Better

Every morning I wake up with a dream about Mota. There is a delivery I am needed for. There is a baby that needs to be resuscitated. There is something that went wrong. By the time I wake up, I have forgotten what it is.
I love Atul Gawande, who inspired this blog. He is a surgeon and writer. He writes in his book ‘Better’:
“I used to think that the hardest struggle of doctoring is learning the skills. But it is not, although just when you begin to feel confident that you know what you are doing, failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part about being a doctor, I have found, is to know what you have power over and what you don’t.”
Every morning I am figuring out what I had power over and what I didn’t while in Mota.
I was only in Mota for three weeks, a very short time period, in retrospect. While I was there, it seemed like ages, because every day was filled with so many new experiences.
Medicine is universal. People get sick and women have complications in labor all over the world. The diseases and the complications differ from place to place, but not as much as you think. What is different is how much resources are available to cure the diseases and tackle the complications.
In the US, we monitor a baby’s heart rate in labor because we have the resources to deliver the baby quickly if the heart rate goes down. In Mota government hospital, it takes an hour to get a patient ready for a cesarean section, and by that time the baby is either dead or the heart rate has recovered.
We had some babies die during labor in Mota. Their ghosts haunt me at night into the morning. The part of me that practices medicine in the USA with seemingly unlimited resources thinks I should have done more to save those babies. The part of me that realizes that we did not have the resources to predict which babies were going die in labor in Mota has made peace with those baby souls. I had no way to diagnose fetal distress in labor and no way to respond to fetal distress quickly enough to save babies. I know that, but boy is it hard to accept that I had no power over something that is such a part of every obstetrician’s fiber in the USA.
The biggest financial payouts in malpractice cases are for neurologically damaged babies. John Edwards, the presidential candidate, made most of his money prosecuting obstetricians who failed to recognize signs of fetal distress and failed to do timely cesarean sections. Many of my hospital’s labor protocols address what to do in cases of fetal distress.
Fetal distress is one of the reasons our cesarean section rate is 30 % in the USA. Because our tools to diagnose fetal distress are not very accurate, we often over diagnose fetal distress. We think a baby is going to have difficulty, but it’s fine. We don’t know and we err on the side of safety, because cerebral palsy is permanent and debilitating. I am trained to look for signs of distress and act on it. And I am well trained. As far as I know, I have never delivered a baby in my career that died in labor or that had severe neurological consequences as a result of the delivery.
So accepting that I had no power to save babies was hard, very hard. Delivering dead babies or babies that died right after delivery was hard, very hard.
And every morning when I wake up, I realize that I still do not accept that I couldn’t have done more to save some of those babies. It is why I will always feel some sorrow when I think back of my three weeks in Mota despite how many mothers we saved.
That brings me back to Atul Gawande, because in the last chapter of ‘Better’, he gives advice on how to grow in medicine, and any profession for that matter. He extols you to change, to obsess over your outcomes, and to change.
He also recommends that you don’t complain, that you count something, that you ask a random question every day. And that you write for yourself and for others.
I am writing

Photo by Joni Kabana

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