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|2012 YP Award Essay 5|
2012 Winner - Essay 5
The Doctors Company Foundation Young Physicians Patient Safety Award
I watched the obstetrical forceps fall to the floor, their handles striking the linoleum tile and emitting a dull, hollow sound soon drowned out by the newborn’s first cry and his mother’s sighs of relief. But the forceps remained, each half bearing traces of blood and amniotic fluid, spattered across the shank, and the leather tops of my shoes.
Two days earlier, the patient had arrived clutching a large purse in one hand and her belly in the other. Now six weeks into my obstetrics rotation, I greeted the patient, who remained silent, her gaze to the ground. The unit doors slid open and a harried-looking man ran in.
“She is my wife,” he stated.
I introduced myself as the medical student on the unit, part of a team of physicians that would care for his wife. He nodded, unimpressed. I stepped behind the wheelchair and invited him to follow me.
I assured him that the team would do our best to accommodate the patient’s needs. The patient, a slender, 30-year-old woman with flowing black hair, was over forty weeks pregnant with her first child and indeed in labor. I had never encountered a request like this, but I respected the patient’s cultural traditions and expected little interference with the normal course of care.
Except that the clinical course turned abnormal overnight, as her labor arrested with no cervical change and cessation of fetal descent. The team proceeded with the standard administration of oxytocin and careful monitoring. But 24 hours later, when we recorded erratic contractions and fetal distress, the attending quickly booked an operating suite.
“Go tell the husband,” she said to me decisively, “that we’re going to ‘section’ her.”
I had developed a good relationship with the patient’s husband. Since he could not see his wife on the unit, I had brought in a telephone connected to her room and visited him frequently with updates. This morning, however, the news of the Caesarian section was met with a scowl.
“No surgery!” he stated resolutely. “In our culture, the knife is forbidden.”
I reiterated my concern over the phone for his wife’s safety and that of the baby, but their beliefs were immutable. Feeling a burden of failure, I returned to the unit to find the mood had shifted from concern to emergency.
“She’s crashing!” came the attending’s booming voice. The OR doors flew open and an anesthesiologist raced into action.
“Gown up!” the attending said firmly to me. My reaction was automatic: left arm, right arm, gloves, and spin. But as I stepped up to the operating table and saw the marking pen drawing the line of incision, the husband’s words echoed in my mind: “The knife is forbidden.”
Forbidden, I thought. He hadn’t said, “I don’t prefer that you do a C-section,” or “Try to avoid going to the OR.” The word was ‘forbidden.’
“Wait,” I blurted suddenly. “They said no surgery!”
The ceiling lamps felt hotter than usual.
“The husband said no, it was forbidden, and they talked on the phone, and she agreed with him!” The words came tumbling out of my mouth.
“She gave us consent for care, and this is the standard of care,” the attending said flatly.
“But she said no,” I replied, the courage having drained from my voice like the blood from my face. My attending threw down the marking pen.
“Our duty is to the patient!” she roared.
I steadied myself on the rail of the table. “Yes,” I pleaded, “but isn’t what she wants as important as what we think she needs?”
“Get the husband on the phone.”
A nurse connected the husband on speaker phone, and he and his wife conversed briefly. They remained adamantly against surgery.
“Do you understand,” asked the attending sharply, “that her life is at stake? And your baby’s life?”
“Yes, doctor,” came the reply. “But she cannot have the knife.”
“THEN SHE WILL DIE!”
A whisper escaped from the patient’s lips: “Then let it be the will of God.”
The OR halted as if a still-life portrait: the attending, negotiating a choice that might crumble into disaster; the patient, steadfast in her belief, surrendering to her faith; and I, the medical student, wondering whether I had said too much, yet perhaps not enough. Even if surgery was the medically necessary choice, was it the right thing to do? And in our quest to protect our patient’s health, had I done enough to defend the patient herself?
“Get me the forceps,” came the attending’s answer, as the scalpel was taken off the field and the obstetrical forceps unwrapped. The delivery was risky and difficult but in the end successful, as the patient gave birth to a healthy boy, whose first cry was met over the phone by his father’s shouts of praise. Exhausted, my attending stepped back from the operating table. The forceps slipped from her fingers and tumbled to the floor.
Gazing at the forceps, I pondered what they represented: a high-stakes, life-and-death situation that challenged our notions of the patient’s best interests; an unconscious systemic failure to consider the impact of her social and cultural identity on her care; and an understanding that the foundation of an unwavering dedication to patient safety was found not simply in checklists or consent forms, but also in our appreciation of the patient herself as richly enmeshed in the narrative of health and illness.
As I complete medical school and become a young physician, my experience with this patient defines my commitment to stand up to threats to patient safety, to speak out on behalf of those whose lives we protect, and to act with courage to eliminate the systemic barriers to better care. In my life and my career, I accept this challenge in service of our profession, our patients, and our common good.
*Please note that all pieces of possible identifying information (names, dates, locations, etc.) have been changed for purposes of privacy.