Anecdotally Speaking

It was one of those icy, wintry nights, when you can feel yourself being slowly petrified into a frozen block of ice by the unrelenting frostiness of the frigid air, as amazingly painful, intense jolts of the bitterly cold turbulence stabs into you, piercing you through to the very bone.

I was working my ER shift that night when the trauma nurse called me away from a routine case. She informed me that an ambulance had just arrived with the victim of a vehicle vs. pedestrian collision. Right away my brain is clicking away because these cases usually involve a lot of serious trauma. As we are hurrying toward the trauma room, she tells me that the case involves a young man who has been run over by a friend's pickup truck. Apparently, he has severe chest injuries.

When I burst into the trauma room, I am at first relieved to see that the patient is awake and sitting up and does not appear to be in any distress. Other than the fact that the whole room is a bustle with emergency personnel who are doing their thing, going about being all professional and all, me included, and no doubt frightening the bejezus out of the poor guy. He looks very anxious. If he didn't think he had anything to worry about before he came in, we sure did give him cause for concern now, if for no other reason than just because of how we were acting, so concerned ourselves!

I take a closer look at him and I see what some of the fuss is about. The paramedics and trauma nurses and everyone else have done their jobs. The patient, a young man of late teens to early twenties, has his oxygen on, his IVs going and his cloths have been removed, in order to make an appropriate assessment of his injuries.

When his shirt came off it was plain to see that diagonally across his chest, running from the lower right liver area up across his chest to his left shoulder area was the most clearly marked imprint of a pickup truck tire tread anyone would ever possibly imagine to see on a persons chest. I mean, a CSI detective could identify the make and model of the vehicle the tire was from, the details of the imprint were so remarkable.

So, OK, the guy was run over by his friend's pickup truck, we could sure see that. His chest should be all crushed, smashed, and squashed to heck, right? Tire treads marked up his chest in plain view. So how come he is sitting there, pretty as pink, watching us buzz around being all concerned, as if he wasn't having any trouble at all? So, I ask him, while I am checking him out, "Say, you got this interesting tire thing on your chest here, what happened?"

"Well," he says, in no distress, because according to my examination, there is absolutely nothing wrong with him. Except for the tire mark. X-rays, tests, observation, everything we did proved the same, no injuries, just the tire mark.

"Well," he says, "My buddies and I were out on the frozen lake with my friend's pickup truck, spinning around, doing donuts and things, you know, having fun." Yes, I do know about that; having fun. He went on, "Well, we found this old hood from an old car. So we thought we could make a sled out of it. We turned it upside down, got a rope and tied it to the back of the pickup truck. Then I got on the upside down hood tied to the truck and my friend and the guys got into the truck and then they started to pull me around on the frozen lake with the truck, you know, like a sled." Yes, unfortunately, I did know, and I knew where this one was going.

"Well, they started going faster and faster, then they started going around in circles. That's when it started to whip the sled around. Oh boy, did it really get going fast then! I could hardly hold on! But the rope was too long. The sled whipped around completely in front of the truck. On the ice, the truck couldn't stop and it couldn't turn. Everything was just sliding around and around and then, boom! The truck ran over me! They called the ambulance and brought me here." He seems disappointed.

I consider him for a moment and then think to myself, "Amazing, remarkable."

"Am I going to be all right, doc?" he asks.

"Yeah, you're going to be all right," I reassure him. "But you're one lucky young man." He nods, agreeing. I nod too. Yea, lucky guy. What else can you say?

Ain't it just heck, getting old? The perils.

I walk into X-ray and find a young man sprawled out on a chair with both of his feet bare, shoes, socks and coils of ace bandages pilled in a heap next to him on the floor. His father sits against the wall, arms folded across his chest. They both greet me with silence. I cross to the view box where I find a set of films hanging that demonstrate views of both the right and left ankles.

I linger over the images, concentrating intently. Then I brace myself with an intake of breath, peer sideways at the father, then at his son, then turn and look incredulously down at the teenage boy's feet. I stare for a few moments in consideration.

Then I pull up a rolling stool and sit directly in front of the lad, poised to perform my examination, when with rapt interest in his answer I ask, "So tell me, what happened. It looks from the x-rays like both of your ankles are broken." The boy and his father exchange glances.

"Not only that," I say as I look up at the father, "but the exact same bone is broken in the exact same place on both sides." I have not seen simultaneous bilateral distal fibular fractures before today; I am really curious to hear how an injury like this has occurred.

The father says, "He didn't break them at the same time, you know."

"Oh really?" I look back to the boy. He speaks up. "I was out sledding on the snow, when this kid with a great big inner tube runs me over. That's how my foot got hurt."

"He keeps on sledding after that," the father adds, exasperated. "My son, don't get me wrong now, but he's not the brightest star in the sky. He keeps on playing around until he gets the other foot busted up too."

"After that I couldn't walk," the boy finishes. He seems disappointed.

I examine his feet. He has the exact same fracture on each foot on the same day. Amazing, remarkable. I look up at him. "Bad luck, man." He nods, resigned. I nod too. Yea, bad luck. What else can you say?

"Dr. Bailey, this is a patient like any other patient, there is no room for error, which means there is no room for nerves, shake it off."

The Chief speaks these words to Dr. Bailey in a moment of self-doubt. A life hangs in the balance and she is hesitant and unsure. Her voice wavers as she nervously implores her mentor to relieve her of the burden of responsibility, "You want to handle this Chief?"

He does not take the burden from her, "I'll be standing by to help but this is all yours." Faltering, Dr. Bailey mumbles orders, "Grey, let me have an 8-0 ET..." She is interrupted by the calm but firm voice of her attending, "Dr. Bailey, this is a patient like any other patient..."

The Chief looks her straight in the eye. This is a brief, focused moment in the midst of a crisis. An intimate moment when mentor wisdom is passed on, the essential stuff not found in textbooks. "Dr. Bailey, there is no room for error, which means there is no room for nerves, shake it off."

There is no incrimination or blame, no reasons or explanation. Just a calm, clear statement of the situation and what is expected. A moment passes as Dr. Bailey considers what the Chief has just said. Then, decision made, she steals her resolve, loosens up her neck and declares in a clear strong voice, "All right, let's do this!" and proceeds to accomplish a difficult intubation procedure.

I appreciate the show "Grey's Anatomy" because it has these moments when it captures pieces of medical practice with a touch of authenticity. I have written on the expectation of perfection before; this scene in the show, I think, dramatizes it poignantly.

There is an essence here, in my mind, about what it is at the heart of the matter that makes one a doctor, about what it means to be a doctor. Doctors are those who do what Bailey did; they step up. When a life hangs in the balance, someone has to step up; someone has to do the job. When she was unsure of herself, Bailey appealed to the Chief, and as the doctor, he could have, and would have, stepped up. However, she was the doctor too. The Chief wanted her to learn that she needed to step up too. So, he pushed her. And she did it. She acted as, and performed as, the doctor. She stepped up and did what needed to be done.

The problem is that the one who takes on the responsibility to step up when it is necessary, to do the job when it needs doing, to be the doctor, that person is just that, a person, human. As a human, that person is fallible, a human prone to error. A human prone to error taking on a job where, as the Chief said, "there is no room for error."

So, that is what being a doctor is. The requirements are clear. They were clear to the Chief; they were clear to Dr. Bailey. There is no room for error, but someone has to step up and do it anyway. The physicians among us say, "I will take on the burden of needing to be perfect in order to do the job that needs to be done." The buck always stops with the doctor.

After it was over, Dr. Bailey looked exhausted, perhaps as much emotionally as physically. The Chief asked her, "Dr. Bailey, are you all right?" She replied that she just needed a minute.

I wonder though, if the Chief's question might not still be a very good question to ask. Because, I posit, it has not been answered very well. With what we ask our doctors to bear, the inhumanity of it, are our doctors all right?

If anyone is looking for evidence that I am certifiable then let me oblige. I have incontrovertible proof that I am loosing it. Let me explain.

An ongoing effort of mine lately has been looking for a way to improve my life by becoming more organized. In evaluating the perpetual backlog of onerous paperwork I amass so easily about me, my personal coach pointed out that I tend to define the hideous paperwork in my life with negative terms. Am I that transparent?

The point being that people are more likely to do tasks that they see as positive and postpone tasks that they see as negative. It makes sense. He suggested that if I could frame ghastly paperwork in a more positive way, turn it around, say, and make it into an adventure, I would be less likely to procrastinate and more likely to get it done.

So, this past week I was looking for a way to put a positive spin on doing dreadful paperwork. A very interesting blog caught my eye. It is called Mindmap of "Getting Things Done" by David Allen, and it has this cool diagram created by some software by a kidney doctor and used by him to organize his thinking. This caught my eye, of coarse, because I am very visual, and I am thinking maybe I can make unbearable paperwork into an adventure with this kind of a visual Mindmap organizing tool thing.

This blog had a link to the book Getting Things Done: The Art of Stress-Free Productivity, by David Allen, which really looked like it was right up my ally, so much so that I ordered a copy.

Still on the lookout for ways to make repulsive paperwork appealing, I found another blog that caught my eye latter in the week. Dr. Maria on her blog "intueri: to contemplate" puts up a post where she mentions that she increased her productivity by shifting how she measures her tasks. Rather than looking at a task as a project and pursuing tasks by project, she now measures tasks in units of time. The switch is working very well for her. I am thinking that since I look at tasks as projects, maybe the switch would be just the thing I need too.

She refers to a thing called GTD, or G.etting T.hings D.one. I clicked the GTD link and it takes me to a wikipedia website that explains this really cool system of organizing things, taken from this book by David Allen which really looked like it was right up my ally, so much so that I ordered a copy!

But wait, you say, didn't I already order a copy of that book? You noticed, huh? Well, I didn't notice, not until both books, both identical books came in the mail, oops. Can you believe it? I guess I really do need to get organized. Absolutely amazing. Nothing to be said about it really. I started reading one of them. It really is pretty good and should be good for me, hmmm.

I certainly must be loosing it. If someone wants to call the guys from the loony bin to come haul me away, I would consider it an act of kindness. Thanks.

I sat at the small square desk in the corner of the exam room holding a crinkled plastic shopping bag stuffed with a variety of prescription medication containers. My new patient had just handed them over to me. I looked closely at the bag. This might take awhile, I thought.

I dumped the contents of the bag onto the desk and began to sort through the array of empty bottles, tubes of cream and hand-held inhalers. The labels disclosed that the prescriptions originated from various doctors and many different places. And they were all labeled with generic names. I soon realized that I was going to need a Physician Desk Reference to look up some of the generic names that were unknown to me.

"Metaproterenol sulfate inhalation aerosol, that would be your Alupent," I said, setting it aside as I started a list. He was nodding. "And this is pirbuterol acetate inhalation aerosol. I think that is a Maxair inhaler." He confirms, "That's right." So far so good. We go on.

"OK, this is a tube of ciclopiroxolomine and this one is desoximetasone and this one is fluocinonide. I'm going to have to look these up." I do. "OK, we have Loprox cream, Topicort and some Lidex. Pretty strong stuff." He is nodding, "Yes."

I pick up one of the bottles. "This one is triprolidine hydrochloride 2.5 mg and pseudophedrine hydrochloride 60 mg, I think that's Actifed. And this one is isometheptene mucate 65 mg, dichloraphenazone 100 mg and acetaminophen 325 mg, that would be Midrin. Do you get headaches?" He nods vigorously, "Oh yes, terrible headaches."

"Let's see, enalapril maleate-hydrochlorothiazide, that's Vaseretic. You have high blood pressure." Again he nods, "Yes, but I ran out of my medicines and I'm not taking anything now. I need to get back on something."

"This one is guanafacine hydrochloride, that's Tenex, for blood pressure, and indapamide, Lozol, also for blood pressure. And triamterene 75 mg/hydrochlorothiazide 50 mg, I think this is Maxide. It's for blood pressure too, and you say your not taking any of these medications right now?" Again nodding, "That's right, I need to get back on."

"Alright, acebutolol hydrochloride and amiloride hydrochloride-hydrochlorothiazide, I'm not sure what these are, I need to look these up." Thumbing through the massive PDR tome, I find what I am seeking. "OK, here it is, it's Sectrol, that's a beta-blocker, for blood pressure too, and the other one is Moduretic, for blood pressure as well. I'm not sure you're going to be needing all of these medicines for your blood pressure."

"Oh good," he replies. "I don't think I was on the right kinds of medicines. Besides, I don't like to take pills." I think to myself, "I can tell."

"And the last two, cyclobenzaprine hydrochloride and orphenadrine citrate. Do you know what they're for?" He takes the bottles and looks them over while I turn the pages in the PDR. "They're for my spasms, I think."

"Here we are, Flexaril and Norflex. You're right, they're muscle relaxers. Have you had back problems?" He nods vigorously again, "Oh yes, terrible backaches."

I finished writing the list of medications, then picked up the plastic grocery sack to replace the odd mixture of medication containers. "Whoops, looks like I missed one." I fished out the elusive, solitary, empty prescription bottle.

I read off the label to myself, "Perphenazine-amitriptyline hydrochloride, what is this? I know amitriptyline hydrochloride, that's Elavil, a tricyclic antidepressant, but perphenazine. It must be some kind of neuroleptic, a type of phenothiazine. What an interesting combination, there must be a lot of side effects with this medicine, how strange."

I ask, "What do you take this for?" He looks over the bottle. "Oh, them's for my nerves, the little blue pills." I look them up. "Oh, OK, this is Triavil, I've heard of this. The perphenazine is called Trilafon. I've never used it. Kind of an older drug."

The medication list was finished. I refilled his sack and handed it back to him. "Well, that's all of them." He speaks up, tentatively, trailing off, "Just one other thing doc." I hesitate, then, "Yes?"

He screws up his forehead, squints his eyes, purses his lips and with what seems like great effort tries to remember something. "There is this one other medicine that I need but I can't remember its name." I wait quietly, not moving.

He goes on. "I think it begins with pro something. It sounds like pro, pro, pro something. I can't remember." His shoulders sag in defeat.

I open the book and turn to the "pro" section. "Procan," I offer. "No, that's not it," he replies. "Wait," I say, "it would be labled with the generic name, not the brand name, silly me. How about procainamide hydrochloride." He shakes his head, "No."

"Prochlorperazine? No, that's Compazine. You wouldn't be on Compazine. Promethazine hydrochloride? No, that's Phenergan; you wouldn't be on that either. How about propafenome hydrochloride, which is Rythmol? That's for the heart." He is shaking his head, "No, no."

"Propoxyphene napsylate?" The name floats out into the air. His face relaxes, his eyes brighten, he slowly raises a finger, points to me, a smile breaks across his weathered face, "That's it doc, propoxyphene napsylate, that's what it is! Yes sir, propoxyphene napsylate. I need some of those." Of coarse you do, I think to myself.

Darvocet-N 100. I should have known. Patients never make me play the "guess what drug I'm thinking" game unless it's a controlled substance. Never for something as boring as Pen-V-K or Naprosyn. Generic names, I'm ready to pull out my hair or scream or something.

There is an urgent call from the hospital regarding a sick patient. I take the call and hear about a patient with congestive heart failure in volume overload. I order Lasix 20 mg IV push, then I hang up the phone and reflect.

I am not sure how long generic furosemide has been available, but it has been around for as long as I can remember. Yet, I always have and I am nearly certain that I always will, order furosemide by saying Lasix, even when furosemide will actually be what is given; I don't mind if it is substituted. So, I ask myself, "Why?

It is simple. Because no one will ever wonder what I mean if I say Lasix. However, if I order Lasix by its generic name furosemide, I can guarantee that the day will come when someone will wonder what it is that I am asking for.

I think that if drugs were always referred to by the brand names that they were given by their original patent holders that patients and practitioners would overall end up being considerably less frustrated, make less mistakes and waste less time. Medical care might be delivered more safely and the experience of its practice might be generally more satisfying.

What's in a name? A lot.

The patient is about my age. I do not know her well. She usually sees one of my partners, but on this day the pain was exceptionally bad so she came to the office to see me for some relief.

It is difficult for patients with chronic pain to see a new doctor for the first time. They have to start all over from scratch. Even with good medical records available they still have to explain everything all over again, answer the same questions again but worse, they must deal with the new physician's doubts and suspicions about the diagnosis, the treatment plan, even about their own veracity.

It is difficult for a physician to see another doctor's chronic pain patient. We all have our own problem patients and so we do not want to inherit another one. Besides, these patients tend to be complicated and time consuming and are often deceitful and manipulative. More often than not, most encounters end up with both parties being dissatisfied in one way or another.

This particular patient suffered from the condition of trigeminal neuralgia, sometimes still referred to by the classic moniker "tic douloureux." I was taught in medical school that this dreaded disorder was one of the most, if not the most, painful conditions known to man. Before effective treatments were available, patients apparently would frequently put themselves to death to escape the relentless agony that this disorder subjected them to.

I read this patient's record and listened to her story. She has been on every treatment possible in every combination imaginable. Most treatments at one time or another have helped to some extent. She has seen a neurosurgeon who thinks that surgery in the area of the nerve may be beneficial. She has a date scheduled for the operation and she is hopeful about the outcome.

She says something when she is telling me about the neurosurgeon that makes me think. She tells me that she can never really explain to people how bad this thing really hurts. Her family, her friends, every one she knows, they try to understand but she says no one seems to get it. It is as if they seem to think she is exaggerating it or making it up, and she feels hurt and cut off and lost.

It is not hard to know why this is the case. If this is indeed the most severe pain a human being can ever experience, then none of us has any frame of reference to relate to her experience. She is indeed alone in her experience. I am thinking what a difficult burden that would be to bear when she already carries an unimaginable one.

However, she told me that the neurosurgeon seemed to understand, that he "got it," and how that was such a comfort to her. I reflected on this. The neurosurgeon has never had trigeminal neuralgia, how could he communicate to my patient this sense of understanding of the unimaginable overwhelming pain she lives with day in and day out?

A quality that I think is essential to practice medicine as a physician is that of sympathy. Some may not agree, but I think to care effectively for a patient requires it. I am told that the term "patient" from the original Latin derives it's meaning from "the suffering one." Physicians help people, sympathy is essential.

However, not everyone possesses another quality. I do not know if it is rare or common, but some exercise it exceptionally well, and some not at all. It is the quality of empathy, to actually be able to understand another person's feelings or difficulties as if you were in their shoes. It is an ability to understand more completely, more thoroughly, more accurately, to identify and to relate.

I think that that is what the neurosurgeon accomplished. It is what I try to accomplish. To imagine what I myself will never experience so that I may understand my patient and thereby better serve them. I think empathy makes good physicians excellent physicians and I think patients are drawn to empathetic physicians.

My patient that day needed empathy, because without it she was alone and lost, oppressed with a horrible affliction. I did my best, I provided medical care for her.

When I interviewed medical schools for admission, they would ask, "Why do you want to be a doctor?" My answer of coarse was, "Because I want to help people." I certainly can elaborate on that answer, but very simply, it is what I do, I help people, and it is a great thing.

The last patient on a busy Friday was a friend of mine. He came in with his wife. We have very successfully treated the effects of his so-called metabolic syndrome. His blood pressure and cholesterol numbers have reached the established targets and he has recently shed ten pounds of extra weight.

He was there to discuss the results of a two-hour post-prandial glucose tolerance test. His fasting blood sugars have been normal, even his hemoglobin A1c has been normal, but the 2 hr pp result was 185. By definition, this would place him in the category of "impaired glucose tolerance," a common development in someone with metabolic syndrome. Some would say he was now a "borderline diabetic."

We spent forty-five minutes before going home for the weekend discussing the significance of the result for him. We talked about the physiology of insulin resistance, beta-cell function and the current theories related to the development of Type II Diabetes. I wanted him to make an intelligent choice out of the myriad of therapeutic options he faced.

The three of us settled on a therapeutic strategy that they were comfortable with and that I think makes sense. From my experience with these things, I expect to see impressive results. I expect to see his glucose metabolism normalize, at least in the short-term, staying normalized perhaps for many years to come.

I may have saved his life that day. Our work on that Friday afternoon may have started a chain of events that prevents diabetes, a stroke, a heart attack or at least postpones such things for years, perhaps decades. I may have given him a longer, healthier life. I will never know, but there is a chance that I might have.

It gives me considerable satisfaction to improve people's lives and health in this way. I expect to live, age, retire and die with these people. As we all grow old together I expect to see the fruits of my labors, the benefits that our current evidence based medical practice is achieving, reducing risk factors and managing chronic diseases effectively.

We are already beginning to see that people are living longer, healthier lives, living well into their nineties, healthy, strong, with their wits about them, enjoying life. This is a great gift to give people. That is what I like to think that I am doing, giving this gift of life and health.

It is always difficult when a patient dies, even more so when the patient is a baby. This is an account of the first time I lost an infant child entrusted to my care. It happened a year and a half after I finished medical school. Just a warning, this account runs a little long.

I was still asleep when I lifted the receiver from the ringing phone. "Hello," I mumbled. It was the operator from the hospital. One of my OB patients called to report that she was bleeding. I was waking up now. I took down the number and dialed.

My patient sounded worried. There had been a sudden large gush of water followed by a large amount of bright red blood. It was the breaking of her waters, a common occurrence at the end of some pregnancies. It usually signaled the start of labor. However, the bleeding signaled trouble.

I was very awake now. I told her to go to the hospital immediately. I would meet her there. As I quickly dressed, my mind ran through the possibilities. What causes hemorrhaging in the last three months of pregnancy?

One possibility is placenta previa, which is the dreaded complication of pregnancy where the placenta covers the opening out of the uterus and tears off when labor begins. Without quick action, this problem might not only kill the baby, but the mother as well. Then there is abruptio placenta, when the placenta detaches from the uterus before birth, again risking the life of both baby and mother. Quick action will be needed to save them. I hurried.

The night was quiet. There was very little traffic on the street. I lived only two miles from the hospital so I arrived quickly. I pulled into a parking space near the emergency room entrance. As soon as I stepped out of my car, my patient drove in and parked her car next to mine. She told me there had been no more bleeding as we walked up to the obstetrics floor together. I relaxed a bit and reassured her.

This particular patient was special to me for a couple of reasons. First, I was a new physician just starting out. I was a Family Practice Resident building a fledgling practice. I was personally responsible for the care of 30 or so pregnant women. She was one of the first patients I had the opportunity to care for from the beginning of the pregnancy all the way through and including the delivery and postpartum care, giving me a chance to get to know her and form a strong bond of trust.

However, there was another reason she was special. She became pregnant at the same time my wife did with our second child. At every stage of my patient's pregnancy, my wife and I were experiencing the same things in ours. My patient and I looked forward to the time when we would both be delivering. At every visit, she would ask how my wife was doing. We would compare notes. We shared together the joy and anticipation of the arrival of our new babies.

We arrived at the OB floor. The nurses went to work. My patient put on a hospital gown, got into the hospital bed, and the nurses hooked her to a fetal monitor. This machine measures the baby's wellbeing by graphing the heartbeat and graphing the uterine contractions. I stood outside the room, causally waiting for them to complete their ministrations before I would step in and do my examination.

They took a long time. They took more time. It was becoming obvious that something was wrong. I stepped to the doorway. The nurse was using a probe that amplifies the baby's heartbeat. The probe was slathered with the messy clear goop that they use to help find the internal sounds. The same goop covered my patient's distended swollen abdomen. The nurse searched from one side to the other, back and forth, up and down. Nothing. No sound. No one in the room said anything. The nurse looked up at me, and then gave up. Trying not to think of the incomprehensible I went to the bed and sat next to my patient. I took up the instrument and began to search for myself.

On every office visit since this baby was three months along, I listened for his heartbeat. On every office visit I heard the reassuring "whoosh, whoosh" sound calling out to me. It was as if the baby was speaking to me in the only way he could, connecting to me, saying, "Here I am, I'm doing OK." However, tonight there was no voice, no reassuring sound, no connection. Only silence.

I hesitated. Think! Think! My mind raced. Is there any explanation for this other than the obvious? Was I missing something? Was I doing something wrong? I had to be sure before I opened my mouth and made things true by speaking them. No, I told myself, there was no way out, no escape from the harsh reality. I would wish it away if I could, but I could not. I stopped my vain search. He was gone. The baby was dead.

The grief came, tears, shock, disbelief, the question how? Dazed, I offered sympathy, support, answered questions. Abruptio placenta? Placenta previa? Probably. We would find out. However, right now, we had another problem. The baby had to come out. I considered the implications. This young mother will have to struggle through who knows how many long hours of labor, enduring probably the most intense physical pain she will ever have, only to deliver a dead baby. There will be no great "prize" at the end of such an ordeal for her, no pink baby to cuddle and hold, just emptiness. It seemed too much to bear.

This was a tragedy of nightmarish proportions. I was reeling. There was an uneasy silence among the nursing staff. We went through the motions of our duties stiffly. I called an obstetrician as a consult. I gave him the details of the case over the phone. He said he would be right over. Bleeding was still a threat to the mother and an emergency c-section could be needed at anytime during the labor to save the mother.

When he arrived, he searched in vain for a heartbeat himself. He then began an examination of the birth canal. Then he became alarmed. The amount of blood and blood clots in the vaginal area seemed dangerously excessive. He called for an emergency c-section for presumed placenta previa, a life-saving procedure for the mother.

Now things really went flying. The healthcare providers had something to do. We had a life to save. We were like knights on white horses. We were eager to push aside the feelings of despair and helplessness that overwhelmed us after losing the life of the baby and replace them with the earnestness of our practiced effort to save the life of the mother.

The floor became a bustle of activity. Nurses, anesthetists, aides, scrub techs, a dozen professionals working in concert to deliver the baby and placenta as quickly as possible in order to save the mother. The obstetrician and I were scrubbed, masked, gowned and ready to start when my patient was positioned, prepped, draped and put to sleep. Deft hands made the incision. Down through the layers the surgeon progressed, quickly reaching the lifeless baby. The limp body was removed and handed off to a waiting nurse who placed it gently, almost reverently, on a newborn warmer that was not turned on.

Then the obstetrician reached in, probing with his fingers, working in an area he could not see as he gazed absently across the room. Satisfied that he had a good grip, he began to gently pull the placenta out through the wound. It all came out in one piece and he laid it out on the drapes next to the wound. We stared. The obstetrician reacted with disgust at himself as he realized that he just performed a c-section that was not necessary.

I looked with a mix of puzzlement, curiosity and disbelief. I did not immediately appreciate the significance of what I was seeing. The umbilical cord, the vital attachment of the infant to the placenta, did not insert securely to the center of the placenta, as it should. Instead, it incredibly attached to the thin filmy membranes that had enclosed the baby and his surrounding water during the nine months of pregnancy. The arteries and veins, which run protected inside the tough umbilical cord, emerged from the cord's point of attachment. They then ran unprotected and vulnerable along the surface of the fragile membranes over to the placenta, attaching there, as they have to, to receive nutrition and oxygen from the mother.

I had never seen anything like it. It was extraordinary, the blood vessels stretching out across the thin membranes toward the placenta. Large fat veins with their thin walls, tougher smaller arteries. It was now easy to see what had happened. When the membranes ruptured, the breaking of the waters, one of the delicate blood vessels was torn and the blood spilled out. However, this blood, this blood came from the baby. It was the baby's blood, the baby's precious blood. The blood came and came and came, until the baby had no more. Then the bleeding stopped. The baby bled to death inside his mother's womb as the result of a freak anomaly. The blood the mother watched pour out, and then stop, was her own baby's blood.

We finished the procedure. The obstetrician left the operating room. My patient was waking up, but was still very groggy. She would not be aware of what was happening for an hour or more. I went over to the still, silent figure laying in the cold warmer. I saw a perfectly formed beautiful newborn baby in every respect, except that the skin did not look quite right. It was grayish, and far too pale. I reached out and touched the baby, not to hold it, but more as if to examine it. It was as if I needed to verify that this was real, that a normal healthy baby with a future of promise and limitless possibilities could be suddenly and tragically lost. Here one moment and gone the next.

As I touched him and reflected, I decided that there is no sight more hideous than this, a dead baby. There is nothing more unfair; there is nothing more wrong. It was almost more than I could bear.

I went to the placenta where it was laying. I carefully spread it out so that the whole anomaly was visible. As I stared at the reality of what was before me, the physical presence of it, I took in the truth of how helpless and powerless I actually am. I took care of this baby and his mother during his entire short life. I was their doctor. They relied on me. I carried with me the whole weight of centuries of accumulated medical knowledge and technology to apply against any enemy or problem that might appear. I was ready, I was prepared, and I was there.

As I looked at this placenta before me, I knew the truth. Absolutely nothing could have saved this child, nothing that I could have done, nothing that anyone could have done. He was doomed and we were powerless. I had never felt so small in all of my experience as a physician and since starting medical school. My view of myself and of medicine itself reached a new level of humility at that moment, and the impression was indelible.

I took the Polaroid camera that was at the nurse's station and photographed the placenta. The placenta was destroyed, but the photograph remains to remind me of that night. I learned important lessons that have shaped me since then. I learned that no matter how certain things appear in life, we are never certain of anything. I learned to be grateful for the good things that happen in life. They may seem to come to me by my own efforts, but that is only an illusion. I learned as a physician that I should do the best job that I can, and then leave the results to God. The results are always in his hands from the start anyway. Finally, I learned that no matter how much I know, it is usually less than what I think I know.

All of the paperwork was done. My patient was tucked away to bed safely. The OB floor settled back to a normal routine. Everything went back to normal, the same as it was before, except for me. I would never be the same again. The pain in my heart would weigh me down for many years, and in fact, it still does today. I suppose it always will. I tucked the Polaroid into my pocket and headed home.

The streets were dead now. No one was out. It was very late. I arrived home and walked in quietly, not wanting to disturb my sleeping wife. I stopped to check on my one-year-old daughter, asleep in her crib. I said a prayer of gratitude for her and watched her for a long time. When I entered my bedroom and saw my wife lying there, I was overcome with a mixture of fear and love.

I woke her as I was putting my ear to her abdomen. I poked gently to wake him. I spoke to him. I listened to his heartbeat. His heartbeat spoke to me loud and clear. "Here I am, I'm doing OK." He moved. He poked me back. I wept. I wanted him to come out so badly, so I could hold him and protect him. I loved him so much. And I was so afraid.

He was born two weeks later and I really did not sleep very well until he was born. I listened to his heartbeat every chance I could get. I prayed and I thanked God for my blessings. When I finally held him in my arms I realized that I knew something that I may not have known before. My son was a gift. And my daughter was a gift. My desire to have them did not bring them to me or keep them with me. I have no power. What I have are extraordinary gifts. What I was then, and continue to be, is awed and grateful.

My patient came to see me in my office one more time after going home from the hospital. She was handling the grief process as well as might be expected. Physically she was recovering well. She asked about my baby. I felt embarrassed that I had one. Somehow, things just did not seem right. We should be comparing notes on how things were going as both of our babies were growing up together. Instead, she would leave, and I would never see her again.

I have often thought about her, and how that night ended up affecting her and her life. I hope she eventually was blessed with the joy of holding a pink, soft, warm newborn in her arms. Because, that is how I would like to have the story end.