New Doc in Town
I had waited five long years to see the skyline of Minneapolis for the last time in my car's rear view mirror. As I was driving to the small town where I would begin my first practice, I remembered the parting words of the old chief at my residency program. He said, "Whatever you do, don't have a maternal death in the first two years of your practice." He said, "it will be the end of your practice. You'll never recover from it. Nobody will forget it."
I thought, well, that shouldn't be too hard. In the five years I'd been in St. Paul, I hadn't had any maternal deaths. I had just finished my training and I thought I knew most of what I needed to know to practice, like most young docs.
My destination was a town of 15,000 where I would be the only obstetrician. I had been there only a few days when I got a call from the emergency room on a Friday night. A young woman about 15 weeks pregnant said she had just been squeezed between her 4 x 4 vehicle and a brick wall. She said she had just bought it used and there was something wrong with the breaks. It had started rolling towards a brick wall and she did not want the chrome bumper to get scratched up. I thought this was a squirrelly story but ordered the routine tests. "When she gets in," I said, "get an ultrasound. We want to make sure that the baby is still living and that she is not abrupting (placental separation from the uterus, which can cause concealed hemorrhaging).
The sonographer said the baby appeared dead, that there appeared to be an abruption, and that there was bleeding in the retroperitoneal space (the space where the blood vessels lead to the uterus). When I got to the hospital, I saw exactly what the sonographer said I would see.
I thought for a while, ordered the usual blood tests for clotting, ordered four units of blood for transfusion, called the operating room personnel to make sure they would be ready, called the anesthesiologist, and arranged for an assistant surgeon, an experienced doctor.
I talked to the patient about my findings, concerns, diagnoses, plans, and of course, choices. With the abruption, we needed to deliver the dead baby. With the dead baby and the abruption, she could have a clotting from disseminated intravascular coagulation (DIC). In addition, she had a broken pelvis.
Usually, with a broken pelvis, the bleeding is finite because the blood coagulation system works. This patient, with a combination a broken pelvis and an abruption, had several reasons to bleed. She could become hypovolemic (low blood volume) and go into shock at any time. Since her blood volume was unstable, we'd have a hard time restoring it.
She understood what was happening and she was ready to go to the operating room, which was precisely where we went. We put the patient to sleep, and I made an incision from the patient's pubic bone to her navel in the midline and quickly entered her abdominal cavity. The uterus was black and blue, indicating bruising. It was a little big for 15 weeks, and appeared to be filling with blood. We were indeed dealing with an abruption. In addition, I could see blood coming from multiple areas of the broken pelvis.
The old surgeon and I made a plan. We concluded that the patient had bleeding from the broken pelvis and the abruption. We could not stop the broken pelvis bleeding and likely would not need to, but we could empty the patient’s uterus. This was important to decrease the risk of her blood failing to clot (DIC). As we talked, the anesthesiologist said, "You've got ten minutes to close her. I'm waking her up. Do not do the D&C."
We did not have time to question the motives of the anesthesiologist, or his irrational sabotage of our surgical plans. We quickly closed the patient's incision and got her out of the operating room. As I thought about what had just happened, I knew that the patient had a useless surgery which didn't fix anything but added to her risk. At the same time, she continued to carry the dead baby and the increasing abruption, which were serious risks. I had promised this patient I was going to take care of her, and we'd actually added to her risk. Then I thought of the old chief's statement about not having a maternal death. My life flashed before my eyes.
I put my patient in the intensive care unit (ICU), where she spent the next three days until she became stable enough to transfer to another hospital. Although periodic clotting studies remained normal, the patienta’s hemoglobin continued to drop through the first night.
Because of the dropping hemoglobin, I spent that night in the hospital so I could check on her each hour. Being the new Doc on the block, I did not know the nurses and they didn't know me. Therefore, I checked in often just to "see" the nurses and the patient. Nurses and patient seemed to look good in spite of everything.
Frequent visits provided the benefits of both coordinated care and emotional support for everybody—patient, nurses and me. That night left an indelible impression on the nurses and me and we formed an enduring bond. Over the next several years, I grew to admire and respect those nurses more than any before or since. This was before the oppressive hand of insurance reviewers. For me it was an idyllic time, when all I needed to do was to care about my patients and the nurses. I could spend my time meeting their needs instead of the insurance company's demands for a detailed explanation of every chargeable action in the patient's chart. I long to return to those days.
It was Friday night and Saturday morning, so there was nobody around, not even all the doctors I'd seen at the recruitment and Christmas parties a short six months earlier. I felt very alone and abandoned.
During these 24 hours, which seemed like an eternity, I had been in contact with the old chief of my residency program. We had agreed to plan no more surgery for the time being. Since the blood was not infected, we would not drain it. Any attempt to remove the blood would maybe increase the bleeding, which had just stopped, or introduce the risk of infection.
When the patient became stable, I knew our window of opportunity had arrived and we took it. I transferred her to one of the attending physicians in my residency program. The physician removed the placenta, the blood clot, the dead baby, and repaired her incision, which had broken open in the trip to the distant hospital.
Being forced to close my incision so quickly meant I closed under less than optimal conditions. No anesthesiologist had ever told me before that he would wake up the patient before surgery was finished.
My patient stayed in the hospital in St. Paul for about two weeks. She returned to our hospital and remained there another two months before going home. She missed all the big complications she could have had. She never got an infection. After the initial episode of bleeding, she had no more. She did not have a pulmonary embolus. After several months, she could walk. We had miraculously avoided all the common complications.
This was the first in a whole series of challenging patients I was to see over the next three years. I had never been prepared for anything like this in residency. Thank God the nurses were great!