The Retrievals S02 - Ep. 4

Summary

The Retrievals S02E04: "The Solutions" – Detailed Summary

Introduction: A New Season of Change

In Season 2, Episode 4 of "The Retrievals," titled "The Solutions," host Susan Burton delves deep into the evolving landscape of pain management during cesarean sections (C-sections) at the University of Illinois Chicago (UIC) Hospital. This episode explores the cultural shifts within the Labor and Delivery (L&D) unit, driven by dedicated healthcare professionals striving to enhance patient care and communication.

Introducing Corey: The Heart of the Unit

The episode opens with the introduction of Dr. Corey de Burgrave, a charismatic anesthesiologist beloved by the L&D team. Corey’s arrival each morning is met with enthusiasm from the staff, highlighting his integral role within the unit.

• Sue (Susan Burton): “I was wondering how many people actually say that spinals and epidurals actually fail” [01:08].

• Corey: “I walk through that door, it's always kind of like a. Okay, like I'm doing something right, because these people are relieved and happy to see me” [02:09].

Mindy, a nurse on the unit, affectionately describes Corey as the "unit baby," emphasizing his rapport with both patients and colleagues.

• Mindy: “Corey is our baby. He is the unit baby. He was a resident with us. He just vibed with us” [02:35].

Clara’s Transformation and the Push for Change

Clara Steele, a patient who underwent a C-section, returns with a transformed demeanor and appearance, symbolizing confidence and resilience. Her experience becomes a catalyst for questioning longstanding practices surrounding pain management during C-sections.

• Clara: “Stop. Like, I didn't understand that. I could simply say, you need to stop. She's not okay” [03:52].

Clara highlights a pivotal shift in the unit's culture, where patients feel empowered to voice their pain and discomfort without fear of dismissal.

Heather’s Initiative: Redefining Pain Management

Dr. Heather, an OB anesthesiologist, spearheads significant changes aimed at improving pain management during C-sections. She emphasizes the importance of both verbal and systemic approaches to address patient pain effectively.

• Heather: “I want to highlight here that even though I've been doing this for 15 years, I'm still learning. I'm still uncovering things that I think I maybe missed the boat on, that I thought I was being empathetic” [07:25].

Heather introduces a systematic approach to pain assessment, integrating regular pain score reminders and detailed documentation within the electronic medical records (EMR). This system not only prompts healthcare providers to address pain proactively but also gathers valuable data for future research.

• Heather: “OK, we're gonna go to sleep, no problem. She said, I don't wanna go to sleep” [10:00].

Teaching the Next Generation: Empowering Residents

Heather conducts a class with anesthesia residents, challenging them to reconsider their perceptions of "difficult" patients. Through interactive discussions, she reveals that patients labeled as difficult are often those who advocate strongly for their own comfort and well-being.

• Heather: “Patients don't feel listened to, they don't feel respected. They don't feel like they have a voice” [09:44].

Residents share their experiences and confront their biases, fostering a more empathetic and patient-centered approach to care.

Corey’s Compassionate Approach: A Case Study

Corey narrates an intense experience with a C-section patient who initially resisted anesthesia. Faced with an emergency, he breaks professional norms by addressing her with informal language and empathy, ultimately persuading her to accept pain management.

• Corey: “She was resistant, but she knew that she was putting herself and her baby in danger” [11:48].

This anecdote underscores the effectiveness of genuine human connection in overcoming barriers to patient care.

Implementing Heather’s System: Measuring What Matters

Heather's innovative system mandates regular pain assessments every 15 minutes, triggering alerts for scores above three and requiring follow-up questions about the nature and location of the pain. This approach ensures that patient pain is consistently monitored and addressed.

• Heather: “If you're not having pain, you're not reminding them of anything” [22:45].

Despite initial pushback, the system has been lauded for fostering better patient outcomes and providing a wealth of data previously absent from medical literature.

Legal Implications and Racial Disparities in Pain Management

The episode delves into the legal challenges surrounding pain management during C-sections. A notable case, Delfina Mota versus United States of America, illustrates the courtroom skepticism faced by patients asserting they experienced unmanaged pain.

• Judge’s Ruling: “The plaintiff's version of the events is not credible” [31:08].

Furthermore, the episode highlights racial disparities, citing a Texas study where Black patients reported C-section pain five times more often than White patients. Clara reflects on the lack of discourse around race and pain, emphasizing the need for broader conversations and systemic changes.

• Clara: “And it should never happen to one of your own” [41:54].

Changing the Culture: Empowerment and Advocacy

Clara, Mindy, and Heather exemplify the new culture at UIC, where speaking up and advocating for patients is normalized and encouraged. Mindy questions fundamental practices, pondering alternatives to awake C-sections and advocating for patient preferences.

• Mindy: “Maybe some women truly prefer not to be awake, and we push them towards being awake during C section” [34:00].

This collective effort not only enhances patient care but also serves as a model for other institutions aiming to prioritize patient experiences and outcomes.

Conclusion: Stories as Catalysts for Change

Susan Burton concludes the episode by emphasizing the power of storytelling in driving medical and cultural transformations. Clara’s story, intertwined with the narratives of Corey, Heather, and Mindy, illustrates how personal experiences can challenge and ultimately change entrenched medical practices.

• Sue (Susan Burton): “Stories are also a kind of evidence. They too can change the way doctors practice medicine” [42:19].

The episode underscores that while systemic changes are essential, the human stories behind these changes are equally vital in fostering empathy, understanding, and continuous improvement in healthcare.

Final Thoughts

"The Retrievals" Season 2, Episode 4: "The Solutions" offers a compelling exploration of pain management during C-sections, highlighting the importance of communication, empathy, and systemic interventions in improving patient care. Through insightful discussions and real-life examples, the episode advocates for a more compassionate and patient-centered approach in the medical field.

Transcript

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[Sue]

Previously on the Retrievals.

[Mindy]

I think that smile was like, I'm having my babies. You made it to take my pictures. You're here. You're one of me, one of our team.

[Heather]

But what if I told you that the patient was a colleague and someone who worked on L and D? Horrific.

[Sue]

Did your records reflect? Like, did they accurately reflect what happened to you? No.

[Clara]

Nothing about it. Isn't there?

[Corey]

I was wondering how many people actually.

[Heather]

Say that in the pre op discuss.

[Corey]

That spinals and epidurals actually fail. Even before, like, during your consent process.

[Sue]

Everybody had been making the same mistake.

[Juliette]

Everybody, not one of them had been.

[Sue]

Asking their patients from Serial Productions and the New York Times. I'm Sue. Hi, I'm Susan Burton. And this is the Retrievals, season two, the C sections. Speaking of seasons, it's been so long since we've been at the hospital that it's almost like we're on a new season of our medical drama. A lot has happened to our character since we left them in the months after Clara's C section. In fact, we have another character to add to the ensemble. Corey. Remember the anesthesiologist who arrived for a shift just as Clara's surgery was ending? Let's bring Corey on stage. Dr. Corey de Burgrave, Interior Hospital. Morning.

[Corey]

Because when I show up at 7am and I change into my scrubs and I go up to the fourth floor and I walk into that, I open those doors, I walk in and there is like. And everyone, all the nurses, everyone yelling like, oh, my God, Corey. Oh, my God, we're so happy you're here. Oh, my God. Sit down. We gotta talk.

[Sue]

This entrance, it's not just ginned up for the season opener. It's a regular occurrence on L and D. Look, there's Mindy. She'll tell you.

[Mindy]

Corey is our baby. He is the unit baby. He was a resident with us. He just vibed with us. He sits in the nurse's station and gossips with us. We've even gone out drinking Together. He's been at parties. He is our baby. And when we heard he was gonna be in attending, we were all ecst. And he's just great with women and patients, and you just trust him immediately. He's adorable to look at, too. So.

[Corey]

I walk through that door, it's always kind of like a. Okay, like I'm doing something right, because these people are relieved and happy to see me.

[Sue]

Relieved. That's how Clara felt when Corey walked in at the end of her surgery. And, oh, here's Clara now. Amazing haircut, Mia Farrow, and Rosemary's baby vibes. This will be her new look for the season. Clara's look isn't the only thing that's new on the unit. She says the culture around pain during cesarean is changing, and there's a lot of parts to this. But there's also a simple way to get at just how profound the shift is. It comes down to one word, One word that in the before times, Clara wouldn't have felt able to say during a C section.

[Clara]

Stop. Like, I didn't understand that. I could simply say, you need to stop. She's not okay.

[Sue]

Yeah.

[Clara]

And the other part of it is that the team is more responsive. So the surgeons themselves. Before, normally, no. That is anesthesia's job. We have our job. We're going to focus on that. But now, I mean, in my experience, I say, if you can stop, stop. She's not okay. They are very, very quick to say, oh, thank you for telling us.

[Sue]

Uh huh.

[Clara]

We can pause here. Absolutely. Everybody in the room is so much more receptive to it.

[Sue]

Sometimes it's not so easy to stop, but there are other times you can. Stopping can be awkward. Everyone's standing there silently, arms crossed, just waiting for the several minutes it might take for the meds to kick in. A nurse might be challenging a hierarchy to say stop. I am concerned it can feel that way for an anesthesiologist, too. Maybe they're working on the kind of unit where the surgeon rules the roost. But there are all kinds of power dynamics. A younger, newer OB working with an older anesthesiologist who claims it's just pressure. She's fine. One OB told me that when a patient is suffering, she can tell because even the muscles inside their bodies are tense. Yeah.

[Clara]

All of us have seen these things and have been troubled by these things, but not really known what or how to do or that it wasn't or that it could be different, you know?

[Sue]

Yeah.

[Clara]

So I think people were just, oh, like, thank God, finally. Yes. Let's go.

[Sue]

And let's do what we've wanted to do all along. Speak up on behalf of patients. To shift a culture like this, Clara says you need to have enough people with buy in people who won't let it go. And you need someone to get people to buy in. You need a Heather.

[Clara]

I mean, it is. It is absolutely. Her role at the hospital, her job title, her credentials, her relationships with everybody, the trust that's there, all of those things. Our why? Right. That she has been able to push through what she has, I think because it is remarkably different.

[Sue]

So what did Heather do exactly? And how did she do it? Well, we're in luck that we can see some of it for ourselves. Let's hurry down to the third floor where Heather is teaching a class.

[Heather]

How many people have been in C sections where you have an awake patient and someone else is like, hey, the patient in four is blah, blah, blah, blah, blah, Right. So you're talking about other patients in front of an awake patient. Right. What's going on in room four? And they're like, oh, that room four sounds bad. They should take care of that one.

[Sue]

Right?

[Heather]

I hope they're okay, you know? Okay.

[Sue]

Heather and her OB anesthesia colleagues have made a bunch of changes since Clara's surgery, ranging from the drugs and the epidurals, Clonidine, to a new system to document and address pain. Some of what Heather wanted to do, like changing the way doctors interact with patients, what tone they take, what language they use, required education. She began with the youngest people, the newest residents, because if you get them, you make it normal for the next four years and forever. And that's who's in the room this morning, mainly anesthesia residents, people still learning medicine.

[Heather]

So I want to highlight here that even though I've been doing this for 15 years, I'm still learning. I'm still uncovering things that I think I maybe missed the boat on, that I thought I was being empathetic. I thought I was being patient centered. And now I'm looking at going, is that really right?

[Sue]

Not just I did this wrong when I was a beginner. I still find myself doing this wrong. This kind of admission is so unusual.

[Heather]

And even getting ready for this lecture, I dug into, like, empathy, patient communication, physician interactions. I can't find anything concrete that tells you exactly what to say. So it makes it really hard. Right. I can give you 100 papers on clonidine. Right. I can tell you exactly where all the data came from. I can't give you one that tells you whether it's better to say this thing or this thing to a patient. Right. But I know that if someone asks.

[Sue]

Me this morning, Heather wants to address what to say during some interactions that are especially challenging, including interactions with so called difficult patients.

[Heather]

So what is a difficult patient? Well, now, you said earlier that you had all kind of heard that phrase, Right? You'd heard difficult. It's been used in the vernacular. Right. So I want you to get into small groups for a second and tell me what do you think a difficult patient is? And then think of examples of patients you've had who were, quote, unquote, labeled as difficult or you felt were difficult. Yes. Okay, let's go.

[Sue]

The residents huddle together in groups. They're wearing gray scrubs, they look young. It's striking to hear them reflecting on patients as other. They're so recently removed from having only ever been patients themselves.

[Heather]

All right, let's come back together if we can wrap up here. Sorry, I didn't mean to cut anybody off mid thought. Okay, guys, so what did you guys discuss in your group? So what is what you know to be a difficult patient or what are some examples of it?

[Sue]

The answer is exactly what you feared.

[Juliette]

Yeah.

[Heather]

I often find that sometimes patients are.

[Juliette]

Labeled difficult also if they just want to be well informed and fully understand what's going on. And they ask a lot of questions.

[Sue]

To be clear, the resident is not endorsing this. No one in the room is.

[Heather]

Patients don't feel listened to, they don't feel respected. They don't feel like they have a voice. And the ones that have the biggest voice and advocate for themselves are labeled as difficult in our system. Right.

[Sue]

A doctor who's just entered the room gets Heather's attention.

[Heather]

Okay. Yes.

[Juliette]

You will never guess what just happened to me.

[Heather]

Oh, no.

[Sue]

The doctor speaking is an attending who'd gone to check on a patient.

[Juliette]

And the surgical center nurse comes up to me and goes, Dr. Waldinger, your patient came back from nuclear medicine. She's a really difficult patient.

[Heather]

Yep.

[Juliette]

So funny, like, literally just happened. Dr. Walpinger.

[Heather]

Yeah.

[Sue]

Corey is in the room, and now he raises his hand and he starts to tell the story of a quote, difficult patient he had for a C section last night. It was a true emergency, a crash. The patient was rushed to the operating room. They did the skin test, and the patient could feel it.

[Corey]

And everyone in the room looked at me, and it was pretty much out of everyone's mind at the same time. Gotta go to sleep. I said, okay, we're gonna go to sleep, no problem. She said, I don't wanna go to sleep. And now everyone's looking at me. And they didn't say these words, but I got the impression, like, just put her to sleep.

[Sue]

Just push it. Corey can't put the patient to sleep if she's refusing. That's against the law. But the alternative is dark.

[Corey]

It was an emergency. And, like, in my mind, it's like, this baby's going to die if I don't. If we don't get this out in the next few minutes. But I can't put you to sleep, and we can't do surgery with you in pain. So it's like the urgent emergent scenarios for me where she. In my mind, I'm thinking, this woman's asking me to perform magic that I can't perform. I have to pick one or the other.

[Sue]

So what'd you do? Corey says that he knelt down, got really close to the patient, and he called her sweetie. I don't know if we're supposed to be calling a patient sweetie, he says, and the room laughs. But sweetie was the turn.

[Corey]

And I think that the second I started getting more casual with her and probably breaking those norms about vocabulary, I think she would. Like, she did a 180.

[Sue]

Later, Corey told me that Saweetie wasn't the only vocab norm he'd broken with the patient.

[Corey]

She was resistant, but she knew that she was putting herself and her baby in danger. So she kept saying, I know everyone in this room. You guys think I'm the biggest dumbass I know. You think I'm just this dumbass bitch. And she wasn't saying it, like, in an adversarial way. She was, like, recognizing, I know that I'm being annoying to you guys. Like, I recognize what you guys must feel about me. So that's part of the. That's one of the things that when I got down and next to her and I just said, like, look, I don't think you're a dumbass. I don't think you're even being a. I've dealt with bitchy people in my life. You are not being that way. I feel for you. I think you're going through something that I can't even imagine. And, you know, nowhere in medical school do they say, should you talk that way? Nowhere. You know, if my boss haven't walked by and heard me say that, I probably wouldn't be the most proud of that. But when I said that, she kind of giggled, and she kind of Started smiling and I was like. It was like these little small things that eventually broke through with her.

[Sue]

The patient still didn't want to go to sleep, but she agreed to allow Corey to give her IV drugs. He held her hand and the baby was delivered. This kind of story doesn't always end this way. Heather tells the room, we've had that.

[Heather]

Before, where we've had someone come to the operating room in absolutely refuse general anesthesia. And the outcome was not as good as yours. So I think that those are really important.

[Sue]

Corey had asked the patient, why don't you want to go to sleep? Heather would have asked this question too, if the answer was, I'm scared. What are you scared of? Which is different from there's nothing to be scared of. What the patient is scared of matters and might determine what you do. The way you ask the question matters too.

[Heather]

So your tone, whether you get casual or whether you heard my. You just heard my voice right now. Hey, we're gonna, you know, my register, my register's up here, right? And hey, we're gonna take really good care of you. Like I know you're scared. My voice drops, my head comes close, I kind of get to their ear.

[Sue]

This might not be the right style for everyone.

[Heather]

Be genuine to your personality. You're not gonna speak the way that I speak, right? You're not gonna use the phrases that I'm gonna use. And don't try to mimicry, you know, kind of mimic people. Cause it's not gonna come out right. So find what works.

[Sue]

But even if the delivery isn't the same, the message is, here's what I can't do.

[Heather]

I can't promise you a pain free surgery, right? But what I can promise you is if you tell me you're having pain, I will give you more medicines. I will work with you, I will be present with you, okay?

[Sue]

You can tell doctors to listen to patients, to partner with patients. And some doctors are going to have an intuitive sense of how to do this. But not everyone will. And yes, teaching helps, modeling helps. But when you're trying to change behavior after something goes wrong in a medical setting, what helps more than either of these things, and research shows this, is if you create a system that encourages, even compels that behavior. Which is another thing Heather did and which I'm about to see in action. That's coming up after the break.

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[Clara]

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[Juliette]

Hi, I'm Juliette.

[Sue]

I'm Joelle. We're from the New York Times games.

[Juliette]

Team, and we're here talking to fans about our games.

[Corey]

What's your vibe when you're playing one of our games?

[Heather]

It makes me feel like I'm procrastinating in a really productive way.

[Sarah Koenig]

It just scratches an itch in my brain.

[Juliette]

We have a routine. I'm doing long distance with my boyfriend. We'll call every night and share our screen. We do connections, the mini, and then strands, always in that order.

[Sue]

Aw. Do you have a favorite?

[Juliette]

The mini. We try and get it under 30 seconds. We rarely get it under 30, but that's always the goal.

[Corey]

Folks will really time themselves. But with spelling bee, I give myself all day.

[Sue]

I play it when my kids are going to bed.

[Juliette]

Do you guys play together?

[Mindy]

My daughter plays.

[Sue]

She likes playing Wordle. If you ever miss a day, there's also archives. That's so great to know.

[Juliette]

And you have it for connections as well.

[Sue]

Lord help me.

[Juliette]

I'm just gonna be doing that all day, every day.

[Sarah Koenig]

New York Times games subscribers get full access to all our games and features. Subscribe [e-mail] games for a special offer.

[Sue]

Cut to the OB floor. It's after class. I'm in the shot now. I've been here the whole time. Let's not make a big deal. But yeah, I'm here on set. Heather and I are standing outside the double doors that lead to the operating rooms.

[Heather]

So we're gonna have to put these on.

[Sue]

Okay, great.

[Heather]

So probably, maybe if you want to use that tray over there and put your lights on for just a second.

[Sue]

Heather hands me a surgical suit. I put the recorder down and step into the white coverall. The material's flimsy, like a whole outfit made out of a dental bib. Once I'm gowned up, we continue down the hall.

[Heather]

So this is like a sterile hallway, which is why you have to have all this stuff on. And then when you go in the operating rooms, that's when you need the mask.

[Sue]

Okay, so.

[Heather]

Oh, you can hear. A baby was born.

[Sue]

Outside the Orange. I tie a mask atop my head and at the nape of my neck and then turn to where Heather is pointing through the window in the door.

[Heather]

So just take a look at how.

[Sue]

Many people are actually in there. Oh, wow. And so this is a caesarean, or.

[Heather]

You'Re in the middle of a cesarean right now. So she's wide open.

[Sue]

I'd been hoping to see a C section this morning, but not expecting to. I'd been told it was unlikely to happen, but at the last minute it's come together. The patient has given me permission to observe. Her baby has already been delivered, so I won't get to see that part. But there's a lot of her surgery left, which means there's a lot of anesthesia care left to administer.

[Heather]

The anesthesia providers at the head of the bed kind of talking to her. So we're really the only ones who are kind of like with her? Yeah, exactly. Which makes it a very intimate relationship.

[Sue]

Very quickly, Heather checks that I'm ready to go inside. I'd asked her what she suggest I notice, and she'd named a couple things, including looking at the patient's open abdomen. Unless you're queasy, she added. It's untested, I said. I've never witnessed any kind of surgery. For months I'd been talking to people about C sections, reading about them, writing about them, but I'd never been in one, and that felt important. I tried to at a couple different hospitals. Can't you just Watch1 on YouTube? Was the response of one hospital flack who turned me down. But it wasn't about gathering the right details. What I wanted, you couldn't get any other way. I wanted to be in the room. We step inside. Heather stays very close to me, not in case I go rogue, but in case I go down, which happens to visitors. But at first I don't even really look at the patient. Heather points things out, but I'm not always sure what she's pointing at. Are those parts of the human body hanging from a pole in little plastic bags? No, they're used sponges affixed to the wall, a big container of blood, like an igloo dispenser. Is that the patient's blood? Or is that blood for the patient in case she needs it? Then we turn to the foot of the bed, and I stare straight into the patient's open abdomen. I'm surprised by how completely unfazed I am. If anything, I want to keep looking. The blue drape hangs at the patient's breast I can't see her head. And maybe the depersonalization helps me. Look at this. Straight on. The flesh is pushed up like when you raise a blind. I'm full of awe. My hands have been balled inside my jumpsuit, but now they loosen. The patient is getting her tubes tied. Heather uses the medical term. I ask if they tie them or cut them off. And the answer is kind of both. We move around to the head of the bed. The patient has a wide, sweet face, freckles. The father beside her, holding the baby. Congratulations, I say to the mother. But then I regret it a little, not knowing what she feels. I'm not meant to interview the patient, just to observe, so I can't ask about pain. But now the patient grimaces. Her eyes open and close, forehead furrows. The attending is momentarily out of the room. Heather moves in. What are you feeling? She says to the patient, leaning down near her face, doing exactly what she just talked about in the classroom. Are you in pain? It's just pressure, says the patient. But how bad? What's the number? Asks Heather. It's eight. Well, if it's an eight, we should do something about it. The patient doesn't want drugs in her IV right now, but she does want nitrous. The OB anesthesia fellow, Lauren, places a plastic mask over the patient's face. Then at a computer, Lauren fills in a pop up window in the patient's chart. And this window. This is what I was talking about when I said that Heather had made a system to compel behavior. It's one of the most significant changes she's made. There's a phrase that's often used in medicine. What's measured matters. So Heather's thought was, okay, if I'm trying to make pain matter to everyone in the room, we've got to find a way to measure it. Now, every 15 minutes, the anesthesia provider receives a reminder to get a pain score from the patient. A tab on the patient's chart turns red if the score is 3 and above. There are prompts for follow up questions about what kind of pain and and where. Information that can be used to decide on an intervention. When Heather initially had the idea, there was some pushback and there was a.

[Heather]

Little bit of like, why are we doing this? I don't want to keep reminding the patient about pain. And I was like, no, if they're not having pain, you're not reminding them of anything.

[Sue]

People have strong opinions about pain. Language. One OB anesthesiologist I talked to someone who is as passionate as Heather, about the issue of pain during cesarean, told me that she asks patients, are you comfortable and do you want me to give you anything? I don't want to emphasize the pain. She said there's pain psychology literature supporting this, that the language that you use can suggest pain to the patient.

[Joelle]

Instead of saying, I'm going to put this needle in your back and it's going to burn for a second, you say, oh, you'll feel mild discomfort. And you. You coach them through them as. As if you're like, somehow gonna change their experience. And I just haven't found that to be true. My personal experience with this has been absolutely 100%. The other direction is that if you don't tell patients what to expect, if you're not real with them, you lose trust so quickly. So I really believe in telling patients the whole story. Unless I have someone who's like, don't tell me anything. I don't wanna know anything. So we do have that conversation as well, but otherwise, I don't know. I just. I don't think it's quite fair to patients to assume that somehow you're going to. You are fully in control by your language of someone's pain experience. I think that really minimizes the problem.

[Sue]

The main purpose of Heather's system is to promote good patient care. But an additional benefit is that there's a lot of data being collected, data about some things that don't exist in the medical literature. Like when a cesarean patient says she feels X, what works best is to give her drug Y. Heather didn't copy her system from somewhere else. She and a colleague made it up themselves and had the tech team hook it into the electronic medical record system. Though some other institutions also assess and record patient pain during C sections, Heather seems to be the first one to do it exactly like this One doctor I talked to praised Heather's system, but noted there isn't evidence that what she's doing is a best practice that will actually help patients. It wasn't a critique. It was a nod to the big picture. There isn't evidence that any tool for measuring cesarean pain works better than any other because these tools don't exist. Pain scores themselves are pretty contentious. People will say they lack context or that if you're a patient, it's really hard to know what number to say. But Heather's not just getting numbers. Importantly, she's getting quotes from patients, too. Because her system not only requires doctors to talk about pain, it gives patients an opportunity to do so. Patients who are not asked about pain, may not speak up about it for whatever reason. Susanna recently sent me a paper that compared the situation of being a patient to being a hostage. These people literally hold your life in their hands. Do you want to disrupt or displease them? Right now, there's a massive study on pain during Caesarean going on in England and Australia, the sonar study. Almost 80% of all OB units in the UK are taking part in it. And one of the questions they're asking patients is essentially, if you were in pain, did you tell your doctor about it? I love this question. I think it's enormously insightful. Some patients cry out and are ignored. Others never say anything to begin with. We need to capture them too. Not every doctor is going to care about pain. Not every patient is going to disclose it. One OB anesthesiologist describes Heather's system as an intervention that makes it easier for people to do the right thing, even the people who think they're already doing it.

[Heather]

I mean, in all honesty, even the patient we just described, I would never have thought that furrowing was an eight. I thought it would have been like a three or four. Right. Looking at her, I thought, oh, it's a mild pain. And she describes to me as severe pain. Right? And so I was like, whoa, whoa, whoa, we have to do something about this.

[Sue]

The father of the baby. FaceTimes with someone who's maybe the grandma. Soon, it's time for me and Heather to leave the room. In the hallway, Heather and I step out of our coveralls. Later, I ask her if the new system means that pain is now documented in a way that's visible to patients. Yes. If you have a cesarean and you request your files, you will see this in there at uic. Caesarean pain is now part of the record. Coming up, let's head to the nurses station after the break.

[Clara]

The New York Times app has all this stuff that you may not have seen.

[Joelle]

The way the tabs are at the top with all of the different sections.

[Corey]

I can immediately navigate to something that.

[Sue]

Matches what I'm feeling. I go to games, always doing the mini, doing the wordle.

[Joelle]

I loved how much content it exposed.

[Sue]

Me to things that I never would.

[Joelle]

Have thought to turn to a news app for.

[Sue]

This app is essential.

[Sarah Koenig]

The New York Times app, all of the times, all in one place. Download it [e-mail] app.

[Sue]

For a long time, Clara Steele didn't talk about what happened with people at work. It was clear to everyone she was moving through it she was back in the or, she was back to who she'd always been on the unit. Someone who spoke up for patience, someone wise you could go to for advice about your own life. Heather continued to use Clara's story, the Jennifer story, in lectures. And a couple times, Clara got into a conversation with a resident who brought up the story or the issues it raised, not knowing it was Clara's. And Clara would say, surprising the resident, I'm Jennifer. Then immediately wonder, God, why'd I do that?

[Juliette]

Do I want to be that vulnerable right now? You know?

[Sue]

But with distance, she did. And then one day, almost three years after the surgery, Clara and Mindy and a few others were at the nursing station. It was a weekend, Mindy remembers.

[Mindy]

Usually when it's like weekends, it's calmer on the unit. So we kind of just like, catch up on life. And we're each other's therapists.

[Sue]

And somehow they got to talking about the surgery.

[Mindy]

And she looked at me. She's like, mindy, I totally forgot you were there. And I was like, in my mind, I'm thinking. She's thinking, like, why didn't you do something for me? Like, why didn't you step in for me? And for her to say, you know what? You're right, I forgot you were there. And I was like, oh, my gosh. So she's not harboring this, like, anger towards me. And I was like, I didn't push it. I didn't ask. More like, what? What do you mean you forgot? Like, I was like, really there?

[Sue]

Yeah.

[Mindy]

So it was kind of like a relief, like, oh.

[Sue]

Later, Clara asked Mindy for the photographs. They both did the same thing with them. Looked at them hard to find the moment the surgery turned. What's different for Clara now is not just being able to intervene during a C section, but more generally. Here's a story from just the other day that illustrates it. A nurse on the unit was telling everyone about a C section she'd just been in, one where the patient seemed to be really in pain. And the surgeon had said, we're almost done.

[Juliette]

I think that those were the words, we're almost done. And I was really disturbed by it.

[Sue]

Who was the anesthesiologist? Clara wondered. It was Corey.

[Juliette]

And so I was pretty like, whoa.

[Sue]

What?

[Juliette]

That seems not at all like, Corey and what he would have done. And I texted him, I have his number. So I texted him. I was like, hey, I just heard this thing, and it doesn't sound like you, but I was really bothered by it. And I just wanted to know how you thought that that went. Did the surgeon really say, you know, don't put her to sleep, or, we're almost done, Anything like that? And Corey clarified. He's like, not exactly. You know what I mean? Like, he could see how you walked away with that. But really what was going on was.

[Sue]

Was that the patient's uterus was outside her body, exteriorized, remember? And it's hard, almost impossible, to make the patient feel nothing during this. Many ob. Anesthesiologists would really prefer surgeons not do this. Organs belong in bodies, you will hear them say. But for the surgeon's part, it's certainly easier to see and repair the uterus when the organ is outside. They're taught this is the safest way to do it. But anyway, yes, there was a moment where the patient was in pain, but Corey was on it. He addressed it with IV meds.

[Juliette]

And he's like. And no one would ever stop me from putting somebody to sleep.

[Sue]

Clara.

[Juliette]

He said, if I had any doubt and thought for even a second, she needed. Her pain wasn't controlled, and she needed to. We needed to convert to general. He said something like, I don't care if the CMO or what chief medical officer told me not to. Like, I would do it. So I was really glad that I was able to, instead of worrying about it, to follow up on it.

[Sue]

And I'm assuming that's not something you would have done in the before times, or maybe you would have.

[Juliette]

No, I'm not sure I would have picked up on it. I think that there was a lot more just sort of acceptance and powerlessness around it. Like, yeah, if I heard something like that, I would think it was bad and wrong, but I wouldn't. No, I wouldn't have followed up on it or anything. I wasn't in the room. It wasn't my patient. You know.

[Sue]

There'S a culture that's enabled Clara to do this, but she's also one of the people making the culture, one of the people showing others how to speak up. So was Mindy. Before I ever met Mindy, I heard about her. There's a nurse named Mindy who will put you in a chokehold if you let a patient be in pain.

[Mindy]

I do. I do think there has been a change, just because I feel more empowered to speak up, too sometimes. Sometimes I still revert back to, I'm just the nurse. I'm just the nurse. But I feel like UIC does have a, like, hierarchy, but I feel more empowered to speak up. There than I ever did before.

[Sue]

Mindy's changed since Clara's surgery, and not just as far as speaking up. She's questioning things, including one of the most fundamental assumptions about cesarean of all.

[Mindy]

I think my biggest thing is, like, why do we do C sections on mamas while they're awake? Like, I understand that. I understand the science behind it, but, like, maybe some women truly prefer not to be awake, and we push them towards being awake during C section. So I just. I. I want to know more. Like, maybe we need to talk more about why we even moved towards this practice. Because, you know, being awake and being like, literally, women when they're being pulled and pushed, and that's scary. Like, I don't know if I, as a patient, want that. Is it all just about patient experience and hearing their baby's first cry? Like, is there alternatives? Like, could we just record it? I don't know. Like, I wonder what. How we got to this.

[Sue]

Oh, my God, Mindy, I am so glad you just said that. Yeah, I have had that same thought, but nobody else has ever brought it up until you brought it up. Yeah, I told Mindy that decades ago, the assumption had sometimes been the opposite, that the patient would prefer to be asleep for a C section. Like, why would anyone want to be awake for that? One British anesthesiologist wrote in 1971 that being awake could be okay for, quote, a woman of the right temperament. But many women would not willingly undergo this experience. Both assumptions. Want to be awake, want to be asleep are problems because neither is universally true. What a patient wants, that's different for every patient. If you're told that one of the benefits of neuraxial anesthesia is that you can be awake for your baby's birth, you may feel like that's something you should want and feel ashamed that you don't for whatever reason, including that you simply do not want to be aware. During major surgery, lots of patients tell Mindy they'd rather go to sleep all the time.

[Mindy]

All the time. They say, I don't want to be awake. I want to go to sleep. And they just literally convince them that it's not the best. But, yeah, no, there's so many patients that should go to sleep that we don't. And they're so terrified, and we don't know what their trauma is going to be. Are they going to relive the beeping of their heartbeat and the, like, suctioning noises and the, like, pulling? And we don't ask women who had C sections how traumatized they are.

[Sue]

There's a growing awareness of what Mindy describes that let's be real, this is a major surgery. Doctors I spoke with, including Heather, wanted to emphasize that most C sections should be done under neuraxial anesthesia, that it's the gold standard for faster recovery, better pain control after birth. But Heather says she's quicker to honor a patient preference for general from the get go than she would have been just a few years ago. While doctors have long avoided general anesthesia for safety reasons, for some patients, safety might mean going to sleep. Here's a sign of the times. In obstetric anesthesia, there's something called a Center of Excellence designation. To get it, your hospital has to meet a bunch of criteria, including one about limiting use of general anesthesia. Recently, there's been discussion about making sure this isn't inadvertently causing patients to suffer. There's also been discussion of adding a new measure of percentage of patients in pain. Redefining excellence can change culture and practice, so, in theory, can a lawsuit. The medical and legal systems can reinforce each other to make change, but there's not much evidence that this works with pain during cesarean. Putting aside the fact that many women are unlikely to want to pursue a lawsuit while traumatized and caring for a newborn, what happens if they try? I talked to one obstetric anesthesiologist who has served as a medical expert witness on a couple hundred cases in the past few years. In that time, he's been asked to review notes on fewer than 10 about pain during cesarean. He says most patients like this are told they don't have a case. When one case actually did get to court a couple of years ago in California, it was heard in federal court. Delfina Mota. That's the patient's name. Delfina Mota versus United States of America. The transcript of the bench trial follows a familiar template, with the judge ultimately finding essentially your story is suspect because no one heard you scream. Lest you think I'm exaggerating, here are some actual lines from his ruling. No one heard plaintiff resist or refuse the procedure. Also quote, plaintiff testified she screamed as the procedure began. However, this scream, of which much was made, was not confirmed by any third party. Nurse Wood did report plaintiff saying, help me and I can feel everything. None of the others heard these statements. The judge ruled against Delfina Mota, who had not finished high school and said she worked as a caretaker. She was 25 years old at the time of her surgery. It felt like I was on fire Delfina testified about the surgeon's first incision. I could feel her hands, her gloves in me. Plaintiff's version of the events is not credible, the judge wrote. She was also, he added, psychologically brittle. Nobody raised doubts about Clara's credibility. Nobody rejected her story. In fact, it was the opposite. I told Clara about an exchange I'd had with a doctor who'd approached me when I visited uic. She's like, I don't know if you know, but we had this thing happen at our hospital. There was a patient who was, you know, in a lot of pain during her caesarean. And, you know, and it's really changed a lot at our hospital. And she's a nurse, and now in caesarean, she's like a real advocate for the patients in the room. And, like, everybody kind of defers to her. Her. Yeah. Is that your experience?

[Clara]

Yeah, yeah. Yeah, it is.

[Sue]

Clara was crying, and I assumed. I understood why, but then the next thing she said showed me that I hadn't.

[Clara]

I think that people. Which, again, it just makes me so mad that it hides. It's just so typical, Right. Because here I am, their co worker, their white co worker.

[Sue]

So now we notice more than 80% of the patients who have babies at UIC are black or Hispanic. There's almost no data on race and pain during cesarean, but a recent study of 110 patients at one hospital in Texas found that black patients were five times more likely than white patients to report C section pain.

[Clara]

And.

[Sue]

Yeah, has that ever been, like, explicitly talked about? Like, wait, guys, we woke up to this when our white co worker, like, when this.

[Clara]

I mean, I talk about it, but I don't know. I don't know that it's necessarily. Yeah. Been a big part of the conversation.

[Joelle]

I think that that's a very valid thing for Clara to say, and God bless her for being cognizant of that and thinking more globally. But if it had been an African American nurse. It's one of your own. So that's what made her so special.

[Sue]

Right.

[Joelle]

Because that should never have happened to one of your own.

[Heather]

Right.

[Joelle]

And it should never happen to anyone. But it was big and dramatic and one of our own.

[Sue]

One of us. One of our own is a phrase other doctors on L and D also used with me. The way they said it was the same way Heather says it, fierce. So why did it matter that Clara was not a patient who left, but one who stayed within her close knit unit? It made what happened to her harder to dismiss, and it made it possible to keep talking about it at first, just among themselves and eventually publicly. Pain during cesarean is an issue. Clara's surgery and what it prompted is a story. It's nowhere in the medical literature. You can't find it in PubMed. And yet, as one obstetric anesthesiologist put it to me, stories are also a kind of evidence. They too can change the way doctors practice medicine. Especially when, as both Susanna and Heather understood, you attach those stories to lessons. Story, lesson, those essential building blocks of so many genres. Including, yes, medical dramas. Medical dramas. We, as in we, the TV watching people, we love them so much. You know who else loves these shows? You know who's watching along with us healthcare providers.

[Joelle]

Grey's Anatomy for me, I've watched all of it.

[Sue]

I'm gonna say it.

[Joelle]

I'm gonna say it. It is my binge watching.

[Juliette]

So many seasons.

[Heather]

I know.

[Joelle]

It's so many seasons.

[Sue]

21. And Heather has a critique.

[Joelle]

All of those shows are designed to have those set of doctors be the only people who can do everything right.

[Sue]

They need to be the heroes of every episode. It's all up to them. But of course, the goal of the work that Heather and others are doing is to get everyone to care about pain during cesarean. It shouldn't be something that matters only to one ensemble on one unit at one hospital. It should be standard. So standard that it shouldn't even be worthy of a storyline. Pain during Cesarian is not a new problem, but for a long time it's been a hidden one. The everyday heroes on our show brought it to light. And now let's tuck our characters in along with the hospital. See Mindy putting her dirty scrubs into the machine and Clara walking across the street to the garage and follow Heather downstairs to the third floor. She has an overnight. She'll be around for a while. Now let's pull back. Get the whole hospital in the frame. Hot orange sky. The day's so long this time of year. And hold that shot. End of show. Bold, centered, all caps. 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 serial newsletter. Music supervision, sound design and mixing by Phoebe Wang. Original music by Dan Powell, Fritz Meyers 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 Greene. The art for our show comes from Pablo Delcon and Eric Tanner. The supervising producer for Serial Productions is Indee Chubu. Additional producing comes from Mahima Chablani, Jeffrey Miranda and Corey beach at the New York Times and Sam Dolnick is Deputy Managing Editor of the New York Times. Special thanks to Mike Hofkamp and Emily Sharp, who are among the authors of the study that found a higher rate of cesarean pain for black patients in Jennifer Schwenk, Katerina Beckman, Rachel Waldinger, Nick Pittman, Kyle Grandillo, Aswati Jiaram, David Gutman and James o'. Carroll. The doctor who came up with the question, if you were in pain, did you tell anyone about it? The Retrievals is a production of Serial Productions and the New York Times.

[Sarah Koenig]

Hi, this is Sarah Koenig, host of the Serial Podcast. If you liked this show, Season two of the Retrievals, and I'm betting you did, and you haven't listened to Season one of the Retrievals, I encourage you to go check that out because I think you'll love season one. Also, the first episode is available for free, but the remaining episodes are exclusive to New York Times subscribers. If you aren't a Time subscriber already, I ask you respectfully, what are you waiting for? When you subscribe to the New York Times, you'll get all the normal, excellent things you get with a New York Times subscription and you can listen to every single show we've made over here at serial productions. That's 14 shows. There's all four seasons of the show that I host, the Serial Podcast. There's S Town and Nice White Parents. There's the Trojan Horse Affair and the Coldest Case in Laramie. There's the Good Whale. These shows have everything seriously investigative reporting, mystery, genre bending storytelling, bizarre plots, superlative writing, a song. You will find what you're looking for, I promise you. You can sign up for a New York Times subscription in either the Apple Podcasts or Spotify apps [e-mail] podcasts and if you do listen to our shows, please let us know. You can leave us a review in a podcast app or email [e-mail] we really do read every email we receive and thanks.