“The Retrievals” is a podcast series hosted and written by Susan Burton and presented in cooperation with the New York Times that focuses on the failure of a Yale fertility clinic to address uncontrolled pain during procedures. As it turns out this was the result of a nurse surreptitiously replacing the pain medication fentanyl with saline to support her addiction. This apparently unfolded over the course of a year or years and involved not just a few patients but perhaps hundreds. Yale’s response to the patients who suffered painful traumatic experiences forever connected to childbearing, highlights profoundly negative corporate encroachment on the practice and values of medical care. Quotes in the multiple-episode series articulated experiences of not being seen, of being ignored or dismissed, and of having suffering trivialized. From a psychotherapist’s perspective, this compounds experience already fraught with confusion and self-doubt and further contributes to damage from the primary injury. But it isn’t the impact of someone’s addiction on those around them that I want to focus on. Rather, it is the clinicians who evidently continued with the procedure despite failing to address uncontrolled pain in an operative setting. As an anesthesiologist, this is a critical failure with multi-factorial contributors that seems important to discuss in the open.
On the Labor Deck which offers every option to navigate the many ways a delivery can unfold, questions of pain control can come up too. The most common scenarios of suffering include failed epidural analgesia, contraindications to an epidural necessitating less effective alternatives, and conversion of labor to a cesarean section with an epidural that is already in place and fails. Inadequate pain control for an elective c/s can also occur but this is less common due to typically utilized spinal anesthesia providing a denser block to sensation.
Imperfect pain control for childbirth can be fraught with frustration for the patient, her family, staff, and the responsible clinician, and it is inevitable. Imperfection is an inherent part of medical practice. Outcomes are important, safe delivery of a healthy baby is the ultimate goal. But acknowledgment of patient experience is critical to communicate that the care environment actually cares while reducing the potential for ramifications such as distrust or more durable post-traumatic syndromes.
It is also critical to recognize impacts of an overarching system which prioritizes production pressure on a doctor’s ability to retain both humanity and honest humility. Not every procedure goes perfectly. Anatomy can present challenges. Patient anxiety can contribute to clinician feelings that must also be contained. And sometimes things on OB can go very wrong very quickly and this is on every clinician’s mind while on shift. Weighing the risks and benefits of alternatives and explaining this to a patient while she is in pain presents additional obstacles to providing the best and most efficient care. Every patient’s individual expectations, pain tolerance, medical history, and family dynamic present must be accounted for and addressed. But none of this is the same as continuing a procedure in the face of uncontrolled pain without offering and effectuating an anesthetic.
Among some of the more difficult scenarios that anesthesiologists inevitably navigate is a failed anesthetic during cesarean section with the need to convert to a full general anesthetic. Weighing risks and benefits with the knowledge that regional anesthesia, or spinals and epidurals, historically led to among the greatest reductions in maternal morbidity and mortality in medically assisted childbirth contributes to a reluctance to change over. It means taking on additional risk in a procedure with known potential for catastrophe (albeit rare), it means mom won’t be awake for the birth of her baby and her partner will not be there to participate. And it can also mean acknowledging failure of one’s own technique. It is not a trivial decision, and all of this has the potential to flood decision making with indecision and sometimes failure to act. And finally, women are anxious during an awake surgery so distinguishing between a failed epidural versus an anesthetic that can be effectively supplemented with reassurance or sedation, presents additional challenges. It is remarkable when all is said and done that so frequently surgery for delivery of a baby goes well and the patient doesn’t suffer uncontrolled pain, complications, or long-term traumatic ramifications.
There are some important techniques to managing one’s own emotional constellation when working in a high-stakes field such as obstetrical anesthesia. Understanding effective emotional boundaries, an ability to contain all of the charged feelings that can come up providing care for awake patients, and effectively deciphering, facilitating, and navigating how patients cope, is not something we typically learn in medical school or training. Anesthesiologists naturally gravitate to preferring this emotionally charged practice, or select themselves out when there is a choice, because obstetrics is so different from the general operating room environment. But addressing pain out of control in a procedure that cannot be readily halted is most certainly in the toolbox, and approaching patients with compassion and honesty is an essential component of providing care as a physician, despite institutional stakes which counter the oath and values of our training.
Maire Daugharty is an anesthesiologist who expanded her expertise by earning a master’s degree in clinical mental health counseling, merging her long-standing interest in mental health with her medical background. As a licensed professional counselor, licensed addiction counselor, and licensed marriage and family therapist, she brings a well-rounded perspective to her private practice, where she works with adult individuals and couples on a wide range of concerns. In addition to her counseling practice, she continues to work part-time as an anesthesiologist and has a deep understanding of the unique challenges faced by clinicians in today’s medical landscape. To learn more about her practice, visit Physician Vitality Services.
