bell to let the nurse know he wants to chat. He has charcole gray hair and a beard.

Chatting. Brian loves to chat - but cerebral palsey has rendered him unable to do that easily as well. His tounge, which seems too large for his mouth and without muscle control to create words, does not serve him well. He has no teeth ("they pulled them - rotten.") He explained to me one day, as I guessed over and over at what he was trying to say. Regardless of the gravity of his words ("I have pain." and "Why me?") he always shows a huge smile when someone finally guesses his words.

Brian is smart - as he explained to me the first day I worked with him - "My brain" (he said over and over, pointing to his head) "Is just like yours. But I can not talk." "That must be so frustrating," was all I could say. After the 15 trial and error attempts - I am surprised by the cleverness of his words. He stops at nothing to tell a good joke. Even a knock knock joke (which was a tough one, being all about timing...) When explaining to him why I was giving him another brown plastic cup of lactulose (a nasty, orange flavored laxitive), I said "Bottom line - you need to poop before we can let you go home. We think your pain may just be constipation" He responded in his mumbled way, which sounded like "I aaaa caaaa". I made guess after guess. Finally he rubbed his thumb against his fore fingers. "I'll pay cash?" I guessed. His eyes crinkled up at the corners and he gave me a huge toothless grin.

Smart alack.

When I came in on Tuesday, a week after he had been admitted, no progress had been made. His pain was still there. He had not pooped. And the doctors seemed to have all but forgotten. He was discouraged, as was I. "I'm fed up." He kept saying. At one point in the afternoon, after giving him another does of morphine and paging his doctors (conflictingly, because morphine constipates), he told me that he wanted to die. I heard him clearly the first time he spoke - but did not want to repeat it to ensure I had heard correctly. "Brian - what can I do to make you feel better. I know we are going round and round and you feel discouraged. "I want to see a shrink," he said. His eyes looked sad. They did not crinkle when I guessed correctly. He just nodded. I went out to the nurses station and paged our social worker. No, she had not met him, yes, it sounded like he should talk to someone, maybe we should get a psych consult. "Psych consult?" I said. That takes at least a day. We need a referral. I want you to come in and talk to him." She didn't know if she had time. "He says he wants to die. He needs to see someone. Please come talk to him, at least explain the services we offer." She came up - and saw the patient. It was the least I could do. I then paged the medical resident. "he is not doing well. Please come up and see him. He is frustrated. He is sick. Things need to move forward. She promised to come up as well.

Being a nurse is gratifying for me in the same way that it is frustrating. If I advocate for my patients, the people with whom I spend 12 hours straight, things can happen. Decisions can be made and be pushed forward. I can speak for my patient who's tongue will not cooperate and run to the phone for my patient who can not walk. I can help him tell his story. But once I ask, I have very little further recourse. If the medical team takes their time, there is not much I can do but explain what is happening to the patient. I had to leave at 8 that night. The medical team had not come. I hope he is not still laying in the same bed, getting morphine. And hopefully he has taken a crap.

When percocet doesn't help the pain

2007-02-15T12:55:00.000-05:00

This week at the hospital has left me feeling useless, with two cases in particular.

Let’s call her Jane. She is a 19 year old woman, barely old enough to be on our floor by years. She came into the hospital late one night for sever pain in her abdomen. After a CT scan showed a twisted ovary (known to be very painful) she was wheeled to the OR have a laparoscopic surgery to UN twist it. However, when the doctors had her sleeping and cut open, there was no twisted ovary to be found. Perhaps not knowing what else to do, and perhaps going by an elevated white blood cell count, they decided it was pelvic inflammatory disease, sewed her up, and sent her up to us. One doctor’s note in the chart said that lesions had been seen on her liver. “? Cancer.”

When I arrived on Monday morning, the nurse giving me report said that she was “a baby”. Used to judgmental nursing reports (but still frustrated by them), I took note, waltzed into her room convinced that all she needed to come out of her shell and stop wincing in pain was a little extra attention and TLC. I arrived in the room, smile and stethoscope in hand, and found a gorgeous tall light skinned black woman lying in the bed. She was thin and muscular from the silhouette of her curled up body under the sheet, and clutching the ratty tails of a once-upon-a-time blanket. Her eyes gazed off into space and she did not make eye contact once as we spoke. Her father, who had spent the night, was chatty and engaged and did not seem concerned by his daughter’s strange affect. She answered my cheery questions with grunts and once or two word phrases. She said she “didn’t feel well” but wouldn’t describe the pain. She would just say “it hurts” and “I don’t know.” When I asked if I could place my stethoscope on her belly to listen for bowel sounds (a standard part of a nurses daily assessment) she winced and covered her belly like I had just asked if I could take a sharp knife and jab it into her abdomen. After some coaxing and assurances that it wouldn’t hurt, I gently listened and heard enough gurgles to satisfy me.

The day continued …. I medicated her with anything I could think of: smiles, foot rubs, narcotic for incisional pain, Torodol (liquid ibuprophen) which her mother stated had worked before, anti-gas medication (I thought the sharp pains could be from gas, a very painful ailment post-abdominal surgery), and benadryl for her itchy skin. Her mother and I encouraged her on numerous occasions to get out of bed, but each attempt left her in tears. Her legs were shaky. Her eyes were distant. Her words were few. She left me feeling at a loss for ways to help make her mood and body feel more joy and less pain. By the end of the day, this strong-bodied19 year old woman who told me that she was in nursing school seemed in more pain, and in a more infantile mental state than when I arrived. She whimpered for her “mommy” when her mother left to get a coffee and take a break, and stayed in the bed with a pillow over her head. Somewhere inside my fledgling nurse soul a balloon popped and I felt deflated.

The next morning I arrived again with a smile. Determined that today would be the day to turn her sadness and mood around and help her find her own smile. Instead I returned to more certain news that lesions were lymphoma (“I just don’t know what else it could be. The Picture is textbook,” the resident explained to me. “Does she know?” I asked. “She knows he scan was not normal, but we do not yet have a definitive diagnosis to give her, so we’re holding off.” Gynecologists aren’t really well equipt to talk about lymphoma, I suppose.) Her mother had spent the night this time, and while her body was cared for, he mental space seemed to be even lower. All I could get as responses to my questions today were grunts. She had no more words to share. I left at the end of the day trying to feel satisfied that today she had taken a walk and spoken with the social worker. My heart aches for her and I still feel frustrated by my lack of ability to truly help her begin to heal. I explained it best to her: “my job is to make you feel better. If I don’t know what you’re feeling, I can’t do my job.” At the end of my shift, I shared the elevator with her father down to the 1^st floor. “I just don’t know what to do to help her.” I admitted. “There is nothing you can do. She is just scared, that’s all.” He is right.

It's not what you hear on NPR

2007-01-23T08:10:00.000-05:00

While there are days that pass that leave me feeling strung out and overwhelmed, the past few weeks have not. Our 'census' as they say, has been low- meaning that our floor is not full. We have a maximum capacity to care for 18 patients - but last night we had only six.

From a nursing perspective - this translates into two things: 1. an easy night, in which we are able to truly care for our patients and not just make sure drugs arrive on time or 2. a phone call, an hour or so before we wake to go into work to ask if we want to stay home- take 'benefit time'.

This is a piece of working that I have never experienced before, and is rubbing me the wrong way. While I don't want to use up all of my vacation time on unexpected days off, I feel useless going in when there are 3 nurses for 6 patients. It leaves me feeling not-needed, which is a slimy feeling.

I worked this Saturday - which followed the week's trend. I started the day caring for 4 patients (my maximum is five on a day and six on a night) but sent one cute old man, all wrapped in blankets, to a rehabilitation floor, and sent one young Arabic man on his way, home with a prescription for percocet and a sheet of instructions. By 3pm I was left with only two patients. One man, hospitalized for the um-teenth time for a chronic infection of his sweat glands (yes, sweat glans appear in the most inconvenient places) seemed to catch on to how the day was going as I once again appeared in his room to check in: "Are you having a slow day? Because no one has ever seen me so much in one day?" I sayed calm. "No, this is just the way I practice nursing. I'm attentive." Ok, so part truth, part lie.

Meanwhile, WBUR, our local NPR station has run a 3 part series on "The Nursing Shortage: Inside out" - In it, they describe the multifaceted problems facing the nursing profession, not the least of which is overwhelmed nurses with 8 patients, feeling that there practice is unsafe. They shared the statistic that a patient who is cared for by a nurse that has 8 patients is 30% more likely to die than a patient who is cared for by a nurse with 4. It is a piece worth listening to:

http://www.insideout.org/documentaries/nursingshortage/index.asp

I suppose rather that get upset that the floor is slow at the moment, I should be grateful that I can give my patients what they deserve throughout the day - I am able to not be a drug pusher and wound binder, but a real nurse. The Florence Nightengale way.

One man, many stories

2007-01-16T22:08:00.000-05:00

The hospital has been quiet this week – a breath from the past month’s madness. Perhaps the surgeons went on vacation and left us with fewer people whom they cut and diced who need a bit of tender care to heal a nice scar. Perhaps the warm weather has made for less falls on the ice, less hip fractures, less battered bodies. For all of this, I am thankful.

Each day brings with it a handful of unique stories amidst hours and hours of routine. Over dinner, often with wine, sometimes with a gourmet spread, but today with pizza, I relay these stories to Caleb who often comments simply “So, blog it.” Each shift contains a funny or heart breaking character, the witness of a beautiful familial moment, too much physical and emotional pain, a lot of morphine, and most likely a frustrating moment with a fellow nurse.

Today contained all of these factors. I will write only about one, but have vowed to do a better job consistently reflecting in writing:

Yesterday I sent home a 30 something year old Brazilian man. A construction worker by trade, he had just undergone a total hip replacement due to pain and arthritis. I had worked with him each shift since his operation over a week ago, and we had developed a nice rapport. Desirous of being macho, but succumbing to the unexpected and constant pain that comes with a joint replacement surgery, I had medicated him, helped him out of bed for the first time, and encouraged him to walk as much as possible. Each time I asked him if he had pain, he would respond – “This is Craaz.” Indeed, there are many things about being in the hospital that are crazy. Yesterday, on Martin Luther King Day, with his family by his side carrying his belongings, he crutched his way out the door towards home.

Today he phoned the hospital asking for me. He said that even with instructions to mention his recent surgery, he was unable to get a physical therapy appointment any sooner than next week. I called the rehab space and conferenced him in by three way call, insisting that he have a sooner appointment. Magically, one appeared and he was certainly thankful. After the third party hung up he said to me: “thank you. You have only done the best for me. Let me tell you though, if you do not speak English in this Country you can’t get anywhere.” While I know technically that’s not true, it was a potent reminder of prejudice that manifests its self in hidden ways today. The day after MLK day, he brought into light one of the many ways this country still has mountains to cross before true tolerance, as dreamed by Dr. King, abounds.

Time Passed

2007-01-16T21:02:00.000-05:00

It has been a while since I have written. Christmas has come and gone. The dawn of 2007 has passed. And amidst day and night shifts, a wonderful Christmas day spent home with my family, and time spent dog sitting with Caleb, I finally sit down to write.

Here are some photos from some highlights of the blog-less month:The new Frank Gehry building on the lower West Side, Caleb with Tuck, our furry friend for the month around the Fresh Pond Resevoir, and Avi with Sophie, this year's chosen lady friend.

Highschool Basketball

2006-12-11T11:12:00.000-05:00

Caleb coached his first game of the season last Friday. It was a blast. The CCSC Cougars lost in the last 20 seconds even though they outplayed the MATCH school from the beginning. It was a joy to watch Caleb coach, the players run, and the fans scream and dance.

A highlight for me was the little sister, named Pootie, of one of the star players. She sat behind me with her parents and screamed in her high pitched 2 year old voice "Geo! Put da basket baaalll in da hooooo...."

I felt like a proud mom.

For a glimpse into the game from the coaches perspective, check out his blog entry: http://ccschoops.blogspot.com/2006/12/opening-loss-that-wasnt.html

This is my home.

2006-12-07T15:29:00.000-05:00

This week has been tough.

Monday was my first day flying solo as a nurse. The past three days have kept my feet running, my brain spinning, and my adrenaline pumping. The busier the floor (and I) get during the day - the more changing of orders for medications, procedures, tests, monitoring, and diets there are - the less I think about the individual experiences and beauty of each of my patients. I hate that. It is so easy to get caught up in the details and the correct protocol (indeed, one could argue that I'm not getting caught up at all, but only paying attention to what's important) that I forget to look at the person behind the layer of blankets, tubes, and hospital gowns.

One patient, a 71 year old Gambian gentleman, reminded me of why I do this job yesterday, and why I can't get lost in the protocol. Known to a few nurses on the floor as "my boyfriend" (indeed, we all call him our own boyfriends, and one nurse threatened to "meet me outside in the parking lot after work to see who gets him"). He is adorable - and has the face of both a wise man and a playful child, wrinkled, proud, thoughtful and genuine. I swear his eyes are blue- although he insisted, that since he comes from the Africa, that this is impossible.

He has been admitted to our floor twice since my start date. The first time, he had his right leg amputated above the knee from a loss of circulation and degenerative vascular disease. He is practically bed-bound, able to hop with his walker when he isn't connected to the myriad drains and tubes and IV antibiotics. He has been in that bed, in room 12a, with the bedside table to his right and the armchair to his left,and his two automatic drain machines positioned on the floor so that he can see the glowing displays for almost two weeks.

Yesterday his TV broke - causing some confusion and anxiety on his part. We gave him the choice to move to the other side of the room (12b) where the TV worked and the view was similar. He was confused and angry and after some thought decided that he didn't want to go... but called for me because he had some questions.

I walked into the room and found him looking worried. I kneeled down by the bed so that we were eye level. "I heard you had some questions for me, what are they? I can give you some answers." With his lilting, magical West-African accent, and his arms opening to display the space around him- he said to me -- trying to explain his dilemma -- "This is my home. Where am I going?"

"You're just moving right over there if you'd like," I said, pointing to the empty side of the room. "It has the same lovely view, and a working TV. I think you'll like it just as much." He pointed to all the equipment around him. "Will this come with me?" "Of course it will, I said." "Alright," he agreed. "If you'll help."

Together the nurses aid and I unlocked and spun his bed to the other side. We lifted and pulled his equipment the 15 feet to the opposite side of the room. I made sure to position his machines so that he could clearly see the on-off buttons. He grinned and laid back in the bed, relaxed. "Thank you." He said. "You are a very good driver."

There are some details that I love to get lost in.

With a bang

2006-11-27T21:10:00.000-05:00

This birthday taught me about the power of community and friendship and staying put and working hard and making roots and making wishes.

Thanks to all of my friends and my family who give me confidence and love and wisdom and put up with my moods, and any drama, and make me one of the luckiest eeking-towards thirty-year olds I know.

convenience

2006-11-17T22:18:00.000-05:00

A pet-peeve:

The way hospitals, slowly but surely, train those who work in them to think less about the people it was built to serve, and more about their own convenience for the evening. We all enter with the intent of helping people. But slowly, men and women, boys and girls, are all turned to patients. As street clothes are removed and gowns are dawned, the people that we want to help transform into people that we work for - and who we expect to work for us.

Last night I was told to ask two separate supportive families (wives, daughters, sons, friends) to leave two sad, hurt, scared patients when it was HS (the hour of sleep). One man wanted desperately to have his wife stay... "but who will help me go to the bathroom?" he asked, worring, when it was suggested that she leave. We have no explicate rules on our floor regarding guests, or visiting hours. However, it was argued that the women were not allowed to be in a room whose beds were filled with men, and that the rooms were too small for the nurses to reach the equipment if there were other family members sleeping in the room. Since I was the nurse who would need to navigate to the IV poles and monitors, and was more than willing to do so, I thought I should make the decision regarding my patients. "No," came the answers from above. "They need to leave." No reason. Just fear of being bothered. Desire to keep the floor quiet and controlled. In exchange, more worrying, perhaps more pain, and less comfort for our patients.

It is this attitude that bothers me.

1:11am and counting

2006-11-16T01:11:00.000-05:00

I am working my first night at el hospital. 6 hours down. 6 to go.

It is super quite on the floor tonight - although every bed is packed with people.

Today's floor is a diverse group - a 26 year old psychotic female who has been gently swaying for the past hour, holding a cup of water, stating that "it gives me balance" when I dare try to remove it - a dying man, with his family, finally sleeping tonight - a 31 year olf Brazilian man, readmitted for a surgery that shouldn't land him in the hospital another time, unable to sleep, perhaps thinking about his adorable baby that visited this evening - an Ethiopian father of three recovering from surgery after a bad break of his wrist, scared to be alone, shrouded by blankets to block out the light he refuses to let me turn off - and many more, slumbering, staring at the ceiling - medicated to fight their pain - wanting sleep - wanting to go home.

Tonight each story intrigues me. Each person brings with them to the hospital such a different perspective and reason. Why is my 26 year old friend in such a state? Some suspect a recent trauma, some suspect a tissue disorder, no one knows, and her words, seemingly plucked from her brain in random order, barely suggest a story and are anything but trustworthy.

In some way tonight, however, her words start making sense, and remind me of how often I too am simply pulling thoughts out of my spinning brain to verbalize. She, a grad student, my age, reminds me of how close we all are to such a line between sense and nonsense. How we only see the world through our own unique eyes, and no one sees it in quite the same way we do.

Week 4 of ornientation. Almost a real nurse.

2006-10-18T21:32:00.000-04:00

My first day on the job. I went with the brown.

Witnessing the suffering of others is a challenge each health care provider, friend or family member of the sick or infirmed faces each day. On my floor, we are blessed with perhaps the happiest of the sad cases. My floor is predominantly post-operative. People come, wheeled in on stretcher or by hospital bed, draped in blankets and clutching their patient controlled anesthesia button. They usually look sleepy and out of it and move gingerly.

Through out their time with us, I watch and help them struggle to perform activities that before said surgery were thoughtless- going to the bathroom, rolling over in bed, sitting up and eating. In general, whether communicating via interpreter in Portuguese, Hindi, Creole or Spanish, or though bad jokes about bad television, days are spent working to improve the patients and get them well enough to be on their way….

In general we wave goodbye a few days after we wheel them to their selected room. I get to watch them go from sick to better, from hobbling to walking confidently with a walker, from gingerly rolling over to voluntarily getting out of bed to ask a question. From averting their eyes when the gown is up and exposing incisions and staples on a once smooth abdomen, to looking and asking questions and partaking it their own care. That is the norm.

And then there are the exceptions. The people for whom I know are facing a long road ahead; people for whom this is not their last stop in a hospital for the near future, who are starting down a path of tough time. Holding hands with her doting partner through a drugged half-sleep, one woman laughed about the new words her three year old was learning, struggling with sad news of a recent diagnosis of pancreatic cancer.

Then there are those for whom the hospital is enjoyable – almost like a vacation. Perhaps those make me the saddest of all. A long and matted-haired, wiry man with a visible protrusion from his neck from a tumor comes out of his room. In one hand he is holding his gown closed so as not to expose himself to the nurses charting behind the desk. In the other, he clutches a dollar bill. “Excuse me,” he asks. “Can you tell me where to get some ice cream?” “Vanilla or chocolate?” I ask. “Both, he answers with a smile. I pick up the phone and call the kitchen. “Can you bring the patient in room 11 some chocolate and vanilla ice cream?” It was as simple as that. He grins with a wide smile and almost skips back to his room to his blasting television.

It’s the little things that get to me.

How bout them apples?

2006-10-18T20:57:00.000-04:00

You know what they say about an apple a day....

My close friend from college spent the weekend with me and gave the perfect excuse to explore the joys and foliage of new england this time of year. We did some climbing, tons of eating, and enough lauging to last 'till the winter.

To my fan club

2006-09-19T07:24:00.000-04:00

After being scolded twice this weekend by my loyal fans, I have kicked myself in front of this computer to update the annals.

After many Mondays spent claiming "I think I will start work NEXT" Monday, and weeks of follow up phone calls, faxes, and getting all my various licensure papers in order, I have finally started, and finished my first week of orientation as a nurse at a real hospital.

Due to self-advocacy and incessant follow up, I have finally landed a job at a community sized hospital about 15 minutes away from my house. The most inspiring fact about this job isn't the union, which will certainly be an interesting component, but the staunch mission of this hospital to create a healthier community. Indeed, it is as close as I have come to the clinic in Haiti mixed with my old Community Health center job. The floor has hired 24 hour interpreters in the 3 most commonly needed languages (Spanish, Haitian Creole, and Portuguese). I have yet to work a shift (that will be Thursday), but am excited for the potential. Perhaps, to all my fellow breastfeeding devotees, the most exciting piece of news is that this hospital has applied for Baby-Friendly status – of which there are only upwards of 50 others in the whole country. Yes, I am proud of this little place and excited to join the team.

Acting as a perfect compliment, I have also started to volunteer for my favorite non-profit, Partners in Health, as a research assistant. I feel when I go to work, as if I am meeting my favorite movie stars. Yesterday, surrounded by good company and co-workers, I attended the most eloquent, opinionated, passionate talk by Steven Lewis, the UN special Envoy for AIDS in Africa. He champions the feminist cause and highlights the severe toll that this disease is taking on the women of Africa. He sited insane and infuriating statistics such as "9% of pregnant women with HIV in Eastern and Southern Africa receive prophylaxis that has been proven to decrease transmission to their unborn baby."

He also stated the crazy fact that the US and England combined spends about 10 billion each MONTH on the War in Iraq (killing people) and less than 8.5billion on AIDS in Africa, a disease that is killing 900 people every hour. His book, a Race against Time, is well-written and passionate and sheds more eloquent light on this topic than I can. I recommend it.

So now, my task is to combine the exciting energy of an international non-profit and with the important work of nursing. Every patient, wherever they are living, deserves the best and most caring care possible. My own mission for the year is to provide this to each patient I have with the same energy that I feel while shrouded by the energy of my personal International-Health stars. Let's see, after 11 hours on my feet, while drowning in IV bags if I can manage this.

I think so.

Here's to good health - for those who really need it right now, those who have it, and those who dedicate their lives to working towards it for others.

Can't focus? Try Concerta

2006-08-30T07:41:00.000-04:00

Last week I began and completed my first job as a real nurse. Save the fact that medications and a small dusty clinic were involved; the experience could not have been much more different than my time in Haiti.

The job was posted on my school's list serve "RN needed for 1 week camp. Salary negotiable" on Monday. By Tuesday at 8am, I had rented a car, printed out Google-map directions, and was heading down the Mass Pike towards the Pocono Mountains. I had brought my bathing suit, a bunch of knitting, two good books and an attitude of adventure.

The week turned out to be less than a week of vacation and adventure. I played both nurse and pharmacist - bagging up hundreds of kids medicines a day (Zoloft, Zyrtec, Abilify, Allegra, Ritalin, Concerta, Singulair, etc.) and distributing the little coin-envelopes at breakfast, lunch, dinner and bed time.

In the time between the busy meals I saw tummy aches, scraped knees, fingers with splinters, unidentified back pain, black and swollen eyes, some stomach bugs and a whole handful of headaches. I pretended that I knew what I was doing sometimes, and knew others, and always gave a confident smile, checking the med recs for possible allergies before I distributed Advil. Amidst it all, there was little time for reading and knitting and the rain rendered my bathing suit all but useless.

The phenomena of medications at camp are a strange statement about our society. Perhaps only when we separate kids from their families, and put them in a group, do we see how truly medicated our children are. Here is a list of stats, printed by the NY Times this summer that puts some hard facts to the overwhelming numbers of pill bottles I encountered. What these numbers don't show are the amount of kids that take 4, 5, 6, or 10 prescription medications a day.

Total

One or more Daily prescription medications: 40%
Asthma/Allergy: 20%
Most prescribed medications:
Zyrtec (allergy)
Allegra (allergy)
Singulair (allergy and asthma)

Attention-deficit disorder/Attention-deficit hyperactivity disorder: 8%
Most prescribed medications:
Concerta
Strattera
Adderall

Depression/Anxiety: 3% (yes. I handed an 11 year old Zoloft each morning, not to mention the 15, 16, 17 and 18 year olds. I thought that adolescents’ and teenage years were supposed to be difficult....)
Most prescribed medicines:
Zoloft
Paxil
Prozac
Wellbutrin

Antipsychotic/Mood disorder: 2% (We had a slightly higher percentage. I think about 3-4% of our kids had 'mood disorders.' I made the mistake of giving one young woman on abilify her pills a few hours late. By that time she had already had a break down. Some are teetering on a scary edge of normalcy)

Most prescribed medicines:

Most prescribed medicines:
Clonidine
Lexapro
Risperdal
Depakote

Add the next category - in my camp - anti anxiety drugs. Trazadone, Clonopin, Xanax. Yikes! They're only 11 years old....

Bed-wetting: 1% (We had only one kid who used a pharmaceutical for this problem. I assume it didn't work like it was supposed to - as this kid showed up to use the washer dryer one morning - an embarrassed look spread across his face as he clutched a plastic bag of wet bedclothes.)

So that was the week - in a nut shell. It illustrated a pharmaceutical crisis that is overwhelming children. When I tried to confirm the appropriateness of doses with my Palm, many of the medications stated that they had not been tested on children. I can not help but repeat my new mantra of 'we don't know what it's doing to kids. We have no idea of the long term effects.' Weight gain, increasingly unstable moods, a rise in autism, and (perhaps worst of all) the concept that "whatever the problem, I will just swallow a little white pill and it will all be better."

Scary thoughts. But, now that the envelopes have been thrown away, and pill bottles have been sent home with kids, a good and challenging week over all.

Delayed cord clamping

2006-08-14T10:55:00.000-04:00

A zen concept. Perhaps slower is better.

http://www.slate.com/id/2146483

This just in:

2006-07-26T22:41:00.000-04:00

I passed the NCLEX.

Whew.

A cup of coffee

2006-07-23T14:37:00.000-04:00

I've been spending most hours of each day this past week at various book stores and coffee shops around Cambridge, studying for the boards that I will take tomorrow. As much as I joke, I am nervous. Not passing renders me job-less for the next three months.

Here's today's best (i.e.: worst) question of the day. For the record, there are certainly some difficult questions, but just enough of a sprinkling of funny ones to make me plug on.

A nurse is performing peritoneal hemodialysis on a client. A second nurse observes her sitting by the client, drinking coffee and eating a donut and discussing the events of the client’s week. The first nurse should

a. Appreciate what a wonderful therapeutic relationship the nurse and client have
b. Grab a cup of coffee and join in on the conversation
c. Ask the client if he would like a cup of coffee as well (how rude of the first nurse!)
d. Ask the second nurse to refrain from eating and drinking near the client.

I'll grab a cup of coffee, thanks for asking….

You go to bed, I'll guard the door.

2006-07-17T23:02:00.000-04:00

With a title like "annals of nursing" it is my duty to share the less glamorous parts of the beginnings of the profession: NCLEX preparation and multiple choice exams.

I will dedicate the next week of my life to studying for - and hopefully to passing - the nursing licensing boards.

I have been, however, less than impressed with the practice questions and study guides, especially regarding cultural competencies. Here is an example question:

A European American (comment: what? a French-American? A Caucasian? An Italian-American?) has just been admitted to your floor and needs a dinner tray ordered. The physician has ordered a "regular diet." Which menu will you chose?

a. raw fish and rice (comment: when was the last time you saw raw fish on the menu in a hospital? perhaps 1918, when oysters were the item of choice)
b. maize and beans (comment: by maize, you mean corn?)
c. steak and potatoes
d. salad, diet cola, low-cal dressing

Yes my friends, the answer they were looking for was, sadly, "c." Leaving out all of us "European Americans" who prefer sushi, salad and even maize, to steak and potatoes.

This question is rivaled by one I encountered while in my “Psychiatric Nursing Practice” class at Columbia. The question was something to the effect of:

You find your client cowering in the corner of his room in an in-patient psych ward. He states that “you’d better be careful. Alien invaders are marching through that door. They want to plant computer chips in our brains. I need to stay here to make sure this floor is safe.” The appropriate response is.

You are hallucinating. There are no aliens
You go back to bed and rest. I’ll guard the door for a while to protect us.
No wonder you’re on a psych floor…
Tell me more about what you’re seeing.

Way to go NCLEX.

Home, again

2006-07-12T15:10:00.000-04:00

I am home. Done with my far-flung adventures full of sea lions, blue-footed boobies, runs through cactus filled hills with smiling kids, clinical work, rickshaws, fabric shopping and delicious new flavors.

It is raining in Cambridge now, suitably, matching my mood.

I wasn't able to write while in India - internet cafes were sterile and air-conditioned and I had no desire to sit inside and miss all of the colorful world outside them. The trip was wonderful on many levels and for many reasons.

I flew to Delhi accompanying, or accompanied by, 34 Indian exchange students returning home after a year in the States. They quickly became my brood, and I missed them immediately after putting them on trains and planes to return to their families.

The trip was almost smooth - save one lost passport on the plane while flying from Frankfurt to Delhi. After having each kid check their bags to make sure they didn't have it (accidentally, of course), and turning the plane upside down with flashlights and the help of the cleaning crew upon landing, we considered it gone. After 3 hours of patient negotiations with 4 or 5 Indian officials, each of whom needed to write in a book, stamp the book, and look her up on the computer, she was able to leave. We reached the hotel by 3am and I was in bed by 4. At about 5am, I sat up, awoken by a knock at the door. "Is Rosha-mam there? We need to talk to her, alone." Rushing outside in my pajamas, quickly analyzing their appropriate modesty, I met three of the students who all appeared, wide eyed, to have seen a ghost. "What's wrong?" I asked. "We found the passport...." They didn't know how or why, but it had turned up in one boy's bag who was neither friends with her, nor sitting anywhere in her vicinity. Some mysteries are better left unsolved.

The rest of my time in India felt more like a home coming than an exotic adventure.

This feeling still strikes me as strange: I am not Indian, I have spent more time in many other countries than India, I have no Indian family members and don't speak more than 10 phrases of Hindi. Why then, does this country, bustling with beggars, rickshaws, incense, diversity and food crackling in hot pots of oil, feel so comfortable?

Perhaps this feeling can be attributed to my family's long-lasting love affair with India: our eating meals on Indian stainless steel plates, our making of chai each Sunday morning, the use of "pani" for water and "tik-hey" for OK. My parents and extended family have incorporated bits and pieces of Indian culture into our rituals and routines and this trip reminded me of the striking power of the every-day and of family tradition.

My aesthetic sense also feels alive and inspired in India - the black and white Hindi text written on the buildings, the bright, bold and beautiful colors of the salwar camises and the stark white of the courta pajamas worn by the Muslim men. India provides stimulation for all senses - horns honking, the breeze of ceiling fans mixed with the pounding heat of the 45 C degree temperatures, the scent of incense and curries, the colors of the clothes and buildings and light of the sun. My mind was never bored.

Or perhaps it is the countries impeccable use of trains and bicycles (in the form of stately black heavy bicycles for one, two or three people, or converted to the ever colorful bicycle rickshaws), my two most favorite means of transportation.

Last, but not least, my company made me feel at home. I stayed with Katherine, an old and dear friend who is conducting research for her PhD in India. She speaks fluent Hindi and now Urdu, can bargain with the best of them, and looks as if she is floating as she walks, her lovely dupattas flowing behind her.

Yes, I fell somewhat in love, and miss India already, but I can't complain.

I have an exciting year ahead - exploring the realities of nursing, taking some classes in Public Health, and learning the ropes of a domestic romantic partnership. I will continue to make chai in the morning, to add garam masala to my veggies, to prance around the house wearing colorful fabrics draped around my shoulders, and I will continue to keep the feelings inspired by India, alive.

Vent fait mal

2006-06-23T18:38:00.000-04:00

(Above: The twins, Asna and Asli. After collecting water at night from the pump)

Alas, the last day here rendered doctor Patti and me the patients. We got hit by some bug - which has hopefully worked it's way out. Thank goodness for Gatorade.

Amidst the not feeling well and spending some hours in bed, I was able to tie up lose ends. The nurses at the clinic gave us thanks and told us that the week was certainly satisfying. I took pictures of the kids playing in the school yard and conversed with some friends about Hatian politics. I napped. I read a bit. Almost like a vacation.

I will post photos on each entry when I get home. Keep checking back.

Aurevoir de Haiti. Na we plu tot...

Not for the weak-of-stomach

2006-06-22T22:30:00.000-04:00

I left the clinic at 5pm today - dirtier than I care to admit. While showering (after a run (cous!) through the thorny mountains with our entourage of faithful supporters), I realized that the white wash cloth I was using was turning grey. How gross.

Things are just plain dirty here in general. Getting totally clean is hard amidst the loose dirt, the dust, the lack of roads and plethora of mud after a rain. Working in a clinic adds a new dimension: snotty noses cut up feet, reports of gross internal bugs and multiple diagnoses of the external ones (they will remain nameless for the weak of stomach). Showering today felt good - but while rinsing my grey cloth, I thought about Asna - the gorgeous young woman, one of the twins, whom I had just seen carrying her huge plastic bucket of water on her head with sweat dripping down her temples and face. Will she shower in that water? Or is that bucket, pumped from a well, the drinking, bathing, and cooking water for her entire family? Getting clean here for me is easy within the confines of these mission walls, but to most rural Haitians, this task is next to impossible. It is no wonder that worms and scabies (oops, I said it, I itch already...) are present in almost everyone we see at the clinic.

Worms: the theme of the day. Suprisingly, however, people do not present here with a chief compliant of worms, as I certainly would if I knew I had them. They present with "cough (tous), cold (gripe), stomach ache (vent fait mal), head ache (tet fait mal), fevers (fievrela) and chills (tremble). However, it only takes the question "do you (or your child) have worms?" to make an easy diagnosis with the answer "yes." Having worms must just be a way of life. Today, each child whose mother said she had worms, received a dose of medicine for the child, one for each of her numerous siblings, her mother, and father. We then gave them a bar of soap and a lesson on the importance of hand washing and the dangers of playing in the dirt. Hopefully this tactic will rid the family of a worm burden for a few months. Having worms is not just gross - but perpetuates a cycle of malnutrition. The worms eat the precious food and use the scarce nutrients from the food the kid eats. This makes them more malnourished, have a weaker immune system, and more likely to eat dirt (the food which often gives them worms). Yuck.

On a more positive and less gross note - things have gone very well at the clinic thus far. I have been working with one American partner and two Haitian nurses in our exam room. Today I felt that we truly collaborated with our ideas and skills. We took turns listening to lungs, peering into ears, pressing on pregnant bellies and shining lights on itchy skin. We talked about why we did and did not think that the patients before us had malaria, typhoid, a bacterial or a viral infection, and talked about what to do. The conversations were in French, mixed with my newly acquired Creole and their newly acquired English. At the end of the day I had no usual reservations about sustainability or importance of what happened today. I think that Narlane and Rita, the two wonderful nurses who I collaborated with learned (if they are lucky) as much as I did today. They gained a new perspective on the people they see every day - and I learned about how people look with illnesses I see only once a year.

On an even MORE positive note - I need to mention the World Cup. Folks here, like everyone around the world I suppose, are into it - and huge fans of Brazil. Yellow and green shirts (not dirty at all) pop up all over the place. I had one patient today who refused to wait for a Malaria test because "Brazil and Japan are playing in a half hour..." I jokingly smacked him on his head with the anti-acids I handed him and sent him on his way. Perhaps a radio version of a good match and a last minute goal from Rinhaldo is as good of a medicine as chloroquine.

SIDA

2006-06-21T15:38:00.000-04:00

AIDS is a taboo subject here. I found out yesterday that people who are dying of AIDS or infected with the HIV virus are not told that they have AIDS – only family members are privy to that information. As an explanation, I was told “people die faster if they know what they are sick from, so they are not told so that they do not give up.”

This logic is so flawed that needn’t be discussed here – but the concept is no less disturbing. In an English lesson yesterday with two aspiring interpreters, we went over the chapter on health related terminology (I figured I could pick up some Creole at the same time). When we got to the word AIDS (sida, in Creole), I asked them. “Is there much AIDS in Haiti?” Jean-Willy responded, “Well, people say that the tests come up positive, but how can we believe them because no body here is dying from it.” That is disturbing.

One non-profit estimate that there are 190,000 people living with HIV in Haiti – 3.8% of the adult population - and 16,000 deaths a year from it. However, I am not sure that I trust these statistics. Tests for HIV are hard to come by and people are even more reluctant to go for testing because after a positive outcome – many services are rendered impossible, not to mention the social ostracism that must ensue. The EMT who is traveling with us explained to me that at the hospital in Gonieve where he had previously done some work, the surgeons did not perform surgery on HIV positive people out of fear. In this small village of LaCroix, I know of one woman who is dying (although she does not know it is from AIDS) and two who just died, orphaning a two year old who visited our clinic (he looked healthy, which is a good sign).

There is no public campaign here, from what I can see. There are no signs like “SIDA kills”, or a drawing of a scary monster chasing a healthy white blood cell present on the streets. I have not seen one condom at the clinic or on the street as trash. None of my patients report using condoms – if they are honest about having sex to begin with. In a conversation with Pastor Pierre, who is the resident expert on many topics, he said, “all the cases of HIV in Haiti come from people who travel to the Dominican Republic.” While there truth to the transmition via Dominican prostitutes and Haitian truck drivers, it is not good that the most educated man in town believes that if someone hasn’t been to, or isn’t sleeping with someone who has been to the DR, that there chances are nil. 190,000 people suggests that it is more wide spread.
I worry that it will become a public campaign when it is at crisis proportions. Dating publicly before marriage here is not ok – but people are certainly having sex. Haitian thoughts about the disease are mixed with ideas of voodoo causing sickness, of fear, of social taboos around sex, and most importantly, of a gaping lack of sexual and basic education. This is not the trip to tackle it – but it is on my mind and repeated fungal infections and thrush in young adults makes me wonder…

The blind leading the blind

2006-06-19T22:40:00.000-04:00

Today's running mantra was 'do no harm,' and it is with that thought that I made most treatment and diagnostic decisions at the clinic today. Treating Haitian patients is fraught with problems and left me feeling unsure at the end of the day if what I did was right and if it helped at all.

One of the problems is that it's hard to get what the medical community calls a 'review of systems' because the answer is always 'yes.'

For example: a woman walks into the clinic and sits down in a chair (to sit: chite). "Sa ou gane?" (what do you have? or what ails you?) "Fievre." And then it begins.... 'do you have a cough?' 'yes' "do you have any nausea or vomiting?" "yes" "do you have trouble breathing?" "yes" and so on and so on until every differential diagnosis that has run through my head (Typhoid, Malaria, regular viral infection, etc) has been cancelled out and I am left with only the word "sick."

To make matters more complicated, the Haitian sense of time seems to be a bit different and many people explained, when asked "how long have you been feeling like this", "22 days." I do not know what is special about the amount 22 , but many people seem to have been sick since around May 28. Decisions about diagnosis and treatment were thus made around a physical exam (did they look sick? did they have a fever? were they losing weight?) and my mantra "do no harm". If medications for the potential illness could hurt, I did not give them. Thus, I treated many cases of malaria today, suppressed a lot of coughs, rehydrated those who may need it, reduced fevers, gave out vitamins, and treated some pretty bad looking fungal infections on little boy's heads.

When discussing this with Pastor Pierre, the leader of this project, his thought was that if they answer 'yes' to every question, we will give more medications and those can be used to treat other people in the family - or saved for the future. They pay a flat fee ($30 Haitian dollars, about $4USD) to use the clinic, and all medications are included. This sounds like a good reason to say "yes" to me.

All in all, the 33 people we saw today - and perhaps their family members - may sleep easier, breathe easier, and hopefully will feel well cared for tonight - as the Haitian heat pulses, the crickets chirp, and the heat lighting flashes...

Sunday in LaCoix

2006-06-18T22:30:00.000-04:00

Haiti, Day 2

Outside the air is thick and heavy and while it is visibly clear, there is no breeze. I can see more stars than I new existed because without my mega-light (thanks dad), there is none. It is hot and if I was not trying to separate my self from the mosquito's and other flying insects, the best outfit would be a bathing suit.

Today, while the official day of rest, was full. It began with a two hour church service in which we (the seven Americans here) were treated as esteemed guests although we looked more awkward and sweaty than anyone, clutching water bottles and holding cameras. Upon entering the church, each member of the community shook our hands, and the old ladies kissed us wetly on our sweaty cheeks. Each person said welcome in their own way: my favorite? Baby Jeffrey that I was lucky to be holding peed in my arms. The church service, accompanied throughout by 17 year old Woodsie on the Guitar, two young drum players, and an aspiring keyboard artist, was full of music, of clapping, of lace on heads, and of joy. Truly incredible smiles and thanks in the midst of striking poverty.

After PB and J offered to us on white bread for lunch, we left for the clinic. I grinned to see that the pharmacy that Patti (the physician with whom I am traveling) spent many hours organizing and labeling last year was still organized. The clinic showed a striking improvement from last year when the pharmacy was cluttered and full of mouse-chewed bottles of expired meds. As we sorted our brought meds and placed them in their proper place on the shelves, I chatted with Judette, the the new nurse who works as a provider in the clinic. She impressed me with her knowledge of medication uses. She, a new grad like myself, works as a full provider in the clinic each day except for the two days a week when Cuban doctors visit. We shared blow-pops and laughed at funny uses for medications. Nurse humor, I suppose.

We then walked around the small village of LaCroix, flanked on either side by kids who ran to hold our hands and play games as we walked. Jason, a 19 year old, wanted to hold mine. I told him he was too big and chose to hold the hand of an adorable 7 year old with braids who spoke no French. After 'quel age ou' (how old are you) and 'what is your name?' we ran out of things to say, but we squeezed each others hands and enjoyed the scenery of the overflowing busses zooming past us. On the walk we past a coconut tree and all sampled warm coconut water released by machete. Some of the prepared kids whipped out spoons and began eating the soft meat. Note to self: always bring a spoon.

I am nervous about what tomorrow will hold. The plan is for an EMT from Vermont and me to run one exam room and Patti and a medical assistant from my old clinic in Vermont to run the other. As much as I learned this year, we did not learn diagnostic skills, and certainly did not specialize in tropical medicine. I hope that my knowledge of medications, my ability to give a darn good bed bath, and prior experience here will see us through.

In the words of my Haitian friend Mezier who is taking his national exam tomorrow - "Pray for me."

Nous sommes arrivee!

2006-06-17T22:01:00.000-04:00

Haiti, Day 1

Or day 0.5, rather. I arrived, through billowing clouds, from New York to a place so totally different that it is hard to believe it is only 3.5 hrs by plane and in the same time zone.

It feels great to be in Haiti again. Greeted by live music as we walked off the plane, with the strong sun shining, I waltzed into this week smiling. The four hour, ninety mile bus ride only made me want to shoot photos and stop and explore.

Perhaps it is my bias, because I want to see improvement, but I have noticed changes since I made the same bus ride over a year ago. 1. The airport was more organized. We did not bribe the customs officials with Viagra and children's chewable vitamins to let us in, tax free. Instead, women and men in uniform inspected the bags and did not even ask for the lollipops on the surface (I, however, had no self control and took two for the bumpy bus ride). We were not mobbed by kids or taxi drivers, but instead found our new white four by four only needing to wave off one man who called 'maman!' through the gate. 2. There was more concrete on Route one, and therefore less huge pot holes. 3. There were no road blocks at all, whereas last year there were at least two. 3. There were no UN officials standing with loaded guns on the roof of their building. Instead, they were sitting in the shade and waved. Over dinner I asked Pastor Pierre, the boss of this complex, if it was too late to talk politics and if not, what changes he noticed since the election of Rene Preval. He said that it is calmer and there have been improvements, if only slight. I concur.

But some things are still the same, and for this, albeit selfishly, I am glad. The rooster still crows the announcement of sunset. The kids I met and played with last year still remember me and want to run ('Cous!!!'), stupidly through the thorny hills to accompany the silly Americans while we stretch our legs. The two twin girls whom I photographed last year still look like models, if only more beautiful.

Tomorrow we will set up our two exam rooms in the clinic with our brought medications and vitamins and prepare to open on Monday. If I can just sort out the French from the Spanish that are currently making word-salad in my brain, I will be all set. I am excited for what the week may hold and hope that I can leave as many smiles as received me.

Thank you to all who helped support this trip - both fiscally and emotionally. Keep checking back if you want updates. I will try to write daily if the power stayes on long enough.

2006-05-19T20:12:00.000-04:00

Today marked the transition between yesterday and tomorrow. Today, I graduated from nursing school. Our nursing school does not call it a graduation, but rather a 'White Coat Ceremony.' We did not march down the aisle, but instead walked up on stage, flanked on either side by our colleagues, and turned while one of our professors helped us to put on our long white coat.

It was an odd day - certainly not filled with the elation of the end of my first bacholers degree - but filled with some sort of pride and satisfaction upon having completed this year. The dean of the school fed us such cliches as "you are the future of nursing" and "the world is your oyster" and most of us spat it back at her with a cynical smile. She also told us, in the words of a famous nurse theororist, that "you are the sight of the newly blind, the leg of the amputee, and the confidence of a new mother." But as I looked around at my fellow nursing students, I would be lying to say that I did not feel a small bit of the cliche somewhere beneath my light blue school of nursing logo that was embroidered onto my white coat. As the rain rattled on the plastic tent roof and the thunder clanked and clashed somewhere in the distance, I did feel some sort of electricity and culmination. Perhaps the joy of chosing a career path that puts patients and people and families first. Perhaps the joy of doing something practical, not theoretical, of gaining a skill set. Perhaps just the joy of completing a task that I had set out too do more than a year ago.

yes, I am proud to enter the field of nursing. It is a mixed up, confused field - unsure of whether it is a profession, an academic dicipline, a focus of research, or just a plain old j-o-b. But somehow it suits me and I am excited to play the role. Even if I never again put on my white coat with the light blue crown.

Because why would I wear the only article of clothing known to raise a person's blood pressure without even moving? No, I am in this profession for the people I will work to heal - and I do not need a white coat to dawn the cloak of nurse.