Wednesday, June 15, 2016

Three Words: Rode the Bed

This post conforms to the blog rules.There's been a paucity of stuff on the blog lately because it's suddenly really tiring to blog. After the huge burst of energy that rose up in answer to the challenges of intern year, I am at an emotional, cerebral, and spiritual low tide.

But these human tides are a natural phenomenon, so this is no surprise. In the mean time, I might do some more simple blogging. Today, I'll tell you a cool story that will take no research or soul-searching. This blog was originally designed to be a story repository so that I could write a book like Danielle Ofri or Perri Klass. So here's a story.

I was in triage seeing a patient with a hypertensive disorder of pregnancy. I had some questions about her management and my chief agreed, so she came over to talk with the patient about management options. I went to the next bay to see the next patient. She was a slender woman in her late second trimester, but there wasn't much time to smile and get to know her. She was obviously in pain: she moved around the bed holding her stomach. As I introduced myself I reached for her abdomen. It was taut, like a basketball.
This shows a single loop of prolapsed cord.
My patient had a whole bunch of loops and a four centimeter cervix

She was in so much pain that I left the room and came back with an ultrasound, immediately concerned for abruption. I scanned her quickly: no abruption that I could see, but her cervix was definitely open. And there was definitely a loop of the umbilical cord going through it. I used color to highlight the cord in the cervix. (The picture on the right.)

That is a very bad situation. Luckily, my chief was closer than she'd ever been all week: right next door. (Typically, she'd be over in L&D, which is a minimum ten-second walk if you go briskly.)

Not bothering to walk out of my patient's room and knock next door, I called my chief while setting up sterile gloves and a speculum. "Gina," I said, "I have a cord next door."

This is a funic presentation. The essential difference is that cord is
not through the cervix outside of the amniotic sac.

"A cord" is a euphemism for "a prolapsed cord," which is an obstetrical emergency. My chief immediately stopped her conversation with the hypertensive patient and she was in the room the next minute. She repeated my scan. "Spec her," my chief said, "it could be a funic presentation."

My very ginger pelvic exam revealed naked loops of cord outside of the cervix. I angled the speculum towards Gina. "Elevate the presenting part," my chief said gravely. "We're going to the back."

A little background: when the cord falls out of the uterus first, the baby can asphyxiate. So, we push up the presenting part of the baby (i.e. the head if the head is down) to take pressure off the cord. Then, the person pushing up rides the bed with the patient as we go back for a C-section, which is the only way to deliver the baby without impinging on the cord in the vagina. Interestingly, my chief and I had just gone over management of obstetric emergencies like this the day before. It was all very academic and educational then; now, it was very real.

This patient was still on a triage cot. In a single motion. I raised the foot of the bed and knelt on it, my hand still elevating the fetal head. The nurse was meanwhile unplugging everything from the triage bay walls: the fetal monitor, the O2 saturation monitor, and the tocometer. She flipped the brake and the cot slowly began to roll down the hall to the operating room.

We picked up quite a speed as we approached the 90-degree turn into the OR hall. I almost fell off the cot! (Thank goodness for side-rails.) As we rolled into the OR, someone put a hat on me and stuffed a mask into my free hand. I knelt on the floor next to the OR table and continued to elevate the presenting part as the patient was placed on the OR table, as a foley catheter was placed (yes), and as general anesthesia was induced.

"Can you feel pulsations in that cord?" asked my chief.

"All I feel is her shaking right now," I shouted from underneath the drape. The patient was shaking from her general anesthesia.

"Skin!" I heard from above me. That's the signal that a C-section is starting: the surgeon calls "skin" and "uterus" so that the nurse can chart time to delivery. Within a few seconds, I felt the pressure of the baby's head disappear. "You can come out now," called my second year.

I extracted myself from underneath the drape. I discovered that someone had attempted to put shoe covers over my clogs while I was genuflecting on the floor. I fixed them awkwardly as I walked over to a computer to put in orders for a PCA for after the general anesthesia wore off.

To ride the bed is an adventure in residency, a tale you tell to lower levels like a grandfather's fishing story. And I got to do it as an intern!

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