We can all do better

This might be a long post, but there’s a lot of things I want to cover.

The crux of it revolves around our latest experience with the healthcare system: my wife and I had a baby yesterday. But we weren’t supposed to.

A few days ago, my wife noticed some dark red blood, and spoke to her obstetrician. After consult over the phone, she went to the doctor’s office, had an ultrasound performed, and was sent to our hospital for some longer monitoring. It was determined that everything was okay, and that the contractions she was experiencing were nothing abnormal, and she was sent home, and given instructions for some bed rest.

Nothing is wrong with any of this. This is what we expected, and we are grateful for the office and hospital staff. We were relieved there were no problems, and expected to wait another six weeks to meet our new daughter.

Until my wife woke me up.

It started at midnight. “This pain is different,” she told me. “And now the blood is bright red.” With her past pregnancies, there was a dramatic shift in the quality of her contractions, and this is what she was experiencing. My wife labored for four hours with our first child, and only two with our second one, and here she was telling me that she was in labor.

Six weeks early.

I’ve always prided myself on my ability to remain calm, and to reassure my patients, and their family members. Except in this case, my patient was my wife and unborn baby, and my patient’s family was myself and two small children. My wife is also a former paramedic, and hasn’t practiced in several years, but she was concerned as well.

After performing my own exam (probably against all recommendations, please don’t tell our obstetrician) her cervix was only minimally dilated, at one, but she was becoming effaced. And there was a lot of bright red blood. Her contractions were coming every five minutes, and lasted about 30 seconds. We both felt that delivery was imminent, unless we could stop it.

So we headed to the hospital, and called the obstetrician on the way. Luckily, the office had a physician in the hospital, and we were assured the doctor would come see us right away after we arrived.

But we got a midwife.

Now, listen. I have nothing against a midwife. Nothing at all. I fully understand how vital a role midwives play, and I am sure they are more than competent. But there were two exceptions in my case. First, this was a woman who was nowhere near full term, and second, we made it perfectly clear that we expected a physician in the room, as opposed to any midwives.

Let’s be realistic: when the shit hits the fan, the midwife is going to call a physician. So let’s just cut the crap, and have the physician in the room in case the shit hits the fan. Meanwhile, we have a woman in labor, with bright red bleeding, who is only 34 weeks along, with a documented history of short labors.

That fan was spinning pretty fast.

Of course, the midwife was upset when I specifically requested a physician. “I’m more than capable of delivering babies” she said.

“And so am I. I delivered a baby just last week in the camping section of a Wal-Mart. But we want a physician, specifically a perinatologist, and some terbutaline might be in order if we have any chance of stopping this preterm labor.”

I try really hard not to walk into situations with a chip on my shoulder, and I don’t volunteer that I am a paramedic unless it is called for. In this case, I felt it was called for. The midwife left the room, probably to soothe her hurt feelings, and we were moved to a delivery room quickly.

But I don’t care about her feelings. We had a situation which she could not handle, and it is my belief she should have called a physician on her own, instead of having to be prodded.

Our perinatologist was a fantastic doctor. Just all-around great. She was very reassuring, and explained everything that was going to happen. She ordered and administered the terbutaline, which gave my wife a lot of comfort, except the contractions didn’t stop. Their intensity decreased, but their frequency did not.

This perinatologist explained after a quick exam that my wife was 4 centimeters dilated, and 60 percent effaced. It didn’t look like we were going to be able to stop this labor. When I mentioned that I was concerned about a possible abruption, she assured us that delivery was the best option after all.

We didn’t see any abruption on the ultrasounds, but that didn’t mean there wasn’t one. The presentation was certainly indicative of placental abruption, instead of a bloody show, which is what the midwife called it.

My wife requested an epidural, and the anesthesiologist was called, and he came into the room only several minutes later. We were pleased with the alacrity the hospital staff was showing to our situation. In the meantime, a nurse and respiratory therapist from the NICU came to talk to us, and answered a few of our questions.

It was explained that everything looked just fine with the baby, and they weren’t expecting any complications, but that the baby might have to spend a little bit of time in the NICU if she was having any trouble. The NICU staff was very professional and reassuring, and they assured us they would be in the room for the delivery, as opposed to regular L&D nurses.

Once the anesthesiologist came in, we became somewhat concerned. Our nurse, who was very helpful and friendly, seemed a little too friendly with the doctor, and it seemed as if they were flirting, for lack of a better term, while he was performing the epidural.

As I was standing in front of my wife, with the anesthesiologist behind her performing the puncture, my wife looked at me and said “my head hurts and my toes feel warm.”

Of course, this caused the doctor pause, and after a few more questions, he removed the catheter, and applied a dressing to her back, then we laid my wife back on the bed. Only mere moments after the injection, my wife mentioned that she couldn’t feel her legs, which indicated to the anesthesiologist that he went too far, and administered a spinal block instead of an epidural.

This damned doctor was so busy flirting with our nurse that he went too far with his needle.

Right about now, I notice my wife looks terrible. She looks pale, complained of dizziness and nausea, and was beginning to sweat.

Her blood pressure was 70/30, and her heart rate was 160.

And I was noticing some late deceleration on the fetal monitor.

Our nurse quickly called the perinatologist, the NICU staff, and another anesthesiologist.

Our second anesthesiologist came into the room, and instead of talking to us, conversed with the nurses in the room, and talked about giving “neo.” Our nurse had already given my wife some ephedrine, with no change in the blood pressure.

The anesthesiologist looked at us and said “there’s nothing to worry about here, all this is normal, and we do this every day.”

Y’all, I about lost it. Just about.

“Don’t tell us there’s nothing to worry about. I’m the son of a physician, and I’ve been a paramedic for 17 years. My wife, your patient, is also a paramedic, and we generally act a little more concerned when we have a diaphoretic, hypotensive, tachycardic patient. And if that patient happened to be in preterm labor, and was having bright red bleeding, and we saw late deceleration on the monitor, we wouldn’t be all nonchalant.”

Of course, I hurt this anesthesiologist’s feelings. So now I’ve possibly made two people cry.

But we weren’t playing. This was a serious situation, and it seemed like there were three people who appreciated the seriousness of it: the perinatologist, the patient, and myself.

In the end, the anesthesiologist left, and the perinatologist and I (yes, she let me deliver) delivered a very, very tiny baby girl. She weighed 4 pounds, 3 ounces. Her apgar scores were 8 and 9, which were impressive and reassuring. The NICU staff determined our new baby girl could stay with us instead of going with them.

So we now have a premature, yet very healthy, baby girl. And we couldn’t be happier. Her mommy, daddy, big brother and big sister are very much in love with her, and we can’t wait to bring her home.

But we all need to do better.

Things should have been explained better to us. Granted, we aren’t typical patients, but we still should have things explained to us.

When you have a chest pain patient, do you tell them “I’m going to give you some aspirin, and I need you to chew them up, instead of swallowing them.”? That’s good, because you should. But you should also tell them “aspirin is going to work by making your blood clot slower. That way, in case you’re having a heart attack, the clot won’t be as big, and it will be easier to fix.”

Do you just administer a breathing treatment to an asthmatic, or do you tell them “this medicine might make more spit in your mouth, and might make you feel a little jittery, but that’s how the medicine works; it works by relaxing your lungs, making it easier for you to breathe, and it makes your heart beat a little faster, too.”

Do we do a good enough job explaining these things? When our patients are really sick, do we get in an ‘automatic mode’ and just do a lot of things quickly? Or do we take the time to explain to our STEMI patients that “you’re having a heart attack, and we are going to do a lot of things very quickly.” Do we tell them that they “are very sick, but I am going to take very good care of you, and not let anything bad happen to you.”

I think we owe that to our patients.

Most of us are very competent, capable providers. But that doesn’t reassure patients.

Touch your patients. Skin-to-skin if you can. I like to put my hand on their shoulder, just at the base of the neck. Look them in the eyes. Don’t tell them “everything is going to be okay” because that isn’t always the case. Tell them what is happening to them. Tell them what you are going to do for them, and tell them why.

Tell them you are going to take good care of them.

And mean it.

Comments

  1. It’s been nice seeing all these posts from you lately. Usually they mean you’re frustrated with something so that sucks but I always enjoy your blog. Congrats on the new baby girl, and I hope she stays happy and healthy!!!

  2. Glad everyone is healthy. I hope you get the time to enjoy your daughter while she is young. Quite eventful birth, sounds like you did what needed to be done for your wife and daughter.
    Very well written, and it has made me think about how I explain things to my patients. I have seen some health care professionals that are great at explaining everything, and some that are horrible.
    Great to see so much writing.
    Stay well.

  3. Flash Larry says:

    I can’t count the number of times I’ve read this. I just read it out loud to my wife and she got madder and madder listening. She is usually a very calm person and has absolutely zero medical training but even she erupted when the doctor said, “This is normal.”

    I’ve read this and thought about it a lot.

    Having someone there to aggressively advocate – and know what’s happening – is, unfortunately, important.

    It is why when I was lying up in the hospital with the seriously abnormal heart rhythm, I was very, very glad my partner was standing next to me because I knew he would be that advocate. And he wouldn’t care if he made people cry either.

    Often we paramedics are the ones who have to be the advocates for our patients when we take them into emergency rooms and encounter this sort of lackadaisical attitude.

    I’ve read and thought about this a lot, about what I do and say. I count myself as one of those people who does explain to patients what I’m doing and why, and why things are happening to them, why they’re being transferred, what to expect – but even a very old dog can learn and I can see how I can do better.

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