“Get me some blood. What the hell is taking so long?” I could hear the anesthesiologist from behind the drape. Then he started to mumble. It is rare that an obstetrical patient hemorrhages to the point of requiring surgery. The nurse caught the brunt of anger and frustration. “If you have to run over to the blood bank and get type-specific blood or universal donor units, do it now,” I said. She left in a hurry. I wasn’t sure if she heard me or just wanted out.
I blamed myself. I had made vacation plans. Not because I wanted to take time off, but because a nurse had shown me a cancer kid’s crayon drawing. She said, “See that little blue car down there at the bottom of the hospital the child drew? That’s your car. I asked the little girl about it and she said that car is always there. It’s part of the hospital so I had to put it in my picture.” The nurse, a patient of mine, leaned in close. “It is time to take a break.”
I went home and told my wife about the artwork. “You’ll listen to a nurse but not your wife. Is that it?” she said. The nurses called all night long; she hadn’t signed up for this, and it was getting old.
I wanted something timeless, classic. I had heard about the Grand Hotel on Mackinac Island in the Great Lakes. I have always been taken with islands and old hotels. I wanted a remote but well-appointed retreat. The restored hotel had a 660-foot long porch that looked over the water. There was horseback riding and formal hackney carriage rides. In fact, there are as many horses as permanent residents on the island.
I reviewed the menus of planned activities, spa treatments, dining, and evening activities. I thought I might like to hike along ancient remains of limestone formations carved out following the ice age.
But it was the evening concerts that caught my attention. I had been brought up in a musical family. All ten children learned to play two instruments and sing well. Each evening we played and sang together, and my father had instructed us on the fine art of musical conducting. As a family we vacationed at Chautauqua, some of us taking piano and organ workshops, and all of us enjoying the evening musical schedule.
The evening performances by the Grand Hotel Orchestra sounded like home. The hotel seemed to have a sense of discipline, an itinerary attractive to those whose heads demanded more than soft pillows. It sounded perfect. When I made reservations, I upgraded to a suite with a view of the lake, where I could drink my morning coffee and read the paper in the sitting room while taking care not to disturb my wife as she slept.
I planned the weekend long enough in advance so I could “clear the decks” as my father used to say before he left his practice and took us on vacation. Still with two days to go there was one patient left undelivered. I brought her in and offered induction.
The labor started off well enough. She made slow progress, but I was patient.
Labor progresses along a schema called Freidman’s Curve, a diagram of “normal” labor that was created by tracking thousands of deliveries. The curve is an average, and if one of my patients labors too fast or slow I remember that it is simply a norm. But then the labor suffered prolonged second stage. When a patient pushes for more than two hours the doctor must consider the three Ps—passenger, passage, power. I felt the baby was not too big and the pelvis adequate but worried about the power. After passing the two-hour standard, I offered vacuum extraction.
In lay language this means applying a suction cup, which looks like a small bathroom plunger, to the baby’s head and assisting the delivery by guiding the normal descent of the presenting vertex. The baby delivered. His parents were happy to see him. I stood at the bottom of the bed. After twenty minutes the placenta slowly delivered. It appeared torn but intact. I repaired the mother’s perineum as she bonded with the baby.
She did not stop bleeding. I inspected her for lacerations. I found no defects.
I gave Methergine and Pitocin to help the uterus clamp down. The bleeding continued.
One of the critical complications of bleeding is disseminated intravascular coagulation. When blood has lost its ability to clot, the patient continues to bleed until she dies or the factors responsible for forming clots are replaced. I sent off all the labs. The patient continued to bleed.
I questioned myself, maybe if I hadn’t offered induction this would not have happened. I wondered if a sonogram had missed a placental or uterine anomaly. Maybe the patient had an underlying blood disorder not yet diagnosed.
There was nothing left but to take her to the O.R., check the vagina again and if nothing was apparent, do a D & C for any placental remnant. If the patient continued to bleed the only procedure left is hysterectomy.
My patient was alert and fully aware. “Do what you need to do,” she said.
What else could she say, I thought. I had been fortunate up to this point—after many years of practice, all my patients were still alive. I had handled pregnancies complicated by cervical cancer, breast cancer, severe preeclampsia, status asthmatics, pulmonary emboli, Addison’s disease, melanoma, ovarian torsion, and a long list of other illnesses. I had performed c/sections in the E.R. following motor vehicle accidents. But I had never lost a patient. The thought had not yet crossed my mind that this could be the one.
In the O.R., I placed her in stirrups and inspected the vagina once again. After performing curettage, I found scant placental tissue. I saw no source of bleeding. We brought her legs down and told her she would have to have an exploratory surgery and a possible hysterectomy. The anesthesiologist put her to sleep. I asked another attending to help me. I wanted experience standing across from me; this was not a resident learning experience.
We opened her up and mobilized her uterus out of the pelvis. It looked as though she had a placenta accreta, a condition where the placental trophoblasts invade the wall of the uterus and extend to the outer surface. Large areas consistent with placental vessels could be seen. The only treatment was hysterectomy.
In an attempt to make me feel better my assistant said, “You would have ended up here no matter what. She needed this hysterectomy.” We proceeded and in a few minutes had stopped the source of bleeding, but by that time the patient’s circulatory system had lost its clotting function.
She bled from everywhere. We packed the pedicles of vessels and ordered blood and blood factors that would restore the patient’s vascular system. The cascade of intravascular coagulation was a diagram I had memorized in medical school and residency. It was not an algorithm now.
I wondered if they served high tea on the porch of The Grand Hotel. Maybe there would be poetry readings before dinner. Without invitation the questions crossed my mind.
I asked the nurse to take the patient’s husband to a room where I could explain her condition. I broke scrub. When a major complication occurs and untoward results are feared, a hospital administrator is called in to protect the hospital’s interest. I know and they know their job is to prepare the family for the worst. She met me at the doors to the O.R. I followed her to the VIP Perry Suite; a room that I had not known existed. All my patients were important, and I never asked for special consideration.
I was led down the hall and entered the room. I saw the husband surrounded by a well-known preacher and what appeared to be family friends. I was surprised that they were from the church my wife belonged to, one I rarely attended. The pastor had established free clinics for the working poor, and I admired his work. I could not believe that these men had time to put on church clothes, white shirts and ties, and get here is such short order. They must have been Saint Luke Deacons. I wondered if they had any idea. I told them we were fighting to save her, but we were not making progress. The minister spoke: “I know you are doing everything you can.” I headed back, scrubbed, and gowned again.
White shirts and ties would not meet the evening dress code for the formal dining room at the hotel. My navy suit and regimental silk tie were already packed.
Blood was being pumped into her body. Swollen from the fluids, her face broken only by the slits of her eyes and the tube in her mouth, I wondered if I was operating on a dead woman. She had taken on the look of a drowning victim full of fluid but no air.
It was early morning. My wife knew something was wrong. She packed the bags into the car and had my son drive her to the hospital in case I could break away at the last minute. She parked in a spot she knew from letting me off when dinners were broken. She didn’t like the dark place even though it was a large hospital campus. She didn’t feel safe there, but my son was with her, so she waited.
The bleeding slowed with the proper replacement transfusions. We closed the patient and wheeled her to the post-op critical care area. But I couldn’t go, couldn’t leave now. I walked down to the car. I told my wife what had kept me. “I can’t leave her like this” I said.
She looked at me. She must have seen something she hadn’t seen before. “I understand,” she said. “Come home when you can.”
I got out of the car and watched her drive away.
Thomas Gibbs most recent essay, Besame Mucho, is a finalist for the Editor’s Award at The Florida Review. His Gettysburg Review essay, “Moved On” was a notable in the 2012 Best American Essays. His work appears in The Kenyon Review Online, Brevity, Dos Passos Review, The Healing Muse, Hospital Drive, Blood and Thunder; Musing on the Art of Medicine, and The Yale Journal for Humanities in Medicine. He has been anthologized by Lee Gutkind in Becoming a Doctor, and The Great Lakes Commonwealth of Letters. He was the 2013 fellow in nonfiction at The Gettysburg Review Conference for Writers. He practices Ob-Gyn in Florida.
Just beautiful – the way you capture the feeling of wanting to be away, but how much this is part of you, is just incredible.
This is a beast of an essay. As a survivor of placenta accreta, I appreciate your gift of showing us, the readers, just enough and not one letter more. Thank you for choosing to write.
Sharon, Thank you. Please write your narrative. You will find the words.
Life and Death in an instance. we take it for granted too often in this field of medicine. This is a well written essay by a caring and accomplished doctor. I really hope you get to Macinac Island!
I enjoyed reading this very much. As an OB nurse with 20years experience, I know how things can sometimes go very wrong. Thank you for sharing your perspective and I hope you eventually made it to the island.
Thank you for reading this work. You know it in one form or another. I travel to the island often, in my mind.
Thomas, this is such a haunting story, and a valued insight into this day in your life (representing, as you tell us, so many, many others). Thank you for sharing it with us.
Thank you for reading the essay and blogging your thoughts.
After a difficult delivery of my first son, I remember overhearing a doctor in the NICU saying how they were continually amazed at how many babies and mothers actually survive childbirth. This essay brought that memory blazing forth once again, even though it is a decade later. Full of tension, tinged with sadness, taut and leaving me with wanting to know what happened–not only with the patient, but with your wife as well. Congratulations.
The patient lived. She makes a donation in my name to the hospital every year. Her son is a pre-med student at Tulane. I am still married-forty seven years. I found out that this is a long time when at my niece’s wedding we were the last couple dancing as the years were called out.