Sections, Circs & Stiletto Heels :: N30010 Clinical Journal Entry #23

I am not in the least way superstitous, but it is Friday the 13th, and today’s clinical was insane. Remember I am in Obstetric/Women’s Health clinical, and we spread out among several units - Labor & Delivery, Triage, Post-partum, and Nursery. Today, I decided to go to the nursery since L&D was pretty much empty, and Post-partum is boring.

I went into the nursery, and 3 babies were there. The hospital has 3 nurseries, and there were apparently 8 babies in this one, but hospital policy is huge on mom-baby bonding so they try to keep the babies with their moms as much as possible. A nurse was in the nursery, and I introduced myself and told her I'd be spending the day with her. Her reply was, "You can't be in here. I'm an LPN, not a RN." Technically, each baby has his/her mom's RN, but the LPN (who we will call "L") cares for them, can give certain medications, do certain tests, etc. She told me, "I don't even work in this nursery. I work in the other nursery, and I have no clue where anything is in here." She seemed frustrated, disinterested in her job, and was very crabby, snappy, curt... you get the idea. She would adamantly tell me what I couldn't do (there's a lot of rules on what a student can and cannot do when it comes to infants) and seemed agitated every time I asked a question. I felt so much prejudice like she thought she was about 100 levels above students, when really, we are all part of the team. Then, when we were doing assessments on the babies, our instructor brought a couple other students in, and L about lost it. She was snapping and arguing with everyone as if this was her turf, and we were amateurs invading her space. It was almost like she was happy to be the boss instead of always answering to RNs, etc. She finally had an opportunity to rule in her own lame ways, and she was going to maximize the experience, I guess. I was ultimately shocked a few different times when one of the babies would start to cry, and each time, L would mumble an expletive followed by, "I don't have time for this!" I didn't understand that one bit, but I didn't understand much of what L did or said... of what she didn't do or didn't say. But I can put up with people who have issues. What I refuse to put up with is someone verbally attacking me. And L did just that. By mid-morning, I think she was done being difficult and turned to complete nastiness. To make a long story short, the RN was going to let me pass Tylenol to one of the babies, and as soon as we went into the nursery to do so, L was starting to give it to the baby. I told her that we were going to pass the med, but she snapped back, "Well you're not allowed, so it doesn't even matter." I told her my instructor OK'ed it, the RN agreed to supervise me, and I had passed meds many times before. Her reply was, "You're a student so you can't, and your instructor just has no idea," and after a lot of short answers, I finally got her to tell me that hospital policy was that students could not pass meds to newborns. Okay, now that made sense, and if she would have told me that in the first place, that would have been fine. So she turns her remarks into a speech on why she doesn't like students, it's confusing because all of the schools have different policies, she doesn't think instructors have a clue.... etc. So then she's back on the Tylenol, telling me why I can't pass it, and I should have known better. "It's okay, it's really no big deal," I said nicely, but she's totally in a rant. Finally, frustrated, I said, "It's fine, whatever, it really doesn't matter!" "It's NOT whatever!" she screamed and went into complete craziness again, about students and instructors and rules and well, I honestly can't tell you what else because that's when I walked out the door. She was talking so fast and loudly that I couldn't get a word in, so I just left. I found my instructor, told her what happened, and said I wouldn't put up with being treated like that. (She said I had no reason to ever walk back into the nursery and was mad that at a teaching hospital, someone could be that nasty to anyone.) Instructor discussed the matter with the charge nurse who actually saw L's insane outburst and reassured my instructor that they've had problems with L's attitude before. So that was an interesting experience (I've never seen any kind of nurse be mean to students during any of my clinicals, and I know it happens, but this was definitely an extreme case.) The problem then became where to go since only a couple moms were in labor, the floor was quiet, etc. My instructor told me I could go study until lunch and by then we'd figure something out.

While L was on break and I was still in the nursery, an opportunity arose to see one of our little guys circumcised. Taking place in a simple procedure room, the simple process was pretty hard to watch. The doctor applied local anesthetic which she said ensured the baby didn't feel anything, but I didn't believe it for a second. She said he was only upset because he was restrained, but I don't care if I see a baby dropped on its head - it couldn't possibly cry as ear-piercingly high, loud, and bad as this baby was while the doctor cut into his little newborn skin. The American Academy of Pediatrics is against circumcision, claiming there is no medical benefit whatsoever, and believe it or not, the nurse I was with told me an increasing number of parents are choosing against the procedure. I'm sure if they saw it done, even more would be against it, but as with anything, there are many points to consider on each side of the issue.

After lunch, nothing had picked up, so our instructor had "Pre-conference" where we meet for an hour and talk about what we're seeing, doing, thinking, questioning, etc. We tell about our patients and learn from each other's experiences and how they apply to what we learn in class. I've never seen an instructor hold pre-conferences before, only post-conferences, but with this instructor, we have both, and I think it helps our learning to have extra time discussing. Plus, it makes the day go by extra fast!

So anyways, after lunch and pre-conference, things were still quiet, so I got the OK to walk around until I found something to do. I decided to go with one of the guys to Triage so I could be the first to see some action. Triage is what we call the first step into the obstetric unit which handles all incoming pregnant patients no matter if they're in labor, false labor, experiencing a bug bite, can't stop vomiting... doesn't matter. They go to OB Triage.

We were just standing around hoping for some action when the pager went off. It said: "26 F, wearing stilettos, ready to come back, having contractions, needs you to be fast because she is picking up her wedding dress in 4 hours." We all started laughing, and even a male OBGYN who was there admitted if he was in labor, he would be wearing flats, not stilettos! I went out to get this patient from Check-In, and this was not a joke. Mom and pregnant daughter, in wheelchair, putting lip gloss on and drinking water claiming to be having contractions. She was chipper and chatty the whole ride back to Triage, and she made sure I knew she had to pick up her wedding dress in 4 hours, so according to her, we weren't allowed to keep her longer than that. Obviously she's never been to the hospital before, and we all knew there was no way she'd be picking up her dress in 4 hours.... not because she was having contractions and would stay to deliver, but she actually was just freaking out and being dramatic (fetal monitors don't lie!) which means we had to keep her a certain number of hours just to make sure nothing shows up on the fetal monitor. Some patients... wow. Oh and after we asked if we could help her RN because we were students, her reply was this, "Umm, no it's not okay! But if I don't have a choice then what am I going to do?" (say that in your head with as much attitude as you can think of) We were not offended as she had probably hoped.

We were bored for a little until people started rushing around. My ears perked up, hoping to hear something exciting, and sure enough, I heard the words "C-section." There's a resident we all love who is ALWAYS at the hospital, and she was putting orders into the computer right beside me. I asked her what was going on, and she said it was a crash C-section. She thought there was a patient in L&D whose monitor traced Baby's heart rate down to 30 (Normal is 120-160) so they were doing a crash section. Unsure of what the rules on crash sections were, I asked if I could observe. She told me that would be fine, so I put on a mask, threw my hair into one of those blue puffy surgical hats and rushed to the OR.

I was surprised to see the tiniest woman I've ever seen in my life on the operating table. She was lying there exposed and shivering, and she glanced at me with fearful eyes. She was Chinese, and she did not speak English. Hoping I wasn't violating a cultural taboo, I put my hand around hers and she squeezed it tight. The anesthesiologist told me she still needed an epidural, and he tried to explain it to her husband who knew a small amount of English. It was getting no where so I asked the anesthesiologist to hold up a needle. He saw it, and I pointed to my back. I said, "Tell her it will help her pain. Ask her if it's okay." The husband said something to her, and I asked, "Yes?" "Yes," he told me. Through him, we explained to her that we needed her to sit up. After 3 failed tries at initiating the epidural in her tiny, bony spine, we helped her onto her side where the anesthesiologist finally got the epidural in. I tried to explain the pain, pressure, stinging, and various other sensations, but the language barrier was too large. We waited until she was numb, and I took my place out of the way of the doctors and nurses in the bustling OR. Beside us in another OR was a resuscitation team to take Baby the instant he was born. One of the nurses told me she guessed he'd be around 4 pounds.

The doctor made a straight slice into our patient's lower abdomen. The blood appeared on one side and slowly appeared along the incision line like a curtain opening. The doctor made cut after cut until she got to what looked like muscle tissue. After a tiny cut, the muscles were literally ripped into 2 pieces. I think it was one of the last layers, but eventually all of the cutting gave way to an obvious translucent bubble - the amniotic sac. With a volcano of amniotic fluid, it was ruptured, and the doctor pulled the baby out. There was no cry like you'd see on TV. A nurse was already waiting with her blanket-covered arms outstretched, and she took the baby straight into the adjacent room while the doctors in this room worked to deliver the cord and placenta, suction the uterus, and start slowly, carefully hand-stitching each and every layer back together.

The suturing took the longest part of all, and the entire process lasted until post-conference time. I peeked into the window of the door separating these new parents from their baby, and I could hear tiny little cries. It looked like the little baby boy was going to make it.

Post-conference was normal. Well, it started out that way at least. We were all exhausted and ready to go home, but we talked a little about our patients, reviewed a little for Tuesday's big exam, and changed plans for the next clinical. We have 2 guys in this clinical group, and honestly, I feel bad for them. They have never in their lives had to care about women's health, while we girls have had to our entire lives. Now they're in a class they're forced to pass that's all about things they'd never in any other case even find out about. There was no warning, either, the class started, and bam, they are forced to see this stuff in lecture, in clinical... all while we girls are having a hard enough time trying to remember these things and asking other women questions we know we likely would not want to be asked. So for the guys, it has to be rough. They're adorable though (as in little, innocent puppy kind of adorable) because sometimes they can just be so clueless. There are a lot of awkward silences when they retell the stories of their days because they're uncomfortable using certain words in front of all of us girls. Granted, they try so hard though. Example - one of the guys was visibly proud he was almost done telling about his patient. He had used a few of "the" words, and he hadn't turned red or stuttered or looked stupid. Then came the moment when he was going to finish his recount by talking about a specific test we do postpartum where we check Mom for blood clots in her legs. It's called Homan's Sign, and once he said it, he continued to tell his story probably unaware that he had just called it the "homo test." I felt so bad, but just as everyone else probably did, too, we all erupted into laughter because okay, this was so funny in the moment, and we just couldn't help it. Poor guy... I'm sure that was just the icing on the cake of his day working on a postpartum unit where he was literally doing things like assessing vaginal bleeding and breast consistency.

Until next week...