Leslie. Until then, she had been an anonymous person with medical problems. Even at that early stage of my training, I’d grown far too comfortable categorizing people as organ systems or diseases. Much of it was simply modeling what I saw senior medical students and doctors do. On the chaotic hospital wards, this approach made it easier to keep track of the relevant medical concern while avoiding getting too attached to the patient. Without realizing it, I’d already done that with Leslie.
We walked back into the room. “I can take it from here,” Carla told the other two nurses, who stepped aside. I introduced myself to Leslie, who sat uncomfortably in the bed at a slight incline. The nurses had dressed her in a baggy cloth gown, loosely draped over her abdomen and thighs to offer some privacy. Blue pads had been placed underneath her to absorb the small trickle of blood from her vagina. From what we knew thus far, she had not had any prenatal care. We were the first medical providers she had seen. “Are you the doctor?” Leslie asked me.
“I’m a medical student. I’m going to get things started.”
“I don’t want you touching me down there,” she said, briefly distracted from her pain.
Like other male medical students on the obstetrics and gynecology rotation, I heard this reaction quite often. Even though it bothered me sometimes, I understood their perspective. A stethoscope across a gowned torso surely felt quite different to many women than being fully exposed to the eyes and hands of an unseasoned twenty-something man.
After my assurance that I would not examine her, Leslie agreed to let me ask her a few questions. Meanwhile, Carla made several adjustments to the fetal monitor, but could not pick up a fetal heartbeat. “Get Dr. Garner in here ASAP!” she said to one of the junior nurses.
The urgency in her voice made me feel like I should have been doing something besides asking questions, but that was all I really knew how to do. I started with the most obvious one:
“How far along are you?”
“I ain’t pregnant,” she answered, even as she was grimacing and writhing in intense pain.
My eyes went down to her abdomen, which protruded to the size of a volleyball. I wanted to ask her what else she thought might explain this, but that seemed a futile question. Instead, I focused on her symptoms of bleeding and pain, but the monosyllabic answers she gave between groans provided me with no helpful clues.
Despite her strange denial about being pregnant, Leslie did not seem acutely psychotic or manic like the women I had seen at the psychiatric hospital. So I searched for other explanations for her behavior. “Have you used any drugs recently?” I asked.
“No,” Leslie said without hesitation.
Just to be certain, I then went through a typical list I’d heard other doctors recite: “Marijuana? Heroin? Cocaine? Meth? Pain pills?”
“No, no, no,” she said, once again shaking her head.
She sounded convincing. Then again, she had also denied being pregnant. Either way, my brilliant idea had gone nowhere. “Do you smoke cigarettes or drink alcohol?”
“I had a cigarette a few days ago. But what’s that gotta do with my pain?”
“Okay,” a woman’s harried voice interrupted me. We all looked toward the doorway, where Dr. Garner, my supervising resident, stood. At five-eleven, with short brown hair and broad shoulders, she struck an imposing figure. After introducing herself to Leslie, she turned her attention to Carla. “Let’s type and screen her. She’s going to need two units of blood.”
Dr. Garner did a quick external exam, listening to Leslie’s heart and lungs, feeling her belly, and inspecting her lower legs and feet for any signs of swelling or poor circulation, while simultaneously asking questions that produced no more information than mine had. All the while, Carla continued to adjust the fetal monitor in hopes of finding a heartbeat.
With Carla having no success, Dr. Garner wheeled over the ultrasound machine. She layered a thick gel on the handheld ultrasound probe, then rubbed it across Leslie’s belly, moving it around so quickly that I could not tell what she saw. She was in no mood to slow things down for teaching purposes; her tense energy signaled that there was no time for that. “I think that this might be an abruption,” she said to Carla.
Leslie was unlikely to recognize this word. It was shorthand for placental abruption, a condition in which there is premature separation of the placenta, the vital connection between the mother’s uterus and the growing fetus.
“There’s no sign of trauma,” Dr. Garner said aloud, sounding as if she was going through a mental checklist. “And her blood pressure is normal.”
These were two of the most common risk factors for placental abruption. Dr. Garner refocused on a third one. With a hard look at Leslie, she began to speak. “I can understand why you would want to deny using illegal drugs, but it’s important that I know right now what, if anything, you might have used recently. It can tell us what might be causing this to happen and could possibly save your life, as well as your baby’s.”
Leslie stared at the wall behind us, her face revealing nothing. Dr. Garner pressed on: “My suspicion is that you might have used cocaine. Your symptoms sound like your placenta might have separated from your womb. Cocaine is a known cause of that.”
Leslie shook her head as she continued to groan. Then, to my shock, Dr. Garner abruptly changed her tone. She took a step toward Leslie, and in a harsh voice suddenly demanded: “When is the last time that you smoked crack?”
Leslie looked directly at the doctor. Tears flooded her eyes. “Two … days ago…”
What? I could not believe what I’d just heard—neither the accusation nor the response. I’d never seen a doctor confront a patient that way. But it had worked, and like a typical self-centered medical student, a part of me felt embarrassed that I hadn’t been able to get this same vital information on my own.
Yet Dr. Garner’s approach troubled me. What was it about Leslie that made Dr. Garner so certain she used drugs? And crack in particular? Was it her appearance, her speech, her race? Some combination? Would Dr. Garner have done that to a Duke graduate student, even one whom she suspected might have snorted a few lines? Or to any patient who looked and acted middle class? What did it say about the vastly different ways that patients could be treated? Moreover, if Dr. Garner hadn’t demanded answers, if she’d continued to accept Leslie’s denials as I had, what might have happened?
My head swam with just as many questions about Leslie’s mind-set. Why had she lied to me, and then, at first, to Dr. Garner? Lying made no sense: The nurses had collected a urine sample and surely it would come back positive to contradict her denial. Then again, denying that she knew she was pregnant didn’t make much sense either, so clearly she wasn’t thinking rationally. And smoking crack while pregnant … didn’t everyone know that was bad? Maybe she had to delude herself into believing that she was not pregnant in order to continue using.
Her face flushed with anger, Dr. Garner continued with the ultrasound. She finally got a clear view of the fetus. “It looks to be somewhere around twenty-two weeks,” she said.
She found no sign of fetal movement nor a heartbeat, yet she kept looking, in much the same way that I later saw doctors doggedly continue CPR when they knew that the patient was dead.
Finally, she gave up: “I’m sorry…” she began, as she removed the ultrasound probe from Leslie’s abdomen and looked directly at her, “but your baby has died.”
Leslie’s groaning stopped. She looked up at Carla, then over to Dr. Garner. They each took one of Leslie’s hands into theirs. In response, she began to wail again.
“No … no … my baby … my baby…”
Her moans expressed a profound sadness like nothing I’d ever heard. This young woman had known all along that she was carrying a child. She probably knew that smoking crack while pregnant was dangerous. But she had tragically underestimated the possible consequences.
* * *
At that point in my training, death had made only brief,
detached intrusions into my medical life. The infamous first-year cadaver dissections, taking place as they did in the basement of a research building, with five students hovering over a formaldehyde-preserved body, felt more like a ritual or rite of passage than a true encounter with death. Our autopsy experience later that year—a postmortem examination of an elderly man who had died a few days earlier from a rare vascular disease—came closer to the real thing, but neither the physician (a pathologist) nor any of us students had known the man in life.
I inched closer to experiencing the personal side of death a few months later during my surgical oncology rotation. There, I followed patients with colon, pancreatic, and breast cancers whose long-term prognoses were poor. Even so, surgeon and patient seemed to have negotiated a silent pact never to look too far ahead, as if exploring that territory might get in the way of what could be done in the short term. Some of these patients probably lived for a few years, while others likely died in a matter of weeks; I never knew for certain, as I soon moved on to the next clinical rotation. Not seeing these deaths allowed me to suspend disbelief about their fates.
But Leslie offered no such escape. Her fetus was too young to have survived on its own, and as a result, in purely legal terms, would not have been considered a person at all. Yet Leslie’s piercing cries made clear the emotional stakes: She had lost her child.
After briefly comforting her, Dr. Garner focused on the medical task at hand. While first trimester miscarriages could sometimes take place safely within a woman’s home, the risks of carrying a larger dead fetus—infection and blood clots, among others—necessitated medical intervention. Dr. Garner gave Carla and another nurse medication orders to stimulate Leslie’s contractions while also dilating her cervix. “Call over to L and D and tell them to get everything prepped for an IUFD,” she said.
This acronym likely meant nothing to Leslie, whose deep cries had slowed to a whimper. But to me, calling the labor and delivery unit to prep for an intrauterine fetal demise communicated a clear and terrible message: We were getting ready to deliver a dead baby.
As an assistant nurse wheeled Leslie down the hall of the triage area toward the adjoining labor and delivery suite, we had a few minutes to collect our thoughts. The impact of what we had just seen hit everyone at once.
“This never gets any easier,” Dr. Garner said. “Does it?”
Carla shook her head. “It’s awful. But in a case like this, it’s for the best.”
Dr. Garner agreed and tried to convince me as well. “Even if we could have gotten a heartbeat and then delivered the baby alive, I doubt it would have survived more than a day,” she said to me. “At this early a gestation, it didn’t really have a chance.”
We’d been taught that twenty-four weeks was the cut-off point for a viable pregnancy. We heard about a few cases of live deliveries at twenty-two and twenty-three weeks, but these infants rarely left the hospital alive; when they did, they were profoundly disabled. With that knowledge, I agreed with Carla and Dr. Garner. We were falling back on the familiar “he’s in a better place” or “she’s no longer suffering” clichés that surviving family and friends so often use for comfort after the death of an elderly or sick loved one. Or at least that was what I thought—until Carla kept talking.
“I knew she was a crackhead,” she said. “I knew it. It’s bad enough to ruin your own life, but to do that to your baby? That’s just unforgivable. Even if she had carried this baby to term, it wouldn’t have stood a chance. Like I said, what happened is all for the best.”
My body stiffened. Dr. Garner, who was walking to the nearby sink to wash her hands, said nothing. Carla was voicing the fear and anger that pervaded the 1980s and 1990s: Crack-addicted moms—primarily poor black women—would birth a generation of “crack babies” who would grow up with serious developmental, psychological, and physical ills, strain limited social resources, and perhaps even threaten the safety of our society. It was in this spirit that a nonprofit California-based program in 1997 started paying drug-addicted women $200 if they agreed to use long-acting contraception or be permanently sterilized. This panic was also enmeshed with the politics of the war on drugs and the fight over abortion, most notably when the state of South Carolina enacted a policy in 1989 that brought criminal charges and punishments against women who used cocaine while pregnant. To many people at this time, pregnant women who smoked crack were true villains.
“Do you plan to talk to her about getting her tubes tied today?” Carla asked Dr. Garner.
Dr. Garner frowned. “She’s nineteen. She just lost a pregnancy. That’s probably not the most appropriate conversation to have with her right now.”
Carla would not be deterred. “I disagree,” she shot back. “I don’t think we should take the risk of sending her out to get pregnant again. A few months ago, we had another crackhead here who delivered her fifth kid. All of them are in foster care, and I bet they all have some kind of serious disability. I don’t think people like her should be allowed to get pregnant again.”
Carla’s view had once been official policy in North Carolina and in over thirty other states. Beginning in the early twentieth century, forced sterilization programs typically targeted criminals and those in mental hospitals, but North Carolina expanded its reach to include the poor, many black. All told, more than seven thousand people were officially sterilized under North Carolina’s laws until the practice was abolished in 1974. While the government had repudiated this policy, Carla was not the first or last person I heard who continued to embrace it.
“We talked about that case on M and M [morbidity and mortality] rounds a few weeks ago,” Dr. Garner replied. “That patient was almost forty and probably had CNS [central nervous system] lupus and neurosyphilis. This girl is healthy and still has time to get her life together.”
“You’re still new to this,” Carla said. “You’ll see. These crack people don’t change.”
“Or maybe you’ve been doing this for too long,” Dr. Garner countered, visibly irritated, as she motioned for me to follow her.
Carla said nothing, although her narrowed eyes and clenched jaw suggested she had a good deal more that she wanted to communicate. She had worked in nursing for over two decades, much of it in obstetrics. I had seen how comforting she could be to women and their nervous family members, but as with many of us in medicine, drug addicts seemed to bring out her worst side. I wondered how long she had been so openly cynical and hostile toward drug-abusing pregnant women. More important, had her opinions affected her clinical judgment?
Leslie had come in with painful vaginal bleeding during a second trimester pregnancy; in hindsight, I wonder whether this was an appropriate case for a medical student to begin seeing without a physician present. Had Carla’s negative assumptions about Leslie affected the way she communicated the urgency of the case to Dr. Garner? Would she have allowed potentially precious time to pass with a different patient, or would she have insisted that Dr. Garner, or even a more senior doctor, attend to Leslie immediately to salvage any chance of saving the fetus?
Had race played a role? Carla, a white woman from the Northeast, seemed especially focused on crack, a drug widely known to be used more often by black people. A national survey in the mid-1990s revealed that black women were ten times more likely than white women to use crack during pregnancy. The same survey, however, found that pregnant white women were more likely to abuse alcohol, a substance that can produce its own distinct set of severe problems: fetal alcohol syndrome. Would Carla have reacted the same way if Leslie had been a married, white suburban schoolteacher who drank three glasses of wine every night?
Much of the hysteria surrounding this feared crack-baby epidemic, which ultimately turned out to be more fiction than fact, fed off preexisting negative beliefs about irresponsible black welfare moms draining the system. This seemed to be Carla’s perspective. Yet if accused of racial prejudice or bias, Carla surely would have denied it. Her comfort in voicing he
r opinions around me indicated as much. She had always been pleasant with me, certainly not treating me any worse than my white or Asian colleagues. Nor had I seen her interact with minority nurses or other hospital staff with anything less than appropriate respect.
When it came to Leslie, however, Carla had a different attitude. And she was not alone. Dr. Garner had accused Leslie of drug use in a confrontational manner I have never seen from a doctor before or since. Years later, I would work in both private substance abuse and eating disorder clinics where some of the well-to-do clients were equally self-destructive, but no doctor there would ever have dreamed of being so aggressive. Still, to her credit, Dr. Garner did make an effort to defend Leslie and encourage Carla to see beyond her prejudices.
And, if I had to be honest with myself, I too felt disdain toward Leslie, perhaps on some visceral level, even more powerfully than Carla did. As a crack-abusing pregnant woman, Leslie had put the worst face of black America on full display for this white medical audience. Much of my life had been devoted to combating and defeating vicious racial stereotypes. But in witnessing the pathology of Leslie’s behavior and the doctor’s and nurse’s reaction to it, I suddenly felt naked, as if someone had stripped me of my white coat and left both of us to share the same degrading spotlight.
So, while I thought of many things to say to Carla at that moment, I kept quiet, trailing behind Dr. Garner as we prepared to remove Leslie’s dead fetus.
* * *
Leslie’s room was at the far end of the hall in the labor and delivery area. It was about twice the size of her previous one in the triage wing, large enough to accommodate several medical providers who could tend to the delivering woman and, under normal circumstances, the first minutes of her infant’s life.
Two nurses stood on either side of Leslie, as she stared vacantly from her bed at the overhead television. The local news report showed clips from Duke’s basketball game. Earlier in the evening, watching this matchup had been the highlight of my day; now it held no more interest than looking at a group of random kids shooting hoops at a local park.
Black Man in a White Coat Page 4