|Lori Ludeman, MD||University of California, Irvine, Department of Emergency Medicine, Irvine, California|
Two months into my intern year I experienced something that I thought only happened on television. It was 3 a.m. on a relatively uneventful night shift. Being one of the newest residents working that evening I expected to get the less desirable cases, and this one felt no different. A new patient showed up on the grease board: a 22-year-old female with a chief complaint of constipation.
“Sounds like a perfect intern case,” said my co-R2, “nothing like a mid-shift fecal disimpaction.”
As one could imagine, my expectations of something remotely interesting happening were fairly tempered. But knowing your role is important, so I marched into the patient’s room to see what was going on.
As I entered the room I found the patient’s mother sitting in the chair and giving off an air of no apparent concern. She nonchalantly informed me that her daughter was in the restroom. The patient had fortunately been given the “Communicable Disease” room, so she was in the only room in the department with a private bathroom. At the time it seemed rather appropriate for a constipation case, but otherwise I thought nothing of it.
That was until I told the patient that I would come and check on her when she was out and we could do an exam. The patient sounded quite concerned and yelled through the bathroom door, “Please don’t go!” She continued, “I haven’t gone to the bathroom in a week and I feel a lot of pressure down there. Something is wrong, something is happening!”
I felt somewhat confused at this point for what my next step would be because I figured she was just constipated and was finally able to go to the bathroom. However, she sounded legitimately scared so I knew that there must have been something more going on. I grabbed some gloves and announced that I needed to come in to make sure that she was okay.
When I entered the bathroom this young woman did not seem relieved to be getting over her constipation, but was instead screaming in apparent agonizing pain. I had just finished a month on an Ob-Gyn rotation and I was quite familiar with the face she was making. To me, it looked like she was in labor.
“Is there any chance that you are pregnant?” I asked when I made the connection. The patient responded with a fairly authoritative “no.” However, as soon as I lifted up her gown, lo and behold, there was a fetus’ head crowning and about to be baptized in the toilet bowl. It is unclear who was more shocked, this young woman or myself, when I exclaimed that she was not only pregnant, but was giving birth at this very moment. Luckily my prior month in labor and delivery was fresh in my mind, so I reacted immediately and carefully guided out the baby’s head and lifted it from the toilet.
The patient was flabbergasted, the mother was beside herself, and I was getting over my disbelief that I had just delivered a baby in a bathroom to a woman who didn’t know she was pregnant. I yelled for the Emergency Department (ED) nurse who entered the room just as surprised as to what was going on as the rest of us. I instructed the nurse to grab the attending physician and two clamps. We cut the cord, and the charge nurse brought in the warmer. The Neonatal Intensive Care Unit nurses and the OB team were there momentarily to assist. The baby had Apgar scores of eight, nine, and besides its existence being a complete and utter mystery five minutes prior, seemed perfectly healthy. We then finished the delivery of the placenta, and but for the unorthodox nature of the experience, there were no physical complications.
The complete spontaneity of this experience encapsulates emergency medicine for me. There is just something unique about the specialty. Every day can be an adventure and arriving at work you do not know what the next twelve hours will bring.
While this particular patient encounter was exciting, it also serves as a microcosm that demonstrates the challenges our healthcare system faces as a whole. It is baffling to most that this type of health illiteracy could possibly exist, yet the emergency department comes across patients like this regularly. Your average individual cannot comprehend how a woman could go through an entire pregnancy seemingly unaware of what was happening to her body, yet the structure in place for this woman seemingly fostered her ignorance.
After the emotion and excitement of the unexpected delivery had died down, I went and spoke to the patient about how it came to this. She freely admitted that she felt as if something was wrong for a few months but was unable, or at times unwilling, to see a physician. The patient explained that she could not retain a regular primary care doctor due to a lack of insurance. Additionally, she had often gone to clinics and low-cost urgent care facilities, only to be shuffled about without any substantive medical attention. She informed me that regardless of the attempts she had made to obtain care, she always ended up in the emergency room as that was the only place she felt able to get a competent diagnosis despite her income. However, she was even reluctant to take this route due to the constant fear of receiving an oppressive bill she would be wholly unable to pay. It is unfortunate that we have people in this country who are forced to gamble with their health in this regard. Emergency departments throughout the nation must bear this burden to serve as the medical safety net for patients such as these.
The ED welcomes patients of all ages, genders, socioeconomic status, and disease processes. No matter who walks through the door you need to be competent, professional, and most importantly, ready for anything. We work closely with not only the other doctors and nurses, but police, firefighters, EMTs, and social workers. It is the quintessential team effort and you need to learn to respond, react, and effectively and efficiently lead when called upon. I believe emergency medicine is the most exciting practice area out there and feel so fortunate to be a member of the emergency family.
As it turned out, my apparent fecal disimpaction proved itself to be a fetal delivery worthy of I Didn’t Know I Was Pregnant, and I do not think many other jobs can say that. I know that I have chosen the right career for me. This story just proves that the life of an ED physician can be fun, unique, and occasionally stressful. But ultimately there is nothing more rewarding as far as I’m concerned. If only someone would think to make a television show about the emergency room. Seems like it could be a hit.
Full text available through open access at http://escholarship.org/uc/uciem_westjem
Address for Correspondence: Lori Ludeman, MD, 837 Gladys Ave., Long Beach, CA 90804. Email: firstname.lastname@example.org. 9 / 2014; 15:627 – 628
Submission history: Revision received July 16, 2014; Accepted July 17, 2014
Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.