Delivery of a Nightmare
Published in Strange Days: Midnight Street Anthology
The call came in the middle of her son’s funeral. One minute Beth was sprinkling dirt on her son’s tiny casket, her husband, the only other mourner, standing apart. The next she was speeding alone through driving rain and streaming tears. A week ago, her sister-in-law would have said, “We each mourn in our own way. He’ll come around.” A week ago, she would have been there for Beth. A week ago, the world was a very different place.
The familiar hospital was in unfamiliar chaos, the Emergency Room entrance crowded with cars and minivans and ambulances. Women’s screams eclipsed orders barked by a harried security guard. One glance and Beth understood why she’d been called in on the day of her son’s funeral. Every would-be patient was pregnant. On gurneys, in wheelchairs, or stumbling through the sliding glass doors, every woman had a hand on her swollen abdomen, some farther along than others. Decidedly lacking were the excited expressions of soon-to-be parents, replaced with shock, fear, pleading.
As Beth changed into scrubs on Labor and Delivery, Liz, the charge nurse of the day, laid out the looming disaster: pregnant women were arriving by the not-so-proverbial busload, in labor, most preterm, many pre-viable. Standard treatment – medications to slow labor for forty-eight hours of steroids to mature the baby’s lungs – was ineffective. Relentless contractions caused rapid cervical dilation. More women were near delivery than there were providers to care for them. Liz laid it out professionally, but an underlying current of panic seeped through.
Beth’s confidence wavered. This was her world, the tiny corner of medicine where she excelled. So why was she feeling inept? She’d been wrong to think she could save her brother, or her son, or maybe even her marriage, but obstetrics she knew.
At the labor board, names were doubled up in single rooms. The clerk stood on tip toe with her dry-erase marker, adding a name under a new column: Pending. The tenth name on the list.
“Doctor for delivery, Room seven.” The overhead announcement should have stirred Beth to action. Would have, a week ago.
“Dr. Markum?” Liz said.
“Yeah. I’m ready.” Beth shook off the cobwebs of uncertainty and answered the summons. This was her universe.
She barely had time to gown before the tiny head appeared, the body following immediately after. Much too small. Transparent skin. Fused eyelids. No need for pediatricians. She schooled her expression. Only her eyes showed above the mask, but the patient needed to see dispassionate competence, mixed with just the right dose of empathy.
Beth lifted the child, barely larger than her palm. She cut the cord and handed her to the labor nurse, who wrapped her in a blanket and placed the small bundle on the woman’s chest. The woman’s sobs shook the bed and Beth’s delusion of normalcy.
She focused on the placenta, tugging gently on the umbilical cord stump, but it wasn’t ready. Not uncommon in a preterm delivery. After several minutes, and multiple overhead calls for deliveries in other rooms, Beth stripped off her gown and gloves, gave heartfelt but inadequate platitudes to the grieving mother, and stepped out.
Next door was much the same. Though this baby was twice the size, he was still four-months premature. He tried to breathe, his tiny chest retracting with each attempt.
“He isn’t crying.” The anxiety in the new mother’s voice tugged at Beth. She needed a normal, happy delivery, she’d had enough drama.
It’s not all about you, Beth.
The pediatrician inserted a breathing tube, but still the chest moved little. Stiff, premature lungs. He needed surfactant. Remembering the scene at the hospital entrance, Beth hoped they had a warehouse full of the life-saving drug. “We’re helping him breath,” said the pediatrician. “We’ll take him to the ICU and I’ll be back as soon as I can with an update.”
And neonatal ICU beds. No way they’d have enough.
The dad snapped a few photos, which they admired, clinging together, crying together. Beth and her husband hadn’t clung together, hadn’t cried together as they watched their one-year-old succumb. His blame and her guilt were a damning combination.
Beth pressed on the patient’s abdomen to encourage delivery of the placenta. The uterus that should have been firm, like a child-size basketball, was instead a rubbery sack. “More Pitocin. And get Hemabate and methergine.” The nurse’s wide-eyed stare was directed only at Beth, whose nod confirmed, they were in trouble.
A few moments later, Beth said, “Your uterus isn’t contracting like it should. We’ll give you some medications to fix it, and maybe even some blood.” The new parents seemed not to register the rising concern in the room. Not necessarily a bad thing.
After every therapy in the arsenal, the blood kept flowing, pooling on the catch sheet, overflowing to the floor. The accelerating beep of the heart rate monitor forced Beth to make the call. “We need to go to the operating room.”
The charge nurse entered. “Dr. Markum, I need a moment.” The urgency of her tone trapped the protest in Beth’s throat. “We don’t have an OR,” Liz explained. “All three are in use for postpartum hemorrhages.”
Ice flowed down Beth’s back, through her veins.
Four patients are bleeding? Less than one percent of patients bleed after delivery. But that was a week ago, in the old world. The new world sucks.
But Beth had a responsibility to her patient. “Then I need one downstairs. We can’t wait.”
“I’ll take care of it,” Liz said. Beth asked about her patient next door. The placenta was still firmly attached. She returned to her bleeding patient.
“If all else fails, I may have to remove your uterus.”
“But we want more kids,” said the patient.
Her husband squeezed her hand, but nodded to Beth. “You do what you have to do. Our son needs his mom.”
In the end, the new mother did lose her uterus, and several liters of blood. She required six units of blood and another six of plasma and clotting factors. But as Beth started closing, clots were forming. She took a long, slow breath. This was a save. Though she could have no more children, she survived to raise her son. Disaster, mostly, averted.
“Dr. Markum?” A nurse she didn’t recognize stood in the doorway. “You’re needed next door.”
A general surgeon pushed past the nurse, hands up and dripping soapy water. “I’ll close for you.”
“What’s going on?” Beth asked.
“Apparently, you guys are having a lot of bleeding upstairs. My cases got cancelled, so I thought I’d see if I can help.” He held out his hands to be gloved by the scrub tech. Beth explained the procedure so far and stepped back from the surgical field.
More bleeding? She scrubbed for the next case, where another general surgeon was poised to open the abdomen. They started the case together, then Beth said to no one in particular, “What the heck is going on upstairs?”
“You’re the obstetrician,” the surgeon said.
“Middle Eastern Flu,” said the scrub tech.
Beth’s heart skipped a beat.
“Can the flu cause postpartum hemorrhage, Dr. Markum?” the surgeon said.
Beth glanced at the scrub tech, who seemed not to notice the dismissive nature of his comment. “Not to my knowledge.” Not last week. She clamped the right uterine artery.
Beth could do nothing about the epidemic, flu or otherwise, she could only fix what she could fix. And so she went from OR to OR. Patients Beth hadn’t met were anesthetized before she entered the room, with blood-stained sheets and gowns, and, more often than not, blood slicking the floor. She removed each hemorrhaging uterus, careful not to damage other structures, leaving the ovaries. Then a general surgeon took over to close and she moved on to the next. When they operated together, she taught the general surgeons how to perform a hysterectomy.
Updates came from staff – pregnant patients were still arriving from the surrounding communities, the same was happening across the country. Meanwhile, the death toll from the flu that had killed her son continued to rise in children and the elderly. The Centers for Disease Control recommended everyone possible remain at home. Still no word on isolating the causative agent.
In the OR, they talked about the epidemic. It started with US and European servicemen in the Middle East. Most died in transit. Beth’s brother had been lucky to reach the States, though it made no difference. Many healthcare workers fell ill, but they survived. So whatever the agent, it was weakened in transfer. Except for children. If the postpartum hemorrhage problem was unrelated, it was an extraordinary coincidence.
Day and night were indistinguishable in the windowless ORs where clocks of the twelve-hour analog variety hung above the doors. A.M. and P.M. had no meaning.
Her son had been in the ground more than thirty-six hours before Beth was ordered to take a break. She’d fallen asleep at the scrub sink, nearly slamming into the faucet. Caught by a scrub tech, she was guided to an empty stretcher in the hallway, her protests evaporating as her head hit the thin pillow.
She woke disoriented – was she a patient? No. Brady. Where was he? When reality breached her stupor, the weight threatened to suffocate her. Right on cue, her phone rang.
“Mom,” said Beth, tears threatening.
“Beth, how are you?” It was her father, his speech slow and guarded, not Dad-like.
“I’m okay, Dad. How are you and Mom?”
“Not so well, I’m afraid.”
“Are you sick?”
“No, no, not sick, but I’m afraid I have bad news. Meg died last night.” Her niece, and her parents’ only remaining grandchild.
“Oh no, I’m so sorry. I’ll call Emma.”
“Um, no, Beth. Please don’t. She…isn’t ready to talk to you quite yet.” But they were sisters-in-law, best friends, how could they not talk at a time like this?
“Dad, she needs me.”
“No, Beth, she doesn’t.”
“She just lost her daughter. I know what she’s going through.”
“She blames you.” It came out harsher than he probably intended.
“But kids are dying all over, I didn’t infect them all.”
“No, but she’s not there yet. She’s focused on Meg.”
Of course she was. Little Meg had attended Brady’s birthday party last week. Beth had cuddled her. Kissed her. Infected her. The toddler might have fallen ill even without Typhoid Beth’s help, but it was easier to have a tangible target.
After an uncomfortable silence, Dad said, “She’ll see reason eventually. But right now… Listen, she asked that you not attend the services.”
Beth’s swallow almost hurt. She changed the subject. “How’s Mom?”
“As well as can be expected. She’s resting now.” She’d lost her son and both her grandchildren in a single week. Her mom was strong, as was her faith, but wasn’t God asking a bit much? Job came to mind, though Beth was far from a biblical scholar.
She ended the call before she might argue the injustice, defend her actions, or worse yet, cry. She had gone to Walter Reed Medical Center to try to save her brother, Emma’s husband. A stupid, self-righteous move. An obstetrician double-checking on some of the world’s best critical care specialists.
She’d been released from quarantine with a clean bill of health. And insisted on going straight home for Brady’s first birthday party. Selfish. They could have waited a week, or more. Beth never did get sick, but still she’d brought this horrific monster home. Brady and Meg had been the first to fall ill. She’d earned the blame of her husband and sister-in-law. And her parents for that matter.
The distraction of work provided a terrible blessing. In thirty-six hours she’d operated on at least thirty women. Enough she’d lost track, of her patients, and her pain. But the women kept coming, and not just in Florida.
She thought of Emma, alone and twenty-five weeks pregnant with a difficult pregnancy. Her husband and child dead. Twenty-five weekers were delivering with immature lungs. Beth called her father back. It went to voicemail. “This is Beth. Listen, pregnant women are going into preterm labor all over. Emma should go to her doctor and ask for steroids. It won’t hurt the baby, and if she does deliver early, it could save his life. Tell her, will you? She needs steroids. It’s really important.” She left a similar message on Emma’s phone, but doubted it would be heard.
Someone cleared her throat nearby. “I’m sorry, but you’re needed in OR fifteen.” Her voice was tentative, apologetic, and there were tears in her eyes.
Beth stood and put an arm around her. “It’s going to be okay. We’ll figure this out.”
“My sister’s pregnant.”
“How far along?”
“Thirty-two weeks. Should I tell her to get steroids, too?”
On the third day of near-constant operating, several militant organizations - al Qaida, ISIS and an alphabet soup of terrorist groups - claimed responsibility for a biologic weapon, “Designed to target the genetic code of the infidels.” Though discounted officially, there was no denying that American soldiers stationed in the Middle East were dying, without widespread civilian fatalities.
During a brief break, Beth looked up her niece’s funeral arrangements, intending to order flowers. “Meg Dunn is survived by her mother, Emma Dunn, and her maternal grandparents. She is preceded in death by her father, Joe Dunn, and her paternal grandparents.” After several flower shops failed to answer, Beth checked online. A headline reported that the number of funerals far outpaced supply of burial services.
We really are in hell, not even any flowers.
That afternoon, the blood bank ran dry, and flowers were forgotten.
Between cases, Beth represented the Obstetrics Department at an emergency blood bank meeting. “If we can’t convince the public to violate the quarantine, we can press healthy family members to donate. They’re already here and have a vested interest. Staff too.”
“But what if they carry the virus?” a blood bank specialist countered, stabbing Beth through her already fractured heart.
The Infectious Disease specialist said, “Then the patient might die of the flu, which beats definitely dying from lack of blood.”
“There’s no time for any kind of testing,” Beth said, standing. “We need the blood now. Whole blood is fine.”
Within hours, against every tenet of Twenty-First Century blood banking, donor blood arrived in the OR tested only for blood type. Units were transfused almost as soon as they were collected. Transfusion reactions that would have been unacceptable the week before, occurred less often than predicted, and even those patients survived.
* * *
Twenty-four hours later, Beth was asked to assist with an uncontrollable hemorrhage. The blood bank could not keep up. There were no more products for this patient with a rare blood type, and no more Type O. They’d tried salvaging blood from the operative field and re-transfusing, but she continued oozing. There was nothing more to be done.
Beth declared her death in the OR amid the shock of everyone involved. Young mothers rarely died, and not from something treatable -- unless it wasn’t. Beth offered to speak with the family, but she was needed in another OR, and then another. Both patients died for want of blood products. It made no sense to continue. Beth left the OR.
Upstairs on Labor and Delivery, she learned the same was beginning in England and France. The link to the Middle Eastern Flu was undeniable, and the terrorist glee unfathomable.
The labor board approached illegible, names spilling into the margins. Beth asked about the red underline on many names. “They’re hemorrhaging,” Liz said.
Beth stared, then rebounded.
Consulting with available staff, she confirmed the patients started bleeding only after delivery of the placenta. Then they lost uterine tone and developed DIC--Disseminated intravascular coagulation. Total consumption of clotting factors, causing uncontrollable bleeding until they’re replaced by transfusion.
“So, what if we could remove the uterus before the placenta separated?” Beth said, an idea percolating.
“There’s not enough time,” said a nurse. “Unless they’re really preterm, the placenta delivers almost immediately after the baby. The labors are short, too. It’s like the uterus sprints for a few hours, then passes out.”
A reasonable description, met by lots of nods.
“Then we need to do Cesarean hysterectomies,” Beth said, the picture clearing.
More murmurs, fewer nods. “You mean as soon as they go into labor, we take them for surgery?” asked a nurse. “What patient would agree to that?”
“My patient in fifteen,” a nurse said. “She’s been asking for a section since she arrived.”
“But we still have several bleeding patients waiting for an OR,” said Liz.
“They can go downstairs with the general surgeons. Let’s take the next open room and do this.”
An hour later, the patient was asleep, and Beth was ready to cut. The optimism in the room reassured and terrified her in equal measure.
“I’d forgotten what a dry surgical field looks like,” said the scrub tech. The suction canister was nearly empty. Like the good old days. Beth delivered the baby, a squalling boy with lungs to make up for all the ones who didn’t cry today.
And then optimism fled in a rush of placenta, and an even bigger rush of blood. Beth operated rapidly to clamp off blood flow to the uterus. “She’s in DIC,” said Don, the anesthesiologist. He ordered blood products.
She’d been wrong. This wasn’t the answer. She met Don’s eyes. “It would have happened anyway,” he said. “She’ll lose a lot less since you’re already getting control.” His phone rang. A brief call. “There’s no blood for her.”
Losing less blood was still too much. This wasn’t just a failure to save…this was a kill. She wasn’t bleeding to death when Beth started. “What’s her blood type?”
“I’m the same,” Beth said. “Draw from me.”
The circulating nurse recoiled.
“Use my foot.” She kicked off her shoe, ignoring the looks bouncing between the staff. “Do it, dammit. This case was my idea.”
The nurse shook her head.
“I’ll do it.” Don moved around the bed.
Beth felt her sock removed, the tightness of the tourniquet, the coolness of the prep, the prick of the needle. Same sequence in the other foot, for IV fluids to replace the blood being drained.
Despite the distractions, she completed the operation quickly. Beth’s blood helped the patient form clots. Hopefully the trend would continue and the oozing would subside. But Beth felt no pride in this save. As she stepped back from the table, her head swam. Liz took her by the arm, and led her the back way to the lounge. “Sit.” She hung another bag of fluids, and handed Beth a Gatorade.
“We need to get the uterus out before the placenta separates. But there’s no time,” Beth said.
Don joined them, accepting another Gatorade. “Maybe before labor starts?”
“Maybe.” She gulped down the drink, unaware she’d been so thirsty. “What if we clamped the uterine arteries before delivery?”
Don chewed his lower lip. “Might work. Babies can handle no flow for several minutes at least.” They were both silent for several moments. “Worth a try,” he said and finished off his drink.
Liz stepped from the room, returning moments later. “Ellie Branson wants to volunteer.”
“Ellie?” She was Beth’s friend, she was the nurse at Beth’s delivery, and she was Beth’s patient.
“She’s a good candidate. Early labor. Not bleeding. Viable baby. We’re moving her to the back now.”
In the OR, Ellie reached for Beth’s hand. “Thank you for doing this.”
“You sure you understand the risks? I don’t know that this will work.”
“I trust you, Beth. I know you’ll take care of me and my baby.”
Words that should warm a physician’s heart made Beth’s run cold.
The mood of the OR was more cautious optimism, and Beth’s movements were more deliberate this time. No motor memory for this procedure. To Beth’s knowledge it had never been done. She dissected carefully, making space to clamp both uterine and ovarian arteries. At last she exchanged a look with Don and the scrub tech. “Let’s do this.”
She worked quickly now. Clamped all four arteries, opened the uterus and withdrew a sleepy, but living baby. He’d been under anesthesia too long, but he would recover. She handed him to the pediatrician and began tying off the vessels and structures to remove the uterus.
“Breathe,” Don said.
Beth glanced at the infant warmer.
“I meant you,” he said. “The baby’s fine, and so is Ellie so far. But you’re turning blue.”
She smiled weakly behind the mask and forced a slow, deep breath. He was right. The baby’s scream lightened the weight, but her shoulders didn’t relax until the uterus was out. Ellie had needed no blood products. She hadn’t bled.
It had worked.
In the recovery room, Liz cried openly as she presented the baby to his father while Beth hugged a groggy Ellie. Moments later the happy family cuddled their small but healthy baby. Their first and last.
“You have to broadcast this,” Don said. “It will literally save millions if this is truly a worldwide plague.”
Beth’s chest filled with pride, relief, gratitude. They’d done it. She’d done it.
At the nursing station, she stared at the labor board, still overflowing, rooms doubled up, with names in the margins waiting for space. Alerted by a sudden silence, Beth turned. All eyes were on her chairman, an obstetrician by degree only. He’d not been in an OR in decades, and in this crisis stood in a pressed suit, with a tie perhaps a bit too tight, his red-face bordering on purple, with virtual steam rising from his generous ears.
“I understand you performed an elective operation in the middle of this crisis.”
It wasn’t a question. Beth said nothing.
“You chose to operate on a healthy friend, rather than a hemorrhaging patient.” ‘Friend’ sounded like a swear word.
“We have no blood for them,” Beth said. “They’ll die with or without surgery. I thought it more important to figure out how to save them.”
“And she did,” Liz said, then deflated at his infamous glare.
“Two patients died while you operated on a patient who could wait.”
Beth’s retort caught in her throat, blocking her breath. The conviction in his eyes burned her retinas. She reminded herself they likely would have died anyway…likely.
“One here in the OR waiting for an anesthesiologist. The other downstairs when the general surgeon got in trouble and there was no one available to help. Those deaths are on you.” He turned his back and strode down the corridor, icy stares in his wake.
Beth’s stomach roiled, her confidence wavered.
No, she’d done the right thing. Ellie survived, others would too, someone just had to stand up and make the tough decision. To accept that some were beyond help and to move on to those who could be saved.
The clerk approached the Labor Board, picked up the eraser, and rubbed out a name, Dunn.
A common enough name, Beth’s maiden name.
A stretcher emerged from the OR suites, a sheet shrouding the occupant.
Beth swallowed hard. This death is on you.
“Where’s her family?” the staff member asked the desk clerk.
“She has no family here. I have one more number for next-of-kin.” She dialed the phone.
Beth’s cell began to ring.