Ambulance by Spencer Nadler

AMBULANCE

 

The newly-minted 1970 ambulance was a gleaming red van-like affair that came with an EMT who doubled as our driver; a senior obstetrical resident sat up front beside him. As the siren wailed, and rooftop red and yellow lights flashed with critical authority, I sat alone on a drop-down seat in the back cabin. The ambulance squad was the first rotation of my medical internship and I was as green as the cabin’s interior.

The EMT, a fiftyish black man named Jamal, was short and muscular with a mane of dreadlocks that he tossed back from his forehead with graceful sweeps of his hand. He sped through town with a brazen sense of entitlement, driving the wrong way on one-way streets or bursting through busy intersections. Stanley Pincus, the obstetrical resident, was tall and lean, fragile-seeming, but the jut of his jaw gave him the dogged look of a man who could successfully handle the most intricate deliveries. I never received details of an emergency until we arrived on the scene, but the fact that Pincus was with us on this run likely meant that a woman was having problems in labor and that her baby might be in jeopardy. I’d already seen Pincus in action; he was an obstetrical dervish, his hands dexterous, his technique flawless. If my girlfriend Rachael ever became pregnant—we had no immediate plans for marriage or parenthood—I’d want a maestro like Pincus on hand.

As we stormed through town to the very top of Main Street, I stared at the large back cabin that provided room for doctors to administer to patients. Older ambulances did not have this enhancement. The cabin contained a collapsible gurney fixed in place by a securing device, an arsenal of first aid equipment packed into wall cabinets, a portable resuscitator to restore a patient’s breathing and a new defibrillator to shock an arrested heart back to life. A large oxygen tank with mask attached was clipped to the wall. Although most of the calls I’d attended during my first week were far from urgent—coughs, fevers, minor cuts—we had splinted a few broken bones, tended to a gentleman with serious wounds as best we could and brought to the hospital a few chronically ill patients who were enduring complications.

Most interns requested specific starting rotations—medicine, pediatrics, or obstetrics and gynecology. I chose surgery, and ambulance squad was a part of that rotation. Experiencing an ambulance run was not a popular way of spending time because the learning process was necessarily less structured than other rotations, and the work less predictable from day to day. The intern often went alone on house calls for the sole purpose of pronouncing a person dead. Paramedics could not legally do so in 1970. But you did not complete this rotation without participating in true emergencies where a patient’s life was in danger and doctors were challenged to sustain life until their patient reached the emergency room.

***

Jamal cut the siren as we turned down a sloping road at the outskirts of town and parked in front of an ivy-covered clapboard house. The sunshine had thinned to a hot and humid dusk as the three of us hurried along a flagstone pathway to the front porch. Directly above us, blackening branches of mature oak trees wound their way into each other’s crowns like giant medusas. Pincus gently put his long delicate arm on my shoulder. “Orthodox rabbi lives here,” he said. “Wife’s in labor, and the midwife—she’s a good one—is having trouble with the delivery. Baby is in distress. How many deliveries do you have under your belt, Becker?”

“One,” I said.

“Well, let’s have a look,” Pincus said.

The three of us were ushered through a dimly lit hallway by an angular-faced young woman wearing surgical greens and walking with a limp. “Hello, Dr. Pincus,” she said. “Glad you’re here.”

“What’s going on, Leah?”

“Twenty-eight-year-old mother of two with no previous delivery problems. She’s in labor with ruptured membranes and her contractions are coming on every minute or so now. The baby’s 39 weeks along,” Leah said. The mother lay on her back, on a queen-sized bed, propped up on pillows. A black kerchief was tied around her head and her kiwi eyes were wide with fear. With a rumpled sheet draped over her straddled legs and pulled it up to her neck she looked as if she feared being accosted. A short, wiry rabbi dressed in traditional orthodox garb—dark suit, white open-collared shirt, black top hat—and wearing a black beard and sidelocks, stood beside her. Where visible beneath the black top hat, his hair was cropped to fuzz.

Pincus remained perfectly at ease. He seemed to thrive in medical quandaries. “Leah told Emergency that Baby’s heart rate was slowing during Mother’s contractions,” Pincus whispered to me. As he talked softly, he gently examined the woman’s distended belly and listened to the baby’s heart rate before, during, and after the mother’s contractions. The rabbi began to bow rhythmically in prayer. His eyes were closed and he seemed to be beyond the realm of Pincus’ activities. “Baby’s heart rate is decreasing from 140 to 60 beats per minute during contractions.” Pincus donned latex surgical gloves and covered his right fingers with a liberal amount of lubricant. “I need to insert my hand into your birth canal to feel for the baby’s head and determine how you’re both coming along,” Pincus said to the rabbi’s wife.

The rabbi popped a troubled hazel eye. “Why can’t the midwife do this?”

“If she could, I wouldn’t be here.” Pincus continued to speak softly, calmly, as he continued his urgent assessment. “I’ll try not to hurt you,” he said to the wife, before gently inserting his right hand between her straddled legs and placing his left hand on her stomach.

The rabbi bowed in prayer with increasing frequency, like a boxer evading his adversary’s blows.

Pincus smiled reassuringly. “Any guesses as to what’s going on, Becker?” He spoke through a fixed smile as if he were a ventriloquist and I was his puppet. Perhaps he was trying not to frighten this couple any more than he had to.

A fascination with facts is what had kept me in the top tier of my medical class for four years. Every available brain circuit seemed to hold a biologic verity of some sort, and in those days this deep pool of data, some of it terribly obscure, stayed with me for months, even years. This was not genius—an occult flair for mathematics or physics—but a more modest ability to hoard a mountain of medical information. A single fact remained with me about the unnatural slowing of a baby’s heart rate when its mother was in labor. “Strong contractions of the pregnant uterus can result in unusual pressure on the baby’s head and cause its heart rate to slow,” I said.

“Very good! Too bad you’re going to be a shrink and waste your hard-earned practical knowledge. Anything else?”

I shrugged, aware that I was already losing facts that I had so carefully stockpiled. “Shrink? I’m doing my surgery residency here.”

“Oh. Good,” Pincus said. “What if there is interference with Mother’s blood flow to Baby during contractions? How could that come about?”

“Pressure on the umbilical cord?” I seemed to remember something more about this lifeline’s involvement in a baby’s distress at the time of birth but the pertinent facts would not come to me.

“See? You just needed a little prodding.”

If Pincus was having fun with me, he was also composed and capable. I was fascinated by this baby’s life struggle in utero.

“We have a vertex presentation,” Pincus said as he further examined the mother. “The baby is coming out of the womb head first. I’m feeling around between the wall of the cervix—the tapered entrance to the womb—and the baby’s head.” By carefully defining his terms in ways that prospective parents could understand—womb as opposed to uterus, birth canal rather than vagina, tapered entrance to the womb instead of cervix—Pincus was preventing the alienating effect of medical jargon on his patient and her husband. He silently beckoned me to join him between the mother’s legs as he removed his hands from her vagina. “Put a pair of gloves on,” he said. Then he plied my right hand with lubricant. “Now, you examine this lady and tell me how wide her cervix has opened.”

“Is this really necessary…to be teaching someone while my wife and baby seem to be in danger?” The rabbi’s hirsute face confronted Pincus with apparent angst.

“It’s my job to administer medical help to your wife and baby, and to demonstrate these skills to the physician I supervise,” Pincus said remaining as cool as a mountain spring.

“Excuse me, ma’am,” I said to the wife before extending my right hand hesitantly into her vagina. By feel, I worked my hand to her cervix and gently poked at it until I felt the baby’s emerging head; it felt like a ripe avocado being propelled by the vastly enlarged muscles of a pregnant uterus. I tried to estimate how much the tiny head had distended the cervix as it passed through en route to life beyond the womb. “About 5 centimeters,” I said.

“Good. Gently run your right index finger clockwise around the baby’s head. What do you feel at 4 o’clock?”

At 4 o’clock the pulsating undulation of an umbilical cord was poking through into the birth canal; it felt like a small segment of three-strand rope that had somehow slithered from the womb between the wall of the cervix and the baby’s descending head.

“Umbilical cord.”

“Good. It’s prolapsed, fallen into the birth canal. Without intervention, the cord gets compressed against the cervix by Baby’s head as it descends, stopping the flow of oxygen-laden blood from Mother. Without this oxygen, Baby can die.” Pincus stuck his jaw at me, eyes twinkling, for he had distilled the essence of a complicated and unusual obstetrical problem despite the rabbi’s interruptions.

“Please don’t say that my baby could die,” the rabbi’s wife said, tears welling in her eyes.

“This problem can be handled with relative ease?” Rabbi asked.

“We’re in much better shape now that we know what the problem is, Rabbi. I think we’ll do fine. But we do have to take Mrs. Klein to the hospital. We want to be sure that your baby is delivered safely.”

“Can I take my hand out now?” I said. Having fingered the pathology, I had a strong urge to allow Pincus’ hands to replace mine. I was in way over my head and certainly had no wish to further upset the rabbi and his wife.

“You must keep your hand in if we’re going to safely deliver Baby. Hold the head up high off the cord with your index and middle fingers so that the cord never gets compressed. At the same time you must keep more cord from falling out of the womb into the birth canal.” Pincus kneaded the muscles at the back of his neck. “A cord sitting outside the womb can go into spasm simply because the temperature is too low. A warm temperature is necessary for the proper flow of blood.”

I placed my fingers on Baby’s head and gently pushed it up off the umbilical cord. Then, with some difficulty, I pushed the small segment of protruding cord back into the womb with my pinkie.

“Baby’s heart rate is now holding steady during contractions. You’re doing fine, Becker,” Pincus said.

***

Leah removed her surgical greens and morphed into a shapely young woman with long blond hair. An Ace bandage was wrapped around her right ankle. Staring at me with a level of detachment she likely reserved for unknown interns, she asked the rabbi if she could drive him to the hospital.

“I’m going to give you something to ease your pain and keep you comfortable during the ride in, Mrs. Klein. Okay? Your delivery will be by C-section,” Pincus said. “I’ll be monitoring you and Baby by listening to the baby’s heart rate with a stethoscope, while Dr. Becker here will be monitoring things from below by holding the baby’s head up off the cord until we get you from the ambulance into the hands of the Labor and Delivery Team. We must move now.”

“I want to stay awake in the ambulance,” Sarah Klein said.

“You will,” Pincus assured her as he injected a drug into her left arm. “Jamal, let’s move Mrs. Klein onto the gurney carefully. Becker you must keep your hands properly positioned throughout the ride in.”

Moving Sarah Klein onto the gurney between contractions was no easy matter: Jamal and Pincus slide-lifted her from the center of her bed to the edge. The rabbi’s wife tried to help using her arms as I crouched awkwardly beside her with my right hand fixed in her most intimate place. At the edge of the bed, Pincus had her roll onto the carefully positioned gurney as he and Jamal placed her at its center. She lifted her legs to a straddled position and covered herself completely with an ambulance blanket. This rolling movement nearly dislocated my right shoulder, as I had to hyperextend it to keep my hand in place. When we moved from the bedroom, I was more comfortable walking backwards so that I could see where my arm was in relation to Mrs. Klein’s legs and effectively keep my fingers deep inside her. Together we moved out onto the porch and along the flagstone path, each of us aware of the other’s position.

At the ambulance, Jamal moved a gurney lever and the unit slowly collapsed to the ground. He opened the double doors at the back and, with Pincus, lifted Mrs. Klein and the gurney beneath her up through the cabin doors onto the ambulance floor. I jumped up in synch with Mrs. Klein and kneeled beside her, trying to safely readjust my position for the ride in. My fingers were relaxed and slightly bent, as their tips gently nudged Baby’s head upward, keeping the cord free from pressure.

“Keep your knees on the floor at Mrs. Klein’s right, and your right elbow between her thighs,” Pincus said to me. “Get comfortable so you can maintain balance and leverage.”

I smiled at Mrs. Klein as we were in very close proximity, and she weakly smiled back. “You’re doing fine, Mrs. Klein,” I said, trying to reassure her.

“Enough talk. Keep focused on the cord and Baby’s head,” Pincus said.

“Do I have to keep the head up when the uterus isn’t contracting?” I asked Pincus thinking that I might have periodic respites.

“Hold that head up all the way to the hospital. And keep as much cord as you can in the womb.”

Just as I thought I had gotten into a satisfactory position beside a mildly sedated Sarah Klein, the sirens roared, the roof lights flashed, and our speed increased uncomfortably. Braced against a bare metal floor, I felt each pothole, swerve, and jumped curb. I couldn’t see Jamal, but I imagined the eerie grin across his face, and his frenetic sense of purpose. Pincus had secured himself on the drop-down seat, which was low enough for him to monitor both the mother and the baby from above with his stethoscope. I was the man on the rigid bottom.

“You supporting Baby’s head?” Pincus asked.

In the midst of my bumpy torment, high humidity and claustrophobia, I tried to concentrate on the problem at hand. “Got my fingers on it,” I said.

“Your index and middle fingers near the center of Baby’s head are enough to do the job. If you then twist or roll your wrist slightly toward 4 o’clock, you can block the cord from slipping through.” Pincus stopped talking long enough to listen to the baby’s heart. “Imagine your fingers moving with the strength and delicacy of a concert pianist.” He gently placed an oxygen mask on Mrs. Klein’s anxious face.

“The oxygen will make it easier for you to breathe, Mrs. Klein,” I said.

“Keep your focus, Becker.”

Easy for Pincus to say, as he sat on the drop-down seat in relative comfort. My back, shoulders and right arm muscles were beginning to cramp, and my awkwardly positioned right hand to feel numb. My fingers had all they could do to maintain the baby’s head aloft. I prayed to God—an unusual intimacy for me—that the umbilical cord would not fall from its womb. “Are there some pillows or a mat I could use for cushioning? The metal floor is pounding the hell out of me.”

“We’ll be there before you know it.”

Within minutes my fingers seemed lifeless, but I relentlessly held the baby’s head high. It felt as though I was on the last few miles of a marathon; I would not give up. “Is there any possible way you can relieve me under here?” I said as I began to feel lightheaded.

“Oh. Come on, now. Suck it up!” Pincus said as he grabbed the dual frequency VHF radio that Jamal had shoved through the opening between cabins. He began communicating with the dispatcher.

“We have a prolapsed umbilical cord here. We’re going to bypass Emergency and go directly to Labor and Delivery for a C-section. Put me though to Sonia.”

While Pincus was about to deliver his standby instructions to the head nurse in Labor and Delivery, it was as if Carmenta, goddess of childbirth, had briefly lost sway: Sarah Klein coughed and loops of umbilical cord slipped past my desperate fingers into the birth canal, where they hung like gallows rope. Although I continued to keep the baby’s head high, my hand was powerless to shove its dangling lifeline back into the womb.

“Cord’s out,” I shouted, my head pounding.

“Just keep the head up. We’ll be all right.” Pincus sat poised like a coach whose superior team had filled him with moxie. “Sonia? We’re five minutes away with a cord prolapse. Want everyone scrubbed and ready when we get there, instruments out on trays.” He held the VHF radio in his hand like an apple he was about to bite into. “Need the anesthesiologist sitting at his machine with his drugs drawn, ready to give general anesthesia. No time for an epidural. And have the neonatologist there with all her life-saving goodies.”

Then Pincus turned his attention to me. “We’re minutes from the hospital now and we have about ten minutes to get this baby delivered.”

“Or what?” Sarah Klein cried. “My baby’s going to die?”

“We’ll be fine, Mrs. Klein,” Pincus said. “We’ll be fine.”

I too wanted to be more reassuring, but I was in no position to do so. As I twisted my body slowly to relieve muscle cramps, I realized that I was soaking in sweat. I glanced up. Pincus’ smile spread above his jutting jaw like a distant horizon. His skin was pink and dry. He enjoyed creating order out of the medical chaos of emergencies.

Jamal surged into high gear and the road seemed to wobble beneath us. Loops of cord ominously bounced against the back of my hand, floating freely.

“Catch onto the cord with your ring and little fingers and let me know if you feel any pulsations in it.”

I wrapped my two free fingers around a portion of the flailing cord.

“Pulsations?”

“Yeah.” Blood pulsing through the vessels in the cord felt like a second heart beating inside me. It was miraculous—despite all that was going wrong—that cord blood continued to pass oxygen to the baby.

“Let’s time them. Say ‘pulse’ each time you feel one.”

“Pulse… Pulse… Pulse…” I said, as Pincus scrutinized his wristwatch.

“Twenty beats per minute. Far too slow. Confirms pressure on the cord.”

“We’re here,” Jamal shouted. In his mad rush, he drove the ambulance over the final steep curb and dropped back onto the asphalt driveway that led into Emergency. My body absorbed its final blow. As the ambulance skidded to a stop, our sinewy driver cut the engine, flung open the back cabin doors and out we all came as smoothly as we had entered. I came out backwards, of course, moving as stiffly as an automaton, my fingers still lifting the baby’s head. Thinking that I was about to be relieved of my stressful duty by some good soul the moment we entered the hospital, I moved gamely in synch with my team.

***

The large open ER had a high-beamed, partially glassed ceiling that reminded me of a train station. Nurses, doctors, and assistants all dressed in surgical greens, were scurrying about attending to dozens of patients with varying injuries and illnesses. With the help of two nursing assistants, we moved directly to the elevators at the far left of the entrance. I knew then that my hand would be the only one elevating the head until the baby was removed at C-section. A wave of disappointment rolled over me, but I held my numb and tingling fingers in the cervix, still pushing against nature’s laboring forces.

A medical school classmate, David Krystal, on his internal medicine rotation, was standing in the elevator when we entered. He looked at me strangely, peculiarly attached as I was to my pregnant patient.

“How ya doin, Bernie?” He was a tall knot of muscles, and his thick brown hair was slicked back.

“Fine, David.”

“Just watched an autopsy on a patient of mine who died earlier this afternoon. Leukemia.”

Our lady, alert to conversation around her, began whimpering after David Krystal had spoken. Pincus put a finger on his lips and pointed his mouth in Krystal’s direction.

“You on Obstetrics? Thought you were on ambulance squad, Bernie.”

“He is on ambulance squad.” Pincus lost his cool for the first time. “We need complete quiet here. Okay, Krystal?”

“Oh. Okay.” David said. “I was only trying to make conversation and…”

Pincus’ jutting jaw and angry eyes brought David’s prattle to a halt. We moved out quickly into a Labor and Delivery room on the second floor. A blurry sea of green—gowned, capped, masked, and shoe-covered operating room people—received us. Multiple arms and hands lifted Sarah Klein onto the operating room table, and I went along with her, intimate as a lover. “Way to hang in there, Dr. Becker,” someone shouted. “We’ll set you free shortly! For now, we’re covering you with sterile drapes so you don’t contaminate the surgical field. Stay between Mrs. Klein’s legs and keep the baby’s head off the cord until we tell you to take your hand out.”

I foundered between Sarah Klein’s legs, exhausted by stress, muscle cramps and confinement, and drenched in sweat. It was as though all of me was attached to my critical head-holding fingers. In complete darkness beneath the drapes, I felt helplessly out of sight, covered over by the daily business of obstetrics. I could barely make out the rapid-fire discourse and commotion above me. I saw the bottoms of green surgical pants and shoe-covers randomly moving about, and felt the cold tile floor beneath me.

Suddenly, the baby’s head lifted from my fingers and someone called my name. “You’re off the hook, Dr. Becker. Ease your way along the floor to the wall behind you, then to the exit door. You can watch us from there.”

By the time I crawled out from under the drapes and stood by the closed operating room door, the baby boy was lying on his back on a small table in the hands of a neonatologist. She was trying to resuscitate him; the labor had been long and difficult, and he seemed as still and silent as death. As I watched this lifeless infant being worked over, my own breathing became slow and shallow.

Suddenly the infant howled, a deep-seated, urgent cry. There was a collective sigh of relief. Pincus turned to me and winked. At least, I think he did. A nurse signaled me with a flick of her head to follow as she exited the operating room. She removed her mask and cap; red pressure lines marred her pretty face. “Come with me,” she said, conspiratorially. She led me to a small office and made us coffee. We talked about the miracle we had witnessed. It was the first time since entering medical school four years earlier that I had helped save a life.

As I walked down the hallway toward the surgeon’s lounge, Rabbi Klein stepped up behind me, his prayer book tucked under his arm. He held my right hand circumspectly, shook it slowly as if assessing the flesh and bone that had aided in the birth of his son. “You’re a fine young man, Dr. Becker.” He paused. “I’m sorry I can’t say the same for your partner Pincus.”

“He’s a devoted doctor, Rabbi.”

“Don’t make excuses for him, Dr. Becker. He doesn’t care about his patients,” Reuven Klein said, his voice rising. “A doctor either has compassion or he does not, and Pincus does not.”

Was his facial appearance one of anger or overwhelming disdain? It was difficult to assess the nuances of his expression when so much of his face was covered with hair. “It’s his bearing, a posture many surgeons have,” I countered. “Let’s be happy that Dr. Pincus saved your baby.”

The rabbi shivered as though his bones were grating in their joints. “What we saw today was God’s doing, young man; you and Pincus were merely his instruments.”

“Nevertheless, Pincus had to concentrate on what he was doing,” I said. “That shouldn’t be regarded as a lack of caring.”

“How do you know such a thing? And his teasing you, belittling you, was a part of his concentration and his caring?” Rabbi said. “Why do you defend this man anyway? He’s certainly not someone you should look up to.”

“I’ve just finished medical school, Rabbi. My head is full of facts but I haven’t yet learned how to be a doctor, how to treat illness with skill. I respect Pincus for his ability to do so.”

“Aha. You must also treat illness with compassion, Dr. Becker. This too is an important part of the healing process.”

It was not my place to argue.

“Our tradition teaches us not to hold a grudge. I‘ve already forgiven Pincus.” His voice softened, and his manner was less intense. When I looked into his eyes, their black opacity had lightened to shards of green and yellow. “I’m a new father, Dr. Becker. There is a bris to be planned.” The edges of his mouth elevated slightly, like a smile. “I must go.”

He turned and began to walk down the corridor with fairy-tale swiftness when he suddenly stopped and walked back to me. “Dr. Becker. You’re not married yet are you?”

“Oh, no. It’s hard to be an intern and have a social life.”

“Good.” He rubbed his hands together as if to warm them. Come to our house tomorrow for Friday night dinner. My sister-in-law will be cooking Shabbos dinner so my wife can rest. Miriam’s not yet married. I’d like you two to meet. I think you’ll be right for each other.”

“OK.”

“Good. Here’s my card. You already know the house.” Then he found a picture of his wife Sarah and her sister Miriam, two faces smiling beautifully into the camera. He shook my hand again and scurried down the hallway before entering the nondenominational chapel at the far end. I followed him and peered through the large glass window. He stood next to a teak shelf covered with Origami cranes where patients and their families had written their hopes and urgent pleas. After reading some of these somber notes, he opened his prayer book and bending from the waist quickly became absorbed in prayer.

***

On Friday night, dressed in my best suit, I drove to Rabbi and Sarah Klein’s home for Shabbos dinner. Miriam had already come alive for me—I pictured her slim yet curvaceous body, pretty face, soft voice, and a heart full of compassion and understanding. In her, I envisioned my life to be.

I placed my trembling fingers—saviors of a baby boy—on the bell, and pushed.

 

The End