Richard Mabry - Code Blue

She saw Harshman's mask move as he opened his mouth to respond, but that response never came.

A nurse holding a phone message slip hurried into the room. "Dr. Harshman, your OB patient, Karen Pearson, is in the emergency room. She's cramping and spotting. What do you want to do?"

For a moment, Cathy thought Harshman hadn't heard. He picked a pair of blunt-nosed scissors offthe instrument tray beside him and began dissecting in the depths of the operative site.

Just as Cathy was about to speak, Harshman looked up from his work. "I know you've seen her, Dr. Sewell. You know about her case. Now she's at term and she's bleeding. The baby's a breech, so I'd scheduled her for a C-section. What would you do?"

"Is there any sign of fetal distress?"

The nurse didn't seem to know whom to address, so she swiveled her gaze between the two surgeons. "Fetal heart tones were one fifty when she came in. They've dropped to one ten."

Cathy didn't hesitate. "This could be an abruptio placenta or a prolapsed cord. Whatever the cause, there's definite fetal distress. She should have a stat C-section."

Harshman nodded once, then turned to the nurse. "I can't leave this patient. Is Dr. Gaines available?"

"He had to drive to the hospital in Bridgeport to handle an emergency there." The nurse didn't throw up her hands, but her voice conveyed the same message.

"Cathy, how many C-sections have you done as surgeon?"

"More than half a dozen-fewer than a dozen. And I've watched and assisted on maybe ten more."

"Contact Dr. Steel," Harshman told the nurse. "Tell him I need him to scrub up and assist me in finishing this case. Then call Dr. Bell. He'll have to scrub with Dr. Sewell. She'll be doing an emergency C-section on Mrs. Pearson."

Cathy bent over the hospital bed, struggling to make her voice comforting and confident at the same time. "Karen, you need an urgent C-section. The baby is in trouble. Dr. Harshman's in surgery and can't drop out. He's asked me to do it. The nurse has told you what it involves, the risks involved. Will you give me permission to do the case?"

Karen Pearson looked up at Cathy. Despite her grimace of pain, there was serenity in her eyes. "Of course. I've been praying that you'd deliver my baby. I didn't really want it to be an emergency, but if that's what it takes, I'm okay."

Cathy nodded to the nurse who stood at the head of Karen's bed. "As soon as the permit's signed, get her up to surgery." She looked down at Karen again. "I'll do my best for you."

"That's all anyone can ever do," Karen said through clenched teeth. "Remember that."

In the women's dressing room, Cathy exchanged her sweat-sodden scrub suit for a clean one. By the time she strode into the pre-op holding area, the anesthesiologist had wheeled Karen into the operating room. He turned and asked, "Epidural or general?"

Cathy didn't hesitate. "No time for an epidural. General. I want her under the moment I'm gowned and ready."

Marcus Bell hurried up, pulling on a surgical cap. He picked a mask out of the box above the scrub sink. "Fill me in. All I know is that you're doing an emergency C-section on one of Arthur Harshman's patients at his request, and you need me to assist."

Cathy adjusted her own mask and began the scrubbing up process that numerous repetitions had made automatic. She explained the situation to Marcus, who, to his credit, listened without interruption or argument.

"When was the last C-section you did?" he asked, when Cathy had finished her explanation.

"Not quite a year ago."

"That's about five years ahead of me. Do you recall all the details?"

She replied with more assurance than she felt. "I know enough. Between us, we'll get through it. We have to. That woman's baby is struggling-fetal heart tones down to ninety now-and we have to get her delivered."

This was it. Go time. Cathy looked around her. The anesthesiologist stood by at the head of the operating table. Dr. Denny, the pediatrician, sat in a corner, ready to take the baby. Marcus took his place across from Cathy, his eyes conveying no message at all. Karen lay on the operating table, her bulging belly tinted a strange orange-brown by the prep solution and outlined in a surreal square by the green draping sheet.

"Everybody ready?" Cathy paused. "Karen, we'll take good care of you and your baby. I promise." She nodded at the anesthesiologist. "Let's go."

In a few moments, Karen was under. The clock had started to run. Cathy had less than ten minutes to get the baby.

"Fetal heart rate?" she asked.

"Holding at a hundred."

Cathy had a decision to make. Did she have time to make a low "bikini" incision across Karen's abdomen or should she save precious minutes by using the long vertical incision employed years ago? Cosmetic result or safety for the baby? Plastic surgery could minimize scars. If she were on that table, she'd say, "Hurry. Save my baby."

She reached out her hand. The scrub nurse slapped a scalpel into it. "Vertical incision." Cathy fixed Marcus with a look that she hoped carried the authority she didn't feel."Get a sponge in one hand, cautery in the other, keep up with the bleeding."

"But -"

Cathy's eyes dropped to the operative field. "Marcus, I have a reason for everything I do, but I don't have time to explain. I'm the surgeon. Help me. That's what assistants do." he plunged the scalpel into the taut flesh of Karen's abdomen. As layer after layer yielded to her dissection, SCathy wondered if her words had offended Marcus. She was surprised to realize that she didn't care. Her priority right now was to do what was best for Karen Pearson and her baby. She'd worry about her relationship with Marcus and all the other doctors on the stafflater. If practicing good medicine and putting the patient first got her ridden out of Dainger on a rail, so be it.

"Down to the uterus. Let's get a self-retaining retractor in."

As he had since her initial exchange with him, Marcus complied without comment. To his credit, he'd been an excellent assistant, anticipating her moves and working in smooth tandem with her.

"I'll make a low fundal incision, then extend it with scissors. The presentation's a footling breech. I know how to do the extraction, but I'll need a second set of hands to do it."

She sent a look at Marcus. He nodded once.

"Fetal heart rate has dropped to eighty-five."

"Here we go," Cathy responded.

Cathy let reflexes, muscle memory, and hours of midnight study take over. In seconds, the uterus was open, the amniotic sac incised, and she reached for the baby. "Dr. Denny, are you ready?"

The pediatrician moved closer to the table. "All set."

The information flashed through Cathy's mind like the words on an electric sign. The largest part of a baby is the head. For a C-section, make the incision big enough to deliver the head and there's no problem with the rest. In this case, the baby's legs would come out first, the head last. She'd have to guess at the incision size. Halfway through the extraction, Cathy saw that her incision hadn't been large enough. "Scissors." She held out her hand, palm up, and felt the firm slap of the instrument.

"Do you-?"

Her eyes never left the operative field. "Marcus, I know what I'm doing."

"Fetal heart rate is eighty."

The words spurred Cathy on. She dropped the scissors and slid her hand down along the baby's head. Words memorized by rote now were turned into action. Hand onto the face, finger in the mouth. Turn a bit. "A little more traction on the legs please."

There! The baby was free. And there it was-a prolapsed umbilical cord, a kink that cut offthe blood supply from mother to child. Cathy clamped and cut the cord and handed the baby offto the pediatrician.

As she worked to complete the procedure, her ears waited for that most wonderful of sounds, the cry of a newborn. There was the gurgle of the suction bulb as Dr. Denny cleared the baby's mouth and nose. A moment of silence, then more suctioning. She was aware of murmuring between the pediatrician and the nurse assisting him. As Cathy was about to turn back toward the bassinet, she heard it. Faint at first, then stronger. The insistent cry that signaled a healthy set of lungs.