One Physician's Journey Back to Self
Doctor's Orders delivers an intimate, behind-the-scenes glimpse inside the life of a busy Ob/Gyn. Pam Swift, MD, shares her deeply personal and emotional journey as she confronts life-and-death medical emergencies, becomes entangled in the medical-legal system, and ultimately suffers a crisis of career.
As the wounded healer, having endured her own “dark night of the soul," Dr. Swift awakens to a universal truth: We create our own reality with the choices we make each and every day. Armed with this new insight, she fights to reclaim wholeness by choosing a life that aligns with her true self.
The Beginning of the End
To prepare for morning rounds on the Maternity Ward, I print out a computer-generated list of my hospital patients. While securing the still-warm page to my clipboard, the date catches my eye—June 30th. I make a mental note to call my best friend and wish her a happy birthday.READ MORE
The early morning hush, along with my usual sense of calm, are shattered when the voice pager clipped to my waistband goes off: BEEP! BEEP! BEEP! “Call 7-2-5-4; call 7-2-5-4.” Although I’ve worn a beeper for years, its bone-jarring alarm never fails to jangle my nerves; adrenalin races through my veins, making my heart pound. I take a deep calming breath, and dial 7-2-5-4.
The clerk in the Delivery Room answers. “Your labor check is here. She’s in room three.”
“Thanks. I’ll be right there.” Rounds will have to wait—again.
With clipboard in hand, I walk down the hospital corridor toward Labor and Delivery. As I approach the entrance, the automatic sliding-glass doors open with a loud whoosh. My senses are accosted by the harsh glare of the overhead lights; I squint until my eyes adjust to their blinding intensity. With each step, my black high-top sneakers squeak on the white linoleum floor.
Because I’m a newly practicing Obstetrician/Gynecologist, it’s my third time on call this week—I’m still low man on the totem pole. The practice I joined is one of the biggest, most prestigious groups in town. I was honored that they’d asked me to join their group when I’d still had two years of residency to complete—they said I was worth the wait. How wonderful it was to join a group whose members I know so well. I know how they treat their patients, and how they treat each other. It’s been more like becoming part of a family than joining a business partnership.
The on-call schedule is tough, but nowhere near as brutal as was residency’s. Those were the days of 36-hour shifts and 120-hour workweeks. In reality, residency is little more than legalized hazing that must be endured in order to join the “Old Boy’s Club.” The culture of medicine still subscribes to the ideal that a doctor should be superhuman. One should be able to make life-and-death decisions without the benefit of sleep, and one should be able to remain emotionally detached—no matter what transpires on the job. I have always disliked “shoulds” in my life.
I enter Labor Room 3 and say hello to my patient, Maria. Her round naked belly protrudes from beneath her hospital gown. Her belly is perfectly round; it looks as if she’s swallowed a basketball. Maria returns my greeting, and I find it hard to believe that she didn’t speak a word of English when we’d first met, during her last pregnancy. She’d recently emigrated from Brazil and spoke only Portuguese. I was so surprised when she came to the office early in this pregnancy speaking flawless English. When I asked how she’d learned a new language so quickly, she’d said, “By watching American soap operas on TV.”
As we exchange pleasantries, I note a thin sheen of sweat on her brow: her body is laboring hard. Despite the exertion, when Maria looks at me, her eyes sparkle with excitement. This is her second child. Her first was delivered by C-section. This time, however, she plans to VBAC (otherwise known as a Vaginal Birth After Cesarean). I examine Maria’s cervix; she’s only four centimeters dilated. I toss my exam glove in the trash and walk over to the sink to wash my hands. While lathering up, I catch my reflection in the mirror above the sink. Once again, I’m dismayed at the sickly hue my skin takes on when paired with the God-awful institutional gray-green scrubs the hospital chose.
As I grab a paper towel from the dispenser and dry my hands, I notice that Maria’s breathing has changed; it’s become increasingly labored. She’s going to move fast. Usually, I can sense how a woman’s labor is progressing by the sounds she makes. When I hear the telltale primal grunt, intuitively I understand the message it’s conveying: She’s fully dilated and the baby’s coming. Quickly, I slip on another glove and examine her cervix to confirm what I already know.
The nurse I’m working with, a thin woman with fiery red hair, removes the bottom section of the bed, sets up the stirrups, and helps Maria scoot to the edge of what remains of the bed. She then gives Maria a quick tutorial on how to push: “With the next contraction, take a deep breath in, hold it, then bear down as hard as you can for ten seconds.”
Her instructions are unnecessary. The ancient mammalian recesses of Maria’s brain are now in control. Maria follows her body’s own instruction. Instinctively, she knows exactly what to do.
With delivery imminent, I quickly take off my long white lab coat and hang it over the supply closet doorknob. The coat must weigh ten pounds with all the crap filling its pockets. Well, it’s not really crap, it’s all essential equipment for my work: a stethoscope, a prescription pad, and a small calculator because I can’t do math and would otherwise be reduced to counting on my fingers.
The final item in my pocket is what I like to call my “ectopic brain.” In this notebook, a small dog-eared binder held together with tattered white (now gray) adhesive tape, I’ve scrawled, nearly illegibly, all the important hospital phone numbers, doses for drugs I commonly prescribe, and important notes about gynecological cancers and obstetrical complications.
Above the breast pocket of my lab coat, my name is embroidered with royal blue thread in large fancy script: Dr. Pamela Swift. Usually, I don’t use my full name, Pamela, because I don’t much like it. Yet, when I’m using my official title, it somehow seems fitting. Mostly, I go by Pam. My husband can get away with calling me Pammy, but nobody else can. Okay, when I tease Sandy at the office by addressing her formally as Mrs. Falls, she counters by calling me Pammy Jo; but other than those two, nobody else gets away with it.
In medical school, I imagined I’d encourage all my patients to call me by my first name as I’ve never been fond of, nor impressed with titles. Yet, much to my surprise, I discovered that due to the extremely intimate nature of my work, I need to use my title to create a boundary—to maintain some space between myself and the other.
Hurriedly, I tie my hair back in a thick ponytail and walk across the room to the delivery table. My brown hair hangs down to the middle of my back in unruly corkscrews. It’s taken me 35 years to finally embrace my curls.
I roll the delivery table to Maria’s bedside and lift the sterile paper drape to expose the glinting steel instruments I will need for the delivery. Having pulled on my blue paper gown, the nurse ties it closed behind my back while I wriggle my hands into the brown latex gloves. Before I get my second glove on completely, the baby’s head crowns. Using my forearm, I hold pressure against the baby’s head to forestall the delivery until I get my glove situated.
With one final, mighty push, Maria gives birth to an adorable baby boy. An ocean of amniotic fluid gushes out after the baby delivers, and splashes onto the floor. My paper shoe covers are soaked. The baby is a little blue after his wild ride down the rapids of his mother’s birth canal, so instead of placing him on his mother’s belly, I lay him gently under the toasty lights of the baby warmer.
The warmer consists of a tiny mattress positioned under a heating lamp. It keeps the naked baby warm, as if under a French-fry warmer. It also provides easy access for tending to the infant. The nurse vigorously rubs the newborn’s body with a towel to dry him off and to clean away the cheesy vernix. With the physical stimulation, the squirming baby lets out a lusty cry and begins to pink up. Such a happy sound—I smile. How I love these quick, easy deliveries. Mother Nature has it all under control; I’m completely superfluous in these uncomplicated births.
Twenty minutes have passed, and the placenta has yet to deliver; it should have by now. Reaching up into Maria’s uterus, I try to get a sense of the problem. Usually, the placenta separates from the wall of the uterus in response to the afterbirth contractions, but I can’t feel any separation. Some placentas are stubborn and require manual evacuation from the uterus. Finding the edge of the placenta with my fingertips, I work at cleaving a plane between it and the uterine wall. The placenta begins to separate, but then I hit a brick wall; the remainder won’t budge. I worry that she has a placenta accreta, a condition in which the developing placenta grows into the muscle fibers of the uterus rather than creating the normal cleaving plane. Women who’ve had a previous C-section are at an increased risk for this condition. As I withdraw my hand, blood begins to stream out. A red stain quickly expands on the bed sheet under Maria. With only a fraction of the placenta separated, the uterine musculature is unable to contract normally to close the exposed blood sinuses.
In an effort to keep calm, I take a deep breath, and then slowly exhale through pursed lips. Maria’s anxious eyes are riveted to mine. “Maria, I need to take you to the OR for a D&C to remove your placenta.”
Her eyes are wide with fear, but her voice is steady as she replies, “Do whatever you have to do.”
“I promise I’ll take good care of you,” I say, trying to reassure her.
A C-section is already underway in OR 1, and the anesthesiologist doesn’t want to start a second case until the first one is finished. I go back to check on Maria. The red stain on her sheet has expanded; she’s lost a good deal of blood in a short amount of time.
“Her pressure’s dropped to 80/40,” the nurse says, with a worried look.
“We can’t wait any longer.” I unlock the wheels of Maria’s bed and start rolling her toward OR 2. I yell to the clerk at the desk, “Call the anesthesiologist and tell her we can’t wait—I need to do this D&C now!”
In the OR, the nurse and I help Maria slide from the hospital bed over to the cold, steel operating table.
An anesthesiologist from the main OR enters the room and gets to work, first placing EKG leads on Maria’s chest, and then wrapping a blood pressure cuff around her upper arm. When he sees how low her first blood pressure reading is, he decides to put in a second, large-bore IV so he can replace the fluid volume she’s lost from all the bleeding. When the second IV is in, he injects several cc’s of Pentathol, and Maria drifts off to sleep. The anesthesiologist then inserts an endotracheal tube and connects it to the ventilator. Once he gives the circulating nurse the nod, she proceeds to place Maria’s legs in the stirrups and prep her for surgery.
Ashley, the resident, and I do a perfunctory scrub of our hands. Cleanliness may be next to Godliness, but in this case, time is of the essence. After our pseudo-scrub, Dahlia, our scrub nurse, gowns and gloves us. We then cover Maria’s legs with sterile paper drapes.
Using a large metal curette, I thoroughly scrape the interior of Maria’s uterus. Then, with my gloved hand, I feel the interior walls of her uterine cavity. I don’t feel any pieces of placenta, yet the bleeding continues. I try to persuade her uterus to contract by vigorously kneading it between my abdominal and vaginal hands; the uterine massage has no effect. “Get me an amp of Hemabate,” I yell to the circulating nurse.
Hemabate, an incredibly strong prostaglandin, usually works miracles in emergency situations like this; it coerces the lazy uterine musculature to contract. The circulating nurse gives the injection into Maria’s deltoid muscle and we wait. No effect.
Ruth, another obstetrician in the community, becomes aware of the commotion in our OR and scrubs in to lend a hand. I gratefully accept her moral support. Over my shoulder, I tell the circulator, “Draw up another amp of Hemabate and give the syringe to me.” This time, I inject it directly into Maria’s uterus. Holding my breath, I wait…and I pray. Still, she bleeds. An old saying from medical school whispers from the dark corners of my mind: “All bleeding stops.” I get angry. No! I will not let Maria die on my watch!
Ruth and I agree—we need to open Maria’s belly. We’ll tie off her hypogastric arteries to stop the bleeding. We reposition Maria in the supine position and prep her abdomen. As I make my incision, the anesthesiologist reports that blood is oozing from around both of Maria’s IV sites. This is not good news. She’s in DIC, disseminated intravascular coagulopathy. She’s bled so much she’s used up all her clotting factors. Ligating the hypogastric arteries is no longer an option; in order for the procedure to work, Maria must have an intact clotting system. Our only remaining choice is hysterectomy. Performing major surgery in the face of DIC is risky; yet without surgery she will surely bleed to death. It’s a double bind. We proceed.
To assess how dire our situation is, the anesthesiologist sends off a platelet count. Normally, a platelet count lies between 150,000 and 350,000. Maria’s count is 8,000. The anesthesiologist calls the main OR for back-up, then he calls the Blood Bank and orders several units of platelets. Within minutes, four anesthesiologists burst into our OR. It’s never a good sign when the anesthesiologists outnumber the surgeons in the OR.
Time expands and takes on a surreal quality. The minutes become hours, and then, time seems to stand still. The faces of the physicians operating with me morph one into the other as one scrubs in while another scrubs out as the hours continue to tick by. The faces around me are in sharp focus, but beyond them, everything blurs into a formless psychedelic dreamscape.
Maria’s anatomical landmarks are all wrong. Because her cervix is fully dilated, there is no demarcation between uterus, cervix, or vagina. As I cut her uterus free, I perforate the bladder. The urologist’s face is added to the never-ending parade of physicians marching before my eyes. He successfully repairs Maria’s bladder—a challenging feat given the relentless tide of blood that continues to well up, obscuring the surgical field.
Finally, mercifully, except for closing the incision, the five-hour operation is complete. As I place each suture, blood oozes from every new needle hole. Because of the DIC, the more sutures I place, the more bleeding I create. I stop. With my hands resting on Maria’s belly, I push back and hang my head. I take in an enormous breath, and release a deep shuddering sigh.
Dahlia looks at me with concern and puts her gloved hand on mine. She gives my hand a squeeze. “Are you all right?”
“Yes,” I lie. I’m not even close to all right, but I appreciate her kindness. I finish closing Maria’s belly.
Dahlia was the first nurse I worked with as a brand-spanking-new resident. She’s a tall, strong, intimidating, Jamaican woman with piercing dark eyes. In contrast, she has one of those mega-high-voltage smiles that dispels all darkness from a room. In a former career incarnation, she’d been a midwife in England. As a first-year resident, I realized pretty quickly that she knew a hell of a lot more than I did, and that I could learn a tremendous amount from her. From the start, we worked well together. We worked as a team, with mutual respect and fondness, as we cared for our patients.
After completing Maria’s surgery, Ashley and I wheel her, via stretcher, to the ICU where her care will be transferred into the very capable hands of intensivist Dr. Hernandez. Maria’s husband walks with us; I explain what has happened.
In the ICU, the team sets to work hanging units of blood, cryoprecipitate, and more and more and more platelets. I hear Dr. Hernandez tell Maria’s husband that I saved her life. Intellectually, I know what he’s saying is true, but emotionally, I feel terribly responsible. It was just dumb luck that I was the one on call, but I feel the weight of the ordeal on my shoulders—it happened on my watch.
Back in the Delivery Room, my partner, Dr. Julio Gonzalez, waits for me. He’s voluntarily manned the Delivery Room while I was “otherwise engaged.” Julio is one of the younger partners in our group. He grew up on a farm in the rural hillsides of the Dominican Republic. Having emigrated to America, he’s made a better life for himself, but still misses the easy pace of life on the farm. A tall, lean, well-muscled man, Julio has that classic male V-shape that makes him look sexy even in those shapeless scrubs.
When I return to Labor and Delivery, he grabs me and hugs me hard. He listens patiently as I tell him about Maria. He allows all the dreadful details to rise up and spill into the empty space between us. Julio is special. He permits himself to feel and express emotion. The female practitioners in our group once voted him an honorary woman. I believe he took it as the intended compliment. When I was a resident, though, he scared me to death. Because his beard obscures his expressions, I was unable to read his face—I couldn‘t tell what he was thinking. He made me so nervous I was a blundering, babbling fool whenever I was around him.
One day, while I was incoherently prattling some gibberish, he grabbed my hand and asked, “What the hell is the matter with you?” Startled, I looked up at him, and was finally able to see that his eyes were not just smiling, they were dancing. At long last, I understood: He thought I was okay. After that seemingly insignificant interaction, forever after, I was calm, collected, and coherent around him. He has become my favorite partner, more like a brother than a business partner.
Julio puts his arm around my shoulder and steers me down the hallway. “Walk with me down to Labor Room 1, and I’ll introduce you to the woman I admitted while you were in the OR.”
I recognize his offer to introduce me to the patient as his way of lending moral support. His mere presence by my side is an enormous comfort after my traumatic experience. He’s helping me get back in the saddle. Under his sheltering wing, I’m able to function and provide this patient with competent care. I deliver her baby as if nothing else is bothering me; as though she and her baby are my sole concerns in the world. She has no idea that this has been the most horrifying day of my career.
Jim McKean on Amazon wrote:
This "intimate, behind the scenes" exploration of the life of an OB/GYN surprised me with its clarity and honesty. I was gripped from the first page. Dr. Swift warns us that some scenes will be "graphic," and they were, but I was so caught up in the drama, feeling as if I were there in the delivery room with her, that everything felt natural. Being in a field that seemed to offer all the positives of medicine, bringing new life into the world, does not work out that way. I was stunned by her experiences, first as an intern and resident, then as a partner in a large practice. The stories about the malpractice suits and the insurance companies only added fuel to my already dim view of their practices. I was charmed by the ending and felt pleased and relief when she chose to opt out and find herself. Well done.
Pattie B. on Amazon wrote:
Dr. Swift has found a wonderful way to introduce the average person into the highs and lows of the medical profession. Her willingness to take us into her personal life and the drama that faces an Ob/Gyn is palpable. We all face challenges in our lives. How we personally deal with those challenges can and does affect how we will live out the rest of our life. Dr. Swift's willingness to bare her soul is refreshing and courageous. I found her use of family history to be most insightful into how she dealt with her own personal challenges, showing that she has an intuitive grasp of family system theory. As a Canadian I found this book very helpful in understanding the medical world of the United States where medicine is not provided by universal health care. It also made me feel glad that I live in Canada.
Cortney Davis on Amazon wrote:
I was interested in reading this book as my husband grew up with Dr. Swift's mother and aunt summers in Sandy Point, Maine. We had met Pam a couple of times on the beach at the 4th of July celebrations. I loved this book and read it in three sessions. I admire her for recognizing the path she chose to follow was not fulfilling. It took great courage to follow her heart and to tell the world about it. It was very emotional, happy, sad and wonderful in between. The family history was also very interesting to me. She is a beautiful writer and I hope there will be more books from her to come. An excellent book.
SBSmithAuthor on Amazon wrote:
This is a wonderfully engaging, moving, honest and insightful memoir. I started reading one evening, could hardly put the book down to go to sleep, and finished it the next day. As a nurse practitioner in women's health, I have shared the world that Dr. Swift reveals in this book, and so can attest that she portrays complex medical events with clarity, and she writes of the difficulties and joys of OB-GYN practice with authority. Most compelling to me, Dr. Swift tells what it was like for her to be an intern, a resident, and then a practicing physician. It's not all glamour and glory, and for a shy, creative person such as the author, it was, for various reasons, often sheer agony. This book should be read by all medical students and by those who desire any career in medicine. Dr. Swift reminds us that we are all given different gifts; it's essential that we embrace the gifts we have received---even if that means making a life-changing decision.
Michael F Myers on Amazon wrote:
I have a new respect for OB/GYN's. As a healthy patient who never had children, I've only seen the normal/routine side of the practice. Can't imagine the emotional and professional challenges of dealing with split-second decisions that mean life or death for mother and/or child. This was a good read.
N. S.Deming on Amazon wrote:
I consumed this book in one sitting – a testament to Dr Swift’s fine evocative writing! As a psychiatrist and specialist in physician health, I think that there are several messages that readers will take away from this slim volume: 1) the understanding of life in the trenches for a busy Obstetrician/Gynecologist in today’s medical world 2) the privileges of being a physician and the altruistic gratification attached to helping one’s patients 3) the fatigue that accompanies this work, a tiredness that never really goes away even with some catch up on days off or vacation 4) the ever-present fear (and reality) of being sued for malpractice and the need to practice defensive medicine 5) the challenge of carving out balance in one’s life and the fight to have time for one’s avocations, family and friends 6) the necessity of supportive colleagueship and sensitive leadership in medical practice - and the oppressive hurt, disappointment and isolation that descends when that is not in place, and ultimately 7) the realization that all physicians must face, that if we don’t take [care] of ourselves we’re no good to anyone. I salute Dr Swift’s agonizing – yet life-saving - decision to leave medicine. This book is not “anti-medicine” or discouraging of medicine as a career choice. Just the opposite, this is a book about resilience, hope and the pressing need for change in the world of medical practice. I recommend it highly to those considering becoming a doctor, to all physicians practicing today (and their loved ones), to deans and directors of medical student and resident education, to employers of physicians and other stakeholders, and to all persons who care about the humanness of their doctors.
Michael Myers, MD
Professor Clinical Psychiatry
SUNY Downstate Medical Center
Kimberly Trider-Grant on Amazon wrote:
As I started reading Doctor’s Orders, it was obvious that my plans for the day would have to wait. I read this memoir in one sitting, only taking necessary breaks to eat and walk my dog.
Reading Pam Swift’s book put me through a full range of emotions. Her words had me laughing, shaking my head in disbelief and crying. The world stopped and I found myself holding my breath as she described incredibly tense scenes delivering babies in the OR. It was stunning to me that any number of complications could arise when all seemed to be going smoothly. How does one think clearly about making life and death decisions while being sleep-deprived?
This memoir will be an eye-opener for anyone who does not appreciate those in the medical profession. I am in absolute awe of the immense responsibility they must shoulder every day.
Doctor’s Orders should be read by all who feel stuck or unfulfilled in their present life/work situation. As per Dr. Swift, one must follow his/her heart and seek out the things that are important and bring joy. Take a deep breath, a leap of faith and go forward.
Westernlu on Amazon wrote:
Well, Pam Swift, I received your book today. I read it cover to cover and spent the whole time crying! It is wonderful!!! It really touched my heart deeply. I admire your life decisions and found them so validating as I think about my choices in life. I have spent so much time "shoulding" on myself, but reading your book has made me tearfully reassess. I am going to be kinder to myself for following my dreams. Congratulations on your book, and to everyone else:This is a must read!
Frank Stagnitta, DVM. on Amazon wrote:
Excellent message. So well written and very moving. I read straight through to the end - had to finish it without stopping. I have the good fortune to know the author and yet her story still amazed me. So glad she was true to herself, pursued her dream and is living the life she was meant to have. It took great courage to share this story and to make these life changes.
This is a moving memoir from one of the best people I have had the good fortune to meet. I knew Pam well in undergraduate school at VA-Tech, but lost contact as our careers took different paths. However, this book shows her as the friend I remember, intelligent, shy, funny and kind. A great story that every physician should read.
Pam Swift, M.D. was a partner in a large private Ob/Gyn practice as well as an attending physician at the teaching hospital located in Danbury, CT. She also served as Medical Director of the Women's Health Center which provided ambulatory Ob/Gyn care for the community's indigent and uninsured women.
After retiring from medicine, Dr. Swift and her husband moved to a farm nestled in the woods of Maine. Some of her new duties include doctoring chickens and midwifing lambs.