Raw Emotion

“29 y/o F presenting with abdominal pain” read the triage statement, the patient name glowing bright red on the main Emergency Department patient board. An indication to all providers that this patient has not yet been seen. Another abdominal pain patient? Sure, I think to myself, I’ll sign up for it. Although there are a hundred possible differentials to consider, at least I have some experience with the workup now. I take a confident swig of my now lukewarm Monster, grab my stethoscope, and head over to exam room 9.

I am one week into my Emergency Medicine rotation at the county hospital, which also happens to double as my first rotation as a 4th year medical student. My plan is to eventually apply to residencies in Emergency Medicine and so I have been looking forward to this experience for quite some time. I consider it an essential opportunity to not only confirm my passion for emergency medicine as a future career choice, but also to gain precious experience in the field. It had only been a few shifts, but I am absolutely loving it. I relish the freedom of taking my own history and physicals, putting in orders, performing procedures, and everything else associated with the fast-paced atmosphere of the Emergency Department. Time flies while on shift and here I am about to see my last patient of the evening.

“Hello there, it’s nice to meet you. My name is Kyle Howarth. I am the medical student on the team, what brings you to the Emergency Department today?” I inquire with my newly minted opening statement. However, as my patient only speaks Spanish, as roughly half of the patient population here does, the interpreter I brought with me translates my question. After a confirmatory exchange from her, I continue on with obtaining her history. She informs me that she had experienced intermittent lower abdominal pain and vaginal bleeding earlier today. I notice that she looks slightly embarrassed to be sharing this with me, but otherwise appears comfortable sitting on the exam room bed, swimming in the large hospital gown provided. I continue with the standard, though of course somewhat awkward, follow up questions and discover that she has not been sexually active in months, but is unsure of when her last menstrual period was. Suddenly she bolts upright, startling the nurse and interpreter next to her. She grabs her abdomen, moans in pain, and a small circle of blood begins to blossom on her gown at the waist. I quickly ask the nurse to grab a pad and am attempting to help her back to the bed when she experiences a large rush of blood with bulky clots, transforming the normal stark white hospital floor into a rapidly enlarging crimson pool…

This is the point where I know that I need help. The words of my resident echo in my head from earlier “if someone is dying in front of you,” he joked, “please come get me immediately.” Well my patient might not be dying, but this is about as serious a situation as I had been involved in by myself. As I hustle down the hallway toward the resident room, the nurse exclaims “Oh! Her urine pregnancy test came back positive!” Jeez, that would have been nice to know a few minutes ago. After what seems like an eternity I arrive at the resident room, find my chief, and in as calm a voice as I can muster ask him if he can please help me with the patient in room 9. While my voice appears calm, my eyes tell a different story and he quickly realizes the seriousness of my request.

I give him the 10 second update along the way and we re-enter the room, donning gloves in the process. My chief immediately puts the patient in a modified lithotomy position. An umbilical cord is visible, and as he applies fundal pressure, a placenta is delivered into our hands. He takes a moment to glance around the floor, pauses a moment, and then stoops down and wraps what I initially thought to be a large clot, but what I now realize to be a tiny fetus, in a blue towel. The realization hits me like a hammer in my chest. My patient just had a spontaneous miscarriage right in front of me.

* * *

A few minutes later, a small group has congregated outside the patient’s room. The nurse manager in the ED explains that someone needs to first explain to the patient what happened and second, outline her options regarding custody of the fetus. She holds up numerous forms to accentuate her point. Oddly enough, I find myself volunteering for this task. This is my patient and as difficult as it is going to be, I know that I need to do this. As I accept this responsibility and take ownership of the papers from her, I realize that I reflexively deepen my voice and assume a serious facial expression in an attempt to display security and confidence in the situation. I briefly wonder if it is convincing anyone, myself included.

As I walk back down the hallway with my chief and the nurse, I think to myself, how in the world am I going to be able to discuss this extremely traumatic situation with this poor woman? Not only that, but how am I going to be able to display the necessary empathy in a language I don’t speak? Every fiber of my being is urging me to turn to my chief resident, ask him to speak with her instead, and assume the natural med student pose in the back of the room, melting into the background.

It’s too late for that now however, and we enter the room. The patient is laying on the gurney, bloody gown still on, and barely maintaining her composure. I hand her a warm blanket to cover herself and wheel a stool over to the side of the bed as the others file in behind me. Am I sitting too close? Not close enough? There really is no blueprint for this situation and I decide that it is time to begin. In a soft voice, I look into her trembling eyes and slowly start to explain what has happened. With every word I try to convey the sorrow that I feel for her. To validate the traumatic situation she has gone through. But this first part is difficult for her, and tears begin to form at her eyes. The interpreter relays to me that she was unaware that she was even pregnant. I wait a moment, reach over to take her hand, and then continue. The room is completely and absolutely silent except for our conversation. The resident and nurse stand still against the wall as I talk. She asks what will become of the fetus and I outline for her that she has the option of taking custody for her own burial purposes or that the hospital can assume ownership, should she prefer. I can see that this decision is overwhelming for her in this moment and suggest that she take some time and perhaps discuss with a family member. Wiping tears from her eyes, she nods, and supplies me with her sister’s contact information. I once more express my sadness that this has happened to her and exit the room.

* * *

I pause in the hallway and take a deep breath, trying to keep my own emotions at bay. Okay, I think to myself, at least that should be the most emotionally draining part of this day. However, this turns out not to be the case. The nurse manager strides over to us once more and informs the resident and I that an estimated gestational age needs to be determined and is required for documentation purposes. Now apparently, the easiest way to do this is to weigh the fetus to determine a rough GA. We borrow a newborn scale from the Peds ED next door and wheel it over. Quickly we realize our first dilemma. This is an overcrowded Emergency Department swarming with doctors, nurses, and patients at every corner and every exam room is full. We can’t just start weighing miscarried babies in the hallway amongst this chaos, that would be ludicrous, not to mention highly unethical. A swift brainstorm leads us to a supply room where at least privacy should be able to be maintained. We push the scale in, close the door, and once again we are surrounded by silence as our eyes both slowly turn towards the specimen container now sitting on the counter.

I remove the lid of the specimen container and for the first time I get a good look. I realize that it really is a formed fetus, with arms, legs, developing bowel protruding from the belly, and a relatively larger, swollen head. A person’s brain often goes to strange places at times like these and my first thought is that it looks like a tiny alien, like some poor rendition that a low budget movie would make. The resident looks up at me and says “we need to put it on the scale.” Now, up until this moment I was fine, I was doing my job in this situation to the best of my abilities and I consider myself usually able to handle tough circumstances. But it really hits me when I have to lift the fetus out of the container and put it on the scale…this is a hard moment for me and for a second I almost lose it. The tiny limbs and engorged head…it’s absolutely heartbreaking. But I continue on because I tell myself that this needs to be done and it is my responsibility. With the weighing complete, the resident silently wheels the scale back to the Peds ED, leaving me alone in the supply room with the fetus I had just put back into the specimen container. I lean over and rest my hands on the counter for support, lower my head, and close my eyes. In part out of respect, but also because that’s all I can handle at this particular moment. I also say a quick prayer for the former life in front of me and the woman down the hall. Wow, I murmur as I open my eyes and stand up straight again, just wow.

* * *

In the days following, a myriad of thoughts flowed through my mind. Could I have performed differently? How is that patient coping right now? However, amongst the questions, I also felt a sense of pride at being involved and of taking ownership of my patient. Yes, this was a traumatic experience for all involved, but in a strange way, I want to be involved in these situations and they are a part of why I look forward to be

coming an Emergency Medicine physician. I want to be there in that moment. That moment where everything is falling or has fallen apart, and hopefully have the skill set to handle it and the compassion to take care of the human in front of me. I believe that experiencing those moments of pure, raw emotion is what really experiencing life is. Other stressors become superfluous and it provides incredible perspective on life, how fragile it can be, and what is actually important.

Of course, I will never forget my patient delivering a tiny fetus onto the floor in front of me, it’s not something that one forgets easily. But the image that will be cemented in my mind forever is being alone in that supply room, leaning over the counter, and just letting those emotions flow through me.

Whose Behind This Story

Kyle Howarth is a fourth-year medical student at the University of Arizona College of Medicine – Phoenix and interested in obtaining a residency in Emergency Medicine. Originally from Sacramento, California he attended UC Davis and graduated with a B.S. in Exercise Biology. In his spare time, Kyle enjoys playing soccer, basketball, and flag football, along with settling down to read the latest Vince Flynn spy fiction thriller. Remaining close with his family and friends, he credits them with his personal development as both a medical student and member of the community.