Shock To The Senses

One of the many unique features of life in the Emergency Department is the variety of sensory assaults we experience.  Much of our pattern recognition of illness, injury or just life situations are fed by more than one source of information from patients.  Of course, we put a lot of time into listening to patients symptoms and hearing what matters to them, but we learn a lot from how they look, as well as how they feel when we examine them.  The sounds and smells around the Department also give us clues to what might be going on. 

There are the various tones and alarms of monitors and public address systems, the broken accordion wheeze of an asthmatic, the staccato rhythm of cardiac compression devices, the sucking clunk of a prosthetic hip being relocated, as well as the unique aromas of all blood (arterial fresh to days old), the sweet ketones of a diabetic patient, and the pungent eye-crossing smell of released pus, to name but a few. 

The expression and cadence of pain is widely variable also, and it was this that alerted us to Mel one Tuesday morning.  Mel was in her first year at University, and, her flatmates told me later, she had had a fairly wild time over the last 10 months or so.

They had brought her to the ED with severe abdominal pain.  This had been there for about 4 hours, and had kept her up through the night.  She is howling with pain one minute, then seemingly calm the next.  We tend to refer to this as colicky pain - rising in severity for a period of time, then settling down to nearly, but not completely, gone.  It is usually caused by something blocking a hollow structure, like a gallstone or kidney stone.  One of the first things we ask all ladies of a certain age is whether they could be pregnant. 

"Of course not".

Whilst we like to believe all our patients at face value, it would be intrinsically unsafe if we did so without at least considering (and sometimes testing for) clinical possibilities that could cause harm to them.  Unknown or unappreciated pregnancy is one of these conditions, except of course there could be (at least) 2 patients to consider.

We get an intravenous drip into her to administer some pain relief and check some blood tests, and her pain rises in severity again.  This culminates in a sharp yelp and a gush of fluid down below.

"I've wet myself - what's happening? Help me! Aaaagh."

I'm on the brink of doing the same - a quick look confirms our suspicions that Mel is indeed not only pregnant, but rapidly about to become a mother.  Her colic was following the unmistakable pattern of labour.  There is not an awful lot of time to appraise her of the situation.

"Well Mel, it looks like you are about to have a baby." (I refrain from the usual congratulations).

"I can't! I won't!"  She is clearly in terrible physical and emotional turmoil, but the priority is to get this baby out safely and to keep her well and comfortable.

Without any of the usual ante-natal checks or care, there is no telling how straightforward these two tasks may be, or how near term the baby is.

We have world-class neonatal and obstetric teams in Lothian, but they are nearly half a mile away from the ED, and the baby's head is crowning in front of us.

We put out a neonatal emergency call through our switchboard and get some equipment prepared for delivery.

"Sorry Mel, this baby's coming out - you'll need to listen to us and accept what's happening just now."

We give her some pain relief, position her to deliver, and help her through the contractions to ease the baby out.  5 minutes after calling them, a team of what must be 15 people lugging lots of neonatal equipment arrive into a room designed for a maximum of 10.

My first job is to try and limit the number of people in the room so that we don't end up in a circus of confusion.  This is where "fetch hot water" becomes very useful, giving well-meaning people stuff to do elsewhere, and streamlining the team.

Some relative calmness descends on the room, the labour progresses with the agonising pattern of contractions broken by the quiet sobbing of realisation for Mel, and culminating in the unmistakable ubiquitous joy that comes with the birth of a healthy baby, and all the sensory overload it brings squawking into the world.

We all breathe a sigh of huge relief, not only because the clinical outcomes are good and we made the right decision not to transfer Mel to the labour unit, but also because Mel leaves the ED with her "Unknown Baby" wrapped in her arms, and seemingly starting the bonding process.