Black Man in a White Coat (5 page)

By the time we arrived in her room, the nurses had already done much of the initial care required to stabilize and monitor her condition. “Anything new?” Carla asked her colleagues.

“BP's a little low but stable,” one said. “Just sent off stat labs. No fetal heart rate yet.”

I looked at the woman. Her skin had a cluster of pockmarks on her left cheek. A small scar zigzagged on her lower chin. Thin lines stretched across her forehead. Her oily hair showed signs of early thinning. She was not yet twenty, but looked closer to thirty.

An older man, around fifty and smelling of cigarettes, stood in the rear corner. He had brought her to the hospital. “I'm her uncle,” he told us.

We stepped outside the room while the other nurses tended to our patient. “Can you tell us what happened today?” Carla asked.

“She called me about an hour ago hollering and screaming. When I picked her up I seen she was bleeding too. I figured I could get her here faster than calling 911.”

“Did she say if anything happened to her? Like an accident? Or someone assaulting her?”

He shook his head. “She just said she hurt real bad.”

“Do you know anything at all about her pregnancy?”

“Nah,” he said, as he looked away. “I ain't seen her in over six months.”

“Okay, thanks,” Carla said. “We're going to need you to stay outside in the waiting room. We'll come find you if we have any more questions or when there are any updates.”

“I'm Leslie's only family,” he said, stepping away. “Y'all please take good care of her.”

Leslie. Until then, she had been an anonymous person with medical problems. Even at that early stage of my training, I'd grown far too comfortable categorizing people as organ systems or diseases. Much of it was simply modeling what I saw senior medical students and doctors do. On the chaotic hospital wards, this approach made it easier to keep track of the relevant medical concern while avoiding getting too attached to the patient. Without realizing it, I'd already done that with Leslie.

We walked back into the room. “I can take it from here,” Carla told the other two nurses, who stepped aside. I introduced myself to Leslie, who sat uncomfortably in the bed at a slight incline. The nurses had dressed her in a baggy cloth gown, loosely draped over her abdomen and thighs to offer some privacy. Blue pads had been placed underneath her to absorb the small trickle of blood from her vagina. From what we knew thus far, she had not had any prenatal care. We were the first medical providers she had seen. “Are you the doctor?” Leslie asked me.

“I'm a medical student. I'm going to get things started.”

“I don't want you touching me down there,” she said, briefly distracted from her pain.

Like other male medical students on the obstetrics and gynecology rotation, I heard this reaction quite often. Even though it bothered me sometimes, I understood their perspective. A stethoscope across a gowned torso surely felt quite different to many women than being fully exposed to the eyes and hands of an unseasoned twenty-something man.

After my assurance that I would not examine her, Leslie agreed to let me ask her a few questions. Meanwhile, Carla made several adjustments to the fetal monitor, but could not pick up a fetal heartbeat. “Get Dr. Garner in here ASAP!” she said to one of the junior nurses.

The urgency in her voice made me feel like I should have been doing something besides asking questions, but that was all I really knew how to do. I started with the most obvious one:

“How far along are you?”

“I ain't pregnant,” she answered, even as she was grimacing and writhing in intense pain.

My eyes went down to her abdomen, which protruded to the size of a volleyball. I wanted to ask her what else she thought might explain this, but that seemed a futile question. Instead, I focused on her symptoms of bleeding and pain, but the monosyllabic answers she gave between groans provided me with no helpful clues.

Despite her strange denial about being pregnant, Leslie did not seem acutely psychotic or manic like the women I had seen at the psychiatric hospital. So I searched for other explanations for her behavior. “Have you used any drugs recently?” I asked.

“No,” Leslie said without hesitation.

Just to be certain, I then went through a typical list I'd heard other doctors recite: “Marijuana? Heroin? Cocaine? Meth? Pain pills?”

“No, no, no,” she said, once again shaking her head.

She sounded convincing. Then again, she had also denied being pregnant. Either way, my brilliant idea had gone nowhere. “Do you smoke cigarettes or drink alcohol?”

“I had a cigarette a few days ago. But what's that gotta do with my pain?”

“Okay,” a woman's harried voice interrupted me. We all looked toward the doorway, where Dr. Garner, my supervising resident, stood. At five-eleven, with short brown hair and broad shoulders, she struck an imposing figure. After introducing herself to Leslie, she turned her attention to Carla. “Let's type and screen her. She's going to need two units of blood.”

Dr. Garner did a quick external exam, listening to Leslie's heart and lungs, feeling her belly, and inspecting her lower legs and feet for any signs of swelling or poor circulation, while simultaneously asking questions that produced no more information than mine had. All the while, Carla continued to adjust the fetal monitor in hopes of finding a heartbeat.

With Carla having no success, Dr. Garner wheeled over the ultrasound machine. She layered a thick gel on the handheld ultrasound probe, then rubbed it across Leslie's belly, moving it around so quickly that I could not tell what she saw. She was in no mood to slow things down for teaching purposes; her tense energy signaled that there was no time for that. “I think that this might be an abruption,” she said to Carla.

Leslie was unlikely to recognize this word. It was shorthand for placental abruption, a condition in which there is premature separation of the placenta, the vital connection between the mother's uterus and the growing fetus.

“There's no sign of trauma,” Dr. Garner said aloud, sounding as if she was going through a mental checklist. “And her blood pressure is normal.”

These were two of the most common risk factors for placental abruption. Dr. Garner refocused on a third one. With a hard look at Leslie, she began to speak. “I can understand why you would want to deny using illegal drugs, but it's important that I know right now what, if anything, you might have used recently. It can tell us what might be causing this to happen and could possibly save your life, as well as your baby's.”

Leslie stared at the wall behind us, her face revealing nothing. Dr. Garner pressed on: “My suspicion is that you might have used cocaine. Your symptoms sound like your placenta might have separated from your womb. Cocaine is a known cause of that.”

Leslie shook her head as she continued to groan. Then, to my shock, Dr. Garner abruptly changed her tone. She took a step toward Leslie, and in a harsh voice suddenly demanded: “When is the last time that you smoked crack?”

Leslie looked directly at the doctor. Tears flooded her eyes. “Two … days ago…”

What?
I could not believe what I'd just heard—neither the accusation nor the response. I'd never seen a doctor confront a patient that way. But it had worked, and like a typical self-centered medical student, a part of me felt embarrassed that I hadn't been able to get this same vital information on my own.

Yet Dr. Garner's approach troubled me. What was it about Leslie that made Dr. Garner so certain she used drugs? And crack in particular? Was it her appearance, her speech, her race? Some combination? Would Dr. Garner have done that to a Duke graduate student, even one whom she suspected might have snorted a few lines? Or to any patient who looked and acted middle class? What did it say about the vastly different ways that patients could be treated? Moreover, if Dr. Garner hadn't demanded answers, if she'd continued to accept Leslie's denials as I had, what might have happened?

My head swam with just as many questions about Leslie's mind-set. Why had she lied to me, and then, at first, to Dr. Garner? Lying made no sense: The nurses had collected a urine sample and surely it would come back positive to contradict her denial. Then again, denying that she knew she was pregnant didn't make much sense either, so clearly she wasn't thinking rationally. And smoking crack while pregnant … didn't everyone know that was bad? Maybe she had to delude herself into believing that she was not pregnant in order to continue using.

Her face flushed with anger, Dr. Garner continued with the ultrasound. She finally got a clear view of the fetus. “It looks to be somewhere around twenty-two weeks,” she said.

She found no sign of fetal movement nor a heartbeat, yet she kept looking, in much the same way that I later saw doctors doggedly continue CPR when they knew that the patient was dead.

Finally, she gave up: “I'm sorry…” she began, as she removed the ultrasound probe from Leslie's abdomen and looked directly at her, “but your baby has died.”

Leslie's groaning stopped. She looked up at Carla, then over to Dr. Garner. They each took one of Leslie's hands into theirs. In response, she began to wail again.

“No … no … my baby … my baby…”

Her moans expressed a profound sadness like nothing I'd ever heard. This young woman had known all along that she was carrying a child. She probably knew that smoking crack while pregnant was dangerous. But she had tragically underestimated the possible consequences.

*   *   *

At that point in my training, death had made only brief, detached intrusions into my medical life. The infamous first-year cadaver dissections, taking place as they did in the basement of a research building, with five students hovering over a formaldehyde-preserved body, felt more like a ritual or rite of passage than a true encounter with death. Our autopsy experience later that year—a postmortem examination of an elderly man who had died a few days earlier from a rare vascular disease—came closer to the real thing, but neither the physician (a pathologist) nor any of us students had known the man in life.

I inched closer to experiencing the personal side of death a few months later during my surgical oncology rotation. There, I followed patients with colon, pancreatic, and breast cancers whose long-term prognoses were poor. Even so, surgeon and patient seemed to have negotiated a silent pact never to look too far ahead, as if exploring that territory might get in the way of what could be done in the short term. Some of these patients probably lived for a few years, while others likely died in a matter of weeks; I never knew for certain, as I soon moved on to the next clinical rotation. Not seeing these deaths allowed me to suspend disbelief about their fates.

But Leslie offered no such escape. Her fetus was too young to have survived on its own, and as a result, in purely legal terms, would not have been considered a person at all. Yet Leslie's piercing cries made clear the emotional stakes: She had lost her child.

After briefly comforting her, Dr. Garner focused on the medical task at hand. While first trimester miscarriages could sometimes take place safely within a woman's home, the risks of carrying a larger dead fetus—infection and blood clots, among others—necessitated medical intervention. Dr. Garner gave Carla and another nurse medication orders to stimulate Leslie's contractions while also dilating her cervix. “Call over to L and D and tell them to get everything prepped for an IUFD,” she said.

This acronym likely meant nothing to Leslie, whose deep cries had slowed to a whimper. But to me, calling the labor and delivery unit to prep for an intrauterine fetal demise communicated a clear and terrible message: We were getting ready to deliver a dead baby.

As an assistant nurse wheeled Leslie down the hall of the triage area toward the adjoining labor and delivery suite, we had a few minutes to collect our thoughts. The impact of what we had just seen hit everyone at once.

“This never gets any easier,” Dr. Garner said. “Does it?”

Carla shook her head. “It's awful. But in a case like this, it's for the best.”

Dr. Garner agreed and tried to convince me as well. “Even if we could have gotten a heartbeat and then delivered the baby alive, I doubt it would have survived more than a day,” she said to me. “At this early a gestation, it didn't really have a chance.”

We'd been taught that twenty-four weeks was the cut-off point for a viable pregnancy. We heard about a few cases of live deliveries at twenty-two and twenty-three weeks, but these infants rarely left the hospital alive; when they did, they were profoundly disabled. With that knowledge, I agreed with Carla and Dr. Garner. We were falling back on the familiar “he's in a better place” or “she's no longer suffering” clichés that surviving family and friends so often use for comfort after the death of an elderly or sick loved one. Or at least that was what I thought—until Carla kept talking.

“I knew she was a crackhead,” she said. “I knew it. It's bad enough to ruin your own life, but to do that to your baby? That's just unforgivable. Even if she had carried this baby to term, it wouldn't have stood a chance. Like I said, what happened is all for the best.”

My body stiffened. Dr. Garner, who was walking to the nearby sink to wash her hands, said nothing. Carla was voicing the fear and anger that pervaded the 1980s and 1990s: Crack-addicted moms—primarily poor black women—would birth a generation of “crack babies” who would grow up with serious developmental, psychological, and physical ills, strain limited social resources, and perhaps even threaten the safety of our society. It was in this spirit that a nonprofit California-based program in 1997 started paying drug-addicted women $200 if they agreed to use long-acting contraception or be permanently sterilized. This panic was also enmeshed with the politics of the war on drugs and the fight over abortion, most notably when the state of South Carolina enacted a policy in 1989 that brought criminal charges and punishments against women who used cocaine while pregnant. To many people at this time, pregnant women who smoked crack were true villains.