Assume the Position: Memoirs of an Obstetrician Gynecologist Read online

  No wonder then that when I was first called to put in my first Foley catheter into the bladder of an elderly female patient, I had no idea where the urethra was or how to insert the Foley. After an hour of torturing the poor woman, I finally implored the nurse to help me, which she willingly did. There was nothing like trying and failing, though, which served as a learning experience. It was humbling and traumatic to both the patient and to me. By the time we graduated medical school, however, we were clearly ready to be interns, without a doubt.

  Internship and residency night call was a whole different ball of wax. The further one got in medical education, the fewer and fewer people there were to ask for advice, opinions and assistance, and the more one was expected to be able to handle problems on their own, especially at night time. The year I began my internship was July 1st, 1976, the bicentennial 200th anniversary of the United States. Pennsylvania Hospital, at 8th and Spruce streets in Philadelphia, was only a few blocks from all the celebration, Independence Hall, the Liberty Bell, and the Delaware River. It was the only hospital in the historical Society Hill section of Philadelphia. President Ford was in town, with thousands of others all crammed in to the same small area for the celebrations. The one assignment that I didn’t want to begin my internship was my two-month stint in the Emergency Room as its intern; of course, that is what I got. Worse yet, my first shift was the late night shift that meant I was the only intern on that night in one of the busiest emergency rooms in the United States that evening. I was fully prepared, or so I thought, to handle whatever came in the door. I was the one who examined and triaged every single patient. There was clearly more advanced help available who would come if I called, but it was my call to determine if I could handle the situation or needed to call for help. In many respects, the hardest cases to manage were the ones that I sent home without anyone else seeing the patient but me. If someone was so sick that they needed hospitalization then I called for resident help. But making the determination that someone was not going to die or get worse if I sent them home with treatment was all on my shoulders. It was a great learning experience. I saw everything from asthma, to heart attacks, to gun shot wounds of the head, to maggot infested plaster leg casts, to nose bleeds, diabetic shock, toe nail hemorrhages, heart failure, and everything in between. I was forever grateful to the late night emergency room nurses, who knew much more than I did.

  Residency night call was again a different experience. This was the beginning of obstetrics and gynecology learning. There were four residents in my year. This meant we were on call in the hospital every fourth night and every fourth weekend. There were four residents on call each night, one from each of the four years in the program, and we all had different workloads and decision-making responsibility. At one point, for several months, one of the women in my year developed vision problems, so we had to then cover every third night and third weekend.

  “Stat C section” was all I needed to hear. I had not been asleep for more than 30 minutes when the phone startled me awake. Instinctively I put on my glasses and glanced quickly at the red digital numbers flashing 12:01 AM. Since I always slept in my scrubs when on call at the hospital, it took only seconds to slip my bare feet into my wooden clogs stained with four years of brown antiseptic Betadine solution, blood, amniotic fluid, meconium, and any other female body fluid that comes from a human being. The soft, smooth wood of the inside of the clogs clung perfectly to my feet and toes, and tempered with years of these fluids, immediately grounded me.

  I had never met the woman who was on the gurney being pushed into the delivery suite where the C- section would occur. One quick glance around and I could see the IV fluids running, nasal oxygen flowing, and my young female intern on her knees, on the gurney between the patient’s legs in the position she had been taught for a prolapsed umbilical cord causing fetal distress – her arm high up inside the vagina, in almost to the elbow, and elevating the baby’s head off the cord which had prolapsed into the upper vagina. This allowed blood and oxygen to flow to the baby about to be delivered by emergency Cesarean. This was a true obstetrical emergency when seconds mattered before fetal death or irreversible brain damage occurred. The intern knew that she and the patient would be moved to the operating table with the patient as one unit, in this position between the patient’s legs, and would be covered by the surgical drapes. She would not remove her arm until I told her to do so.

  As Chief Obstetrical resident on call that night, I was in charge and would be doing the emergency surgery. My mission was to have a healthy mother and baby, and to make sure everyone was doing the tasks they had been trained to do in this emergency. There was no other option, as often is the case when dealing with Mother Nature gone awry. The nurse anesthetist was monitoring the IV line and oxygen while drawing into syringes the medications needed to administer general anesthesia, and placing a heart monitor and pulse oximeter. The scrub nurse put on her surgical gown and opened the sterile instrument trays and drapes. The two circulating nurses poured sterile fluids, recorded notes and times, and did whatever anyone else asked them to do, including making sure the pediatric resident was on her way to the operating room to care for the newborn the moment birth occurred. Antiseptic brown Betadine solution had been poured on the mother’s abdomen. I always loved the way it glistened on a scrubbed belly right before I was to cut it open. It was like a medical symphony happening before my eyes, yet barely open, unblinking, and basically unable to see because my glasses had fogged up due to the rapid temperature change from the on call room to the frigid operating room.

  Always cold, on this night the tiled walls of the operating room were particularly frigid. The outside temperature in downtown Philadelphia at midnight in January, with snow falling, was in single digits. As I finished a 30 second scrub, I could see through the one outside window from the third floor onto Spruce street, illuminated by one yellow street light. It was mostly black outside, with snowflakes falling, the window frosted, which told me the inside room temperature was something above single digits. I glanced at the operating room clock that now read 12:03 AM. Two minutes earlier I had been dreaming of snow skiing in the Rockies somewhere. It felt like I almost got my wish!

  I did my best to reassure the patient that she and the baby were going to be fine, perhaps hard for her to accept from a guy she had never met, laying there with someone’s arm inside her vagina, and all the hustle and bustle surrounding her. Everyone had already explained to her what was about to happen before I showed up on the scene, so a calming presence from me was the best thing I could offer her at that moment. For some strange reason, despite the fact we had never met and I was about to put a surgical knife into her abdomen, she was remarkably calm and composed, and seemed to trust me, or so I thought. At this point, the only part of her body I could see was a small rectangle between the blue surgical drapes, exposing the belly button down to the pubic bone. Her face was now behind the anesthesia screen. And of course she had company under the drapes between her legs, my intern, who was now reporting to me that the umbilical cord between her fingers was pulsatile, although weakly so. Time continued to be of the essence. The nurse anesthetist had sedated the patient and was now intubating her. Everyone was quiet and still at this moment. I stood waiting and realized I was the only male in the room, an increasingly more common occurrence. “GO”, I heard, as the intubation was completed.

  I put out my right hand and without a word a scalpel appeared in it, slapped in place against my rubber gloves by the scrub nurse. With just the right amount of pressure so as not to enter the abdominal cavity and uterus, but enough to cut into the abdominal wall midline through skin, fat, fascia and muscle with one swipe of the hand, bleeders squirting all over the place and hitting the one small area of my glasses not already fogged over, the surgery began. Next I took scissors and opened the abdominal cavity carefully so as not to injure bowel or bladder, dropped the bladder out of my way with the scissors, and cut into the uterus until I saw the ba
by’s face. I then placed my fingers into the uterus, spread the uterine incision open just so far as to give me enough room to get the baby out but not so far as to tear the uterine arteries, a potential disaster should it occur. I slipped my hand under the baby’s head, elevated it onto the abdominal wall, suctioned out the mouth, clamped the cord, and handed him to the pediatrician who was now in the room. Another birthday party, one of maybe 10,000 I have attended in my lifetime. No wonder my own birthdays were always anticlimactic.

  I took a moment to let the circulating nurse take off my glasses and clean the blood off them. It was instinctive on her part without me even asking. She just figured it might be a good idea if I could see before putting the patient back together.

  Now there were two guys in the room! He was blinking, which seemed like such a good idea to me that I decided to do the same thing, perhaps the first blink in the last five minutes since awakening. The operating room clock read 12:06 AM. After removing the placenta, the only thing I saw inside the uterus was the poor intern’s gloved hand, which I shook as I told her she did a great job. One of the weird things we do as obstetricians, one hand of hers through the vagina into the now empty uterus, the other was mine through the abdomen and into the uterus. A little encouragement from the chief resident to the intern was always in order! She removed herself carefully from under the drapes, and went back to work on the labor and delivery deck. Her sleepless night was only beginning. Hopefully mine was about to end shortly.

  Sometimes rank in the world of white -coated doctors counts for something. As an intern, her polyester white coat was waist length short. As a Chief Resident, I got to wear mine down to my knees. And my senior faculty mentors wore thick starched white cloth coats almost down to their ankles. Seniority in a teaching hospital was everything. I got to sleep again, and she didn’t. Four more years and she would be in my shoes. I suspect hers would look like mine did at this point.

  Somewhere around 1 AM I was back in the on call room, snuggling under the covers, my blood stained scrubs still on, too tired to change them right now. That could wait. Sleep was more precious. I had a long day ahead with “Morning Report” awaiting presentation to our Chief of Service, several teaching clinics, more scheduled surgeries, and who knew what else Mother Nature might bring my way as the day dawned.

  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 a
nd 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.