Complications, continued

So there I was - standing in the exam room of a regular doctor's office with a hemorrhaging patient, an attending, "Dr. Green," wrapped up in fixing the problem, and a half-stunned intern gripping an ultrasound with bloody gloveless hands.

"I need 4 misoprostol right now... and bring a runner with you" I stepped out of the room and ran to get the meds, breathlessly telling the other MA "this is not good, we need you in here" as I passed.

Immediately Dr. Green told the other MA to grab another doctor in the office, "Dr. Lee." The doc, an OB GYN as tall as tree, walked in calm and smiling, and Dr. Green showed him the image of the patient's uterus on the ultrasound screen after briefly introducing her.

"See this... on the anterior wall. I don't like it. I think this is accretia. We need to get her into the OR. Can you set that up for me?"

He gazed at the slightly fluxing screen, his eyes scrunched as he deliberated, "Will do, how are we going to get her there?"

"She's going to need a stretcher. I don't know how we're going to work that. Can you get you us a stretcher?"

"I'll borrow one. We'll figure it out." He quickly stepped out of the room. The intern flashed me a wide-eyed glance that I could read as if the words were scrawled on her face... "Can you believe this is happening?"

The office building is located across the street from a medium-sized hospital, and connected to it by a pedestrian bridge. Our practice is actually a satellite of a different hospital and is only at this particular location twice a week, so our doctors are pretty unfamiliar with this neighboring hospital. Fortunately, Dr. Lee works on L&D there all the time and knows it like the back of his hand.

Finally, Dr. Green had a chance to fully explain what the hell was going on to the patient.

"I think that the pregnancy implanted itself into the scar from your c-sections. Now you're bleeding quite a bit. I'm going to have to finish this in the operating room, where I'll have light and all the resources I need, and we can put you under anesthesia so you won't be in so much pain. Ok?"

The patient, who hadn't said a word during this entire ordeal, moaned weakly and replied, "ok."

There was a strong knock at the door moments later, and a stretcher waiting outside the door. We couldn't fit it into the exam room, so the doctor and I supported the patient as she slowly half-stumbled to the stretcher, spattering blood all over the floor as she went and leaving a trail from the exam table to the stretcher. She had probably lost about 2 units in the exam room al0ne. We covered her the best we could and took off, following Dr. Lee's lead.

Rushing across the pedestrian bridge over to the adjacent L&D floor elevator, we nearly ran into a hospital food service guy, who froze and watched us pass in utter shock.

In the elevator, Dr. Green explained to the patient, who wanted 2 more children, that a hysterectomy may be necessary to stop the bleeding and save her life. However, she added, "I'm going to do everything in my power to save you and save your fertility. I'm going to get you home to your kids and hopefully make sure you can have more kids in the future." The patient cried silently... I can't even imagine how surreal and scary this whole thing must have been.

We reached the ER. They were expecting us and had a room ready, and the nurses were obviously anxious and a little excited. It's a small ER with no trauma services, so God knows when they last had a hemorrhage on their hands.

As a million new people did a million things to my patient at once, I briefly stood at the head of the bed and rubbed her shoulder, "they're going to take great care of you." I looked into her eyes but felt she was not really there. The nurses shot me a hundred questions, and it felt strange giving a hand-off report after not doing one for so long.

I met Dr. Green and Dr. Lee outside the room as they were talking to the ER doc, but soon we were following Dr. Lee as he led us up to surgery.

[To be continued, yet again. Sorry guys... ]



It was a routine dilation and evacuation for a miscarriage. I was assisting the doc, passing off instruments and keeping an eye on the patient. It sounds strange but I like working with miscarriage patients, because it feels like one of the few patient populations that I can really make a difference with. They're going through a rough time, and it seems to me that having a supportive, caring but unintrusive caregiver means a lot to them.

Everything was fairly routine. The doc was a tad concerned that the patient had 3 c-sections and no vaginal deliveries - which meant she really had none of the advantages of being multiparous. If she had given birth vaginally her cervix would have been much more pliable, and we needed to dilate her to about 6 mm. I wasn't aware that the doctor had another concern in mind. We did the procedure under ultrasound guidance by the resident, which is pretty unusual. Usually no ultrasound is needed.

So we're humming along and everything is going normally... until we start applying the suction. The patient started yelping in pain. Now, pain in a D&E is normal and expected. But that little alarm went off in my head and I couldn't really decide whether the woman was just overly expressive or was experiencing an abnormally high level of pain.

I spoke to her softly and tried to soothe her - which is hard to do without physical contact, but I couldn't do that with a pair of gloves on and the doctor constantly needing me to pass off sterile surgical equipment. She continued howling.

Then, by the doctor's facial expression and the way she seemed agitated and rushed when she asked for more 4x4s or more suction or this or that... it became obvious this was far from routine... it became glaringly obvious when we started reaching about double the amount of blood and tissue I'd expect from a 6-7 week miscarriage in the suction containers.

The doctor removed the suction from the cannula in the woman's cervix, and blood started flowing out of it as if it was a kitchen sink faucet at about half of it's max flow. And it didn't stop. At this point, I snapped in to the mode. That zone you get it in when you realize you have a sick patient on your hands and you have to do something about it or they may die.

[I'll finish this later, I need to study for midterms. So I'll leave you with that cliffhanger.]