Alpha and Omega

“After all, what’s a life, anyway? We’re born, we live a little while, we die. A spider’s life can’t help being something of a mess, with all this trapping and eating flies. By helping you, perhaps I was trying to lift up my life a trifle. Heaven knows anyone’s life can stand a little of that.”

– Charlotte the spider – Charlotte’s Web, by E.B. White

Birth and death are both part of any physician’s career.  While the newness of taking part in either wears off over time, the uniqueness of the experience doesn’t.  Holding ultimate responsibility for another human being’s life in your hands is a hard experience to describe.  It’s sort of like an all-encompassing weight – not a physical weight, like trying to hold something heavy in your arms or slung over your back.  It’s more like a mental weight – a crisp, sudden heaviness that comes with the realization that what you do in this moment is going to irrevocably deflect the path of another person’s life.  It fills your body and your mind with a powerful yet dizzying energy.  While I’ve come to expect and even anticipate this in practice, there is nothing else in life that ever comes close to replicating it.

My first clinical experience with death was seventeen years ago, when I was a 19-year-old emergency department (ED) technician in Worcester, Massachusetts.  I’d gotten my Emergency Medical Technician (EMT) license as a freshman in college and that summer, thanks to the incredible generosity of my neighbor and mentor Dr. Mary-Ellen Taplin, I got a job working in the Worcester Medical Center ED.  I’d been there a few weeks when an ambulance brought an elderly patient in with full cardiac arrest.  Her heart had stopped, she collapsed, her family called 911, and now the ambulance crew had brought her here.

As an ED technician I couldn’t start an IV, I couldn’t give any drugs, and I didn’t know how to implement the Advanced Cardiac Life Support protocol that practically everyone else in the room had trained in.  But I was an EMT and I did know how to do CPR, though at that point despite compressing the chests of more mannequins than I could count I’d never actually done it on a person.

So after we transferred the woman from the ambulance’s stretcher into the ED bed I climbed up a small step-stool, grasped the knuckles of my left hand with the palm of my right hand, and began giving a real patient CPR for the first time as the entire ED team tried to save her life.

We didn’t.

After twenty minutes of resuscitation, during which I learned exactly how hard it really is to give good quality chest compressions to an actual adult human, the ED physician called the code and declared her dead.  I was drenched in sweat, physically exhausted and had no idea what happened next.

As it turned out, my job as an ED technician also involved helping prepare the elderly woman’s frail body after death.  We cleaned the blood from her IVs, changed her sheets, dimmed the lights and allowed her family to stay with her for what seemed like a long, long time.  When they were ready to leave, I remember being surprised at how quickly the warmth had drained from her body.  We fastened a body tag to her toe to supplement the ID band around her wrist, moved her body to the box-like morgue stretcher, and draped it with a clean white sheet.  A more experienced ED technician led the way to the morgue where we opened a small door the size of a college dorm-room refrigerator, transferred her body to a metal slide, pushed her inside, closed the door and affixed another label to the door’s tag slot.

That was it.

We left the morgue, washed our hands, walked back upstairs, and went back to work.  I have no recollection whatsoever of the rest of my shift that day, but will never forget the woman, her family, the morgue, or the tag.

My first clinical experience with birth (not counting my own) was thirteen years ago, when I was a 24-year-old medical student in Durham, NC.  I was a little over halfway through my second year of medical school, the year that Duke medical students rotated through all the basic medical and surgical specialties.  It was spring and I was excited to start my rotation on Labor and Delivery because medical students on Labor and Delivery got to deliver babies.  Not stand to the side while the real doctors delivered babies – I mean actually deliver the baby with your own two hands while a resident stood directly over your shoulder, gowned and gloved and prepared to intervene at any moment.

I remember cleaning my hands with the betadine scrub brush, gowning and gloving just like I’d learned on my surgery clerkship, and sitting on the metal stool at the foot of the soon-to-be mother’s bed with the dutiful resident hovering over my left shoulder.  It wasn’t this mother’s first baby and we expected her to deliver pretty quickly.

The mother-to-be (again) was already in the stirrups of the specialized Labor and Delivery bed ready to push, and by the time I was on position the baby’s head was already crowning.  The resident coached me through how to carefully deliver the baby’s head, checking to ensure his umbilical cord hadn’t slipped around his neck and making sure the shoulders didn’t follow too quickly.  There’s sort of a pop when a baby’s head completely delivers that I remember seeming a little shocking, but the resident didn’t look worried so I made sure to hide the fear from my face as well.

With his head safely delivered and no evidence of a nuchal umbilical cord the resident talked me through how to gently tilt the soon to be newborn’s body so we could deliver one shoulder and then the next… and that’s when I realized exactly how slippery a baby can be.

His first shoulder delivered just as expected, but as his second shoulder emerged the rest of the baby followed with a speed I hadn’t appreciated was possible during childbirth.  I managed to catch his tiny butt with my right hand while the resident flipped the rest of him up onto my left forearm and into a stable position.

Pound for pound, at that moment my adrenaline level and the newborn’s adrenaline level must have been just about the same as the fact that I almost (but didn’t) just drop a baby sank in.  But thanks to a quick hand (all that baseball I played as a kid had finally paid off), a superbly mindful resident, and a whole lot of luck, I didn’t – and now this new person was alive, screaming, pink, and pooping right in my hands.  I handed him to his mother and she smiled, his slippery little body now nuzzled against her outside in much the same way he had been nuzzled against her insides for the last nine months.

I think I delivered at least one more baby on that 24-hour shift and assisted with several more over the course of my rotation on Labor and Delivery, but this first experience with birth is what’s stayed with me.  The look on his mother’s face when she held him, the intense fear of almost dropping a baby as slippery as a greased pig, the hands of the resident imperceptibly hovering then shooting forward at just the right moment, and the silent reassurance I gave myself that the resident’s deftness must have been a sign that it wasn’t the first time she’d had to help a hapless medical student not drop a newborn.  All in all, it was truly like nothing I’d ever experienced.

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