Assume the Position: Memoirs of an Obstetrician Gynecologist (8 page)

     Before leaving Hahnemann during my fourth year of medical school, I was asked to serve on the medical school admissions committee.  I saw this as some sort of personal vindication that I had now come full circle from my college thesis and my original rejection notices from medical schools.  I enjoyed reviewing applications of new potential medical students and my role in the decision making process.  This was quite a turn of events five years after being rejected from medical school myself.

     Choosing where to do my postgraduate training, internship and residency was a major event for a graduating medical student.  There was a matching program that required applications, personal travel, interviews at the hospitals with the program directors, letters of recommendation, then finally ranking of the favorite programs by the applicants and favorite applicants by the programs. On a countrywide match day at an appointed time universal to all programs, we received an envelope with the name of the program with which we matched.  We were then bound to attend this program by prior agreement, so it was a very exciting event.  I matched with my first choice, Pennsylvania Hospital in Philadelphia.

They accepted only four applicants in the entering internship class for obstetrics and gynecology.

    (The four exhausted interns in my first year at Pennsylvania Hospital, Philadelphia.  Left to right, Steven Block, Bruce Rosen, Betty Pitcher, and myself.)

Pennsylvania Hospital, founded
in 1751 by Benjamin Franklin and Dr. Thomas Bond to care for the "sick, poor and insane of Philadelphia",
is located at 8
th
and Spruce streets, in Philadelphia, Pennsylvania.  It
housed the Nation’s first medical library and first surgical amphitheater. 

(18
th
Century Pennsylvania Hospital)

It currently has over 500 beds, 25,000 yearly admissions, and over 4500 births per year. Dr. Benjamin Rush, medical researcher, social reformer, and signer of the Declaration of Independence, was on staff.  The ‘Lying In” or maternity hospital was started in 1803. The cornerstone of the Lying In hospital is located at 8th and Spruce Streets. Benjamin West, early American artist, donated “Christ healing the sick in the Temple”, which now hangs in the historical wing of the hospital.  Connecting the modern hospital with the historical wing is a long hallway covered with bronze plaques bearing the name of every intern who served the ‘sick, poor and insane” of Philadelphia from 1751 until the present, including my name somewhere on those walls. Located in the old historical Society Hill section of Philadelphia, a stone’s throw from the Delaware River separating Pennsylvania from New Jersey, it was a quick wintery jog in the early morning from there to Independence Hall and the Liberty Bell, down to the Delaware river, and back to the hospital, a path I often ran at 5:30 in the morning.

     During my internship I spent three months in the neonatal intensive care unit (NICU) on a neonatology rotation.  Neonatology at the time was a new specialty in the pediatrics realm, caring for sick babies during their first 28 days of life.  The ‘Father of Neonatology’, one of the country’s experts, was at Pennsylvania Hospital. Spending three months with him was a special experience.  There were three of us in training with him during this rotation:  a pediatric intern and a resident from the University of Pennsylvania, and an obstetrics intern from Pennsylvania Hospital.  It was critical for us to learn how to care for sick babies.  Depending where we might wind up in clinical practice, rural or otherwise, we might be the only person available to keep these young, often critically sick infants alive for an extended period of time until help could arrive.  So we learned what kinds of problems put these critically ill infants in the intensive care nursery in the first place, how to intubate them, place them on respirators and make the proper respirator machine settings if they were too premature to breath on their own.  We learned how to put in umbilical lines for fluids, dosages for antibiotics and other critical medications, and how to maintain acid base balance, critical for early infant health.   It was all-terrifying for me.  After all I wasn’t a pediatrician. The patient’s couldn’t communicate their medical needs. There was so much to critically assess in such a short period of time, in such a small human being.   Even more terrifying was every third night on call when I was the only one in the NICU caring for up to 20 or more premature babies at times. As we were required, we attended each of the Cesarean sections as the ‘pediatrician’. Although I would have preferred to be performing the delivery itself, during this three-month period I was on the receiving and not the delivering end. 

     One night I was called to attend what appeared to be a routine repeat Cesarean section on a mom who had arrived in active labor.   Still in the “once a C section always a C section” era everything was expected to be routine with the baby, so I was expecting nothing out of the ordinary.  I was handed a term baby that for some reason had awful Apgar scores, was blue with minimal shallow respirations, grunting and retracting.  This was a clinic patient with no financial resources or insurance, it was past midnight, and I was it as far as pediatrics for the evening.  Clinic patients were almost always entrusted to the resident house staff in training, i.e. me.  I stabilized the baby, intubated and bagged it immediately, put in umbilical catheter lines, checked x-rays for line and tube placement, took it to the neonatal ICU, and waited for initial labs and blood gases to come back.  When I was satisfied with the results, I called the Father of Neonatology and Chief of Service on the phone to inform him of a new admission to the NICU, apologized for waking him, gave him the details and numbers, and asked if I missed anything.  He said:  “Is this a fourth floor baby or a fifth floor baby?” which meant was it a ‘ward’ baby or a “private” baby, in his language non-pay or insurance. I responded that it was a ‘fourth floor baby”, meaning no insurance.  He said, ‘Keep up the good work and I will be in later this morning.”

     By the time of morning rounds, after an exhausting night with no sleep, I was so proud of the work I had done.  I kept this baby alive all by myself while not only producing perfect laboratory acid base numbers but also caring for all the other neonates in the neonatal ICU.   The Father of Neonatology arrived for morning rounds.  When it came to this baby he took one look at it, pulled out the endotracheal tube and turned off the respirator.  I was aghast.  He said,  “You have just saved a Mongol for the world.  If he is going to live, he is going to do it on his own.”  I suspect he knew the infant would make it without the respirator, but I couldn’t have made that judgment at that time.  I had never seen a newborn Down syndrome baby before so I missed the diagnosis completely but had I made the diagnosis I would not have done anything differently.   He put a name card on the baby’s bassinet and called it ‘baby Rick’ Smith, named by him after me.  Each day on rounds for the next month he would begin the presentation of baby Smith with the same comment.  “Rick saved this Mongol for the world”.  And I did.  He went home one month later.

     The training program at Pennsylvania Hospital in general was excellent.  Our Chief of Service, nationally renowned, had the highest standards and expected the same of each one of us.  Every morning at 7:30 AM was ‘Morning Report,’ where all residents would gather and sit in silence as the Chief Resident of Obstetrics would discuss the statistics for births the prior day, indications for each Cesarean Section which had been performed, whether on the resident (public patients) or private (insured) attending physician service.  The Chief Resident would usually come in around 6 am each day to get this information and review all the pertinent charts.  Morning report was a learning experience for the whole resident staff, but no one other than the Chief Residents and the Chief of Service could speak.  Among other things we would learn when Cesarean sections should, and should not, be done.   The Chief Resident on the Gynecology service would present all cases scheduled for surgery in the operating room that day.  If in the opinion of the Chief of Service a case had not been evaluated or selected properly for surgery the Chief of Service would just cancel the case and send the patient back to the clinic for further evaluation, even if the patient was in the pre op holding area. Often times the surgery was cancelled for something simple like not knowing what the patient’s blood count was before surgery; or an adequate medical trial of therapy hadn’t been tried before surgery was entertained, or the indications for the procedure were inadequate.  Peer review happened every day under the Chief’s tutelage that served me well for my future endeavors. He set an example for us as to how correct medicine should be practiced. Nothing else was acceptable.  It just became part of my mindset.

     One night in the middle of the night I was performing a particularly difficult forceps delivery and rotation of the fetal head while still in the birth canal.  I heard someone breathing over my shoulder.  I looked around and there was the Chief of service who had appeared out of nowhere, inquiring if I had met all indications for applications of the forceps, why I was using this particular forceps as opposed to another.  He checked the application of the forceps to the baby’s head himself, and then permitted me to continue as he watched the whole delivery, then quietly left the room, what I took to be silent approval. For me, I felt a sense of accomplishment and satisfaction that I had been silently observed, and passed with flying colors.

Multiple births were common at Pennsylvania hospital, particularly because there were world-renowned infertility specialists on staff.  During one 48-hour period I had occasion as Chief resident to deliver triplets and sextuplets.  The triplets were known and expected. The sextuplets were not.  The mom had severe preeclampsia, a pregnancy induced syndrome that increased risk for both mother and baby, heading towards eclampsia with life threatening seizures and hypertension.  We were trying to extract every hour possible out of her before delivering what we thought were her premature twins. It was a fine balance.  When one baby suddenly died in utero and her blood pressure shot way up we had no choice but to proceed to immediate Cesarean Section, thinking we were going to get one dead and one living baby.  Ultrasound was in its very infancy in 1977 such that the staff and residents were just learning how to use it and interpret it. Pennsylvania Hospital had one of the first Antenatal testing units and ultrasound machines. We needed it to identify how many babies we were dealing with, and whether they were alive or without heart beat.  At the time of the Cesarean I put my hand in the uterus and pulled out the first baby who was alive.  The second one I pulled out I of course expected to be the dead baby but it too was alive.  I kept putting my hand into the uterus, pulling out living baby after living baby, while placing stat pages for more pediatricians.  The first five were all alive and only the sixth was dead.

     Then there was a true record multiple-birth I attended, perhaps a world record.  In the ‘Old Days’, women in early labor would get enemas, walk, evacuate their lower bowels, and deliveries were much cleaner for everyone. Somewhere during residency in the late 1970’s this process changed and/or some women refused enemas.  So be it. Mother Nature is what she is.  As this patient pushed with the baby’s head on the perineum out from the rectum also came stool followed by a ball of white squiggly material that at first I had trouble identifying.  As the ball disintegrated and began to move all over her perineum up to and over the crowning baby’s head, it became obvious that these were pinworms, hundreds if not thousands of them.  The Guinness Book of world records would have been proud to witness this record number of deliveries from one person at the same time.   I wasn’t. Watching worms crawl out of someone’ s rectum, over her perineum onto the baby’s head, and then having to remove them was less than thrilling for me. All in a day’s work, I suppose – but an experience never to forget!