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By Tamara Moores Todd
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I languidly watch the nurse start my IV iron drip. After what felt like a lifetime of pregnancies (three babies in four years), I snuggle into my bed, finally able to relax.
I did it. My beautiful daughter was born yesterday.
My mother watches the squishy baby lovingly while she sleeps in the bassinet. My husband and our three-year-old daughter and two-year-old son are on their way. We're so excited to have the kids all meet for the first time.
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Despite trying iron replacement with pills for months on end, it didn't work for me. So I have had IV iron three times total throughout my previous pregnancies.
The OB team is giving my dose today, conveniently postpartum day one, so that my recovery will not be hampered by my iron deficiency anemia. New data also shows a decreased rate of postpartum depression with adequate iron stores, I remind myself.
Contentment hums in me because I'm grateful my OB team knows this. They're setting me up for a smooth recovery from this four-year marathon, building all these babies with my body, with my one beautiful life.
The nurse and I are vibing. She is endearing and enthusiastic, a new grad just starting her career on the postpartum floor, thrilled by the joy of new mothers and their babies.
This is my third child, we know the ropes, smooth and easy as it goes.
I watch the iron slowly move through the IV tubing as she inches the syringe plunger forward, drip-drip-drip, finally making contact with my bloodstream, as it has done so many times before.
Slam! I feel my throat close shut.
My lungs are blocked against a sudden obstruction. It...feels like I have taken the last true breath I will ever take. No, no, no: This is all wrong.
Fire fills my throat, my lungs, my chest. I grab the nurse's hand: "Mandy, Mandy, something's wrong, epi," is the last sentence I'm able to say.
Pain, pain, pain. I see fear fill her face. She stops the iron and leaves at a run.
I am shaking. No breath, no breath, my mind, honed by a decade of emergency medicine, knows this is anaphylaxis. Really bad anaphylaxis. F**k. F**k. F**k.
Tears leak from my face as the fire of hypoxia consumes me. I never truly knew the pain of not breathing, the physical unabiding suffering while my body shuts down but my brain is still firing, thinking, feeling.
...
An uncontrollable scream rips from my mouth, my chest, my lungs, as my back feels filled with a thousand sharp knives, a pain as deep and primal as labor, which I had experienced less than 24 hours ago.
My back is arching, my chest is tearing apart, my face is a balloon swelling. I can't breathe, I can't breathe, I can't breathe.
"Rapid response room 501" rings throughout the hospital.
"Code code code" whispers throughout eternity.
It does not matter that I'm an emergency physician; that I have intubated hundreds of patients, led hundreds of codes; or that I have trained code teams throughout my healthcare system how to do better via simulation practice.
It does not matter that I was high school valedictorian, top in my medical school class, highly awarded in residency, now with multiple director titles as an attending physician.
It does not matter that I have given state medical briefings next to our governor, and national presentations to esteemed audiences.
None of it matters. All of that history and knowledge compressed to a single moment—my newborn daughter whisked away safely as 20 people jam into my room, dancing, weaving, muttering.
Peripartum mortality levels remain abysmally high in our country, but it does not matter that I know these statistics; that in my career I have even designed software to change this fact. It does not matter.
In this moment, I am just a woman, who just had a baby, and I am dying.
I see the code team come in, their practiced eyes watching, asking, knowing. "I am one of you," my brain wants to tell them, I know the rush of adrenaline, of fear, of purpose, as they dance the resuscitation rumba.
I see the resident wearing black scrubs. Ten years ago, I wore those same scrubs, training in this hospital for my residency in emergency medicine. I see the tired crusty attending wearing a Patagonia jacket. I am them, and they are me.
My mind chides them as they fail to assign roles aloud, watching through the eyes of a teacher. I have trained code teams for years, I know this game, I could help them, my brain screams. But it does not matter.
I cannot speak more than a whisper as my vocal cords are inching together. I am the epitome of stridor. I am dying.
"Epi" squeaks out of my mouth over and over again, the one thing I beg for, as my face engorges and my airway narrows, squelching closer and closer to that final obstruction.
My body shudders, arches, convulses: Panic consumes me, desperate for a full breath that just...won't...come.
I hear the sobs of my mother as she tries to call my love, her phone trembling in her hand. He and our kids are at the grocery store; they were buying me flowers, beyond excited to introduce our little toddlers to their new baby sister.
"Don't come to the hospital, there's something wrong with Tamara," I hear her wavering voice drift to me like a caress, a dream.
He was so proud of me as I brought our daughter into this world yesterday, I am so proud of him and us for daring to live our story of adventure and of family. He is the one great love of my life.
But the story is changing, the multiverse is splitting, death is coming. He will raise our children well, but without me.
F**k. F**k. F**k. Guttural, horrible gasping noises are radiating from me. I am unraveling, unmaking, unmade. I keep raspily screaming, it's now well beyond my control.
In this esteemed edifice, where I honed my medical skills, where I crafted my persona, inside and out as cool, competent, collected, I am no longer that professional facade.
Instead, I lay here in my bloated, ravaged postpartum body, screaming in muffled whispers and dying with pain and rage.
"Epi," I whisper and squeak, begging again for the thing that will save me, that will let me raise my children, let me embrace my lover, let me have another chance at life, a rebirth, the fire is unbearable.
Yet as long as I feel pain, I cling onto hope: There is still time. The people and their various roles watch me, assess me. I see the practiced detached eyes of the house supervisor nurse run over me: "Let's get another IV."
No, my brain groggily yells, please give me epinephrine.
I want to tell them I feel the fire of distributive shock, that my airway is seconds from being lost forever, I feel the pathophysiology of my bronchioles clamping down, I am in the depths of ischemic death of all my end organs.
My hypervascular uterus is cramping, dying, dying as my blood pools in my capillary beds, my lifeblood going further and further away from my brain in the lakes of flaccid anaphylaxis.
My medical school professor Dr. Werner would be proud of my brain, citing this depth of pathophysiology as I lay dying, my mind darkly mutters to me.
Murmurs as people prod and poke me, I hear their voices clearly even now, months later.
"But she's not wheezing."
"That's because I'm barely moving air," I want to say, but I can't, as my airway swells even further, my body consumed by shaking.
"Let's get an ABG."
Damn. My hissing chant of "epi, epi, epi" continues.
My mind flashes through a scrolling reel of all the worst similar cases I have cared for in my life as a physician: The young new mother who died quickly and hauntingly within a few minutes of arrival to the emergency department; the floor patient who had lost their airway and pulses almost exactly how I was about to lose mine.
I had been the code team attending physician that day. I expertly carved a surgical airway into that patient's neck and recovered their pulses, but despite that victory, they died a few days later due to hypoxic brain injury.
I know my future, I know my fate. Frustration, fear, and PTSD are my companions as I wriggle and sweat and drag each small gasp through the collapsing slot canyon of my voicebox. Doom unbidden, uncontrollable is barreling toward me.
Through the haze of my tears and my swollen eyelids, I see one of my friends from residency holding my hand as my body dies.
She is the attending pediatrician on service today. She made sure my newborn daughter was safe, and then came back to be with me. How comforting, I think, to at least have a friend hold my hand.
I who have led code teams innumerable, am powerless. I am dying, so close to gone.
I hear questions float around me.
"What's the dose of epi?"
"0.3," I squeak out
"Do we give it IV or IM?"
"Thigh!" I wheeze. Please, please, please give it. Give it now, give it now, give it now.
I see the terrified look on my nurse's face, the one who gave me the medicine that is killing my body from anaphylaxis.
She is such a new nurse. My heart breaks for her, this was not her fault, I am now the case that will haunt her. I want to reassure her that I do not blame her, that I know the sleepless recriminations that come, that she is gifted and that the world is lucky to have her talents.
But I cannot. I feel my lungs burning, burning, burning as the trapdoor swings forever closed in my trachea.
Finally: The sweet sting of the needle.
Seconds pass as the code team stares at me, their dance continuing. My wrist burns as a resident gets that damn ABG.
Unnecessary, my brain mutters, still commenting on the ways the code team could do better, the teacher in me still wanting to lead my care. But I suppress my inner critic.
I am not the doctor today. I am just a woman, who just had a baby, who just maybe won't die today after all.
"Odd," I think as my first sips of air start whistling their way through my lungs.
My mind starts babbling about the oddities of why epinephrine is actually making my heart rate return to normal from its previously panicked rate of 160 bpm, now that the oxygen/carbon dioxide exchange can wend its way through the capillary diffusion gradient.
The hemoglobin gleefully whisking new oxygen to my starved body, my blood returning to normal circulatory patterns, my trachea and lungs are opening, opening, opening.
...
Afterward, with tentative laughter, they tell me I'm the first code patient who knew her medications better than the code team. I attempt to laugh too, and shake my head. It's true. In the emergency department, I actually care for a lot more cases of anaphylaxis than the internal medicine code team does.
There are certain superstitions in medicine: It's the nice patients who get awful cancer, and it's the doctors who get all the weird healthcare complications.
"Of course in this case it was the ER doc who got anaphylaxis," they tell me, trying to return to a normal cadence of conversation after the terror that just enveloped us all.
They turn their minds back to the rest of the day, another case, another patient.
I try to pull the shattered shards of myself back together.
I introduce my newborn daughter to her siblings for the first time 30 minutes later, my face still swollen, barely recognizable, trying to feel the joy of their oh-so-anticipated greeting through the horror of this true near-death experience.
My daughter is now six months old, I have returned to working in the emergency department, the wheel of time turns.
Images from these critical seven minutes often flash into my mind throughout my days now. The somatic memory lives in my body, surprising me randomly with its intensity.
As the dark comedy of life goes, my first patient in the emergency department after I returned from maternity leave presented with anaphylaxis, albeit a less severe presentation than I had been.
Even so, she received epinephrine from my emergency team in under two minutes, I made damn sure of it.
The Debrief
I specialize in emergency medicine and clinical informatics, and I teach simulation best practice, so my debrief is from this perspective.
As I asked questions and learned, it turned out I was a casualty of a medication error. A different formulation of iron (iron dextran) had been ordered for me that day. I had only ever previously received iron sucrose.
All IV iron medications have a very small rate of anaphylaxis, but iron dextran has an eight times higher likelihood of anaphylaxis than Iron Sucrose and other IV Iron formulations.
Studies since 1999 have cited that iron dextran has both the highest rate of anaphylaxis and the highest severity of anaphylaxis, with a likelihood of death of 15.8 percent once anaphylaxis begins.
Comparatively, iron sucrose has a likelihood of death of 0 percent when iron sucrose triggers anaphylaxis.
Decisions regarding which medications are available to administer in a healthcare system are usually made by its Pharmacy & Therapeutics (P&T) committee.
Debate exists nationally on whether iron dextran should be included in a hospital's formulary, and some healthcare systems have eliminated it from theirs due to this extraordinarily disproportionate rate of anaphylaxis and mortality compared to other Iron formulations.
There are always risks in eliminating a medication too, as iron dextran has a cost ratio that historically made it a preferred item, especially from the 1970s-1990s.
Due to the siloed nature of American healthcare, in these grey areas of clinical best practice, each healthcare system has certain intrinsic leeway to make its own operational and safety guidelines, and therefore variation is inevitable.
From an informatics perspective, most medications in electronic medical records (EMRs) sort in an alphabetical basis in the search field. Iron dextran sorts alphabetically before iron sucrose in the EMR, and I suspect it was clicked because it was listed first in the search results: "D" comes before "S".
Did the humble ABCs almost kill me? TBD. Ironically, we also use the ABCs as our rote and ritual in codes: Airway, Breathing, Circulation.
Healthcare is beyond complex, and the Swiss Cheese model is often cited as the ultimate cause of error: When multiple unlikely/unplanned items combine in an unexpected way to eventually affect an individual patient.
In my case, the most impactful factors were likely:
- The foundational choice of medication formulary by P&T committee (which medications are stocked in a hospital);
- Common standard EHR programming functionality (alphabetizing choices);
- User interfaces for how a doctor selects a medication (providing a search bar instead of a quick clickable list of common medications or ordersets);
- Lack of premedication protocols in standardized ordersets;
- Lack of additionally configured Best Practice Advisory EHR pop-ups (which could have provided a "just in time warning" when this ordering error was made).
One could list further factors for pharmacy workflow (the individual who sent the medication to the floor from central pharmacy), nursing workflow (the individual who administered the medication), and beyond.
But for now, I am alive, thoughtful, humbled, forever imprinted with the trauma of this moment, and am asking myself: What will I do with this experience?
Ultimately, I try to see the days brighter, even in the standard hustle and grumble and stress of a typical day. I hug my family tighter, look at them longer.
In my work days, I ask how we can do better in healthcare, for all of us, and especially for vulnerable women in the time of childbirth. For I am them and they are me.
I, while defying death daily in my work, looked at my demise from a new angle, on the precipice of my own eternity. And now I ask what will I do with this rebirth, with my one wild and precious life?
Change comes from large moments and from small moments, and I am convinced now more than ever that we owe our community, our patients, and our friends better lives, better health, and better systems to support our health at large.
We have no other option. We must do better. And I'll do my damn best to make damn sure we do. Will you join me?
Dr. Tamara Moores Todd is an emergency medicine attending physician. She is double board certified in emergency medicine and clinical informatics. She works clinically in emergency departments and leads teams that configure, design, and optimize electronic health records and other software to support healthcare systems and clinical best practices. She is a proud mother of three and married to Chris Todd.
All views expressed are the author's own.
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