On a weekend night, I received a strange phone call from an emergency room resident. “This is an emergency,” he said, adding fragments of details, “… vaginal bleeding … her heart rate is in the 150s.” It was hard to figure out what was happening and his tone was oddly calm. “Is she in an exam room?” I asked. “No,” he replied, “we’re in the trauma bay.” I ran downstairs with my colleague, and there she was sitting up calmly on a stretcher. A swan in a crowd of chaos. She was connected to a cardiac monitor chirping 130–150 beats per minute. The floor was littered with bloody gauze and torn-apart medical supply packaging. One nurse started a blood transfusion while another placed a second IV in the patient’s opposite arm. As we spoke to the patient, the attending ER physician directed orders and retrieved the instruments we needed. “I gave birth two weeks ago,” she said, lamenting, “I had a bad experience.” I lifted up the sheets to find her sitting in a puddle of blood. I placed a speculum and couldn’t see her cervix; too much blood pooling too quickly. I did a manual exam, and her cervix was dilated. My colleague did a sonogram, and there it was, either a piece of placenta or a large clot holding open her bleeding uterus. We thought about phoning the facility where she delivered. Thought it would be useful to know what happened. Moot point. We took her to the operating room. I thanked my lucky stars that, for once, it was like the TV dramas. The doors flung open, and the bright, fluorescent room was immaculate. All the equipment was in its place. Two anesthesiologists and two nurses were in the room, waiting for our patient like flight attendants. The anesthesiology resident began to explain general anesthesia to her. He was young and well-kempt, stress-free in a sterile environment. I imagined him drinking cocktails with his friends. He’d be the type to pin a flower on his blazer. He looked shocked when the patient, in a moment of fight, snapped out of her fatigue and grabbed his arm, “Just save my life.” She had already lost a liter of blood. Once we got past the clots, out came my horror. A chunk of what I thought I might see, but, on some level, was hoping I wouldn’t: placenta. A giant piece of placenta was left in her uterus, almost two weeks after she gave birth. I felt nauseated. We used an ultrasound in the operating room to guide our instruments around her large fibroids, accomplices to her uterus retaining so much tissue. Finally, after several medications, liters of IV fluid, a short procedure, and a blood transfusion, she was back. She did not go into shock, and she stopped bleeding. It did not take long for my relief to give way to anger. I imagined her delivery. I imagined her pushing through pain and her bravery as she embraced a newborn. I imagined her terror when she, at home by herself, began to hemorrhage and begged a family member to watch her children so she could call an ambulance. I thought about how she trusted her delivery provider. I thought about how, in a developed country — where there are prenatal clinics, sonograms, hospitals, blood banks, operating rooms and skilled healthcare personnel — no woman should ever die of a postpartum hemorrhage. This one, who did everything right, almost did. My outrage extended beyond her. I thought about all the bad information women are fed, the stories of perfect pregnancies followed by perfect deliveries. Even before childbearing years, how teenage girls watch tampon commercials and are made to believe the uterus shouldn’t bleed. Vaginas should remain clean, pink and soft. Periods should be compact and floral scented. Sex should be discrete. Pregnancy should be celebrated and not prevented or terminated. It is normal for a woman to be in pain, but she shouldn’t ever show it. The uterus shouldn’t bleed. And so, girls grow up to become women making bad decisions: Using their flesh to negotiate intimacy or love. Letting others make decisions over their bodies. Unprotected sex. Presenting too late to prenatal care. Not presenting at all. Children to solve relationship problems. Birth plans focused on comfort, but not safety. All the while not understanding their own organs, the ones powerful enough to foster new life, the ones that stretch and contract and grow and bleed. I wish I could blame it on the media, but the entire culture within health care is also at fault. Many of our patients don’t see a gynecologist or start prenatal care because they aren’t aware they could be seen without health insurance. A pregnant woman can’t have a clinic visit and sonogram in the same day because insurance won’t cover it. A mother is dropped from her plan because between caring for her children at home and working two jobs; she couldn’t make her thrice-weekly appointments on time. Birth control doesn’t need to be covered by employee health insurance. Abortion centers must change their infrastructure impossibly. And so on, and so forth. I rudely joke to myself that it’s the fact that our genitals are all internal which makes access to care so difficult. If the providers who are trained to care for women cannot do so in the most basic of services, how can we expect women to care for themselves? I deliberated these things, huffed and puffed and by 4 a.m. was still dazed by my own cloudy preoccupations. In the recovery room, the patient held my hand and cried. She said, “I kept thinking to myself, ‘I may not ever see them again.’” All she could think about was her children. Jenna T. Nakagawa is a resident physician who blogs at her self-titled site, Jenna T. Nakagawa. Source
