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The Incredible Hulk in L&D?

People are complicated. Everyone is a mix of good and bad. I have been reading about and watching the television biography of Oliver Sacks. I  have also been preparing a podcast on the history of obstetrics, which made me confront J. Marion Sims’ racism in the context of his important contribution to women’s health through perineal repair. Both were complex human beings. As humans, we have incredible kindness and generosity, moments of pettiness, and sometimes even random cruelty. Unlike in comic books and superhero movies, there are seldom clearly identifiable and immutable heroes and villains.  In law, it seems to me that the vast majority of the time, lawyers have to deal with the worst of human nature. In medicine, we get to see and sometimes be both sides.

Now, I have been myself for quite a long time and have been reasonably self-aware for at least some of that. I realize that I have a tendency to take on too much, and because I have trouble with saying no, I tend to overwork. I also love new projects and new challenges, particularly when there are underserved people involved.

I also know that when I get overwhelmed and tired, my anger gets out of control. I lose it. This happens mostly if bureaucracy and inefficiency compromise patient care. I have always hated people saying, “that’s not my job,” and when I feel that this devolves extra work onto me when I am overwhelmed, the sharp side of my tongue is released! This is not an admirable trait and one I have struggled against my whole life. Like the scientist Dr. Bruce Banner, my less than rational alter ego is released. All my verbal adeptness becomes weaponized, and I can be nasty and cutting, which is in marked contrast to my usual warm and fuzzy persona.

 COVID has made everything harder. Resources are restricted. People who are working in person are getting burnt out. Those who are seeing clients and patients only virtually feel guilty and defensive about not being able to care for people as effectively as they once did.

My difficulty right now comes from losing the two nurse clinicians that I partner with in my Obstetrics clinic. These two women have been my colleagues and partners in crime since I started at the CLSC. Together we have managed a busy teaching clinic with our very vulnerable patients. I trust them completely, and now they are both gone! Not really gone, but both off work for a considerable period of time. They have not been replaced because getting new nurses when they are all being redeployed to the COVID wards is a vain prayer. There have been other changes making our lives more bureaucratic and downloading work onto doctors and nurses rather than onto administrative staff and technicians.

Then came Perle’s real hard, super intense day. The week before, I had a stressful clinic with a challenging learner and no nurse. I was running from room to room, checking vitals, sanitizing the room, re-examining and re-interviewing the patients and doing telephone calls, bookings for blood tests, ultrasounds and inductions. Then I looked at the following week’s clinic and saw that it was even more overbooked. I had a panic attack. “I can’t,” I told my husband. “I simply cannot physically manage this!”

I tried to reach out for help, but it was Friday, and people were already signed out. I left a message with the booking agent telling her that she had to decrease the number of patients in my clinic. 

On Monday, I was on call in L&D. I had three patients in labour, all inconveniently nearing fully dilated at the same moment, two of whom had ineffective epidurals. Anesthesia, who had a patient crashing in post-op, was not immediately responsive to my pleas. My friend Hélène came in to deliver her patient. This patient is one of those lucky women who have almost no pain in labour. We had arranged her induction because she had arrived almost sitting on the baby’s head at her last birth. Ten minutes after rupturing her membranes, she was still smiling calmly as she pushed. I stayed in the room to watch Hélène coach the resident through a masterful, gentle delivery.

Then the calm was broken. My own patient was crying in pain. Her epidural was not working, and she was eight centimetres dilated. There was a patient in triage, and on postpartum, a woman who did not want to leave that morning had decided that she needed to get home now! I heard my name everywhere, like the cry of seagulls: “Perle, Perle, Perle”!

At that moment the booking agent called me. I stepped out of the crying patient’s room, telling the resident to stay by the bedside. I saw the anesthesia resident moseying slowly down the hall. “Can you help her out?” I said to him, gesturing to the room I had just left, where the screams and moans were echoing into the hallway despite the nitrous oxide being used. “Uh, OK,” he said, “this one first?”

 I nodded as I returned to the phone call, “Hi,” I said to the booking agent. “Oh, Dr. Feldman,” she replied, anxiety evident in her voice. “How can I move those patients? It is so hard.”

“Put them in the residents’ clinics, or ask my colleagues or the NP’s to see them, or put them in the walk-in. Just get it done!” I snarled. I felt my heart rate rise. I am sure at that moment, my eyes glowed, and my skin turned green!

“Perle!” There was an urgent cry from inside the room. I hung up. I walked in, grabbed a pair of gloves and helped the resident prepare for an imminent birth. The anesthesia resident had his gloves on after I did. The nurse skewered him with a withering stare. “Too late,” she said.  We delivered the baby after 2 mighty pushes. It was not as gentle and controlled as Hélène’s delivery but a happy outcome. A surprise baby conceived after cancer treatment. My resident looked up at me, “that’s the second time I’ve done a delivery without an epidural, both today!”

“Dr. Feldman, we need you in room two.” Another nurse came to the door, “she wants to push.”

“Go check her,” I told the resident, “I will finish the repair.”

“Should I break the bed?” the resident asked me.

“Absolutely not!” I replied as I threw sutures into the repair as fast as possible. Just as I was running to Room Two, the phone rang. It was someone from the clinic. “Are you busy?” she asked me.

“Yes,” I said as I sprinted down the hall.

“OK, the booker is upset, and if she quits, it will be your fault.”

“I can’t talk right now,” I said and hung up.

Fighting tears, I walked into Room Two, and there was my patient, lying on her side intensely concentrated, holding her husband’s hands.

“The Anesthesia staff doctor came and redid her epidural,” said the nurse. “As soon as she had pain relief, she wanted to push.”

This time the resident was feeling more confident. Now with two deliveries under her belt on the same day and a patient who was comfortable and felt in control, she was able to do a gentle, side-lying delivery. I was able to stand next to her and talk both her and the patient through the maneuvers. As the mother lifted her baby to her breast, I felt that wash of joy that I always get with a beautiful delivery. I had satisfied both my inner birth junkie and my teaching addiction.

The next day I saw that my clinic had been revised to a reasonable level of chaos.

I went to the booker’s office with an offering of chocolate and an apology. “Thank you for working so hard to fix my clinic. I’m sorry I was so short with you.”

“Oh no, Dr. Feldman,” she said. “I was not upset, anything for you!”

“Well, I appreciate everything you do and how hard you work.”

We both told the truth, and we both lied. Maybe, just a little.

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