This epistle is dedicated to a dear friend. She is a great ER nurse who recently "caught" a baby.
Docs, nurses, cops, and EMT's don't deliver babies. Women deliver babies. Everyone else involved just helps. The hospital where I "live" has a busy OB service. More than 3,000 babies a year enter this troubled world from within our doors. Highly trained labor and delivery nurses and special care nursery staff along with obstetricians, anesthesiologists and pediatricians all work hard to ensure a safe and healthy outcome for mother and child.
Occasionally the delivery occurs in the ER. ER docs and nurses are trained, have the appropriate equipment and are ably backed up by the L&D and nursery pros. Deliveries in the community are the responsibility of police, firemen, and EMS personnel. The mother and child arrive in the ER and stop only if not stable enough for transport upstairs.
A recent episode highlights an unusual OB and neonatal case. The call was for a precipitous delivery in an apartment. The mother was OK but the baby was reported to be blue. The night ER staff was ready with a warming stand, and all the equipment for entubation and resuscitation of the newborn. The baby arrived crying lustily. His face was blue but the rest of his body was pink. He had good muscle tone and good respiratory efforts. His oxygen saturation was 100%. The blue face was caused by bruising from his too rapid descend through the birth canal. His mother's use of cocaine was probably a factor in his hasty entrance.
The twilight zone of deliveries resides in the cars that drive up to the ER entrance with a usually male driver yelling that his wife/girlfriend is having the baby in the car. In my 30+ years of ER experience, I have done 2 "auto" deliveries.
The first was in a small car. It was February and the ambient temperature of 20 degrees (F). The delivery was easy. The cold was the problem. Being a much younger "world's oldest ER doc", I placed the baby on the mother's stomach, wrapped both in a blanket and lifted them up in my arms and rushed into the ER. All went well for mother and baby.
My second drive-up delivery was very different. My "old" friend (the nurse to whom this blog is dedicated) ran out to the minivan in response to the husband's cries for help. A rather large woman of about 110 Kg was lying on the passenger's seat that was in the reclined position. The mother's feet were up on the dash and between her legs the nurse saw two tiny feet dangling from the vagina. The nurse's calls for help were clearly heard in the ER core as she yelled my name. I grabbed some gloves and went through the ER waiting room to the minivan. An obstetrician (who no longer works at our hospital) arrived almost at the same time.
A breech delivery is when any part of the lower half of the baby leads the way down the birth canal. This unfortunate mother was scheduled to have an elective Cesarean section at 8:00 AM that day for an ultrasound proven breech presentation. I was faced with a double footling breech delivery. Most emergency medicine residencies give little training in the management of abnormal deliveries. Ultrasound has decreased the unexpected brow, breech, or shoulder presentations. The OB doc who met me at the minivan offered only the advice that I should get the mother upstairs and then turned and reentered the hospital.
There was no way to safely lift and transport this woman from the van to the ER. My mind and hands recalled a single leg and full breech delivery that I had done while on my obstetrical rotation, during my EM residency back in the seventies. I probed and brought out the upper arm and then the lower arm and finally the baby's head. I clamped and cut the umbilical cord and rushed the baby into the ER. The mother followed soon there after. The baby had a broken clavicle but was otherwise perfectly healthy.
My nurse-friend and I were shaken by this close call. My partners all commented that they had never seen any type of breech delivery and were relieved that I (not they) had been working that night. The nurse shared with me that she had nightmares about this case. The what ifs were hard to digest. I slept well that morning, after my shift ended and I arrived home. Being OCD, I brushed up on all less than normal deliveries with a very old textbook from my medical school collection.
There is nothing more satisfying to anyone who works in health care than being part of a delivery. The birth of another human being is awe inspiring. It was a privilege to have had the opportunity to assist these 2 women. My dear friend currently works in the ER of a tertiary care hospital that handles most complicated OB cases in our region. Her occasional per diem shift in my ER and our friendship keep us connected. The case of the double footling breech is our special bond.
Saturday, November 20, 2010
Saturday, November 13, 2010
GGB redux
One of my earliest blogs was about falls in the elderly and the subsequent ER visits from the injuries suffered. I bloviated about the neurological, cardiac and pharmacological issues that led to these all too frequent events.
A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.
Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".
After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.
The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.
I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.
One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.
There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.
The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.
A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.
Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".
After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.
The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.
I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.
One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.
There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.
The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.
Wednesday, November 3, 2010
Resquiescat in pace
RIP. As a new member of the medical staff of my hospital in the early 80's, I needed advise and guidance. A smiling pediatrician welcomed me to Local General Hospital. Dr M worked in a large multispecialty group practice. He later started his own office with his wife who managed the practice. Children from his practice would arrive in the ER after a phone call from M. The information would often include insights into the dynamics of the family. Having M's friendship and confidence was greatly appreciated by a naive ER doc.
I was privileged to be Dr M's personal ER doc. He and his beloved wife honored me by their confidence in my abilities. When my nephews needed a new pediatrician, Dr M welcomed them into his "family" of patients. Eight days ago M made his last visit to the ER. He had suffered a cardiac arrest at home. Despite CPR by his wife and the best efforts of EMS, ER and intensivists at our hospital, Dr M died on Halloween morning.
A memorial service was held this morning. I had worked the past three nights and grabbed two hours of sleep. A shower and my best dark suit made me presentable to say goodbye to my friend. The church was packed with colleagues, family, friends and patients. The receiving line at the wake last night began forming an hour before the viewing began. A reading from "Winnie the Pooh" was given by one of M's son. His other son who joined his office 5 years ago, read a pertinent passage from the New Testament. The CEO of our hospital gave a deeply felt and moving eulogy. A life long friend added a eulogy that gave insight into M's personal life.
What is the measure of a man? Dr M was a loving husband and father. Friend, mentor, care giver, teacher. He served as president of the medical staff, member of the board of trustees, and tirelessly raised the profile and brought in donations for the hospital. The loss of this extraordinary man will be felt by everyone who was embraced by his warmth and humanity.
The epitaph for Dr M is what he told my sister-in-law and the parents of all his kids, "take him home and love him".
I was privileged to be Dr M's personal ER doc. He and his beloved wife honored me by their confidence in my abilities. When my nephews needed a new pediatrician, Dr M welcomed them into his "family" of patients. Eight days ago M made his last visit to the ER. He had suffered a cardiac arrest at home. Despite CPR by his wife and the best efforts of EMS, ER and intensivists at our hospital, Dr M died on Halloween morning.
A memorial service was held this morning. I had worked the past three nights and grabbed two hours of sleep. A shower and my best dark suit made me presentable to say goodbye to my friend. The church was packed with colleagues, family, friends and patients. The receiving line at the wake last night began forming an hour before the viewing began. A reading from "Winnie the Pooh" was given by one of M's son. His other son who joined his office 5 years ago, read a pertinent passage from the New Testament. The CEO of our hospital gave a deeply felt and moving eulogy. A life long friend added a eulogy that gave insight into M's personal life.
What is the measure of a man? Dr M was a loving husband and father. Friend, mentor, care giver, teacher. He served as president of the medical staff, member of the board of trustees, and tirelessly raised the profile and brought in donations for the hospital. The loss of this extraordinary man will be felt by everyone who was embraced by his warmth and humanity.
The epitaph for Dr M is what he told my sister-in-law and the parents of all his kids, "take him home and love him".
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