Audible Bleeding
by Mike Litrel, M.D.

placenta. I knew that much - it had to come out, for the bleeding to stop. The patient did not have an epidural. When I reached in to extract the placenta, she screamed. Then the bleeding really got started.

As I waited in growing anxiety for someone to respond to my pages for help, I desperately pressed down on the patient's uterus in an attempt to slow the bleeding. You could actually hear the blood pouring off the operating room table, into a bucket on the floor. There had been a macabre joke that had gone around during medical school - something like, "Audible bleeding is a bad sign."

It suddenly came to me that it had not been a joke.

Now the nurse was getting agitated, too. When a Grady nurse, impervious to emergencies and utterly jaded after a lifetime on Grady's halls, begins to get nervous, it's a bad sign. She, too, began to call on the intercom for an upper level resident. The patient's husband could tell that things weren't going well. Aside from all the blood, there was the color of my face, which I think turned green after my heart rose up in my throat 10 minutes before.

I began to see that the idea of becoming a doctor had perhaps not been my smartest career move. At that moment I could have been sitting somewhere shuffling papers on a nice desk in a freshly pressed shirt and tie - not standing in a cold room, clothes and shoes covered with blood, responsible for a woman who was rapidly slipping into shock.

There had to be a better way to earn a living.

Finally I heard voices in the hall. Help had arrived! I could hear Tom, my Chief Resident, and Dr. Randall, the Residency Program Director, speaking together just outside the door. I assumed they were wrapping up the emergency matters that had been occupying their attention the past half hour, but gradually it became evident that the tone of the conversation was decidedly casual - a few snippets about call schedules and so on...

I couldn't take it any longer. I opened the door. In the most professional voice I could muster I said, "I could use some assistance here."

Dr. Randall took one look at me in my surgical gown, literally drenched in blood, and exclaimed, "Good Lord!"

His next motions, I knew, would be to throw off his jacket, don his scrubs and rush in to save the patient.

But I was wrong. He gestured to my Chief. "Tom, take care of this." And turned away without so much as a glance backward.

It took some time before Tom could bring the bleeding under control. "Gosh, Mike, this just isn't normal," he kept saying. He called for surgical instruments I had never heard of, and performed a procedure I had never studied. Eventually, he stabilized the patient and the bleeding stopped. She would be fine, but would require a blood transfusion and a prolonged hospital stay.

When I asked Tom how the other emergencies had gone, he was confused. He had been off the floor with administrative duties, and Valerie had been in charge.

I found Valerie eating strawberries in the doctors' lounge, watching her soap opera. Did I want a strawberry, she asked me. No, I said, pointing to my blood-soaked garments. I was going to change. She shrugged her shoulders and resumed watching her soap.

As I changed my scrubs in the locker room, I struggled to make sense of what had just happened. It took a few moments to piece it together, and then a wave of anger flooded over me. I had been initiated into Residency - the Grady way. Without even checking on the patient, the third year resident had assumed that the Intern was just panicking, and would eventually figure it all out.

At 8 p.m., I ended my first day as a doctor. I crawled slowly into my car - like a beating victim in a street crime - and as I drove home, I realized there was no prettier sight than Grady Hospital, seen through a rear view mirror.

I wasn't in Kansas anymore.

Dr. Litrel is in practice at Cherokee Women's OB/GYN in Woodstock and Canton and is a Clinical Assistant Professor at Emory University School of Medicine. He lives in Towne Lake with his wife Ann and their two sons Tyler and Joseph. (mikelitrel@attbi.com)

It was July 1, the first day of my Internship.

I had looked forward to this day ever since my third year in medical school. During that year I had spent a month in Labor and Delivery at the hospital, delivering a dozen babies. And I had discovered my calling. The moment I held that first baby in my hands, I knew I'd found what I wanted to do for the rest of my life - I wanted to be an obstetrician.

So July 1 found me embarking on a four-year residency in OB/GYN at Atlanta's Grady Hospital. Bearing the light green badge which declared me officially a resident - no longer a medical student - I presented myself to Labor and Delivery. I was a jumble of emotions - confidence, eagerness, a little fear.

I found out later I was on the right track with the fear part. Terror might have been more accurate.

The Labor and Delivery team consisted of four residents - a second year resident, a third year, a fourth year (called the Chief in the final year of training), and me - the lowly Intern. My job was to evaluate people in the triage room and decide if they needed to be admitted. If they did, I signed them out to an upper level resident, who would oversee their care and make sure no mistakes were made. I also got to do routine vaginal deliveries and C-sections, under the guidance of the Chief.

By lunchtime that first day, I had evaluated a dozen patients and delivered a baby under supervision. As I ran from patient to patient making assessments, my confidence grew. I really was a doctor. This was going to be great.

Less than six hours later, I encountered a clue that my next four years might not be all I had dreamed of. One of my patients in triage was unusually agitated, and as I took her history I found out why.

She had just killed someone. "Yup, I sliced his throat from ear ta ear," she said. I looked with no success for a trace of remorse. That's when I realized that the blood covering her clothes and obviously pregnant belly belonged to someone else. And that she was handcuffed to the exam table. It seemed that the two large guards stationed outside the door were not standard fixtures.

Valerie, the third year resident, suppressed a yawn when I told her what was going on in the triage room. "Murder is not clinically relevant - how dilated is her cervix?"

She sent me to the operating room for another delivery. I noticed she made no signs of following me to supervise. I asked her if I was to do only my second delivery of Internship alone. "What? You still need my help?" she asked incredulously.

Apparently not. "No, I'll be alright."

The baby delivered without difficulty. But the placenta - the organ connecting the baby and mother - didn't follow. I began to worry. The patient began to bleed heavily. I asked the nurse to call an upper level resident. The patient continued to bleed. I called for help again. No one came.

I was surprised. There must be some kind of serious emergency going on for no one to arrive to help. Maybe a couple of quadruplet deliveries, or a multiple-car accident involving a half dozen pregnant women.

It was up to me to handle the emergency. My heart was beating like a drum. I took a deep breath and told myself to relax and be professional. I decided I would manually extract the