And finally, finals

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

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

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

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

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?

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

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)

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

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

Day off

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

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

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

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

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

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.