Dr. Mitch Wagner stood in the middle of the triage unit, doing
what he loved best—orchestrating the activity of triage. It was
early evening, and the unit was bustling with activity. Nurses were
busy admitting and evaluating mothers. Some were in labor, oth
ers complained of terrible nausea and vomiting, and there were
those with vague complaints of abdominal pain. This was why
Mitch got up every morning, to play master of his universe—mas
ter of maternity triage.
Mitch reflected on how his life had brought him to where he
was now. His father had been a well-respected orthopedic sur
geon in Manhattan. During those early years, his father wasn’t
home much. In addition to being busy with office hours and sur
geries, he also presented at conferences. But when he was home,
he spent time with Mitch. He paid attention to him, showing
interest in his friends and his life at school.
After his parents divorced, he stayed in close touch with his
father. They saw each other during the week when his father had
the time. Always before the end of the visits, his father spoke about
plans for medical school, even while Mitch was still in grade school.
Mitch was smart, and school was easy for him. He attended
private school on the Upper West Side. Once Mitch had started
school, his father didn’t just encourage him to go into medicine;
he expected it. Clearly, there was no option for Mitch to consider
another path. His mother offered no opposing ideas either. “Do
what your father tells you. It’s best.” In high school, he impressed
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JULIE HATCH
his teachers when he memorized the periodic table of elements
before the end of the first week of ninth-grade chemistry class.
He was a straight-A student and captain of the freshman track
team. He was a son any parent would be proud of.
Mitch wanted to be a doctor, but he didn’t want to go into
orthopedics like his father. Orthopedics was for jocks, guys who
had spent many afternoons getting their broken bones and dislo
cated joints put back together. To be an orthopedic doctor, you
had to be good with tools—drills, saws, screws, and metal plates.
He was a track runner, not a jock or a tool guy.
Nope, he was drawn to obstetrics and gynecology. It was the
one area of medicine where he could practice both medicine and
surgery. Once, when Mitch was in tenth grade, his father found
him looking at one of his gynecology textbooks and knocked him
hard on the top of his head.
“What the hell is the matter with you? You don’t want to be
an obstetrician.” His father said that ob-gyn was not a manly area
of medicine, like orthopedics was. “And think about the crazy
hours you’d be working, the outrageous malpractice insurance,
and you’re looking at women’s crotches all day. Trust me, after
two days, it gets old.” His father scoffed. “It’s sissy medicine.”
Senior year in college was when Mitch told his father about
his final decision to specialize in ob-gyn. His father made no
attempt to hide his disappointment. His derogatory remarks
caused a deep crack in their relationship.
His father’s disapproval weighed heavily on Mitch, causing
him to frequently doubt himself and his decision. He lived under
that cloud that he would never be a good enough doctor in his
father’s eyes. However, when he was in triage and delivering
babies, he was in his element. He was good at what he did, and
the mothers needed him. That felt important and powerful—
something he never felt around his father. He persisted, even in
the dark times of serious self-doubt. He was determined to show
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THE VERY BEST OF CARE
his father that he could succeed and that his work mattered, even
while his father’s voice played over in his head, “Sissy medicine.”
He snapped out of his reverie when he heard Amanda call his
name. Amanda was his right-hand nurse. So smart and compe
tent, she worked by his side whenever they were on duty together.
While evaluating a patient, she called over to Suzanne, another
experienced nurse, to give her a hand. Suzanne had recently
started working at Metro, having moved from Georgia, where
she had worked at Vanderbilt University Hospital. A laboring
mother whom Mitch recognized from prior triage visits was strug
gling with her pain.
“It’s likely back labor,” Mitch said, looking over Suzanne’s
shoulder. “Just get her positioned right to relieve the pressure
that the baby is putting on her sacrum.”
Amanda helped Suzanne as they tried to get her more com
fortable. Nothing worked. The patient was crying, in so much
pain that she couldn’t sit still.
“Amanda,” Mitch said from behind her. “Let’s just get the
baby out. She can’t go on like this.”
Amanda handed Suzanne a vial and told her to give it. It
would help with the pain.
Suzanne looked at Mitch. “Dr. Wagner?”
He nodded.
Suzanne injected the medication. Two minutes later, the
mother was writhing, screaming in pain, and clawing at her belly,
trying to escape the building contractions that just wouldn’t abate.
She was sweating, pulling at her johnny, legs spread wide, yelling
for Dr. Wagner to get the goddamn fucking baby out of her now!
Mitch stood over the patient. He gave her a small dose from
one of the vials on the cart next to the patient, then positioned
himself between the mother’s legs, ready to deliver the baby. An
uneasy feeling started to build in him, a vague sense of impending
doom. His brow furrowed, and a small bead of sweat ran down the
44
JULIE HATCH
back of his neck. He yelled for Amanda to get over and help him,
unaware that Amanda was right behind him. He showed Amanda
his reason for concern. The baby was breech. Why hadn’t any
one known this? Didn’t anybody check the baby’s position? This
delivery was going all wrong. A breech delivery is trouble, and
double trouble when nobody is prepared for it.
Suzanne slapped a mask over the patient’s face and turned
up the oxygen that blended with a sweet-tasting gas. The patient
instantly relaxed and soon fell asleep. With the baby already
descending out the birth canal, bottom first, there was no time for
a C-section. It had been a while since he’d done a breech deliv
ery. He’d learned from the seasoned doctors who had experience
and knew what they were doing, but it was tricky. Mitch reached
up inside, grabbed the baby’s shoulders, and pulled hard. Suzanne
put all her weight into pushing on the mother’s abdomen, forcing
the baby down and out. Finally, the butt appeared, along with a
set of testicles, followed quickly by the body. The head was not so
quick to follow. It was stuck. The mother, waking up despite the
anesthetic gas, screamed again. The baby’s body hung by its neck
from the mother’s vagina. His legs were blue and motionless with
his head still stuck inside. Mitch gave another half a dose, hoping
one more good contraction would push the head out. Instead, the
contracting uterus tightened the cervix around the baby’s neck.
“Oh, shit, this isn’t good,” said Suzanne.
Mitch commanded, “Amanda, get her back to sleep.”
Amanda covered the patient’s face again with the gas mask.
Instantly, the patient fell asleep, relaxing her muscles. Amanda
and Suzanne both put all their strength into pushing on the
mother’s belly from above while Mitch pulled from below. A
minute later, the baby boy was born. He was limp, blue, and life
less, with an Apgar score of 0 at one minute.
“Shit,” Amanda said under her breath, then yelled, “I need
help over here! Full resuscitation!”
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THE VERY BEST OF CARE
Doctors and nurses scrambled to intubate the baby, quickly
inserted an umbilical line, and pushed medications to get his heart
rate going. Apgar score was 2 at five minutes. Mitch was tending
to the mother, stitching up her episiotomy, while another phy
sician called out orders for more meds for the baby and to keep
giving chest compressions and ventilations. By ten minutes, the
baby’s Apgar score was 5. Not terribly optimistic for his future,
but one never knew for sure.
Two nurses and a respiratory therapist took the baby to the
NICU while the mom went to recovery. Standard blood work
was sent on the mom, including toxicology. Drugs needed to be
ruled out as the reason for preterm labor.
Thirty minutes later, the tox screen results came as a sur
prise. There was a dangerously high level of Pitocin in her blood.
Suzanne showed the results to Amanda, who brought the results
to Mitch. After a pause, he gave reassurance to Suzanne and
Amanda that it made sense. He had given the mother some extra
Pitocin at the end to get the baby out faster.
“But, Dr. Wagner, that much?” Suzanne questioned.
He shrugged. The results must be a mistake. He’d dou
ble-check it with the lab. Several minutes later, while Suzanne
was writing her notes, she started talking out loud to herself about
meds, breech babies, low Apgar scores, and poor outcomes. She
exclaimed, “Oh my God! What have we done?”
Mitch grabbed her arm and hushed her. In a loud whisper, he
replied, “We haven’t done anything. The baby would have died
in utero if we hadn’t delivered him. You saw the monitor. He was
compressing the umbilical cord, cutting off oxygen to his brain.
We had no choice. We all did a fine job in saving this baby’s life.
And you, Suzanne, should be congratulated for your help.”
In shock, Suzanne walked out of triage and away from Mitch.
“Where is she going?” Mitch asked Amanda. “Go get her.
Stop her!”
