Just another Wednesday

by Adrian Sângeorzan
translation from Romanian by Caroline Carver & Roxana-Andreea Dragu [MTTLC student]
click aici pentru versiunea română

 

 
Working a shift means that for 24 hours you become isolated from the rest of the world and even from the rest of your own life, which has to be set aside for a day. This isolation can be a source of frustration, as well as a refuge. Every time I wanted to hide from something, the hospital I worked in was the best and farthest place to go. The surgery room was my spaceship. What is more, since I’ve been working shifts for more than 30 years, I no longer suffer from jet lag. Because of working nights and sleeping during the day or not at all, I got rid of sudden time zone shifts, just like astronauts who circle the Earth at high speed. They go to sleep looking at Australia and when they wake up they’re above Europe. We doctors see almost the same places every day, but, although we lead very static lives, when we work shifts the world around us can move at very high speed. The images we see switch quickly as we move amongst people. When we end our shifts in the morning, we bid each other good night, like soldiers do. There is a kind of military feel to American hospitals, especially in the surgery and emergency departments, though without any “Yes, Sir”, “No, Sir”. A kind of controlled discipline, mixed with the bursts of adrenalin of those in the front line, who always move in the direct face of danger.
There are easy shifts, when I can read, or even write, and wild shifts, which leave you worn out and jumbled with fatigue and tension. Then you go home, driving very carefully, because you’re tired and distracted and you don’t want to have any accidents. You doze off a bit at a crossroad, waiting for the green light, but you are quickly woken by the driver behind you, for in New York everybody honks if you don’t step on the pedal at once. You get home, you have something to eat, you take a shower, but you don’t feel like going to sleep straight away. Sometimes you feel like a soldier who’s just come back from a dangerous mission and, looking back, realizes that much of what happened during the night before at a certain point hung by a thread which passed through your very hands. You need some time to “decompress” before coming back to normal. You think of the women you’ve operated on and who, once they’ve come back to life and put to sleep by morphine, are still under observation in ICU. And they start getting mixed up in your tired head. You fall asleep with your beeper and you cell phone at your side.

There are shifts when the delivery room seems like a station where trains are either all late, or arrive more than one at a time at the same platform. The 12 delivery rooms in my hospital are sometimes all full and they look more like waiting rooms. Luxury rooms, some of them, where the TV is running loud, people are eating, drinking soda, zapping through TV channels and watching games, commenting and ordering Chinese until midnight, when the Chinese fast-food restaurants around the hospital close.

It is just the woman who’s come to give birth and around whom everything happens that’s not allowed to eat or drink and has to lie still in bed, while both she and the baby are connected to the monitors that we watch from all over. Sometimes we are more connected to the monitors and observation sheets, which are also quite electronic, than to the patients lying there in the flesh. Late in the evening, if we have a little break, we order Chinese or Indian, too, and we take the time to breathe in the common room.

Delivery rooms today are no longer sealed, even frightening temples of pain. The corridors are full of relations fretting about and, in this motley crowd, we who wear scrubs are often a minority. It is the place where people are brought into the world and where every day you witness how fear, anxiety and pain can blend harmoniously with the greatest moments of joy we, human beings, can experience. A delivery room, with all its monitors, syringes, tubes, personnel and equipment is after all a corridor of life. If you are not a little moved by the joy and spectacle of birth, I don’t think you can last for so many years in the tension of delivery or surgery rooms.

When I first started working in communist Romania in the 70s and 80s, no family member was allowed inside the delivery room. Not even the husband, who, after bringing in his wife in pain, had to return home and wait for news from the hospital. Delivery rooms were airtight chambers. I was one of the privileged few who participated in my daughter’s birth, but that was only because I worked in that delivery room. I had no idea if it was a boy or a girl, what week of pregnancy the mother was in, what her RH was or other routine tests they do today.  It was a time when we were left completely in the hands of nature, which proved to be kind to us. After my daughter was brought into the world and I saw that everything was fine, I stood there and looked at her as if she were a miracle. For minutes and minutes on end. Besides, I wanted to have a good look at her features, for fear she might get mixed up. That miracle is yours and yours alone.

In America there would be no problem if only the husband or the father were allowed in the delivery room. And perhaps the pregnant woman’s mother. Maybe even the mother-in-law, who needs to supervise everything. But when, aside from them, there are also present five aunts and as many loud and eager cousins and neighbors , it becomes very crowded.

Newborns simply refuse to come at a specific time and sometimes they are so long in coming that a second and third shift of aunts and friends turns up, nothing but fresh reinforcements that add to the apparent ongoing turmoil. Just when you think that things are starting to take a positive turn, as one of the pregnant women gives birth and the crowd scatters like they do when the game has been won, other pregnant women show up, brought in by their families, by taxis, city, police or JFK Airport ambulances or even by fire department ambulances. Depending on which ambulance is first at the place where it’s called.

Wednesdays are usually some of the toughest days. Aside from all the women who go into labor naturally, the surgery schedule is loaded, as the clinics servicing the hospital send in many pregnant women to have labor induced.  Add to that the doctors with private patients who are well aware that Wednesday is the middle of the week and it’s best not to leave for the weekend what you can do on a Wednesday. The reasons for which labor needs to be induced are many and constantly growing, as are the reasons behind c-sections. We live in a world where ”natural” medical mistakes or failures are no longer acceptable under any circumstances and therefore need to be avoided at all costs. Even at the cost of causing other, acceptable ”failures”, which at least we can control.

On one of those Wednesdays it was snowing peacefully. It was cold, but the weather in New York quickly changes its mind. At lunchtime the barometer dropped suddenly, it started pouring outside, thunder and lightning being rather apocalyptical for a winter day, but since it was New York, we weren’t very scared. This, however, triggered many births, waters broke, pains and bleeding started and the delivery room was taken by storm. The triage, which is a kind of emergency room for sorting out pregnant women, was crammed all the way to the chairs in the waiting room and to those in the corridors. Relations had come by the dozen, as it is boring to stay home in such weather and it’s a known fact that, in a delivery room like the one in my hospital, there is always something worth seeing. We knew that calling hospital security to take some of the countless attendants out was useless, dangerous even, as there can always be around someone eager to quarrel or fight. Most of them are quiet people, who respect what we do there, some of them born in our very hospital, which has recently celebrated a hundred years since its founding. At the time it was founded, by some well organized, kind-hearted nuns, the area was in full development and has been so for over a century. Our hospital has been rebuilt from the ground up several times.

22 years ago, the day I emigrated, it was the first hospital I saw as I was coming from the airport, for it is located on the exact highway that leads to JFK. Everyone knows it, it’s hard to miss on the way to the famous airport. That’s because of the traffic accidents which keep the trauma department constantly busy, because of so many cops brought here with bullet wounds and of certain movies in which mobsters, bandits or cops with holes in their chests ended up at Jamaica Hospital. It has been growing for the last 20 years, becoming one of the biggest hospitals in Queens. Every time I see TV vans around the hospital, I know something has happened. It was one of those days. As I went into the hospital, I saw that the main corridor was being guarded by a long line of policemen, some in parade uniforms, surrounding the main entrance in perfect order. I thought they must have been waiting for some big V.I.P. who needed to be well guarded.  Then one of the nurses from ICU appeared, pushing a wheelchair with an old man whose neck was still bandaged and who could no longer walk. It was one of the street cops who had recently been shot and survived, after the team of surgeons had taken a few bullets out of him. His colleagues wanted to honor him.

That Wednesday would have started fairly well if one of the doctors from the psychiatry department hadn’t sent home a patient who was not only far from cured, but very angry as well. Psychiatry is very nice and interesting when read about in books, but in practice things are very different. The patient, who lived not far from the hospital, only ran home to get his already loaded pistol. Then he returned to the hospital, determined to shoot the doctor. Only you don’t get into the psychiatry department that easily. That was happening on the exact Wednesday when I had my shift and I already had three c-sections on my list. As it often happens, one of them turned into an emergency. The baby’s heart rate had gone down and, after turning the woman on all sides to reduce the pressure on the umbilical cord, we rushed her into the surgery room.  The anesthesiologist, however, was nowhere to be found. But, after a few desperate pages all over the hospital, he responded. He sounded anxious and told me he couldn’t come up to the second floor.

‘Aren’t you watching TV? The SWAT guys had us locked in the cafeteria. ‘

‘SWAT? What are they doing here?’, I asked.

‘Watch the news!’

I immediately turned on one of the TVs and Jamaica Hospital was live on the news. Unable to find the psychiatrist, the man with the gun had gone into the hospital security room and threatened to kill the security staff if they didn’t bring the psychiatrist to him as fast as possible. I was still on the phone with the anesthesiologist.

‘I’m watching, but what the heck am I supposed to do? The baby has to come out now!’

‘You said you learned how to do a rachidian anesthesia in your country.’

‘She needs to be intubated quickly and I’m not very good at that. What do we do?’

‘I have no idea. There’s a guy at the door, armed to the teeth, who says that no one is getting out of here…’

I called the head anesthesiologist and I could almost see him shrugging impotently at the other end of the line. In the meantime, the baby’s heart rate went down again and only came back to normal when we put the woman on all fours. There was clearly pressure on the umbilical cord, so I, who ended up in almost the same position as the woman, just asked her to stand still like that. The scene was both tragic and grotesque and I felt speechless. It was a Muslim woman from Bangladesh, who obeyed no one but her husband. These women don’t do anything at all without looking at their husbands for approval. The husband, a swarthy little man with a braided beard and some sort of turban on his head, didn’t understand anything of what was going on and was watching the whole spectacle horrified, while translating my instructions to the woman. I’m used to them. There are thousands of them in the hospital area and almost all of them are called Begum. Even computers get confused because of their names. At first, all the husbands tell me conspiringly that they want their wife to be assisted by a woman in giving birth, but we eventually come to an agreement, if I promise not to enter the delivery room unless there are major complications. And that was exactly the case now and the man couldn’t understand why I wasn’t doing anything and was keeping his wife in that grotesque position. They are respectful people, easy to get along with, even when they speak incomprehensible English or none at all. I didn’t know what to do and I was watching the baby’s heart on one of the computers with one eye, while keeping the other on a TV screen nearby. The unborn baby’s heart was doing better again and on the news they were showing the siege in my hospital, which was going on two floors beneath us. The SWAT team, equipped to the teeth, were just rushing into the hospital. I ran towards the emergency exit and the first person I ran into was a detective who was standing between floors, gun in hand.

‘I need an anesthesiologist. It’s urgent, I yelled at him. He’s stuck in the cafeteria.’

‘Impossible, doctor. There’s an armed man shooting inside Security.’ Two shots were heard immediately to confirm that.

‘Who’s he shooting at?’

‘No idea. He’s looking for some psychiatrist…’

The man had no time for my caesarian. He was very focused, as everything was happening right next to us. I returned to the surgery room, where the Begum patient was standing on all fours, with her head in her arms, which seemed to keep her baby alive. I exchanged a few glances with the resident who was supposed to assist me, then with the nurse who had prepared the instruments, empty glances in which there was no visible panic yet. The two students who dogged my every step were paralyzed. They were the only genuine Americans in the room, coming from somewhere in the quiet American Southwest and they seemed the most scared. New York now appeared to them as it had been foretold at their Baptist or Methodist churches on Sundays or as they had seen it in the toughest movies.

‘What do we do, doctor?’ Mr. Begum asked me; his facial expression had changed a lot and was now overcome with such fear that not even the huge beard or the turban covering his forehead could hide it.

‘It’s a boy, doctor! My first son!’ I pretended not to hear that last remark. I knew that, in their culture, a boy meant much more than a girl, but I couldn’t care less about the baby’s gender. I just wanted to get him out as soon as possible. In the meantime, two more shots were heard from below. I remembered my shifts in Romania during the revolution in ’89, when there was some heavy shooting outside at night and a bullet passed through the surgery room window and shot down a piece of the ceiling. That happened while I was trying to do a rachidian anesthesia on a patient who needed a c-section. In those days, the nurse would bring a case of long, thin needles for rachidian anesthesia, all reused, resterilized for many years. Bent, with their tips dulled by all the vertebrae they had hit before reaching the spot they were supposed to. I would always pick the least bent needle, with the least dulled tip, which I would press against the metal case’s edge to make it sharper and less painful. It would make a grim sound, which still rings in my ears today. Sometimes the woman would turn away in fear. I did hundreds of such anesthesias, sometimes even for gynecological surgeries and I have no idea how they worked, given those needles. The anesthesiologist was around somewhere, having a smoke, and only intervened if the woman needed to be put to sleep and intubated. That Wednesday, Thompson the anesthesiologist was trapped by the SWAT team and I was staring at the rachidian kit traumatized; a big, sterile, brand new kit, packed in an enormous box. It takes you a few minutes just to unpack it and lay it on the table. Meanwhile, the hands of patient Begum started shaking and she lay down on her side. The baby’s heart rate went down again.

‘Ask her to stand in the same position’, I told her husband… The woman’s knees were shaking and her hands were tired. She seemed at the end of her strength. Her husband told her something in Bengali in a harsh tone, which may have seemed harsh only to me. It was clear to me that these people communicated in a different way than we did. The woman reassumed her painful position. We were all watching the TV in the corridor, where they kept sending live everything that was happening in the hospital. A reporter, whose blond tresses were being blown by the wind, was just saying that the SWAT team had gone into the hospital, locking the gunman in the hospital security service office. Boom! Another gunshot. The pregnant woman lay on her side again and the unborn baby’s heart went down again from 90 to 70 and wouldn’t go back up. I told the chief resident to try an amnio infusion, which means inserting a special plastic tube past the baby’s head and into the uterus, allowing us to pump in a sterile liquid, which could decrease the pressure on the umbilical cord. Meanwhile I ran to the exit on our floor, where the detective was at his station, gun in hand.

‘Do you have any children?’ I suddenly asked him.

‘Why do you ask?’

‘There’s one in the delivery room that needs to get out immediately. Unless you bring me that anesthesiologist who’s trapped in the cafeteria, the baby might die. The anesthesiologist’s name is Thompson. Please bring him here. He then whispered something in his walky-talky and vanished down the stairs. He reappeared after a couple of minutes with Thompson the anesthesiologist, carrying a bag with the food he hadn’t got to finish.

‘Damn it, you can’t even have a quiet lunch in this hospital. Let’s go, man!’

I’d known Thompson for a few years and, although he sometimes got on my nerves, I have to admit that he was one of the best anesthesiologists I had worked with. He was a Brooklyn mulatto, crazy about music, who sang to patients in the surgery room while we were operating on them. He always had an iPod or a CD-player on him. On a good day he would even dance. When we worked shifts together, he would bring his guitar and, if it was a quiet day, he would thrum it in the next room till late at night. I couldn’t complain, as, if it was quiet across the corridor, I could read or write something. Until the first emergency came up, there was a peaceful, artistic and creative mood in the air. I have another colleague who plays classical music on a bassoon and it can get much worse when I work shifts with him. The bassoon produces bizarre, low-pitched notes, which can make you think of the sound of an alarm or a boat entering the harbor. Sometimes he sits for hours making mouthpieces for his instrument, which takes him 7 to 8 hours a week. Thompson was young, unmarried and a favorite among nurses. One day, while I was operating on a Romanian woman under rachidian anesthesia, Thompson asked her what kind of music she liked. Her husband, who was there, too, asked me in a bit of a fright:

’Is he serious?’

’Sing us a doina, I said to him, it’s a kind of Romanian blues, which starts with ”frunză verde”.’ And he sang us something that resembled Ray Charles, throughout which he just kept saying frunsa verde!

He couldn’t have sung to the Begum patient, because he had put her to sleep and intubated her in three seconds flat. A c-section done with great urgency is a terribly quick, even brutal surgery, at least until the baby is taken out. Every minute counts. After cutting through the skin and the fascia in one movement, everything is opened up in great haste, practically tearing through the anatomic layers with your fingers: peritoneum, muscles, uterus wall, until you get to the baby that needs to be saved. Sometimes it can only take a minute or two, if you have a good team. Residents are trained for such extremely urgent  c-sections.

I remember the terrified face of a surgeon in our hospital, who witnessed one of these emergencies. It involved his own wife. He left very frightened and later told me that it looked like some kind of rescuing harakiri. Two minutes later, the Begum boy was fine again, so we all gave a sigh of relief and continued the surgery at normal speed.

Thompson went out in the corridor at one point and told us the siege had ended, the psychiatry guy had given himself up and no one had been killed. The doctor he was after had gone home earlier and all he did was give the security people a terrible fright and destroy their monitors by emptying his gun into them. Thompson seemed completely unmoved by that whole madness. During the c-section, he told us about his experiences from years before, when he was still a resident at one of the hospitals in the Bronx.

After one of those shootouts that mobsters or drug dealers have every now and then, the ambulance had brought into the hospital a man riddled with bullets, who had been lucky enough not to have got any of his vital organs pierced. For 10 hours, a few teams of surgeons ultra specialized in organs and lesions patiently fixed all the injuries in his lungs, arteries, kidneys and everything else that had been caught in the unpredictable trajectory of bullets on their way to do their job. They poured in liters of sweat, blood and talent, until they brought him out of the surgery room alive. After the surgery, Thompson even accompanied him in the elevator, on the way to ICU. Before the doors closed, another man slipped in. He took out a gun, which he hastily screwed a silencer on and, before blowing the injured man’s brains out, he politely told Thompson:

’Shame for all that work, doc! Good job, anyhow!’

That Wednesday, when I came out of the surgery room, I accidentally stepped on the Begum husband’s hand. He was praying with his two brothers, kneeling right outside the surgery room door. I apologized, slipped between them carefully  and went down into the hospital cafeteria to grab a bite. On days like these you feel hungry all the time and, If you have many shifts, you risk getting fat. You eat out of nervousness without even realizing it. There was still a lot of fuss on the main corridor. The SWAT team were gathering their equipment, ballistic shields, special fiber optic scopes to spy under doors with, automatic weapons, two trained dogs. Everything went back to normal in a few minutes, as if nothing had happened.

A few months later I was returning from a trip to Romania and I took a taxi from JFK. Begum, the driver, recognized me. He took out his wallet, opened it like a book and gave it to me through the privacy window. Inside it there was the picture of his first son, who had almost fallen victim to local terrorism.

The cafeteria was almost deserted. After my meal, I went into the staff room and tried to lie down for a few minutes. Before I even got into bed, the phone rang and I had to rush to one of the delivery rooms, where a newborn’s shoulders had got stuck after the head was born. Shoulder dystocia, as it is called, is a frequent complication these days. Newborns probably eat a lot before birth, too, along with their mothers, out of anxiety perhaps, having waited for months to enter the unknown. It’s often mothers with gestational diabetes who give birth to big, wide-shouldered babies. The head can be born fairly easily, but the shoulders get stuck inside the mother’s pelvis. It is as if somebody managed to get their head out through a tight door, which then closed, preventing them from coming out. That can trigger a sudden emergency which can turn into a big tragedy. I don’t remember seeing so many children getting their shoulders stuck in Romania in the 80s. However I remember well that, towards the end of communism, there was little food available and children weighed less at birth. There is no such problem in America. We live in a world where all you have to do is reach out and put the food in your mouth.

This time it’s a petite Mexican woman who’s at her fourth birth. The newborn had been “made” in America, with a lot of food at hand and weighed over four kilos, although the mother was not diabetic. The head was out and had already turned blue. The head resident had already tried, by herself, all the procedures in the chart we all must know, without any luck and had waited unacceptably long before calling me and alerting the entire team on call. It certainly wasn’t the time to tell her she had done wrong. Because of the high number of shoulder dystocias and of the trials they caused, a new alert system had been implemented for the last two years, one based on codes, norms and steps to be followed to the letter, on top of declaring a state of emergency, during which team work is crucial. We had to put the whole delivery and surgery room staff through countless tests and manikin simulations, which we all go through every year, from students, nurses and residents to shift leaders.

This concerns extreme situations, like postpartum bleeding, umbilical cord prolapse or acute foetal distress, which need to be solved rapidly. Titles and hierarchies vanish, the team and the system become more important than the individual and, in extreme situations, it may not necessarily be „the boss” who takes the initiative, but whoever present is ”quickest on the trigger”. American hospitals are counted among the so-called ”high reliability organizations”, along with giant carriers, which have 6000 people, 150 fighter planes and ammunition on board, along with airport control towers and nuclear power plants. All these institutions perform high risk work, where every detail of a potential danger needs to be known, predicted in time and, most importantly, contained through team work whenever it is encountered.

According to American statistics, which are to be trusted, 48 000 people still die because of medical errors every year. More than in the entire Vietnam war. I have seen a few times how those in my hospital’s ”Trauma team” react when they’re called to an emergency and leave the hospital cafeteria with their food still in their mouths. Once at the side of the injured patient, they know exactly what to do, step by step, using as few words and gestures as possible. I read that one such Los Angeles team was sent to practise with the Ferrari Formula 1 racing team, whose few members manage to change all the wheels on a race car, fuel it with gas and check the engine and the plugs in six or seven seconds, while the driver drinks a bottle of water.

On that Wednesday shift, as I looked at the blue head of that still unborn baby, I knew there was no time to waste. I looked at the resident’s hands, which were smaller than mine – an important detail. She quickly got my intention and said to me fearfully:

’I’ve never done it! I’ve never even seen it done.’

We needed to take out one of the baby’s arms, which was far up in the mother’s uterus. A difficult and rarely used procedure. I myself had only done it three or four times. Having small hands is important in this case, but where was I supposed to get a pair of those? I looked at my right hand, which seemed to have broadened after I turned forty. You have to stick your hand in past the baby’s head, which is already out, all the way up into the uterus, where you need to find the baby’s arm, which you have to take out without breaking  it, after which the baby’s diameter narrows and birth is triggered. Easy to say, very hard to do. There is no space whatsoever between the baby’s compressed body and the mother’s bones, but somehow you have to slide your hand through the narrowest place in the world and bring out that baby, which will otherwise suffocate. You have about five to seven minutes’ time and it’s usually up by the time you get to this last maneuver. At first I thought I would never be able to reach into that woman’s uterus, but these are situations of great urgency, which can push you forward. Aside from this maneuver, I saw no other hope for the baby.

Purely theoretically speaking, there would have been some other procedures, all extreme and traumatic, which can only be found in the history of medicine and which I’ve never seen , not even in Romania: forcefully pushing the baby’s head back and performing a c-section (the Zavanneli maneuver, used, I think, only by Dr. Zavanneli a very long time ago, in a hospital in central US), deliberately fracturing the fetus’s clavicle to reduce the shoulders’ diameter or surgically sectioning the mother’s pubic symphysis. These maneuvers are hardly conceivable today, although they are mentioned in some books. Once I got my right hand through that strangling tightness, I eventually managed to reach the baby’s arm and pull her out alive. Her Apgar score was low, but she got better after a few minutes and started to cry miserably.  One of her hands was a bit limp, palsied, but it made a complete recovery after a month of physiotherapy.

The problem actually turned out to be my right hand. It swelled and hurt. Two hours later I went down to radiology, where I found out that one of the bones in my hand was slightly cracked. I had a bone fissure like the kind caused by a trauma. I put a cold compress on it and I lasted till morning. Then I bore a splint for a week and I quickly learned that I could do a gynecological exam with my left hand as well.

Although everything ended well, four months later I received a subpoena from a big lawyer firm in Manhattan. There followed a typical ”shoulder dystocia” trial, very frequent in America, which ended five years later, when I saw the little girl playing with a doll. I was acquitted after the woman’s husband said that I was the one who had finally managed to get the baby out. The English term for it is ”dismissed”, which means set free, exempted, let off the hook, given the bum’s rush, excused from who knows what. It depends on the dictionary you consult and on the mood you’re in.

There was still plenty of time before changing shifts and we all had the feeling that there was still something in store. I heard old doctors in Romania talk about a ”law of series”, something very empirical, of course, which implied that when you get a rare, serious case, odds are that another one should turn up soon. In other words, it’s good to be on your guard. On a shift like that, you involuntarily enter a state of alert anyway. Our adrenalin was spilling, overflowing, we were all ready to face any situation. Nobody had died, the newborns were all crying at the top of their lungs, everything was stable, under control, so we couldn’t complain. The chief resident, a blond American from somewhere in the West, said half-jokingly that we needed to track down ”the jinx”. The word jinx translates into Romanian as ”piază rea”, although it sounds as empirical and medieval as ”the law of series”. After all, it was a Wednesday and it wasn’t the 13^th. Americans have superstitions, too, but there’s no room for them in our world.

The chief resident had given birth to a little girl four months before and every three hours she would milk herself by attaching a mechanical pump to her breasts. I was shocked when I saw her the first time. She was sitting in the common room, almost naked from the waist up. She had a big, rather scary looking she-bear’s head tattooed on her shoulder. During the break, after attaching the breast pump under her scrubs, she somewhat jokingly pointed to one of the students who had been our shadow throughout the shift:

‘He’s the jinx. He’s been following me since this morning, telling me he can’t wait to see some action. How do we get rid of him? I gave him 30 bucks and sent him out in the cold night to get fresh coffee and some food from wherever he can. It was a Japanese American who, although small, spoke in an extremely deep, low-pitched voice, like the people who announce the unimportant boxing matches on TV. You were almost afraid to even ask him something. Moreover, he had a kind of eczema or irritation on his face, which had been getting bigger and redder as the shift went by. He was happy to have landed such a shift, although he seemed quite frightened. The student was gone for less than an hour, during which three pregnant women gave birth, rather smoothly, one after the other. The two midwives were in top form and gloating triumphantly, as if they wanted to prove to the world that, as long as they still existed, natural birth would never disappear. Thank God. We shared their happiness, but it didn’t last long. Although sent far into the depth of night, the student with the low-pitched voice did return after all, freezing, bringing coffee and doughnuts, his mission completed; with him came trouble. The chief resident had filled two bottles with her mother’s milk and was in good shape, ready for action.

The hospital’s Emergency System alerted us that we should be ready, as a case was on its way. We’re not alerted beforehand unless the case is serious. They were bringing in a pregnant woman they’d found in a pool of blood at one of the “shelters”, that is one of the homeless facilities not far from the hospital. The nurse who had handled the overnight triage told us she already had three women with minor problems, from the same shelter, under observation. One of them used to show up once or twice a month, mainly just to eat and sleep. That day she had come for the same reason, saying that the shelter was hell and you couldn’t sleep there. The same nurse, who had worked at the shelter for a few months, told us that the “hell” was caused by drug dealers who regularly brought cocaine and crack, which they distributed for free at first, to hook the poor bastards there. The ambulance people notified us that the woman they were bringing in had no pulse and they weren’t sure whether she was still alive or not. My hand had swollen a little, but I could move my fingers well, which was quite promising. It was about 4 a.m. and we prepared the surgery room for either kind of birth,  that is either “upstairs” or “downstairs”, as we used to say, as a third kind doesn’t exist yet. The cardiac defibrillator was taken out of a corner, too, and dusted. When they showed up with the woman on the stretcher, she had come round. She moved her hands without difficulty, couldn’t speak, but her eyes were open and bright. I asked what month of pregnancy she was in and she showed me eight fingers. How many children? Any c-sections? She showed three fingers twice. So three c-sections. Two of her veins were already connected and colourless liquids were quickly dripping in them. The stretcher was soaked in blood and the woman was as pale as a ghost. The bleeding had gone down, as there was nothing left to bleed. Before laying her on the table, she managed to say one word. “Previa”. The first year resident quickly found her on the computer. Not only did she have previa, but total previa,  and that sent chills down my spine. Not only did the placenta completely block the exit from the uterus, but it may have passed through it to the outside. The deep-voiced student was sent to get blood, while I and the chief resident scrubbed in. I had to get a larger size glove for my right hand, but I no longer felt any pain. Cutting in after three c-sections which had been performed through the same incision is like going through a solidified tissue of fibrous adhesions. I went with the incision up to the navel. You just cut in little by little and you don’t know where you are until you get to something familiar. The first familiar thing I got to was an intestine loop stuck to the abdominal wall, clutched by a little hand which had come out of the uterus. What saved that newborn were precisely those awful adhesions, which kept it still into the uterus and prevented it from being pushed out and into the abdomen, which would have completed the disaster. The uterus was torn, but it was almost glued to the abdominal wall. Adhesions can be useful, too. I cut the uterus the “classic” way, namely from the bottom to the top, and opened it up like a book. I managed to take out the baby, which came round with difficulty, but did eventually. The placenta could not be extracted, nor did I try to extract it, because it was “accreta” and, after struggling for an hour to remove the uterus, we discovered that it was “percreta” as well. The greatest fear of any obstetrician performing a c-section. In its obstinacy to grow and nourish the fetus, the placenta can get through the thin uterus wall and continue to grow into the urinary bladder, which lies right next to it. The placenta, which nourishes us while “in utero” and which is life itself, can exceed its purpose and go further than it’s supposed to. In the meantime, the people around were pumping blood, plasma and thrombocytes into that woman, who had nothing left of her own blood. Her urine, sent to be tested, was full of cocaine, but that didn’t change anything. Meanwhile, the anesthesiologist suddenly tells me that the woman no longer has a pulse and the monitor starts screaming because her heart has stopped. I hear the speakers announce “Code 99 in the delivery room” on and on again, as if we weren’t there and didn’t see what was going on. Everyone shouts at me to step aside and take my hands off the woman, who isn’t bleeding one drop any more. “Boom”! An electric shock from the defibrillator almost throws her off the table. The monitors look the same. Then Thompson the anesthesiologist injects adrenalin straight into her heart. “Boom”- comes the second electric shock, which almost hits me as well. Then life, which hasn’t gone too far away, reemerges from a corner of the surgery room. The straight line and the monotonous peep of the monitor are gradually interrupted and beep-beep, the woman’s heart starts to beat timidly, feeling its way forward, and the blood gushes out again. The life, the joy! Now, where was I? I opened the bladder from above. It had been completely and fatally penetrated by the placenta. I resected the dome – that is the upper part – which was bleeding heavily. I took out the uterus, with the bladder attached and I sewed everything up as fast as possible. I was well aware that blood, if replaced several times, would no longer coagulate and we would be powerless witnesses to the woman’s exsanguination, as she would bleed out of every sting. The electrical defibrillator was lying in wait, too, like a crocodile. A whole team was working feverishly around the woman, waiting to finally hear me say “Done, we’re closing her up”.

To this day I remain convinced that, for that woman, a mother of four, that Wednesday was a very lucky day. A day when her luck was extended upon us as well. Especially at the end, when I saw her urine turn ink blue. As I was sewing her up, I asked Thompson to inject some methylene blue into her veins, to check if, due to the speed and pressure of the operation, I had not hurt or bound her ureters. The blue urine was proof that I had not changed the course of nature too much, although I had managed to prevent it from having its own way that night.

I threw off my gloves and sweat soaked paper gowns and went out to change. Five minutes later, they paged me back and the anesthesiologist told me he couldn’t wake her up or extubate her, because she could no longer breathe spontaneously. She seemed to be in a coma. He opened one of her eyes and showed me her unresponsive pupil, which was not a good sign. She was alive, her heart was beating, but she could have been decerebrated, her brain could be dead as a result of the hypoxia she had suffered. He asked me to go with him and talk to her family, who were waiting in the corridor. The husband, two children, a brother, a sister and a few people whose origins, accent or religion I was not able to determine. Thompson the anesthesiologist explained to them that she might not recover and that, until she came out of the coma, we wouldn’t be able to tell if her brain had been affected. Nobody said another word. Nobody asked any questions. Her husband merely whispered that they wanted to pray. They put their hands together and started mumbling something that didn’t sound like English. Then they opened their hands and put them on their heads. I had no idea who they were or who they were praying to. Thompson put his hands together, too, almost automatically, and started muttering some kind of prayer. I, too, tried to do something similar, although my right hand was really swollen and I could no longer cross my fingers. I looked at them in silence, thinking about one of the prayers I still remembered from one of my grandmothers. I couldn’t remember it very well.

It was now 8 in the morning, the other shift had arrived, we changed shifts and I went down to the cafeteria with the deep-voiced student and the two residents. We all sort of stank of sweat and tension. We ate in silence and drank a cup of tea. I asked the student, a little mockingly, if he still wanted to take up obstetrics once he graduated. He nodded. Then I went into one of the staff rooms and was out like a light. I didn’t feel like going home, although I couldn’t be of any more help to anyone. When I woke up around noon, the woman’s pupil had started to respond to light, then she blinked a few times and towards evening she came back to life and recognized her husband and children and, eventually, even me. Four days later she walked home on her own two feet.