Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (11 page)

You prod the woman's chest with your outstretched hand. “Now, you sit there and stay quiet, because
you
were the one who was killing your baby and
I'm
the one that's trying to save its life.
Okay?
”

You stomp back to the Isolette. No one looks at you.

“Hold CPR,” you growl.

The monitor shows a heart rate of 75.

“Epinephrine,” you say, entranced by the monitor.
Think,
you say to yourself,
think, think, think.

“I don't know what's the matter with this damn pop-off valve,” the respiratory therapist who must have arrived in the middle of all this chaos mutters. You just barely hear her.

The pop-off valve protects the lungs by venting the respiratory circuit should the airway pressures get too high.

“You are bagging too hard,” Helen tells her.

You look at Helen and then at the respiratory therapist. The answer is so simple it makes you want to cry.

“Pneumothorax,” you say in awe.

Everyone looks at you, blank-faced. Then they look to the respiratory therapist who, oblivious to it all, is still fussing with the pop-off valve.

“Pneumothorax. The kid's got a pneumothorax.” But as you say this suddenly you are not sure. It's possible, but there are other potential causes, all of which at this panic-stricken moment escape your mind. A pneumothorax is one thing, though, that could explain what is happening. It is also something you could fix.

You backtrack over to the view box and peer up at the x-ray. Was it there and you missed it? You search the image and think there is perhaps a little line there, in the apex of the left lung. Perhaps. Not clear.

A pneumothorax occurs when air is trapped in the lining of the lung. This can happen if the lung lining ruptures for any reason, and artificial ventilation is a very common reason. A simple pneumothorax causes the lung to collapse, making it harder for the patient to breathe. There is also a special kind of pneumothorax called a tension pneumothorax that can be more dangerous than that. Tension pneumothoraxes have a paradoxical effect. Every time the patient breathes, the amount of air in the lining of the lung
increases,
causing the lung to collapse more and more. Eventually the lung will collapse down to a useless stump. The more the patient struggles to breathe, the worse the pneumothorax becomes. The patient becomes cyanotic—blue. Having lost blood pressure, the heart can no longer pump blood.

If the condition is not corrected, the patient will die. Right in front of you.

The pressure created by the Ambu bag can easily cause the lung wall to rupture and a pneumothorax to develop. Maybe that's what happened here.

Treating it is simple. You must vent the lining of the lung so that the air can escape and the lung can, at least partially, rein-flate. This can be done most easily by “needling” the chest, which is exactly what it sounds like. You stick a needle in the chest wall between two ribs (second and third at the mid-clavicular line). The lung will remain partially collapsed, but the pressure in the lining of the lung will be gone. The patient can breathe again.

“Give me a twenty-gauge needle,” you tell Helen.

Carol is still doing CPR. You watch her for a moment and you doubt yourself, doubt the monitor, the Ambu bag, the needle. And yet, fiercely, you know you are right. There can be no other explanation.

Besides, you think, if it is something else, then the baby will he dead anyway.

“Hold CPR.”

You listen to the lung fields as the respiratory therapist bags. There are breathing sounds on both sides—that doesn't rule out a pneumothorax, though. The chest is so resonant that it's easy to be misled. You listen closely. It does seem to you that the lung sounds on the left side are a little softer than the ones on the right. “There,” you say aloud and point with the needle. You are talking to yourself, trying to steady yourself, steady your nerves.

A 20 gauge needle—a little longer than this baby's finger. You unsheathe it from its hub and brace your fingers against the baby's chest wall. It's all of one piece, aiming, inserting, pushing deep through the muscles, and then a slight pop. You are either in the lining of the lung or in the lung itself. The difference is literally life and death.

Air, you swear to God you feel air.

“Restart CPR?” Carol asks you.

You raise a hand. “No, wait,” you say. Everyone turns to the monitor. The heart rate is 65…

65…64…64…64…68…69…

There it is, the comeback. In a couple of heartbeats the rate is over 70, over 80, 85.

“Pneumothorax…” Carol sighs. “A tension pneumothorax.”

As you palpate the baby's neck, you feel, clearly, unequivocally, a carotid pulse, a brisk carotid pulse. Let's face it, in your heart you hear a choir of angels.

“Jesus,” is all you can say. “Jesus, Jesus, Jesus.”

You are finished, done for. You look at your watch and cannot believe that all this took only forty-five minutes. It has been the longest forty-five minutes of your life.

But you can't linger this way. “We need another chest x-ray in here,” you shout out. “And transport, what's the status of transport?”

“En route,” the clerk yells back. “They should be here in ten.”

“I need that doctor for report. Get him back on the line, would you?”

You look around at the acute room, which looks like a disaster area. Blood, mucus, amniotic fluid, are everywhere. The mother is huddled on the bed, her knees still up, legs parted, the way you left her after the delivery. She is weeping quietly.

You need to put a chest tube in; this will vent the lung better than the needle. For now this is fine. You are not worried about anything. Right now, the baby is alive, moving, wiggling those little hands in the air. A live baby. And what they say is true, you do feel like God—no, not God, really—just like a manifestly great human being. Carol, the pretty nurse, looks beautiful now and she is glowing at you. Even Helen, the nurse who hates you, is glowing a bit, though not specifically in your direction.

You've finished. You've won. The problems that remain—a premature baby with severe hypoxia at birth and a crack habit from the moment of conception—these are not your problems. Nothing can take the edge off this glow.

Congratulations. You have just saved a life.

4

B
ORN UNDER A
B
AD
S
IGN

R
ULE
#1: There is no real preface to disaster. One minute I was drinking some silt-like, end-of-the-pot coffee from a Styrofoam cup. The next minute I was palpating the belly of an immensely pregnant sixteen-year-old girl in active labor, contractions two minutes apart.

Sterile gloves. Betadine. A quick check to find out how far labor had progressed.

The girl lay on the hospital gurney, legs bent, belly distended, her little stick arms draped doll-like over the bars of the gurney as she awaited the next contraction.

“Something's wrong,” she said. Bur what did she know? This was her first baby, after all.

“Nothing's wrong,” I told her evenly. “You're just having a baby.”

I was near the end of my residency, and by now, nothing fazed me. I had become a medical automaton shorn of wasteful emotions, emotions like concern, compassion, surprise. An example: two days before, a man had walked into triage with a knife buried to its hilt in his skull, he
walked
in, and the most I felt was a sort of risible annoyance—now I'd have to call neurosurgery and that asshole resident on call always gave us such a runaround.

So I shrugged when the nurse, Darla, announced she couldn't find a fetal heartbeat. I wasn't worried…

…but I should have been. I was moonlighting that day at a local hospital where backup was limited, usually, to either a very busy or a very sleepy doctor on the other end of a phone. This was not like my training grounds, a teaching hospital where, when things went bad, you could call every kind of specialist known to man. I had been told up front by the director that obstetrics coverage was at least a half hour away (and not to even think of trying to find a plastic surgeon).

I had to slide my hand in past the wrist before I felt anything. What I finally felt, though, was…I wasn't sure what it was. It felt like a string of grapes.

That's odd, I thought. I stood there a moment repeating to myself, Grapes, grapes, grapes. I then brought my hand out, looked at it, checking to see if there was something wrong with it, and then I returned to the vaginal vault. Even though I told myself I couldn't be feeling them, the grapes remained. Why would there be grapes in the vagina? Some primitive part of my brain, some subcortical region, knew before it reached any level of actual consciousness, and my heart started pounding unmercifully as I thought still, Why? Why? And then suddenly I was fully aware of why.

These were toes.

I hadn't lost contact with all emotions. There remained one feeling that could still overwhelm me, one sensation that began now at the back of my neck and radiated into my throat and my heart. This was the only emotion available to an exhausted, overstressed resident.

The emotion was fear.

The baby was breech—that is, upside down. Instead of the head presenting first as in a normal pregnancy, here the buttocks were presenting first—not only that, but with this one the foot had descended. I felt around—I could feel only one. The other must have been hung up in the uterus.

“I've got a foot here,” I told the nurse. “This is a footling breech.” I turned to the patient. “Who's your obstetrician?”

The girl looked at me, frightened. “I don't have one.”

“You never saw a doctor during your pregnancy?”

“I was supposed to see one next week.”

The hell she was. She was full term. She should have seen somebody seven months ago.

There
was
one other emotion available for rapid access. Anger. The quick judgment of an overextended doctor. The patient had had a high-risk pregnancy and never knew it. I turned to the unit clerk, who was standing next to the door, arms folded. She'd seen it all. “Whoever's on for OB, call 'em now.”

The clerk ran back to the desk. I crawled up on the gurney and knelt closer to the patient. The girl went through another contraction, and now that her nightmare had come true, she started sobbing. In addition, she grabbed my arm in a vise-like grip. I had to pry her fingers off one at a time.

“Look, I can't help you unless you help me,” I told her.

“I am helping you. I'm just scared.”

This last statement was accompanied by a wail so pitiful, even I softened a little. “You're going to be okay,” I told her grudgingly.

If this were a normal delivery and if labor progressed, I would go ahead and deliver the baby in the ER room; but breech deliveries are extremely difficult. I was way out of my league.

And we still couldn't get fetal heart tones.

“I've called up to the obstetrics ward,” the unit clerk shouted from the desk. “No doc there! I'm calling the on-call guy now.”

I took over the Doppler and vainly mapped out the woman's abdomen. There was nothing but the rhythmic plash of blood in the mother's aorta. I tuned the Doppler back over to Darla, shaking my head.

In a moment the unit clerk shouted back again. “I've got the obstetrician's wife. She says he's in the shower. He'll get dressed and be there as soon as he can, but it's going to be a good half hour.”

“What are you going to do?” one of the nurses asked me. I was still up on the gurney, sitting on my haunches.

“I don't know,” I said.

The other nurse shushed us. “I've got something,” she said, and we all listened for the Doppler tones, the rapid, whiplash sound of a normal fetal heartbeat. All we heard, though, was just a slow swish, slower than the mother's pulse. Everyone counted silently, gazing at their watches. Seventy-eight, half of what it should be. Fetal distress.

What I remembered, hazily, was this: the biggest problem with breech deliveries is the head. The head is the largest part of the baby; during a regular labor it is delivered first. If it hangs up in the birth canal, labor doesn't progress. Ultimately, the child may require a C-section delivery, a comparatively simple procedure. In breech babies, however, the rest of the baby is delivered first; the head is delivered last. If the head hangs up, you have a child half in and half out of the birth canal. To deliver the baby, you have to open the pelvis and cut down through the uterus and the cervix—a massively complicated procedure—and only if you are lucky is the baby delivered alive.

Should I wait for OB or try the delivery?

If the head hangs up, the baby's dead and I'm dead, I thought. I would be hung out to dry by anybody who reviewed the case.

With prolonged fetal distress, though, every minute is a catastrophe.

Darla counted again. “Fifty-six,” she announced. A half hour is a long time for a baby with that slow a heartbeat. And it was dropping.

I put my gloved hand back up the birth canal. I wasn't sure, but it seemed that the leg had descended farther, and I could now feel the buttocks beyond.

“Do something!” the girl shrieked.

So close, so close. Another monumental contraction, and then it seemed to me that the baby slipped down another notch. Think, I told myself.

“Well,” I said, “let's do it.”

The trick with breech deliveries is to corkscrew the baby out, turning it slowly so that first one hip is delivered and then the other, then one shoulder and then the other. I held gentle traction on the legs and the baby began the slow rotation. It didn't require much traction; this baby was ready to come out.

The unit clerk called from the desk. “I've got OB back on the line. He's on his car phone.”

“Tell him we've got fetal distress and that labor is progressing. I'm trying to deliver the baby.”

Consultation. “He wants to know how far along you are.”

“Tell him we've delivered one hip. What should I do next?”

More consultation. “He says to deliver the other hip.”

I wiped my forehead with my wrist. “Oh, tell him
thank you
.”