I hope I don’t see it again
Red rivers with nary a pain.
An expert you’ll need
When the postpartum bleed
Comes from placenta that’s been retained
My anesthetic, being strictly local, doesn’t interfere with me cracking jokes during my surgery. The prep was more painful than the needles and Novacaine, but I don’t know why the squamous cell carcinoma growing on my forehead for the last couple of months would be tender. But it is, and the scrubbing hurts. I keep my eyes shut and I tell a few warm up jokes to the nurse prepping me.
The plastic surgeon, Dr. Paula Formosa, has a great sense of humor and when I’m not telling jokes (It was so cold I saw a lawyer with his hands in his own pockets…) she gives me a running commentary.
We wait for the Roger, the pathologist to read the frozen section and say whether or not the entire tumor has been removed, and I tell a long involved joke about Navajos, sheep, dogs, and tourists. Right after the punch line I hear the door open and the pathologist’s voice comes through announcing a good, clean removal.
Roger and I went archery elk hunting in western Colorado in 1989, along with a dermatologist (since deceased) and Dolf. Roger and I both brought home bull elk, and I got a deer as well. We’ve been friends for a very long time. He offers to buy back the flint lock muzzleloader pieces he sold me 18 years ago that I haven’t turned into a functioning firearm, yet.
While Dr. Formosa finishes the wound closure I listen to the nurses talking, and just before she lifts the surgical drapes from my face I declaim a limerick that starts, “There once was nurse named Michelle…” It’s not my best work, even though it took me more than three minutes to put it together, but it is so unexpected and both in and out of context that the laughter paralyzes the OR for about a minute.
In the recovery room I call St. Luke’s Labor and Delivery. My patient went into labor as I was on my way to my surgery, and when I call she has dilated to about 5 centimeters. About three in the afternoon, Bethany drops me off at the hospital and I take the back stairs up to OB. I change clothes and I check my patient, rupturing the membranes and placing a scalp electrode.
Then I go down to the doctors’ lounge in the basement to search for food. With nothing in my stomach since last night, I settle for a soggy chicken salad sandwich and a marginal apple and find them delicious. I go online and check lab results and scanned documents.
The irony doesn’t escape me that I’m cramming more into an hour than any sixty minutes deserve at a time in my life when I’ve decided to slow down.
Still famished I return to second floor to raid the OB kitchen for a bag of chips and two oranges, and I retire to the doctors’ room.
Very late in my obstetrical career I learned about non interference. The nurses call it “laboring down,” it’s a trendy concept. I think of it as Not Interfering With The Flow Of Feminine Energy. My part of the process involves not going in to see the patient between the time I arrive to greet until she’s very close to delivering.
That I, a male, would have anything to do with labor and delivery is an accident of history. The era of men in obstetrics, an exclusively European phenomenon in the last 500 years, is rapidly drawing to a close. Most OB residencies sport no more than a token numbers of Y chromosomes. I have been privileged to see a part of the human condition that very few men in the course of human existence have seen. Each delivery is a thrill.
It’s also like riding a rollercoaster without a grab bar.
Every half hour or so I walk from the television twenty three steps to the nurses’ station to make sure nothing is passing me by. In between times I doze and flip through the channels and ice my incision with a closed can of Sierra Mist.
It’s the worst TV set in the entire hospital and has no remote control, and the room is ten degrees cooler than the hallway. I start to shiver and I get up and prop the door open with a chair.
About seven the secretary sticks her head in and says, “Dr. Gordon, they need you immediately.” This time I sprint down the hallway. The baby’s head has delivered, and I put on gloves, clear the front shoulder, then the back shoulder, and the baby slides right out. I suction the baby’s mouth and nose, clamp and cut the cord. The nurse assures me that not ten minutes ago the cervix was still 8 centimeters.
The baby does well, a sense of rightness and completeness envelops the room. I have been privileged to be a part of this unique island of peace for more than three decades.
Twenty minutes later the placenta delivers slowly, stubbornly, and it exits asymmetrically.
Then the bleeding starts. Brisk, dark red uterine blood flows at a frightening rate. Not my first postpartum hemorrhage, I ask for one of the nurses to start Pitocin. The bleeding slows.
It starts again. I use two hands to massage the uterus, one outside and one inside. The bleeding stops.
Then it starts again.
Further uterine massage does no good. I ask for Methergine, for the second time in my life.
It helps for less than a minute, but the blood pressure comes up.
I ask for help.
Obstestrician from group A in fact is on the OB floor, but he’s doing a C section, and won’t be available soon. Obstetrician from group B is on call for the other group, and I ask that she be called. By phone she suggests Hemabate.
Hemabate came into the armamentarium twenty years ago but I haven’t needed it in all that time.
It doesn’t help.
The patient feels OK, she’s not dizzy, and there’s no pain at all. I calmly tell her she’s bleeding a lot more than usual and that I’ve called a specialist, as I watch her life force drain steadily out. Fear grips me, the rollercoaster without the grab bar.
I ask for two units of blood to be typed and cross matched, and I remember why, when I was in New Mexico, our hospital wouldn’t start an OB program if we didn’t have a blood bank.
By cell phone, the obstetrician asks for 1000 micrograms of Cytotec to be given per rectum. Which I do, then I change gloves.
Obstetrician from group B comes strides in smiling. I relax as the cavalry, Marines, Angelina Jolie and John Wayne arrive. With fluid economy of motion, she takes a surgical gown and a pair of gloves from the cart, and slips them on. Less than fifteen seconds after her entrance she is ready to go. I stand aside, and she slides her hand right to the problem area.
She turns to me and in a voice I can hear but no one else can she says, “Yeah, it’s retained placenta. You know in residency they used to call me Roto Rooter.” I wish there would be a more graceful nickname for someone who performs the task at hand with such grace under pressure. I admire her work. She saves the patient’s life with style and professionalism. With a few deft swipes of the fingers, she removes the pieces of afterbirth stuck inside the womb, and when she removes her hand, the bleeding has stopped.
I have no doubt that in a non industrial society the patient would have died.
I started delivering babies in 1977 and in all that time I have never seen a case of post partum hemorrhage caused by retained placental products.
The patient has been a Woman of Steel, tolerating an immense amount of pain with no chemical relief.
We explain to the patient that she’ll need to go under anesthesia to have the uterus thoroughly scraped. She asks if she can have her tubes tied at the same time.
Then the embarrassment starts. The patient had spoken to group A before delivery regarding sterilization, but I called group B when I was in a crunch.
I step out to the nurses’ station with Obstetrican from group A, to find Obstetrician from group B just done with his C section, and they discuss the situation.
The situation is thoroughly my fault, and nobody has gotten mad at me. In fact, they’re downright civilized about it. While the two obstetricians dialogue back and forth I marvel at how docs from competing groups cooperate.
The Sioux City medical community is a hotbed of functionality. We waste less than two percent of our time and energy in backbiting and politicking. Our turf wars are time limited and don’t bring about deep rifts. If Dr. X has a beef with Dr. Y and either tries to bring in Dr. Z, there will be a notable lack of recruitment.
The two consultants collaborate on a regular basis. When they’ve finished not being territorial about who does what procedure, Obstetrician from group A and I talk about how wonderful life is without infighting. She thinks it’s because everyone has plenty of work. I think it’s because the larger community works hard at getting along.
While we wait for the OB operating room to be readied after the caesarean section, I go to the nursery and examine the baby. She sleeps peacefully under the warmer, and the grandparents, aunts, sister and cousins watch through the chicken wire glass. The little girl has been born into a large, warm, caring family.
I come back to the surgery area and I watch the consultant clean the inside of the patient’s womb under general anesthesia.
I change back into street clothes and meet Bethany in the lobby. The incision is aching and my back hurts, I can tell it’s been almost three weeks since my Enbrel or my omega 3 fish oils.
When I get home, I start to write, and my friend and college buddy Bob calls from California. He has been a good sounding board for my writing. We talk about how life is going for both of us. It’s very late when we ring off.
Neither one of us is sleeping well.