Today was my most challenging day of clinical work yet, but it had nothing to do with charting, the number of patients or the attending on shift. Instead, today was about experiencing humanity and embracing the emotion of caring for others in their most trying moments. As a third-year medical student on my second rotation, I have not lost a patient, seen a code or experienced serious trauma. I have not had to cope with loss yet. I recognize my innocence and realize that it must change eventually. That process began today.
I arrived in labor and delivery over lunch because a patient I was helping care for had spiked a fever after nearly 18 hours of rupture. To make matters worse, her contractions were fading and her cervix had not changed in three hours. As we treated her for chorioamnionitis, placed an intrauterine pressure catheter and scalp electrode and started pitocin, I got the eerie feeling this would not be a smooth delivery. Hours later, after ramping up the pitocin, she felt the urge to push. Between her family and the medical team (including several students), we packed 10 people into the undersized and poorly lit room. For two and a half hours, we encouraged her, cheered for her and challenged her to push harder. She fought like a champ, never complaining or missing a contraction to take a break. She was determined, but after a few late decelerations it became clear that her baby was stuck at a +1 station. Soon the discussion of options began — cesarean section, or episiotomy and assisted delivery. This baby had to come out.
Moments later, after a verbal consent, lidocaine was injected and an episiotomy cut was made. Having only heard about episiotomies, I thought they were an antiquated and somewhat barbaric practice used by “old school” physicians to accelerate deliveries. Turns out, I was wrong. Though she tolerated it well, the same could not be said for her husband, mother and sister. I looked around and there were tears flowing from multiple faces as I pumped the vacuum onto the baby’s head and the midwife completed the assisted delivery. Out came the baby, seven pounds, five ounces, and dredged in a wave of chunky green meconium.
Despite the gruesome ending, I realized that the tears represented both joy and terror. This was not the way that any patient or provider envisions a delivery going. A husband watching his wife literally cut open to remove the baby. A mother watching her daughter push and push for nearly three hours. It was a lot to take in. But when the baby began a steady cry, none of that mattered. I delivered her placenta, helped sew up her perineum, and congratulated her. Then I walked out, with the shock of it all mostly muted by the satisfying outcome.
Before I even sat down at the nurses’ station, the attending updated me on a new patient — a 21-year-old G8P1 at 23 weeks and in labor. That was enough for me to realize we were not looking at a happy ending. She then looked at me straight-faced and said that the baby girl had died at least a week earlier, likely due to a partial abruption at 17 weeks, which was either secondary to her meth use or to undisclosed trauma. This time there would be no crying infant, no warmer and no joyful family. It was going to be a bloody, painful and tearful funeral. She asked, “Do you want to be involved?” I had a way out — but I didn’t even consider saying no.
As we read her records, we found a slew of emergency room reports of mysterious injuries, self-harm and depression. This young girl, hardly older than my sister, had experienced more trauma in her lifetime than anyone should ever have to face. I will never know her full story, but she could very well be a victim of rape, sex trafficking or God only knows what else. One could easily label her as “just another meth addict,” but as I stood beside her, watching her scream in agony as her uterus contracted around her dead child, I saw beyond the surface. She was a suffering young woman, and all I could do was hold her hand and promise her that we would take good care of her. Soon after, I stood before her, gowned, gloved and masked, helping deliver her limp, lifeless little girl. Unlike my last delivery, which was difficult but fascinating, this was just plain difficult.
After the baby had been delivered and wrapped up, the physician had removed her gown and gloves and left me to watch the patient, deliver her placenta and monitor blood loss. At first, I was honored by her trust, but then I realized that this meant sitting before our weeping patient and helplessly watching her mourn. As I watched her from within my faceshield, I could not help but feel like a bit of an executioner. I knew this was not my fault, but as one responsible for helping end her nightmare, I could not help but feel like I was both contributing to and relieving her suffering. She sat there holding her stillborn child, sobbing uncontrollably, praying for forgiveness and saying, “I hope she did not hurt when she died.” It was the most heart-wrenching thing I have ever seen. It did not matter in that moment what had caused the miscarriage — the root of this tragedy was far deeper than any decisions this girl had made in the last 23 weeks.
Nearly 30 minutes after the baby had been delivered, her cervix was closing up and plans were made to do an urgent dilation and curettage to remove the still-attached placenta. The pain meds were wearing off and her screaming made the hairs on my neck curl. I remained there — watching her and silently praying for it all to be over. Just as more pain medication was administered and the anesthesiologist was called, she let out one loud cry and out came the placenta. It was dramatic, tragic and relieving. Her physical suffering was over, but the emotional trauma was just beginning. All I could do before leaving was help clean her room, get her a glass of juice and offer my most sincere condolences.
Today, her road to recovery (I hope) is just beginning, and while I hope she can forget about me and the role I played tonight, I am thankful to have learned through her suffering. As students, our first call is to care for our patients, while also learning from the experiences we share with them, regardless of the outcome. Although it is tempting to step back and protect oneself from the intensely emotional moments, my encouragement is to lean in. Don’t hesitate. Capture the moments you share with your patients, then take the time to reflect on all that you can learn from them. The most powerful lessons often reach beyond the medicine, but the only way to learn them is through experience.