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“Sometimes You Have to Just Walk Away…”

There is a particular statement that I have heard on Labor & Delivery units — not just on one, but on every single unit where I’ve attended women’s births. I have heard it from nurses, I have heard it from OBs and anesthesiologists, I’ve even heard it from midwives.

What happens before the statement is made is that a woman is laboring. She is in pain, and she is doing something to express that pain: perhaps she is calling to her family members for help; perhaps she is unable to keep still in the bed, causing the fetal heart monitor to fall off. Perhaps she is saying over and over that she can’t get comfortable, or begging to be allowed up out of bed to walk, although she will not be allowed to because of her epidural. She may be asking why she is still in pain despite the fact that she had an epidural. She may be loudly vocalizing her contractions — she may be screaming as they occur. Perhaps she has been doing some combination of these things for hours.

The nurse has wandered in and out of the room and said that the woman can’t possibly be in that much pain at only 4 centimeters dilated. The anesthesiologist has been called in and swears that the epidural is in correctly and that the woman is just feeling pressure, not pain. The midwife, shame on her, has stood three feet from the woman’s bed and said that she can ask the anesthesiologist to replace the epidural catheter, if that’s what the woman would like.

Everyone clears out into the hallway, leaving the woman alone in her room. And then someone turns and says to me, the student, as if offering some great wisdom: “Sometimes you have to just walk away and then she’ll calm down.”

I am recording this here because this statement should never become normal or acceptable to me, no matter how nonchalantly it is said, no matter how reasonably intentioned the person who says it. Bear in mind that I don’t mean a situation where a woman asks for privacy to labor (privacy being something that she will never get in a hospital), but rather one in which the clinician judges that the woman would be better off by herself.

The assumption behind this statement is, first and foremost, that the woman will essentially be alone in her labor. There is no expectation that she should be continuously supported throughout labor (as has been shown over and over again in research to lead to the best outcomes), no expectation that one should do anything other than spend a few minutes at a time dealing with her.

This statement also represents the feeling that a woman asking for help in labor is, after a certain point, just a complaining, attention-seeking, pain in the ass. Her pain, discomfort, or distress isn’t real — especially if you already gave her medication. She’s just being melodramatic, and what she really needs is for you to ignore her a little bit so that she can spend some time alone in her room. Like a child. You acknowledge that the woman is having anxiety and frustration — and your reaction is to walk out.

I have recently had the realization that the people who make this statement are also fundamentally ignorant — despite being professionally involved with women giving birth, they have almost no idea how to comfort them, calm them, and make them feel cared for. It’s not exactly their fault; most clinicians have lots of patients and are taught to use very few tools to relieve suffering apart from epidural anesthesia. Nevertheless, it is galling to see that this is apparently good enough for them, and that they consider it natural not just for women to be in pain in labor, but to suffer deeply as well. (The difference between these things is a topic for another time, but sufficed to say that they do not have to go hand in hand.)

Finally, this statement begs an obvious question: If you’ve left the room entirely, returning only hours later or when she shouts loudly that she is going to push the baby out right now so you’d better get in here, how on earth would you know if you helped her to calm down?! You left her alone, you fool — you have no idea whether she is curled up in a knot of suffering, or whether she’s actually glad to be rid of your ham-fisted, anxiety-provoking presence.

I know that there are some future midwives reading this post, so my reminder to all of us is this: the next time you hear someone offer you this particular “wisdom”,  remember that a gentle hand, a low voice, and a calm, steady presence can be the difference between a happy, healthy birth and a violent, traumatic one. Go back into the room and stay with her.

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Encountering the Newborn

When I first decided to become a midwife, people would often remark, “Oh, you must just love babies!” or “You probably can’t wait to have your own babies!” (Do people who announce they want to become obstetricians get the latter reaction too? I’m guessing not so much.) In reality, midwives mostly care for babies when they’re still inside the mother. Midwives take care of women, pregnant and not; once a baby is out in the world, it’s generally the midwife’s purview only for the first few weeks of life.

The truth is that prior to nursing school, I didn’t think that babies, especially newborns, were all that fascinating. I was sure I would be fascinated by my own, but newborns as a whole seemed largely to sleep, and when they were awake they seemed largely to scream. Nothing too thrilling there.

Then I got to do my OB nursing rotation, and had an excuse to spend hours inspecting newborns: observing their entry into the world and their adjustment to its climate; their experimentation with their limbs, muscles, joints; the perpetual, quiet movements of their mouths; the almost elderly expressiveness of their foreheads.  As obvious as it may seem to anyone who has actually had a child, I discovered that for the brief periods when newborns are awake and alert, they get up to plenty of very subtle business. You just have to be paying attention to see it all.

But there is an encounter even beyond that. If you are attending a woman’s birth, and you get very lucky, you get a chance you stare into the eyes of a human being only a few minutes old. The conditions must be right: the room cannot be so bright that the baby refuses to open its eyes; the nurses cannot have applied so much antibiotic ointment that the baby physically cannot open its eyes; the baby cannot be too exhausted from a difficult labor or too dopey from analgesic drugs — and of course, the woman has to allow you to do it.

Today I got lucky. Despite enduring a long labor, the tiny girl emerged pink, alert and calm. Once she had been tidied and bundled according to hospital policy, and had a chance to be adored by her mother, I held her while the mother made herself comfortable on the bed. The girl fixed her eyes on mine, and I was reminded of the special color of the irises that only newborns have: a deep, dusky blue like the lightless ocean floor.

As a child, I remember the first time that I stared into the eyes of a bird — a pet canary — and was startled and frightened to find that they were not human eyes. It was my first understanding that my perspective was not that of all creatures, and that the minds of almost all others would be unknowable to me in the most fundamental way.

The eyes of a newborn force me to confront this fact again; there is a recognition that we come from the same root, but their look is otherworldly, ancient. As if they were a new immigrant from another universe. I am reminded that they have just gone through a process that I also went through, but have irretrievably forgotten. The preciousness with which we cradle them seems the only reasonable response.

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Ripping Off the Band-Aid

When I moved to China in 2009 with the intent of writing about my experiences there, I believe I began simply by beginning. When too much has happened in your life, you begin to feel as though you can never catch up in recounting it all — meaning that perhaps you never try. So now, as then, I’ll just begin again, and hope that the stories of the past year that I have wanted to share will simply surface.

If this is the first of my posts you’ve read, let me save you a little trouble: when I moved back to America in 2012, I tried writing about nursing school as it was beginning — but what ended up coming out was a lot of narishkayt about how much homework I had. It’s true that in the past 16 months I’ve sat through lecture upon lecture, studied for hours and days on end, and passed my nursing boards a few months ago — but so did everyone else in my class.

I’m now in my second semester of midwifery school, and since this past week I had my own patients for the first time (as in, alone in a room with a pregnant woman doing her 20-week prenatal visit), I have been thinking about the many firsts of the past year: the first patient I cared for as a nursing student (a 54-year old man with liver failure), the first patient whose body I bathed (an 81-year old woman with a small bowel obstruction), the first patient I had who made me feel so insignificant and incompetent that I cried in the medication room (a 16-year old girl — of course — with bone cancer and a serious attitude).

The first patient I had who died in my care. She was 3 years older than I am. I was alone in the room with her, my hands on her chest.

The first patient I had whose life I knew I had changed, and who in turn changed me. She was a Chasidic woman, and though I have now seen perhaps 75 women give birth (not many, in the life of a midwife), this woman immediately held some special power over me. I stayed with her for 12 hours as she labored with her 6th baby, predicted to be not much larger than the 7 lbs of each of her previous children. She labored all day, struggling with her daughter still inside her, doing the slow dance of the birthing woman that speaks of a deep and private pain. Towards the end of her labor she lost almost all of her English, speaking only Yiddish, a language in which I could not then communicate — but she dropped her head on my shoulder and wailed to me that she could not, that this work was not possible. And somehow, with the low words that were all she wanted, I helped her to believe that indeed she could. She gave birth to her 11-pound daughter not long after, and the love I felt for that moment, for her strength, is still with me. One of the great moments of my life.

I began learning to speak Yiddish in earnest a month later, and found a deep ethnic identity that I did not know I had lost — another first. Perhaps more about that later on.

*****

Autumn has arrived in earnest in the past few days, and it’s approaching midnight — both of which I will blame for the mawkish turn of this post. I used to write poetry, and this moment in my life is a time that is probably deserving of such attention, but I’m finding it enough to read the poetry of others. I recently found Rachel Eliza Griffiths’ slim volume,”Miracle Arrhythmia,” on the shelves of a second-hand bookstore in Brooklyn. Recently I’ve been thinking of ordinary things that anchor a life — of food, of sleep, of mending tears in a shirt. This is what I read tonight:

Portrait of a Sunday Woman

Once I saw your mother as a wife.
Sunday morning she stood at the stove,
pressing her wrist simply against her hip.

She wore a robe, red as temper.
Her shorn hair glowed like a burn. Fire
haloed the filter of her cigarette.

One bare breast welcomed the sun; steam
curved from the tin kettle. She wiped
her eyes, over and over.

Turning her head, silent as a bird, your mother
lifted a wedge of lemon and sucked
the dull dream from rind.

By then I had been kissed by a man and knew
something of the crumple around the corners of
the mouth on those godless mornings.

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Forged

When I was considering applying to nurse-midwifery school, I read a lot of nursing students’ blogs. Invariably, these students reached a certain point at which they caved; they had previously had lots of nice ideas about how they were going to lead balanced lives, in which school was simply one of their pursuits, but eventually they gave up that pretense. FINE, they would say, addressing nursing school as an evil taskmaster. You win! Here is every ounce of my energy and every hour of my time! Let me know when you’d like a pound of my flesh!

Since I’m an arrogant jerk, I thought that they were kidding. Or that they didn’t know how to manage their time well. Or maybe that they were just sort of slow. You will notice, however, that I stopped blogging after week 3 of the summer term – that’s about when I too gave in and acknowledged that basically all I was going to to do this summer was commute, sit in class, go to the hospital, and study – every day, approximately 16 hours a day.

I’m now on vacation, which means that I made it through the first term and am gearing up to begin the second in less than two weeks. Before it all gets going again, I want to try to write something here that might be helpful for anyone else considering this education.

The kind of accelerated BSN/MSN program that I’m in involves a totally unreasonable, uncivilized amount of work: all-day lectures, constant examinations, basic care of real patients beginning in week 2. It’s also a kind of academic work that, for someone with a liberal arts undergraduate degree, resembles nothing so much as weight training. Whereas most of my previous education involved polishing my skills of writing, critical analysis, and argumentation, 80% of my work this summer has been the straight memorization and application of large quantities of information: I spend my weekends bench-pressing pharmacology. It has been a muscular, at times numbing, process.

The rapidity with which this process not only educates you but prepares you to take on a new identity as a clinician is breathtaking, and quietly thrilling. They call this first summer Boot Camp because it is the academic and clinical equivalent of shaving your head, waking you up at 5am with reveille, and running you through combat drills until you’re not totally positive that you remember your full name.

Your vocabulary is remade, and you annoyingly delight in telling friends and family members the medical terms for common conditions and physiological processes. (“Did you know that your stomach growls are called borborygmi?” “I see that your baby has a club foot – did you know the name for that is actually congenital talipes equinovarus?!!”) You can see how completely insufferable you are becoming but you can’t do anything about it because you’re so stuffed with new information that you JUST HAVE TO TELL SOMEONE.

You come to find it normal to get up at dawn, spend a full day at the hospital, come home and study for six or seven hours. You ask unsuspecting friends to remove their shirts so that you can listen to their lungs. You conduct full physical assessments of your parents, figuring that if they’ve agreed to support you through grad school they might as well see that you’re learning something. You practice identifying physical anomalies by scrutinizing fellow passengers on the subway. (Nail clubbing! Bouchard’s nodes! Acanthosis nigricans!)

When your lab instructor sets out a table of needles, bottles of saline, and sterile swabs and offers you the chance to inject your classmates, you feel not horror but elation and recognize this as the highlight of your week.

After a couple months in the hospital you realize that you can no longer smell the eerie, sterile, chemical aroma of the unit that you initially found so disturbing. You find that you are increasingly comfortable touching the bodies of sickly strangers. You are humbled, but no longer surprised, when patients stand in front of you naked as the day they were born, asking for your help to clean themselves.

This is how these programs begin to turn a bunch of East Asian Studies majors, financial analysts, and Peace Corps volunteers into advanced practice nurses and midwives: they kick your ass until you’re pretty sure this is what your life has always been like.

I know I’m going to regret saying this, but I can’t wait to start again in September (when I am considering blogging about something other than the sheer volume of work that I have). Having finished the first term of this education, and with the perspective that comes from being on vacation, I feel completely remade – and exhilarated.

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Open Your Mouth And Say “Aaah”

Somehow, it’s the end of week three – and I’m still sort of standing!

I really thought I was doing well; I’ve been on top of my work, doing well on tests, even managing to get a decent amount of sleep. And then today, after my 6am wake up for my weekly four hour pharmacology lecture, I realized that I am actually feeling an overwhelming sense of exhaustion and the desire to sit in a cool, dark room for the entire weekend. (Not that that’s an option, what with all the studying I need to do.)

Has it really only been three weeks of class? Hasn’t it been more like three months?

I keep reminding myself that this summer is a sprint: intense and over before you know it. Truly, there are aspects of this program that I’m loving – why don’t I go ahead and write them down to keep myself from turning this post into an unsavory whinge-fest:

  1. For the most part, the standard of the teaching is very high. I have enormous respect for my professors and instructors, and am constantly concocting little reasons to schedule an office hours meeting with them, despite the fact that I don’t have any questions of an academic nature. Just so that I can hang out with them and ask them about their lives and careers.
  2. My classmates are excellent – sharp, engaged, compassionate, and with a dizzying variety of backgrounds and accomplishments. I’m glad to know them and proud to be counted among them.
  3. I’m loving learning how to conduct a full physical exam. During this summer we’re each paired with a classmate on whom we practice inspecting, palpating, percussing, and auscultating from head to toe; I swear it’s like being given the keys to a secret garden of weirdness. Did you know that your optic disc looks like the sun setting inside your eye? Or that your ear’s tympanic membrane looks like mother of pearl? Or that there’s actually a reason that they ask you to open your mouth and say “aaaah” at the doctor’s office, apart from making you look like an idiot? (It’s to visualize your pharynx and tonsils, as well as to ensure that your soft palate rises symmetrically while your uvula stays midline – indications that your cranial nerve X isn’t damaged.)

Interestingly, I’m feeling a little more tepid about the thing that other members of my class seem most excited about: the one day each week that we spend in a hospital unit learning how to be actual nurses. There’s nothing like suddenly being assigned to care for an ill stranger in a hospital to make you realize that you are ignorant in the most fundamental of ways: how should you speak to the patient? How should you touch them? How do you walk the fine line of providing care appropriate to the professional role of a nurse, without veering into non-professional areas like socializing with them or being their “fetcher?” (Hint: pouring water from a pitcher on the bedside for a shaky patient whose medications give them dry mouth is a-OK – fetching them (or their cousin) a Coke from the vending machine – NO A SPRITE! NO A GINGER ALE! – just because they want one, is not.)

This isn’t my first time interacting with people and providing them with intimate care in a hospital setting – but the last time I did anything like this, it was as a doula in China. And those women weren’t sick – they were just pregnant. True, they were sometimes in pain, but the pain of “back labor,” and how to manage it, isn’t the same as someone who has back pain following surgery for a herniated disc. Those women didn’t have open sores as a result of being bedbound in their homes; they didn’t have central lines that needed cleaning or tracheostomy tubes that needed suctioning. They were never so neurologically impaired that you couldn’t tell if their sudden grimacing was because you were hurting them or because some mental demon was flashing before their eyes.

Or perhaps it was something about the hospitals I visited in China made that those experiences so different from this one. The hospital to which I am currently assigned is such a nice institution: it’s recently built, it mostly serves the surrounding community (as opposed to being a magnet for transfers from other communities or hospitals), it isn’t a level I trauma center. It is well staffed, and mostly calm. They even have “quiet hours” during the day on the unit where I work in which the lights are dimmed and people speak in hushed tones to allow the patients to get rest during the day.

As much as this is all to promote a healing environment for those being treated there, it also creates an otherworldly atmosphere that I find unsettling. When I enter the hospital I feel as if I’m leaving the world of the living and entering a place of sterility and suspension – a place somewhere between this world and the next. No matter how nice you try to make it, a hospital is a place that serves as a land of limbo for the sick and dying; it makes my heart hurt to be in one.

I didn’t have this feeling in China, and perhaps, perversely, it has to do with the fact that the hospitals I was in were nowhere near as “nice” as the one I work in now – they were chaotic and dirty. Families wandered all over the place, carrying in food, clothes, and supplies for their loved ones (who are otherwise not provided with these things by the hospital itself). At the hospital that I visited in The Valley, a stray animal or two could often be seen roaming the halls.

While this made them much worse places from a clinical standpoint (my God, the rates of infection), they felt like places in which life was happening on a continuum with the outside world. I felt, oddly, more comfortable in them.

My role is different now, of course. The expectations that my wonderful preceptor has for me and my classmates are high, which puts me in a state of mild terror every time I have to do something new – although I am pleased to say that I was able to rally my Spanish skills somehow to interact with the first patient for whom I was responsible, who did not speak any English at all.

I’m uneasy just at the moment. I hear that it passes.

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Meltdown Tuesdays!

This morning when I got up, I was feeling pretty good. I had been studying for days, felt like I basically understood what I had been taught so far, and was ready to take on Tuesday, my longest day of the week at school.

Oh plus, I had my first test of the year yesterday and I aced it. (NURSING SCHOOL I OWN YOU.) Et cetera.

I was even feeling pretty good around 4pm today, 7 hours into my 11-hour day of in-depth discussions about varieties of hideous, crusty, skin lesions and a lecture about hospital bureaucracy in New York State.

(This is where you start wishing you had my life, right?)

Things started to deteriorate about 30 minutes into my advanced physiology lecture, when I realized that I wasn’t entirely clear what the professor was talking about, and broke down entirely at the 2-hour mark (that’s 9 hours into the day, for those keeping track at home), when I realized that I just. didn’t. get it. I could see the professor standing at the front of the hall, and I could hear that there were words coming out of her mouth about the cellular-level workings of the endocrine system, and that’s about it.

I started to panic that I wasn’t ever going to understand this material, or any of the hideous crusty skin lesion material, and that I am going to fail, AND that the real point is that I am possibly a complete dolt.

Good thing that was about when we got a break and I was able to go hide in the bathroom for 5 minutes and collect myself.

I somehow made it through the final two hours of the lecture, had a moment of sanity with a new friend who admitted that she had no idea what a beta-1 adrenergic receptor was either, and collapsed into a mostly empty subway car headed back to Brooklyn. Suddenly, I had a stroke of genius – a moment that clearly proves that I am not a huge dolt – because I knew what would fix the tizzy of utter dejection and despair that I had worked myself into!

THE BOSS. The Boss would fix this.

I will leave you to imagine the break dance I did down the middle of the A train (as well as to ponder how you are going to find a headscarf as fetching as Steve Van Zandt’s).

I felt the panic dissipate, like a fever breaking. (Which is known as the defervescent third stage of pyrexia, just by the way.) I remembered one of my realizations from last week, which was that, as long as I study for hours and hours, I’m going to do just fine. I put my focus on tomorrow, when I’ll get to do such fascinating things as practice physical assessments on my unsuspecting labmates by poking around their ears and inspecting their skin for any suspicious looking moles – and then thought even further ahead to Thursday, when I will spend my first day in a hospital unit. Taking care of actual humans. Who don’t really care whether or not I had a meltdown during my physiology lecture.

And I emerged from the subway, back home in Brooklyn, to a gentle rain falling.

So when next Tuesday comes around and I’m curled up in a little ball on the floor wondering how I’m going to go on – remind me that Tuesdays are the worst, alright?

And that The Boss knows best.

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The End of Week One!

In case you’re wondering how this first week of class went, allow me a brief, illustrative anecdote: I was intending to update here on Tuesday night, after the second day of class. Instead, I fell asleep in the laundromat over my notes on vital signs.

What I’d really like to tell you is that this week wasn’t as tough as I thought it would be, that I had just psyched myself out in advance and been worried for nothing – but that isn’t the truth. The truth is that I came home after 7 hours of class on Monday and reported to RP that the day had been terrifying, and that I came home on Tuesday after 11 hours of class half-convinced that this whole grad school plan was really, REALLY not going to work out.

Thank goodness I didn’t post on Tuesday night, hm?

I’ve since calmed down. Or rather, I’ve since spent hours and hours studying, and then calmed down. There are a few things that I’ve had to recognize:

  1. I am not being modest when I say this: not everyone in my program is finding this as difficult as I am. I think mostly what this summer is exposing is what each of us has just been doing; I have classmates who just graduated from other institutions with degrees in biology. I have classmates who have spent the past 5 years as nursing assistants in hospitals. They know a lot more about the topics we’re studying this summer – physiology, say, or physical assessment – than I do. They’re looking pretty relaxed right about now.
  2. Having said that, lots of my classmates are finding this just as difficult as I am. I’ve stopped a few people in the lecture hall during breaks just to confirm that I am not alone in already being sleep-deprived — check. People are already starting to show up to lectures in their pajamas, so I didn’t feel so bad when I looked at myself in the mirror today and noticed that, after only 5 days of lots of stress and less sleep than normal, I look terrible.
  3. The structure of the program means that students are bound to feel overwhelmed at the beginning; not only are we taking seven courses this summer, but we move from topics that are highly abstract to highly concrete as if it were no big deal. Yesterday I spent 8 hours memorizing facts about the nervous system. The day before, I learned how to change a bed pan.
  4. I’m not going to be doing much socializing for a while. Or possibly ever again.
  5. I’m going to be just fine as long as I don’t much other than study.

I was hoping to move through this summer with no problems, and with time to see friends, read novels, and hang out in Prospect Park. Between nursing fundamentals, physical assessment, advanced physiology, and pharmacology, it’s pretty clear that none of those things is going to be happening for the next couple months. And while it’s a little embarrassing to admit, I had been hoping that this process was going to be fun. I can now see that I’m going to have to take a slightly more adversarial position on the whole business, at least for this summer.

Nursing school: I am going to OWN YOU. Watch out!

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