The View from the Vue (36 page)

During the past one hundred years, there have been two truly major advances in obstetrical practice. Caesarean section has been one; the other, oxytocin.

Like caesarean section, oxytocin constitutes a means of expediting delivery. It is a hormone, normally secreted by the pituitary gland, and it can be synthesized. When administered to a woman in labor, it makes the uterus contract with greater force.

A hundred years ago, when uterine activity was weak and labor ineffectual, that meant real trouble. There were no good therapeutic options. The options then in vogue for stimulating uteri were either useless or did their job too well, producing such vigorous contractions that the baby would die and the uterus often would rupture. Caesarean section meant almost certain death for the mother. Consequently, labor often dragged on for three or four days, or even longer. Finally, with the mother exhausted, dehydrated, and infected, her attendant would have no choice but to reach in and pull the child out of the woman by brute force, a procedure which too often served as the
coup de grace
for both principals.

By the mid-1950’s, however, the physiology and chemistry of oxytocin had become well understood, and it was then possible to do something about a lazy uterus. A small quantity of oxytocin could be mixed into a bottle of sugar water and administered intravenously. The faster the infusion rate, the more vigorously would the uterus contract. Hence a flow rate could be established that would produce a physiologic level of uterine activity to overcome a desultory labor.

In 1961, the Bellevue attitude toward oxytocin was one of caution. The dangers of the earlier uterine stimulants had not been forgotten; in addition, some of the oxytocin pioneers had used the drug indiscriminately, with unfortunate results. So we used oxytocin when we had to—but we knew that we’d damn well better be able to prove we
really
had had to.

On my very first day as a third-year medical student on obstetrics, I was assigned to help care for a seventeen-year-old who had come to the hospital almost with her first contraction. I sat at the bedside, compulsively timing the pains for hours on end, but nothing very much happened in the way of getting the baby delivered. The resident came in and broke her bag of waters, hoping that this act of aggression might stimulate and accelerate her labor, but she merely continued along her non-progressive way.

After eight hours of this, I began to feel punchy. By twelve hours, I was frankly hostile, and by sixteen hours, I was a raging misogynist. At eighteen hours, the first-year and senior residents came in and shook their heads sagely. My heart leaped: Might they be about to section her?

Not a chance. Down we went for X-ray pelvimetry, which demonstrated that the girl’s pelvis was more than adequate for delivery of a normal child. The two residents studied the films at great length.

“What do you think?” asked the first-year resident. “Time for a little oxytocin?”

“I suppose,” answered the senior. “But we’ll have to check it out with the chief.”

An endless half hour later, the chief resident was on the floor, looking at the X-rays. “All right,” he finally said. “You want to give her some oxytocin, huh?”

The two younger residents nodded.

The chief laughed. “You know we can’t do it without the approval of the attending. And you know who the attending is today, don’t you?”

The first-year resident looked dismayed. “Aw shit,” he muttered. “Not Haskins?”

Now the chief resident nodded, still laughing.

Forty-five minutes later, the three residents led Dr. Haskins into the labor room. Haskins was an ancient-looking man with stooped shoulders, thin white hair, a tremendous gray mustache, and a pair of watery blue eyes behind horn-rimmed spectacles. He wore a bemused little smile.

Dr. Haskins shuffled over to the bed and laid a trembling hand on the patient’s abdomen. After he had timed and calibrated a few contractions, he haltingly performed a pelvic evaluation. Then he turned to face the residents.

“So you think she needs oxytocin, do you?” he asked.

“We’d like to give it a try,” said the chief.

“Well, let me tell you,” said Dr. Haskins firmly. “Oxytocin can be a dangerous drug. A very dangerous drug. Why, all she needs is a little tincture of time. You know what I do in cases like this? Why, I just go out into the hallway and I smoke a big black cigar. And by the time I’m done, the patient is usually ready to deliver.”

The first-year resident rolled his eyes at me. Then they all walked out, admonishing me to keep a good eye on her.

Dr. Haskins could have smoked every big black cigar between New York and Cuba and that girl still wouldn’t have been ready to deliver. My eyelids kept fluttering shut, and my mouth came to taste like Saturday at the county dump. Night passed into morning, and my charge had been hard at it for thirty hours.

At that point the senior resident came into the room with a syringe in his hand. He took down a bottle of 5 percent dextrose in water, injected the contents of the syringe, and swirled the bottle around. Then he connected the bottle to the woman’s intravenous tubing and started the mixture dripping slowly into her vein. He winked at me.

“Now you’re gonna see some action, kid,” he said.

“Oxytocin?” I asked.

“Uh-huh.”

“I thought Dr. Haskins wouldn’t let you use it,” I said.

“That was last night,” said the senior resident. “Today our attending is Bill Crawford. He’s a younger guy, and he doesn’t shit at the mention of the stuff. We just called him up and presented the case, and he gave us the okay over the phone.”

While the resident was talking, the patient had a contraction. This was nothing less than miraculous. For thirty hours the contractions had been as weak as they could have been, but this one was a winner. The uterus became rock-hard, stayed that way for almost a minute, and then eased up. The girl, who up till then had been emitting a series of soft Ay’s with each contraction, now let go a fell-blooded roar.

“Great,” said the resident. “Now we’re in business. You see how fast the oxytocin is dripping—eight drops a minute? Well, it’s your job to keep it going at that rate. Not seven, and not nine. And make sure she keeps having good contractions, too.” With that, he charged out of the room.

In no time at all I learned why he had run away so fast. In those days, intravenous drip-flow rates were notoriously variable, being altered with every minor movement of the patient’s limbs. The order to maintain a steady flow was a water torture far more devastating than the famous Chinese one. Every five minutes or so, I had to line my watch up behind the drip chamber, count the drops, and note the number of elapsed seconds. Then, when it was going too fast or too slowly, I adjusted the flow meter. Invariably I’d overshoot the mark and be forced to readjust. By the time I was finished re-re-readjusting the flow rate, it would be time to count the drops again.

I came to hate that innocent patient with an unmentionable ferocity. I fervently wished I could shackle her arm from neck to fingertips so that she’d be unable to wiggle her extremity and screw up the flow rate. I rained curses down upon that nine-months-old moment of passion that was causing me so much misery. I despaired of ever being free of the woman.

But it was now a whole new ball game. The oxytocin drip was producing a series of Brobdingnagian uterine contractions, the patient was yodeling, the cervix was dilating, and the baby was descending. Within six hours she was safely delivered. Although the baby was not born in the best of condition, he was resuscitated with relative ease.

In truth, at the end of the thirty-six-hour ordeal, none of the three of us—baby, mother, and obstetrician—was in very good shape. Today that wouldn’t happen. The oxytocin would be given much earlier, and it’s very doubtful that the labor would last as long as twenty-four hours. Even better, there now exist constant-flow infusion pumps to provide a continual, steady intake of oxytocin. The days of the watch and the drip chamber are no more.

Thus, in retrospect, the modern obstetrics of the early 1960’s at The Vue doesn’t look so very bright and shiny and up-to-date. Matter of fact, the present-day crop of residents absolutely shudders at the mention of some of the things we did. Imagine practicing obstetrics without a fetal heart-rate monitor or a constant-flow oxytocin pump, and with the operating room half a hospital away. They all consider themselves very lucky indeed to have been born late enough to be able to work under truly modern conditions.

It’s been eighteen years since I first set eyes on The Vue, and twelve years since I left. During those twelve years I’ve taught and practiced medicine at five other institutions in five different cities, and at the moment I’m living more than three thousand miles from New York. Nevertheless, a part of my mind still seems to be at Bellevue.

More of my dreams are on location at The Vue than at any other single place. Furthermore, when my phone rings at night and I struggle upward through the mists, I sometimes think that it’s a nurse calling from B-3 to tell me the messenger just wheeled in another L.O.J.L. with congestive heart failure.

I experience similar occurrences even during my waking hours. I may be walking along a hospital corridor in Seattle and suddenly find myself hurrying toward B-2 to answer a stat page. Then the flyspecked walls vanish just as abruptly as they had appeared and I continue in the direction of my real destination.

I also have patient-related
deja vu
experiences. When I see a patient with a particular disease, I frequently recall the individual at The Vue in whom I first encountered the condition. And not only the individual, but usually also her specific location on the ward, the outcome of her case, and the month of the year I treated her.

When I tell my Bellevue stories to non-medical people, I understand why they sometimes ask me, “Come on—did that
really
happen?” The reality of The Vue is a long way indeed from what they’ve seen on
Marcus Welby
and
Medical Center
.

“Yes,” I assure them, “it really did happen. Every bit of it. That’s the way it was at The Vue.”

At that point, they are likely to ask me another question. “If it was all such a charge,” they say, “why have you never gone back? Why didn’t you finish your training at Bellevue and then stay there as an attending?”

Actually, there are a couple of answers to that. For one thing, I’ve had all I can handle of the quality of life, New York style. I think in order to spend a lifetime in that place, you have to be more than a little masochistic. For another thing, I believe it’s unwise to remain to teach at the institution where you had your training. It takes much too long for your associates to admit that you’re no longer wearing short pants.

So, I can’t go back to The Vue again. But I sure am glad I once was there.