Luke Burns, MD

When the first patient suspected of having COVID-19 appeared on L&D, it was like the arrival of a pregnant celebrity. We tiptoed carefully around her room, minimizing our visits as much as possible. We found ourselves constantly hitting the refresh button on her pending SARS-CoV-2 lab result, awaiting confirmation that the coronavirus had finally arrived. Only one physician, the attending, was permitted at the patient’s delivery.

In those early days, the protocols for other COVID-19-positive adults in the hospital were well-established, but the rules for pregnant patients were still being created on the fly. Were new mothers permitted visitors while in labor? Would they be allowed to breastfeed? Would they be permitted to even meet their newborns immediately after birth?

We were not even quite sure how COVID-19 would manifest in pregnancy. Suddenly we were second-guessing all our previous diagnoses. Did the new admit in room 7 really have atypical preeclampsia, or was her isolated thrombocytopenia actually caused by the new coronavirus? That patient with the gastrointestinal bug waiting in triage…should she be tested, too?

Changes to our residency program came swiftly. An emergency meeting was called a few days after the virus hit our state. We were told we would be divided into two teams, with half of the residents scattered into skeleton crews across the hospital and the other half sent home as backup in case anyone was exposed or fell ill.

I already had been working straight through for a couple of weeks when I was told I would be staying for a couple weeks more. Spending so much time in the hospital meant that news about the Coronavirus reached me in bits and pieces. Each morning I would drive to work in the dark and learn on the radio how many people had died during the night. Then each evening as I drove home in the dark, I would learn how many had died during the day.

Meanwhile, things on L&D gradually started to change. It seemed like each day brought a new set of rules. In an effort to minimize co-mingling among staff, our anesthesia, midwifery, and family medicine teams stopped attending our normally boisterous morning sign-outs. Suddenly, everyone had to start wearing masks.

All things considered, however, not much had changed on our floor. It turns out that delivering a baby during a global pandemic does not differ much from the days before we had ever heard of COVID-19. Elective inductions were still going ahead. We did skin-to-skin and delayed cord-clamping. Even the pregnant women who were COVID-19-positive could still have a relatively “normal” birth experience, albeit in a room of people covered head to toe in protective gear.

In fact, it was “on the frontlines” that I felt the most the distant from the pandemic itself. I felt guilty responding to messages from family and old friends, those not in medicine but trapped in their homes by an invisible enemy ravaging their cities and towns. 

And after getting past the familiarities, 

The truth is, I hardly felt like I was on the frontlines, maybe more 

. If battling COVID-19 is truly the violent conflict our president would have us believe it is, then I felt like I was still a few trenches away from the hand-to-hand combat.

That has not stopped us from adopting the language of soldiers. Residents speak of being 

. Our daily briefings from administration quote Winston Churchill and urge us to “Stay the course.” The residents outwardly smile at this drama, but each still clings to their N95 mask like it’s a Kevlar vest.

After 3 weeks in the hospital, it was time for me to return home for my pandemic-mandated shore leave. I would be at home for another 2 weeks, enough time for any sign of an infection to manifest itself.

I had been working 14-hour days and overnight weekend call and had only a tangential understanding of how the outside world had changed during that time. It was a shock. When did they close all the restaurants? What do you mean I can’t have my friends over for dinner? What is “Zoom” and how do my parents know how to use it?

The first time someone walking toward me on the sidewalk swerved away to preserve my government-mandated 6 feet of personal space I nearly burst out laughing. Later that day I texted my fiancÃ© from the supermarket, incredulous. 

Do you know they’ve hired someone whose job is to wipe down all the supermarket carts?

My own sense of hubris started to creep in slowly. At the hospital, passing a sign each day that cheerfully implored me to 

, I had lost touch with the awfulness of this disease. In this otherwise anxious world we now inhabit, it had been wonderful to do something as joyful as deliver babies every day. All the while, three floors above me, patients were dying on ventilators.

It was only after I left the wards that I really began to be afraid of COVID-19, after I was able to step back and see the bas-relief impression it had left in the world outside of the hospital. Now I sit glued to the radio for updates on the virus. I read articles from China on its effects on pregnant patients and brush up on the pathophysiology of ARDS. I call my parents every day. We “Zoom.”

 I am getting ready to return to the hospital. I know from my co-residents and from the numerous update emails from my department that things are different now. We are accepting transfers from inundated hospitals in the area and sanitizing and reusing dwindling supplies of PPE. COVID-19-positive pregnant women have had bad outcomes directly related to the virus. The world at my hospital is starkly different from the one I left-and it may have changed yet again by the time you read these words.

Physicians, especially those in training, are known for using humor to ride out difficult times.  When I return to L&D, I will likely try my best to smile, joke, and commiserate with my co-residents. But beneath a stifling N95 mask, I will be gritting my teeth.

Articles

Navigating patient care in L&D during the global COVID-19 pandemic gives one resident cause for pause and reflection. How would it manifest in pregnancy?

The last normal place in the hospital


	At the start of my inpatient Maternal Fetal Medicine rotation last month, I was called to triage to counsel a mother with monochorionic, diamniotic twins. 

This particular patient, unemployed and underserved, had had very little prenatal care. She knew how far along she was and that she was having twin girls, but the high-risk chorionicity of her pregnancy had been missed at her initial prenatal visit, and she had not undergone an ultrasound since. It was only now, presenting to our triage with a painfully distended abdomen, that she learned her fetuses actually shared a single placenta. Because of this missed diagnosis, the woman had not had the regular ultrasound surveillance that might have detected the twin-twin transfusion syndrome now affecting her pregnancy. 

The patient was so polyhydramniotic, she was having difficulty breathing. She was in shock. We discussed that her condition was now considered Stage IV, and the twins were unlikely to survive. We offered her an amniocentesis, knowing that removing the excess fluid in the remaining amniotic sac would relieve some of the discomfort of her swollen abdomen, but she declined.

The woman asked us to scan her abdomen a final time. One of her fetuses was hydropic, while the other was severely growth restricted.  She sobbed quietly, and her boyfriend, sitting on a chair by the bed, played tinny music from her phone to comfort her. After the scan we stepped out of the room, letting the patient rest a while.
	 


	An hour or so later, an urgent phone call brought me back to triage. Our patient had gotten up to use the restroom when her water broke. Now she was bleeding, hemorrhaging onto her bed. I launched into emergency mode, frantically directing the various people in the room. 

“Place a second IV! Have you called anesthesia? We’ll need to make sure she’s typed and crossed for four units. When was her last CBC? Is OR 3 ready?”

Amid the chaos occurring in this tiny room, I felt a tap on my shoulder. It was my attending, who leaned toward me and asked calmly, “Have you told her what’s happening?”

In medical school, they tried to teach us how to deliver bad news. Find a quiet room, make sure you’re sitting down, look earnest, begin with a warning shot: the results are back and I’m afraid they are not good.

In reality, I find it impossible to have this much control over my environment in the hospital, especially in the midst of an evolving crisis. In clinic recently, I was asked by a midwife to help troubleshoot a malfunctioning ultrasound machine. I managed to fix the technical problem, but in doing so, I noticed that the fetus had no heartbeat. And so it was me, a stranger this couple had never met but the one caught holding the ultrasound wand, who told them they had had a miscarriage. 

This is not surprising in a profession that oscillates so rapidly between good and bad news. One of my attendings uses the phrase psychological whiplash to describe it. It is the idea that an ob/gyn can enter a room to deliver a baby, taking part in all the joy of that ecstatic, high-energy process and moments later, cross the hall and deliver a stillborn child while whispering commiserations to a grieving couple. Entering and leaving each room without clinging to the residue of emotion from either encounter is incredibly difficult and mentally taxing. 
	


	Back in triage, with my patient hemorrhaging on the bed in front of me, my attending asked me again. “Have you told her what is happening?”

In all the frenzied panic, in ordering the chaos around me, I had completely forgotten about the patient. I had forgotten what she must be going through, what was likely going through her mind, how she must feel at the sight of so much of her own blood. 

I was frozen, inarticulate, uncertain of exactly how I could explain what was happening. I wanted to say that when her water broke the placenta had likely abrupted, peeling off the uterine wall. This would most certainly lead to the death of her fetuses and, if we did not act quickly, would be life-threatening for her too. I wanted to sit down next to her, to console her. Here again was another imperfect opportunity, another time-critical moment to comfort this patient, to be the one to gently convey this terrible news.

But I was silent. I was stuck in place. After so much heartache and tragedy already, in the middle of this horrendous scene, I could only think of the next steps needed to keep this patient alive. In the quiet room, tinny music still played from the cell phone. 

Finally, my attending stepped in, leaning close to the patient to explain what was happening. She held her hand all the way to the operating room and was beside her when she returned.
	 


	So far, my training has taught me to be an excellent resident. I can place orders, respond to consults, and write progress notes. I can recite the antihypertensive regimen necessary to control severe-range pressures or the Amsel’s criteria for diagnosis of bacterial vaginosis. 

But I am still hoping residency will train me to be to be an excellent doctor. I am still hoping it will teach me to adapt, to see through the rigid guidelines to the terrified patient beneath. I hope that in the midst of an emergency, I can not only be level-headed and calm and make the right decisions, but also make them with warmth, generosity, and compassion. 

Although residency teaches doctors to deliver babies, how to deliver bad news must also be a part of the curriculum.

The other difficult delivery

No tool better personifies the surgeon than the scalpel. It’s the only instrument an individual can legally plunge into the skin of another person in a room full of observers. It’s hard not to feel an electric energy every time the room falls quiet and the attending says, “The knife to Dr. Burns, please.”  Holding the instrument like a pencil, I slowly etch its blade into the skin, cognizant that I am tattooing the patient, scarring her for life. A nurse behind me yells, “incision!”, marking the beginning of the case, the first step into the unsealing of the abdominal cavity. 

After that dramatic entrance, the truth is that the scalpel is usually put away and rarely makes another appearance throughout the rest of a procedure. Most surgeries continue with electrocautery, scissors or even blunt dissection with gloved fingers. The ultra-sharp blade of the scalpel is far too dangerous to use anywhere beyond the first few layers of skin.

By the end of my first year of residency, after opening the skin on numerous cesarean sections, postpartum tubal ligations and laparoscopic oophorectomies, I felt fairly confident wielding a scalpel. I had also used it to marsupialize Bartholin cysts, excise post-radiation tissue and even drain an abscess on someone’s forearm. 

And then came the final day of my intern year, when I was standing in the OR, scalpel poised above the patient’s skin. It was the end of a long day of laparoscopic surgeries and I was working with one of my favorite attendings. She was new to her job, fresh out of residency and, like me, had just finished her own difficult year of uncertainty and self-doubt. While we maintained a professional work ethic in the OR, we were friends outside of work and I felt more at ease with her than I did with other attendings.

Our last case was an elective laparoscopic salpingectomy. At my institution, most surgeons start the surgery with a 5-mm nick in the bellybutton with a scalpel. It’s meant to be quick and shallow, just wide enough to accommodate a camera port. 

My attending gestured for me to begin, and I placed the tip of the knife into the patient’s navel -“incision!”- then sliced carefully toward the pubic bone. But something felt different. Instead of the rubbery firmness I had come to expect with epidermis, the tissue was soft and yielding. It was like dragging a spoon through pudding and, before I knew what had happened, half the blade had gone beneath the surface.

Something in the attending’s voice when she said, “That’s way too deep,” made my breath catch. Then she paused and told me to place the Veress needle. Instead of meeting resistance the needle glided through the incision. 

The attending’s face froze. She gripped the tissue on either side of the incision with both hands and tented it up for closer inspection. Just as she did so, a soft, low hiss filled the room.

She released the skin and spoke quietly, without looking at me. “The only time gas comes out of the peritoneum is if we cut into bowel.”

The lower half of my body suddenly went numb. This was it, my worst nightmare. A patient had come in for an elective procedure and I’d thrust a knife so deep into her belly that I’d cut into her intestines. I imagined calling in the general surgeons and pictured the irreparable damage I’d wrought to the patient’s organs, the ostomy bag she would wake up with. I thought of the attending-my friend-and the blow to her confidence, of how she might never trust a resident again. 

The attending completed the rest of the abdominal entry without my help. The room, previously buoyant and full of scrub staff discussing weekend plans, was silent. My eyes peered up at the monitor screens as I watched the attending enter the abdomen with the camera. She peered straight down at the bowel. She swept left, right, cephalad and caudad. We inserted the other instruments and gently moved the bowel, running its length and investigating for scalpel marks. There was nothing.

My attending managed to crack a smile, but I was so shaken that I could barely hold my instruments. We finished up the rest of the case without issue, took another final survey of the abdomen, and closed the patient’s incisions. Later, when I sought out the attending in the physician’s workroom wanting to debrief, I felt like bursting into tears. What went wrong?

She smiled and said, “Simple. You made a classic second-year resident mistake.” 

She turned to me and explained what she meant. “When you first held a scalpel you were too scared to go deeper than a few nanometers. But as the year has worn on, as you built your confidence, you started cutting deeper and deeper. And today you went too deep.”

Seeing that I was upset and not quite convinced, the attending reached out her arm and placed it gently on my shoulder. “You’re not a bad doctor. Believe it or not, none of the attendings you meet were born in scrubs as gynecological surgeons. We had to start from the bottom. We had to make mistakes.” She paused. “And we had to avoid hubris.”

Despite the confidence in our intraoperative assessment, the attending later told me she called the patient after the surgery every day for a week. The patient, pleased but a little bit surprised by the attention she was getting from her surgeon, made a full recovery from her surgery. Her bowel was fine, uninjured, and we never found an explanation for the ominous hiss of air that came from within the abdomen.   

Of course, the next time I operated, I was back to scraping nanometers off the surface with my scalpel. The next attending admonished me for not committing to a deeper incision, saying I should be confident enough now to press harder with the knife. But I had learned my lesson.

My intern year was a bewildering experience, an indescribable amalgamation of joy and fear and terror. I can hardly remember most of it.  But surviving it had made me begin to feel invincible. After that day in the OR, I feel vulnerable again, and, more important, human. As I begin to adapt to more responsibility, I raise my own self-expectations. But I also anticipate more errors, more mistakes, more lapses in judgement. I need to learn to forgive myself and to seek wisdom from those, like my attending, who have been there before. I am no longer afraid to take the knife when it is handed to me. I just have a greater respect for the scars it might leave behind.

A resident is reminded that a mistake can sometimes be an unfortunate necessity for keeping his level of confidence in check.

Residents Corner - Hubris

There are no doctors in my family, and only a single nurse, my Aunt Frances. When I was accepted to medical school, she took me aside and made me promise to do one thing: Never take the nurses for granted.

I have always found the culturally accepted animosity between doctors and nurses baffling. Medical TV shows would have us believe the two groups are like animals from different species, insisting we are preternaturally destined not to get along, that we come from different worlds.

Frustrated with this concept and determined to heed my aunt’s advice, I committed to do my utmost to buck this trend. At first, it was easy. Throughout my clinical rotations in medical school, I had no trouble befriending nurses and doctors alike; each group was as likely to cheer or chastise me. I hung out at the nurses’ station almost as much as the residents’ workroom. But during my first month as an intern, I noticed something had changed. 

A patient came in to the labor and delivery ward at term with decreased fetal movement. Her elevated labs and pressures in triage were consistent with preeclampsia with severe features. Her induction was started but, dulled by a magnesium drip, proceeded slowly. Eventually, though, she dilated to 6 cm and, expecting her to make some change in active labor, I dutifully reported to the nursing station to reexamine the patient. But the nurse was reluctant to accompany me to the patient’s room.

“She’s been up all night, she’s so upset, she feels awful on the magnesium, and it’s only been a couple hours since you last checked. Can’t you just give her a little longer?”

I was confused. The patient’s variability on fetal heart rate (FHR) monitoring was minimal, and she was in active labor. Her category 2 tracing was not dire, but it wasn’t exactly reassuring given her preeclampsia. The 

American College of Obstetricians and Gynecologists

 Practice Bulletin I had stayed up the night before memorizing clearly stated she needed to be checked every 2 hours. And after all, this was hardly my decision. My attending and senior resident had instructed me to go assess the patient’s labor. I was just doing what I was told. 

With my aunt’s words echoing in my ears, I pleaded my case as gently as I could to the nurse. She pleaded with me, too, insisting the patient needed rest. Eventually the charge nurse overheard our conversation and told her colleague she had to stick with protocol. As the nurse stood up to join me, she said quietly, “I’m just trying to advocate for my patient.”

I was shocked. Wasn’t I trying to advocate for the patient? And wasn’t she “our” patient? I didn’t want her to have an eclamptic seizure or a stroke, I didn’t want her baby to spend his first 24 hours of life in the neonatal intensive care unit. By the nurse presenting herself as the patient’s advocate, I instantly felt categorized as an antagonist. 

We arrived in the room and I did a cervical exam. The patient’s condition remained unchanged. After placement of an intrauterine pressure catheter, and another hour of waiting, the patient was taken to the operating room for a cesarean delivery for arrest of dilation. 

I was still upset about the nurse’s words. By accepting the narrative that she and I had different agendas for our patients, she only reestablished the supposedly natural, eternal conflict between doctor and nurse I had been trying so hard to defy.

After that, I grew cynical. I stopped spending time in the nurses’ station and instead retreated as often as I could to the physicians’ workroom. I was cordial and friendly with the nurses, but I didn’t go out of my way to make friends. 

And then one day, a different nurse stopped me in the hall of the labor and delivery floor to ask a question about a patient. “I have the patient in room 9,” she said. “Are you taking care of her?”

“Yes, of course,” I said. “I’m taking care of everybody.” She looked confused. How could I be taking care of a dozen laboring patients at once? 

This short conversation brought home two conclusions for me. First of all, this nurse and I had fundamentally different definitions of the word “care.” The level of deep, committed, responsive care she was expected to provide was entirely different from the clinical medical care I was offering. I am hardly an automaton and endeavor to spend time getting to know my patients beyond their medical diagnoses. But it would be impossible for me, managing an entire labor floor, to have the same intimate relationship with every patient that the nurse could offer.

Second, I realized that neither of us really understood the other’s job. I thought back to my conversation with the nurse who told me she was advocating for her patient. I had not realized then just how much time she had spent taking care of this patient, one-on-one, and how she had been this patient’s source of comfort and reassurance. How could she not see herself as an advocate and a defender, especially against possibly unnecessary interventions from a doctor who was only able to visit this patient every few hours?

I decided to quit holing myself up with the other physicians. Whenever I had a free moment, or a question about a patient, I resolved to go sit in the nurses’ station and have an actual interaction. I began asking questions about the nurses’ jobs, about the hundreds of varied tasks they were responsible for, things I had always taken for granted. While sitting there, I saw just how often they got up to check on their patients and how closely they monitored the FHR tracings in front of them. Likewise, they saw just how often my pager went off, summoning me to one of the many patients I was taking care of concurrently. 

To be honest, expending that level of emotional effort can be exhausting. Unsurprisingly, it turns out that building bridges with colleagues can be as tiring as the work itself. Ultimately, however, I believe it is a valuable practice. By knowing one another as people, by fully understanding not only how alike we can be but just how vastly different-and equally important-our jobs are, we begin to better understand how our roles complement each other.

And that is an important truth: the jobs are vastly different. How else would we both be able to “advocate” for a patient and yet suggest completely different management plans? But that is why doctors and nurses have been a part of the Western model of medicine since the nineteenth century: they both play roles on the spectrum of medical care. One could not function without the other. 

In the “animal kingdom” of modern medicine, perhaps we’re not so different after all.

When a resident’s promise to appreciate nurses is challenged, a conversation with one illustrates how both roles play an integral part in patient care.

Luke Burns, MD

Articles

The last normal place in the hospital

The other difficult delivery

Residents Corner - Hubris

Building bridges