Bittersweet

Please note that some of the language in this piece is coarse. If you find that offensive, read my science posts instead.  We shall begin our story in media res.

“Is the heart still beating?” whispers Dr Sanders, my attending for today.

“Of course the heart’s still beating, what do you take me for, an intern?” Dr Rike snarks back quietly. We stand at the foot of a patient’s bed. We’re attempting a cephalocentesis, transabdominally. Using ultrasound Dr Rike placed the needle in a fluid filled space in the skull. We drain almost half a liter – a quarter of a big coke bottle. We’ve removed enough fluid for our patient to deliver her baby vaginally. That’s the only thing the patient wants. She doesn’t want a C-section, because she understands that this won’t help, and her religious convictions tell her that a vaginal birth is what she should do. Early in her pregnancy she didn’t want to terminate for the same reasons. Her fetus had severe holoprosencephaly, and won’t likely survive long after birth.

 She wants to at least, say hello to her baby. She also wants to say goodbye.

Let’s rewind to this morning. On labor and delivery, we start the day at 4-5 in the morning, rounding on the post-partum patients. New mothers are usually awake anyway.

After that, the next big part of the work day is “board checkout” at around 6:30 in the morning. This is when the doctors who were in the hospital overnight tell the doctors coming in for the day about all of the patients on the floor.

A lot of what is said is basic medical stuff “25 year old G3P1102* with type I diabetes, on an insulin pump.” Some of what they say is just off topic banter, one way to keep up morale after staying up 36 hours straight. “So dude, Baja Fresh for dinner at 3am? More spectacular than Samuel L Jackson in Snakes on a Plane!”

This is also where medical students get our assignments for the day. The resident running the floor will tell us which patients we’ll be seeing (usually 2-4 at any given time), which doctors we’ll be working with (generally a resident, sometimes a fellow and an attending). Every so often they’ll assign actual responsibilities, like a student getting a delivery, or helping on a procedure.

Sometimes assignment’s are a punishment “George you get to take care of the 23 year old in room 10, good luck she bit the on call resident. Too bad you were late, the others picked up some fun patients!” Some are rewards “Opal introduce yourself to the 27 year old in 15, I like how you handled yourself on the C-section yesterday last week.” But if you’re lucky, your assignment is because the doctor you’re working with just plain likes you. “John, Dr Rike called dibs on you for his patient in 94, she said something about lunch later too, you lucky dog you.”

Sometimes it’s more complicated “Room 20, G1P0** 18 year old female. Baby has holoprosencephaly. Significant hydrocephalus, we’re going to have to do a cephalocentesis because mom wants a vaginal birth”

“Prognosis?” asks one of the interns.

“Not good, there’s nothing above the brainstem” – The baby doesn’t have most of her brain. She has enough that she may breath on her own, for a while. At least potentially, she could live for a few hours outside the womb. Maybe a few days. Not long.

“Why are we delivering her at all?” 

Silence. A few people wince at this one. The voice sounds frustrated, and more than a little callous. It’s the voice of an intern who knows she’ll be handling parts of 3 or 4 births today, taking care of many of the women who gave birth yesterday, and “triaging” many of the pregnant women who come up from the ER. Admittedly, she’s going to be a bit overworked. More importantly, like everyone else she doesn’t want to think too hard about delivering a baby that’s going to die. Soon. Everyone is going to die, we all know that, and it’s hard for us to deal with when the patients have lived full lives. Yet there seems something perverse about a universe that will let a child enter this world for a few short breaths, and then leave again so quickly.

“The family wants to say goodbye, it’s the right thing to do. If you can’t do it, don’t take the case,” Dr Rike chastises the intern. She doesn’t take the case.

“Why have an intern do it at all? Holoprosencephaly, bad prognosis, this is a student delivery. Even they can’t fuck this one up,” that one is from the attending.

More cringes, “Oh what, you know it’s true, and they need to learn somewhere. You damn resident’s aren’t even letting them see half the patients. It’s not even as if you need the deliveries. You’re just afraid to ask the patient if a student can even go in the room. Grow  a pair, it’s May, these kids are 3/4s docs at this point.” The attending in question, by the way, is female.

She continues “So who’s been good lately? Rike pick your own student after checkout. What’s the patients name again? Mrs Christine. Good luck to whoever gets her.”

Dr Rike is the fellow – she’s finished a residency in OBGYN and is in specialist training in maternal fetal medicine. She flagged me down after board checkout. I still hadn’t figured out if this was a punishment, a reward, or because Dr Rike likes me. After breakfast (well, a biscotti while running between rooms) and coffee, I’m betting on “likes me”. She took me in to meet Mrs Christine and Mr Christine. Mrs Christine was a kid. She was 18 and looked younger. But was also maybe the bravest woman I’ve ever seen. Most women about to give birth are afraid. Mrs Christine just said “I’m ready.”

Dr Rike explained that the baby had hydrocephalus – excess fluid in the head, that could prevent the baby from delivering vaginally. We discussed the young family’s options, and proceed with the cephalocentesis. After the procedure, Mrs Christine seems relieved. Over the course of the day we check in on her every 2 hours. Her labor progresses normally, her cervix begins to dilate, and efface. That means that it gets wider, and shorter, so that the baby can leave the uterus. It was an uneventful afternoon after a busy morning, and felt like the calm before the storm. I spent some more time with my patient, she told me she had a name picked out: Hailey. Hailey Christine.

 The delivery started suddenly. We had just finished night board checkout – much like in the morning, except the day team checking out to the night team. As it happened I was on call, so I would be staying the night. As soon as checkout was over, Dr Rike grabbed me by the shoulder and said “Gown up, you’re on big guy!”

We jogged down to Mrs Christine’s room. I flopped open a pair of sterile gloves, put on OB boots, and a sterile gown. As I was getting prepped, Dr Rike spoke to Mrs Christine “is it ok if Whitecoat delivers little Hailey? I’ll be right here next to him, but he really knows his stuff.” Mrs Christine was unsure at first, but Dr Rike reassured her that I would take perfect care of her baby. Mrs Christine smiled, and then pushed.

Hailey’s head began to emerge. She had a beautiful full head of hair.

“Don’t screw up,” I thought.

Hailey’s head came most of the rest of the way out, and I placed my hands on either side of her head, around the ears. “guide the shoulder out… No traction, don’t pull. Just guide. This baby’s coming out whether you want her to or not, you don’t need to help much” Dr Rike whispered.

“Get your hand under the neck,” I did as she told me.

Then I guided the head up, just enough to help Hailey’s other shoulder out. Almost too quick for Dr Rike to even instruct me further, Hailey was out, flipped into the crook of my arm. I suctioned her airway, and she started to cry.

“She’s beautiful!” said Mrs Christine.

She was beautiful. The gaping space that wasn’t so beautiful on ultrasound wasn’t visible on the outside. She was just a beautiful baby.

Not normal, not normal. Her cry was wrong, too high pitched, it sounded like it was being interrupted. She held her arms and legs wrong, too tightly. Too her mom, heck, to all of us in the room, she was beautiful.

I held Hailey in the air as Dr Rike clamped the umbilical cord and let Mr Christine cut the cord. I’ve never seen someone so happy as Mrs Christine after I gave placed Hailey in her arms. 

“Congrats!” Dr Rike says to the happy parents. “Congrats!’ she whispers to me, “We’ll talk more after we leave.”

Happy as everyone was, to me something still felt wrong. I couldn’t help but wonder, “what next?” Everyone in the room knew the answer. Hailey didn’t have long. The parent’s seemed to already be ready for that. The were just enjoying snuggling their baby.

 Today she is beautiful. Today her mom is happy. Maybe that’s enough. They certainly seemed to think so.

Still something feels wrong, as we walk out of the room. On a floor full of families at the beginings of a new part of their lives, this family is finishing a part of their life. They’re getting closure.

 Maybe thats not true, maybe I just needed closure, and they were just happy to have their baby girl. Even if for a brief moment.

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Around 3am, I ran into Mr Christine while trying to catch dinner. He stopped me, thanked me for helping. He said he’d always remember I was the only man he wanted in the room when his wife gave birth. I’m touched obviously, and over french fries we chat for a minute.

 He tells me, “I know we don’t have long. But does anyone? Something can happen to you any time, or anyone else. Is it any different because we knew months ago that we’d have a couple of days at best now?” I don’t weigh in, I’m really no more sure than he is. “Anyway, she’s something special. To us. Maybe not to everyone out there, but to us. Maybe I’d feel differently if we’d had kids before now, kids who had had a chance to be normal. So far she’s all I’ve ever known, and I’m more than happy with that .”

We both stand to leave, and and he before he walks away he says “Come by tomorrow please. We’d love to see you again.”

 

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 I was off of call at about 9 that morning. After I was relieved by the next student on call I went over to the Christine’s room, Dr Rike happened to be in the room. The room was filled with family, so it was a tight squeeze. After a short hello and some small talk, Dr Rike and I said we’d return later. Before we left, Mrs Christine asked if we would come back before Hailey left. We both promised we would.

It wasn’t long, we got the page at about 11. Hailey wasn’t doing well. Her heart wasn’t beating right, her breathing was slowing down.

If she was just sick, and we had thought she would recover, we’d be getting a tube into her trachea, to help her breath. Maybe they’d even pace her heart. People would be crowding around this poor little baby to do invasive, painful things. When we do that, it’s almost surreal seeing things kick into action. Time seems to slow down. Your heart speeds up a notch. You know every moment is precious.

This was different. Noone was getting ready to stick a tube down her throat. Noone was piling around baby Hailey. Yet we all still knew every moment just as precious, as Mrs Christine held her baby close, and Mr Christine held them both. A few minutes of silence later, she had passed. Mrs Christine smiled a little, and said “She’s gone home.”

 

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 *G3P1102 means a woman who has been pregnant 3 times including current pregnancy (G3), one child born at term(the first 1), one born early (the second 1), no miscarriages or abortions (the 0), and two children living (the 2).

**G1P0 would be a woman pregnant for the first time.

All names, and other identifying details have been changed. Whenever possible people are pastiches rather than individuals. This goes for doctors, student, patients, anyone else. Other disclaimers as per my disclaimers page on the sidebar.

Please direct all science related comments to my previous post “Holoprosencephaly and Cephalocentesis: an Overview“.

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Tags: Medical School, Medicine, OBGYN, Personal

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