The double tragedy of medicine’s battlefield mentality

The mother of the dead baby sat in her husband’s arms and simply asked “why?” over and over through the Vietnamese interpreter. I had no way to answer the question. I didn’t know why. There was nothing to point to. No defect in the child or mother or the actions taken in L&D.

All I could do was say “I am so sorry” … for your baby, for you … for everyone involved.

It was a nightmare, losing a baby during childbirth in my family practice residency. It was the thing each of us dreaded the most. What happened afterwards was even more devastating in the long run. What happened was … nothing.

It had been a normal evening  on call. The family practice residents ran our community hospital. I would end up delivering over 250 babies in my two years here. It was just before midnight, three women in labor, I had just changed out of my clothes into green scrubs and the typical long white jacket.

As I walked past the first labor room on the left I heard an obvious deceleration on the external monitor. HR dropped from 140 to less than 60 for almost a full minute with what looked like a late pattern. The mother was a Hmong woman who did not speak English. This was her third child. No previous problems in childbirth.

She was doing just fine. Dad was standing by the bed in the half light of the labor room. Everything was quiet – that’s how I had heard the deceleration. The night shift had just come on. A calm scene really, except for the yellow light of my nerves jangling from the deceleration.

Exam showed her to be 7 cm dilated, head well applied, normal contraction pattern. The decelerations continued. Protocol called me to rupture the membranes and apply a scalp electrode. I opened the amnion hook, had the nurse stabilize the external monitor puck and apply some fundal pressure. The father held the mother’s hand as they spoke quietly to each other in a language I couldn’t understand.

I ruptured the membranes – a small amount of clear fluid. The heart rate dropped immediately to zero as if it had tipped off the edge of a table and fallen to the floor. 140 – 60 – 20 – nothing. Vaginal exam showed no prolapsed cord, no bleeding or any other abnormality. I was the only doctor in the hospital. The OB attending was 15 minutes away.  This baby needed to be out right now.

With much shouting to push, my fingers completing the dilation of the cervix and good cooperation from the mom. We had the baby out within three contractions.

No nuchal cord, no abruption, no blood anywhere. The child was normal except it had been without a heartbeat for almost 5 minutes at this point. Full resuscitation. Epi down the tube. Chest compressions. Nothing. [Heart breaking. Are we getting anywhere? I do not want to call the code and give up.] Suddenly, five minutes of chest compressions and two doses of Epi in … we have a heartbeat at 160. [Hallelujah] Stop the chest compressions. Let’s tape the tube and call the NICU in the big city down south.

As the nurse and I begin to breathe again … I feel a gentle tap on my shoulder. The father is standing next to me and points at my left hand. I notice that this whole time – as I stabilize the ET tube and the child’s head – the tip of my left pinky has been touching the baby’s open eye. I thank the father, change my grip and close the upper lid. I begin to realize this heartbreak of the last 20 minutes is only the beginning.

We got the call three days later. The child showed no signs of brain activity and the ventilator had been turned off. I released the breath I had been holding since that night in this moment of final recognition. The baby was dead. That is not supposed to happen to anyone … ever. Not to the baby, not to the family and not to any resident.

The director of the residency program and the OB staff held a case review. No “fault” was found. Procedure had been followed. The baby’s post mortem was normal. All actions were deemed “appropriate.” I was not to blame. That was very little consolation. The baby was dead. My mind ran over and over the events like a gerbil on a wheel.

A little piece of me died that day. Deliveries were never the same joyful wonder they had been before, they were bullets to be dodged. For years and another 300 deliveries I would occasionally be jolted awake at night by a vision of an amnion hook with a trigger on it.

In the days and weeks afterwards, it gradually dawned on me that something I had always taken for granted was not  happening.  We were a small residency, only 8 of us running our community hospital. It felt like a family. I had always assumed any tragedy would be met by a rallying around the unfortunate resident.

Here was our collective worst nightmare and nothing happened. Nothing except the case review and my meeting with the family – both agonizing experiences where I was by myself. I felt tainted, like a failure, an outcast in the wilderness.

I don’t blame anyone. I am certain the first reaction among my colleagues was, “OMG it happened.”

Followed by, “thank God it didn’t happen to me.”

It’s the same thought process as a soldier in battle when his best friend goes down as they storm the beach. I don’t know if I would have thought the same things if it had happened to another resident. I don’t know if that fear would have stopped me from reaching out to them.  Here’s what I do know.

Most of the physicians I have worked with have their own version of this story; something bad that happened followed by complete isolation. It has hurt us all. Let’s vow to end this compounding of the natural tragedies that occur in our profession. Losing a baby is bad enough. Coming away from the experience feeling that no one really cares and we are all on our own in the end … is a wound on a wound. This does not have to continue. We do not have to let our own fear stop us from supporting our colleagues in their hour of greatest need.

If you are still reading this article, I want you to know something with crystal clarity. Your physician colleague who suffers a bad outcome wants you to come and talk with them. Sit and have coffee, put a hand on their shoulder. Make them a “hot dish” so they don’t have to cook for a couple days. Do it again and again until they say, “enough already.”

There are some stories even our significant other and parents can never understand, only another doctor can fathom the feelings. The next time tragedy strikes in your medical community, reach out to your sisters and brothers. Please don’t run from them because of your own discomfort. They are not contagious, nothing is going to rub off on you.

Don’t let the natural “battlefield mentality” win out. Notice it and act in spite of it. It will make a huge difference to your friend. I promise.

This is the time when you can step up and pay it forward. Just be there when it counts the most. You never know when you will desperately want them to do the same.

Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

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  • http://www.thehappymd.com/ Dike Drummond MD

    Thanks for posting my article here Kevin. This was difficult to write and re-experience. I hope that my story here gives other docs the courage to tell their untold stories and that all of us can start to rally around our colleagues in need instead of running away from our own fears.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • KelvinSG

    As a father and working as an IT professional, I will not be able to fully understand the kind of working environment and pressure experience by a doctor in a hospital.

    I can only imagine the tremendous amount of stress resting upon the shoulders of medical professionals when an emergency situation arises.

    For me, when an fortunate event turns for the worse, at worst a machine or software fails and people experience inconveniences. In medical arena, a patient may die. The emotional damage to the attending doctor is immeasurable.

    Your job’s paycheck will never in anyway ease your scars. What you do daily are a great service to mankind.

    Please find strength to continue your journey which at times appears lone and painful. I believe many of your patients, current and past, will cheer you on if they know what you are going through.

    • http://www.thehappymd.com/ Dike Drummond MD

       Kelvin … thanks so much for your kind words. Much appreciated.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • galenofpergamum

    I never thought about how isolated we are when we have bad outcomes. They torture me too. We don’t talk about it, to colleagues or family. I am still haunted by events as long as 20 years ago, even knowing I wasn’t at fault or couldn’t have done anything differently to change the outcome. People outside medicine don’t understand, and really don’t care anyway…why should they? They have their own problems, in fact, many people blame doctors for not saving the unsavable. I think this is the burden we bear, like soldiers from battlefields in your analogy, and we’ll take it to our graves.

    • http://www.thehappymd.com/ Dike Drummond MD

      The majority of physicians are traumatized by their training … in my experience. We have stories we don’t tell others … like the one I wrote down in the article. The typical response in the medical community – and in  the military and law enforcement and nursing and so many others – is to run away from the unfortunate doctor … because we are just so happy the tragedy didn’t happen to me. It does not have to be that way. A tragic outcome could be a cue to gather around the doc in the middle to support and comfort them. We can change this behavior once enough people realize how damaging it is.

      My intention with this article is to raise the awareness of our profession on this issue. Wouldn’t it be so very different if there were “emergency support teams” deployed when there is a bad outcome  … like the volunteer fire department. The beeper goes off and you gather at the house of the unfortunate doc with a tuna casserole and all of your shoulders for them to cry on. It could happen.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • http://www.mywhitecoatisonfire.com/ Lumi St. Claire

    Thank you so much Dike, for posting such a personal and important story that is often treated as taboo by medical culture.  We can’t exist in a contagion theory model when our colleagues experience bad outcomes, and then feel betrayed when they abandon us in our time of need.  Care team debriefing after tragic experiences is used far too little, and I agree that we need to adopt a more collective and supportive way of getting through these times, which stay with us for years and years to come.

    Bravo for tackling such a sensitive subject.

    ~lumi
      http://mywhitecoatisonfire.com

  • doctorsonpurpose

    Very touching story, Dike, and an issue that is so critical to be aware of and start dealing with on a larger scale.  I appreciate you taking on this issue and opening yourself up.  You’re inspiring!

    As an ER doc for over 20 years I’ve been involved of plenty of tragic situations (including a couple I know I could have prevented.) In those 20+ years I’ve never been invited by a peer to open up and discuss what I’m dealing with after a difficult encounter.  We just keep our heads down and move on.  And most of us don’t take the opportunity to share at home either, partly because we don’t want to bring that “stuff” into our family life, but also because the level of understanding of what we’re experiencing is typically not there.

    So we “deal” with all the heartache and tragedy that’s just part of another day at work, and we either become numb to it, or it eats at us from the inside out.

    We need to find a way to open up to each other and help each other release the fears that build up and imprison us.  It’s time for a community to come together around this critical issue.  And not just this issue, but the other areas of medical practice that are keeping us all from being as effective, happy and successful as we could be (and deserve to be.)

    Who else wants to participate?  I know Dike’s in.

    • http://www.thehappymd.com/ Dike Drummond MD

       Thanks for your support Bob … the ER is a place where these kinds of events happen much more frequently than OB or Family Practice. I imagine a little piece of you dies each time and you end up without a whole lot of your spirit left. To write these experiences down as a way of clearing is the point of “narrative medicine” and to have a peer support group would be something I would think a healthy minority of folks would take advantage of.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • http://www.thehappymd.com/ Dike Drummond MD

     Care team debriefing would be lovely … much better than the care team run-ning away-ing that happens now. I have a vision of a “hot dish” delivery and emotional support team on call for these inevitable events. I would volunteer to be a member and carry one of the beepers.

    Dike
    Dike Drummond MD
    http://www.thehappymd.com

  • http://www.facebook.com/people/Susan-Conforti/100000518831931 Susan Conforti

    Maybe the hospital chaplain could reach out to the doctors as well as the families when tragedies strike. 

    • http://www.thehappymd.com/ Dike Drummond MD

       Great idea Susan. Remember that the doctors are dealing with tragedies like the one I wrote about over and over and over again. If I were an actual Obstetrician … I have no idea how many of those outcomes I would have experienced.

      Each time a doctor does not get support and stuffs the emotions of the situation … because it is just too painful … they give up a little piece of their soul and become less available to their patients. We can get it back … and not all by ourselves. Chaplains are trained to support in those kinds of situations ( I assume ) … let’s make sure they are on my mythical “outreach team” for the next bad outcome.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

  • 1npmkt

    Your experience is not singular to physicians Dike… often the staff you work with is deeply traumatized and similarly isolated and ignored by other staff, even friends and colleagues, often by various persons who were all involved in the “incident”. I know this to be true as I worked in OB/NICU for over 10 years as an RN. I have similarly experienced deeply felt, unexplainable at times, loss of tiny lives and similarly been shunned by those who should have provided compassionate understanding and support. I left OB because of just such an experience as you described. I likely would have continued in the field IF there had been less of a punitive and more of a healing response from my colleagues. I completely understand your anology of the “battefied mentality”… for me, an ironic form of PTSD developed… I nearly abandoned health care because of the truama. I chose instead to move to a field as far away from hospitals and OB as possible allowing me to continue to utilize my education and years of experience. I am now a nurse practitioner; when a traumatizing event occurs in a co-workers life, either personal or professional, I do not hesitate to offer my condolences, support and understanding as I know even a small show of support can make all the difference in that person’s life, and future choices. Perhaps, to some, this will sound overly dramatic, but my life has been shaped by just such an experience and the aftermath as you described Dike… thank you for taking the time and having the courage to “shine the light of day” on an experience that happens all too often.

    • http://www.thehappymd.com/ Dike Drummond MD

      1npmkt … I agree completely. Many people are traumatized up and down the chain of participants and witnesses to an event like this. AND many professions have similar risks and similar battlefield mentalities to be overcome.
      Anyone in healthcare from doctor to nurse to the entire care team … right along the line to housekeeping
      Military, law enforcement, firefighters, social workers, councilors … and many more.

      We are all traumatized when things like this happen … even if they are “normal” and no one is “at fault” or “did anything wrong”. It just makes it worse when we are abandoned at the very same time. Make that hot dish … hold their hand … that’s what I say.

      I am sorry it took an experience like this to shape your career and I hope the path you are pursuing has meaning for you.

      Dike
      Dike Drummond MD
      http://www.thehappymd.com

      • 1npmkt

        Thank you Dike for you insightful reply… you have not only revealed a hazard of various occupations which involve working with human beings who are at risk for “bad outcomes” but also offering solid, workable suggestiongs on how each of us can help our co-workers/colleagues deal with and work through the events if or more likely when they happen. Again… my many thanks.

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