Assume the Position: Memoirs of an Obstetrician Gynecologist (9 page)

     Late one night a ‘private’ patient of one of the attending physicians was in labor.  He had been there earlier to visit her and then departed for what everyone assumed would be a short rest.  When it was time for her to deliver, stat overhead and beeper pages and calls to his office were unanswered.  Since I was the senior resident on call that night I was expected to cover for him so I did the delivery.  He never did answer or show up.   Later that morning when his office opened he was found dead on his office desk.  It turned out he was having sex on his desk with one of the hospital nurses and died right there on the spot.  The nurse bolted and left him lying there with his pants down, so it was pretty obvious to those who found him what had happened.  What a way to go!  The last time I was in the lobby of this historical Women’s Lying In hospital I saw his portrait on the wall next to other titans who had served the institution well over the decades. I just couldn’t help thinking this story was the real reason he was being honored.

     My four years of training eventually came to an end.   It was true that formal education had stopped, but after becoming a member of the American College of Obstetrics and Gynecology with life long board certification, it was really illusory that education ever ended.  As long as there were patients to be seen, as long as medical science progressed and changed, as long as new journals were published and read, as long as peer review remained important to me, education would never cease.  It was simply a lifelong process.

     With the completion of my formal training, my wife and I had decided to move to Phoenix, Arizona where I had a nice job offer awaiting me.  I was about to join two former Philadelphia physicians, one of whom also trained a few years ahead of me at Pennsylvania Hospital.  While still in my residency, he had returned to Philadelphia one week to recruit a prospective partner.  I subsequently went to Phoenix to visit, see the practice, and meet his partner and their families.  I had always wanted to go West, but never had the courage to do so by myself.  Since my wife wanted the same thing, it was an easy decision for us. We visited Arizona again together on a home hunting expedition, and for my wife to see her new community.  We liked what we saw.  Opportunity for both of us was everywhere.  It seemed like a good place to raise a family. Phoenix was a place for the sun to shine on us!   We left friends and family behind for a new beginning.   My parents couldn’t understand.  “Where is Arizona?” they said.  “And what happens when we have grandchildren?”  “Fortunately there are airplanes,” I explained.

(An Arizona cowboy.)

     There were many things to learn during my internship about Labor and Delivery.  One of the things that plagued me as an intern trying to master Obstetrics at Pennsylvania Hospital was how long to leave a woman in labor in the labor room before moving her to the delivery room and table. If the timing was late she would deliver in the unsterile labor bed; and if the timing was early she would labor for a far longer time than desired while in the uncomfortable stirrups on the delivery room table, a situation I had difficulty mastering at first.  One could read about labor and delivery all day long in the textbooks, but learning how to manage labor varied with the individual.  It took years of experience, observation, and an understanding as to what was within the norms and what was outside of acceptable limits.    When in doubt about these things, the best person’s brain to pick was often one of the well-seasoned labor and delivery nurses. So I asked Greenie, who had been there for 37 years, for some advice.

“Doc,” she said,  “When they ask for the ophthalmologist (eye doctor) you know it is time to move them”.  

    ‘Huh?”, I muttered, scratching my head.   She said it sounds like this.  “AYYYY, doctor! “AYYYYYYY, doctor!”

     I had been trying to figure it all out from results of my pelvic exams.  She had the answer without the exams. Listen to the patient, she told me.  Look at her face! Read her sense of urgency, tension, pain and emotion. Listen to the crescendo in her voice.  See the furrowed brow and the sweat bead on the upper lip.  Watch the little blood vessels in her face pop. A valuable lesson, indeed!  I got it, and never forgot it. Why didn’t they tell Greenie to just write it down in the textbook?

     Most of the women for whom we cared while in Labor at Pennsylvania Hospital were young, black, poor, and often uneducated.  Obviously pregnant, these women were our clinic patients, and received the best care available in Philadelphia.   As residents we learned to administer our own epidurals during labor for pain relief, and although we became quite proficient at them, if the patient wasn’t cooperative it was not an easy procedure.  I remember well one young 13 year-old clinic patient who came into labor and delivery screaming at the top of her lungs without a support person.  She was out of control, writhing in bed, on all fours at times, alternatively climbing over the bed rails and standing on the bed, refusing an examination and refusing to be touched or to even have an IV placed.  No amount of calm persuasion, talking, or any sort of communication was effective.  She was demanding pain medication.  I did my best to explain to her that nothing was going to happen to help her unless she cooperated, we were not going to do anything to hurt her or her baby, and nothing could be done until we examined her first.  She refused.  There were only two or three times in my career when I raised my voice to a patient, this being the first. It only happened as a last resort when education, communication, discussion, calm persuasion, and all else failed.    I closed the door to the labor room so that it was just she and I.  In no uncertain terms, with a calm but raised voice, I explained to her that I would not return until I heard her call out nicely and asked for me to help her, no matter how long she stayed in there and screamed.  I wrote my name on a piece of paper for her.  I let her know it was her call. Then I walked out, shut the door, and waited.  I didn’t permit anyone else to go in the room.  It took about a half an hour of what sounded like self-administered torture in the room before she asked for help, which she then got.  She permitted an exam, she got IV fluids, she got an epidural, she quieted down, and she got a healthy baby.  It was just not easy.

     One night at 5PM I came on call to the Labor and Delivery deck as Chief obstetrical resident for the evening to find a busy labor floor with 8 patients in labor, and a woman in the corner room of the labor and delivery suite, apparently in that labor room all day and cared for by other residents during the day.  She was in her early third trimester and in and out of lucidity all day.  She had a psychiatric history, and the staff had been waiting all day for a psychiatric consultation to come and evaluate her.  Almost exactly at 5 PM when the shift changed and I was now in charge, she went into shock with monitors beeping and blaring.  There were no signs of outward bleeding, but the fetus was now in serious distress as well.  A quick exam revealed her abdomen to be distended with no bowel sounds, vital signs unstable, in apparent hemorrhagic shock.  I quickly placed her legs up and out, and placed a needle and syringe into her abdominal cavity through the vagina. It returned fresh blood from the abdominal cavity.  The young woman was now in cardiac arrest.  A stat code was called, IV’s were started, blood and heart medication were administered, she was intubated and rushed to the operating room where an emergency surgery was performed to attempt arrest of the heavy internal bleeding from a ruptured cornual pregnancy, a form of ectopic pregnancy growing outside of the uterine cavity at the juncture of the tube and uterus.  These abnormal pregnancies, rare and catastrophic, often will grow unnoticed until late in gestation before rupturing with resultant hemorrhage.  It was the first and only time I ever did surgery on a patient in cardiac arrest, but it was a last and belated attempt to save her. If bleeding and vital signs could be stabilized, there was a slim chance of saving her life. It took me about five minutes to do an emergency hysterectomy, the fastest surgery I have ever done in my life.  What the residents caring for her had assumed was a ‘psych’ patient because of her varying states of consciousness and ramblings during the day turned out to be a woman going in and out of consciousness due to blood loss and shock.  She subsequently died on the operating table. This was just about the worst situation one could walk into to begin a night on call, but one never knows when the need to perform an emergency Cesarean Section or Cesarean hysterectomy will be necessary. Disasters like this were fortunately few and far between for both patient and physician, but always lurked around the corner in the world of obstetrics, which in a teaching hospital served to remind us all to be ever vigilant, a lesson none of us every forgot.

     Obesity is just a bad thing.  No two ways about it.  No matter what causes it, no matter why a person is obese, it only serves to make their own lives shortened and worse than whatever else life would have been for them.  And it certainly doesn’t make it easier as a physician to deal with obese patients. But in medicine, as in cards, one has to learn to deal the hand one is dealt.  One patient came into Labor and Delivery during residency weighing somewhere between 500-550 pounds, best guess, since there was no way to weigh her.   She said she had prenatal care elsewhere, but certainly not in our clinic and we were unable to retrieve any records.  If she hadn’t told us she was pregnant and in labor we would not have known.  We were able to pick up an occasional fetal heart tone with an external Doppler ultrasound device, but were unable to pick up anything with fetal monitoring.  When it came time to examine her in the labor bed, I put on a sterile glove, pulled down the sheet and asked her to let her legs drop to the side.  She told me they already were. Instantly I knew I was in trouble now since I couldn’t even see the vagina to do a cervical exam. There were layers of thigh fat obscuring the view.  So I began to dig my way in, moving the thigh fat to the side with the assistance of nurses on each side to further retract her inner thighs.  Eventually I could see the external vagina, but could not get my arm or hand near enough to get into the vagina, let alone up to the cervix for a pelvic exam, and she could not drop her legs to the side any further.  It was futile.  Kudos to the baby’s father, whoever that was! Since she was reasonably comfortable, her vital signs were stable, and we could not monitor her on the fetal monitor, we sent her away from the labor floor to a regular post partum bed to wait more regular contractions before we brought her back.  About 30 minutes after she arrived to her regular bed we got a stat call to run up to her room. After one push I found a five-pound healthy baby between her legs and the rolls of fat. Some people are just lucky.

     What a contrast of experiences one sees at a teaching hospital!  One lady, again in the 500-pound range and a patient of our obstetrical clinic during residency, was scheduled for a repeat Cesarean section.  She was brought to the operating room and prepared for surgery. The anesthesiologist had opted to administer a regional anesthetic, or spinal, rather than a general anesthetic with intubation that he had determined to be riskier in her case.  After a difficult and valiant attempt at the spinal, he laid her on her back in preparation for surgery, and while she was having her abdomen prepped she began to have a grand mal seizure, likely a result of the spinal medication.   I had a 500-pound woman in front of me seizing on the operating table with a baby inside of her that we could not monitor.  The table and literally the room were shaking in rhythm with her as she seized. All we could do was try to keep her on the table without injuring herself.   Mindful of the first rule of medicine,  “Primum non nocere” or “Do no harm”, I could not do a stat Cesarean section on her until she herself had been stabilized, which everyone around her was working so hard to do.  When the patient was finally in stable condition, intubated and medicated to stop the seizures, only then could I begin the surgery.  Cutting through that many layers of adipose tissue (fat) is always an experience.  Much like a knife going through butter, it begins rather easily, but then as one incises further and further deep into the adipose tissue, one realizes how much further down are the other layers of the abdomen, the muscle, the fascia, the peritoneum, the uterus, and then the baby. It was like digging a ditch with a scalpel.   In this situation it is not something one can rush through.  I had no idea what shape the baby was going to be in, but I was not about to jeopardize the mother’s life.  As luck would have it, the baby was in good condition, and all turned out well for the Mom. But what a huge layer of risk she added to her life, and that of her child.

     Lucky, too, was a patient of mine who walked into my office one day in Phoenix, a first time Mom near her due date.  I can still picture her walking down the hall way with that uncomfortable open leg waddle most term pregnant patients have, one hand behind her back.  I greeted her, asked how she was doing, and she replied great, but that she wasn’t sure what was going on and just wanted to come in for a checkup.  My nurse put her in the exam room, got her into a gown, and told her I would be right in.  I came in about five minutes later and chatted with her, and then said, “OK, time for an exam”.  She put her legs comfortably in the stirrups.  I proceeded to examine her, and ran smack into the baby’s head sitting right on the perineum ready for delivery.  We had an emergency delivery kit in the office that my nurse hurriedly retrieved. I had her push once, and out slid a healthy baby girl.  Everyone in the office was excited, especially the other women in the waiting room as we wheeled her through with the newborn in her lap on the way to the hospital.  I am sure most of the women waiting said,  “If she could do that, so can I”.  I just never saw it happen before or after, but she totally missed her labor. Good for her.  Lucky.

     As a new obstetrician on staff at my hospital in Phoenix I was clearly being observed carefully by the nursing staff who of course wanted to know what the new kid on the block had to offer, and whether they were comfortable with me.  First impressions were important. Before the first week passed, I was indeed dismayed to find that the first three pregnant patients that I managed did not make it to the delivery room.  One in fact delivered hurriedly in the emergency department before she ever got to the Labor and Delivery suite.  One was an emergency Cesarean section and delivered in the operating room, and the third was a late spontaneous miscarriage also handled in the emergency department.  I felt as if the staff were wondering if I would ever get someone to the Labor and Delivery suite. But that quickly passed as I settled in and the nursing staff came to know me better.  I always did as much teaching as I could, and always had the family practice residents at my side since I frequently supervised them on their own patients and let them deliver many of my own.  In those early days at the 250-bed community hospital in Arizona adjacent to our office, I felt like I had taken a step backwards from the high tech teaching institution from where I had come in Pennsylvania.  The equipment was outdated as were the monitors, the facility was old and in serious need of updating and modernization, there was no NICU, and epidurals were not being given.  In fact, I was the only obstetrician on staff trained to give epidurals.  If a patient wanted one, the anesthesiologist would have to be called in, often in the middle of the night, and they were reluctant to come and sit with the patient for hours until they delivered.  So I just took to administering my own epidurals again, which everyone advised me against in the fear that something would go wrong since I had no back up.  But I did so for the first few years. I was trained to do so and comfortable doing so. I eventually became chairman of the OB-GYN department, and set up an epidural program whereby epidurals were administered by nurse anesthetists and supervised by anesthesiologists. The old adage applied that if you want something done right do it yourself.

     One weekend when I was on call, a new patient whom I had only seen once in the office, with her husband in tow, came into Labor and Delivery in active labor on Sunday afternoon.  I was at home and got a call from the OB nurse about her arrival, but with the comment that her husband said if I was on call and came in to the hospital and touched his wife he was going to kill me. I had no idea what his problem was, but she needed attention, and I was it for the day.  He demanded another Doctor be called to care for his laboring wife.  I made an attempt to find someone else who would care for these people. Not surprisingly I was unsuccessful. Asking someone to give up a Sunday afternoon to care for a patient with a violent husband was met with expected resistance from others.   I informed the nurse I was on my way in but that she was to get hospital security and have him removed from the labor suite first.  When I arrived I saw this gentleman from the rear, wearing a cowboy hat and snake skinned boots glancing over his shoulders at me while being forcibly hauled off by two armed security guards.  He muttered rather loudly that he would kill me some day.  He was distraught about something.  She turned out to be very nice and had an uneventful delivery.  Forcibly removing someone from the labor room was not my thing but I saw no other way to deal with it in this case.