Stanford Continuing Studies Class, 2008
Narrative non-fiction writing assignment
A Truthful Account
Interview Questions for a former Labor and Delivery Room nurse
What is your name and date and place of birth?
My name is Bonnie and I was born in 1943 at Mt Carmel Hospital in Detroit, Michigan.
When did you did you decide to go to become a nurse?
I decided to become a nurse when I was a very little girl, maybe as young as 3 or 4 at the end of the World War II. At that time, the newsreels at the movies were full of nurses in the military, always portrayed as very heroic, which made being a nurse seemed a lot more romantic idea than being a teacher, which was about the only other job for women that I was familiar with.
Of course, the issue of gender-specific roles was still big in the 1950s. Of course I wanted to grow up to be a mother, but I also wanted to be a nurse. My grandmother did a lot of sewing and was very creative and made me a little nurse’s uniform – a white apron with a red cross, the classic white scarf with a red cross on the middle. This realistic uniform was finished off by a long, very official looking blue cape. My outfit reminded me of the nurse in Farewell to Arms.
I have a picture of myself at the age of 5 or 6 playing nurse, all dressed up in my nurse’s uniform holding a toy stethoscope and sitting on the front steps of our house with my girlfriend Diane Gresham. Nursing might not have been in my DNA, but it certainly was in my future.
When and where did you go to nursing school?
I went to nursing school in Orlando, Florida in 1961; all our clinical training was at Orange Memorial Hospital. I learned obstetrical nursing in a segregated hospital, where I got to observe and participate in two entirely different systems, side by side in the same hospital, at the same time, same staff, same type of patients, totally different management, dramatically different outcomes. It was a profound, a one-of-a-kind study contrasting two extremes – knock’em out, drag’em out obstetrics for white labor patients, and non-intervention, normal birth for our black mothers.
Tell me a little about your nursing school program – when, where, anything remarkable
Well, the whole idea of nursing school was remarkable to me. It was the first time I’d ever been outside of the compulsory education system, the first time I was ever treated as an adult, the first time I had an opportunity to learn things I was actually interested in.
Just a few months before, I was a high school student diagramming sentences and do boring arithmetic homework. Then I was in educational setting of my own choice, one that was dramatically different and provided very interesting information. It was years before popular TV dramas like ER and Grey’s Anatomy and those ‘reality shows’ that provide oceans of detail about what goes on everyday in hospitals. In the 50s and 60s, kids under 16 couldn’t even visit someone in the hospital, so I really knew almost nothing about these things before I went to nursing school.
One of the best and most useful aspects of my training was the wisdom imparted to our first year class by the director of our nursing program – Miss Etta McLaughlin. She had trained in the 1930s at Mt Sinai Hospital in NYC and from our perspective, she had “seen it all”. We were spellbound by her stories. In the post-antibiotic world of the 1960s, she talked about treating diseases like pneumonia, TB, syphilis and post-operative infections in a pre-antibiotic era. We students were impressed by her descriptions of what it was like to stand by helpless and watch people die because there was no effective treatment for commonplace infections. Our class quickly developed an abiding loyalty to the “miracles” of modern medicine.
Miss Etta was “old school” or maybe I should say “old world”. She wore a starched and spotless nurse’s uniform and organdy nurse’s cap with such dignity that she was a larger-than-life inspiration to us all. We hung on her every word and wanted to emulate her style. To me, nursing was a form of religious vocation – a “calling”. I wanted to go to Africa and be a nursing nun just like Audrey Hepburn in the “The Nun’s Story” and save mothers and babies from desperate circumstances.
But what impressed me most about nursing school were two things Miss Etta said during the first few days of the program, when she was trying to impart a context for the profession of nursing. She started off by describing nursing as a service to our patients. Our nursing school motto was the Latin phrase “To Serve Humanity is to Serve God” and it was her goal was to teach us how to be a compassionate human being. Personally, I thought she did a great job.
She started by defining what it meant to be a healthcare “professional”, which was putting the well being our patients above our own. That included our physical safety, since we would be required to care for patients with contagious disease, violent alcoholics and acting-out psychiatric patients. It also meant putting our own personal convenience, economic advantage or career development secondary to the welfare of our patient.
In that context, the nurse’s professional obligation was to protect her patients from all manner of dangers – including sources of infection, wrong drugs, whatever. This included a duty to advocate for the patient’s safety even if that meant going against the “powers that be” – head nurses, hospital administrators and those famously arrogant surgeon-types.
This ethical obligation even meant protecting the patient against himself. For example, someone who insisted the doctor give him a shot of penicillin for a cold. Of course, medical professionals know that antibiotics are not effective against a virus, so a doctor would be obligated to decline, even if the patient gets mad at him and threatens to go elsewhere. I was really impressed by this idealism.
Miss Etta’s second “pearl of great price” was told in the form of a story about a peasant woman who was a fish vendor. The story goes like this: Every day this elderly woman sat at a small table in the middle of the village market. On the ground next to her was a bucket of filled with an undulating mass of live eels. In order to prepare them for sale, she’d reached down and randomly grabbed a writhing eel and used two large straight pins to tack each end of the eel down to her cutting board. Then she took her knife and slit its body from end to end and removed the meat.
Of course, the people in the village were used to this and didn’t think much about it. But one day a stranger came by. After watching her for a few minutes, he asked if it wouldn’t be more humane to kill the eels first, or at the very least knock them unconscious, before slitting them open. She replied “Why I’ve been doing this for 20 years, they ought to be used to it by now”.
The obvious moral of the story is that everyday healthcare professions do fear-provoking and painful things to patients. However familiar these routines may be to the doctor or nurse, they are still anxiety provoking and painful to the patient. It was a story that had a profound and continuing effect on my practice as a nurse and even in other areas of my life.
Insightful as these stories were, an awful lot of my nursing school experience was just awful for a kid just out of high school with so little life experience. I remember trying to provide nursing care to a 50 year-old woman dying of cancer, who had a colostomy and a stem-to-stern abdominal incision that had eviscerated (broken open). It was my job to poke sterile gauze into this messy, foul-smelling wound that would never heal, while her colostomy kept running like a river, defying my best efforts to keep anything sterile. Here was this helpless, hopeless woman dying alone in a charity ward, in the care of me, an 18-year old student nurse who didn’t have a clue.
Another major trauma was my clinical rotation in pediatrics at a huge hospital for profoundly disabled children. Sunland Training Center provided custodial care to the youngest, sickest patients in the state,. The hospital was in enormous building converted by an old TB sanatorium with 6 floors of open wards with floor-to-ceiling windows. It housed over a thousand of patients from newborns to late teens, all mentally and physically handicapped. Some had horrible birth defects, others were physically perfect but had the mental age an infant. Some were blind and deaf because their mothers had contracted Germen measles during pregnancy.
I particularly remember a 12-year old girl that I nicknamed “Sleeping Beauty”. She had the mental age a 7-month fetus but a perfect body that was turning her into a beautiful young woman with dark hair and alabaster skin. I felt so sorry for her mother, to see her daughter growing more lovely each day and to know that the kiss of a lover would never awaken her.
Most of these children were so disabled that they were either tube fed or had a tasteless blender food spooned into them three times a day by over-worked and under-paid nurses aids. These kids spent 24 hours a day confined to metal cribs with tall bars, in neat rows of 30 on each side, 60 to a unit, two units to each floor. In preparation for their daily bath, we lined their beds up every morning like a long wagon train snaking around the room.
The nurses worked in teams of two, stripping each kid naked. When it was their turn, a nurse’s aid on each side would grab an arm and leg and whisk them from bed to the porcelain slab in the center of the room. Other nurses would soap them up and then spay them off with a hose in a manner more reminiscent of dog grooming. The aids changed the bed linens and then dried, diapered and dressed each freshly scrubbed child and pushed their bed back into place.
I was simultaneously horrified and fascinated by this and desperately needed to understand why. Was Mother Nature a just a b-i-t-c-h? Was it bad genes, bad nutrition, bad luck, bad medical care, was it no medical care at all? I had to know, so I read the chart of all 60 babies and children on our floor. I discovered three major and one minor explanation for these catastrophes. The most frequent cause was obvious — birth defects like spina bifida, and hydrocephalus.
The second was invisible and mysterious — maternal infections like rubella or German measles during the first 12 weeks of pregnancy, which caused heart defects, blindness and deafness. And third were mostly man-made birth injuries – damage during labor or birth that was the result of obstetrical care they did or didn’t receive. The fourth category was a small number of children who had infections like meningitis, been hurt in a bad fall or car accident or been abused by someone.
Because I aspired to future motherhood, I was particularly interested in the category of “birth injuries”. At this point in my nurses’ training, I still hadn’t rotated thru obstetrics and I was enormously curious about childbirth. I also hoped to learn something that could protect me and my future family against the kind of tragedy I saw all around me.
About half of the patients on our floor — about 30 out of 60 kids — had a diagnosis of “birth injury”. Their charts described such things as precipitous birth, uterine rupture subsequent to induction, long labor with difficult forceps delivery. The stories of damage inflicted on these kids was the same on several charts, things like: “mother says nurse held the baby back until doctor arrived” or “mother given a large quantity of narcotics just prior to delivery, baby severely depressed, was resuscitated, low Apgar scores, postnatal seizures”, etc.
I recall one chart that described a general anesthesia accident in which the mother stopped breathing. She and her baby were both brain damaged and both required custodial care in different hospitals. According to the baby’s chart, two older children were left in the care of their father.
I was surprised at how many of these so called “birth injuries” were actually preventable, how often they represented a lack of appropriate care, poor care or incompetent care. This included neglected labors like: “doctor refused to come in for three days”, or excessive use of drugs like: “mother given 15 doses of narcotics over a two day period”. Sometimes the nurse held the mother’s legs together to keep the baby from delivering before the doctor arrived because she was afraid of getting in trouble with the doctor or losing her job.
Now days we would call this kind of thing “iatrogenic” or just plain malpractice. But suing doctors was extremely rare at the time, so doctors got away with a lot. At least some of those birth injuries are now being prevented by the threat of litigation. Medical science now has ways to prevent the malformations caused by maternal infection by immunizing women against rubella.
Anyway, this awful rotation finally came to an end and I was sent back to the main teaching hospital. Unfortunately, I found the complicated care required by medical and surgical patients to be very taxing and unpleasant. The real job of being a nurse was nothing like the fantasy I grew up with. Working in pediatrics was even worse – a 3-year old dying of brain tumors, a 5-year old scalded by an abusive parent. It was more that I could bare.
On top of all this horror and anxiety, our nursing instructors never missed an opportunity to remind us that there were a “1000 way to kill a patient without ever entering their room of laying a finger on them”. They were referring to mistakes like ordering the wrong drugs, failing to give the right drug or dose, other critical errors. Another source of angst for me as a shy 18year old was giving a bed bath to adult men, especially the obvious question of bathing ‘certain parts’.
However, Miss Etta explained this away with one of her famous little similes. According to her, the trick to bathing male patients was to “bath down as far as possible” without bumping into a certain appendage, then go to the patient’s feet and to “wash up as far as possible”, again avoiding the aforementioned appendage, and then to hand the warm soapy washcloth to the patient and instruct him to bath “possible”, while we demurely stepped out of the room.
Tell me about the first time you attended a hospital birth as a student nurse?
I was an incredibly young and naive student nurse from a family that didn’t acknowledge any biological functions of the human body that occurred below the Mason-Dixion line, which eliminated sex and childbirth both. I literally hadn’t figured out exactly how the baby came out when I was exposed to life-changing experiences as a student nurse that ran the gambit from the ridiculous to the sublime.
The first baby I saw born was the perfect place to start for someone like me. While I was rotating through the operating room, I got to see a Cesarean section. Now I always referred to this as my ‘starter baby’, but at the time I was utterly flabbergasted. For some strange reason I can’t explain, I was surprised when the baby was lifted out of the mother’s abdominal incision as “finished product” – a totally formed, perfectly lovely 7 ½ pound baby girl. She cried and waved her arms and kicked her feet and thoroughly charmed me.
It sounds absurd now, but I thought a newborn baby would start off as a shapeless blob of some sort and the nurse would it taken off to the nursery and after several days of special care, it would grow into a cute baby to be presented to the parents and taken home.
Months later it was my turn to rotate through the maternity department. This was an enormous relief to me because maternity patients are, thank heaven, all female and they are healthy, therefore not likely to be suffering from some awful disease or expected to die. I anticipated that the work would be happy – lots of new moms and new babies, proud papas, cigars being passed around, balloons, stuff like that. What’s not to like?
Not only was the work pleasant, but in my mind it was also holy. It seemed that somehow the mysterious off-limits delivery rooms – actually a sterile operating rooms — were the ‘holy of holies’, the next thing to an alter. In my warped 19-year old psyche, this was where sacred act of human reproduction — giving birth — was to occur, all nicely scrubbed and sterilized and as far from the messy aspects of sex as you could get. Of course, the obstetrician was the high priest of childbirth and labor and delivery room nurses were their faithful handmaidens. Naturally, I aspired to be an insider and take part in that sacred ritual.
Having so recently stared into the face of what happens when good obstetrical care is absent or deficient, I expected that our obstetrical residents and L&D nurses would be ‘angels of mercy’, that they would go to any length to protect mothers and babies from all the awful birth-related damage I had seen. I was sure these problems were associated with the “bad old days”, things that happened 5 or 10 years ago. You know, when you’re less then twenty yourself, ten years is half a life-time, which was when those children in the Sunland Training Center had been born.
I assumed that every obstetrician was as horrified as me at these tragedies and stupidly expected that all the iatrogenic causes had been accurately identified and eliminated. For sure, our doctors and nurses would never give too many drugs or hold any mother’s legs together to keep her from giving birth before her doctor arrived or anything else that would introduce unnecessary harm. Unfortunately, that turned out to be a fantasy about nursing that I could never reconcile.
But back to your question. During the first hour of the first day of my first rotation as a student in the labor and delivery room unit, at exactly 7:25 in the morning and while I was still being “oriented” to the unit, a young “unwed” mother was wheeled through those swinging double doors that grace every L&D in the western world, your know, the ones that say “NO ADMITTANCE – Authorized Personnel Only” in big black letters. The way she was sitting crooked in the wheelchair made it immediately apparent that something very unusual was happening.
When you combine this clue with the pushing sounds coming out of her mouth, even a dummy like me could figure out she was about to give birth. It was so exciting.
The unflappable nurse grabbed the wall phone and told the hospital operator to page the resident for a delivery. In the good old days before everyone had their own packet pagers, this meant announcing “OB resident Stat to the delivery room” over the hospital loud speaker, which we could hear as we practically threw this mother-to-be on a gurney and raced down the hall and through the door to a double-wide delivery room.
In 1962, the delivery rooms were typical of the era, which were similar to the operating rooms you see on the TV show M.A.S.H. – a single large room equipped with two operating tables and two anesthesia machines separated by a folding screen that was placed in the middle so the patients on each OR table could not see one another. Doctors, nurses and nurse anesthetists routinely slipped back and forth between two simultaneous deliveries, proving assistance wherever it was needed most. In obstetrics, this was one of the ways that babies got mixed up and given to the wrong parents.
On this particular day, another delivery was already in progress on the other side of the screen. As we came crashing into the empty side, the nurse anesthetist came around the screen and instantly sized up the situation, which is to say, there was no time to move the mother to the OR-style delivery room table. The anesthetist immediately reached for the anesthesia mask, turned on the Cylopropane anesthetic gas and came around to the head of the gurney with the black rubber face mask in hand, ready to render this young mother unconscious, which was the way everyone gave birth at the time.
The laboring woman couldn’t see the nurse anesthetist, who was behind and out of her line-of-sight, so it was a great shock when this anesthesia mask seemed to fall down from the sky and be pressed firmly over her mouth and nose and cut off her air. This young woman – really just a girl of 16 — probably had never even been a patient in a hospital before. Anyway, she grabbed the anesthetist’s wrist with one hand and clawed at the facemask with the other while she shook her head from side to side, all in an attempt to get away from the mask.
The nurse anesthetist continued to chase the labor patient’s bobbing head around the top half of the stretcher, while saying “Oh honey, you’ve got to have this, it hurts too bad not to, you couldn’t stand it”.
At this precise moment, the OB resident that had been paged showed up on the run. Standing at the foot of the stretcher out of breath and surveying the scene, he barked: “Let her go, she’ll know better next time”. Later I thought about his comment, which was mean, if not punitive, like he was teaching her a lesson for not being a good patient.
Anyway, a minute later, on the next push, the baby just slipped out. I was amazed to see this 16 year old give birth with no fuss or effort or outward signs of pain or difficulty. This was a crystal clear moment for me, a moment of cognitive dissidence, although I didn’t know that word at the time.
My eyes and ears were assailed by two incongruous stories; if one of them was true, then other had to be false. These two seasoned professionals — a nurse anesthetist and OB resident — had both just equated normal childbirth to intolerable pain requiring general anesthesia and at least one of them alluded to extraordinary regret by the mother-to-be for being so “foolish” as to refuse it.
Yet what I had just seen did not look like a train wreck or anything else that would require general anesthesia. The mother didn’t scream or yell or writhe in pain, there was no blood or gaping wound, nothing but the perfect miracle of that slippery little head peaking out timidly at first, instantly followed by the baby’s whole body, both feet, a big gush of pink amniotic fluid and the umbilical cord trailing along behind.
I remember the pool of steamy amniotic fluid and how the cord glistened as the baby lay there on the stretcher between the mother’s legs, a perfectly formed baby girl, weighing approximately 7 ½ pounds.
This was my very first ever normal birth and it seemed to happen outside of time, a moment suspended forever in my memory. However, in the real world, the clock was still ticking and the next act of this play was not happening. As a student nurse I was too “green” to appreciate the significance of the umbilical cord’s quiescence. In a live baby, the umbilical cord is big around as your thumb, intensely purple, spirals like a fat phone cord and pulses with every beat of the baby’s heart for several minutes after the birth. For this baby, the cord was smooth, pale, slender and oh-so-still.
The umbilical cord was not the only thing that was too still and too quiet. The baby did not move, did not cry, did not try to breathe, did not have a heartbeat. After the shocked and grieving mother was moved out of the delivery room, on the same stretcher that she had given birth on, I asked the wise, older nurse “why?” What would cause this perfect little baby to be stillborn? She just shrugged her shoulders said “some babies just don’t make it, nobody knows why”. With that she turned and with quietly dignity walked off to resume her duties as a humble servant in the Church of Obstetrical Medicine.
Why did you decide to work in the labor and delivery room after your graduated?
Two reasons. First I hated regular nursing and second, I loved mothers and babies and the privilege of witnessing what was to me the sacred moment of birth, to be the first person after God to see and touch and appreciate God’s newest miracle.
Do you have children of your own before you became a delivery room nurse?
No, but I do feel strongly that you can be a good Labor room nurse without first having children, at least I was. However, I was better, a lot better, after I had my first baby.
Can you give me your background in L&D nursing – when you started, how long you worked, how many hospitals you worked at?
What did like about your job?
What didn’t you like?
When did you retire? Why?
Anything I missed that you’d like to tell me about?
========= Parking lot =========================================
Even though we were taught the aseptic principles and the use of isolation techniques, gloves and masks and hand-washing and that kind of thing, which are generally effective against the spread of contagious disease, still and all, if you are caring for someone with a potentially fatal disease, you may have to expose yourself. In a situation that is life-threatening to the patient may become life-threatening to you as a healthcare provider, as it is sometimes necessary to do things quickly and without time or ability to follow every dot and jittle of the safety precautions.
For example, doing CPR. You may have to decide if you are going to let this stranger, who may be a drunk or IV drug user, die or risk your life by doing mouth-to-mouth resuscitation to save his life. I actually had this kind of thing happen once on a Saturday morning at the Trader Joe’s grocery store in Menlo Park.
A voice on the public address system asked if there was a doctor in the store and if so, please come immediately to isle 3. It was unlikely that a physician or EMT was in the store, so I went to isle 3 to check it out and found an elderly black women lying on the floor unconscious, right in front of the Charm bathroom tissue. She was surrounded by her frantic daughter, a son-in-law and two little girls about 4 and 6, but no one else was there to help. I told the daughter that I was an emergency room nurse.
Then I kneeled down and picked up her wrist and found a pulse, which was racing at about 200 beats a minute. As I was holding her wrist and telling her daughter that the EMTs would be along soon, her mother’s pulse started to slow down, got really erratic and then had 3 or 4 very, very slow beats – 5 seconds between each of the last dozen beats – then her heart just stopped altogether. It was a stunning turn of events.
I bent down and put my mouth on hers and started to do rescue breathing, which was the first time I’d ever resuscitated someone outside of a hospital. It was also the first time I used my own mouth instead of a positive pressure mask and ambu-bag. Doing mouth-to-mouth breathing was a shock, because her mouth was so warm and soft and her humanity was so, so ……. intense, so profound. I’d worked in the emergency room for 7 years but never felt this way about my ER patients.
The experience was so uncharacteristically intimate. My mind automatically blotted out the store, and the two kids and all the other people around us the way that dancing or making love to someone makes them so real to you, while everything and everyone else becomes insignificant. I could have been naked and I wouldn’t have noticed because I was so involved and committed to what I was doing. Talking about it still makes me emotional and, I don’t know, kind of nostalgic. It was a very special, one-of-a-kind experience.
Anyway, a man showed up about a minute later and started doing chest compressions. Finally the EMTs arrived and took over. I learned later that she had a heart condition and had just gotten out of the hospital a few days earlier and that she was pronounced dead on arrival at Stanford. After I finished grocery shopping and was checking out, the man who helped do CPR came over to me and in a whisper asked me if he did “OK”. He went on to say he was a psychiatrist and hadn’t done any physical medicine for 20 years and wasn’t sure he knew what to do. I thanked him for helping and assured him that he’s done just fine.
