As a physician-in-training in the late 1970s, I rotated among a variety of inner-city public hospitals, honing clinical skills with patients who were grateful to have someone, anyone, care enough to take care of them.

There were plenty of street people who needed to be deloused before the “real” doctors would touch them, and there were the alcoholic diabetics whose gangrenous toes would self-amputate as I removed stinking socks. There were people with gun shot wounds and stabbings who had police officers posted at their doors, and rape victims who were beaten and poisoned into submission and silence. Someone needed to touch them with compassion when their need was great.

As a 25-year-old idealistic student, I really believed I could make a difference in the six weeks I spent in any particular hospital rotation. That proved far too grandiose and unrealistic; yet there were times I did make a difference, sometimes not at all positive, in the few minutes I spent with a patient.

As part of the training process, mistakes were inevitable. Lungs collapsed when putting in central lines, medications administered caused anaphylactic shock, pain, and bleeding from spinal taps—each error created a memory that would never allow such a mistake to occur again. It is the price of training a new doctor, and the patient always—always—paid the price.

On my last night finishing my six-week obstetrical rotation at a large military hospital that served an army base,  my supervising resident physician and the nurses had kept me busy trying to get me to the *100* delivery mark as a point of pride and bragging rights during my time with them. I had already followed and delivered babies for four women that night and had fallen into bed at 3 AM in the on-call room, hoping for two hours of sleep before getting up to go home.  Delivering 99 babies over six weeks sounded like enough to me.

I was shaken awake at 4:30 AM by a nurse saying I was needed right away. An 18-year-old woman had arrived in labor only 30 minutes before, and though it was her first baby, she was pushing and ready to deliver. My 100th had arrived. The delivery room lights were blinding; I was barely coherent when I greeted these almost-parents as she pushed, with the baby’s head crowning. The nurses were bustling about doing all the preparation for the delivery, setting up heat lamps over the bassinet, getting the specimen pan for the placenta and suture materials for the episiotomy ready.  I noticed there were no doctors in the room so I asked where my supervising resident physician was.

Still in bed? Time to get him up! Delivery was imminent.

By this time, after 99 deliveries, I knew the drill. Gown up, gloves on, sit between her propped up legs, stretch the vulva around the crowning head, thinning and stretching it with massaging fingers to try to avoid tears. I injected anesthetic into the perineum and with scissors cut the episiotomy to allow more room, a truly unnecessary but standard procedure in all too many deliveries at the time. Amniotic fluid and blood dribbled out and splashed on my shoes and its sweet salty smell permeated everything. I was concentrating so hard on doing every step correctly, I didn’t notice whether the baby’s heartbeat was being monitored with the doppler machine, or whether my resident had come into the room yet or not. The head crowned, and as I sucked out the baby’s mouth, I thought its skin color looked dusky, so I checked quickly for a cord around the neck, thinking it may be tight and compromising. No cord was found, so the next push brought the baby out into my lap.

Bluish purple, floppy, not responding, not breathing, nothing.

Quickly clamping and cutting the cord, I rubbed the baby vigorously with a towel. Nothing, no response. A nurse swept in and grabbed the baby and ran over to the pediatric heat lamp and bed and started resuscitation. Chaos ensued. The mother and father began to cry, the pediatric and obstetrical residents came running, hair askew, eyes still sleepy, but suddenly shocked awake with the sight of a cyanotic unmoving baby.

I sat stunned. I tried to review in my foggy mind what had gone wrong and realized at no time had I heard this baby’s heartbeat from the time I entered the room. The nurses started answering questions fired at me by the residents, and no one could remember listening to the baby after the first check when they had arrived in active labor 30 minutes earlier. The heartbeat was fine then, and because things happened quickly, it had not been checked again.

It was no excuse, and it was completely unacceptable medical care. It was a terrible, terrible error. This baby had died sometime in the previous 30 minutes. It was not apparent what happened until the placenta was delivered and it appeared it was partially abrupted—prematurely separated from the uterine wall so the circulation to the baby had been compromised. Potentially, with continuous fetal monitoring from the moment this mother walked in the door, this would have been detected and the baby delivered in an emergency C section in time. Or perhaps not. The pediatric resident worked for another 20 minutes on the little lifeless body.

Later, in another room, as part of my training, this young doctor insisted I practice intubating the baby’s body so I’d know how to do it on something other than a mannequin. I couldn’t see the vocal cords through my tears but did what I was told, as I always did. In the delivery room, the parents held each other, sobbing, while I sewed up the episiotomy in silence. I had no idea what to say and was mortified to be complicit in their tragedy.

So I told them I was so sorry, so sad they lost their baby, felt so badly there had been no way to know sooner. There was nothing I could say that could possibly comfort them or relieve their horrible loss.

When I left them, my obstetrical rotation was completed.  I changed clothes to go home, gathered up my things, and walked out into a sunny day that appeared absolutely ordinary, yet nothing was the same: not for me, not for the parents, and not for a baby who almost-was but not-quite.

I never told anyone what had happened; I was so ashamed of the part I had played. It settled deep in a hidden box in my heart, unconfessed yet always festering.

As a family physician, I went on to deliver hundreds of babies during my career but could never forget the baby that might have had a chance. If all had been different that day, this baby would now be in his 40s with children of his own, his parents now proud and loving grandparents.

I wonder if I’ll meet him again someday, this little soul that almost was, if I’m ever forgiven enough to share a piece of heaven with innocent babies who never were able to draw a breath.

Then, just maybe then, God’s mercy will feel real as I confess my sorrow and regret. Only those who know such guilt laid bare can understand such grace freely given.

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