WhiteCoat

Constipated

Why is it that people suffer with a treatable problem and then, after several weeks, come into the emergency department at 3:00 AM for treatment?

This is what was running through my mind when I picked up the chart of 16 year old young girl who was complaining of constipation for the prior few weeks.

She was in the room with her mom, and her mom did not appear happy. The patient said that she was bloated and she kept moaning in pain from the pressure caused by her stool. Her mom kept telling her to “just push it out then.” The patient could feel the pressure in her rectum, but she said she couldn’t push out the stool.

Great. That means that I get to spend the next 15 minutes and half dozen rubber gloves digging poo from her behind. Glamour work. In all fairness to the patient, though, when I pulled back the sheet, her stomach was pretty distended.

So I pressed on her stomach and … wait a minute. “When was your last period?”
“About a month ago.”
“Hmmmm.”

I get the gloves out to do a rectal exam and aren’t I surprised to see the a head of black hair bulging out of the patient’s birth canal.

“Whoa! WHOA! … DON’T push! You hear me?!? DON’T PUSH!”

I haven’t delivered a baby in a couple of years and I wasn’t looking to refresh my skills that night. We call the OB floor and get her upstairs to labor and delivery.

That’s not the end, though. My luck isn’t that good.

About 10 minutes later we get a frantic call from the labor and delivery nurse saying that the patient is pushing and the obstetrician hasn’t shown up yet. Dang it.

I go upstairs and hear the typical bustling of everyone preparing for the delivery. You can see the baby’s heart rate of 130-140 on the monitor and can also see the pressure waves caused by contractions of the mother’s uterus right underneath the baby’s heart rate. The rise in the uterine pressure tracing on the monitor regularly precedes the mother’s pain by about 10 seconds. There isn’t time to do an epidural and I don’t want to give the mother something that will cause the baby to have trouble breathing. I just want to get the baby out.

I get gowned up and ready to go. Just before showtime, the obstetrician saunters in. Half of me wants to hang around and watch the delivery, but there are patients in the emergency department, so I get the gown off and head downstairs, breathing a little sigh of relief.

You guessed it. Not over yet.

Fifteen minutes later it’s another frantic call – this time from the nursing supervisor. The newborn baby is coding.

Whaaaat!??

I don’t care who you are. When you hear these words, your heart drops. When you’re an ED physician and you hear those words, you know the buck stops with you. Time to put up or shut up. I grabbed the Broselow tape and raced up the stairs.

This time it wasn’t the usual bustling about. Everyone was tense. Nervous. Upset. A limp baby was laying on the bassinet. You could see hands shaking as they were looking for IV sites. The nursing supervisor’s hands were visibly shaking as she pushed the intubation kit into my hands. Despite all the tension, things were actually going smoothly. The baby looked bad, though. She either was the victim of intrauterine infection or she was stillborn. Her skin was peeling like she had been badly sunburned. Most of the time if you need an IV line in a newborn, you can use the umbilical vein. This poor baby’s umbilical cord was so friable we couldn’t find the vessels to insert an IV line.

I intubated her and put a central line in her neck. We coded her for more than a half an hour and never got a pulse. Retrospectively, the baby was probably stillborn and the heart tones we were hearing were those of the mother.

Pronouncing someone dead is never easy. Pronouncing someone dead who has never experienced the joys of life is downright difficult. Tonight it was even more trying. The OB nurse and one of the lab techs were both pregnant. They just stood there with tears streaming down their faces. I had to stop each of them before they left and remind them that the patient had no prenatal care and didn’t even know she was pregnant. “Don’t personalize it,” I told them. “Two completely different situations. This isn’t going to happen to you.”

Didn’t stop the tears. In fact, I probably made them cry harder. Damn.

Sometimes being a doctor just sucks.

You guessed it. Not over yet.

I get a call from the ED nurse.
“Sorry, but there’s a patient down here in a lot of pain. You aren’t going to believe the complaint.”
“Let me guess … constipation.”
“Yep.”
“Are you friggin kidding me?”
“Nope. It’s a lady who hasn’t had a bowel movement in over a week.”
“Wonderful. Get a pregnancy test.”
“She’s 71 years old.”
“I don’t care. Humor me.”

31 Responses to “Constipated”

  1. Angela says:

    Was the woman overweight? I don’t understand how someone can not know they are pregnant (past a certain point anyway).

    She was a little overweight, but not significantly so.
    Personally, I think it was part that she did not know what the changes in her body meant and part plain ol’ denial.

  2. Steph says:

    I can actually understand how one wouldn’t know that they were pregnant. Given that my conception wasn’t consensual, I did my absolute best to forget it ever happened. Even if the circumstances were merely unpleasant, denial and the “it was only once” theory can come into play pretty hard. My monthly cycles were irregular, so it was easy to misremember the last time I had my period, and assume I couldn’t be pregnant based on that timing.

    I figured it out at about 5 months, but I didn’t gain all that much weight – I only went up a single size, and even at 9 months, most people didn’t think I was pregnant. Labour wasn’t what I expected either, it was short (2 hours) and concentrated in my lower back. It was never a regular series of contractions and didn’t come close to the worst pain I’ve ever experienced.

    I’m not suggesting it’s likely that one could truly give birth without ever realizing that they were pregnant, but I don’t think it’s outside the realm of believability. Denial and an unusual pregnancy can combine to be pretty powerful.

  3. mwarner6 says:

    OMFG. Just sad! I’m in awe! Reality is stranger than fiction. Thank you for the gripping story!

  4. Kat says:

    WoW, is that really possible to not know you are pregnant? How could she be getting her period then if she was? That’s amazing; nice work doc. Glad you could get that off your chest a bit.

  5. Please, could you finish the story? You forgot to tell us what was the reaction of the PATIENT, and the reaction of her MOTHER!

    Please tell us!

    Eileen
    Dedicated Elementary Teacher Overseas
    elementaryteacher.wordpress.com

    The patient was very subdued throughout everything. She didn’t say much at all. When I told her that she was about to have a baby, she said nothing to me. As soon as I left the room, she told the nurse that she was going to give it up for adoption and wanted to know how to do so.
    The mom was hard to read. Part of me thinks that in her heart she knew that the patient was pregnant, but I don’t know for sure. Before the delivery, the only thing that I heard her say to someone on her cell phone was “you’re not going to believe this…” She may not have known. She just didn’t seem as surprised as I would have expected for someone that just learned that their 16 year old kid is 9 months pregnant.
    I didn’t really see the patient after the delivery. We were working on the baby in a different room. The patient’s mother was standing outside of the room I was in as I walked out. I tried to explain what had happened. She just kept saying that she wanted to see the baby. I told her that the baby didn’t look very good and it might not be a good idea. She insisted. So I let her in the room. She stood there with her hand over her mouth for a few seconds just staring at the baby. Then she turned around and walked briskly down the hall. I never saw her again after that.

  6. Tex says:

    Yeah, what happened to Mom and Mom’s Mom?
    I guess their reaction was subdued.

  7. #1 Dinosaur says:

    Tales abound of teens delivering without “knowing” (ie, acknowledging, even to themselves) that they’re pregnant.

    My problem is with the delayed recognition that the baby wasn’t alive. Doesn’t anybody stop long enough to listen for heart tones — or even get her on a monitor to look for a rhythm — especially in the presence of signs of intrauterine demise like desquamation and umbilical cord friability?

    Still a very sad situation.

    We did have her on the monitor. I heard what I thought were fetal heart tones when the patient was in the ED.
    Up in L+D we had the toco on the mom and were getting consistent heart rates in the 130-150 range with the fetal monitor. In retrospect, the thing that should have tipped me off is that there wasn’t very much variability in the heart rates.
    I don’t do many deliveries, so up until then, I had never seen a baby who looked that way. I thought it may be chorioamnionitis or staph infection. I had no idea what a friable umbilical cord meant.
    We did check and there weren’t heart tones after the baby was delivered. Absence of heart tones is not a contraindication to CPR. Should we not code a newborn if the newborn is delivered with no heart tones? I’m not aware of any literature supporting such a decision.
    Even with a retrospectoscope, I still don’t know that I would have done too much different after the delivery … perhaps not have worked on the baby so long. Then again, pronouncing a baby dead is a lot easier said than done.

  8. SeaSpray says:

    Very Sad. :(

    I came in one day just after the ED doc delivered a baby. The teenage girl and parents also said they didn’t know she was pregnant. I never understood then and I still don’t. The baby kicking and that heavy pressure feeling you have with a full term pregnancy has to be recognizable.

    A friend of mine that worked in OB said she usually loved her job but when things got bad they were really bad and everyone is so tense and it is stressful.

    A very interesting story…thanks for sharing.

  9. shadowfax says:

    Holy cr*p. What a story. It would be a great story if not for the nightmare finish. As it is, it’s gotta rank up there with the sh*ttiest of days.

    Nice work, though, even if the outcome was not good. Intubation in a neonate — good. Central line — awesome.

  10. BlackSails says:

    Poor Ms. Peel, not even knowing she was pregnant.

  11. DP says:

    Didn’t stop the tears. In fact, I probably made them cry harder. Damn.

    Sometimes being a doctor just sucks.

    Naw. They cried harder because they stopped holding back, once they realized you understood. Tears are often cathartic for women. When a woman has a crying catharsis going, don’t try to stop the tears. Affirm their feelings like you did, maybe give them an understanding hug, and let them finish crying.

    I’m betting you’re an excellent doctor. Maybe it sucks to lose a patient, especially this little innocent life. What a tragedy. ED docs have to be risk-takers, and part of what they risk is their emotions.

  12. ebbystouch says:

    It is hard to imagine not knowing you are pregnant but I guess it can happen especially to a teenager who doesn’t know what pregnant feels like and realizing that she hadn’t had a BM in a while seemed a natural ’cause’ for the bloating.

    Sad ending. But a reason for parents to pay closer attention to their children. As a teenager I had a best friend whose mother didn’t know she was pregnant until she delivered..so I know first that this can happen. AND yes she was “full figured” so the belly didn’t look out of the ordinary.

  13. Steve Grant says:

    That was a turning point of the story that Ms.Peel don’t know about her pregnancy.

  14. jewaira says:

    An interesting post.

    I guess a doctor sees alot of unusual cases.

  15. Bahia says:

    Wow. What a story.

  16. AmyH says:

    Wow. What a powerful post.

    It takes a special person to do your job. I am full of respect for you and your peers.

  17. SeaSpray says:

    I can understand that a parent might not know, but perplexed at how any female could be unaware she is pregnant if she makes it to the last couple of months. The kicking or a little foot pressing against the stomach. Some of those kicks are so strong that others can feel them. Shoot…one night while on break in the ED, the ED doc asked me if he could put his hand on my stomach because he SAW my baby kicking. He was also a pediatrician and didn’t have kids yet. My point being that even others can see the baby moving in later pregnancy. Maybe there is some psych dx for girls/women that are able to deny their existing pregnancy.?

    Then there is the sensation of carrying something heavy in there and it’s not too much pizza. Or the fact that you cannot lie comfortably on your stomach. Your inny navel popping out. Having to pee all the time…oh wait…I do that now. Oh-oh honey…I have something to tell you… ;)

  18. DP says:

    People, the baby was stillborn. She may not have done a lot of “kicking” in the last few months.

  19. Steph says:

    @SeaSpray – Again, some of the things you mentioned aren’t necessarily common to all pregnancies. My navel never popped out, I was able to lie on my stomach comfortably right up until labour began. Size 8 jeans fit me just fine. I only peed 3-4 times a day, up from my usual once, but not something anyone else would feel was out of the norm.

    To be clear, my ignorance/denial was only able to last for about 5.5 months. Mostly, I started lactating very early, which made it difficult to deny. But the day I realized I was pregnant goes down as one of the most mentally painful days of my life – I relived the rape all over again. I was terrified, alone, desperate, confused, and hopeless. The mind will do a lot to avoid that sort of pain.

    I don’t know what the situation or history was here, and probably no one will know the full story behind the girl herself. But I can understand, now, how someone could find herself in that position.

  20. SeaSpray says:

    Hi Steph- first I want to say that I am very sorry that awful crime happened to you.

    I was talking about the last couple of months in a pregnancy. The baby kicking is a significant thing.

    I do believe there could be a psychological component in extreme cases.

  21. Laura says:

    it is a sad case. i can understand the ob nurse’s tears because sometimes we do cry at such deliveries in ob and the nicu….hey, where was nicu? why call the ed to a neonatal code? usually they scurry like cockroaches when a baby codes because that is nicu’s job.

    I was at the rural hospital where I moonlight. The NICU is in the helicopter on the way to the tertiary care center.
    That being said, this mom and the baby got care as good as, if not better than, the care I have seen at the tertiary care centers where I have worked. The nurses and techs ran things like pros and I was sure to let the director of nursing know it.

  22. Karyn says:

    I am acquainted with a woman who was told in the ER “No, Ma’am, your appendix hasn’t burst. You’re in labor.”
    Now, she wasn’t oblivious to the changes her body was going through, she’d been consulting with her doctor for months. But because she and her husband were adamant there was no chance of pregnancy, her doc had never tested for it. She had been spotting through most of the pregnancy, as well. She just figured her period was going all wonky…
    She, at least, had a happy ending, as the baby was a shock, but not an unwelcome one.

  23. Laura says:

    hey doc, i seriously meant nothing bad with my comment. i just was curious and had no clue that it was such a small facility that’s all. i have no doubt the nurse rocked at that delivery….they always do. ;)
    seriously, this is always a tough kind of delivery to attend whether it has been awhile for the care provider or it is your 15th in the current shift. it isn’t the way things are supposed to be at least according to the average layperson who assumes L&D and the NICU are such “happy places” to work.
    My heart and prayers are for everyone involved because i can imagine what everyone must be feeling having been on both sides of the delivery bed in a stillbirth.
    peace.

    No offense was taken. I probably should have mentioned that in the story. Things that were apparent to me in my stream of consciousness while I was there apparently weren’t as clear when I was trying to explain them.

  24. AK says:

    Several years back, I worked third shift in the lab at a small but busy hospital. I was the entire staff of the lab and got to go do all the blood draws. At the time, there was only one ob doc in the county who would accept uninsured women. I was there at the bedside when he gave a college woman in labor a hard time about not getting prenatal care. She replied that she had not realized she was pregnant, had been told that she could not get pregnant, and came in for “upset stomach”. Yes, she was a bit heavy and yes, the baby (healthy in this case) was given up for adoption. I have read elsewhere first hand accounts of women who did not realize they were pregnant, but that was the only time I was there to hear it from the source.

  25. Rogue Medic says:

    It is nice to see that you were aware of the reaction of the pregnant nurses and able to say the right thing to them. At least it is what they needed to hear. Too many people would have been caught up in their own feelings and left as quickly as possible to avoid dealing with the situation.

    Women denying they are pregnant is not surprising. There are significant hormonal changes that complicate the mother’s reactions to the changes in her body. The changes are gradual and this is not the only area of medicine where people try to come up with other explanations for significant symptoms.

    I had a cardiologist with tombstones on his ECG refuse transport to the hospital. He did not call 911. He was at a wedding, had vomited all over his clothes; he was pale, cool, and sweaty; he insisted that he knew what he was doing and did not want to ruin the wedding by leaving. I try to avoid weddings, but something tells me that the guy covered in vomit and looking like death does not improve the celebratory atmosphere of the wedding – unless you happen to be in his will. :-)

  26. I’m guessing you don’t have an obstetrician in house then? You guys did good. Dino has a point that the way the baby looked could have been a clue that it was stillborn… but it’s not like the attempt to code it made anything worse, except for you and your team.

  27. John says:

    how do you not know you’re pregnant?

    This is insane!

  28. [...] blog is written by an ER doc – and is chock full of real life experiences. The post that caught my attention was about a girl who came to the ER at 3AM for constipation – and gave birth to a baby. The story [...]

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