Serial - The Retrievals S02 Episode 4: The Solutions

Episode Date: August 7, 2025

Sometimes you can’t wait for research to tell you what to do — you just have to go ahead and do it. We get back on L&D with Clara, Mindy and Heather. Subscribe now to get early access to this episode. Our newest podcast, “The Retrievals, Season 2” is out now. Search for it wherever you get your podcasts, or follow it here: lnk.to/retrievals2 To get full access to this and other Serial Productions and New York Times podcasts on Apple Podcasts and Spotify, subscribe at nytimes.com/podcasts.To find out about new shows from Serial Productions, and get a look behind the scenes, sign up for our newsletter at nytimes.com/serialnewsletter.Have a story pitch, a tip, or feedback on our shows? Email us at [e-mail] 

Previously, on the retrievals. I think that smile was like, I'm having my babies. You made it to take my pictures. You're here. You're one of me, one of our team. But what if I told you that the patient was a colleague and someone who worked on L&D? Horrific. Did your records reflect, like did they accurately

reflect what happened to you? No, nothing about it, isn't there? I was wondering how many people actually say that in the pre-op discussed that spinals and epidurals actually fail, even before, like during your consent process. Everybody had been making the same mistake. Everybody. Not one been asking the patients.

From serial productions in the New York Times, I'm Susan Burton, and this is The Retrievals, Season 2, The C-sections. Speaking of seasons, it's been so long since we've been at the hospital that it's almost like we're on a new season of our medical drama. A lot has happened to our character since we left them in the months after Clara's C-section.

In fact, we have another character to add to the ensemble. Corey, remember? The anesthesiologist who arrived for a shift just as Clara's surgery was ending. Let's bring Corey on stage. Dr. Corey to Berggrave. Interior, Hospital, mourning. Because when I show up at 7 a.m.

and I change it to my scrubs and I go up to the fourth floor and I walk into that, I open those doors. I walk in and there is like, and everyone, all the nurses, everyone yelling, like, oh my God, Corey, oh my God, we're so happy you're here. Oh my God.

Sit down. We got to talk. This entrance, it's not just chinned up for the season opener. It's a regular occurrence on L&D. Look, there's Mindy. She'll tell you. Corey is our baby. He is the unit baby.

He was a resident with us. He just vived with us. He sits in the nurse station and, like, gossips with us. We've even gone out drinking together. Like, he's been at parties. He is our baby. And when we heard he was going to be in attending, we were all, like, ecstatic. And he's just great with,

women and patience, and you just trust him immediately. He's adorable to look at, too, so. I walk through that door, it's always kind of like a, okay, like, I'm doing, I'm doing something right, because these people are relieved and happy to see me. Relieved. That's how Clara felt when Corey walked in at the end of her surgery. And no, here's Clara now. Amazing haircut. Mia Farrow and Rosemary's baby vibes. this will be her new look for the season. Clara's look isn't the only thing that's new on the unit.

She says the culture around pain during Caesarian is changing. And there's a lot of parts to this, but there's also a simple way to get at just how profound the shift is. It comes down to one word, one word that in the before times, Clara went to felt able to say during a C-section. Stop. Like, I didn't understand that I could simply say,

you need to stop, she's not okay. Yeah. And the other part of it is that the team is more responsive. So the surgeons themselves, before normally is, no, that is anesthesia's job. We have our job. We're going to focus on that. But now, I mean, in my experience, I say, if you can stop, stop, she's not okay. They are very, very quick to say, oh, thank you for telling us.

We can pause here, absolutely. Everybody in the room is so much more receptive to it. Sometimes it's not so easy to stop, but there are other times you can. Stopping can be awkward. Everyone standing there silently, arms crossed, just waiting for the several minutes it might take for the meds to kick in. A nurse might be challenging a hierarchy to say stop.

I am concerned. It can feel that way for an anesthesiologist, too. Maybe they're working on the kind of unit where the surgeon rules the roost. But there are all kinds of power dynamics. A younger, newer OB, working with an older anesthesiologist who claims it's just pressure, she's fine. One OB told me that when a patient is suffering, she can tell because even the muscles inside their bodies are tense. Yeah, all of us have seen these things and have been troubled by these things, but not really known what or how to do or that it wasn't, or that it could be different, you know. Yeah.

So I think people were just, oh, like, thank God, finally. Yes, let's go. And let's do what we wanted to do all along. Speak up on behalf of patience. To shift a culture like this, Clara says, you need to have enough people with buy-in, people who won't let it go. And you need someone to get people to buy in.

You need a Heather. I mean, it is. It is absolutely her. at the hospital, her job title, her credentials, her relationships with everybody, the trust that's there, all of those things are why, right, that she has been able to push through what she has, I think, because it is remarkably different. So what did Heather do exactly? And how did she do it? Well, we're in luck that we can see some of it for ourselves. Let's hurry down to the third floor, where Heather is teaching a

class. How many people have been in C-sections where you have an awake patient and someone else is like, hey, the patient in four is blah, blah, blah, blah, right? So you're talking about other patients in front of an awake patient, right? What's going on in room four? And they're like, oh, that room four sounds bad. They should take care of that one, right? I hope they're okay. You know, like, okay. Heather and her OB-Nesthesia colleagues have made a bunch of changes since Clara's surgery, ranging from the drugs and the epidurals,

clonidine, to a new system to document and address pain. Some of what Heather wanted to do, like changing the way doctors interact with patients, what tone they take, what language they use, required education. She began with the youngest people, the newest residents, because if you get them, you make it normal for the next four years,

and forever. And that's who's in the room this morning mainly, anesthesia residents, people still learning medicine. So I want to highlight here that even though I've been doing this for 15 years, I'm still learning. I'm still uncovering things that I think I maybe missed the boat on that I thought I was being empathetic, I thought I was being patient-centered,

and now I'm looking at going, is that really right? Not just, I did this wrong when I was a beginner. I still find myself doing this wrong. This kind of admission is so unusual. And even getting ready for this lecture, I dug into, like, empathy, patient communication, physician interactions, I can't find anything concrete that tells you exactly what to say. So it makes it really hard, right? I can give you 100 papers on Clonidine, right? I can tell you exactly where all the data came from. I can't give you one that tells you whether it's better to say this thing or this thing to a patient, right? But I know that if someone has to say, this morning, Heather wants to address what to say during some interactions that are especially challenging, including interactions with so-called difficult patients.

So what is a difficult patient? Well, now you said earlier that you'd all kind of heard that phrase, right? You'd heard difficult. It's been used in the vernacular, right? So I want you into small groups for a second and tell me what do you think a difficult patient is? And then think of examples of patients you've had who were, quote unquote, labeled as difficult or you felt were difficult.

Yes? Okay, let's go. The residents huddled together in groups. They're wearing gray scrubs. They look young. It's striking to hear them reflecting on patients as other. They're so recently removed from having only ever been patients themselves. All right, let's come back together if we can wrap up here.

Sorry, I didn't mean to cut anybody off mid-thought. Okay, guys, so what did you guys discuss in your groups of what is what you know to be a difficult patient? Or what are some examples of it? The answer is exactly what you feared. I often find that sometimes patients are labeled difficult also. If they just want to be well-informed and totally understand what's going to. going on and they ask a lot of questions. To be clear, the resident is not endorsing this.

No one in the room is. Patients don't feel listened to. They don't feel respected. They don't feel like they have a voice. And the ones that have the biggest voice and advocate for themselves are label as difficult in our system, right? A doctor who's just entered the room gets Heather's attention. Okay.

Yes. You will never guess what just happened. Okay. The doctor speaking is an attending who'd gone to check on a patient. And the Surgeistenter nurse comes up to me and goes, Dr. Waldinger, your patient came back from nuclear medicine. She's a really difficult patient. So funny. Like, literally.

Just happened. Dr. Walker, yeah. Corey is in the room, and now he raises his hand. And he starts to tell the story of a, quote, difficult patient he had for a C-section last night. It was a true emergency, a crash. The patient was rushed to the operating room. They did the skin test.

and the patient could feel it. And everyone in the room looked at me, and it was pretty much out of everyone's mind at the same time, got to go to sleep. I said, okay, we're going to go to sleep, no problem. She said, I don't want to go to sleep. And now everyone's looking at me, and they didn't say these words,

but I got the impression, like, just go ahead and just push it. Corey can't put the patient to sleep if she's refusing. That's against the law, but the alternative is dark. It was an emergency, and in my mind, it's like,

this baby's going to die if I don't, if we don't get this out in the next few minutes. but I can't put you to sleep and we can't do surgery with you in pain. So it's like the urgent, emergency scenarios for me where in my mind I'm thinking, this woman's asking me to perform magic that I can't perform.

Yeah. Like I have to pick one or the other. So what you did? Corey says that he knelt down, got really close to the patient, and he called her Sweetie. I don't know if we're supposed to be calling a patient sweetie, he says.

And the room laughs. But Sweetie was the turn. And I think that the second I started getting casual with her and probably breaking those norms about vocabulary. I think she would, like, did she get away. Later, Corey told me that Sweetie wasn't the only vocab norm he'd broken with the patient. She was resistant, but she knew that she was putting herself and her baby in danger. So she kept saying, I know everyone in this room, you guys think I'm the biggest dumbass.

I know you think I'm just this dumbass bitch. And she wasn't saying it like in an adversarial way. She was like recognizing, I know that I'm being annoying to you guys. I recognize what you guys must feel about me. So that's one of the things that when I got down next to her and I just said like, look, I don't think you're a dumbass. I don't think you're even being a bitch. I've dealt with bitchy people in my life.

You are not being that way. I feel for you. I think you're going through something that I can't even imagine. And, you know, nowhere in medical school do they say, should you talk that way. Nowhere, you know, if my boss haven't walked by and heard me say that, I probably wouldn't be the most proud of that. But when I said that, she kind of giggled, and she kind of started smiling.

And I was like, it was like these little small things that eventually broke through with her. The patient still didn't want to go to sleep. But she agreed to allow Corey to give her IV drugs. He held her hand, and the baby was delivered. This kind of story doesn't always end this way, Heather tells the room. We've had that before, where we've had someone come to the operating room in absolute your food's general anesthesia. the outcome was not as good as yours.

So I think that those are really important conversation. Corey had asked the patient, why don't you want to go to sleep? Heather would have asked this question too. If the answer was, I'm scared. What are you scared of? Which is different from there's nothing to be scared of. What the patient is scared of matters

and might determine what you do. The way you ask the question matters. too. So your tone, whether you get casual or whether you just heard my voice right now, hey, you know my register. My register's up here, right? And hey, we're going to take really good care of you. Like, I know you're scared. My voice drops. My head comes close. I kind of get to their ear. This might not be the right style for everyone. Be genuine to your personality. You're not going to speak the way that I speak, right? You're not going to use the phrases that I'm going to use and Don't try to mimic people because it's not going to come out right.

So find what works for you. But even if the delivery isn't the same, the message is. Here's what I can't do. I can't promise you a pain-free surgery, right? But what I can promise you is if you tell me you're having pain, I will give you more medicines. I will work with you. I will be present with you, okay? You can tell doctors to listen to people.

to partner with patients. And some doctors are going to have an intuitive sense of how to do this. But not everyone will. And yes, teaching helps, modeling helps. But when you're trying to change behavior after something goes wrong in a medical setting, what helps more than either of these things, and research shows this, is if you create a system that encourages, even compels that behavior, which is another thing Heather did, in which I'm about to see in action.

That's coming up after the break. Cut to the O.B. Floor. It's after class. I'm in the shot now. I've been here the whole time. Let's not make a big deal. But yeah, I'm here on set. Heather and I are standing outside the double doors that lead to the operating rooms. So we're going to have to put these on. Okay, great. So probably maybe if you want to use that tray over there and put your mic down for just a second. Heather hands me a surgical suit. I put the recorder down and step into the white cover all.

The material's flimsy, like a whole outfit made out of a dental bib. Once I'm gowned up, we continue down the hall. So this is like a sterile hallway, which is why you have to have all this stuff on. And then when you go in the operating rooms, that's when you need the mask. Okay. Now you can hear a baby was born. Outside the OR, I tie a mask at top of my head and at the nape of my neck, and then turn to where Heather is pointing through the window in the door.

So just take a look at the people. Oh, we're actually in there. Oh, wow. And so this is a caesarian. Yeah, so they're in the middle of a cesarean right now, so she's wide open. I've been hoping to see a C-section this morning, but not expecting to. to. I've been told it was unlikely to happen. But at the last minute, it's come together. The patient has given me permission to observe. Her baby has already been delivered, so I won't

get to see that part. But there's a lot of her surgery left, which means there's a lot of anesthesia care left to administer. And then the anesthesia providers are the head of the bed kind of talking to her. So we're really the only ones who are kind of like, like, yeah, exactly, which makes it a very intimate relationship very quickly. Heather checks that I'm ready to go inside. I'd asked her what she suggests I notice, and she'd named a couple things, including looking at the patient's open abdomen.

Unless you're queasy, she added. It's untested, I said. I've never witnessed any kind of surgery. For months, I'd been talking to people about C-sections, reading about them, writing about them. But I'd never been in one, and that felt important. I'd tried to at a couple different hospitals. Can't she just watch one on YouTube?

Was the response of one hospital flack who turned me down. But it wasn't about gathering the right details. What I wanted, you couldn't get any other way. I wanted to be in the room. We step inside. Heather stays very close to me, not in case I go rogue, but in case I go down, which happens to visitors.

But at first I don't even really look at the patient. Heather points things out, but I'm not always sure what she's pointing at. Are those parts of the human body hanging from a pole in little plastic bags? No, they're you sponges. Affixed to the wall. A big container of blood, like an igloo dispenser. Is that the patient's blood or is that blood for the patient in case she needs it? Then we turn to the foot of the bed, and I stare straight into the patient's open abdomen.

I'm surprised by how completely unfazed I am If anything I want to keep looking The blue drape hangs at the patient's breast I can't see her head And maybe the depersonalization helps me look at this straight on The flesh is pushed up Like when you raise a blind I'm full of awe

My hands have been bald inside my jumpsuit But now they loosen The patient is getting her tubes tied. Heather uses the medical term. I ask if they tie them or cut them off, and the answer is kind of both. We move around to the head of the bed. The patient has a wide, sweet face, freckles,

the father beside her holding the baby. Congratulations, I say to the mother, but then I regret it a little, not knowing what she feels. I'm not meant to interview the patient, just to observe, so I can't ask about pain. But now the patient grimaces, her eyes open and close, forehead furrows. The attending is momentarily out of the room. Heather moves in.

What are you feeling, she says to the patient, leaning down near her face, doing exactly what she just talked about in the classroom. Are you in pain? It's just pressure, says the patient. But how bad, what's the number? asks Heather. It's eight. Well, if it's an eight, we should do something about it. The patient doesn't want drugs in her IV right now, but she does want nitrous. The OB-anesthesia fellow, Lauren, places a plastic mask over the patient's face. Then at a computer, Lauren fills in a pop-up

window in the patient's chart. And this window, this is what I was talking about when I said that Heather had made a system to compel behavior. It's one of the most significant changes she's made. There's a phrase that's often used in medicine. What's measured matters. So Heather's thought was, okay, if I'm trying to make pain matter to everyone in the room, we've got to find a way to measure it.

Now, every 15 minutes, the anesthesia provider receives a reminder to get a pain score from the patient. A tab on the patient's chart turns red. If the score is three and above, there are prompts for follow-up questions about what kind of pain and where, information that can be used to decide on an intervention. When Heather initially had the idea, there was some pushback. And there was a little bit of like, well, why are we doing this? I don't want to keep reminding the patient about pain, and I was like, no.

If they're not having pain, you're not reminding them of anything. people have strong opinions about pain language one OB anesthesiologist I talked to someone who's as passionate as Heather about the issue of pain during cesarean told me that she asks patients are you comfortable and do you want me to give you anything

I don't want to emphasize the pain she said there's pain psychology literature supporting this that the language that you use can suggest pain to the patient Instead of saying, I'm going to put this needle in your back and it's going to burn for a second, you say like, oh, you'll feel mild discomfort. And you coach them through them as if you're like somehow going to change their experience. And I just haven't found that to be true. My personal experience with this has been absolutely 100% the other direction, is that if you don't tell patients what to expect, if you're not real with them, you lose trust so quickly. So I really believe in telling patients the whole story.

Unless I have someone who's like, don't tell me anything, I don't want to know anything. So we do have that conversation as well. But otherwise, I don't know, I just, I don't think it's quite fair to patients to assume that somehow you're going to, you are fully in control by your language of someone's pain experience. I think that really minimizes the problem. The main purpose of Heather's system is to promote good patient care. But an additional benefit is that there's a lot of. of data being collected. Data about some things that don't exist in the medical literature.

Like when a cesarean patient says she feels X, what works best is to give her drug Y. Heather didn't copy her system from somewhere else. She and a colleague made it up themselves and had the tech team hook it into the electronic medical record system. Though some other institutions also assess and record patient pain during C-sections, Heather seems to be the first one to do it exactly like this.

One doctor I talked to praised Heather's system, but noted there isn't evidence that what she's doing is a best practice that will actually help patients. It wasn't a critique. It was a nod to the big picture. There isn't evidence that any tool for measuring caesarian pain works better than any other, because these tools don't exist.

Pain scores themselves are pretty contentious. People will say they lack context, or that if you're a patient, it's really hard to know what number to say. But Heather's not just getting numbers. Importantly, she's getting quotes from patients, too. Because her system not only requires doctors to talk about pain, it gives patients an opportunity to do so.

Patients who are not asked about pain, may not speak up about it, for whatever reason. Susanna recently sent me a paper that compared the situation of being a patient to being a hostage. These people literally hold your life in their hands. Do you want to disrupt or displease them? Right now there's a massive study on pain during caesarean going on in England and Australia, the sonar study. Almost 80% of all OB units in the UK are taking part in it.

And one of the questions they're asking patients is essentially, If you were in pain, did you tell your doctor about it? I love this question. I think it's enormously insightful. Some patients cry out and are ignored. Others never say anything to begin with. We need to capture them, too. Not every doctor is going to care about pain.

Not every patient is going to disclose it. One OB-anesthesiologist describes Heather's system as an intervention that makes it easier for people to do the right thing. Even the people who think they're already doing it. I mean, in all honesty, even the patient we just described, I would never have thought that furring was an eight. I thought it would have been like a three or four, right? Looking at her, I thought, oh, it's a mild pain.

And she describes to me a severe pain, right? And so I was like, whoa, whoa, whoa, we have to do something about this. The father of the baby facetimes was someone who's maybe the grandma. Soon it's time for me and Heather to leave the room. In the hallway, Heather and I step out of our coveralls. Later, I ask her if the new system means that pain is now documented in a way that's visible to patients. Yes, if you have a caesarian and you request your files,

you will see this in there. At UIC, Cesarian pain is now part of the same. of the record. Coming up, let's head to the nurse's station. After the break. For a long time, Clara still didn't talk about what happened with people at work. It was clear to everyone she was moving through it. She was back in the OR.

She was back to who she'd always been on the unit, someone who spoke up for patience, someone wise who could go to for advice about your own life. Heather continued to use Clara's story, the Jennifer story, in lectures, and a couple times Claire got into a conversation with a resident who brought up the story or the issues it raised, not knowing it was Clara's,

and Clara would say, surprising the resident, I'm Jennifer. Then immediately wonder, God, why did I do that? Do I want to be that vulnerable right now? But with distance, she did. And then one day, almost three years after the surgery, Clara and Mindy and a few others were at the nursing station.

It was a weekend, Mindy remembers. Usually when it's like weekends, it's calmer on the unit. So we kind of just like catch up on life and we're each other's therapists. Somehow they got to talking about the surgery. And she looked at me, she's like, Mindy, I totally forgot you were there. And I was like, in my mind, I'm thinking, she's thinking, like, why didn't you do something for me? Like, why didn't you step in for me?

And for her to say, you know what? You're right. I forgot you were there. And I was like, oh, my gosh. So she's not harboring this, like, anger towards me. And I was like, I didn't push it. I didn't ask more. Like, what do you mean you forgot?

Like, I was, like, really there. Yeah. So it was kind of like a relief. Like, oh. Later, Clara asked Mindy for, the photographs. They both did the same thing with them, looked at them hard to find the moment the surgery turned.

What's different for Clara now is not just being able to intervene during a C-section, but more generally. Here's a story from just the other day that illustrates it. A nurse on the unit was telling everyone about a C-section she'd just been in, one where the patient seemed to be really in pain, and the surgeon had said, We're almost done.

that those were the words. We're almost done. And I was really disturbed by it. Who was the anesthesiologist? Clara wondered. It was Corey. And so I was pretty like, whoa, what? That seems not at all like Corey and what he would have done. And I texted him. I have his number. So I text him. I was like, hey, I just heard this thing.

And it doesn't sound like you, but I was really bothering. by it, and I just wanted to know how you thought that went. Did the surgeon really say, you know, don't put her to sleep, or we're almost done, anything like that? And Corey clarified. He's like, not exactly, you know what I mean? Like, he could see how you walked away with that, but really what was going on was. Was that the patient's uterus was outside her body, exteriorized, remember, and it's hard,

almost impossible to make the patient feel nothing during this. Many OBA. and anesthesiologists would really prefer surgeons not do this. Organs belong in bodies, you'll hear them say. But for the surgeon's part, it's certainly easier to see and repair the uterus when the organ is outside. They're taught this is the safest way to do it. But anyway, yes, there was a moment where the patient was in pain. But Corey was on it. He addressed it with IV meds. And he's like, and no one would ever stop me from putting somebody to sleep, Clara. He said, if I had any doubt and thought for even a second she needed her pain wasn't controlled and she needed to we needed to convert to general

he said something like I don't care if the CMO or what chief medical officer told me not to like I would do it so I was really glad that I was able instead of worrying about it to follow up on it and I'm assuming that's not something you would have done in the before times or maybe you would have no I'm not sure I would have picked up on it I think that there was a lot more just sort of acceptance and powerlessness around it. Like, yeah, if I heard something like that, I would think it was bad and wrong. But I wouldn't, no, I wouldn't have followed up on it or anything. I wasn't in the room. It wasn't my patient, you know.

There's a culture that's enabled Clara to do this. But she's also one of the people making the culture. one of the people showing others how to speak up. So was Mindy. Before I ever met Mindy, I heard about her. There's a nurse named Mindy who will put you in a chokehold if you let a patient be in pain. I do. I do think there has been a change just because I feel more empowered to speak up to.

Sometimes. Sometimes. I still revert back to I'm just the nurse. I'm just the nurse. But I feel like. Like, UAC does have a, like, hierarchy, but I feel more empowered to speak up there than I ever did before. Mindy's changed since Clara's surgery, and not just as far as speaking up. She's questioning things, including one of the most fundamental assumptions about cesarean of all.

I think my biggest thing is, like, why do we do C-sections on Mama's mother-aware, like I understand that I understand the science behind it but like maybe some women truly prefer not to be awake and we push them towards being awake during C-section. So I just I want to know more like maybe we need to talk more about why we even move towards this practice because you know being awake and being like literally women when they're being pulled and pushed and that's scary. I don't know if I, as a patient, want that. Is it all just about patient experience and hearing their baby's first cry?

Like, is there alternatives? Like, could we just record it? I don't know. Like, I wonder how we got to this. Oh, my God. Mindy, I am so glad you just said that. Yeah. I have had that same thought, but nobody else has ever brought it up until you brought it up.

Yeah. I told Mindy that decades ago, the assumption had sometimes been the opposite, that the patient would prefer to be asleep for a C-section. Like, why would anyone want to be awake for that? One British anesthesiologist wrote in 1971 that being awake could be okay for, quote, a woman of the right temperament, but many women would not willingly undergo this experience.

Both assumptions, want to be awake, want to be asleep, are problems because neither is universally true. True. What a patient wants, that's different for every patient. If you're told that one of the benefits of neuraxial anesthesia is that you can be awake for your baby's birth. You may feel like that's something you should want and feel a shame that you don't, for whatever reason, including that you simply do not want to be aware during major surgery. Lots of patients tell Mindy they'd rather go to sleep. All the time. All the time. They say, I don't want to be awake. I want to go to sleep. And they just literally convince them that it's not the best. But yeah, no, there's so many

patients that should go to sleep that we don't. And they're so terrified. And we don't know what their trauma is going to be. Are they going to relive the beeping of their heartbeat and the like suctioning noises and the like pulling? And we don't ask women who have C-sections how traumatized they are. There's a growing awareness of what Mindy describes that, let's be real, this is a major surgery. Doctors I spoke with, including Heather, wanted to emphasize that most C-sections should be done under neuraxial anesthesia, that it's the gold standard, faster recovery, better pain control after birth. But Heather says, she's quicker to honor a patient preference for general from the get-go,

than she would have been just a few years ago. Well, doctors have long avoided general anesthesia for safety reasons. For some patients, safety might mean going to sleep. Here's a sign of the times. In obstetric anesthesia, there's something called a Center of Excellence designation. To get it, your hospital has to meet a bunch of criteria,

including one about limiting use of general anesthesia. Recently, there's been discussion about making sure this isn't inadvertently causing patients to suffer. There's also been discussion of adding a new measure of excellence. Percentage of patients in pain. Redefining excellence can change culture and practice. So, in theory, can a lawsuit. The medical and legal systems can reinforce each other to make change.

But there's not much evidence that this works with pain during cesarean. Putting aside the fact that many women are unlikely to want to pursue a lawsuit while traumatized and caring for a newborn, what happens if they try? I talked to one obstetric anesthesiologist who has served as a medical expert witness on a couple hundred cases in the past few years. In that time, he's been asked to review notes on fewer than 10 about pain during cesarean. He says most patients like this are told they don't have a case. When one case actually did get to court a couple of years ago in California, it was heard in federal court.

Delphina Mota, that's the patient's name, Delphina Mota v. United States of America. The transcript of the bench trial follows a familiar template, with the judge ultimately finding, essentially, your story is suspect because no one heard you scream. lest you think I'm exaggerating. Here are some actual lines from his ruling. Quote, no one heard plaintiff resist or refuse the procedure. Also, quote, plaintiff testified she screamed as the procedure began. However, this scream, of which much was made, was not confirmed by any third party.

Nurse Wood did report plaintiff saying, Help me, and I can feel everything. None of the others heard these statements. The judge ruled against Delphina Mota, who had not finished high school, and said she worked as a caretaker. She was 25 years old at the time of her surgery. It felt like I was on fire, Delphina testified, about the surgeon's first incision. I could feel her hands, her gloves in me. Plaintiff's version of the events is not credible, the judge wrote.

She was also, he added, psychologically brittle. Nobody raised doubts about Clara's credibility. Nobody rejected her story. In fact, it was the opposite. I told Clara about an exchange I'd had with a doctor who'd approached me when I visited UIC. She's like, I don't know if you know, but we had this thing happen at our hospital. There was a patient who was in a lot of pain during her cesarean. And it's really changed a lot at our hospital.

and she's a nurse, and now in Caesareans, she's like a real advocate for the patients in the room, and like everybody kind of defers to her. Yeah. Is that your experience? Yeah, yeah. Yeah, it is. Clara was crying, and I assumed I understood why.

But then the next thing she said showed me that I hadn't. I think that people, which again, it just makes me so far. fucking mad that it has it's just so typical right because here i am they're co-worker they're white co-worker so now we notice more than 80% of the patients who have babies at uIC are black or Hispanic there's almost no data on race and pain during cesarian but a recent study of 110 patients at one hospital in Texas found that black patients were five times more likely than white patients to report C-section pain. And, yeah. Has that ever been, like, explicitly talked about? Like, wait, guys, we woke up to this when our white co-worker, like, when this

I mean, I talk about it, but I don't know. I don't know that it's necessarily, yeah, been a big part of the conversation. I think that that's a very valid thing for Clara to say, and God bless her for being, you know, cognizant of that and thinking more globally. But if it had been an African-American nurse, it's one of your own. So that's what made her so special, right? Because it was, that should never have happened to one of your own, right? And it should never happen to anyone.

But it was big and dramatic and one of our own. One of us. one of our own is a phrase other doctors on L&D also used with me the way they said it was the same way Heather says it fierce so why did it matter

that Clara was not a patient who left but one who stayed within her close-knit unit it made what happened to her harder to dismiss and it made it possible to keep talking about it at first just among themselves and eventually

publicly Pain during cesarean is an issue. Clara's surgery and what it prompted is a story. It's nowhere in the medical literature. You can't find it in PubMed. And yet, as one obstetric anesthesiologist put it to me, stories are also a kind of evidence. They too can change the way doctors practice medicine.

Especially when, as both Susanna and Heather understood, you attach those stories to lessons. Story, lesson, those essential building blocks of so many genres, including, yes, medical dramas. Medical dramas. We, as in we, the TV watching people, we love them so much. You know who else loves these shows? You know who's watching along with us?

health care providers Gray's anatomy for me I've watched all of it I'm going to say it I'm going to say it it is my binge watching It's so many seasons I know it's so many seasons

21 and Heather has a critique All of those shows are designed to have those set of doctors be the only people who can do everything right They need to be the heroes of every episode

It's all up to them But of course the goal of the work that Heather and others are doing is to get everyone to care about pain during caesarean. It shouldn't be something that matters only to one ensemble on one unit at one hospital. It should be standard, so standard that it shouldn't even be worthy of a storyline.

Pain during caesarian is not a new problem, but for a long time it's been a hidden one. The everyday heroes on our show brought it to light. And now let's tuck our character. in, along with the hospital, see Mindy putting her dirty scrubs into the machine, and Clara walking across the street to the garage, and follow Heather downstairs to the third floor. She has an overnight. She'll be around for a while. Now let's pull back, get the whole hospital in the frame, hot orange sky, the day is so long this time of year, and hold that shot. End of show. Bold, centered, all caps.

The Retrievals is written and reported by me, Susan Burton, and produced by me, Julie Snyder, and Ben Phelan. Julie edited the series. Ben did research and fact-checking. Be sure to sign up for our newsletter, where each week we'll share more reporting from the show, listener stories, and reading lists. Go to NYTimes.com slash serial newsletter. Music supervision, sound design, and mixing by Phoebe Wang. Original music by Dan Powell, Fritz Myers, and Nick Thorburn. Additional music in this episode by Marian Lazzano. Carla Pallone composed our theme song, and it was remixed by Dan Powell.

Additional production by Mac Miller. Additional mixing by Catherine Anderson. Editing help on this episode from Jessica Weisberg and Jen Guera. Our standards editor is Susan Wessling. Legal review from Dana Green. The art for our show comes from Pablo Delcon and Eric Tanner. The supervising producer for serial productions is Inde Chubu. Additional producing comes from Mahima Chiblani, Jeffrey Miranda, and Corey Beach at the New York Times,

and Sam Dolnick is Deputy Managing Editor of the New York Times. Special thanks to Mike Hoffkamp, and Emily Sharp, who are among the authors of the study that found a higher rate of cesarean pain for black patients in Texas, Jennifer Schwank, Katerina Beckman, Rachel Waldinger, Nick Pittman, Kyle Grindillo, Aswati Giarram, David Gutman, and James O'Carroll, the doctor who came up with the question, if you were in pain, did you tell anyone about it? The Retrievals is a production of serial productions and The New York Times. Hi, this is Sarah Koenig, host of the serial podcast. If you like this show, season two of the retrievals, and I'm betting you did, and you haven't listened to season one of the retrievals, I encourage you to go check that out, because I think you'll love season one also. The first episode is available for free, but the remaining episodes are exclusive to New York Times subscribers. If you aren't a time subscriber already, I ask you, respectfully, what are you waiting for? When you subscribe to the New York Times, you'll get a time subscriber already. If you aren't a time subscriber already, I ask you, respectfully, what are you waiting for? When you subscribe to the New York Times, you'll get

all the normal, excellent things you get with a New York Times subscription, and you can listen to every single show we've made over here at serial productions. That's 14 shows. There's all four seasons of the show that I host, the serial podcast. There's S-Town and Nice White Parents. There's the Trojan Horse Affair and the Coldest Case in Laramie. There's the Goodwale. These shows have everything.

Seriously, investigative reporting, mystery, genre-bending storytelling, bizarre plots, superlative writing, a song. you will find what you're looking for, I promise you. You can sign up for a New York Times subscription in either the Apple Podcasts or Spotify apps or at n.ytimes.com slash podcasts. And if you do listen to our shows, please let us know.

You can leave us a review in a podcast app or email us at serial shows at nyatimes.com. We really do read every email we receive. And thanks.