Living Breathing Medicine Podcast – Growing from Grief with Dr. Lee Blecher

Dr. Cecily Havert speaks with Dr. Lee Blecher, a family medicine doctor at Fairfax Family Practice in Fairfax, Virginia. Dr. Blecher shares the importance of personal life experiences in caring for patients. As a part of teaching new doctors, Dr. Blecher demonstrates emotional honesty and vulnerability. Part of that lesson came from a difficult experience during his fellowship, in which a patient delivered a full-term stillborn infant.

Content advisory: This conversation includes sensitive topics such as fetal demise, infant death, and miscarriage, which some listeners may find upsetting. Please use discretion, and keep yourself safe and grounded while listening.

Episode Highlights:

• 0:27 – Dr. Cecily Havert introduces Dr. Lee Blecher, a family medicine doctor with Inova Fairfax, and discusses his extensive background in family medicine, women’s health and obstetrics. Disclaimer – this conversation contains discussions about fetal demise, infant death and miscarriage, which some listeners may find upsetting. Please keep this in mind if you do choose to join us in this conversation and work to keep yourself safe and grounded.
• 2:24 – Dr. Blecher begins the episode with an excerpt from his blog, “The Butterfly and Me.”
• 3:01 -5:44 – What does the butterfly mean when you see that on the door in labor and delivery? Dr. Blecher explains the meaning behind the butterfly, how it was used by the hospital, and the background of his story.
• 5:44 – 7:57 – “Where you aware of what was going on with the patient in the moment? Or were you more focused on the job at hand?” Dr. Havert asks Dr. Blecher about the experience he had in his 20’s, and the perspective he gained because of it.
• 8:00 – 11:36 – Dr. Blecher shares a personal story of loss that he and his wife experienced together, and the providers discuss the importance of being there for your patients during such difficult times.
• 11-36 – 12:39 – Dr. Havert shares a personal story of loss that she experienced, and how it has shaped how she practices medicine.
• 13:19 – 15:46 – As the providers discuss their past relationship, they talk about the importance of being present in the situation and being a good advocate for your patients when they are going through a traumatic experience.
• 15:46 – 16:33 – Dr. Havert shares another personal story of loss and remembers how she felt going through that experience.
• 17:12 – 19:20 – There is no better teacher than experience. The providers discuss how their perspectives changed over time and how life experiences help shape you personally and professionally.
• 19:20 – 24:27 – “And because the lesson really was not about my story, it was about making amends, learning from mistakes, and applying a life experience to our patients.” The providers discuss the humility of medicine, and why it’s important to share your experiences.
• 25:33 – 30:09 – Sometimes, the best thing you can do is not try to fix the problem, but just to listen, be present, and ask the right questions.
• 31:26 – Dr. Havert thanks Dr. Blecher for his time. Dr. Havert also announces that Nurse Practitioner, Christy Davenport, join us next Friday for a conversation about mental health.

The Butterfly, and Me – By Dr. Lee Blecher

Have you ever walked onto a hospital unit and felt as if you were hit by a sucker punch? Have you ever felt that the air was heavier than normal; that the air was so thick you could cut it with a knife?  Have you ever walked onto a hospital unit and felt that things weren’t quite right?

I can still feel that pit in my stomach from that early morning in 2002 when I was a fellow on labor and delivery. It was five in the morning, the typical time I would arrive.   Usually there’s a mix of a lightness because people are coming off the night shift; a sense of relief that things are coming to an end for those nurses, but also a sense of sleepiness since they were all tired. This time there was clearly not a sense of relief.

I couldn’t quite tell what was going on but things just felt different. So I continued on my normal activities of chart checking the postpartum patients, and looking at the labor and delivery board.  I was   hoping for an easy start to the day, but somehow when I saw a 20 bed unit full with 20 patients, I started off the day feeling a little overwhelmed. But on top of that, one room had a butterfly next to it.

I’d never seen that before.  I felt too busy to ask about it, and went on my way to see the postpartum patients. It wasn’t until 7 o’clock at sign out that I find out what that meant.

There were 19 tracings but 20 rooms were filled. That in and of itself isn’t always necessarily something negative.  Often time’s people get delivered and are still in the room, but somehow with the butterfly next to the patient’s name, this felt different.  I should’ve known.

I would have figured it out if I was paying attention to the external fetal monitors at the nursing station. But then again, I think the crux of this story will be that this day, I really wasn’t paying attention

During sign out we heard the story of the butterfly– a woman laboring who was to deliver a term stillborn.  Rounds were over and I prepared to see all the patients assigned to us, but there were also two ER consults to see, and a C-section waiting.  I remember having two emotions as I walked down the hall. I was tired and overwhelmed, as well as irritated and annoyed at the on-call team for leaving me a mess.  I wish I had seen then what I know now, that I really had an opportunity to make a difference in this patient’s life. Instead she was just another case to get through.  It has taken me a long time to get over that guilt.

The patient was a G3 P2002 who was at 39+ weeks gestation. She had had an uncomplicated prenatal course other than late prenatal care.  She was admitted early in the prior evening with decreased fetal movement, and contracting; although not very strongly or regularly. She had been evaluated in Triage and although her fetal monitor showed a nonreactive strip, it was without decelerations.

According to the on-call team she had been progressing through the evening and had reached 5 cm dilation when the fetal heart tracing started to exhibit significant deep variable decelerations. They tried the routine resuscitate measures which initially worked.  However when it happened again they rushed her back for an emergency C-section.  For some reason that I am not sure of, while she was on the operating room table the attending physician asked everybody to stop to get an ultrasound to look at the baby before they made the incision. At that time it appeared that the baby did not have a heartbeat. The attending physician decided to not perform the procedure and brought the patient back to the labor room to deliver her dead baby. This had occurred around 330 in the morning.  When I arrived at five, I think people had just started to process the event and clearly there was controversy about how this was handled.

So now what was left for me was to deliver this butterfly baby. On the one hand this can seem like an uncomplicated situation because the risk is already negated.  I really remember feeling this way and sometimes I wonder how I could have felt so sterile, clinical, and insensitive. I want to shake that young physician and redo that day.   On the other hand, delivering a dead baby is actually higher risk. The mother can have increased chance of septicemia, preeclampsia, and amniotic fluid emboli. In addition, she is at high-risk for high-grade peroneal tears.

After conferring with my attending, we decided to increase her epidural so that we could give her higher doses of Pitocin in order to speed up her delivered.

I felt at the time I was just going through the mechanics of this delivery.  Through the course of the day I checked on her as I would any other patient. I really didn’t make any special attempt to sit with her, or try to interact with her.  I wasn’t callous or insensitive, but I didn’t provide any measureable sensitivity or extra comfort. I know the nurses were exceptionally good at this, so in some ways I deferred that responsibility entirely.

Through the day she progressed very slowly–even in the face of high-dose Pitocin. I was starting to wonder if this woman would eventually need a C-section to remove a dead baby. The irony of that would’ve been even more tragic. Thankfully after another six hours she delivered her son vaginally. Unfortunately, she suffered a 4^th degree tear.

We attempted to repair it the tear at the bedside to save her from indignity of having to go back into the operating room. However this made the repair more challenging and it took longer. I remembering feeling solely focused on the repair and not even remotely taking into consideration my patient’s needs, feelings, or the gravity of her loss.

In hindsight and with a little more maturity I now know that I could have, NO, I should have, handled the situation differently. But another event occurred that made me realize what a difference I should’ve made in this woman’s life.  This time it was me and my wife who were the patients.

As I was writing this, I paused and remembered something my wife wrote in an on-line blog:

“My husband and I bought cemetery plots today. We are both only 42 years old and (thank God) in good health, but we are trying to do the responsible thing. My parents purchased plots when they were around the same age and we figured it’s always smart to prepare for the future.

Unfortunately, there were no available spaces right next to our family plots, but we were pleased to find a nice spot just a short distance down the pathway. In some ways, the location is probably just right–close to my parents and family, but not too close.

The thing that makes me a little sad–but also a little happy–is that (in 120 years) we will not be buried right next to our daughter. Four years ago this month, we lost a very difficult pregnancy at 21-weeks gestation.

When the pregnancy ended, my husband and I were devastated, but we were surprised when the state declared it a death with an official death certificate, which required us to dispose of the remains. We were told about various options, but we couldn’t deal with it right then. Thankfully, my mother stepped in and said she would handle things. After speaking to our family rabbi who has known me since I was a little girl and officiated our wedding, my mother made the arrangements for the burial.”

In 2010 my wife and I were pregnant with our second child.  After going through multiple fertility treatments, and suffering through three prior miscarriages, we were grateful to finally be pregnant.  But, unlike our first pregnancy this was more complicated. Nothing in this pregnancy was easy. Tragically, that pregnancy ended at 21 weeks gestation. We lost our daughter; she may have been named after my mother.

This is a tragedy no matter when it happens, but somehow given all that we had been through, it was as if salt was being rubbed into a very open wound.  We were shocked, overwhelmed, and lost. Devastated and demoralized.   The only other time I remember feeling that grief was when my mother died.  To this day my wife and I remain significantly affected by this loss.

To make matters worse, our general OB seemed to abandon us—he didn’t seem to know how to look at us, what to say to us, and in general didn’t help us navigate the system. He only offered my wife some Zoloft and asked “you’re not depressed are you?”  We felt abandoned. Yet, our high risk doctor as well as the infertility specialist were empathetic, supportive, and gave us what they could.

When we walked into the hospital to deliver our daughter, I felt a similar sense of heaviness, doom, and sadness that I had felt 8 years prior.  Clearly this time it was more intense, personal, and painful.

That feeling stays with me even to this day. Not only because of the searing pain of personal loss, but also the sense of guilt when I think about how I handled that butterfly case.  Knowing that there were doctors that were there for me and my wife, but also feeling the disappointment and anger with the doctor that abandoned us, made me realize how much more I could’ve done for this patient.

I never really processed that well, and suffered silently.

But I have learned that the best way to deal with a mistake is not to stay in a feeling of guilt. But to learn, grow, and do better. I feel like the amends I’ve made to this patient are through a “living amends.” By adjusting how I handle patients, and always remembering to do the right thing.   I wish I could find her, reach out, and tell her about how I’ve changed. I wish I could share our mutual losses.  But I can’t.

I wanted to conclude with how my wife’s blog ended:

“It took me about a year to finally ask my mother what had happened and where our daughter was buried. At that time, my mom told me that she was right by my fraternal grandmother, in the family plot.

My grandmother was a very special person. She was hard-working, loving, and a great Jewish cook. She was a tough lady too; she was a Holocaust survivor. My grandmother didn’t talk about that time in her life very much, but we knew that she had lost practically her entire (first) family. Besides her mother, father, and many sisters and brothers, she also lost her first husband as well as her first child–a baby daughter. Of course, the little girl once had a name, but my grandmother never spoke of it.

Today, my husband and I feel extremely blessed to have two beautiful, healthy children. I do not think I will ever “get over” this significant loss; instead we as a family try to remember our daughter in special ways. We planted a beautiful tree with soft pink leaves by the swing set in our backyard, and plant trees in Israel every year. And we talk about her with our two kids.

I would certainly never try to equate what my grandmother and I went through, but I am glad they are together. There is no better place for my daughter to be.”

Additional Resources:

• Pregnancy loss resources from VCU Health

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