Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (12 page)

The other hip slipped through. I had my hands on the baby's waist and kept pulling gently. Two OB nurses with an Isolette appeared at the door.

“Well,” one of them said, “another fine mess.”

Both the baby's legs were out, and the baby kept descending with traction. I could get my fingers up near the shoulders and hooked one of them, easing it down. One shoulder popped out, a turn, then the other. Textbook.

I got my fingers up to the neck, and that is when I felt the cord adjacent to it. I couldn't feel a pulse.

“He's hung up on the cord,” I told Darla. “I don't know how.”

“Can you push it back up?” Darla said. “I mean…”

“I don't think so. The bulk of the traffic is moving in the other direction.”

The lower half of the baby dangled like a doll, blue-black and lifeless. I got my hands over the shoulders and began again, pulling gently. I could feel the walls of the cervix give a little, the baby slide out a little more and a little more. The bones of the skull progressively overlapped as the baby's head descended farther and farther. It stopped. I tried a little more traction, nothing, and so eased up. The moment I released my grip on the shoulders, the baby's head, as if on its own volition, popped out.

We all stared down. It was a normal, if very blue, baby, a boy.

Everyone began frantically to prepare for the next step, the resuscitation, but while we were fumbling with the resuscitation equipment, the bag-valve-masks, the endotracheal tube, the Isolette, the baby made it easy for us. He took one deep breath and started howling.

“My baby!” the mother said.

That night I lay in bed, staring at the ceiling, too exhausted to sleep. And too angry. It was the worst kind of anger—anger at myself. Yes, I delivered the baby and all went well, but what if it hadn't? I would have been hung out to dry by any obstetrician. This was a sin, a terrible error of judgment. According to the medical world, a sin of commission is far worse than a sin of omission. If I hadn't delivered the baby and it was dead at C-section, nobody could really criticize me. After all, how was I going to deliver a breech baby? But if I had attempted the delivery and the baby's head had hung up in the birth canal, it would have been a medical catastrophe. The baby would probably have died, and I would be defenseless. It didn't matter that I was trying to save the child's life; I would have been caught up in the medical process of blame. I had taken too great a chance…but thank God, thank God…

My thoughts wandered, and for some reason I thought of a question people occasionally ask me: have I ever seen a miraculous occurrence after a death in the Emergency Department? After all, what better place for dissatisfied specters to haunt? I always say no—monitors haven't flown across the room, resuscitation tables have not levitated, no ghostly presences have been felt by me. But I have seen enough miracles and near-miracles happen to the living to wonder if God just might suspend the rules of chance and physics, occasionally, that lives might be touched, here and there, at least once in a while, by grace. Especially in the ER, most especially on Friday or Saturday night, when it is really busy: an overlooked x-ray pops up at the last minute, just before the patient is discharged, and changes the diagnosis radically; an ECG is glanced at for the second time; a family member mentions something in passing. And now a breech delivery in the ER ends with the birth of a beautiful baby boy. For myself, while I mainly concede a strict Cartesian universe in which truth can be determined only with controlled clinical trials, that night I thanked God from the deepest part of my heart for saving my sorry ass once again. I thanked Him for letting the odds go the patient's way—for that flicker, that brief glimpse, of grace.

Six days later I had another delivery. Moonlighting, same hospital.

A woman, thirty-five years old and seven months pregnant with her first baby, presented to the triage desk complaining of abdominal pain. Premature contractions? The nurse signed her in and sent her into the waiting room.

While in the waiting room, the woman's bag of water broke suddenly, and she began to leak amniotic fluid onto the floor. The nurse rushed her back into the ER proper and came to get me.

I still had not recovered from last week's delivery. I kept having dreams about reaching out and feeling toes, feeling feet. I craved a normal, head-first ER delivery, all panic and chaos, climaxing with the delivery of an irate, squalling, but otherwise just great baby. I wanted the expectedly unexpected—a healthy woman whose labor had proceeded more quickly than foreseen.

I was thinking this as I pulled on my gloves and the nurse said the ritual, “You're going to feel something cold and wet.” I slipped my hands into the vaginal canal and I felt…

…I didn't know what I felt. There was the cervix and the os, or opening, and there was something sticking out from it. It felt like a piece of wood, like a little tree log extending into the vagina.

This was in the days before near-universal ultrasounds in pregnant women, so that surprises such as twins could occur. But I had never had a surprise of this magnitude.

“What the hell…,” I said. There was a rivulet of fluid, and then this
thing
slithered out onto the cart.

It was a fetal body, its skinny neck topped off by a great bubble of membranes with a wrinkled, gray, gelatinous mass under it. Two gigantic bulging eyes—like the eyes of an enormous fly—stared blindly at the ceiling. Long gray folds of flesh draped down to the grinning mouth.

“Jesus Holy Christ,” the nurse hissed.

“Anencephalic
…” I whispered. I stared down at this monster. I could not believe what I was seeing. “It's an
anencephalic
baby.” The gelatinous mass was the brain.

Stedman's,
the venerable medical dictionary, defines anencephaly as the “markedly defective development of the brain, together with the absence of the bones of the cranial vault. The cerebral and cerebellar hemispheres are usually wanting with only a rudimentary brain stem and some traces of basal ganglia present. Colloquially, individuals with this malformation are sometimes called ‘frog babies.’”

To me, the baby's head looked exactly like the head of a giant housefly.

“Is it my baby? My baby?” the woman cried.

The nurse and I looked down, too stunned to move.

“Is the baby alive?”

I was so stunned I hadn't even checked for a pulse. I put my band down on the umbilical cord. There was a pulse.

I saw it all laid out before me: the neonatal resuscitation, intubating the baby so it could breathe (it hadn't so much as made a gasp in front of us), IV in the umbilical stump, the drugs, the fluids, a helicopter ride to a neonatal intensive care unit, the days, weeks, even months in the unit, the hundreds of thousands of dollars, the grim prognosis, the inevitable heart-wrenching end. I thought about all of this, and I said:

“No, dear. I'm afraid your baby is dead.”

The woman struggled up a little.

“Is it a girl?”

I looked down. I hadn't even noticed. “No, he's a boy.”

“Can I see him?”

The nurse and I looked at each other. The nurse shook her head.

“No, dear,” I said. “Later, later.”

I cut the cord and delivered the placenta. The pulse was gone in a minute or so. There was never even a hint of the baby's taking a breath. Nothing.

That night, I went home to bed and, as usual, stared at the ceiling and reviewed what had happened. What I had thought would haunt me didn't, really. When I closed my eyes, I didn't see the ethics of the life-and-death decision I had made laid out before me so I could worry over it. It somehow didn't bother me, although probably it should have. What I saw instead was that baby—that inhuman fly baby. I couldn't get out of my mind how terrifying and evil it looked. But then I thought about the mother. This woman had tried to conceive for ten years and now, finally, she was pregnant. After I had delivered the placenta, she had sat on the cart in the pelvic room, weeping, saying, “It's all my fault. I'm bad, I'm bad. It's all my fault, and I wanted that baby so much,” while Darla, the nurse, held her and rocked her and tried to comfort her. Meanwhile, the rest of us all sat out at the desk trying to figure out whether we should call the coroner and report a death or just send the body straight to pathology as a stillbirth (coroner, it turned out).

Now I couldn't sleep. I kept going back and forth between the image of the fly baby and the weeping mother until finally I got out of bed and foraged for some beer from the refrigerator. I sat down by the window and looked out over the city. It was late; a few cars passed by, a dog barked. Somewhere in the distance a car alarm went off and then almost immediately stopped. Efficient thieves. A cat picked its way across the street, otherwise nothing. Except, of course, somewhere in this city, someplace I couldn't see from my window, that mother was crying and still blaming herself.

So much for grace.

After that I grew up as a doctor and began supervising residents who now had to make their own tough calls and then go home and stare at the ceiling at night. I, on the other hand, got lots of practice shaking my head in disbelief.

One afternoon, a resident sat going over a case with me. The patient, a twenty-year-old woman, had presented a week before with new onset seizures. She had no past medical problems. Her second seizure occurred in the ER as she was being loaded with Dilantin. The ER physician then admitted her to the hospital under the family-practice physician on call. The patient did well, had no further seizures and was sent home seventy-two hours later. Now she had returned with a low-grade fever, burning when she urinated and some crampy lower abdominal pain.

The resident drummed the clipboard nervously with his pen. “I think she has a urinary tract infection,” he said.

“I'll buy that.” I shrugged. I was only half listening to the presentation.

A nurse shouted from the patient's room on the other side of the ER:

“She's
crowning!
”

The resident and I looked at each other.

Someone else shouted,
“She's in labor! She's having a baby!”

We rushed across the ER and back into the cubicle where this young woman lay, knees drawn up and open wide and the dark dome of a baby's head just visible between the lips of the vagina.

It is always now, when you are trying to put them on, that gloves assume a life of their own; fingers won't go in right or the glove tears into shreds. The woman was moaning and beating the aluminum bed rails with her hands as I wrestled with the glove. I finally got one on and slid my fingers down, beside the baby's head, under the strained skin of the vaginal opening. This must be the girl's first baby, I thought grimly. The vaginal walls had never been stretched, and the vaginal opening was too small for the baby's head to pass through. She needed an episiotomy, an incision to open up the edge of the vagina—usually done with sterile scissors. I shouted for someone to find the OB tray. The risk was that if the skin wasn't cut, it might tear—a mess.

The baby's head strained against the skin, which was purplish now as it bulged. It seemed like an hour or so (it always does) before the nurse returned with the obstretrics tray. The other ER attending began tearing it open to get at the neonatal resuscitation equipment for the baby. I fumbled with the scissors he handed me.

Most obstetric physicians I had trained under taught us that the vaginal wall at this point during delivery is entirely anesthetized. But most of these doctors were men. Every woman who has so much as felt the cold steel of scissors or scalpel on her skin has gone through the ceiling. This time was no different. The woman screamed and beat the cart railing while I cut into the flesh. The vaginal entrance opened wider and the baby practically popped out into my hands.

The baby was dead.

It was clear it had been dead for a while—no pulse, no respiratory effort, but it was more than this. The skin was macerated and yellow and the fingertips and toes had started to necrose. The baby was very dead, perhaps a week or more.

“What is it?” the girl shouted. “What's wrong with me?”

“It's a baby,” I said, peeling off my gloves. “And I'm sorry, but it's dead.”

What else could I say?

“A baby!” the woman shouted. “I'm pregnant?”

“You
were
pregnant,” the nurse said evenly. I glanced up; I understood her look. How could anyone be so stupid?

“How can I be pregnant? I've had my periods!”

“It's a miracle,” the nurse said dryly.

“I can't be pregnant,” the girl said. “I would know that, wouldn't I?”

I shut my eyes and pressed my fingers against them. Something was wrong. “Wait a minute.” I turned on the resident. “What was this woman here for last week?”

“Seizures. First-time seizures.”

“A week ago?”

“Six days.”

I looked at the baby. It looked about six days dead. I looked back at the resident.
“Eclampsia.”
I nearly whistled it. “She was
eclamptic.”

It was interesting to watch this transformation pass like a pin-ball into the various potential scoring places of the resident's brain before it finally dinged. Pay dirt.

“Eclampsia.
Oh, my God.”

This was very bad. When this woman had presented six days ago, she was seizing not because of an underlying seizure disorder but because she was pregnant, unbeknownst to her and everyone else. She was having a complication of her pregnancy. Eclampsia is a condition in pregnancy that involves the mother's toxic reaction to the fetus. It usually occurs in the last month of pregnancy.

The initial symptoms are an elevated blood pressure, leg swelling and protein in the urine. That is preeclampsia. When the patient has a seizure, that is true eclampsia—a full-blown catastrophe requiring immediate delivery of the fetus, otherwise the baby's life, and sometimes the mother's life, is in severe jeopardy. That's what happened here. The patient had come in to the hospital seizing and nobody had thought to get a pregnancy test. A lethal mistake—but one, I'm afraid, any doctor might make. A busy Friday night—trauma in the next room, people stacked up in the hallway—and another seizure patient…