Chapter 9: A Very Long Shift, Part I

September 15, 1987, Greater Cincinnati, Ohio

“I heard from Doctor Phillips that you’re leaving a week early,” Doctor Kelly said when I saw her on Tuesday morning at Good Samaritan.

“And did he opine?” I asked.

Doctor Kelly frowned, “I actually got into it with him, and was reprimanded for ‘insolence’.”

“You didn’t need to do that,” I replied.

“Yes, actually, I did,” Doctor Kelly declared. “One of Doctor Phillips’ objections to female doctors is that we’re ‘too emotional’. He feels showing any emotion is a sign of weakness. That was why I sent you out for a walk and told you to stay away when you were emotional. He’s an insensitive, emotionless dinosaur who has no business running an OB ward.”

“And you told him that?”

“What do you think had me written up for insolence?”

“Actually written up? As in your file?”

“Yes, but I simply don’t care. Let him try and make an issue of it. He’ll have a full-scale rebellion on his hands from the Attendings who are nearly all women. They all agree with me, by the way. And I have no intention of seeking an Attending role at this hospital so long as he’s Chief of OB. The Residents and medical students actually want to solicit your help in that regard.”

“How so?” I asked.

“Write an accurate, truthful, and complete evaluation of the service, and what’s wrong with it. That can’t possibly affect your evaluation, as you don’t turn in your evaluation until you receive yours. And yours is going to be glowing, because all the Residents love you and we’d all love to have you on our service.”

“He’s going to make your life hell if I do that.”

“He can try,” she replied. “It’ll be obvious retaliation, and he’ll sink himself. I’m a PGY3 who has had glowing reviews, and per hospital rules, I can only be dismissed for negligence or a criminal act. He can’t really hurt me. I’ve already been in touch with two hospitals here in Cincinnati and one in Dayton about an Attending spot for next June. I’ll have interviews early next year.”

“May I think about it?”

“Yes, of course, but I think I know you well enough after six weeks that you’ll do it. You’ve been nothing but honest, direct, and forthright. You put the well-being of your patients first, no matter the consequences. I saw that especially with that young girl you helped, as well as the way you expressed your empathy, as best as a man could, to all your patients.”

“Thanks.”

“You’re going to make an excellent Doctor, Michael Loucks. Do us all a favor and help us get rid of a bad one.”

I agreed with her about Doctor Phillips, and she was correct that an honest evaluation couldn’t affect my own evaluation, but Doctor Phillips could certainly try to cause trouble for me, or for Doctor Kelly. She was willing to accept the risk, and as I thought about it, I was in the perfect position to do what she’d asked. My study group had agreed we wanted to change medicine for the better, and this was a prime opportunity to do so.

The one thing that could harm me, though, was violating the Mafia-like code of silence amongst doctors, though that was something that my study group believed needed to end. I believed that doctors needed to hold each other accountable, and I was willing to submit to my fellow physicians and be held accountable. And that was for the entirety of patient care, not just ensuring I performed the necessary procedures in the correct manner.

“I’ll do it,” I said.

“Good. When I spoke with Doctor Forsberg, I suggested that she allow you to assist with a delivery this week, even though that’s not something Third Years ever do here.”

“Thanks,” I replied. “What do you want me to do today?”

“I’m on call for the ER this week, so be aware of that. Go see Ms. Nixon, please, and do her admission exam and update her chart.”

“Right away, Doctor.”

I checked the board at the nurses’ station and went to the correct room where I saw a pretty young woman, probably a few years younger than me, who had a killer smile and short, red hair.

“Hi,” I said, after following the knock-wait-enter protocol. “I’m Mike. I’m a medical student and I’ve been asked to check your admissions paperwork, check your vital signs, and get a readout from the fetal monitor.”

“Rookie mom gets the rookie doctor?” she asked with a bright smile.

“Worse,” I replied with a smile, “not even a doctor! A Third Year medical student on my second clinical rotation. But I know how to do the things I was assigned to do.”

“Sorry, I wasn’t questioning you, I was teasing, but it clearly fell flat.”

“And I’m sorry I didn’t realize you were teasing. I usually have a good sense of humor.”

“But not at the hospital?”

“Just some personal stuff recently,” I said. “Let me check your chart.”

I looked over her chart and saw nothing amiss, and noted that she was, indeed, two years younger than me, and as she’d said, primigravida.

“Do you have a partner for labor and delivery?”

“My best friend will be here in a few minutes. She’s coming from Springdale.”

“I’m from McKinley,” I said. “Where’s Springdale?”

“Not far from here, really. It’s basically I-275 and I-71.”

“OK. I know where that is,” I replied, putting the chart back in the holder at the end of the bed. “OK to take your vitals?”

“Yes, of course.”

I started with her pulse, which was 74, then took her blood pressure which was 126/72. I warmed my stethoscope by holding it between my hands, then listened to her heart and lungs.

“These gowns are SO stylish,” she groused. “And leave ZERO to the imagination!”

“I don’t believe they were intended as a fashion statement,” I chuckled.

“They could at least cover up my butt! I mean, not that I’m ashamed of it, but still!”

“I hear you,” I replied. “But the point of the gowns is that they can be removed quickly in an emergency, and also make it easier to do exams such as the one I just did, especially if the patient is comatose. It’ll make things easier for putting the fetal monitor on you as well.”

I flipped the switch on the console, then carefully put the belt around Ms. Nixon. I attached the leads and then started the strip.

“I see your ring,” Ms. Nixon said. “What does your wife think of you working OB and getting ‘up close and personal’ with other women?”

I took a deep breath and let it out, fighting back tears.

“She died a little over two weeks ago, just after delivering our daughter.”

“Oh, God, I’m SO sorry,” Ms. Nixon said ruefully.

“You didn’t know,” I replied.

“But even so, I feel about an inch tall.”

I knew the only way I’d keep it together was to focus on medicine.

“Your baby’s heartbeat is strong and in the correct range. When was your last contraction?”

“Mike, really, I’m so sorry!” she said plaintively. “Please forgive me!”

“It’s OK,” I said. “I need to run the strip for ten minutes, and see at least one contraction. When was your last one?”

“About a minute before you came in, but very, very mild.”

“And how far apart?”

“At least ten minutes, maybe longer. I came in because my water broke.”

“OK,” I replied.

I watched the monitor for the requisite time, but didn’t see a contraction. I waited another five minutes, then I disconnected the monitor and tore off the printout.

“I need to review this with Doctor Kelly,” I said. “We’ll be back shortly.”

“OK,” Ms. Nixon said sullenly.

I left the room and went to find Doctor Kelly.

“I messed up,” I said.

“How so?” she asked.

I explained what happened and Doctor Kelly nodded sympathetically.

“There’s a lesson there, Mike. We don’t share information about our private lives with patients, because we never know how they’ll respond, or what they might do with that information.”

“I’m not sure how I should have responded to that question, then.”

“First, you try to deflect or sidestep the question, if you can. If not, give a non-committal answer, or, and I know this goes against your nature, tell a little white lie along the lines of she understands it’s a necessary part of your training. The times when you share the way you did with the young girl have to be limited to very, very special cases, where you’re sure it’s the right thing to do.”

“Sorry,” I replied.

“This is all part of learning what’s called ‘bedside manner’ in the real world. No matter what they teach you in medical school and no matter what you find in the textbooks, the real world is different and much more complicated.”

“So what do I do?”

“Let her know you accept her apology, and be a doctor. I want you to do the necessary exams. In addition to training, it’ll reassure her that you’re willing to treat her and are looking out for her health.”

“Why would she think I wasn’t?”

“Think about how she feels right now. She’s concerned she upset you and if you’re upset, that you might not be as attentive to her or dismiss her concerns or whatever. She may only have that thought subconsciously, but she will have it, or something like it. Let’s go.”

I followed Doctor Kelly back to Ms. Nixon’s room, and after Doctor Kelly introduced herself, picked up the chart, and looked to me.

“Ms. Nixon, I know you didn’t mean to say anything hurtful, and I should have simply accepted your apology.”

“I had no idea,” she repeated. “I’m sorry.”

“I understand,” I replied.

“Sheila,” Doctor Kelly said, “we need to do an internal exam. Part of Mike’s training is that he be supervised doing the exam, and then I confirm his findings with my own exam. If you’re uncomfortable with that, then Mike will step out and I’ll bring in a nurse to assist me.”

“He can do it,” Ms. Nixon said. “I trust him.”

“Mike, what’s the procedure for a PROM?” Doctor Kelly asked.

I had checked my notebook on the way to see her and knew that meant ‘Premature Rupture of Membranes’, which was anytime the membranes broke before active labor. Given I hadn’t seen a contraction, and Ms. Nixon had only reported a mild one, Doctor Kelly’s request was meant to avoid a digital exam.

“A speculum exam and nitrazine test,” I replied. “No digital exam to avoid potential infection.”

“Correct. Would you get the test kit and speculum, please?”

I got the necessary equipment and brought it to Doctor Kelly, who had washed her hands and put on sterile gloves. I did the same, then opened the kit for her so she could do the exam.

“Mike, insert the swab via the test port, please, then put it on the nitrazine paper.”

“What’s that for,” Ms. Nixon asked.

Doctor Kelly looked to me and nodded.

“To confirm that your water broke. Amniotic fluid will turn the nitrazine paper from orange to dark blue.”

I retrieved the sample, put it on the test paper and it did, indeed, turn dark blue.

“Presence of amniotic fluid confirmed,” I said to Doctor Kelly.

“OK. What’s next?”

“Fetal ultrasound,” I replied. “I’ll get the cart.”

“Is something wrong?” Ms. Nixon asked.

I waited for Doctor Kelly to answer.

“Your water broke, but you aren’t as progressed as we typically see at this point. We need to do an ultrasound to check on your baby, but there is nothing to worry about. This happens occasionally, and we just take extra precautions.”

That was true, at least for the moment, but the clock was ticking, as if her labor didn’t progress, she’d have to be induced or have a C-section. I left to get the ultrasound cart and brought it back. I set up the machine and handed the transducer to Doctor Kelly, then squirted warm gel onto Ms. Nixon’s stomach. Doctor Kelly performed the exam, and from what I could see, everything looked normal, though there was no amniotic fluid present.

“Everything looks good so far,” Doctor Kelly said. “Let me call Doctor Blalock and let her know.”

“She should be here,” Ms. Nixon said. “She said she was going to meet me.”

“It’s possible she is here and I haven’t seen her. Let me check with the nurse. Either way, I’ll speak with her and then come back to talk to you.”

The door opened just then and a pretty young blonde woman came in.

“Hi, Shelly!” Ms. Nixon called out.

“Hi, Sheila! Ready to have this baby?”

“I am, but either he or she is not cooperating or my body isn’t cooperating.”

Doctor Kelly and I left the room and walked to the nurses’ station.

“What’s our concern?” Doctor Kelly asked.

“Lack of progress,” I replied. “Our textbooks said fourteen to twenty hours, depending on the patient, and that IV antibiotics were given after twelve hours, but that is a judgment call on the part of the physician. After twelve hours of no progress, the physician should evaluate the situation and decide if induction is warranted, or if a C-section should be done. That decision is made in consultation with the patient, but the preference is for a Pitocin drip combined with dinoprostone.”

“Very good. Risks?”

“Pitocin is responsible for a significant number of malpractice claims because improper administration can be extremely risky and lead to all manner of complications, often resulting in an emergency C-section. It is very useful, but the dosage has to be controlled and the patient closely monitored. The risks for a C-section are mostly related to normal surgical risk, as well as possible fetal distress.”

“What would you do, Mike?”

“I don’t have the experience to make that judgment call.”

“That is always going to be possible, even after you’re an Attending. You will encounter something you’ve never encountered before and you’ll have to rely on your general medical education and your wits. Get used to doing that now, when a Resident can correct your analysis.”

“I believe in minimal intervention,” I said. “So I’d watch and wait, then do the least invasive thing, which would be dinoprostone gel with a Pitocin drip. I’d only do C-section in case of fetal distress or a complete lack of progress after fourteen hours. Well, that’s what I’d recommend to the patient, but then I’d listen to her response and discuss the options with her and allow her to make a decision, unless there was an emergency which required immediate intervention.”

“Want to hazard a guess as to Doctor Phillips’ preferred solution?”

“General anesthetic to shut up the annoying woman in labor and a C-section because it’s easier for him.”

“Right the first time.”

“That is, in my opinion, exactly the wrong way to approach medicine.”

“One more piece of evidence as to why we need a new broom to sweep this department clean. Someone with the right ideas.”

“You don’t have to do a sales job,” I replied. “I already agreed to write the evaluation.”

Doctor Kelly smiled, then asked the nurse about Doctor Blalock. She was in the hospital, but the nurse did not know where, so Doctor Kelly had her paged. The phone rang almost immediately, the nurse answered, and handed the phone to Doctor Kelly, who gave Doctor Blalock the details and recommended treatment.

“She’s on her way up,” Doctor Kelly said. “She wants to do an exam and speak with Ms. Nixon before recommending a course of action. She did receive it positively, though.”

“Ms. Nixon is Doctor Blalock’s patient, so I’d expect that.”

“Normally, I’d offer you the chance to follow this case all the way through, but I’m not sure you can take me up on that. You seem well-rested, but I know you have obligations.”

I thought about it and decided I didn’t want to miss this opportunity, especially as Friday would be my very last day in the hospital. If Lara could stay, or Annette could watch Rachel, then I could do it.

“This afternoon, after Annette arrives home, I’ll call and see if either my friend Lara can stay or Annette can watch Rachel, or some combination of the two. Given I’m skipping a week next week, I’d like to avail myself of this opportunity.”

“OK. Just let me know when you find out. Let’s go meet Doctor Blalock.”

We went back to Ms. Nixon’s room and waited outside until Doctor Blalock arrived. Once she did, the three of us went into the room. Doctor Blalock repeated the entire set of exams, from vitals to ultrasound to speculum exam, though she did skip the nitrazine test.

“Your baby is fine, Sheila,” Doctor Blalock said. “Your water broke earlier than is typical, but there is no immediate concern. We’re going to wait and see what happens. For now, just relax. It’s OK to walk around, go to the cafeteria, or even go outside if you like. If you feel any pain of any kind, feel nauseated, or feel your heart racing or you have palpitations, or you feel faint, tell a nurse or doctor right away. We’ll check on you once an hour, so please come back to your room every hour, if you decide to walk.”

“Sheila,” Doctor Kelly said, “Mike will monitor you. He’ll come by every hour, on the half-hour, to check your vitals and take a fetal heartbeat reading.”

“OK,” Ms. Nixon replied and the two doctors left.

“I’ll be back in about an hour,” I said. “Are you planning to go for a walk?”

“Yes. We’ll probably go down to the cafeteria. I take it that it’s OK to eat?”

“Lightly, yes, but avoid caffeine,” I said.

“Bummer!” her friend Shelly exclaimed. “Why?”

“It’s a stimulant and can cause increased blood pressure and heart rate, and increased urine output. The main concern would be its effect on the patient’s blood pressure. High blood pressure is a risk for pregnant women in general, and doing anything to increase it would be a bad idea.”

“I’ve been drinking coffee and Coke my entire pregnancy!” Sheila declared.

“And if Doctor Blalock said your blood pressure was OK, that’s not a problem. But, given the circumstances, I’d advise against it, especially given the side effects of Pitocin, which can increase heart rate and blood pressure.”

“Sheila said you’re a medical student,” Shelly said. “How long before you’re a doctor?”

“About twenty months,” I replied.

“And you’re going to be an obstetrician?”

“No, this is a required rotation. I plan to be a trauma surgeon. That’s a doctor who works in the ER but can also perform surgery. It’s a relatively new specialty.”

Sheila got out of bed and went to the closet to get her robe.

“Nice ass!” Shelly teased.

“Shut up!” Sheila ordered.

She got her robe and put it on, and the three of us left the room. They went towards the elevators while I went to the nurses’ station. There were no patients who needed my attention, so I went to find Maryam so we could get coffee. We got our coffee and brought it back to the lounge in OB so that we’d be available quickly if anyone needed us.

“Did you get your shift assignments for the ER?” I asked Maryam.

“Yes. I’m on 10:00pm to 10:00am, starting Sunday evening, running through Friday morning. That’s for the first two weeks. The second two are the opposite shift, starting at 10:00am on Sunday morning and running through Thursday evening.”

“Then we’ll be working together for a few hours most days.”

“I’m glad they could give you a shift that allows you to be at church every Sunday.”

“More importantly, that allows me to have a set schedule for Rachel and whoever is helping me with her.”

“I wish I could help more, Mike,” Maryam said. “Sorry, I mean Deacon.”

I smiled, “It’s OK. I’m wearing my doctor’s uniform of scrubs and white coat. Here at the hospital, everyone knows me as Mike.”

“But you’re clergy!” Maryam protested.

“And that means only that I have a specific ministry to perform, not that I’m some kind of holy man!”

“But...”

“It’s OK, Maryam. In private, or when we’re at work, it’s OK to call me Mike. For me, it would be OK anytime, but I know other people might be offended if you use just my name.”

“If you’re sure,” she said.

“Positive.”

“Thank you. I wish there was something I could do to help you.”

“Doing things like this, having coffee together, and working together is plenty. You have an obligation to your medical training just as I do.”