Monday, December 5, 2011


    One of the best parts of anesthesia residency was my obstetrics rotation at Grady Hospital in downtown Atlanta. There was so much to do and learn: maternal and fetal physiology and pathophysiology, placing epidurals and spinals, managing C-sections, and the fine art of anticipating and preventing obstetric disasters. Our attendings were refreshingly committed to teaching, and we participated in daily morning and afternoon conferences. We read a lot. In the course of a day, we'd find ourselves alternately humbled and redeemed. We learned never to sit in the green armchair, which was reserved for one of our anesthetists. After a couple of weeks on the rotation, we'd all bring covered dishes and have a YOYO party. For the junior residents, "you're on your own" signified readiness to take overnight call; for the seniors, it meant getting Saturdays off.
     The labor and delivery ward, sort of an organized chaos, seemed to have a life of its own: it was an undulating, pulsing swirl of constant activity where things could go south at any given moment. We were expected to know about every single patient on that floor, and kept track of all of them on a dry erase board in our lounge. At the behest of our attendings, we knew what gauge IV line these patients had, and what their platelet counts were. We made sure their blood type and screens were up to date, and we got them consented for their epidurals well in advance. We ran a pretty tight ship. For many of us, our obstetrics experience was where our book knowledge and newly-honed epidural skills seemed to crystallize, and we felt like anesthesiologists for the first time. Just across from labor and delivery, there was an obstetrics ICU where patients who were experiencing a serious pregnancy-related complication were managed. The two nurses who regularly worked back there were both very obese, unabashedly passive-aggressive, and possessed disturbingly labile personalities and unpredictable temperaments. If they happened to like you, they'd call you "Boo." Those of us who grew up in the South recognize "Boo" as an idiomatic term of endearment, kind of like calling someone "Honey" or "Sweetie." Some of us fared better than others with Miss Smith and Miss Brown*, but we all walked on eggshells with them. Although residents come in all flavors, we were an exceptionally nice group, perhaps the nicest of which was a guy named Jim. Jim was mild-mannered, with a calm demeanor and a quiet voice. He was also wickedly smart, and could quote studies and possibly even entire textbook chapters...he really knew his stuff. Despite being a little shy, he was warm and friendly, and really tried to connect with our patients and the labor and delivery staff.
     One day, we got called to put an epidural in an ICU patient whose baby had died in utero. For patients with an intrauterine fetal demise (IUFD), labor was induced with medication, and an epidural was placed shortly afterward so they could tolerate the delivery. This was generally a solemn undertaking, quite a departure from the usual excitement surrounding the birth of a new baby. To our surprise, the mood in this patient's room was unnervingly jovial. There were about 20 family members of all ages, milling around, laughing and talking loudly, and eating Popeye's fried chicken. I don't remember which one of us had the morbid task of placing the epidural; it definitely wasn't me. We dosed it up with local anesthetic, and then, we waited. Jim was scheduled to take call that night, but had missed out on this spectacle because he'd had some kind of appointment during the day. He returned later in the afternoon, received report on the patients, and began his call. Somewhere in the course of that 16 hour shift, Jim unknowingly became immortalized.
     When we arrived for work the next morning, labor and delivery was unusually slow, and we suspected that Jim must have had a quiet night. We fixed our coffee, and waited for our attending to arrive for morning conference. Then, we heard the cackling. It was issuing from back in the ICU, and it grew louder and louder, until it became almost fitful, like a convulsion of hysterical silliness. Curious, and a little worried, we crept back there to see what in the world was going on. The nurses, who would normally be in report, were all intently focused on Miss Brown. She was especially animated that morning, telling one of her stories, giggling hysterically, and slapping her ample thighs with each salvo of laughter. To our horror, she was talking about Jim. Sometime during the night, Jim had been called back to the ICU to remove the epidural catheter from the IUFD patient. In his usual pleasant way, he had tried to engage the patient and family, and began cooing at the lifeless baby swaddled up in the bassinet, gently jiggling it, saying "Hey, Boo!" Miss Brown had immediately descended upon him, whisking him away from the room, and taking sadistic delight in informing him of his unfortunate faux pas. Somehow, Jim hadn't received the crucial piece of information that this was indeed a dead baby. It was a true Monty Python moment. In Jim's defense, the celebratory atmosphere in that patient's room, with the chicken-eating and lively conversation, belied the somber nature of the event which had just taken place, and any one of us could have just as easily mistaken the inanimate bundle in the crib for a sleeping infant. We all willingly took the heat. It was our fault that Jim didn't know about the deceased baby, an unfortunate scenario which underscores the critically important nature of timely, precise communication amongst physicians. The worst part of it all was the cruel irony: Jim's wife was pregnant with their first child. The Boo thing couldn't have happened to a nicer guy.  Jim's self-deprecating, dry sense of humor about his awkward and inelegant experience gave the rest of us permission to move forward on the learning curve, reinforcing that we need not take ourselves so seriously all the time, and emphasizing perhaps the most vital aspect of surviving life in the field of medicine: sometimes, we just have to laugh.

* names changed to protect the innocent and the guilty. I have also taken artistic license in reconstructing certain insignifcant events in this story.

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