Assume the Position: Memoirs of an Obstetrician Gynecologist (13 page)

(I know you think this was the patient.  Although she looked similar, this photo was taken at a museum in Vienna, Austria)

     My nurse who had been with me for a number of years was top notch.  Between the two of us we never missed anything. She knew my work habits well, the way I practiced and when and what I needed. We always had a professional relationship and I respected her contributions to my office life immensely.  She often made my days easier just by anticipating my needs.  About one month after the above episode, during a lunch hour when I was in my corner office with my feet on the desk reading a medical journal, there was a knock on my open inner office door.  There was a young police woman standing there, a particularly shiny Phoenix police badge on her chest, gun in holster, and a piece of official looking paper in hand.  She asked me to identify myself which I did then told me she had a summons for my arrest for sexual harassment of a patient.  My heart sank to my ankles.  I asked to see the summons that was very specific.   Unable to even move my feet off the desk, I took time to read the summons, to think what I was going to do next and to catch my breath. I could feel the color drain from my face and my adrenaline pumping.  I was regretting the fact that I rarely had a nurse with me in the exam room for routine exams unless a procedure of some sort was necessary.  Psychogenic shock was beginning to set in.  Whatever the charge was, I knew it wasn’t true.  My thoughts immediately went back to the young naked woman from a few weeks earlier.   Just being charged by someone, however falsely, was enough to ruin my career. I told the officer there was a mistake. She told me she needed to handcuff me and take me to the station for formal charges.  I told her there was no way I was being handcuffed and led out of my office.  Her response was simple enough:  “Are you resisting arrest?”  I nodded affirmatively. Ultimately I chose not to resist as she handcuffed me and went to my desk.  She picked up the desk phone and called her back up officer who immediately appeared.  He had an electronic box of sorts which he placed on my desk and pressed a button.  I was in semi panic mode, a place where I rarely if ever went.  Music came on as she began to take off her clothes. My delighted office staff appeared from around the corner.  They watched my horror in delight.  Handcuffed at my desk I was about to receive a lap dance from the ‘officer’, now down to her skimpy panties and nothing else. I was in such shock that I couldn’t even enjoy the experience, naked as she was and handcuffed as I was.  Of course this occurred two days before my birthday, the furthest thing from my mind at that point. I never forgave my nurse for that one. I was a sitting duck and she got me.  Such was life in an OB GYN office.

     Shortly thereafter my front desk receptionist came to me and said, “ There is a guy on the phone who wants to know if you would do a hysterectomy on him without seeing him in the office first.”  I looked at her like she was crazy.  The answer was of course ‘no’ but I would be happy to see him if he thought he needed my services.  So he made an appointment.  When he arrived, balding and with a full beard, I learned he had been working as a male nurse for two years in a local hospital. He had been on male testosterone for that period of time and wanted ‘his’ uterus and ovaries removed.  Thereafter he had plans with a plastic surgeon to have a bilateral simple mastectomy to remove his atrophied and hairy breasts that had been tightly bound.  He then was moving to Seattle for a definitive surgery and a new life after a sex change operation.  But first he wanted to get rid of his female organs.  So I agreed and performed the abdominal surgery that usually required three days of hospitalization.  After all it was a major surgical procedure.  The first morning of surgical rounds I found him sitting bolt upright in a chair as if nothing had happened to him. He demanded to be discharged.  I had never discharged anyone after this kind of surgery on the first post-operative day, because the intestines usually weren’t ready for food yet, the pain was too intense from the abdominal incision, and people just weren’t ready to move or even sit up.  But I discharged him that day.  As I subsequently tell the story for a laugh, I always used to say:   “Well, he took it like a man!”  The reality is that he took it like a very determined person.  He was ready for the next phase of his life. 

     I had a patient who came in to me once with the complaint as follows:  “ My husband says I smell like a dead skunk that has been left in the desert for weeks on end”.  I wasn’t sure what that smelled like, but I was accepting the statement as fact.  She was put in the exam room and left waiting for me to enter.  When I did, I was relieved that I honestly couldn’t smell anything and then proceeded to examine her. When I placed the speculum in the vagina, I understood immediately what the problem was.  High up in the vaginal vault were two tampons, one on top of the other.  Evidently, two months earlier she had put in one last tampon at the end of her menstrual period, got drunk that night, and left the tampon in place for over a month, so that when she resumed her next period, she put in new tampons and never removed the old one through two menstrual cycles.  Little choice but to remove it, put it in the trash can, thoroughly rinse the vagina with Betadine antiseptic and send her on her way.  The real problem was after she left and my nurse came in the room to an overwhelming odor coming from the trashcan.  The windows in the exam room didn’t open. She wrapped up and closed the trash bag and took it way, and used most of a whole can of scented Lysol to try to get rid of the smell.  The exam room was left unoccupied for the next several days until there was no trace whatsoever of the smell left, which is how long it took.  So if one ever wonders what a dead skunk smells like that has been left in the desert for several days, you can now imagine!

     And such was the office life of a busy Ob-GYN physician; never the same from one day to the next, or from one room to the next.  Always interesting, unpredictable, challenging, and as varied as the women themselves.

     Night call began during my second year of medical school.  I couldn’t wait to have my own beeper.  It was a rite of passage and seemed to make me feel important that I was needed by someone in the middle of the night.   I was eager to begin this phase of life about which there was often myth and mystery for the uninitiated medical student.  The on call room for medical students at Hahnemann Medical College was on the 18
th
floor of the hospital, two floors above the inpatient psychiatric unit, and immediately above the hospital operators who were the ones calling us.  It was always a thrill greeting the operators before retiring to the Spartan room with maybe a dozen beds, nothing more than a long dormitory room with a night stand and phone between every two beds. One could literally go all night without getting a call (rarely) and still have no sleep, since everyone else’s phone was ringing even if mine wasn’t.  But ring they did.  Medical students did ‘scut work’; starting IV’s, drawing blood and blood gases, putting Foley catheters into the bladder, and generally anything the interns and residents needed done that they wanted someone else to do for them so they could get some sleep.  Hahnemann was unique in that rarely did anyone demonstrate how to do anything especially in the middle of the night.  One was just supposed to figure it out or else ask the intern for help.  But if one asked for help, our lack of knowledge would then be obvious and wound engender the response that if I wanted to do it myself, I would never have called you in the first place. Such was a big city teaching hospital.  It was all part of the maturing experience.

      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 1
st
, 1976, the bicentennial 200
th
anniversary of the United States.  Pennsylvania Hospital, at 8
th
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 baby’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.