Are We Too Late?
A doctor and a family grapple with life and death
By Henry Lowe
Carl was already sound asleep when the pager attached to his waistband beeped. Reluctantly, he left his rosy dream of a buffet dinner with his wife, and returned to the reality of the dimly lit office where he was taking respite after a difficult caesarean. The luminous dial on his wristwatch indicated 2:10 am. He stretched out his hand for the telephone beside the sofa and dialled the unfamiliar number shown on his pager.
The voice that answered was that of his first call resident, Nikki. “Carl, urgent consultation at A&E. Come to cubicle 6 right away. I think we have a ruptured ectopic in shock!”
In an instant, Carl was fully awake. He ran down the three flights of stairs to the A&E department on the hospital’s ground floor. Even at this time of the day, it was business as usual: entering through the swing doors to the hall-like space, he found scores of people waiting on the benches to his right, with a couple of nurses busily working at the triage station in the middle. Several occupied stretchers and wheelchairs lay in the surrounding corridors, waiting to be brought either to the wards or to vacated cubicles. To his left were eight cubicles, each hidden behind drawn curtains.
He found cubicle 6 quickly and asked, “Nikki, you here?”
“Come in, Carl!”
He pulled back the curtain. Lying on the bed was a blanket-draped teenaged girl with her eyes closed, pale as a sheet, taking shallow, rapid breaths. Nikki leaned over her right side, trying desperately to insert an intravenous cannula into a vein in her forearm. The two puncture holes on the back of the girl’s hand and lower forearm told Carl that this was Nikki’s third attempt. On the other side stood Paul, a colleague from the A&E department, who was attaching gum labels to three blood specimen tubes and writing on the request forms, including a blood typing and cross-matching form. Bending over the teenager’s pelvis was a petite nurse, pressing with her whole body weight on a wad of gauze over the patient’s left groin. Carl then knew that they had only managed to obtain blood specimens from the femoral vein coming from the leg. This meant that other peripheral veins were collapsed, inaccessible for blood sampling. A sure sign of shock.
Nikki started to report without looking up from her task, “Ying, age 15, no history obtained, found unconscious at home about an hour ago and brought here in a taxi by her parents Mr. and Mrs. Tang.”
Paul continued, “Already in shock at presentation about eight minutes ago. No history of trauma, nor evidence of external bleeding. Rectal examination and Ryle’s rube aspiration are negative.” He looked up at Carl. “Take a look at her abdomen!” He took over from the nurse the task of applying pressure with the gauze wad on the femoral vein. At the same time, he motioned to the nurse to send the blood specimens straight to the laboratory.
“Got it!” Nikki shouted. She had successfully inserted the intravenous cannular, connecting the free end to a three-way valve, and begun running in a solution of normal saline. Glancing at the clock hanging on the wall, Nikki declared, “IV saline started full rate at 2:18!” Paul responded, “Noted, NS full rate 02:18,” and made an entry in the notes.
Carl turned to the anxious-looking middle-aged couple standing near the head of the bed. The man was in his early fifties: short, overweight, slightly balding, wearing a crumpled shirt and slacks which were at least a size too large. He had a hassled look and was clearly distressed. The woman by his side was a bit taller, older than her husband. She was wearing a smart dress, but wrinkles were showing through her hurriedly applied makeup. Carl wondered what kind of person would take the time to dress up and put on makeup before bringing her unconscious daughter to the hospital in the middle of the night. She displayed a commanding air, and was looking at the medical staff with a surprising degree of defiance. Her eyes betrayed considerably less concern than her husband’s for their unconscious daughter. From the way she positioned herself in front of her husband, it was clear who the boss in the family was.
Carl addressed them after checking the patient folder. “You are Mr. and Mrs. Tang, her parents?” They nodded. “I believe my colleagues have explained to you what they suspected was happening with your daughter. I am now going to examine her.” In his peripheral vision, Carl spotted fury returning to Mrs. Tang’s eyes. Carl peeled away the blanket and exposed the partially undressed teenager. Her blouse was pulled up to the level of her rib cage, while her jeans were down at her pelvic bones. Carl could see that, even at 15, Ying was well developed with a shapely figure. However, her pale, distended abdomen bulged at the flanks, at odds with her body frame.
With more than five years of experience on the job and due to sit the Specialist Exit Assessment Examination soon, Carl could make a spot diagnosis immediately. Nevertheless, he bent down and gently felt the abdomen, confirming the soft, bulging flanks. Ying stirred slightly from the pain. He then began tapping the skin with his fingers, starting from the midline and working his way over to her right side. Then, turning the body almost ninety degrees to her left, he tapped again from the midline toward the right flank, revealing a clear extension of the resonant sound.
Carl straightened and shifted his gaze from the teenager to her parents. He had expected both parents to be gravely concerned. However, while the father was clearly worried, the mother showed more bewilderment, disbelief, and confusion.
“I’m afraid your daughter has free-moving fluid in her abdomen. Given her age, the lack of any medical history which you can provide, and the way she presents, this free fluid is most likely coming from a source of bleeding occurring inside her abdomen. We call this condition internal bleeding. I suspect there are probably two litres or more of blood in her tummy. To save her life, we must operate on her right away!”
Before Carl could explain further, Mrs. Tang interrupted with a series of rapid questions: “What do you mean by internal bleeding? What could have caused it? What do you mean when you say you’re going to operate on her?” Mrs. Tang did not appear to accept Carl’s diagnosis.
Without moving his eyes from the parents, Carl addressed the nurse who had returned after sending off the blood specimens, “BP and pulse?”
“BP 86 over 55, pulse 116,” the nurse read from the monitor.
Fixing his gaze on Mrs. Tang, Carl said calmly but in an urgent tone, “Let me explain the most critical issues first. Her blood pressure and pulse rate indicate that Ying is in shock. The clinical features indicate that shock is most likely due to bleeding from an internal organ which is injured or damaged, and the blood is collecting inside her tummy. The internal bleeding and shock explain the swelling in her tummy, and the shifting dullness I demonstrated to you just now provides the clinical evidence. This form of internal bleeding is most likely coming from a ruptured ectopic or tubal pregnancy, since there are no other obvious explanations for the bleeding. If it is allowed to continue, it will kill her.”
Carl paused for some seconds to allow his message to sink in before he gestured with his right hand over the teenager’s abdomen and explained, “This is an emergency and we have no time to waste. We have to cut open the tummy wall, drain the blood collected inside, find the source, and stop the bleeding. This usually involves tying, cutting, and removing the affected part, most likely a ruptured uterine tube.”
This was followed by a moment of deathly silence before the couple spoke almost simultaneously.
The father asked in a faint voice “What do you mean by…”, but he was cut short by the loud and angry voice of the mother.
“An operation that cuts open her tummy!? Why? That will leave an ugly scar! How could she face people in the future? I am sure there are other ways. Can’t you give her medication to stop the bleeding? Or do keyhole surgery instead?”
“In her current condition, the simplest and safest way is to cut open the tummy and stop the bleeding as quickly as possible. We must operate on her as soon as possible because active bleeding from a ruptured ectopic pregnancy is very dangerous. It cannot be treated with medication!”
By now, the parents were visibly shaken, but the mother recovered quickly. Wringing her hands, she exclaimed, “What do you mean by an ectopic pregnancy? How dare you accuse my daughter of getting herself pregnant? We are devout Catholics. I am a schoolmistress, and my daughter is a good girl! How dare you accuse her of behaving improperly!”
Carl was used to handling unreasonable patients and their family members. He looked steadily at the mother. In a quiet voice, he replied, “When was her last menstrual period?”
At this moment, the nurse interrupted urgently, “BP 70 over 40, pulse 126.”
Then without waiting for the mother to answer, Carl addressed Nikki, “Inform the operating theatre that we have an urgent laparotomy. Get the senior anaesthetist to prepare for resuscitation. Are the consent forms ready?”
Paul looked up from a bedside gadget and interrupted, “Bedside test shows haemoglobin of 6. I will start transfusion as soon as blood is available. I’ve requested 4 units but there may not be sufficient samples to cross-match 4 units. I’ve also requested some group O Rh negative blood if available!”
Nikki’s pager sounded repeatedly. She checked the number and turned to Carl, “I have to reassess someone in the labour ward. In case I’m held up in the delivery, I’ll send in Joy the intern to help.” Carl nodded and replied, “Do what you have to do!” As Nikki left in a hurry, Carl made a sincere plea to the parents, “Mr. and Mrs. Tang, there are only two of us in the hospital covering both obstetric and gynaecological patients. There’s no time to waste, and we can’t be held up here. Your daughter needs surgery immediately, and because she’s a minor we need your consent. Even if she were fully conscious, we’d still need your consent for surgery. Please help us to save her!”
The mother now appeared indignant. “On what grounds can you say that my daughter is pregnant? She has irregular menses, and I can’t remember when her last period was. She is a good student in a girls’ school and has never had a boyfriend. She has severe cramps whenever her period comes. I am sure this time is similar, and she has just fainted from the pain. In fact, she had some spotting this morning. Her period is probably coming today.” Mrs. Tang’s face was livid.
Mr. Tang, now in a deathly pallor, spoke in a voice that seemed to emanate from the bottom of a well, “Ying always comes home after school or her extracurricular activities. She’s never spent a night away from home.”
Carl turned to the nurse and asked, “Got any urine for testing?”
Paul replied as he pumped the saline into Ying’s vein, “We couldn’t obtain a urine specimen. I’m going to insert a bladder catheter to collect a sample for testing and monitor the urine output to determine her response to fluid replacement.” The nurse quickly fetched a bladder catheterisation set.
Carl shook his head at the parents. “This is a matter of life and death for your daughter. There is no insult or disrespect to you or Ying, and we’re not here for any moral judgement. We are here only to save lives. We will do some more tests, but any further delay in treating the bleeding could be lethal. You can see that her heart rate is getting faster and faster!”
The nurse was just leaving to test the urine sample collected from the catheter. Carl asked her to bring the portable ultrasound machine from the treatment room.
The parents were becoming more agitated. Fear was now written in the father’s eyes.
“Doctors, the dipstix test result!” The nurse held up the plastic dipstix against the printed label on the bottle, where the colour changes were shown for easy reference. The two doctors looked at it and then at each other.
“Mrs. Tang, I’m afraid the pregnancy test is positive!” Carl faced the couple. He quickly squirted some jelly onto Ying’s abdomen and grabbed the probe of the small portable ultrasound machine the nurse had just brought in. He smeared the jelly across the girl’s abdomen. In an instant, shifting, flaky displays of black, grey, and white appeared on the screen. Carl made a systematic survey of the abdomen as he pointed with his fingers to the white lines and grey and black shadows on the screen. “You can see the tummy wall here. Here are the bowels, and the dark areas are fluid collected in the tummy. So, I can confirm with the ultrasound that Ying has a large collection of fluid inside her tummy. I am almost a hundred percent sure that she has a ruptured ectopic pregnancy!”
“BP 82 over 50, pulse 132,” the nurse announced.
“Third bottle of saline started. I’m now commencing colloid infusion. The blood bank just called – they don’t have any group O negative blood available now, so the transfusion can only be given when the first matched unit is available,” Paul explained.
As he was putting away the ultrasound machine, Carl appealed urgently to the parents. “It’s critical; we must operate on Ying now. A further delay will be disastrous. We cannot start blood transfusion until matched blood is available, and the fluids we’re giving her now are temporary measures. The continuing blood loss cannot be compensated by the intravenous fluids, and her increasing heart rate means that her blood loss is getting more and more severe. If the shock continues, and especially if it worsens, her heart may stop, and she could die. Even if her life is spared, her brain could suffer from the effects of shock and she may not wake up. Or, once she wakes up, she could experience lasting damage. Please sign the consent for anaesthesia and surgery now so we can save her. Feel free to ask me any questions now or later.”
Then glancing at the clock, Carl added, “It is now 2:40 am, 22 minutes since we began fluid replacement. She’s deteriorating. It will take some ten minutes to get from here to the operation table, so we can’t afford to waste more time!” The mother was silent, inert, staring at her daughter’s supine form in disbelief. The father took the consent forms with shaking hands and started reading.
Just then an alarm came from the blood pressure monitor. Paul shouted, “Cardiac arrest, 02:41h!” He started chest compression while the nurse dashed outside the curtain and returned with a resuscitation set. Carl leapt onto the bed, kneeling over Ying, and took over the chest compression from Paul. Paul opened the resuscitation set, took out a plastic tube and inserted it into Ying’s mouth. After securing it in place with tapes, he held a large black bag connected to a triangular rubber mask, which he placed over Ying’s mouth and nose, and started squeezing the bag, carefully timed with Carl’s chest compression efforts. Two more nurses appeared from nowhere and joined in the resuscitation, one taking over from Carl while the other tended to the intravenous infusion.
As Carl climbed down from the bed, he said coldly to the parents, “You’ve wasted too much time!” Then, ignoring them, he released the brakes on the wheels of the bed and, together with the third nurse, he wheeled it out of the cubicle. A nursing sister appeared and stared the parents in the eye. She handed them a ballpen and instructed, “Sign here and here if you want to save your daughter!”
Mr. Tang sheepishly complied while his wife remained motionless. The nursing sister quickly added her signature and stamped her name chop on the witness box of both forms. Then, chasing after the bed, she slipped the signed forms into the folder of medical records and placed it on top of the sheet covering Ying. While Paul and two nurses continued the resuscitation and the two porters pushed the bed, the entourage entered the lift, which was kept waiting by a third porter. Carl had already sprinted up the stairs on his way to the operation theatre two storeys above, to change into surgical attire and to scrub up for the impending surgery.
Coming to their senses at last, the parents were directed to another lift which would take them to the operating theatre.
As they were entering the lift, they suddenly heard loud voices coming from inside the drawn curtain of the nearest cubicle. A man’s voice was pleading frantically, “Please! Please save him…”.
At the same time, a woman was wailing, “He’s only a child, please bring him back! Are we too late?”
These voices were shut off abruptly by the lift doors. Inside the steel box, Mr. Tang stood trembling as he clutched tightly onto the handrail. Mrs. Tang leaned against the wall, her tears cutting paths through her hastily applied face powder and rouge.
Henry Lowe is a retired physician who has many interests in life, one of which is telling stories to both the young and not so young. His stories are drawn largely from his experiences and lessons he learned in life; yet he has found that on many occasions the moral of each story tends to be overlooked or ignored by the characters involved, as well as some of the listeners. He hopes that by writing down and publishing these stories he can provide both entertainment and service to people at large.
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