The Retrievals S02 Episode 2: The Speech

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Speaker 4 I just remember all of a sudden just being like, oh my god, I don't feel good.

Speaker 5 Previously on the retrievals.

Speaker 4 It was an unfathomable amount of pain

Speaker 4 and I remember

Speaker 4 begging them to stop.

Speaker 6 And one of the attendings She looked at me and told me to tell her that it was okay. That's one thing I I regret the most, that I didn't say, like, it's not okay.

Speaker 3 I felt horrible.

Speaker 8 And

Speaker 8 then I got mad.

Speaker 10 And then I got really mad.

Speaker 5 From Serial Productions and the New York Times, I'm Susan Burton. And this is the retrieval season two, The C-Sections.

Speaker 12 And I got really mad, and I was like, I am going going to talk to the provider.

Speaker 13 I don't even know what to say.

Speaker 14 I'm so angry.

Speaker 5 Usually this scene happens in a hospital corridor. There's a template for this.

Speaker 5 One doctor dressing down another, maybe shouldering furiously out of an OR, stripping off gloves, throwing them into a bin with an emphatic gesture, and turning to face their colleague.

Speaker 5 The one doctor, passionate and outraged about what just happened in that room, and another who we can tell did not make the right choices, but genuinely feels bad.

Speaker 5 How it happens on our show, in real life, is Dr. Heather Nixon is at home in pajamas on her day off.

Speaker 5 She's just learned that her colleague, Clara, was in agonizing pain during her C-section.

Speaker 5 Heather is the head of obstetric anesthesia. Making sure patients are not in agonizing pain during their C-sections is her job.

Speaker 5 Heather puts in earbuds and calls the anesthesiologist from Clara's Clara's surgery.

Speaker 15 And I said, hey,

Speaker 3 what the hell happened?

Speaker 5 To Heather, at first the anesthesiologist seems confused. But we gave her all these meds, he tells her.
The two of them begin reviewing the events.

Speaker 5 The anesthesiologist says that he'd given Clara an anti-anxiety drug, midazolam.

Speaker 15 He kept saying to me, well, well, she has anxiety.

Speaker 16 And so we kept giving her like anti-anxiety medicines.

Speaker 11 And I said, but she was telling you she was in pain.

Speaker 15 And he's like, oh, well, she had anxiety.

Speaker 11 She was just very anxious.

Speaker 5 The anesthesiologist had repeatedly mislabeled Clara's pain as something else.

Speaker 13 It was also, well, you know, the patient was having a lot of pressure.

Speaker 14 And I, and that's when that word really became a dirty word to me.

Speaker 8 I was like, yeah,

Speaker 9 but no.

Speaker 5 In addition to medazolam, the anesthesiologist had given Clara fentanyl and ketamine.

Speaker 5 Giving extra drugs is standard when a cesarean patient is in pain.

Speaker 5 But he'd given way more drugs than Heather would give before making the call that the only way to relieve the patient's suffering is to convert to general anesthesia, to put the patient to sleep.

Speaker 15 And I said, well, why didn't you just put her to sleep? Like, what was your reservation?

Speaker 10 And he said, well, I was afraid of losing her airway.

Speaker 5 General anesthesia is the kind where you get a breathing tube to keep your airway open.

Speaker 5 But for decades, doctors have been taught that pregnant patients are hard to intubate, that they have difficult airways.

Speaker 15 I said, but in any other setting, you would have put this patient to sleep.

Speaker 10 If you were on the third floor, which is where our Maino is, and you were doing a cardiac case, you would just put the patient to sleep.

Speaker 14 You have no fear of that airway.

Speaker 13 You handle difficult airways all the time.

Speaker 5 And the problem is that in doing everything possible to avoid general anesthesia, a doctor can create an even more dangerous situation. Which is what happened here.

Speaker 15 And I was like, well, but you administered like four times the amount of meds that we would normally do.

Speaker 15 Like, didn't you even worry that the patient was gonna stop breathing at some point because you're given so much anyway?

Speaker 8 Like, wouldn't it have been better to have a breathing tube in place?

Speaker 5 When I talked to this anesthesiologist, he said that he felt terrible about this case. But overall, he emphasized that he'd done what, in his judgment, would keep the patient safe.

Speaker 5 To Heather on the phone that morning, It seemed like the anesthesiologist was rationalizing every choice he'd made.

Speaker 5 But these weren't just his personal rationalizations, they were collective ones.

Speaker 8 He was using all the language, all the culture, all the fears that have been bred into us for years.

Speaker 15 She's got anxiety, so maybe it's just anxiety.

Speaker 14 Pressure is normal, right?

Speaker 11 I gave her all these medicines, so she's not going to remember it.

Speaker 13 I don't want to harm her with taking on her airway.

Speaker 5 Heather hangs up.

Speaker 5 What was wrong was not that this doctor had a set of beliefs about C-sections that were out of the ordinary.

Speaker 5 What was wrong was that these beliefs were ordinary.

Speaker 5 Heather walks across the room to the kitchen, stands in front of the coffee maker.

Speaker 5 Heather has never had a patient who was screaming, make it stop. She would never let it get to that.
Has she had patients who felt something during cesarean? Yes, all the time.

Speaker 5 Patients who've been uncomfortable? Yes.

Speaker 5 Patients even up to the level of, well, I'm not torturing you, but you're really not okay.

Speaker 5 Yes, that too.

Speaker 5 She's heard about patients who've, quote, felt everything.

Speaker 5 But to Heather it always seemed like, okay, the patient felt more than they expected to feel, but they misunderstood, because what doctor would allow that kind of suffering?

Speaker 5 Now she wonders if she's the one with the misunderstanding.

Speaker 5 Cut to the dining table. It's dark now.
Heather's face lit by her laptop. We're not sure whether it's the same day or another, but we have the impression that she's been in this position for hours.

Speaker 5 She's on social media, TikTok, Reddit, reading accounts of painful C-sections.

Speaker 5 Patients who've been through this say they feel cutting. They feel pulling, and yeah, okay, a doctor will tell you that pulling is normal, but not this kind.

Speaker 5 They feel outraged that they are screaming in pain and that an attending continues to teach your resident like nothing is abnormal. They feel their organs being moved around.

Speaker 5 What does that feel like to have someone lifting out your insides?

Speaker 5 Gross and scary, says one patient. They are given drugs, but the drugs make them not remember.
Or they do remember. They remember their vigilance.

Speaker 5 They remember listening to the monitor, waiting for their heart attack.

Speaker 5 Because they are scared they will die from this pain. They get to the point where they want to die.

Speaker 5 I felt everything.

Speaker 5 It's not an exacting description, but it gets at the way that this pain is totalizing.

Speaker 5 Heather is startled.

Speaker 15 How do I not know that this happens, right?

Speaker 15 How do I not know that patients afterwards are choosing to not go back and have a second baby, are choosing to not have C-sections, even if there's harm to their child because they're so petrified?

Speaker 14 How do I not know that a significant number number of women do not feel empowered enough to say, I hurt?

Speaker 13 I could have read all those stories on the internet.

Speaker 14 I could have looked at all the accounts and been like, oh, well, it was an emergency C-section.

Speaker 15 And so they must have dosed the epidural and it didn't quite work.

Speaker 13 And maybe the OBs didn't know and they just started.

Speaker 10 And then, of course, they went to sleep or something like that, right?

Speaker 10 Never, ever would I have thought that across the nation, women interoperatively were consistently having tremendous pain.

Speaker 13 And so that was a moment where I was just like, okay,

Speaker 14 it happened to this individual who I know and trust, and it's real.

Speaker 11 It's real and it happens.

Speaker 13 And I hate to say that that was the moment that I actually realized that.

Speaker 5 But something has to happen to

Speaker 5 shake a person up.

Speaker 10 It took a little bit of a toll on me for a little bit just to kind of try to figure out, like,

Speaker 14 okay, how do we you know kind of what do we do here

Speaker 5 medical dramas they're often used to explore social issues in the writer's room you work that into the plot what if so-and-so got aids what if there was a pandemic

Speaker 5 but for our characters The social issue isn't being grafted on. It's just what happened to them.

Speaker 5 Heather closes her laptop. She doesn't yet know exactly what to do, but she knows she's going to do something.

Speaker 5 With the light from the laptop screen gone, the room is dim, and we now fade completely to black.

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Speaker 5 Why would a patient be in severe pain during a C-section?

Speaker 5 One kind of answer is something like, the doctor didn't listen to her, and that might well be a play in an OR.

Speaker 5 But why would her block, why would her epidural or spinal, fail to begin with?

Speaker 5 There are all kinds of reasons, like maybe the needle was inserted off center, maybe the catheter moved, maybe the doctor underdosed it.

Speaker 5 When a block fails, there are lots of things anesthesiologists can do to fix the problem. But the fact that this is a problem, the fact that blocks do fail, comes as a surprise to most patients.

Speaker 5 What also comes as a surprise is that even when a block is working properly, it's unlikely to numb you 100%.

Speaker 5 All the time, Heather gets the question: I'm not going to feel anything, right?

Speaker 5 Well, you might.

Speaker 5 You might feel pressure, including pressure from deep inside your abdomen. This is the origin of that phrase, it's just pressure.

Speaker 5 But pressure can be painful.

Speaker 5 The sensation a patient feels during a C-section is most often mild, bearable, and limited to certain parts of the surgery. But there's a whole range.

Speaker 5 What might be tolerable for one patient might be excruciating for another.

Speaker 5 The only thing that will knock out all sensation is general anesthesia. If you or your mother had a cesarean before the 1980s, there's a good chance you had general.

Speaker 5 But general has not been the first choice for cesarean for a long time. It carried risks for pregnant patients.

Speaker 5 Some people I spoke to pointed to a 1997 paper that showed a way higher mortality rate for general anesthesia during cesarean as a turning point that led to the teaching avoid general at all costs.

Speaker 5 Others observed that it had been falling out of favor for decades before then.

Speaker 5 General is a lot safer now than it used to be, and any anesthesiologist who does cesareans regularly is likely to be comfortable using it.

Speaker 5 But on the whole, the taboo against it remains strong.

Speaker 5 Pain during a C-section won't kill anyone, but general anesthesia might.

Speaker 5 And maybe nobody has ever died on the operating table from C-section pain,

Speaker 5 but plenty of patients have feared they would.

Speaker 5 There are all these common phrases doctors say during Caesarean.

Speaker 5 We're almost finished. It's just a few more minutes.

Speaker 5 What's clear from patient accounts is that these phrases are as dirty as, it's just pressure.

Speaker 5 Because for the patients who feel pain during cesarean, the experience isn't finished after they leave the OR.

Speaker 5 It isn't just a few minutes that people are affected by this.

Speaker 5 And now one of those people is Clara.

Speaker 5 Clara stays home with the twins for four months, and then her leave is over.

Speaker 5 Shot of the staff elevator opening, Clara and the crowd stepping out onto the fourth floor. Clara's not just going back to work.
She's going back to the site of what happened.

Speaker 5 And as soon as she arrives, she is flooded with rage.

Speaker 22 I mean, even the sight of the logo made me angry. Walking in the hall made me angry.
I couldn't believe I had to be there. I couldn't believe I was back.

Speaker 22 Everything about it made me so mad.

Speaker 22 You know, that feeling of like this thing happened and the world is still moving, you know, spinning. It's that thing, right?

Speaker 5 Yeah.

Speaker 5 Clara's anger was diffuse. Anger at the system that allows this to happen.
Anger that it had happened to her.

Speaker 12 But there was also

Speaker 22 welcoming, caring coworkers, right? You come in. They're so happy to see you.
How are you? How are your babies?

Speaker 12 Show us the pictures.

Speaker 5 In the hallway a co-worker in scrubs comes toward clara with outstretched arms clara pulls out her phone we see this happen again in almost identical sequence clara beaming

Speaker 5 and then we see clara frozen in her tracks outside the double doors that lead to the ors she did not she could not go back to the operating room and it was kind of understood Again, Mindy, the nurse who'd taken photographs of Clara's surgery.

Speaker 5 She and her co-workers felt protective of Clara.

Speaker 6 And in the beginning, it was a very understanding environment. People would adjust their assignments.

Speaker 6 But after a while, it started becoming like,

Speaker 6 I mean, I'm not a charge nurse. I don't make assignments, but I would hear, like, okay, like,

Speaker 6 when,

Speaker 6 what is happening? Like,

Speaker 6 is this still a thing? Can she go back to the operating room?

Speaker 6 Because

Speaker 6 you can't have restrictions, honestly.

Speaker 6 Like, there's only a few nurses like for terminations or abortions that have stated their medical religious beliefs, but going into an operating room is part of your job description and part of, you know, it was never official because if it wasn't official, like I cannot go into an operating room, then I think she would not have been able to continue working labor and delivery.

Speaker 5 And almost every day, Clara did wonder whether she could keep working this job.

Speaker 5 You could say she had occupational retraumatization, or you could say reminders of her surgery were everywhere.

Speaker 5 Except for one significant one. Clara never saw the anesthesiologist from her C-section around the hospital, which didn't surprise her.

Speaker 5 He wasn't an obstetric specialist, and he mostly worked on a different floor. She'd never seen him before that night anyway.

Speaker 5 But she wondered about him.

Speaker 4 Within a few weeks or a month of being at work, I went to the records office to get my records.

Speaker 4 Of course, they were, they sent me like gobbledygook. It didn't mean anything.
And afterwards, at some point, I actually just went in my chart and navigated to, you know, that day.

Speaker 4 And I saw his name and I googled him.

Speaker 9 You know, but

Speaker 4 it's just a doctor. It's just a whatever anesthesiologist.

Speaker 5 Yeah.

Speaker 5 Did your records reflect, like, did they accurately reflect what happened to you?

Speaker 4 No, nothing about it is in there.

Speaker 4 There's nothing in the surgical report that says anything.

Speaker 5 It was as if it hadn't happened. In the surgical report, there was no record of Clara's pain, of her own experience.

Speaker 5 There's a phrase in medicine, a relatively new one, the patient experience.

Speaker 5 It's meant to capture the idea that it's not just the outcome of the treatment that matters, but what the patient feels during it. It's a well-intentioned phrase, but it's odd that it needs to exist.

Speaker 5 Like it's a name for something that had been left off the list.

Speaker 5 Guys, the patient's experience.

Speaker 3 Oh shit.

Speaker 5 Of course there was someone at the hospital who'd been thinking a lot about the patient experience.

Speaker 9 Heather.

Speaker 5 Now we see Heather in her office on the third floor. Black leather couch, hot pink pillow.
Heather has been sleeping here some nights, and not just because of her clinical schedule.

Speaker 5 She's been working on a speech.

Speaker 12 A speech.

Speaker 5 A speech is a staple of TV storytelling, a character using a ritualized occasion to get up there and deliver an indictment or something inspiring, to call out bad behavior or to uplift, or to tell one special person how they felt all this time, the whole past four years.

Speaker 5 The occasion for Heather's speech is a medical conference. And this next thing will sound like an improbable coincidence, because in fact fact it was.

Speaker 5 Before Clara's surgery, Heather had been assigned to prepare a speech on pain during C-sections for a major national conference. She'd planned to focus on technical tips.

Speaker 5 Then Clara's C-section happened, and a how-to started to seem beside the point.

Speaker 5 Over the years at conferences, Heather had sat through dozens of lectures on things like the optimal drugs to put in your spinal. And Heather appreciated these lectures.

Speaker 5 But it was like all this time people had been talking around something rather than saying it directly. In a lot of ORs, patients are in pain.

Speaker 5 Pain during cesarean was a subject that had been getting a little buzz around it. There was a reason that this had been assigned out for a speech.

Speaker 5 A doctor who'd begun to do research on it told me that for a long time, it had been a hush-hush topic. something that caused discomfort.
Maybe because, she said, no one wants to say,

Speaker 5 I had a patient under my care and I watched her be in pain.

Speaker 5 But look, we've all been in this situation, Heather imagined she could say, and no one feels good about this, right?

Speaker 10 Like, it's not like we're all just like, oh, everything's fine.

Speaker 15 And looking up at the ceiling, we're all like, ugh, we're all groaning internally saying, I'm very uncomfortable with this and not listening to that discomfort.

Speaker 15 This is okay. You know, we're going to get her out of here.
It's going to be fine. Can we just finish, right?

Speaker 5 Back when Heather was a resident, no one had talked about cases like this.

Speaker 17 Instead, you'd go home and you'd have a glass of wine because you were like, oh, that was rough.

Speaker 15 Like, I didn't like that.

Speaker 5 Though a lot has changed since then, there's still not as much frank talk about this as there should be. And that was what Heather wanted to try at the conference.

Speaker 15 Like, let's rip the band-aid off and, like, really have an honest discussion about why is this happening.

Speaker 5 Heather wasn't sure if this would work.

Speaker 5 It depended on the willingness of people to actually stand up and come to the microphones and speak, to risk the judgment of their peers for choices they'd made in the OR or hadn't.

Speaker 5 Some doctors in the audience would be aware of pain during cesarean as a growing concern.

Speaker 5 Others maybe wouldn't have a sense of the true scope of the problem because in their own practices, in their own institutions, pain was well managed.

Speaker 5 But even the people who thought they had it right, did they really,

Speaker 5 did they really know what was going on for their patients?

Speaker 5 This kind of thing would not be typical for this conference at all. Heather worried that people would judge her for standing on a scientific stage with an unscientific speech.

Speaker 5 But over the past several months, she'd come to understand that this problem wasn't limited to extreme cases like Clara's.

Speaker 5 The problem was that pain during cesarean had been normalized. To varying degrees, it was happening all the time, and patients were being harmed by that.

Speaker 5 She needed her colleagues to see what she had.

Speaker 15 I'm not going to make this a scientific presentation.

Speaker 11 I am going to make this something that is emotional because for the patient, it is, right? The consequences are emotional and devastating. And I want the audience to feel that.

Speaker 17 I want everyone to be a little horrified.

Speaker 14 I want everyone to be a little outraged. I want everyone to be like, yep, we got to fix this.

Speaker 13 Yep, there is a problem.

Speaker 14 They need to have the same eye-opening moment that I've had, that I can't believe that I'm just having.

Speaker 5 And now we see Heather's flight to the conference soaring up into the air. Because why not?

Speaker 5 What happens when she lands? That's coming up after the break.

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Speaker 5 Establishing shot of the Sheraton, New Orleans. The scene is a standard medical conference.
Doctors mill around in enormous open space, drinking coffee, wearing lanyards.

Speaker 5 It's SOAP 2023, the annual national conference for obstetric anesthesia.

Speaker 24 Today we have some excellent talks for you.

Speaker 5 First up, we're going to have... Now we see Heather on stage in a ballroom, a jumbotron on either side.
She's wearing a pale blue suit.

Speaker 16 Good morning, everyone.

Speaker 13 So we've had some changes in the schedule.

Speaker 5 It's 8 a.m. on a Saturday.

Speaker 5 Doctors are still filing into the room.

Speaker 5 This year at SOAP, there are over 300 presentations of papers and 20 main stage talks and panels. Of those talks, only one is on interoperative pain during cesarean.

Speaker 5 Heather's.

Speaker 5 Heather begins with a play on the phrase that everyone will say in their own talks. It's literally in the rules that you have to do it.

Speaker 16 I have no financial disclosures to make, but I do have several disclosures to make.

Speaker 5 Her disclosures are that this will not be a usual talk at all.

Speaker 16 My actual disclosures include audience participation is absolutely expected. So I hope you have your coffee in hand because I feel like this is a topic that there's really not a lot of consensus on.

Speaker 16 We don't have strict guidelines.

Speaker 8 There is a spectrum of practice.

Speaker 16 There's maybe some misinterpretations and we need to all get on the same page about how we approach this.

Speaker 16 And then finally Some of the content may be very graphic or explicit. It may be a little disturbing.
And I'm hoping that's the case because I'm trying to to generate some urgency around this issue.

Speaker 10 So we're going to start with a story.

Speaker 16 My story starts with a patient named Jennifer. She's admitted to L and D at 37 weeks for a twin gestation.

Speaker 5 Now her obstructor. Jennifer is Clara.

Speaker 5 Heather had asked Clara's permission to use her story for the speech and promised to de-identify her.

Speaker 5 Heather narrates through Jennifer slash Clara's labor, the decision that she needs a C-section, the move to the OR.

Speaker 16 We start the C-section, baby's delivered.

Speaker 9 After that,

Speaker 16 it gets a little dark.

Speaker 5 Heather says that the patient starts moving around, that she starts to feel pain,

Speaker 5 that the anesthesiologist gives her additional meds.

Speaker 16 Jennifer gets 150 of ketamine,

Speaker 11 300 of fentanyl, and six of midaslam.

Speaker 5 We see a couple reaction shots. One doctor even withdraws a little in her chair, and we understand how out of range these doses are.

Speaker 5 On the jumbotron behind Heather, we see an eerie gray scale image of a cesarean delivery. PowerPoints for presentations.
Normally you're showing graphs and data.

Speaker 5 But the only information Heather wants to convey right now is feeling.

Speaker 5 Heather continues with the horror of the surgery, through to the moment an obstetric colleague showed up for his morning shift, and the nurses grabbed him and pulled him into the OR.

Speaker 16 He looks at the OB field.

Speaker 16 He sees that they're on skin, walks to the front of bed, and he sees a father who has an ashen face, is shaking, and a patient who is thrashing with tears falling down her face.

Speaker 16 So he takes, unfortunately, it's the end of the case. There's not much he can do, takes the patient to the PACU.

Speaker 10 And I get a call. Okay?

Speaker 17 So

Speaker 16 I kind of tip my hand in saying, this is not some ethereal case.

Speaker 11 This happened on my unit.

Speaker 16 This is why I'm here today.

Speaker 16 But what if I told you that the patient was a colleague and someone who worked on L ⁇ D?

Speaker 9 Horrific.

Speaker 16 And so when I went to her,

Speaker 16 she wasn't really ready to talk about it. And I said to her, I'm going to do something about this.
I'm going to make sure that this doesn't happen again.

Speaker 16 But I need your help. And when you're ready, I'd like you to give a statement.

Speaker 10 So, here's Jennifer's statement.

Speaker 16 I want them to know that for weeks after birth, I could not close my eyes without hearing my screams in my head.

Speaker 16 I want them to know that I could not wash my own incision.

Speaker 16 When my husband came near to wash it because she had to ask him for help because she couldn't physically physically touch it without her hands locking up, I was scared.

Speaker 16 There were wrenching sobs every time I needed to

Speaker 16 wash it. She had a visceral reminder of her pain on her body.

Speaker 16 I want them to know that despite all the fucking ketamine and whatever else, I could still feel pain.

Speaker 16 I was just hallucinating and could not make sense, but I can remember begging them to stop.

Speaker 5 Usually at a medical conference, people are typing on their laptops or holding their phones up to the screen to take pictures of the slides.

Speaker 5 This room is still.

Speaker 10 So this is a harrowing story.

Speaker 16 It made me mad, it made me sad, it made me frustrated, and it made me really take a deep dive into what is going on in our country.

Speaker 16 If you go to Google, and you search intraoperative pain for cesarean delivery, you will see horror stories across this country.

Speaker 16 And this is really staggering because nowhere else in anesthesia do we allow this to happen.

Speaker 17 Nowhere, right?

Speaker 10 If you have a block that doesn't work for an ortho case, your patient goes to sleep. We don't suffer through it.

Speaker 16 We don't bite the bullet. We don't ask our patient to just take it.

Speaker 16 So, I'm going to ask just this room at this moment, how many people in the last month have had a patient who's had severe interoperative pain?

Speaker 5 There are hundreds of people in the room. We watch as half of them raise their hands.

Speaker 9 Half.

Speaker 5 Heather had asked how many people in the last month had a patient who had severe pain during their C-section.

Speaker 5 And half of the doctors raised their hands. Okay.

Speaker 16 So this is not rare. We have a group of experts in the room who clearly are experiencing this on a daily basis and we're just beginning to talk about it.

Speaker 5 And it's crazy that we're just beginning to talk about it because it's a known problem, Heather says. She ticks through all the different kinds of knowing.

Speaker 5 There's medical literature, there's litigation, there's doctors' own experiences in the operating room.

Speaker 5 So what that means is that there's an active kind of not knowing.

Speaker 5 And that act of not knowing is as much of a problem as the pain itself.

Speaker 16 So how do we fix this? How do we think about this? And how do we change what's happening?

Speaker 16 So why is this happening? All right. I'm going to assume that everyone in this room is passionate about what they do.
They love obstetric patients. They're here to learn.
They want to do the best.

Speaker 16 And I'm going to assume that no one gets into medicine to hurt people.

Speaker 9 Okay.

Speaker 10 We want to help people.

Speaker 16 So what is the disconnect?

Speaker 5 Heather's put the questions to the group plainly.

Speaker 5 How willing they'll be to wrestle with them is anyone's guess.

Speaker 5 She opens the discussion to the room. The first person to speak is a doctor from New York City named Dan.

Speaker 26 When we think about why this happens, I think there is this specter in the back of our heads that says, oh crap, the spinal is not working.

Speaker 26 If I have to induce general anesthesia, there's a chance, because we've all been, we all have PTSD, that the pregnant airway is horrific. that I'm going to lose the airway and the mom will die.

Speaker 26 And I think that is what is, I mean, I'm afraid I'm going to say it, that is a fear of mine that I will lose the airway.

Speaker 26 And then they'll be like, well, yeah, she was uncomfortable, but maybe you could have muscled through and at least she'd be alive.

Speaker 26 And so that is the balance that I find when I'm dealing with this in the operating room. And I don't know if other people have had that same discussion in their head.

Speaker 5 No warm-up. No superficial comments before the room really gets going.
Dan goes deep straight away.

Speaker 5 Sometimes I'm scared, he's saying. I'm scared of the biggest thing of all.
And in that situation, it seems like the better choice is pain.

Speaker 5 Heather meets Dan's vulnerability with some of her own.

Speaker 15 So I think that that's a wonderful point.

Speaker 16 We were taught since we were, I mean, since fellowship, since I was a baby, I was taught, don't take on the airwave. Pregnant is the big bad wolf.
Stay away from it. This is how moms die.

Speaker 16 You'll never recover.

Speaker 16 The family will never recover.

Speaker 16 And so, especially towards the end of a case, you might be like, Is it do I really need to?

Speaker 13 Right?

Speaker 16 This is the gray area that's ugly and it doesn't feel good. And at the end of the day, I don't feel satisfied with my job because maybe I did the right thing, maybe I didn't.

Speaker 16 And I'm honest enough to admit it, I've been in that situation several times where I've looked at this and been like, Do I really want to do this?

Speaker 16 Even when the patient maybe had some discomfort

Speaker 5 from the stage, Heather sees one of the women she trained with in fellowship giving her a look like, same.

Speaker 5 People start lining up behind the mics. There's a doctor who practices in New Jersey.

Speaker 24 So that for me, it's not just about, oh, the patient's comfortable or she's just exaggerating. It's sometimes that fear that if I do get into a general anesthesia, no one knows how to help me.

Speaker 5 And there's Zevi.

Speaker 28 So I'm Zevi. I'm also from New York City.

Speaker 28 I actually really appreciate your point about saying the quiet part out loud, where we're hearing.

Speaker 5 The part that spinals and epidurals can fail.

Speaker 5 When do you tell the patient this thing that you know to be true, but that may sound so alarming to them?

Speaker 5 These things fail. Wait, what? You're telling me this now?

Speaker 28 I was wondering how many people actually say that in the pre-op discuss that spinals and epidurals actually fail.

Speaker 28 And if they do fail, we test for it and we have options to fix it beforehand, even before, like during your consent process.

Speaker 29 So I'm Andy. I'm from Stanford.
I just wanted to share one of my techniques.

Speaker 29 Sometimes I either have a patient where maybe there's a language barrier, they're exhausted, they're really scared, and I think my block is working, right?

Speaker 18 Because my block's going to work.

Speaker 6 But, you know, to take my ego out of it.

Speaker 5 We are tight on Andy's face so that you can see she's being self-deprecating, not cocky. Gently reminding the group to be alert to their own hubris.

Speaker 5 Doctors continue to come forward, asking questions, offering tips, letting out frustrations.

Speaker 30 Intraoperatively, I think that the pain versus pressure question is a trope that I really hate in our specialty.

Speaker 27 But to sort of give the patient the feeling of, don't worry your pretty little head about this, it's fine,

Speaker 27 that is horrible.

Speaker 27 It is horrible to not feel listened to. And so I think we all have to.

Speaker 5 Heather had been worried that there would come a moment like, okay, it's great we're talking about this, but what do we do? Where's the algorithm we follow if a patient is in severe pain?

Speaker 5 She wasn't sending anyone off with an algorithm to follow because that algorithm didn't exist.

Speaker 5 And it's clear that the audience is eager to come up with solutions.

Speaker 5 There's a lot of crowdsourcing, Heather and others talking about everything from specific doses of medicine to styles of communication.

Speaker 5 Heather has scoured the medical literature for relevant research on this.

Speaker 5 But for today, the goal is not to settle on a fix. This is steps to solve a problem.

Speaker 3 Step one, talk about the problem.

Speaker 5 That was what Heather wanted. And apparently, it was what the room had wanted too.

Speaker 31 First of all, thank you for this session.

Speaker 31 When I come to SOAP meetings, I always think of all the sessions and what are some of the points and concepts that I can take home and actually use in my practice Monday morning.

Speaker 31 And this, if there's ever a session that's worth missing the coronation of King Charles for, this is it.

Speaker 31 Thank you. Thank you.

Speaker 31 But the comment I had, there's been a number of comments.

Speaker 5 It turns out what's hard is not getting people to talk about this. What's hard is getting them to stop.

Speaker 16 So you guys have exceeded my expectations in audience participation. So hold where you are right now as next, okay?

Speaker 16 And then I'm going to get through just a little bit more material and then I'll ask, I'll take your question or comment, okay?

Speaker 16 So one of the things that when I talked to Jennifer, she said,

Speaker 13 where were my OBs?

Speaker 16 Why didn't they say anything?

Speaker 16 When we did the MM on this case, when we asked the OBs, what were you thinking?

Speaker 16 One of them said, it was horrific.

Speaker 13 It was horrendous.

Speaker 11 And they never said a word.

Speaker 16 Everyone in the room knew something was wrong, and no one said anything except the patient and the patient's husband.

Speaker 5 The audience is quiet.

Speaker 5 They've also been in ORs where it felt impossible to intervene.

Speaker 5 They know there are dynamics in that room that can make it hard for people to speak.

Speaker 5 That morning of Clara's surgery, there were at least 13 people in the OR:

Speaker 5 the surgeon, the OB resident, the attending anesthesiologist, the anesthesia resident, the scrub tech, the circulating nurse, a backup nurse, a NICU nurse, at least two other NICU specialists, Clara, Clara's husband, and Mindy.

Speaker 5 Mindy.

Speaker 18 Cut to the hospital now, the nurse's station.

Speaker 5 We're back at UIC. We see Heather's image on a computer monitor, and Mindy and other nurses gathered around.

Speaker 6 Like they just told us, like, hey, guys, Dr. Nixon's giving a

Speaker 6 talk about intraopertive pain. You guys should join.
So, like, but we didn't know exactly what it was going to be.

Speaker 6 that it was going to relate to our department specifically at the beginning of that presentation.

Speaker 6 And we all sat there like pins dropped when we heard her say, what if it was a staff member and she was in her and Clara was there that day and Clara was in the back hallway somewhere and we all like were looking at each other like it's about Clara and we were all like.

Speaker 5 We see Clara now alone in an empty office. She's not hiding.
She's protecting herself. She knew this talk was on the calendar for today.
It's actually not the day of the soap talk.

Speaker 5 It's a day Heather gave a similar talk for Grand Rounds at UIC.

Speaker 6 And then when the whole story dropped that Dr. Nixon did a presentation on her, I think we asked her if she was okay and she was just like, yep, and walked away.

Speaker 6 So it was like, all right, she doesn't want to talk about it.

Speaker 5 And Clara didn't.

Speaker 5 The reason was that she often blamed herself for the pain.

Speaker 5 Maybe it wouldn't have happened if you hadn't insisted on trying for a vaginal birth. If you'd been more prepared, prepared, if you'd moved your body more, if you hadn't been so hysterical.

Speaker 5 All of this might have surprised her co-workers, but it wouldn't have surprised anyone familiar with birth trauma.

Speaker 32 So I'm Tracy Vogel, and I'm from Pittsburgh, and my career path is taking me in a very different direction.

Speaker 5 And right now, I've cut back to the hotel ballroom, close on a doctor in the aisle at the mic.

Speaker 5 Tracy trained in OB anesthesia at Stanford, but after 20 years, she got to the point where she was seeing so much trauma that she felt like she could make a bigger difference treating that trauma than offering anesthesia.

Speaker 32 I'm the director of a perinatal trauma-informed care clinic. I think there are two in the country right now.

Speaker 32 There's so much to say.

Speaker 32 I wish every seat in this room and this lecture was being

Speaker 32 televised, or you know, the video went to every anesthesia provider because I can tell you this happens a lot more than you think it does.

Speaker 32 I can't stand here and over

Speaker 32 overemphasize the impact that this has on individuals, their relationship with their babies in the terms of decreased bonding, decreased breastfeeding success. You mentioned the husband in this room.

Speaker 32 The impact on him, on the partners, on their relationships. Believe me, I've worked with so many women.
I hear 11 traumatic stories a week.

Speaker 32 These are individuals that go on to to get divorced.

Speaker 32 They can't even care for themselves. It rocks relationships.

Speaker 32 The mental health complications, I have women who are still having suicidal ideations years later.

Speaker 32 Their birthdays of their children become nightmares. The impact is so severe.

Speaker 5 Heather's talk lasts 90 minutes. And before she leaves the stage, let's take the temperature of the room.

Speaker 5 Close-up of a doctor peering at us with momentary surprise through his glasses. He practices on the island of Newfoundland.
He's been live tweeting Heather's speech.

Speaker 5 Swing to another doctor, this one from Texas.

Speaker 5 For him, pain during cesarean never became normal. He has a presentation he gives to small groups called, Just Put Him to Sleep.

Speaker 5 And over here, this woman. For years, she'd been focused on pain after cesarean.
That's where a lot of them were.

Speaker 5 But recently she actually wrote an editorial titled, Are We Finally Tackling the Issue of Pain During Caesarean Section?

Speaker 5 And just one more doctor.

Speaker 9 Long blonde hair.

Speaker 5 Her uterus ruptured during labor and she felt it. She'll start crying if she talks about it.
She grew up in a rural town and the pain inside her body was the pain of a branding iron.

Speaker 5 And as they rolled her into the OR for an emergency cesarean, she was scared her anesthesia wasn't going to kick in in time, but she resolved not to say anything if it didn't, because she didn't want a single minute to be wasted.

Speaker 5 She didn't want her baby to die.

Speaker 5 Her anesthesia did work, but that experience taught her something subtle and important, that even when a cesarean patient is in excruciating pain, she may not report it.

Speaker 5 What Heather has just articulated, it speaks to these doctors, and, safe to assume, wide shot now, to most of the hundreds of others in the room.

Speaker 5 But what about all the people not here?

Speaker 5 Let's back out of the ballroom now, into the large, carpeted, empty, open space.

Speaker 5 The people inside that ballroom either specialize in obstetric anesthesia or just love it. But there are only several hundred OB anesthesiologists in the whole country.

Speaker 5 The rest of the 50,000 anesthesiologists in the U.S., the ones you're more likely to deliver with if you're delivering a baby just based on numbers,

Speaker 5 would they feel the same urgency about this?

Speaker 5 We're in the elevator now, going down.

Speaker 5 And how about all the obstetricians, the nurses, everyone else in the OR, the whole team?

Speaker 5 And even if you do get all those people on board, which again, tall order, what do you actually do to change an entire culture? What are the concrete steps you take to do something that abstract?

Speaker 5 What are the solutions?

Speaker 5 Elevator door opens onto a new location.

Speaker 5 We step out not into the hotel lobby, but into a rural landscape. A woman in tall rubber boots is walking three glossy black retrievers through a muddy field.

Speaker 5 Heather wondered, How do you solve this problem?

Speaker 5 On the other side of the ocean, up north in the English countryside, a former wedding photographer with no medical training had been quietly working on the answers.

Speaker 5 That's on the next episode of The Retrievals.

Speaker 5 The Retrievals is written and reported by me, Susan Burton, and produced by me, Julie Snyder, and Ben Phelan. Julie edited the series.
Ben did research and fact-checking.

Speaker 5 Be sure to sign up for our newsletter, where each week we'll share more reporting from the show, listener stories, and reading lists. Go to nytimes.com slash serial newsletter.

Speaker 5 Music Supervision, Sound Design and Mixing by Phoebe Wang. Original music by Dan Powell, Fritz Myers, and Nick Thorburn.
Additional music in this episode by Marion Lozano.

Speaker 5 Carla Pallone composed our theme song, and it was remixed by Dan Powell. Additional production by Mac Miller.
Additional mixing by Catherine Anderson.

Speaker 5 Editing help on this episode from Jessica Weisberg, Laura Starcheski, and Jen Guerra. Our standards editor is Susan Wesling.
Legal review from Dana Green.

Speaker 5 The art for our show comes from Pablo Delcon and Eric Tanner. The supervising producer for Serial Productions is Inde Chubu.

Speaker 5 Additional producing comes from Mohima Chablani, Jeffrey Miranda, and Corey Beach at the New York Times. And Sam Dolnick is deputy managing editor of the New York Times.

Speaker 5 The doctors who came to the microphone during Heather's talk include Dan Katz, Bill Kamen, Emily McQuaid Hansen, Andy Trainor, Zevi Hamburger, Klaus Kahyer, and Tracy Vogel, whose trauma-informed care tools are online at the Empowerment Equation.

Speaker 5 Other doctors whose presence I alluded to include Simon Ashe, Mike Hoffkamp, he's the doctor with the Just Put-Him to Sleep presentation, Ruth Landau, author of the Are We Finally Tackling editorial and other important work on pain during cesarean, and Laura Sorabella.

Speaker 5 Special thanks as well to Susan Beachy, Lawrence Sen, Rebecca Meinhart, Brenda Kamdar, Purvis Selton, Alicia Ba'itoup, Leah Shah Damarin, Diane Wong, Jean-Viev Gallarnau, and Anna Whalen, a maternal fetal medicine specialist who's written about returning to work on LD after birth trauma.

Speaker 5 The Retrievals is a production of Serial Productions and the New York Times.