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Just like *snap* that. - Nobody wears a white coat any more... — LiveJournal
...a tribute to becoming a doctor.
Just like *snap* that.
Came in this morning to a flurry of folks erasing names from the board, writing numbers, "NTBCP", where once were station and dilation and effacement and did you want an epidural? Four deliveries in the hour or so before I came on duty, and M looking mighty tired. He always looks tired; he's not all that interested in OB and thus attracts all the busy nights. I walked into the triage room to meet the last of the early-morning triage, nice couple, very sweet, 1-2 cm but SROM'd. (That's "spontaneous rupture of membranes", which is doctor for "her water broke at home".) So that bought her a birthing bed, since the chance of chorioamnionitis goes up and up and up as you get further and further from rupture without delivering, and we started some pitocin, and talked about cats. People I like. Doing well on pitocin, promising to be a good delivery and with a proctor who lets the residents deliver.

Around about 12:30 I was in triage, talking to a patient, and the faint sound of the overhead paging system came to me. I heard "mumblemumblemumble STAT" and wondered, but there's no way I can be useful in any sort of emergency situation, not with my level of knowledge, so I figured it didn't apply. Then the nurse put her head into the door. "Dr. B? You might want to get out here right now." So I dropped the chart, apologized to the patient (nice girl, didn't even look insulted that I was running out on her), and bolted for the nurses' station.
There was the nice lady's monitor. The thing that had caused such commotion was still up on the screen: a baby with a heart rate in the 140's, perfect, beautiful accelerations, not a thing to concern oneself with - and then suddenly the baby's heart tracing disappeared. Gone, except for scattered dots in the 60's, then 120, then 60 again. And the entire staff of labor and delivery was putting the hustle on.

"What's going on?" I had a right to ask; I was, at the time, the only physician on the floor except anaesthesia. I got the answer in a rush and flow of words.
Crash C-section. Possible abruption. Baby's heart rate in the 40's. Do you know where any OB's are? I didn't. Neither did anyone else. Ten minutes before, my proctor had bid me a momentary farewell to go back to his office. Everyone was off the floor. And there was a baby dying in front of us. I did the only thing I could: I looked at the nurse and said "What can I do?" She nodded.
I held the door for the bed as we wheeled back a pale and anxious-looking woman who had been so happily talking to me an hour before, oxygen on her face, everything moving at a dead run. I fetched water from the blanket warmer and helped get everything lined up; declined to scrub when the OB fellow came in, and stepped back out of the OR's, stomach twisting and sick. This woman needed a doctor, not a resident.
Two OB's came at a dead run as they were getting her on the table; they didn't stop long enough to hear the story before putting on boots and masks. Time was at an absolute essence. And I walked back along the hallway to where father and grandfather were standing, watching, pale as ghosts. I stood with them, awkward, not sure what to say. I tried a silence-breaker. "Got a little crazy out here. How are you doing?"
We were just sitting in there, he said, looking at me in sideways glances, trying to be polite, trying to see through the wooden doors of the OR suite. Talking about baby names. Everything was fine. He didn't have to complete the thought: and then it wasn't. I stood there, listening to him speak, telling me how normal things had been, watching the doors. We all watched the doors. A scrub nurse came out. "Congratulations," she said, looking him in the eye and shaking his hand. "You have a baby boy." Beat. How is he? "NICU is working on him. He came out a little pale, and he doesn't want to breathe real well. But he's only been out for about forty-five seconds now." How is... "She's fine. Sound asleep and very stable. We'll let you know when we have more news."

I know what "a little pale" means. I know what "doesn't want to breathe real well" means. I know what "NICU is working on him" means, and none of those mean anything good for a baby whose heartbeat went crashing like this little man's did. And I realized that as the nurse walked away, that the father of this baby was looking at me. "What does 'a little pale' mean?" he asked me, and you could hear the question in his voice, the unspoken bad-luck question. Is my baby dying?
It's hard to reassure someone when you are not reassured yourself, and now is not the time to say "I don't know, exactly," so I told him what I did know. I told him that it sounded like his baby was a little shell-shocked, that he might have been without oxygen in the minutes it took to get to section, that babies were resilient creatures and that the NICU here at this hospital was top-notch. He fixated. Without oxygen. Yes. Without oxygen. I left out the part where I thought 'a little pale' sounded like 'bleeding out' to me. We'll have to see what the NICU says, I don't know how he'll do, I don't know much more than you do at this point. Pause. Silence. He nodded. Without oxygen. And I stayed a bit longer before I slipped away; I didn't know what to say so I told him that if I could help I would, that I would listen if he needed. He seemed to appreciate it.
Back in the nurses' station I got the story I'd anticipated. They'd gone vertical midline through the skin, transverse at the uterus, and pulled out a baby who'd more or less exsanguinated in utero, white as death, not breathing, APGARs 0 at one minute and 1 at 5. NICU put in chest tubes and lines and did compressions and gave epinephrine and coded that baby for twenty minutes back in the OR because once they got fluid in him he had a pulse and babies are resilient. And in the end, intubated, lines everywhere, he went alive to the NICU. And everyone was talking about it, because nobody could believe it.

I stopped into the NICU on my way to dinner. The charge nurse looked up at me with the eyes of a NICU charge nurse and said "Can I help you?" in a voice that made me glad I had a reason to be there. "I'm the OB resident on call, I..." She cut me off, gentling suddenly, sweetness. You want to see the baby. I did. I saw him, full-term, pale still, a ghost of a baby boy on his warmer, ET tube no bigger than my pinky, sleeping or unconscious. Wires and tubes and lines everywhere. He slitted open his eyes, seemed to look around, gaze predominantly up to his right. EEG I couldn't read with a big sign: "Mark when you touch." I didn't touch, although I wanted to, wanted to see if his skin was as cool as it looked. I found his nurse. He's doing better. Room air, breathing around the vent, moving on his own. But we can't tell yet, it's too soon to tell. Sweet baby, perfect, pale, and an uncertain prognosis. We don't know yet if there is brain damage - but the L&D nurses look at me with tired and cynical eyes that no longer believe in miracles, and they tell me there must be, that the child was born dead or nearly so. I suppose, in the end, we will see.

The tentative diagnosis: Vasa Previa; a vessel running through the membranes of the amniotic sac made itself and its incomplete state known when they examined the membranes. Perhaps, the nurses speculated, the movement that the mother felt was baby flailing as it began to bleed. Who can tell? We could hardly have responded much faster: Mom felt something leaking and a large fetal movement at 13 past the hour; she put her call light on. At 23 past the hour, the nurses had found baby's heart rate and the pool of blood and knew something terribly wrong was going on; the page had gone out for "Any OB in the house to Labor and Delivery, STAT" - the page I'd heard only the end of. At 39 past the hour - sixteen minutes after the call for crash section - baby was out. There isn't much faster response than that, anywhere.

But sometimes it happens, just that fast.

Tags: , ,
now feeling:: sad sad

7 whispers echo . o O ( ... ) O o . whisper a word
deadrose From: deadrose Date: July 27th, 2005 05:58 am (UTC) (etched in stone)
Stories like that make me feel so thankful for my healthy headstrong daughter. When I was pregnant with her, I hired a midwife, even though OHIP would have paid for the birth (living in Canada then). Long story, suffice to say that the head of OB-GYN at the hosp didn't bother to notice the large cystocele from the birth of my son, ergo, diaphragm didn't fit, pregnant the first time I ovulated.

But anyway, I had my first contraction at 6:30 pm. Sac ruptured, or so I thought till I went to the bathroom and found my underwear full of frank blood. Phoned midwife who broke assorted speeding laws, did the most delicate exam ever (in case it was a placenta previa), then stuffed me in the back seat of her car and broke a few more laws. I wasn't bleeding out, but it certainly wasn't normal either. By the time we got to the hospital, less than one hour after the first contraction, I was already at 8 cm, the FHTs were good, so they figured there wasn't going to be much time difference between a vaginal birth or a section and let me continue while they hustled in an ultrasound tech to see what was going on. Turned out my (very large) placenta had implanted on the fundus and into the horns, so as soon as I started contracting, I had a partial abruption.

She was too quiet right off, but when she heard my voice she opened her eyes and got a deep breath and pinked right up, ended up with 8/9 apgars! By 8:30, 2 hours from that first contraction, everything was done and we were peacefully in bed together.

Truly my miracle baby, my only girl, and after that precipitous a labor, my last child, too. As a side note, last year I had a hysterectomy for a submucosal fibroid that had made me severely anemic. Its location? Right there on the fundus. Cause? Effect? Who knows.

ayradyss From: ayradyss Date: July 27th, 2005 02:12 pm (UTC) (etched in stone)
Miracle indeed. And a midwife to be proud of.
feathered From: feathered Date: July 27th, 2005 06:22 am (UTC) (etched in stone)
My god, Nykki, these stories are harrowing. Thank you for posting them, they're fascinating too, but I feel sad for you. It sounds so hard, emotionally; I don't think I could do it. So in addition to being sad at your stories they always fill me with admiration and awe of you.
bradycardia From: bradycardia Date: July 27th, 2005 01:28 pm (UTC) (etched in stone)
I hope you don't mind that I added you yesterday. I am a Med student from Ireland, going into final year. I just finished OBGYN so your stories have a particular resonance.
Can I ask what NTBCP stand for?
ayradyss From: ayradyss Date: July 27th, 2005 01:57 pm (UTC) (etched in stone)
Needs To Be Cleaned, Please :)

Welcome! I have cousins-in-law in Ireland :)
bradycardia From: bradycardia Date: July 27th, 2005 02:09 pm (UTC) (etched in stone)
For a small country, we have managed to spread our influence far and wide!
From: silmaril Date: July 27th, 2005 03:06 pm (UTC) (etched in stone)
I have rarely read words that went by faster. Just like that, indeed.

7 whispers echo . o O ( ... ) O o . whisper a word