Dr. Frank Mills was a 34-year old obstetrics resident who had lived most of his life near
his parents in Richmond, California. Recently, he had moved to Miami, where he lived in a
3-bedroom house with a pool, and spent weekends hosting small parties and barbeques. Dr. Mills
was friendly and charming, but could sometimes come across as arrogant and boastful. He enjoyed
medicine, but his real passions in life were cooking, surfing, and ping pong - in that
order.
It was another night in the maternity unit. In front of the coffee machine, Dr. Mills
was talking his with his colleague Dr. Holt about a party he was planning for the 4th
of July. A few moments later, a nurse approached them and said, “Dr. Mills, we have a 37-years-old
woman who’s 39 weeks pregnant and hypertensive.” Dr. Mills said he’d be there in a moment,
and then resumed his conversation with Dr. Holt: “So, what do you say? You should come
by on Saturday night. It’s going to be the best 4th of July ever!” He smiled and went
to see the patient.
“Hello there, my name is Dr. Mills. What seems to be the problem?” he asked the frightened
woman. The woman explained that over the past few days she’s been having blurry vision,
a pounding headache, and feeling more anxious. She was spending the weekend with family and
thought the symptoms were from being sleep deprived. She didn’t want to worry her parents,
so she waited until today to check her blood pressure back at her home. Normally her blood
pressure was around 120/80, but today it was 155/100. She knew that she was supposed to
call if that happened, so she called and was told to come in. Dr. Mills calmed her down
and explained the plan, “We’ll be admitting you to the hospital and doing some lab tests
to make sure that you and the baby are safe”. The woman agreed.
The initial lab work showed that there was protein in her urine - evidence of preeclampsia.
A nonstress test was done to assess the fetus and it was reassuring. About eight hours later,
the woman’s conditioned worsened. She was having more swelling and had more protein
in her urine as well - all signs of preeclampsia. On top of that, she had begun having vaginal
bleeding. Dr. Mills ordered another nonstress test, and this time it wasn’t normal.
“Abnormal fetal strip, heavy vaginal bleeding, preeclampsia - this patient needs an urgent
delivery” - Dr. Mills thought aloud. “Transfer her to the labor and delivery unit, and let’s
induce labor with oxytocin.” The nursing team with many more years of experience disagreed
unanimously: “This woman may be having a placental abruption and needs an immediate
C-section!” The nursing team wanted to involve the overnight attending, but Dr. Mills felt
like he could handle the situation without additional help. He suggested setting up continuous
fetal heart monitors, and the initial tracing showed that the fetal heart was returning
to normal. Dr. Mills felt triumphant, and initiated intravenous oxytocin to induce the
labor. Unfortunately within an hour, the fetal heart rate became abnormal again, and the
woman began having worsening abdominal and back pain. At that point, Dr. Mills proceeded
to have the woman undergo a C-section.
Over the ensuing weeks, it became clear that the baby had sustained severe brain damage
in the form of hypoxic-ischemic encephalopathy. In reviewing the case with his attending,
all of the “normal” fetal strips had subtle changes that were concerning, and had been
missed. Within a few months, Dr. Mills received a letter stating that his hospital was being
sued and that he had been named specifically because he had managed the patient in the
hours leading up to the delivery.
Now - to rewind this back - let’s imagine that Dr. Mills had gotten in contact with
the overnight attending when he initially got the concerning fetal strip and had been
challenged by the nursing team. He would have likely gotten the technical and clinical experience
he needed to help make the best decision for the patient. An earlier C-section might have
given this baby less time without oxygen and a better postnatal prognosis. The moral: Recognize
the limits of your knowledge and experience and reach out sooner, rather than later, for
help.