Why is it that people suffer with a treatable problem and then, after several weeks, come into the emergency department at 3:00 AM for treatment?
This is what was running through my mind when I picked up the chart of 16 year old young girl who was complaining of constipation for the prior few weeks.
She was in the room with her mom, and her mom did not appear happy. The patient said that she was bloated and she kept moaning in pain from the pressure caused by her stool. Her mom kept telling her to “just push it out then.” The patient could feel the pressure in her rectum, but she said she couldn’t push out the stool.
Great. That means that I get to spend the next 15 minutes and half dozen rubber gloves digging poo from her behind. Glamour work. In all fairness to the patient, though, when I pulled back the sheet, her stomach was pretty distended.
So I pressed on her stomach and … wait a minute. “When was your last period?”
“About a month ago.”
I get the gloves out to do a rectal exam and aren’t I surprised to see the a head of black hair bulging out of the patient’s birth canal.
“Whoa! WHOA! … DON’T push! You hear me?!? DON’T PUSH!”
I haven’t delivered a baby in a couple of years and I wasn’t looking to refresh my skills that night. We call the OB floor and get her upstairs to labor and delivery.
That’s not the end, though. My luck isn’t that good.
About 10 minutes later we get a frantic call from the labor and delivery nurse saying that the patient is pushing and the obstetrician hasn’t shown up yet. Dang it.
I go upstairs and hear the typical bustling of everyone preparing for the delivery. You can see the baby’s heart rate of 130-140 on the monitor and can also see the pressure waves caused by contractions of the mother’s uterus right underneath the baby’s heart rate. The rise in the uterine pressure tracing on the monitor regularly precedes the mother’s pain by about 10 seconds. There isn’t time to do an epidural and I don’t want to give the mother something that will cause the baby to have trouble breathing. I just want to get the baby out.
I get gowned up and ready to go. Just before showtime, the obstetrician saunters in. Half of me wants to hang around and watch the delivery, but there are patients in the emergency department, so I get the gown off and head downstairs, breathing a little sigh of relief.
You guessed it. Not over yet.
Fifteen minutes later it’s another frantic call – this time from the nursing supervisor. The newborn baby is coding.
I don’t care who you are. When you hear these words, your heart drops. When you’re an ED physician and you hear those words, you know the buck stops with you. Time to put up or shut up. I grabbed the Broselow tape and raced up the stairs.
This time it wasn’t the usual bustling about. Everyone was tense. Nervous. Upset. A limp baby was laying on the bassinet. You could see hands shaking as they were looking for IV sites. The nursing supervisor’s hands were visibly shaking as she pushed the intubation kit into my hands. Despite all the tension, things were actually going smoothly. The baby looked bad, though. She either was the victim of intrauterine infection or she was stillborn. Her skin was peeling like she had been badly sunburned. Most of the time if you need an IV line in a newborn, you can use the umbilical vein. This poor baby’s umbilical cord was so friable we couldn’t find the vessels to insert an IV line.
I intubated her and put a central line in her neck. We coded her for more than a half an hour and never got a pulse. Retrospectively, the baby was probably stillborn and the heart tones we were hearing were those of the mother.
Pronouncing someone dead is never easy. Pronouncing someone dead who has never experienced the joys of life is downright difficult. Tonight it was even more trying. The OB nurse and one of the lab techs were both pregnant. They just stood there with tears streaming down their faces. I had to stop each of them before they left and remind them that the patient had no prenatal care and didn’t even know she was pregnant. “Don’t personalize it,” I told them. “Two completely different situations. This isn’t going to happen to you.”
Didn’t stop the tears. In fact, I probably made them cry harder. Damn.
Sometimes being a doctor just sucks.
You guessed it. Not over yet.
I get a call from the ED nurse.
“Sorry, but there’s a patient down here in a lot of pain. You aren’t going to believe the complaint.”
“Let me guess … constipation.”
“Are you friggin kidding me?”
“Nope. It’s a lady who hasn’t had a bowel movement in over a week.”
“Wonderful. Get a pregnancy test.”
“She’s 71 years old.”
“I don’t care. Humor me.”