Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (8 page)

The nurse smiles. She hadn't liked you from the moment you walked in the door. “We don't do OB at this hospital.”

“What do you mean you don't do OB at this hospital?”

“Everybody goes to Lying-in on the other side of town.”

You pause, stumped, and then you have a verbal tantrum. That's okay, though—all real doctors have them. “Well, why didn't she go across town to Lying-in?”

The nurse's smile broadens. She enjoys making you sweat. “Why don't you ask her?”

She turns away to go back to where the patient is. Her place is taken by another nurse, older but more kindly looking. You still haven't moved. “Well, you must have an OB/GYN doctor on call or something,” you say to the kinder-looking nurse.

“I guess so,” she says and leans out to call to the unit secretary. “Who's on for OB?”

“I think it's Dr. Panks,” the unit secretary shouts back.

“No, he's retired,” your nurse calls.

“Well, he's on the list.”

“Dr. Panks?” shouts the nurse who hates you. She's calling from somewhere in the bowels of the ER. “Dr. Panks is up on the third floor. He had a big stroke two weeks ago. He's delivered his last baby.”

“Honey,” the nice nurse standing before you says. She puts her hand on your shoulder, and as she looks down at you, you suddenly see that she's thinking about how young you look. Then you realize how young you feel. “Honey,” she says. “You'd better get in there.”

And so you abandon your Chinese food and rise slowly from the chair. You're thinking, maybe this is just premature labor…maybe…just Braxton Hix contractions, the pseudocontractions of false labor…maybe, you know, very early labor, and there would be time to transfer her to another hospital.

It's not just that you've never
delivered
a baby—it's that you've barely even seen one delivered. You did do the mandatory OB-GYN rotation in medical school, but that rotation wasn't much. You were assigned to the university hospital, along with fifteen other medical students, during the time of a great managed care-induced upheaval. During the six weeks you were on rotation, only five patients delivered. You managed to be there for three of them, but of course the residents had first dibs on the delivery. There were so few deliveries that they weren't about to let the medical students do anything. Besides, there were so many medical students that you had trouble even finding a spot to stand so that you could see what was going on. Finally, on the last day of your rotation, a resident actually sat you down between the hoisted legs of a freshly delivered mother with a gaping episiotomy. The resident gave you thirty seconds of unintelligible instructions, some 5'0 Vicryl thread on a cutting needle and told you to get to work. You applied yourself vigorously, trying to maintain an expression that conveyed you knew what you were doing, but the fact was that this was your first clinical rotation and the only previous suturing you had done was on a dead pig. The resident watched you for almost forty-five seconds before grabbing the needle driver away from you, pushing you off the stool and setting to work himself. That was the full extent of your hands-on OB experience.

You did have several pediatric rotations during your fourth year, and six weeks in the neonatal intensive care unit. That was back in the days when you thought about becoming a pediatrician—actually, a neonatologist, specializing in high-tech infant care. There you have had a fair amount of experience. You are pretty sure you could resuscitate a baby, but getting that little sucker out into the bright lights and big city—that could be a problem.

As you slowly rise from the chair, you look into the kind face of the nurse before you. In a voice with a tremble and a high pitch, one you don't even recognize as your own, you say, “How…how…how far apart are the contractions?”

The nurse just jerks her thumb toward the acute room.

Get in there.

You walk down a hallway that seems impossibly long and impossibly dark. You can hear the woman wailing. “It hurts,” she's screaming. “It hurts, oh God, it hurts.” You think, Of course it hurts, you idiot. You're having a baby. In the room is the third nurse, younger and very pretty. “Breathe,” she keeps telling the woman. “Just breathe.”

“What the fuck does breathing have to do with it?” the patient screams back. “
I'm having a fucking baby!
”

The patient is a woman half-crouched on the end of the gurney. The nurse who hates you (at some point you learn her name is Helen) is standing over the patient, helping her struggle out of her pants. The patient is thin, gaunt almost, with dirty blond hair and a pendulous belly, striated with stretch marks, and stick-like arms and legs.

You are only two steps into the room when you smell it. Alcohol. She's drunk.

You may not know much about delivering babies, but you are training to be an ER doctor and you know a
lot
about alcohol.

She has half her clothes off when she pushes Helen away and screams, “Stop it, stop it! You're hurting me.” You are struggling to get a pair of gloves on when Helen is knocked back into you. You step around her and use your only available weapon, your elbow, to push the woman back onto the examining table.

You lean over her. “You're
drunk,
” you say.

“Yeah?” she says. More like a statement.

You look at her and somehow you can see the rest.

“How much crack have you smoked tonight?”

“That's none of your fucking business,” she says in return.

You can see her with a crack pipe in her hand. It's a picture so vivid you have to close your eyes. A crack addict, for sure. That explains why she would be stupid enough to come to this hospital. Then you think, Oh my God, the first real delivery I've ever had and it's a crack baby.

She struggles up toward you, wailing, “I hu-ur-urt.”

“Sit down,” you yell back. There is a note of authority in your voice that you've never heard before, but it is almost masked by an equal amount of desperation.

“Sit down,” you shout again. “I mean
lie
down.”

“I can't,” she wails. “I'm having a ba-aa-aa-by.”

You shove her back down angrily. Helen is on one side and the pretty nurse, whose name is Carol, is on the other. You all struggle to get the damn pants off. Finally you get your first look at the vaginal area. The introitus, the vaginal entrance (or in this case the vaginal exit) is closed. The baby isn't exactly popping out, thank God. You at least can finish getting your gloves on.

“Anybody try to get fetal heart tones?” you ask in a sudden moment of clarity.

“I'll get the Doppler,” Carol says.

You stare down at the woman's bulging abdomen. “How many babies have you had?” You are still shouting. You know you have to shout to get through to her; she is totally skanked.

“Seven,” she wails. “Ohhhhhh, my God.”

“
When are you due?
”

Carol, Doppler in hand, leans over her, applying jelly from a bottle to a spot just under navel.

“When are you due?”

“Please, Jesus,” she says and starts panting. “Please Jesus, please Jesus, please Jesus.”

Helen leans over her. “Do you have a doctor?” she asks. “Did you get prenatal care?”

“Lying-in,” she moans. “I'm supposed to go there.” She begins writhing her way through another contraction.

You've finally gotten sterile gloves on, but they are immediately contaminated when the woman tries to sit up again and you push her back down. Helen has the bottle of Betadine, an antiseptic, and begins pouring it over the woman's crotch. The patient starts shrieking again and rears up, knocking Carol out of the way. You push her back down again and put your face close to hers. “Don't move,” you tell her in a fierce whisper. She looks up at you and, for a moment, is still.

You turn to Helen. “Do we have the stuff to resuscitate the kid? Laryngoscopes and stuff, in case this baby's in trouble?”

“I'll get the neonatal crash cart,” she says.

“And the Isolette?” you ask the kind-looking nurse, who now just looks very frightened. The Isolette is a warming unit in which the baby is “gently cradled after its eventful passage into a new world,” as the textbooks say.

“Okay.” You brace yourself against the end of the gurney and lean forward. Her bent legs are on either side of you. You insert two fingers of your right hand through the lips of the vagina. They slide in a couple of centimeters and then you meet an obstruction. The baby's head…is it a head? Yes, it's a head. With your two fingers you explore the vaginal vault. You are feeling for the cervix, an anatomic landmark whose present condition can give you a clue as to just when this baby is going to pop out.

Ordinarily the cervix is about three centimeters long; it protrudes like a little short nose into the vaginal vault. During a delivery, as the baby is pushed out of the uterus, the cervix flattens, and the cervix's central opening dilates. This is what you are feeling for as you try to figure out how close that baby is to the real world and the rest of its life.

You sit on a stool next to her, grope around for a bit and finally peg this lady at about eight centimeters. She is going to deliver soon. No chance to get her to another hospital.

As you grope around inside the patient, she is moving all over the gurney. “Stop it,” she keeps telling you. She rises somewhat to slap at your arm. “You're hurting me.”

“
I'm
not hurting you,” you say. “
You're
having a baby. That's what's hurting you.”

“I know,” she says, still wiggling all over. “But you don't have to be so rough.”

“
Lie still!
” Helen thunders and for a moment again the patient lies still.

Helen has taken over the Doppler and is moving it across the woman's abdomen, still looking for fetal heart tones. “I'm not getting anything here,” she says.

Carol bangs through the doors with a blue cart, the pediatric crash cart.

“She's eight centimeters dilated,” you tell them. “Not quite there.” You turn back to the patient. “When is your due date?”

“I don't know,” she says, and she begins thrashing around again.

“What do you mean you don't?”

She looks you square in the face and spits out the words. “I mean I don't know because, you asshole, I don't know.”

This stops you. The chaos is overwhelming. She doesn't know her own due date, you think to yourself. You stand there for a moment, a gloved hand buried deep inside this woman, baffled as to what to do next. Weird words and phrases fling themselves into your consciousness from some deeper place. They are words that dazzled you in medical school:
platypelloid pelvis, deflexed vertex, synclitic, anaclitic.
You must have known what they meant once, though now they seem incomprehensible. But as you try to remember, raising your free hand up to your forehead, there is a stab of bright light in your forehead. Déjà vu.

You dreamt this before, or maybe lived it. About a case of appendicitis. You were a first-year medical student, and you were standing in an OR suite with the dean of the medical school. He was ordering you to perform an appendectomy on a young boy laid out before you both on an operating table. You had instruments in your hand, but you were doubting yourself, saying, “But if I do surgery on him, I know I will kill him.” The dean seemed to loom larger and larger before you until he towered over you. He was bellowing the whole time, “I don't care if you kill him or not, just do it.” You remember now, if not the whole dream, at least the feeling it evoked, the terror. You remember then that feeling that you could hurt someone; they could be trustingly asleep and you would destroy them.

That feeling is here now, though it's not so overwhelming or paralyzing as it was in the dream. You look down at the patient and she seems very far away. You look around and that's when you see that everyone is moving very slowly—there is time, you think, there is time to think. You reposition your hand as the Woman starts grunting, going through another contraction.

“You get anything?” you ask Helen, who is still trying to get fetal heart tones with the Doppler.

“Nothing,” she tells you.

You turn to the other nurses. “Tell the unit clerk to get on the phone now. Call University and get the pediatric transport team. Tell them we have a baby…tell them we're about to have a baby that's high risk.” You turn back to the woman. “Did you see anybody while you were pregnant—any doctor?” But the Woman just wails in response.

You feel again for the span of the cervix. It seems wider now, bigger than even a moment before. The cervix itself seems stretched to a thin lip that rings the baby's head. You can feel the bones of the skull, unfused bony plates that override each other as they are squeezed through the birth canal. You can sense the compressive forces bearing down on that eggshell head. Oh, Jesus, you think. Oh Jesus, Jesus, Jesus. This woman is going to die, the baby is going to die, I am going to get sued and I'll never be able to work another shift in another ER anywhere in the world ever again.

There's a splat. Blood and amniotic fluid on the floor and on your shoes, a gusher of fluid from the vagina. Her bag of water has broken. You think, I've got to look for meconium staining, a sign of fetal distress, but suddenly the woman is louder than ever before.

“
I gotta push
” she shouts. “
I gotta push. I gotta push.
”

“
Don't push
” you shout back, sounding as desperate as she is.

“I gotta push. I gotta.”

“Just pant, honey,” Helen is telling the woman. “Pant, pant.”

“Please, dear Jesus,” you pray, and as you say this you can feel the head move forward, moved by a primordial force that could move the ages. The baby's head has left the uterus, descended into the vagina and is now burrowing its way out to light and air. The vaginal lips are opening, moving, spreading, embracing the glimpse of a massive egg, a scalp coated with black hair. The lips of the vagina are ovoid now, embracing this misshapen form. That's when you lose all sense of what is going on. You put your left hand over your heart and put out the right hand to do what may be the stupidest thing, to date, you have ever done as a doctor. You give the head a little shove to see if it will go back inside.