Stuck in the Mud

INTRODUCTION

Unit 2 is out of service, requesting backup.”

The ambulance call came just as I arrived in our rural emergency department, and I wondered what “out of service” meant for my patient.

“Unit 2, say again,” the dispatcher replied.

“Jim, I’m up to the rims in mud out here. Send out a truck or something.”

Minutes earlier I was sitting at home waiting for the usual phone call. Every couple of hours I’d be called to drive in and see the lineup of non-emergency visits: runny noses, drunks, empty pill bottles. Still, each call night was stressful and unpredictable because of this occasional urgent call from a scared nurse.

“Fifteen-year-old, bleeding pretty bad, don’t know how far along she is; nobody knew she was pregnant.” The nurse stumbled through the presentation. “EMS has gone out but is probably 30 minutes away.”

“Okay; I’ll be right there,” I responded, “and somebody call to see if Nelson is around just in case we need help.”

Dr Nelson retired several years ago. Officially an obstetrician, he was trained in the days when you could do a little of everything, from appendectomies to setting bone fractures. Now the small town was left with family physicians for all deliveries, and it was an hour to the big city for surgical backup. But Nelson was still available if you could find him, out on his horse or down at the old theater.

The obstetric nurse met me in the ER. “I’ve got the fetal monitor here, ampicillin, forceps, whatever you need.” Marilyn was competent and confident. “Should we plan to deliver down here, or do you want to go up to the labor room?” Delivery had never occurred to me, as I thought we were dealing with a first trimester bleed. That’s when the call came in.

“Unit 2 is out of service, requesting backup….”

“You’d better go out there,” Marilyn warned. “They won’t manage this well.”

It took a moment for her words to sink in, proposing that I go out and rescue this girl. Two feet of April snow was melting rapidly, covering everything in thick Montana mud. One ambulance was already stuck, and another with me in it could put us all in deep. But most of all, it was the reservation: hundreds of square miles of littered farms, poor roads, and wasteland. Ten thousand people lived out there, surviving on a little farm income and a lot of government handouts. Some said there were thousands of rifles cached out there, though in 4 years of emergency call I’d never once seen a gunshot wound. Technically our town was on their land, “between the 2 rivers,” as the original treaty acknowledged. But in the past century the town and surrounding ranch land was somehow carved out of what was theirs.

The majority of my patients were Native American, and just a few years earlier I was excited by the opportunity to serve them as I finished residency. Here was a third world country on the outskirts of my wife’s home town, offering me the opportunity to aid the underserved without living in a tent or exposing my kids to exotic infections. Just like the African charity advertisements, I pictured myself lifting children from the muddy squalor, immunizing them, feeding them, and even dancing to the drums of their ancient heritage.

But in 3 years my idealism waned, and my enthusiasm dried up. Hair-spray drunks vomiting blood at 3 am. An insatiable demand for codeine. Baby-bottle tooth decay. Fatherless children of teenaged mothers, adopted by obese diabetic grandmothers. Beer-bottle lacerations a foot long. I was overwhelmed, and my hope in being a savior to the third world nation turned instead to resentment of being there at all. Swamped by everyday medical problems, I could not even begin to deal with the poverty, racial tensions, and poor public health. Nor would my own prejudices allow me to “dance to the drums” and be a part of their culture.

“Hospital emergency, have you got a doctor there?” The radio again.

“Go ahead Randy; what’s up?” I replied.

“Doc, your gal here’s in real trouble,” the police officer said. “There’s a little baby foot coming out of this girl’s … um, groin area.”

“Footling breech,” I said to Marilyn. “Randy, hold that foot in. I’ll be right there.”

I rode in the front of the ambulance so I wouldn’t get dizzy and so I could think. We passed through town on our way to the highway. A dead looking town, I had always told my wife when we visited. It was typical of a farm town that size, with 50-year-old decrepit buildings greeting visitors as they drove through the one stoplight. The Cahoon Hotel, a dilapidated, abandoned brick structure, was now a hotspot for drug deals. Scruffy-looking Native American men hung out there and watched the cars go by. Their seemingly untroubled daily life stood in stark contrast to my urgency and my desire to help their people. Perhaps not unlike the meeting of our cultures 2 centuries ago.

I recalled a paper I wrote in graduate school criticizing the Tribal Council for the alcohol problem on the reservation. Council members should abstain from drink, I asserted, and widely expand the school-based prohibition programs. My public health professor called me in to talk about the paper. “Have you ever taken a course in ‘cultural competence’?” she asked. It was the first time I’d heard the term, but the implication that I was incompetent at something was insulting. She never graded the paper. I passed the class but was frustrated that my term paper received no marks— like an unsigned treaty with uncertain terms.

Darkness set in as the ambulance moved along. The reservation was a treacherous place to drive, even on good paved roads. Horses and cattle roamed freely and often wandered onto the lonely highway. Drunk drivers were common, and pickup cabs were often crammed with 6 or 8 passengers. Snow covered the trash most of the year, but now as spring came on, you could see entire fence lines covered with Dairy Queen cups and grocery bags. I was eager to live and serve there after residency, but more recently I daydreamed of cozy monotonous clinics in the city where my friends worked.

We finally arrived at the scene, a muddy access road with a collection of police waving us down. They led me to a 4-wheel-drive truck and opened the doors. The girl was unclothed, streaked with blood and dirt, lying in fetal position with her legs tightly closed. Despite pain and fear, she remained calm and silent. For 9 months she had been silent, disguising an unwanted pregnancy beneath baggy clothes and feigned illness. We loaded her carefully onto the padded gurney and into the ambulance. I crouched next to her and put my gloved hand between her legs, holding back a footling breech and hoping we’d make it to the hospital before the umbilical cord prolapsed.

Marilyn covered her with 2 blankets, then checked and reassured me that the fetal heart tones were normal. She put an oxygen mask on the girl and then started to massage her back and whisper in her ear. Belinda was her name, the nurse told me. I sat there bewildered, my mind racing with thoughts of what to do in case of hemorrhage. Belinda embodied all that I had come to hate about the reservation: the dearth of preventive medicine, rampant promiscuity and drug abuse, and my own inability to befriend and aid an ailing people. Here was the child that I pictured, needing a nursing father to lift and nourish her. Instead, I had become angry and distant, resenting my ineffective role in the slew of medical crises.

Dr Nelson and a dozen others helped us out of the ambulance and into the labor suite. “Poor girl,” he said to me later. “No support all this time.” He, too, stayed near her head and whispered comfort to her, while I held on and wished that he would assume care at her pelvis.

“It’s just a simple upside-down delivery,” he said when we were all set up. “Here we go now.” He placed my hands on both of the infant legs, emphasizing that it was my procedure to perform. The body was out easily. “Now sweep for the arms,” he said, as he guided me along. Next was the forceps application, a bit trickier in breech than in the few cases of cephalic presentation where I had used them. “And just an easy pull,” he continued. It was effortless in his hands: out came a remarkably healthy baby boy, and with his first cry the room filled with excitement and applause. Still the teenage girl said nothing and had cried neither in joy nor in pain through the entire event.

I never saw her again. In fact, I had never really seen her. We hadn’t spoken to each other at all. The usual doctor-patient bond from sharing this matchless experience was entirely absent, not only with Belinda but with all my Native American patients. There was an ethnic wall I’d never breached despite my initial good intentions. I was supposed to love the people and serve them, just like the altruistic ads that had inspired me during training. Instead, I saw my prejudices for the first time. I felt angry, frustrated, and powerless to resolve the social and medical ills pervading the rural area.

The girl’s grandmother was in my office almost a year later to refill arthritis medications when her own doctor was out of town. After the moment it took me to realize who she was, suddenly the whole incident came flooding over me. She spoke only a few words in broken English, confirming that she was raising the boy as her own. I wanted her to say more. I wanted someone to validate that my work had meaningful purpose, if not to save a nation then at least to help a scattered few. Cultural competence may never be my achievement, but service can not possibly be worthless.

She started to leave, then turned back and smiled, nodding to me. “You came to us,” she said. “You came.”