Birth and Death in The Wilderness— What a Week
Birth and Death in The Wilderness — The Inevitable Circle of Life
The call came through over the radio and woke me from a near comatose sleep in my efficiency apartment above an after-hours, somewhat make-shift emergency room on a remote island in The Bering Sea. “There is a woman on her way to the clinic in labor” the dispatcher sounded as surprised as me. I am a very deep sleeper and an extremely vivid dreamer so I called and asked the dispatcher to repeat — just in case.
Pregnant women are expected to leave the island around week 32 to prepare to deliver in a safe, controlled environment on the mainland. We are a minimum three hours medevac from the mainland. I had recently visited a friend on the island of Nevis in the Caribbean where an island home birth did not go well and everyone, including the midwife, was grieving. My heart started pounding in disbelief. I really thought it was another intense dream. The dispatcher repeated himself and followed with “Do you want me to call anyone else?”. Out the window a pick-up truck slid sideways screeching into the dirt parking lot below. “I want you to call everyone”. I hung up the phone and ran downstairs in my little silk pajamas and flip flops out into the dark rainy Aleutian night. I have not delivered a baby in over twelve years and I had an OB standing right there as I was in physician assistant school at the time. Now I am in medical school and working part time. I am only theoretically trained in how to handle this situation.
“I want you to call everyone.”
The rain was pounding like little needles through the icy Aleutian air. I ran out to the pickup truck and opened the passenger door “let me grab a wheelchair and we will get you inside”. The mother replied “I don’t know if there is time”. There was no time. The baby flew out and I caught him in my bare hands. He was blue. He was smurf blue. I did not know that human creatures could be this shade of blue. “Why is he blue!?” his mother yelled. The cord was around his neck. I held him upside down by his ankles in my left hand. His slippery little feet were wedged in between my fingers. I unwrapped the cord from his neck with my right hand. He was not breathing. My heart was in pieces and I promised myself that I could cry later. I used my flimsy silk night shirt to wipe the amniotic mess away from his mouth and — not knowing what to do next — I smacked him on the behind. He cried. It was the most beautiful, wonderful, amazing cry I ever heard. His skin turned pink and he continued to cry. Now what?
I am standing in flip flops and pajamas in the rainy arctic night holding a naked baby upside down still attached to his mother by the umbilical cord. It was then that “everyone” showed up thankfully. One of the paramedics ran up and asked for orders. He brought the wheelchair, clamps, sterile scissors, and a blanket. The moment ‘I’ becomes ‘we’ in emergency medicine is quite comforting. I love teams. We wrapped the baby and put him under an incubator until we could be assured mother was okay as well. There are three things babies need — erythromycin ointment in their eyes, vitamin K (I always remembered this because my friend Frances’ father discovered that vitamin K stopped bleeding in human patients with jaundice), but what was the third thing? We called the Providence OB Hospitalist for instructions. They were outstanding. The third thing was the Hepatitis B vaccine.
We placed the baby on his mother’s chest and worked with them on attempting to feed. We checked his blood glucose and stayed with mother and baby 14 hours until the Lifemed team arrived. They cannot fly after dark out here. There is no radar so “Civil Twilight” dictates when any non-military planes can land. Lifemed sends a neonatal nurse with the flight crew to remote locations. They are outstanding partners and an incredible resource when you are deep in the Alaskan wilderness. In a case where there was little to no compliance with prenatal care it was very reassuring. We tucked mom and baby in with the flight crew and they were off.
“One of the island residents who was born here on the island has metastatic cancer and wants to die at home.”
We were not technically experienced in hospice care but we would of course work with mainland hospice and assist in implementing their plan and, when the time came, we would handle the death. We do not keep the heavy hitting pain medications that many terminal metastatic cancer patients need in our little dispensary but hospice sent them with the medications they needed. We would prepare and adjust our protocols to accommodate this request. The gravity of this last wish was not lost on us.
The call came through a few days after the birth. The terminally ill islander had passed in their sleep. I accompanied two police officers and two first responders to the house. It was not the first time I have gently placed someone into a thick black body bag and I am sure it will not be the last. This experience was slow, respectful and methodical in contrast to the frenetic birth. Usually deaths out here are unexpected and there is an attempt to resuscitate and investigative work that must be done. Everyone knew this death was coming and wanted to help the patient exit the world on their own terms. I completed and signed the death certificate and wished the patient luck in the beyond. I was in awe of their resolve all the way to the end.
A year later I stopped by the house of the child I delivered to give him a birthday present. He is a calm curious child and I tell myself there is a bond between us. The circle of life has never been so profound and pervasive as it was that week. I specialized in Wilderness Emergency Medicine and chose the farthest outpost on US soil I could find. I wanted to sharpen my physical exam and diagnostic skills. I wanted to have to “Macguyver” solutions for patients and learn how to coordinate complicated medevacs.
There is a difference between Wilderness Medicine and Rural Medicine. In Rural Medicine you are maybe an hour away from tertiary care by ambulance — in Wilderness Medicine you might have to call the United States Coast Guard and request a C130 to come medevac patients to safety. This might take days. You might have to mold yourself into a makeshift ICU in the meantime. Far out in The Aleutian Islands Wilderness, I had the privilege of working with and caring for the heroic men and women of the United States Coast Guard, the rugged brave Bering Sea fishermen and women, and the hardworking folks from all parts of the Earth who process your fish. I was accustomed to trauma and medical emergencies out here, however, the most unlikely things I could do in the middle of the wild night were deliver a baby and then handle a hospice style death. That is the thing about Wilderness Emergency Medicine — you never know what to expect and must be prepared for anything. The paradoxical unexpected birth and expected death within days of each other — way out here on an island in the middle of The Bering Sea — is with me every day. The circle of life continues.