Audible Bleeding
by Mike Litrel, M.D.

Then the bleeding worsened.

I waited with growing anxiety for someone to answer my pages for assistance. As the patient's husband and the nurse looked on, 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, splashing into a bucket on the floor. There had been a macabre joke that had gone around during medical school - "Audible bleeding is a bad sign."

Now I knew it had not been a joke.

The nurse was growing agitated, too. When a Grady nurse, impervious to emergencies and jaded after a lifetime on Grady's halls, begins to get nervous, it's a bad sign. She also called for help on the intercom. The patient's husband could tell that things weren't going well.

I began to wonder if becoming a doctor had perhaps been a flawed career move. At that moment I could have been quietly and serenely shuffling papers at a nice desk in a freshly pressed shirt and tie, not standing in a cold operating room, clothes and shoes covered with blood, desperately trying to save a woman who was rapidly slipping into shock.

Finally I heard voices in the hall. Help had arrived! I could hear William, my Chief Resident, and Dr. Morgan, the attending professor on call, 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 - an exchange 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. Morgan took one look at me in my surgical gown, soaked 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. "William, take care of this." And he turned away without so much as a backward glance.

It took some time before William 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 William how the other emergencies had gone, he was confused. He had been off the floor with administrative duties. Stephanie, the third year resident, had been in charge of labor and delivery.

I found Stephanie eating strawberries in the doctors' lounge, watching her favorite 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 paging for help in a temporary panic and would eventually figure it all out.

At 8 o'clock that night, my first day as a doctor ended. I crawled slowly into my car, aching like the victim of a street beating. As I drove home, I realized there was no prettier sight than Grady Hospital, seen through a rear view mirror.

The road before me was dark, and I had no map to tell me the correct route. Like so many of us, I would not see why I was here until I had the perspective of time, many years later. What did God have in mind for me now?

This article is a reprint from a prior issue of The TowneLaker.

Dr. Litrel is a surgeon in private practice with Cherokee Women's Health Specialists in Canton and Towne Lake. He is a Clinical Professor at Emory Medical School and the Medical College of Georgia. Dr. Litrel lives in Towne Lake with his wife Ann and their two sons, Tyler and Joseph.. E-mail: mikelitrel@comcast.net.

It was the first day of my internship, July 1, and I was embarking on my four year residency at Grady Hospital in Obstetrics and Gynecology. Bearing the light green badge which declared me officially a resident - no longer a medical student - I presented myself to Labor and Delivery. I felt a jumble of emotions - confidence, eagerness, and a little fear.

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

The Labor and Delivery team consisted of four residents: a second year resident, a third year, a fourth year (called a 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.

She had just killed someone. "Yup - I sliced his throat from ear ta ear," she declared. She expressed not a trace of remorse. I realized that the blood covering her clothes and obviously pregnant belly belonged to someone else. Then I noticed that she was handcuffed to the exam table. The two large guards stationed outside the door were not standard fixtures.

Stephanie, 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. She made no move to follow 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 respond to my call for 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 placenta. I knew that 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.