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Observations of an OB-GYN Resident---- 1963 to 1966
Charles R.
Oberst, M.D.
There are many residents who have finished this program and esach has their story to tell. These are my memories- from 40 years ago- some faded and yet some still quite vivid. These are not all of my memories, but some are best left unsaid. All of my stories are personal. Louisville General Hospital (1914-1983) Our wards, 4A and 4E at the Louisville General Hospital, were at opposite ends of the fourth floor. These housed the female surgical patients. They were large wards, with approximately 40 to 44 patients. There were 18 to 20 beds on each side with four to five patients on the sun porch. Each bed had a chair and a drawn curtain between it and the next bed. The post partum floor was 3B. Salary The salary was 50.00 every two weeks at the Louisville general Hospital. Time Off Basically we worked thirty-six hours on and 12 hours off and we were off from noon on Saturday until Monday morning once a month. Our on call schedule was generally every other night. Teaching Program A. Topic or Journal presentation. Topic or journal club presentation was each Wednesday afternoon. B. Pathology by Dr. Douglas Haynes. This occurred on Friday afternoon at which time Dr. Haynes quizzed the residents as we reviewed the slides from the previous week’s surgical specimens. Dr. Haynes did not know the cases ahead of time but always got the path diagnosis correct. C. Patient Rounds These occurred on Tuesday afternoon and Saturday morning after grand rounds. Dr. Douglas Haynes or Dr. Harold Jack Kosasky would visit each ward patient. The chief resident would present the brief history and current status of the patient. Dr. Haynes favorite move was to pull back the sheets and look at the patient’s abdomen. It there was a dressing he always removed it. He did not like bandages or wound coverings even if the surgery was less than 24 hours old. D. Monthly LOGS Meetings. LOGS were always on the 4th Monday of the month. At the time of our residency most meetings were held on the second floor of Hasenours Restaurant (now closed), which was at Barrett & Oak, which was a central location of the city. The meeting started with a cash bar but most of the residents had their d4rinks paid fro by the local physicians. The meals were excellent (always steak and potatoes) nothing gourmet. The waitresses favored the young doctors. A topic was presented and discussed. After the program, the residents and local doctors would adjourn to the high-backed wooden booths on the first floor to drink beer together. They would trade stories and it was great camaraderie. The best part was that the residents and the retried doctors would get their meals free. There was a great town and gown relationship. During our residency, the local doctors ran the organization and determined the speakers and format. Later under the new chairman, Dr. John Queenan, the system was changed and the local doctors no longer controlled the organization or the agenda. E. Grand Rounds Grand rounds were held every Saturday morning at 8:00 a.m. in the third floor classroom opposite the OB office in the old Louisville General Hospital. Resident’s attendance was mandatory and it was for the residents only. The dress code was clean white shirt with tie and white trousers. Only the full time faculty wore the long white coats. The classroom was filled with the brightest and most interested local doctors. The residents presented a case to the visiting doctors. At each decision point, the presentation stopped and the local doctors had to decide the next step. The case presentation continued till the scenario was completed. It was the resident and their visiting monthly consultant versus a room of town physicians. The visiting staff would challenge the resident’s decisions and the discussion would wax warmly. However, if the resident began to take too much heat, one of the visiting doctors or faculty would invariably step in and defend the resident. It was a fun and a good “give and take” learning session for all. It was an opportunity for the town doctors to evaluate the residents and vice versa. This continued each Saturday morning until the new chairman, Dr. John Queenan, changed the meeting date from Saturday morning to Wednesday morning, then to Tuesday morning, and the format was changed from case discussions to topic presentations with loss of audience interaction. The site was changed from Louisville General Hospital to Norton’s Hospital. The outside attendance decreased and to help fill the room, the OB nurses were encouraged to attend and the attendance still fell and so medical students were made to attend. After grand rounds on Saturday, ward rounds were made and the day ended at noon for the residents who were not on call for the weekend. F. W.O. Johnson Lectureship. Dr. W.O. Johnson was the department chairman preceding Dr. Haynes. Each year a formal paper is presented by a visiting professor. G. Professional Meetings We had one paid out of town meeting, which occurred during our final year of residency. H. Yearly Formal Papers First year 1963, Dr. George Bartles and I reviewed every case of ovarian tumors ever recorded in Jefferson County Hospitals in women 18 and under. It was a comprehensive and excellent paper and should have been published, but without help and encouragement, it was not. Second Year 1964 Septic shock abortion. There were 8 cases of septic shock in 123 cases of infected abortions. The mortality rate varies from 5-40%. We lost no patients--- probably because of or early diagnosis and aggressive protocol. We had a first year resident at the bedside constantly, the local abortionists who helped to contribute cases to my study was an old nurse, Anna Haynes, no relation to our Dr. Haynes. This paper was presented at the District V in 1967 and published in the KMA Journal. It received second prize --- the Ephraim McDowell Award. Third Year- 1965-1966 “Urinary Tract Injuries during Pelvic Surgery” The History of Bladder and Ureteral Injuries and Repairs in Louisville General Hospital. It received the Ephraim Mc Dowell award and was published in the KMA Journal. Every resident that plans to practice OB-GYN – should read these papers. They are excellent with plenty of pearls for early recognition and treatment of these trying cases. I. Indigent OB- GYN clinic for indigent patients until 1967. It was staffed by the first year resident with an outside consultant available. J. Weekly Staff Case Surgeries The senior resident scrubbed weekly with our two full time staff, Dr. Douglas Haynes and Dr. Harold Jack Kosasky. They used these weekly cases to hone their surgical skills. V. Teachers 1. Dr. Harold Baker- A Johns Hopkins trained doctor who always worked with the first year residents. He came in every Friday morning. Dr. Baker had Job-like patience as he led us through our first hysterectomies. Mostly he helped keep our cases on the surgery schedule. Dr. Baker assisted the residents on radical or Wertheim hysterectomies with excellent long-term results. All of us have modified our surgical technique as we matured as surgeons, but still, we classify ourselves as Dr. Baker trained. My most vivid memory of Dr. Baker was when Dr. Baker got an emergency call from Pee Wee Valley Hospital that a patient was bleeding badly from a hysterectomy being done by one of the family doctors. Of the three residents available, I was the least experienced but Dr. Baker selected me to go with him to Pee Wee Valley Hospital. We literally flew out the curvy La Grange Road (there was no I-71) to Pee Wee Valley in Dr. Baker’s red convertible. There were no seat belts. I was scared to death. At the hospital I don’t remember who was giving the anesthesia because the anesthetist was on a stretcher nearby giving his blood to the patient. As we quickly scrubbed, I stressed to Dr. Baker that I didn’t know anything about surgery. He placed my fingers to staunch the bleeding and said, “Your don’t have to do more, I’ll do the rest.” When asked about a speech from a prominent visiting VIP from Boston on endometriosis, Dr.Baker said, “Bull, with a Boston accent is still bull!! Dr. Baker retired a couple of years ago and spends much of his time in Arizona with his wife Julie. God bless him. 2. Dr. Harold Jack Kosasky Dr. Kosasky came to Louisville in 1961. It was standard procedure that the full time faculty would operate one case a week with the senior resident assisting. Dr. Kosasky always did his weekly case even if there were not enough cases for his 8:00 a.m. case. The faculty anesthe
( Sorry, the disk containing this portion of the paper is corrupted and the written copy of the paper is not available at this time)
ter a career in the United States Army. He made us do as much surgery as we could through the vagina, i.e. sterilization, ovarian cyst, tubal pregnancy even with the abdomen swollen with blood, and to do vaginal hysterectomies in the nulliparous. We became quite proficient in vaginal surgery. Dr. Wolfe’s seminal work with the laparoscope did not start until after my residency. 4. Dr. Douglas Haynes Dr. Haynes was precise and formal and was always prompt. He would occasionally do his famous operation- where no hysterectomy clamps were used. He used an aneurysm needle to place the sutures. He would then tie his knots down very gently. This is a euphemism for just plain loose. I would always tie the sutures on my side and try to grab his suture and tie it tight, as I had to take care of the patient post operatively, Dr. Haynes stated “ Dr. Oberst, approximate, do not strangulate. One of Dr. Haynes’ patients began bleeding quite a lot. Dr. Haynes asked the anesthesiologist “what if we run out of this patients blood type?” the rather uninhibited and outspoken anesthesia resident replied “ I guess you are *&$#’ Dr. Haynes straighted and said “Indeed” VI First year resident experiences: A experience at Jewish Hospital: As a new first year resident, I was immediately assigned to the indigent OB clinic at Jewish Hospital. The Obstetric service was discontinued at Jewish Hospital in 1967. 1. First Breech The OB nurse to deliver a baby at Jewish Hospital called me. When I examine the patient she was indeed ready to deliver and was a frank breach. I told anesthesia that I had never delivered a breach before. Dr. Sheldon Mann was the most senior anesthesiologist at Jewish Hospital and could be one of the feistiest and crustiest but he was always nice to me. He said, “Don’t worry, I’ll tell you what to do.” He blocked the patient, I draped her and he said, “Get down there and be ready.” Dr. Mann pushed hard on the fundus and out came the baby, the mother, baby and a very scared first year resident all did fine. Luck and serendipity--- I learned that in a breach delivery a properly timed push is very important. 2. Shoulder dystocia I was called again early one evening to Jewish Hospital to deliver a 19-year old primagravida. I delivered the head and we all have experienced the sickening snapping turtle effect of shoulder dystocia. The head sucked back into the introits and the baby shoulders simply would not budge. No matter how hard I pulled or how hard the nurse pushed or whatever I did, I could not deliver the rest of the baby. I immediately called for help; I do not know how long I tried to deliverer this baby or how long I waited for help from the senior resident at General Hospital. Eventually Dr. A.B. Harris a rather jovial and always pleasant OB Doctor came along. Sadly, he died in March of 2003. The nurse told him I needed help. He quickly scrubbed in and wrestled with the baby and got the posterior shoulder free and delivered it. It was a 10 lb. 8 oz football player of a baby girl. The baby was dead. I learned early how to talk to a waiting family and tell them the sad news. I simply explained to the family that the baby was too large for this little mother. I learned that to just sit, listen, touch and grieve with the family is more important than words. About a week later I got a note in the mail from the patient thanking me for doing everything I did. Included was a picture of this “little baby.” The photograph of that perfectly formed large newborn in her fine baby clothes with a bonnet and a casket burned an indelible image into my brain. When I returned to General Hospital after this delivery, a much shaken new first year resident, the chief resident was still there- sitting, talking, and drinking coffee and still making no effort to come to Jewish Hospital to help me. 3. Post maturity A 43-year-old primagravida in the Jewish Hospital prenatal clinic went over her due date. Each week I called my consultant, Dr. Glen Bryant, who was a top notch OB doctor (throughout the years, always one of my favorite people, about the need to deliver this large obviously mature baby. Dr. Bryant encouraged me to observe and to wait for spontaneous labor. The patient was a very nice black lady who talked with a Jamaican accent. Each week I called my consultant who said to “continue to observe.” At about 44 weeks the fetal heart stopped. My consultant now said I could induce her. Progress was scant. The irony was that we now had to do a Cesarean Section for cephalopelvic disproportion and failure to progress so we could deliver this large but now dead baby. This patient followed me into private practice and remained with me for many years. She would never allow herself to get pregnant again. B. First year resident experiences in surgery at general hospital Case 1 On Nov. 22, 1963, I was in the operating room with Dr. James Hyman doing a Bartholin Gland Duct Cystectomy. The O.R. Nurse interrupted and said “Dr.Oberst, your wife is on the phone.” We had no beepers or cell phones. “President Kennedy has been shot in Dallas and they are taking him to Parkland Memorial Hospital. “My wife and I met at Parkland Memorial Hospital during my internship. The doctors in the emergency room of Parkland Memorial Hospital who were caring for the President of the U.S. were my fellow interns who had advanced to a senior residency status. They were now ministering to our mortally wounded president. The doctors and nurses in the emergency room at Parkland were our old friends and we and the rest of the world followed the Presidents brief stay there. Case 2 Conization with Senior Resident With the patient under general cyclopropane anesthesia, I was injecting the cervix with a dilute solution of vaso-constricting epinephrine. The faculty anesthetist walked into the room and asked what I was injecting. I told him and he said, “Damn” and kicked the rolling metal kick bucket so hard it flew off the floor and bounced off the wall. I asked what was the matter, what’s wrong? The senior resident said epinephrine and cyclopropane can cause cardiac arrhythmia. I looked at him with dismay and said, “Why did you not tell me. You are supposed to be teaching me the right way.” Case 3 48-year-old black lady very scared was admitted for a vaginal hysterectomy with a mild prolapsed of the uterus. She was afraid she was going to die from the surgery. She was trembling and fearful on admission but when she saw me a brand new first year resident, who’s duty was to do her admitting history and physical, her face brightened and she said, “you are my doctor and your not going to let me die.” I replied, “ No, I am not your doctor, I am but a first year resident, I draw blood, answer the phone, run errands, and get coffee fro the real doctors.” She repeated, “ you are my doctor, you are my doctor.” I reviewed her old record and to my amazement there was a 5 yellow page history and physical done by me as a junior medical student when she had a varicose vein operation, five years before. The next morning, Dr. Eric Hoecher our senior resident was doing the surgery and the patient became anoxic and infracted her heart. She died in the recovery room. Her anesthesia was given by a new oral surgery resident. As anesthesia can tell you, it is not wise to operate on someone who is hyper ad afraid of dying. Second year student Case 1 A pretty 15-year-old girl was admitted from the E.R. with a history of an infected criminal abortion done by our old local nurse abortionist, Anna Haynes. In the ER the patient was noted to have a catheter in the uterus. At her bedside on Ward 4AI was taking her history when her answers became confused or nonsensical. I reached up from my chair and grabbed her by the arm and said “listen you- pay attention to me.” With that her eyes rolled back into her head, and she dropped her blood pressure into septic shock. I learned from that simple experience that cerebral anoxia can be and early manifestation of septic shock. We loaded her up with Chloromycetin, Penicillin and Solucortef and then took her to the OR quickly and emptied out her infected uterus.
Dr. Sebastian Faro (an infectious disease OB/GYN doctor) in the 2003 February issue of OB/GYN News from a meeting in St. Louis stated that with sepsis- when the systems begin to fail: 1. There is a decrease in the WBC’s despite the overwhelming infection. Hence a white count below normal, i.e. 4000-5000 heralds septic shock. 2. Decrease in urine output 3. That cerebral anoxia with confusion frequently precedes the drop in blood pressure in septic shock. I reported these very observations in 1967 (almost 36 years ago) in the KMA Journal in my paper on septic abortions. Senior Resident As a senior resident on obstetrics, late one night, I was called because a multiparous patient precipitated in the labor room and would not stop bleeding. She had a cervical laceration that extended through the apex of the vagina into the broad ligament. I called the outside OB consultant for the month, Dr. Bill Durham, who said “if you cant stop the bleeding then I guess you have to take it out.” This would be my first and my only emergency post partum hysterectomy in my entire career. The patient continued to bleed as we went to the O.R. to get to the operating room we had to change from the 3rd to the 4th floor using the elevator. The patient was in shock and given only oxygen instead of anesthesia as I opened her abdomen. The patient was given type specific uncrossed matched whole blood. When Dr. Walter Wolfe, our full time staff arrived, I had the bleeding stopped and the uterus almost out. It was a fearful, heart pounding case. At 7 a.m., the next morning, after no sleep, Dr. George Bartlels and I, with our wives left for a 5 day OB meeting in Chicago, the only one out of town department paid meeting allowed during the residency. We had borrowed Dr. Bartel’s brother’s car and half way to Chicago, we started dragging a muffler. Some little farm gas station attendant cut off the muffler and we went on our way. For 5 days, till I returned, I never knew what happened to this patient who had had a Cesarean hysterectomy. I found out that the patient went home in 4 days, which was 1 day earlier than the 5 days stay for a normal elective C-Section. Third year resident responsibilities As a chief resident we were: 1. To meet with the outside consultants to staff the surgeries. All attending doctors were great. Some made us more honest than others in trying to get surgery approved. 2. Tell Dr. Haynes of any serious problems or complications on the wards. His answer was always “Dr. Oberst, do what you have to do.” Dr. Haynes would say, “take the time to think, but when the time comes to act, quit thinking and act.” Dr. William Powers said Dr. Haynes always said, “now don’t get me into trouble.” VIII. Other Observations 1. Our C-Section rate was about 4.5 to 5 % instead of the current 20 to 25%. Maybe there were fewer lawyers then. 2. All breeches delivered vaginally unless an X-ray showed a potential 3. No diagnosis of fetal distress a. C-Section for abruptio placenta could be done only for maternal reasons, i.e. excessive maternal bleeding. The status of the baby was not a factor. b. Sever preecclampsia- ecclampsia treatment Treatment at that time consisted of isolation in a dark quite room in the labor and delivery area to avoid unnecessary stimuli to prevent seizures. The preecclampsia was treated with 10 cc of MgSO4 deep IM (very long needle) into each buttocks, with or without zylocaine. The fetus was monitored with every 15 to 30 minutes with a fetoscope. (I wonder if any of the current residents know what a fetoscope looks like). A C-section would be done only for maternal indication. 4. Obstetrical deaths were rare. The only obstetrical death during our residency I remember was a post partum patient with an infection that received IV Tetracycline. She became jaundiced and died. We learned that Tetracycline and a liver compromised by a pregnancy is a bad mixture. Fortunately I was not on that service at that time. 5. Prolapsed Cord. I can remember vividly having my hand under the she4ets in the laboring patients vagina holding the baby’s head up off the prolapsed cord – waiting for the elevator so we could transfer the patient from the delivery room on the 3rd floor to the operating room on the 4th floor. There was no surgery in the delivery room. 6. There were no Fellows; therefore we as residents did it all. 7. Except for precipitous deliveries we did medial lateral episiotomies. The current fad, and I call it a fad is not to do episiotomies. There is also an explosion of perineal problems. 8. As a senior resident, Dr. Haynes would approve (if we had good reason) a Cesarean hysterectomy to give us experience i.e. removing a large very vascular uterus imme4diately post partum. 9. We worked long hours, got more experience and because of that were better doctors. 10. Maybe our home life suffered, but most of us still have our first wife. My long hours were my “rite of passage” The older generation set medicine and its demands above everything-personal life, family, hobbies etc… The current generation accepts the demands of medicine but also want a second life of family and the opportunity to pursue other interest. 11. Dr. Bill Russell, our chief resident, drove a Buick Rivera, which was the top of the line Buick. This car was the nicest of all the resident’s cars in the parking lot—better than most of the faculty. He was near Dr. Haynes’s age. We had to survive Dr. Bill Russell’s handwriting. When he scribbled his notes only he and God knew what they meant. The next day, only God knew what it meant. IX. Parties 1. I think Dr. and Mrs. Haynes had an annual Party at their house. I am not sure as I only attended one. 2. Dr. William Powers and his wife Mary invited the residents to his home. It was a lovely evening with their silver and best china. I never forgot it and when I was in practice, my wife and I tried to follow his example of inviting the residents out. We did this on an annual basis until the program became too big and lost its closeness. 3. The resident’s graduation party—there was none! I did receive a certificate of residency. Summary of residency Dr. Haynes was always neat and meticulous. Perhaps fastidious is a better word. The medical students were called either Mr. Or Miss. (Never Dr.) When quizzing a medical student, the medical student replied, “Yes, if your menstrual cramps are bad enough. “Dr. Haynes replied “Not my menstrual cramps.” A student said, trying to be philosophical, not every question deserves an answer. Dr. Haynes replied, “My questions always deserve an answer.” Dr. Haynes lectures were legendary. Organized, complete and factual, filled with much OB history and many, many proper names “Best lecturer we ever had, was a common student assessment. The residents were always called doctor. I am not certain if I have ever heard Dr. Haynes call anyone by his or her first name. Certainly not me after nearly 40 years of association. In the operating room, Dr. Haynes would tell me “Dr. Oberst, the beginning of wisdom is to call structures by their correct name.” Sometimes, in just being polite, he would tell me, “Dr. Foberst, maybe in Knowing you don’t know the answer is a good start to knowledge.” Summary on our Residency A residency program can be judged by where the residents come from and where they go. All were men. All were from American schools. All were in the top of their class. All were from American schools. All were in the top of their class. All were ex-military and all worked long hours. There were no complainers in our group. We had strong supportive spouses, most of who worked, cared for our children and were there to comfort us and revive us when we got home. The residents become an extension of their teacher. They will emulate his mannerism, his philosophy, his judgment, and of course take away his expertise. The program’s success or failure reflects the department’s ability to find the right rough stones and turn them into diamonds. The true test of a teacher is that he leaves his convictions in his residents with the will to carry these convictions to the next generation. If teaching and molding of the students and other resident doctors is of the highest priority, then look at this group: Dr. Marvin Yussman, a Professor at the University of Louisville School of Medicine. Dr. David Archer, a Professor at Eastern Virginia Medical School and frequent speaker and T.V. panelist. Dr. Ronald Levine, a Clinical Professor at the University of Louisville School of Medicine. Seminal work and international speaker on laparoscopy. Dr. Marshall Mahan, a Clinical Professor at the University of Louisville School of Medicine. Dr. Jack Hoffman, Clinical Professor at the University of Arizona. Dr. William Russell taught at the University of Arizona. Dr. Richard Blair, brief faculty member at the University of Louisville school of Medicine. Dr. Charles Oberst, longtime clinical professor at the University of Louisville School of Medicine. Dr. George Bartels and Jack Hoffman, first in their community to do colposcopy, laproscopy and ultrasounds. The need to excel—to be the best—drove us all. Perhaps it was innate but Dr. Haynes recognized it and put together this wonderful mix of residents. I hope that Dr. Douglas Hayes is as proud of this group—as we are proud of each other. We looked at our teachers and our attending and said, “Will we be as good? Deep in our hearts we knew we would be better! Although today there is more technology with more accurate diagnoses and there is less patient touching, there should not be less feeling for our patients. In treating patients, some would say it is important to have knowledge, others say it is important to have knowledge; others say it is more important to care. Dr. Haynes would say both are important. My personal thanks to Dr. Ronald Levine. Dr. Levine picked me up on these early cold mornings in time for our 7:00 morning rounds. This enabled my wife, with our one-year-old baby to stay at home for another hour and a half. Dr. Haynes: a chairman to be remembered A. Dr. Haynes had Strong core beliefs and they were obvious to those around him. B. Preparation: his lectures and presentations speak to that. C. The courage to make a decision even when not politically popular, such as flunking a medical student or dismissing a resident instead of letting him or her slide through. D. The ability to communicate his core beliefs.
1. There was never any doubt about his direction or department policies. 2. He was always available. He did not send much time away from the department visiting or lecturing. 3. He might compromise or give a little but he never changed his core values. E. Dr. Haynes would say, “Dr. Oberst, you take care of the little problems and I will have fewer big problems. F. Empowerment – he allowed us flexibility. He trusted us to trust our own judgment. G. To paraphrase Pete Seeger in the “Bitter and The Sweet”, where have all of the hours gone—long time passing – where have all of the years gone—long time ago. Thank you Dr. Haynes for this wonderful journey. You were the engine that pulled this train. Thanks for the ride.
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