While You Were Sleeping

While You Were Sleeping
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"Hi, Ms. Silverstein, I'm Dr. Herlihy. It's nice to meet you. I'm the chief resident on the floor tonight, and I'll be back to check on you early tomorrow morning." Ms. Silverstein is 33 weeks pregnant with preeclampsia, a disorder of high blood pressure in pregnancy, and she has been staying in the hospital for the past week. I introduce myself quickly, note that her pressure is comfortably 120/80, and wish her a good night. Tonight is my first night on call as a third-year resident and my first time running the labor floor. Ms. Silverstein’s nurse approaches me as I step out the door and confirms the timing and dose of her blood pressure medication. I ask for a set of labs to be drawn at midnight to assess her liver and kidney function and go in search of the intern.

My intern has been a doctor for only four days, and it's my responsibility to teach her. Thus far, I've shown her where the bathroom is and taught her how to order food delivery. The whiteboard that tracks the location and progress of each patient is full – a collage of letters and numbers in blue and black ink quickly summarizes the state of the floor. There are two patients waiting to go to the operating room for cesarean delivery, three waiting to be evaluated in triage, and six scheduled for labor induction throughout the night. A large TV screen displays the electronic fetal monitoring or "tracings" for each patient, which allows us to continuously monitor babies’ heart rates and mothers’ contraction patterns during labor. The blue and yellow lines marching across the screen indicate that the woman in the third bed may be in active labor, and I send one of our senior physician’s assistants to assess her quickly while I go to evaluate a woman in her second trimester.

I draw back the curtain, and I'm relieved to see a young girl lying in bed comfortably, playing on her phone. "As a rule, anyone who is texting is unlikely to be in labor," I whisper to my intern. Her cervical exam confirms she has not yet started dilating. We cover her abdomen in blue gel to perform an ultrasound, and just as we identify the baby's head, the head nurse sends out a floor-wide broadcast asking for an open operating room. Simultaneously, the hands-free phone dangling from my lanyard rings and I hear, "Dr. Herlihy, we need you in room 38!" I rush out, leaving the intern to finish the ultrasound, and pass two paramedics wheeling a woman strapped to a stretcher.

In room 38, a woman is in active labor and the baby’s heart rate is dropping precipitously. I quickly check her cervix to assess for rapid progress of labor, one of the potential causes of decreasing fetal heart rate, and find her cervix is eight centimeters dilated; she will soon be ready to deliver. Her nurse places an oxygen mask on her face and turns her on her side to improve blood flow and oxygen delivery to the baby. The room is momentarily frozen, all eyes on the fetal monitor, until slowly the heart beat quickens and returns to the familiar gallop associated with healthy labor. I reassure a worried soon-to-be father that this is a regular occurrence as I slide out the door to attend to the next patient.

The woman on the stretcher has never been seen in our clinic before and speaks only Arabic. Background music of the interpreter service phone line dances in my ears as I try to assess why she arrived by ambulance. At last, a woman answers and introduces herself, then asks my trembling patient why she is at the hospital.

“I broke my water, and I’m feeling pain,” the interpreter translates, and I smile with relief. “Excellent, how many children have you had?” I inquire, as I reach for the admission forms. “Four C-sections.”

My smile tightens as I face the prospect of doing a fifth C-section at 1 o’clock in the morning. With each C-section, scar tissue inside the abdomen builds and welds organs to one another in an unruly jumble. We roll her to the operating room and seat her on the table for the anesthesiologist. I stand in front to brace her against the pressure of the spinal needle, and her cherry red finger nails dig into my arms. Her forehead against mine, we take a collective breath and find a moment of calm amidst the orchestra of machines beeping, instruments clanging, and footsteps echoing on the hard, sterile floor. Her operation is uncomplicated, and I silently thank the labor floor gods and her previous surgeon as we close her skin.

Six patients scheduled for induction roll in one by one, and we “admit and pit” them – a cheeky expression for using the medication Pitocin to initiate contractions. I’m halfway through my last, “Welcome to Mount Sinai,” speech when interrupted by an ear-piercing scream from down the hall. The door flies open, and my intern’s eyes are wide in excitement. I excuse myself and together we trot down the hall as she relays that a patient, Mrs. Sanchez, just came in fully dilated and ready to deliver.

“Have you done a delivery yet?” I stop in front of our new guest’s door.

“No.”

“Perfect.”

Mrs. Sanchez is moaning in distress as her nurse hurries to place an IV. I confirm that the baby’s head is low, and it’s time to start pushing.

“Okay, here’s what I need you to do. With the next contraction, I want you to take a big breath, and then hold it for ten seconds while you push down with all your effort.”

Mrs. Sanchez pushes, and we all cheer as I guide my intern’s hands to gently control the baby’s arrival into the world. Her face beams with joy, and I can tell that her frustration with the steep learning curve has been replaced with a feeling of accomplishment. As we wrap up, George Harrison announces, “Here comes the sun,” from the alarm on my cell phone, and I’m startled to realize that it’s already six thirty. With 10 patients to see before the 7 a.m. shift change, I sprint up the stairs two at a time to the fifth floor and work my way down. The clock reads 6:59, and Ms. Silverstein, my patient with preeclampsia, is just waking up as I tiptoe into her room. Her blood pressure cuff inflates and reads a steady 117/76.

“How are you this morning?” I ask, glancing sideways at my bloodshot eyes, wrinkled scrubs, and disheveled hair in the mirror.

“I feel good,” she responds, “How are you?”

“Never better.”

Note: Patient names have been changed to protect their privacy.

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