Monday, September 28, 2009

"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
"In an emergency, take you own pulse first."*SocialTwist Tell-a-Friend

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