Sunday, March 11, 2007

I'm Still Here

It has been a very wild two weeks, and in keeping true to fashion, I've been slacking on all that is not essential to day to day survival. Unfortunately, blogging is one such thing, though I do find myself half-composing posts in my few stolen minutes between home and hospital quite often. Believe it or not, last weekend we actually tackled several tasks on the dreaded to-do list. In the last two weeks, I also had another birthday. Yet another reminder of how ancient I am becoming.

As I have mentioned before, I feel like my mind is stuck somewhere in 1998/1999 (not coincidentally, this is circa the early medical school years for me, when I ceased to be a person and started to become a bot). I am now finding myself emerging from my "bot haze" with most of my faculties intact, save this faulty sense of time. It is still jarring for me to realize that the time with which I most identify was 8 years ago! I suppose I could allow myself to be really bitter that the better part of my 20s (supposedly the greatest years of a young life) were spent slaving in med school and residency, but I also know that I wouldn't be reaping the benefits of that hard work a little earlier in life. All of that aside, I know that I am still relatively young and hopefully I have a lot more life in front of me, so I am trying to bring myself into the now. At any rate, I had a really nice birthday, very low key, as birthdays tend to get when you get older.

I had a really scary delivery recently. The kind that makes you feel completely helpless, even though you have done everything "right." The labor was quite innocuous, actually, which can lull you into a false sense of security. She was a primiparous patient, just a few days over forty weeks, and she came into the hospital in the early morning hours in early labor and progressed, more or less, on an unremarkable labor curve throughout the day. I was very pleased when she came in laboring, as she had an induction set for 41 weeks, and I much prefer patients to labor on their own, if possible. One notable characteristic of this young mother is that she is pretty terrible with any kind of discomfort...She just doesn't "do" pain very well. Any time I had to check her cervix in the office (even for the GBS swab) she would clench and scream. Needless to say, she got her epidural early during the course of labor, and was generally happy until it came time to push.

Right about the time that she had been pushing for about 30 minutes, her epidural began to wear off. Her labor nurse came out to the nurses' station and told me that the patient was having a full blown panic attack and refusing to push. When I entered the labor room, the patient's fear was palpable. She was completely out of control, clawing at the nurse, punching her husband, and kicking her legs and feet. She reminded me of a frightened, trapped wild animal. It was a sight to behold. The baby's head was at +2 station, and while the fetal heart tracing was still reassuring (as it had been throughout labor) the baseline had started to creep from the 130s into the 150s. I tried to calm the patient enough to try an operative delivery, but the patient would have none of it. She refused and demanded a section. She kept screaming, "There's too much pain. Something is wrong! I can't do this." After a few minutes of trying to reason with an irrational person, I left the room to call the OR for an urgent section, fuming the whole way. As the nurse began to prep the patient, I guess that the primal urge to push outweighed irrational fear, and by the time I returned to the labor room with the consent for the section the baby was crowning. The patient was no less panicked, but now she was pushing in earnest. The baby was delivered in three pushes, it had a triple nuchal cord, and was as white as a ghost. I had never seen a live baby that white before, and for that split second, I thought the baby was dead.

Then *I* began to panic. Oh my lord, she was right! There *was* something wrong, and despite the reassuring tracing, the baby was in trouble. I milked and clamped the cord and stimulated the baby, and thank God, she opened her eyes. I handed her off to the nurse, and after the longest minute of my life and a little blow-by 02, she began to squall. She remained white as a sheet, and rather floppy, but she was breathing well and her heart rate remained normal. My mind raced through the occult abruption? There was very little bleeding, and once the placenta was delivered, there was no more than a 5% marginal separation of the placenta, certainly not enough to constitute significant fetal blood loss. Uterine rupture? Mom's vital signs had remained normal throughout, and an inspection of her uterus revealed it to be intact. The baby's blood counts were normal, and though she had signs of volume depletion (decreased blood pressure, mild tachycardia) and received IV fluids overnight, there never was a satisfactory answer for her distress at delivery. She was able to go home with her parents on her second day of life, pink and sassy.

An interesting aside, as related to me by the baby's father's family, was that he (the baby's father) was born at full term, white and not breathing, and he had to be intubated for his first few days of life. There was never an adequate explanation for his distress, either. Needless to say, I earned a few gray hairs over this (possibly familial?) trait, and it served to make me even more aware how very unpredictable this field can be, and how close we come to the brink of tragedy for either mom or baby with every single delivery. Truly humbling as a physician, and frightening as a pregnant mother.

(Bah, CindyLou unplugged the computer immediately before I completed the post, so I had to go back and write it all over again. I feel like the truncated version somehow loses it's punch, but it's the best that I can do. Ah, well.)