“Where’s she at?” Dr. Leucke said.
“Um,” I said, “about eight.”
“All right,” he said. “All right.” I had no idea if I was right. I was guessing she was dilated to eight centimeters, just because I could tell she was pretty close. But actually, I had no idea.
I didn’t have time to stop feeling nervous before the woman started pushing. The nurse stood by her head, encouraging her. “Okay, Rachel,” Dr. Leucke said. “You just stand here by me, and catch him like a football.”
“Like a football?” I asked. We didn’t have a football team in Port Aransas.
“Yeah, just catch him with your whole body and cradle him. Babies are slippery. You don’t want to drop him.”
So that’s what I did. The mother gave a loud yell, and suddenly the baby’s head popped right out of the mom’s vagina. Just the head. It was surreal and for one stunned moment I thought, Oh my god, that’s a human head.
Then I remembered that of course, of course it was supposed to be there. Dr. Leucke guided the baby’s shoulders out, and all at once the boy slithered into my arms, bloody and wet and hot from the inside of his mother’s body. He was, for that moment, the most brand new human being in all the world.
“Good job, mama,” the nurse said. I was staring down at the baby. He was red and wrinkled and angry, and as soon as Dr. Leucke took him from me, he began to cry.
“Go ahead and clamp that cord,” Dr. Leucke said. He showed me where to clamp it. “Usually, we have the dad cut it, but he’s not here. She’s up from Mexico. You go ahead and cut the cord, Rachel.”
So I did. I cut the cord, and then held it taut as the woman’s uterus clamped down to deliver the placenta. Finally, with a gush of bright blood, the placenta slithered out. It was purple and it reminded me of a big jellyfish washed up on the beach. People eat these things, I thought, looking at it. Then I watched as the baby was weighed, checked over quickly, and handed to his mother. He was absolutely perfect, and she smiled and lay back on her pillow.
We pulled off our bloody smocks, said congratulations to the mother, and headed out. “Go get some sleep, Rachel,” Dr. Leucke said. “I’ll see you back here at eight.”
“I DELIVERED MY FIRST BABY LAST NIGHT,” I told Margaret over coffee a couple of hours later.
“Was it so, so beautiful?” she asked.
“Sure,” I said. “It was beautiful. But I was terrified. And I fucked up trying to check her.”
“Mmm, that’s okay,” Margaret said. “Normal. Did you catch it?”
“Him,” I said. “Yeah.”
“Nice! How was the delivery?”
“It was pretty old-school,” I said. “I think.”
“Oh yeah?” Margaret asked.
“Yeah, like, the woman on her back in stirrups instead of walking around or squatting or whatever. We cut the cord immediately, and then the baby was weighed and stuff before he was handed to his mother.”
“Old-school for sure,” Margaret said.
I finished my coffee and headed back to the hospital to meet Dr. Leucke. I was excited to see the baby, but he was gone. “He had a little cough, maybe a touch of pneumonia,” Dr. Leucke explained. “So we sent him out to Odessa.”
The mortified flush that I had felt when I messed up the woman’s genital exam rushed through me again, only this time it wasn’t just about me messing up, or about the woman being violated during labor.
This time, it was about the baby. Pneumonia in a newborn is usually caused by E. coli. The E. coli could have been introduced by my glove, during the vaginal exam I messed up. I had touched the anus, rushed through washing my glove, and plunged my hand back into the birth canal. I felt sick, like this tiny baby’s pneumonia was entirely my fault. I had caused it by trying to do what I was told instead of confessing to the fact that I had no idea what I was doing.
Worst of all, the exam I had done was entirely for practice—it offered no benefit to the mother. And she, being in the middle of labor, being a Spanish-speaking woman delivering in a foreign country—well, she really had no way to refuse.
My very first baby was in an ICU in Odessa, getting antibiotics dripped into his blood and oxygen blown into his face instead of lying in his mother’s arms. And it was pretty much my fault.
A few days later, Dr. Leucke let me know that the baby had recovered just fine and was on his way home. I breathed a sigh of relief, but I vowed not to forget my lesson. If I didn’t confess to my own ignorance on the wards, I could be putting my patients in danger.
THE NEXT DELIVERY I SAW was an emergency cesarean section. This time, it happened during the day. I was working with the other doc in town, Dr. Billings, at his office near the Alpine hospital. We were in the middle of scraping a suspicious bump of skin off a farmhand’s back when a nurse poked her head into the room. “The hospital needs you now, Dr. Billings,” she said.
Dr. Billings and I wrapped up the procedure and hopped in his Jeep to go to the hospital. He joked that he could use a flashing light on top, but in the meantime I could roll down my window and make a siren noise. “Cops don’t really stop you anymore around here once they know you’re the doctor,” he explained, “but I like to let people know when it’s really an emergency.”
That seemed fair enough. Last week, Dr. Leucke had told me a story about driving ninety-five miles an hour from Fort Davis to Alpine for an emergency delivery. The local cops knew him, too, but apparently Dr. Leucke whizzed right past a state trooper who didn’t recognize his car. The trooper started chasing him, and by the time they got close to Alpine they had set up a roadblock to stop the doctor. “I made it to the delivery, though,” Dr. Leucke said. “That kid is on the football team now.”
Dr. Billings and I rushed into the hospital and straight to the operating room. “Have you assisted on a C-section before?” he asked me as we headed in.
“Um, no,” I said.
“But you did surgery, so you have some idea what to do?”
“Yes sir,” I said.
“Okay, change and meet me in there,” he said. “We’ll scrub up once she’s anesthetized.”
The operating room was in the very center of the small hospital. It was so quiet and contained in there that it felt like a church. I changed into a pair of scrubs and found Dr. Billings already in the OR. The nurse anesthetist nodded to me, and I went to meet the patient. She was calm, and young, and sitting up. Her face looked open and trusting, even as the pain of labor washed across it with each long contraction. She pointed to her chest and said her name, “Maria Dolores.”
Maria Dolores, I thought. The suffering of Mary.
“Soy Rachel,” I said. “La estudiante de medicine trabajando con Dr. Billings” [I’m Rachel, the medical student working with Dr. Billings]. She nodded, and her eyes moved back down to her belly. Dr. Billings gently moved her to the side of the bed, and had her sit up so the anesthetist could put a needle in her back for spinal anesthesia. Spinal anesthesia is similar to an epidural, but it works faster and doesn’t last as long, so we often use it rather than epidurals for cesarean sections. You would give an epidural to control pain throughout a labor that could last many hours, whereas a spinal is good for rapid anesthesia in surgery.
The lights in the operating room were all dim, except for one bright light shining down over Maria Dolores. Her legs dangled over the side of the operating table; her feet were small and bare. Dr. Billings stood in front of her to steady her as the nurse anesthetist prepared to put the needle in her spine. He placed his arms around her so that the light fell on his arms and shoulders, and she leaned forward so that the side of her face rested against his chest. All was quiet, and then I could hear Dr. Billings praying over her as the needle slid in.
When Maria Dolores was lying on her back on the operating table, Dr. Billings and I stepped out to scrub. “She’s had a C-section before,” he explained to me. “And she was going to try to deliver vaginally, but the baby’s heart monitor started showing s
udden, extreme decelerations. So we’re doing this stat. We’re going to cut right down her belly instead of across. You’ll see the difference when you do your ob-gyn rotation. A scheduled C-section uses a low transverse cut. This is a stat. It’s different.”
Back in the operating room, the moment of quiet before the surgery was over. We stepped in and began moving very quickly. The nurses had poured Betadine all over Maria Dolores’s belly, and Dr. Billings made a long cut and then we both put our hands in the edges of the cut to tear it wider. Blood spilled out the edges of the cut, over the side of the operating table and onto the floor.
“Look at that, look at that, Rachel,” Dr. Billings said when we were inside. Instead of the thick muscular wall of the uterus that I expected to see underneath the skin of her belly, there was only a thin membrane. I could see the hair of the baby’s head just underneath.
“She already perfed,” Dr. Billings said. That is, Maria Dolores’s uterus had broken open from the force of her contractions, probably along the line where her uterus had been cut before. “If this had taken five minutes longer,” he said, and didn’t finish. The tissue-thin amniotic membrane was the only thing keeping this baby from floating free in her mother’s abdomen.
Dr. Billings carefully opened the amniotic membrane and began to maneuver the baby out. “It’s a girl!” he said. “She’s breathing!” And as soon as he had said it, miraculously, the baby girl began to cry. A minute later, I was crying, too. Some things in medicine really are miraculous; there’s no other word.
THE NEXT SATURDAY I was back with Dr. Leucke for his monthly trip out to the free clinic in Candelaria. This clinic is funded entirely by donations from the Lutheran church, in which Dr. Leucke is an elder. It doesn’t take much once the doctor volunteers his time—a few hundred dollars a month for basic antibiotics and other medicines, supplies, and the cost of lab tests. Plus toys for the local kids. Dr. Leucke transports the clinic supplies in big Tupperware boxes in the back of his SUV.
Candelaria is a colonia—one of the border towns so poor and so isolated that they don’t even have city services. We drove through the desert for an hour and a half, first through the mountain pass and then through Presidio, the American town across the river from Ojinaga. Ojinaga has somewhere between twenty thousand and seventy thousand inhabitants—nobody seems to know for sure. But there’s a hospital there. In Presidio, there are only clinics. Presidio also has a dusty grocery store, a lot of rusting cars, and the shotgun shacks surrounded by barbed wire where the Border Patrol workers live. They look like the FEMA houses in Galveston, and may have been built by the same people.
After Presidio, we turned north to follow the path of the river toward Candelaria. The road was paved until we got within a few miles, and then it became a dirt track. Candelaria was just a cluster of houses along a few dirt roads beside the river. “The kids here take the school bus into Presidio,” Dr. Leucke said. “It’s two and a half hours on the bus every day. You want groceries, you want batteries, you want a pair of socks . . . Presidio.”
Kids ran up to the SUV when Dr. Leucke pulled up next to a small adobe church. He hopped out and started saying hello to them and handing around toys—mostly bright, bouncy balls. “I delivered half these kids,” he told me. The kids scattered and began chasing one another around in the sunshine, scattering up dust.
We walked into the church, which was cool and dim. People were waiting for us in there—three or four moms with little kids, an elderly couple, and a few younger people on their own. “Hola, doctor,” a woman called out. Dr. Leucke said hello, introduced me, and we set to work.
We set up the clinic inside the church itself, in a chapel that had been converted into an exam room thanks to a donated bed. Christ on the cross watched everything we did—a particularly gory Christ, I thought, with blood painted down the sides of his face. Dr. Leucke set up for a while on one end of the church’s nave so that I could do pap smears on the exam bed in the chapel. They all went smoothly. I put the samples in a little cooler to be taken back to Alpine for analysis, and let the women know that we would have their results next month. I felt bad for them—waiting on pap smear results is stressful. It would be hard to wait a whole month.
In this incredibly resource-poor setting, we practiced in a different way. Kids who had viral illnesses would sometimes get antibiotics. Dr. Leucke would have me explain to their moms in Spanish: “Don’t give him the antibiotics yet. You only need them if he isn’t getting better by Wednesday. If he still has fever, or he’s getting worse, then he can start taking the antibiotics.” The pills were meant to cover for the possibility of a bacterial infection developing. Next week, the nearest doctor would be in Presidio, and he’d only be there Tuesday and Thursday. So, if a kid started to go downhill, Dr. Leucke wanted them to have antibiotics on hand already. We would also give the moms bottles of ibuprofen for fever, and sometimes cough syrup.
Patients kept coming all afternoon. Half were from Candelaria, and half had waded across the river from the little Mexican town there. Everyone spoke Spanish, and only the junior high and high school–age kids spoke English. It wasn’t just viral illnesses, either—one kid was a cancer survivor, one woman had a rare lung disease that Dr. Leucke had caught, and some of the elderly people were pretty frail.
Late in the afternoon, we ran out of antibiotics. There was just one more family to see—a mother and two kids who had come over to the clinic from Mexico. The mom explained that her kids were sick—feverish and shaking, with sore throats.
“Okay, let’s have a look,” Dr. Leucke said. And sure enough, both the two-year-old and the five-year-old looked bad. You know a two-year-old is sick when he doesn’t even try to fight you putting your otoscope in his ear. His ears were clear, but I saw white patches all over his tonsils. He was feverish at 102 degrees, and I also felt small, hard, swollen lymph nodes down the sides of his neck.
“I think he has strep throat,” I told Dr. Leucke. Dr. Leucke nodded. The five-year-old had it, too.
“I wish we still had some amoxicillin,” Dr. Leucke said. “These kids are really sick.”
Strep throat is not exactly a medical emergency, but it has to be treated. In the days before penicillin was widely available, strep throat killed a lot of people. If left untreated, it can lead to rheumatic fever, and rheumatic heart disease, and early death. The use of penicillin and related antibiotics to treat strep infections is one of the simple, cheap cures of which medicine should be most proud. But at this moment, in this improvised clinic in an adobe church on the Mexico border, we were out of amoxicillin.
I expected Dr. Leucke to do something bold at this moment—to load the kids in his car to take them to Presidio, or to tell the mom she needed to get them to Ojinaga urgently for antibiotics. But he didn’t. He comforted the mother, gave her Tylenol to keep the kids’ fevers down, and sent them on their way. He let her know that it was a bacterial infection, but we were out of antibiotics. If she could make the trip to Ojinaga, she should. She nodded and thanked us, but her brow was furrowed with worry.
We broke down the clinic and loaded it back into the SUV after they left, then we drove home slowly on the unpaved mountain road, past the Chinati Hot Springs. The sun set over Big Bend, bathing the mountains in pink and orange. Dr. Leucke and I were quiet.
“I wish we hadn’t run out of antibiotics,” he finally said. “Those last two were really sick.”
Back at the mansion that night, I thought of those two kids shivering and sweating in their house across the river. I looked up the incidence of rheumatic fever in kids with untreated strep throat. How many would get that condition, which would limit and likely shorten their lives? The answer was 3–5 percent. But would those kids get it? Would they make it to Ojinaga? I’d never know.
Dr. Leucke’s little free clinic on the border was miraculously cheap, and it was okay medicine: we caught some things, treated some things, did some screening tests. But it was not the best medicine, and I felt t
hat these people, who were so poor, really needed the best. What if the presence of the monthly free clinic kept them from going into Presidio or Ojinaga, where they could get better care?
I had heard similar arguments made about St. Vincent’s: some people think free clinics are altogether a bad idea, that we are a stopgap measure designed to help medical professionals feel better about injustice in medicine. My friend Merle called St. Vincent’s “a moral safety valve”—the fact that it existed allowed UTMB employees to keep practicing in an unjust system without our anger or frustration boiling over, because it made us feel like we were doing some good even inside a broken system. Merle worries that free clinics don’t really help the community as much as they help students (who need the training) and providers (who need to feel like we are moral people, donating our expertise for charity).
In Galveston, though, there was always the counterargument: There was no other option for most of our patients. Even with the help of St. Vincent’s, some would die of treatable diseases. It would be cruel to abandon them completely, when I had no real faith that the system would step in to pick up the slack.
I tossed and turned in bed that night, thinking these questions over. Was second-rate care better than no care at all? What would it feel like to place your life in the hands of students, or of charity? I thought of the laboring mother from Mexico who had birthed her boy here, in the country with the most technologically sophisticated medical system in the world, only to have him sent to Odessa with pneumonia because of a medical student’s nervous stupidity. She was probably sitting by his crib now, in a dark NICU room shepherded by machines, listening to each fragile breath. I wished I could sit with her a while, so that I, too, could reassure myself that the boy was still breathing. So that I could say I was sorry.
Then I thought of the other mother, who had waited on the pew of an adobe church with two boys shivering from fever. We had let her cross the river again with only Tylenol to treat them. Any of those boys could die—soon, or later.
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