New Midwife on Duty

 

IMAG1906-1I know it has been a while since my last post, and since I have now been over a month working at my new job as a Nurse Midwife, I figure it is well past time to update my devoted blog readers on my life these past couple months.

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To start with, I think I have gathered a new philosophy for life. Avoid doing hair and make up before work for at least the first couple weeks when starting a new job. People will get used to you looking good and put together. Then when you happen to take a shower at work and don’t redo your hair and make up, people ask if you are feeling alright. And since lately I feel my day is generally filled with scrubbing in to assist on C-sections every day, I really question why I bother doing my hair at all before work, since I usually spend the entire day wearing my scrub cap.

A surprising aspect of my new job that I have found being in my new job is that my tolerance to submit to possibly unnecessary c-sections has become a lot lower. While still I’m a midwife very fond of promoting normal birth, I have started to find that so many of the women I care for are so high-risk for complications, that opting to side with doing a cesarean almost feels like the safer thing to do for this population. loadBinary.aspxSo many of my patients already that have seemed to be perfect candidates for normal birth seem to end up with difficult deliveries, dystocias, hemorrhages, strangely shaped placentas that won’t come out, and seriously their vaginas seem to basically explode pushing the baby, resulting so many large, painful lacerations requiring long and difficult repairs. While I have heard many times that this is a tough job to start with as a new midwife, I have found it  keeps me up with my critical thinking and practical skills that may not be used very much in a very “normal birth” kind of setting. While I don’t particularly enjoy those teeth grinding, sweating bullets situations, it definitely keeps me more aware and up on my little midwife toes.

While I was a little traumatized by many of the birthing practices I saw in Argentina, I do frequently find myself thinking “what would the Argentineans do?” when I am in a grind. For example, one practice we learn here in the States that I really loathe doing is clamping and cutting a tight umbilical cord around the neck. new-picture-4I have had a couple experiences in training and at work where after cutting the cord around the neck after the head is born, it is only to find the shoulders to be tight and difficult to deliver. Cutting the cord before the baby is born leaves the baby without a life line that is crucial during a tight shoulder scenario. These babies usually need more help than usual getting started breathing and reacting after birth, and it is terrifying. What I found in Argentina is that they rarely even check for a cord around the neck after the baby is born, and even when there is one, there is no worry, because there is never any unlooping or cutting the cord before the body is born. 1-s2.0-S1526952307000062-gr1Rather, they deliver every baby by what is referred to as the “somersault maneuver.”  This technique is accomplished by simply tilting the baby’s face downward to the mother’s thigh after the head is out, then the rest of the body is then delivered in something like a flip, or somersault fashion, keeping the neck (and cord) close to the vagina to prevent pulling. When I first had this explained to me, and even after seeing it and being taught to do it hands on, I never ever thought I would have the coordination to pull this stunt off. Not when I’m in the middle of a delivery and nervous enough as it is! Strangely enough, the first few vaginal births I had after coming back from Argentina, I found my hands automatically flipping the baby out every time without trying; it just seemed like the natural thing to do, especially with a cord around the neck.

images-5Another interesting fact is that I rarely have patients that speak English. And translators are not always readily available. While I am able to speak easily to my Spanish speaking patients, trying to communicate in Creole is a challenge I am not yet ready to face. I spent a day or so seriously studying the language, trying to memorize words and phrases, feeling ready to start learning Creole as my third language. “No gen pwoblem” right? Yeah, the next day I forgot everything, but felt a little more in touch with the broken French and clicking that I feel I will never able to reproduce.

Nonetheless, I am getting by. After a full 60-hour work week, I feel I can do [almost] anything. I can say I continue learning new thing every single day, and while I do miss my job as a nurse at times, I am glad to be in the profession I have come so far to do. I say my prayers daily, before and after work, and often during the day, because I know that “You Lord give perfect peace to those who keep their purpose firm and put their trust in You.” It was a verse that I kept with me all through midwifery school, and I will continue to live by it now as a professional.

If you have ever watched the show “Call the Midwife,” you will notice in the very beginning of the show, where the opening credits start, there is a visual of someone’s diary, and it says “Chapter 1: Why did I start this?” I highly recommend watching that show, its British but its phenomenal. And if you do watch Call the Midwife, this is an EXCELLENT parody to the show and a couple other, and it is absolutely hysterical. I know my fellow midwives will enjoy this one…

 

 

 

 

 

 

 

La Parterita en Mendoza Parte 2

Finishing my final weeks in Mendoza has undoubtedly been the experience of a lifetime, both personally and professionally.

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Not only did I get the opportunity to meet and work with an incredible group of people throughout the placement, but I also had the opportunity to travel to Buenos Aires, meet some “familia,” and learn a little bit more what it means to be Argentinean.

As I mentioned in Parte 1 of my trip, things are very different in Mendoza, everything from the slow, easy pace of life to the routine practice of episiotomies on primagravidas. And what an odd balance of conservative and liberal interventions there are!  One day, while sitting around with other parteras drinking maté, we came to the discussion of prenatal care and genetic screening.   Interestingly enough, they don’t typically do any of our routine blood work for genetic screening, but on the other hand, will do 3 ultrasounds instead, at least one ultrasound each semester, starting around 12 weeks. It is in this way that they screen for physical abnormalities, fetal anatomy, and an estimated fetal weight at the end of the last trimester.

As a very ambitious homework assignment from my Spanish teacher, I took my official State Midwifery practice protocol and translated it into Spanish. Took a lot of time and effort on my part, but I definitely feel it helped to enable the other midwives to have a better understanding of the role and practices of the Nurse-Midwife (“la Enfermera-Partera”) in the United States.

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Most things were more or less the same, and some very different. Parteras in Mendoza pretty much only work in the practice of birth. It was explained to me that very rarely are their midwives involved in prenatal or postpartum care, and almost never involved in non-obstetric gynecologic care.They are also unable to prescribe medications outside of Oxytocin or cervical relaxants during labor, not even antibiotics. They also do not First Assist or participate at all in cesarean deliveries. On the other hand, their midwives will often deliver twins and breech births, although, they did mention that breech births often are by cesarean delivery unless the woman has been laboring well prior to arrival at the hospital.

versusIt still strikes me in amazement at the conservative approach they use with fetal monitoring however. Even for the “high risk” patients and patients on oxytocin, they only use the doppler to listen for fetal heart rate “every 30 minutes,” or whenever they finish another round of maté. Although I can’t blame them, sitting around in waiting is a practice that comes with the labor and delivery territory, feast or famine. But in the US, I feel like we always are at least trying to “seem” busy, whether it is watching the fetal monitors, comforting patients, doing CEU’s. In my hospital in Mendoza, there is no sense of really going above and beyond, and no one seems to mind either way. As if their practice of FHR monitoring didn’t shock me enough, the method they use for timing contractions is even stranger to me. Although they document contraction rate every 30 minutes with the fetal heart rate, it was explained to me that they count how many contractions there are in 10 minutes, measured by manual palpation. However, I have to say I don’t honestly think I ever saw anyone stand there for 10 minutes straight feeling for contractions. It was more, asking the mother how many she thinks she had in the last 10 minutes and going by that, although there are not actually any clocks in the room. Or taking a guess based on how often you can hear them call out from down the hall. It is also interesting the way they document everything. While each patient does have an official “chart,” (a pile of papers paper clipped together, in no particular organization), they will write their initial assessment (in more or less a similar format to our SOAP notes), and then all additional progress notes are written where ever seems like a good place, on no particular page in the chart. On my first day, I was really confused when trying to read the charts. Whereas in the United States we typically document cervical exams with brackets (for example: dilation/effacement/station), in Mendoza, they don’t seem to have much specific attention to effacement and station, but they use the same format not to document cervical exams, but on contraction monitoring. For example, # contractions in 10 minutes/length of contraction/intensity. Imagine trying to figure that out. It was very striking to me also, that keeping track of FHR decelerations and timing with contractions is much harder, because there is no tracings to review later. In this sense, one would imagine, especially since almost all the patients receive Oxytocin, that there would be a greater attention to a specific assessment of FHR in relation to timing and frequency of contractions. But no, not really of a whole lot of concern there. Interestingly enough, there were very few times I saw (or rather heard) fetal bradycardia. In those instances, there were no heroic interventions like putting on maternal oxygen, internal fetal monitoring, or even stopping the Oxytocin. Occasionally I saw they might tighten the clamp on the IV to slow the Oxytocin a bit, but the extent of interventions they generally take is just changing maternal position. Once the heart rate comes up after, the doctors seem pretty satisfied and don’t push the issue any further. And the most amazing part of it all, is that nearly all of these babies come out screaming, hardly ever needing resuscitative efforts, not even bulb suctioning. Go figure. Bulb1While on the topic of resuscitation, you will recall in the first blog that I mentioned there are no baby warmers or resuscitative devices kept in the room. If the baby is having a slower time getting started crying, they simply poke their head out the door, shout “Neo!” down the hall, and just keep drying and stimulating till the Neo team arrives. It might be 10-15 seconds before anyone shows up, and usually the baby is already crying by then. But if the baby did need further resuscitation, the Neo team would grab the baby and run about 30-50 feet down the hall to the nursery. Incredible.

Another interesting concept is that there is no such thing as an “obstetric nurse” in Mendoza. All nurses have more or less only basic training, can give IV medication and start IV’s but none are allowed to do vaginal exams or push with patients, only midwives and doctors.

Also very interesting and rare sight to see in the US: a patient was pushing in the dilation room, and the baby was not descending as expected, despite her pushing efforts. I have seen very often in the US sitting the patient up in order to implement the natural force of gravity, and letting the patient “labor down.” Occasionally they would do this in Mendoza, but for this patient, when the FHR started slowing, instead of having the patient just sit up and rest rather than push, the midwives instead had her stand and squat to push. They then said they will know how she is progressing based on the amount of bloody show dripping on the floor. What?!

IMAG1792As a midwife, we are taught to embrace women in their experience of childbirth. However, labor coaching is not a common practice for the midwives of Mendoza. Rather than sitting with a patient and massaging or coaching her (as I felt a need to do), the other midwives/docs sit around in their on-call room drinking maté and chatting until someone started pushing or until it was time to check FHR again. To me, I felt torn between the desire to help and be with these women during their pain, while other part of me also felt a need to establish myself in discussions with the other providers and participate with them, whether be it checking cervixes or discussing the weather. It was a struggle to keep a balance between both obligations, because its so uncommon to be actively engaged in the patient’s labor outside of routine monitoring and pushing etc. Despite my best efforts to teach and show them labor coaching techniques, my teaching often seemed in vain. After only a few minutes, the midwives would stop and encourage me to go with them to talk instead.

IMAG1786-1In professional sense, the experience in Mendoza has left me with a combination of feelings: intrigued,  terrified, enlightened, humbled, and thankful. When leaving for this trip, I had different plans about my participation as a Midwife in Mendoza, seeing it as being a sort of residency, an extention of my education of sorts. Boy was I in for a surprise. After all I saw from the first day onward, I certainly held myself with caution about what practices and routines I allowed myself to participate with. Taking everything with a grain of salt. Allowing myself to see and understand their practices, but not immerse myself enough to make habits or adopt them. Having a short and flexible schedule every day was helpful, knowing when things were becoming too overwhelming, and when I needed to take a step back.

I am beyond grateful for the experience, and recommend to anyone considering. Step out of the comfort zone, learn the unthinkable, appreciate what you do and what you have. From my time in Mendoza, I am taking back with me both the good and the bad, and ready to step into my new career with a new outlook for my profession. IMAG1794

La Parterita en Mendoza- Parte 1

 

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For those they haven’t been in the loop, I have spent the last week and a half living and working in beautiful Mendoza, Argentina. I have been working with midwives here in a very busy public hospital, in a high risk obstetric unit.  While I always knew from the beginning that things were going to be really different here, I had no idea the extent of how much I would be surprised by. Also, the language barrier caught me quite off guard on my first day. I have had pretty good knowledge of the Spanish language before coming here, being able to translate and speak with patients at work etc. I knew how to ask questions, take a 

medical history, instruct someone through child birth, and give discharge education. ImageBut it never occured to me that it wouldn’t be the patients I would have difficulty talking to, but rather the staff. Being able to have normal everyday discussions became the biggest obstacle. Also, I never realized until being here how much of my knowledge of Spanish was quite dependent on “Spanglish,” and being able to throw in a word or two in English if I didn’t know how to say them. Here at the hospital NO ONE knows ANY English. Nada. So it was definitely a bit of a struggle my first couple days to be able to keep my mind in constant focus every minute to what’s being said, and training myself to stop translating in my head, but rather to simply think in Spanish. Fortunately, we have a really great Spanish teacher at the house who comes a couple hours twice a week to do lessons. I am happy to say I can finally speak outside of the present tense at last! This has definitely opened the field for conversation in the hospital, and I am becoming quite confident in my ability to talk with other people in the hospital about the differences between their practices and ours in the States, the things that quite literally blew my mind. ImageFor starters, when women come in labor, they are taken into a “dilation room,” which has about 6 or 7 “beds,” which are more like a table with a paperthin mattress, and they are required to basically lay there and suffer until they are complete. No epidurals, no pain medicine, no visitors with them, just sitting or laying on the beds sobbing and moaning for hours. There is absolutely no privacy, they do vaginal exams in front of everyone else, and the door of the room wide open, but no one seems to mind it nonetheless. What really surprised me however, is  when they do get to completely dilated, the woman holds her bag of IV fluid and Pitocin, and walk down the hall to the delivery room, dripping amniotic fluid and bloody show on the floor like nothing.Then they go into the delivery room which is basically a metal table with stirrups (if they are lucky) otherwise there is just 2 metal poles they have to prop their feet against. No pillows, no adjustable bed, nada. Not even a baby warmer, no oxygen or resuscitation supplies, nothing. 

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And because I understand we in America are probably a bit overly aggressive about 

continuous fetal monitoring, I was not surprised that they only listen for heart tones every 30 minutes. Even the patients on Pitocin. 

But I was quite surprised that, even after the long walk down the hall with the baby basically crowing, they really don’t monitor the baby while she’s pushing, except when they were using forceps to deliver. And might I add no pain medication is given. The patients are draped with this “sterile” white cloth and instructed to push right away, the doors of the room wide open and everything.Image What really astonished me, one of the midwives told me that for primagravidas, it is routine to just go ahead and cut a mediolateral episiotomy before they start pushing. They do give some lidocaine first, but I couldn’t help but feel the pain of it for the patient.

ImageAs if that wasn’t enough torture for this sheltered little midwife, they have a tech or one of the other nurses or doctors stand or straddle the head of the bed, and apply fundal pressure. Knowing that just the mention of fundal pressure could cost you your license, I felt mortified at the site. After all is said and done, the patient and her baby are put on a stretcher to cuddle and bond in the hallway for a few hours until they are taken to the postpartum unit. ImageAfter a first impression like that, it was hard to get the courage to go back. But the following day, it was a little better in the hospital, as there was a class of medical students there, and they invited me to join in their class for the day. I still mostly was just observing things, helping to get some heart tones and check a cervix here and there, but I felt more confident in communicating with the others, and the professor there was very helpful and very easy to understand. But after a few hours of paying super close attention to every word around you, it gets quite mentally exhausting. After a beautiful walk home in the Mendoza sunshine, it was time for Spanish class and “social activities” with the roommates.  

The end of the first week definitely wrapped up on a good note. There are different midwives every day, and where as the midwives there on the other days were not unfriendly, they were not able to slow down and interact with me as much as the midwives there on Friday, which was a guy midwife and a woman midwife. After having seen the work flow from the previous days, I had a little bit better idea of how everything works, who is who, etc., and so there was less need for them to explain all that, and we were able to have really good conversations (in Spanish), drink Mate, and they were very facilitating to me, letting me check dilation and they even let me assist to deliver 3 babies today, which was really great.  

This past week was a bit funky in terms of the work week, because Monday and Tuesday there were problems with the buses working, and the bus never showed up. So I spent the day being productive with my Spanish studies. Wednesday I went in, but it seemed like it was “C-section day.” When I arrived, there were about 7 patients all gowned and prepped for surgery. ImagePossibly a day for the residents to practice their surgical skills I suppose. There were a couple midwife students from Mendoza there with me that day, so it was nice to be able to bond and work with them, as I still basically see myself in the student role. However, the same way I needed to do so many deliveries in order to graduate, they also do, and we did have one vaginal birth we did do. The patient came in contracting every 1-2 minutes, and before they even checked her in the dilation room, I could already see the head presenting. Thinking were just going to have a baby in the bed, I went ahead and grabbed my gloves, and to my surprise, they actually had her get up and walk down to the delivery room. By the time the patient was on the table the head was crowning, and the student still had not got her gloves on. I went ahead and kept my hands supporting the perineum, and basically told her to get her gloves on or I’m going to deliver this baby myself. Like any ambitious midwife student, she made the sacrifice of trying to get the other glove on, and delivered the rest of the baby with only one glove. Priceless. ImageAnd, ironically, as much as I am not a fan of doing routine episiotomy for first pregnancy births, this was the first one that they didn’t cut (obviously there was no time), and go figure, she gets a third degree tear. 

While a lot of the practices here have reason behind it, some of their habits will never fail to surprise me. Particularly, the common use of open toed sandals, flip flops, and even heels. One day, after a resident put a foley catheter in for a c-section patient, there weren’t any foley bags, so she just tied a glove around the end of the catheter and taped it instead. I also don’t ever think I will understand the “sterile technique” here either. A doctor might put on sterile gloves to do a cervical exam, and then dip her sterile gloved fingers into the jar of KY jelly they use for the fetal heart monitor. What?!

Nonetheless, I am having a really great experience out here. I am so much better able to appreciate not only the quality of the healthcare back home, but also the philosophy behind it, driven by empathy, compassion, and lawsuits. It is so strange to see these high risk women, no prenatal care, minimal fetal monitoring, and strangely aggressive birth interventions have babies that always come out screaming, with no need for oxygen, suction, or calculating Apgar scores. Yet back home, we practice with such strict protocol, doing everything by the book, and still seem to have more problems with babies needing some resuscitative efforts. It is both very humbling and enlightening to acknowledge such a concept. I feel like in comparing the conservative/aggressive nature of birth interventions here versus the US, I don’t really find  that one medical culture necessarily has does or doesn’t do more than the other, but they almost sort of compliment each other like a Yin and Yang, by being more aggressive in some practices, and more conservative with others. And its not that they do these interventions just because thats what they were told, but they just take a position on the other side of the controversy than we do for that specific intervention. Between learning the language and learning their practices and philosophies, it has definitely been a very mind stimulating process thus far. And as such, makes a perfect welcome for a doing some wine tasting after work. Image

New beginnings at the end of the road

Recently, I was moved by the successful start of a very special persons nursing career. In the short time working with her, I hope Laken was able to learn as much from me as I did from her. I always tell students that I enjoy them shadowing me because I remember the mental conflicts I often had as a nursing student, not just in applying the psychomotor skills we learn in lab, but also in the behind the scenes practical logic that they dont teach you in a class room, learning answers to questions you never thought of, and the confidence to know the right kind of short cuts, and when you should take them. I’ve been a personal cheerleader for Laken this summer, encouraging her self esteem and confidence with the best guidance, constructive criticism and positive support I knew how to offer. Now my baby bird has passed her boards, and about to start her first job as an RN, a real nurse. And it would not be beyond reason for her to have her own reservations and anxieties, being nervous about moving into this phase of her life and career. But she knows well that, as her mentor, I will always be a source of encouragement and support in her times of doubt. I have heard myself say many times “dont be scared, you are going to be great.” Strangely, this is encouragement that I have not only been giving, but receiving more and more myself recently. As my own impending graduation date grows frightfully close, I have found my own fears and reservations becoming more apparent in my plans leading up to, and after December 15 2012. The question crosses my path far too often; “where are you going to go after you graduate?” My generic response  is “I just want to graduate.” But as we move at high speed to that sanctioned date, I’m starting to find myself feeling it becoming less of an exciting milestone, and more of a sobering obligation. In undergrad, I used to say “for high school graduation you say ‘congratulations’; For college graduations, you say ‘my condolences'”. Without a doubt college is the best 4 years of our lives, you are a college kid, not a “real grown up.” Who would want that to end? For some, we continue on to grad school, telling ourselves that we are determined and ambitious, advancing our degrees and our education to improve our careers and professional opportunities. I dont doubt that this is the primary intention for everyone that goes straight into grad school. But recently, I have noticed additional characteristics that make me feel sadness over graduating. Its not so much a fear of the unknown, about not passing my boards or not getting a job (well yes, these are some fears), but it is also a fear of losing a part of my identity. I have always been a student, and the last 6 and a half years especially, I have been consistent, eager, and hardworking towards my degrees. I have learned ways to use my brain to learn in ways I never imagined. In grad school, studying often became a hobby (as evidenced by this blog). Its not that I believe that graduating is going to stop me from learning. I learn something new everyday, through academics or otherwise. But being a student was like having a security blanket from reality. A sort of limbo excusing you from the realities of life. Getting married, having kids, settling down, finding a permanent job, etc. (not that these things are something people dont do as students). But being a student, particularly going directly into grad school gives sort of an excuse to delay some of pressures of real life. There is always a goal, an objective, a reason to wait until after graduation to think of these things. After spending so much time and effort investing in this goal, how do you proceed once you have achieved it? Sure, getting my masters is by no means the end of the road for nursing. We had a great assignment for class where we describe where we see ourselves in 1, 5, 10, 20 years; the typical pregraduation assignment. I started with typical ambitious responses, but then it started beginning alot more sobering than I anticipated. There are so many paths to choose: DNP? PhD? Practice? Research? Legislation? With so many possibles, it is overwhelming to think of starting over with a new set of lifetime goals. Until now, my immediate goals of graduating allowed me to put these ideas off while I focused on the first step. But the pressure is on. Whats next? And my answer is not just to avoid further overwhelming discussion about my future, but Im also tring to convince my self that “I just want to graduate.”

Out of my element….

I am a very lucky girl. No doubt about that. I have a magnificent family and friends that care about me and all the trials and triumphs of my daily life. But because my phone has not stopped the notifications of my concerned and curious loved ones, I am going to try to keep my sanity and save myself from feeling like a broken record, and give a single recollection of the last 24 hours in this new lifestyle. Started work today as an official RN, whoop whoop. But surprisingly, I have no exciting stories about my first day of work. It was really just your typical New Employee Orientation day. Lots of enthusiastic smiles, cheesy learning activities, guest speakers, paperwork, and free lunch. Can’t complain about getting paid to chill in a nice conference room listening to inspirational speeches about what a great choice I made coming to work at Parrish. I don’t doubt for a minute the incredible learning opportunities and “Healing Experiences” that are in store for me here. Let’s just say that, I’m not sure the new job is my biggest adventure anymore….

I am trying to learn how to live with my new neighbors. And I don’t mean the people. The blood sucking mosquitoes. gnats, horse flies, no-see-em’s etc are nearly debilitating…literally drawing blood in minutes of being outside. I have always been unusually prone to getting bug bites., but this is some serious harassment. I have had to take the dog for a walk armed with protection, and I’m not referring to the pepper spray or taser that I conveniently keep to ward off creepers. No, no, now when people see me walking towards them, they cross to the other side of the street. Yes, I am that weirdo walking the funny looking dog, wearing bright red knee-high rain boots, oversized basketball shorts, and a jacket with the hood pulled tight around my face. To make matters worse, Diesel, being so excited about all the new smells and places to pee, gets so distracted he forgets that he needs to poop. I can tell–everytime I see him get ready to get in the squatting postition, he seems to catch a whiff of interest nearby. He is in canine bliss while I get devoured by insects. I LOVE my new house. I am so happy with my new home, and I can’t help but spend all of my thoughts thinking of new, creative projects and ideas for the house. Most recently, the influence of my brilliantly handy father sparked my  creativity as I attempted to rig up some extra night lights before bed (just in case I get paranoid in the middle of the night), rearranging lamps and extension cords etc to get more light and visibility…without turning on actual lights of course. Anyway, after about an hour of unplugging, replugging, and not getting anywhere, I gave up and decided to just settle with the half dozen nightlight plug-ins I started with. Despite my parents’ disagreements with my pack rat clutter, there was, surprisingly, a system to the madness. I cant seem to find anything lately. Not even important things, but simple things that are always in the way until when you need them. Like stamps. I used to keep them in the silverware drawer in the kitchen, only because they were with my groceries one day, and I put them in there so I didnt throw them out, and for months, thats where I kept stamps. Yesterday, (in my attempt at being organized) I specifically recall putting them in a designated safe place in my new office/study/guest room. This afternoon, I nearly unpacked half the house trying to remember where I put them. Similarly, out of my entire collection of random pens of every shape, size, and color that I would usually keep scattered throughout the house, the one day I am looking for a RED pen to do some editing, the only color (out of literally hundreds of pens) is black–not even a blue pen to give SOME kind of contrast. Nope. Go figure. How’s this for Murphy’s Law…I typically make it a habit to only buy wines with twist off tops instead of corks. You can probably imagine my frustration from my countless failed attempts to open a bottle of wine. Impossible. I don’t doubt it has everything to do with the constant slippery, soapy film I can’t seem to wash off my skin with the soft water around here. I tried to open a jug of milk this morning for breakfast, and couldn’t get a grip for the life of me. Or the fact that every dish I wash (and I have washed every single bowl/plate/fork and spoon I’ve used) won’t feel completely rinsed from slimey soap suds, making me feel the need to put more soap and start scrubbing again. Speaking of my cleaning concerns, as I was showering tonight I was just starting to put two and two together (about the constant soapiness and soft water) and absentmindedly realized I was trying to scrub my face with….conditioner. Is it the weekend yet???

Vagina…she who must not be named

      I have started to find that I frequently use the word “vagina” as a part of my everyday vocabulary. To my friends, not much surprises them anymore. But when talking to people I have just met, I often notice the look of shock at how I easily throw around the word, and I do realize they may initially feel that I have very inappropriate conversations. Ok, I’m sorry for your discomfort, but here’s the truth…VAGINA is one of the most important elements of life. No one should feel ashamed or uncomfortable to talk about it, not ever! One of my favorite mentors, the brilliant author and midwife Ina May Gaskins, described the attitudes associated to the many words referring to a woman’s genitalia. In the preface to her most recent book Spiritual Midwifery, she states how modern culture perceives the vagina as a dirty, inferior organ [to the penis] that is constantly used in a negative “vulgar” context.

Why?!?!

Another writer, Lissa Rankin, was told that her article 15 Curious Things You May Not Know About the Vagina was originally accepted to be published on a major news website (for its brilliant facts and ideas), but was then rejected after the company execs found the word to be “too saucy” for the public…WTF?! She comments about this subject, further adding that several tampon commercials were banned for their use of the word vagina on TV, and it is often censored on the radio (http://www.owningpink.com/blogs/owning-pink/sperm-trumps-vagina-wtf).

What has our society come to, that we feel the need to reject and degrade such a significant organ? Fortunately, my mother has been a transcriber for an OB/GYN practice for as long as I can remember, so books and diagrams of the female reproductive system have always been a “normal” presence when I was growing up. However, I feel much sympathy for women that grow up under the ludacris influence of conservative masculine society that strongly encourages avoidance of the entire concept altogether. Thus women are uninformed and uncomfortable with their bodies and how they work. This can have a variety of consequence  related to low self esteem, not feeling “normal,” being afraid to ask questions, and being fearful to seek routine care. Goodness how difficult puberty must have been! Believe it or not, I have actually come across people that TRULY believe that the vagina is an endless cavity, and that tampons and contraceptive products can get forever lost into their body. Sorry to break it to you guys, but it IS actually a dead end up there…its hardly likely that anything would ever get so “lost” that you couldn’t find it with your fingers. Heaven forbid girls to ever touch themselves….(see my blog”The soft squishy thing”).

Here is one of my favorite Ina May quotes from Spiritual Midwifery  that pretty much sums up this entire blog, and of which I think every woman should live by…

“There is nothing vulgar about my body, and if some words suggest the opposite to many people, I think they need to hear these words proudly spoken (and see them written) enough that innocent words no longer possess such a crazy-making power over us. I just might want to have a cunt one day, and a twat the next. On the third day, I might decide that pussy is my favorite word!”

I think one of my favorite parts about my seemingly “inappropriate” common use of these words, its that it often leads to a great conversations, igniting people to openly ask all those unanswered questions they’ve had, and really bring about the topic of the female reproductive system in a far more intriguing manner than your 5th grade sex ed class. The truth is, I learn SO MUCH about these things everyday, and I could talk for hours with “did you know…?” and I really love to inform people about this stuff (if you haven’t already picked up on that..).

So I encourage everyone….ask questions, get answers, know your bodies (women), and know understand how it works (men), talk to your kids (better you give them the facts than let others give them myths) and don’t fall into the anti-feminist influence that says you are dirty and vulgar for doing so.

Empower yourselves ❤

Don’t break my heart…

Over the past couple weeks, I have been haunted by the unexplained symptoms experienced by someone very close to me. After consulting the primary care provider, an EKG revealed the presence of a heart arrhythmia, which was ultimately diagnosed as atrial fibrillation (Afib). Although not as serious as ventricular fibrillation (Vfib), Afib can cause the atria of the heart to sort of twitch in a way that can lead to unorganized electrical activity an can render the heart ineffective as a pump. Because of this, arrhythmias such as Afib can result in poor blood circulation and organ perfusion, and if severe enough, can lead to detrimental outcomes such as ischemic stroke, blood clots, and heart failure. There are several different classifications of Afib, which is based on the duration of the arrhythmia, and can be essential for determining a plan of care. The first is paroxysmal Afib, which is associated with episodes that last less than 7 days, and will return to normal function on its own. Persistent Afib episodes are often longer than 7 days, and do not terminate without treatment of antiarrhythmic agents and/or a cardioversion procedure (essentially delivering electric shocks to the heart from a device). Arrhythmias that have persisted longer than 1 year with failed treatment attempts is classified as permanent Afib (Edmunds & Mayhew, 2009).

Initially, my grandmother sought treatment for a sensation of hearing loss, and the primary care doc started her on a treatment for an inner ear infection with antibiotics, an antihistamine, and an intranasal steroid to relief symptoms of congestion associated with sinus inflammation. She was also prescribed a beta-blocker (metoprolol), in addition to the two antihypertensive ACE Inhibitors she was already taking (Diovan and fosinopril).

The ACE inhibitor drugs are particularly beneficial in treating hypertension, because they can reduce peripheral blood pressure without having a significant effect on heart rate or cardiac output. However, the mechanism of action of these agents works on the way the kidney reabsorbs water by altering the sodium-potassium exchange, resulting in less fluid absorption (Edmunds & Mayhew, 2009). In some instances, this can not only pose a risk for dehydration, but it can lead to renal insufficiency and result in elevated levels of potassium (hyperkalemia) that can cause irregular heartbeats and muscle weakness. Recall that digoxin toxicity is often related to levels of potassium. Interestingly enough, Edmunds and Mayhew (2009) recommend that anyone taking a combination of ACE inhibitors and dig should have their blood levels monitored, and dig levels should not exceed 1.0 ng/mL, especially in women, and the elderly, since their body mass composition can predispose them for drug toxicity. Furthermore, due to the metabolic pathways of ACE inhibitors, it is not uncommon to see drug interactions resulting in increased levels of digoxin.

So, we have our hypertension treatment plan consisting of two ACE inhibitors and now a beta blocker.

However, the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure no longer recommends beta blockers as a first line therapeutic for hypertension, especially in the elderly, due to the high risk of development or exacerbation of diabetes mellitus. This is caused by the adverse metabolic effects that can cause an elevation of blood glucose levels, as well as increased insulin resistance. Furthermore, antihistamines can increase the efficacy of beta blockers, leading to serious adverse effects.Interestingly enough, antihistamine agents such as loratidine are not recommended in patients with hypertension and diabetes, and special formulations are indicated for these patients (of which my grandmother was not on). The mechanism of action of beta blockers is to act on the receptors in the heart (and often the lungs) to help relax and dilate blood vessels and airways, which results in decreased heart rate, lowered blood pressure that reduces the force exerted by cardiac contractions (Edmunds & Mayhew, 2009). As expected, common side effects would be related to the reduced cardiac output, such as bradycardia (slow heart rate), dizziness, fatigue, weakness, nausea, vomiting, depression, hyperglycemia, renal failure, and stroke. In some patients, compensation for hypotension may result in rapid, unorganized heart rates (sound familiar?) and slowing the electric conduction system in the heart.

After being referred to the cardiologist, she was started on Multag (a similar drug to amiodarone, which is an antiarrhythmic) that acts by reducing the irregular impulses from the electric conduction system in the heart. This drug is often initially prescribed with a beta blocker to prevent a rapid atrioventriacular spasm in response to the drug (which would likely explain the increase in Metoprolol from 50mg to 100mg). However, providers should always express caution when managing patients that are taking multiple cardiac drugs to prevent additive effects or interaction that can cause drug toxicities, and cardiac depression. Many other drug effects, including beta blockers, digoxin, and ACE inhibitors, are increased with use of Multag. It is also known that this agent can also worsen arrhythmias, and may contribute to severe sinoatrial node dysfunction and heart block (Edmunds & Mayhew, 2009). In monitoring for toxicity, drug levels and EKGs should be frequently reevaluated, and patients should be educated to seek consult if there are any new or uncomfortable symptoms.

After one week of treatment, my grandmother returned to the cardiologist for EKG results, and her medications were changed once again. She was told to discontinue the metoprolol, switched instead to nadolol (also a beta blocker), and have her anticoagulant increased (which would normally be expected since arrhythmias carry the potential to create blood clots, however I’m curious about the awareness of the increased potential of the anticoagulant from the cardiac drug interactions). Additionally, she was advised to start taking Digoxin. She began feeling increased nausea and light head-ness around this time.

 

 

 

 

 

Digoxin is a potent drug that works by decreasing the heart rate and blood pressure to produce stronger contractions and make the heart work more effectively as a pump. Because of the potency of this drug, there is a narrow therapeutic range for blood levels, increasing the risk of toxicity. Therefore it is crucial that anyone that is prescribed these drugs be monitored closely and made aware of the potential for bradycardia, hypotension, stroke and cardiac arrest, all of which are associated with severe digoxin toxicity. When prescribing digoxin, it is essential to take a thorough patient history to determine current medications, and any previous liver or kidney problems, as this can lead to decreased clearance of the drug, causing it to accumulate and become toxic. Additionally, assessing potassium levels is a critical component of therapy, as digoxin can result in hyperkalemia, which can further worsen arrhythmias, and even result in cardiac arrest. ANY patient taking digoxin should be aware of the signs of digoxin toxicity: fatigue, weakness, syncope, dizziness, visual changes i.e. the presence of a yellow halo around objects), sensation of a pounding or racing heartbeat, poor appetite, nausea, vomiting, diarrhea (Edmunds & Mayhew, 2009). Furthermore, other medications can have a significant impact on the effects of digoxin, that can lead to increased absorption, reduced renal clearance, and most importantly, an additive effect that is seen with many of the beta blockers and calcium channel blockers (recall that these drugs are often used in combination to treat arrhythmias).

After two days of treatment, my grandmother was still experiencing dizziness and feeling light headed, and eventually fainted while in the shower. The cardiologist decreased the dose of the beta blocker, and advised her to continue taking the other medication. For the next week, her nausea and vomiting got worse, as well as severe weakness and loss of appetite. After 8 days of taking the new regimen of drugs (on top of all the initial anti-hypertensives, the cardiologist finally recommended she discontinue the digoxin (after a week of my advice to consult a pharmacist/stop the digoxin/get a second opinion). Interestingly enough, although the digoxin was discontinued at this time, what the doctor failed to take into consideration was the long life of the drug in the body before it gets excreted (6-8 days!). The following day, the symptoms were unbearable, and following ambulance transport to the ICU, she was diagnosed as having digoxin toxicity. Shortly after being stabilized, EKG revealed problems with the sinoatrial node (SA node) which is the primary pathway of the heart’s elecrical conduction system. The (new) cardiologist recommended that she undergo a cardioversion procedure.

This is similar to the way a defibrillator machine works during CPR. The patient gets sedated, and electrodes that are placed on the chest deliver volts of electricity to the heart in a sort of “atrial kick” to try to jump start it into beating regularly. Following the procedure, my grandmother’s heart rate was extremely low, and the cardioversion electrodes (still in place for monitoring for complications) were required as a temporary pace maker for her.

As a plan of treatment, the focus is to try to safely restore a regular rate and rhythm. Treatment may consist of a variety of medications such as beta blockers, calcium channel blockers, antiarrythmics, and anticoagulants. In most of these agents, the mechanism of action is to slow down the emission of sporadic electrical impulses by prolonging the conduction period in attempt to make the heart contract more efficiently. This often leads to a decrease in the heart rate, and in many cases, these agents are used as antihypertensives due to their effectiveness at lowering blood pressure. In some situations, several agents are combined to produce a more effective response, but it is critical to monitor patients when taking these drugs. Once again, health care providers should be emphasizing the importance of follow-up and evaluation to determine the interactions of the drugs, and strongly educate their patients on early signs of toxicity.

In the personal experience previously mentioned, it seems there not only was a lack of patient education, but poor attention to details, patient history, drug interactions, and evaluation skills. Further, when finding that heart drugs were provided by both the primary care doc and the cardiologist, there also appears to be a absence in the collaboration amongst healthcare providers that is crucial to delivering optimal patient care amongst the different disciplines. Due to the inability to identify early signs as toxicity, there was a prolonged duration of preventable suffering that, with proper patient education and monitoring, could have been eliminated at onset. Regardless of possible association with inconsistent care, complications have resulted in bigger problems and stress on loved ones. Although nothing is accomplished through blame, I truly believe that early anticipation of problems can result in prevention of further complications through individualizing patient care and improving communication, assessment, and education. Prayers to my dear Grandmother, one of the most loving and genuine people I know. Lucky Lil should not need luck when it comes to her health; those doc’s better know I’m watching their every move.