Tuesday, July 24, 2007


I couldn't go back to sleep after getting called to place an epidural for a laboring woman at about 3:45 this morning, , so here I am, walking down Memory Lane again. After a string of fairly gentle call nights, I was due for a busier one, and I got it. It's 5 a.m. I've had two hours of sleep.

My call started yesterday. My first case yesterday involved an elderly man with numerous medical problems including a serious heart condition that made me warn the nurse on my team - a smart, reliable guy with years of E.R. and O.R. experience - "FYI - if he codes, he dies." I wanted to be sure we were all on the same page. With the kind of heart lesion this guy had, conventional CPR, using external chest compressions, was not likely to help him. My seasoned O.R. nurse said something like, "Yeah, let's not go there today." No, let's not. The patient did fine.

After that there was a cute little 8-year-old who needed her broken wrist fixed. She did fine too.

Then I drove to one of our other hospitals, where I got paged to do an epidural for a woman whose baby had died inside her. It was her first pregnancy. I was sad, but glad I was able to contribute to some physical pain relief, even if I couldn't make a difference to her emotional pain.

As soon as I left her room, there was a flurry of activity because another woman needed a C-section for worrisome fetal heart rates. Placing the spinal in this woman, who was morbidly obese, was difficult. We got through it and got the baby out, which was a good thing because it had been swimming in meconium.

After I was done with that, the vascular surgeon paged me and said there was a young guy in the E.R. who had pulsatile bleeding from his arm after he smashed it through some glass. When the E.R. nurses brought the patient down to the O.R., the smell of alcohol emanating from his mouth as he answered my preop questions was so overpowering I thought I was going to pass out. I anesthetized him, watched over him, woke him up. He looked happy as a clam later when the recovery room nurses were wheeling him upstairs to his room.

By then it was past midnight. I was too wound up to sleep. I read a little more of The Last Duel, which is riveting, an outstanding piece of writing and research. I hear it's Martin Scorsese's next film project, and what a worthy project it is. I'm thrilled for Eric Jager. Eventually I got to sleep, but I awoke a couple of hours later when the phone in the call room rang - 3:45, epidural please. *sigh*

Which brings me to Epidurazilla. No, not the 3:45 woman, who actually turned out to be fairly pleasant when she finally got some pain relief after holding out for hours without. But the way she walked right past me - actually, around me - in her room without even looking my way triggered a memory. I hadn't dredged up this memory in a while, but I found myself thinking of a woman from a hospital in my past.

Believe me, I understand labor pain. I understand how it can not only blind you to the people around you but also make you perfectly disinterested in being in any way civilized to anyone. If you're like me, all you can think about is the PAIN - when it's coming, how you're going to survive it when it's here, and what you can do so it won't be so BAD. When I was having contractions at 9 centimeters of dilation, between humiliatingly loud sobs of agony and blubbering whimpers of dread, I wanted to ask my husband to cut off my head. I hope I was still somewhat nice to people, but you know, I may very well have turned into an Epidurazilla myself, especially when I assumed the position to receive my epidural, had to hunch over with my nurse standing in front of me, and found that her enormous breasts were an inch away from my face and suffocating me. Yet as I recall I was a paragon of obedience and cooperation.

But I digress. Back to Epidurazilla, a ghost from OB wards past. Epidurazilla was pale, skinny, educated, and rich. She came to the hospital with a plethora of accoutriments. A CD player and George Winston piano CD. Burt's Bees lip balm. Popsicles, which she ordered her labor nurse to fetch and over which she showed considerable exasperation when people had trouble locating them, even after she sent her husband out to help (read, supervise) the nurses.

When I arrived in her room after her nurse paged me there for an epidural, I began to introduce myself, "Hi, I'm Dr. - "

"SHH!!" she cut me off, with an irate swat of her hand. I had unfortunately begun to speak just as a contraction was beginning. My mistake; I'm usually pretty good at timing the conversation, but I was a little off that time.

I understand not being able to focus on someone's words when your insides feel like they are being yanked from Alaska to Dubai, ripped into pieces, and set on fire. I've been there. But usually the NICE women either pant until the contraction is done and ask you to repeat what you said, or manage to groan, "Sorry-doc-just-a-sec..." I had never been shushed and swatted at before.

That pretty much set the tone for this woman's interactions with the entire staff. The more I listened to her snapping at people and ordering the hospital staff around, the more I felt like saying, "Yes, Massuh" to her face. She was impatient with the questions I asked her as part of my preop evaluation and with the directions I gave her to facilitate placement of the epidural. She gave me the impression after it was placed that she felt quite entitled to have it there now and what took us all so long to serve her anyway? It was clear she was used to relating to people as their superior and had scads of servants at home waiting on her hand and foot.

I'm ashamed to admit it, but when I checked on this woman the following day during my rounds, I was civil, and even dutifully kind, but nothing more. Usually I'm warm and sweet, but I couldn't be my usual self with her. That's ultimately a reflection of me, not of her, I regret to say. And to her credit, at the end of our conversation, she did thank me.

Overall I was so appalled by what I saw of this woman's demeanor with the nurses, and other docs too, that I googled her. And there it was, confirmation of what I suspected. Engagement announced in the society pages of a prominent national newspaper. Wealthy family united in marriage to another wealthy family. Advanced studies in Paris. Ivy League degree.

She must be one of the stereotypes people think of when they think of Ivy League schools. So then I started to wonder, have I ever been like that? I went to a "prestigious" college. I speak a foreign language or two, on a good day. My family is relatively well-off and well-known in our country. Part of what bothered me about Epidurazilla was the familiarity of her behavior. I've seen it before. The stereotype of the master or mistress who's mean to the servants or who barely even notices their service comes up on Philippine TV shows a lot. Although some of the wealthiest people I know are also the kindest, most humble, most generous people, I know there is a basis for the stereotype. But there was more to it than that. I think I was also bothered by Epidurazilla because I recognized in her a capacity for narcissism and elitism that I fear within myself. I think when I met her, I thought, "I could totally have become that, under the wrong circumstances..." My husband doesn't think so, bless his heart; I'm touched by his faith in my character; but we all know the potential evil that lurks within us, and I don't imagine for a second that I'm any less vulnerable to its traps than the next person.

I said to a couple of my friends, "Please, if I EVER start speaking or behaving like an entitled prima donna, please whap me across the face, okay?" My husband's pretty good at being honest with me if I fail to be at my best, so I'm hopeful all these allies and teachers can help keep me in line.
(The photo shows one of my friends placing a lumbar drain, not an epidural, but the procedures are similar and for the most part, with a little local anesthetic, well tolerated by patients.)


Rebe said...

I check in to the hospital tomorrow for a 3 night stay (breast cancer w/tram flap) and I look forward to being totally sweet to everyone so that they will be sweet right back. At least I hope I am when under the influence of whatever pain killer they give me ;)

T. said...

I wish you well, Rebecca, and I have no doubt you will be sweet with or without painkillers!

Lyss said...

"FYI - if he codes, he dies." To the non-medical professional, that sounds kind of harsh. (Did he have a DNR or something?)

Mitch Keamy said...

you just know that some people aren't likely to be resuscitatable; that doesn't mean you won't try-it just means you're pretty sure it won't work. So you make decisions about your anesthetic technique that do not push the patient's physiology in certain ways that you might ordinarily consider. Normally, this is a trade-off between safety and comfort. For instance, if I am not sure I can easily breath for a patient once they are unconscious (anesthetized patients don't reliably breath for themselves), I may elect to place a breathing tube in their windpipe while they are still awake; an unpleasant procedure, but potentially more safe. We don't do this for/to everyone, because it is unpleasant. This is what I took as a fellow anesthesiologist from t's comment. The nuts and bolts of medicine are pretty stark; there are no "do-overs" in the OR. That breeds a certain practical-mindedness (bloody-mindedness?) about things that isn't harsh-just real. Fire fighters, paramedics, radiation divers, combat soldiers, cops; they've all got it, too. Fire fighters call burn victims "crispy critters" amongst themselves, but will sacrifice their lives for those same people. Compassion is pretty complicated up close.
sorry t to wax on on your blog; feel free to delete this comment if it doesn't suit...


T. said...

Mitch, your explanation was so eloquent and spot-on. Thank you very much for making up for the gaps in my narrative. It's so easy to lapse into insider-speak, for which I apologize, Lyss!

I just meant to convey very quickly and concisely to the nurse working closely with me that, as Mitch suggested, the patient's physiology was extremely precarious, and we had to be super-ginger with almost every step of the process - a sort of "Let's get this right, ok?" rallying call.

One might ask, why do a surgical procedure at all in someone for whom just walking around poses a risk and exacerbates heart failure? The answer is, he REALLY needed the procedure done, and we just had to do our very best to make sure he came through.

Hope this clarifies things a bit, and again, sorry if I failed to convey all the above initially!