Just Here Trying to Save a Few Lives

by Pamela Grim

  “Hold CPR.”

  Asystole. Nothing.

  “Restart CPR.”

  Carolyn put a hand on my shoulder. “Nothing's working, honey.”

  I hung my head.

  “It's time to wave her good-bye.”

  Julie stopped CPR and looked down at me—waiting.

  I looked at my watch. “One more round of drugs,” I said. I stood looking at the monitor, turning my back to the patient.

  Epi, atropine.

  “Hold CPR.” I gazed up at the screen, trying to will her back. She must come back, she must.

  Asystole on the monitor.

  I looked at my watch and raised my hand in the air. “Okay, code called twelve thirty-five.”

  Julie stepped heavily down from the footstool and peeled off her gloves. Carolyn stood, arms crossed, staring at a wall. Gupta was looking at the first ECG we had gotten.

  “Wow,” he said. “Perfectly normal. Can you believe it?”

  I stood watching the monitor until Carolyn disconnected it from the patient. Nothing left. I turned away from them all, mumbling, “I've got to tell the family.”

  I walked slowly out through the back door to the waiting room thinking, Pump failure, pump failure, as I shuffled along. I was trying not to think about what could have happened. What if she had come in yesterday? Or the day before, when there would have been a cath lab available?

  I stopped at the door to the waiting room and looked in through the window. There the husband and the daughter sat, not looking particularly anxious—after all, the last time he had seen his wife and she had seen her mother, the woman had simply been complaining of some chest pain.

  Yesterday…, I thought.

  I walked in, feet still dragging, and sat down beside the husband. He looked at me trustingly. I felt like I was about to shoot a puppy.

  “Your wife had a massive heart attack,” I told him. “Her heart lost the power needed to pump blood. She had problems with her heart rhythm as well, problems I couldn't correct.” I took a deep breath and stared down at my hands. There was nothing more I could do except just say it.

  “I'm sorry, sir, but your wife has died.”

  The air was empty for a moment. I couldn't even look at them.

  “Well,” the husband said in a wan voice. “I lost a partner.”

  “We tried everything we had,” I told him. “We gave her TPA and everything else, but her heart…just failed her.” I looked up.

  His face was blank. He shook his head but said nothing. There weren't the words; there was nothing at this moment to say. Finally he held up one hand and with the other pulled his daughter close to him.

  “I'm sorry,” I said, just to say something. I had been in this room many times under similar circumstances, and I knew—or rather felt—that in all honesty, I had no more to offer this family than some professional sympathy for a heartbreak that would touch me only for a moment.

  Neither of them spoke, neither cried. They just sat there huddled together. The daughter rocked her father back and forth, back and forth.

  “Dad,” she said. That was the only thing she said.

  We sat for a moment in silence. This was not the first time I wished I had the religious faith of some evangelical Christian, someone who was certain, someone who knew about God and his plans—because I certainly didn't. The only thing left that I could do, now that I had notified the family, was just the miserable bureaucratic stuff: talk to the coroner, fill out the forms, complete the last medical record ever filed on this patient—all those temporal things where faith, thank God, was not an issue.

  I have thought often about that family: the farmer's wife, the farmer and the daughter. I wondered about the two survivors. Who did the laundry now? Who fed the cat?

  One day about a year later, I saw the whole family once more in an unlikely spot. I was in the Midwest for a medical conference on—naturally—clot-busting drugs. On the afternoon of the last day, I decided to take a break, go for a walk in the park across from the hotel. It was a brilliant winter day, almost spring, and people were out walking just to take in the sunshine. I had strolled up a hill to a reservoir when I saw them: the husband, the wife and the daughter. They were all younger now, much younger—the parents were no more than a few years out of high school. Already, though, the wife was doughy plump and the husband as thin as a rail. Their daughter, this daughter, was a blond girl in pigtails. She couldn't have been more than four or five. The husband and wife held hands as they walked while the daughter ran on ahead. The couple seemed to radiate a sort of serene security, a security in each other, in their daughter, in their life, that most people I knew could only dream of.

  I was standing on a lip of land that dammed a small reservoir, a lakelet at the top of the hill. The couple was walking up toward me along a dirt path. The daughter reached the top first and she stood pointing at the lake, which was invisible from below, shouting, “Can you see? Can you see?” The parents waved, still holding hands, and kept moving slowly up the hill toward her. At one point, the husband stopped, pulled his wife up close and kissed her.

  I closed my eyes. A happy marriage, I thought, and this thought produced a prayer. Please God, it ran, please protect that man and that woman from knowing the future. Please never let them see what I can—from where I stand—so clearly see: all happy marriages end in tragedy.

  3

  LESSONS IN EMERGENCY MEDICINE

  How to Deliver a Baby

  THIS IS YOUR FIRST real job as a doctor. After four years of medical school and most of an emergency medicine residency, you look like a doctor: handsome, chiseled profile, great abs. You know how to act like one (“Nurse, get me a tourniquet, stat”). But you've never had a chance to play one unsupervised. You are still in training, still a resident. (In emergency medicine that's four years of long days and even longer nights.) As a resident you have a degree to practice medicine, but all your moves are still closely supervised by “attendings,” physicians who have finished their training and passed their board certification exams. You still have a way to go for that. But you do have a medical license—you can moonlight as a doctor, especially at jobs where you see simple things, like sore throats and colds. That's what's brought you here, to a tiny ER at tiny Grace Hospital. “It's a breeze,” the ER director told you. “Kids with sniffles, sprained ankles. Most nights you just sleep.”

  The downside is that it's an hour and a half drive out here and you are in the middle of nowhere. This particular nowhere is located on the edge of a beaten-down industrial city, a steel town on the skids. This is your first night, and so far you've seen a weird collection of farmers and urban deadbeats. But that's okay. You are on your own now, making the decisions that will help you save lives. You are “the Man.” Also you are getting paid something above the $10 an hour wage you make as a resident. Life is good. Now it has quieted down, and if all goes well, you can get back to the call room and get a few hours of sleep in.…

  It's about 2:15 A.M.—you've just settled down to some Chinese takeout food—when you hear the shouting. It's a woman's voice, but you can't understand what she's saying. The shouting is followed by the voice of a nurse saying loudly, “Just breathe, just breathe.”

  Another nurse sticks her head in the door where she finds you, mid-chew, on your moo shu pork.

  “You better get in here,” she says. “This one is about ready to pop.”

  A delivery, you realize. A baby. You scowl at the nurse. “What is she doing here?” you say grumpily. “Get her up to Labor and Delivery.” This is the routine in your training hospital. OB/GYN residents deliver babies. That's what they're there for.

  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.