This is from the sixteenth chapter from my best-selling book, Bryson City Tales. I hope that you’ll enjoy going back to Bryson City with me each week, and that if you do, you’ll be sure to invite your friends and family to join us.
THE EPIPHANY (PART 1)
One day during morning rounds the call came over the hospital intercom. “Dr. Larimore, stat to the ER.” I was in the EKG reading room, on the other end from the ER. I quickly ran the couple of hundred feet.
The patient appeared whiter than the sheets on which she lay, and she was gasping for breath with very rapid, shallow breaths. Even more ominous was a rapidly expanding pool of bright-red blood on the floor under her gurney—at least four or five feet in diameter. Worse yet, there were several waterfalls of blood actively dripping from the edge of the sheet covering the patient.
“Dr. Larimore, get over here!” Louise shouted. “She’s hemorrhaging from the vagina.” I ran over as Louise continued her history. “She had a positive pregnancy test last week, and her last period was about three or four months ago,” yelled the ER nurse, who was cutting off the woman’s clothes, while Betty, the lab director, was starting an IV and drawing blood for lab samples. Nancy Cunningham had run in to help us and was starting oxygen.
“Let’s set up for an exam, now!” I ordered. “Louise, get the Gyn tray!” In moments the stirrups were set up and the patient pulled down to the end of the bed, flat on her back, legs spread— we call it the dorsal lithotomy position. I quickly gloved and turned my attention to the woman’s perineum, which had blood coming from the vagina at a remarkable pace. “What’s your name?” I asked her. She didn’t answer but just stared at the ceil- ing. We were losing her.
Louise, who knew everyone in town, filled in some of the details. “Her name’s Doreen, she’s eighteen, been married about six months. Just out of Swain High last May. Works down at the plant.”
“Doreen, I’m going to do a quick exam. I’ll be as gentle as I can. I suspect you’re losing your baby. We’ll do everything we can to help you.” In my heart I was thinking, I don’t want to lose you, Doreen. Fight for me. Lord, I prayed, help Doreen. Help me!
I went to work, quickly inserting a sterile speculum, and dis- covered what I was expecting to discover. Doreen’s cervix, the opening to her womb, was about three-quarters of an inch dilated, and hung up in it was a dark clot of material—what medical professionals usually called “the products of concep- tion,” what I called a preborn child who was miscarrying. Around the tiny baby and placenta the uterus was hemorrhaging—and hemorrhaging big-time. The cure would be to remove the little body and placenta as quickly as possible.
“Ring forceps!” I asked Louise for an instrument I could use to gently extract the fragile mass. It came out intact and I exam- ined it. All I could see was the placenta. This was not unusual, as the tiny preborn child could often pass without being noticed—or sometimes could be absorbed by the womb before the miscarriage.
“Nancy, let’s give five units of Pitocin IM and add twenty units to the fullest IV bag and slow the flow of that bag to 125 cc’s per hour.” The Pitocin, normally used to induce labor, would hopefully stimulate the uterus to contract, and the contraction of the muscles should then slow or even stop the bleeding.
“Walt,” Betty said, “I’ll run the usual labs and get some blood set up. Looks like you’ll need it.”
“Thanks, Betty,” I called out as she headed toward the lab.
I placed the mass in a formaldehyde container that Louise had opened. Then I quickly removed the speculum. Louise was work- ing in tandem with me as though we had done this many times together. Obviously, for once I was doing what the older physicians would have done in the same circumstances. It felt good.
Louise squeezed some sterile K-Y Jelly onto my outstretched fingers. “Doreen, we’ve gotten the miscarriage out safely. Now I need to examine you on the inside. Can you take some deep breaths?” She still seemed dazed and incommunicado but did begin to breathe deeply. I did a rapid manual exam. I could feel no other products inside the uterus. Then with my inside fingers I lifted the uterus up toward the abdominal wall. With my outside fingers, I began to push and massage. “Doreen, this may be uncomfortable, but it will help the Pitocin stop the bleeding. Can you bear with me a moment?” She nodded. As I massaged the uterus I could feel it shrinking and hardening. Thank you, Lord, I prayed.
Nancy asked, “How about a second line?”
“Great idea. Will do. It needs to be a large bore needle and normal saline. We’ll use that line to transfuse her.”
“Done.” Nancy had the IV inserted in seconds. This nurse was good, real good!
The uterus was continuing to contract, and very little blood was now flowing. “Vaginal pack,” I said.
“Yes, sir,” responded Louise. She turned to get one from a nearby cabinet. I slowly inserted the pack, which is a roll of nar- row sterile gauze. Whew, I thought to myself, I think we’re going to make it!
“Good job, Dr. Larimore,” Louise whispered. She fairly glowed.
“Hematocrit is ten,” announced Betty as she rushed back into the emergency room. “Blood is O negative. I’m cross match- ing for six units.”
Each transfusion of packed red blood cells would increase Doreen’s hematocrit by about three points. A hematocrit of forty would be normal, but if we could transfuse her to twenty-five or thirty, she could build her blood count from there just by taking some oral iron.
“Betty, bet we won’t need more than four or five units, but let’s do get started as soon as the units are ready.”
“Yes, sir,” she said, and headed back to the lab.
I took off my gloves and went to stand at Doreen’s side. I took her hand in mine. “You OK?”
She turned her head away, tears now flowing freely. She shook her head no.
“Are you having any pain?”
“It just feels like menstrual cramps.”
“Doreen, I’m sorry we had to work so quickly. But we had to stop the bleeding. I’m expecting you to make a full recovery, but we’ll need to give you some blood to replace all that you’ve lost. I’m hoping you’ll be abl e to go home in a day or two.”
(TO BE CONTINUED NEXT FRIDAY)
- The Murder (Part 1); (Part 2); (Part 3)
- The Arrival (Part 1); (Part 2)
- The Hemlock Inn (Part 1); (Part 2)
- The Grand Tour (Part 1); (Part 2)
- The Interview (Part 1); (Part 2); (Part 3)
- Settling In (Part 1); (Part 2)
- First-Day Jitters (Part 1); (Part 2)
- Emergency (Part 1); (Part 2)
- The Delivery (Part 1); (Part 2)
- The “Expert” (Part 1); (Part 2)
- The Trial (Part 1); (Part 2)
- Shiitake Sam (Part 1); (Part 2)
- Wet Behind the Ears (Part 1); (Part 2); (Part 3)
- Lessons in Daily Practice (Part 1) — Anal Angina; (Part 2); (Part 3); (Part 4)
- White Lies
- The Epiphany (Part 1)
© Copyright Walter L. Larimore, M.D. 2016. This blog provides a wide variety of general health information only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment from your regular physician. If you are concerned about your health, take what you learn from this blog and meet with your personal doctor to discuss your concerns.