S02 Episode 4: The Solutions

Previously, on the retrievals.

I think that smile was like, I'm having my babies.

You made it to take my pictures.

You're here.

You're one of me, one of our team.

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

Horrific.

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

No, nothing about it, isn't there?

I was wondering how many people actually say that in the pre-op discuss that spinals and epidurals actually fail even before, like during your consent process.

Everybody had been making the same mistake.

Everybody.

Not one of them had been asking the patients.

From Serial Productions and the New York Times, I'm Susan Burton, and this is The Retrievals, Season 2, The C-Sections.

Speaking of seasons, it's been so long since we've been at the hospital that it's almost like we're on a new season of our medical drama.

A lot has happened to our characters since we left them in the months after Clara's C-section.

In fact, we have another character to add to the ensemble, Corey.

Remember?

The anesthesiologist who arrived for a shift just as Clara's surgery was ending.

Let's bring Corey on stage.

Dr.

Corey DeBurgrave, Interior Hospital, mourning.

Because when I show up at 7 a.m.

and I change into my scrubs and I go up to the fourth floor and I walk into that floor, I open those doors.

I walk in and there is like an everyone, all the nurses, everyone yelling like, oh my God, Corey, oh my God, we're so happy you're here.

Oh my God, sit down.

We got to talk.

This entrance, it's not just ginned up for the season opener.

It's a regular occurrence on L ⁇ D.

Look, there's Mindy.

She'll tell you.

Corey is our baby.

He is the unit baby.

He was a resident with us.

He just vibed with us.

He sits in the nursing station and like gossips with us.

We've even gone out drinking together.

Like he's been at parties.

He is our baby.

And when we heard he was going to be in attending, we were all like ecstatic.

And he's just great with women and patients.

And you just trust him immediately.

He's adorable to look at too.

I walk through that door.

It's always kind of like a, okay, like

I'm doing something right because these people are relieved and happy to see me.

Relieved.

That's how Clara felt when Corey walked in at the end of her surgery.

And oh, here's Clara now.

Amazing haircut.

Mia Farrow and Rosemary's baby vibes.

This will be her new look for the season.

Clara's look isn't the only thing that's new on the unit.

She says the culture around pain during cesarean is changing.

And there's a lot of parts to this, but there's also a simple way to get at just how profound the shift is.

It comes down to one word.

One word that in the before times, Clara wouldn't have felt able to say during a C-section.

Stop.

Like, I didn't understand that I could simply say, you need to stop.

She's not okay.

Yeah.

And the other part of it is that the team is more responsive so the surgeons themselves

before normally is it no that is anesthesia's job we have our job we're going to focus on that but now

i mean in my experience i say if you can stop stop she's not okay they are very very quick to say oh thank you for telling us uh-huh we can pause here absolutely Everybody in the room is so much more receptive to it.

Sometimes it's not so easy to to stop, but there are other times you can.

Stopping can be awkward.

Everyone's standing there silently, arms crossed, just waiting for the several minutes it might take for the meds to kick in.

A nurse might be challenging a hierarchy to say, stop.

I am concerned.

It can feel that way for an anesthesiologist, too.

Maybe they're working on the kind of unit where the surgeon rules the roost.

But there are all kinds of power dynamics.

A younger, newer OB working with an older anesthesiologist who claims, it's just pressure, she's fine.

One OB told me that when a patient is suffering, she can tell because even the muscles inside their bodies are tense.

Yeah, all of us have seen these things and have been troubled by these things,

but not really known what or how to do or that it wasn't, or that it could be different, you know?

Yeah.

So I think people were just, oh, like, thank God, finally, yes, let's go.

And let's do what we've wanted to do all along.

Speak up on behalf of patients.

To shift a culture like this, Clara says, you need to have enough people with buy-in, people who won't let it go.

And you need someone to get people to buy in.

You need a Heather.

I mean, it is.

It is absolutely her role at the hospital, her job title, her credentials, her relationships with everybody, the trust that's there.

all of those things are why,

right, that she has been able to push through what she has, I think, because it is remarkably different.

So what did Heather do exactly?

And how did she do it?

Well, we're in luck that we can see some of it for ourselves.

Let's hurry down to the third floor where Heather is teaching a class.

How many people have been in C-sections where you have an awake patient and someone else is like, hey, the patient in four is blah, blah, blah, blah, blah, right?

So you're talking about other patients in front of an awake patient, right?

And what's going on in room four?

And they're like, oh, that room four sounds bad.

Okay, I don't like that.

They should take care of that one, right?

I hope they're okay, you know?

Like, okay.

Heather and her OB anesthesia colleagues have made a bunch of changes since Clara's surgery,

ranging from the drugs and the epidurals, clonidine, to a new system to document and address pain.

Some of what Heather Heather wanted to do,

like changing the way doctors interact with patients, what tone they take, what language they use,

required education.

She began with the youngest people, the newest residents.

Because if you get them, you make it normal for the next four years

and forever.

And that's who's in the room this morning mainly.

Anesthesia residents, people still learning medicine.

So

I want to highlight here that even though I've been doing this for 15 years, I'm still learning.

I'm still uncovering things that I think I maybe missed the boat on that I thought I was being empathetic, I thought I was being patient-centered, and now I'm looking at going, is that really right?

Not just,

I did this wrong when I was a beginner.

I still find myself doing this wrong.

This kind of admission is so unusual.

And even getting ready for this lecture, I dug into like empathy, patient communication, physician interactions.

I can't find anything concrete that tells you exactly what to say.

So it makes it really hard, right?

I can give you a hundred papers on clonidine, right?

I can tell you exactly where all the data came from.

I can't give you one that tells you whether it's better to say this thing or this thing to a patient, right?

But I know that if someone asks me this morning, Heather wants to address what to say during some interactions that are especially challenging,

including interactions with so-called difficult patients.

So what is a difficult patient?

Well, now you said earlier that you'd all kind of heard that phrase, right?

You'd heard difficult, it's been used in the vernacular, right?

So I want you to get into small groups for a second and tell me what do you think a difficult patient is, and then think of examples of patients you've had who were quote unquote labeled as difficult or you felt were difficult.

Yes?

Okay, let's go.

The residents huddle together in groups.

They're wearing gray scrubs.

They look young.

It's striking to hear them reflecting on patients as other.

They're so recently removed from having only ever been patients themselves.

Alright, let's come back together if we can wrap up here.

Sorry, I didn't mean to cut anybody off, mid-thought.

Okay, guys, so what did you guys discuss in your group?

So

what is what you know to be a difficult patient?

Or what are some examples of it?

The answer is exactly what you feared.

I often find that sometimes patients are labeled difficult also if they just want to be well informed and truly understand what's going on and they ask a lot of questions.

That kind of to be clear, the resident is not endorsing this.

No one in the room is.

Patients don't feel listened to.

They don't feel respected.

They don't feel like they have a voice and the ones that have the biggest voice and advocate for themselves are labeled as difficult in our system, right?

So a doctor who's just entered the room gets Heather's attention.

Okay.

Yes.

You will never guess what just happened to me.

Oh no.

The doctor speaking is an attending who'd gone to check on a patient.

And the surgery center nurse comes up to me and goes, Dr.

Waltinger, your patient came back from nuclear medicine.

She's a really difficult patient.

So funny.

Like literally.

Just happened.

Dr.

Waltinger.

Corey is in the room.

And now he raises his hand.

Yes.

And he starts to tell the story of a, quote, difficult patient he had for a C-section last night.

It was a true emergency, a crash.

The patient was rushed to the operating room.

They did the skin test, and the patient could feel it.

And everyone in the room looked at me, and it was pretty much out of everyone's mind at the same time.

Gotta go to sleep.

I said, okay, we're gonna go to sleep, no problem.

She said, I don't want to go to sleep.

And now everyone's looking at me, and they didn't say these words, but I got the impression, like, just put her to sleep.

Just push it.

Corey can't put the patient to sleep if she's refusing.

That's against the law.

But the alternative is dark.

It was an emergency, and like in my mind, it's like this baby's going to die if we don't get this out in the next few minutes.

But I can't put you to sleep, and we can't just hurt you with human pain.

So it's like the urgent emergence scenarios for me.

In my mind, I'm thinking, this woman's asking me to perform magic, but I can't perform.

I have to pick one or the other.

Corey says that he knelt down, got really close to the patient,

and he called her sweetie.

I don't know if we're supposed to be calling a patient sweetie, he says.

And the room laughs.

But sweetie was the turn.

And I think that the second I started getting more casual with her and probably breaking those norms about vocabulary, I think she would like, dude, she did away with me.

Later, Corey told me that sweetie wasn't the only vocab norm he'd broken with the patient.

She was resistant, but she knew that she was putting herself and her baby in danger.

So she kept saying, I know everyone in this room, you guys think I'm the biggest dumbass.

I know you think I'm just this dumbass bitch.

And she wasn't saying it like in an adversarial way.

She was like recognizing, I know that I'm being annoying to you guys.

Like I recognize what you guys must feel about me.

So that's part of, that's one of the things that I got down and next to her.

And I just said, like, look, I don't think you're a dumbass.

I don't think you're even being a bitch.

I've dealt with bitchy people in my life.

You are not being that way.

I feel for you.

I think you're going through something that I can't even imagine.

And, you know,

and nowhere in medical school do they say, should you talk that way?

Nowhere, you know, if my boss hadn't walked by and heard me say that, I probably wouldn't be the most proud of that.

But when I said that, she kind of giggled and she's, she kind of started smiling.

And I was like, it was like these little small things.

It eventually broke through with her.

The patient still didn't want to go to sleep, but she agreed to allow Corey to give her IV drugs.

He held her hand and the baby was delivered.

This kind of story doesn't always end this way, Heather tells the room.

We've had that before, where we've had someone come to the operating room and absolute your food's general anesthesia and the outcome was not as good as yours.

So I think that those are really important conversations.

Corey had asked the patient,

why don't you want to go to sleep?

Heather would have asked this question too.

If the answer was, I'm scared, what are you scared of?

Which is different from, there's nothing to be scared of.

What the patient is scared of matters and might determine what you do.

The way you you ask the question matters too.

So your tone, whether you get casual or whether you heard my, you just heard my voice right now.

Hey, we're gonna, you know my register.

My register is up here, right?

And hey, we're gonna take really good care of you.

Like I know you're scared.

My voice drops.

My head comes close.

I kind of get to their ear.

This might not be the right style for everyone.

Be genuine to your personality.

You're not going to speak the way that I speak, right?

You're not going to use the phrases that I'm going to use, and don't try to mimic, you know, kind of mimic people because it's not going to come out right.

So, find what works for you.

But even if the delivery isn't the same, the message is.

Here's what I can't do.

I can't promise you a pain-free surgery, right?

But what I can promise you is if you tell me you're having pain, I will give you more medicines.

I will work with you.

I will be present with you, okay?

You can tell doctors to listen to patients, to partner with patients, and some doctors are going to have an intuitive sense of how to do this, but not everyone will.

And yes, teaching helps, modeling helps, but when you're trying to change behavior after something goes wrong in a medical setting, what helps more than either of these things, and research shows this,

is if you create a system that encourages, even compels, that behavior, which is another thing Heather did, and which I'm about to see in action.

That's coming up after the break.

This episode is supported by Choiceology, an original podcast from Charles Schwab.

Hosted by Katie Milkman, an award-winning behavioral scientist and author of the best-selling book, How to Change.

Choiceology is a show about the psychology and economics behind our decisions.

Hear true stories from Nobel laureates, historians, authors, athletes, and everyday people about why we do the things we do.

Listen to choiceology at schwap.com slash podcast or wherever you listen.

If you find yourself bewildered by this moment where there's so much reason for despair and so much reason to hope all at the same time, let me say I hear you.

I'm Ezra Klein from New York Times Opinion, host of the Ezra Klein Show.

And for me, the best way to beat back that bewildered feeling is to talk it out with the people who have ideas and frameworks for making sense of it.

There is going to be plenty to talk about.

You can find the Ezra Klein Show wherever you get your podcasts.

Cut to the OB floor.

It's after class.

I'm in the shot now.

I've been here the whole time.

Let's not make a big deal, but yeah, I'm here on set.

Heather and I are standing outside the double doors that lead to the operating rooms.

So we're gonna have to put these on.

Okay, great.

So probably maybe if you want to use that tray over there and put your mic on for just a second.

Heather hands me a surgical suit.

I put the recorder down and step into the white coverall.

The material is flimsy, like a whole outfit made out of a dental bip.

Once I'm gowned up, we continue down the hall.

So this is like a sterile hallway, which is why you have to have all this stuff on.

And then when you go in the operating rooms, that's when you need the mask.

Okay, so.

now you can hear a baby was born

here we'll grab outside the or

i tie a mask atop my head and at the nape of my neck

and then turn to where heather is pointing through the window in the door so just take a look at it we're actually in there oh wow and this is a cesarean or something yeah so they're in the middle of a cesarean right now so she's wide open

i've been hoping to see a c-section this morning but not expecting to i've been told it was unlikely to happen But at the last minute, it's come together.

The patient has given me permission to observe.

Her baby has already been delivered, so I won't get to see that part.

But there's a lot of her surgery left, which means there's a lot of anesthesia care left to administer.

And then the anesthesia providers are the head of the bed kind of talking to her, so we're really the only ones who are kind of like,

yeah, exactly.

Which makes it a very intimate relationship very quickly.

Yeah.

Heather checks that I'm ready to go inside.

I'd asked her what she suggests I notice, and she'd named a couple things, including looking at the patient's open abdomen.

Unless you're queasy, she added.

It's untested, I said.

I've never witnessed any kind of surgery.

For months, I'd been talking to people about C-sections, reading about them, writing about them.

But I'd never been in one, and that felt important.

I'd tried to at a couple different hospitals.

Can't you just watch one on YouTube?

Was the response of one hospital flack who turned me down.

But it wasn't about gathering the right details.

What I wanted, you couldn't get any other way.

I wanted to be in the room.

We stepped inside.

Heather stays very close to me.

Not in case I go rogue, but in case I go down, which happens to visitors.

But at first I don't even really look at the patient.

Heather points things out, but I'm I'm not always sure what she's pointing at.

Are those parts of the human body hanging from a pole in little plastic bags?

No, they're used sponges.

Affixed to the wall, a big container of blood, like an igloo dispenser.

Is that the patient's blood or is that blood for the patient in case she needs it?

Then we turn to the foot of the bed, and I stare straight into the patient's open abdomen.

I'm surprised by how completely unfazed I am.

If anything, I want to keep looking.

The blue drape hangs at the patient's breast.

I can't see her head.

And maybe the depersonalization helps me look at this straight on.

The flesh is pushed up, like when you raise a blind.

I'm full of awe.

My hands have been bald inside my jumpsuit, but now they loosen.

The patient is getting her tubes tied.

Heather uses the medical term.

I ask if they tie them or cut them off, and the answer is kind of both.

We move around to the head of the bed.

The patient has a wide, sweet face, freckles.

The father beside her holding the baby.

Congratulations, I say to the mother, but then I regret it a little, not knowing what she feels.

I'm not meant to interview the patient, just to observe, so I can't ask about pain.

But now the patient grimaces.

Her eyes open and close, forehead furrows.

The attending is momentarily out of the room.

Heather moves in.

What are you feeling?

she says to the patient, leaning down near her face, doing exactly what she just talked about in the classroom.

Are you in pain?

It's just pressure, says the patient.

But how bad?

What's the number?

asks Heather.

It's eight.

Well, if it's an eight, we should do something about it.

The patient doesn't want drugs in her IV right now, but she does want nitrous.

The OB anesthesia fellow, Lauren, places a plastic mask over the patient's face.

Then at a computer, Lauren fills in a pop-up window and the patient's chart.

And this window, this is what I was talking about when I said that Heather had made a system to compel behavior.

It's one of the most significant changes she's made.

There's a phrase that's often used in medicine, what's measured matters.

So Heather's thought was, okay, if I'm trying to make pain matter to everyone in the room, we've got to find a way to measure it.

Now, every 15 minutes, the anesthesia provider receives a reminder to get a pain score from the patient.

A tab on the patient's chart turns red.

If the score is 3 and above, there are prompts for follow-up questions about what kind of pain and where,

information that can be used to decide on on an intervention.

When Heather initially had the idea, there was some pushback.

And there was a little bit of like, well, why are we doing this?

I don't want to keep reminding the patient about pain.

And I was like, no, if they're not having pain, you're not reminding them of anything.

People have strong opinions about pain language.

One OB anesthesiologist I talked to, someone who's as passionate as Heather about the issue of pain during cesarean,

told me that she asks patients, are you comfortable and do you want me to give you anything?

I don't want to emphasize the pain, she said.

There's pain psychology literature supporting this, that the language that you use can suggest pain to the patient.

Instead of saying, I'm going to, you know, put this needle in your back and it's going to burn for a second, you say, like, oh, you'll feel mild discomfort.

And you coach them through them as if you're like somehow going to change their experience.

And I just haven't found that to be true.

My personal experience with this has been absolutely 100% the other direction is that if you don't tell patients what to expect, if you're not real with them, you lose trust so quickly.

So I really believe in telling patients the whole story, unless I have someone who's like, don't tell me anything.

I don't want to know anything.

So we do have that conversation as well.

But otherwise, I don't know.

I just, I don't think it's quite fair to patients to assume that somehow you're going to, you are fully in control by your language of someone's pain experience.

I think that really minimizes the problem.

The main purpose of Heather's system is to promote good patient care.

But an additional benefit is that there's a lot of data being collected.

Data about some things that don't exist in the medical literature.

Like when a cesarean patient says she feels X, what works best is to give her drug Y.

Heather didn't copy her system from somewhere else.

She and a colleague made it up themselves and had the tech team hook it into the electronic medical record system.

Though some other institutions also assess and record patient pain during C-sections, Heather seems to be the first one to do it exactly like this.

One doctor I talked to praised Heather's system, but noted there isn't evidence that what she's doing is a best practice that will actually help patients.

It wasn't a critique.

It was a nod to the big picture.

There isn't evidence that any tool for measuring cesarean pain works better than any other,

because these tools don't exist.

Pain scores themselves are pretty contentious.

People will say they lack context, or that if you're a patient, it's really hard to know what number to say.

But Heather's not just getting numbers.

Importantly, she's getting quotes from patients too.

Because her system not only requires doctors to talk about pain, it gives patients an opportunity to do so.

Patients who are not asked about pain may not speak up about it for whatever reason.

Susanna recently sent me a paper that compared the situation of being a patient to being a hostage.

These people literally hold your life in their hands.

Do you want to disrupt or displease them?

Right now there's a massive study on pain during cesarean going on in England and Australia, the sonar study.

Almost 80% of all OB units in the UK are taking part in it.

And one of the questions they're asking patients is essentially, if you were in pain, did you tell your doctor about it?

I love this question.

I think it's enormously insightful.

Some patients cry out and are ignored.

Others never say anything to begin with.

We need to capture them too.

Not every doctor is going to care about pain.

Not every patient is going to disclose it.

One OB anesthesiologist describes Heather's system as an intervention that makes it easier for people to do the right thing.

Even the people who think they're already doing it.

I mean, in all honesty, even the patient we just described, I would never have thought that furrowing was an eight.

I thought it would have been like a three or four, right?

Looking at her, I thought, oh, it's a mild pain.

And she describes to me as severe pain, right?

And so I was like, whoa, whoa, whoa, we have to do something about this.

The father of the baby FaceTimes with someone who's maybe the grandma.

Soon it's time for me and Heather to leave the room.

In the hallway, Heather and I step out of our coveralls.

Later, I ask her if the new system means that pain is now documented in a way that's visible to patients.

Yes.

If you have a cesarean and you request your files, you will see this in there.

At UIC, cesarean pain is now part of the record.

Coming up, let's head to the nurse's station after the break.

For a long time, Clara still didn't talk about what happened with people at work.

It was clear to everyone she was moving through it.

She was back in the OR.

She was back to who she'd always been on the unit.

Someone who spoke up for patience.

Someone wise you could go to for advice about your own life.

Heather continued to use Clara's story, the Jennifer story, in lectures.

And a couple times Clara got into a conversation with a resident who brought up the story or the issues it raised, not knowing it was Clara's, and Clara would say, surprising the resident, I'm Jennifer.

Then immediately wonder, God, why did I do that?

Do I want to be that vulnerable right now?

You know.

But with distance, she did.

And then one day, almost three years after the surgery, Clara and Mindy and a few others were at the nursing station.

It was a weekend, Mindy remembers.

Usually when it's like weekends, it's calmer on the unit.

So we kind of just like catch up on life and we're each other's therapists.

And somehow they got to talking about the surgery.

And she looked at me, she's like, Mindy, I totally forgot you were there.

And I was like,

in my mind, I'm thinking, she's thinking,

like, why didn't you do something for me?

Like, why didn't you step in for me?

And for her to say, you know what?

You're right.

I forgot you were there.

And I was like, oh my gosh.

So she's not harboring this like anger towards me.

And I was like, I didn't push it.

I didn't ask more.

Like, what?

What do you mean you forgot?

Like, I was like, really there.

Yeah.

So it was kind of like a relief.

like, oh.

Later, Clara asked Mindy for the photographs.

They both did the same thing with them.

Looked at them hard to find the moment the surgery turned.

What's different for Clara now is not just being able to intervene during a C-section, but more generally.

Here's a story from just the other day that illustrates it.

A nurse on the unit was telling everyone about a C-section she'd just been in, one where the patient seemed to be really in pain.

And the surgeon had said, We're almost done.

I think that those were the words.

We're almost done.

And I was really disturbed by it.

Who was the anesthesiologist?

Clara wondered.

It was Corey.

And so I was pretty like, whoa, what?

That seems not at all like Corey and what he would have done.

And I texted him.

I have his number, so I text him.

I was like, hey, I just heard this thing and it doesn't sound like you, but I was really bothered by it.

And I just wanted to know how you thought that went.

Did the surgeon really say, you know, don't put her to sleep or we're almost done, anything like that?

And Corey clarified.

He's like,

not exactly.

You know what I mean?

Like, he could see how you walked away with that, but really what was going on was...

Was that the patient's uterus was outside her body, exteriorized, remember?

And it's hard, almost impossible, to make the patient feel nothing during this.

Many OB anesthesiologists would really prefer surgeons not do this.

Organs belong in bodies, you will hear them say.

But for the surgeon's part, it's certainly easier to see and repair the uterus when the organ is outside.

They're taught this is the safest way to do it.

But anyway, yes, there was a moment where the patient was in pain.

But Corey was on it.

He addressed it with IV meds.

And he's like, and no one would ever stop me from putting somebody to sleep.

Clara, he said, if I had any doubt and thought for even a second she needed her pain wasn't controlled and she needed to, we needed to convert to general, he said something like, I don't care if the CA, the CMO or what chief medical officer told me not to, like, I would do it.

So

I was really glad that I was able, instead of worrying about it, to follow up on it.

And I'm assuming that's not something you would have done in the before times.

Or maybe you would have.

No, I'm not sure I would have picked up on it.

i think that there was a lot more just sort of acceptance and powerlessness around it

like yeah if i heard something like that i would think it was bad and wrong

but i wouldn't

no i wouldn't have followed up on it or anything i wasn't in the room it wasn't my patient you know

There's a culture that's enabled Clara to do this, but she's also one of the people making the culture, one of the people showing others how to speak up.

So is Mindy.

Before I ever met Mindy, I heard about her.

There's a nurse named Mindy who will put you in a chokehold if you let a patient be in pain.

I do.

I do think there has been a change just because

I feel more empowered to speak up too.

Sometimes.

Sometimes.

I still revert back to

I'm just the nurse.

I'm just the nurse.

But

I feel like like UAC does have a

like hierarchy, but I feel more empowered to speak up there than I ever did before.

Mindy's changed since Clara's surgery, and not just as far as speaking up.

She's questioning things, including one of the most fundamental assumptions about Cesarean of all.

I think my biggest thing is like, why

do we

do C-sections on mamas while they're awake.

Like, I understand that,

I understand the science behind it, but like

maybe some women truly prefer not to be awake and we push them towards being awake during C-section.

So, I just, I want to know more.

Like, maybe we need to talk more about why we even move towards this practice.

Because, you know, being awake and being like literally women when they're being pulled and pushed and that's scary.

Like, Like, I don't know if I, as a patient, want that.

Is it all just about patient experience and hearing their baby's first cry?

Like, is there alternatives?

Like, could we just record it?

I don't know.

Like, I wonder what,

how we got to this.

Oh my God, Mindy, I am so glad you just said that.

Yeah.

I have had that same thought, but nobody else has ever brought it up until you brought it up.

Yeah.

I told Mindy that decades ago, the assumption had sometimes been the opposite, that the patient would prefer to be asleep for a c-section.

Like, why would anyone want to be awake for that?

One British anesthesiologist wrote in 1971 that being awake could be okay for, quote, a woman of the right temperament, but many women would not willingly undergo this experience.

Both assumptions, want to be awake, want to be asleep, are problems because neither is universally true.

What a patient wants, that's different for every patient.

If you're told that one of the benefits of nuraxial anesthesia is that you can be awake for your baby's birth, you may feel like that's something you should want and feel ashamed that you don't for whatever reason, including that you simply do not want to be aware during major surgery.

Lots of patients tell Mindy they'd rather go to sleep.

All the time.

All the time.

They say, I don't want to be awake.

I want to go to sleep.

And they just literally convince them that it's not the best.

But yeah, no, there's so many patients that should go to sleep that we don't, and they're so terrified.

And we don't know what their trauma is going to be.

Are they going to relive the beeping of their heartbeat and the like suctioning noises and the like pulling?

And we don't ask women who had C-sections how traumatized they are.

There's a growing awareness of what Mindy describes: describes, that let's be real, this is a major surgery.

Doctors I spoke with, including Heather, wanted to emphasize that most C-sections should be done under Neuraxial anesthesia, that it's the gold standard, faster recovery, better pain control after birth.

But Heather says, she's quicker to honor a patient preference for general from the get-go than she would have been just a few years ago.

While doctors have long avoided general anesthesia for safety reasons, for some patients, safety might mean going to sleep.

Here's a sign of the times.

In obstetric anesthesia, there's something called a center of excellence designation.

To get it, your hospital has to meet a bunch of criteria, including one about limiting use of general anesthesia.

Recently, there's been discussion about making sure this isn't inadvertently causing patients to suffer.

There's also been discussion of adding a new measure of excellence, percentage of patients in pain.

Redefining excellence can change culture and practice.

So, in theory, can a lawsuit.

The medical and legal systems can reinforce each other to make change.

But there's not much evidence that this works with pain during cesarean.

Putting aside the fact that many women are unlikely to want to pursue a lawsuit while traumatized and caring for a newborn, what happens if they try?

I talked to one obstetric anesthesiologist who has served as a medical expert witness on a couple hundred cases in the past few years.

In that time, he's been asked to review notes on fewer than 10 about pain during cesarean.

He says most patients like this are told they don't have a case.

When one case actually did get to court a couple of years ago in California, it was heard in federal court.

Delphina Moda, that's the patient's name, Delphina Moda v.

United States of America.

The transcript of the bench trial follows a familiar template, with the judge ultimately finding, essentially, your story is suspect because no one heard you scream.

Lest you think I'm exaggerating, here are some actual lines from his ruling.

Quote, no one heard plaintiff resist or refuse the procedure.

Also, quote, plaintiff testified she screamed as the procedure began.

However, this scream, of which much was made, was not confirmed by any third party.

Nurse Wood did report plaintiff saying, help me, and I can feel everything.

None of the others heard these statements.

The judge ruled against Delphina Moda, who had not finished high school, and said she worked as a caretaker.

She was 25 years old at the time of her surgery.

It felt like I was on fire, Delfina testified about the surgeon's first incision.

I could feel her hands, her gloves in me.

Plaintiff's version of the events is not credible, the judge wrote.

She was also, he added, psychologically brittle.

Nobody raised doubts about Clara's credibility.

Nobody rejected her story.

In fact, it was the opposite.

I told Clara about an exchange I'd had with a doctor who'd approached me when I visited UIC.

She's like, I don't know if you know, but we had this thing happen at our hospital.

There was a patient who was, you know, in a lot of pain during her cesarean, and, you know, and it's really changed a lot at our hospital.

And

she's a nurse, and now in cesarean, she's like a real advocate for the patients in the room.

And like everybody kind of defers to her.

Yeah.

Is that your experience?

Yeah.

Yeah.

Yeah, it is.

Clara was crying, and I assumed I understood why.

But then the next thing she said showed me that I hadn't.

I think that people,

which again, it just makes me so fucking mad

that it ha

it's just so typical, right?

Because here I am, their co-worker, their white co-worker.

So now we notice

more than 80 percent of the patients who have babies at uyc are black or hispanic

there's almost no data on race and pain during cesarean but a recent study of 110 patients at one hospital in texas found that black patients were five times more likely than white patients to report c-section pain and um yeah

has that ever been like explicitly talked about Like, wait, guys, we woke up to this when our white coworker, like, when this, I mean, I talk about it, but

I don't know.

I don't know that it's necessarily

been a big part of the conversation.

I think that that's a very valid thing for Clara to say.

And God bless her for being, you know, cognizant of that and thinking more globally.

But if it had been an African-American nurse,

It's one of your own.

So that's what made her so special, right?

Because it was, that should never have happened to one of your own, right?

And it should never happen to anyone, but it was big and dramatic and one of our own.

One of us, one of our own, is a phrase other doctors on L ⁇ D also used with me.

The way they said it was the same way Heather says it.

Fierce.

So why did it matter that Clara was not a patient who left, but one who stayed?

Within her close-knit unit, it made what happened to her harder to dismiss, and it made it possible to keep talking about it, at first just among themselves, and eventually publicly.

Pain during cesarean is an issue.

Clara's surgery and what it prompted is a story.

It's nowhere in the medical literature.

You can't find it in PubMed.

And yet, as one obstetric anesthesiologist put it to me, stories are also also a kind of evidence.

They too can change the way doctors practice medicine.

Especially when, as both Susanna and Heather understood, you attach those stories to lessons.

Story, lesson.

Those essential building blocks of so many genres, including, yes, medical dramas.

Medical dramas.

We, as in we the TV watching people, we love them so much.

You know who else loves these shows?

You know who's watching along with us?

Healthcare providers.

Gray's Anatomy, for me, I've watched all of it.

I'm going to say it.

I'm going to say it.

It is my binge watching.

It's so many seasons.

I know.

It's so many seasons.

21.

And Heather has a critique.

All of those shows are designed to have those set of doctors be the only people who can do everything, right?

They need to be the heroes of every episode.

It's all up to them.

But of course the goal of the work that Heather and others are doing is to get everyone to care about pain during Caesarean.

It shouldn't be something that matters only to one ensemble on one unit at one hospital.

It should be standard.

So standard that it shouldn't even be worthy of a storyline.

Pain during Caesarean is not a new problem, but for a long time it's been a hidden one.

The everyday heroes on our show brought it to light.

And now let's tuck our characters in, along with the hospital, see Mindy putting her dirty scrubs into the machine, and Clara walking across the street to the garage, and follow Heather downstairs to the third floor.

She has an overnight, she'll be around for a while.

Now let's pull back.

Get the whole hospital in the frame.

Hot orange sky, the day is so long this time of year.

and hold that shot.

End of show, bold, centered, all caps.

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.

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.

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.

Carla Pallone composed our theme song, and it was remixed by Dan Powell.

Additional production by Mac Miller.

Additional mixing by Catherine Anderson.

Editing help on this episode from Jessica Weisberg and Jen Guerra.

Our standards editor is Susan Westling.

Legal review from Dana Green.

The art for our show comes from Pablo Delcon and Eric Tanner.

The supervising producer for Serial Productions is Inde Chubu.

Additional producing comes from Mahima Chablani, Jeffrey Miranda, and Corey Beach at the New York Times.

And Sam Dolnick is deputy managing editor of the New York Times.

Special thanks to Mike Hoffkamp and Emily Sharp, who are among the authors of the study that found a higher rate of cesarean pain for black patients in Texas.

Jennifer Schwenk, Katerina Beckman, Rachel Waldinger, Nick Pittman, Kyle Grandillo, Aswati Giaram, David Gutman, and James O'Carroll, the doctor who came up with the question: if you were in pain, did you tell anyone about it?

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

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