By Luke P. Burns, MS4
Elevated blood pressures are an important omen of brewing pre-eclampsia in pregnant women.
As vascular remodeling in the placenta goes haywire, microthrombi block up blood vessels and prevent adequate perfusion of vital organs. Blood pressure rises to dangerous levels, the patient suffers from an intractable headache and organ systems fail one-by-one.
An acute, persistent systolic blood pressure over 160 mmHg is worrisome enough for obstetricians to recommend immediate treatment with antihypertensives. Often the only recourse is delivery.
When Ms. R came in for her outpatient visit, her systolic blood pressure was well over 200 mmHg. She adamantly denied using drugs at any time during her pregnancy, but a urine toxicology screen was positive for methamphetamines.
I was several weeks into my sub-internship on the Maternal Fetal Medicine service when I met Ms. R. When we saw the elevated blood pressures, my resident begged her to go to hospital. The perinatologist attending joined him, describing the risks of preeclampsia, the stroke and fetal demise that accompanied numbers so high. I could see how frustrated they were. This woman’s reluctance to be admitted was killing her baby, but also killing herself. When Ms. R left the office with a prescription for more nifedipine and a vague promise to follow up, I could tell that both physicians felt like they had failed her.
The resident buried his head in his hands, slumping forward on the desk. “She’ll be dead within a year.”
The next day my resident and I were back on the inpatient service, halfway through rounds, when we received a page. It was Ms. R, and she had decided, reluctantly, to come to the hospital to be admitted.
As I checked in Ms. R and performed a physical exam, I praised her for making the right choice to come in to the hospital. She rolled her eyes and waved away my platitudes.
“I only came in because I wanted you all to quit bugging me,” she said. But as I struggled to find any amniotic fluid on the ultrasound, I noticed her peering nervously at the screen.
Whether it was the vasoconstrictive properties of the methamphetamine or true pre-eclampsia, something was preventing adequate perfusion of her placenta. The 27-week-old fetus it supplied was being choked of a blood supply.
The decision was made to proceed to immediate cesarean section. In the mad jumble of consultations and consent forms that precede every hastily-scheduled surgery, a voice rose above the crowd.
“Does anyone know if Ms. R wants a tubal?”
Tubal ligation, the most permanent form of contraception, is a simple procedure during a cesarean section, and is something we offer every patient, regardless of age.
No one was sure, and the team was about to move on to discuss the details of the surgery when I raised a hand.
I knew that Ms. R wanted the procedure. One of the first things she had told me when we met was how adamantly she wanted her ‘tubes tied’, how the Catholic hospital that delivered her last child had refused to perform this procedure on moral grounds, how this current pregnancy was unwanted, how she was homeless and barely able to support herself, let alone more children.
The attending turned his attention on me. So where was the consent form she was supposed to have signed, weeks ago, to this effect?
Due to the permanence of tubal ligations, mothers in California are required to sign consent long before the procedure takes place, allowing them enough time to think about such a serious decision. Without this prior permission, the tubal ligation could not happen even if the patient was now requesting the procedure. Now on the day of Ms. R’s surgery, she might once again be denied the tubal ligation.
But I had prepared for this. Earlier in the day, I had called up Ms. R’s outpatient clinic and requested the completed consent form be faxed over. I had thought nothing of it at the time. It was a standard medical student task and just one of a dozen other checkboxes on my to-do list that morning.
But the resident was ecstatic. “You probably just saved this patient’s life,” he told me. I was baffled. Why was he getting so worked up over a bunch of paperwork?
The cesarean section went beautifully. Holding retraction in the operating room, I caught a glimpse of the tiny infant as he emerged. In the hands of the pediatricians I could not help thinking he looked like a shriveled old man, eyes glaring up at us like he had been woken up too early from a deep sleep.
Ms. R recovered without issue, and her blood pressures went back to a normal level. She checked herself out of the hospital two days later, leaving her infant behind, still intubated and on a feeding tube.
I didn’t think about Ms. R for a long time after that. A few months later, I noticed her name on a patient list. But she wasn’t the patient.
It was her son, K. He had been assigned as my patient on the first day of my rotation in the neonatal intensive care unit, or NICU. He was still tiny and still on a feeding tube, but he was growing well. He was so premature that he had not even reached his scheduled birth date yet.
I felt so sorry for K. Born to a mother who clearly did not want him, nobody could be certain what kind of neurological issues he might have in the future, or even if he would survive his stay in the NICU. I knew that Ms. R had faced horrendous challenges herself, but I could not help quietly cursing her for abandoning him, for what she did to him, for what she exposed him to. How could someone do this to their own child?
And then one day, Ms. R was there.
Accompanied by her social worker, we met in a family conference room. I did not expect her to remember me, but her eyes grew wide when I walked in and she smiled with recognition. She looked wonderful. Her clothes were neat, her hair was combed, and her face was calm and peaceful. She told me her life had changed since K’s birth.
“I dumped his dad, quit the drugs and checked into a women’s center. I’m getting clean and they’re going to let me take K home when he’s ready.”
Suddenly, I remembered how my resident had reacted when I produced Ms. R consent form for the tubal ligation. Ms. R had not wanted to be pregnant. Her pregnancy had nearly killed her. I understood my resident’s triumph. Now, finally, an intervention had been performed that would allow her to break the cycle of poverty, pregnancy, dependence and abuse. This experience had changed her, had allowed her to reach a period of stability in her life. She was taking control, living for herself, and setting her own rules. She was the master of her own destiny again, and not beholden to a man who had refused to visit her in hospital, even as she nearly died carrying his child.
The task of filling out some paperwork had seemed so mundane, so quotidian at the time. As a medical student, sometimes these tasks are the only ones I am really qualified for. Surrounded by men and women with such advanced training, it can be hard to feel like I can have an impact.
But this little task had a gargantuan, life-altering impact. Faxing some paperwork had changed Ms. R life. Medical students do not need to wait until they graduate to start making a difference for their patients. A single kind word from a trainee, or an extra five minutes of listening may transform the entire experience of sickness and death for another human being.
So my advice for any students doubting their role on a medical team: know that you can change a life, no matter how insignificant you may feel.
And get good at sending faxes.
*All names in this post have been changed to respect the privacy