The Respiratory System

My physiology class is systematically taking me through every system of the body and relearning the entire system from a cellular physiological standpoint. Can you say TEDIOUS?

I just finished up 4 days of studying the physiological aspects of the respiratory system. Why is this important to a future midwife you may be asking? Well, I kinda did too, when I began my monumentous journey through all of the material including 2 APA papers on the subject. Well, I am always pleased when I am able to apply the learning I am doing on a practical level for my practice now as a nurse and later as a midwife.

The gem of knowledge I will take away with me from this lecture involves the physiological response to excess interstitial fluid leading to peripheral and pulmonary edema. As a nurse in a high-risk obstetrics department I often take care of patients with PIH and pre-ecclampsia. And, I always knew the importance of assessing for pulmonary edema vigilantly. However, I never knew the complicated and intertwined physiological processes that must happen in a cascade effect in order to produce pulmonary edema.

In a very short form, if interested, please read on:
When the renal system malfunctions by failing to filter sodium and water appropriately, fluid overload occurs. This can result in peripheral and pulmonary edema. Excess fluid volume increases hydrostatic pressure and pushes fluid into the tissues. And, when renal disease is present, there is a decreased production of plasma proteins which results in decreased oncotic pressure of the blood. In the absence of sufficient onconic pressure, the venous system is unable to facilitate enough reabsorption. This can lead to increased peripheral vascular resistance, creating an opposing force to left ventricular output. The result is pulmonary edema (Black & Hawks, 2005, p. 214). Additionally, the lymphatic system is altered as it usually helps to compensate by removing residual fluid from the tissues.

Really, very interesting...

Black, J. M. & Hawks, J. H. (2005). Medical-Surgical nursing: Clinical management for positive outcomes (7^th ed.). St. Louis, MI: Elsevier/Saunders

Week of Certifications

While working in OB, you need to maintain various certifications... Most of which you don't use on a daily basis.. some of which I've thankfully never had to put into practice... However, this past week I had to use my most recently obtained certification - TWICE...

A couple months ago I went to an ALSO conference and became ALSO certified. ALSO stands for Advanced Life Support in Obstetrics. and it covers various OB emergencies that arise occasionally that require additional training. Some topics covered include CPR in the pregnant woman (different than basic CPR), Perimortum C-Sections, Breech births, Postpartum hemorrhages, Shoulder dystocia, etc. Things you never want to have to deal with... But need to know how.

It was great to have the certifications "In my pocket" so to speak and know exactly what to expect/do when the situations arose. Not all of the nurses on our unit are ALSO certified, so not all of them knew exactly what steps to take... and it was reassuring to me that I did and was able to help others through the situations...

Everything went well with both situations and I wouldn't want to have to have them happen again... But, I'm glad I was there when they did happen, so that I could have the hands on experience under my belt and learn from them. I was in on a postpartum hemorrhage and a true shoulder dystocia.

In the postpartum hemorrhage situation, I was lucky enough to have a doctor there who is interested in my continued learning. He included me in the process the whole time... Took my suggestions and input and used it. And, afterward, he sat with me to process the situation so when I am there alone one day, I will be able to move quickly to the necessary steps.

All in all, certifications are a pain the butt to get and keep up on.. But in the rare cases they are needed... It feels good to kind of be on "automatic pilot" in an emergency and know exactly what steps are needed.

Today was a struggle

There were a few things adding up to make a difficult day today... The one thing that is hindering me the most at this point is my circadian rhythm. In working night shift half of the week and being off half of the week, my body just gets adjusted to working when all of a sudden I stop and expect my body to readjust to "normal" life. The result is a mess. Even when I'm off, I wake up at 1am and am ready to eat "lunch." I was awake from 1am-4am last night... and could. not. sleep. Then, I cannot stay awake during the day. It just sucks.

So, today, I got up for the day at 7am, after just a couple hours of sleep and had a specific list of things I had to get done for school and my family. Then, what happens? I get a full blown migraine --- Because I didn't sleep! So, I HAD to take time out and take a pill and lay down... So, what happens? I go to sleep! What a mess.

It was about 1pm and I literally said to myself, "If I do not get up, push forward through this headache and do my studying, I will NOT become a midwife." So, with that in my mind, I did it.

I ticked off one thing after another on my "to do" list. I read 2 chapters of bio-statistics... Listened to all of the lectures to go with it. Did the review sheet for the module. And, took the bio-statistics exam and got a 100%.

Then, I went on to make a healthy, good tasting dinner of chicken Parmesan for my family. And, after dinner, I took my daughter out for some needed mother-daughter time.

It may sound like I'm patting myself on the back... But, darn it... It was a hard day, and I struggled through every part of it...

I have to just thank God for the strength and determination he gave me to get off that couch and take the next step. Each step counts. I'm glad that this step is out of the way.

On to tomorrow. and the next day... for the next 2.5 years... Ummm... we'll see.

Biostatistics Underway

I did my first on-line Bio-statistics class module. And, I found it surprisingly manageable! This is due to the fact that last spring I took a 4 credit college, graduate-level statistics course. So, it is fresh in my mind... And, it covered a lot more than what we will cover in this course.

When I was researching which school to attend, both Frontier and University of Cincinnati required an undergraduate statistics course be completed; but, Frontier required one within the past 10 years. And, Frontier also did not require you to re-take statistics at the graduate level if you had one in the last 10 years. If you did not have one in the last 10 years, then you simply had to take a statistics course offered at Frontier. University of Cincinnati both required a statistics course during undergraduate school AND a Bio-statistics course at the master's level.

Since my undergraduate statistics work was over 10 years ago, I decided to be safe and re-take the course while awaiting acceptance into my master's degree program with the thought that if I went to Frontier, then I would not have to take their program (taking it from the University near my home works better because my husband works there and I get a 75% discount)... And, if I decided to go to University of Cincinnati, at least I would be re-freshed on the statistical processes, etc.

Well, I decided to go to University of Cincinnati, and it seems my bet paid off. With my advanced physiology course being SO in depth and difficult, it is refreshing not to have to work my butt off at re-learning statistics!!!

Enjoying an easy course: Bio-statistics... Who would have thought I would be saying that!!

Knee Deep in Physiology

So, the first few days of graduate school have gone by. I was supposed to start on Thursday... But I received a shock MONDAY morning when my online course content was available to me! It took my breath away, literally. I was not ready to start classes until Thursday. I felt utterly unprepared... As if, a mere 3 days would make any difference at all... I felt like I was being cheated out of my last three days on earth.

I can only explain my feelings as being traumatized by my nursing school experience and NOT wanting to re-enter that state of living... Work, School, Clinicals... No sleep... No family time.

But, here I am... I refused to open any books or do any on-line work until THURSDAY, thank you very much... But, now I'm knee deep into Physiology... Tomorrow I will start bio-statistics...

Remember the action potentials? How bout DNA/RNA transcription/translation? The sodium potassium pump? Mitochondria and Endoplasmic Reticulum... Yep, that's my world right now.

I'm striving to connect what I learn to my future as a midwife... so when I find little gems in the midst of advanced physiology that directly connect to childbearing women I get a little thrill.

Today I was able to connect the action of lysosomes to the process of uterine involution after childbirth. Lysosomes act as an intracellular digestive system... and when regression of unneeded or unused tissues is needed, the lysosomes get to work. Another example of this occurs in the mammary glands after lactation has ceased. Tissue dissuse lead to increased lysosome activity.

So, while spening 8 hours today studying advanced physiology I was able to directly relate a small part of what I learned to what I practice.... The whole base knowledge will be needed, I know... But, I love connecting it as I go!

Preparations

My before graduate school preparations are in full swing. These are things that, in my mind, if I get them done, they will enable me to be successful in school. What do they include this time around?

Because I will have next to no time apart from work, clinicals and studying for classes and exams, I am worried about my house work getting done. So, here's how I am handling that:

1) I've given the kids more chores. They already have several chores they do on a daily basis - But, they get paid a monthly allowance for these chores - AND, they are getting older now... So, I've added one more chore per child. I now have no kitty cat duties... the sweeping, scooping and changing of the litter are no longer my responsibility. It's not even my cat... Surely, it was an acceptable thing to ask the kids to take care of their own animal?

2) I've set up an interview with a perspective house cleaning service. They would come into the house and do all of the vacuuming, dusting, wiping of kitchen counters & appliances, cleaning of the light fixtures and ceiling fans, scrubbing the floors and cleaning the bathrooms. If I could get these chores off of my plate, it would be a major relief and free up a lot of time for me to study.

Additionally, I am worried about creating a work space for me to study in. In the past, I have used the kitchen table, my bed or my favorite chair in the living room. But, the drawback to not having a specific study space is that if meal time comes and I am at the table, I have to pack up my current project and move it... and I am generally right in the middle of all of the normal household commotion. So, I have begun looking for a desk - just for my computer and my school books. I would like to put it in a place that is away from the action.. Perhaps my bedroom... But, it gets very cold down in my bedroom in the winter... I'm still working on this.

There is still one thing weighing on my mind: The cooking/grocery shopping. That is a never ending, time-sucking cycle that worries me. My husband can shop if I make him a very specific list... But half of the tings I buy are things I pick up while going through the aisles. And, often after working all night and sleeping all day, I am able to wake up and make dinner and have it on the table by 5:30 when he gets home... But will I be able to spend that time cooking? Or will I have to fit an hour or two of homework/studying in?

That's where I am at. In a frenzy trying to get my life in order - to basically not be here for 2 & 1/2 years. :(

Starting Again

Only a couple of weeks left and I will be starting the last leg of my journey: Graduate School leading to becoming a CNM.

I have nothing but feelings of dread about school at this point. I think I should have some excitement mixed in there... But, NO... Just dread.

I registered yesterday for my first two classes at University of Cincinnati: Advanced Physiology and Biostatistics for evidenced based practice. I'm putting off buying books until I get home from Vacation at the beach.

I took out the largest loan I've had to take out yet for one year of school.

I'm just scared that I may invest this much time, energy and money into something that I am not able to follow through on... I think it's my fear that I am not deserving of my destiny... My dream to become a midwife and this is the last step that I need to complete in order to achieve it...

But, you, dear reader, are not my psychiatrist... I'm just voicing my fears... Normal as they are. They are there; along with the feeling of dread about entering back into the state of being overwhelmed with work + family + school + clinicals = Me at my limits. I do not look forward to going back into that state.

But, our family as a whole has decided this is the best thing for all of us. 2.5 years that, when over, will enrich our lives forever. I'm just going to buckle down and do my best.

The Joy of Birth

My husband asked me a few weeks ago if the joy I used to get when attending a birth was still there now that I am at a birth nearly every day I'm at work. I told him, regrettably, that it did become somewhat routine for the most part. I am usually busy tending to the needs of the patient, making sure the doctor's orders are followed, lab work is normal, set up is ready in time for the birth and keeping a watchful eye on the fetal heart rate tracing - doing interventions as needed and alerting the doctor of any problems. Pretty clinical most of the time.

I hadn't really thought about it much... But, yeah... for the most part the joy I used to experience as a doula at births is largely gone. It made me sad to realize this.

Then, about a week or so ago, I attended a birth that transported me to that old joyful experience once again. It was a breath of fresh air. I can't put my finger on exactly why this particular birth touched me again... but it did. I found myself laughing and cheering at the end.. and when the baby was actually born, I was clapping! The labor nurse: clapping!! The doctor looked over at me and said, "You can start the pit now." And it snapped me back into reality: Oh, I am the nurse. Oops!

It was lovely. I wish I could say each birth still touched me the same way.. But I am at least glad to say that I am still able to be moved by birth.. If not every birth then some.

2 Years

This week marks 2 years that I have been working as a Labor and Delivery Nurse. The time flew by... I know it's so cliche to say so... But it feels like it!

I have had many experiences in the short 2 years I've been doing this and I've learned a ton. I've cried more than a couple times... some times out of joy sometimes out of sadness and even out of frustration.

Some of the memories I've made will stay with me forever - I hope.

I remember my first medication error. I thought I would just die... I administered someone a percocet instead of a Tylenol with codeine. Thankfully, it wasn't a grand error in the scheme of things... But it did make me a better nurse. I became even more vigilant when administering medications to patients. The best way for me to learn, I've found is to actually get in there, do it and learn from my mistakes. Our hospital's medication administration system is antique to say it nicely... and this coming year we will be updating it to the "bar-code" system... which will aid in preventing further errors like this one that devastated me as a new nurse.

I remember the first time I had to resuscitate an unresponsive newborn. I've gone through many certifications as a new maternity nurse, but the one I use most often - even daily - is my neonatal resuscitation certification.... That combined with my ever available co-workers make "catching a baby" one of my favorite things to do.... Thankfully it is few and far between that I actually have to put into action the resuscitation measures ... but it has happened a couple times... all with good outcomes.

I remember the handful of times I got the privilege of delivering the babies - when the doctors didn't make it to the birth in time. It is an awe-inspiring event for you to be the first set of hands that touch the fresh, new baby... Yours are the hands that check for the nuchal cord... that gently guide the head and shoulders over the perineum... It is just awesome and part of what motivates me to keep moving forward towards my ultimate goal of being a midwife.

I remember with sadness the few fetal demises I had the opportunity to be a part of. The heaviness in that room when the breathless baby enters the world... Never to take it's first breath or cry its first cry... It stays with you forever.... Peace little ones...

I remember the joy of attending my first VBAC and first vaginal breech birth with our new rouge, trail-blazing physician, whom I absolutely LOVE!!!

I've been blessed to have been led to this particular place of employment as my first experience as a labor and delivery nurse. I kind of thought I would find aspects of this job I liked... But overall I thought it was going to be a necessary step towards the direction I feel compelled to head into; But, I have honestly come to absolutely LOVE being a labor and delivery NURSE.... Yes, it is still a necessary step towards my goal of becoming a certified nurse midwife... But it is a step I will cherish forever and one I could honestly be very happy at for a long time.

Open Letter to Medical Students

This is a open letter to all Medical students thinking about a career as an OB/GYN from a L&D nurse.

Please think long and hard about your decision. Consider all of the factors that there are to consider. Do not be swayed easily into this profession by beautiful bellies and babies; because if you are, you may end up regretting your decision for a long, long career. Your happiness and that of the nurses around you demands that you think LONG and HARD about the realities of being an OB/GYN.

Some of these realities include:
- Pregnant women - AKA your patients - have babies at ALL hours of the day and night.
- You will be expected to be on call during ALL hours of the day and night.
- When pregnant women - AKA your patients - come to the hospital in the middle of the night to have a baby it is not because they have an evil plan and were waiting for YOUR night on call to do so.
- When your patient needs orders or procedures nurses are not able to provide alone, you - the doctor - will be called during ALL hours of the night.
- You will be expected to work the day after you are on call all night and your patients will still need things that day - again, there is no evil plan to make you miserable.. they just need medical attention.
- Nurses are not allowed to make treatment and diagnostic decisions without the guidance of a doctor... that is you... and yes, this will happen at ALL hours of the night.
- You are no better or higher of a person than anyone else. You have no right to take out your frustrations with work or lack of sleep on anyone who needs your assistance (including your patients or their nurses) during ALL hours of the night.
- You make significantly MORE money than the nurses you are rude to when they wake you up in the middle of the night.... and YOU decided to choose this profession.
- When nurses order chinese food: watch out. (Yes, they may be the ones with the evil plan....)

Did I mention you will have to work during the night time - and it is not the end of the world?

Just sayin...

Night-time Nerves

Why am I up at 4am on a night I'm not doing the night shift on the OB unit? I'm a nervous wreck about my teaching debut today!

I accepted an offer to teach OB clinicals for half a semester at my Alma Mater. So, now I am the nervous instructor where once I was the nervous nursing student.

The source of most of my anxiety comes from the fact that I am doing my clinicals at a hospital that I do not work at. I have to use their pyxis/electronic medication computer system, etc. and learn their protocols, etc. I just wish it were at the hospital I am already working at where those details were not a source of stress to me and I could just focus on mentoring the students.

Another source of stress is in the details. As a practicing nurse on OB, when I assess a postpartum woman's fundus, I feel it and can automatically tell if it is appropriate or of concern without really thinking much about it. But, now I have to go back to my textbook days and be able to site that at X number of hours postpartum the fundus should be midline, firm and at X-finger-breaths below/above the umbilicus, etc. etc. Another example: when I listen to bowel sounds on a post cesarean section mother, I put my stethoscope on her abdomen and can tell relatively quickly what we are dealing with. But, that will not be good enough. I will have to now instruct student to listen to each quadrant in a clockwise motion before palpation for X number of seconds and count the number of bowel sounds heard and their characteristics in order to successfully assess the patient. See what I'm saying?

And, as I former student who lived for the DETAILS, I know there will be a student or two who are just waiting to test the new instructor and deem her fit/unfit to instill knowledge into them.

Anyway, dispite all of my fears, I am looking forward to it. I used to do doula work at this hospital, so I am hoping to see some of the doctors and nurses I used to work with years ago. And, it is a new experience. One I am thankful to have.

Wish me much luck, please!

Doctor Drama continues

With the risk of sounding like a broken record here, I'm going to talk about problems with another doctor. Dr. "Hostile," whom I talked about before has somehow been able to maintain an appropriate attitude while around me ever since our conversation. So, I suppose he is showing me proof that doctors can hear your complaints and change - If they want to. He still has his quirks.... but he is SOO much more respectful... I'll deal with the quirks.

This other doctor, I'll dub "Dr. Miserable." She is just that: miserable. She is a relatively young doctor who hasn't been practicing very long. But, she truly acts like she hates her job. She gets upset when she is called in while she is on call. She audibly sighs and says things like, "Great!" or "It figures" to our request for her presence on the unit. What can I say: women come in and have babies. It is kinda what we do here.

I do agree being an OB/GYN is a demanding job. But, do I have sympathy for her? Ummm, NO! She chose this career. She is being amply compensated for her efforts and I am about done hearing how miserable she is. She made a comment one evening while working late at the hospital that she only saw her daughter 5 hours in the last week. Well, shall we compare notes? I just worked 5 straight 12 hour night shifts. I wake up 1 hour before leaving for work and spend 1/2 an hour getting ready... So, in the last 5 days I've only seen my children 2.5 hours. And, I don't get paid nearly as well as she does to NOT see my family.

The point is everyone on maternity works hard. Everyone is stressed at one point or another. But, the difference is in the actions of the people. If we as nurses acted like the doctors freely do and wear our emotions on our sleeves and huff and puff and sigh and yes - even swear at people when we were asked to do OUR JOB - we wouldn't be working there long... would we? But, it seems to be totally acceptable for the doctors to be able to do that.

We need to work together. Everyone would rather be at home with their families. Everyone would like to be independently wealthy. But, few are. The rest of us have to work together and not make things worse on everyone else by being disrespectful to others because of our own personal misery.

The last night I worked another nurse took Dr. Miserable into an empty room and addressed her actions... So, here is hoping that she listened and will respond appropriately in the future. We shall see. She is so young, though... and has so many years ahead of her to practice medicine... If she truly hates it, I hope she can figure it out and move on to anohter field. For her own good as well as those she has to work with.

Standing up for Myself

Just to follow up on my previous post about a certain "Dr. Hostile" and my need to address his behavior in order to respect myself. Well, I DID address this particular doctor. I clearly outlined his behavior, attitudes and actions and the affect they have on me as a nurse. I told him his actions - regardless of intentions (because he supplied a few excuses such as being busy, etc.) - were rude and disrespectful to me as a nurse. I was true to myself and addressed every issue I felt I had with this doctor.

To my surprise he actually heard me. I doubted that things would change significantly; however, in the several weeks since our conversation, his actions and attitude has been more than appropriate. He includes me in the decision process, asks for my professional opinion and has not once been rude or disrespectful towards me.

I am not the only one who has witnessed a change in him since our conversation, either. Multiple other nurses have expressed their pleasure in his new efforts to not be a "PITA." Whether these changes will be long-term or not is still questionable. But, at least I feel like I stood up for myself and proved to him that I was not going to be disrespected "just because."