Thursday, May 27, 2010

Baby Tale

I recently learned of the retirement of Barbara Hunt. Barbara was a nurse I first worked with at Shands Hospital in Gainesville back in the waning years of the last millennia. Barb had been an ED nurse for over thirty years, which is amazing when you consider that, like most women, she is only 29. She was nursing even before she was gleam in her father eyes. Barb and I worked a lot of night shifts together. She was the Charge Nurse, I was the attending physician, and the chain of command reflected exactly the order indicated by the sentence. There are a lot of stories we shared, most of which have been forgotten in the wake of the daily battles, but one story stands out over fifteen years later.

It was about 2 AM when a woman in labor was brought to the door. Contrary to popular belief, delivering babies is not something we do in the ED. We do not seek out the opportunity to usher new life into this world, or to have an infant named after any of us. If you’re in labor, our goal is to get you to the delivery suite as soon as possible, because a delivery is the ED is either something that happens all by itself or is an absolute disaster, and there is nothing in between. It’s one of the few times in the ED that we actually run. (I reviewed this paragraph for accuracy with Matt Forester, one of our ED techs, who scoffed at me. He noted, “Hey when you’re a tech you run all the time. It’s just you lazy ass doctors who don’t. You just roll around in your office chairs.”) Unlike Prissy, while we do know something about birthing babes, it’s nothing we’re particularly interested in doing.

But there are exceptions, and one of them is if there is obvious crowning. Crowning occurs when the top of the scalp can be seen in the perineum (lay term: “Down there.”) Most of the time, in the name of patient decency, we don’t really check this in the waiting room. We don’t have to. We know a baby is crowning when the mother yells “IT’S COMING!” in a particularly shrill tone that is only heard during childbirth and never reproduced in any other exclamatory setting.

(There are two other noises we use as clinical clues during labor. These are known as “tachylordy” and “bradylordy,” from the Latin root words for “fast” and “slow.” Tachylordy is seen in the early stages of labor, when the woman will wail “LORDYLORDYLORDYLORDY!” in a quick, statacco, high-pitched voice. More ominous for imminent delivery is bradylordy. When you hear a deep, long, guttural. “LORRRRDY. LORRRRDY,” there’s a kid on the way.)

So when this woman made the noise, we knew we were going to have baby. Well, maybe not us directly, but we were at least going to be put in the position of standing about gawking as nature took it’s course. While I am not an obstetrician, one of the things I do remember from medical school is that primates have been having babies for millions of years, and in general they’re pretty good at doing so no matter if there’s a physician around or not. (They seem to be even better at the process of conception, but that’s another story). So after a hurried conversation between Barbara and myself as the ED techs struggled to get her on a bed, we determined that our best strategy was to stand by and provide reassurance and say soothing things like, “It’ll be okay,” and “It’ll be over soon,” and “Steve Spurrier will be back next season, you’ll see.” (It was Gainesville, after all.) While we did this, another nurse went running for an instrument pack, just in case we had to do anything. To be honest, Barbara did most of the reassurance. My job was to stand up straight, look concerned, and quietly try to figure out how to avoid doing anything more.

Working with remarkable speed (for they didn’t want to be part of this any more than I did), the techs got her on the bed, and got her clothing off. (We said a little prayer of thanks for stretch pants.) Unfortunately, the brakes on the bed were locked and we couldn’t get them to loosen up. So we shovel her onto the bed, one side of her plastered against the wall which she was now beating with her fists while calling out the name of an unidentified male in an “aggressive” fashion, all of us standing on the other side in no position to do anything useful at all. (As embarrassing as it is to say, there’s no way to do any effective work in the pelvic region from the side. No snickering, please. Thank you.)

After twenty years on the job, there are very few sphincter tone moments in the ED. (Sphincters are circular muscles that control flow through the gastrointestinal tract. There’s one between the esophagus and stomach, one between the stomach and small intestine, and one between the rectum and the outside world. It’s this latter one that concerns us here.) When they do occur, it’s usually not when people think it might be. Running a cardiac arrest or major trauma is simple, and there’s really not a lot of risk to it. The patient’s in bad shape, and in general all you can do is improve the situation. It’s not like you can make someone who’s dead a lot deader. Everyone’s list is different, but here’s part of mine:

The moment you’re waiting to see if fluid comes out of the needle you just placed in someone’s spinal canal.

The moment you defibrillate someone who had a pulse, but needed electricity, waiting to see if the pulse comes back.

The feel of the needle bumping down the collarbone as you try to start an IV in a vein you can’t see. (Tone doubles if the patient has a blood clotting problem to start.)

Being told that a patient who came into the ED walking and talking isn’t doing so anymore. (This is ALWAYS bad.)

A colleague or risk manager calling to say, “Remember that patient you saw last night?”

Needing to catch a baby.

Needing to catch a baby.

Needing to catch a baby.

So there I am, peering over he left knee, looking at the top of an infant head. She’s pushing hard. Really hard. The head’s not moving. All sphincters hit overdrive.

The equipment pack has arrived, and I’m looking through the contents. I already know what’s in there. Looking to check my equipment is a stall tactic. I know that if the baby doesn’t come, I’m going to have to do something called an episiotomy, which is where a small slit is made in the lower portion of the birth canal to give the baby’s head more room to move. I did exactly two in medical school. I managed to avoid doing deliveries during my ob/gyn rotation during residency by volunteering to see all the gynecology consults down in the ED while those folks who actually wanted to do this for a living happily took all my experience. So while I know technically what I’m supposed to do, I am absolutely terrified of having to do it.

She’s pushing to no avail. I’ve got to do something. So I fondle the instruments absent-mindedly while Barb gets out some sterile towels and places a bedpan between the patient’s knees. We’ll reposition this under her hips at the time of delivery under to catch any fluids (There will be fluids. Delivery is not pretty).

It’s been a few minutes. It’s time. I start to pick up a syringe full of local anesthetic which I’ll inject into the area to be cut.

I don’t know what it is about the ED, but sometimes just the threat of care makes things better. It can’t tell you how many times people have come in with severe problems that resolve the moment they hit the door of the ED, or the number of parents who swear their child had a fever of 136 degrees but now are doing just fine under the glow of the hospital lights. And I think what happened here is that she saw the syringe and the needle, gave one last push, thrusting her hips in the air as she exhorted her infant to join the world in (once again) “aggressive” language. And as she did, we saw an infant sail out of her pelvis, shoot two feet up in the air in a parabola that would make a mathematician proud, and land with a resounding THUNK in the bedpan. It was a three point shot from behind the arc at the buzzer, and there was nobody happier than me as I suctioned the baby, got it breathing, cut the cord, and wrapped him up in warm blankets. Crisis over, mother and child were whisked to labor and delivery for further care and clean-up. Rumor has it the child was named after the unidentified male without an aggressive prefix.

“You were going to cut her, weren’t you?” I remember Barbara asking me later that night.

Truth be told, I have no idea what I would have done. Would I have kept stalling? Would I have been brave? Fifteen years later I still don’t know. But I’m certain that given the same situation, my sphincter would react exactly the same way.

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