Birth Story #128: Hurricane Hardt and the Case of the Purloined Robe

All facets of medicine are difficult to teach, including childbirth care.  I know some people will argue that childbirth is inherently different than all the pathology-based medicine we practice in the other areas of medicine, and I'm not going to argue the point, but learning about birth in all its complexity is very much like learning about, say, diabetes management in that you need to see a lot of cases and learn more than one approach to the topic in order to feel confident when the next patient walks into your exam room.  

Young doctors learn from teachers just like any other apprentice does, and I think we all want to learn from good teachers, those professionals who are knowledgeable, kindhearted, competent, hardworking, articulate, and who had the rare gift of being able to sift through the overwhelming detail of a textbook like Robbins' Pathology and repackage the clinically-relevant facts for us to remember.  Good teachers are all too rare but we've all encountered a good share of them, and in appreciating their skill and their good example, we tend to intensify memories of all the bad teachers we've had to endure--the rude, lazy, easily-angered, often-wrong residents and attendings who subjected us to the I-had-to-suffer-so-you-damn-well-have-t0 school of medical education.  Painful as it is to work with these people, it is important to recognize how much you learn from them, either from one of their rare moments of clarity and good judgement, or from their daily meanness, which can teach you what a doctor should not do better than any rulebook.  Here's a story involving one such attending physician, Dr. Hardt.

I was the intern on OB rotation when Dr. Hardt came to serve as a locum tenens OB/GYN at my residency hospital.  She was one of the several locums we had to work with after one of the long-standing attendings moved to Texas.  The old OB was a swaggering little bantam of a man, a bit overbearing but he had confidence in the residents and gave us enough freedom to take care of patients semi-autonomously while at the same time remaining discreetly in the background to ensure we didn't cause any catastrophes.  We were all sorry to see him go, and even more sorry when Dr. Hardt arrived for her two-month contract.

Dr. Hardt was a recent graduate from OB/GYN residency.  She was tall and heavy, with dark, intense eyes and the kind of harsh speaking voice that makes you believe the paint is going to peel off the walls if her diatribes continue too long.  She was trained in the hard-core obstetrical style and was a believer in elective primary C-section.  "If it were up to me, every woman would have an ultrasound before ten weeks and a C-section at 39 weeks," she once said.

"Why?" I asked.  The beauty of being an intern is you can ask questions like this of people like Dr. Hardt and they won't think you're being snarky.

"To save their vaginas," she answered, deadpan.  Which begged the question:  what was she hoping to save the vaginas for, but even I didn't dare ask her that.  

Anyway, Dr. Hardt was the kind of attending physician who had to second-guess everything an intern chose to do, even if she had no quarrel with the decision.  She had this annoying habit of checking on my orders and re-examining patients right after I'd already seen them.  I was already in the second half of my intern year and had delivered 120 babies and I probably thought I knew everything I needed to know.  Even if this were not true, I didn't like Dr. Hardt bursting through the door when I was coaching a woman during the second stage and saying things like "This is never going to work," or "She gets another forty minutes, and if she's not delivered I'm going to section her."  Pretty soon the residents had nicknamed her Hurricane Hardt because of these frequent bomb-droppings and because of her tendency to scream and panic whenever a patient's fetal heart tones were the least bit abnormal.

One day we were having an average-busy day on Labor & Delivery, with about three births and any number of women to triage, admit, or send home.  All day long, a young first-time mother named Deysi had been laboring slowly along.  She was being induced for cholestasis of pregnancy and had been tinkering along for several days and was finally in active labor.  Hurricane Hardt insisted on Pitocin augmentation and aggressively managed the Pit herself, adjusting the IV pump rate herself and driving our L&D nurse crazy by doing so.  Finally Deysi was completely dilated and, even though she wasn't feeling a strong urge to push, The Hurricane insisted I start her pushing with aggressive breath-holding, count-em-out coaching.  I don't know why she was so determined to get Deysi delivered that afternoon, but I could tell we were all in for it--Deysi most of all--if we didn't look like we were doing everything we could, so I sat at Deysi's side and coached her as warm-heartedly as if I'd never met Hurricane Hardt.

Pushing went slowly and was hard for poor Deysi.  Our L&D unit didn't encourage changing positions during labor as much as we should have, and I already knew The Hurricane didn't believe in anything but dorsal lithotomy position.  I did adjust the bed so Deysi could be semi-sitting but it still took a heck of a lot of coaching to get the baby to move down.

About an hour into pushing, The Hurricane blew in.  "What station is she?" she demanded.

I examined Deysi.  "Almost plus-two," I said.  We talk about the station of the baby's presenting part, a reference to how far above or below the ischial spines the part is located.  Plus numbers indicate progress in descent of the fetus.  

As always, Hurricane had to re-examine Deysi to confirm my impression.  "Yeah, I think you're right," she said.  "Why don't we vacuum her?"

"Well, it's only been an hour and she's just beginning to get the rhythm--"

"Oh never mind that," sniffed Hurricane.  She ordered our nurse to get set up for a vacuum delivery and I watched in amazement as she uncovered the delivery table and unfolded the blue sterile gown waiting there.  In an instant I saw she was planning to vacuum the baby herself.  She didn't even offer me the chance to do it, even though I was the learner and she--in theory--the teacher.  

Despite her tendency to barge around all the time, Hurricane was the slowest gowner I've ever met.  I was still coaching Deysi hard, hoping to avert the vacuum-assisted delivery I didn't think was necessary.  Our nurse was still getting the baby warmer set up and opening up vacuum equipment, so there was a delay of about ten or fifteen minutes.  During this time, Hurricane Hardt stood apart, apparently not interested in what was going on.  She was the kind of person who had the most anxiety and caused the most chaos when she was in the middle of deciding what to do.  Once she'd decided to act, she was much quieter and more manageable.  

Deysi's pushes were strong and effective.  I think she knew Hurricane was about to do something crazy and she bought into the need for long, strong pushes.  The baby's head was beginning to peek through the labia during a push.  "You know, Dr. Hardt, she's making good progress--" I began.

The Hurricane blew me away and stood at the bottom of the bed.  "Let me see," she said, and examined Deysi with the next push.  Our nurse was still opening packages and hooking up tubing, and she looked at me behind Hurricane's back and winked, and I knew she was waging a go-slow protest.

"Come on!" yelled The Hurricane.  I thought she was yelling at me and the nurse, but she was actually shouting at Deysi.  I swear I could see the paint on the walls bubble and melt.  "Come on!  Push!  One, two, three..."

All of the sudden, Deysi's perineum began to bulge.  "Okay, she's going to do it on her own," said Hurricane.  "Never mind the vacuum, Theresa can do this."  She stepped aside and waved me back to the bottom of the bed.

I looked at her for a moment.  I was astonished at how rude and presumptuous this woman--The Hurricane--was.  One moment I can't be trusted to do an accurate exam, the next I'm pulled back into the delivery position with no gown to protect me.  (These days I don't wear a gown very often, but then again I rarely deliver in lithotomy with the bed broken down either.)

There wasn't much time to be pissed off.  Deysi was pushing as though her life depended on it, and her next push brought the crown of the baby.  I stepped into position, and three pushes later, the baby was born into my uncovered arms, along with what seemed like ten liters of vernix-filled amniotic fluid which washed over me once the baby's body was out of the way.

Hurricane Hardt left the room and I finished up, making sure mother and infant were well settled.  Deysi was delighted with her new daughter and looked tired but very, very relieved.  I felt the same way, except wetter.  The L&D nurse looked at me.  "You should see yourself," she said.

"Later," I said wearily and left the room.  We were using Labor Room 201, which opened directly onto the nurse's desk.  Things had quieted down while I was fighting the Hurricane and there were three or four nurse's seated at the desk.  When I emerged from 201, they emitted an audible shriek of horror.  "Oh my god, Theresa, you've got to change scrubs," said one of them.  She took me by the elbow and walked me back to the locker room.  "Look at yourself," she demanded.

I was wet from the patch pocket of my scrub top down to my soggy socks.  I'm telling you, there really was a lot of amniotic fluid behind that baby.  I had streaks of vernix from the wrist to the elbow of my left arm, and a Nike swoosh of terminal meconium stained my top at waist-level.  I was red-faced and sweaty, and generally looked like something that had been pulled out of a river.  I looked at myself but was too tired to react, other than say, "Hardt took my gown."  And then I changed scrubs.

The moral of this story is:  Always have a rain slicker in case of a Hurricane.  

Comments

[Kathryn]

Can you imagine being that woman trying to give birth? This just makes me SO ANGRY. I can't even get the words out. How did you let her do it, and make it worse by coaching pushing and keeping her on her back? All of this is insane. What will it take to make doctors and women back off and let the mother's birth their babies??? What kind of climate is that to be in when you are the most open, vulnerable you will ever be in your entire life? Midwives. We need more midwives.

[dragonfly]

Wow, she sounds like a real pearl to work with. Glad the baby was delivered fine in the end though with a minimum of intervention (apart from a Hurricane in the room).

[doctorjen]

We had one of these attendings when I was training. She once did a very similar thing to me, except she did go ahead and vacuum without me, then repaired her large episiotomy without me - and then 2 weeks later when the lady was readmitted with a huge infection from the attending forgetting a piece of gauze in the vagina, the same attending blamed the left gauze on me! She never let me close enough to the patient to even be able to see clearly what she was doing, and then tried to claim it was the "stupid family practice resident" who left a gauze in there.
She makes my short list of doctors whose behavior is so awful that I hope to NEVER act ANYTHING like them!

[CountryMidwife]

I just HATE to say it, but female OBs are the worst... sad, sad, sad.