Playing Doctor

Initial Visit?

Tuesday, March 1

Dr Erik’s Science project

Hour two through four

I am explaining to the girl’s husband that the ultrasound did not see any motion in the heart of the fetus.

I continue, saying that it also showed ‘a lack of fluid around the baby. Suggesting that your wife’s body is reabsorbing the fluid.’

I am torn about the semantics of the situation. Should I be saying ‘baby’ acknowledging the loss he will be feeling? Or should I opt for the technically correct ‘fetus’ perhaps softening the emotional impact?

The girl has been brought up from the Labor and Delivery floor and is now in the medical Intensive Care Unit. This reassures me.

Labor and Delivery nurses are superb at what they do, bringing new life into the world. But when things go bad, they can get emotional. They are used to seeing life begin, not end. I have left codes on their floor to see the nurses crying in the station. I thank them for the help they gave during the code. I try not to show any scorn for allowing their emotions to frazzle them ten minutes previously when I needed a well-oiled machine.

Thankfully, when a code is called in my hospital, ICU nurses are also part of the code team. As soon as they arrive, I excuse the L&D nurses and let nurses from my team take over. They can operate a code flawlessly. When I call for a drug, they respond by verbally confirming the dose they already know that I want. They call my attention to things that I might miss. They suggest plans of action. When the decision is made to intubate, they have everything ready without me saying anything but ‘miller three, seven and a half tube’ often they are the ones who say that, simply confirming what they suspect I will use. With them there I can think about the patient, rather than the process.

So with the patient in the ICU, I breathe a bit easier, knowing that if things head south for the girl, I have flawless support. Though the fetus inside her is dead.

‘Your baby is dead,’ I say.

‘It’s probably for the best,’ he says.

I try to read him. Is he affectless? Is he just numb from the news? I don’t know how to respond to what he’s said.

I have to admit I have a flash of anger. Had she taken the Tylenol intentionally? Was this all a botched attempt at a self-induced abortion? I start to feel…what? Angry that abortion isn’t safe and legal? It is. So am angry that it isn’t an emotional option for people so they commit stupid atrocities to their own body? I start to feel… Well, I start to feel period.

So I find that little box inside me and put my feelings in it, and there we go…All better.

‘We’re going to give your wife some medicines to induce labor,’ I say reassuringly, ‘to expel it.’

It’s a busy day in the hospital. Though the OB/GYN comes up to check on the woman occasionally, a dead fetus does not require the close monitoring that a live one would. So it largely falls on our team to monitor her progression. We are simply trying to rid this woman’s body of what ails her.

My attending starts referring to her room as ‘Doctor Erik’s Science Project.’

After an hour or two, her heart rate increases to about 150 bpm, and her blood pressure climbs significantly. I suspect she is in pain, so I order some morphine. It does not help. I talk to my attending. He points out the obvious.

‘Erik,’ Dr Pasteur drawls, ‘you’ve induced labor, what did you think her cardiovascular response was going to be?’

My intern comes up to me. ‘Something’s going on in her room. The nurses said they don’t want me. They want you.’

I go in and see there’s a bloody pool of fluid between the patient’s legs. The head of the fetus is already out. The placental sac has not ruptured and the head is obscured through its thin lining with a small amount of fluid surrounding it. I ask the nurse to page an OB/GYN physician. I lift the head slightly, and the rest of its body slides out easily. The bleeding continues. I examine the fetus and the placenta. The placenta is in almost a single piece, but there is some missing.

And she is still bleeding.

There is much activity in the room. The nurse, the flawless ICU nurse, is hyperventilating. A second nurse sits her down and puts her head between her legs.

I introduce my hand into the uterus, feeling along its sides for a piece of retained placenta, which can cause hemorrhage. There is one sizable chunk, about the size of a cafeteria’s slice of pumpkin pie. I remove it and massage the uterus from the outside with my left hand and from the inside with my right hand. After a bit the bleeding slows considerably, but I am relieved when the OB/GYN arrives and confirms that the uterus does not have any retained placenta.

I see the OB/GYN look at the ICU nurse, sitting on a step stool with her head between her legs. Neither of us say anything, but it is the same look I give the Labor and Delivery nurses when I leave a code and see them in the station crying.

We examine the fetus.

‘What do we do with this?’ I ask.

‘It goes to pathology.’ She tells me.

‘In what? I don’t have a specimen cup big enough for that. And it’s too small and slimy for a body bag’

It turns out they have a kit designed for fetuses. We get one from the L&D floor and send it to pathology.

With most patients, the worst case scenario is 100% mortality. With pregnant patients, there is the possibility of 200% mortality. We already had 100%. The next step was preventing doubling that percentage.

Tomorrow, hours five through seventy of...

Doctor Erik’s Science Project

And here’s a hint about the outcome, it’ll go up on Uncynical Wednesdays.


Blogger Molly writes:

This is incredible. I had no idea that was how a dead fetus was "expelled." I guess I always assumed that the woman would be unconscious. Wow. Thanks for the lesson, doc!


Blogger hot babe writes:

This is better then ER (back when it was good).


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