It’s a busy Monday with patients backed up in the waiting room, and at least four of mine waiting for cat scans before I can make a decision or disposition. I go back to see the PA in fast track who is overwhelmed with charts and start seeing a few of them. The ED is so backed up that no new patients can be brought back into empty beds. We have reached gridlock, rather early in the day.

My partner runs up to me (there are only 2 of us working), and tells me he just got a call on the radio from medics who are busy delivering premature twins. They are on their way with the first one who is not doing well. My partner says, “I’ll need your help.”

We clear out the trauma bay & plug in the incubator just as the first ambulance rolls in. The baby’s skin is ashen gray. They are holding oxygen to his face. He’s retracting with each shallow breath and doesn’t cry.

I scrambled to find a 3.0 endotracheal tube to intubate the little guy with my heart pounding out of my chest. My hands are shaking. I insert the miniature blade into his mouth and am shocked at how delicate the proceedure is. I see the little tiny vocal cords open & close with each insufficient respiration. The tiny tube is too big to fit between his cords, but at least with the laryngiscope blade in his trachea he makes little squeaking noises like a kitten…he’s at least crying now.

We can’t find a smaller tube so I try a second time and fail. Knowing that trying a third time to put a big tube through a small hole is futile, I offer the proceedure to anesthesia who’s just shown up. I am able to find a 2.0 tube and can’t believe how small it is. As they continue working on the baby, the 2nd ambulance arrives with the mother and the undelivered 2nd twin.

She’s not having strong contractions. The baby hasn’t decsended and it’s been almost an hour since the first was born. The family practice resident and i disagree on the baby’s presentation. She thinks it’s breech, I think it’s cephalic. we have no ultrasound machine with which to confirm. The baby has a heart rate that seems adequate, but we’ve got no fetal monitoring equipment at our hospital thanks to the closure of our L&D unit due to rising malpractice costs.

We decide to transfer Mom to the women’s hospital. About 15 minutes later the NICU transport team arrives as well. Baby Boy A is doing better. He’s pink and warm. They take the breathing tube out and he is doing fine on his own. It looks like he’ll be OK, at least for now.

I return to the department only to see a waiting list of twenty-seven patients in the waiting room. Did I mention there were only two of us working? Seeing half that number of patients during an entire shift is a sorta-busy day. Trying to see all of them NOW just isn’t going to happen. I wonder who is dying in the waiting room. I look through my patient’s labs & imaging and still don’t have results. My fast track patients I had abandoned are yelling, “What about me?”

“I’m sorry, we have had some emergencies going on”, I offer.

“That was hours ago,” the patient informs me.

And so it goes.