Dean's Newsletter

Dr. David Guzick, M.D., Ph.D.

This is a story of a couple from Ontario, Canada, Andrew and Tara Chisholm, who were directed to Strong Memorial Hospital by Province of Ontario government for obstetric and neonatal care. It is a story about how a young, healthy couple living in a medium-sized town can find themselves, rather suddenly, in need of tertiary care medical services that aren't readily available in their area to address a life-and-death clinical situation. It is also a story of URMC's dedication as a health care system to provide state-of-the-art medical care—with a genuinely caring spirit—to all those who need it.

Andrew and Tara Chisholm live in Brantford, Ontario, a city of about 90,000 people located on the Grand River in Southwestern Ontario. They knew each other for about 10 years, began dating 5 years ago and were married last year. There is a history of twins on both sides of the family; when Tara discovered that she was pregnant, Andrew and Tara wondered whether she was carrying one or two babies. Sure enough, at 18 weeks gestation an ultrasound examination revealed twins. Tara was then followed more closely by her obstetrician.

As she approached 25 weeks of gestation, Tara developed some symptoms of painless bleeding prompting evaluation by her obstetrician, but she did not show any evidence of significant uterine activity. In the early morning hours of Sunday, June 8, 2008, however, at 25 weeks and 3 days gestation, Tara began to have uterine cramping and was told to go immediately to her local hospital for evaluation. She was observed in the Labor and Delivery area, using uterine and fetal monitoring. There was some evidence of irregular uterine activity, but no contractions per se. Her cervix was found to be 1–2 cm dilated. The hospital staff knew that if Tara did indeed go into labor, she would need to be sent to a hospital with an intensive care nursery capable of caring for very premature infants. Her cramping became more regular and the staff was convinced that she was, indeed, in early labor. She was given a dose of corticosteroids, and efforts were begun to identify a hospital in which she and her premature twins could be managed. (A full-term baby's lungs naturally produce surfactant, which lubricates the lining of air sacs within the lungs, so that they can stay open without collapsing during breathing. Antenatal corticosteroids promote surfactant production in premature infants, which hopefully reduces the need for respiratory treatment after birth.)

In such situations in Ontario, there is a service that makes inquiries regarding the availability of maternal and neonatal beds. There are tertiary care neonatal intensive care units at McMaster Children's Hospital in nearby Hamilton, Ontario, at the Children's Hospital of Western Ontario (part of the University of Western Ontario Health Sciences Center) in London, Ontario, and at the Hospital for Sick Children of the University of Toronto. Amazingly, the hospitals in these cities responded that they couldn't accommodate Tara and her about-to-be premature twins. The Ontario referral service then considered the most proximate geographic region that could potentially provide the needed obstetrical and neonatal services. Interestingly, they looked in the direction of Western New York rather than an adjoining Province. Buffalo, evidently, could not provide the needed service. But when they called Strong Memorial Hospital, we welcomed this couple to our medical center.

The next issue was how to get from Brantford, Ontario to Rochester, NY. Ordinarily, a helicopter would be the preferred mode of transit, but the helicopter was in use. It was estimated that it would not return for 2 hours and there was concern about the weather. So, instead, they were driven by ambulance to Strong. Because of the twins, there were two nurses in the ambulance, and two Emergency Medical Technicians. With the ambulance full, there was no room for Andrew, so he had to drive on his own. The trip by ambulance took only 2.5 hours, and Andrew arrived about 1.5 hours later.

Tara arrived at Strong at about 3 pm. She was taken directly to Labor and Delivery, where she was evaluated by our resident staff. Tara was found to be 3–4 cm dilated, and she was set up with continuous uterine and fetal monitors. Uterine contractions were evident, and the fetal heart tracings of both twins were reassuring. An attempt was made to stop labor medically, but Tara's contractions continued unabated. In the brief period of time it took to do all of this, Tara's contractions continued and she was re-examined at 5:30 pm. She was now fully dilated. The presenting fetus was in breech presentation. Both because of the marked prematurity and breech presentation, an emergency C-section was needed.

Here is where our pro-active approach to patient safety really paid off, as Tara was taken to a special operating room in the gynecology operating suite on another floor that is held empty for times when both of the "regular" C-section operating rooms in Labor and Delivery are full. This was one of those times. (On average, about 9-10 deliveries occur per day at Strong Memorial hospital, of which about 25% are by Cesarean Section. Thus it is very rare for more than 2 C-Sections to be going on at any one time, but when an O.R. is needed on an emergency basis, it must be available and ready. The only way to ensure a ready O.R. is to prevent it from being used for routine O.R. cases--which are often still going on at 5:30 in the afternoon. While not "efficient" from the standpoint of O.R. utilization, it is necessary from the standpoint of patient safety. When the third C-Section O.R. was needed for Tara, it was ready and waiting for her.)

Another area where redundancy adds to patient safety is our back-up system of attending coverage. The Maternal-Fetal Medicine faculty member, who would ordinarily be responsible for referred patients such as Tara, was doing one of the C-Sections at the time that Tara was found to be fully dilated. Therefore, our 2nd-call attending in the hospital was contacted. Dr. David Gandell is a community-based, part-time faculty member who was on call for his practice (Rochester Gynecologic and Obstetrical Associates). When he was paged about Tara, he evaluated her immediately and called the stat page for the C-Section. He recounts that two anesthesiologists he "has worked with quite often – Steven Finkelstein and Stefan Lucas – were great. They appeared within minutes and expertly and efficiently prepared Tara for her anesthesia. At the same time, the pediatric team from the Golisano Children's Hospital NICU were setting up to take care of the twins as soon as they were born, nurses from L&D were counting and arranging the instruments, and my residents and I were prepping for the surgery. I comforted our patient, let her know what was happening, and assured her that we would do the best job we could for her and her babies. I was so impressed with how well our system worked, and how we could be a resource even for someone traveling from another country to get care. I was distressed and surprised that she could not get care nearer to her own home, but really proud that I was part of the team that took care of her, and proud to be part of our institution."

The C-Section was uneventful and Aeva and Alec Chisholm were born weighing 700 g and 750 g, respectively, at 25 3/7 weeks gestation. Now, about 3 ½ weeks later, they have grown to 770 and 860 g. Very premature babies such as Aeva and Alec have a tough start in life, with numerous complications. According to their neonatologist, Dr. Sanjeer Amin, Assistant Professor of Pediatrics, "babies born at this gestational age and weight have about a 70% chance of survival. This is considerably greater than the survival rates that we were able to achieve only a few years ago, due to advances in treatment. If they survive the first two weeks, however, the likelihood of survival is much greater. Unless there is some serious complication at this point, it looks good that Aeva and Alec will make it." Dr. Amin goes on to say what a pleasure and privilege it has been to be able to take care of these precious babies and to work with such a delightful couple as the Chisholms.

Andrew and Tara have been staying at the Ronald McDonald House, which is on the top floor of the Golisano Children's Hospital. This has provided them tremendous convenience, in that they are only steps away from Aeva and Alec. They express heartfelt appreciation for all that we have been able to do for them and their newborns. Above else, what was wonderful to hear was their statement that everyone they have come into contact with at the medical center has shown genuine caring. They emphasized that these are not just words but that they can feel the sincerity of the caring spirit of the nurses, staff and physicians who have entered their lives during this profoundly life-altering event.

Dr. Gandell said it this way: "What a privilege—what we do every day is special, but every now and then you feel that there is something truly special. When you realize that Tara and her husband had to cross international boundaries on an emergency basis to make sure that Tara could deliver in a hospital that could provide the care that she and her preemie twins needed, and that we were able to deliver this care expertly and with compassion, it gives fresh meaning to my profession."

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
University of Rochester

Dean's Newsletter

Posted July 07, 2008:
Access to medical care at URMC: an obstetrical-neonatal example

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