by Pamela Grim
Air, you swear to God you feel air.
“Restart CPR?” Carol asks you.
You raise a hand. “No, wait,” you say. Everyone turns to the monitor. The heart rate is 65…
65…64…64…64…68…69…
There it is, the comeback. In a couple of heartbeats the rate is over 70, over 80, 85.
“Pneumothorax…” Carol sighs. “A tension pneumothorax.”
As you palpate the baby's neck, you feel, clearly, unequivocally, a carotid pulse, a brisk carotid pulse. Let's face it, in your heart you hear a choir of angels.
“Jesus,” is all you can say. “Jesus, Jesus, Jesus.”
You are finished, done for. You look at your watch and cannot believe that all this took only forty-five minutes. It has been the longest forty-five minutes of your life.
But you can't linger this way. “We need another chest x-ray in here,” you shout out. “And transport, what's the status of transport?”
“En route,” the clerk yells back. “They should be here in ten.”
“I need that doctor for report. Get him back on the line, would you?”
You look around at the acute room, which looks like a disaster area. Blood, mucus, amniotic fluid, are everywhere. The mother is huddled on the bed, her knees still up, legs parted, the way you left her after the delivery. She is weeping quietly.
You need to put a chest tube in; this will vent the lung better than the needle. For now this is fine. You are not worried about anything. Right now, the baby is alive, moving, wiggling those little hands in the air. A live baby. And what they say is true, you do feel like God—no, not God, really—just like a manifestly great human being. Carol, the pretty nurse, looks beautiful now and she is glowing at you. Even Helen, the nurse who hates you, is glowing a bit, though not specifically in your direction.
You've finished. You've won. The problems that remain—a premature baby with severe hypoxia at birth and a crack habit from the moment of conception—these are not your problems. Nothing can take the edge off this glow.
Congratulations. You have just saved a life.
4
BORN UNDER A BAD SIGN
RULE #1: There is no real preface to disaster. One minute I was drinking some silt-like, end-of-the-pot coffee from a Styrofoam cup. The next minute I was palpating the belly of an immensely pregnant sixteen-year-old girl in active labor, contractions two minutes apart.
Sterile gloves. Betadine. A quick check to find out how far labor had progressed.
The girl lay on the hospital gurney, legs bent, belly distended, her little stick arms draped doll-like over the bars of the gurney as she awaited the next contraction.
“Something's wrong,” she said. Bur what did she know? This was her first baby, after all.
“Nothing's wrong,” I told her evenly. “You're just having a baby.”
I was near the end of my residency, and by now, nothing fazed me. I had become a medical automaton shorn of wasteful emotions, emotions like concern, compassion, surprise. An example: two days before, a man had walked into triage with a knife buried to its hilt in his skull, he walked in, and the most I felt was a sort of risible annoyance—now I'd have to call neurosurgery and that asshole resident on call always gave us such a runaround.
So I shrugged when the nurse, Darla, announced she couldn't find a fetal heartbeat. I wasn't worried…
…but I should have been. I was moonlighting that day at a local hospital where backup was limited, usually, to either a very busy or a very sleepy doctor on the other end of a phone. This was not like my training grounds, a teaching hospital where, when things went bad, you could call every kind of specialist known to man. I had been told up front by the director that obstetrics coverage was at least a half hour away (and not to even think of trying to find a plastic surgeon).
I had to slide my hand in past the wrist before I felt anything. What I finally felt, though, was…I wasn't sure what it was. It felt like a string of grapes.
That's odd, I thought. I stood there a moment repeating to myself, Grapes, grapes, grapes. I then brought my hand out, looked at it, checking to see if there was something wrong with it, and then I returned to the vaginal vault. Even though I told myself I couldn't be feeling them, the grapes remained. Why would there be grapes in the vagina? Some primitive part of my brain, some subcortical region, knew before it reached any level of actual consciousness, and my heart started pounding unmercifully as I thought still, Why? Why? And then suddenly I was fully aware of why.
These were toes.
I hadn't lost contact with all emotions. There remained one feeling that could still overwhelm me, one sensation that began now at the back of my neck and radiated into my throat and my heart. This was the only emotion available to an exhausted, overstressed resident.
The emotion was fear.
The baby was breech—that is, upside down. Instead of the head presenting first as in a normal pregnancy, here the buttocks were presenting first—not only that, but with this one the foot had descended. I felt around—I could feel only one. The other must have been hung up in the uterus.
“I've got a foot here,” I told the nurse. “This is a footling breech.” I turned to the patient. “Who's your obstetrician?”
The girl looked at me, frightened. “I don't have one.”
“You never saw a doctor during your pregnancy?”
“I was supposed to see one next week.”
The hell she was. She was full term. She should have seen somebody seven months ago.
There was one other emotion available for rapid access. Anger. The quick judgment of an overextended doctor. The patient had had a high-risk pregnancy and never knew it. I turned to the unit clerk, who was standing next to the door, arms folded. She'd seen it all. “Whoever's on for OB, call 'em now.”
The clerk ran back to the desk. I crawled up on the gurney and knelt closer to the patient. The girl went through another contraction, and now that her nightmare had come true, she started sobbing. In addition, she grabbed my arm in a vise-like grip. I had to pry her fingers off one at a time.
“Look, I can't help you unless you help me,” I told her.
“I am helping you. I'm just scared.”
This last statement was accompanied by a wail so pitiful, even I softened a little. “You're going to be okay,” I told her grudgingly.
If this were a normal delivery and if labor progressed, I would go ahead and deliver the baby in the ER room; but breech deliveries are extremely difficult. I was way out of my league.
And we still couldn't get fetal heart tones.
“I've called up to the obstetrics ward,” the unit clerk shouted from the desk. “No doc there! I'm calling the on-call guy now.”
I took over the Doppler and vainly mapped out the woman's abdomen. There was nothing but the rhythmic plash of blood in the mother's aorta. I tuned the Doppler back over to Darla, shaking my head.
In a moment the unit clerk shouted back again. “I've got the obstetrician's wife. She says he's in the shower. He'll get dressed and be there as soon as he can, but it's going to be a good half hour.”
“What are you going to do?” one of the nurses asked me. I was still up on the gurney, sitting on my haunches.
“I don't know,” I said.
The other nurse shushed us. “I've got something,” she said, and we all listened for the Doppler tones, the rapid, whiplash sound of a normal fetal heartbeat. All we heard, though, was just a slow swish, slower than the mother's pulse. Everyone counted silently, gazing at their watches. Seventy-eight, half of what it should be. Fetal distress.
What I remembered, hazily, was this: the biggest problem with breech deliveries is the head. The head is the largest part of the baby; during a regular labor it is delivered first. If it hangs up in the birth canal, labor doesn't progress. Ultimately, the child may require a C-section delivery, a comparatively simple procedure. In breech babies, however, the rest of the baby is delivered first; the head
is delivered last. If the head hangs up, you have a child half in and half out of the birth canal. To deliver the baby, you have to open the pelvis and cut down through the uterus and the cervix—a massively complicated procedure—and only if you are lucky is the baby delivered alive.
Should I wait for OB or try the delivery?
If the head hangs up, the baby's dead and I'm dead, I thought. I would be hung out to dry by anybody who reviewed the case.
With prolonged fetal distress, though, every minute is a catastrophe.
Darla counted again. “Fifty-six,” she announced. A half hour is a long time for a baby with that slow a heartbeat. And it was dropping.
I put my gloved hand back up the birth canal. I wasn't sure, but it seemed that the leg had descended farther, and I could now feel the buttocks beyond.
“Do something!” the girl shrieked.
So close, so close. Another monumental contraction, and then it seemed to me that the baby slipped down another notch. Think, I told myself.
“Well,” I said, “let's do it.”
The trick with breech deliveries is to corkscrew the baby out, turning it slowly so that first one hip is delivered and then the other, then one shoulder and then the other. I held gentle traction on the legs and the baby began the slow rotation. It didn't require much traction; this baby was ready to come out.
The unit clerk called from the desk. “I've got OB back on the line. He's on his car phone.”
“Tell him we've got fetal distress and that labor is progressing. I'm trying to deliver the baby.”
Consultation. “He wants to know how far along you are.”
“Tell him we've delivered one hip. What should I do next?”
More consultation. “He says to deliver the other hip.”
I wiped my forehead with my wrist. “Oh, tell him thank you.”
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).