Anecdotally Speaking

The superfluous, a very necessary thing. --voltaire

Thursday, January 04, 2007

 

A Patient Dies

It is always difficult when a patient dies, even more so when the patient is a baby. This is an account of the first time I lost an infant child entrusted to my care. It happened a year and a half after I finished medical school. Just a warning, this account runs a little long.

I was still asleep when I lifted the receiver from the ringing phone. "Hello," I mumbled. It was the operator from the hospital. One of my OB patients called to report that she was bleeding. I was waking up now. I took down the number and dialed.

My patient sounded worried. There had been a sudden large gush of water followed by a large amount of bright red blood. It was the breaking of her waters, a common occurrence at the end of some pregnancies. It usually signaled the start of labor. However, the bleeding signaled trouble.

I was very awake now. I told her to go to the hospital immediately. I would meet her there. As I quickly dressed, my mind ran through the possibilities. What causes hemorrhaging in the last three months of pregnancy?

One possibility is placenta previa, which is the dreaded complication of pregnancy where the placenta covers the opening out of the uterus and tears off when labor begins. Without quick action, this problem might not only kill the baby, but the mother as well. Then there is abruptio placenta, when the placenta detaches from the uterus before birth, again risking the life of both baby and mother. Quick action will be needed to save them. I hurried.

The night was quiet. There was very little traffic on the street. I lived only two miles from the hospital so I arrived quickly. I pulled into a parking space near the emergency room entrance. As soon as I stepped out of my car, my patient drove in and parked her car next to mine. She told me there had been no more bleeding as we walked up to the obstetrics floor together. I relaxed a bit and reassured her.

This particular patient was special to me for a couple of reasons. First, I was a new physician just starting out. I was a Family Practice Resident building a fledgling practice. I was personally responsible for the care of 30 or so pregnant women. She was one of the first patients I had the opportunity to care for from the beginning of the pregnancy all the way through and including the delivery and postpartum care, giving me a chance to get to know her and form a strong bond of trust.

However, there was another reason she was special. She became pregnant at the same time my wife did with our second child. At every stage of my patient's pregnancy, my wife and I were experiencing the same things in ours. My patient and I looked forward to the time when we would both be delivering. At every visit, she would ask how my wife was doing. We would compare notes. We shared together the joy and anticipation of the arrival of our new babies.

We arrived at the OB floor. The nurses went to work. My patient put on a hospital gown, got into the hospital bed, and the nurses hooked her to a fetal monitor. This machine measures the baby's wellbeing by graphing the heartbeat and graphing the uterine contractions. I stood outside the room, causally waiting for them to complete their ministrations before I would step in and do my examination.

They took a long time. They took more time. It was becoming obvious that something was wrong. I stepped to the doorway. The nurse was using a probe that amplifies the baby's heartbeat. The probe was slathered with the messy clear goop that they use to help find the internal sounds. The same goop covered my patient's distended swollen abdomen. The nurse searched from one side to the other, back and forth, up and down. Nothing. No sound. No one in the room said anything. The nurse looked up at me, and then gave up. Trying not to think of the incomprehensible I went to the bed and sat next to my patient. I took up the instrument and began to search for myself.

On every office visit since this baby was three months along, I listened for his heartbeat. On every office visit I heard the reassuring "whoosh, whoosh" sound calling out to me. It was as if the baby was speaking to me in the only way he could, connecting to me, saying, "Here I am, I'm doing OK." However, tonight there was no voice, no reassuring sound, no connection. Only silence.

I hesitated. Think! Think! My mind raced. Is there any explanation for this other than the obvious? Was I missing something? Was I doing something wrong? I had to be sure before I opened my mouth and made things true by speaking them. No, I told myself, there was no way out, no escape from the harsh reality. I would wish it away if I could, but I could not. I stopped my vain search. He was gone. The baby was dead.

The grief came, tears, shock, disbelief, the question how? Dazed, I offered sympathy, support, answered questions. Abruptio placenta? Placenta previa? Probably. We would find out. However, right now, we had another problem. The baby had to come out. I considered the implications. This young mother will have to struggle through who knows how many long hours of labor, enduring probably the most intense physical pain she will ever have, only to deliver a dead baby. There will be no great "prize" at the end of such an ordeal for her, no pink baby to cuddle and hold, just emptiness. It seemed too much to bear.

This was a tragedy of nightmarish proportions. I was reeling. There was an uneasy silence among the nursing staff. We went through the motions of our duties stiffly. I called an obstetrician as a consult. I gave him the details of the case over the phone. He said he would be right over. Bleeding was still a threat to the mother and an emergency c-section could be needed at anytime during the labor to save the mother.

When he arrived, he searched in vain for a heartbeat himself. He then began an examination of the birth canal. Then he became alarmed. The amount of blood and blood clots in the vaginal area seemed dangerously excessive. He called for an emergency c-section for presumed placenta previa, a life-saving procedure for the mother.

Now things really went flying. The healthcare providers had something to do. We had a life to save. We were like knights on white horses. We were eager to push aside the feelings of despair and helplessness that overwhelmed us after losing the life of the baby and replace them with the earnestness of our practiced effort to save the life of the mother.

The floor became a bustle of activity. Nurses, anesthetists, aides, scrub techs, a dozen professionals working in concert to deliver the baby and placenta as quickly as possible in order to save the mother. The obstetrician and I were scrubbed, masked, gowned and ready to start when my patient was positioned, prepped, draped and put to sleep. Deft hands made the incision. Down through the layers the surgeon progressed, quickly reaching the lifeless baby. The limp body was removed and handed off to a waiting nurse who placed it gently, almost reverently, on a newborn warmer that was not turned on.

Then the obstetrician reached in, probing with his fingers, working in an area he could not see as he gazed absently across the room. Satisfied that he had a good grip, he began to gently pull the placenta out through the wound. It all came out in one piece and he laid it out on the drapes next to the wound. We stared. The obstetrician reacted with disgust at himself as he realized that he just performed a c-section that was not necessary.

I looked with a mix of puzzlement, curiosity and disbelief. I did not immediately appreciate the significance of what I was seeing. The umbilical cord, the vital attachment of the infant to the placenta, did not insert securely to the center of the placenta, as it should. Instead, it incredibly attached to the thin filmy membranes that had enclosed the baby and his surrounding water during the nine months of pregnancy. The arteries and veins, which run protected inside the tough umbilical cord, emerged from the cord's point of attachment. They then ran unprotected and vulnerable along the surface of the fragile membranes over to the placenta, attaching there, as they have to, to receive nutrition and oxygen from the mother.

I had never seen anything like it. It was extraordinary, the blood vessels stretching out across the thin membranes toward the placenta. Large fat veins with their thin walls, tougher smaller arteries. It was now easy to see what had happened. When the membranes ruptured, the breaking of the waters, one of the delicate blood vessels was torn and the blood spilled out. However, this blood, this blood came from the baby. It was the baby's blood, the baby's precious blood. The blood came and came and came, until the baby had no more. Then the bleeding stopped. The baby bled to death inside his mother's womb as the result of a freak anomaly. The blood the mother watched pour out, and then stop, was her own baby's blood.

We finished the procedure. The obstetrician left the operating room. My patient was waking up, but was still very groggy. She would not be aware of what was happening for an hour or more. I went over to the still, silent figure laying in the cold warmer. I saw a perfectly formed beautiful newborn baby in every respect, except that the skin did not look quite right. It was grayish, and far too pale. I reached out and touched the baby, not to hold it, but more as if to examine it. It was as if I needed to verify that this was real, that a normal healthy baby with a future of promise and limitless possibilities could be suddenly and tragically lost. Here one moment and gone the next.

As I touched him and reflected, I decided that there is no sight more hideous than this, a dead baby. There is nothing more unfair; there is nothing more wrong. It was almost more than I could bear.

I went to the placenta where it was laying. I carefully spread it out so that the whole anomaly was visible. As I stared at the reality of what was before me, the physical presence of it, I took in the truth of how helpless and powerless I actually am. I took care of this baby and his mother during his entire short life. I was their doctor. They relied on me. I carried with me the whole weight of centuries of accumulated medical knowledge and technology to apply against any enemy or problem that might appear. I was ready, I was prepared, and I was there.

As I looked at this placenta before me, I knew the truth. Absolutely nothing could have saved this child, nothing that I could have done, nothing that anyone could have done. He was doomed and we were powerless. I had never felt so small in all of my experience as a physician and since starting medical school. My view of myself and of medicine itself reached a new level of humility at that moment, and the impression was indelible.

I took the Polaroid camera that was at the nurse's station and photographed the placenta. The placenta was destroyed, but the photograph remains to remind me of that night. I learned important lessons that have shaped me since then. I learned that no matter how certain things appear in life, we are never certain of anything. I learned to be grateful for the good things that happen in life. They may seem to come to me by my own efforts, but that is only an illusion. I learned as a physician that I should do the best job that I can, and then leave the results to God. The results are always in his hands from the start anyway. Finally, I learned that no matter how much I know, it is usually less than what I think I know.

All of the paperwork was done. My patient was tucked away to bed safely. The OB floor settled back to a normal routine. Everything went back to normal, the same as it was before, except for me. I would never be the same again. The pain in my heart would weigh me down for many years, and in fact, it still does today. I suppose it always will. I tucked the Polaroid into my pocket and headed home.

The streets were dead now. No one was out. It was very late. I arrived home and walked in quietly, not wanting to disturb my sleeping wife. I stopped to check on my one-year-old daughter, asleep in her crib. I said a prayer of gratitude for her and watched her for a long time. When I entered my bedroom and saw my wife lying there, I was overcome with a mixture of fear and love.

I woke her as I was putting my ear to her abdomen. I poked gently to wake him. I spoke to him. I listened to his heartbeat. His heartbeat spoke to me loud and clear. "Here I am, I'm doing OK." He moved. He poked me back. I wept. I wanted him to come out so badly, so I could hold him and protect him. I loved him so much. And I was so afraid.

He was born two weeks later and I really did not sleep very well until he was born. I listened to his heartbeat every chance I could get. I prayed and I thanked God for my blessings. When I finally held him in my arms I realized that I knew something that I may not have known before. My son was a gift. And my daughter was a gift. My desire to have them did not bring them to me or keep them with me. I have no power. What I have are extraordinary gifts. What I was then, and continue to be, is awed and grateful.

My patient came to see me in my office one more time after going home from the hospital. She was handling the grief process as well as might be expected. Physically she was recovering well. She asked about my baby. I felt embarrassed that I had one. Somehow, things just did not seem right. We should be comparing notes on how things were going as both of our babies were growing up together. Instead, she would leave, and I would never see her again.

I have often thought about her, and how that night ended up affecting her and her life. I hope she eventually was blessed with the joy of holding a pink, soft, warm newborn in her arms. Because, that is how I would like to have the story end.

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