Chapter 10: A Very Long Shift, Part II

September 15, 1987, Greater Cincinnati, Ohio

The Pitocin kicked in after about forty-five minutes and Ms. Nixon had a series of contractions, about ten minutes apart. I stayed with her for about thirty minutes, watching the monitor and checking her vitals as I’d been instructed, then went to talk to Doctor Blalock who ordered the same amount of Pitocin to be administered in the next IV bag. I changed the IV bag and injected the Pitocin into the new bag.

“What exactly is Pitocin?” Ms. Nixon asked.

“A trade name for oxytocin,” I replied. “It’s made from a naturally occurring peptide of the same name. Oxytocin is pseudo-Greek for ‘quick birth’.”

“Yeah, right,” Ms. Nixon groused. “This is anything but quick!”

“Hey, as the song goes, ‘You gotta have patience’,” Shelly said, singing the ABBA lyric.

“Oh, please, anything but that!” I groaned.

“Not an ABBA fan?”

“They’re OK, but my little sister had their albums and played them constantly to the point where I couldn’t stand hearing any of their songs. Given everything is OK, I’m going to go take a nap. Martin, another medical student, will come to check on you for the next hour.”

“If you needed relaxation therapy...” Shelly said with an inviting smile.

“Shel!” Ms. Nixon said urgently.

“He’s not upset,” Shelly said.

“We called it ‘stress relief’ in college,” I said lightly. “And I do appreciate the offer, but there are considerations beyond just medical ethics.”

“I’m not a patient,” Shelly protested.

“No, but you’re here supporting Ms. Nixon,” I replied.

“Sheila,” Ms. Nixon said. “Please, call me Sheila.”

“There’s also the consideration that I’m an ordained minister, and that would be a violation of my vows.”

“You’re a pastor?” Shelly asked.

“No. I’m a Russian Orthodox deacon.”

“You were married, though...”

“Shel,” Sheila warned.

“Honestly, it’s OK,” I replied, then turned to Shelly, “Yes, I was married. Russian Orthodox clergy can be married, so long as they marry before they’re ordained. That’s why I married immediately after I graduated from college. We can chat later, I want to get my nap in now so I don’t miss the good stuff!”

Both women laughed and I left the room and let Martin know I was going to take a nap for an hour. I asked the duty nurse to wake me, then went to the lounge, turned off the lights, and lay down on one of the cots. Thankfully, I fell asleep very quickly and slept soundly for an hour before the nurse roused me.

I went to talk to Martin, then to Doctor Kelly, and was happy to hear that Sheila’s contractions were now about eight minutes apart, which meant she was making progress.

“How are you feeling?” I asked Sheila when I entered the room.

“OK. My contractions are seven or eight minutes apart, which Doctor Kelly said was good.”

“Let me check your vitals, please.”

I did and everything was normal, though she felt a bit warm. Because of that, I took her temperature. It was 37.6°C or 99.8°F which meant about a degree of fever on the American Fahrenheit scale. My textbooks had varied with some using metric and some using Fahrenheit, but the chart at Good Samaritan used Fahrenheit, so that’s what I wrote down.

“And?” she asked.

“A low-grade fever. Let me go speak with Doctor Kelly.”

I left the room and reported to Doctor Kelly.

“No other changes?” she asked.

“Her blood pressure is slightly elevated, but that’s been true since the Pitocin kicked in. Otherwise, everything is consistent.”

“Is a low-grade fever a side effect of Pitocin?”

“I don’t believe so. My notes list various cardiac effects, elevated blood pressure, subarachnoid hemorrhage, blood clotting problems, nausea, and anaphylaxis.”

“Most likely source of a change in temperature?”

“In this case, I’d suggest infection, given PROM. Blood draw to check white cell count.”

“You’re missing something,” Doctor Kelly said. “Think about the physiology of temperature regulation in the body. Where does it begin?”

“With the hypothalamus,” I replied.

“And what happens when a pyrogen induces a fever?”

I wanted to smack myself on the forehead because suddenly the answer was obvious.

“Prostaglandin E2 is released,” I replied. “And that creates a systemic body response that causes increased temperature. We administered prostaglandin E2 vaginally in gel form.”

“So, your conclusion?”

“Nothing to see here; move on.”

“Keep an eye on it,” Doctor Kelly said. “It could be infection, which was a good suggestion given PROM, but the most likely cause of a low-grade fever such as this is the prostaglandin.”

“Differential diagnosis,” I replied.

“Which would include?”

“Infection, metabolic disorders, and cancer as the primary causes. Primary diagnostic tool would be a CBC; a tox screen would rule out any pharmaceutical causes, such as MDMA or cocaine.”

“Good. You learned something tonight.”

“To remember my physiology!” I replied. “I’d like to do a CBC as a precaution.”

“Don’t trust your diagnosis?”

“It’s an inexpensive set of tests that will rule out something, which if we catch now, could be easily treated with little or no adverse effects. It might indicate that we should perform a C-Section to protect the baby.”

“Go ahead. I’ll sign off.”

“OK to explain this to Sheila?”

“First name basis?”

“At her request.”

“Yes, it’s OK to explain what we just discussed. It’s not advice; you’re simply explaining why we’re running the test. As for the reason for the fever, you can relate what we discussed, so long as you stick to what we just discussed.”

“Will do.”

“Bring me the form, then run the blood down to the lab personally.”

“Yes, Doctor.”

I went to the supply room and retrieved the necessary items to draw blood for a CBC, then went to Sheila’s room.

“The most likely cause of the fever is the prostaglandin gel,” I said. “But because your water broke earlier than is typical, out of an abundance of caution, I’m going to draw some blood for testing to rule out an infection.”

“Did you figure it out?” Shelly asked.

“This is actually a good example of why I’m not allowed to give medical advice or make a diagnosis. My first thought was an infection, but Doctor Kelly asked me about the physiology of elevated body temperature and once I remembered how it works, I realized it was likely the prostaglandin gel that caused the low-grade fever because that’s the hormone that regulates body temperature. That said, we’re doing the blood test because it’s relatively inexpensive and if there is an infection, we want to catch it immediately.”

“How do you remember everything?”

I smiled, “The same way you do with studying law. And just the same as you and my friend, I have to look things up because I can’t remember everything. Doctor Kelly is an OB, so she’s focused on that, whereas right now I’m a generalist who will focus on emergency medicine. There’s just too much to know for someone to know everything, which is why patients are treated by teams of doctors with varying specialties. The same is true for the law, right?”

“Yes. Some people specialize in civil litigation, some in criminal defense, some in wills and probate, and so on.”

“If I were going to be an OB, then I’d do multiple rotations in OB and apply for an OB Residency. Instead, I’ll do multiple ER rotations, multiple surgical rotations, and apply for a newly created Residency in trauma surgery.”

Assuming, of course, that my proposal went anywhere. I hadn’t heard anything further, but between my marriage, Elizaveta’s pregnancy, my clinical rotations, and then the events of the past three weeks, it hadn’t really even crossed my mind. But that was something to worry about later; I had a patient to care for, and that had to take top priority. I drew the blood, filled out the necessary form, and took it to Doctor Kelly for her signature. She signed, checked the box next to ‘stat’ and the one next to ‘active labor’, and then I took everything to the lab.

“Thirty minutes or less or your money back!” the tech said with a grin.

I thanked him, then headed back upstairs. Thirty minutes later, I went back down to the lab to get the results. I quickly scanned them, and there was a slight elevation of her white blood count — 11,500 leukocytes per microliter of blood, with the reference range being 4,500 to 10,500. I looked at my lab notebook, which I always carried, in addition to whichever notebook was appropriate for the service I was on, and shook my head. I headed up to find Doctor Kelly.

“Slightly elevated white count at 11,500. The most likely cause is stress, and it could also be a reaction to the Pitocin.”

“We’d likely have seen signs of anaphylaxis if it were the Pitocin that caused it, but you’re right to mention it. As for stress, I agree, that’s the most likely cause. What would you do?”

“Repeat blood test in an hour and monitor her temperature in addition to her other vitals. If her temperature increases or her white count is further elevated, then IV antibiotics.”

“You wouldn’t prescribe the antibiotics prophylactically?”

“According to my instructors in medical school, the theory on antibiotic use is changing. In the past, they’ve been given out, if you’ll pardon the expression, like candy. Current thinking is that you should avoid them unless absolutely necessary, and if you do need them, ensure the proper one is selected in the proper dosage and the full course is followed.”

Doctor Kelly nodded, “And your own minimalist viewpoint confirms that, right?”

“Yes, though I’m not sure if it should.”

“Did they tell you, in one of your ‘how to be a doctor’ classes that medicine is as much ‘art’ as it is ‘science’?”

“Yes, though I’m a scientist through and through.”

“You’re going to have to explain resurrection to me, then,” Doctor Kelly said with a wry smile. “I could use that ability as a physician!”

“The usual definition of ‘miracle’ is something which cannot be explained by science,” I replied. “But in many cases, that’s due to our lack of understanding, rather than whatever it is that happened defying the natural order of things. Those rare instances which DO seem to do that, have to be carefully evaluated, and, from an Orthodox perspective, most of them are rejected. Or, perhaps it’s better to say not authenticated.”

“You don’t see the contradiction?”

“No, because the Orthodox Church is not, and never has been, at odds with science. If you ask me about, say, Creation, I’ll answer that what is written in the Scriptures is true from a spiritual perspective, seen with the «nous» — the eyes of the soul. That does not mean that the events in Genesis are literally and historically true, nor do they need to be to convey spiritual truths.

“A parallel would be the man for which this hospital is named — the Good Samaritan. He’s mentioned in a parable by Jesus which says nothing about whether such a specific person actually existed as a historical figure. And, it turns out, it doesn’t matter, as the spiritual truth doesn’t depend on the existence of an actual historical person. That’s the story of Genesis in a nutshell.”

“Interesting. We can chat more later. For now, follow your treatment plan.”

“Will do.”

I returned to Sheila’s room and took her vitals, checked her temperature, and then checked the fetal monitor.

“Results?”

“A slightly elevated white count which could simply be the result of stress,” I said. “We’ll do another blood test in about an hour.”

“Just load her up with antibiotics,” Shelly suggested.

“That used to be the thinking,” I replied. “But the latest research has shown that’s not the best approach. The thinking now is to use antibiotics as seldom as possible and when they are needed, to select the best one for the diagnosis and ensure the full course is used. In the hospital, that’s easier to do than when they’re prescribed by a family physician.

“Part of the problem is that antibiotics are overprescribed because parents demand them, and before the latest research, nobody felt that created any concerns. The problem was, in addition to prescribing antibiotics for viral infections, for which they do no good, that parents would stop the antibiotics as soon as their child felt better, because some antibiotics have side effects such as diarrhea. And that leads to bacterial mutations which are resistant to antibiotics. You may have heard about MRSA — Methicillin-resistant Staphylococcus aureus — a bacterial infection that is resistant to the most common antibiotics.”

“Wait! Prescribing antibiotics makes things worse?” Shelly protested.

I nodded, “It can. Overprescribing or not following the full course certainly has that potential. An hour won’t make a significant difference, and if we see other signs, or increased fever, we’ll act.”

“Didn’t you say the gel that was used caused fever?”

“Yes, I did. But we haven’t reapplied any prostaglandin because Sheila is progressing through her labor. I’ll be back to check on you soon, Sheila.”

“Thanks for taking care of me, Mike! You’ve actually spent more time with me than the baby’s father!”

“All part of the service,” I replied.

“Do you provide any other services?” Shelly asked invitingly.

“Shel, stop!” Sheila commanded.

“You used to be a lot of fun, Sheila!” Shelly protested.

“And you’re being insensitive, both for what happened and the rules he has to follow.”

“He doesn’t seem upset to me!” Shelly declared. “And as soon as you have your baby and are out of here, the rules wouldn’t apply!”

I decided to let the girls debate, and simply left the room. I wasn’t offended by Shelly, but I also wasn’t at all interested in getting involved with her. Medical ethics had to control my behavior, even if others in the profession bent those rules. And that was without taking into account my own emotional state or my ordination.

I checked on Sheila every fifteen minutes for the next hour and her fever hadn’t increased, though the frequency of her contractions had. Right after I drew blood, Doctor Blalock did an ultrasound to check on the baby’s progress, and was unsatisfied, as even though the baby’s head was engaged, he, as I could see from the ultrasound, wasn’t making progress down the birth canal.

“I’m going to recommend a C-section at this time,” Doctor Blalock said after completing the exam. “Your baby is not making progress despite your contractions. Increasing the dose of Pitocin won’t resolve that.”

“What are the risks of waiting?” Sheila asked.

“Infection, which we already suspect, fetal distress, and side effects from the Pitocin. You’ve been on it about five hours, which isn’t a problem, but at this rate, I don’t believe you’ll make significant progress before morning.”

“It sounds as if I don’t have a choice,” Shelly said.

“You do, but I’d advise you to have the C-section.”

“OK,” Sheila agreed.

Doctor Blalock discussed the procedure further and they agreed on a spinal block.

“Mike,” Doctor Blalock said, just before midnight, “get the consent forms, get them signed, then prepare Sheila for surgery, please. I’ll write the necessary orders on the chart.”

September 16, 1987, Greater Cincinnati, Ohio

I left to get the consent forms and then returned to the room. I checked the chart and saw that Doctor Blalock had ordered lorazepam, and termination of the Pitocin drip. The spinal block was noted, but that would be administered by an anesthesiology Resident.

“First,” I said. “I need to go over the consent form with you. Per hospital rules, I need to read it aloud, then have you acknowledge you understood, then sign.”

“Read it to me? Why?”

“I asked the same question,” I replied. “Not this hospital, but another one in the area, had someone sue because they signed the form without reading it, and claimed they couldn’t read.”

Shelly laughed, “Ya’ gotta love lawyers!”

“Or not!” Sheila replied. “Go on, Mike.”

I read her the consent form, which was the standard surgical consent form with an additional section about the risks to the baby.

“Way to fill me with confidence,” Sheila said, reaching for the clipboard.

“Every medical procedure has risks,” I replied. “You signed your admission paperwork that included a similar disclosure.”

She signed the form and I witnessed her signature by signing the line underneath. That accomplished, I went to the supply room and got a bag of Ringer’s, then went to the nurses’ station so that the duty nurse could open the restricted supply cabinet so I could get the lorazepam. I signed the inventory sheet, wrote the drug and the patient’s name next to my signature, then went back to Sheila’s room. I changed the IV bag for a fresh one that wouldn’t have Pitocin, then injected the lorazepam.

“That will start taking effect in about ten minutes,” I said, “possibly quicker, and it will start relaxing you. I need to clean your abdomen with alcohol and have you put on a fresh gown.”

“No razor?” Shelly asked with a smirk.

“They stopped doing that routinely in the 70s,” I replied. “And the C-section incisions are higher up the abdomen. Sheila, just pull the gown up from your stomach, and I’ll turn the sheet down for modesty. Once I’m done, I’ll step out and you can pull the gown over your head and put on the clean one.”

“OK,” Sheila agreed, pulling up her gown.

I carefully turned down the sheet and blanket to ensure I didn’t expose her groin, then cleaned her abdomen, from just below her breasts to her waist.

“I’m going to step out so you can change,” I said.

“No need,” Sheila said, pulling the gown over her head.