ResidentYear 4 (Chief)

The 4th year as chief was divided into 3 rotations of 4 months each. I chose OB, Gyn and Tumor/ Endocrinology in that order to get the hard stuff out of the way first and coast the last 4 months. Since there were 3 of us, we were on call every 3rd night but could get called in if the chief in house was chicken shit and didn’t want to supervise the 3rd year under him, naturally one of them was and being single he always called you in.
I knew how treacherous Ob could be from my days of acting chief so I made sure I was in the house on my call night.
I also had a rule for my team of residents (my Indians) under me when it came to presenting cases in staffing conference.
Rule #1 When presenting you can give all the information you want; but when I get up to discuss the case you don’t interject anything to dispute what I say.
Rule # 2 If the outcome is bad the chart can some how end up missing!
Rule 3# I will never bail out on you, all cases live and die with me.
My resident’s were loyal to me for always having their back and in the end I will relate how this almost cost me my career.
Some of my most interesting and complicated OB cases occurred in my chief year.
There are 4 or 5 complications that are so horrible that one hopes they never encounter them in their career, 1. Abdominal pregnancy 2. Double footling breech at term 3. Shoulder dystocia
4. Ruptured uterus 5. Complete placenta previa. maybe you don’t want to read about this but these things happened in my training and I feel compelled to share this with the reader. Unfortunately these situations do present themselves and every one I know wishes that they could magically punt the case to someone else. Every one of these cases occurred on my watch in my chief year.
There is a minor point I want to address before I forget; about how OB was managed at IU and at the “G’s”. The regimen for Eclampsia at IU were giving barbiturates for the convulsions and when I got to the “G’s” I was balled out for not knowing that Magnesium sulfate was the preferred treatment. The other thing was patients in labor were followed at IU with rectal exams but at the “G’s “ we routinely did vaginal exams. Once I realized that the IU’s OB department was seriously behind the times in management of patients, I really felt empowered with this new knowledge that trumped my Medical School training.
Since this is a chronicle of my life, I don’t want to dwell on this too much, but you are what you’ve been taught and to realize that the teaching was woefully wrong makes you wonder what other things you were taught weren’t written in stone. And after 5 years in St. Louis I returned to Indianapolis and found they were still routinely doing rectal exams on patients in labor to my astonishment.
One of my horrible cases was an abdominal pregnancy (the baby develops outside the uterus) that was almost at term and went into spontaneous labor. We suspected the problem and were ready with lots of blood and help. Usually the placenta is left in place after the baby is delivered and no attempt is made to remove it. But in her case it started to detach itself from the root of the major intestinal blood supply and blood filled the abdomen immediately. I had my assistant put his hand on the aorta and compress it and I called for Dr Smiley who was on the golf course and in those day no pagers, they could only send some one to bring him to the phone. He was pissed I had called him and said put in some big sponges and towels and over sew them to the bowel and close her up. This we did and she survived and later required about six follow up surgeries for bowel obstruction.
The next case was a previa where the placenta covers the cervix and is in front of the baby and we had to do a C-section in about 10 minutes than take out the uterus in a 20 year old to stop the bleeding.
The last case was a young woman with a shoulder dystocia ( the shoulder won’t come through the birth canal) and in attempting to dislodge it the uterus was ruptured. She subsequently died and because it was being managed by a 3rd year resident, I presented it at the mandatory maternal death conference to discuss the errors due to his inexperience and not intervening sooner.
Let me go back and put this in perspective, the case that I presented was on my watch because the 2 other chiefs asked to be released from their contracts early. One was going to California to practice and the other was going into the military and I was covering OB, GYN and the Tumor/Endo service I was assigned to. I had allowed the 3rd year to manage the OB’s since he would be chief in about 6 weeks, and here is what transpired.
A young married woman with her first pregnancy came in with no prenatal care in active labor. It was determined that she had a large baby and the head was not well down in the pelvis. The resident ordered an x-ray (pelvimetry) which was read as her having adequate space to deliver. After 24 hrs she made little progress and was rested a while and it was felt that she should have pitocin to augment her contractions. What indeed happened is she pushed the baby’s head out and the shoulders got stuck and at that point I was called. In maneuvering to dislodge the shoulders her uterus ruptured and she bled to death before the hemorrhage could be controlled plus we loss the baby.
I presented the case exactly as above. And Dr Monat “ the Great White Father “ said to me in a conference filled with nurses, staff and my fellow residents “who gave you the authority to have Dr B manage the case” and I responded “ you and Dr Smiley when you made me a chief”. Why I am presenting this is to show that even though Dr B will be a chief in 6 weeks his lack of experience may have led to him not intervening with a C-section earlier and I was honest enough to present it in conference.” “ And if you and Dr Smiley allowed me to be chief for 2 years and think now I am incapable of allowing a resident to learn than I quit” and added “ fuck you both” and walked out and went home. My wife was surprised to see me at this early hour since I had just left for the hospital a couple of hours before and she asked why? and I replied “I quit”. She said “ What! Have you lost your mind?” “Probably, but I’m not going to take anymore of Monat’s shit and Smiley didn’t stand up for me”
Now the situation escalated because there were no chiefs to run the service and Smiley and Monat would have to do the chief’s work for about 6 weeks. After about a week of them trying to cover 3 services, I got a call from Frankie saying that Smiley wanted me to come back in and I said not unless he and Monat apologized. The story ends with that apology and I finished my residency at Homer G. Phillips Hospital on that note. I will say that when I needed references both wrote glowing letters on my behalf so things did not end on a bitter note.
Just like in medical school, I was not about to compromise my character, loyalty and values.