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Sometimes, it's not so much fun. - Nobody wears a white coat any more...
...a tribute to becoming a doctor.
ayradyss
ayradyss
Sometimes, it's not so much fun.
If you're easily upset or softhearted, skip this one. I'm talking about "a bad outcome" in obstetrics.

I'm still raw from this one, shaking inside. I don't know what to say, quite, so I'm just going to tell the story.
I'm on OB call this block - every third day, 7 AM to 7 AM, in the hospital catching babies. The other day, Dr. S was on for the perinatology (high-risk obstetrics and maternal-fetal medicine) service. She's a tiny woman - probably about a third of me - with a soft voice and a military manner. And she's so very very good with her patients.
I knew her patient was in-house because the nurses had made sure of it. I leave the perinatology patients alone unless requested - and Dr. S does make requests of me, from time to time - or an emergency develops. It was pure chance, therefore, that I was standing at the nurses' station when the nursing staff called out from the room. "Get Dr. B in here - now." I didn't glance at the monitor until I was in the room, and my heart just stopped.
Fetal heart tones in the basement - 50's, 40's, instead of 150. Nobody in the house but me, and Dr. S on the way already. There's one algorithm in obstetrics that nobody forgets: Fetal Distress = Proceed to most rapid route of delivery. I gloved up, checked for baby's head, and started breathing - it was right there, available for delivery. Not the time to wait on niceties like "your doctor's coming, hold on," so we had her start pushing. Baby's heartbeat hovered in the 50's the whole time.
Dr. S arrived, threw a gown on, and reached down. I'm not sure exactly what she did with her hands, but it was like magic; baby's head came flying out, followed by the rest of baby, pale and small but moving at least, trying to breathe, followed by the end of the umbilical cord. Abruption. She tossed the word out matter-of-factly, handed baby over to the NICU folks who were waiting by, and exhaled, looking at me. Now we wait.

NICU means neonatal intensive care unit, O Best Beloved, and they're the folks who come when we're worried about baby. They took him, warmed him, and then started muttering to each other. Dr. S stood up, looked over at the baby on the warmer, and her military came out in a little growl. Get someone else in here right now.
The advanced people came running for the Code Green siren, which is the scariest sound I ever hear. There was a lot of bustling and rubbing and getting out the bag-and-mask ventilation, and someone said "Check now, do you have a pulse yet?" and I thought I was going to die.
They did compressions for a few minutes, maybe five, seemed like forever, while Dr. S sat on the bed and I knelt beside it and the baby's mother just watched in silence. There was nothing to say - holding our breath, praying - waiting.

And then they had a pulse, and spontaneous breathing, and there was a little hand waving up over the edge of the warmer, and the universe seemed to take a giant gasping breath. Time started. They were still giving oxygen, but he was moving and breathing again and I thought, O Best Beloved, I thought everything was going to be okay. His father came over from his silent vigil in the corner, looking down at him and taking his hand before they picked him up to show him to his mother and whisked him away to the NICU for post-resuscitation care.

I heard from the nurses an hour or so later, sitting at the table in the station between triage patients. "Don't tell mom - NI hasn't told her yet - but the baby has a diaphragmatic hernia."
My heart stopped, O Best Beloved. Suddenly the whole resuscitation picture made sense, and it was a horrible sinking kind of sense. A diaphragmatic hernia is a congenital defect where the diaphragms don't completely develop, leaving room for the intestines to occupy the space in the chest where the lungs ought to be. In best-case scenarios, babies require intensive care and likely have lifelong lung problems. In the worst case, the lungs don't develop at all, and I don't think I have to explain that outcome to you.

I went down to the NICU first chance I had, found the on-call physician. He didn't bother with niceties, just beckoned me over to the X-ray viewer and pulled up a series of films. I know him - he knows what my clinical skills are. He didn't have to say anything. Baby was born with maybe 1/3 of one lung developed at all, and that one blew out at the first attempt at ventilation. There was air where air should never be, and a tiny pathetic shadow of a lung silhouetted in the left chest, while bowel coiled through the right, a serpentine intrusion preventing any pretense that his right lung was formed.
I was there for an hour, watching the oxygen monitors, the heart rate, the tiny baby form swelling with subcutaneous air, drained off with an IV catheter, little arms waving in protest. The last-ditch efforts of the team got his saturations to 70% for a few seconds, before they dropped back to 50%, hovering there. $children's_hospital was on the way via chopper, hoping that there was something more that could be done.

I took a call from Dr. S, who'd heard the news. "Go upstairs. If mom is stable, get her out of the hospital so she can go with baby." I scampered, not sure what to tell mom. She'd seen, by then. She knew he was sick. I hedged. You know he's very sick. He needs his mommy, we're going to let you go with him to $children's_hospital so you can be with him. When they get here, we'll know more. What good is it to tell her that her child might never make it there? Wait for the experts to decide.

I got paged to C-section, slept fitfully while waiting for yet another section to be ready, and met Dr. S over the OR table. That's when they paged me to tell me. Your baby expired. Mom still wants to go home. So clinical. We do that, O Best Beloved, to keep from crying.
I met the NICU doctor over breakfast a day or two later and got the story.
The chopper had arrived in time, but even with both NICU teams working their hardest, baby never recovered enough to be safe to transport. The neonatologists from $children's_hospital looked at the films and heard their team and decided that he wasn't a candidate for ECMO (lung bypass machine), which is the only thing they have that we don't. So they took the tubes and the wires off and let his mother hold him until he died.

Five hours and twenty-five minutes old. It tests the faith, sometimes. It really does.

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now feeling:: sad sad

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Comments
From: (Anonymous) Date: August 5th, 2008 02:32 am (UTC) (etched in stone)

Tears

You brought tears to my eyes reading this. What a tough situation for you, the mom and the dad. Enjoy every day with your precious daughter!
Love,
Mom/Grandma Bever
From: (Anonymous) Date: August 6th, 2008 12:45 am (UTC) (etched in stone)
I love you!
Michelle
2 whispers echo . o O ( ... ) O o . whisper a word