Gynecologist Reflections

By Robert A. Siegel M.D. F.A.C.O.G.

This is a physician’s true story encompassing a myriad of authentic patient histories. Readers will find themselves intimately connected to the patient, the doctor and the too often dramatic medical issues which they are bound to resolve together. Each episode vividly depicts an individual woman’s unique medical and emotional challenge which intrudes upon her health and life. Medical problems are not only harrowing enough to tear individuals and families apart but can also act to strengthen individual resolve and bind family members closer together. Many episodes inspire hope, end happily and provide an opportunity for a sensitively appropriate sense of humor. The patient is the primary focal point. The doctor’s moral, ethical, legal, physical and psychological challenges are conflated with those of the holistically treated patient. The bond that grows between the doctor and patient is the writer’s spiritual sustenance for the practice of medicine and the professional fulfillment of a childhood dream.

• Language: English
• Publisher: Lulu Publishing Services
• Release date: Jan 4, 2018
• ISBN: 9781483468358

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REFLECTIONS

Copyright © 2017 Robert A. Siegel, M.D., F.A.C.O.G..

All rights reserved. No part of this book may be reproduced, stored, or transmitted by any means—whether auditory, graphic, mechanical, or electronic—without written permission of the author, except in the case of brief excerpts used in critical articles and reviews. Unauthorized reproduction of any part of this work is illegal and is punishable by law.

ISBN: 978-1-4834-6834-1 (sc)

ISBN: 978-1-4834-6836-5 (hc)

ISBN: 978-1-4834-6835-8 (e)

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Lulu Publishing Services rev. date: 11/6/2017

Clarion Review   

Siegel shares his triumphs as well as his tragedies, and gives ample credit to his patients and their partners.

Gynecologist Reflections is Robert Siegel’s unusually humane and humble memoir. He collects his experiences from decades of medical practice, offering a look at a little-explored field of medicine and at the powerful human relationships that develop around pregnancy, labor, and birth.

Although the book’s title is awkward, Gynecologist Reflections is well written. Siegel has a natural and wholesome tone, and tends to focus on the characters in his vignettes. He does not lean on highly technical language, instead using layperson’s terms. Short asides explain why he made certain decisions, without detracting from the tension of the moment.

In one story, Siegel needs to break a newborn’s clavicle to complete a vaginal birth. Another physician comes into the delivery room and places Siegel’s hand on the baby’s shoulder. He says, That’s the clavicle on the anterior shoulder that we feel. Push it onto the pubic ramus. Forget about moderation. Push as hard as it takes to break it and push until it breaks.

Despite the clarity of the book’s scenes, Siegel spares the splatter and gore that some medical-minded writers seem to revel in. He attends many caesarean births, but doesn’t describe what the surgery looks like. There’s no need to: birth is a messy process, but it’s also a sacred one that brings people close together as new life enters the world.

Siegel mentions episiotomy, vaginal delivery, and medical interventions, but always keeps the focus on people.

Siegel shares his triumphs as well as his tragedies. He’s a good storyteller who doesn’t linger on icky details. He’s not self-aggrandizing. Mostly, he gives credit to his patients and their partners. His descriptions of fathers’ happiness at holding their babies for the first time are especially touching.

Although medical terminology stays firmly in the background, it is a present factor. It’s interesting to see how OB-GYN technology has changed over time, from the handheld Doppler to ultrasounds. Siegel’s stories also hint at the vibrant, changing culture outside of the Brooklyn hospital where he worked. One father, whom he calls Thelonious, invites Siegel to come see his jazz quartet play. Siegel regrets that he has to pass, but he barely has time for even a bathroom break.

A combination of Call The Midwife and House, Gynecologist Reflections is an engaging memoir about a robust career. Caring for the female kind was a life’s honor, says Siegel in the introduction. After reading his book, it’s easy to see why he feels that way.

CLAIRE FOSTER (October 6, 2017)

STARRED REVIEW

A retired ob-gyn shares the personal drama, tragedy and comedy that he’s seen arise through patients’ medical issues in this insightful, impressive autobiography.

Siegel’s sensitively written book spans his entire medical school experience and career. Peppered throughout the chronology are numerous vignettes of cases that demonstrate the many challenges he faced toward seeking positive outcomes. He also chronicles his personal sacrifices and struggles.

The author’s residency took place at a hospital in a rough part of Brooklyn, where he saw more than his share of difficult cases, from a dangerous ectopic pregnancy to the end-stage cervical cancer of a woman in her 40s. In the latter, Siegel recognized the importance of compassion and empathy in sharing the news that she was terminal. People like Lilly must not go unappreciated, unnoticed, unrecognized, and unmemorialized [sic] like a passing breeze, He writes.

Siegel was in private practice from 1980 to 2008 in Pennsylvania and New Jersey, working long hours on little sleep and severely compromising family time while taking on patients with issues such as incest-related venereal disease, pelvic infections, difficult cesarean births and ovarian cancer. Through it all, he was driven by adrenalin, responsibility, motivation and duty.

The author writes in an engaging narrative voice and has a literary flair for description (Entering the brain of a dead person felt like invading an unguarded vault of memories …) while moving from one absorbing, heart-wrenching or memorable experience to the next. He also has the unique ability to relate complex surgical procedures in words clear to the lay person while giving credence to the critical minutiae of surgical skills necessary to save lives.

Overall, the author’s treatise shares the beauty and truth of one man’s dedication to women’s health care, which should inspire the careers of many an aspiring doctor and enthrall anyone fascinated with medicine.

Dedication

To My Unconditionally Loving Parents

Miriam and Louis Siegel

I

Introduction

"To whom much is given, much will be required (Luke 12:48). I always believed that this oft quoted maxim applied directly to me. I was privileged and blessed to become a physician with all the awesome responsibility associated with that professional station in society. I wrote this book because my life experience mandated it and because I, myself, was compelled by a personal need to do so. Moreover, part of our human condition influences us to memorialize that which we believe to be the most significant events of our lives in photos, visual arts, or books. Perhaps it’s part of an inherent, individual, and unique personal memorializing instinct". This instinct is inherent in our human psyche. Think about the Grotte de Lascaux (Lascaux Caves) in southwestern France where paintings on cave walls depict the quality and condition of human life 17,000 years ago.

Recording my memories, thoughts, and emotions into a book may validate my professional life and help all of us to understand the temporal and spiritual purpose of our lives on earth. What I write about here is, hopefully, the essence of my most socially relevant personal experiences. When this book is completed, God willing, perhaps I’ll put it on a shelf and from time to time refer to it when I question the value of my professional life to my family, friends and society.

There is a story for every person who ever lived. All such stories are no less than and no more important than my own. This book will be a record of my dream to become a physician and the personal struggle and sacrifices necessary to reach that goal.

The meaning of this book for the reader is entirely different. I truly want you to be entertained and enlightened. My goal is to elicit your emotions, as you follow the dramatic stories below -- perhaps sadness and tears, perhaps happiness and laughter, but if I fail there, I pray that I will engage you in serious thought concerning our all too vulnerable human condition.

You shouldn’t have to use a medical dictionary, or for that matter, a dictionary at all. Although written for the lay person, an obstetrician-gynecologist, doctor or medical student may also find this book useful personally and professionally.

I attempt to avoid a narcissistic, me-me description of the events inside this book, but I am no doubt present every step of the way. I was raised in the lap of middle class luxury, nurtured by my parents with unconditional love and the teachings of humanity, honesty, and responsibility. I hold that I possess no special gift that sets me apart from most other people. I was a late starter in medicine. By the time I started medical school, I clearly understood the responsibilities and rewards of a medical career. It is during the quiet hours of early morning or late evening that I give thanks to my personal God. I had the good fortune to be close to the more nurturing gender of our species, my loving and dedicated mother. Caring for the female kind was a life’s honor. I recall my accomplishments and errors with much seriousness in these later years of my life.

The book opens with a preview of my specialty, residency training and private practice experiences. There are brief sketches of my childhood and younger years, followed by a more detailed account of the preparation for and the practice of obstetrics and gynecology.

I do not make much mention of my personal and family life, while it was my primary moral underpinning and motivation to practice medicine.

This is not a text book or a drug store novel. I omitted didactic facts and figures in order to penetrate deeply into the real life medical problems of people like you, your loved ones, friends, colleagues and coworkers. Nevertheless, you will learn much about the practice of obstetrics and gynecology through the eyes of those who practice it and the heartwarming, dramatic and tragic stories of those whom it serves.

The individual stories you read, describe in detail a broad range of medical problems, some quite common, some rare, some emotional, a few deeply disturbing and some downright humorous. We’ll probe deeply into medical dilemmas that leave few acceptable medical alternatives or solutions and the dramatic questions these dilemmas pose for patients, doctors and family members. Nevertheless, readers themselves are always left to decide the meaning of each story. As you encounter drama, tragedy or comedy, don’t credit me with it, it’s just the way it all happened.

Although this book often reads as a novel it is a true account as I vividly remember it. Some names and places, other than places of residence and training are changed for privacy reasons.

So share with me this professional journal spanning an entire medical career, including medical school, internship, residency and private practice. I most earnestly tried to avoid the literary toxins of self indulgence and self righteousness.

Much of the content of this book was written during my practice years and organized, compiled, edited, and published in my retirement years. As the cover of this book implies, my goal was to learn how to be a doctor, and then learn the specialty of obstetrics and gynecology. Ultimately, I learned as much about people and my personal self as I did about medicine.

I welcome reader’s comments, opinions, shared experiences, or just say hello.

II

Heads Up Encounters Alicia and Alicia

B rooklyn is the second largest of New York City’s five boroughs with a population of more than two million. Besides the high density population, it suffers with extreme seasonal polarities of temperature. It’s hotter than the equator in the summer and freezing cold in the winter. But it’s still better to be nice and warm inside the Brooklyn Jewish Hospital and Medical Center, working your butt off, than freezing to death outside. I was the obstetrical resident covering labor and delivery.

Pregnant patients from the emergency room were sent upstairs to the obstetrical unit with both obstetrical and non-obstetrical problems. Generally, regular docs don’t want to touch pregnant patients if they can help it. The E.R. physicians grew impatient waiting for the obstetrical resident to arrive. The resident was perpetually late, sometimes dangerously late. They were always in the middle of a delivery or an emergency all their own. Besides, with the most fragile high risk stuff going on, a resident can’t safely leave the labor and delivery floor. I had just finished a very bloody, but o.k. delivery. I learned early on from a patient who almost fainted. When greeting a new patient, damn it, change your bloody scrubs and booties. A blood soaked doctor arriving on the scene doesn’t engender much confidence and scares the hell out of patients and family. I suppose the patient thinks, Do I really want to be next?

The nurse informed me that a patient was waiting for me in the treatment room. I recognized Alicia from the clinic, 30 weeks pregnant, doing well. She had this cute, memorable little space between her two front teeth that complemented her pleasant personality and pretty face. Her husband, Thelonius, was one of the few guys who came in with their pregnant wives or girlfriends. He always asked short but pertinent questions about his wife’s progress. Alicia has a sore throat with some congestion. People are never quite sure what they can do or take when pregnant. There’s no temp and her vital signs are good. The ears are clear, tympanic membranes pink and shiny, and no lymph glands palpable about the neck and throat. There was some congestion at the posterior pharynx, nothing more. The tonsils were fine, no exudate or swelling, and lungs clear as a bell. I took appropriate cultures that would pick up a myriad of bacterial organisms. After taking a blood and urine test, I told her about the safe medications to use over the counter and gave her some samples including antibiotics to cover strep and your average infectious bugs, at least until I get the culture results back. I also gave her the doctor mom prescriptions, like rest, lots of fluids, and keep warm, and let Thelonius wait on you. I looked at him and he laughed when I said, doctor’s orders.

I’m a sanitation man and I’ve got plenty of sick days saved up, so, yes sir. The heck with the moonlighting job for a while. Come and hear me play sax some time, doc. Here’s my card. If you like straight ahead jazz, I’ll knock your socks off. Thelonius couldn’t possibly understand. If I had time to hear his jazz, I’d have time to take a leak.

I’ll see you both Wednesday for your appointment at the clinic. When I left the room, as tired as I was, I had to laugh thinking about the day I took Alicia’s ultrasound and she found out she’s having a girl. Oh golly, doc, can you tell what she looks like? I love my husband very much, but what if she looks like Thelonius? You see, Thelonius wins all his points from being a hard-working, talented, and diligent man.

Tuesday night and resident check out rounds were done. I was on call and thought I would lie down for ten, just to get blood to my brain, not even sleep and then start the evening work. I passed by the treatment room and there was Alicia and Thelonius waiting for a resident.

As I walked into the room I looked at the lab work that I had ordered once again, everything normal and negative. Alicia is complaining of a cough and now her temp is 100.7. All was the same on her physical examination, except for occasional and isolated expiratory rhonchi (wheezing) over the bronchial areas, both sides, and mid-field. Ordinarily, I would send someone like this, if not pregnant and if first visit, back home on bed rest and antibiotics for a case of uncomplicated mild bronchitis. In this program though, all the residents were brain washed, and rightfully so, to admit anyone to the hospital if they come back reaching out for help the second time for the same problem. One resident last year did an assigned project to pull all charts on all patients over the last three years, not admitted and coming back for the third time with the same problem, again reaching out for help. I remember Dr. Singer, the director of my residency program, winding up that conference showing how many those second or third complaint patients came back either dead, near death, or permanently screwed up. The lesson well taught.

Alicia was admitted to an antepartum room and co-managed with the residents and attendings of the internal medicine, infectious disease, and obstetrical departments. More diagnostic tests were done and she was placed on additional broad spectrum antibiotics, even though throat and sputum daily cultures were negative. In a sense, she was over-treated. As you might have expected, we call it shot gun therapy. This is what doctors often do when the stakes are high and the causative factor is in question. The goal was to prevent confined mild bronchitis from progressing to severe bronchitis, which is the stage just before pneumonia. The entire obstetrical staff knew Alicia and we made rounds on her three times a day, and at least once in the middle of the night, instead of the usual once every 24 hours on morning rounds. This was ordered by the chief resident. Her bronchitis did stay stable for over a week, but then became severe with temps hovering about 102. We shielded her abdomen as best we could and did limit radiation exposure, but we needed to know if pneumonia was starting, even though rales (fluid) were not heard over the lungs with the stethoscope. The result of the chest x-ray was negative, no pneumonia.

Another week went by. The bronchitis was relentless. And although it wasn’t worsening, it was not improving. As a more junior resident, my duty was to perform ultrasounds, just about daily for Alicia. I would measure the biparietal diameter of the baby’s head, then the abdominal circumference. With a push of one blue button followed by the noise of a computer, the baby’s weight printed out.

Alicia was talking with the nasal cannula of oxygen in place, always adjusting the tube, not for her comfort, but, I’m sure, to make certain her baby gets what it needs. I’m not worried about me, doctor. It’s my baby. You know it’s all planned out before we are even born. I believe that. My appetite isn’t that good, doctor, but look, I ate everything on my tray, even the saltines. Is my baby gaining weight?

The baby was gaining normally, and we were hitting on 32 weeks. It was 3 a.m. and I stopped by Alicia’s room to make the usual night rounds. Two days ago antibiotics were alternated and some added, hoping to kill the microorganisms in her bronchial tubes that were never found on culture. There were also routine visits from the respiratory medicine department technicians to administer vaporized and medicated positive pressure breathing exercises, all to keep the airway passages open. We also had her connected to the fetal monitor much of the day, just to keep an eye on the uterine contractility and baby’s heart rate. Alicia was sound asleep. Thelonious had essentially moved in and was also asleep on a cot not too far from her. I lifted her slightly under her right side, but just enough to get a good listen to her entire lung field without waking her. At first I wasn’t sure if I were hearing the movement of the sheets and gowns through the stethoscope or real crackling, rales, a sign of fluid in the lungs, and in this case, indicative of pneumonia. The rales were diffuse, all over in all lung fields, and bilateral. I called the resident on medicine, who, with myself and Thelonious, wheeled her stretcher to the radiology department. Alicia by now had awoken, but wasn’t ready to talk. The resident was better at reading chest x-rays than I was, but I understood exactly what he saw. It would have been better if it were a lobular involvement, meaning local, bacterial, and treatable with antibiotics. But it was diffuse, viral, and non-treatable with antibiotics. When we got back to her room, the chief on medicine told her that she has viral pneumonia. Alicia was frightened, and only kept talking about her baby. Her breathing was labored, meaning she was working to breathe. I was stunned to see such change since she was checked 8 hours earlier when her lungs were clear.

As happens in such cases, the room began filling up with specialists and sub-specialists, in spite of the untimeliness of the hour. Thelonious was helpless in trying to understand it all, give Alicia support, and still keep his composure. Even the internists needed medical advice from the pulmonologist, infectious disease specialist, and immunologist. Dr. Singer called in another head of department in obstetrics from a Manhattan hospital to share thoughts. The conference room next to labor and delivery filled, as each doctor evaluated Alicia and wanted to share his/her knowledge and experience with the other members of this impromptu team. The neonatologist, a pediatric sub-specialist, who would eventually have to take care of this premature baby, soon arrived. The other residents and myself were helping stabilize Alicia, as much as could be done. The perinatologist, Dr. Kleiner, an obstetrical sub-specialist who handles complex pregnancies and rare events, had vital information. He became the one to put it all together and be the spokesman for Alicia and her baby. Alicia’s arterial blood oxygen saturation levels were steadily sinking. She would soon need help to breathe. The anesthesiologist discussed the possibilities and problems of continuous long term intubation. In other words, Alicia would essentially be pharmacologically paralyzed and sedated, without movement or discomfort, so as not to fight the respirator and tube in her throat, and on constant ventilation support. Pneumonia treatment would continue, even though not effective, and antibiotics also, to control a secondary bacterial infection, like staphylococcus, streptococcus and pneumococcus to name a few. She would be moved immediately to the intensive care unit.

Dr. Kleiner began speaking to Alicia, who was literally out of breath. She would soon be anesthetized. He spoke directly and firmly, no time to waste on emotion, but with empathy, kindness, and compassion coupled with directness and control. He got real close to her, not at all afraid of germs, and wore no mask so Alicia could understand him more clearly, and so he presented a human face for her to connect with.

Mrs. Powell, I’m Dr. Kleiner, in charge here. We are going to help you right now, but you need to make a decision. We have to place a tube in your throat so the ventilator will breathe for you. You will feel no pain and be totally unconscious. Right now both you and the baby are not getting enough oxygen. We are seeing changes on the fetal heart rate monitor because of the low oxygen. After you go to sleep we can do a cesarean section right now. There would be extra space for your lungs to expand, plus the negative effect that pregnancy might be having on your ability to fight this infection would be gone. The chances of a recovery could be 70/30 in your favor. In other words, the pregnancy can be preventing your recovery, and it’s definitely not helping. At 32 weeks the baby has a risk of dying from prematurity, or there could be long term developmental problems. At 35 weeks the chances of a healthy baby are just about totally in your favor. We can keep you asleep for 3 more weeks. The drug effect on the baby is negligible and the baby will grow with intravenous replacement. If you choose to go to 35 weeks, there may still be a beneficial effect for you, but the longer you are sick, the harder it will be for you to recover. Pneumonia can be fatal. There is little time. If you can’t decide, we will do the cesarean now. If you decide to wait, and if anything drastic happens to you or the baby in the interim, we are moving to a cesarean, regardless.

Alicia put one arm around Thelonius’s neck, and pulled his head and ear to her mouth, and whispered to him. Thelonius began crying and screaming, No, no, let them take the baby now. We can take our chances with the baby, but I can’t take chances with you. We’ll have another. It’s about you. You just got to get better any way you can and as fast as you can. I need you!

Thelonius looked up at Dr. Kleiner with a horrible grimace, Don’t listen to her doctor. She doesn’t know what she’s saying.

Dr. Kleiner put his ear to Alicia’s mouth to verify her wishes, held her forearm, and said something soft and kind that I couldn’t hear. Then stood up and ordered, Put her down now, and get her to the intensive care unit. We’re on a 3 week count down.

Dr. Kleiner took Thelonius to a quiet spot, and it was just the two of them talking. Morning rounds were approaching, as residents and interns came filing in. Dr. Singer called the house staff to his office. The new residents were getting the scoop of last night’s excitement as we were walking.

Doctors, this case is very unique. In almost four decades, this is unchartered territory for me. So we will adapt. I want one on one doctor care for this patient. This means you will be watching and coordinating this case 24/7, and making sure that the ten different doctors seeing her are communicating and on the same track. There is a call room in the I.C.U. where you can rest if you have to. The minute we see contractions, fetal distress, or the patient’s condition severely compromised, it’s a cesarean. So I need a more senior resident. I only want volunteers, since most of you have families and are already overworked. As soon as the word, volunteers was heard, all hands in the room went up simultaneously, even the grouches, whiners, and lazy asses. As touching as it was, Dr. Singer stood up, You are truly my people. The chief will work out an alphabetical schedule, so Dr. Arnold, you are first. Just one more thing, I heard some of the residents talking about why not take the baby now. Our first priority as obstetricians was, is, and always will be, mother first, as is in this case. You see mother has the right and privilege to protect her unborn child. We are going to make sure that no one dies in the process. So, again, mother first."

Alicia got more than one on one care. Nurses were all over her, even when they didn’t have to be. They were monitoring life support systems, doses of medications, always checking the tubes, cannulas, and catheters. Intravenous fluids were not sugar or salt water anymore. There was serious intravenous hyperalimentation so the baby would receive all the nutrients it needed for proper growth, vitamins, minerals, supplements, amino acids, and electrolytes. There was hardly a time when one specialist or another wasn’t in her room. Seeing a baby clinging to mother for life, as all babies do, but now to a mother who was herself clinging to life was more than two nurses could handle. They were taken off the case because their emotional involvement started to interfere with their care. Her medical management had to be strictly business.

Thelonius would carry the emotional part of it all.

The night watchman security guard does have power, as he allowed Thelonious to sleep on a cot in the hallway. The nurses did also allow him to be in Alicia’s room more than the rules permitted. If there were anything good about all this, the baby was actually growing every day, and on a high growth curve. Alicia herself was stable. Occasionally the doctors would attempt to slowly get her off the respirator, but unsuccessfully. Her terrible disease neither worsened nor improved.

So the decision was made, but not by the doctors but by happenstance. A day and a half before 35 weeks, mid-morning, there were really strong uterine contractions associated with decelerations of the baby’s heart rate. Now, for sure, it’s a no brainer. For mother and for baby, this pregnancy is over.

Dr. Kleiner came in. Nothing he could have been doing was as pressing as this. He performed the cesarean, the chief assisted, and I was the second assistant. That’s really a fifth wheel, unless one of the other two obstetricians faints, which never happens. The baby was still struggling a little at 35 weeks, but the pediatric and neonatology team had it all wired tight. Although there are those who say all babies look alike, this one was definitely a pretty Thelonious. The surgery was swift and neat. Alicia skipped the recovery room, and went straight back to the I.C.U., now with even more intensive and postoperative care. Thelonious was jogging back and forth between Alicia and the nursery. What he really wanted was to see Alicia open her eyes again and get better.

I came to work a little early the next day, just to catch up on Alicia’s condition. Dr. Kleiner, the anesthesiologist, and the nurse were trying to keep Alicia calm, as the tube in her throat should only come out when she’s fully awake. The oxygen and medications were cut back and she was actually attempting to breathe on her own, but fighting the respirator. Thelonious got a little upset and asked the anesthesiologist to take out the tube.

Can’t you see? My wife’s hurting. Take the tube out please. When are you going to take the tube out?

Let me do my work. Alicia will tell me when the tube should come out.

Just then, Alicia reached over with both hands to grab the tube. The nurses took her hands to keep them out of the way, and the anesthesiologist gently removed the tube saying, Now!

Breathing wasn’t easy for her, as she needed to learn again what the machines were doing for her during the last three weeks. There was a nurse on her both sides encouraging Alicia to breathe. The anesthesiologist himself was suctioning so much mucus, blood tinged exudate, and serous fluid, telling her not to speak. Not even a minute went by and she sat right up, placed her two hands over her flat belly, and then put it all together, Where’s my daughter?

Thelonius grabbed her face with both hands and turned to Alicia, She’s over 5 lbs, and she’s pretty, and I thought I’d never see your eyes again.

Alicia did improve. Blood oxygen concentrations were perfect. Her appetite and spirits were wonderful. The premature nursery nurse brought the baby to her, protected from infection in the covered bassinet. It was that twenty minutes a day that Alicia lived for. She’s much better than the worst she’s been, but there were still concerns. Rales were much improved, but basilar rales persisted in the lower lung fields. Her chest x-ray just wouldn’t completely clear. She had been on just about every medication that might help. Another concern was that her white blood cell count wasn’t increasing anymore. It was actually decreasing, meaning her body wasn’t mounting a positive response to this infection, because her immune system was tiring. The continuous low grade temp with sporadic high spikes were also worrisome to everyone.

I was off that weekend, Friday night to Monday morning. This was my reward for enduring those brutal weekends on call. I spent the weekend cuddling with my family in our safe little world. But disturbing flashbacks of the hospital troubled me, so different from med school. There was a weekend visit to the outlaws. My kids don’t even know that they are getting spoiled on top of being spoiled.

I was came into the locker room at 7:15, Monday morning. I wanted to make a little time to stop by and see Alicia before morning rounds. Randy, a resident co-worker, was coming out, then doubled back to follow me in.

You’ll hear it at rounds, Bob. Noon meeting will be in the prayer room on the second floor. Yesterday Alicia died. I was on call this weekend. Saturday afternoon she went downhill fast. Just before the anesthesiologist had to re-insert the endotracheal tube, when the medication to put her out again was being infused, she and Thelonius were just face to face staring at each other, not talking. When her eyes closed, Thelonius literally collapsed. He had to be carried out of the room. I think they both knew it was the end. Ten hours later she died. How much could that poor human body take? Bob, I think I’m going to be sick.

Every night after work, I took the back way to the parking lot so that I would pass by the nursery, hopefully to see Thelonius. It was so heart-warming to see the baby’s name in pink on the bassinet, Baby Alicia.

Thelonius was talkative, thank God, The social worker laid out some options for me, including foster care, and even adoption. She’s concerned that I have no family support. You see, neither of us have family. We were both orphanage kids, but we had all we needed, each other. Well doc, it’s always been Alicia and me. Now it’s still going to be Alicia and me. We always made it before without charity or stranger help, and we’ll make it now. I’m already back to work at my day job. This baby needs a roof over her head. I wish everybody would stop feeling sorry for me. The guys in my quartet want me back. I don’t know if I’ll ever pick up a horn again, but if I do, I’ll be the best I can. All these guys, their wives and girlfriends are already biting and clawing at each other, over who will get to take care of and love this little angel. I’m good man, and thanks to you and everyone, as he reached out his hand.

How could I ever begin to believe that any of this is about me? I’m looking at my short time in medicine. And I’m looking at what the future holds. I can now see the tough part. Patients come into my life, with serious needs. A connection is made. Then they’re gone. And I’m gone. I move on with my life and they move on with their lives. Sadly, it will not be for me to ever know how baby Alicia grew up or if Thelonius ever picked up his saxaphone again.

A Broken Clavicle for the Gift of Life

About half way through my second year of residency, I was still holding my own. On the obstetrical rotation I was in charge of all vaginal deliveries. Initially I needed to call the chief for help, maybe a case of a breech delivery, midforceps, or postpartum hemorrhage. Lesser more routine stuff, I was o.k. When a cesarean became necessary, and if the chief was happy with my work, I got to do the case under his guidance, supervision, and teaching. As months passed, an aura of confidence surrounded me. Sometimes the chief would get involved with a life threatening gynecology case, but he was always there when I needed him, so I didn’t worry about the what ifs. And if I really had to do a cesarean, I was secure operating unsupervised, with an intern or even a medical student assisting me. That thin layer of confidence was broken when I got to see how serious obstetrics really is, when trying doesn’t help, when working at it doesn’t help, when there is no time or energy to be nervous, when life is slipping away, when I’m the only one in charge, and when I used up all my knowledge, skills, and tricks. How could I have seen, in such a short time in this program, all the emergencies that could occur in this world of obstetrics? And more serious, how could I remember every step in every emergency from reading a book without the actual hands-on case experience? Anyway, I read a more than one concise and thorough obstetrical textbook, and memorized as well as I could. I would have to work hard to muster up the nerve to even walk into a place like this.

Dr. Bendix, my chief, reminded me to watch out for Mrs. Robertson’s blood sugars in labor and how they can change fast, Ups and downs can kill a fetus, so keep it level. You know the numbers. On this case, the other day, Dr. Singer asked my opinion about how this patient should deliver. Then he criticized me. I said the mother should have a cesarean section. This baby, I’ll bet, will be over nine pounds, easy. Then Dr. Singer went on about patients deserving the right to normal labor and delivery, and going on again about our low cesarean section rate. He said if we start sectioning patients because we think the baby is too big, where will it end? Damn it, he’s right.

As the night wore on, the chief ran up to me at the nurse’s station, The senior resident on gynecology needs another pair of hands in the O.R., real bad. I’ll be back soon. And make sure that you get the nurses to help Mrs. Robertson push. Some of the nurses get a little lazy, especially if they don’t like you. And keep the contractions strong and regular. You know the routine.

Mrs. Robertson is a large complaisant woman. The baby’s fetal heart rate tracing is great. She’s been pushing over an hour in bed and exhausted. This is a proven tested multiparous pelvis, having previously pushed out an eight pounder, but this one could be bigger. The delivery room is a better place for her to push and get this done. She’ll have better leverage and strength to push with her legs up and flexed. The handle grips on the delivery table will help, and it will be easier for the nurse to give fundal pressure over the uterus while the patient is pushing during a contraction. I’ll have much better light and everything I need for delivery on the table next to me. Her contractions were weakening, longer spacing, and shorter in duration, so I turned up the Pitocin drip. The baby is tolerating labor well. About a half hour later I could start to see caput of the baby’s head between contractions, and in a perfect direct occipital anterior position, the best in the world for delivery. This patient is the perfect candidate for an indicated low forceps delivery. Each blade went on easily and locked easily. If they don’t lock at the handles with facility, they are on incorrectly. Guiding the long needle along the floor of the vagina, I administered a pudendal block, being careful to avoid the pudendal artery, and lots of lidocaine on the perineum to ease the pain for Mrs. Robertson. Plus patients don’t push well if excessive pain distracts their focus. I waited for the next contraction. The nurse applied firm, but not excessive pressure from above. With the strength of artificially Pitocin induced contractions, plus forceps assistance, and a large episiotomy to provide the space for this sized baby, we’ll actually have a baby delivered. With consistent, continuous, gentle outward and upward extraction of the forceps, I had the perineum just where I wanted it, with the correct thinness to accomplish a good incision without a bloody mess. I instructed the nurse concerning methods to hold and anchor the handle of the forceps blades so the baby won’t slip back up. With my left hand and fingers, like a V, I protected the baby’s head. With my right hand I made my episiotomy incision with the bandage scissors. I wanted to incise deeply into the pubococcygeal portion of the levator muscle, so I incised the transverse perinei and bulbocavernosus muscles lateral to their midline attachments. Great! We’re having a baby. The head did come out with relative ease when we put it all together. Suctioning the baby’s mouth, before the first breath, became increasingly and speedily more difficult as the baby’s head, already fully out, sucked severely back onto the perineal fat of the patient’s chubby thighs, like sinking into a soft mattress. The normal process of moderate downward posterior traction on the anterior shoulder, and then upward anterior traction on the posterior shoulder had absolutely no effect. It was as if something were pulling the baby back inside the womb, I couldn’t budge it. It was difficult just to squeeze my fingers between the mother’s thighs and the baby’s head because of the head wanting to retract tight up against the mother. I knew what I was looking at. That something holding back a successful delivery is the baby’s shoulders, and this is shoulder dystocia. The baby’s shoulders are impacted inside the mother’s pelvic bone structure. As seconds went by, the baby’s face swelled up like a balloon, and quickly got blue, not a pretty site, all the while getting bigger and bluer. I told the circulating nurse to call Dr. Bendix from the operating room, like now, and don’t take no for an answer.

Tell him there’s shoulder dystocia! And set up the next room for a cesarean section and call anesthesia. And get the pediatrician up here now!

I know that more pulling and traction is not the answer, for fear of injury and permanent paralysis to the baby’s arms. My mind’s eye quickly and automatically went into the memory bank, and I started to do what I had read in the textbook over and over again.

I told one nurse to note the exact time and to place the fetal Doppler lower down to listen to the baby’s heartbeat more effectively as I work. The umbilical cord is being compressed with these large shoulders. I could listen to the heartbeat going down to seriously low levels, but not yet death levels. The other nurse was ordered to stop fundal pressure and begin moderate suprapubic pressure by downward pushing applied to the fetal head for the traction effect, just above the pubic bone. Another nurse was instructed to get her legs out of the stirrups, and put them up as sharply flexed as possible over her abdomen. I forget the physics of it all, but the change in angles of spine and pubic bones give more room to accomplish delivery. This strategy can then actually free the anterior shoulder. I tried full delivery again and it was as if I had nothing. I heard the nurse, One minute, doctor. The fetal heart is 60, down from 140.

I went for the posterior shoulders trying to sweep the posterior arm across the chest, but I just couldn’t reach it after three attempts. I’m running out of tricks.

Two minutes doctor, fetal heart 40.

I remember reading about Rubin’s maneuver, on the bottom of the list when nothing else works and that’s now. I went around the table and began to apply force to the abdomen in a rocking manner. Hopefully, this would abduct both shoulders, decreasing shoulder to shoulder diameter, thus freeing up the anterior shoulder first. Then I could go for the posterior one, the finish line. I began to get that feeling that we all know well from experience, grasping at straws.

I went back between the patient’s legs again to try one more time for the posterior approach. Seeing the baby’s face, so close and yet so far, just sped up my adrenalin more. The pediatric resident thankfully was already on the scene. I had used up all my options, and all I could remember was to push the head back in and move on to a cesarean, easier said than done. This could take pressure off of the cord, and get a live healthy baby. But I just couldn’t accomplish it. The edematous and swollen face grew worse and really did preclude the baby’s replacement back inside to the vagina. I did remember reading about breaking a baby’s clavicle, but had no idea where to begin. The last possibility would risk killing a baby trying to get it out. I can break the clavicle and deal with those complications, like maybe puncturing a lung or stabbing a heart with a broken sharp ended clavicle bone. The anesthesiologist had arrived, attempting to keep the patient calm in all the emotional and physical pain.

Three minutes, doctor, I think 40, no, 30.

As I palpated (manually manipulated) to determine how I could break the clavicle, I couldn’t remember in my studies exactly how to do it. Which shoulder should I break, where will I break it and should I break both.

Dr. Bendix came dashing and crashing through the swinging doors of the delivery room. His head was over my right shoulder and we were ear to ear. I told him, rapid fire, what I had done so far. He went around closer to the baby, grabbed my right hand, and placed it in a specified spot, then said, Don’t move your hand. That’s the clavicle on the anterior shoulder that we feel. Push it onto the pubic ramus. Forget about moderation. Push as hard as it takes to break it and push until it breaks. When it’s done, you’ll feel it and hear it. If you can’t do it in a few seconds, get up, and I’ll do it. It was exactly as Dr. Bendix had instructed. The baby came into my lap with the usual maneuvers, but carefully with a broken clavicle floating around. The baby did miraculously well, a low one minute Apgar score, but a nice 8 at five minutes.

The chief left as quickly as he entered. While I was repairing a most difficult episiotomy, the orthopedic resident came in and reported that the baby’s fine. No splinting would be necessary, and because it’s a baby, the fracture will heal fast. While I was suturing, it was like Snow White and the Seven Dwarfs, whistling while I work.

A Doctor’s Worst Nightmare

In a few months I’ll be chief, looking forward to the responsibility and to my surprise, not scared. Like a kid who can’t wait to grow up, adulthood being chiefdom. I was exactly on time for 8 a.m. morning obstetrical rounds, 7:45. It is when residents gather, adjacent to the chalk board, standing in a circle to present cases. We assess progress or lack of progress in labor. We assess patients’ condition and develop action plans. The nurses are erasing and adding 24/7. It’s a scene in a state of constant flux—the cervical dilation, presenting fetal station, patient’s vital signs, and anything pertinent is up on the board. The doses of uterine labor stimulants and suppressants, the ever so delicate balance of blood sugar and insulin infusion to prevent sudden fetal death, antibiotics to kill pelvic bacteria, and anticonvulsants for seizure prevention are just normal morning conversation for us. This is where Dr. Singer defies the laws of physics, as we know them. The center of a circle is supposed to be in the center, like a nucleus of a cell. But here the center is on any spot of the circumference, wherever Dr. Singer stands.

As I walked down the hall there were only two patients in labor. So what’s all the buzz at the nurse’s station, more people than I had ever seen. Past the doors to labor and delivery, and to the cesarean section suite, at the doorway the nurses and aides were cleaning up a dreadful amount of blood. Everyone seemed to be in a zombie mode, working slowly, yet deliberately. One nurse was carrying a big bundle of blood soaked sheets, drapes, and gowns. I saw Dr. Singer and two residents talking next to a woman who was covered and dead on the operating table, with her dead feet sticking out of the uncovered sheets. I had seen deceased patients before, the last two years of medical school, pre-internship, and internship. This was different. I was stunned and taken aback. This is not supposed to happen, only maybe in third world countries. The medical terminology is maternal mortality, and it did happen, right here in Brooklyn. I went to the nurses to look at the chart. Oh please, it was Tara Wilson. I saw her for so many prenatal visits. She laughed at my silly jokes. Tara always came with her sister, also pregnant. Dr. Singer went to the gathering residents, There has been a maternal death. Rounds will be at 9. Everyone go to work.

Randy, a second year guy pulled me over to a corner.

"Tara was the chief’s case, Dr. Avery’s case. I was working with him all night on this patient. He performed a vaginal birth after cesarean, everything according to our protocol, by the book. The baby’s heartbeat had late decelerations unresponsive to intrapartum resuscitation and then bottomed out with the baby’s head at a +2 station, so he did an emergency midforceps delivery. He was slick and smooth, doing a wide outer rotation first, not an easy midforceps delivery, and then switching to outlet blades, one at a time, so it wouldn’t slip back, and no pauses. The baby was great, had a crappy Apgar score at one minute, and at 5 minutes, a 10. There was not one forceps mark on the baby. Did you ever hear of anything like that? You know, these babies are usually floppy, unresponsive, and all marked up with with forceps applications in those kinds of deliveries. He did have one very serious tear high up in the vagina, right lateral fornix, with massive hemorrhage. There was more than one arterial pumper. The arteries retracted back into the adjacent tissue and were hard to find. He was smart and called for back-up, every resident he could find plus two guys from general surgery. There were docs retracting the vaginal walls on both sides, and from above and below. I was assisting his vaginal vault surgery, holding the suture taught, serious suctioning, and cutting sutures. We had an intern also suctioning so he could work in a flood of blood. All the time blood being transfused, going as fast and safe as possible, and clotting factors too. She had already been given four units. His suturing was awesome and got the laceration fixed, tight and dry. I’m glad it wasn’t me in that hot seat. Like out of the blue she began hemorrhaging through the cervical opening far from his repair, even with the placenta completely out, and uterus well contracted. He did a manual exploration from below and found a hole in the uterus, so he had to go in. She was immediately given general anesthesia. Avery opened her up and down with cutting more than one layer at a time to save seconds. Man that’s tricky business. I was first assistant on the hysterectomy. The belly was full of blood, even up under the diaphragm, liters. The transverse scar on the uterus opened up and went right deep into the uterine artery on the left side. He isolated the bleeder and sutured it dry. Dr. Avery then went directly to a hysterectomy. The uterine wall was so thin that there was no way he could get approximation. I had never seen a cesarean hysterectomy before, everything is so vascular and bloody, and much more suturing, and much more difficult to achieve hemostasis. It’s not your regular hysterectomy. When he got to the vaginal cuff the patient went into shock, blood pressure bottomed out. I never saw a doctor work so focused, fast, and furious, and not a drop of sweat, and his hands weren’t even shaking. Mine hands were shaking and my mask was soaked. More blood and clotting factors went in. Avery couldn’t work any speedier and still be human. He closed the peritoneum and fascia all in one continuous running locking non absorbable suture to save time. When he got to the skin she just bled out and died. There’s just so much blood that you can give a non-stop hemorrhaging patient. We all gave cardiopulmonary resuscitation, and Avery lead the team, pumping, and no time to pray. When Dr. Avery gave her the electric paddles and intracardiac epinephrine without response we all knew it was over. By then Dr. Singer had arrived and had to escort Dr. Avery away from the patient with both arms."

Randy looked at his watch, "I’ll be 4