Nearly Bleeding to Death From a Cesarean Section

There was a woman who had to be in ICU after a c-section. On her maternity floor she was eventually found unresponsive with a soaking wet abdominal dressing. She was given O2 by facemask and her hemoglobin level was around 4 (this is 1/3 normal). She was brought back to consciousness and emergently taken to the OR for exploration and a possible hysterectomy. No obvious bleeding was seen, but something like 4 liters of blood were sucked out of her abdominal cavity. It was probably a slow intra-abdominal bleed, following a path of least resistance out of the uterine incision instead of out her vagina. She was given something like 5 units of blood and 10,000 ml (!!!) of IV fluids in the OR. That's more than five 2 liter bottles in one sitting. I've never heard of that much being given in my life.

She spent the next day in the ICU in critical condition. Four units of blood the next day along with multiple blood products (platelets, plasma, etc) to recover her clotting ability. The way her labs were trending, she was entering a condition called DIC (disseminated intravascular coagulopathy) where her body uses up so many factors involved in clotting that she would start to bleed spontaneously from all sorts of places—mouth, nose, eyes, ears, skin, and certainly her uterine incision. DIC is freaking scary. I know I'm new, but I've never seen anyone survive full-blown DIC. She really owes her life to the ICU nurse who aggressively blasted liters of blood products in a handful of hours. The same nurse also demanded that the interventional radiologists (guys who can use x-rays and guidewires to go into your blood vessels and fix them) see her that day, because after all those blood products her hemoglobin was still low. After their evaluation they went in and embolized (closed off, probably by electrocautery) her uterine artery.

The next day she was doing much better. Still in pain, but able to get up to the chair.

This is her first child, and she expressed the wish to keep her fertility if possible. I'm not sure what her stopping up her uterine artery means in terms of that, but it doesn't sound good.

Why did she have a C-section? It was a scheduled section for breech presentation. I'm not an OB, but I can't help feeling that a breech vaginal birth might have been safer for her. However, standard protocol now is to section all breech babies. I'm not sure what the reason is, or what study led to deciding that, but I've heard from midwives and frustrated OBs who wish to perform breeches but are not allowed to. It seems like even if breeches are dangerous, there's two problems with doing them on every mother. The first is that people have the impression that c-sections are minor surgical operations. They're not. A section is a major abdominal surgery with multiple risks. The second is the risks of a breech birth are against the baby (e.g. cord compression by the descending head); the risks of a section are against the baby and mother. So sectioning all breech babies presumes consent by all mothers to place themselves at higher risk to eliminate a possible risk to their baby. I don't know that this is a fair decision, and I don't think most mothers are informed that this is the choice they are being compelled by the healthcare industry to make.

The Nursing Birth blog just posted reasons why you might die in childbirth in the modern developed world. Hemorrhage related to obstetric procedures, such as caesarean section, causes 13.4% of maternal deaths.

Update: Since this writing, Canada's society of obstetricians decided to reverse their position on c-sections being the standard treatment for breech births, and set an initiative to teach new obstetricians to attend vaginal deliveries of breech babies. Read more in Give Breech a Chance: Canada Reverses C-Section Policy. One hopes their American counterpart will follow suit.

Other posts on c-section complications:
Breech Babies (patient scheduled for a section, baby turned, sectioned anyway)
Obstetrics: causing a problem and then fixing it

Image credit: The Cesarean Art collection was created by an artist (who wishes to remain anonymous) after a traumatic c-section. You can read this interview for more info. Used with permission.

Quantify Your Nursing Care!

Finger pricks
Photo by Bethany L King

I've done 627 blood sugar tests on patients in the last year.

Every year we get have to get certified in order to use the Accu-chek^tm blood sugar meters on patients. If we don't, then the bar code on our ID which we use to log in to the device expires. The test involves running one 'quality control' sample (a fake test with what amounts to fake blood), and then taking an online quiz. I realized if the online quiz server knows whether or not I ran the quality control, then IT KNOWS WHO I AM, and it probably knows other things about me—like how many accuchecks I've done. So I asked our resident Accu-chek guy if he could find out how many I've done. He told me to e-mail him a guess. Well, I figured I do an average of 3-4 a day (some days none, some days much more), times 3 days a week, times 52 weeks a year = 468 to 624 accuchecks. So I was off by 3, and now the Accu-chek dude wants me to pick his lotto numbers.

627 drops of blood squeezed out of fingers. Sounds like a lot, but when I worked it out that's only a little more than two tablespoons of blood.

This reminds me of the estimated statistic that nurses walk 4-5 miles during a 12-hour shift. (Some nurses with pedometers claim up to 10 miles a day.) But as healthcare becomes more computerized, there's a potential for lots more geeky computer records like these. Most hospitals have computer charting for medication records and for charging patients for particular items, so you could theoretically know how many pills you've passed, how many Foley catheters you've inserted, how many tubes of blood you've drawn, etc. Hospitals with 100% computer charting could take your 0-10 pain scales and give you a cumulative number of how much pain you've treated for all your patients, i.e. 795 on a scale of 0-1000. Or the sheer number of pages of discharge planning and documentation you've had to do, which would be a frightening number indeed. I'm not sure you could determine anything of value from these things, e.g. to improve quality of care. But it does seem meaningful in a small way. I've touched 600-something fingers (considering some are repeats), which is certainly a weird thing to think about. I'm kind of curious about how many patients I've restrained, and how many I've performed post-mortem care on. I interact with a large number of people in a large number of ways, and it is interesting to see it quantified.

Brain Death Part 3

The man I've been writing about (here and here) died. His bleed was on the right side of the brain, 8.3 cm from front to back. This shifted (herniated) the right side of the brain into the left, and also downwards onto the brainstem and cerebellum. The sulcae (the folds of the brain) were completely obliterated by the swelling. All of this swelling not only damages the neurons and organization of the brain, but also impedes bloodflow to the brain. They performed the apnea tests, where they take him off the ventilator, watch for respiratory movements, and analyze his blood gases. They also saw no cerebral bloodflow on CT. (You can read more about the criteria for brain death here.)

His sister was able to come in from the nursing home before they took him off the ventilator permanently. It appeared that she and her brothers were coping well. I'm glad, because I'm not sure how quickly they would be able to comprehend this sudden change in his status.

They also asked for a priest, which I wholeheartedly support...but it would've been nice for him to receive the Anointing of the Sick before he became brain dead for two days. I always say this: people should be calling a priest when they come in the ER, not when they're being taken off the ventilator. If you're being taken off a ventilator, your destination in the afterlife is probably already booked for you.

I'm finding it hard to explain brain death to people. I think it's hard to realize that you only need a two things to keep your heart going: respirations, and enough blood pressure to perfuse all your body organs, or at least your lungs and heart. He had his own beating heart, but the other two processes were being provided by us: the breathing (by the ventilator) and the blood pressure (by synthetic hormones that cause blood vessel constriction, like norepinephrine and vasopressin). Without these, his pressure was falling to below the levels needed to keep his heart alive, and could not breathe, so his heart would have quickly died too. The blood pressure support and the oxygenation are what let his heart keep beating. All of this can be accomplished more or less without a working brain. After all, the heart is more or less its own automatic pacemaker, and beats "spontaneously" given enough oxygen and the right mix of electrolytes (particularly sodium, potassium, and calcium). Allegedly you can remove heart tissue and it will still 'beat' or produce regular electrical activity.

I think this is the first true brain death case I've seen, where sudden destruction of the brain (massive hemorrhage and herniation, in this case) led to someone's death.

This more or less ended up being a three-part post:
Part 1: Never Say Your Family Is Crazy...
Part 2: My First Brain Death?

My First Brain Death?

The man I spoke about before, with the stroke and alcohol dementia, and the schizophrenic brother, is probably brain-dead. He was diagnosed with a massive brain bleed today on CT, and when neurosurgery came to evaluate him, they said severe brainstem injury is extremely likely. I did a quick little neuro eval for experience's sake. His pupils are fixed and constricted. He's negative for 'doll's eyes': if I grasp his forehead and rotate his head from side to side, his eyes remained fixed in the direction of his face, instead of moving to stabilize the image hitting the optic nerve. (The oculocephalic reflex detects head movement and tries to keep your eyes fixed on the image, rather than moving with your skull; this reflex works even when you're unconscious and, apparently, even in the dark.) And his corneal reflexes are absent—he didn't blink when I touched his eyes. It seems significant for some reason that I did this without gloves. I instinctively patted him on the head as a sort of apology for jerking his head around.

It's bizarre because if you look at him, he's still the same huge guy on a ventilator with multiple drips running. He's floppy when you move his arms and legs, but he was already somewhat floppy. His blood pressure took a dive during the night, necessitating pressure support, but that's the most detectable change from how he's been for weeks—that is, until you check neurological response, or lack thereof. It seems strange that he could have a massive brain bleed, and swelling and herniation of his brainstem, but from the outside his head and face look absolutely the same. The hard skull hides everything.

I don't know how his family will take this. I'm sure all they think is that he came in with a stroke and that he's sick, but I doubt they knew how grave his situation had become. His brother will probably think we murdered him.

The organ banking system was notified (as it must be, by law) to see if he's a candidate for donation, and ironically, despite being an alcoholic in renal failure who's been on a ventilator for weeks, he's initially eligible. I wish I was there tomorrow to see his apnea tests and whatever else they do to determine brain death. He might not be that eligible after they come to evaluate him, but there's still the tissue and eye folks I spoke about in a prior post. I don't know how all this will work with his family, however, considering the decision-maker is still in a nursing home and the no one is willing to let the visiting family members decide anything because of their mental statuses.

__
So this ended up being the middle of three posts about this man.
Part 1
Part 3

Eye Bankers

As I was shaving today, I felt like I was shaving off a layer of skin for a skin graft. This reminded me of when I saw a woman from the Illinois Eye Bank take corneas. The patient had just died in the ICU before my shift, so I took him down to the morgue. A woman my age dressed in business casual carrying a duffel bag was already there. She donned gloves, unzipped his bag, and with what looked like a normal pair of little scissors, snipped jaggedly around the cornea, including some of the sclera (the white). She dropped both into a little vial filled with preservative. She said they'll keep for about a year.

She's a tissue procurement specialist. She only does eyes, but people who work for the organ and tissue banking system can do any tissues. Managing an organ donation requires nurses and doctors, but procuring tissues is something anyone can technically do, since they are procured from cadavers. Skin, blood vessels, bones—she mentioned knowing someone who had removed an entire humerus. It's a messy job, she said, but a well-paying one. I think it would be fun and interesting, like playing surgeon. The only problem is it's one week on call, one week off; I can't do that while in nursing school.

I also think it's interesting that your cornea is made of cells. It seems like a clear covering over your pupil, but it's made of cells. When you see the world, you're looking through your own cells.

Never Say Your Family Is Crazy Unless You Really Mean It

We had an interesting case in the ICU. The man is 350 pounds. He was mugged and has a metal plate in his head, he is severely alcoholic, and he's had a stroke. Whenever he's been conscious over the last several weeks, he's been extremely confused and combative. He's been taken off the ventilator twice (during which he's combative again), and put back on. His respiratory status is crappy, probably from a knock-out combo of long-term confusion, sedation, pneumonia, obesity (obstructing the trachea), and probably alcohol dementia. He's going to need a tracheostomy. He'll also need a feeding tube put in to maintain his nutrition. But what happens to this patient in the long run? When we wake him up, is he going to fight with people forever? Where will he go?

He has some siblings. One is even taller and bigger than my patient. He has schizophrenia. He has an enormous fairy-tale beard. He shouts things randomly. He started exclaiming about peanuts one day. I passed by him and he shouted "did you see that ***king faggot!?!" at me, and then turned around, trundled off, and shouted the same thing at the wall. He curses randomly and calls the African-American nurses "monkeys". He jumps out of the room shouting that he heard people talking about him. Another brother, who always accompanies him, is shorter and walks with a cane. He had a stroke and has some difficulty talking and understanding things. He seems meekly aware of his mentally unstable brother, and mumbles things like "You're just hearing things," "They're just trying to take care of him," and "Don't get us kicked out of here again..."

These two drive themselves to and from the hospital, which somewhat boggles the mind.

They have a sister who takes care of them. She is considered the only legitimate decision-maker. But: she is now in a nursing home. The patient's doctor had a fun time trying to call her to do a phone-consent for the tracheostomy and g-tube.

I don't know where I'm going with this story. I guess some family situations are just startling. I really feel bad for them. I don't know what would correct it, though. Alcohol surely didn't help; being overweight surely didn't help; maybe they could've lived healthier and avoided the strokes; but you probably can't avoid the schizophrenia. Did any of them have children? Why are these four people wandering the earth, essentially on their own, in this state?

UPDATE: I posted twice more about this sad case:
Part 2: My First Brain Death?
Part 3

Pregnant Woman Alarms Fellow Restaurant-goers by Eating Sushi

It is a tradition in US culture to holler at pregnant women who eat seafood. But a while back Medscape sent this article to my inbox: Seafood Intake During Pregnancy May Benefit Neurodevelopment of Children (requires free user registration):

Compared with maternal seafood consumption of more than 340 g per week during pregnancy, seafood intake of less than 340 g per week was associated with an increased risk of the child being in the lowest quartile for verbal IQ...increased risk for suboptimum outcomes for prosocial behavior, fine motor, communication, and social development scores. For each outcome measure, the lower the intake of seafood during pregnancy, the risk was higher for suboptimal developmental outcome.
"We recorded no evidence to lend support to the warnings of the US advisory that pregnant women should limit their seafood consumption," the authors conclude. "By contrast, we noted that children of mothers who ate small amounts (less than 340 g per week) of seafood were more likely to have suboptimum neurodevelopmental outcomes than children of mothers who ate more seafood than the recommended amounts."

This is why I hate the new 'common knowledge' about pregnancy concerns. They're usually based on stupid studies or bad logic. Mercury may be a valid fear with some species of fish, or fish from some locales, but that's not the point. The point is that anyone who knows about a good, normal diet knows that fish is helpful to your constitution in ways that vegetables and land-animals and other good foods are not. So it's not that hard to think logically if someone says "Hey, that fish might have mercury poisoning from all our dumb pollution," and alter your diet accordingly. Right now you just have a bunch of people, from idiots in the grocery store to doctors, telling gestating women who eat chips and pop all day that they shouldn't eat very nutritious and important baby-developing foods.

When I wrote about this in my Livejournal, a reader pointed out to me that Junk Food Science wrote an article about pregnant women eating fish:

...the body of the highest-quality and most careful research has never shown that the amount of fish — and the amounts of methylmercury in the fish — eaten by American pregnant women and children put them or their babies at risk. And even among populations eating ten or more times the fish Americans eat, scientists have found no credible evidence of neurotoxicity...

So what gives? Litigation. If you were a doctor, what would you tell people about fish? If you're a good doctor, you'd probably err on the side of caution, telling patients to limit their intake. If you could lose your job every time someone asked you a question, you'd be cautious too. And if you're an unscrupulous or wimpy doctor, or you're the television news media, you'll have women throwing out their cans of tuna even while they're chugging diet soda.

Off the record, and this is not medical advice: my wife has eaten sushi while pregnant, and my children are geniuses.

Epidurals, Pit, and Sex in the Hospital

Today I saw an epidural insertion, which almost made me pass out. They use a four-inch-long fat needle which is curved at the end to aim the catheter up or down in the space outside the spinal cord. The anesthesiologist inserted the needle at least three inches in and wiggled and moved it around much more than I would've imagined possible, trying to find the epidural space. Meanwhile blood is dripping out the hole. She said she aims it up (toward the head) in first time mothers because she figures labor will be long, and aims it down (toward the butt) in multiparous moms because she figures labor will be short but more intense. She used the 'lack of resistance' to check the placement - she kept trying to inject air through the catheter until she was able to do so, at which point she knew she was there. It seemed like 10 cc or so of air - I wonder what happens to it?

The mom was so passive about the epidural in general. She didn't really want it, and later said she wasn't sure if she wanted it or not, and seemed really reserved. The nurses assumed she would get it eventually. In fact, it mostly happened because the oncoming day-shift anesthesiologist wanted to have the the night anesthesiologist do it, who was apparently sleeping in a room on the floor. So they kinda concocted the idea that the nurse would tell the patient she'd have the night doc "talk to her", and then page him to wake him up. The day doctor decided she'd do it after all, though, so they just kinda started doing it. I'm not saying it wasn't consent, and I'm not saying things like this don't happen all the time in the whole hospital, but it wasn't exactly informed consent. Then after the catheter was put in, the nurse informed her that she'd have to put a urine catheter in. I think I'd want to know that beforehand, since most women I know who've had epidurals have gotten UTIs, but we nurses don't think of these things because we're not the ones who have to deal with it.

What else? She's been in the hospital for almost a week because of high blood pressure - they would've released her had she agreed to twice-weekly checkups, but she said she couldn't do that. She had a balloon filled with saline inserted in her cervix to dilate it. She was started on Pitocin this morning. She started with painful contractions that stayed painful even after the epidural, and the anesthesiologist was in there all day adjusting it. She received Fentanyl IV and epidurally and the baby's heart rate, which should speed up and slow down with contractions, went completely straight at about 135/min. The nurse showed me that and said the Fentanyl had sedated the baby. Anyway, she made some progress before I left. I hope she doesn't end up sectioned.

When her water broke they inserted an intra-uterine pressure monitor. Her contractions went up to 95 mmHg - normal contractions are around 40! Which is probably why they were so painful.

Oh, and she was caught having sex with her SO (husband, actually, I think) last night. The nurse PUT A STOP TO IT. Personally I wouldn't have said anything. Maybe they were trying to kickstart labor? Edit: Or maybe they were taking advantage of one of those fantastic birthing beds!

Originally posted February 10, 2009

Being a man in the delivery room

Probably the #1 thing I'm taking away from this crash-course in hospital birthing is how unpleasant it would be to be a father at a hospital birth. Fathers are kind of useless spare tires in the hospital delivery room: you're there for emotional support if the mother needs you, but the staff assumes she won't—her emotional support is the doctor and the epidural. Other than that, what do you do? There's not even room by these beds for dads. They don't strap women's legs into the lithotomy stirrups anymore, so a dad might be able to hold up a leg if the nurses let him.

I can't imagine being a dad watching helplessly while my wife is in this big contraption:



Or this:



Or this one, made by a railway manufacturer (see the site):



I think you can drive this down the street and shoot babies at people. It's like a first person shooter. But seriously - look at the physical distance this bed makes around the woman. No one can really approach her except whoever's brave enough to get in the birthing crosshairs.

I'm sure lots of dads have wonderful experiences at the hospital. But after being with my wife, at home, helping into whatever position she wants for labor, I couldn't tolerate just standing there. I tried to find images of dads holding up moms for labor, but they seems scarce. But the last two births, I held my wife while she was laboring standing up. She delivered the last one standing up. I had an actual job to do. I even had to go to the bathroom at one point, but I was afraid to ask! Who else was going to hold her?

I've only seen one dad at a birth, and he was looking unhappy, looking useless, not knowing where to stand, not knowing what to say, crying, unsure if he should approach the bed, and then unsure he should approach the baby - but craning his neck to see her across the room in the heated baby contraption they put her in for the initial assessment. I was with his baby, and he was not. I felt like grabbing him and pulling him over. It was awful.

Dads in the hospital room can be jettisoned by the staff at their discretion, which means they aren't necessary. What does that do to the dad? Maybe this or that dad doesn't care, but this has to affect the male psyche in our country, or any country where this is a common childbirth practice.

Originally published February 17, 2009 on LJ during my ob rotation

Man Nurse Exposes Self to Web While Nursing

The post about my needlestick was featured in the latest Change of Shift, which was hosted at code blog. I wasn't even all the way at the bottom! It's this blog's first real web exposure.

I was looking over my top Google search queries, and two of my highest rankings are for man nurses baby and can a man nurse a baby. I'm the second link! Holy cow. Should I lay off writing about babies for a while, or is any first-page ranking good exposure? Should I write an article about male breastfeeding? At least I'm on the first page for nurse diaries and #1 for man nurse diaries. You know, for the -2 people in the world who search using those terms.

I'm also one of the Top 50 Nursing Blogs on Facebook via NetworkedBlogs. Okay, fine, there's not a lot of traffic for nursing blogs on Facebook, but it's still cool.

And hey—thanks to those of you who subscribed! If you haven't subscribed to get the feed, feel free to do so. It makes it a little easier to follow new posts.

Brain injured kids

While we spend most of our clinical hours for pediatrics in a large children's hospital, we are rotated out periodically to work at a long-term acute care children's facility. It's sort of a nursing home for children with severe brain damage or who are ventilator-dependent. It's a world I never really knew existed. It's an older one-story building, quite nondescript on the outside. On the inside, high-pitched alarms are constantly going off, but nobody seems to heed them—they are apnea (breathing) alarms, I learned, and they're always going off falsely. There is more staff than patients. Each room has four or five children in it, and a sitting staffmember. Pediatric hospital cribs and little toddler beds are placed wherever they fit. Most of the children are up, dressed, and in their specialized wheelchairs by the time we get there. Most of the children have large heads, large eyes, small bodies, and tracheostomies with those big humidified air hoses. And each kid has a story.

One kid was a near-drowning case. The mother jumped off a bridge with her eight month old child. She died, but her baby was saved after extensive resuscitation. Now she's eleven years old, the size of a toddler, and severely brain damaged, but smiles at her caregivers. The suicide/infanticide attempt took place in New York, but since the father lives here the child was transfered. He's apparently not really in the picture, but the little girl has adult siblings who come to visit.

We saw a boy and a girl, 8 and 9 years old, with genetic malformations of the face and jaw (can't recall the name) which blocked their breathing at birth and necessitated a tracheostomy. Despite that they've grown well and can run around, interact with people, and use sign language. They'll have multiple surgeries as they grow. One surgery involves screws in the jaw which stick out of the face; the nurses turn the screws slightly every day, widening the jaw to stimulate bone growth. The girl has family issues between the mother who isn't her custodian and the grandmother who has apparently moved away, so they don't know where she'll end up. The boy had an illegal Mexican immigrant family which has entirely disappeared. He might be put up for foster care when he's old and well enough. The two children have been together in the same facility since they were babies, and they act like siblings—playing, fighting, getting into trouble, everything. Nobody is looking forward to their probably inevitable separation, though that might be years away.

There was another little boy who was born, they said, without cerebral hemispheres. He has his lower brain and is healthy; he was, in fact, one of the few kids without trachs. He has a normal-sized head with an internal shunt to his abdominal cavity to drain the fluid that constantly fills the empty part of his skull. He was up in his wheelchair, wearing a tan plaid button-down shirt and pants, with his eyes closed. Do they ever open? What does he feel? The staff said he sometimes cries or whimpers, but I think that's the only reaction they get.

My patient probably has the happiest story there, ironically. He was a healthy ten-year-old who was hit by a car, sustained a traumatic brain injury, and entered a coma: pupils fixed and dilated, unresponsive to pain, spastic limbs, everything. MRIs showed diffuse white matter destruction and diffuse hemmorhaging, and an EEG showed slow waveforms. They worked him up for brain death twice, but he had some spontaneous efforts at breathing and cough/gag reflex. Now he's twelve. He's off the vent (still has a trach), can stand and pivot with help between the bed and the wheelchair, makes simple choices when prompted, and laughs at jokes. He's getting intense physical, occupational, and speech therapy. But he'll never be back to normal—he basically has cerebral palsy and will probably always have the trach (though they're evaluating a speaking valve). His family is very involved—parents, siblings, cousins, everybody.

It's a hard place to see, and you probably gain some saintly qualities working there. The staff is amazing, and so is the care. These kids don't get bedsores. If they were adults who sustained brain injuries and needed long-term care, they wouldn't fare this well. But there are a lot of ethical questions that come to mind there. Many of my fellow students have a "You wouldn't do this to a dog" reaction when they see some of the lower-functioning patients who barely respond, or don't respond, or just cry. Doubtless there are some who could've been allowed to go to heaven. Anyone who is making critical, prudent life-or-death decisions should probably have to rotate there to see what's involved in the care of these children after they leave the NICU/PICU and 'go home'. But it's hard—there's not a lot of ethical guidance in the healthcare profession, and prognosis is hard to judge while you're doing CPR. And look at my kid. I've seen patients in the state he was in, and I probably would've assumed he was brain dead. But if he was really that far gone, how did the higher-functioning portions of his brain survive?