Assume the Position: Memoirs of an Obstetrician Gynecologist (14 page)

     Falling asleep didn’t always come easily with adrenaline circulating in my system, something that would get easier to master over the years, although staying asleep for more than a few hours became a lifelong struggle and fact of life for me, as it is for many obstetricians.  Random thoughts would enter my mind as I lay under the covers in the darkened room.  Winter snow skiing, summer body surfing in the Atlantic City waves, weekend racquetball games, even challenging Franz Klammer to a downhill race for the Gold.  Mother Nature in its many forms seemed to be the central theme, including the challenge, the mastery, the failures, but always ‘The Challenge’ of doing it well and correctly.  I was frequently on the edge.  It wasn’t about winning.   It was more about the effort and recognizing my own limitations, something central to being able to practice medicine well.  The two were intimately and inextricably related for me. Not having any idea at any given moment as an Obstetrician what Mother Nature had in store for me was just part of life as an obstetrician.  One always had to be alert, ready, sober, and awake even when sleeping.  Thus the inception of what was to become a lifelong sleep disorder, an occupational hazard for me, and probably most other OB-Gyn physicians, something with which I have struggled for decades.

   
 
When I arrived in Phoenix to join my two partners, night call changed again.  There were only three of us, so when we were all in town, it was an every third night every third weekend rotation.  The only problem for me was as their newest junior associate and employee, and the proverbial low man on the totem pole, they were away a lot more than I was.  But I was happy since I could now sleep at home rather than in the hospital.  I lived close enough to the hospital that I could easily drive back and forth even multiple times during the night if necessary.  Many times when someone was in labor, it was just easier to sleep at the hospital in the on call room provided.  I would let the nurses know when to awaken me.  They always obliged, even sooner if the situation warranted.   I could slip in and out from bed at home often without my wife knowing I had left and returned, although as time wore on she got more sensitive to my comings and goings.  There were times when I would be the only car on the road in the middle of the night. After a delivery was over, if all was quiet, I would speed home to catch a few winks before the day began.

     Speeding was a nemesis for me. One early Sunday morning I was simply driving too fast on my way to the hospital to examine a patient in early labor. There was no particular rush on my part. But I got pulled over by a cop.  I explained I was an obstetrician on my way to deliver a baby and needed to get to the hospital right away.  He asked which hospital, asked for the patient’s name (which of course would be a HIPPA violation had HIPPA existed then), and proceeded to follow me to the hospital parking lot, then into the labor suite and asked to see the patient’s chart with her name on it.  I was kind of surprised he didn’t ask to examine the patient too, but that was where I had it all over him.  I got off.  Another time it was 2 or 3 AM and I was on my way home in my bloody scrubs after a difficult delivery.  I was stopped for speeding about three blocks from my home. The officer came up to the car, took one look at me in my scrubs with fresh blood on them, and said:  ‘You been drinkin”?   I felt like asking him if he had been drinking, but I kept quiet.   I said, “ No, I been deliverin’ babies”.  No other word exchanged other than “ Here is your ticket”.  I am not sure where he thought the blood came from, but that didn’t seem to bother him.

     A weekend on call in private practice meant do what you can do by yourself and only call your partners if absolutely necessary.  Simply put, it was your weekend and yours alone.  Occasionally we would need each other for one thing or another, but I tried my best never to call for help.  My personal record was 8 deliveries in one weekend that essentially meant someone or other was contracting the whole weekend.  No sooner was I putting in the last stitch for what I thought was the last delivery at 3 AM, dreaming of going home for a few hours of sleep, than I heard in the labor suite: “ Hey doc, guess what, I am in labor and they told me to come right to the hospital”.  Such was the life of a busy OB GYN physician.

     Night call became harder as I got older.   Constant sleep disruption led to a worsening sleep disorder.  Fortunately I learned to function with very little sleep.  I could fall asleep fairly easily because I was exhausted but staying asleep became a problem probably because of the constant phone calls night after night and trips back and forth from bed to hospital.  I often would recall an experiment I learned about in psychology class in college.  A rat had been placed on a large cork in a tub of water.  The investigator would wait until the rat was asleep then knock it off the cork into the tub of water, awakening the rat, to again place it back onto the cork and repeat this over and over again every time the rat fell asleep.   Eventually the rat became psychotic, whatever a psychotic rat looked like.  It seemed only a matter of time before this was to happen to me.

     One night of many I awakened my wife mid night for a ‘romp in the hay’.  She never particularly liked the mid evening forays but then with three kids, my crazy nights, exhaustion, it had to happen when I was awake so I gently awakened her.  Once she got her motor going we were usually ok. Our motors were going pretty strong when the phone rang around 2:30 AM or so.  Usually it was the answering service paging me but this night it was a direct call from the Labor and Delivery nurse.   “We need you now” she said.  ‘I am coming, I am coming, right now”, I breathlessly responded.  I do believe the irony went over her head.

     Another night I was awakened in mid night by one of the Pediatricians to whom we referred all our babies.  It was usually me needing his services in the middle of the night and not the other way around, which is why I suppose he didn’t mind awakening me.  He explained to me that he and his wife had sex earlier in the evening. I congratulated him and asked if he was always going to call me when that happened, and privately wondered why this was the first call.  After all what else could I say in the middle of the night? Evidently she couldn’t get her diaphragm out.  I explained to him it was supposed to stay in for several hours anyhow, then I asked if he wanted me to come over to take it out at 2 AM.  He said “No thanks!”  Then I said, “ John, you are a physician.  Put your damn fingers inside and pull it out. There is nothing in there you are going to hurt, and nothing in there that is going to hurt you!” 

     Nightlife also meant social life for us.  Everything of course depended on my on call schedule.  We rarely wanted to, or could go out when I was on call.  If we did, the night often got interrupted and my wife would have to find a ride home with someone else if I left to attend someone in labor. Worse still, if we were at a wedding, a large hospital function, or a Bar Mitzvah, as my wife says, I was often in a corner with women lined up who wanted to tell me something or other, or worse yet about their own labor experience.  Alcohol seemed inclined to make that happen.   So we only went to big functions out of necessity, and preferred to dine out alone, or go to a movie or small parties with friends.

     Nightlife was just a continuum of day life as an obstetrician.  Nothing changed that much except there were no office hours, and I could be at home with my family until the phone rang.  I became adept at taking naps whenever possible, my dog Max always at my bedside napping with me.    We did our best to always have family dinner together, and I did my best to always give my kids their nighttime baths and read them a story before bedtime.  Not infrequently, when my daughter was little, I would fall asleep in her bed while reading night time stories to her– “Good night Moon”, with the music box on.  She would tip toe out to my wife and say:  “Mommy, shhhh!  Daddy is asleep in my bed and I want him to sleep there tonight. Don’t wake him up.”  Invariably I would awaken a few minutes later since I couldn’t stay asleep anyhow. But it was cute!

     My first surgical experience was as a second year medical student during my first OB GYN rotation at Reading Hospital.  My mentor was a most interesting guy in many respects.  One of the things most of us liked about him was that he let us do almost everything even though we had no idea what we were doing since we were only medical students.  But he had a tremendous amount of confidence in himself, and even though he let us operate, he was always by our side, always attentive, and always teaching.  For a second year medical student, it was not only nerve wracking but also quite amazing.  I would not have been comfortable doing that myself for a second year medical student. There were three of us on the rotation at one time.  One was a woman in my class who was short, maybe half my size, and smart as a whip.  He was teaching us how to do laparoscopic surgery, putting a telescope into the abdominal cavity through which one looked, made diagnoses, and then performed surgeries.  He showed us how to put in the abdominal trocar, a sharp instrument that required controlled blunt force to put in, after which the sharp part is removed, a sheath left in place, and the blunt laparoscope inserted through the sheath.  The dangerous part was insertion of the sharp trocar since it was done without being able to see into the abdomen at that point.  Knowledge of anatomy was critical.  He outlined the anatomy for us and was careful to show us proper technique.  After observing several cases, he let us place the trocar ourselves.  Of course the patients were anesthetized with legs up in stirrups.   I grasped the trocar as shown, and inserted it as shown without problems.  I was surprised at how much force one had to use to get it through the abdominal wall, sharp as the trocar was.  The next case my female compatriot was up. Because of her short stature she had to stand on a stool to get in the proper position. She then pushed with all her might but the trocar did not go into the abdomen.  She tried a second time with even more force, and it plunged way too far and fast into the abdomen and impaled the bony sacrum where it was stuck. He extracted the trocar, which was not the problem.  The question was had it also damaged blood vessels or perforated bowel on the way in.  Fortunately for the patient, and for all of us, it had not. She narrowly missed all vital structures and blood vessels. I never have seen a trocar impaled in the sacrum before or since! Thank goodness.

     Learning operating room sterile technique was not as easy as one might expect.  During another second year surgical rotation at Atlantic City Hospital, the very first thing we had to learn was how to scrub at the sink, then make it past the operating room door without touching anything, how to hold our hands so dirty water from the elbows wouldn’t drip on clean hands, how to ask for and receive a sterile towel to dry our hands, then how to get into the surgical gown and gloves without contaminating anything or anyone on the scrub table, and finally how not to contaminate the surgeon when standing at the table. If one watches an experienced surgeon do it, it is much like a well-performed symphony. Watching a medical student do it is only a bit funnier than watching a medical show on TV where they have no concept of what to do with a surgical mask or at a scrub sink.  The first time I tried, I never made it to the surgical table.  The scrub nurse kept sending me back over and over again so that by the time I got it right, the case was over.  Humbled once again. But eventually I got the hang of it and once down pat, it was like rote.

     Blood and I got along just fine.  Some people are squeamish at the sight of blood.  Not me.  Red oxygenated blood is actually a beautiful color.   But I have seen grown men, husbands of Cesarean section patients who wanted to be in the operating room at delivery, literally hit the anesthesia machine with their heads as they were on their way down to the floor.  Then the people in the operating room have to take care of the husband rather than the person on the operating table, never a good thing.  For the uninitiated, the amount of blood admixed with amniotic fluid at the time of a Cesarean section can appear huge. Even for the initiated or about to be initiated it can at times be overwhelming.  When I was a second year resident performing a Cesarean section with a newly minted intern, he got nauseous and faint in the operating room, never a good thing for a brand new intern who is under the microscope anyhow.

     There was always the unexpected to deal with in medicine that could occur at any time or place, day or night. One day when on the gynecology service as a third year resident I was in the midst of a particularly difficult abdominal hysterectomy. There was considerable bleeding in a deep abdominal hole with less than optimal visualization, blood welling up from below and obscuring my view of the surgical anatomy.  The scrub nurse took off her gloves and began to leave the room.  I was stunned and asked her where she was going.

    ‘Hon”, she said in her thickest Philadelphia accent, “it is three o’clock and my shift is over.”

      “Where is your replacement?” I responded because clearly there wasn’t anyone else scrubbing and there wasn’t going to be.

      “You have all the instruments you need, the needles and sutures are there, and you can arm everything yourself”, she responded with some arrogance.

      I said: “If I were the chief of neurosurgery you wouldn’t be doing this.”

      “Hon “ she said, “you are not the Chief of Neurosurgery”.

     Neither was I a world-renowned infertility specialist as was one of my Professors during residency.  He was published, lectured all over the world, pontificated here there and everywhere, and had patients come from everywhere for his world renowned surgical expertise. The only problem was that the infertility specialist insisted that only third year, and when possible always a Chief resident, assist him at surgery. In reality we would do the surgery and he would assist. He was inept at the operating table.  He was no longer capable of doing this delicate surgery with the precision it required.  It was a quiet deception that was ongoing, and I didn’t like any part of it.  As a third year resident, when I had a chief tell me to assist, I had no choice.  But as a chief resident, I never assisted him myself, especially since he was the only surgeon I have ever scrubbed with who actually cut me with a scalpel. I always gave the cases to third year residents.

     As the attending surgeon in private practice, I never felt more comfortable and secure than in an operating room.  It was for me a sanctuary in many respects.  Surgery was often the highlight of my day.  I enjoyed the satisfaction it gave to both the patient and me when it was done well with the proper indications.  But anything could go wrong on any given case, so it was imperative to never put a patient in the operating room unless the surgery was indicated, and all more conservative methods of treating the condition had either been offered and rejected, or offered and tried and then failed.  There was nothing worse than having a complication at surgery on a patient who didn’t have to be on the table. So I never put anyone on that table unless they really had to be there.   For me, when the case began, the OR door was shut, nothing on the outside world could interfere.  People who called and needed me when I was in surgery had notes left on the outside of the door for me to answer when the case was over.  Whatever else might be going on in my office or elsewhere in the hospital had to wait, because rarely could one leave a case in the middle to attend someone else, unless there was no choice. There were a few times when in the middle of a case, a patient would come in labor and deliver precipitously, and there was for one reason or another no one else available.  On those rare occasions I would scrub out, do the delivery, then come back to the OR and finish the case, but only left if the patient was stable.  The operating room was truly as the British called it, the Theater.  But it was my theater, and I felt very comfortable on the stage with the bright lights on.  It was a refuge from the outside world, and for me, calming.

     Theater takes on different meanings depending on the day.  In the midst of a difficult case one day, the OR phone rang in my room.  The circulating nurse answered the call.  My wife had been put through to the OR.  She was with our three small kids at K Mart and locked the car keys inside the car.  Attention K Mart shoppers!  I had one of my office employees come down to the OR to get my keys, take them to her, and solve the emergency!

     Unexpected disasters would occasionally occur. One Labor Day weekend a married, fairly young four-month pregnant patient came in with an acute abdomen.  The workup indicated a ruptured large ovarian cyst with a viable intact intrauterine pregnancy.  Surgery was indicated not only because of the pain, but because she was bleeding into her abdomen.  When I opened her up I found a large, aggressive ruptured ovarian cancer.  I removed the ovary and put out a call to the gynecologic oncologic surgeon who fortunately was available and near by the hospital on this holiday weekend.  He came in; we discussed the case, and determined that her best chance for survival was to remove the pregnant uterus and other ovary then and there. We both left the operating room with her asleep and on the table to discuss the case with her husband in the waiting room, who gave us permission to do the definitive surgery. Of course it ended the pregnancy and her fertility, but there really was no choice involved. Her life was at stake.  Unfortunately she died the same week her baby was due to have been born, a mere five months later. What a most unfortunate tragedy.

     A ruptured pregnant uterus in a woman who is in labor is also a surgical emergency and requires immediate surgery to save the baby’s life, and the mother’s.  It is a difficult but urgent diagnosis to make and happened to one of my patients in labor. Roughly one fifth of the maternal blood supply flows to the uterus every minute.  Theoretically, in five minutes a patient can bleed to death. She was rushed to the operating room with little time for explanation to her panic stricken husband, but time was of the essence. I opened her abdomen and indeed the uterus was ruptured with the baby floating free in the abdomen. The baby was delivered quickly and did well, but the uterine rupture was so extensive that the bleeding could only be controlled by an emergency hysterectomy, a difficult and bloody operation on a full term pregnant woman, but life saving.  I was working quickly, instruments and sponges were flying, and appropriate care was taken to make sure all went well, which it did. Considering it was the middle of the night, everyone performed admirably and the whole team was to be commended.  As I was closing the abdominal wall and the nurses were performing the instrument and sponge counts, they determined that a surgical forceps was missing.  So we moved the patient while still anesthetized and unconscious to see if it was under the drapes or behind the patient.  It was not.  I called in the x-ray tech to take a stat film with the patient on the table.   Bright as day it lit up – inside the patient. So I had to open her up again to retrieve it.  Once again, everyone was to be commended for performing their respective jobs correctly, in this case instrument counting by the nurses, during an emergency surgery.  Had the scrub and circulating nurses not done things correctly, at some point an additional surgery and anesthetic would have been necessary when the instrument was found and caused problems, perhaps months later. So I went out to the waiting room to talk to the still panicked husband with a good news/bad news scenario.  His baby was alive and well, as was his wife, who had to undergo an emergency hysterectomy.  No more children for them, which neither of them cared about since this was their sixth.  And then I slipped in the part about the forceps, a mere blip on the screen at that point. He didn’t blink an eye.  Honesty pays.  A malpractice suit avoided.

     There is an old adage that one should not operate on family members.  There is nothing illegal about it, nor is it unethical, nor would I recommend it for most people.  But my wife chose to become a patient of our practice for many reasons.  She liked my two senior partners, and she liked the fact that I was always around should I ever be needed for anything.  So when she got pregnant for the first time, she saw my partners for her obstetrical care and I kept my watchful eye on everything from the sidelines.  I had always told her from the time we met that it was likely she was going to have a C-section.  I was fairly good at assessing the bony pelvis, and I knew hers was small. What of course I didn’t know then was the size that a future child would be.   It does take a passage and a passenger to make that final determination.  So as she grew with our first son, she went from about 98 pounds dry weight to over 150 pounds and wound up carrying an 8-pound boy who went two weeks beyond his due date before she went into labor.  Her labor was managed by one of my partners, but it became clear progress was slow and protracted, and that no matter how much time we gave her, she was going to wind up in the operating room.  After a pretty horrendous and busy day for me, not to mention how difficult her day was for her with a prolonged and protracted labor, with emergency surgeries, an office full of patients, other labors to manage, and a bad prior night on call in addition to knowing she was in labor, I managed to keep tabs on her labor until we finally decided that it was time for a Cesarean section.  It was after midnight.  My partner took the reigns at the table and I assisted him.  He made a particularly small cosmetic incision so that when it came time to get my son out of the uterus, he struggled immensely.  Then, for whatever his reasons were, he asked me to take over.  I succeeded and delivered a healthy son.  Subsequently I performed other procedures on her at her request, including a laparoscopy, another abdominal surgery for a large ovarian cyst, and an endometrial ablation for abnormal bleeding. She got the best care available and I enjoyed being able to provide it.  Many people asked me how I could operate on my wife.  For me it was a pleasure to be able to help her with her problems. For her, she was very comfortable with me doing the procedures otherwise she would not have asked.  The only thing that did bother me was before the laparoscopic procedure I looked over the anesthesia screen to see her face after she was asleep, and her eyes were wide open.  I asked the anesthesiologist to tape them closed.  Of course, I never billed her insurance for the procedures.  I tell people that one of the many differences between me and OJ is that we both cut open our wives.  The difference is that I put mine back together with loving care.