Thursday, August 28, 2014

The Hospital Circus

My daughter Scarlet was just 4 days old when a routine pediatric visit detected an elevated heart rate over 200.  There were no discernible symptoms, so we were all surprised.  The pediatrician explained, "there is a range of normal and this exceeds that range, and if left untreated her heart will start to enlarge and you don’t want that”.  Off to the children’s emergency room we go.

Upon entering the ER, an entourage of personnel appear, each asking various questions and each commenting “she looks a little jaundiced”…”yeah, she does”…”hmmm”.  They confirm a heart rate of 230, and hook her up to an EKG to get a more detailed analysis.  A cardiac specialist arrives and tells us that this sort of thing occasionally happens, for reasons unknown, but that it has nothing to do with the labor or pregnancy.  After reviewing the EKG readout, he states that it’s most likely something called SVT, which is easily fixed using a medication called adenosine that gets administered through an IV.  As they hook up the IV, he explains that this will work immediately but that Scarlet will need to continue receiving treatment over the course of a year, at which time we would reassess things.  They administer the dose - heart rate drops to normal levels, everyone sighs, then it shoots right back up.  Let’s try it again with a higher dose.  Same result.  Ok, let’s get another EKG printout.  

The specialist goes to work analyzing the printouts and begins making some kind of calculation.  He then concludes confidently that the proper diagnosis is actually something called atrial flutter - essentially, instead of blood flowing directly from the upper chambers to the lower chambers of the heart, it’s looping around the upper chambers first.  This is good news, he explains, because it will not involve any ongoing medication.  We simply correct the rhythm, and then we’re done forever.  Sounds great to me.  There are two treatment solutions: 1) chemical, via oral medication called propranolol 2) electrical, via shocking the heart.  While he prefers the 2nd method due to it’s greater efficacy, he suggests we start with option # 1 because at this time of day (roughly 8 PM) we will need to stay overnight in the PICU for constant monitoring no matter what, so we might as well try the less invasive method first.  The PICU sounds like a nice relaxing place to not get any sleep…can’t wait.

The plan is simple: give her one dose now, followed by a second dose 6 hours later, and a third 6 hours after that.  If by noon tomorrow the tachycardia has not corrected, we will then proceed with shocking the heart.  How long will the propranolol take to work?  No way to know, he explains…”maybe it takes only one dose, maybe all 3, maybe it doesn’t work at all…the heart rate will be under constant supervision so we’ll just have to see how things develop…make sure you don't feed Scarlet after 8 AM, because if we need to shock her heart we want her to be on an empty stomach”.  Roger that.

The first dose is given, and we wait in the ER room while our PICU suite is being prepared.  1 to 2 hours later, they set up a portable monitor and start transporting us.  I notice the monitor shows a heart rate of 135, so I ask the nurse if that's an accurate reading of her heart rate.  “Yes”, she replies.  Wow, it looks like it already worked!!!

Into the PICU we go.  A new cast of characters is now in the mix.  Two nurses are getting things situated while discussing the plan with the chief of the floor.  One nurse comments, “she looks a little jaundiced”.  The other nurse responds, “yeah, she does”.  I ask if the 2nd dose of medication will even be necessary, given her heart rate has already stabilized.  The chief replies, “you’re going to need all 3 doses, otherwise the heart rate is just going to climb back up”.  I guess he knows something the specialist doesn’t.  The chief then says, “no feeding after 7 AM”, to which a nurse replies “oh, I was going to say 6 AM”.  I inform them the specialist instructed 8 AM and the chief says “well, you can go up to 7:20”.  Fine.

They do a general inspection of Scarlet, ask the same background questions the ER staff did, and put her on IV fluids.  A nurse then comes in hourly to assess things, mentioning at one point, “my daughter was jaundiced too and had to be under a light for 3 days”.  Thank you for sharing that.  

Around 1 AM a new woman enters the room and explains she is the resident nurse tonight, and that if we have any questions or concerns to just ask her.  Then she takes a look at Scarlet and comments, “she looks a little jaundiced…has anyone told you anything about her being jaundiced?”  Only the fools within this hospital.  I explain her bilirubin tests were fine 2 days ago, and that earlier that day she was examined by the pediatrician who said nothing of jaundice.  “Hmmm, she’s looking jaundiced, and it can start creeping up around this time…we’re gonna need to do a bilirubin test”.  If you say so.  As I look around the room, I’m struck by the seeming absurdity of attempting a visual assessment of jaundice in a room with yellow walls and yellow lighting.  But I’m no doctor, I suppose.  The resident nurse then tells me, “no feeding after 8 AM”.  Got it.

Fast forward to 3 AM.  Scarlet’s heart is still holding between 115 and 130 on average.  I let a nurse know that it’s time for Scarlet to receive a 2nd dose of the propranolol.  “Yeah, the pharmacy doesn’t have it ready yet, I just called - they’re making one up now”.  Got it, no worries, it’s just my newborn’s heart rate we’re talking about here…it can wait.  3:30.  4:00.  4:30, the 2nd dose is administered.

Fast forward to 7:30 AM.  I find the resident nurse and ask if the 3rd does will be pushed back, since the 2nd dose was given 1.5 hours late.  “The 2nd dose wasn’t given at 3 AM?” she asks.  No.  “Why not?”  How the fuck should I know?  I explain that pharmacy apparently didn’t have it ready, for whatever reason.  She looks to the other nurse, “why wasn’t I told about this?”  Silence.  She takes about 1 second to ponder my revelation, and says, “we’ll still give her the 3rd does at 9 AM as planned”.  Ok.

9 AM arrives - no one comes in with the 3rd dose.  Her heart rate is still exactly where it had been since transporting to the PICU.  Now there’s a big head honcho on the floor, who I’m told by a nurse is “the boss”, presumably of the entire hospital, and he’s walking with a bunch of student doctors and nurses from room to room discussing each case.  At 10 AM they get to my room, and the cardiologist on call joins them (the cardiac specialist from last night is no longer on site).  They begin discussing Scarlet’s situation right outside the room, in plain view and earshot.  I’m not sure if I should act normal, stay extremely still, or throw feces at them.  The resident nurse from earlier is in the pack, and she starts giving a play by play: “heart rate elevated, they initially tried adenosine, then switched to propranolol, she’s had glucose checked every 4 hours, and she looks jaundiced so I ordered bilirubin tests” _ (side note: it took 3 bilirubin tests for them to finally let go of their jaundice fixation).

Bossman then asks the same series of background questions.  Is she peeing and pooping?  Yes.  Any history of heart problems?  No.  Etc, etc.  I hear him say something about the specialist wanting to given another dose of adenosine, so I insert myself into the conversation, explaining the specialist had initially considered doing so, but ultimately decided against it upon confirming his analysis of atrial flutter.  Bossman asks if anyone knows what the heart rate was during labor, and I inform them that it was between 140 and 160 for the duration of the labor.  Bossman turns to me, “how was the baby delivered”?  Vaginally.  “Was it a normal delivery?”  Yes, the baby came out of the vagina and not the anus.  He turns back to the huddle, “well if she’s peeing and pooping and breast feeding, I’m not that concerned given how great these heart rate numbers are looking”.  

As the huddle begins to disband, I ask the obvious: “so is Scarlet still going to get a 3rd dose?”  The cardiologist responds “yes, we’re going to give her the 3rd does…she’s going to be on this medication for a while, about 9 months, so we’ll be giving you medicine to administer at home as well”.  I calmly explain that my understanding from the specialist was that once the issue was resolved by this afternoon, there would be no further medication required.  She looks at me like I have two heads, and asks if perhaps I misunderstood the specialist.  No, definitely didn’t misunderstand anything.  In fact, come to think of it, I’m the only person here who actually had a face to face conversation with the man.  She says “well, I’m going to check in with him, so I’ll see what he says…hey, I’d love to be wrong about this”.  She walks out with her associate, and eventually comes back in to report that we don’t need the 3rd dose after all, and there will be no further medication required - we just need to do a final EKG and Echocardiogram for definitive confirmation.  Great!  

2 hours later, someone comes in to do the EKG and Echo.  I’m told the results are being sent to the cardiology floor for analysis.  1 hour later, the cardiologist appears to say everything looks great and we can go home - we just need to wait for a nurse to prepare discharge papers.  Shortly after, the cardiologist’s colleague from earlier comes into the room to give us a script for the propranolol medication that Scarlet will be receiving at home.  Uhhhh, what?  I explain that the specialist informed the cardiologist that such was not necessary.  The colleague says “oh, I spoke to the cardiologist earlier and she told me this would be necessary”.  “Right, well it would seem that the cardiologist spoke to the specialist after speaking with you, but neglected to follow up with you”.  She says, “oh, ok, well then I’ll just confirm that with her, but it sounds like we won’t be needing this after all”.  Another 2 hours later we have discharge papers.  Get me the fuck out of here.  

The moral of the story is, while hospital staff are tremendously skilled and caring people, the environment in which they work is often frenzied and the communication therein can be highly dysfunctional.  And while it may be tempting to assume that this all must have occurred in some dilapidated institution with substandard personnel, rest assured the facility in question was very well regarded.  So never assume that anyone knows what is actually going on…this is not to say don’t trust your doctor, but rather, don’t assume that your doctor has been fully informed.  It is imperative that you attentively listen to everything that is said in your presence, ask whatever questions you may have, be highly observant, and not be too grief stricken or exhausted to monitor what is happening, or too intimidated to politely inform of any contradictions in procedure.  

In addition, it has never become clearer to me that if left to their own devices, hospital personnel would eventually start transporting patients to underground bunkers.  They are accustomed to encountering horrific situations and are therefore extremely paranoid about everything…this is entirely understandable, but it’s important to concede that this approach inevitably brings risk of unnecessary testing and treatment.  So patients and families need to provide a balance, when necessary, in order to make sure things don’t snowball out of control.  In the end, if I had not been as watchful during the above 24 hour saga, Scarlet would have received medication that she didn’t actually require…potentially 9 months worth!  So let this be a cautionary tale.  And please, conduct a thorough inspection of your children, because they're looking a little jaundiced from here.

Sunday, August 24, 2014

Birth Lessons

In the months prior to conceiving, my wife began “preparing her vessel” as she liked to put it.  She was regimenting her diet, working out regularly, and seeing an acupuncturist.  It was important to her that she have an unmedicated natural delivery, and after much careful thought, we agreed that birthing at home was the most appropriate setting.  Home birth requires a high degree of preparation mentally and physically, and we were both fully committed to the cause, devouring as much reading material as possible, taking birth classes, watching birth videos and lectures, doing birth specific exercises, eating organic and being nutritionally mindful, etc.  So by the time labor was upon us, we were ready.

The first initial contractions began late evening on August 14th.  They were inconsistent and intermittent, so I figured real labor wouldn’t begin until the following afternoon.  I was in the middle of re-formatting my studio, a process that had been underway for weeks, and I had been working the entire day - now knowing that labor was around the corner, I decided to put in some extra work that night to cover a little more ground before the birth put everything on hiatus.  Close to midnight, labor started picking up and by 3 AM it was in full swing.  With only 2 hours of sleep under my belt, I woke up and started timing the contractions over the next hour…they averaged 57 seconds long, every 4:30.  It’s going down, folks.

Lesson #1:  Whatever work related projects, fitness routine, family drama, or other activities that you’ve got going on, none of it deserves your attention once the initial labor contractions begin.  If contractions could talk, their onset would translate to: “hey asshole, drop your bullshit, get focused, and get some rest…you’re gonna need it”.

At around 6AM the doula arrived.  I feed the cats, make breakfast, and set up a birth pool that we had rented.  We then proceed to work like seasoned masseuses, utilizing various massage techniques during and in between contractions, along with frequent words of encouragement, while Heather is vocalizing with every contraction and attaining full-body relaxation.  At 11:45 AM, the midwives arrive and do an internal exam to establish where things are.  My wife requests that they not tell her how dilated she is, and I agree - what’s the point in knowing - let’s just keep working.  

1 PM brings a surprise power outage to the neighborhood, something that hasn’t happened since Superstorm Sandy in 2012 (at least on this particular day it was cool and sunny).  As we’re all scratching our heads trying to figure out how to heat up water with no electricity, my wife blurts out in between contractions “hook up the new propane tank and boil water on the grill”.  Ingenious!

By 3 PM the power was back online - yes!  4:10 PM, the midwives do another internal evaluation and simply report “you’re making progress”.  The work continues…in the pool, on the bed, on the toilet, in the shower, lying down, sitting up…drinking, snacking, peeing regularly.  

8:25 PM, another internal evaluation.  “You’re at the same place you were last check”.  Really?  Whatever, back to work.  Labor outside, labor inside, from this position to that position.  Soon my wife starts reaching a point where she expresses doubt about whether or not she can really do this, an expected signpost during Stage 1 of labor - this is encouraging, and we in turn continue to encourage her.  She eventually vomits (twice), and while ostensibly a terrible occurrence, in truth it is another good indication of progress.  

10:15 PM, another evaluation…no change.  The mood now shifts considerably, and the midwives raise the prospect of transporting to the hospital.  I’m completely blindsided by this.  Ok, what’s the story here, where are we at?  “She was 4 cm at noon, and she’s been 7 cm since 4 PM, and the baby has not dropped at all”.

They breakdown the situation further, explaining the holdup is resulting from the position of the baby.  Although head down, it’s not the traditional vertex position…it’s occiput posterior (OP).  Normally at around 7 cm the baby’s head will have made contact with the cervix, and the resulting pressure, in conjunction with the contractions themselves, dilate the cervix the rest of the way.  In our case, the OP presentation was preventing the baby’s head from being able to engage the cervix, thereby stalling progress, and the all-forward nature of how Heather was carrying (you couldn’t tell she was pregnant from behind) was not helping matters.

Lesson # 2:  Some things are simply out of your control.  In the case of birth, nothing can mandate the presentation of a baby - you can take steps during pregnancy to encourage optimal positioning (which we did), but you cannot guarantee what the presentation will be the day labor begins.  All you can do is play the cards you’re dealt as best you can.  Such is life.

The midwives decide to administer IV fluids in order to help boost her energy levels (she wasn’t able to eat by this point), and they communicate in no uncertain terms that we’re approaching a crossroads - it’s time to dig deep or transport.  My wife rises to the occasion.  We work for another 4 hours, utilizing specific positions and rebozo techniques to counteract the OP presentation, along with aroma therapy, acupressure points, nipple stimulation, and herbal remedies that had been exploited on and off throughout labor.  A caravan develops as Heather walks throughout the house, with the doula in front of her, me behind her, and the midwife’s assistant holding up the IV fluids on a broom stick leading the parade - surely a peculiar sight to see out of context - when a contraction came, we all paused and Heather would lean back onto my lap as a midwife deftly placed a chair under my legs.  

Her “shelf” was dropping (the high point of the baby in the abdomen) and amniotic fluid had released (suggestive of a break high in the amniotic sac, as opposed to a traditional rupture)…both very encouraging.  Her vocalizations took on a new caliber of intensity, as her contractions got even longer and harder - she was deep in the labor zone, as were we all.  She began reciting affirmations, along with everyone else.  “I can do this”  /  “You can do this”  /  “Welcome it”  /  “I welcome it”  /  “You’re body won’t give you anything you can’t handle”  /  “My body and baby know how to birth”  /  “The pain will lead you to the baby”  /  “Follow the pain to the baby”.  Whatever heights were reached before, we were now in uncharted terrain.  My wife got to a place she didn’t think she could get to, and she continued charging ahead.  The atmosphere was electric, and we all felt that we had turned the corner.

At 2 AM, the midwives do another evaluation….7 cm, no change.  The devastation and disappointment was palpable.  I can tell from everyone’s facial expressions that it’s game over, but I can’t accept it.  I insist Heather can still do this, but my wife is protesting.  They clear the room, and I tell Heather, “I don’t care that you’re still 7 cm - no woman dilates on a set schedule - you could be at 10 cm in the next 30 minutes for all we know - and we have been seeing other indications of progress - you are so close, you can do this”.  “Zack, you don’t understand, I can’t do this anymore”.  “Yes, you can”.  

The midwives return and explain that Heather’s degree of exhaustion has gone too far, that her uterus has become too fatigued, and that in their medical opinion it is time to transport.  I recognize that I’m the only one who thinks continuing is an option, and it angers me - I’m angry that they are giving up on her, I’m angry that I am failing my wife in not being able to convince everyone (including her) that she can still do this, and I’m angry that on some level I too know it’s time to transport.  Of course, contractions are still coming, and as I’m anxiously trying to figure out some way to salvage this, my wife’s vocalizations take on yet another caliber of intensity, only this time the sound she’s making is of a very different nature, and it goes right through me.  Some vocalizations signify working your body to the brink of its capacity, and some vocalizations signify working your body beyond the brink of its capacity.  In that instant, it became clear to me that my wife was no longer laboring, she was being tortured.  

“Ok, we’re going” I declare.

Lesson # 3:  There’s what you want your birth to be, and there’s how it actually goes.  Unfortunately these two things don’t always match.  It’s imperative to never let one’s attachments and desires, however important and cherished they may be, get in the way of making objective assessments.

Now, there are 2 hospitals we can transport to.  One is 20 minutes away, and the other 40 minutes, but the further hospital is the preferred choice of the midwives in a non-emergency.  There is no fetal distress whatsoever, so it’s up to Heather.  She opts for the preferred hospital 40 minutes away.  The midwives call in advance, and begin packing their stuff.  I’m secretly hoping that by the time we get Heather into the car or to the hospital, she will have completed transition and we’ll birth this baby in the car.  Heather begins apologizing to me and everyone, for which we all admonish her, while I mask my grief that this is really happening…I don’t want her to know how upset I am, because as the midwives explain, there’s still a lot of work ahead - this baby still needs to be born, and the top priority now is having a vaginal birth at the hospital.  Off we go.

Driving at 3 AM through winding country roads while your wife is laboring in the backseat is not something I recommend doing while sleep deprived and exhausted…but with adrenaline pumping, you’d be surprised at how efficiently you can accomplish this.  Oh, hello deer - hitting you is the last thing I need right now.  My wife was miraculously silent during the entire drive, apparently summoning the will from not wanting to cause me to panic, while I too was miraculously silent for not wanting to cause my wife any additional distress…if we’d been in separate vehicles, I would have been weeping.

It’s close to 4 AM as we arrive at the hospital.  Quick pee outside in front of the ER entrance (my wife, not me) and we proceed inside.  Heather continues to apologize to everyone, and a nurse tells her reassuringly “hey, you got to 7 cm all on your own, you should be proud of yourself”.  All I’m thinking is “fuck you, lady”.  The hospital midwife on call assesses dilation at 8 cm.  The anesthesiologist eventually arrives around 5 AM to administer an epidural just as Heather vomits for a 3rd time, at which point they also start her on a conservative drip of Pitocin.  Basically, although her uterus was still contracting regularly, it was now so fatigued that the contractions were believed to be too ineffective to dilate her cervix the rest of the way…so the plan was for the epidural to allow her to go to sleep in order for her body to rest, while the Pitocin beefed up the contractions in the meantime without her being aware of them.  The birth team disperses, and Heather and I try to get some sleep.

Lesson #  4:  The amount of routine unnecessary medication and intervention during labor is disturbing - from induction to epidurals to episiotomy to cesarian - such measures should always be a last resort, yet too often they are utilized out of convenience, ignorance, habit, or paranoia.  However, when there is a true medicinal purpose, intervention can be a truly beautiful thing.  Never stubbornly refuse an intervention for the sake of principle alone - if you genuinely need help, accept it.

A couple of hours later, the hospital midwife checks her dilation.  No change.  “We’re gonna up the Pitocin a little bit and give it another hour”.  One hour later, no change.  “We’re gonna up it a little more and give it more time”.  Another hour later, no change.  My wife is starting to panic, but I remind her that the baby isn’t in any distress, and it’s simply a question of giving her body the time it needs, to which the hospital midwife responds “well I don’t want to say we have all the time in the world - this is a really protracted labor, and if we don’t see progress relatively soon, we’re going to have to start having a very different conversation”.  You’ve gotta be fucking kidding me.  “But we’re gonna up the Pitocin a little bit more and see what happens”.

30 minutes later, our birth team walks back into the room like knights in shining armor.  At the next check, Heather was 9.5 cm _ [cue angelic choir] _ and before we knew it she was feeling the urge to push (by which point the epidural had worn off).  And push she did, with a fervor and intensity that belied she had been in active labor for over 30 hours.  After another gauntlet of birthing postures to facilitate the baby’s positioning, finally at 11:24 AM on August 16th, Scarlet Sage Hemsey was born.  The sense of triumph that pervaded all of our spirits in this moment was extraordinary…it felt like snatching victory from the jaws of defeat.

Lesson # 5:  Throughout our stay at the hospital, I was thinking about all the time and energy that we had put into birthing at home, all of our efforts during the last 9 months of pregnancy (and prior), and the 30 hours of laboring we had just completed before transporting - this tremendous investment, and it was all for nothing.  But the truth is that our investment had in fact paid off, just not in the way we had expected it to.  The hospital was on the verge of doing a cesarian section when Heather finally dilated to 10 cm, so if Heather had not already been birthing at home for those 30 hours, or if she had decided to birth at the hospital from the outset, C-section would have been a certainty.  In the end, home birth is what made vaginal birth possible.

Lesson # 6:  The more learning and preparation you do in advance of labor, the more confident you will be when it’s underway.  However, there is a potential pitfall for expecting parents who know all the intricacies of birth, what to expect, and have a clear vision of what lies ahead…and that is if / when labor strays from how it was imagined to be, it can be extremely scary and disconcerting, and very difficult to let go of prior expectations and accept what you’re presented with.  You can do all the reading in the world, but none of it will allow you to truly anticipate what labor will feel like or how your particular labor will unfold.  So know what to expect, but don’t have any expectations.

Lesson # 7:  Hindsight is not always 20/20.  If I could go back in time, there are a variety of things I would try in an effort to change the outcome…maybe if we had spent more time in these birthing positions instead of those, Heather would have progressed faster…maybe if Heather listened to music, she could have focused or relaxed more…maybe if I had made more fresh fruit juice (perhaps 6 glasses instead of the 2 that I did), she would have had more energy…maybe if I called her acupuncturist for a home visit during labor, she would have been able to do something to affect the baby’s position and/or Heather’s stamina…or maybe we could have driven over bumpy roads and bounced that stubborn baby downwards.  But the reality is there’s no way to know if any such alterations would have affected the outcome (and if they did, whether for better or worse).  In navigating labor, all you can do is make your best on-the-fly judgement each step along the way.

Lesson # 8:  Initially looking back, I thought maybe I was wrong to have championed my wife onwards at 10PM when the prospect of transport was first raised.  Perhaps she endured 4 more hours of pain unnecessarily.  However, in truth, I think it would have been a disservice to her to have done otherwise.  Even though our rallying ultimately did not affect the outcome with respect to transporting, I believe it was extremely valuable to my wife’s psyche  to have been able to summon the willpower and determination that she did during those last hours at home, and I truly feel that her birth experience would have been diminished without it.  While we should absolutely seek to protect the well being of our loved ones, we should never doubt their resolve.  I believed in my wife then, and I still believe in her now.

I remember thinking to myself at one point during labor, “who would ever want to be a midwife or a doula?  This is so exhausting”.  But when it was all said and done, I understood.  My deepest gratitude to Susan Schmidt, Cathy Gallagher, Nancy McDaid, and Julie Hartman.  I am forever in your debt.