The mountains in Castañer, Puerto Rico were very fertile, not only in terms of tropical plants and fruits, but also for people. Sometimes we had more deliveries in a day than postpartum beds, so it became our policy to dismiss patients soon after they had delivered. After all, before Hospital Castañer was established, babies in the mountains were born at home without electricity or running water. It was a major improvement to deliver in a modern hospital under sterile conditions with doctors and nurses, then to rest even for a few hours.  

Soon I discovered another curious phenomenon: no males (fathers or husbands) were ever in the waiting room while their wives or daughters were in labor. The men dropped off the women in labor and disappeared before we could pull their records. Birthing was a woman thing. The macho thing was to drink rum at the closest tienda and return after the newborn arrived. They couldn't let their cronies know they were concerned about their wives' pain.  

One weekend while on call, I delivered eight babies. One of the mothers was a grand-multip (multiparous - she had delivered more than eight babies). After delivering a normal healthy baby girl, this mother's uterus became sluggish and did not want to clamp down. She began losing large amounts of blood. I vigorously massaged the uterus and gave her Methergine intravenously to help stimulate uterine contractions, which would, I hoped, stop the bleeding. But the bleeding continued, so I was forced to reach inside the uterus with instruments to remove pieces of retained placenta, which were causing the problem. After removing these retained parts and giving sufficient intravenous fluids, I controlled the bleeding. She lost well over two pints of blood during this procedure.  

We took the woman to the postpartum room and carefully watched for continued bleeding. The next day it was time for her to be discharged. Her bleeding had stopped and her blood pressure and pulse were normal. I sat with her and explained how much blood she had lost and, therefore, I wanted her to go home, stay in bed for a couple of days and drink lots of fluids. I told her she might feel dizzy or weak and instructed her to carefully monitor the amount of bleeding. I urged her to return to the hospital immediately if she soaked more than one pad an hour. I said I wanted to keep her another night, but we needed the bed for other women who were in labor. Late that afternoon I discharged her.  

That night I lay awake worrying about this woman. I had never seen a patient lose so much blood during delivery and felt that, because she was a grand-multip, she might be having problems. I imagined her bleeding in her sleep and even dying. At daybreak I called Bruni, our OB nurse, and told her we were going to make a house call to visit the patient because I was worried about her. We got into the hospital Land Rover and began our long trek up the mountain. She lived only three miles from the hospital as the crow flies, but it took over 45 minutes to get there by jeep. As we completed the last hairpin turn up the mountain, I spotted my patient's house way up near the top.  

The house was hanging over the side of the mountain, precariously built on long stilts with a spectacular view of the valley.  The small, two-room wooden house with its tin roof was surrounded by dense tropical vegetation and banana and coffee trees. A variety of fruits and vegetables grew in clearings below the house. As we got closer, I could see a woman running up the mountain from one of the garden areas.  It was a steep incline and, from our perspective, it looked as if she were climbing a sheer wall. When we reached the house, several of the kids came out to greet us. Joining them were two typical Puerto Rican dogs, barking excitedly. They looked like a cross between a hyena and a fox terrier. Chickens scattered everywhere. The kids invited us to come in. I asked, "How are your mother and your new baby sister doing?"  

"They are just fine. Mother's in bed. Would you like to see her?"  

"Yes, I would."  

I went into the austere bedroom, made of wood with no interior finishing. A small wooden window was open to let in the light. A single bed pushed up against the wall was apparently where the whole family slept. My patient was lying in the center of the bed, covered to her neck with a quilt with only her head peeking out. When I walked over to examine her, I became alarmed because she was hot and sweaty. It felt as if she had a fever. She was also breathing rapidly.  

I looked at Bruni. "Oh, no. I think she's developed septic shock and is running a high fever."  

But when I tried to pull down the covers to examine her abdomen, the woman held on tightly. I noticed her hands were covered with dirt. When I finally pried the covers from her tightly gripped fists, I discovered she was fully clothed.  

Bruni began laughing. "This is the woman we saw running up the mountain a few minutes ago."  

Sure enough, while I lay awake all night worrying about her, she was contemplating getting up at the crack of dawn to tend her garden. She was not going to let a birth and a little blood loss slow her down. When she saw my jeep coming, she became worried because of my strict instructions to stay in bed.  She knew I would be upset with her. As members of a paternalistic society, our patients did everything they could to please us doctors. This patient viewed me as a father figure and did not want to do anything to displease me. Of course, I was relieved that her "fever" and labored breathing were the result of her sprint up the mountain, not from septic shock. Once the patient knew her charade was over, we all had a great laugh and she prepared some "cafe con leche" for us before Bruni and I began the long trip back down to the hospital.  

Like me, many doctors worry more about their patients than some patients worry about themselves. That's the price we pay for knowing the worst-case scenarios and feeling responsible for their outcomes.  

LARRY J. MILLER, M.D. is a board-certified emergency medicine physician, recognized internationally as an industry leader, researcher, instructor, and successful businessman. Dr. Miller practiced Emergency Medicine at the Baptist Health System Hospitals in San Antonio for 31 years, where he treated more than 130,000 emergency patients. He was chairman of the Emergency Departments of the 5 Baptist hospitals for more than 15 years and Medical Director for 10 EMS agencies in South Texas for more than 30 years. Dr. Miller was the founder, CEO and Chairman of the Board of Vidacare Corporation, and the developer of the EZ-IO. Dr. Miller was granted more than 144 patents for Vidacare technology and received FDA clearance for 18 indications.

Dr. Miller taught intraosseous physiology to medical schools around the world, directed intraosseous research at the University of Texas Health Science Center, human clinical trials at 5 universities, and published over 27 research papers. He received the Innovation of the Year Award from the Wall Street Journal in 2008 for his development and commercialization of the EZ-IO, which has been credited with saving the lives of more than 4 million patients world-wide. He also received the Medical Device Innovation of the Year award from the Wall Street Journal in 2012 for his invention of OnControl for cancer biopsy. In December of 2010 Dr. Miller carried out an extensive humanitarian campaign in Haiti help to save lives from the ravishes of Cholera. More than 10,000 people died from this deadly disease, mostly of dehydration because medical personnel could not start an intravenous (IV) line. He worked with Project Hope, Physicians Without Boarders, and Samaritan’s Purse to teach the locals how to give IV fluids through the EZ-IO, enabling them to successfully save the lives of thousands of patients.

He and his team developed Vidacare Corporation into one of the most successful medical device startups in the past 15 years, selling the company to Teleflex for $300 Million. Dr. Miller received the Humanitarian of the Year Award from the University of Michigan in 2017 for his work in Haiti and development of the EZ-IO. He is the author of 3 books about Emergency Medicine, Missionary Medicine, and Suicide. He serves as medical director for Health Hero America and Acacia Medical Mission in South Texas, where he actively treats patients. He serves on the BODs of several medical device companies and the Advisory Board for the University of Michigan Medical School. For the past 9 years he and his wife, Monica, have served as medical missionaries in El Salvador, caring for some of the poorest people on earth.