by Barbara Ebel
“Tell them to get a pediatrician for Ms. Barker’s baby,” he yelled. “Stat.”
The distressed patient on the delivery table grimaced and contorted her face, but with the clue that her baby was also in trouble, she let out a soulful cry.
Annabel darted two quick steps and hollered towards the nurses’ station. “They need a pediatrician.”
She breathed deeply and spun around to go back inside. She had completed her surgery rotation and had seen trauma cases, but this was the first time she’d seen that much blood pouring out of someone. From childbirth? This was insane.
Within seconds of her being gone, the group in the room came to another decision.
“We can’t contain this,” the female physician declared. “Bonnie Barker, you’re going to the OR.”
Annabel realized the physician must be Ling Watson, her new team’s chief resident. As she stepped back into the hallway, a strong-muscled orderly was backing an empty wheelchair out of a nearby room. “There’s an emergency in here,” she said. “Can you help them transport a patient to the OR?”
The man went inside, where Dr. Watson gritted her teeth and bimanually palpated the woman’s abdomen as well as inside her vagina. Confusion swept over Annabel. Was this some kind of CPR on the woman’s uterus after birth … something to help a bleeding situation like this one?
No further words were spoken as the bed flew down the corridor to swinging doors … straight into the obstetric floor’s own OR. Masks, bonnets, and shoe covers seemed to magically attach themselves to everyone going in. Annabel stopped short and busted into a women’s locker room and threw on scrubs. After getting properly attired, she rushed into the OR where Bonnie Barker’s life depended on the medical team.
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The patient’s vital signs were registered on the monitors and beeped from the head of the table, where the anesthesiologist had already arrived. He was stripping open an IV package and a tourniquet was wrapped on the patient’s left arm. When he whipped it out, he expertly slid the large-bore IV into a vein. Annabel realized the patient needed a larger IV than she already had. Fast replacement blood was needed to substitute for what she was losing.
The monitors painted a gruesome picture. Ms. Barker’s blood pressure sagged and her heart rate bounced higher and higher. Dr. Watson continued her bimanual compressions. The patient became more quiet.
Ling Watson’s eyes met the doctor at the head of the table. “Pitocin?”
“I just gave another ten units slowly,” he said.
As Annabel contemplated the drug, she remembered hearing that it was the same as oxytocin - a neurotransmitter in the brain. But why were they using it now? Meanwhile, someone thrust two units of blood through the door and wiggled them at her. She grabbed them and verbally cross-checked the bags with the blood bank slips with a nurse to make sure … correct patient and correct blood.
The anesthesiologist pulled the tab from one of the units and stuck the blood bag into an IV fluid setup and into a pressure bag. After pumping it up, blood began streaming into the woman’s vein.
“I’ll get blood for labs,” the anesthesiologist said.
“Yes, she could have a coagulopathy,” Dr. Watson said.
The anesthesiologist drew blood from the patient’s other arm. Soon an OR tech ran outside with the filled vials for the lab.
Dr. Watson slid her hand off of Bonnie Barker’s abdomen and nodded at Dr. Gash to help her out.
Caleb Gash stood on the other side of the table and began palpating. “What about a uterine laceration?”
Ling took her hand out of the woman’s vagina. Blood clung to her glove and dripped down. She eyed the drapes, the floor, and back between Bonnie’s legs. “Thank God,” she mumbled.
“Slowing?” Caleb asked.
“Like someone has turned off the faucet.”
The three senior doctors in the room made eye contact with each other, acknowledging silently that the life-and-death situation was turning around. The patient’s uterus was clamping down; beginning to behave itself.
The anesthesiologist took down the empty unit of blood and hung the next one. Bonnie Barker’s blood pressure and heart rate began reversing their deleterious directions. Her oxygen saturation stayed acceptable with the oxygen the anesthesiologist had placed over her face with a mask.
“Let me take a good look,” Dr. Watson said. “Make sure I don’t have to ligate any blood vessels. Get me a Foley catheter as well,” she said to a nurse.
She leaned over Bonnie’s abdomen as much as she could. “Ms. Barker, we thought the anesthesiologist was going to have to put you to sleep and I would need to do a surgical repair to stop the bleeding. However, it is slowing down. We’re waiting on blood work, which will tell us more as well.”
Annabel had her hand close to the patient; Bonnie’s arm was stretched out on an arm board. The patient acknowledged Dr. Watson’s words by giving Annabel’s fingers a light squeeze.
The time remaining in the OR took longer than the emergent manner in which the doctors and nurses sped Ms. Barker from her room to the OR and palpated her uterine fundus and resuscitated her. When they finally steered her bed out of the OR, they brought her to the recovery room where they could watch her closely.
Dr. Watson and the anesthesiologist sidled next to each other.
“At least seven hundred cc’s blood loss in the delivery room,” she said.
“At least six hundred cc’s blood loss in the OR,” he said.
“A major postpartum hemorrhage is a hell of a way to start the day.”
Caleb Gash and Annabel stood nearby. He gave her a small nod. “Welcome to OB.”
CHAPTER 3
Annabel stood for the longest time while the senior physicians talked at Bonnie Barker’s bedside and then backed up to a corner, where they discussed the case in almost a whisper. She shifted her weight from one foot to the other, watching the post anesthesia care unit or PACU nurse tend to her patient. From the doorway, the patient’s partner stuck his head in and cleared his throat.
The PACU nurse waved at him. “Don’t be shy. You can visit for a few minutes. Bonnie will most likely be ready to nap soon after all she’s been through.”
He nodded and stepped in, but stood closer to Annabel than the bed. “How’s the baby?” he asked her.
“I don’t know. You can probably find out from the staff in the nursery or the pediatrician in charge. I take it you’re the dad?”
He looked at his sneakers and contemplated her question. “Yeah,” he said, nodding towards Bonnie. “But she quit me after she got pregnant.”
“Quit you?”
“She didn’t want to see me much after that. Like some big feminist idea to raise the kid with or without me. Turned down getting married. I mean, I offered after she didn’t want an abortion. I’m an accessory to her becoming a mother and this is only the beginning of this kid’s life.” He eyed Annabel. “What happened back in the room looked pretty scary. By the way, I’m Tony. How come there are so many of you doctors taking care of her? She won’t be able to pay a humongous bill from each of you.”
“I’m a third-year medical school student, not a full-fledged doctor yet like them over there.” She pointed to the corner and finally sat on the edge of an empty stretcher. “In other words, I’m free of charge and I’m here to observe, learn, and gain experience.”
“Low man on the totem pole. Figures. You have a glazed-over expression like you’re clueless.”
“It shows that much?”
Without a parting comment, and with a soft stride, he was alongside Bonnie, who made a poor attempt to acknowledge him. Annabel wondered if it was only because of weakness from her harrowing experience, loss of blood, and resuscitation. She frowned and glanced at the doctors huddled together in the corner. At the moment, Tony wasn’t the only one being left out to dry.
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The orderly who helped out earlier passed by in the hallway and stopped when he saw Ann
abel. “Time you learn where to hang out when you’re not with a patient or doing scut work,” he said. “I’m Emmett.”
“I’m Annabel Tilson,” she said as they went down the hall and behind the main desk of the labor and delivery wing. “I bet you are aware of everything that goes on around here.”
His furry black eyebrows inched skyward and he laughed. “More than most.” He pointed towards the spacious room. Each of his forearms had a tattoo, but they were difficult to appreciate due to his dark olive skin tone.
“Pick a spot,” he said. “This is the lounge those docs back there use, but Dr. Fleming and Dr. Ridley, the anesthesia residents, are here more often. That’s cuz they’re posted here this month running ragged with what I call ‘mother’s pain.’ There’s no other pain like it in the whole world or the whole universe … I’m sure of it. If I’d been born the unfortunate sex of a woman, I wouldn’t be doing what other members of my sex do. No sir. No thank you. No spitting out babies for me. I’d make sure I stayed a childless woman, if you know what I mean.”
The smile lines around his eyes disappeared as he spoke. When he finished, he added one more thing as he grabbed an empty wheelchair to transport back to the ER. “Dr. Fleming is at the white board in there.” He leaned over. “She’s the real deal.”
Annabel thanked him. She sat inside at a round table while the anesthesia resident used an eraser to remove a name. The woman shot her a glance.
“You must be a new student. Welcome. I’m Kristin Fleming, a fourth-year resident; a third-year anesthesia resident.”
“I’m Annabel, a third-year student. A fourth year in residency is a long way off for me.”
“I hear you. You have a long haul, but you’ve done a lot already. The journey is what’s important, Annabel, not the end result.” She put the eraser down, and with a spring to her step, she pulled out a chair. Dark, wide-rimmed glasses sat on her broad nose and two sets of earrings made up for her otherwise lack of jewelry. She was flat-chested, tall, and extended her lanky upper limbs on the table.
“I missed the case that just came out of the OR,” Kristin said, “because I was in a patient’s room doing an epidural for a woman’s labor. Did you go in?”
“I followed and stayed out of the way. I always hate the beginning of a new service because I feel so helpless.”
“That’ll change. You’ll be doing scut work before you eat lunch. That, in and of itself, is useful to the team.” She contracted her lips in a pucker like some people furrow their forehead in thought, and then mumbled under her breath,“If you can call them a team.”
“So true about the scut work, but don’t get me wrong. I’m not complaining. I make the most of my rotations and end up having the most memorable, off-the-graph experiences. I love medical school and wouldn’t change what I’m doing for all the gold in Fort Knox.”
“Awesome. You interested in OB/GYN?”
“I don’t have a clue. My dad’s a neurosurgeon and I have an uncle who’s a paramedic, so I had little exposure to that type of specialty talk at home.”
Kristin nodded as Dr. Watson and Dr. Gash strutted in. They went straight to the couch and sat cozily next to each other. Ling unfolded a sheet of paper, flattened it down on the short table, and then noticed Annabel. “You might as well join us,” she said. “Are Barker’s lab results back yet?”
“I don’t know,” Annabel said, hesitating to sit across from them.
Ling rolled her eyes like Annabel was a fly on the wall. “It’s obvious you inherited her as a patient. All right then … sit down. Now is as good a time as any to explain the rotation to you despite what you might have heard. Every medical school doles out their OB/GYN rotation the way they want, but this is how we do it here. Ours is short compared to surgery or internal medicine. Four weeks is all you have unless you become totally impressed and enraptured like I am with the last remaining natural God-given act on the planet – childbirth. If you are, then I’ll see more of you in a few years when you do a residency.
“However, the four weeks are basically split up. Two weeks of obstetrics and two weeks of gynecology, except that clinic days will be a combination of both types of patients. There’s only one test at the end of the four weeks, which obviously covers the whole kit and caboodle. This week you’ll do OB during the day and next week, you’ll be on the twelve-hour night shift. The other student, Stuart Schneider, will be alternating the days and nights with you. We don’t care what twelve hours you’re doing when bi-monthly grand rounds are scheduled. You must attend that lecture no matter what. You’ll most often see our attending doctor in clinic.”
Ling tilted her head at Caleb. “Anything else you want to tell her?”
“Sure. We discuss patients once in the morning and late in the afternoon, but that is not set in cement because there may be active patient care going on … like what happened this morning. Our course of action around here depends on what’s going on with a parturient’s uterus and vagina.”
“Keep up with the status of the patients on the board and write a daily note on everyone,” Ling added. “It’s not uncommon to salvage some time to study during the day, so do it. Dr. Gash and I won’t be holding your hand. Don’t forget that around here we’re not only taking care of this predominantly young female population, but the safe delivery of their infants rests with us. That is a huge responsibility so, most of the time, we’re on auto-pilot and not paying attention to students.”
Dr. Watson’s pager buzzed. She got up and disappeared out the door. Caleb leaned forward, ready to follow the chief resident. “Find out any updates on Bonnie Barker and her baby,” he said.
“How unusual was that this morning?” Annabel asked quickly.
“Here’s your fact for the day. Information to commit to memory. For a normal birth of a single baby in a vaginal delivery, Mom loses, on average, five-hundred milliliters. That equates to two full cups of blood. Our patient lost well over double that amount. As a matter of fact, she lost more than a fifth of her prepregnant entire blood volume.”
Annabel shuddered. Caleb rose and stuffed a notepad in his pocket.
“What about a cesarean section? What’s the normal blood loss for that?”
“An entire one-thousand milliliters and, it goes without saying, you better learn everything there is to learn about Pitocin.”
Annabel pulled out her pocket-size handbook on obstetrics and gynecology, and when she glanced back up, Caleb was gone. She thumbed through the index, ready to get her facts straight. In the first two years of medical school, she’d heard more about oxytocin because it was a protein produced by the pituitary gland; a naturally occurring hormone of male and female mammals that increases the concentration of calcium inside muscle cells which, in turn, controls the contraction of the uterus. She read that the synthetic, man-made version of oxytocin, is Pitocin and, apparently, used in obstetrics all the time for stimulating uterine contraction.
A “pop” sounded from the round table where Kristin Fleming opened a soda can and began pouring. Annabel broke from her reading. It was time to do her patient’s follow up.
“Pitocin comes in handy,” Kristin said, peering over her glasses. “It can induce abortion and be life-saving to control bleeding after childbirth. And labor? They don’t call it that for nothing. Damn hard on a woman. Exhausting and painful as hell.”
“You must be the guardian angel in all of this … providing their pain management.”
“So true. However, labor, plain and simple, can wear a body out. No matter how much a woman tries, her body just can’t or won’t push that baby out. Pitocin can induce labor or strengthen the contractions of labor. Often, that synthetic drug is as valuable to them as an epidural. They just don’t realize it.”
Annabel nodded. It was the same old thing. Patients often didn’t realize the intricacies of the medical care they were receiving. No different from customers understanding the minute details of a tax accountant working on their tax return or an a
rchitect trying to make a particular geographic landscape work with a certain house plan.
“Thanks, Dr. Fleming.”
Kristin gestured with her glass. “You’re welcome.”
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The newborn nursery and neonatal intensive care unit, or NICU, was on the same floor as obstetrics and gynecology, but straight forward off the central elevators.
The faces peering into the main nursery on the right were mostly lit up with smiles. Other individuals and family members giggled, pointed, and made funny faces at the swaddled infants in their bassinets. The scenario on the left, however, painted a different picture. The NICU housed the premature infants having difficulty or ones with congenital abnormalities needing specialized care, or pre or postop premies that were in dire straits … their battle to live begun way too prematurely without so much as taking their first steps on Mother Earth.
Standing to the side of visitors, Annabel scoured the names of the babies in the main nursery and saw a card for “Baby Girl Barker.” She wondered how a mother could carry a baby for months and not have a name picked out. Even if the mother didn’t know the sex by ultrasound, she figured a woman would at least have a name for a boy and a girl. But then again, maybe she was waiting to see what the baby would look like and a name would spring into mind. She wasn’t that familiar with newborns, but her impression was that they weren’t that distinctive. They had to grow into their facial and bodily features as well as their personalities. She shrugged her shoulders and stared at the female newborn who appeared scrawnier than the two babies on either side of her.
Annabel recognized the physician hurrying past her as the pediatrician who had showed up in Bonnie Barker’s delivery room. He seemed to be giving another doctor information as they walked together and opened the door to the nursery. “Another thing,” the pediatrician said. “The Barker baby’s position at birth? Breech.”