How I Remember It

It's a cold winters day in February. Friday exactly, the day most people pack it in, take it all home. I’m on the 2pm to 10pm shift. Not bad. Usually those are peak hours, a good time to work. But on this Friday afternoon it’s a little slow.

I working with one of our new docs. She just completed her residency last year. She’s green, nervous, frequently seen looking up doses for penicillin and the like. She has potential but needs some polishing. I know only I can help this young apprentice to one day be an ER Jedi.

At my hospital there is one thing every ER doc fears……..Delivering a Baby.

In our current health care climate, many hospitals have gotten out of the Labor and Delivery business. Mostly because of profit and liability issues. Anyway, not all hospitals have an L&D suite or staff Obstetricians. At my hospital we don’t have any ER coverage for OB/Gyn. So we don’t birth no babies.

Anyway back to me.

On this blustery Friday afternoon we are strolling along. Suddenly a red truck speeds to a stop outside our ambulance doors. A young man jumps out and appears to be yelling for help through the glass. Sometimes patients do this. We always go check it out, but it better be good.

It’s good......... His girlfriend is in labor.

Tension heightens as the staff help the 19 year old out of the car and checks out the situation. This could be an emergency, the next sounds from the room…

"We need a doctor in here."

The patient is screaming, obviously in the throws of a contraction. She says she is 5 and half months pregnant. That’s 22 weeks. A baby is considered full term if over 35 weeks. A non viable fetus is less than 20 weeks. 22 weeks is no mans land. 22 weeks is premature. 22 weeks is bad. If born, the baby could live, but at 22 weeks there will be complications. We are talking neonatal breathing machines, umbilical IV lines and feeding tubes.

This girl is 19 years old, this is her first pregnancy, she has had no prenatal care. To make things even better she is stick skinny. By that I mean she has a very small pelvis. In Alabama there is a thing referred to as birthing hips. Good birthing hips are wide and the misses can spread her legs far apart creating a wide opening. I’ve seen good birthing hips that you could pass Volkswagen through. Bad birthing hips are small framed girls, tight pelvis and it’s even worse if it’s your first pregnancy. Bad birthing hips define this young mother.

So the first step is to see where we are. I slip on a glove, add a little KY jelly and insert my fingers into the vagina hoping to feel a closed cervix. What I actually feel is a baby’s head. The nurses are staring at me in anticipation waiting on the news....... "We are going to have a baby here." is my response. "Oh sh*#!" is the general refrain.

Accounts of what happened next differ, but this is how I remember it….

The nurses generally begin to panic. There is confusion. Some of the staff are yelling, some are starting to cry, a few passed out and one or two are on their knees praying. This is a scary situation, they need leadership, they need a hero.

So I stand tall and brave between this young girl’s thighs. I take both my hands to my v-neck collar of my scrub shirt and rip it down the middle exposing my pectoralis muscles and 6 pack abdomen just beginning to glisten with sweat. I run my fingers through my perfect hair and raise my hands to shoulder height. "Gloves!" I call, and gloves are placed onto my steady hands. "Gown!" I call and I am draped like a priest giving his most holy service. In a calm, confident tone I look at the charge nurse, "Get me the delivery tray, I am going to usher in the miracle of life."

My young assistant doctor is panicking. "Excuse me Doctor Gibson, but her pelvis is too small! You will never get the baby out! No doctor in his right mind would even try this! What are we going to do?" I have no choice but to slap her firmly across the face. "Dr. Barnett, remain calm. I am no ordinary doctor." Ashamed that she has lost her composure, she quietly gathers herself.

I insert my index fingers into each side of patient’s vagina around the child’s head. I begin to stretch the vagina open with all the strength in my fingers. An IV has been started but I can’t give any pain medications. Narcotics in a preterm delivery could depress the child’s respirations. Mom is going to go naturally. Mom is pushing and screaming. I am stretching, a ER tech in the back of the room just vomited. The contraction subsides.

The baby’s head is facing the wrong direction. Meaning its nose is facing up. Usually babies come out with the nose facing the floor. Ideally I would like to try to rotate the baby but there is no time and the child is lodged into position. Another hurdle I must overcome.

This is getting bloody. I call for suction. I continue to stretch. I can see the head well now. If the baby gets stuck, I am going to have to start cutting. I must stretch, she must push hard!

At the crescendo of the 5th contraction the baby’s head pops out. One more good stretch and I reach my fingers under the child's armpit, rotate the body and with one more push the baby is out.

"Clamps" I state commandingly.

"Scissors!" The child is now free.

I am now holding the child across my right forearm and tap it on the bottom. The room is filled with silent awe.

The next sound we hear are the eeking of a newborn’s cry.

Elation fills the room. Tears of fear have turned into tears of joy. Nurses and complete strangers are hugging, music is in the air and as I listen closely, I can hear the sounds of angels singing.

View from the Other Side

I have a work routine. I dress in scrubs, sometimes a white coat. I talk with patients, extract their symptoms, do an exam and formulate a problem list. This is usually followed by ordering some labs, sometimes X-rays, and starting treatment. I chat with friends. I have my perspective, this is my side and that’s where I live.

I have never been a patient. I’ve never been on the other side. Until recently....

I was visiting my parents in Birmingham and we were having a "fun day". We ate greasy hamburgers for lunch, had afternoon coffee and met my sister and her family for some spicy Chinese food. Fun enough?

In the past few years I have had some stomach problems, initially self diagnosed as indigestion, later as gastritis and finally an ulcer. The cause of my stomach problem is all on me. Fast food is often my best option and I have a daily habit of a 6 pack of diet coke. Not to mention my job can be a little unnerving at times.

So on February 6th I woke up at two in the morning in excruciating pain. I basically felt like I had been stabbed in the stomach and someone was twisting the blade. I drank a half bottle of pepto, no luck. I took a Prilosec, no help. I drank milk. I drank water. I tried to make myself puke. Nothing helped and my pain was only getting worse. Changs sweet and spicy chicken is having its revenge. Damn the Asians!

It’s funny (not gay), when you are at your weakest moments, how your imagination can run away with you. Is it my stomach? It's never been this bad. Could be gall bladder. Could be a kidney stone. Probably not appendix, but could be. This is killing me. Could I have a gall stone lodged in my common bile duct? Possible. Could I be developing pancreatitis? That's really pain full and this is really pain full. That could mean surgery. Could I have a perforated ulcer? This is actually my worst fear. That's definitely surgery. This is not going well.

So I come to the first decision every person on the other side (the patient) makes. They decide to come to the hospital. This was not as easy as I thought.

It's the middle of the night. I'm not at home. I am about to ask my 74 year old mother to drive me to the ER. I'm in agony. This completely sucks. After 30 more minutes of anguish I decide there is no other option.

I have one friend who practices in Birmingham. I call and of course she is not on shift. At this point is doesn't matter. If I am leaking my stomach contents into my peritoneum there is only one place I'm going in Birmingham: UAB.

I arrive and am quickly triaged. I go straight back. (Usually not a good sign). I meet Dr. Buckman. He is about my age. He knows I am a fellow pit doc (that's slang for ER doc. If you really want to be in the know refer to the ER as "the pit". Usually because the ER is always located on the bottom floor of the hospital but also considered by many as a place of primordial ooze that some of the most basic forms of life miraculously survive. Anyway, it is 4am now and Buckman looks a little tired. I give him a succinct story about my symptoms but leave out my list of possible diagnoses. That's his job. I should stay out of the way.

He examines me and says "I think you've got a perforated ulcer". Oh great! This Buckman is a real wordsmith. So much for sugar coating.

That means major surgery. I'm 300 miles from home. I've got obligations this weekend and I'm back on schedule in the ER starting Monday. I am not prepared for this and my entire career is based on being prepared for an emergency. It's just not a good time.

Buckman plays his trump card, "Well, if you've got it, there are no other options."

I know he's right. There is an unintended psychological warfare going on in the hospital. I am in severe pain. I have on a hospital gown and a pair of boxers. One person walked in while I was changing and I'm pretty sure at least 3 people saw me naked. But since I've got this burning fire poker in my belly, I could hardly give a care. I'm pale and feel lousy. I don't know any one's name. Someone whom I have never met and who has never met me could be opening my abdominal cavity in the next few hours. I am at their mercy. I feel helpless.

So to make a long story short, I ultimately did not have a perforated ulcer, just an ulcer. I got outstanding treatment and was discharged in a much improved condition.

As for my treating physician, Dr. Buckman was a flat out stud. I knew he was concerned. Not by what he said but by what he did. He showed up in X-ray after I had my films done. Later I saw him again in the CT scan control booth looking at my images as they were being developed. He didn't have to do that, but he knew that something could be bad and he didn't sit around and wait on the answers to come to him. He actively sought them out. It's those kind of actions that separate the great from the good.

Barbara, my nurse, was fantastic. Like all great ER nurses she has the most face to face time with the patient. She started an IV, was quick with the meds and double checked the doses at the bedside in my clear sight. I only got a small dose of pain medicine (my request) but she hooked me up to the monitor just to be safe. I (and she) knew that probably wasn't necessary but still it was comforting. She wasn't taking any chances and I really appreciated that. I joked with her and she joked back. I was facing a crisis but I was confident she knew my case and was looking out for me. She was a pro.

There is a thing called "The Patients Bill of Rights". As a physician, I have always rolled my eyes at this idea, thinking what is the point? I am on the patients side. I want to get the diagnosis right. I want them to get the right treatment. But now I know the Patients Bill of Rights is not about me, it's about the patients' trust.

So I have written the ER Patients Bill of Rights:
1. The Patient has the right to be afraid. We know that you don't know us and that is naturally frightening in this critical time.
2. The Patient has the right to be believed. I will believe you are sick.
3. The Patient must know that the doctors and nurses are asking them for their trust.
4. The Patient must trust that I will do the best for you to come up with the right diagnosis. Not of of fear of being sued, but because I want you to get better.
5. We (including you) are part of a team. We must all work together and do our best to solve this problem.

*This Bill of Rights may not apply to everyone. If you come in weekly and have cried wolf too many times, you have betrayed our trust. And this is a two way street.

So what have I learned from being on the other side?
It's miserable. But when it's miserable I want to be the kind of doctor that (and I can't believe I'm saying this) is a comforter. It's not just getting the diagnosis and providing treatment. It's about reaching out and really helping someone in a time of need.