Loading summary
Transcript136 lines
- [00:00]
Heather Nixon
This podcast is supported by On Investing, an original podcast from Charles Schwab. Each week, hosts Liz Ann Saunders, Schwab's chief investment strategist, and Cathy Jones, Schwab's chief fixed income strategist, along with their.
- [00:14]
Susan Burton
Guests, analyze economic developments and bring context.
- [00:17]
Heather Nixon
To conversations around stocks, fixed income, the economy and more.
- [00:21]
Susan Burton
Download the latest episode and subscribe@schwab.com oninvesting or wherever you get your podcasts.
- [00:33]
Heather Nixon
I just remember all of a sudden.
- [00:35]
Susan Burton
Just being like, oh, my God, I don't feel good. Previously on the Retrievals.
- [00:41]
Heather Nixon
It was an unfathomable amount of pain. And I remember begging them to stop. And one of the attendings, she looked at me and told me to tell that it was okay. That's one thing I regret the most, that I didn't say, like, it's not okay. I felt horrible and. And then I got mad. And then I got really mad.
- [01:19]
Susan Burton
From Serial Productions and the New York Times, I'm Susan Burton, and this is the Retrieval season two, the C sections.
- [01:30]
Heather Nixon
And I got really mad and I was like, I am going to talk to the provider. I don't even know what to say. I'm so angry.
- [01:41]
Susan Burton
Usually this scene happens in a hospital corridor. There's a template for this. One doctor dressing down. Another maybe shouldering furiously out of an or, stripping off gloves, throwing them into a bin with an emphatic gesture and turning to face their colleague. The one doctor passionate and outraged about what just happened in that room. And another, who we can tell did not make the right choices, but genuinely feels bad. How it happens on our show in real life is Dr. Heather Nixon is at home in pajamas on her day off. She's just learned that her colleague Clara was in agonizing pain during her C section. Heather is the head of obstetric anesthesia. Making sure patients are not in agonizing pain during their C sections is her job. Heather puts in earbuds and calls the anesthesiologist from Clara's surgery.
- [02:34]
Heather Nixon
And I said, hey, what the hell happened to Heather?
- [02:39]
Susan Burton
At first, the anesthesiologist seems confused, but we gave her all these meds, he tells her. The two of them begin reviewing the events. The anesthesiologist says that he'd given Clara an antianxiety drug, midazolam.
- [02:54]
Heather Nixon
He kept saying to me, well, she has anxiety. And so we kept giving her like anti anxiety medicines. And I said, but she was telling you she was in pain. And he's like, oh, well, she had anxiety.
- [03:04]
Susan Burton
She was just very Anxious, the anesthesiologist had repeatedly mislabeled Clara's pain as something else.
- [03:11]
Heather Nixon
It was also, well, you know, the patient was having a lot of pressure. And that's when that word really became a dirty word to me. I was like, yeah, but no.
- [03:23]
Susan Burton
In addition to midazolam, the anesthesiologist had given Clara fentanyl and ketamine. Giving extra drugs is standard when a cesarean patient is in pain. But he'd given way more drugs than Heather would give before making the call that the only way to relieve the patient suffering is to convert to general anesthesia to put the patient to sleep.
- [03:44]
Heather Nixon
And I said, why didn't you just put her to sleep? Like, what was your reservation? And he said, well, I was afraid of losing her airway.
- [03:51]
Susan Burton
General anesthesia is the kind where you get a breathing tube to keep your airway open. But for decades, doctors have been taught that pregnant patients are hard to intubate, that they have difficult airways.
- [04:02]
Heather Nixon
I said, but in any other setting, you would have put this patient to sleep. If you were on the third floor, which is where our men are, and you were doing a cardiac case, you would just put the patient to sleep. You have no fear of that airway. You handle difficult airways all the time.
- [04:19]
Susan Burton
And the problem is that in doing everything possible to avoid general anesthesia, a doctor can create an even more dangerous situation, which is what happened here.
- [04:29]
Heather Nixon
And I was like, well, but you administered, like, four times the amount of meds that we would normally do. Like, didn't you even worry that the patient was gonna stop breathing? Breathing at some point because you're given so much anyway? Like, wouldn't have been better to have a breathing tube in place.
- [04:42]
Susan Burton
When I talked to this anesthesiologist, he said that he felt terrible about this case, but overall, he emphasized that he'd done what, in his judgment, would keep the patient safe. To Heather on the phone that morning, it seemed like the anesthesiologist was rationalizing every choice he'd made. But these weren't just his personal rationalizations. They were collective ones.
- [05:07]
Heather Nixon
He was using all the language, all the culture, all the fears that have been bred into us for years. She's got anxiety, so maybe it's just anxiety. Pressure is normal, right? I gave her all these medicines, so she's not going to remember it. I don't want to harm her with taking on her airway.
- [05:33]
Susan Burton
HEATHER hangs UP what was wrong was not that this doctor had a set of beliefs about C sections that were out of the ordinary. What was wrong was that these beliefs were ordinary. Heather walks across the room to the kitchen, stands in front of the coffee maker. Heather has never had a patient who was screaming, make it stop. She would never let it get to that. Has she had patients who felt something during cesarean? Yes, all the time. Patients who've been uncomfortable? Yes. Patience. Even up to the level of, well, I'm not torturing you, but you're really not. Okay. Yes, that too. She's heard about patients who've felt everything. But to Heather, it always seemed like, okay. The patient felt more than they expected to feel, but they misunderstood because what doctor would allow that kind of suffering? Now she wonders if she's the one with the misunderstanding. Cut to the dining table. It's dark now, Heather's face lit by her laptop. We're not sure whether it's the same day or another, but we have the impression that she's been in this position for hours. She's on social media, TikTok, Reddit, reading accounts of painful C sections. Patients who've been through this say they feel cutting. They feel pulling. And yeah, okay, a doctor will tell you that pulling is normal, but not this kind. They feel outraged that they are screaming in pain and that an attending continues to teach a resident like nothing is abnormal. They feel their organs being moved around. What does that feel like to have someone lifting out your insides? Gross and scary, says one patient. They are given drugs, but the drugs make them not remember. Or they do remember. They remember their vigilance. They remember listening to the monitor, waiting for their heart attack because they are scared they will die from this pain. They get to the point where they want to die. I felt everything. It's not an exacting description, but it gets at the way that this pain is totalizing. Heather is startled.
- [07:42]
Heather Nixon
How do I not know that this happens? How do I not know that patients afterwards are choosing to not go back and have a second baby, are choosing to not have C sections even if there's harm to their child because they're so petrified? How do I not know that a significant number of women do not feel empowered enough to say I hurt? I could have read all those stories on the Internet. I could have looked at all the accounts and been like, oh, well, it was an emergency C section, and so they must have dosed the epidural and it didn't quite work and maybe the obs didn't know and they just started and then of course they went to sleep or something like that, right? Never, ever would I have thought that across the nation, women interoperatively were consistently having tremendous pain. And so that was a moment where I was just like, okay, it happened to this individual who I know and trust. And it's real. It's real and it happens. And I hate to say that that was the moment that I actually realized that.
- [08:52]
Susan Burton
But something has to happen. To shake a person up took a.
- [08:57]
Heather Nixon
Little bit of a toll on me for a little bit. Just to kind of try to figure out, like, okay, how do we, you know, kind of what do we.
- [09:12]
Susan Burton
Medical dramas. They're often used to explore social issues in the writer's room. You work that into the plot. What if so and so got aids? What if there was a pandemic? But for our characters, the social issue isn't being grafted on, it's just what happened to them. Heather closes her laptop. She doesn't yet know exactly what to do, but she knows she's going to do something. With the light from the laptop screen gone, the room is dim and we now fade completely to black. You just realized your business needed to hire someone yesterday. How can you find amazing candidates fast?
- [09:57]
Heather Nixon
Easy.
- [09:58]
Susan Burton
Just use Indeed. Join the 3.5 million employers worldwide that use Indeed to hire great talent fast. There's no need to wait any longer. Speed up your hiring right now with Indeed and listeners of this show will get a $75 sponsored job credit. To get your jobs more visibility at indeed.com NYT just go to indeed.com NYT right now and support our show by saying you heard about Indeed on this podcast. Indeed.com NYT terms and conditions apply. Hiring Indeed is all you need.
- [10:27]
Heather Nixon
Don't just imagine a better future.
- [10:28]
Susan Burton
Start investing in one with betterment. Whether it's saving for today or building wealth for tomorrow. We help people in small businesses put their money to work. We automate to make saving simpler. We optimize to make investing smarter.
- [10:41]
Heather Nixon
We build innovative technology backed by financial experts. For anyone who's ever said, I think.
- [10:46]
Susan Burton
I can do better. So be invested in yourself. Be invested in your business. Be invested in Better with Betterment. Get started@betterment.com Investing involves risk. Performance not guaranteed. If you could hear love, what would it sound like?
- [11:10]
Heather Nixon
Son, can we talk about your drinking?
- [11:14]
Susan Burton
Yeah, Dad, I think we should. Helping those closest to you think about their excessive drinking. Maybe that's what love sounds like. More@rethinkthedrink.com An OHA initiative. Why would a patient be in severe pain during a C Section? One kind of answer is something like the doctor didn't Listen to her. And that might well be a play in an or. But why would her block, why would her epidural or spinal fail to begin with? There are all kinds of reasons, like maybe the needle was inserted off center, maybe the catheter moved, maybe the doctor underdosed it. When a block fails, there are lots of things anesthesiologists can do to fix the problem. But the fact that this is a problem, the fact that blocks do fail, comes as a surprise to most patients. What also comes as a surprise is that even when a block is working properly, it's unlikely to numb you 100% all the time. Heather gets the question. I'm not going to feel anything, right? Well, you might. You might feel pressure, including pressure from deep inside your abdomen. This is the origin of that phrase. It's just pressure. But pressure can be painful. The sensation a patient feels during a C section is most often mild, bearable, and limited to certain parts of the surgery. But there's a whole range. What might be tolerable for one patient might be excruciating for another. The only thing that will knock out all sensation is general anesthesia. If you or your mother had a cesarean before the 1980s, there's a good chance you had general. But general has not been the first choice for caesarean. For a long time, it carried risks for pregnant patients. Some people I spoke to pointed to a 1997 paper that showed a way higher mortality rate for general anesthesia during cesarean as a turning point. That led to the teaching avoid general at all costs. Others observed that it had been falling out of favor for decades before then. General is a lot safer now than it used to be, and any anesthesiologist who does cesareans regularly is likely to be comfortable using it. But on the whole, the taboo against it remains strong pain during a C section won't kill anyone, but general anesthesia might. And maybe nobody has ever died on the operating table from C section pain. But plenty of patients have fewer. They would. There are all these common phrases. Doctors say during cesarean, we're almost finished. It's just a few more minutes. What's clear from patient accounts is that these phrases are as dirty as it's just pressure. Because for the patients who feel pain during cesarean, the experience isn't finished after they leave the or. It isn't just a few minutes that people are affected by this. And now one of those people is Clara. Clara stays home with the twins for four months, and then her leave is over. Shot of the Staff elevator opening. Clara and the crowd stepping out onto the fourth floor. Clara's not just going back to work. She's going back to the site of what happened. And as soon as she arrives, she is flooded with rage. I mean, even the sight of the.
- [14:54]
Heather Nixon
Logo made me angry. Walking in the hall made me angry. I couldn't believe I had to be.
- [14:59]
Susan Burton
There and couldn't believe I was back. Everything about it made me so mad.
- [15:04]
Heather Nixon
You know, that feeling of, like, this thing happened and the world is still moving, you know, spinning. It's that thing, right?
- [15:10]
Susan Burton
Yeah. Claire's anger was diffuse. Anger at the system that allows this to happen. Anger that it had happened to her.
- [15:20]
Heather Nixon
But there was also welcoming, caring co workers. Right. You come in, they're so happy to see you. How are you? How are your baby? Show us the pictures.
- [15:33]
Susan Burton
In the hallway, a co worker in scrubs comes toward Clara with outstretched arms. Clara pulls out her phone. We see this happen again in almost identical sequence. Clara beaming. And then we see Clara frozen in her tracks outside the double doors that lead to the ORs.
- [15:51]
Heather Nixon
She did not. She could not go back to the operating room. And it was kind of understood again.
- [15:57]
Susan Burton
Mindy, the nurse who'd taken photographs of Clara's surgery, she and her co workers felt protective of Clara.
- [16:05]
Heather Nixon
And in the beginning, it was a very understanding environment. People would adjust their assignments. But after a while, it started becoming like, I mean, I'm not a charge nurse. I don't make assignments. But I would hear, like, okay, like, when what is happening? Like, is this still a thing? Can she go back to the operating room? Because you can't have restrictions, honestly. Like, there's only a few nurses, like, for terminations or abortions that have stated their medical, religious beliefs. But going into an operating room is part of your job description and part of, you know, it was never official, because if it wasn't official, like, I cannot go into an operating room, then I think she would not have been able to continue working labor and delivery.
- [16:56]
Susan Burton
And almost every day, Clara did wonder whether she could keep working this job. You could say she had occupational retraumatization, or you could say reminders of her surgery were everywhere. Except for one significant one. Clara never saw the anesthesiologist from her C section around the hospital, which didn't surprise her. He wasn't an obstetric specialist, and he mostly worked on a different floor. She'd never seen him before that night anyway. But she wondered about him within a.
- [17:28]
Heather Nixon
Few weeks or a month of being at work. I went to the records office to get my records. Of course, they sent me, like, gobbledygook.
- [17:37]
Susan Burton
It didn't mean anything. And afterwards, at some point, I actually.
- [17:40]
Heather Nixon
Just went in my chart and navigated.
- [17:43]
Susan Burton
To that day and I saw his.
- [17:46]
Heather Nixon
Name and I googled him. But he's just a doctor.
- [17:51]
Susan Burton
It's just a. Whatever. Anesthesiologist, yeah. Did your records reflect, like, did they accurately reflect what happened to you? No.
- [18:01]
Heather Nixon
Nothing about it is in there.
- [18:04]
Susan Burton
There's nothing in the surgical report that says anything. It was as if it hadn't happened. In the surgical report, there was no record of Clara's pain, of her own experience. There's a phrase in medicine, a relatively new one, the patient experience. It's meant to capture the idea that it's not just the outcome of the treatment that matters, but what the patient feels during it. It's a well intentioned phrase, but it's odd that it needs to exist. Like it's a name for something that had been left off the list. Guys, the patient's experience. Oh, shit. Of course, there was someone at the hospital who'd been thinking a lot about the patient experience. Heather. Now we see Heather in her office on the third floor. Black leather couch, hot pink pillow. Heather has been sleeping here some nights, and not just because of her clinical schedule. She's been working on a speech. A speech? A speech is a staple of TV storytelling. A character using a ritualized occasion to get up there and deliver an indictment or something inspiring. To call out bad behavior or to uplift or to tell one special person how they felt. All this time, the whole past four years, the occasion for Heather's speech is a medical conference. And this next thing will sound like an improbable coincidence, because in fact, it was. Before Clara's surgery, Heather had been assigned to prepare a speech on pain during C sections for a major national conference. She'd planned to focus on technical tips. Then Clara's C section happened, and a how to started to seem beside the point. Over the years, at conferences, Heather had sat through dozens of lectures on things like the optimal drugs to put in your spinal. And Heather appreciated these lectures. But it was like all this time, people had been talking around something rather than saying it directly. And a lot of ors patients are in pain. Pain during cesarean was a subject that had been getting a little buzz around it. There was a reason that this had been assigned out for a speech. A doctor who'd begun to do research on it told me that for a long time it had been a Hush, hush topic. Something that caused discomfort, maybe because she said, no one wants to say. I had a patient under my career, and I watched her be in pain. But look, we've all been in this situation. Heather imagined she could say, and no one feels good about this, right?
- [20:47]
Heather Nixon
Like, it's not like we're all just like, oh, everything's fine, and looking up at the ceiling. We're all like, ugh. We're all groaning internally saying, I'm very uncomfortable with this and not listening to that discomfort. This is okay, you know, we're going to get her out of here. It's going to be fine. Can we just finish?
- [21:03]
Susan Burton
Right back when Heather was a resident, no one had talked about cases like this.
- [21:08]
Heather Nixon
Instead, you'd go home and you'd have a glass of wine because you were like, ugh, that was rough. Like, I didn't like that.
- [21:15]
Susan Burton
Though a lot has changed since then, there's still not as much frank talk about this as there should be. And that was what Heather wanted to try at the conference.
- [21:24]
Heather Nixon
Like, let's rip the band aid off and, like, really have an honest discussion about why is this happening?
- [21:30]
Susan Burton
Heather wasn't sure if this would work. It depended on the willingness of people to actually stand up and come to the microphones and speak, to risk the judgment of their peers for choices they'd made in the OR or hadn't. Some doctors in the audience would be aware of pain during cesarean as a growing concern. Others maybe wouldn't have a sense of the true scope of the problem because in their own practices, in their own institutions, they pain was well managed. But even the people who thought they had it right, did they really. Did they really know what was going on for their patients? This kind of thing would not be typical for this conference at all. Heather worried that people would judge her for standing on a scientific stage with an unscientific speech. But over the past several months, she'd come to understand that this problem wasn't limited to extreme cases like Clara's. The problem was that pain during cesarean had been normalized to varying degrees. It was happening all the time, and patients were being harmed by that. She needed her colleagues to see what she had.
- [22:37]
Heather Nixon
I'm not going to make this a scientific presentation. I am going to make this something that is emotional because for the patient, it is right. The consequences are emotional and devastating. And I want the audience to feel that. I want everyone to be a little horrified. I want everyone to be a little outraged. I want everyone to be like, yep, we gotta fix this. Yep, there is a problem. They need to have the same eye opening moment that I've had that I can't believe that I'm just having and.
- [23:08]
Susan Burton
Now we see Heather's flight to the conference soaring up into the air because why not? What happens when she lands? That's coming up after the break.
- [23:23]
Heather Nixon
Ollie knows the back to school chaos all too well. Schedules, carpools, relearning algebra 2.
- [23:30]
Susan Burton
It's a lot for you and your crew.
- [23:31]
Heather Nixon
Ollie makes wellness an easy and delightful part of your routine. Need immune support?
- [23:36]
Susan Burton
Kids will enjoy Try kids multi plus.
- [23:38]
Heather Nixon
Probiotic Is bedtime a struggle? Go with kids sleep for gentle support Moms support your immune system, nutrition and more with women's multi Grab these products@ollie.com or retailers nationwide. These statements have not been evaluated by the Food and Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.
- [23:58]
Susan Burton
This is a true story.
- [23:59]
Heather Nixon
It happened right here in my town.
- [24:02]
Susan Burton
One night 17 kids woke up, got out of bed, walked into the dark and they knew never came back from.
- [24:10]
Heather Nixon
The director of Barbarian.
- [24:12]
Susan Burton
A lot of people die in a lot of weird ways. You're not going to find it in the news because the police covered everything.
- [24:18]
Heather Nixon
Lola Onokus Dave.
- [24:22]
Susan Burton
This is where the story really starts. Weapons Rated R Under 17 not admitted without parent Establishing shot of the Sheraton New Orleans. The scene is a standard medical conference. Doctors mill around in enormous open space drinking coffee, wearing lanyards at Soap 2023, the annual national conference for obstetric anesthesia.
- [24:47]
Heather Nixon
Today we have some excellent talks for you. First up we're going to have now.
- [24:50]
Susan Burton
We see Heather on stage in a ballroom, a Jumbotron on either side. She's wearing a pale blue suit.
- [24:57]
Heather Nixon
Good morning everyone. So we've had some changes in the.
- [25:01]
Susan Burton
It'S 8am on a Saturday. Doctors are still filing into the room. This year at SOAP, there are over 300 presentations of papers and 20 main stage talks and panels. Of those talks, only one is on intraoperative pain during caesarean. Heather's Heather begins with a play on the phrase that everyone will say in their own talks. It's literally in the rules that you have to do it.
- [25:27]
Heather Nixon
I have no financial disclosures to make, but I do have several disclosures to make.
- [25:32]
Susan Burton
Her disclosures are that this will not be a usual talk at all.
- [25:37]
Heather Nixon
My actual disclosures include audience participation is absolutely expected. So I hope you have your coffee in hand because I feel like this is a topic that there's really not a lot of consensus on. We don't have strict guidelines. There is a spectrum of practice. There's maybe some misinterpretations, and we need to all get on the same page about how we approach this. And then finally, some of the content may be very graphic or explicit. It may be a little disturbing. And I'm hoping that's the case because I'm trying to generate some urgency around this issue. So we're going to start with a story. My story starts with a patient named Jennifer. She's admitted to L and D at 37 weeks for a twin gestation.
- [26:27]
Susan Burton
Jennifer is Clara. Heather had asked Clara's permission to use her story for the speech and promised to de identify her. Heather narrates through Jennifer Clara's labor, the decision that she needs a C section, the move to the or.
- [26:43]
Heather Nixon
We start the C section. Babies delivered. After that, it gets a little dark.
- [26:50]
Susan Burton
Heather says that the patient starts moving around, that she starts to feel pain, that the anesthesiologist gives her additional meds.
- [26:59]
Heather Nixon
Jennifer gets 150 of ketamine, 300 of fentanyl, and 6 of midazolam.
- [27:07]
Susan Burton
We see a couple reaction shots. One doctor even withdraws a little in her chair. And we understand how out of range these doses are. On the Jumbotron behind Heather, we see an eerie grayscale image of a cesarean delivery. PowerPoints for presentations. Normally, you're showing graphs and data, but the only information Heather wants to convey right now is feeling. Heather continues with the horror of the surgery through to the moment. An obstetric colleague showed up for his morning shift, and the nurses grabbed him and pulled him into the or.
- [27:44]
Heather Nixon
He looks at the OB fields. He sees that they're on skin. Walks to the front of bed, and he sees a father who has an ashen face, is shaking, and a patient who is thrashing with tears falling down her face. So he takes. Unfortunately, it's the end of the case. There's not much he can do. Takes the patient to the pacu and I get a call. Okay, so I kind of tipped my hand in saying this is not some ethereal case. This happened on my unit. This is why I'm here today. But what if I told you that the patient was a colleague and someone who worked on L and D? Horrific. And so when I went to her, she wasn't really ready to talk about it. And I said to her, I'm going to do something about this. I'm going to make sure that this doesn't happen again. But I need your help. And when you're ready. I'd like you to give a statement. So here's Jennifer's statement. I want them to know that for weeks after birth, I could not close my eyes without hearing my screams in my head. I want them to know that I could not wash my own incision when my husband came near to wash it because she had to ask him for help, because she couldn't physically touch it without her hands locking up. I was scared. There were wrenching sobs every time I needed to wash it. She had a visceral reminder of her pain on her body. I want them to know that despite all the fucking ketamine and whatever else, I could still feel pain. I was just hallucinating and could not make sense. But I can remember begging them to stop.
- [29:42]
Susan Burton
Usually at a medical conference, people are typing on their laptops or holding their phones up to the screen to take pictures of the slides. This room is still.
- [29:53]
Heather Nixon
So this is a harrowing story. It made me mad, it made me sad, it made me frustrated, and it made me really take a deep dive into what is going on in our country. If you go to Google and you search intraoperative pain for cesarean delivery, you will see horror stories across this country. And this is really staggering because nowhere else in anesthesia do we allow this to happen. Nowhere. Right. If you have a block that doesn't work for an ortho case, your patient goes to sleep. We don't suffer through it. We don't bite the bullet. We don't ask our patient to just take it. So I'm going to ask, just this room at this moment, how many people in the last month have had a patient who's had severe interoperative pain?
- [30:43]
Susan Burton
There are hundreds of people in the room. We watch as half of them raise their hands. Half. Heather had asked how many people in the last month had a patient who had severe pain during their C section? And half of the doctors raised their hands.
- [30:58]
Heather Nixon
Okay, so this is not rare. We have a group of experts in the room who clearly are experiencing this on a daily basis. And we're just beginning to talk about it.
- [31:10]
Susan Burton
And it's crazy that we're just beginning to talk about it because it's a known problem. Heather says she ticks through all the different kinds of knowing. There's medical literature, there's litigation, there's doctors own experiences in the operating room. So what that means is that there's an active kind of not knowing. And that act of not knowing is as much of a problem as the pain itself.
- [31:34]
Heather Nixon
So how do we Fix this. How do we think about this? And how do we change what's happening? So why is this happening? All right, I'm going to assume that everyone in this room is passionate about what they do. They love obstetric patients. They're here to learn. They want to do the best. And I'm going to assume that no one gets into medicine to hurt people. Okay? We want to help people. So what is the disconnect?
- [31:59]
Susan Burton
Heather's put the questions to the group plainly. How willing they'll be to wrestle with them is anyone's guess. She opens the discussion to the room. The first person to speak is a doctor from New York City named Dan.
- [32:17]
Heather Nixon
When we think about why this happens, I think there is this specter in the back of our heads that says, oh, crap, the spinal's not working. If I have to induce general anesthesia, there's a chance, because we've all been. We all have ptsd, that the pregnant airway is horrific, that I'm going to lose the airway and the mom will die. And I think that is what is. I mean, I'm going to say it. That is a fear of mine, that I will lose the airway and then they'll be like, well, yeah, she was uncomfortable, but maybe you could have muscled through and at least she'd be alive. And so that is the balance that I find when I'm dealing with this in the operating room. And I don't know if other people have had that same discussion in their head.
- [33:01]
Susan Burton
No warm up, no superficial comments before the room really gets going. Dan goes deep straight away. Sometimes I'm scared. He's saying, I'm scared of the biggest thing of all. And in that situation, it seems like the better choice is pain. Heather meets Dan's vulnerability with some of her own.
- [33:22]
Heather Nixon
So I think that that's a wonderful point. We were taught since we were. I mean, since fellowship, since I was a baby, I was taught, don't take on the air. Pregnant is the big bad wolf. Stay away from it. This is how moms die. You'll never recover. The family will never recover. And so especially towards the end of a case, you might be like, do I really need to?
- [33:44]
Susan Burton
Right?
- [33:45]
Heather Nixon
This is the gray area that's ugly and it doesn't feel good. And at the end of the day, I don't feel satisfied with my job because maybe I did the right thing, maybe I didn't. And I'm honest enough to admit it. I've been in that situation since several times where I've looked At this and been like, do I really want to do this? Even when the patient maybe had some.
- [34:03]
Susan Burton
Discomfort from the stage, Heather sees one of the women she trained with in fellowship giving her a look like, same people start lining up behind the mics. There's a doctor who practices in New Jersey.
- [34:19]
Heather Nixon
So that for me, it's not just about all the patient's comfortable or she's just exaggerating. It's sometimes that fear that if I do get into a general anesthesia, no one knows how to help me.
- [34:33]
Susan Burton
And. And there's Zevi.
- [34:35]
Heather Nixon
I'm Zevi. I'm also from New York City. I actually really appreciate your point about saying the quiet part out loud where we're here.
- [34:43]
Susan Burton
The part that spinals and epidurals can fail. When do you tell the patient this thing that you know to be true, but that may sound so alarming to them? These things fail. Wait, what? You're telling me this now?
- [34:56]
Heather Nixon
I was wondering how many people actually say that in the pre op discuss that spinals and epidurals actually fail. And if they do fail, we test for it and we have options to fix it beforehand, even before, like during your consent process. So I'm Andy, I'm from Stanford. I just wanted to share one of my techniques. Sometimes I. I either have a patient where maybe there's a language barrier, they're exhausted, they're really scared, and I think my block is working right because my block's gonna work, but, you know, to take my ego out of it.
- [35:30]
Susan Burton
We are tight on Andy's face so that you can see she's being self deprecating, not cocky. Gently reminding the group to be alert to their own hubris. Doctors continue to come forward, asking questions, offering tips, letting out frustrations intraoperatively.
- [35:46]
Heather Nixon
I think that the pain versus pressure question is a trope that I really hate in our specialty, but to sort of give the patient the feeling of, don't worry your pretty little head about this. It's fine. That is horrible.
- [35:59]
Susan Burton
It is horrible to not feel listened to.
- [36:02]
Heather Nixon
And so I think we all have to.
- [36:03]
Susan Burton
Heather had been worried that there would come a moment like, okay, it's great we're talking about this, but what do we do? Where's the algorithm we follow if a patient is in severe pain. She wasn't sending anyone off with an algorithm to follow because that algorithm didn't exist. And it's clear that the audience is eager to come up with solutions. There's a lot of crowdsourcing. Heather and others talking about everything from specific doses of medicine to styles of communication. Heather has scoured the medical literature for relevant research on this. But for today, the goal is not to settle on a fix. This is steps to solve a problem. Step one, talk about the problem. That was what Heather wanted, and apparently it was what the room had wanted, too.
- [36:51]
Heather Nixon
First of all, thank you for this session.
- [36:54]
Susan Burton
When I come to SOAP meetings, I.
- [36:56]
Heather Nixon
Always think of all the sessions and what are some of the points and.
- [37:00]
Susan Burton
Concepts that I can take home and actually use in my practice Monday morning.
- [37:04]
Heather Nixon
And this, if there's ever a session that's worth missing the coronation of King Charles for, this is it. So thank you.
- [37:14]
Susan Burton
But the comment, there's been a number of. Turns out, what's hard is not getting people to talk about this. What's hard is getting them to stop.
- [37:23]
Heather Nixon
So you guys have exceeded my expectations in the audience participation. So hold where you are right now as next. Okay. And then I'm going to get through just a little bit more material and then I'll ask. I'll take your question or comment. Okay? So one of the things that when I talked to Jennifer, she said, where were my obs? Why didn't they say anything? When we did the M and M on this case, when we asked the obs, what were you thinking? One of them said, it was horrific. It was horrendous. And they never said a word. Everyone in the room knew something was wrong.
- [37:59]
Susan Burton
They.
- [37:59]
Heather Nixon
And no one said anything except the patient and the patient's husband.
- [38:05]
Susan Burton
The audience is quiet. They've also been in ORs where it felt impossible to intervene. They know there are dynamics in that room that can make it hard for people to speak. That morning of Clara's surgery, there were at least 13 people in the OR. The surgeon, the OB resident, the attending anesthesiologist, the anesthesia resident, the scrub tech, the circulating nurse, a backup nurse and NICU nurse. At least two other NICU specialists. Clara, Clara's husband, and Mindy. Mindy cut to the hospital now, the nurses station. We're back at uic. We see Heather's image on a computer monitor. And Mindy and other nurses gathered around.
- [38:51]
Heather Nixon
Like, they just told us, like, hey, guys, Dr. Nixon's giving a talk about intraoperative for Tif Payne. You guys should join. So, like. But we didn't know exactly what it was going to be, that it was going to relate to our department specifically at the beginning of that presentation. And we all sat there like pins drop when we heard her say, what if it was a staff member? And she was a nurse, and Clara was there that day. And Clara was in the back hallway somewhere. And we all, like, were looking at each other like, it's about Clara. And we were all like.
- [39:28]
Susan Burton
We see Clara now alone in an empty office. She's not hiding. She's protecting herself. She knew this talk was on the calendar for today. It's actually not the day of the soap talk. It's a day. Heather gave a similar talk for grand rounds at UIC.
- [39:44]
Heather Nixon
And then when the whole story dropped that Dr. Nixon did a presentation on her, I think we asked her if she was okay, and she was just like, yep, and walked away. So it was like, all right, she doesn't want to talk about it.
- [39:58]
Susan Burton
And Clara didn't. The reason was that she often blamed herself for the pain. Maybe it wouldn't have happened if you hadn't insisted on trying for a vaginal birth. If you'd been more prepared, if you'd moved your body more, if you hadn't been so hysterical. All of this might have surprised her co workers, but it wouldn't have surprised anyone familiar with birth trauma.
- [40:24]
Heather Nixon
So I'm Traci Vogel, and I'm from Pittsburgh, and my career path is taking me in a very different direction.
- [40:30]
Susan Burton
Cut back to the hotel ballroom. Close on a doctor in the aisle at the mic. Traci trained in OB anesthesia at Stanford, but after 20 years, she got to the point where she was seeing so much trauma that she felt like she could make a bigger difference treating that trauma than offering anesthesia.
- [40:47]
Heather Nixon
I'm the director of a perinatal trauma informed care clinic. I think there are two in the country right now. There's so much to say. I wish every seat in this room and this lecture was being televised or, you know, the video went to every anesthesia provider. Because I can tell you this happens.
- [41:08]
Susan Burton
A lot more than you think it's does.
- [41:11]
Heather Nixon
I. I can't stand here and over overemphasize the impact that this has on individuals, their relationship with their babies in.
- [41:22]
Susan Burton
The terms of decreased bonding, decreased breastfeeding success.
- [41:26]
Heather Nixon
You mentioned the husband in this room, the impact on him, on the partners, on their relationships. Believe me, I've worked with so many women I see, I hear 11 traumatic stories a week. These are individuals that go on to get divorced.
- [41:41]
Susan Burton
They don't. They can't even care for themselves.
- [41:43]
Heather Nixon
It rocks relationships, the mental health complications. I have women who are still having.
- [41:50]
Susan Burton
Suicidal ideations years later.
- [41:53]
Heather Nixon
Their birthdays of their children become nightmares. The impact is so severe.
- [42:05]
Susan Burton
Heather's talk lasts 90 minutes. And before she leaves the stage, let's take the temperature of the room. Close up of a doctor, peering at us with momentary surprise through his glasses. He practices on the island of Newfoundland. He's been live tweeting Heather's speech swing to another doctor, this one from Texas. For him, pain during cesarean never became normal. He has a presentation he gives to small groups called Just Put him to Sleep. And over here, this woman. For years, she'd been focused on pain after cesarean. That's where a lot of them were. But recently, she actually wrote an editorial titled are We Finally Tackling the Issue of pain during Cesarean Section. And just one more, doctor. Long blonde hair. Her uterus ruptured during labor and she felt it. She'll start crying if she talks about it. She grew up in a rural town, and the pain inside her body was the pain of a branding iron. And as they rolled her into the OR for an emergency Caesarean, she was scared her anesthesia wasn't going to kick in in time, but she resolved not to say anything if it didn't because she didn't want a single minute to be wasted. She didn't want her baby to die. Her anesthesia did work, but that experience taught her something subtle and important, that even when a cesarean patient is in excruciating pain, she may not report it. What Heather has just articulated, it speaks to these doctors and, safe to assume, wide shot now, to most of the hundreds of others in the room. But what about all the people not here? Let's back out of the ballroom now into the large, carpeted, empty open space. The people inside that ballroom either specialize in obstetric anesthesia or just love it. But there are only several hundred OB anesthesiologists in the whole country. The rest of the 50,000 anesthesiologists in the US the ones you're more likely to deliver with if you're delivering a baby just based on numbers, would they feel the same urgency about this? We're in the elevator now, going down. And how about all the obstetricians, the nurses, everyone else in the or, the whole team? And even if you do get all those people on board, which, again, tall order, what do you actually do to change an entire culture? What are the concrete steps you take to do something that abstract? What are the solutions? Elevator door opens onto a new location. We step out, not into the hotel lobby, but into a rural landscape. A woman in tall rubber boots is walking three glossy black retrievers through a muddy field Heather wondered, how do you solve this problem? On the other side of the ocean, up north in the English countryside, a former wedding photographer with no medical training have been quietly working on the answers. That's on the next episode of the Retrievals. The Retrievals is written and reported by me, Susan Burton, and produced by me, Julie Snyder and Ben Phelan. Julie edited the series. Ben did research and fact checking. Be sure to sign up for our newsletter, where each week we'll share more reporting from the show, listener stories and reading lists. Go to nytimes.com serialnewsletter music supervision sound design and mixing by Phoebe Wang Original music by Dan Powell, Fritz Myers and Nick Thorburn Additional music in this episode by Marian Lozano. Carla Pallone composed our theme song and it was remixed by Dan Powell. Additional production by Mac Miller Additional mixing by Katherine Anderson Editing help on this episode from Jessica Weisberg and Jen Guerra. Our standards editor is Susan Wessling. Legal review from Dana Green. The art for our show comes from Pablo Delcon and Eric Tanner. The supervising producer for Serial Productions is Inde Chubu. Additional producing comes from Mahima Chablani, Jeffrey Miranda and Cory beach at the New York Times and Sam Dolnick is deputy managing editor of the New York Times. The doctors who came to the microphone during Heather's talk include Dan Katz, Bill Kamen, Emily McQuaid Hanson, Andy Traynor, Zevi Hamburger, Klaus Kallier and Tracy Vogel, whose trauma informed care tools are online at the Empowerment Equation. Other doctors whose presence I alluded to include Simon Asch, Mike Hofkamp he's the doctor with the Just Put him to Sleep presentation Ruth Landau, author of the Are We Finely Tackling Editorial and other important work on pain during Cesarean and Laura Sorbella. Special thanks as well to Susan Beachy, Lawrence Senn, Rebecca Meinhart, Brinda Kamdar, Purvis Sultan, Alicia Biitoub, Leah Shah Damarin, Diane Wong, Genevieve Gallarneau and Anna Whelan, a maternal fetal medicine specialist who's written about returning to work on L and D after birth trauma. The Retrievals is a production of Serial Productions and the New York Times.