Dude, Where's My Stethoscope?

by Gray, Donovan

  An hour later I was back in the radiology suite reviewing another film when one of my colleagues showed up. He pulled out the chest x-ray of the patient with the cough I had seen earlier.

  “I already looked at that one,” I said. “It’s normal.”

  He seemed taken aback.

  “What did you say to him?” he asked.

  “I told him I didn’t see anything on his x-ray.”

  He started laughing.

  “What’s so funny?” I asked.

  “He called me at my office in a big panic saying he had just had an x-ray at the hospital but the doctor who had ordered it didn’t know how to read it.”

  “What made him say that?”

  “You told him when you looked at his x-ray you didn’t see anything.”

  Needless to say, ever since that day I’ve changed the way I tell patients their x-rays are normal.

  Rocky II (The Sequel)

  It’s yet another Saturday morning and I’m back for more punishment in the ER. Where did all the people in the waiting room come from? Five minutes ago the joint was empty. Maybe spontaneous generation does exist after all.

  My leadoff patient is none other than the infamous Rocky. Once again he’s toxic and on the verge of hurling. Whenever he shows up like this I usually end up admitting him for a day or two to help him dry out. Things are a little different today, though – there are only two empty beds left in the entire hospital. If I admit him to one of them I’ll be snookered if I need beds for sicker patients later on in my shift. To the best of my knowledge, Rocky has never had any potentially dangerous alcohol withdrawal problems such as the DTs or seizures. After careful consideration I make an executive decision to turf him to a detoxification centre. I ask the ER charge nurse to have switchboard locate the closest detox centre’s intake worker.

  “Aren’t you forgetting something?” she asks.

  “What?”

  “They won’t want to take him the way he is now.”

  True enough. Detox centres don’t like their alcoholics drunk and barfy; they like them dry and stable. Most of them will only take “clients” who have been alcohol-free for at least a couple of days.

  “Yeah, I know that.”

  “So how are you going to convince them to take him?” she persists.

  “I’m going to stretch the truth a little bit.”

  She looks at me askance as her index and middle fingers carve a pair of scare quotes into the air above her head.

  “Stretch the truth a little bit?”

  “Okay, I’m going to lie.”

  Switchboard puts the call through.

  “Hi, this is Luba at the Pink Elephant Detox Centre speaking. How may I help you?”

  “Hi Luba, this is Dr. Gray calling from the ER. I have a patient here I’d like to transfer to your facility.”

  “Certainly. What’s your client’s name?”

  “Rocky Emesis.”

  “Rocky Emesis?”

  “Er, yes. Are you familiar with him?”

  “Extremely. When was his last drink?”

  “Um… I don’t think he’s had anything so far today.”

  “What condition is he in right now?”

  “Not too bad.”

  “Would you mind holding for a minute, doctor?”

  “No problem.”

  The instant I’m put on hold, some god-awful Perry Como-esque lounge lizard tune starts playing. Whoever invented muzak should be drawn and quartered. My mind drifts. Luba must be discussing the case with someone higher up the food chain. Does that mean she suspects I’m bullshitting her? I cross my fingers and continue holding.

  Nearly a minute later she clicks back on.

  “I’d like to speak to the client, please,” she says.

  Oh crap. Is the Rock Man coherent enough to pass a detox phone screen?

  “Um, I think he’s in the bathroom right now.”

  Pretty lame, but it’s the best I can do on the spur of the moment.

  “He’s not vomiting, is he? We definitely do not accept clients who are actively vomiting.”

  How about if they’re passively vomiting?

  “Oh no, he’s not vomiting, he’s just having a pee.”

  “So he’ll be out shortly, then. I’ll wait for him.”

  I jog over to Rocky’s stretcher. He’s fast asleep.

  “Rocky! Wake up!”

  “Eh?”

  “I’m trying to get you a bed at the Pink Elephant. Come talk to the nice lady and tell her you’re okay.”

  “Feel kinda pukey.”

  “Just tell her you feel all right!”

  “Okay, okay.”

  I drag him over to the phone.

  “Hi, Luba. This is Dr. Gray again. Here’s Rocky.”

  I hand Rocky the phone. Is it just my imagination, or does he look a little green? Must be the fluorescent lights.

  “Hello?” I hear Luba say.

  “Huurr… .”

  “Hello?”

  “Huuurrrraaaalp!” replies Rocky as he covers the telephone with more Pop Tarts and Big Macs.

  I guess I’ll be admitting him after all!

  Alanna’s Birth

  On the evening of June 2, 1993, Jan went into labour. The next morning our eldest daughter, Ellen, was born. Everything went smoothly.

  On September 3, 1994, our second daughter, Kristen, arrived. Once again there were no complications.

  By mid-October the following year Jan was two weeks away from the end of her third pregnancy. Over the preceding two weeks she had noticed a slight reduction in fetal movements, but it hadn’t been enough of a decline to concern us. On the morning of October 21 the baby stopped moving altogether. We contacted Miles, our family doctor. He was partway through a 24-hour shift in the emergency department. He asked Jan to come in for a non-stress test. To our relief, during the test the baby stirred a little. There wasn’t much beat-to-beat variability, though, so Jan was admitted for induction of labour.

  By suppertime the Syntocinon drip was producing regular contractions and active cervical dilatation. At about 7:00 p.m. we started to see a few late decelerations. They made me jittery. I don’t do obstetrics, but I know late decelerations can sometimes be a sign of fetal distress. Half an hour later an artificial rupture of membranes was performed. The amniotic fluid that gushed out was nearly black with meconium. Our baby was in trouble.

  Switchboard was asked to put the OR team on alert. As Miles deliberated over whether or not to proceed directly to a C-section, one of the ward nurses rushed into the room to show him a rhythm strip from an inpatient who was complaining of feeling light-headed. His heart rate was only 30, and his blood pressure was 75 systolic. Miles and I looked at the tracing together and concluded he was in complete heart block.

  I knew exactly what he was thinking: This can’t wait. Now he had a second critically ill patient to deal with, and we were the only two doctors in the building. On the monitor behind Miles I could see our baby’s heart rate was taking an extraordinarily long time to recover from the last uterine contraction. I caught Jan’s eye. She looked scared.

  “How about if you take care of Jan and the baby and I’ll go treat this guy in heart block?” I offered.

  “Good idea,” he said. He turned his attention back to the fetal heart monitor. I abandoned my wife and followed the nurse back to the cardiac patient’s room.

  First we started him on a dopamine drip and titrated it up until his pulse and blood pressure improved. We then attached the external pacemaker to his chest and tested it to make sure it would work properly if we needed it in a hurry. Once that was finished I got on the horn to the internist on call at the Timmins and District Hospital, which was our closest referral centre. He agreed to insert a transvenous pacer as soon as we got the patient down to their ICU. I called our ambulance attendants and asked them to start working on transfer arrangements. When I hung up the phone and turned around, Miles was standing in the doorway. The look on his face
said bad news. He gave it to me straight: “The baby’s heart rate dropped down to 60 and stayed there. I’ve scrambled the OR team and we’re setting up for an emergency section.” My guts went ice cold.

  I went into the operating room to spend a few minutes with Jan before the surgery. My colleagues were bustling about setting up equipment, but the only thing I could hear was the beep…beep…beep… of the fetal heart monitor. It was agonizingly slow.

  Our regular anaesthetist was out of town that day, but fortunately for us a retired GP-anaesthetist in the community bravely volunteered to put Jan under. When he was ready to begin the induction, Trish the charge nurse shooed me out of the room.

  “Go on now. Today you’re a dad, not a doctor. I’ll call you when we’re done.” It felt strange leaving the OR and hearing the sliding doors snap shut behind me.

  This I learned later: Dr. Hill quickly cut through the layers of tissue until he got to the uterus. He opened it up, reached in and began to pull. Several seconds passed and still no head emerged. He kept working at it. Nothing.

  “What’s wrong?” someone asked.

  “Stuck.”

  He continued struggling. Sweat beaded on his brow. Eventually he muscled the head out. It was purple. The baby’s eyes were closed. She wasn’t breathing.

  “Cord’s around the neck. Damned tight,” he muttered.

  He strained until he was able to pry the noose-like cord encircling her neck and wriggle it over her head. She remained limp and unresponsive.

  “Another loop,” he said as he removed a second strangulating coil of umbilical cord from her neck. “And another. And another!”

  The cord had been wrapped around her neck four times, choking her every time she tried to move. He hauled the rest of her flaccid body out of the uterus and cut the cord.

  Miles grabbed the Ambu bag and started ventilating her. While he bagged, Catherine, a nurse who often helped with neonatal resuscitations, listened for a heartbeat. It was barely detectable. She immediately began chest compressions. They worked together feverishly. Moments later the Ambu bag shattered into half a dozen pieces. Catherine and Miles stared at each other, wide eyed. This was unprecedented. The equipment is tested regularly.

  “We need another Ambu bag, stat!” Miles yelled at Trish.

  “That’s the only one for newborns we have in the OR! I’ll go get one from the delivery room on unit 4!” She darted out of the room. Our child lay inert on the table. Catherine started mouth-to-mouth resuscitation. Miles took over chest compressions.

  I was standing in the hallway just outside the OR when Trish burst through the sliding doors. Arms and legs flailing, she looked like the devil himself was chasing her. When she saw me she stopped running, said “Hi” nervously, and speed-walked over to the door to unit 4. She went in and shut the door quietly behind her. The instant it closed I could hear her sprinting down the hallway. I leaned against the wall and tried to breathe. I didn’t know what to do. Should I go inside and try to help? Would I be able to make any sort of meaningful contribution, or would I just get in the way?

  Trish came thundering back. As soon as she came through the door she glanced at me furtively and slowed to a walk. She was carrying a neonatal Ambu bag. I wanted to scream, “For God’s sake, Trish, run!” When she disappeared through the operating room’s opaque sliding doors she started running again.

  Roughly 20 minutes later Miles came out to see me. He looked grim. I steeled myself for the news that our child was dead.

  “It’s a girl,” he said. “The cord was wrapped around her neck four times and she came out flat. Her one-minute Apgar was only one. We ventilated her and did chest compressions…”

  …but she didn’t make it…

  “…and she recovered.”

  “What?” I couldn’t hear anything over the blood pounding in my ears.

  “She’s okay, Donovan, at least for the time being.” He smiled.

  “Oh, God. Thank you, Miles.”

  “I’m going to transfer her to Timmins because I’m concerned she may develop delayed respiratory problems.”

  “Okay.”

  I went into the OR to meet my new daughter. She had beautiful brown eyes and a shock of curly black hair. Aside from her rapid respiratory rate she looked remarkably well, considering what she had just been through. Catherine and Trish let me hold her for a little while. I wanted to talk to Jan, but she was still deeply anaesthetized. I asked Trish to tell her I’d call at the first possible opportunity. After that I raced back to our house, sent the babysitter home and arranged to have a neighbour stay with Ellen and Kristen until Jan’s parents could fly in from Winnipeg. Once all of that was done I packed an overnight bag and began the long drive down highways 11 and 655 to Timmins.

  I arrived at the Timmins and District Hospital to find our EMTs unloading the patient with heart block from the ambulance. He and my daughter had travelled together in the same rig. The attendants informed me they had already taken my daughter to the neonatal unit. When I got there a pediatrician named Dr. Inman was examining her. Her breathing seemed to be more laboured than it had been earlier, but it was hard for me to be sure – it’s difficult to maintain any semblance of objectivity when the patient in question is your own child. When he completed his evaluation he told me she was stable for the time being, but that he intended to keep a close eye on her over the next several hours. He felt that due to the asphyxia and meconium it was possible her respiratory status could worsen, and if that occurred she might require intubation. The word intubation made me wince – I had visions of barotrauma, collapsed lungs, chest tubes, chronic pulmonary disease… . He patted my shoulder.

  “Try not to worry,” he said. “She looks like a fighter. I think she’ll do all right.”

  I had planned to rent a room at a nearby hotel, but the pediatrics staff kindly arranged for me to use one of the hospital on-call rooms. I telephoned Jan to let her know what was happening. She described how awful it had been waking up after the C-section to find the baby and me both gone. I tried to reassure her and promised I’d call back soon. After that I went to bed. It took a long time for me to fall asleep. A few minutes later the telephone rang. It was Dr. Inman.

  “You’d better come back to the unit. Your daughter’s getting worse. I think we’re going to have to intubate her.”

  “I’ll be right there.”

  I hung up the phone and cried.

  She looked ghastly. Her respiratory rate was well over 70, and her chest and abdomen heaved with each breath. Despite maximal supplemental oxygen her blood oxygen saturations (sats) were only in the low 80s. Dr. Inman explained that although it still wasn’t clear whether the problem was transient tachypnea of the newborn, respiratory distress syndrome or meconium aspiration, if she wasn’t put on a ventilator soon she’d tire out and stop breathing. I gave my consent for the procedure and left the room. I wanted to stay with her, but I couldn’t bear to witness my own child being intubated.

  When I returned the tube was in place and a respiratory therapist was bagging her. Her oxygen sats had climbed to 90 percent and her colour was better.

  “The procedure went well,” Dr. Inman said. “Right now she’s heavily sedated. You’d better go get some sleep. You have a long day ahead of you tomorrow – we’ll be flying her down to the neonatal ICU at McMaster first thing in the morning.”

  The Medevac jet arrived at 10:00 a.m. The transfer team consisted of two NICU nurses. Like everyone else who had treated our daughter (now named Alanna) thus far, they were real pros – meticulous, skillful, and caring. They reviewed the entire case, examined her thoroughly, started two more IVs and switched her over to their own infusion pumps. After communicating with their base neonatologist they adjusted some of her medications. They then detached her from the hospital ventilator, put her in their specialized transfer isolette and reconnected her to a portable ventilator. Once all that was finished they pulled out a Polaroid camera, snapped a picture of her and handed i
t to me. I thanked them and put it in my knapsack. I later found out that in cases where critically ill infants die shortly after Medevac, oftentimes the pre-transfer snapshot is the only photograph the parents have of their baby taken while the child was alive. I asked the team how I’d find McMaster Children’s Hospital when I got to Hamilton. They said as long as there were no other patients requiring air ambulance evacuation they’d make room for me on the jet. I could hardly express my gratitude. An hour later we were in the air.

  A ground ambulance met us at the airport in Hamilton and drove us to the hospital. Alanna had held her own during the transfer. It was beginning to look like she might survive this ordeal. As we navigated the hospital corridors on our way to the NICU, thoughts I had been keeping tightly caged broke free: Did she go too long without oxygen? Was she brain-damaged? Would she develop cerebral palsy or be profoundly handicapped? The uncertainty was maddening.

  The NICU was a brightly lit sea of chaos. Each isolette was like a life raft bobbing in the turbulence. Some of the infants within the isolettes weren’t much bigger than the palm of my hand. It was hard not to stare. I tried to stay out of the way as the transfer team got Alanna settled in. Once the changeover was complete I had a brief meeting with the attending neonatologist. He said he planned to keep Alanna on her existing ventilator settings for the rest of the day. If she remained stable, they would start trying to wean her off in the morning. He asked me where I’d be staying in Hamilton. I had no clue. He gave me the phone number and address of a nearby Ronald McDonald house. I called them and secured a room. I then pulled up a seat and spent the rest of the day watching my daughter’s fragile little chest rise and fall in synch with the mechanical bellows.

  To everyone’s surprise, Alanna tolerated weaning exceptionally well. After two days of respiratory support she graduated to breathing on her own. Shortly after she was liberated from the ventilator her nurse wrapped her in a warm blanket and let her sit with me in a rocking chair. It was wonderful. I wanted to cradle her in my arms forever.