Full Throttle…into the Fog

IMG_1662

The walk to class each morning from the parking lot down the hill…

We’ve been having some weird weather here lately…lots of dense, heavy fog in the mornings, grey, grey, and more grey…and then in the afternoons, it burns off into blindingly brilliant sunny blue skies. It’s a bit of whiplash, really, to go back and forth between the two, but as someone who thrives on every drop of sun possible in these dark winters, I don’t feel like I should complain too much.

Mostly, I find the current weather a fitting metaphor for my outlook on life in general these days. I vacillate between feeling confident and excited about what I’m learning, to feeling slightly terrified and (almost always) overwhelmed with the sheer amount of content we’re taking in. I knew what I was getting into with nurse-midwifery education…but on the long days, I wonder how effectively I’m actually learning all of this…and am I really becoming the midwife I want to be? The reality of 20 minute prenatal appointments is startling. I have yet to see through the fog of my self-doubt that I will ever be able to run an efficient 20 minute prenatal.

Perhaps even more unsettling to me is the question of whether I want 20 minute prenatals to be what my practice looks like. I know that I’m not really called to homebirth midwifery…but 20 minute prenatals feel impossibly short. I just don’t know. In an overburdened system, maybe this is the best we can hope for? Group prenatal care is a wonderful alternative, but it’s often an inaccessible alternative to many of the patients in the clinic where I’m working this term, as we expect participants to come without their older children, and for many, it’s impossible to find affordable child care for the 2+ hour group appointment.

Most evenings I come home unable to really engage in meaningful conversation with my partner or housemates, because I’m either too tired or too busy with homework, or both. I know eventually this will change…but in the meantime, it’s hard to trust that eventually the fog will lift and things will feel easier.  I know so many wonderful midwives who make the most of those precious 20 minute appointments, and I just have to trust that I will be able to do the same. More than ever now, I find myself reaching back for the reasons that propelled me here to midwifery school in the first place–they’re the things that will keep me going, one step at a time.

Learning to Fly

Oh, friends, I’ve been writing so many blog posts in my head, but somehow, they’re just not making it onto the [virtual] page. Lest you think I’ve been swallowed alive by clinical this summer, I’m taking a deep breath, settling in, and going to write a post about how things are going so far, because otherwise, I’m pretty sure I’ll forget what it feels like in this moment, to be on the cusp of learning how to fly more independently as a L&D/PP nursing student.

The Setting
My clinical site is a small, community hospital with about 150 beds total. 14 of those are in the Birth Place, a LDRP (Labor/Delivery/Recovery/Postpartum) unit. Some days all 14 beds are full…some days not so much. Except when I have other school stuff scheduled, I’m there when my preceptor is there, which is every Wednesday and Friday, every third weekend, and every third Monday (but the Monday’s are not the same week that we just worked a weekend, if that makes sense). My preceptor works a day shift, 7am to 7:30pm…so that’s when I’m there.

There’s anywhere from three to five nurses on any given day, sometimes more if they know procedures are scheduled. There are two scrub techs who double as HUCS, and they set up tables, do the hearing screens, help with vitals if needed…basically, know everything about the unit. There’s one OR, no NICU, and they really only take mostly low-risk patients after 36 weeks. So…lots of mostly normal birth going on here. Inductions and epidurals, to be sure…but not a lot of crazy complications or anomalies.

My Day
It’s different every day, depending on if my preceptor gets assigned a labor patient or postpartum patient. If it’s a labor patient, we’re 1:1, for postpartum 3:1. At this point, I’m starting to do more independent care…so we’ll go in together and meet patients, but unless there’s something I don’t know how to do, I’m mostly doing stuff on my own. What is that stuff, you ask?

Skillz
Well, for laboring patients, I’m helping get them admitted and settled into their rooms. I put the monitors on, take their vitals, do a physical assessment (listen to heart, lungs, check deep tendon reflexes, assess edema). I talk about what an induction will look like. I (try to) start their IV site if they need one (most patients will get one unless they specifically ask otherwise). I chart all those things in Epic. I get them water, or juice, help them order meals. I bring them birth balls, rocking chairs, or telemetry units so they can walk around the unit if they’re on monitors. I give medications, for nausea or pain, or if they have other home meds they take. I’ll hang a bag of fluid, or antibiotics if they need it. I’m in the room every half hour if they’re in active labor and getting pitocin (which I’ll also hang), monitoring their EFM strip and charting it. Oh, and you know, providing labor support as needed. Many patients on our unit end up getting epidurals, so I help with that, too–hanging a bolus of fluid, all the charting involved, regular vitals, etc.

Before the actual birth, I help the scrub techs get the birth table in the room, which has all the supplies the midwife or OB will need–cord clamps, sutures, placenta bowl, hemostats, sponges, etc. I bring in a lamp for the provider, and a mirror for the mom if she wants it, and an extra trash bag and dirty linen container. I bring in the baby warmer, turn it on, and make sure all the resuscitation equipment is ready to go, just in case (usually, babies stay skin to skin with mom, unless they need a little help with breathing). And I’m helping the mama as she’s pushing. I’m checking in with the baby nurse, giving updates about how labor’s been going. If mama hasn’t peed in a while, I might insert a Foley catheter, or straight cath her, depending on the preference of the provider.

After birth, I’m helping the provider as they wait for the placenta, handing over suture materials during any laceration repair needed. Or I’m helping do vitals and physical assessment on baby, giving vitamin K and Hep B and erythromycin (or “eyes and thighs,” as those meds are referred to, as the first two are injected in the baby’s thighs and the other in the eyes). I’m assessing mom’s bleeding, palpating the fundus to make sure the uterus is clamped down. Sometimes I’m administering more pitocin, depending on bleeding. I’ll help get her up to the bathroom for the first time, teach her perineal care if she has stitches. I’ll get more pain medication to her.

Of course, then there’s breastfeeding support. I’m getting better at finding the most succinct way to explain baby latches, and learning the gentle art of more hands-on support as they try to nurse for the first time.

Looking back on all this now, it sounds so simple and straightforward…but in all honesty, it took me the first few weeks to figure out the general rhythm, where things are, when and how to chart that she moved positions in labor, or got in the tub, or successfully latched. Plus all the little secrets: where to find the stretchy belly bands to hold the monitors, which most mamas like better than the velcro belts…or how to put a wash cloth in with the monitor to hold it in place better. It hasn’t been until the past week that I felt I could even begin to contemplate walking into a room without my preceptor and feel remotely competent.

But friends, it’s starting to happen! I imagine myself a bit like those awkward, clumsy baby robins you see in the spring. You know the ones…they’re all huddled together in the yard, flapping ridiculously, with their mama watching nearby, peeping encouragement or advice. But she knows that she can’t do it for them, so mostly stands back, even as they flap and flap and start squawking with frustration as they watch their siblings get airborne for seconds at a time.

It’s the strangest of sensations, but I’m starting to feel more like a nurse each day. Of course, there’s still so much more to learn…but those little moments in which I notice my feet aren’t on the ground and my wings are flapping just so and I’m not crashing back to the nurse’s station in search of that thing that I swear I saw in the supply room the other day…those moments are worth all the long hours of lecture and papers and reading. I know that this feeling will be short-lived, because in a few weeks, I’ll wrap up clinical and then move on to grad school, where everything will be new again…but at least for these last four weeks, I’m going to relish this feeling.

Oh, Benner

For anyone who’s been through nursing school, you’ve probably heard of Patricia Benner. She’s about as close to a nursing guru as you can get, I think. Which is to say, she’s a seminal practitioner, scholar, and teacher within the world of nursing. You can’t walk two steps in nursing school without bumping into her work somehow. Truthfully, there may be, from time to time, some eye-rolling that happens when yet another Benner paper is referenced in class. But I digress.

On the very first day, our faculty introduced us to Benner’s novice to expert theory. Basically, she identified five stages of nursing formation: novice, advanced beginner, competent, proficient, and expert. This sounds really, really basic and yet at the same time, when it was published, it was revolutionary. What make this paper so groundbreaking was the way in which she made visible the often invisible ways in which expert nurses “intuitively” know and practice.

As a novice nurse, I see this all the time. I walk in the room with my preceptor and in two seconds, she’s already assessed, interpreted, prioritized, is starting to act, and is reflecting and evaluating as she goes. She doesn’t do this linearly, it just happens. I, on the other hand, feel like I have to walk through every freaking line of the Adult Assessment doc flowsheet on Epic to make sure I’m not forgetting something.

Anyone who knows me knows I’m not an extraordinarily patient person. In fact, the only people who ever have commented on how calm and patient I am were my former doula clients. Everyone else falls over laughing at the very idea that I could be patient. So no surprise that fumbling my way through the rather ungraceful stage of being a nursing student is sometimes excruciating for me. Just get me to the expert stage, please!

And yet.

I can start to see little glimmers of how it might feel to just walk in a room and know where to start…how I might slowly ease into that place when I can competently (can we aspire for gracefully?) multi-task my assessment to minimize disruption to my patients.

In the meantime, I take heart in the whole 10,000 hours talk that was big a few years ago. And this short little video from Ira Glass on the craft of storytelling…and practice.

 

clinical reflection 1

This week was actually Week 3 of clinical…it’s going by so fast! I want to take more time to write and reflect, but it feels difficult to find the time. There’s always more work and the reflections often get set aside in place of trying to stay afloat on assignments.

To be honest, this fall has been challenging in several ways, starting with time management. Funny enough, my nursing mentor that I worked with yesterday singled out my time management as a strength of mine, which I think is hilarious. I felt behind all day long, whether it was because I couldn’t find the right dressings in the med room, or because she had to re-check a manual blood pressure I charted, or because my fingers just couldn’t press the right scroll button on Pyxis, or because Epic is…well, an Epic Monster to navigate.

So, in lieu of a more thoughtful, well-crafted reflection, here are a few tidbits of things I’ve learned in the past three weeks:

  • how to empty catheters and teach patients how to take care of them at home (when you’re on a urology unit, you get to see a lot of catheters)
  • go slow with the Pyxis (the touch screen is super sensitive)
  • answering the call light right away takes so little, but it means so much to the patient
  • warm blankets can totally change a patient’s mood
  • take slow, deep breaths. lots of them. often. yes, the patient’s need their meds…but they need them from a nurse who is calm and focused and completely present in the moment
  • eat breakfast before your shift, even if you don’t feel like it
  • keep practicing manual blood pressure, even if everyone uses the electric cuffs. you never know when you’ll need to check (and re-check)
  • listen. listen, listen, listen.