Thursday, 15 January 2009

Playing a part

So, I’m on nights again and it’s 4am, when we get the obligatory call from the labour ward. Why is it that labour ward always call at four in the morning? You can pretty much set you watch by it.
The reg and I have had to call in our consultant to help deal with one of those middle-of-the-night dramas that we docs worry about and I take the call from the labour ward.

“One of our ladies would like an epidural, could you come over and do it for her?” comes the voice of the midwife. I tell her that things are kicking off in theatres, but one of us will be over shortly.

“Do you want to go and do it, while I take this patient to ITU?” the reg asks me.
“Sure,” I reply
“Just give me a call if you need a hand.”

I trek across to the maternity unit and make my way to the labour ward and Emily, one of the midwives, greets me as I walk in.

“Hello there,” says Emily.
“Good morning,” I reply
“It’s this lady here,” she tells me as she gesticulates at the board. “It’s her first baby, and I’ve just examined her. She’s 8cm dilated, but she seems to be stuck there.”
“OK, fine,” I say. “Big girl?”
“No, not really.”
“Sensible girl?”
“She seems to be.”
“OK, I’ll go say hello. Hannah’s her name yeah?”
Emily nods at me and we make our way to the room where Hannah is in labour.

A lot is made about the “art of medicine,” and I totally agree that often, practicing medicine is much more of an art than a science. The relationship between doctors and patients is a real example of how much this is the case. Sometimes, I find myself almost acting out a part when I see patients and I’ve learned to play several parts quite well. I can do “chin-scratchingly knowlegable” (with or without actual beard), I can do “gentle and reassuring,” I can do “jokey banter,” I can do “serious,” “stern,” “grumpy,” “dizzy” or “cross.” And I think I can do all of them pretty convincingly. Which of these “hats” I decide to wear with any particular patient depends on the situation.

Generally, labouring women in the middle of the night, don’t want me to sit down with them and discuss their thoughts and feelings about the role of pain in childbirth, they just want something – anything to take the pain away.

I decide that I’m going to be “cheerful and chatty” and I breeze into the room where Hannah and her husband are waiting.

“Good morning! Hannah is it?”
Hannah, looks up at me, briefly stops sucking the Entonox (aka “gas & air”) and croaks a weak, “yes.”
“My name is Dr Michael Anderson, I’m one of the anaesthetic doctors and I’ve been asked to come and see you because you would like an epidural, is that right?” She nods, “Have you read about epidurals?” She nods again, “Good, well there’s just a couple of things I’d like to re-iterate…”

And I go off on my “epidural spiel.” I then ask her a few questions about her health and the pregnancy, scrub up and get started.

As I’m getting the kit ready, I talk to her about herself, whether she’s excited about actually having her first child, baby names etc… etc… As Emily manoeuvres Hannah into the sitting position, Hannah asks me.

“Could you talk me through everything that you are doing?”

This poses a bit of a problem. When you explain any skill to someone else, be it epidural insertion, making a football swerve, cookery, you want what you are doing to go perfectly otherwise you look like a bit of a tit, or in this case, incompetent. You don’t know how things are going to go until you actually do them. Never-the-less, I don’t envisage that I won’t be able to get the epidural into Hannah, so I say “sure thing.”

“Right Hannah, you’re going to feel some really cold liquid on your back now, this is the alcohol prep we use to kill any bugs that are on your skin… OK, now here’s a sticky drape that I’m just going to put on your back… What I’ve got now is some local anaesthetic. What this does is numb this area of your back. It stings a bit when it goes in, I’m afraid, but the stinging will ease in about ten seconds or so…”

“I’ve got a contraction!!”

“OK Hannah, use your gas and I’ll wait. Just let me know when the contraction has passed.”

“OOOOHHH!!!, AAAARGH!!!!” comes her reply, as another contraction takes full hold. Hannah certainly has a good set of lungs on her, but it gives me a good guide as to when to wait. Basically, if she’s not screaming, I’m OK to carry on.

Her cries die down so I say, “has that passed now?” She nods. “OK, I’ll carry on. I need you so curl right up as much as you can now. Put your chin on your chest and really slouch those shoulders down.” She complies. “What I have here is the epidural needle, you’ll feel some prodding and pressure, but you shouldn’t feel any sharp pain. If you start to feel pain in your back, just let me know and I’ll put some more local anaesthetic in… What I’m doing now is looking for the right spot in your back, the spot I’m looking for is cunningly called the epidural space and if you can imagine, it’s about half a centimetre squared and it’s about five centimetres deep into your back…” I feel the give on the syringe I’m holding as my ‘loss-of-resistance technique’ tells me that I’ve found the epidural space – probably. “And there it is… I’ve found the right space, so I’m going to put the plastic tube in now… You may feel funny tingling sensations in you bottom or your legs as this goes in…”

Hannah gives a little jump, “Oooh! I really can!”

“People often feel twinges,” I go on. “Now, I just need to do a couple of tests to make sire that this is in the right place, before we can use this, I need to know that the plastic tube hasn’t gone into your spinal fluid or into a vein…” I look down at the epidural catheter, but already, I can see that the tubing is filling up with blood.

Bollocks. I’m going to have to take it out and do it again.

“I’ve got another contractiioonn AAARGGHH!!!!” shrieks Hannah.

As her contraction reaches its crescendo, I ponder if I should attempt to move the epidural catheter and try to wiggle it out of the vein or take it out completely and try again. On balance, I feel it’s safer to remove it.

“It’s passed…” gasps Hannah

“Ok,” I reply. “This epidural isn’t in quite the right place, I’m going to have to take it out and put in another, try and keep as still as you can for me.” I ask Emily for another epidural pack.

The second time, it goes in fine. I satisfy myself that I’m happy with its position.

“Now, Hannah, I think it’s in the right place now, so I’m going to give you a test-dose of the painkilling mixture.” I check the bupivicaine/fentanyl mix with Emily and give a small dose into Hannah’s new epidural. “OK, that seems to be going in fine. We need to stick this in now, after all this – we don’t want the epidural falling out do we?”

We stick down the epidural and ask Hannah to lie back down on her back.

“Can you lift up your legs for me?” I ask. She can. “Do you feel any different?” Hannah scrunches up her face at me. “Be honest,” I urge.

“I can’t say I do really,” she tells me.
“You’re not meant to,” I say. Now I’m going to give you a proper dose.” I say as I squirt the epidural mix in. “Does it feel cold in your back?” She nods at me. “Like I said earlier, it’ll take about 20 minutes or so to work and in that time, Emily will be checking your blood pressure. But after that, the pain will be much more bearable. I’ll go and do my paperwork, but I’ll come back in a few minutes.”

“You’re welcome.”

When I wander back in ten minutes later, Hannah beams at me. “It’s working?” I enquire.
“Yes, it’s working! Thank you sooo much!!”
“You’re very welcome. Later on today, after you’re baby’s been born, someone from the anaesthetic team will come and see you to make sure that things are OK. But I’m going to leave you alone now, I wish you all the best and congratulations in advance for the new baby.”
“Thank-you” says Hannah again. I leave her room, thank Emily for her assistance and walk back to ITU feeling very proud of myself.


Anonymous said...

awww great!! well done you! x

angus said...

Great post, very informative and human, really interesting, I look forwrd to the next one.

Jo said...

Fantastic post! Your patients are so lucky to have you looking after them :-)

Dr Michael Anderson said...

Another of the things that's so great about being an anaesthetist is that when you do get called at 4am to sort something out, you're really making a tangible difference. It beats clerking in the "off-legs" patients at 4am or running roud rewriting drug charts

Homer said...

Nausea prevented me reading all of this post (needles, ew) but re: the 4am thing, don't most mammals give birth just before dawn? I forget the evolutionary advantage supposedly thus conferred.

Anonymous said...

Please, please, please never call a labouring woman a 'girl' to a midwife again. I really love your blog, but please, don't call them girls.