No Crystal Stair

We had an exam last night in Maternity/OB (final next Tuesday!). Usually there are not a lot of meds to remember for maternity since technically the patients aren’t “sick.” Other than epidurals and such during labor most of what you’ll see is postpartum—percocet and motrin for pain, maybe a stool softener if mom had a episiotomy. But when something goes amiss—antepartum, intrapartum, or postpartum—that’s when you get hit over the head with all kinds of stuff—pitocin to start or augment labor, tocolytics to stop labor, hydralazine  for hypertension, magnesium sulfate to prevent seizures (in eclampsia), methergine for hemorrhage, and injection-only insulin for diabetics since oral agents are teratogens. It’s enough to make your head spin and this is only scratching the surface of all the meds I need to know!

So needless to say I can already tell that pharm is going to be a beast. Everyone makes it sound like such a “bird course,” and that “it’s just straight memorization”…OK, if you say so. You not only have to learn the names (trade and generic) of about a gillion drugs, but also the actions, interactions, indications, contraindications, side effects, rationale for why you are or aren’t giving it…the list goes on. You have to know all of these things to be able to challenge that brand new resident’s order for your pregnant patient to receive coumadin (which crosses the placenta), or to be able to question why he wrote an order for methergine when your patient’s blood pressure is already 160/100. You have to know all of these things because in the end YOU are giving the patient their medications—YOU are their last line of defense before a potential medication error occurs. Yes, Mr. Resident that wrote the order should have some accountability as well, but everyone will be looking at YOU because YOU should have caught it. 

So although the wonderful world of maternity is coming to a close, I now have to prepare myself for a whole new kind of headache. One of my favorite poems, “Mother to Son” by Langston Hughes, sounds just like the plight of a student nurse. Nursing school for me ain’t been no crystal stair…

HESI Smesi

It’s that time again—maternity HESI in T-minus 9 hours. For those unfamiliar with this particular form of headache, HESI is yet another test we take in addition to our regular exams/quizzes. I like to think of it as nursing SAT’s. It’s not quite the NCLEX but it’s supposedly a pretty good indicator of how well you’ll do on the real thing. In our program it doesn’t figure directly into your actual class grade (so depending on if you do well or poor on it, it may feel like a waste or a relief) but they’re currently giving us a few points (on a sliding scale) towards our final exam depending on how well we do.

So I’ve been up to my eyeballs in case studies, practice questions, and reviews/rationales most of this week in preparation (I don’t throw away any free points!). And for some reason, one concept that really gets my panties all in a twist is GTPAL, which basically gives you a summary of a woman’s obstetrical history. I wish they would just do away with that mess and write it the hell out. Damn, you don’t have to abbreviate everything!

Here’s a little scenario from one of my case studies I did last night: Jane Doe, who is currently pregnant, has previously given birth twice, twins born at 35 weeks and a singleton born at 39 weeks. All of these children are alive. She also has a history of having had one miscarriage (the more medicalese term would be “spontaneous abortion”) at 9 weeks into the pregnancy. What is her GTPAL?

Well first a refresher on the acronym/abbreviation itself. Gravidity is the number of times pregnant, including the current pregnancy (which is what I always forget to count). Term is any birth after the end of the 37th week, and Preterm is any birth between 20 and 37 weeks. Both term and preterm include live and stillborn babies. Abortion is any fetal loss, whether spontaneous or elective, up to 20 weeks gestation. Living refers to all children who are living (duh). Multiple fetuses (twins, triplets, etc.) are treated as one pregnancy and one birth. It’s just too many variables and parameters and whatnot…it makes me cross-eyed. So…Jane’s GTPAL is 4-1-1-1-3—four pregnancies including the current one; one baby born at 39 weeks; one set of twins born at 35 weeks; one miscarriage/spontaneous abortion at 9-weeks; three living children.

Well I don’t know about you, but I’m spent…

Touchdown!

At first I thought it was going to be like our last few clinicals where I was bored to tears. For the first two hours or so, we watched the nurses eat their full-course breakfasts complete with omelettes, bacon, home fries (which everyone complained were too salty), bagels smushed with avocado (WTF?), and toast—with Smart Balance spread of course. We did not partake in their feast though one nurse offered me a Starburst. When they were done eating they proceeded to cackle about the Kardashians, the Gosselins, and just about every other celebrity as they perused their mile-high stack of trash mags. The conversation then shifted to Martha Stewart, how they liked their Bloody Mary’s spicy, and so on. One even remarked, “Oh, I remembered to bring my iPod today.” None of them wore stethoscopes (not much patient care going on anyway) and honestly you couldn’t tell the nurses from housekeeping as both wore varicolored scrubs.

But it got better.

When it was all said and done I got to see a vaginal birth, a C-section, an epidural placed, and a D&E (dilation and evacuation). Just for that stroke of luck, you can bet your sweet ass that I won’t see anything else the rest of this rotation. The vaginal birth was great—as the mother of three I had been wanting to be on “the other end” for once. The baby was big (8+ pounder) and mom was small which unfortunately landed her with a third-degree laceration (tear) in the end. The C-section was a lot faster than I’d thought it would be—if I had blinked I would have missed it. The patient came in actually wanting to try a VBAC, but the doc wasn’t having it. I think they did entertain the idea at first until her blood pressure went up and the baby starting having decels. Third patient had a history of a LEEP and was dilating slow as molasses (which I’m told often occurs with LEEP patients). She was only 2 cm dilated when they gave her the epidural (I thought you had to be at least 4 cm), but she just couldn’t take the pain anymore—the Nubain just wasn’t cutting it. They were also augmenting her labor with Pitocin (which in my experience creates the worse contractions), and she was now having contractions every 2-3 minutes. Hell I’d want my epidural too. It was the D&E that kinda bothered me. A D&E is a surgical/therapeutic abortion done in the second trimester. Basically the cervix is dilated and the contents of the uterus are removed by vacuum. They use an ultrasound to make sure they got all the tissue out. But it just seemed like there was blood everywhere—they were slinging it and tossing bloody gloves and instruments and whatnot. And right after that—we got to eat lunch! Sheesh…

That’s all for now folks—a nap is definitely in order!

Some Boo-boos You Can’t Kiss Away…

A lot of boo-boos and ouchies in clinical today. First, I had a postpartum mom with a fourth-degree episiotomy. She was postterm so of course the baby was big, and they “had to” use the vacuum to assist with the delivery (I’m not a big fan of vacuums and forceps and such). To me, the situation just screamed C-section, but hey what do I know? So for those not fluent in the language of OB, a fourth-degree is the most garbungular type of episiotomy you ever want to have. This cut goes not only through the skin (first degree), muscle (second degree), and rectal sphincter (third degree), but through the rectum as well. “Ouch” really does not even graze the surface. I’ve had a second-degree episiotomy myself and while I hardly noticed it compared to the “ring of fire” during birth, afterward it felt like I slid down a razor-blade-lined water slide and landed in a pool of lemon juice. So I could only imagine what my patient was going through. And those puppies take time to heal. Cold packs help reduce the swelling and pain; and sitz baths circulate (warm) water to the area increasing circulation which promotes healing. You have to be careful with sitz baths though; if you sit in that water too long (which is a breeding ground for bacteria) it increases the risk of infection–15 minutes per sitting is fine. Some women also find witch hazel pads (better known as Tucks) to be soothing.

Second, I got to see a circumcision performed. Let’s just say it made me want to go home and profusely apologize to my 10-year-old son. It just seemed like so much trauma for that little piece of skin they removed. However, the doc that performed it informed me that it “really wasn’t that traumatic for the baby.” Yeah, okay–if that helps you sleep better at night… She used the Mogen Clamp method, which I wasn’t familiar with though all of the methods look pretty unpleasant to say the least. For those of you that have the curiosity and the stomach, you can find a video of the procedure here. I will say I’m glad that the myth (or maybe it was just denial) that babies do not feel pain was finally debunked–it is obviously so not true.

An Ounce of Prevention…

Things are pretty much status quo around these parts…Temple nurses are still on strike…I’m still like six chapters behind in my reading (and yet I have time to blog)…still cranky and sleep-deprived…and still downing venti lattes from Starbucks (aka “iced caramel jet fuel”) like there’s no tomorrow.

In other more exciting nursing news, HR 4601 The National Nurse Act of 2010 has arrived. One of the functions of this Congress-appointed nurse (hey, the Office of the Surgeon General already has their MD…), will be to help promote a national culture shift towards disease prevention—in other words, “Health Care NOT Sick Care.” If you take a look around you’ll see that many of the diseases we are now seeing in almost epidemic proportions are actually preventable ones—obesity, cardiovascular disease, type II diabetes and so on. Part of the reason we are experiencing this health care crisis is because we are spending billions of dollars treating the consequences of our country’s no-exercising, cigarette-smoking, fast-food-eating lifestyles. And according to this report, if the rate of obesity continues to rise as it has been it will add almost $344 billion in health care costs by the year 2018. Well no wonder there’s no financial aid money to be had…  And this is just obesity alone! This doesn’t take into account all of our other vices such as heart disease, hypertension, even some cancers …hell tooth decay is preventable if people would brush and floss and step away from the Sugar Daddys…

Of course some people don’t think HR 4601 is such a great idea (and I mean what would the world be like without our beloved naysayers?). They want to know why the government should have to fund such a position. And why can’t nurses just band together and form this initiative themselves (with their own funding) if it is so necessary? If we can bail out the automotive industry and the banks and so on, then I don’t see why we can’t invest in something that can potentially improve the health and wellness of our nation—with the added “side effect” of actually saving some money.  A mere eight days after the earthquake in Haiti hit, over $300 million dollars had already been raised. Don’t get me wrong—to see everyone pull together to help Haiti in their time of need was and continues to be a beautiful thing. But I don’t understand why we often hesitate to lend “our own” that same helping hand. When the rate of childhood obesity has more than tripled in the past 30 years, when a 9-year-old has to learn how to self-administer insulin… personally I think that warrants some type of action—just a little food for thought…

The bottom line is that we are spending entirely too much money on treating preventable illnesses and diseases instead of trying to head them off at the pass. I thought everyone knew that an ounce of prevention is worth a pound of cure…