I see her soul seeping out of her body. I widen my fingers and enlarge my hands to push it back in. However, I cannot get her soul to rejoin her body. My hands return soiled in her blood. This is the recurrent nightmare I have had this year which comes on the heels of failing the Complex Family Planning (CFP) subspecialty board exam.
While I have religiously experienced impostor syndrome after exiting the testing centers for Step 1, Step 2, and the American Board of Obstetrics and Gynecology qualifying (written) and certifying (oral) exams, I have never overtly failed an examination. During Step 1, there was a 2-hour power outage. The last half of residency I was waddling around L&D with my spontaneous twin gestation belly followed by futilely pumping between gynecologic surgeries. Having exhausted my milk supply for my 8-month-old daughters over sleepless nights, I sat for the qualifying exam. Shortly into my attending career, I became a single parent. At the height of the pandemic and one week before the certifying exam, I solo quarantined with my twin toddlers courtesy of a daycare COVID exposure, pre-vaccination. Not only did I pass each of these exams, but I did so with flying colors.
The CFP exam was not marred by any of these adversities and yet, I was three points shy. In a sense, I was not surprised. I am not fellowship trained. And so, the preceding 12 months were a whirlwind of being an ob/gyn attending, single parenting, and furiously studying. I read and reread anything CFP: practice bulletins, committee opinions, clinical recommendations, consensus statements, and textbooks. I slept with the US Medical Eligibility Criteria for Contraceptive Use under my pillow. I transformed my novel, albeit then elusive, expertise into resident didactic lectures that I frequently reference during patient care to this day. And yet, I was three points shy. I am grateful for those three measly points. I numerically failed the CFP exam. I knowledgeably did not.
During a parading postpartum hemorrhage, I exhausted the Society of Family Planning Clinical Recommendation: Management of hemorrhage at the time of abortion algorithm status post an obstetric delivery. In that overnight moment, I irately recalled the multiple-choice-questions challenging me to choose a single intervention. I feigned ignorance and chose simultaneous uterotonic administration, laceration repair, and help. When that did not yield hemostasis in the setting of unstable vital signs, I chose to administer multiple doses of methergine, an uncommon and valid L&D workflow in a life-threatening hemorrhage. The repeat dose, I am convinced, generated a hypotensive blood pressure that did not match the clinical scenario.
It was baffling as tone, trauma, and tissue had been addressed, blood product replacement aggressively initiated and uterine tamponade in situ amongst the above-named measures. The patient cradled and coo-ed at her cheesy vernix-covered newborn. Anesthesia was bedside, the ICU notified, and ancillary services on standby for potential life-saving measures. Simultaneous interventions that cannot be prioritized in multiple choice questions. The paralyzing fear and chaotic multi-tasking of a rapidly deteriorating patient that cannot be captured in a standardized examination. Studying for it, however, steadied me in clinical knowledge, checklist utilization, and closed-loop-communication. It was not forgotten, discarded information after either a passed or failed mandatory exam.
I wish I could say I saved her life. I did not. What I can say is that I did everything possible to save her life which I may not have done earlier in my career. Last year, the facts were fleeting like the mole in whack-a-mole. This year, they are anchored and accessible by memory, teaching PowerPoints, and literature. The literature defended my choice to administer subsequent methergine doses less than two to four hours apart when the suspicion was that it had caused her cardiac arrest. That repeat dose I hope gave her additional time with her newborn and for me to compete with Mother Nature. Mother Nature won via a catastrophic obstetric event diagnosed post-mortem by family-approved autopsy.
And it is the difference of three points that has expanded my baseline knowledge, academic instruction, and patient care. Three measly points which has inspired me to add clinical research and therapeutic writing to my career. Three exquisite points which has allowed me to transform her soul from angry to peaceful and cope with this devastating loss. For weeks, I dreamt of her soul seeping through my bloodied hands angry at me for not maintaining her heartbeat, the breath of her body, and the rhythm of her life. But because of those three points and Round 2 with the CFP exam, I know that I did not miss any interventions and in the words of my chief “[I] gave her the best possible chance of living.” I can set her soul peacefully free in a field of California wildflowers – brilliant poppies floating in a lavender scented breeze is what I imagine. Regardless of future exam outcomes, I am armed with a continually evolving skill set supported by literature and the confidence that I am doing the best that I can as an ob/gyn attending and single parent in this world fraught with Mother Nature’s contempt and administrative and political limitations. And for that, I am grateful.
Samantha Fernandes is a board-certified obstetrician/gynecologist at Kaiser Permanente Mountain View. Her professional interests center around family planning, teaching, and writing. Her personal interests revolve around adventuring with her twin daughters especially as a single parent. All names and identifying information have been modified to protect patient privacy.
Image by Alphavector / Shutterstock
