S02 Episode 2: The Speech

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

Previously, on the retrievals.

It was an unfathomable amount of pain.

And I remember

begging them to stop.

And one of the attendings, she looked at me and told me to tell her that it was okay.

That's one thing I regret the most, that I didn't say, like, it's not okay.

I felt horrible

and um

and then I got mad

and then I got really mad

from Serial Productions and the New York Times I'm Susan Burton and this is the retrieval season two

the C-sections

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

I don't even know what to say

I'm so angry

usually this scene happens in a hospital corridor there's a template for this 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 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.

How it happens on our show, in real life, is Dr.

Heather Nixon is at home in pajamas on her day off.

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

Heather is the head of obstetric anesthesia.

Making sure patients are not in agonizing pain during their C-sections is her job.

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

And I said, hey,

what the hell happened?

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.

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

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

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

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

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

She was just very anxious.

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

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

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

I was like, yeah, but no.

In addition to midazolam, the anesthesiologist had given Clara fentanyl and ketamine.

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

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.

And I said, well, why didn't you just put her to sleep?

Like, what was your reservation?

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

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

But for decades, doctors have been taught that pregnant patients are hard to intubate.

that they have difficult airways.

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

If you weren't 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.

You have no fear of that airway.

You handle difficult airways all the time.

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.

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

Like, didn't you even worry that the patient was going to stop breathing at some point because you're given so much anyway.

Like, wouldn't it have been better to have a breathing tubent, please?

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.

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

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

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

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

Pressure is normal, right?

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

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

Heather hangs up.

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

What was wrong was that these beliefs were ordinary.

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

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.

Patients who've been uncomfortable?

Yes.

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

Yes, that too.

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

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?

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

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.

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

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.

They feel outraged that they are screaming in pain.

and that an attending continues to teach a resident like nothing is abnormal.

They feel their organs being moved around.

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

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.

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

Because they are scared they will die from this pain.

They get to the point where they want to die.

I felt everything.

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

Heather is startled.

How do I not know that this happens, right?

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?

How do I not

know that a significant number of women do not feel empowered enough to say, I hurt.

I could have read all those stories on the internet.

I could have looked at all the accounts and been like, oh, well, it was an emergency C-section, and so they must have dosed the epidural and it didn't quite work.

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

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

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

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

it happened to this individual who I know and trust.

And it's real.

It's real and it happens.

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

But it something has to happen to

shake a person up.

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

okay, how do we, you know, kind of, what do we do here?

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?

But for our characters, the social issue isn't being grafted on.

It's just what happened to them.

Heather closes her laptop.

She doesn't yet know exactly what to do, but she knows she's going to do something.

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

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.

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

One kind of answer is something like, the doctor didn't listen to her.

And that might well be a play in an OR.

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

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

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.

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

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

Well, you might.

You might feel pressure, including pressure from deep inside your abdomen.

This is the origin of that phrase, it's just pressure.

But pressure can be painful.

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.

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

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.

But general has not been the first choice for cesarean for a long time.

It carried risks for pregnant patients.

Some people I spoke to pointed to a 1997 paper that 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.

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

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.

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

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

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

but plenty of patients have feared they would.

There are all these common phrases doctors say during cesarean.

We're almost finished.

It's just a few more minutes.

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

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

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

And now one of those people is Clara.

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

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.

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

I mean, even the sight of the logo made me angry.

Walking in the hall made me angry and couldn't believe I had to be there and couldn't believe I was back.

Everything about it made me so mad.

You know, that feeling of like this thing happened and the world is still moving, you know, spinning.

It's that thing, right?

Yeah.

Clara's anger was diffuse.

Anger at the system that allows this to happen.

Anger that it had happened to her.

But there was also

welcoming, caring coworkers, right?

You come in, they're so happy to see you.

How are you?

How are your babies?

Show us the pictures.

In the hallway, A coworker in Scrubs comes toward Clara with outstretched arms.

Clara pulls out her phone.

We see this happen again, an almost identical sequence.

Clara beaming.

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, she and her coworkers felt protective of Clara.

And in the beginning, it was a very understanding environment.

People would adjust their assignments.

But after a while, it started becoming like, I mean, I'm not a church nurse.

I don't make assignments, but I would hear like, okay, like,

when,

what is happening?

Like, is this still a thing?

Can she go back to the operating room?

Because

you can't have restrictions, honestly.

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.

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

You could say she had occupational re-traumatization.

Or you could say reminders of her surgery were everywhere.

Except for one significant one.

Clara never saw the anesthesiologist from her C-section around the hospital, which didn't surprise her.

He wasn't an obstetric specialist, and he mostly worked on a different floor.

She'd never seen him before that night anyway.

But she wondered about him.

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

Of course, 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.

And I saw his name and I Googled him.

You know, but

it's just a doctor.

It's just a whatever anesthesiologist.

Yeah.

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

No, nothing about it is in there.

There's nothing in the surgical report.

that says anything.

It was as if it hadn't happened.

In the surgical report, there was no record of Clara's pain, of her own experience.

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

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.

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

Guys, the patient's experience.

Oh shit.

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

Heather.

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.

She's been working on a speech.

A speech.

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.

The occasion for Heather's speech is a medical conference.

And this next thing will sound like an improbable coincidence, because in fact it was.

Before Clara's surgery, Heather had been assigned to prepare a speech on pain during C-sections for a major national conference.

She planned to focus on technical tips.

Then Clara's C-section happened,

and a how-to started to seem beside the point.

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.

But it was like all this time people had been talking around something rather than saying it directly.

And a lot of ORs, patients are in pain.

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.

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,

I had a patient under my care.

and I watched her be in pain.

But look, we've all been in this situation, Heather imagined she could say.

And no one feels good about this, right?

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

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.

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?

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

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

Like, I didn't like that.

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.

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

Heather wasn't sure if this would work.

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.

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

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.

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

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

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.

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

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.

She needed her colleagues to see what she had.

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

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.

I want everyone to be a little horrified.

I want everyone to be a little outraged.

I want everyone to be like, yep, we got to fix this.

Yep, there is a problem.

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

And now we see Heather's flight to the conference soaring up into the air.

Because why not?

What happens when she lands?

That's coming up after the break.

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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.

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

Today we have some excellent talks for you.

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.

Good morning, everyone.

So we've had some changes in the schedule.

It's 8 a.m.

on a Saturday.

Doctors are still filing into the room.

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.

Heather's.

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.

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

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

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.

We don't have strict guidelines, there is a spectrum of practice, there's maybe some misinterpretations, and we need to all get on the same page about how we approach this.

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 generate some urgency around this issue.

So we're going to start with a story.

My story starts with a patient named Jennifer.

She's admitted to LD at 37 weeks for a twin gestation.

Now, her obstructor

is Clara.

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

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

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

After that,

it gets a little dark.

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

that the anesthesiologist gives her additional meds.

Jennifer gets 150 of ketamine,

300 of fentanyl, and six of midaslam.

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.

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.

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

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.

He looks at the OB field.

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.

So he takes, unfortunately, it's the end of the case, there's not much he can do.

He takes the patient to the PACU.

And I get a call.

Okay?

So

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

This happened on my unit.

This is why I'm here today.

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

Horrific.

And so when I went to her, 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.

But I need your help.

And when you're ready, I'd like you to give a statement.

So here's Jennifer's statement.

I want them to know

that for weeks after birth, I could not close my eyes without hearing my screams in my head.

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

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

There were wrenching sobs every time I needed to

wash it.

She had a visceral reminder of her pain on her body.

I want them to know.

that despite all the fucking ketamine and whatever else, I could still feel pain.

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

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.

This room is still.

So this is a harrowing story.

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.

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

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

Nowhere, right?

If you have a block that doesn't work for an ortho case, your patient goes to sleep.

We don't suffer through it, we don't bite the bullet, we don't ask our patient to just take it.

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?

There are hundreds of people in the room.

We watch as half of them raise their hands.

Half.

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

And half of the doctors raised their hands.

Okay,

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.

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.

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

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

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

So, how do we fix this?

How do we think about this?

And how do we change what's happening?

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.

And I'm going to assume that no one gets into medicine to hurt people, okay?

We want to help people.

So, what is the disconnect?

Heather's put the questions to the group plainly.

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

She opens the discussion to the room.

The first person to speak is a doctor from New York City named Dan.

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.

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

And I think that is what is, I mean,

I'm going to say it, that is a fear of mine that I will lose the airway.

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.

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.

No warm-up, no superficial comments before the room really gets going.

Dan goes deep straight away.

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.

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

So I think that that's a wonderful point.

We were taught since we were, I mean, since fellowship, since I was a baby, I was taught, don't take on the airway.

Pregnant is the big bad wolf.

Stay away from it.

This is how moms die.

You'll never recover.

The family will never recover.

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

Right?

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.

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?

Even when the patient maybe had had some discomfort.

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

People start lining up behind the mics.

There's a doctor who practices in New Jersey.

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.

And there's Zevi.

Oh, I'm Zevi.

I'm also from New York City.

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

The part that spinals and epidurals can fail.

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

These things fail.

Wait, what?

You're telling me this now?

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

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

So I'm Andy I'm from Stanford.

I just wanted to share one of my techniques and 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?

Because my block's going to work.

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

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.

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

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

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

That is horrible.

It is horrible to not feel listened to.

And so I think we all have to.

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?

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

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

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

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

But for today, the goal is not to settle on a fix.

This is steps to solve a problem.

Step one, talk about the problem.

That was what Heather wanted.

And apparently it was what the room had wanted too.

First off, thank you for this session.

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?

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

Thank you.

Thank you.

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

It turns out what's hard is not getting people to talk about this.

What's hard is getting them to stop.

So you guys have exceeded my expectations in audience participation.

So hold where you are right now as next, okay?

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?

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

Where were my OBs?

Why didn't they say anything?

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

One of them said, It was horrific, it was horrendous, and they never said a word.

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

The audience is quiet.

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

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

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

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.

Mindy.

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

We're back at UIC.

We see Heather's image on a computer monitor, and Mindy and other nurses gathered around.

Like they just told us, like, hey guys, Dr.

Nixon's giving a pain a talk about intraopperative pain.

You guys should join.

So like, but we didn't know exactly what it was going to to be,

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

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, oh.

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.

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

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.

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

And Clara didn't.

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

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

All of this might have surprised her coworkers, but it wouldn't have surprised anyone familiar with birth trauma.

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

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

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.

I'm the director of a perinatal trauma-informed care clinic.

I think there are two in the country right now.

There's so much to say.

I wish every seat in this room and this lecture was being televised or, the video went to every anesthesia provider because I can tell you this happens a lot more than you think it does.

I can't stand here and over

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.

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.

These are individuals that go on to get divorced.

They don't, they can't even care for themselves.

It rocks relationships.

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

Their birthdays of their children become nightmares.

The impact is so severe.

Heather's talk lasts 90 minutes.

And before she leaves the stage, let's take the temperature of the room.

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.

Swing to another doctor, this one from Texas.

For him, pain during cesarean never became normal.

He has a presentation he gives to small groups called, Just Put Him to Sleep.

And over here, this woman.

For years she'd been focused on pain after cesarean.

That's where a lot of them were.

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

And just one more doctor, long blonde hair, 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.

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.

She didn't want her baby to die.

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.

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.

But what about all the people not here?

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

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.

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.

Would they feel the same urgency about this?

We're in the elevator now, going down.

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

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?

What are the solutions?

Elevator door opens onto a new location.

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.

Heather wondered, how do you solve this problem?

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.

That's on the next episode of The Retrievals.

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 Marian 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 Wesling.

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.

The doctors who came to the microphone during Heather's talk include Dan Katz, Bill Kamen, Emily McQuaid Hansen, Andy Traynor, Zevi Hamburger, Klaus Kahyer, and Tracy Vogel.

whose trauma-informed care tools are online at the Empowerment Equation.

Other doctors whose presence I alluded to include Simon Ashe, Mike Hofkamp, 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.

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

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