Feature

Hero Work

Five stories that will make you believe that, on their best days, doctors really do have superpowers.

August 2013

Special Delivery
Coaxing new life while cheating death.

Friday, February 10, 2012, 8 a.m. to 10:10 a.m.
➥The labor and delivery deck at Saint Joseph’s Hospital in Uptown has long been one of the busiest such services in Denver. Each year, nearly 4,000 infants are born within the walls of the Baby Place, a 14-suite unit designed to feel more like a destination spa than a medical center. Although the slate tile, soft color palette, and wall art set a serene tone, “L&D,” in hospital parlance, is always bustling.
The morning of February 10, 2012, was no different. The typical hum of activity—nurses in blue scrubs flitting between rooms, white-coated doctors reviewing charts in the hallway, the occasional labor pain–induced scream escaping from an open door—met Dr. Joyce Gottesfeld as she came on for her 8 a.m. shift. Like any other day, a roster full of patients in varying stages of labor awaited the obstetrician-gynecologist. Gottesfeld checked the charts of each, including a spritely brown-haired, brown-eyed 33-year-old who was having her first child. C. Smith was only about five centimeters dilated after having been admitted the previous evening to be induced. As Gottesfeld began visiting each of her eight patients that morning, Smith was getting an epidural from the anesthesiologist.
When Gottesfeld finally laid eyes on Smith, her husband, A. Smith, and Smith’s mother, things were looking up. Although the patient mentioned she was uncomfortable and feeling tremendous pressure, Gottesfeld assured her that was good news—Smith was fully dilated and nearly ready to deliver. Except for some minor decelerations in the baby’s heart rate—usually attributed to the epidural—labor was proceeding beautifully. The doctor said she was going to check on another patient while the nurses set up the room and that she would be back shortly.
Gottesfeld could not have known just how quickly she would be paged back to Smith’s suite—or that what would happen next would be unlike anything she’d ever experienced in her 16-year-long career.

10:11 a.m. to 10:30 a.m.
➥“Down tones” is doctor-speak for when a baby’s heart rate slows dangerously during labor. When that happens—which is not uncommon—the baby isn’t getting enough oxygen. Nurses paged Gottesfeld back to Smith’s suite for that exact reason. Changing the mother’s position or putting her on oxygen can sometimes resolve these decelerations—but in Smith’s case the typical solutions weren’t working. Gottesfeld couldn’t believe it: 10 minutes ago this was an easy delivery in the making; now we’re talking a crash C-section.
At least, that’s what she thought was happening until Smith went pale, said she felt sick, and began to vomit. By the time they got her to the labor and delivery operating room (OR) to do the emergency
C-section, Smith was frothing at the mouth and having a seizure. Seconds later she had no pulse.
There’s a not-so-short list of pregnancy-related conditions that can be life threatening for mom and/or baby: placental abruption, preeclampsia, uterine rupture, postpartum hemorrhage. At the top of the list, though, is a little-understood yet catastrophic complication called amniotic fluid embolus (AFE).
Amniotic fluid embolus occurs when some of the material from the fetus inexplicably enters the maternal bloodstream. Although not completely understood, researchers believe AFE causes two phases of life-threatening complications. In the initial phase, fetal contents enter the mother’s heart and lungs, resulting in obstruction of blood flow into the lungs and problems with oxygen absorption. A reaction similar to anaphylaxis (an allergic reaction) can take place, causing high pressure in the arteries leading to the lungs. Cardiogenic shock, a condition where the heart isn’t strong enough to pump the blood the body needs, can also take place. In the second phase, something called disseminated intravascular coagulation, or DIC, occurs. This complication, which happens in 83 percent of AFE cases, causes the body to consume all of its blood-clotting factors, leading to uncontrollable bleeding.
AFE only occurs in 1 out of 20,000 deliveries (about 200 times annually in the United States), but recent studies suggest at least 30 percent of the time it is fatal for the mother, and only about 15 percent of women who do survive are neurologically intact. Neonatal mortality rates are directly related to how quickly doctors can deliver the baby after the mother goes into cardiac arrest.
Gottesfeld, anesthesiologist Dr. Bruce Lowry, obstetricians Drs. Gerald Zarlengo and Lynette Vialet, and a host of other physicians and nurses knew they had less than five minutes to deliver Smith’s baby. At the same time, they had to save the infant’s mother. A Code Blue had been called over the hospital’s PA system seconds after Smith’s heart stopped. In response, a line of nurses, physician’s assistants, and residents formed to take their turns at two exhausting minutes each of chest compressions before going right back to the end of the queue. Lowry intubated Smith and Gottesfeld began cutting her way into the patient’s uterus. “I can tell you, as a physician, you’re just stunned,” Gottesfeld says. “I was trained for this. I knew what it was. It could’ve been a heart attack or a massive stroke, but it was probably an AFE. And you’re just kind of dazed.”
Less than five minutes later, Gottesfeld delivered a blue and unresponsive nine-pound baby girl, who was immediately intubated. Shortly thereafter, the baby was taken to the neonatal intensive care unit (NICU), where she was placed on a mechanical ventilator and her body temperature cooled to help her brain recover from the lack of oxygen. For the time being, the baby was in serious but stable condition.
The same could not be said of her mother. No one knows why an amniotic fluid embolus happens—there’s no way to predict who might get an AFE—but the doctors at Saint Joseph did know the delivery of the 33-year-old’s baby was only the beginning.

10:31 a.m. until 11:50 a.m.

➥ The next three overhead pages that went out were for a cardiac anesthesiologist, a cardiothoracic surgeon, and a massive blood transfusion protocol. These are not common requests from L&D—so when they do come from the second floor, everyone in the hospital pays attention because it’s clear that something has gone terribly wrong on a floor where things shouldn’t take a tragic turn.
Dr. Peter Hession, a young cardiac anesthesiologist just eight months out of his fellowship, didn’t immediately think AFE when he heard the page he had to respond to. It was high on his list of possible diagnoses, but he’d never actually seen one before.
Fortunately for Smith, Dr. Kevin Miller was more familiar with AFE. A longtime cardiothoracic surgeon, Miller was in the main OR on the first floor just minutes from putting his own patient on bypass when the page for his services squawked overhead. With an anesthetized patient on his table, Miller couldn’t just leave—but when residents from L&D came to beg the doctor to come upstairs, Miller made the decision to leave his patient in the care of other physicians and took some of his team and another heart-lung machine to the second floor.
Saint Joseph’s blood bank received the third call to arms: Smith was going to need a lot of blood and blood products—quickly. The bank readied and sent up eight units of packed red blood cells, and kept them coming.
When Miller got upstairs there were 25 to 30 people in the L&D OR. It was, he thought, a remarkably well-controlled chaos. It had been nearly an hour, but the code team was still in line doing CPR. Although the patient was not responding, doctors were still attempting resuscitation efforts like defibrillation, epinephrine, and amiodarone. Coolers of blood were arriving. People were running back and forth from the OR to the pharmacy and the lab. Hession was getting a transesophageal echocardiogram to confirm the heart was in fact stunned from an AFE and not something else. The patient had begun to bleed from everywhere—the C-section incision, her uterus, the IV sites, her nose, and her mouth. Miller knew he needed to get the woman hooked up to the heart-lung machine posthaste.
To do that, Miller would normally attach the machine through a patient’s aorta, but that procedure requires a sternotomy—a huge incision in the middle of the chest. Smith was already bleeding too much to handle a major surgery; instead, Miller placed the heart-lung machine tubes, called cannulas, into the femoral artery in her leg.
Miller turned the machine on. After an hour and 15 minutes, the chest compressions finally stopped and the OR went quiet. Smith’s heart and lungs didn’t have to struggle to function any longer—the machine was doing all the work. It would simply take time for the organs to recover on their own. Her out-of-control bleeding was now the primary problem.

Early afternoon through late evening
➥ The normal human body contains a little more than five liters of blood. Smith was bleeding so badly that if doctors and nurses had stopped giving her blood products for even a short amount of time, she would’ve died. But blood is a precious—and limited—resource. The blood bank at Saint Joseph only has about 150 units of blood and 120 units of frozen blood products at any given time. Smith was quickly depleting the hospital’s stores. Doctors needed to slow her bleeding.
Gottesfeld reopened Smith and tried to staunch the bleeding in the uterus; the procedure had little effect. Around 2 p.m., they decided to move her to the intensive care unit (ICU), where they would continue their efforts. But after just minutes there, they knew more aggressive treatment was necessary. They took her to the interventional radiology lab to try a procedure called a uterine artery embolization, which they hoped would lessen her bleeding by manually clogging some of the vessels that go to the uterus.
It appeared to be working. Gottesfeld thought they might have turned the corner—until she looked at Smith’s leg. “I’m the gynecologist, but I don’t think this looks right,” Gottesfeld said to her colleagues. Cold and mottled, the patient’s leg was dying: The large tubes from the heart-lung machine were impeding blood flow in Smith’s small artery.
For the second time that day, Miller was stat paged—this time to the radiology department. “I thought about putting the machine into her other leg,” Miller says, “but I was afraid she was already going to lose the first leg. She was still really bleeding but I knew I had to cut her open; I had to do a sternotomy and connect it to her aorta.”
That became the plan. Miller cracked her sternum and placed the heart-lung machine tubes directly into Smith’s heart. At the same time, Gottesfeld had made the decision to do a hysterectomy, and the vascular surgeons would have to repair the artery in Smith’s leg and do a limb-saving surgery called a fasciotomy. All four surgeries happened simultaneously in Saint Joseph’s main OR. More than once during the approximately seven-hour-long surgery, Gottesfeld brought Smith’s husband into the OR to say goodbye. His wife—no matter what they did and no matter that they’d given her more than 200 units of blood—was still bleeding.

Just after midnight, February 11
➥ After hours in the OR, doctors brought Smith to the ICU. They were still putting in blood as fast as they could, and it was coming back out just as quickly. The key to winning the battle against the bleeding caused by DIC is time. Doctors had to keep Smith supplied with blood until her body began to once again produce its own clotting factors, which would slow—and ultimately stop—the bleeding. But that wasn’t happening yet. Smith had received intermittent anesthesia—she had no conscious awareness of what was happening to need it consistently—and it began to concern Hession that she wasn’t at all responsive. He knew the prognosis was becoming more and more grim. Miller agreed. Doctors once again brought Smith’s husband in to say goodbye.
By 2 a.m., the doctors began to discuss whether they’d reached the point of futile care. “We were burning valuable resources,” Miller says. “The blood bank was calling and saying, ‘We’re down to the last units of platelets in town.’ She had endured more than an hour of CPR. We had no idea if her brain and kidneys and other organs had been damaged. We began to wonder if she was even recoverable.”
Miller went into Smith’s ICU room—they were still giving her blood—and walked around her bed. He examined her. He held her hand. He adjusted one of the tubes.
And then she opened her eyes.
“She looked at me,” Miller says. “I knew then we couldn’t stop. She was there. Her brain was there. I was amazed and encouraged. That’s all that it took.”
Gottesfeld brought Smith’s husband and mother back up to the ICU, this time to say hello.
Over the next several hours, Smith began to equilibrate, her bleeding slowed slightly, and knowing his patient was doing well on the heart-lung machine, Miller finally took a nap.

The next 48 hours
➥ The rest of the day on February 11, Smith was kept under anesthesia and remained on the heart-lung machine, which would give her body time to recover. As the day wore on, she required less and less blood.
The next day, Sunday, Miller saw that Smith’s heart and lungs were recovering. That afternoon, Hession, Miller, and a team of vascular and general surgeons took Smith back to the OR, where they removed the heart-lung machine, stopped some bleeding in her belly, performed a follow-up procedure on her leg, washed the excess blood from her abdomen, and took her back to the ICU. She improved. Her heart and lungs were working on their own. Her kidneys, liver, and intestines were functioning well. She was still sedated and intubated, and she was still getting some of the 270 total units of blood products she’d ultimately receive—but her body was experiencing an extraordinary recovery.

February 15
➥ A palpable pulse of energy shook Saint Joseph Hospital on Wednesday when doctors extubated Smith. For six days, everyone who had been involved—directly or indirectly—had been starved for any morsel of information about her progress. The tiniest updates had rippled through the hospital; the possibility that Smith was going to be able to talk was as heartening as finding out days before that her infant daughter had recovered from her nightmarish entry into the world.
Not long after the tube came out of her throat, Smith did indeed begin to talk—and she had a pressing question: “Are we still in network?” In her drug-induced haze, she thought her husband had taken her to a hospital in another city—and she was worried that their insurance would not cover her medical expenses. A sad commentary on the state of America’s health-care system? Maybe. More important, it was a clear sign to the doctors that Smith was neurologically intact.
Then she wanted to know about the baby, who Gottesfeld immediately—and against hospital rules—brought up to see her mother. “I think they could have sold tickets to the one-way show up to the ICU,” A. Smith says. “Our daughter became the princess of Saint Joe’s.”

February 24
➥ Fourteen days after the birth of her daughter, Smith left Saint Joseph. She was still nursing major incisions in her abdomen, chest, and leg; she was on an array of antibiotics and painkillers; and she had a newborn to care for at a time when she felt like she might not ever be able to care for herself again.
Time began to heal her physical wounds. Except for a small infection in her leg and some fluid buildup in her pelvic area, Smith had remarkably few complications considering the extent of her medical crisis. The emotional wounds, however, were harder to deal with. Smith and her husband were both struggling—but in different ways.
Smith missed many of her daughter’s “firsts”—her first feeding, her first diaper change, her first noises, her umbilical cord falling off. She couldn’t care for her daughter without help for many months—and when that time did come it was a very dark day for the new mother. “I felt sad and helpless and, most of all, I felt wronged,” she says. “I kept thinking that I’ll never know what it feels like to give birth or hold my newborn child—because I can’t have another child.”
While Smith battled those thoughts, her husband wrestled with something not unlike post-traumatic stress disorder. He had watched his lifeless daughter be delivered and seen his wife nearly die. He made medical decisions he wasn’t prepared for. Then he had to say goodbye to Smith—more than once. And when they finally got home, he had to care for two people instead of one.
By midsummer, though, Smith was well enough for a mini vacation to Crested Butte, where the family took a hike and where the baby sat up by herself for the first time. Smith says she remembers the day later that summer when she told her husband, “I feel strong.”
Today, a year and a half after that fateful February day, the family is doing well. The scars—physical and emotional—are still there, but they’re fading. The memories, however, are vivid. Smith tells the story about the first time she remembers—really remembers—seeing her daughter. Smith was still in the ICU, but she had left her room to have lunch with her husband and the baby. “She was big and beautiful and felt like a little stranger to me,” Smith says. “I remember thinking in that moment, I went through all of this and you look just like your dad.”

The Top Docs
Kevin Miller
Thoracic and Cardiac Surgery

GeralD V. Zarlengo
Obstetrics and Gynecology

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