Assume the Position: Memoirs of an Obstetrician Gynecologist Read online

  During my internship I spent three months in the neonatal intensive care unit (NICU) on a neonatology rotation. Neonatology at the time was a new specialty in the pediatrics realm, caring for sick babies during their first 28 days of life. The ‘Father of Neonatology’, one of the country’s experts, was at Pennsylvania Hospital. Spending three months with him was a special experience. There were three of us in training with him during this rotation: a pediatric intern and a resident from the University of Pennsylvania, and an obstetrics intern from Pennsylvania Hospital. It was critical for us to learn how to care for sick babies. Depending where we might wind up in clinical practice, rural or otherwise, we might be the only person available to keep these young, often critically sick infants alive for an extended period of time until help could arrive. So we learned what kinds of problems put these critically ill infants in the intensive care nursery in the first place, how to intubate them, place them on respirators and make the proper respirator machine settings if they were too premature to breath on their own. We learned how to put in umbilical lines for fluids, dosages for antibiotics and other critical medications, and how to maintain acid base balance, critical for early infant health. It was all-terrifying for me. After all I wasn’t a pediatrician. The patient’s couldn’t communicate their medical needs. There was so much to critically assess in such a short period of time, in such a small human being. Even more terrifying was every third night on call when I was the only one in the NICU caring for up to 20 or more premature babies at times. As we were required, we attended each of the Cesarean sections as the ‘pediatrician’. Although I would have preferred to be performing the delivery itself, during this three-month period I was on the receiving and not the delivering end.

  One night I was called to attend what appeared to be a routine repeat Cesarean section on a mom who had arrived in active labor. Still in the “once a C section always a C section” era everything was expected to be routine with the baby, so I was expecting nothing out of the ordinary. I was handed a term baby that for some reason had awful Apgar scores, was blue with minimal shallow respirations, grunting and retracting. This was a clinic patient with no financial resources or insurance, it was past midnight, and I was it as far as pediatrics for the evening. Clinic patients were almost always entrusted to the resident house staff in training, i.e. me. I stabilized the baby, intubated and bagged it immediately, put in umbilical catheter lines, checked x-rays for line and tube placement, took it to the neonatal ICU, and waited for initial labs and blood gases to come back. When I was satisfied with the results, I called the Father of Neonatology and Chief of Service on the phone to inform him of a new admission to the NICU, apologized for waking him, gave him the details and numbers, and asked if I missed anything. He said: “Is this a fourth floor baby or a fifth floor baby?” which meant was it a ‘ward’ baby or a “private” baby, in his language non-pay or insurance. I responded that it was a ‘fourth floor baby”, meaning no insurance. He said, ‘Keep up the good work and I will be in later this morning.”

  By the time of morning rounds, after an exhausting night with no sleep, I was so proud of the work I had done. I kept this baby alive all by myself while not only producing perfect laboratory acid base numbers but also caring for all the other neonates in the neonatal ICU. The Father of Neonatology arrived for morning rounds. When it came to this baby he took one look at it, pulled out the endotracheal tube and turned off the respirator. I was aghast. He said, “You have just saved a Mongol for the world. If he is going to live, he is going to do it on his own.” I suspect he knew the infant would make it without the respirator, but I couldn’t have made that judgment at that time. I had never seen a newborn Down syndrome baby before so I missed the diagnosis completely but had I made the diagnosis I would not have done anything differently. He put a name card on the baby’s bassinet and called it ‘baby Rick’ Smith, named by him after me. Each day on rounds for the next month he would begin the presentation of baby Smith with the same comment. “Rick saved this Mongol for the world”. And I did. He went home one month later.

  The training program at Pennsylvania Hospital in general was excellent. Our Chief of Service, nationally renowned, had the highest standards and expected the same of each one of us. Every morning at 7:30 AM was ‘Morning Report,’ where all residents would gather and sit in silence as the Chief Resident of Obstetrics would discuss the statistics for births the prior day, indications for each Cesarean Section which had been performed, whether on the resident (public patients) or private (insured) attending physician service. The Chief Resident would usually come in around 6 am each day to get this information and review all the pertinent charts. Morning report was a learning experience for the whole resident staff, but no one other than the Chief Residents and the Chief of Service could speak. Among other things we would learn when Cesarean sections should, and should not, be done. The Chief Resident on the Gynecology service would present all cases scheduled for surgery in the operating room that day. If in the opinion of the Chief of Service a case had not been evaluated or selected properly for surgery the Chief of Service would just cancel the case and send the patient back to the clinic for further evaluation, even if the patient was in the pre op holding area. Often times the surgery was cancelled for something simple like not knowing what the patient’s blood count was before surgery; or an adequate medical trial of therapy hadn’t been tried before surgery was entertained, or the indications for the procedure were inadequate. Peer review happened every day under the Chief’s tutelage that served me well for my future endeavors. He set an example for us as to how correct medicine should be practiced. Nothing else was acceptable. It just became part of my mindset.

  One night in the middle of the night I was performing a particularly difficult forceps delivery and rotation of the fetal head while still in the birth canal. I heard someone breathing over my shoulder. I looked around and there was the Chief of service who had appeared out of nowhere, inquiring if I had met all indications for applications of the forceps, why I was using this particular forceps as opposed to another. He checked the application of the forceps to the baby’s head himself, and then permitted me to continue as he watched the whole delivery, then quietly left the room, what I took to be silent approval. For me, I felt a sense of accomplishment and satisfaction that I had been silently observed, and passed with flying colors.

  Multiple births were common at Pennsylvania hospital, particularly because there were world-renowned infertility specialists on staff. During one 48-hour period I had occasion as Chief resident to deliver triplets and sextuplets. The triplets were known and expected. The sextuplets were not. The mom had severe preeclampsia, a pregnancy induced syndrome that increased risk for both mother and baby, heading towards eclampsia with life threatening seizures and hypertension. We were trying to extract every hour possible out of her before delivering what we thought were her premature twins. It was a fine balance. When one baby suddenly died in utero and her blood pressure shot way up we had no choice but to proceed to immediate Cesarean Section, thinking we were going to get one dead and one living baby. Ultrasound was in its very infancy in 1977 such that the staff and residents were just learning how to use it and interpret it. Pennsylvania Hospital had one of the first Antenatal testing units and ultrasound machines. We needed it to identify how many babies we were dealing with, and whether they were alive or without heart beat. At the time of the Cesarean I put my hand in the uterus and pulled out the first baby who was alive. The second one I pulled out I of course expected to be the dead baby but it too was alive. I kept putting my hand into the uterus, pulling out living baby after living baby, while placing stat pages for more pediatricians. The first five were all alive and only the sixth was dead.

  Then there was a true record multiple-birth I attended, perhaps a world record. In the ‘Old Days’, women in early labor would get enemas, walk, evacuate their lower bowels, and deliveries were much cleaner for everyone. Somewhere during residency in
the late 1970’s this process changed and/or some women refused enemas. So be it. Mother Nature is what she is. As this patient pushed with the baby’s head on the perineum out from the rectum also came stool followed by a ball of white squiggly material that at first I had trouble identifying. As the ball disintegrated and began to move all over her perineum up to and over the crowning baby’s head, it became obvious that these were pinworms, hundreds if not thousands of them. The Guinness Book of world records would have been proud to witness this record number of deliveries from one person at the same time. I wasn’t. Watching worms crawl out of someone’ s rectum, over her perineum onto the baby’s head, and then having to remove them was less than thrilling for me. All in a day’s work, I suppose – but an experience never to forget!

  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.)

  Chapter 3 Labor and Delivery

  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 th
e 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.