Ob/Gyn Reacts: ER Doctor Goes Rogue | Love’s Labor Lost
– Ahhhh! It's stressing me out so much. Hey guys, welcome back. Mama Doctor Jones, OB-GYN and mom to four. Today, we're going through
an episode of a show that you guys have been asking me to go through for a very long time. Episode called Love's Labor Lost, and it came out, I think in like 1995. It won an Emmy. Let's jump right into
season one episode 19 of ER. (elegant music) I do remember watching this show with my mom when I was little and it's kind of
nostalgic watching it now.
Hey mom, text me when you see this and tell me if you remember watching this episode
back when it came out. – Our baby's due in two weeks and I have to pee every 30 seconds. It burns and my stomach hurts. – Sounds like a bladder infection. Does this hurt? – No. – Okay, so right off the bat, I'm curious why she's in the ER. Almost every hospital
that has the facilities to care for pregnant patients will not see pregnant patients at this gestational age, in the ER, particularly for what seems
like a non emergent visit. – Initial BP is 130 over 90, but over a couple of
hours, BP's been fine.
Around 120 over 80. FHT is normal. No cramps or spotting. – He said her initial blood
pressure was slightly elevated. 130 over 90. That's not terribly high. She's near term pregnant. Her follow-up blood
pressures have been normal. So none of that sounded
immediately concerning to me based on what he's said at this point. – UA shows white cells
too numerous to count, bacteria two plus protein. CBC is normal, no fever. – Simple cystitis. Fluids, rest, and of course, a Bactrim. – So, bladder infection. – I liked how he explained to
the patient what that means. A simple bladder infection. Translating for people who
are using medical terms that everyone may not
understand is super important. They're talking about
treating with Bactrim, which is an antibiotic.
I probably would not choose
Bactrim at near term. I might go with Keflex or something else. It increases the risk
of some complications like jaundice after delivery. It's not overtly contra-indicated. If it's the only thing we
can use, it's an option, but it wouldn't be like my go
to when I have other options. I'm a little worried because her blood pressure was
slightly elevated initially, and she has protein in her
UA, which is urinalysis. So that makes me a little
concerned about preeclampsia. If that's it, it's early. I think it'll probably get worse if that's what this is
going to center around because we need to have the drama. – Near term antibiotic
of choice is Macrodantin. Want you to take these.
Lots of fluids. Rest and follow up with
your doctor in the morning. – The salt competes with the bilirubin for the binding sites on albumin increasing the risk of neonatal jaundice. – He saves lives, he teaches. – I think that management
is probably fine, honestly. Again, I'm still a little worried about the protein in the urine. If they have an obstetrician in house, ideally she would be seen then. I don't know. Maybe they don't have
an OB in that hospital, but I don't know. That's fine. The reason I'm hedging on this is because I'm sure she's, something else has to change or this episode wouldn't
be so highly recommended from you guys for me to watch.
– My wife's unconscious in the car. Dr. Green! Please somebody help me! – Pre-eclamptic. Four grams, IV. – Your wife has eclampsia. – Is she going to die? – No, no. We just need to get her
admitted and medicated. – She's seizing! – This would be extremely unusual to have one very tiny elevation
in your blood pressure and go straight into
seizing, but not impossible. You can kind of hear in the background, he said her blood
pressure is 160 over 110. That is a severe range blood pressure. She's seizing. So now she has eclampsia, which is protein in the urine,
elevated blood pressures, which has now developed into seizures. Kind of in passing you
heard them say mag in which means they're giving her magnesium. Most of the time, the
recommendation is stabilize mom, and then get baby on the
monitor and decide what to do.
– O2 to 15 liters. (monitors beeping) – Alright, lets hyper ventilate her. Get dop tones, – Fetal heart tones strong at 140. – Why? Where is the OB? Why is there not an OB? I need an OB. I'm freaking out. They keep talking about what
the O2 setting should be on, but she doesn't have oxygen on. She doesn't have a mask on at all and then when he was
putting that jugular in, I mean it was like not a
needle, just like a catheter. She needs to have a baby today. If her seizures stop and
she is able to be induced, that might be an option, but if she's not dilated and
it's going to be 12 or 24 hours before you can have a baby, then it might make sense to
go ahead and do a C-section.
– What did Coburn say? – Well, she's at St Luke's and she says, she'll be here as soon as she's finished with her repeat C-section. Oh, and she wants me
to start an induction. That is of course, if I feel comfortable. – She said that? – Yeah. – What a bitch. – I have a problem with both that representation of the person that they were talking to
and with that management. Under no circumstances
would an ER doctor in an ER, be starting an induction
on an eclamptic patient. Not happening. If she's too busy at the other hospital to come over and see this patient, they need to find another
OB to come right now. Unacceptable. Second, nobody's ever induced in an ER. That would never happen. That's not realistic. Third, if someone calls you
and they're consulting you and you can't come right that second, the right thing to do is say, here's what we need to do. You can go ahead and do
that if you're comfortable. To which the person on
the phone should say, yeah, I am comfortable. Thank you for making sure that
I was comfortable with that since I'm consulting you, which means I'm not the
expert in this category.
That's a bad attitude to have. I don't like that. – I just spoke with Dr.
Coburn, her OB attending, and she agrees that we
need to deliver you soon. – Does that mean you
have to do a C-section? – I want to deliver naturally. – Your eclampsia's under control. The baby's in good shape
and the cervix is favorable. I'd say we do a trial of labor. – I think that's a fine way to go. Her blood pressures are normal. Her cervix is two and 80% thinned out. Inducing labor and seeing
if she can go ahead and get close to delivery without getting really
high blood pressures again seems like a reasonable option.
– Yep. – Do you feel competent to
handle this down here without me? We're getting slammed upstairs. – I think I can muddle through. – All right, I'll check
back with you at say 2300? – Roger. Carol? – Yeah. – Could you give Mrs.
O'Brian 0.5 Pitocin IV? – You're inducing down here? – We're going to start here and
then we'll get her up to OB. – Okay. – No, not only not
okay, but not realistic. Would never happen. What can possibly be going on upstairs that is so much more important than an eclamptic patient in the ER? Transfer this lady to labor and delivery.
They have an OB doctor there. I know he's a resident, but he's still more of an
OB doctor than an ER doctor. That doesn't make any sense to me. Take her upstairs. This is dangerous. Bad plan. Change of plan. – Is it normal for the baby's heart rate to be going down like that? – As long as it's only
briefly and it stays over 120. – I disagree with that statement. That baby does not look happy and it's not perfectly fine as long as it's not less than 120. The pattern is very important and that pattern looks concerning. – They're still busy upstairs. I gotta call again. – Dr. Green! Something's wrong. The baby's heart, the
monitor's down to 90. Something's not right. It's not supposed to go that low, right? – So 90 is a heart rate that definitely you
should do something about, but is not always an emergency. It absolutely warrants
them running to the room to see what's going on, but it's not like always a terrible thing. Sometimes it's as simple
as repositioning mom, turning off the medicine, stopping the induction
for a period of time, to see if you can fix it.
However, I still am extremely bothered by the fact that they
are so busy upstairs, that the eclamptic patient, which is a relatively rare
major problem in obstetrics is the one sitting in the
ER laboring on Pitocin. Like this is just not realistic at all. – Now we can get a pressure
reading inside the uterus. This scalp electrode monitors
the pulse rate more exactly. She's eight centimeters dilated. Completely effaced. Won't be long. – So what they're doing now is putting an intrauterine pressure catheter in. Again, this would never be done in the ER, but I'm just going to
talk to you guys about it so you know what it is. The intrauterine pressure catheter is like a piece of IV tubing and it just sits next to the baby's head and it monitors the
pressure of contractions.
So the external monitor
that's on her abdomen will tell us when she has a contraction, but not how strong the contractions are. The internal monitor will
tell us how strong they are. I don't know that this is
the best time to place that. She's making excellent progress and someone whose cervix
is already changing, it doesn't really matter what
their pressure catheter says because the cervix is
changing and that's the goal and we don't need to know that. Why do another intervention if it's not going to
change your management? The scalp electrode that
they're talking about, so this is a monitor that
goes on the baby's head. The reason we use this is because the external monitor
is not always very reliable. It's relatively reliable that if the baby's having decelerations and you need a really exact reading, a scalp electrode will monitor
the baby's actual pulse.
Not have to just trace
movement of the heart. So it's much more accurate. The way that it goes in is with, it has a teeny tiny little
spiral looking needle thing and it goes just very
superficially into the baby's head. The way I explain it to patients is, you know when you were in middle school and people would take like a safety pin and just put it through
the superficial layer of skin on their finger
and it would look creepy, but didn't really hurt them. That's how it goes on to baby's head. I see some viral stuff going around Facebook about this sometimes and people really demonizing
scalp electrodes, and I get it. Like you don't want the scalp electrode on the baby's head, but again, it's an extremely superficial needle that goes right on the baby's
head to monitor the pulse.
It's less invasive than an IV and it can provide a lot of
very valuable information. It certainly should be
explained to the parents of what you're doing and how
I explained it to you just now is how I would explain
it in labor and delivery, if my patient needed to have that. – We need to get her up to OB. – I'll see if I can light a
fire under someone's butt. – Something wrong? – Nope, we're okay. Page Coburn again. – Well that was a terrible
explanation on his part. He said is everything okay, and I would have answered that
question, everything's fine. Nothing is an emergency right now. Baby's having some heart rate
drops that we need to address.
We can watch them for a period of time. We don't need to do
anything right this second, except try to make them better. If we're not making them better then we may need to reevaluate the plan and if there is a safer
way to deliver the baby, like a C-section, if we're
not ready to deliver, because we can watch this for awhile and it's not an emergency, but we can't watch it for hours and hours. – Fully dilated, 100% effaced. It's time to start to push. – Already? – Yep. – Here? – Here. Carter, go up to OB and drag Drake down.
Tell him to bring some forceps. Okay, go, go. She's not progressing. The baby's heart rates dangerously low. I'm going to start the pudendal block. – I'm going to try to stop addressing how unrealistic all of this is because I just can't handle it, but I can tell you what
a pudendal block is. So, a pudendal block
is a local anesthetic, which is injected into the pudendal nerve. The pudendal nerves provide
the nerve innervation for the perineum. So where the baby causes
pain when crowning is served by the pudendal nerves, and you can easily reach where those are by doing a cervical type exam. It's not really feeling of the cervix, but from a patient standpoint, it feels like having a cervical exam and you inject the local anesthetic and that helps to provide a nerve block to decrease the pain of crowning. An ER doctor would never do this. There's even a whole lot of OB doctors who don't do this procedure. I do. It's actually relatively
easy if you're trained in it, but an ER doctor just would
not be trained on this.
Again, I just like, they're
not going to go up to OB, bring a doctor and forceps down and deliver this baby
with forceps in the ER. None of this makes sense. – No one will blame
you if you wait for OB. – The baby monitor says now or never. – Why put your ass on the line? – Because I've come this far, I'm going to see it through. What is she coming by camel? – Ahhhh! An ER doctor would never
put forceps on a baby. Never, never, never. Many, many obstetricians are
not even trained in forceps. They are a very skilled procedure.
You can cause significant harm if you don't know what you're doing, and this would never happen, ever. Forceps are very safe in the hands of someone
who knows how to use them. So I always explain this to my patients, like, it's like using a scalpel. If I don't know how to use a
scalpel and I'm not a surgeon, I could hurt you very,
very bad with a scalpel. As a surgeon, I could
still hurt you very bad, but it's very unlikely
because I know what I'm doing.
Forceps are the same way. If someone who has no
idea what they're doing, tries to put forceps
on and pull a baby out, they can cause significant harm. – Page OB! – Do something! – Let's try a Woods. – That's stressing me out so much. – It's not working! Zavanelli! – What are you doing? – Zavanelli, we've got
to push the baby back in. – Then what? – Almost. – Now they've got a shoulder dystocia. I don't know how they got
all of these problems. Oh, maybe it's because they are delivering this baby in the ER, instead of labor and delivery and none of them know what they're doing. Sorry. Ahhhh! Shoulder dystocia means that the shoulder is stuck on the pubic bone.
So if you imagine that one
of the shoulders is stuck. The diameter here is
what you're looking at. You want to decrease this diameter. If you can deliver the posterior arm, which is the arm that's on the bottom. So closest to the floor, after
the baby's head comes out, if you can pull that out and deliver it, see how this is a smaller diameter, you've decreased the AP diameter from this shoulder to this side, that will often resolve
the shoulder dystocia. If you can't deliver that arm, there's other maneuvers to do. They're going to go through
each of those maneuvers at least three or four times before you jump to Zavanelli. Essentially doing a C-section, but having to push the
baby back in to get it out, which is extremely difficult
to do, extremely difficult.
Zavanelli is a last resort
to try to save a life and that is either the mom's
life or maybe mom and baby. Most of us will knock on wood, never meet to do a Zavanelli procedure. Although most of us know
someone who has had to do that. So it's extremely rare, but it's not something that never happens. I hope that I never experience that. – We've gotta do an emergency C-section. I need your consent. – You don't know what
the hell you're doing! Have you ever done this before? – I've scrubbed in many times. – No, I want somebody else in here. – Look, we can't wait. If we wait five more minutes,
your baby's brain dead. – Trying to participate
in suspension of reality and not be so annoyed
that it's very wrong, but just very not realistic.
(monitors beeping) – Get respiratory down here. – 7.5. – If we're at this point, the chances that mom and baby
make it out of this alive and with no major morbidities is very low. Mainly I would say the biggest thing that's gone wrong in this is that they've failed
to get the right people involved in the care of this patient. If they let it get to that point, and then they have a happy outcome, I'm going to be pissed, because that is not how this would happen. Obviously I want this to be
a happy outcome, but geez. – BP's 200 over 130! (table falling) – It should never get this
chaotic in the hospital. It doesn't even matter
if somebody is dying. There shouldn't be chaos
in an operating room or an emergency room like this ever. – Everybody just take a
deep breath, all right. – And what he did right
there was exactly right. As the leader of what's
happening right now, he's responsible for making sure that everybody is staying calm, and that includes the
patient, the patient's family and especially the staff
whose working with him.
Saying, okay, everybody calm
down, take a deep breath. Let's pay attention to what
we're doing is really important. You can't let things like this get to where everybody's running around, knocking stuff over. People die that way. You have to keep your cool. – Somebody physically go up to the OB and drag somebody down here, okay? Go! – I'm sorry, but there is
not an OB on the planet who would know that that's going on and need to be dragged down.
I guarantee you, if the OB
knew what was happening, they wouldn't need to be dragged. The communication from
the ER to the other floor right now is abysmal. The problem that has happened is an overestimation of confidence in doing something that
you don't usually do. Remember earlier, when I
said that when the OB said, are you comfortable with that? It wasn't like, oh, like,
are you comfortable? You're so dumb.
It was like, I just need to be sure that you're actually
comfortable doing this, if we're going to do it and he acted like how
would somebody ask me that? What a total bitch. This is why, I think, and I tell all of my
medical students this, what makes you a good doctor or any kind of healthcare professional is being able to know when
you don't know something and to say, I don't know, and I need someone who knows, or we need to look this up. There are so many points in this where someone on this team
should have said, I don't know. We've got to find somebody who knows. They can't just keep doing things flying by the seat of their pants.
It's dangerous. – Scalpel. Grab with those clippies. – I'm having a lot of trouble
commenting on this guys. I know this episode won Emmy's. I know you guys love it because you keep telling
me that you remember it and that it stuck with you, but it's just not very realistic. – Grab an army Navy. – Suction. – The long scissors. – Retract there. – I'm in. – Isn't there something
about a bladder flap? – Pickups. – Suction. – I'm dividing the peritoneum. – Hemostat. – Okay, we're in. – I can't even begin to
go over the inaccuracies because there are so many. Like how the OR is open to a waiting room where everybody can see what's happening. Like how half the people
in the operating room don't have on a mask and aren't gowned. How all of the steps of the
C-section they just talked about were completely out of order.
– I think I'm in. – Oh my God. – Two liters in there. She's got an abruption. – She's bleeding out. – Conner, change. Gown up. Suction his nose. Umbilical clamp. He's not breathing. – Of course, he's not breathing! Why would you expect him to
be breathing at this point after that utter chaos? Aside from the fact that there is no way that an ER doctor would be
doing a Zavanelli procedure, if you just erase all that, so inaccurate. I'm having a hard time. Maybe I'm not even going to post this one.
– Conner, get in here. Follow my hand down. Feel the aorta? Pulse it. Push down on it and don't let go. You got it? – I think so. – Don't think, do. – I got it. – What is going on with mom? They think that compressing the aorta is going to keep her from
bleeding out right now? She's dying. She's dying. – I think I'm in. Bag him. Quick listen. I'm going to try an umbilical line. Release this clamp. Come on little guy, come on. – What's going on in here? – I intubated. The baby went bad. – You just cut her open
when you shouldn't have, and you left her on the
OR table bleeding out and there are 15 other people in the room who could do neonatal resuscitation but you're the only one apparently
capable of doing surgery, which you're not trained
for that, but whatever, and you left your patient on the table.
– You knew she'd abrupted? – No, once I got in there. Baby nearly died. – Who is this and what's
he doing in there? – John Conner, med student,
and I'm pressing on the aorta. – It's a damned mess. What'd you use a chainsaw? Get an NICU transport team over here and the OB resident on call. You should've let me know you were in over your head. – So not the right time to
be addressing this like that, but yes you should have. Why did you not call her again when the patient was five centimeters, then the patient was eight centimeters? Like there was all this time where he should have
been in touch with her. However, at the time
that this is happening, he should have given her a quick rundown of where we're at with the
patient, what's going on, and she should have been
scrubbing and getting gowned up and getting in to save or salvage whatever's going on surgically.
Not yelling about the situation. – Go be with your baby. There's nothing you can do down here. – She's gonna be okay, right? – She's stabilized. Go with your son. – Dr. Green, she's crashing! (dramatic music) – Pull her off that
respirator and bag her. – Her blood stopped clotting. She's going into DIC. – Ah, damn. Order up 10 units. – This is extremely hard for me. DIC after an abruption
causing a patient to code is something that can really happen. So that part is realistic, but the whole string of events
that led up to this happening is just really not. I just think it's really
important to point out because I don't know if anybody
ever watches this anymore. I know it's a really old show now, but that could be very scary watching it and I guess there certainly is a reality where this could happen, but I can't fathom why any
of that string of events would have happened in that way in the ER and I know it wouldn't
have happened that way under the care of somebody
trained in obstetrics.
(monitors beeping) – Again, 360. – You know, I did a lot of ranting about this isn't realistic, and I tried to do a
little teaching in there, but the biggest takeaway from
this episode that I get is medicine is a team sport that requires excellent communication, and when you don't do that, when you can't act as a team, when you can't admit your
own scope of practice and your own degree of
understanding and ask for help, that's when you become dangerous. (monitors beeping) – I'm calling it. Time of death, 06:46. – I didn't really expect
this episode to go this way. Watching something like
that unfold is really hard. Maternal mortality, while it's not something that
we as healthcare providers feel in the same way that a family member or a friend feels it when
their loved one dies, most of the time, it's somebody
that we care about a lot. It's not something we see
all the time, thank God, but it is something that happens. It is very, very, very common for it to end the career
of the obstetrician.
Not because they were forced out, not because they were bad at what they do, but because it's just
extremely hard to move past. (emotional music) I don't know how to end this. That was extremely depressing. I hope that I would
make different decisions than the team that was taking
care of her in this episode and I would hope that I
would communicate better and admit my scope of
practice more quickly. All right, I don't know how to end this. That was extremely depressing. So I'm just going to,
thanks for being here.
Subscribe if you want to. Be kind to yourself, to each other, to me. In the comments be kind, and
I will see you next time. (upbeat music).
