"In an emergency, take you own pulse first."*

There is nothing quite like waking up to an emergency, especially when it is not.

After a day of ectopic pregnancies, patients sick with the flu, and routine deliveries that belonged to the county hospital but managed to find their way to our labor rooms, my head was on the pillow and my mind just thinking about REM sleep when the phone rang.

"They're taking the patient in room 4 for a stat!" The next sound is the dial tone.

Instantly the light is on, my feet are in my shoes, and the cap and mask at the bedside are in my hand as I run out the door. I imagine this is a bit like a fire fighter going down the pole, propelled by an adrenaline rush into the unknown. My mind is foggy trying to remember the patient in room 4. I am not in charge of this patient's care but I try to keep a mental list of each patient in the 18 labor rooms. If something happens I could end up taking care of any of the patients in the labor area until her physician arrives.

"They are in OR 2!" the intern yells as I run down the hall way.

I get to OR 2 and no one is there. Well, maybe it was a dream.

I turn around to exit the OR suite as the double doors fly open. A large Hispanic woman is on the stretcher surrounded by people pushing her into the room. I ask everyone to stop.

"What is happening?" I demand. My pulse rate has maxed out at what feels like 200 beats per minute but I manage to keep my voice level.

"The nurse could not find heart tones." the second year resident pants. "I put the sonogram on and the heart rate is sixty so we came back here. I called a stat C-section."

Taking the monitor from the nurse I locate the fetal heart tones, introduce myself to the patient staring up at me, eyes wide. Covering her up a bit, I introduce myself, then ask the nurses "Where is anesthesia?" No way to do a C-section without anesthesia. (Well there is but that is another post.)

"Right here, I was just called," the anesthesiologist enters the room.

The fetal heart tracing is looking rather normal and the lady, though quite large, has a small fundal height. "Please tell me about this patient," I ask the second year resident as the upper level resident enters the room.

"She is here for high blood pressure. She is 26 weeks and breech. She may be having a placental abruption." The fetal heart tracing still appears normal for a 26 week baby. (40 weeks is term.) Nothing has been below 120 beats per minute.

I have noticed a faint scar just above her pubic bone. "How many pregnancies, deliveries, and C-sections?" I ask.

"Three pregnancies, two C-sections," is the reply. There are ten people in the room in addition to the patient. One person is translating and I realized the patient speaks no English. I thought I was sacred. She must be losing her mind with fear.

"Well, the fetal heart tracing looks OK now." I say to the second year resident. Let's get the sonogram machine and look again at the baby. Then to the special care nursery team, "I don't think we are going to do an emergency C-section. We'll call you if we decide we need to deliver this baby."

The scan looks normal. The biophysical profile is a perfect 8 out of 8. I explain to the patient through the translator that her baby is doing fine. There must have been a variable deceleration in the heart rate that is common for preterm babies.

Taking the patient back to her labor room to continue her monitoring and medication for her extremely high blood pressures, I read her chart. She does not have preeclampsia which would be treated by delivery. Apparently she has chronic hypertension and has not been taking her medication so she was admitted to the hospital tonight for blood pressure control.

A few minutes later I am sitting in the resident area writing my note about the earlier events. This is a chance for the second year resident and I to talk. I begin, "The good thing about being a second year resident is you don't really have to make any big decisions. The first thing you should do, IN THE LABOR ROOM," I emphasize this to hopefully save another false alarm with this resident, "before you move the patient."

Continuing, I explain, "call you upper level, call anesthesia, tell them to open the C-section room, but don't move until you have everyone there." I wait a few minutes to let that sink in. "It would be bad enough to lose a premature baby, but it would be much worse to lose a mother, especially one who has two children."

We sit quietly for a minute. I am remembering how difficult it is to be the second year resident. I was my most difficult year of residency. I even had a maternal death. Yet, what I said is true. The beauty of residency is there is always someone to call. In two years, nine months and three days, this young resident will be in practice. Then the decision will be all hers. Hopefully we will have her ready. Tonight was a step in that direction.

*quote from one of my attending physicians 28 years ago

I dunno

To the 16 year old in labor: "Have you ever been pregnant before?"

"Yeah, I had a baby last year."

"When last year?"

"August." A pause. "I think it was August."

"How much did your baby weigh?"

"Dunno."

"Is the baby doing alright?"

"Dunno."

"Doesn't the baby live with you?"

"No."

"Why doesn't the baby live with you?"

"I gave her to my mamma."

"Don't you live with your mother?"

"Yeah."

"Well, if you live with your mother and the baby lives with your mother, why don't you know how she is doing?"

"Well, that baby don't live with my mamma no more."

"Why doesn't your baby live with your mother any more?"

"She gave the baby to my grandma."

The 4th floor

I frequently take a short cut path through the 4th floor. It is a medicine unit where a number of very sick patients from the emergency department wait for a room to open up the specialty area where they will receive treatment. I can usually save 5 minutes of waiting for an elevator because the stairwell on this floor is not locked as it is on the obstetrical floors.



Today, I finally realized the short cut is not worth it. I take this path to save time. However, for the fourth time in as many weeks I have run into a former patient with a relative in the hospital. I stop to talk and spend more time than I had hoped to save. Today it was a woman about my age there with her husband. From our previous conversations I knew he had been diagnosed with cancer some time ago. She is there, very anxious, and I am a friendly face.

I sit with her for a while and listen to what has happened with her husband. I remember how very difficult it is to wait with a loved one. I have had family and friends in the same situation forever grateful to see a friendly face in the swarm of medical personnel.

Perhaps there is a purpose besides time saved when I take this "short cut." I believe I will continue. That is at least on the days I have the time.

Sometimes the best teacher ...

How much have you learned from those not given the title of teacher? Here is a story from my third year of medical school that reminds me how much I have learned from those we tend to think of as the supporting cast.

I was on my second full night of call in the obstetrical unit at the county hospital. Well Known College of Medicine staffed a large hospital primarily devoted to obstetrics in the poorest ward of Largest City, Texas. In the single month of my obstetrical rotation I delivered forty babies assisted only by the Licensed Vocational Nursing staff.

As medical students we joked that it was "see one, do one, teach one. " The chief resident would show you how to do a delivery. Next one of the third or fourth year residents would watch you do a delivery. You were checked off as a "delivery doctor." At that point you were on your own. The only condition was any repair of an episiotomy or laceration had to be inspected by an upper level (third or fourth year) resident. Legend had it a new third year student had once sown a vagina shut. I thought this unlikely and worried more about unrecognized third and fourth degree lacerations, the improper repair of which could leave a woman incontinent for life.

One reason that Friday night in October is so clear in my mind is it was the woman's first baby. It was also my first solo delivery. I had to cut a small episiotomy which I meticulously repaired but all senior residents were in the OB chief resident's call room. The most important thing about that particular night: It was the night the world learned Sue Ellen shot JR in the television series "Dallas."

At any rate this story is not about what the residents were doing. It is about a group of my real heroes in that chapter of medical school, the LVN's. I was convinced the LVNs knew more obstetrics than many of the attending staff. For the most part, the attending staff were just too busy to be bothered because they were putting together the next edition of a textbook.

Checked off by the resident from my last delivery, I took the patient to the recovery room and finished the paperwork in her chart. Out in the hall I heard a nurse call "delivery doctor!" Finished with one delivery, I rushed to help push the stretcher back to a delivery room for another.

No sooner than we had the woman on the delivery table and in the stirrups than I could see the baby's head crowning. I pulled on my gloves and helped the head out of the vagina. Immediately I realized there was not just one or two, but three loops of cord so tight around the baby's neck I could not reduce it over the baby's head nor could I delivery the baby.

Seeing the panic in my face, one of the LVN's picked up two Kelley clamps, and clamped all three of the loops of cord together. "Cut here, doc!" she commanded. I did just what she said. The cord fell away and the baby almost delivered itself into my waiting hands.

After placing the baby on the mother's abdomen, I looked up at the nurse. "You're gonna be alright, doc!" she exclaimed.

I thanked her and we both went back to work. Whenever I have a tight nuchal cord which needs to be cut rather than reduced over the baby's head, I think of that LVN working nights in a hospital full of medical students and residents. I doubt I was the only one who learned such a valuable lesson from her.

Degrees of sadness

Yesterday an old friend from my private practice days asked, "What is the saddest thing you have seen while doing this job?"

My answer was, "A fifteen year old lying on as stretcher in the ER with a dead baby between her legs." I went on to explain what made this even worse for me was the fact the young woman was not upset. She acted as if for her this was a daily occurrence.

When I inquired who brought her to the emergency room, I was told, "An ambulance."

The girl told me she called the ambulance when her contractions became so painful she couldn't stand them any longer. This was necessary because she lived with her grandmother who was wheelchair bound and did not drive. The baby was dead when she delivered him shortly before her arrival. From looking at the baby, I suspected he died even before labor began.

I then ask if I could speak with her grandmother.

"She ain't here." Was the curt reply.

"Could I call and talk with her on the telephone?" I asked.

"Well, I guess you could, 'cept we got no phone at home." With this she opened her palm to show me the cell phone she was clutching. She had used to it to call the ambulance. In fact she seemed more worried about what her grandmother would say (or do) when she was caught with the cell phone, than she was about the fact she had just delivered and her baby was dead.

I did talk with the grandmother, the girl, and the social worker later that day. Hopefully things are better now. I don't know. I think about her every time I am on call and at times when I am not.

Sad, however, has reached a new level today.

Today my mental portrait of sad is a beautiful, 8 pound 4 ounce baby boy who came out screaming last night. He is now struggling to withdraw from the narcotics his mother has been taking throughout her pregnancy.

An oxymoron

Safe sex.

Today many people feel this should be our focus of attention when it comes to talking about sex with those who have it, might have it, or have had it. I disagree. There is nothing 'safe' about sex. Here is a capsule of my morning and the case in point.

In one room is a nineteen year old pushing out her third child. She does not even look at the baby. Her three year old sleeps on the pull out couch. The one year old is home with the grandmother. The new baby is screaming, a sign of good health in a newborn, but I can't help thinking this child has more to scream about than most. How will she ever get the emotional support she needs to grow and develop, get an education, develop skills which will keep her from ending up right back here as the mother in a few years?

Next door is a thirty five year old 23 weeks and 6 days into her first pregnancy. Her cervix is too short to hold the baby in and her bag of water broke spontaneously last night making delivery likely in the next twenty four hours. The cause of this situation is likely the human papilloma virus (HPV) which infected her cervix years earlier growing abnormal precancerous cells. These cells had to be remove not once but twice in the last ten years. Now with a shortened cervix her first pregnancy will produce a premature infant who will weigh just about a pound at birth. The card I am required to wear with my name badge says that in our nursery her baby has a 76% chance of survival. Of those babies which survive, 67% of will be neurologically normal. In other words, her chance of a normal baby are just over 50%.

The rest of the patients? One is having a baby with a severe heart defect which will require surgery shortly after birth , one has a baby with trisomy 21, and a third, already delivered, has dangerously high blood pressure caused by her pregnancy.

So, I propose we stop using the term "safe sex." There is no such thing. We should instead speak of responsible sex while helping those who will, are, and have had sex learn to deal financially and physically as well as mentally and emotionally with the consequences.

Air and light

Back in the mid to late '70's when I was working on my biology degree, the conventional wisdom was living things need food, water, and sunlight for growth. I realize things have changed somewhat. Food is now grown under artificial light in nutrient replenished fluids producing amazing crops. Yet, I cannot help my belief of the need for natural light and warmth from the sun, a slight breeze on the skin, and fresh air for the lungs. It seems these are necessities for human well being.

One big problem with shift work is it can rob people of the natural diurnal variation. With that comes the lack of what I believe are essential nutrients, fresh air and sunlight. Bright fluorescent bulbs burn 24/7. The hospital air is a standard issue: cold and filtered. Chilled to about sixty eight degrees and pushed through laminar flow filters to decrease infection. So what is a body to do?

Here is a solution. The hospital complex now spans about four blocks. I am suppose to stay on one of those for my shift. I know of no rule that states when things are slow I cannot walk around that block. I do. And I do this at least four times in a twenty-four hour period. Occasionally more. Routinely I try for mid morning, early and late afternoon and once in the evening. I can even cut the diagonal which is the quickest way from the front door of labor and delivery to the ambulance bay of the emergency department. At times this is necessary. On the walk back, if there is not another emergency in labor and delivery I can stop at the prayer garden which is just off this path.

None of these routes are a walk in the woods. Many of the vistas include views of local skyscrapers which depending on the light can be picturesque. There are homeless or near homeless people on every corner. A number of times I am ask directions by visitors who are lost. However trees, flowers, and patches of grass dot this area. And the fountains! Believe me, no relgiously affiliated hospital has ever been build without fountains. There are six here at last count, smelling a bit like swimming pools but adding soothing sound of moving water to the venue.

A bit at a time I am figuring this out. After several months I am still sleeping mostly at night. I have not eaten fast food. I am writing and reading more. Now I have this habit of getting some air and sunshine.

In case you didn't know

Just so you know what we are dealing with here is an excerpt from the Dallas Morning News today.


AUSTIN – Texas, a leader in teen pregnancy and the state where more teens give birth to subsequent children than in any other, maintains one of the most restrictive policies in the nation for minors to obtain prescription birth control.
Not even young parents in Texas can get birth control without their own parents' permission at nearly a third of the family planning clinics on contract with the state health department.
While most privately and publicly funded clinics in North Texas prescribe contraceptives without insisting that parents be notified, all 10 school-based clinics run by Parkland Health & Hospital System in Dallas must have a parent's signed consent. One in Carrollton-Farmers Branch, at the school district's insistence, can't prescribe any birth control.

The article goes on to say that one city in Texas, which is not Houston or San Antonio, has the highest rate in the nation of teens having their second and third child while still teenagers. Old enough to have a child but not old enough to legally obtain birth control. Texas wisdom at it's finest.

Sunday's child?

At times I have serious doubts about whether anyone reads this blog. At other times I feel afraid to say how I feel or divulge too much. Today, while I do care, I think those of you who might read this and contemplate going into medicine need to know some days are, as a former resident classmate of mine would describe, "Just the pits!"

It really began last night. One of the doc's in my group had a death in the family and called to ask if I would take his call on Tuesday so he could go to the funeral. He had tried to call others but no one is in town except those of us on call. I had something really important planned for Tuesday but it wasn't as big as a funeral, so I ended up telling him I would do it.

With that mind set I came to work only to be confronted with a sick patient in the emergency department. She needs some treatment and then surgery tomorrow which I will have to do on a holiday weekend when things are slower than normal. To make things even worse, she is mentally ill. After a conversation with her and then with the family, I had to take a walk around the block to make sure I was thinking straight.

Next, I was confronted with a belligerent family. There seem to be several on this holiday weekend where the hospital is overflowing and understaffed.

So that is how this Sunday has gone.

Enough of this self pity. It is time to get back to work.