Babel: The Voices of a Medical Trauma

Tricia Pil

Editor's Note: This week, on the eve of Pulse's second anniversary, we offer a remarkable piece. It is the true story of a hospitalization as told from three points of view: first, the recollections of the patient (who happens to be a physician); second, events as recorded in the medical charts by doctors and nurses; and third, the version put forth by the hospital.

FRIDAY

Patient:
It is fall 2005, and I am nine months pregnant. A healthy 33-year-old pediatrician, I am a longtime patient of Doctor A and Doctor B, who delivered my two young children at this hospital. My husband and I are eagerly anticipating the birth of our third child.
One evening after dinner, the contractions start coming every five minutes. My husband and I pack our bags and drive to the hospital. I am nearly 4 cm dilated. After observation, Doctor C calls Doctor A, makes a diagnosis of false labor and sends us home.

Chart:
9:25 pm: 33 year old gravida 3, para 2, 38 5/7 week seen in office this AM almost 3 cm. Negative PMHx, c/o contractions q 5 min. Cervix 3+. Will ambulate 2 hours.
12:15 am: Continued contractions q 5 min. Spoke with Doctor A--home or stay--patient chooses to go home. Keep appointment Monday for induction.--Doctor C

Hospital:
Your presentation to Triage was discussed with Doctor A by the OB Triage Specialist. Since there was no change in cervical dilation, you were discharged.

SATURDAY

Patient:
My water breaks the following night, and I call Doctor B. After saying "Hold your horses," he grudgingly tells me to return to the hospital. By the time we arrive, my contractions are coming every minute. No one is behind the emergency room desk. My husband finally finds an off-duty orderly willing to get a wheelchair to take me to the birthing center. There, the secretary refuses to call a nurse until I sign papers explaining the hospital's privacy policies.

Chart:
Registration 10:45 pm. Triage admission 10:45 pm.

Hospital:
After 10:30 pm a call bell is present on the counter in case the triage nurse is not at the window. The "off duty orderly" who wheeled you upstairs to the birthing center may not have known the proper sequence to follow. Documented registration time is 10:45 pm and the time placed in the triage room is 10:45 pm which indicates swift placement into a triage room. There are some forms that must be signed for each admission.

Patient:
In triage, Doctor D prepares a fern test to determine whether the fluid that has soaked the bed and wheelchair has come from a ruptured amniotic sac, when that fact is clear even to my lay husband. Nurses are shouting at me not to push, but I am involuntarily bearing down with each contraction. By the time we rush towards the delivery room, the baby is crowning. He is born in the hallway.

Chart:
10:59 pm: Boy delivered 8 pounds, 1 ounce. Spontaneous vaginal delivery.--Nurse A

Hospital:
You delivered in the labor and delivery room 14 minutes after arrival by the OB Triage Specialist.

Patient:
I am left lying there, waiting for Doctor B. When he arrives I ask, "Where were you?" He answers, "I can't come until they call me." He yanks the placenta out, and I bite my lip. At one point, while he is sewing my laceration from the birth, I exclaim, "Ouch! I can feel that!" He replies, "Aww, that's just the deepest one," and keeps on going. He disappears as soon as he is done.

Chart:
11:25 pm: BP 136/76, HR 85. Hemoglobin 14.
Delivery Note: Precipitous labor, arrived at triage 8 cm, dilated and delivered on arrival by Doctor D. I arrived in room just after delivery. Placenta spontaneous and repair of second degree laceration under local. Group beta strep positive--no antibiotics given.--Doctor B

Hospital:
Doctor B was on-call for his practice that night and was physically on the premises. However, since your delivery progressed so quickly he did not make it from his prior location. He does not recall "yanking" your placenta.

SUNDAY

Patient:
We are moved to the postpartum floor. Seven hours later, I suddenly feel weak, dizzy and nauseated. I say, "Somebody help me, I don't feel well." The next minute, I'm hemorrhaging. There is blood spurting everywhere, clots the size of frying pans. I think I am going to die. Panicky nurses and residents crowd the room. The crash cart is wheeled in, my baby is wheeled out. My husband is shouting, "Somebody get Doctor B!" I am being stuck everywhere for an IV. Someone says that there will be a "procedure," and then my underwear is cut off, injections slammed into my buttocks, my legs are forced open and somebody shoves an entire forearm into my uterus and pulls out clots. Three times. I scream and scream and scream. The pain is unbearable, and I feel brutally violated.

Chart:
7:30 am: Called to see patient passing clots. Passed two medium size clots. Blood pressure 110/67…100/60…90/58. Pulse 88…96. Patient uncomfortable, vomited x 2. Bimanual evacuation lower uterine segment with 3 large clots. Orders: IV, Pitocin IV, Methergine IM, Morphine IM, Zofran prn. Discussed with Doctor B.--Intern

Hospital:
Once again, we refer you back to your private physician for a detailed discussion about the hemorrhage you outlined.

Patient:
Everyone flees the room.
I am curled in a fetal position, crying and shaking. No one comes to explain why, how or what has just happened. When my husband stumbles down the hall afterwards, other new mothers stop him to ask if his wife is okay after what they have heard. They are the only ones who ever ask if I am all right.

Chart:
7:40 am: BP 90/58. Will continue to observe.--Night Nurse B
8:00 am: IV running. Patient medicated with Zofran for nausea. Resting comfortably. Will monitor.--Day Nurse C

Hospital: [no response]

Patient:
Doctor B makes rounds. "You doctors make the worst patients." Then he asks if I am up for an early discharge. He stands in the doorway, making more eye contact with my chart than with me. I never see him again.

Chart:
8:40 am: Hemoglobin 11. BP 90/60.
Afebrile, vital signs stable. Fundus firm, lochia moderate, perineum ok. Doing well. Orders: Discontinue Pitocin at 12 noon if lochia normal. Heplock IV.--Doctor B

Hospital: [no response]

Patient:
My husband notices that the expiration date on the bag of Pitocin--the intravenous medication used to treat postpartum hemorrhage--is fourteen days overdue. A nurse quickly removes the bag and assures me that Pitocin is good for two weeks past its expiration date anyway.

Chart:
1:50 pm: IV infiltrate right forearm. Catheter discontinued.--Nurse D

Hospital:
Each unit where Pitocin is supplied is checked on a monthly basis. The Pitocin label has two dates on it. One date is the compound date, and the other is the expiration date. Is it possible you noticed the compound date?

Patient:
I lie dazed and in shock, unable to eat or drink. When my baby is brought in to nurse, I numbly put him to my breast and go through the motions. Patient-care assistants come in once per shift to chart my vital signs. Nurses avoid the room and act as if nothing happened.

Chart:
12 pm: BP 100/70. 4 pm: 90/60.
Intake: Regular diet. Quantity sufficient. Output: Voided. Quantity sufficient.
Infant weight 7 pounds, 10 ounces. Breastfeeding score 10/10. Assessment within normal limits.--Nursing notes

Hospital: [no response]

MONDAY

Patient:
Doctor A rounds. "I'm surprised you decided to leave that first night." I am stunned. When I finally answer that we were discharged from the emergency room on his orders, he replies, "I thought you came in looking for a sneak induction." He writes my discharge orders a day early and leaves, also never to be seen again.

Chart:
12 pm: BP 90/60. 8 pm: 96/58.
No complaints. Feeling better. Doing well breastfeeding. Orders: Home tomorrow AM.--Doctor A
Infant weight 7 pounds, 5 ounces.
Infant nursing well at frequent intervals. Exam significant for icterus [jaundice]…facial bruising…Precipitous delivery, maternal group beta strep positive without antibiotic treatment. Discharge planned for Day Five if course in hospital remains uneventful.-- Doctor E

Hospital: [no response]

TUESDAY

Patient:
On the morning of discharge, I tell the nurses repeatedly that my baby is very sleepy, not nursing well and starting to vomit. He has lost 10 percent of his weight in the forty-eight hours since birth. The discharge nurse tells me to "stop worrying like a pediatrician mother," his vomit is just spit-up, and he is not sleepy, just "content." We are handed formula samples and hurried out the door.

Chart:
1:45 pm: Infant weight 7 pounds 3 ounces. Bilirubin 12.7. Report given to Doctor F via Nurse E. Patient discharged to home with infant after discharge instructions and supplemental nursing that patient requested in case she decided to supplement infant. Patient's condition stable.--Nurse F
MD verbal order: Discharge home with mother. Cancel home health.

Hospital:
There was no emesis or spitting documented. Status reports were given to Doctor F and nursing notes indicate that Doctor F wanted your baby to be supplemented. The nursing notes indicate that you were informed of this and were provided instruction on supplemental nursing.

Patient:
Within one hour of getting home, my baby throws up again, drenching the bassinet. We rush him to the pediatrician's office and are sent immediately to the emergency room of another hospital. He is jaundiced, lethargic and dehydrated. The ER staff struggles for IV access, sticking his arms, legs and scalp. He is admitted that evening, five hours after our hospital discharge, still wearing his hospital leg bands. It is my thirty-fourth birthday.

Chart:
6 pm: Infant weight 7 pounds, 3 ounces. Bilirubin 16.9. Sleepy, floppy, jaundice to umbilicus. Admit.--Emergency room notes

Hospital:
Once again your pediatrician can address your concern in this matter as well.

WEDNESDAY, THURSDAY, FRIDAY

Patient:
My son remains hospitalized, lying in an incubator receiving intravenous fluids and phototherapy. He doesn't come home for good until he is nearly a week old, requiring yet another week of home phototherapy and daily home care visits before regaining his strength and weight.

Chart:
Diagnosis: Obstetrical Trauma Not Otherwise Specified.
Disposition: Return in approximately one year.--Doctor G

Hospital:
We are sorry that you were so unhappy with your stay. After a thorough investigation of your allegations, we have concluded that the care you received was appropriate. Thank you for taking the time to express your concerns.

In the months after my son's delivery, it was as if a curtain had descended over my life. In addition to a terrible feeling of numbness, I was haunted by flashbacks and nightmares about what had happened. Billboards for the hospital where I'd delivered, people dressed in scrubs, pregnant women, a favorite red velvet cake that now resembled to me a large blood clot and, worst of all, my own baby--the sight of any of these could trigger flashbacks and bouts of heart-stopping, sweat-drenched panic.

For my postpartum checkup, I saw a new obstetrician, who listened uncomfortably to my tearful story and ultimately dismissed my symptoms as hormone-induced baby blues, "Mother Nature's way of kicking women when they're down."

After five months of worsening symptoms, I finally self-referred to a psychologist who began treating me for post-traumatic stress disorder (PTSD). It was only then that I started bonding with my infant son.

On the eve of my son's first birthday, the first anniversary of the event, I wrote a letter of complaint to the hospital and to the physicians who'd been involved in our care. It had taken me that whole year to verbalize what had transpired. Even as I mailed the letter, I struggled with feelings of disbelief, anger, shame and betrayal that something like this could have happened to me, a physician, "one of their own."

I wrote the letter because I wanted the doctors and hospital staff to understand my perspective and to appreciate the devastating impact that this event had had on my life and family.

I also wanted them to consider the inept and unfeeling care we'd received from first to last--including the failure to get me into a delivery room quickly enough, the brutal response to the hemorrhage (which better care might have prevented in the first place) and the inappropriate discharge of my ill newborn.

I wanted them to change the way they conducted business so that no one else would have to endure what I did.

Naively enough, I wasn't even thinking of a lawsuit--that is, until I received the hospital's letter of reply three months later, the one extensively quoted above. In that infuriating moment I suddenly understood why patients sue. The response, with its defensive, denying, callous tone, was like a slap in the face--like being traumatized a second time.

The following week I called a malpractice lawyer and told him my story.

He listened sympathetically and then zeroed in on the key word--damages. Aside from my psychotherapy bills, it was hard to pinpoint a lasting physical injury to me or to my baby. "This case would be worth a lot more if we had three motherless children or a brain-dead baby in a wheelchair," he said. That's when I politely thanked him for his time.

I wanted an apology, answers and change--not money.

I never did receive a response from any of my physicians.

As someone who has been on the receiving end of care that felt both incompetent and uncaring, if not cruel, I'm sure that we medical professionals can do better. As someone who looked for explanations and received none, I'm hoping that we can change, getting beyond blame-shifting, defensiveness, denial and complicit silence--and moving instead towards transparency, disclosure, apology and healing.

As a physician, I hope that we can learn to more actively engage our patients in their own care. I hope that we can reexamine the ways in which we respond to our own errors and share the lessons we have learned with our medical students and residents.

If we can do this, perhaps then we could rise above the babble of Babel, our voices joined in a common language of human care and compassion.


About the author:

Before the events described above, Tricia Pil MD worked for six years as a pediatrician in private community practice. In the aftermath of the trauma, because of PTSD triggers present in the healthcare environment, she was unable to return to clinical practice. She went back to college, rediscovered a love of writing and earned a second undergraduate degree in English literature. She is now a science writer and health sciences project coordinator at the University of Pittsburgh School of Medicine. She hopes to use her professional background as a pediatrician, her personal experience as a patient and her skills as a writer to continue advocating for patient safety and for increased awareness of postpartum PTSD.

She wishes to thank James Conway, Jane Roessner PhD and Frank Davidoff MD at the Institute for Healthcare Improvement and Linda Kenney at Medically Induced Trauma Support Services for their steadfast encouragement and support. And she thanks Karen Katunich PhD "for saving my life."

Story editor:

Diane Guernsey

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